Treating the 60-plus cosmetic patient

/Home/Cosmetic Laser Treatments/Anti Aging Laser Treatment/Anti Aging Treatment

Treating the 60-plus cosmetic patient
Dec 1, 2006
Lisette Hilton
Dermatology Times

Patients who are in their 60s, 70s, 80s and older tend to have different needs, cosmetically, than their younger counterparts.

Dermatologists need to recognize those needs and anticipate pitfalls associated with older skin in order to best help elderly patients with their quests to look younger and refreshed.

Environmental damage ongoing

Do not forget to warn elderly patients about sun protection, says Marsha Gordon, M.D., vice chairman and clinical professor, department of dermatology, Mount Sinai School of Medicine, New York.

"Often, patients over 60 will say to me that the damage has been done. That is the wrong way of looking at it, because the damage continues every day that we get sun," Dr. Gordon says. "When a patient comes in to see me, the first thing we talk about is great sun protection Û not just a high SPF sunscreen, but also full spectrum, including UVA and UVB and other sun protection techniques."

Addressing dry skin becomes more important with age, according to Dr. Gordon. As patients age, their oil glands become less active. There is even a suggestion in the literature, Dr. Gordon says, that facial dryness (from winter weather, for example) can cause low level inflammation.

Dr. Gordon makes it a point to review a moisturizing skincare regimen with her age 60-plus patients. She emphasizes not so much the active ingredients but rather the formulation of products.

"It comes down to finding a formulation that is the right mix for an individual and sometimes this means trial and error," Dr. Gordon says.

Staying on the same page

The consultation with the patient should be realistic and touch on what is age appropriate, says Heidi Waldorf, M.D., associate clinical professor at Mount Sinai Medical School, New York, and the director of laser and cosmetic dermatology at Mount Sinai.

"At least in my practice, most 60-year-olds do not want to walk out with 20-year-old lips," Dr. Waldorf says. "Either they need realistic expectations Û or you do Û about what looks appropriate. So you need to plan your cosmetic treatments appropriately for the patient's expectations," Dr. Waldorf says.

Dr. Gordon says, generally, the goal should be to soften wrinkles as much as possible and shave maybe a decade from one's appearance.

"If we are shooting for something too extreme, we are not going to have a very natural look, and my goal is to make people look naturally great for their age," Dr. Gordon says.

Older generations of patients lose subcutaneous tissue. Sunken cheeks and deep crevices around the mouth are telltale signs.

Dr. Gordon addresses the loss of volume and deep wrinkling with fillers. She uses a layered approach, with a robust filler to address deep recontouring and a fine-line material filler to smooth the etched lines on the surface.

Tread lightly, advance cautiously

Where using peels on older patients is concerned, Dr. Gordon says that dermatologists should keep in mind that skin cell turnover rate slows with age.

Very often, older patients have a dull, dry look to their skin; so, they can benefit from exfoliating.

"On the other hand, the blood supply to their skin and healing might not be as good as when they were younger. Until I learn a particular patient's skin inside and out, I go gingerly. I always start with a light peel or a gentle at-home exfoliating program where we build up slowly to see what they can tolerate," Dr. Gordon says.

Dr. Gordon addresses brown spots first with less aggressive peels and bleaching creams. If those do not work, she might refer a patient for laser treatment.

Botox (Allergan Medical) use in older patients also has its caveats. Dr. Gordon says that the dermatologists' rule of thumb administering Botox to an aged population should be: Go gingerly.

"We first should learn how that individual patient's muscles respond to Botox," Dr. Gordon says. "An 80-year-old might not need as much as a 30-year-old because their muscles may not be as thick and as strong. Also the 30-year-old has more elasticity in their skin, so if I slightly overtreat they are less likely to have a problem. When I treat older patients with Botox, I always tell them that I am going to start with a slightly less than full dose. I ask them to come back in two weeks and we will see how they are doing."

Dr. Waldorf says it is particularly important with older Botox patients to get a good history of prior cosmetic surgeries.

"A lot of the patients in that age group might look great because they have had prior cosmetic surgery. Ask what they have had and when and, then, ask if they are planning any procedures. Cosmetic eyelid surgery, for example, can affect whether we feel the orbital rim. You cannot just count on the eyebrow being in the correct anatomic position and the lower lid may be very tight," Dr. Waldorf tells Dermatology Times.

Look at the big picture

Another important consideration, especially with 60-year-old and older patients, according to Dr. Waldorf, is their possible use of blood thinners and other medications.

"A lot of people in their 60s are on prophylactic aspirin or even vitamin E," Dr. Waldorf says. "We need to know about anything they are taking Û whether it is a prescription or nonprescription medication Û because it can have implications on treatment, including how much a patient is going to swell and bruise, etc."

Dermatologists should take careful notes when they first start treating elderly patients, Dr. Gordon says. Noting the history of successes and mistakes helps the dermatologist to go forward and become more aggressive or less aggressive with treatments.

"I am always a little cautious with things like deep peels in an older population because I just do not know how great the microvasculature is," Dr. Gordon says. "Err on the side of caution. Take good notes, and, once you get to know the patient, you will know what that person can handle."

Disclosure: Dr. Waldorf is on the scientific advisory board for Unilever Dove. Dr. Gordon is a consultant for St. Ives.

A subscription may be required to view this article.