Other atrophic skin changes: clinical guidelines

List of Abbreviations

ICD — International Classification of Diseases

Terms and Definitions

Skin atrophy is a pathological process resulting from age-related, metabolic, inflammatory, and trophic changes in all layers of the dermis and epidermis, leading to connective tissue degeneration manifested by a decrease in the volume of collagen and elastic fibers, resulting in skin thinning.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Skin atrophy is a heterogeneous group of chronic disorders whose main symptom is the thinning of skin structures: the epidermis, dermis, and subcutaneous adipose tissue. The underlying mechanism involves the complete or partial destruction of collagen and elastic fibers, which are one of the main components of the dermal connective tissue.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The etiology and pathogenesis are specific to each type of atrophy.

It is customary to distinguish two pathways in the onset and development of skin atrophy: physiological and pathological. The physiological pathway includes aging (an involutional process) and pregnancy, whereas all other cases are the consequence of pathology.

Involutional skin atrophy is a progressive decline in the functions and reserve capacity of the skin resulting from chronological processes driven by factors such as ultraviolet irradiation, oxidative stress, mitochondrial dysfunction, and skin cell apoptosis, accompanied by the formation of atrophic changes in the epidermis and dermis. [1, 2]

There is a thinning of the epidermis due to a reduction in the number of cell layers in the stratum malpighii and the size of individual cells, flattening of the epidermal ridges, thickening of the stratum corneum with inadequate development of the stratum granulosum, as well as an increased melanin content in basal layer cells. The thinning of the dermis is accompanied by destructive and hyperplastic changes in fibrous structures, a decrease in the number of cellular elements including tissue basophils, thickening of vessel walls, and atrophy of hair follicles and sweat glands. Due to reduced mitotic activity of basal keratinocytes, the interdigital index—the ratio of the length of the dermo-epidermal junction between two points to the straight-line distance between them—decreases, impairing the delivery of nutrients. Dermal atrophy is observed, the number of fibroblasts is reduced, collagen fibers become thinner, elastosis may occur, and the distribution of subcutaneous adipose tissue is disrupted [3, 4].

Involutional skin atrophy is a natural process influenced by the following etiological factors:

- chronological processes;

- genetic factors;

- photodamage caused by ultraviolet and infrared radiation;

- lifestyle: unbalanced diet, smoking, alcohol and drug use;

- catabolic processes resulting from chronic intoxications (e.g., infectious and oncological diseases, adverse environmental conditions);

- endocrine disorders;

- gravitational changes [2].

1.3 Epidemiology of the Disease or Condition

Skin aging is controlled by exogenous and endogenous factors and is an inevitable process. The face is affected to a greater extent because it is exposed to light radiation, pollution, gravity, and repetitive muscle contractions associated with facial expressions, which gradually leads to alterations in skin texture and facial contours. Gender differences in a number of morphofunctional characteristics of the skin are determined across different age periods and define the specific features of skin aging in men and women. In both women and men, the aging processes are directly related to sex hormone levels.

In men, high levels of testosterone and dihydrotestosterone activity are maintained for a sufficiently long period, which accounts for the prolonged preservation of facial sculpting. Dynamic wrinkles form in men and women through a similar mechanism and in identical locations as a result of facial expression, but their severity and depth are greater in men. [4]

These differences are the result of both hormonal changes and lifestyle variations. At the same time, the most significant changes in women develop during the climacteric period and are caused by an estrogen-deficient state, which is why they are frequently referred to as "hormonal skin aging". [4]

1.4 Features of Coding the Disease or Condition

L90.8 — Other atrophic disorders of skin.

1.5 Classification of the disease or condition

The condition is classified according to its cause, clinical course, and prevalence.

Three main types of aging are distinguished based on etiological factors [5]:

· Chronological (physiological) aging;

· Menopausal (hormonal) aging;

· Photoaging.

According to I.I. Kolgunenko, signs of aging are grouped by age into two main categories [6, 8]:

- signs of premature skin aging appear up to the age of 50, with the following subcategories:

- from 21 to 30 years;

- from 31 to 40 years;

- from 41 to 50 years;

- natural skin aging occurs from 51 years and older, with the following subcategories:

- Early form — from 51 to 60 years;

- Intermediate form — from 61 to 75 years;

- Late form — 76 years and older.

The author distinguishes major (obligate) and minor (optional) signs of aging (correlating clinical changes with morphological ones) and identifies six types of aging [6, 7, 8]:

Ø The «tired face» type is observed in the early stages of skin aging and manifests as decreased tone of soft facial tissues and muscles, dry and dull skin tone, early appearance of folds and wrinkles in the corners of the mouth, tear troughs, and deepening of the nasolabial folds. These changes give the face a weary, tired appearance.

Ø The wrinkled type , characterized by degenerative-dystrophic changes in the epidermis and dermis, lipodystrophy, dehydration and decreased skin elasticity, and multiple expression wrinkles.

Ø The deformational type , caused by gravitational ptosis of soft tissues and edema.

Ø The combined type , characterized by a combination of features of the wrinkled and deformational types.

Ø The muscular type , typical for residents of Central Asia and the Far East, who have well-developed facial muscles and sparse subcutaneous adipose tissue. Facial aging in this type is manifested primarily by pigmentation disorders, skin wrinkling of the upper and lower eyelids, pronounced nasolabial folds, and downturned corners of the mouth. The contours of the facial oval are preserved well into old age.

Ø The combined type of late facial and neck aging , caused by late stages of involutional changes — «senile haggard face» (after 75 years).

Major (obligate) signs of facial and neck aging: loss of soft tissue elasticity; dryness and thinning of the skin; wrinkling (and folding) of the skin; senile deformation.

Minor (optional) signs of facial and neck aging: edema and pastosity around the eyes; skin porosity; telangiectasias, rosacea, spider angiomas, ruby spots; hypertrichosis (hirsutism); hyperpigmentation; seborrheic keratoses, papillomas.

According to the classification by O.S. Panova, the following classes of facial skin involutional changes are distinguished:

Class I (21–30 years)

A. Superficial expression wrinkles

B. Expression and superficial static wrinkles

C. Expression and superficial static wrinkles, initial skin texture changes

Class II

A. (31–38 years)

Moderate expression and static wrinkles; initial skin texture changes

B. (33–42 years)

Deep expression wrinkles, moderate static wrinkles against the background of altered skin texture

Class III

A. (39–47 years)

Moderate expression and static wrinkles; initial skin texture changes

B. (43–55 years)

Deep expression wrinkles, moderate static wrinkles, pronounced skin texture changes, minor skin excess

C. (47 years and older)

Deep expression and deep static wrinkles, significant skin excess, coarse skin texture changes

Depending on the location of the main age-related changes, the following facial aging types are distinguished [7]:

- periorbital type;

- perioral type;

- lateral type;

- submandibular type;

- mixed type.

1.6 Clinical presentation of the disease or condition

The clinical presentation of skin atrophy caused by involutional changes involves all skin layers and manifests as soft tissue gravitational ptosis, epidermal thinning, skin xerosis, edema, expression lines and other wrinkles, hyperpigmentation and vascular skin changes, facial contour alterations, benign senile formations, as well as, depending on the body area, unwanted hair growth, striae, and excess skin of the upper and lower eyelids [7, 8, 11].

2. Diagnostics, medical indications and contraindications for diagnostic methods

The diagnosis is established based on the characteristic clinical presentation.

2.1 Complaints and Anamnesis

Depending on the type and stage of skin aging, patients may present with complaints of dry skin, decreased firmness and elasticity, edema, dynamic and static wrinkles, drooping of the corners of the eyes and mouth, loss of facial contours, double chin, and excess skin of the upper and lower eyelids [7].

When taking the medical history, one should consider bad habits such as smoking, alcohol abuse, unbalanced diet, living in an unfavorable ecological environment, presence of hereditary and other comorbid conditions, frequency of ultraviolet exposure, and hormonal status [2, 12].

2.2 Physical Examination

For objective clinical manifestations of the condition detected during physical examination, see the "Clinical Presentation" section.

2.3 Laboratory Diagnostics

Laboratory diagnostic tests are not used.

2.4 Instrumental Diagnostics

Comments: Profilometry allows for the assessment of skin relief and the severity of aging signs [13, 30, p. 81]. Profilometry involves the creation of a 3D relief to assess the condition of wrinkles and skin microstructures before and after treatment using computer analysis of high-resolution photographs obtained via digital dermatoscopy [13].

Comments: Performing mexametry allows for the quantification of melanin content and erythema levels in the studied skin area before and after treatment [26].

Mexametry is based on the absorption and reflection of light by the main skin chromophores.

Comments: Vapometry is performed to determine transepidermal water loss (the rate of water evaporation from the skin surface) [9].

Comments: Confocal laser scanning microscopy is performed for the early detection of specific signs of aging [13]. Characteristic signs of skin aging include epidermal atrophy; epidermal hyperplasia with uneven disappearance of melanin; and a decrease in the number and altered structure of collagen and elastic fibers.

2.5 Other Procedures

Consultations with other specialists

• Comment: Timely prescription of hormone replacement therapy makes it possible to slow down skin aging processes [34].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

The choice of aesthetic correction method depends on the clinical presentation, presence of contraindications, and the equipment of the cosmetologist's office.

3.1 Non-invasive methods

evidence – 5)

Comments: Topical cosmetics may be used in the form of cleansers, lotions, gels, creams, and high-concentration serums. The choice of topical cosmetics and their form is made individually, taking into account indications, individual skin characteristics, patient preferences, season, and climatic conditions.

Comments:

1. Vacuum skin massage is performed in a course of 10 procedures (2–3 times a week).

2. Medical facial massage (cosmetic, plastic) is performed in a course of 10 procedures (2–3 times a week).

Skin brossage (brush massage) is performed in a course of 10 procedures (2–3 times a week).

Vibrational exposure (vibrational-plastic massage) is performed in a course of 10 procedures (2–3 times a week).

Skin cryomassage is performed in a course of 10 procedures (2–3 times a week).

Comment:

1. Ultrasonic peeling for skin cleansing and xerosis correction – performed once every 1–2 months.

2. Ultrasound therapy for the correction of hyperpigmentation, fine wrinkles, and skin laxity – performed in a course of 10–15 procedures (2–3 times a week) [31].

3. High-intensity focused ultrasound (ultrasound lifting) for the correction of soft tissue gravitational ptosis – 1 procedure. If necessary, the procedure can be repeated after 1–1.5 years [30, 31].

Comments:

Phototherapy is performed in a course of 4–6 procedures (once every 7–10 days) [35].

Non-ablative laser therapy is performed once every 3 weeks, in a course of 4–6

procedures [20, 36].

Research results have shown that the combined use of radiation/light therapy and hyaluronic acid-based fillers for the correction of age-related changes is safe and increases the efficacy of both procedures [21].

Level of Evidence CGrade of Recommendation 5Level of Clinical Effectiveness C (level of evidence – 5)

- superficial chemical peels are performed in a course of 4–5 procedures (once every 7–10 days) [37]

- medium-depth chemical peels are performed in a course: 3-5 procedures (every 3-4 weeks) [30]

GDR CLE 5Grade of recommendation C (level of evidence – 5)

microcurrent therapy for skin and subcutaneous tissue diseases in a course of 10 procedures (2-3 times a week).

Level of evidence CGrade of evidence 5Level of recommendation C (level of evidence – 5)

Comments: the choice of procedure parameters depends on the initial state of muscle tone, skin and subcutaneous tissue thickness, degree of hydration of the underlying tissues, and electrode area [29].

Facial neuromuscular electrical stimulation in a course of 10 procedures (2-3 times a week) [30].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: the choice of procedure parameters depends on the initial muscle tone, skin and subcutaneous tissue thickness, degree of hydration of the underlying tissues, and electrode area [30].

Comments: RF radiofrequency therapy — a course of 3-5 sessions (once a month) [30,36].

3.2 Invasive methods

Comment:

Mesotherapy is performed in a course of 5 procedures (once a week). The choice of product for mesotherapy depends on the indications for its use.

Biorevitalization is performed in a course of 4-6 procedures (every 2 weeks). The choice of product for biorevitalization depends on the indications for its use.

contouring using injectable tissue fillers [19,39].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comment: The choice of tissue filler and the frequency of procedures depend on its properties and indications for use.

Ablative fractional laser photothermolysis is performed using a carbon dioxide laser or an Er:YAG erbium-yttrium-aluminum-garnet laser [35].

Non-ablative fractional laser photothermolysis is performed using an Er:Glass erbium glass laser [35].

Comment:

Research results have shown that the combined use of laser therapy and hyaluronic acid-based fillers for the correction of age-related changes is safe and increases the efficacy of both procedures [21].

Botulinum toxin type A – hemagglutinin complex**. Intervals between injections are 3-4 months [38].

Level of evidence BGrade of evidence 4Level of recommendation B (level of evidence — 4)

Comments: The combination of botulinum toxin type A – hemagglutinin complex** with a dermatological peel potentiates the rejuvenating effect of these procedures. Relaxation of the facial muscles responsible for dynamic wrinkles promotes collagen remodeling and stimulates skin regeneration [24].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Not developed

5. Prevention and Dispensary Observation

Not developed

6. Organization of Medical Care

Management of patients with other atrophic skin changes is carried out on an outpatient basis.

7. Additional Information

Comorbidities and endocrine pathology can affect the baseline condition. To prevent skin involutional changes, it is recommended to use topical cosmetics for cleansing, moisturizing, nourishing, and protecting the skin from adverse environmental factors [28].

A proper lifestyle is important — adherence to work, sleep, and rest schedules, proper nutrition, hygienic skin care, quitting smoking and bad habits, and regular physical activity [31].

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Kubanov, Alexey Alekseevich — Academician of the Russian Academy of Sciences, President of the Russian Society of Dermatovenereologists and Cosmetologists (RODVK), Director of the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health.

2. Kondrakhina, Irina Nikiforovna — Doctor of Medical Sciences, Head of the Consultative and Diagnostic Center of the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, member of the RODVK.

3. Gallyamova, Yulia Albertovna — Doctor of Medical Sciences, Professor, Professor of the Department of Dermatovenereology and Cosmetology of the Russian Medical Academy of Continuous Professional Education, member of the RODVK.

4. Makhakova, Yulia Buyandylgerovna — Candidate of Medical Sciences, Head of the Educational Department of the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, member of the RODVK.

5. Alifanova, Irina Sergeevna — Dermatocosmetologist at the Consultative and Diagnostic Center of the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, member of the RODVK.

6. Kolsanova, Olga Alexandrovna — Candidate of Medical Sciences, Chief Freelance Cosmetologist of the Ministry of Health of the Samara Region, member of the RODVK.

7. Egorova, Elena Petrovna — Dermatocosmetologist at the Consultative and Diagnostic Center of the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, member of the RODVK.

Conflict of interest: The authors declare no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Medical specialists: dermatovenereologists, cosmetologists.

2. Residents and trainees of continuing professional education courses in the specified specialty.

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

1. Procedure for providing medical care in the profile "dermatovenereology", approved by Order of the Ministry of Health of the Russian Federation No. 924n dated November 15, 2012.

2. Procedure for providing medical care in the profile "cosmetology", approved by Order of the Ministry of Health and Social Development of the Russian Federation No. 381n dated April 18, 2012 (as amended on February 21, 2020).

Appendix A3-1. Classification of age-related facial skin changes

(Panova O.S. 2000)

Class I (21–30 years)

A. Superficial expression wrinkles

B. Expression and superficial static wrinkles

C. Mimic and superficial static wrinkles, initial changes in skin texture

Class II

A. (31–38 years)

Moderate expression and static wrinkles; initial skin texture changes

B. (33–42 years)

Deep expression wrinkles, moderate static wrinkles against the background of altered skin texture

Class III

A. (39–47 years)

Moderate expression and static wrinkles; initial skin texture changes

B. (43–55 years)

Deep expression wrinkles, moderate static wrinkles, pronounced skin texture changes, minor skin excess

C. (47 years and older)

Deep expression and deep static wrinkles, significant skin excess, coarse skin texture changes

Appendix A3-2. Signs of aging across age groups

(Kolgunenko I.I. 1974)

Group 1 — up to 50 years (signs of premature skin aging) Subgroups:

Ø from 21 to 30 years;

Ø from 31 to 40 years;

Ø from 41 to 50 years;

Group 2 — 51 years and older (signs of natural skin aging)

Subgroups:

Ø from 51 to 60 years — early form;

Ø from 61 to 75 years — moderate form;

Ø 76 years and older — late form.

Appendix A3-3. Classification of facial skin aging types

(Kolgunenko I.I. 1974)

Ø The "tired face" type is observed in the early stages of skin aging and manifests as decreased tone of facial soft tissues and muscles, dryness and dull skin color, early appearance of folds and wrinkles in the corners of the mouth and tear troughs, and deepening of nasolabial folds. These changes give the face a weary, exhausted appearance.

Ø The fine-wrinkled type is characterized by degenerative-dystrophic changes in the epidermis and dermis, lipodystrophy, dehydration and decreased skin elasticity, and multiple mimic wrinkles.

Ø The deformational type is caused by gravitational ptosis of soft tissues and edema.

Ø The combined type is characterized by a combination of features of the fine-wrinkled and deformational types.

Ø The muscular type is typical for residents of Central Asia and the Far East. Facial aging manifests predominantly as pigmentation disorders, skin folding of the upper and lower eyelids, pronounced nasolabial folds, and downturned corners of the mouth. The contours of the facial oval are preserved well into old age.

Ø Combined type of late aging of the face and neck — "senile emaciated face" (after 75 years).

Major (obligate) signs of facial and neck aging: loss of soft tissue elasticity; dryness and thinning of the skin; wrinkling (and folding) of the skin; senile deformation.

Minor (optional) signs of facial and neck aging: edema and pastosity around the eyes; skin porosity; telangiectasias, rosacea, spider angiomas, ruby spots; hypertrichosis (hirsutism); hyperpigmentation; seborrheic keratoses, papillomas.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Patients should remember to follow a healthy lifestyle, quit bad habits, and adhere to proper nutrition. It is important to cleanse and tone the skin daily and use other topical care products selected according to skin type.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Absent