Vol. 3, n. 3, September-December 2007

Transcript

1 Vol. 3, n. 3, September-December 2007 Histopathology and photoaging Giulio Ferranti Anti-aging principles into cosmetic products. The certitudes Piera Fileccia Multicenter study for the evaluation of tolerance and efficacy of a new integrated aminoacidic treatment on the aging face Adele Sparavigna, Riccardo Forte, Francesco Saverio Dioguardi Long chain polynucleotides gel and skin biorevitalization Maurizio Cavallini, Marco Papagni Vitiligo Activity Index, a new activity evaluation index for bilateral vitiligo vulgaris Giovanni Menchini, Claudio Comacchi Use of self adhesive polyurethane dressing to gain compression of haemangiomas of infancy. Preliminary observations Lucia Restano, Carlo Gelmetti Efficacy, tolerability and cosmetic acceptability of Toléderm in patients with inflammatory cutaneous diseases of the face Serena De Trane, Maria Concetta Fargnoli, Francesco Sera, Ketty Peris Poly-L-lactic acid: advices for the best results with low side effects Dvora Ancona Elastosis perforans serpiginosa induced by D-penicillamine Laura Scuderi, Lidia Francesconi, Franco Dinotta, Rocco De Pasquale, Maria Rita Nasca, Giuseppe Micali Targetoid hemosiderotic hemangioma: a trombosed hemangioma with low and complete clinical-dermoscopic regression Elisabetta Perosino Hirsutism: treatment with eflornithine cream combined with laser therapy Lucia Brambilla, Biancamaria Scoppio, Silvia Mariel Ferrucci A classical drug in a new formulation Stefano Veraldi Microcirculation, skin and anthocyanosides Antonino Di Pietro Indexed in: EMBASE, EMNursing, Compendex, GEOBASE

2 Cari Colleghi, si chiude un anno di successi. Molti i traguardi raggiunti. Realizzati in pieno i progetti prefissati per il Un bilancio estremamente positivo per l ISPLAD e la Dermatologia Plastica italiana. Abbiamo effettuato n. 15 corsi di aggiornamento in quasi tutte le regioni italiane, con essi sono stati coinvolti oltre partecipanti e circa 100 docenti. Abbiamo avviato una collaborazione con i colleghi francesi con cui si sono svolti tre interessanti simposi. Abbiamo stabilito un contatto con i colleghi brasiliani i quali cominciano a iscriversi numerosi alla nostra associazione. Con la Spagna si è consolidata una fruttuosa amicizia e collaborazione scientifica. Ma altri importanti rapporti abbiamo in corso con vari paesi. Ad aprile in collaborazione con l Istituto Superiore di Sanità abbiamo organizzato a Roma un eccezionale Convegno sulle reazioni avverse ed effetti collaterali delle terapie estetiche. Incredibile il successo del nostro sito che nel 2007 ha visto oltre pagine lette, un vero boom. Siamo riusciti a parlare di ISPLAD e Dermatologia Plastica in oltre 130 articoli sui maggiori giornali in edicola. E infine la nostra rivista JPD che si è confermata sempre più un valido e serio riferimento scientifico; cominciano ad arrivare da tutto il mondo richieste dei lavori pubblicati. Ma già siamo in piena attività per il 2008, molte sono le iniziative che abbiamo in programma. Vi annuncio una campagna di prevenzione sulle macchie cutanee che faremo a marzo e il nostro appoggio ad una iniziativa importantissima: la Fondazione Onco-Cure di cui diamo l annuncio in questo numero. Vi lascio ricordandovi che dal 6 all 8 marzo a Milano ci sarà il nostro 2 Congresso Internazionale. Un evento pensato in grande, con oltre 200 relatori e moderatori, circa 100 giornalisti presenti con le più importanti testate di salute e benessere, un programma scientifico di grande valore che spazierà in tutti i temi più attuali della dermatologia: l invecchiamento, le reazioni avverse alle terapie estetiche, il management medico e gli aspetti legali, l oncologia cutanea etc.. Non mancheranno i corsi pratici di aggiornamento, numerosissimi saranno i workshop sulle novità delle terapie dermoplastiche e le nuove tecnologie. Vi aspetto quindi a Milano, sicuro che ci ritroveremo in tanti con l entusiasmo, l amicizia e la voglia di imparare che contraddistingue tutti noi. Girate la pagina e troverete un altra attestazione di stima nei nostri confronti! Dear Colleagues, A successful year ends with many of our goals attained. The objectives we set at the beginning of the year have all been fully accomplished. This is extremely positive news for ISPLAD and Italian Plastic Dermatology. We organized 15 refresher courses in almost all the regions of Italy, in which 2,000 participants and approximately 100 teachers were involved. We embarked on a collaboration with our French colleagues, which resulted in three very interesting symposiums. We have established a dialogue with our Brazilian colleagues, of which many have registered as members of our association. We ve built up a fruitful friendship and scientific collaboration with Spain. In addition, we have many ongoing relationships with various other nations. In April, in collaboration with the Istituto Superiore di Sanità, we organized an outstanding conference in Rome on adverse reactions and side effects of aesthetic therapies. The success of our website, in 2007 was incredible: 2,600,000 read pages is a real boom. We were able to discuss ISPLAD and Plastic Dermatology in 130 articles of the major journals in circulation. Finally, recognition of our journal JPD as a valid and serious scientific reference continues to grow. A multitude of requests for its published content have started to arrive from all over the world. We have a full schedule of activities planned for 2008 and many of them are already being implemented even as we speak. I take this opportunity to introduce you to our prevention campaign against cutaneous blemishes which will start in March and our support of an important initiative: the Onco-Cure Foundation, whose announcement will be published in this issue. I leave you with the reminder that from the 6 th -8 th of March, our 2 nd International Congress will take place in Milan. This will be a very big event involving 200 speakers and moderators, and an estimated 100 journalists from the most prominent publications on health and wellness. The scientific program of this congress will touch upon all the most current and relevant topics of Dermatology: ageing, adverse reactions of aesthetic therapies, health management, legal aspects, Cutaneous Oncology e.t.c.. We will continue to offer our practical refresher courses, of which many will be workshops on recent developments in Dermoplastic Therapies and new technologies. I hope to see everyone in Milan along with all the enthusiasm, friendship, and desire to learn that distinguishes us all. Antonino Di Pietro 1

3 Journal of Plastic Dermatology Editor Antonino Di Pietro (Italy) Editor in Chief Francesco Bruno (Italy) Co-Editors Salvador Gonzalez (USA) Pedro Jaen (Spain) Associate Editors Francesco Antonaccio (Italy) Mariuccia Bucci (Italy) Franco Buttafarro (Italy) Ornella De Pità (Italy) Giulio Ferranti (Italy) Andrea Giacomelli (Italy) Alda Malasoma (Italy) Steven Nisticò (Italy) Elisabetta Perosino (Italy) Andrea Romani (Italy) Nerys Roberts (UK) Editorial Board Lucio Andreassi (Italy) Kenneth Arndt (USA) Bernd Rüdiger Balda (Austria) H.S. Black (USA) Lucia Brambilla (Italy) Günter Burg (Switzerland) Michele Carruba (Italy) Vincenzo De Sanctis (Italy) Aldo Di Carlo (Italy) Robin Eady AJ (UK) Paolo Fabbri (Italy) Ferdinando Ippolito (Italy) Giuseppe Micali (Italy) Martin Charles Jr Mihm (USA) Joe Pace (Malta) Lucio Pastore (Italy) Gerd Plewig (Germany) Riccarda Serri (Italy) Adele Sparavigna (Italy) Abel Torres (USA) Stefano Veraldi (Italy) Umberto Veronesi (Italy) Managing Editor Antonio Di Maio English editing Rewadee Anujapad Direttore Responsabile Direttore Generale Direttore Marketing Consulenza grafica Impaginazione Pietro Cazzola Armando Mazzù Antonio Di Maio Piero Merlini Clementina Pasina Registr. Tribunale di Milano n. 102 del 14/02/2005 Scripta Manent s.n.c. Via Bassini, Milano Tel / Fax scriman@tin.it Abbonamento annuale (3 numeri) Euro 39,00 Pagamento: conto corrente postale n intestato a: Edizioni Scripta Manent s.n.c., via Bassini Milano Stampa: Arti Grafiche Bazzi, Milano Sommario pag. 9 L istopatologia ed il foto-invecchiamento Giulio Ferranti pag. 13 I principi attivi antiaging nei prodotti cosmetici. Le certezze (Prima di due parti) Piera Fileccia pag. 19 Multicenter study for the evaluation of tolerance and efficacy of a new integrated aminoacidic treatment on the aging face Adele Sparavigna, Riccardo Forte, Francesco Saverio Dioguardi pag. 27 Long chain polynucleotides gel and skin biorevitalization Maurizio Cavallini, Marco Papagni pag. 35 Vitiligo Activity Index, a new activity evaluation index for bilateral vitiligo vulgaris Giovanni Menchini, Claudio Comacchi pag. 41 Impiego di lamine autoadesive di poliuretano per il trattamento compressivo degli emangiomi infantili. Osservazioni preliminari Lucia Restano, Carlo Gelmetti pag. 49 Efficacia, tollerabilità ed accettabilità cosmetica della crema Toléderm in pazienti affetti da patologie infiammatorie cutanee del volto Serena De Trane, Maria Concetta Fargnoli, Francesco Sera, Ketty Peris pag. 55 Acido L-polilattico: consigli per ottenere i migliori risultati con minimi effetti avversi Dvora Ancona pag. 61 Elastosi perforante serpiginosa indotta da D-penicillamina Laura Scuderi, Lidia Francesconi, Franco Dinotta, Rocco De Pasquale, Maria Rita Nasca, Giuseppe Micali pag. 67 Emangioma emosiderotico targetoide: un angioma trombizzato a lenta e quasi completa regressione clinico-dermoscopica Elisabetta Perosino pag. 71 Irsutismo: trattamento con eflornitina crema in combinazione con laser terapia Lucia Brambilla, Biancamaria Scoppio, Silvia Mariel Ferrucci pag. 85 Una molecola classica in una nuova via di applicazione Stefano Veraldi pag. 89 Microcircolo, cute e antocianosidi Antonino Di Pietro È vietata la riproduzione totale o parziale, con qualsiasi mezzo, di articoli, illustrazioni e fotografie senza l autorizzazione scritta dell Editore. L Editore non risponde dell opinione espressa dagli Autori degli articoli. Ai sensi della legge 675/96 è possibile in qualsiasi momento opporsi all invio della rivista comunicando per iscritto la propria decisione a: Edizioni Scripta Manent s.n.c. Via Bassini, Milano 7

4 L istopatologia ed il foto-invecchiamento Giulio Ferranti SU M M A R Y Histopathology and photoaging The term photoaging describes the damage to the skin caused by intense and chronic exposure to sunlight. In this article the major changes in the photoaged skin histological structure are shown. The knowledge of the skin histopathology in photoaged skin is useful to follow the possible improvements due to therapies. KEY WORDS: Hystopathology, Skin, Photoaging Figura 1. D e r m a t o l o g o / I s t o p a t o l o g o Laboratorio di Istopatologia IRCCS IDI, Roma Il ruolo dell istopatologo nello studio dell invecchiamento cutaneo correlato all insulto attinico, è, a volte, considerato non di primaria importanza, in particolare per la difficoltà di procedere ad una biopsia incisionale nelle aree foto-esposte, ove la pregiudiziale estetica è molto significativa. Tuttavia i dati che si possono ottenere da un attenta valutazione istologica sono senz altro utili per ben definire il processo di foto-invecchiamento. Possiamo suddividere le alterazioni osservabili al microscopio, in modificazioni epidermiche ed in alterazioni dermiche. Per quanto riguarda le prime, la presenza di una vacuolizzazione pre s s o- ché lineare subito al di sotto della membrana basale (Figura 1), è un aspetto frequente nella cute foto-danneggiata. Analoghi vacuoli si osservano negli spazi intercellulari dello strato basale (Figura 2) e di quello malpighiano (Figura 3), anche se l alterazione primaria si sviluppa in sede intrac e l l u l a re, ove le micro - v a c u o l i z z a z i o n i sono facilmente osserv a b i l i. Tali alterazioni esitano in una distorsione parziale o totale delle cellule sia dello strato basale che degli strati più s u p e r f i c i a l i. Analogamente ai cheratinociti, anche i melanociti risultano alterati. In particolare, grossolane vacuolizzazioni schiacciano e deformano il loro n u c l e o. O l t re alla presenza delle modificazioni sopradescritte, i cheratinociti mostrano alterazione della forma e delle dimensioni, con perdita della loro normale polarità, sino ad assumere aspetti francamente displastici (cheratosi attinica) (Figura 4). Una ulteriore manifestazione microscopica, che correla con una gravità c rescente del danno foto indotto, è la p resenza, nello strato basale, di cellule colonnari, di colorito scuro, definite 9

5 G. Ferranti Figura 2. Figura 3. Figura 4. Figura 5. come cellule discheratotiche, ovvero cellule staminali. Risalendo lungo l epidermide, si osservano cellule piuttosto grandi e chiare in seno allo strato spinoso. Un dato, spesso significativo, è rappresentato dalla presenza di uno o più cheratinociti necrotici, che, a volte, aggregandosi gli uni agli altri, vanno a costituire aree piuttosto estese di necrosi dell epidermide. Il danno da foto-esposizione intere s s a anche le cellule di Langerhans che risultano ridotte di numero, ed i melanociti, la cui produzione di melanina mostra grossolane irregolarità (Figura 5). I corneociti appaiono spesso rigonfi, mentre la presenza di granuli pulvirulenti, riferibili a glicogeno, possono completamente infarc i re il citoplasma di alcune cellule malpighiane. Se le alterazioni dell epidermide, in corso di foto danneggiamento, sono piuttosto specifiche, ma a volte, sfumate, quelle relative al derma mostrano aspetti evidenti, grossolani ed, istologicamente, molto significativi. L elemento focale è certamente rappresentato dalle alterazioni osservabili a livello della trama elastica. È infatti p resente una maggior produzione anomala di fibre elastiche che appaiono frammentate, ispessite, a volte disposte in strutture grossolanamente longitudinali ovvero aggregate in piccole masse amorfe, sia nel derma superficiale che profondo (Figure 6-7). I n t o rno alle fibre elastiche maggiormente alterate, è possibile osserv a re alcuni macrofagi contenenti piccoli frammenti di tali fibre. Si associano anche melanofagi (Figura 8), pre v a l e n- temente in sede perivasale, nel derma p a p i l l a re. Sia nelle aree con minima f i b rolisi, sia nelle aree in cui le fibre elastiche si deformano sino a costituire masse solide amorfe, è possibile osserv a re alcuni mastociti. Le alterazioni della trama elastica, non repertabili nel derma papillare subito al di sotto della membrana basale dell epidermide (g renz zone) (Figura 9), sono l elemento più caratteristico del danno cutaneo foto-indotto ed è l elemento maggiormente distintivo anche rispetto al cro n o - i n v e c c h i a m e n t o. Il riconoscimento dei parametri istopatologici che caratterizzano il fotoinvecchiamento può essere utile nello studio della patogenesi di questo processo ed anche nel monitorare eventuali miglioramenti correlati alle tante terapie proposte per arg i n a re tale p a t o l o g i a. 10

6 L istopatologia ed il foto-invecchiamento Figura 6. Figura 7. Figura 8. Figura 9. etture consigliate l Montagna, Kirchner S, Carlisle K. Histology of sun-damaged human skin. J Am Ac Dermatol 1989; 21: Braverman IM, Fonferko I. Studies in cutaneous aging. I. The elastic fiber network. J Invest Dermatol 1982; 78: Braverman IM. Elastic fiber and microvascular abnormalities in aging skin. Dermatologic Clin 1986; 4: Sams WM jr. Sun-induced aging: clinical and laboratory observations in man. Dermatol Clin 1986; 4: O Brien JP. Actinic granuloma: an analysis of its origin in elastosis ( aging ) and a definition of necrobiotic (vascular), histiocytic and sarcoid variance. Int J Dermatol 1985; 24: Lavker RM. Structural alterations in exoposed and nonexoposed aged skin. J Invest Dermatol 1979; 73:59-66 Gilchrest BA, Blog FB, Szabo G. Effect of aging and chronic sun exposure on melanocytes in human skin. J Invest Dermatol 1979; 79:141-3 Gilchrest BA, Murphy GF., Soter NA. Effect of chronic aging and ultraviolet irradiation on Langerhans cells in human epidermis. J Invest Dermatol 1982; 78:85-8 Gilchrest BA, Soter JS, et al. The human sunburn reaction: histologic and biochemical studies. J Am Ac Dermatol 1981; 5: Lavker RM, Sun T-T. Epidermal stem cells. J Invest Dermatol 1983; 81:121-7 Pinkus H, Mehregan AH, Staricco RG. Elastic globes in human skin. J Invest Dermatol 1965; 45:81-5 Chen H, Yuan J,Wang Y, et al. Distribution of ATPase positive Langerhans cells in normal adult human skin. Br J Dermatol 1985; 113: A b e rer W, Schuler G, Stingl G, Hönigsmann H, Wo l ff K. Ultraviolet light depletes surface makers of Langerhans cells. J Invest Dermatol 1981; 7 6 : Tsuji SA. A new elastic system component, elastic sheet in the human dermis: an electron micro s c o- pic study. Br J Dermatol 1988; 118: Lavker RM, Kligman AM. Chronic helioderm a t i- tis: a morphologic evaluation of cronic actinic dermal damage with emphasis on the role of mast cells. J Invest Dermatol 1988; 90: Chen VL, Fleishmajer R, Schwartz E, et al. Immunohistochemistry of elastotic material in sun-damaged skin. J Invest Dermatol 1986; 8 7 :

7 I principi attivi antiaging nei prodotti cosmetici. Le certezze (Prima di due parti) Piera Fileccia SU M M A R Y Anti-aging principles into cosmetic products. The certitudes Non invasive aging treatment is very requested by dermatologic patients. There are a lot of active and very tolerated principles into cosmetic products. The most important nowadays are antioxidants,!-hydroxy acids and retinoids. Antioxidants are active against environmental stress,!-hydroxy acids provoke tissue reparation via chemical flogosis and retinoids act by receptorial link and genic stimulation. The target are epidermis and dermis mechanisms and association of two or more molecules is important for wide activity on cutaneous aging and photoaging. KE Y W O R D S: Aging, Antioxidants,!- h y d roxy acids, Retinoids Specialista in Dermatologia, Roma I ntroduzione L indagine annuale dell UNIPRO, l associazione che riunisce le imprese cosmetiche e profumiere italiane, conferma la crescita del comparto cosmetico nel nostro Paese: i dati del primo semestre 2007 (1) attestano un aumento del fatturato pari a 2,7% rispetto all anno precedente, per un valore complessivo del mercato prossimo agli milioni di euro. La farmacia registra un trend di crescita costante negli ultimi 5 anni, superiore a qualunque altra categoria nel settore. Alla fine del 2007 si prevede un incremento del 5% delle vendite in questo canale. Analizzando la suddivisione per categorie di prodotti, si evidenzia che i cosmetici per il viso sono quelli più venduti in farmacia (29,3% del totale) con una netta prevalenza, tra questi, dei prodotti antietà e antirughe (122 milioni di euro in totale nel 2006), a riprova che un canale a cui si attribuisce serietà e competenza professionale è quello che meglio può dispensare questi prodotti. Ed è sul terreno degli antirughe e antietà che si poggia la maggior parte delle prescrizioni di noi Dermatologi Plastici, per cui l aggiorn a- mento e la cosmetovigilanza sono indispensabili per la nostra competenza pro f e s s i o n a l e. Con questo lavoro si vuole fare il punto tra i golden standard attualmente utilizzati nelle formulazioni cosmetiche e compre n d e re quali sono le più promettenti tra le molecole che ci vengono proposte dall industria cosmetica, infaticabile nel lanciare sul mercato nuove formulazioni per l invecchiamento del viso. olecole antiaging: le certezze M Le molecole inserite nei cosmetici per l invecchiamento della pelle devono avere un doppio target d attività: epidermide e derma, con speciale risalto per il rapporto epidermico, che ne giustifica la definizione di cosmetico. Non possiamo, tuttavia, accontentarci solo di questo, visto che il bersaglio dell invecchiamento, sia crono che foto, è il derma. Nella nostra analisi prenderemo in esame solo quelle molecole che hanno dimostrato un azione congiunta sui 2 tessuti, magari a seguito di idonea veicolazione. La scelta si restringe agli antiossidanti, agli alfaidrossiacidi e ai retinoidi. 13

8 P. Fileccia Antiossidanti L aggiunta degli antiossidanti nelle formulazioni cosmetiche ha lo scopo di ridurre il fotodanneggiamento, quando vengono applicati sulla pelle prima dell esposizione agli UV (2). La s i n e rgia tra le diverse molecole antiossidanti provoca aumento di MED e PPD, aumentando così il potere fotoprotettivo dei filtri solari presenti. La sfida è favorire la penetrazione transcutanea delle molecole nella forma attiva. Vitamina C (acido l-ascorbico) La vitamina C è l antiossidante del compartimento acquoso del corpo per eccellenza. L uomo e gli altri mammiferi non sono in grado di essere autonomi rispetto al loro fabbisogno. Lo stress ossidativo ambientale abbassa i livelli di vitamina C della pelle (3). Fortunatamente l apporto esterno riesce a comp e n s a re questa situazione, vista la capacità di penetrazione transcutanea della sostanza: studi con formulazione di vitamina C 10% marc a t a hanno mostrato nel maiale una penetrazione dermica fino a 8,2% e 0,7% nel sangue (4). La concentrazione più appropriata nel cosmetico è 20%. Per il trasporto è importante ridurre la carica elettrica, acidificando il mezzo (ph 3,5). I derivati stabili, come l ascorbil-6-palmitato o il magnesio ascorbil fosfato, non vengono metabolizzati dalla pelle. La vitamina C è un preziosissimo contenitore del danno da UV: prelievi istologici dimostrano una riduzione delle s u n b u rn cell di 40-60% e del danno al DNA-UVA indotto del 62%. La sua principale attività è la stimolazione dire t- ta della sintesi del collagene, essendo l acido ascorbico il cofattore enzimatico della prolin- e lisil- idrossilasi. Studi in vitro hanno mostrato che i fibroblasti senescenti proliferano come quelli neonatali in presenza di vitamina C ed anche questi ultimi incrementano di 4 volte la pro l i f e- razione se esposti a piccole dosi di acido ascorbico. Di pari passo va la sintesi del collagene: i f i b roblasti senescenti, in terreno arricchito da vitamina C, producono più collagene dei fibroblasti neonatali (5). Un altro elemento contro il fotodanneggiamento è l inibizione della tirosinasi, con miglioramento delle age spot, e dell enzima elastasi, con riduzione dell elastosi solare. Un attività importante della vitamina C è lo stimolo della sintesi di alcuni lipidi superficiali, aumentando sia l idratazione superficiale che l attività della barriera epidermica (6). Vitamina E (RRR-!-tocoferolo) La vitamina E è il più importante antiossidante del compartimento lipidico dell organismo. È maggiormente presente nel corneo, specialmente nelle assisi più interne (7). Venendo consumata rapidamente per lo stress ambientale, la sua applicazione topica è particolarmente vantaggiosa (8). La forma attiva nei tessuti dei mammiferi è l isomero RRR-!-tocoferolo, per cui il potere antiossidante delle forme esterificate, più stabili, è minimo (9). Gehering (10) ha dimostrato che l applicazione topica di vitamina E aumenta l idratazione del corneo e il potere barriera. Esperimenti in vitro (11) hanno confermato una riduzione dell espressione dell attività collagenasica attraverso l inibizione dell attività proten chinasi C. In definitiva, nonostante la grande quantità di dati presenti, mancano studi clinici che definiscano razionale e concentrazioni. All opposto, le scienze di base hanno fornito dati certi sulla fisiologia, meccanismo d azione, penetrazione, bioconversione e fotoprotezione: questi studi confermano un azione anticarc i n o g e n e t i c a, fotoprotettiva e stabilizzatrice di barriera (12). Ubichinone (Coenzima Q10) L ubichinone permette alla cellule di utilizzare l ossigeno, essendo inserito nella tappa fondamentale della respirazione mitocondriale e, per la sua potente attività antiossidante, controlla la produzione radicalica nelle tappe di produzione dell energia. È un antiossidante lipofilo, direttamente inserito nelle membrane cellulari e lavora in sinergia con la vitamina E nella tutela del comparto lipofilo dell organismo (13). L organismo, pur essendo in grado di sintetizzarlo, perde questa attitudine con l avanzare del tempo. Infatti, il Coenzima Q10 è considerato come un biomarker dell invecchiamento, visto che il suo declino si correla molto bene con l invecchiamento cellulare. La supplementazione topica migliora questa carenza, risultando utile nella prevenzione e trattamento dell aging cutaneo. Nel lavoro di Hoppe (14), volto a mostrare gli effetti del coenzima Q10 nella prevenzione del fotoinvecchiamento, si evidenzia la penetrazione fino agli strati vitali dell epidermide, riduzione dei livelli di ossidazione nei cheratinociti umani, della profondità delle rughe e dell attività collagenasica in fibroblasti UVA-irradiati. 14

9 I principi attivi antiaging nei prodotti cosmetici. Le certezze Gli!-idrossiacidi (AHA) Gli!- i d rossiacidi sono un gruppo di acidi org a- nici idrofili, strutturalmente correlati tra loro, derivati da fonti naturali (acidi della frutta) o sintetizzati in laboratorio. Sono stati usati per anni come esfolianti, idratanti ed emollienti. Le molecole più usate nel cosmetico sono l acido glicolico e l acido lattico. L acido glicolico è incolore, inodore e insapore. Nei prodotti cosmetici la concentrazione oscilla tra 5 e 15%. D i t re (15) ha paragonato gli effetti dell acido glicolico, citrico, lattico, tutti a concentrazione 25%, al placebo in applicazione topica per 6 mesi sull avambraccio. Si è avuto un ispessimento del 25% sulla cute trattata attivamente, con stimolazione del turn-over epidermico e, a livello dermico, aumento dei mucopolisaccaridi acidi, miglioramento della qualità delle fibre elastiche e aumento della densità delle fibre collagene. Il meccanismo che è alla base di queste attività potrebbe essere l attivazione del Tr a n s f o rm i n g G rowth Factor a ph acido. S m i t h (16) ha studiato l effetto dell acido lattico al 5 e 12% applicato per tre mesi su 24 soggetti. Il trattamento al 5% ha migliorato la consistenza e lo spessore epidermico all ecografia, senza alcun effetto sul derma; il preparato al 12% ha portato ad un aumento dello spessore e della consistenza in ambedue i comparti cutanei, con miglioramento visibile della rugosità. I prodotti cosmetici con concentrazioni di AHA < 8 % sono poco eff i c a c i. Gluconolattone, acido lattobionico Il gluconolattone è la molecola più importante della seconda generazione di AHA. La sua struttura (Figura 1), che contiene un nucleo ciclico, presenta 4 gruppi -OH, che re n d e la molecola meno aggressiva per la pelle e con uno spiccato effetto idratante, specifica per zone s e n s i b i l i come il contorno occhi e labbra. L acido lattobionico appartiene alla terza famiglia degli AHA ed è composto, come si evidenzia in Figura 2, da una molecola di acido gluconico legata a una di galattosio con un legame etereo. O HO O OH OH OH Figura 1. Struttura chimica del gluconolattone. CH 2 OH O OH OH OH Galattosio CH 2 OH OH O OH OH Acido gluconico COOH Figura 2. Struttura chimica dell acido lattobionico.!-idrossi acido L acido lattobionico esercita un azione antiossidante molto forte, per la capacità di chelare il f e r ro; inoltre, per i suoi 8 residui OH, ha un importante effetto idratante, che contribuisce a m i g l i o r a re il tono cutaneo e a ridurre le rughe sottili (13, 17). I retinoidi I retinoidi sono stati tra i maggiori artefici della nascita della cosmesi dermatologica. Lo studio degli effetti dei retinoidi sulla pelle ci ha insegnato molto più di quanto potevamo immaginare. La ricerca scientifica su questo argomento ha dimostrato come un prodotto topico può modif i c a re l apparenza della pelle, interfere n d o p rofondamente con la sua struttura senza eff e t t i collaterali dannosi. Il golden standard tra i retinoidi è la tre t i n o i n a, forma acida della vitamina A (retinolo) e suo m e t a b o l i t a. Gli studi iniziali dell attivita della tretinoina sul fotoinvecchiamento risalgono a K l i g m a n n e g l i anni 80 (18), che, dopo osservazioni su modello murino, confermò che anche sull uomo l applicazione topica di tretinoina allo 0,05% determinava un ipertrofia dell epidermide, eliminazione pro g ressiva dei cheratinociti displastici o atipici, dispersione uniforme dei granuli di melanina, neoformazione di collagene nel derma papill a re e neoangiogenesi. È importante pure chiarire, come fece K l i g m a n qualche anno dopo (19), che la risposta al prodotto non è immediata, infatti necessita di almeno 6 mesi, che i cambiamenti sono più istologici che macroscopici e che la neoangiogenesi, forse non così adeguatamente valutata, dà alla lunga un aspetto più colorito e migliora l ambiente interstiziale, rimuovendo metabolici tossici accumulati in un tessuto privato della sua fisiologica i r rorazione. Ma, come dice lo stesso K l i g m a n Retin A is an authentic drug with a substantive capacity to pre v e n t and treat disease e, come tale, in Italia non è 15

10 P. Fileccia ammesso nelle formulazioni cosmetiche. Quali delle attività standardizzate con l uso della tre t i- noina sono evidenziabili utilizzando i re t i n o i d i ammessi, cioè il retinolo e la re t i n a l d e i d e? R e t i n o l o Il retinolo rappresenta l ingrediente più comune delle creme a n t i a g i n g. Appartiene alla famiglia dei retinoidi. Nell organismo il retinolo viene convertito nella sua forma attiva, l acido trans-re t i n o i c o ( t retinoina), attraverso un prodotto intermedio, la re t i n a l d e i d e. Nel tempo si è creata una confusione tra i dermatologi sulla capacità del retinolo topico di far re g re d i re i segni del fotodanneggiamento, nonostante la pletora di prodotti cosmetici antiaging che lo contengono. Non c è consenso generale sulla conversione del retinolo ad acido retinoico sulla pelle: il primo è c i rca 20 volte meno potente del secondo, quindi per avere bioequivalenza è necessario raggiungere concentrazioni superiori (20). In uno studio recente su 24 pazienti sono state prescritte le concentrazioni 0,15-0,3-0,6% da applicare per un periodo di 6 mesi. Le modificazioni cliniche ed istologiche si sono avute con le 2 concentrazioni più alte in tutti i pazienti ma solo nel 40% di coloro che utilizzavano 0,15%. R e t i n a l d e i d e I cheratinociti trasformano il retinolo in retinaldeide e quindi in acido retinoico, processo enzimatico in 2 tappe che coinvolge una deidrogenasi. L uso della retinaldeide è interessante per 2 motivi: 1. supera la prima tappa di ossidazione del re t i- n o l o ; 2. poiché solo le cellule ben differenziate sono in grado di operare l ulteriore ossidazione retinaldeide " acido retinoico, è possibile controllare la trasformazione e migliorare la tollerabilità (21). La retinaldeide è infatti meglio tollerata dell acido retinico, che causa irritazione locale, riducendo la compliance del paziente. C onclusioni L esame delle molecole più attive per c o m b a t t e re i segni dell invecchiamento cutaneo rende conto dei grandi pro g ressi che sono stati fatti nella comprensione dei meccanismi intrin- seci ai tessuti la cui alterazione o, più semplicemente, il pro g ressivo esaurimento, porta alla p e rdita delle caratteristiche della pelle giovane e sana. È giusto, come ha intuitivamente pensato Kligman nel coniare il termine cosmeceutico attribuire a questa classe di prodotti un attività dimostrata e misurabile e una tollerabilità che ne permetta un uso indiscriminato su qualunque tipo di pelle, in un arco di età di almeno quaranta anni, magari più volte al giorno. È nel giusto chi afferma che la scienza dermatologica ha fatto grandi passi avanti da quando ha imparato a interessarsi all invecchiamento. Le tre categorie trattate - antiossidanti,!-idrossiacidi, retinoidi - sono quelle che hanno consolidato nel tempo le loro premesse di attività e tollerabilità ed è da loro che si parte per proporre nuove molecole che arrivino a potenziare i ragguardevoli risultati raggiunti. Alla prossima per parlare di questi progressi! B ibliografia 1. UNIPRO: I numeri della cosmetica. Marzo Burke KE. Photodamage of the skin: protection and reversal with topical antioxidants. J Cosmet Dermatol 2004; 3: Shindo Y, Wit E, Han D, et al. Dose response effect of acute UV irradiation on antioxidants and molecular markers of oxidation in murine epidermis and dermis. J Invest Derm 1994; 23: Darr D, Combs S, Dunsten S, et al. Topical vitamin C protects porcine skin from UV radiation-induced damage. Br J Dermatol 1992; 127: Savini I, Catni V, Rossi A, et al. Characterization of keratinocyte differentiation induced by ascorbic acid: protein kinase C involvement and vitamin C homeostasis. J Invest Derm 2002; 118: Uclida Y, Behne M, Quiec D, et al. Vitamin C stimulates sphingolipid production and markers of barrier formation in submerged human keratinocyte cultures. J Invest Dermatol 2001; 117: Chiu A, Kimball AB. Topical vitamins, minerals and botanical ingredients as modulators of environmental and c h ronological skin damage. Br J Dermatol 2003; 149: Burton GW, Traber MG, Acuff RV, et al. Human plasma and tissue! tocopherol concentrations in response to supplementation with deuterated natural and synthetic vitamin E. Am J Clin Nutr 1998; 67: Gensler HL, Aicklin M, Peng YM. Importance of the form of topical vitamin E for prevention of photocarcinogenesis. Nutr Cancer 1996; 26:

11 I principi attivi antiaging nei prodotti cosmetici. Le certezze 10. Gehering W, Fluhr J, Gloor M. Influence of vitamin E acetate on stratum corneum hydration. Azneimittelforschung 1998; 48: Ricciarelli R, Maroni P, Ozer N, et al. Age-dependent i n c rease of collagenase expression can be reduced by alpha.tocopherol via protein kinase C inhibition. Free Radic Biol Med 1999; 27: Thiele JJ, Hsieh SN, Ekanayake-Mudiyanselage S. Vitamin E: critical review of its current use in cosmetic and clinical dermatology. Dermatol Surg 2005; 31: Rona C, Vailati F, Berardesca E. The cosmetic treatment of wrinkles. J Cosmet Dermatol 2004; 3: Hoppe U, Bergemann J, Diembeck W, et al. Coenzyme Q10, a cutaneous antioxidant and energizer. Biofactors 1999; 9(2-4): Ditre CM, Griffin TD, Murphy GF, et al. Effects of alpha-hydroxy acids on photoaged skin: a pilot clinical, histologic, and ultrastructural study. J Am Acad Dermatol 1996; 34: Smith WP. Epidermal and dermal effect of topical lactic acid. J Am Acad Dermatol 1996; 35: Green BA, Wildnauer RH, Edison BL. Lactobionic acid: a novel polyhidroxy bionic acid for skincare. Neostrata Company, Inc., Princeton, NJ, USA 18. Kligman A, Grove GL, Hirose L, et al. Topical tretinoin for photoaged skin. J Am Acad Dermatol 1986; 15: Kligman A. Topical retinoic acid (tretinoin) for photoaging: conceptions and misperceptions. Cutis 1996; 5 7 : Kang S, Duell EA, Fisher GJ, et al. Application of retinol to human skin in vivo reduces hyperplasia and cellular retinoid binding proteins characteristic of retinoic acid but without measurable retinoic acid levels or irritation. J Invest Dermatol 1996; 105: Saurat JH, Didierjean L, Masgrau E. Topical retinaldehyde on human skin: biological effects and tolerance. J Invest Dermatol 1994; 103:

12 Multicenter study for the evaluation of tolerance and efficacy of a new integrated aminoacidic treatment on the aging face Adele Sparavigna 1 Riccardo Forte 2 Francesco Saverio Dioguardi 3 SU M M A R Y Multicenter study for the evaluation of tolerance and efficacy of a new integrated aminoacidic treatment on the aging face Age-related changes in the dermis mainly consist of reduced thickness and flattening of the dermo-epidermal junction. In aging skin less efficient biosynthetic activities make the newly formed collagen more easily attacked by collagenases and metalloproteinases. We have evaluated the activity of a specific treatment based on an injectable aminoacid mixture plus low molecular weight hyaluronic acid along with food and cosmetic supplementation of the same aminoacids. In the used mixture the aminoacids glycine, proline, leucine and e lysine are in a stechiometric ratio specifically studied to improve collagen neo-synthesis. The aminoacidic treatment produced a very statistically significant reduction of skin roughness evaluated both clinically and instrumentally; in particular, profilometric parameters were significantly decreased after 1 month and dramatically decreased after 4 months. Our results demonstrate that specific aminoacid formulations as substrates to collagen synthetic pathways may have a positive role in improving the ageing signs of the skin. KE Y W O R D S: Aminoacidic treatment, Aging face 1 Derming, Clinical Research and Bioengineering Institute 2 Italian Society of Aesthetical Medicine 3 Department of Internal Medicine, University of Milan I ntroduction A g e - related changes in the dermis mainly consist of reduced thickness and flattening of the dermo-epidermal junction (1). This is particularly true for sun-exposed skin and during menopause in women (2, 3). The alterations of the dermal connective tissue, corresponding mainly to a reduction of the extracellular matrix, are highly responsible for the wrinkling and sagging of the skin, since they determine deep modifications in the mechanical properties of ageing skin. Several studies have demonstrated that ageing unbalances the enzymatic activities related to the synthesis, remodelling and catabolism of the extracellular matrix components in the dermis: collagen, elastin and glycoaminoglycans. As a result, not only do ageing processes induce a reduction of the extracellular matrix, but its quality is also affected. Moreover, in aging skin less efficient biosynthetic activities make the newly formed collagen more easily attacked by collagenases and metalloproteinases. Nowadays, skin can be stimulated to improve quali-quantitative ageing alterations by the intradermal injection of biological substances able to induce a revitalization of the dermis. The most frequently used substance is natural, not cross-linked, low molecular weight hyaluronic acid. In fact, with ageing there is a decrease in the content of glycoaminoglycans in the dermis, in particular of hyaluronic acid, the major non-sulphated glycoaminoglycan of connective tissue ground substance. The reduction in hydrophilic glycoaminoglycans leads to a direct reduction in water content and skin turgor. Interestingly, not only can the injected simple hyaluronic acid molecules 19

13 A. Sparavigna A, R. Forte, F.S. Dioguardi provide ground substance enrichment and deep hydration of the skin, but they also strongly stimulate fibroblasts to sinthetize new ground substance (4). Moreover, recent publications have suggested the possible positive role of the current greater availability of specific aminoacid mixtures as substrates to collagen synthetic pathways in human organs (5-7). Collagen has a complex molecular structure, due to its particularly regular aminoacidic content. Although there are several different collagen types, in each type every third aminoacid one is glycine, the smallest of all aminoacids. The quite monotonous composition of collagen peptides is not only limited to the highly regular recurrence of the glycine residue, but is also present in the following two positions, called positions X and Y, where position Y is hydroxyproline (OHpro) in 50% of the cases, and hydroxylisine (OHlys) in most of the remaining sequences. These aminoacids are very rarely found in proteins other than collagen. They are fundamental in a cascade of events allowing a reaction forming interand intra- molecular bonds strongly entangling three peptides into fibrils and firmly tightening them into the complex collagen units. Having one glycine every third aminoacid allows peptides to bend regularly and form a left-handed helical structure, entwined with two other peptides in a super-helical structure twisted to the right, greatly similar to the structure of a rope. This gives extraordinary tensile strength and flexibility to collagen fibers. Based on the above, a new integrated treatment was prepared, consisting of a specific aminoacidic functional cluster assembled in order to physiologically promote local collagen synthesis through chemotactic stimulus (see Table 1 for the composition) and which includes intradermal injections (injectable aminoacidic mixtures plus low molecular weight hyaluronic acid), cosmetic treatment and food supplementation. The present study was performed in order to evaluate the activity of this integrated treatment on the aging face. aterials and methods M Five dermatological centers participated in the study. Investigations were carried out in 103 healthy female volunteers, aged 35 to 60 (average age: 47). All the enrolled subjects had low to moderate skin ageing/photo-ageing, a c c o rding to a re f e rence photographic scale, and had given their informed consent. Exclusion criteria were: pregnancy or lactation, use of permanent fillers in the past, presence of other systemic pathologies, like autoimmune disease, diabetes, liver and renal insuff i c i e n c y, heart failure. Subjects who for any reason had taken drugs like aspirin or other NSAID s, or systemic cortic o s t e roids during the three month preceding the p resent study, were also excluded. The objective of the study was to evaluate the tolerance and efficacy of an intradermal injectable product associated to cosmetic treatment and food supplementation (J a l u p ro a n d P ro g l y m e, Professional Dietetics s.r.l., Milan, Italy) over a treatment period of twenty-two weeks. The study was performed according to a multicenter open study protocol, and the treatment under investigation was administered as follows: 4 intradermal injections - done directly by participating dermatologists using the injectable product (Jalupro ); injections were done once a week, and the first one was done two weeks after the basal visits (subjects had already started to take cosmetic and food supplements two weeks before). Food supplement - one ampoule/day of aminoacid food supplement (Proglyme, in water or in any other drink) was taken by the subjects from week T-2 to the last intradermal implant, for a total of six weeks. Cosmetic treatment - from T0 to T4: aminoacid cream, applied on the face twice a day (morning and evening) and liquid patch applied twice a week (30 minutes of setting). T h ree evaluation visits were performed during the study: at baseline (T0), 1 month after the last L-Proline L-Glycine L-Lisine L-Leucine Injectable vials 37,6 50 5,4 7 Oral solution 43,8 50 5,2 - Cream 37,6 50 5,4 7 Liquid patch 37,6 50 5,4 7 Table 1. Aminoacidic composition (%) delivered by tested products. 20

14 Multicenter study for the evaluation of tolerance and efficacy of a new integrated aminoacidic treatment on the aging face intradermal implant (intermediate visit, T1) and at the end of the study period (final visit, T4, four months after the last intradermal implant). Clinical evaluations The tolerance of the study treatment was evaluated by recording and monitoring any adverse event and by dermatological assessment of objective symptoms as erythema, oedema, papules, pustules or other symptoms at baseline and on each successive visit. During the visits the following clinical evaluations (visual score) were performed on the right or left face side, according to a previously completed randomization list: skin roughness (at the level of nasolabial folds and periocular area according to reference photographic scales, skin smoothness (surface microrelief), skin tonicity and skin brightness. The efficacy of the study treatment was assessed by visual evaluation conducted at baseline, at T1 and at the end of the study. Wrinkles grade (at the level of nasolabial folds and in the area around the eyes) was determined using a reference clinical and photographic scale (0= no wrinkles, 1= very mild, 2= mild, 3= quite evident, 4= evident, 5= very evident, 6= marked, 7= very marked. 0, 1 and 7 are exclusion criteria). Surface microrelief evaluation was performed according to a cheek surface photographic scale (1= very regular, 2= regular, 3= irregular, 4= very irregular). Skin tone and skin brightness were evaluated using a visual score (0= very mild, 1= mild, 2= medium, 3= marked, 4= very marked for skin tone and 1= very opaque, 2= opaque, 3= normal, 4= luminous for skin brightness). At the end of the treatment (final visit) each volunteer gave her personal judgment on the efficacy of the study treatment on deep and superficial wrinkles, as well as on elasticity, smoothness and brightness of the skin. In this paper, we have arbitrarily decided to define as antiageing activity on the face the possible positive influence on skin aging evaluated and measured locally through any eventual improvement in the thickness of nasolabial skin folds, as described in I n s t ru m e n t a l Evaluations. Instrumental evaluations A part of the enrolled subjects (n= 21) was also submitted to instrumental evaluations using the optical profilometry technique previously described in the literature (12-14). These subjects were also administered an additional intradermal injection at T4 and were reevaluated at T6 months. At baseline and subsequent visits (T1 and T4) skin replicas at the level of nasolabial folds were taken (right or left side, according to a randomization list). Replicas were obtained using silicone rubber (Optosil, Heraeus Kulzer GmbH & Co, KG) and allowed the evaluation of the dimension of the wrinkles by computerised image analysis. Image analysis of the replicas (optical profilometry): this evaluation was conducted through a computerised image elaboration (Image Pro Plus, Media Cybernetics Inc., USA). Replicas were illuminated with a 45 incident light, which creates shadows behind crests that can be photographed, digitised and analysed. The shadows were transformed into a grey scale, where grey intensities were directly proportional to shadow intensities and therefore to wrinkle depth. Shadows were detected by thresholding. By defining an area within the image, and by tracing a segment of known length in a defined position across the wrinkle and perpendicular to it, it was possible to calculate the following profilometric roughness parameters: R a = roughness average parameter which is the arithmetic mean of all ordinates from the mean line of the profile. R t = maximal depth of wrinkles. At baseline (T0), T1, T4 and T6 frontal and profile standard pictures of the 21 volunteers were also taken. Self-evaluations During the final visit, each volunteer filled in a questionnaire regarding the efficacy of the treatment under study on deep and superficial wrinkles, as well as on the elasticity, smoothness and brightness of the skin of their faces (using the same score for each item: very marked; marked; medium; mild; absent). Statistical analysis of data The statistical evaluations of the visual and instrumental data (adjusted means and standard deviation) and their relative graphs were performed at the times required by the protocol. The statistical analyses of the clinical and selfevaluation data were performed using the Wilcoxon and Friedman tests. The analysis of all parametric data was done using the Student s t test. 21

15 A. Sparavigna A, R. Forte, F.S. Dioguardi Figure 1. R esults Clinical evaluations To l e r a n c e - The tolerance of the tested products was judged as very good and no adverse event occurred during the study period (final investigators opinion: 81%= excellent, 18%= good). The good tolerance was confirmed by the volunteers opinion; as a matter of fact, only few subjects underlined the appearance of a slight erythema with a burning sensation following the first cream and/or liquid patch application and lasting few minutes. Clinical evaluations performed during the entire treatment period demonstrated the absence of relevant clinical signs as erythema, oedema, papules, pustules or the like. Clinical evaluation of efficacy - The evaluation of the efficacy of the treatment under study took into account the above mentioned aging signs. An example of treatment efficacy is shown in F i g u re 1. The statistical evaluation of the clinical data was performed using the Wilcoxon test. One month after the last intradermal implant (T1), a significant and important improvement of nasolabial folds (p <0.001) in 74% of the treated cases was obtained; in particular, in 59% of the subjects the visual score improved by 1 degree, in 12% of the subjects by 2 degrees and in 3% of the subjects it improved by 3 degrees. Data obtained at the end of the test (T4), confirmed T1 0% 2% 0% 11% 4% 0% 26% 30% 1% 0% 2.1% 0% 6% 4% 11.5% 29% 29% 1% 49.5% 47% 63% 51% 58% 69% 52% 71% 48.5% 0% Wrinkles skin area around the eyes Worsened Improved by 2 grades 26% 12% 0% 0% 1% Skin tonicity Skin brightness Cutaneous microrelief Not changed Improved by 3 grades Improved by 1 grade 47% 0% Wrinkles skin area around the eyes Worsened Improved by 2 grades 35.4% 15% 0% 0% 0% Skin tonicity Skin brightness Cutaneous microrelief Not changed Improved by 3 grades Improved by 1 grade Figure 2. Visual evaluation one month after the last intradermal implant (T1). Figure 3. Visual evaluation at the end of the treatment period (T4). 22

16 0% 0% 18% 1% 0% 0% 44% 2% 81% 54% Excellent Good Medium Poor Bad Excellent Good Medium Poor Bad Figure 4. Tolerance evaluation of the tested product by the investigators at the end of the study. Figure 5. Efficacy evaluation by the investigators at the end of the study. Absent 12% 35% 35% 15% 42% 35% 24% 53% 30% 50% Figure 6. Efficacy evaluation by the volunteers at the end of the study. 28% 45% 15% 23% 15% 15% 7% 5% 4% 4% 3% 1% 3% 1% 0% Deep wrinkles Superficial wrinkles Skin tonicity Smoothness Skin brightness Light Medium Marked Very marked results; in fact, in 72% of the subjects a statistically significant improvement (p <0.001), at least 1 degree, was still present (in 62% of the subjects it improved by 1 degree; in 10% of the subjects by 2 degrees). No worsened case was o b s e rved. 1 month after the last intradermal implant (T1), a very significant impro v e m e n t in skin roughness in the periocular area was found in 51.5% of the subjects (p <0.001); in p a r t i c u l a r, in 49.5% of the subjects the visual s c o re improved by 1 degree and in 2% of the subjects it improved by 2 degrees. More o v e r, at T1 one could see a very significant (p <0.001) i m p rovement in skin tonicity in 74% of the subjects (improved by 1 degree in 63% of the subjects and by 2 degrees in 11% of the subjects), in skin brightness in 88% of the subjects (improved by 1 degree in 58% of the subjects, by 2 degrees in 26% of the subjects and by 3 degrees in 4% of the subjects), and in cutaneous micro relief in 30% of the subjects ( i m p roved by 1 degree in all subjects), as re g a rds all enrolled subjects. Evaluations performed at the end of the study (p <0.001 T0 vs T4 for all considered visual scores) confirmed the T1 results, showing the bio-revitalizing activity of the study treatment. In fact, a statistically significant improvement (p <0.001) in the scores of wrinkles around the eyes, s k i n t o n i c i t y, skin brightness and cutaneous microrelief was found respectively in 53% (improved by 1 degree in 47% of the cases and by 2 d e g rees in 6% of the cases), 64.6% (impro v e d by 1 degree in 51%, by 2 degrees in 11.5% and by 3 degrees in 2.1% of the cases), 85% ( i m p roved by 1 degree in 52%, by 2 degrees in 29% and by 3 degrees in 4% of the cases) and 29% (improved by 1 degree in all cases) of all studied cases. No worsened case was noticed. Volunteers judgment on eff i c a c y - 82% of the volunteers appreciated the efficacy of the tre a t- ment on deep wrinkles (12% as very marked, 35% as marked, 35% as medium) while 92% of the subjects noticed the effect on superficial wrinkles (15% as very marked, 42% as marked, 35% as medium). M o re o v e r, 92% of the subjects reported an i m p rovement in skin tonicity (24% as very marked, 53% as marked, 15% as medium), 95% in skin smoothness (30% as very marked, 50% as marked, 15% as medium) and 96% in skin brightness (28% as very marked, 45% as marked, 23% as medium). The significance of the self-evaluation data was demonstrated by a Friedman test. A further assessment of global e fficacy performed by the investigators confirmed these results (54%= very good, 44%= good, 2%= medium). 23

17 A. Sparavigna A, R. Forte, F.S. Dioguardi Instrumental evaluations An instrumental evaluation of the profilometric parameters was conducted on 21 of the 103 enrolled subjects. The statistical evaluation of the profilometric data was performed with a Student s t test. The image analysis of nasolabial folds at T0, (baseline), T1 (intermediate visit) and T4 (final visit) provided the following results: statistically significant reduction, at T1 and T4, of average R a (p <0.001 from mean basal value of to at T1 and 10.5 at T4, corresponding to 24% of reduction at T1 and 40% at T4); statistically significant reduction, at T1 and T4, of R t (p <0.001 from mean basal value of to at T1 and at T4, corre s p o n d i n g to 25% of reduction at T1 and 32% at T4). M o re o v e r, re g a rding the comparison between data at T1 and T4, a pro g ressive and statistically significant improvement of the R a p a r a m e t e r (p <0.05 T1 vs T4 for R a ) corresponding to a 26% reduction was demonstrated. T6 evaluations (clinical scores of nasolabial folds, wrinkles around the eyes, skin tonicity, skin brightness, cutaneos microrelief and optical profilometry on nasolabial folds skin replicas) were performed two months after the additional intradermal implant. For all considered parameters, the results obtained from the comparison of T6 and T4 did not show any statistically significant variation, underlining how the bio-revitalizing effect (i.e., using physiological drives for promoting improvement of biological activities) of the study treatment seen at T4 was still present at T6, although during this period (from July to September) all subjects had exposed their face to strong sun irradiation for a long time and had not regularly taken the cosmetic and food supplements of the treatment under investigation. D iscussion The activity of intradermal injections of hyaluronic acid as a biorevitalizer is already well-known: several studies in the literature report a good antiage efficacy due to extracellular matrix augmentation, deep hydration and even antioxydizing activity of hyaluronic acid. Adequate aminoacids refueling of the skin is evidently indispensable for the maintenance of its integrity or repair. One of the first studies on this matter observed the negative incidence of protein-energy malnutrition effects on infection rate, healing, and mortality in elderly burn patients (8). Later, some other papers dealt with alterations of macronutrients balance and skin, especially regarding diabetes (9), anorexia nervosa (10) and postmenopausal women (11). All those papers linked poor availability of nutrition substrates and damage or atrophy of the skin. More recent studies have suggested the possible positive role of the current greater availability of specific aminoacids formulations as substrates to collagen synthetic pathways in other organs (5-7). Food supplementation with aminoacids has represented the first approach to the problem of atrophy in aging skin. This is certainly useful for the systemic treatment of the entire tegumentary apparatus. Ageing faces require stronger and more localized treatment, and in this case an intradermal injection of aminoacids could be a more effective choice, even more so if accompanied by the use of skin care cosmetics containing similar aminoacids formulations. For this reason, we have decided to evaluate the activity of a specific treatment based on an injectable aminoacid mixture plus low molecular weight hyaluronic acid along with food and cosmetic supplementation of the same aminoacids. In the used mixture the aminoacids glycine, proline, leucine and e lysine are in a stechiometric ratio specifically studied to improve collagen neo-synthesis. The aminoacidic treatment under study produced a very statistically significant reduction of skin roughness evaluated both clinically and instrumentally; in particular, profilometric parameters were significantly decreased after 1 month and dramatically decreased after 4 months. In particular, regarding the profilometric parameters, an important and significant decrease of average and maximum depth of nasolabial folds (filling efficacy) was demonstrated, while the reduction of the visual score of periocular wrinkles showed how the study product had an important lifting activity on the wrinkles (antiage activity). Clinical evaluations and efficacy judgements by the volunteers significantly confirmed the efficacy of the treatment. In conclusion, our results demonstrate that specific aminoacid formulations as substrates to collagen synthetic pathways may have a positive role in improving the ageing signs of the skin. The treatment protocol defined for the study was found effective. It remains to be established 24

18 Multicenter study for the evaluation of tolerance and efficacy of a new integrated aminoacidic treatment on the aging face whether this treatment can be used for combination antiageing therapies, that is if it would be possible to combine it with other treatments like chemical peeling, laser resurfacing and fillers and, if so, using which protocols. A knowledgments The Authors wish to thank the following dermatologists who participated in this multicenter trial: Rigoni C., Cantù A., Frasca N. (Italian Women Dermatologists Association) Politi G.R. (Medical Center, Albenga) R eferences 1. Waller JM, Maibach HI. Age and skin structure and function, a quantitative approach (I): blood flow, ph, thickness and ultrasound echogenicity. Skin Research and Technology 2005; 11: Chen L et Al. The use of high-frequency diagnostic ultrasound to investigate the effect of hormone replacement therapy on skin thickness. Skin Research and Technology 2001; 7: Pierard GE et Al.Comparative effect of hormone replacement therapy on bone mass density and skin tensile properties. Maturitas 2001; 40: Ghersetich I. Management of aging skin. Journal of the European Academy of Dermatology and Venereology 1995; 9 (Suppl.1): 51-51(1) 5. Vinciguerra P, Camesasca F, Ponzio D. Use of aminoacids in refractive surgery. J Refract Surg 2002; 18(S):S Vinciguerra P, TorresMugnoz I, Camesasca F. The role of amino acids in corneal stromal healing: a method for evaluating cellular density and extracellular matrix distribution. J Refracte Surg 2002; 19(S2):S Babraj JA, Smith K, Cuthberson DJ, Rickhuss P, Dorling JS, Rennie MJ. Human bone collagen synthesis is a rapid, nutritionally modulated process. J Bone Miner Res 2005; 20: Demling RH. The incidence and impact of pre-existing protein energy malnutrition on outcome in the elderly burn patient population. J Burn Care Rehabil 2005; 26:93 9. Bauer ES. Foot Ulcers. N Eng J Med 2000; 343: Strumia R. Dermatological signs in patietns with eating disorders. Am J Clin Dermatol 2005; 6: Raine-Fenning NJ, Brincat MP, Muscat-Baron Y. Skin aging and menopause: implications for treatment. Am J Clin Dermatol 2003; 4: Camarosa JG, Anthoine P, Tribo Boixareu ML, Serra Baldrich E and Aubert L. Demonstration of anti-wrinkle efficacy of a cosmetic product. Correlation between clinical observation an instrumental methods. J Appl Cosmetol 1997; 15: Corcuff P, Leveque JL. Skin surface replica image analysis of furrows and wrinkles. In Serup J, Jemec GBE (eds). Non-Invasive methods and the skin. CRC Press, Boca Raton, 1995; Schreiner V, Sauermann G, Hoppe U. Characterization of the skin surface by ISO-parameters for microtopography. In Wilhelm KP, Elsner P, Berardesca E, Maibach HI (eds). Bioengineering of the skin: Skin surface imaging and analysis. CRC Press, Boca Raton, 1997;

19 Long chain polynucleotides gel and skin biorevitalization Maurizio Cavallini Marco Papagni SU M M A R Y Long chain polynucleotides gel and skin biorevitalization Nowadays dermatological aesthetic treatments requires the use of well tolerated, tested, low invasive procedures, allowing the patients a prompt return to normal social life. This is why skin biorevitalization is a very frequent treatment, also because it can be used as an antiaging therapy by itself, as well as to prepare the skin for other aesthetic procedures. Authors describe the clinical experience on skin biorevitalization with long chain polynucleotide gel (Plinest ) for intradermal infiltration a class III medical device, biocompatible, natural, entirely resorbable and not requiring allergy test. 143 patients of both sexes were submitted to 3 or 4 sessions of intradermal infiltration with the product in study according to the type of skin. The evaluations were performed before and 30 days after the last treatment. Results: The physician global assessment was positive in 91% of the cases, with a clinical improvement due to the reduction of superficial fine wrinkles and to a best appearance of the skin mainly pronounced in the cheeks, in the periocular area and in the neck. A digital skin measurement system for hydration, sebometry, ph and elasticity was performed in 14 patients. Data showed increase in hydration, and improvement of elasticity (21,8%). The product was very well tolerated and the injections did not cause much pain. There were no cases of severe side effects due to the product used in the study. The data obtained till now are in accord with the action of stimulous of secretion of collagenic and non collagenic proteins by fibroblasts, due to the activity of long polynucleotides molecules, but a greater number of cases are suitable to confirm these clinical results. KE Y W O R D S: Polynucleotides, Biorevitalization, Biostimulation, Aesthetic medicine, Aging Department of Plastic Surgery IRCCS Galeazzi Hospital - Milan, Italy I ntroduction The desire for a healthy youthful skin belongs to a wide range of age: from the third decade of life wrinkles can appear, mainly in sun exposed areas of the skin. The aging process depends on both intrinsic and environmental factors. Intrinsic factors are due to genetics and in women it depends on changements in hormone production during peri and post menopausal period. There are several environmental factors of skin aging among which UV radiation plays an important role. With aging the skin changes in different layers but there is no doubt that wrinkling of senescent skin is almost entirely the result of changes in the dermis (1, 2). In the aging process the dermis diminishes in bulk, in absolute terms the collagen decreases with age, elastic fibers are reduced in number and degenerate; and a steady decrease in the number and size of cells like fibroblast also appears (3). T h e re are many treatment options, but nowadays in aesthetic medicine patients prefer low invasive, well tolerated pro c e d u res, making the skin f resher and younger. The best compliance is with t reatments allowing the patients the pro m p t re t u rn to social life and without the interruption of normal daily activities. This is the reason why the skin biorevitalization is one of the more frequent treatments in aesthetic medicine. This study focuses on an original and new class III medical device for skin biorevitalization con- 27

20 M. Cavallini, M. Papagni taining long chain polynucleotides gel. The product must be injected into the superficial derma and the integration between the gel and the matrix of the dermis optimize the biore v a l i z a t i o n action of the skin. The purpose of this study is to describe the clinical experience on skin biorevitalization with long chain polynucleotides gel, focusing on s a f e t y, tolerability, techniques and clinical eff e c t s. atients and methods P The product P l i n e s t is a gel, consisting of highly purified - natural origin long chain polynucleotides (20 mg/ml concentration) (4). It is marked in pre-filled glass syringe with 1.3 ml of high molecular weight sterile and apirogenic polynucleotides. It is a class III medical device, biocompatible, of natural origin and allergy testing is not necessary. The product underwent many in vitro and in vivo tests, showing the absence of local and systemic toxicity respecting the UNI rules of medical devices (cytotoxicity for dire c t contact, allergic sensitization, mutagenicity test- Ames test, intracutaneous re a c t i v i t y, Irritation test). In the clinical use it is noted a high tolerability and total absence of important side eff e c t s. Infiltration techniques P l i n e s t is a handy product that can be injected into derma with very thin needles (30G), which greatly reduce any discomfort to the patient. The implant techniques used were : the serial puncture injections (micro wheals technique), the re t rograde linear injections and the cross-link technique. the serial puncture technique or micro wheals technique consists of serial intra dermal injections every 0,5-1 cm of small quantity of the p roduct to cover all the area to treat. This t e c h- nique can be used to treat the skin in every part of the face and of the body. the linear technique consists in the filling of superficial and/or medium dermis, following the wrinkles or the Langer lines, or in larg e a reas as the cheek or in the nasolabial folds. the cross-link technique consists of a net of linear intersecting infiltrations. It allows the p roduct to distribute over the whole area, and is mainly suggested for treating larger areas, for instance the cheek re g i o n. P a t i e n t s F rom June 2005 to May 2007, 148 patients of both sexes (134 females and 14 males), with ages ranging from 32 to 75 years, w e re treated with long chain polynucleotides for skin biore v i t a l i z a t i o n. Inclusion criteria included: healthy patients, ages ranging from 18 to 75 years, written informed consent, five or more years of school, phototype I-IV and if female not in pregnancy or bre a s t - f e e- ding. Exclusion criteria included: severe concomitant diseases, hypersensitivity to the product in s t u d y, abuse of alcohol or other drugs and smoking (>20 cigarettes a day). Clinical evaluations were carried out before treatment (T0) and 30 days after the end of the initial treatment phase (follow up visit). The treatment efficacy was evaluated by patient and physician assessment and by the analysis of digital pictures. The objective and subjective tolerability of the product used was evaluated during each intradermal infiltration. The physician assessment was evaluated with a quartiles scale (worsened, unchanged, i m p roved, highly improved) (5). The patients satisfaction rate was evaluated during the followup visit and has been re c o rded with a 0-10 visual analogue scale (VAS) with 0 designated as the absence of improvement and 10 the best improvement with the best satisfaction of the patient. The VAS was chosen because it is easily adminis t e red and is well accepted by patients (6). Treated areas Face 132 Neck 55 Décolleté 14 Back of the hands 9 Total 210 Table 1. Treated areas. Figure 1. Physician global assessment. 28