Abstract: Smoking causes profound, deleterious changes to the skin similar to those caused by photodamage. Many of the mechanisms by which these effects occur are also thought to be mediated by parallel pathways involving oxidation. This preliminary, open pilot study was conducted in order to determine the efficacy of a proprietary, multi-ingredient cream containing specially selected antioxidants in reducing facial wrinkling and other cutaneous manifestations of smoking. A group totaling 11 smokers was given the cream to use twice daily for 6 months. Both subjective (patient self-evaluation and satisfaction) and objective (laser profilometry using latex skin replicas and corneometry) measurements were taken at periodic intervals to assess patient response. Corneometry results showed a 37.2 % increase in moisturization after 6 months. Profilometry analysis revealed a significant decrease in complexity and depth of wrinkles and furrows, as well as a substantial smoothing, or restructuring effect for nearly all participants. Patient self-evaluation showed uniform improvement across multiple parameters, including skin texture, color, softness, and fine lines at the conclusion of the study, and 100% of patients expressed a desire to continue using the cream, with 73% deeming it “Excellent.” None of the subjects quit smoking during the study. With the restriction of the pilot character of this investigation, these results demonstrate that the specially-compounded, proprietary, antioxidant-based cream studied is highly effective in the treatment of unsightly smoking-related skin conditions.

AN OPEN, PILOT STUDY TO EVALUATE THE EFFECTS OF A MULTIPLE-INGREDIENT
CREAM ON THE CUTANEOUS MANIFESTATIONS OF SMOKING

James H. Sternberg, MD, Vartan Libaridian Ph.D., Y. Michelle Volynsky Ph.D., Gabe Green MS.

Lung cancer, heart disease, emphysema and stroke are obvious sequelae of cigarette smoking, emblazoned on every cigarette pack and advertisement in a boxed Surgeon General’s Warning for all to see. However, they are so oft-repeated in the media that cigarette smokers, addicted to nicotine and its pleasurable effects, have become utterly desensitized to the gravity of these serious diseases. A casual perusal of Hollywood movie sets, rock concerts, fashion shows, older movies, and even video games reveals that actors, models, and musicians, and others who rely heavily or exclusively on their physical appearance for their livelihood smoke disproportionately far more than the average population! To quote the hit song of pop music superstar (and smoker) Alanis Morissette, “Isn’t it ironic?” Therefore, a potent inducement for many people to quit smoking may be to inform them of the harmful, and quite visible, effects of smoking on the face and skin in general

“Smoker’s Skin”

“Smoker’s Face” was first defined in the medical literature by Model in 1985 although smoking had been linked with premature wrinkling as early as 1856 , and “cigarette skin” in 1965 . We propose the catchall term “Smoker’s Skin.” Smoker’s Skin is distinguished by increased facial wrinkling, accentuated peri-oral rhytides, gauntness, and facial discoloration. Smoking can result in premature wrinkling of facial skin, but even more importantly, synergistically exacerbates the premature wrinkling caused by sun overexposure , . Smoking has also been associated with an increased incidence of squamous cell carcinoma of the skin , and lip . Studies have found that women have a higher risk of smoke-induced wrinkles than men . This is likely associated with the relatively hypoestrogenic state – caused by cigarette smoke-induced hydroxylation of estradiol – created in the female smoker, which may cause dryness, atrophy, and thus, wrinkling. There is also evidence that Asian skin is adversely affected by smoking.

Radical Notions

There are over 300 theories to explain aging . The most popular and widely tested is the free radical theory of aging. This was followed by the membrane theory of aging. There is also the inflammatory theory of aging and more recently the “disposable soma” theory. Reactive oxygen species (ROS) are part of the inflammatory problem. Any attempt at a thorough explanation of the aging process will no doubt contain facets of many of these theories. Free radicals are highly unstable molecules having an unpaired outer-shell electron actively seeking another electron. They occur in all tissues of the body and all parts of the cell. They are particularly damaging because they initiate chain reactions, creating more free radicals. These reactions release heat, cause inflammation, and can result in dermal matrix damage, damage to the cellular membrane, cytoplasmic organelles, and nuclear DNA. Damage to DNA, of course, creates mutations and is therefore carcinogenic. DNA damage is, also, more pointedly for our purposes, “perhaps one of the most senescence-provoking types of damage a cell can experience, in both dividing and non-dividing cells.”

Reactive Oxygen Species (ROS)

Reactive oxygen species (ROS) is a term that encompasses both free radicals and other reactive molecules, i.e. molecules that can cause oxidative stress. Some examples of these “other reactive molecules” include singlet oxygen, molecular oxygen, and hydrogen peroxide, which, though not free radicals themselves, are still potent oxidizing species and therefore capable of precipitating damaging consequences.

ROS may be intrinsically generated or arise from extrinsic insults. Intrinsic aging is chiefly a result of chemical reactions associated with normal metabolism (the normal metabolism of oxygen generates superoxide anion, hydroxyl radical, and hydrogen peroxide), genetic mistakes, and random DNA repair errors. In fact, the lion’s share of internally generated free radicals is a result of mitochondrially- produced adenosine triphosphate (ATP), the molecule that provides the energy for most cellular activities.
Extrinsic aging results from lifestyle factors such as UVB and UVA rays (sun or tanning-salon exposure), cigarette smoking, alcohol consumption, ionizing radiation, and other sources. The skin is particularly susceptible to the creation of free radicals as it has a large surface area with direct contact to environmental insults. Free radicals are very short lived and under normal circumstances will be neutralized at their place of origin.

Photodamage vs. Smoking-Mediated Skin Damage: Parallel Lines?

Ultraviolet light (UVL) skin damage and smoking skin damage are mediated by many of the same mechanisms and have been shown to be multiplicative. An example of this would be the coincident increase in MMP-1 (matrix metalloproteinase-1), an inflammatory enzyme in both the cases of : a) non-sun exposed skin of smokers, and b) UVL-exposed skin of non-smokers. In other words, smoking skin damage and UVL skin damage share some of the same pathways leading to Smoker’s Face. Thus, a skin regimen designed to improve smoking skin damage should also be helpful for photodamage, i.e. for facial skin rejuvenation.

The object of any skin repair regimen is to reduce extrinsic damage, interdict intrinsic damage and repair existing damage without causing irritation. When choosing “special” ingredients we took into consideration repair of existing damage to collagen, elastin, glycosaminoglycans, and decreasing activation of free radicals, activator protein-1 (AP-1), jun/AP-1, nuclear factor kappa-b (NF-k-B), matrix metalloproteinases (MMP), and other pro-inflammatory cytokines, e.g. Interleukin-1 and 6 and Tumor Necrosis Factor Alpha.

Skin Repair Mechanisms

The skin has evolved many ways to protect, preserve and repair itself from both intrinsic and extrinsic damage.

ROS, for the most part, are oxidants. The body has developed a sophisticated system of skin antioxidants (free radical scavengers). There is an enzyme system made up of the “ases”, e.g., superoxide dismutase, glutathione peroxidase, glucose-6-phosphate dehydrogenase, and catalase. The non-enzyme systems include, in order of skin concentration, vitamin C, glutathione, vitamin E, and ubiquinone. The highest concentrations of non-enzyme antioxidants are in the epidermis, which represents the first line of defense from extrinsic damage.

The rationale for using topical antioxidants is based on the observation that following extrinsic skin damage, e.g. photodamage, there is a measurable decrease in endogenous antioxidants, the assumption being that they are expended in neutralizing these UVL induced oxidants. An example of this is demonstrated in a study by Theile, et.al., showing that the SC (stratum corneum) is a susceptible site for UVL induced depletion of vitamin E. In addition, a study by Lopez-Torres, et.al., showed that topical administration of alpha-tocopherol protected epidermal antioxidants from depletion. This study also showed an increase in dermal antioxidants. A further interpretation of this study propounds an underlying mechanism involving the up-regulation of a network of enzymatic and non-enzymatic antioxidants. If this is the case it suggests the efficacy of multi-ingredient topical antioxidant skin products. A study by Steenvoorden et.al ., concluded that the best results regarding photodamage were found when using a combination of various anti-oxidants, postulating a synergistic result. Quoting from Dr. Boh’s article in Cosmetic Dermatology “If the science supports the hypothesis, combinations of different antioxidants can be formulated within a single product to provide the user with maximum antioxidant protection.”

Smoking-Related Skin Changes

The following skin changes have been reported secondary to cigarette smoke:

1. Smoker’s Face
a. “Cigarette skin” is pale, gray and wrinkled – found in 79% of smokers
b. Cigarette smoking is an independent risk factor for the development of premature wrinkling
c. “When excessive sun exposure and cigarette smoking occurred together, the risk for developing excessive wrinkling was multiplicative.”
d. “A statistically significant risk was found for smoking habit, sun exposure, and age for facial wrinkling.

2. Elastotic Changes in Skin:
a. Elastin in non-sun exposed skin in smokers is thicker and more fragmented than age- matched non-smoking control subjects .
b. Elastic fiber damage resembles solar elastosis (located in the papular dermis) except for its deeper location (reticular dermis).
c. “Cigarette smoking is associated with an increase in elastosis, which may contribute to the clinical features of “smoker’s face.”
d. There is an increase in plasma neutrophil elastase activity in cigarette smokers that is fivefold higher than that in nonsmokers.

3. Increase in Free Radicals (ROS):
a. “One puff of a cigarette generates 10,000 free radicals”
b. Cigarette smoke contains 4,000 toxic constituents.
c. Direct cigarette smoke stream skin exposure induced a 200% increase in lipid peroxidation

4. Increase in Matrix Metalloproteinases: (MMPs))
a. Human fibroblasts treated with tobacco smoke extract showed increased MMPs preventable with L-ascorbic acid and water soluble Vitamin E
b. There is a 100% increase in MMP-8 in suction blister fluid in smokers. .
c. “Tobacco smoke plus UVA cause aging of human skin through additive induction of MMP-1 expression”

5. Decreased Collagen Production:
a. Synthesis of subcutaneous collagen in smokers is specifically impeded.
b. Smoking decreases the synthesis rates of type 1 and 3 collagen in skin in vivo.

6. Decrease in Vitamin C, A & Glutathione:
a. Smokers have a threefold higher incidence of low serum ascorbic acid independent of decreased ascorbate intake.
b. Oxidants in smoke accelerate metabolic turnover of ascorbic acid. (Hypovitaminosis C was observed in 24% of active smokers, 12% passive smokers, not in non-exposed non-smokers).
c. Smoking depletes antioxidants (plasma ascorbate, alpha tocopherol and glutathione selenoenzymes) and cause DNA mutations.
d. Environmental tobacco exposure (“secondary smoke”) in children results in significant alterations in serum ascorbic acid levels.

7. Microcirculation:
a. One cigarette results in 60-90 minutes of cutaneous vasospasm resulting in decreased nutrients and tissue oxygenation.
b. Smoking one cigarette decreases microcirculation 38% in smoker’s vs. 28% in non-smokers.
c. Microcirculation recovery phase (5 minutes) for habitual smokers vs. non-smokers (2 minutes) suggests that microcirculation becomes accustomed to smoke .
d. A single dose of vitamin C 2h before smoking reduced, and in some abolished, the negative acute effect on microcirculation. .
e. Carbon monoxide inhibits oxygen binding in a competitive manner (200:1) resulting in tissue hypoxia.

8 Decreased Wound Healing
a. Smoking interferes with or interdicts elective cosmetic surgery because of decreased subcutaneous collagen production in smokers.
b. Smoking is associated with aberrant wound healing by decreasing synthesis of collagen I & III and decreasing MMP-8.
c. Heavy smokers (pack or more/day) have necrosis developing in a flap and/or full thickness graft more frequently than non-smokers.

9. Exacerbation of Skin Problems:
a. Heavy smokers are at risk of aggravating psoriasis and show a poorer outcome in cases of malignant melanoma.
b. Hypothesized abnormal response to nicotine in patients with palmoplantar pustulosis resulting in inflammation.
c. Smoking and alcohol are risk factors for infectious eczematoid dermatitis.
d. Patients with head and neck cancer on radiation therapy who continue to smoke have lower response and survival rates.

10 Infrared (heat) Damage Increases Pre-existing Photodamage.

11. Increased Incidence of Squamous Cell Carcinoma of Facial Skin & Lip:
e. The major risk factors for lip cancer are smoking and actinic radiation .
f. Increased incidence of recurrence of squamous cell carcinoma in both current and former smokers vs. non-smokers .
g. “Shisha” and “Goza” (flavored tobaccos smoked in hookahs or water pipes) smoking may predispose patients to oral cancer.
h. Smokers showed a 50% increase in the risk of squamous cell carcinoma compared with never smokers

12. Association with HIV skin related conditions:
a. HIV positive smokers developed oral candidiasis and hairy leukoplakia sooner then non- smokers.

13. Decrease in skin moisture:
a. Smokers have a significant decrease in stratum corneum moisture.

14. Premature Grey Hair and Hair Loss Among Smokers.


MATERIALS AND METHODS:

Setting: Dermatology private office.

Subjects: A newsletter requesting volunteers to participate in a 6-month study to evaluate a “facial skin repair cream” for cigarette smokers only was sent to patients. The first 14 responders (12 women and 2 men) that were current smokers with a minimum of 10 pack-years of smoking were selected. There was no consideration to age, sun damage, gender, or skin type as a basis for selection. Mean subject age was 60 years. All subjects gave written informed consent before the study and signed a full-disclosure release form. Baseline digital photographs were taken from each subject to ascertain subsequent clinical response.

Preliminary Testing for Irritancy: The oil in water (O/W) emulsion cream, labeled, The Smokers Facial Repair Cream, was submitted to Biometrex, Inc. for 48-hour irritation patch evaluation. The final conclusion was: “Under the conditions of this study, the test material (lot# 003-138-11) Smoker’s Cream did not indicate a potential for irritancy when applied for 48 hrs to the skin of human subjects.”

Treatment regimen: Before commencing treatment, subjects were instructed to curtail use of any other topical preparations containing “active ingredients.” They were then shown how to perform an open patch test using the study cream, and instructed to do so for three days to rule out allergic reactions. Subjects applied the test cream twice daily, morning and at bedtime, as a pea-sized dab to the cheeks, forehead, and chin, spread evenly, for 24 weeks. Subjects were advised to minimize exposure to the sun throughout the study, but to apply an effective sunblock if sun exposure was unavoidable (sunblock to be applied 15 minutes after test cream). Subjects were allowed to use their usual non-medicated moisturizer 15 minutes after the test cream if they experienced dryness, and were further instructed to stop use of the cream if they experienced irritation and/or discomfort. None of the subjects were instructed to quit smoking during the course of the study, and in fact, none of them did.

Skin replicas. Silicone skin replicas were taken from subjects at identical sites on the perioral (left upper lip), and left outer canthus (“crow’s feet”) areas at baseline, 7 weeks, and 30 weeks. All study personnel were trained in the skin replica technique and the same technician performed the skin replicas whenever possible. The silicone rubber impression material used was Silflo. Replicas were categorized by subject number and initials, date, and facial region, and forwarded to Dermscan Laboratories in Lyon, France for image analysis.

Laser profilometry ; computerized analysis .

Computerized image analysis of silicone skin replicas is a reproducible, objective technique for measuring skin topography. The method used takes into account the three dimensions of the wrinkle to deduce the geometric parameters such as maximal depth, complexity and volume. Let us define these parameters:

• Complexity (or visual impact in %). This is the microrelief undulation and collection of
depth and number of wrinkles; a complexity decrease induces a smoothing effect.

• Median depth of microrelief furrows (in µm). A decrease characterizes a skin smoothing
effect.

• Anisotropy (in %).This shows the direction of each type of microrelief furrow. Skin anisotropy is thought to result from preferential orientation of collagen fibers in the dermis, and is a function of age, so that anisotropy is increased, reflecting a diminution in the “arrangement of collagen networks” as skin ages due to stress. A decrease in anisotropy shows that the skin furrow’s network has fewer privileged directions, therefore a restructuring effect. This effect can result in an improvement in the overlying skin.

The determination of the geometric parameters of the wrinkle was accomplished with the spatial
data knowledge (in 3D) of each surface point.

The image analysis software is based on the following principles:

• location of the analysis zone by comparing prints taken at different treatment times,
i.e. the zone containing the part of the wrinkle or microrelief to be analyzed.

• data acquisition with a mechanical or optical sensor on a 5x5 mm surface (for the
wrinkle analysis) and 3x3 mm surface (for microrelief analysis).

• comparison of the numbered zones and location of the homologous zones, at
different treatment times, from identical points.

• determination of the maximum depth of the wrinkle, its volume, and the complexity of
the surface.

• determination of the median depth of the microrelief furrows, of the complexity of the
surface , and of the anisotropy.

Corneometry: The Corneometer 820 evaluates the hydration state of the skin surface by the use of electrical capacitance. Subjects were allowed to acclimatize to ambient temperature in a climate-controlled room. The degree of hydration was measured by taking three readings from the left zygomatic arch/cheek. This was done at baseline, 12 weeks and 24 weeks. The water content of the stratum corneum was evaluated with a Corneometer capacitance meter. The higher the water retained, or, the greater the capacitance, the better the results, i.e. increased skin hydration.

Ingredient Selection: The criteria for selecting these “special” ingredients were their availability as non-prescription items and scientific evidence of their efficacy. It should be kept in mind that many of these published “scientific” papers, not unlike this one, are pilot studies with small numbers of subjects and may not be double blind/vehicle controlled.

SPECIAL INGREDIENTS :
• Glutathione
• Retinyl Palmitate
• Phytic Acid
• Alpha-Lipoic Acid
• Tetrahexyldecyl Ascorbate
• Grape Seed Oil
• Palmitoyl Pentapeptide (Pal-KTTKS)
• Mixed Tocopherols
• Selenium
• Ceramide-3
• L-Ergothioneine

As previously mentioned the special ingredients were selected on the basis of over the counter availability, compatibility, safety, and potential for efficacy vis-a-vis the above-annotated potential secondary side effects due to smoking,

Glutathione is a tripeptide with powerful antioxidant properties synthesized in the liver from cysteine, glutamic acid and glycine. Glutathione reductase and glutathione peroxidase are essential as free radical scavengers, reducing intracellular hydrogen peroxide and lipid hydroperoxides in cellular membranes. Smoking depletes antioxidants (plasma ascorbate, alpha tocopherol and glutathione selenoenzymes) and causes DNA mutations. A study to assess changes in matrix metalloproteinase-1 (MMP-1) using human fibroblasts stimulated with tobacco smoke extract or UVA concluded that both tobacco smoke and UVA cause increases in MMP-1 independent of each other. However the maximum increase in MMP-1 was seen when fibroblasts were treated with both UVA and tobacco smoke extract, indicating that the two factors are additive. . “MMP-1 induction was significantly higher in low glutathione (GSH) content fibroblasts compared to that in high GSH fibroblasts, indicating that the differences in glutathione content define the susceptibility of fibroblasts towards UVA and/or tobacco smoke-induced MMP-1 expression.”

Summation: Antioxidant, regenerates Vitamin C, decreases MMPs

Retinyl Palmitate: Vitamin A refers to a group of lipophilic compounds known as retinoids. Retinol, a naturally occurring form of vitamin A, is metabolized to retinoic acid in vivo by a two-step conversion. Retinoic acid is one of the most extensively studied retinoids and is well documented for its rejuvenation properties. It has been postulated that retinyl palmitate (the ester of retinol and palmitic acid), as used customarily in cosmetic products, is hydrolyzed in the skin to retinol, which is then oxidized to retinoic acid. A study by Boehnlein,et al. using a radiolabeled lipophilic compound of retinyl palmitate on human skin and guinea pig skin showed 18% and 30% absorption, respectively. Retinol was the only detectable metabolite of the retinyl palmitate, and in human skin, 44% of the absorbed retinyl palmitate was hydrolyzed to retinol. Their conclusion was “the use of retinyl palmitate in cosmetic formulations may result in significant delivery of retinol into the skin.” A study by Voorhees, et.al. comparing all-trans-retinol (ROL) with all-trans-retinoic acid (RA) and measuring ROL-derived metabolites hypothesized that ROL may be a prohormone of RA because it produces changes in the skin similar to those produced by RA but without measurable increase in plasma RA or irritation.” Fisher, et al. felt that since human skin can convert ROL to RA given a sufficient concentration of ROL it should provide therapeutic and protective results topical similar to RA. The distillation of all these results suggests that retinyl palmitate is an excellent ingredient choice because it combines the established benefits conferred by topical retinoids with the absence of irritation normally associated with the direct topical application of those derivatives.

Summation: Antioxidant, improves intrinsic & extrinsic skin damage via conversion to retinol/retinoic acid in skin, may reduce c-jun protein, inhibits AP-1..

Phytic Acid, also referred to as inositol hexaphosphate (IP6), is a natural antioxidant that may decrease lipid peroxidation and has been shown to chelate multivalent metal ions. A study and Medline search by Fox and Eberl revealed a large body of animal evidence showing that phytic acid may play a role in both prevention and treatment of various cancers, including skin cancer. Phytic acid has been used topically for treatment of benign hyperchromic lesions of the skin. It blocks iron and copper in the formation of melanin.

Summation: Antioxidant, tyrosinase inhibitor, antineoplastic.

Alpha-Lipoic Acid is a very potent antioxidant and anti-inflammatory compound. Percutaneously it is rapidly absorbed throughout all skin layers. It is both lipophilic and hydrophilic and therefore active in both the cytosome and the phospholipid membranes. Once absorbed most of it is reduced to dihydrolipoic acid (DHLA), an unstable molecule, but a more potent antioxidant than lipoic acid. Both forms have metal-chelating capacity and scavenge free radicals, where as only DHLA is able to regenerate endogenous antioxidants (vitamins E & C, glutathione) and repair oxidatively damaged proteins. There is both a direct and indirect anti-inflammatory activity. Alpha-lipoic acid has an inhibitory effect on two important inflammatory mediators, nitric oxide and TNF-alpha. Alpha-lipoic acid has also shown to exert an anti-inflammatory effect via an attenuated activation of NF-kappa B and activator protein-1.

Summation: Antioxidant, regenerates Vitamin E, C and glutathione, anti-inflammatory (inhibits activation & transcription of NFk-b & AP-1)

Tetrahexyldecyl Ascorbate (Ascorbyl Tetrapalmitate) is a lipid soluble form of vitamin C. The active form of cutaneous vitamin C is L-ascorbic acid, a water-soluble molecule present in the body as ascorbate. L-ascorbic acid is a very unstable molecule, and thus very difficult to work with, but an excellent antioxidant and anti-inflammatory nonetheless. This instability has led to formulations of “stable” derivatives with divided camps on which is the best. Vitamin C is not synthesized in humans and therefore must be provided by diet or other pharmacological means. Pinnell’s research has shown that you can achieve higher levels of antioxidants in the skin from topical application than from an increase in dietary sources, given the right formulation. Vitamin C has been shown to stimulate production of type I & III collagen, and increase levels of tissue inhibitor of matrix metalloproteinase 1 (TIMP-1) and pro-collagen. It is a cofactor for several hydroxylases.

Summation: Antioxidant. Neutralizes or interdicts ROS, UVA & UVB damage; stimulates collagen; anti-inflammatory; promotes healing; prevents UV immunosuppression. Increases tissue inhibitor of matrix metalloproteinase 1.

Grape Seed Oil, a product also known as grape seed or grape seed extract, is a by-product of red wine manufacturing. The oligomeric proanthocyanidins are naturally occurring antioxidants in various fruits, nuts, etc. They have been shown to be very active as antioxidants, in oxidative stress reduction and chemoprevention. In a study with grape seed proanthocyanidin extract (GSPE) and vitamin C and E, measuring comparative protective effects, using tobacco-induced oxidative stress and apoptotic cell death in human oral keratinocytes, showed that GSPE provided better protection then Vitamin C and E, singly and in combination . Resveratrol, a phytoalexin found in grapes, has been shown to suppress activation of NF-Kappa B . It has also been shown to inhibit tumorigenesis in a mouse skin cancer model.

Summation: Antioxidant, anti-skin cancer, suppresses NF-Kappa B.

Palmitoyl Pentapeptide is composed of a five amino acid fragment of procollagen I (Lys-Thr-Thr-Lys-Ser, abbreviated as KTTKS) attached to a fatty acid (palmitic acid), resulting in a lipophilic molecule (Pal-KTTKS ) with enhanced penetration into the skin. Skin peptides are naturally occurring protein fragments that result from various metabolic processes. Many of these fragments have the ability to initiate repair mechanisms in human skin, e.g. wound healing and tanning. A study found that this pentapeptide was the minimum sequence required to “dramatically” augment extra-cellular matrix production and stimulate production of collagen types I &, III and fibronectin. A later, vehicle-controlled study compared a retinol cream (700ppm) vs Pal-KTTKS lipopeptide cream (3ppm). The 16 subjects were evaluated at 2 and 4 months. The comparisons were done with skin replicas and digital image analysis. The results showed that both creams showed improvement at 4 months, however the Pal-KTTKS peptide effects were seen sooner (at 2 months). The vehicle showed no significant effect.

Summation: Repairs extracellular matrix, stimulates new collagen production.

Mixed Tocopherols (Tocopherols): Vitamin E is the major lipid-soluble non-enzymatic antioxidant. Biologically, the most active tocopherol is the alpha fraction and to a much lesser degree the gamma fraction. Vitamin E is lipophilic and protects cell membranes from lipid peroxidation. The act of neutralizing the lipid radical chain reaction reduces the vitamin E molecule to an inactive state. As previously mentioned, regeneration of vitamin E can occur in the presence of vitamin C, restoring its functional capacity. This can also be done by ubiquinone (CoQ10), glutathione and alpha lipoic acid. Topical vitamin E will reduce sunburn cell production and is photo-protective. It has also been shown to prevent UV-induced systemic immunosuppression.

Summation: Lipid-soluble antioxidant, anti-inflammatory, photo-protective, promote healing.

Selenium (Se) is essential as a trace element for the production and maintenance of many selenoproteins and Se dependent metalloenzymes, including glutathione peroxidase and thioredoxin reductase. Glutathione peroxidase protects cell membranes from damage. Thioredoxin, a redox mediator, is produced under conditions of oxidative stress and is secreted by tumor cells. Thioredoxin reductase provides reducing power for biochemical processes and has been reported to combat oxidative stress. Selenium containing compounds can increase intracellular thioredoxin reductase activity. There is data to suggest that selenite and selenodiglutathione inactivate AP-1.

Summation: Essential for: Enzyme antioxidant production, antioxidant, inactivate AP-1

Ceramide-3: Ceramides are one of the most important human epidermal lipids. They are a major player in both the skin barrier and water-holding functions of healthy human stratum corneum. A recent study showed that a ceramide-3 containing emollient applied to an area of skin barrier dysfunction significantly decreased existing erythema and transepidermal water loss. A study by Imokawa in 1986 found that..”structural lipids present in the intercellular spaces of the stratum corneum, especially ceramide, play a critical role in the water-holding properties of the stratum corneum.”

Summation: Skin barrier function, humectant (stratum corneum and granular layer).

L-Ergothioneine is a natural component of the human body obtained from diet. L-Ergothioneine is an analog of L-carnitine, its unique activity is derived from its thione (C=S) moiety. It facilitates transport of nutrients into mitochondria and acts as an antioxidant for the by-products of energy production. Ergothioneine is a powerful antioxidant for hydroxyl radicals and is active in inhibiting formation of these radicals.

Summation: Antioxidant, inhibits hydroxyl radicals.


RESULTS

Study population: Of the 14 initial subjects, 11 were eligible for further analysis (three dropped out of the study for personal reasons). Results were obtained using the methodologies described above at baseline, and at the intervals as specified for each type of measurement above.

Skin replicas: Of the 11 valid subjects, eight subjects (73%) had acceptable skin replicas for the profilometry portion of the study (replicas of dubious quality were discarded by the laboratory) with 18 replicas analyzed in total for this group of eight subjects. Four replicas from week 7 and two replicas from week 30 were technically unacceptable and were therefore excluded from consideration. Acceptability was determined by the technicians employed by Dermscan Laboratories with no input from the investigators.

Laser profilometry (microrelief study): After seven and 30 weeks, the analysis by Laser Profilometry of prints showed a smoothing effect of the product on the cutaneous microrelief, revealed by a decrease in the median depth of microrelief furrows and also by a decrease in the complexity, which was noted on a majority of the volunteers. Specifically, in terms of complexity decrease, 3 out of 4 subjects showed a smoothing effect at week 7, and 4 out of 6 subjects showed a smoothing effect at week 30. Median depth of microrelief furrows was reduced in 3 out of 4 subjects at week 7, and 5 out of 6 subjects at week 30. After 7 weeks, a restructuring effect (decrease in the anisotropy) was observed for all the volunteers. This is illustrated in Figure 1.
 

Laser profilometry (wrinkle study): After 7 weeks and 30 weeks of treatment, the analysis by Laser Profilometry of prints showed a global decrease in the wrinkles (complexity, depth and volume),
noted on the majority of the volunteers. With regard to complexity, 100% of subjects showed a positive effect after 7 weeks, and 5 out of 6 showed a positive effect after 30 weeks (see Figure 2). Wrinkle depth was reduced in 3 out of 4 subjects at 7 weeks and 4 out of 6 subjects at 30 weeks. Wrinkle volume was uniformly reduced at both 7 weeks and 30 weeks in 100% of the subjects (see Figure 3 for depth and volume results). Pictorial representations of the laser analyses show a marked decrease in the “groove”, hence, depth of the wrinkle. Figures 4e, 5e, and 7e show before and after computer-generated analyses of wrinkles on the eye area of three subjects, whereas, Figure 6l shows a scan of wrinkles on the lip area.

Aside from the obvious flattening of wrinkle depth shown here, another visual aid is helpful: the color variance between the before and after pictures illustrates the change in depth and thickness of the wrinkle, with red tonalities, representing “peak altitudes,” resolving to a blue-green hue, indicating decreased altitude, and thus, a smoothing effect on the skin, with treatment.






Corneometry: Of the eleven valid subjects, two did not follow up for corneometry readings, leaving a total of 9 subjects with complete sets of data at baseline, 3 months, and 6 months. Fig. 8 shows that moisturization was uniformly and significantly increased for all subjects, with an overall mean increase in moisturization of 37.2% over 6 months. More significantly, most of the moisturization increase occurred after the initial 3 months.



Subject Self-Evaluation: At 12 and 24 weeks, subjects were asked to evaluate the effects of the cream as they saw them, with respect to certain specific parameters: skin texture, skin color, skin softness, fine lines (“crow’s feet”), fine lines (upper lip), fine lines (cheeks), pigmentation, sun damage, and overall improvement. After 24 weeks:
• 91% of subjects reported an overall improvement.
• 73% felt that skin texture, skin, color, fine lines (“crow’s feet” and upper lip), and sun damage had improved.
• 64% felt that there was an increase in skin softness.
• 55% indicated that pigmentation and fine lines (cheeks) had improved.
As illustrated in Figure 9, subjects noticed the majority of the improvement after 24 weeks. In fact, one patient who had felt her skin was worse (skin softness) at 12 weeks, reported a dramatic improvement at 24 weeks.




Patient Satisfaction: At the conclusion of the study, subjects were asked to rate the cream as “Bad,” “Good,” “Very Good,”or “Excellent.” An overwhelming majority (73%) rated the cream as “Excellent,” 18% deemed it “Very Good,” and 9 % “Good.” None of the subjects rated the cream as “Bad.” There was a uniform acceptance of the product, with 100% of subjects wanting to continue using the cream.

Adverse Reactions: Twelve percent of the subjects experienced mild, transient dryness that disappeared promptly with the addition of of moisturizer directly following test cream application. None of the subjects dropped out because of adverse reactions.

Macrophotography: This was planned as a blinded before and after photo evaluation to assess changes. Due to a problem with our software we were unable to fairly reproduce many of the photos. We have, however, included before and after unaltered photos of two patients, labeled as Figure 10 and 11. In both subjects, we believe there can be seen a subtle improvement in fine lines in the periorbital area over the six month treatment time.



Figure 10


Figure 11

CONCLUSION:

Tobacco smoking results in unwanted visual skin changes. These changes can be linked to specific noxious byproducts resulting in unwanted chemical reactions in the skin. It is becoming clear that photoaging and tobacco-smoke induced aging follow many of the same pathways. Homeostatic mechanisms, under genetic control, will distribute dietary supplements to various parts of the body as required. The beauty of dealing with skin (the largest organ in the body ) is that we have direct access to any part of it and can apply the appropriate combination of modulatory chemicals to that part. Pinnell‘s studies show that it is possible to achieve higher concentrations of vitamins in the skin with topical application than by increasing oral intake . The many referenced studies would lead us to conclude that if we can keep the oxidant/antioxidant skin milieu in favor of the antioxidants we can interdict the cutaneous changes manifested as “Smokers Skin”.

The two objective criteria to evaluate the results of this study have shown that, in this test group, the smokers repair cream resulted in diminution of wrinkles and increase in skin hydration in the majority of the subjects. The SUBJECT SELF-ASSESSMENTS were also positive for Improvement. The Smokers Repair Cream was well tolerated with 100% subjects’ satisfaction.

Current research does not show that the use of antioxidants have prolonged the maximal life span, however their use may enhance the quality of life both from a systemic and/or a cutaneous aspect. As a result of this study we recommend that for your general health you stop smoking and for your cutaneous health you use a multi-ingredient “repair” cream and sunblock as a regular regimen.

No one dies from old skin, however, there is no reason to die with old skin!