Skin Aging and Modern Age Anti-Aging Strategies

  

    
Natural Compound or Mineral 
    
Mechanism of Action(s) Involved in Maintaining    Skin Health 
  
  

    
1. Collagen
    
Building block of collagen and elastin fibers-improves    skin and nail health;
      
inhibits matrix metalloproteinases (MMPs); stimulates    fibroblast function
  
  

    
2. Ceramides
    
Provides the major component    of the lipid “mortar” of the stratum corneum essential in the structure and    maintenance of skin barrierintegrity; also involved in cell proliferation,    differentiation and apoptosis
  
  

    
3. Beta Carotene
    
Provitamin A molecule, acts    as an antioxidant, anti-inflammatory agent and blocks ROS formation and/or    ability to quench free radicals; prevents cellular damage, premature skin    aging and skin cancer
  
  

    
4. Astaxanthin
    
Potent antioxidant;    anti-inflammatory agent; prevents DNA damage & enhance mitochondrial    function, provides UV protection; activates the Nrf2 pathway toto stimulate    production of other antioxidants; inhibits MMPs; stimulates collagen    production and wound healing
  
  

    
5. Coenzyme Q10
    
Antioxidant; anti-aging properties-enhances collagen;    potential treatment for psoriasis; accelerates generation of ATP levels after    irradiation of fibroblasts
  
  

    
6. Colostrum
    
Contains, growth factors and    other immune regulatory factors that promote growth of keratinocytes and    wound healing
  
  

    
7. Zinc
    
Importance for skin    morphogenesis, repair and maintenance such as wound healing 
  
  

    
8. Selenium
    
Acts as a cofactor for glutathione peroxidase (GPX)    removing harmful peroxides; involved in DNA synthesis and repair; prevents    oxidative stress
      
and UVB-radiation; also acts as an antioxidant
  

Table 10: Summary of natural compounds and minerals used as supplement for skin health [174].

Cosmetological care

A. Daily skin care: Healthy and functioning skin barrier is important protector against dehydration, penetration of various microorganisms, allergens, irritants, reactive oxygen species and radiation. The skin barrier may be specifically adjusted to allow penetration. For this reason, daily skin care may increase skin regeneration, elasticity, smoothness, and thus temporarily change the skin condition [2]. Protection, prevention, cleansing, and moisturizing are the key components of an effective skincare routine. Because most sun damage results from every day, incidental UV exposure, rather than occasional bursts while on vacation, dermatologists recommend daily use of sunscreens. In general, gel-based and bar cleansers are best for oily complexions, whereas cream or lotion-based ones are better for normal to dry skin. Moisturizers supply humectant agents, which draw water into the stratum corneum from the environment and dermis below. Moisturizers also include occlusive agents that act as a barrier to trans-epidermal water loss. In almost all cases, products contain both humectants, like hyaluronic acid, urea, and allantoin, and occlusives, including petrolatum, mineral oil, and lanolin. The classical moisturizers are used for treating dryness in the photoaged skin: polyols (glycerin, propylene glycol, butylene glycol and sorbitol), urea, lactic acid and salts, hyaluronic and salts, pyrrolodone-5-carboxylic acid and salts, panthenol, amino acids and proteins (collagen and proteins from wheat, rice, silk, soybean, and oat). More sophisticated peptides and proteins are presently used as moisturizers. It concerns generally more lipophylic quaternary N-alkyl derivatives of proteins or small polypeptides with long side chains (ester binding) to increase the lipophilic character: binding to the horny layer and a better percutaneous absorption. Recently, the use of small peptides, which mimic the amino acid sequence of collagen or enzymes (biomimetic peptides), has been proposed as moisturizers [56]. Surface-smoothing silicone derivatives or filmogen proteins such as quaternized proteins orsilk, rice and oat, and skin feel agents are used in antiaging products. The high adsorption to the skin surface provokes a smoothing of the skin surface and is at the same time humectant. For a better percutaneous penetration, small fragments of hyaluronic acid were also suggested. Humectants are present in the water phase of a formula; occlusives are in the oil phase. Oil in water formulations tend to be lightweight gels, lotions, and serums and are best suited for normal to dry skin. Water in oil formulations may be ointments or creams and offer superior hydration for dry skin [80]

B. Correct Sun-Protection: [81] Reported that avoidance of sun exposure at peak times and textile sun protection are important pillars of a modern prophylactic approach. Besides, antioxidants and DNA repair enzymes may be added to topical sunscreens in order to enhance the protection before and even after sun exposure [81]. The FDA regulates sunscreen as an over-the-counter medication. Currently, 16 UV filters are listed, 14 organic filters and two nonorganic filters, including zinc oxide and titanium dioxide. The FDA has changed its guidelines to address broad-spectrum sunscreen use, which involves UVA and UVB coverage; water resistance, to indicate the time duration the sunscreen is effective; and Sun Protection Factor (SPF). SPF-30 or higher is recommended and can be labeled as reducing the risk of skin cancer and early skin aging [82, 83]. Nutritional antioxidants act through different mechanisms and in different compartments, but are mainly FR scavengers: (a) they directly neutralize free radicals (b) they reduce the peroxide concentrations and repair oxidized membranes (c) they quench iron to decrease ROS production (d) via lipid metabolism, short-chain free fatty acids and cholesteryl esters neutralize ROS. The most important source of antioxidants is provided by nutrition. To the most known systemic antioxidants belong vitamin C, vitamin E, carotenoids, and from the trace elements copper and selenium. There are also studies demonstrating that vitamins C and E combined with ferulic acid impart both a sunscreen and an anti-oxidant effect [2].

C. Aesthetic non-invasive procedures: Noninvasive skin tightening has become one of the most common cosmetic aesthetic procedures being performed today. According to the American Society for Aesthetic Plastic Surgery (ASAPS) surveys released in 2014 and 2015, there has been a 12% increase in the demand for cosmetic procedures, with Americans spending more than $12 billion and having 10 billion procedures in 2014 [84]. A noninvasive device combines multipolar RF and PEMFs and is referred as (MP) 2, which stands for “Multipolar Magnetic Pulse.” The device was introduced for the non-ablative treatment of skin laxity and cellulite [85].Lee et.al, 2014 reported that combined multi-polar radiofrequency and pulsed electromagnetic field device is safe and effective for rejuvenating aged skin in Korean subjects [88].

Pulsed Electromagnetic Fields (PEMFs) are induced by short pulses of electrical current that penetrates into the skin and results in the stimulation of molecular and cellular activities. It has been used in medicine for bone growth, wound healing, cardiovascular disease, and other conditions. Pulsed electromagnetic fields increase collagen fiber production by dermal fibroblasts and stimulate angiogenesis, leading to wound-healing effects. Radio Frequency (RF) devices remain a dominant technology in the noninvasive management of skin aging, as it is a safe and effective treatment for a broad range of skin conditions. It can induce wrinkle reduction, cellulite improvement, laxity and body, and skin contouring improvement. When radiofrequency is applied by an alternating current, an electric field is generated, which achieves skin tissues, generating thermal energy. The heat is not diminished by tissue diffraction or absorption by epidermal melanin and is then appropriate for treatment of all skin types [85, 86]. RF with micro-needling is effective and safe in improving skin laxity and texture. Pairing skincare cosmeceutical products pre- and post-procedure is beneficial as it enhances patient results, patient experience, and reduces patient downtime. Reported that combining the multi-ingredient anti-aging facial moisturizer pre- and post-RF micro needling was safe and tolerable for the patients [229].

Topical anti-aging preparations

A. Retinoids: Topical vitamin A has the ability to diminish the signs of aging by decreasing fine lines and wrinkling. In addition, there is a normalization and enhancement of elasticity. Improvement of skin tone and texture is a benefit of vitamin A, which enhances skin lightening when used in conjunction with skin lighteners [95]. The most widely utilized ones include retinol, retinyl esters (e.g., retinyl acetate, retinyl propionate, and retinyl palmitate), and retinaldehyde. Through endogenous enzymatic reactions, all of these are converted ultimately to trans-retinoic acid (trans-RA), which is the active form of vitamin A in skin. Specifically, retinyl esters are converted to retinol via esterases. Retinol (ROL) is then converted to retinaldehyde by retinol dehydrogenase. And finally, retinaldehyde is oxidized to RA by retinaldehyde oxidase. Retinol and retinal must be metabolized in the skin to the active trans-retinoic acid. The incorporation of retinol and probably also retinal in cosmetic preparations poses the problem of stability (slow oxidation of retinol in function of time) [8], [90]. Topical natural retinoic acid precursors such as retinaldehyde or ROL are less irritant than acidic retinoids. Retinoids may be combined with other compounds with complementary actions against ageing, nutritional deficiency and cancer, such as antioxidants, to potentiate their beneficial effects in the skin [100].

Figure 10. Chemical structures of retinoids [91-93]. First generation retinoids include tretinoin (all-trans RA), isotretinoin (13-cis-retinoic acid), and alitretinoin (9-cis RA). Second generation retinoids include etretinate and acitretin. Third generation retinoids include adapalene, tazarotene, and bexarotene [93]. Designed synthetic retinoid, seletinoid G, by using computer-aided molecular modeling, and investigated its effects on the expression of extracellular matrix proteins in human skin in vivo. The molecular mechanisms by which retinoids improve aged human skin have been difficult to investigate largely due to lack of appropriate in vitro models [94]. Reported that topical application of 0.4% ROL to aged human skin leads to remarkable skin changes in both epidermis and dermis through affecting three major types of skin cells, epidermal keratinocytes, dermal endothelial cells and fibroblasts. Topical ROL significantly increases epidermal thickness by stimulating epidermal keratinocytes proliferation, which involves c-Jun transcription factor, a major deriving force for keratinocyte proliferation. In addition to epidermal changes, topical ROL significantly improves dermal ECM microenvironment; increasing dermal blood vessel formation by stimulating endothelial cells proliferation and ECM production by activating fibroblasts. Topical ROL also stimulates TGF-β/CTGF pathway, the major regulator of ECM homeostasis, and thus increased the deposition of mature collagen in aged human skin in vivo. Additionally, the restoration of dermal ECM may provide a better, more permissive environment for the proliferation of dermal endothelial cells and epidermal keratinocytes, and activation of dermal fibroblasts (TGF-β/CTGF pathway). Coupling of the proliferation of keratinocytes and endothelial cells, and dermal fibroblasts activation forms a self-enforcing environment, which might explain the remarkable anti-aging effects of ROL in aged human skin [94]. Reported that ROL anti-aging effects include the inhibition of UV-induction of matrix metalloproteinase’s, and the promotion of collagen synthesis in photoaged skin.5, 10 In clinical studies, topical retinol treatment significantly improved fine wrinkles.11 and affected markers of photoaging, including matrix metalloproteinase, collagenase, and collagen.12 Retinol was effective in producing retinoid-mediated histological changes, such as keratinocyte proliferation [96], [97]. Reported that treatments with adapalene 0.3% gel and tretinoin 0.05% cream in cutaneous photoaging did not differ significantly regarding clinical evaluation of the following criteria: global cutaneous photoaging, periorbital wrinkles, ephelides/ melanosis, forehead wrinkles, and actinic keratosis. They concluded that adapalene 0.3% gel is a safe and effective option for the treatment of mild or moderate photoaging [97]. Tretinoin is a prescription strength retinoid approved by the US FDA for acne and for the mitigation of fine facial wrinkles, mottled hyper pigmentation, and tactile roughness of facial skin. Topical application of tretinoin inhibits AP-1, thus suppressing the expression of MMPs and preventing the degradation of collagen. An increase in epidermal thickness and anchoring fibrils is observed, and intrinsically aged skin may also benefit from the topical application of retinoids. Prescription strength tretinoin affords the most potent retinoid effects, but often results in limited utility and decreased adherence due to irritation reactions (ie, burning, scaling, and dermatitis) [11], [91], [98]. Bakuchiol is a meroterpene phenol abundant in seeds and leaves of the plant Psoralea corylifolia [101]. Reported that bakuchiol, having no structural resemblance to retinoids, can function as a functional analogue of retinol. Volcano plots showed great overall similarity of retinol and bakuchiol effects on the gene expression profile [101]. Reported that demonstrates that bakuchiol is comparable with retinol in its ability to improve photoageing and is better tolerated than retinol. Bakuchiol is promising as a more tolerable alternative to retinol (bakuchiol 0.5% cream twice daily or retinol 0.5% cream daily) [102]. Reported that retinaldehyde 0.1% and 0.05% creams used to treat photoaged skin both were well tolerated and improved skin hydration and texture. Retinaldehyde 0.1% cream improved the melanin index as well [99]. An improvement of thephotoaged dermal matrix by topical application of a cosmetic “antiaging” product containing alipoentapeptide, white lupin, and retinyl palmitate was reported by [142]. Also, synthetic retinyl-N-formyl aspartame has also been demonstrated to improve skin roughness and wrinkles. However, studies of retinyl esters, such as retinyl palmitate and retinyl propionate fail to show good efficacy [105].

B. a-Hydroxy Acids (AHAs): Hydroxy acids, also called fruit acids, are among non-organic acids which have been used in the treatment of skin disorders since about 50 years ago. They are some of the most widely used and studied anti-aging skincare compounds. AHAs act on both the epidermal and the dermal levels. When applied to the skin, AHAs stimulate the exfoliation of epidermal cells in the stratum corneum by interfering with the ionic bonding between these cells. This results in the sloughing off dull and rough skin and promotes cellular renewal. Initially used for treatment of hyperkeratosis and other skin conditions affecting subcutaneous turnover, AHAs were found to promote softer, smoother skin, faded wrinkles, lightened age spots, and decreased blemishes. AHAs also improve the subcutaneous barrier function, increase epidermal proliferation and thickness and restore hydration and pursiness through an increase in hyaluronic acid. The well-known benefits of AHA’s include exfoliation, moisturization, reduction of fine lines and wrinkles, collagen synthesis, firming and skin lightening. Although these naturally occurring organic acids are often referred to as fruit acids because they are found in many common fruits such as citrus fruits (citric acid), apples (malic acid), and grapes (tartaric acid), the two most widely used AHAs are not components of fruit. Glycolic Acid (GA) is a sugar cane derivative, and Lactic Acid (LA) is derived from milk [95], [103].

B.1. Glycolic Acid (GA): [104] demonstrated that GA reduced UVB-induced type-I procollagen expression and secretory collagen levels, when applied topically onto human keratinocytes and the C57BL/6J mice dorsal skin. The UV-induced MMP-9 level and activity were reduced by GA pre-treatment. Concomitantly, GA reverted Mitogen-Activated Protein Kinase (MMP-9) activation and inhibited the extracellular signal-regulated kinase activation (p38, pERK) triggered by UVB. Finally, GA triggers the Transient Receptor Potential Vanilloid-1 (TRPV-1) channel to initiate the anti-photoaging mechanism in keratinocytes. These findings clearly indicated that the mechanisms of GA promote skin protection against UVB-induced photoaging and wrinkle formation [104]. Application of 5% GA cream for 3 months has been shown to improve skin texture and discoloration of photoaged skin. In another study, 8% (glycolic acid or L-lactic acid) for 22 weeks, the majority of patients (76% for glycolic acid; 71% for lactic acid) reported a noticeable improvement in the appearance and smoothness of photoaged skin [105]. In a study of 50% GA peels by Newman et al, there was improvement in mild photoaging of skin. Other significant improvements were noted, including decreases in rough texture and fine wrinkling, fewer solar keratoses, and slight lightening of solar lentigines. Histologic analysis showed thinning of the stratum corneum, granular layer enhancement and epidermal thickening. Some specimens showed an increase in collagen thickness in the dermis. GA peels do not affect deep wrinkles or deep pigmentations [106].

B.2. Lactic Acid (LA): Lactic acid (as sodium lactate) is a wellknown part of the skin’s natural moisturizing complex, and is considered to be an excellent moisturizer. LA also contributes to the cell cycle in human keratinocytes [107]. Treatment with 12% LA resulted in increased epidermal and dermal firmness and thickness and clinical improvement in skin smoothness and in the appearance of lines and wrinkles. Both the lactic and glycolic acid peelings were effective in reducing fine wrinkles on the external-lateral region of the eyes, after three applications (85% LA versus 70% GA) [109]. Recently more attention has been drawn to Alpha Hydroxy Acids and Poly Hydroxy Acids (AHA and PHA) due to their excellent moisturizing and antioxidant properties. Reported maintenance of the epidermal barrier integrity during application of Lactic Acid (LA) and lactobionic acid and the opportunity to use them on sensitive skin types including couperose skin [112]. One of the reasons lactic acid is widely used as exfoliator and chemical peeling agent is its profound effect on desquamation of the skin. Desquamation is due to the dissociation of the cellular adhesions, which occurs as a result of reduced calcium ion concentration in the epidermis by chelating action of AHAs [113], [114] also showed that LA not only increased the production of ceramide in the stratum corneum, but also appeared to improve the ratio of ceramide 1-linoleate to oleate as compared to vehicle following 1-month topical application of 4% L-lactic acid. The increased ratio of ceramide 1-linoleate to oleate has been suggested to play an important role in increasing skin barrier function [114].

C. β-Hydroxy Acids (BHAs): Beta Hydroxy Acids (BHAs), such as salicylic acid, are very similar to AHAs except for difference in their solubility. In the other hands, they are lipid-soluble in contrast to water solubility of AHAs. This structure allows them to penetrate into the skin through sebaceous follicles, making it appropriate for patients with oily skin and open comedones. In addition to prove anti-inflammatory effect of BHAs (e.g. salicylic acid), the skin irritancy effect of them have also been proved to be less than AHAs. Beta hydroxy acid found in skin-care products works best in a concentration of 1-2% [103]. Salicylic Acid (SA) is a BHA, which has action to normal keratinization, decreases inflammation, and reduces sebum production with a comedolytic effect. The concentration of salicylic to treat acne is 0.5–5% [116]. SA has been used in the treatment of photoaging with in-office peels of 20–30%. These can be quite helpful in patients who are unable to tolerate AHAs since irritancy levels tend to be less with salicylic acid. In addition, it can be quite useful to combine or alternate both AHAs and BHAs since their mechanisms of action differ, and using both may be quite beneficial [95]. Reported that daily use of a ceramide containing cleanser and cream that also has SA offers an effective, easy and comfortable option for dry skin conditions. After treatment subjects reported a significant improvement in the quality of their professional life, self-image, and social life. The products were shown to be safe, comfortable, and well tolerated [115]. Reported that salicylates activate Adenosine Monophosphate-Activated Kinase (AMPK), which is now considered as a promising target to slow down aging and prevent age-related diseases in humans [116]. A topical combination containing 10.4% L-lactic acid, 2% salicylic acid and alpha-hydroxy acid/retinoate conjugate (ethyl lactyl retinoate) was used in the topical treatment of females of ages 20 to 58. After 4 weeks, improvement was achieved, which remained continuous and cumulative in the eighth week [97]. 2% supramolecular salicylic acid has a similar efficacy with 5%benzoyl peroxide 0.1%adapalene in mild to moderate acne treatment. The skin barrier (skin hydration value and TEWL value), skin brightness (L* value) and erythema (a* values) indicators showed similar statistical improvement [118].

D. Ascorbic Acid (AA): Vitamin C is a water-soluble antioxidant which protects skin from oxidative damage and rejuvenates photoaged skin. It has been utilized as a skin lightener (e.g., via tyrosinase inhibition and/or its antioxidant effect). It also has been reported to have anti-inflammatory properties since it reduces the erythema associated with post-operative laser resurfacing. In addition, AA also serves as an essential co-factor for the enzymes lysyl hydroxylase and prolyl hydroxylase, both of which are required for posttranslational processing in collagen (Types I and III) biosynthesis. Thus, by stimulating these biosynthetic steps, ascorbic acid will increase the production of collagen which will lead to wrinkle reduction [90]. Vitamin C deficient individuals may experience easy bleeding, bruising, and poor wound healing [130]. In addition, topical vitamin C increases levels of tissue inhibitors of collagen-degrading matrix metalloproteinase-1 (MMP-1) [95]. Normal skin contains high concentrations of vitamin C, which supports important and wellknown functions, stimulating collagen synthesis and assisting in antioxidant protection against UV-induced photodamage. Vitamin C uptake from the plasma and transport across the skin layers is mediated by specific Sodium-Dependent Vitamin C Transporters (SVCTs) that are present throughout the body and are also responsible for transport into other tissues. Interestingly, cells in the epidermis express both types of vitamin C transporter, SVCT1 and SVCT2 (Figure 8) [131].

Figure 11. Delivery of nutrients to the skin [131]. The location of the vitamin C transport proteins SVCT1 and SVCT2 are indicated. Red arrows depict nutrient flow from the blood vessels in the dermis to the epidermal layer. Nutrients delivered by topical application would need to penetrate the barrier formed by the stratum corneum [126]. Reported that topical serum containing L-Ascorbic acid, soluble proteoglycans, low molecular weight hyaluronic acid, and a tripeptideprotected against oxidative damage and dermal protein loss caused by photo- and chronological aging in human skin explants. in vivo, the serum hydrated skin for 6 hours, and users perceived increased skin brightness, hydration, and fewer wrinkles [126]. Reported that 2.5 ml of serum containing 20% L-ascorbic acid with hydrate from strawberries was used topically in every of 4 treatments. The impact of active substance on skin firmness and elasticity as well as the degree of hydration and skin tone was more efficient after micro-needle mesotherapy [127]. Reported 2-O-β-d-glucopyranosyll- ascorbic acid (AA-2βG), a unique AA derivative identified in Lycium barbarum, exhibited enhanced free radical scavenging activity compared with AA and its synthetic derivative AA-2aG. AA-2βG protected hydrogen peroxide-induced cell death in murine macrophage RAW264.7 cells. Treatment with AA-2βG eliminated oxidative stress and the ratio of cellular glutathione to glutathione disulfide more effectively than AA and AA-2aG [128]. Reported three times higher anti oxidant properties of than rutin, measured by the action radical scavenging activity by the Ferric-Reducing Activity of Plasma (FRAP) test. However, the mixture of ascorbic acid and rutin (Ascorbic A. + Rutin) had approximately 20% higher antioxidant properties compared to Ascorbic A alone. The F–C test showed that AA + Rutin acted two times stronger than AA. or Rutin alone [129]. Reported topically applied vitamin C (concentration of 5% and a pH of 5.5 in a novel complex with Rosa moschata, the musk rose oil and proteoglycans) is highly efficient as a rejuvenation therapy, inducing significant collagen synthesis in all age groups with minimal side effects [132].

E. Vitamin E: The very properties that make alpha-tocopherol such a powerful antioxidant causes it to break down in the presence of oxygen or upon exposure to light. For that reason, a-tocopherol acetate, which is the more stable esterified form, is used in cosmetics. Since a-tocopherol acetate is not an antioxidant and has no antioxidant activity, it must first convert to its active alpha-tocopherol form. Years of debate questioned the ability of alpha-tocopherol acetate to be delivered to the skin and bio-converted to an active form. Finally, in 1990, the bioconversion of alpha-tocopherol acetate to free alphatocopherol was able to be demonstrated. The use of vitamin E in skin care has anti-aging benefits based on its moisturization properties but mostly on its protective capabilities. Vitamin E enhances the photo protective to protective effects of sunscreen, and when combined with vitamin C, the two are even stronger as photoprotectants [95]. Unfortunately, oral supplementation of vitamin C and E has proven insufficient in preventing skin aging owing to their poor solubility, inefficient skin permeability, or instability during storage [136]. Topical vitamin E (a-tocopherol) used as a component of skin products has anti-inflammatory and anti proliferative effects in concentrations between 2 and 20%. It acts by smoothing the skin and increasing the ability of the stratum corneum to maintain its humidity, to accelerate the epithelialization, and contribute to photo protection of the skin. The effects are not as strong as with vitamins C and B3 [133]. Most of the OTC antiaging creams contain 0.5%–1% of vitamin E. Topical application of the gel containing 2% phytonadione, 0.1% retinol, 0.1% vitamin C, and 0.1% vitamin E has been seen to be fairly or moderately effective in reducing dark under-eye circles, especially in cases of homeostasis. Topical application of vitamin E can rarely cause contact dermatitis, erythema multiforme, and xanthomatous reaction [134]. The interaction of vitamins E and C has led to the idea of “vitamin E recycling”, where the antioxidant function of oxidized vitamin E is continuously restored by other antioxidants (Figure 9). This “antioxidant network” depends upon the supply of aqueous antioxidants and the metabolic activity of cells [135].

Figure 12. The interdependence of vitamins E and C, and glutathione, in the scavenging of free radicals and regeneration of the reduced antioxidants [131]. Vitamin E is in the lipid fraction of the cell, whereas vitamin C and glutathione are water-soluble and present in the cytosol. Vitamin C is only one player in the antioxidant arsenal that includes enzymatic defenses (catalase, glutathione peroxidase and superoxide dismutase) as well as other non-enzymatic defenses (vitamin E, glutathione, uric acid and other putative antioxidants such as carotenoids). Vitamin E is a promising chemo-preventive and pharmacologically safe agent, which can be exploited or tested against skin cancer [137]. Experimental evidence suggests that topical and oral vitamin E has anticarcinogenic, photoprotective, and skin barrier-stabilizing properties [138]. The topical use of resveratol, a polyphenol from red grapes with great anti oxidant activity in skin care formulation reported that significant improvement in fine lines and wrinkles, skin firmness, skin elasticity, skin laxity, hyper pigmentation, radiance, and skin roughness over baseline in 12 weeks after using a topically applied proprietary blend containing 1% resveratrol, 0.5% baicalin, and 1% vitamin E. Ultrasound measurements in the periorbital area showed an average improvement of 18.9% in dermal thickness suggesting significant dermal remodeling [139]. Combination of vitamin E, vitamin C, and ferulic acid can reduce the incidence of oxidative stress-induced tumors, and their antioxidant effects are much better than the use of vitamin C alone [140]. Demonstrated that topical 5% alpha tocopherol may actually promote carcinogenesis when applied on chronically UVB-damaged skin while treating with a more stable antioxidant compound may offer therapeutic benefits [141].

F. Coenzyme Q10: Coenzyme Q10 (a ubiquinone) is a powerful free radical inhibitor that inhibits lipid peroxides from forming in plasma membranes. Q10 plays a very important role in cellular energy production and works in the mitochondrial ATPenergyproducing pathway of the cell. Q10 levels diminish with age, as does cellular energy production, which may improve by adding Q10 [950]. Additionally, UVR, which leads to oxidative damage, significantly reduces skin’s Q10 levels. Approximately 46% of total Q10 was found to be present in the reduced form in human epidermis. Q10 scavenges ROS and protects cells against oxidative stress. Concluded that suppression of the PKA-ERK 1/2 signaling pathway may be one of the important mechanisms by which Q10 protects astrocytes from UVB-induced oxidative damage [149]. Reported that quinone values on the skin surface were significantly increased after treatment with Q10-containing formulas demonstrating that the powerful antioxidant Q10 can be delivered directly to the uppermost layer of the skin [143]. Q10 is an insoluble, poorly permeable antioxidant with great biological value which acts as anti-aging and anti-wrinkle agent. Q10 nano-structured lipid carrier (Q10-NLC) had greater antioxidant properties and topical skin penetration than the Q10- emulsion [144]. Also, reported Q10 nano-emulsion having enhanced solubility and permeability with improved anti-wrinkle efficiency [146]. The concentration of Vitamin E and Q10, which together with squalene play a key role against external oxidative insult, has been shown to decrease significantly during ageing. Topical application was found to be more effective than oral administration in terms of sebum levels of lipophilic antioxidants and squalene [145]. Also, reported oral supplementation with CoQ10 did not significantly affect skin hydration and dermis thickness [148]. As an effective fatsoluble antioxidant and an essential element of the mitochondrial respiratory chain, Q10 may have healing effects on wound tissues by decreasing oxidative stress and improved mitochondrial efficiency. Reported the anti-inflammatory and wound healing effect of Q10 in mice [146]. Despite the lack of evidence, large numbers of people in the population are taking oral Q10 and other vitamins and cofactors in the hope that these agents will slow senescence and expand longevity [150].

G. a-Lipoic Acid: Lipoic acid is a very powerful antioxidant that has the unusual advantage of being both water and fat soluble and is an important cofactor in mitochondrial dehydrogenases. a-Lipoic Acid (ALA) is a sulfhydryl compound found naturally in virtually all plant and animal species and in both prokaryotic and eukaryotic cells. In the human body, it is bonded to lysine residues and acts as a cofactor in various multi enzyme complexes. Nevertheless, there is often little or no free ALA in tissues, so a topical antioxidant formulation containing this natural antioxidant could be used to protect the skin against the effects of ultraviolet rays, such as photoaging and skin cancer [156]. Studies have shown the ease with which lipoic acid is able to penetrate the skin, after which it converts into its active byproduct dihydrolipoic acid. Topical application of 3% lipoic acid has demonstrated its ability to decrease UVB-induced erythema, which demonstrates its photo protective and anti-inflammatory properties. Also, a 12 -week study demonstrated that using a topical cream containing 5% ALA was quite effective in treating signs of photoaging [95]. ALA and its reduced form, dihydrolipoic acid, are powerful antioxidants that have many physiological functions, including free radical scavenging of reactive oxygen species, generation of cellular antioxidants, chelation of metal ions, and inflammatory suppression (when given orally) [155]. Though ALA is normally administered in oral or injection, it is rarely used topically because of its bad penetration. Developed novel nanocapsule of ALA, named a-Lipoactive (nLA), to improve skin permeability. In in vivo experiments, it was found that nLA is very effective for improving UV-induced pigmentation and epidermal thickening [151]. Demonstrated application of topical 30% poloxamer gel loaded with ALA cubosomes. Reduction in facial lines, almost complete resolution of fine lines in the periorbital region and upper lip area and overall improvement in skin color and texture in most volunteers. There were no instances of irritation, peeling or other apparent adverse side effects [152]. In a similar study with 5% Cubosomal ALA significantly increased epidermal thickness with effective and safe modality for improving aging face [154]. Were unable to detect protection using ALA alone or together with vitamins C and E. According to them, a commercial formulation of ALA provided no protection [153]. Reported that rheological features, such as viscosity, thixotropy and compliance, and the presence of a hydrophilic polymer strongly influenced the release of ALA from topical emulsion dosage form [156].

H. β-Glucans: β-Glucan is a dietary fiber, found in many natural sources, and controls chronic metabolic diseases effectively. The in vivo cholesterol binding and reduction in the skin thickness by β-glucan were highly encouraging [160]. Although isolated from different sources, including oat, barley, and reishi mushrooms, the most biologically active are isolated from cell membranes of baker’s yeast (Saccharomyces cerevisiae). In the epidermis, where macrophage-derived cells include both keratinocytes and Langerhans cells, β-Glucans act to stimulate the protective qualities of these cells as our first line of defense. Topical β-Glucans can accelerate wound healing and increase resistance to infection by enhancing macrophage-mediated phagocytosis. Studies have also demonstrated that β-Glucans have photo protective properties similar to those of vitamin E by their ability to sustain levels of reduced glutathione in the skin following UVR. β-Glucans are extremely soothing and calming to the skin through their reinforcement of skin macrophages, which have implications in minimizing irritancy potential of products. The potential uses of β-Glucans in dermatology are numerous. In personal-care products for shaving, where nicks and cuts, razor burn, irritation and folliculitis are problematic and the protective, wound-healing, anti-irritating effects of β-Glucans can be quite helpful. The photo protective effects of β-Glucans as well as their ability to so the, moisturize, and protect the skin from potential irritation that can occur with other treatment products, makes them quite useful in anti-aging skin regimens [95]. Topical application of β-glucans is increasing, since their pluripotent activity (antioxidant, anti-inflammatory and regenerative effects, immune modulation, radioprotection, moisturization and rejuvenation) might help as a complementary therapy in managing various skin diseases and conditions. Macrophages, keratinocytes and fibroblasts are considered the main target cells of β-glucans during wound healing. β-glucans enhance wound repair by increasing the infiltration of macrophages, which stimulates tissue granulation, collagen deposition and reepithelialization [157]. A long-term use of glucan showed reduction of wrinkle depth, height and overall roughness, which is probably caused by stimulation of fibroblast and increase production of collagen. A cell turnover and regenerative extract of β-glucan is believed to support healthy immune surveillance [158]. Dammarane ginsenosides are considered to play a major role in the anti wrinkle activities of ginseng. These compounds are strongly linked with cellulose, pectin, or β-glucan [159]. Investigated the immunomodulatory and antiinflammatory activity of an Imunoglukan P4H^® cream, containing β-glucans (pleuran), in patients suffering from atopic dermatitis, where use of β-glucan-based cream as a supportive complementary therapy [161]. The topical application of Imunoglukan P4H^® showed significant improvements in both subjective and objective symptoms of atopic dermatitis and a significant decline in disease severity; exacerbation was observed [162]. Sensitive skin is frequently complaint in dermatology consultation with cutaneous manifestations such as stinging, redness, dryness, and burning sensation that affect the quality of life. Its pathogenesis is mainly related to dysfunction of neurosensory, skin barrier, and also immune activity. Confirmed the effectiveness, tolerance and anti sensitive function of a new complex cream composed by Yunnan Portulaca oleracea extract, Prinsepia utilis oil, beta-glucan, and sodium hyaluronate extracted from mushroom. The proposed daily care safe moisturizer provided a statistically significant improvement in clinical grading scores for dryness, roughness, and erythema at 28 days compared to baseline [163].

H.1. Ceramide: The stratum corneum is comprised of corneocytes surrounded by inter-cellular lipids including ceramides, free fatty acids, and cholesterol. Ceramide predominant moisturizers have become a mainstay of treatment of skin disease. Ceramides constitute (on a weight basis) approximately 47% of the SC lipids [186]. Moisturizing treatment involves a four-step process: a) repairing the skin barrier, b) increasing water content, c) reducing TEWL and d) restoring the lipid barriers’ ability to attract, hold and redistribute water. Interestingly, a statistically significant higher ceramide/cholesterol ratio was found for men than for women, as reported by [183]. Reported reduced activities of ceramide-generating epidermal acid Sphingomyelinase (SMase) and ceramide synthase in the inner epidermis of aged skin, explaining its reduced capacity in barrier repair [182]. The effect of Ceramide cream on enhancing skin barrier function and hydration might be explained by its unique ingredients. Ceramide cream increases skin hydration and improve barrier function which may make it suitable for use on dry skin [179]. Several studies have demonstrated that ceramides play an essential role in both the barrier and water-holding functions of healthy stratum corneum, suggesting that the dysfunction of the stratum corneum associated with ageing as well that observed in patients with several skin diseases could result from a ceramide deficiency. A 2-week topical application of a sonicated streptococcus thermophilus preparation led to significant and relevant increase of stratum corneum ceramide levels [180]. Demonstrates that a proprietary combination of ceramide PC-104, palmitamide MEA, glycerrhetinic acid, and grape seed extract in a glycerin, dimethicone, and petrolatum vehicle was effective in reducing the signs and symptoms of mild-to-moderate atopic dermatitis and other types of pruritic dermatoses (e.g., senile itch, cosmetic intolerance syndrome) in children and adults [184]. Reported skin-identical ceramide complex cream improved contact dermatitis with a decrease in Three-Item Severity (TIS) and an increase in skin hydration, implying a repair of the skin barrier [185]. Advancements in cosmetic chemistry have resulted in the development of bio-identical synthetic ceramides that are commonly incorporated into skin care products (notably CER-1, CER-3, and CER-6), which have been shown to function similar to natural ceramides [186]. Reported limited penetration of ceramide species into SC and accumulation on to the skin, suggesting that topical replenishment of CER may not be an effective approach to improve the barrier properties of healthy skin [187].

Figure 11: Delivery of nutrients to the skin [131].

    

    

    Figure 11:  Delivery of nutrients to the skin [131].
    
    

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Figure 12: The interdependence of vitamins E and C, and glutathione, in the scavenging of free radicals and regeneration of the reduced antioxidants [131].

    

    

    Figure 12:  The interdependence of vitamins E and C, and glutathione, in the scavenging of free radicals and regeneration of the reduced antioxidants [131].
    
    

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Figure 13: Schematic depiction of β-glucan pluripotent mechanisms in wound healing [157].

    

    

    Figure 13:  Schematic depiction of β-glucan pluripotent mechanisms in
wound healing [157].
    
    

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Figure 14. The molecular structures of the Ceramides (CER) present in human stratum corneum [225], indicated according to the numbering system (based on chromatographic migration) and according to their structures. A, a-hydroxy fatty acid; H, 6-hydroxysphingosine; N, nonhydroxy fatty acid; P, phytosphingosine; S, sphingosine.

Figure 14: The molecular structures of the Ceramides (CER) present in human stratum corneum [225].

    

    

    Figure 14:  The molecular structures of the Ceramides (CER) present in
human stratum corneum [225].
    
    

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Figure 15: Collagen fiber structure, absorption/metabolism and deposition into skin cells and dermal layers.

    

    

    Figure 15:  Collagen fiber structure, absorption/metabolism and deposition
into skin cells and dermal layers.
    
    

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J. Nicotinamide: Niacin (vitamin B3) has two potential forms that can be used in cosmeceuticals: niacinamide (nicotinamide) and nicotinic acid [193]. Topical nicotinamide (the active form of vitamin-B3) has been shown to improve fine lines and wrinkles, hyper pigmented spots, red blotchiness and shallowness (yellowing), as well as elasticity. In addition, nicotinamide has been demonstrated to increase the skin’s production of collagen and ceramides, and to stimulate keratinocyte differentiation, leading to improved barrier function and skin appearance [95], [105]. Nicotinamide cream is a more effective moisturizer than white petrolatum on atopic dry skin, and may be used as a treatment adjunct in atopic dermatitis [188]. Reported its anti-inflammatory, antioxidant and immunomodulatory properties, as well as an epithelization inducing action. Nicotinamide also improved tissue regeneration through the increment of fibroblast proliferation, collagen synthesis, and vascularization [189]. Nicotinamide and clindamycin gels were significantly more efficacious in oily and non-oily skin types, respectively. Skin type is a significant factor in choosing between topical nicotinamide and clindamycin in patients with acne vulgaris [196]. Because topical clindamycin, like other antimicrobials, is associated with emergence of resistant microorganisms, nicotinamide 4% gel is a desirable alternative treatment for acne vulgaris [190]. Niacinamide 4% induces a decrease in pigmentation, inflammatory infiltrate, and solar elastosis. Niacinamide is a safe and effective therapeutic agent for melasma, compared to 4% hydroquinone. Niacinamide was effective in approximate 40% of patients, showing outstanding clinical results [191]. In ageing skin, topical application of niacinamide improves the surface structure, smoothens out wrinkles and inhibits photocarcinogenesis. It is possible to demonstrate anti-inflammatory effects in acne, rosacea and nitrogen mustard-induced irritation [192]. Nicotinamide also increases the production of the epidermal proteins keratin, filaggrin, and involucrin [194]. Nicotinamide increases collagen production in fibroblast cultures and reduces the increased dermal glycoamino glycosides in photo damaged skin. The glycation between protein and sugar resulting in formation of crosslinked products gives a yellow color to the skin. As nicotinamide is a precursor of antioxidant NADPH, it has anti glycation effects, thus preventing shallowing of skin. In a double-blinded, split face, randomized controlled trial, 5% nicotinamide cream was compared to “vehicle only cosmetic” in 30 Japanese women on face for 8 weeks. There was a significant decrease in wrinkles and skin roughness with nicotinamide [195].

Figure 16: Bio-actives from probiotics for dermal applications [113].

    

    

    Figure 16:  Bio-actives from probiotics for dermal applications [113].
    
    

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Figure 17: The proposed mechanism by which astaxanthin inhibits oxidative stress-induced mitochondrial dysfunction, and development and progression of diseases [211].

    

    

    Figure 17:  The proposed mechanism by which astaxanthin inhibits oxidative
stress-induced mitochondrial dysfunction, and development and progression
of diseases [211].
    
    

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K. Zinc: The skin is the third most zinc (Zn)-abundant tissue in the body. Zn is a cofactor for over 1000 enzymatic reactions and is necessary for over 2000 transcription factors. Zn-finger proteins function for DNA interaction, RNA packaging, activation of transcription, regulation of apoptosis, folding and assembly of protein, and lipid binding. Zn also functions as an intracellular signaling molecule, like calcium, by transducing extracellular stimuli into intracellular signaling. Additionally, about 10% of human proteins bind to Zn. affects 17% of the world’s population who are in the condition of general malnutrition due to starvation, severe illness and alcohol addiction [214]. The importance of zinc for humans was acknowledged in the Middle East (Iran, Egypt), in the early 1960s, in patients with growth retardation, hypogonadism, hepatomegaly, splenomegaly, dry and wrinkled skin, and severe iron deficiency anemia [215]. A Zn-deficient diet alters the expression of keratin polypeptides in rats because of impaired keratinolytic enzyme activity. Zn is required for the proliferation of keratinocytes and the suppression of inflammation in Keratinocytes. Zn facilitates the melanocyte proliferation and the autophagy. Zn promotes lipogenesis and glucose transport via its insulin-like effects on 3T3-L1 fibroblasts and adipocytes [214]. Topical preparations like zinc oxide, calamine, or zinc pyrithione have been in use as photo protecting, soothing agents or as active ingredient of antidandruff shampoos. Its use has expanded manifold over the years for a number of dermatological conditions including infections (leishmaniasis, warts), inflammatory dermatosis (acne vulgaris, rosacea), pigmentary disorders (melasma), and neoplasias (basal cell carcinoma) [216].

L. Anti-pollution preparations: Demonstrated that SIG-1273 reduced cell death by 66%, outperforming niacinamide, ascorbic acid, and a-tocopherol, commonly used actives in antipollution skin-care products [232]. Reported Cryptomphalus aspersa secretion with regenerative(hyaluronic acid, peptides) and antioxidant ingredients(ectoine, coffeeberry oil, and olive oil), according to the type and area of the face, on the improvement of signs of skin aging. Ingredients from formulations studied have been shown to reduce the signs of skin aging by the multiple extrinsic factors known today as ultraviolet, visible, and infrared solar radiation; pollutants; aridity conditions; or even endogenous factors, such as dietary factors [233]. A film-forming Exopoly Saccharide (EPS) called as alteromonas ferment extract was included in the formulation for its anti-adhesion effect. EPS significantly reduced particle adhesion to skin and protected keratinocyte membranes from lipid peroxidation, preserved cell integrity, and normalized the collagen net work in skin exposed to heavy metals, hydrocarbons, and particulate matter. Reported that daily application of the facial cream containing an EPS, carnosine, and niacinamideover 5 days had a protective effect against pollutioninduced changes [234]. Reported that clinical application of a multi component powder, including three naturally occurring standardized extracts rich in polyphenols (grape seed extract, green tea extract, oak wood/bark extract) allows the prevention of any metal deposition within the SC following exposure in a polluted environment and plays an effective role in counteracting skin damages induced by air pollution [235].

Systemic Anti-aging preparations

A. Collagen supplementation: In 2016, the collagen market was valued at an estimated 3.71 billion USD and is projected to reach 6.63 billion USD by 2025. Collagen supplements, originating from various sources (eg, porcine, bovine, marine) and available in numerous formulations (eg, protein, gelatin, hydrolysate, peptides), are marketed as improving skin integrity and modulating skin aging. When denatured by heat, collagen forms gelatin, which has been used for centuries as a food source and traditional medicine in Europe and China. Further enzymatic hydrolysis of gelatin produces Collagen Hydrolysates (CH) composed of peptides of varying lengths, conveniently formulated into liquid drinks and jelly sticks for oral consumption. In the past decade, CHs have gained popularity as a nutraceutical supplement. Reported promising preliminary results for the short and long-term use of oral collagen supplements for wound healing and skin aging. Oral collagen supplements also increase skin elasticity, hydration, and dermal collagen density. However, even with this increase in patient interest and market share, the use of collagen supplementation in dermatology remains controversial due to the lack of regulation on quality and quantity of ingredients in OTC collagen supplements [164], [171]. Reported improvement of general skin conditions, acting in different mechanisms by oral supplementation and topical application of hydrolyzed proteins [165]. Reported significant improvement in after 8 weeks of supplementation in women aged 35-55 years but study failed to reach a level of statistical significance with regard to skin moisture and skin evaporation [166]. Oral administration of Low-Molecular-Weight Collagen Peptide (LMWCP), which is a fish-derived collagen hydrolysate, promotes recovery of collagen fibers and normal elastic fibers in the skin from degraded collagen and abnormal elastic fibers caused by UVB irradiation in hairless mice [167]. Reported that LMWCP is a safe health functional food ingredient with anti-skin photoaging efficacy which can effectively improve hydration, elasticity, and wrinkling in human skin at the dose of 1000 mg once daily [168].

Figure 15. Collagen fiber structure, absorption/metabolism and deposition into skin cells and dermal layers. It is generally thought that collagen (derived products) are hydrolyzed into amino acids in the GIT prior to being absorbed into the blood circulation, which are then deposited into the skin cells and/or utilized as building block components for extracellular matrix proteins produced by fibroblasts. ALA = Alanine, HYP = Hydroxyproline, GLY = Glycine, PRO = Proline, and Ser = Serine. Oral supplementation with collagen bioactive peptides (hydrolyzed fish collagen) combined with chondroitin sulphate, glucosamine, L-carnitine, vitamins, and minerals significantly improved the clinical parameters related to skin aging and joint health [169]. Reported that orally administering Collagen Peptide NS (CPNS) to rats, the plasma concentrations of Gly-Pro and Pro-Hyp increased dramatically. The CPNS consumption significantly attenuated UVB-induced wrinkle formation, transepidermal water loss, and epidermis thickness, and increased skin hydration [170]. An association between oral administration of collagen peptides combined with vitamin C and extracts of Hibiscus sabdariffa and Aristotelia chilensis was observed by. Female adult patients received an oral nutritional supplement from a sachet and were instructed to consume 1 sachet diluted in 200 mL of water once daily for 12 weeks. Clinical evaluation by high frequency ultrasound and cutometry showed significant improvement of firmness and elasticity and an increase in dermal thickness by ultrasound after 3 months of use [171]. Reported that collagen peptides modulate the metabolism of extracellular matrix proteins by human dermal fibroblasts (in culture) that were derived from sun-protected and sun-exposed body sites [172]. Examined the effects of collagen hydrolysates from sliver carp skin on UV-induced photo-aging in mice and found that LMW peptides exerted beneficial effects when compared to high molecular weight CHs on HA levels and moisture content of the skin [173].

B. Probiotics: Lactic acid bacteria consist of 26 genera now, and play an essential role in the food industry in the manufacture of many fermented products (cheese, yogurt, fermented vegetables, etc.). Application of these organisms is now being extended to the area of health improvement, as their pro biotic activities become known. Lacto coccus lactis H61 improved skin status in Japanese women with oral intake of heat-killed or live cells. With regard to live cells in fermented milk made by strain H61, the reported effects are attractive and it is expected that consumption of H61-fermented milk will increase [175]. It is also reported that oral intake of Lactobacillus rhamnosus SP1 improves the appearance of adult acne [176]. Oral intake of yoghurt made by using Lactobacillus delbrueckii subsp. bulgaricus 2038 plus Streptococcus thermophilus 1131 for 4 weeks improved skin elasticity and the degree of dryness in cheeks of women [177]. Also reported that the intake of fermented milk containing Bifido bacterium breve strain Yakult plus galacto oligosaccharides for 4 weeks increased hydration levels of the stratum corneum in women [178].

C. Astaxanthin: Astaxanthin is ubiquitous in nature, especially found in the marine environment as a red-orange pigment common to many aquatic animals such as salmonids, shrimp, and crayfish. The ROS lead to skin aging via oxidative damage that are induced by UVR. Therefore, topical formulations which have antioxidant effect could reduce aging level [200]. Reported that topical formulations of astaxanthin-loaded algae extract could be suggested as topical antiaging formulations [199]. Comparative studies examining the photo protective effects of carotenoids have demonstrated that astaxanthin is a superior antioxidant, having greater antioxidant capacity than canthaxanthin and β-carotene in human dermal fibroblasts [200]. In particular, astaxanthin inhibits ROS formation and modulates the expression of oxidative stress-responsive enzymes such as heme oxygenase-1 (HO-1), which is a marker of oxidative stress and a regulatory mechanism involved in the cell adaptation against oxidative damage [205].

Figure 17. The proposed mechanism by which astaxanthin inhibits oxidative stress-induced mitochondrial dysfunction, and development and progression of diseases [211]. Astaxanthin exerts significant antioxidant activities not only via direct radical scavenging, but also by activating the cellular antioxidant defense system through modulation of the Nuclear factor erythroid 2-related factor (Nrf2) pathway. Demonstrated that astaxanthin protected against early burn-wound progression by attenuating ROS-induced oxidative stress in a rat deep-burn model [201]. in vitro, astaxanthin effectively suppresses cell damage caused by free radicals and induction of MMP-1 in skin after UV irradiation [202]. Reported that an enriched astaxanthin extract from H. pluvial is increased collagen content through inhibition of MMP-1 and MMP-3 expression in human dermal fibroblasts [203]. Reported that astaxanthin-treated wounds in mice showed significantly increased expression of wound healing biological markers such as collagen type I a 1 (Col1A1) and basic Fibroblast Growth Factor (bFGF) [204]. The immunomodulatory action of astaxanthin has been also reported in dogs and cats, enhancing both cell-mediated and humoral immune responses. In these studies, astaxanthin increased Natural Killer (NK) cell cytotoxic activity, suggesting that astaxanthinmay regulate NK cells that serve as an immune surveillance system against tumors and virus-infected cells [206,207]. Astaxanthin is reported to improve the DNA repair capacity of cells exposed to UV radiation. In particular, astaxanthin was capable of minimizing DNA damage and influencing the kinetics of DNA repair [208]. Human cells possess multiple protection mechanisms against UV-induced ROS, either by preventing damage or by damage repair. Camera et.al, 2009 reported that astaxanthin inhibits the UV-induced DNA damage and increases the expression of oxidative stress-responsive enzymes [209]. Suggested that longterm prophylactic astaxanthin supplementation may inhibit agerelated skin deterioration and maintain skin conditions associated with environmentally induced damage via its anti-inflammatory effect [210].

D. Colostrum: Colostrum is the initial milk or “first milk” that is produced by mammals (including humans) immediately following parturition. As expected, colostrums was more effective than milk with the total lipid, linoleic acid, linoleic acid, ganglioside, and glycolipid contents were higher in colostrums when compared to milk. In addition, with further analysis, the fat globule fraction provided the strongest stimulation for wound repair that contained Epidermal Growth Factors. The milk fluid produced by all female mammalian species after birth has the function to meet the complete nutritional requirements of the neonate and, at the same time, provide all of the biochemical needs and support the many biological functions of the immature newborn to help the newborn survive and develop. Starting in the 1980s and through the mid-1990s, supplemented cell culture medium with milk or colostrums was reported to improve the growth rate of many cell types including skin (fibroblasts). Peptides from milk protein hydrolysates improved the growth of human keratinocytes in culture. Medium supplemented with 300 μg/mL for 12 days where the average molecular weight of 800 Da containing a high concentration of amino acids promoted the growth of the keratinocytes by 108% [174]. Colostrum is the only known natural source of the enzyme, telomerase, which may help to slow down the aging of DNA. In fact, there is evidence that short telomeres and a lack of telomerase can exert a longevity-promoting effect via prevention of cancer [212]. Colostrum also includes EGF and IGF-1, which are known to assist in the repair and regeneration of cells. EGF and IGF-1 play essential roles in wound healing, which makes colostrum an important potential adjunct to the skin’s repair following a surgical cosmetic procedure. Let’s not forget about the lactoferrin in colostrum, either. Lactoferrin helps manage the immune response in the skin cells, which means supplementing with lactoferrin may potentially help a person increase his or her skin’s anti-inflammatory response [213].

E. Selenium: Selenium (Se) is an essential trace element in the human body and plays an important role in the body via selenoprotein, which contains selenium. Selenoproteins (glutathione peroxidase, thioredoxin reductase, methionine sulfoxide reductase-1 and endoplasmic reticulum-selenoproteins, etc.) have antioxidant effects and are involved in regulating antioxidant activities [217]. Se and the seleno proteins are essential for keratinocyte function and skin development. A lack of seleno enzymes in the mouse epidermis leads to abnormalities in the skin and hair follicles, premature skin aging, and premature death. Additionally, several studies have shown that Se pretreatment can drastically protect keratinocytes, melanocytes, and fibroblasts from UV-induced cytotoxicity. Low doses of Se were very potently protective against UVA-induced cytotoxicity in young keratinocytes, whereas the aged keratinocytes require four times more Se than the young keratinocytes to be protected from UVA-induced cytotoxicity [218,219]. Se protects Keratinocyte Stem Cells (KSCs) against senescence via preservation of their stemness phenotype through adhesion to the basement membrane [219]. Showed that Vitamin C (250 mg/kg), vitamin E (250 mg/kg) and Se (0.2 mg/ kg) exerted antioxidant effects and consequently may prevent skin damage caused by streptozotocin-induced diabetes (65 mg/kg) in Swiss albino rats [220].

F. Hyaluronic Acid: Hyaluronic Acid (HA) is part of the body’s connective tissues, and is known to cushion and lubricate. Aging destroys HA. Diet and smoking can also affect your body’s level of HA over time. Skin care products with HA are most frequently used to treat wrinkled skin although they don’t replace anything the body has naturally lost. These are very effective moisturizers [119]. UV radiation damage causes initially a mild form of wound healing and is associated at first with an increase of dermal HA. As little as 5 min of UV exposure in nude mice caused enhanced deposition of HA, indicating that UV radiation induced skin damage is an extremely rapid event. The initial redness of the skin following exposure to UV radiation may be due to a mild edematous reaction induced by the enhanced HA deposition and histamine release. Repeated and extensive exposures to UV ultimately simulate a typical wound healing response with deposition of scar like type I collagen, rather than the usual types I and III collagen mixture that gives skin resilience and pliability [120]. HA based formulations (i.e., gels, creams, intra-dermal filler injections, dermal fillers, facial fillers, auto logous fat gels, lotion, serum, and implants, etc.) exhibit remarkable anti-wrinkle, anti-nasolabial fold, anti-aging, space-filling, and face rejuvenating properties. This has been achieved via soft tissue augmentation, improved skin hydration, collagen and elastin stimulation, and face volume restoration. HA, alone or in combination with lidocaine and other co-agents, showed promising efficacy in skin tightness and elasticity, face rejuvenation, improving aesthetic scores, reducing the wrinkle scars, longevity, and tear trough rejuvenation [125]. Reported significant improvement of wrinkles’ grade around the eyes, vertical lip lines and wrinkles’ severity of nasolabial folds after the first injection and the effect increased after the second injection. Aging/photoaging grade and surface micro relief improved 2 months after the first injection procedure. The treatments were very well tolerated by the volunteers as determined by the selfgrading score [121]. Reported that Cross-Linked Hyaluronic Acid (CLHA) patches were not an irritant, whereas a clinical study showed that application of single CLHA patches significantly improved skin hydration at the periorbital region for 3 days and at the nasolabial fold for 6 days. Patch application also improved superficial wrinkles at the periorbital region for 3 days and at the nasolabial fold for 1 day. The absence of side effects indicated that application of these CLHA microstructure patches is both safe and convenient for moisturization and anti-wrinkle effects [122]. Reported that CTP-EGF has a superior ability, compared with natural EGF, to permeate skin and induce HA synthesis and collagen formation. Thus, it has great potential to be used in cosmetics and therapeutic agents to improve wrinkles and health of the skin [123]. There exist many different types of HA gel fillers that differ in their HA concentration, particle size, cross-linking density, duration, and presence of lidocaine. High-density, largeparticle fillers are recommended for deep dermal injections while the low-density, small-particle fillers are recommended for fine lines. HA gel is used by several healthcare professionals include the plastic surgeon, primary care provider, dermatologist, nurse practitioner and the internist to enhance cosmesis. HA fillers are injected to restore volume lost due to age or disease, provide facial contour, and help maintain a youthful appearance. Filler injection has become one of the most commonly performed procedures in a dermatology cosmetic practice [124].

G. Poly-L-lactic acid: Poly-L-Lactic Acid (PLLA) is injectable filler used for restoring facial fat volume loss. Polydioxanone Cog thread and Poly-L-Lactic Acid (PLLA) thread have been used clinically for lifting and antiaging purposes [221]. PLLA is an effective treatment for patients seeking to correct volume loss due to aging. Although the US FDA has approved PLLA for use in people with the HIV in 2004, it is well-suited for patients seeking cosmetic treatment. By 2009 PLLA were FDA-approved for the correction of nasolabial fold contour deficiencies and other lines and wrinkles. There have since been limited but promising results with off-label use of PLLA for non-facial volumization as well, including the hands, neck/décolleté, abdomen, and gluteal area [222]. PLLA is a safe, biodegradable volumizer used to reverse the signs of aging by gradually correcting volume loss. Patients should be aware of possible adverse reactions during the course of treatment [221]. Injection of PLLA in the deep dermis or subcutaneous tissue may cause an immediate augmentation of the treated tissue. This is a temporary but immediate response that is due to tissue edema and fluid from the reconstitution of the product. It will resolve within 2 to 3 days after injection. Once the carrier substance is absorbed, the poly-L-lactic acid particles induce an inflammatory response through phagocytosis by tissue macrophages. This is a similar process to suture re absorption in the skin. The inflammatory response breaks down the poly-L-lactic acid into lactic acid monomers and is then metabolized to carbon dioxide and water while stimulating the production of new collagen type-I fibers in the skin. Approximately half of the product is digested within 6 months. The duration of action is 12 to 24 months [223]. Reported that PLLA and Cog sutures were effective in facial rejuvenation (studied in female rats); both increased dermis thickness and stimulated collagen production [110]. Repeated PLLA treatments may improve skin quality in a time-dependent manner. Pigmentation, erythema, and pore size were significantly decreased, whereas radiance and smoothness were significantly increased at 12 months. No treatment-related adverse events occurred. Repeated PLLA treatments may improve skin quality in a time-dependent manner [111]. The process of hydration, loss of cohesion and molecular weight, and solubilization and phagocytosis of PLA by the host’s macrophages, degrades PLA into lactic acid microspheres and eliminates CO2 by way of respiratory excretion. Crystals are left behind to stimulate collagen and a granulomatous reaction. This inflammatory reaction elicits resorption and the formation of fibrous connective tissue about the foreign body, causing dermal fibroplasias that leads to the desired cosmetic effect [2]. Reported that powdered polydioxanone injection induces collagen formation more effectively than PLLA injection [223].

H. Hormone Replacement Therapy: In postmenopausal women, dermal collagen decreases, and skin becomes thinner [241]. Hormone Replacement Therapy (HRT) has been shown to be effective in alleviating menopausal symptoms. However, its use is controversial owing to potential health risks, such as thromboembolism and cancer. Bioidentical hormone therapy has also been used by dermatologists for its anti-aging effects on the skin, but little is known about efficacy and side effects of bio identical hormones in this field [236]. Women’s Health Initiative (WHI) study showed a higher risk for breast cancer, stroke, cardiovascular disease, and thromboembolic events with combined treatment of estrogens and progestin. Synthetic progestin’s mostly used worldwide include medroxy progesterone acetate (most frequently used in the US), norethidrone acetate, cyproteron acetate, norgestimate, norgestrel, and dydrogesterone [238].The HRT impact on skin thickness and dermal density was demonstrated early when estrogens were initially administered to postmenopausal women. Such replenishment therapy was therefore considered as an attempt at alleviating in part skin atrophy and xerosis in postmenopausal women. Indeed, HRT controls in part the dermal thickness and laxity, and the collagen content and density, as well as the tissue mechanical reactivity to stress [237]. Physicians and patients have become extremely reluctant concerning HRT following the WHI study. Numbers of HRT prescriptions in the US rose from 58 million in 1995 to 90 million in 1999, corresponding to 15 million women per year. Numbers remained stable through to 2002. Within 3 months after publication of the results of the WHI study, prescriptions of various formulations of combined estrogens and progesterone dropped by 33% to 66% [238]. Reported association between risk of venous thromboembolism and different types of HRT. Transdermal treatment was the safest type of hormone replacement therapy when risk of venous thromboembolism was assessed. Transdermal treatment appears to be underused, with the overwhelming preference still for oral preparations [239]. Both oral and transdermal estradiol caused a significant decrease in FSH while only transdermal resulted in a significant decrease in LH. Oral estradiol, though not transdermal estradiol, increased serum high density lipoprotein, thyroxine binding protein and growth hormone binding protein [240]. Applying estrogen cream to the skin after menopause improves the external appearance of facial skin [241].There is strong evidence that transdermal estradiol has a cardioprotective effect [243]. Due to their lack of first-pass hepatic metabolism, transdermal products achieve clinical benefits while minimizing patient exposure to estrogens, which is consistent with the most recent clinical guidelines [244]. Also, by increasing skin collagen content, and increasing acid muco polysaccharides and HA, estrogen therapy encourages the growth and development of vaginal epithelial cells which make up the thick layers of the vaginal wall, and condone a moist, supple and elastic environment [242]. Reported that nanostructured formulationof progesterone (10%) combined with estriol (0.1%) + estradiol (0.25%) is safe and effective in re-establishing optimal serum levels of estradiol and follicle-stimulating hormone and relieving the symptoms of menopause [243], also concluded that use of transdermal nanoformulations in hormone therapy can relieve climacteric symptoms and prevent other postmenopausal symptoms [245].

H.1. Epilogue: As more and more anti-ageing and antioxidant skin care products flood the market, there is growing concern about definitions and experimental proof of effectiveness. The physician has an important role in understanding which treatment options are appropriate for mild, moderate, and severe photoaging, and in educating patients on the risks and benefits of each. The choice of the right active compounds, the verification of their activity inside a cosmetic formulation, their stability and synergistic effects should be the first step toward the creation of modern and effective products. To be active inside the skin, the antioxidants have to penetrate into the living layers of the skin, where free radicals are generated and should be effective against ROS. This is possible only if the topical applied formulation holds the potential to be effective. Moisturizing and emollient products are gaining increasing importance in dry skin treatment, maintenance of daily care of normal skin as well as ancillary therapy of many skin diseases. Consumers are nowadays more focused on their health and appearance. As a result, there has been an increasing demand in topical antiaging formulations with natural and nutraceutical ingredients. Novel and innovative delivery systems are transforming the new product development in the cosmetic field because of consumer perceivable benefits and optimized sensory attributes. The applications of novel drug delivery systems can be found in many cosmetic products. Nanomaterial is nowadays used in almost all the major cosmetic industries. The truth is, there is no magic pill at present that will retard aging. But that is not to say there is not simple lifestyle and dietary adjustments that can make people live longer. A cosmetic product that produces clinically objective effects on the most-reported signs of aging is an attractive option for those unable to avoid extrinsic aging factors but wishing to improve their appearance without resorting to more invasive measures.

Summary

Skin care products with anti oxidative and anti-aging claims are one of the most fast-growing market for cosmetics worldwide. Antiaging in dermatology primarily focuses on the prevention of skin aging with UV protection (clothing and sunscreens), free radical scavengers (synthetic or botanic), and cell-protecting agents. Many synthetic and natural products have been reported to enhance levels of antioxidant enzymes, which make them therapeutic candidates to mitigate UVmediated damage and to prevent the health consequences of UV exposure. Topical hormonal prescriptions are also an option if UV damage has not been the leading culprit for aging. Chemical peeling leads to a marked increase in collagen formation, the deeper the better. Ingredients in cream preparations can reduce superficial skin folds (polyphenols, amino acid peptides). Modulators of regular pigmentation are important for anti-aging preparations. New approaches are being designed to exploit the signaling pathways to delay or even prevent free-radical induced symptoms of aging. There are too many products on the market, from so many brands, with more and more ingredients, and at various price points. Selecting the right anti-aging product is definitely a daunting task, but this guide is meant to simplify the process and help to choose the right anti-aging skin care products for an individual skin.

Highlights

1. Skin aging is a complex biological process influenced by combination of endogenous or intrinsic (genetics, cellular metabolism, hormone and metabolic processes) and exogenous or extrinsic (chronic light exposure, pollution, ionizing radiation, chemicals, toxins) factors.

2. Skin aging is characterized by features such as wrinkling, loss of elasticity, laxity, and rough-textured appearance.

3. Anti-aging medicine encompasses lifestyle changes, hormone replacement therapies, as needed, determined by a physician through blood testing; antioxidants and vitamin supplements; and testing protocols that can measure not only hormone levels and blood chemistry but every metabolic factor right down to the cellular level.

4. Cell senescence limits cell divisions in normal somatic cells and may play a central role in age-related diseases.

5. The major perceived risk factors are unhealthy eating habits, stress, less exercise, dehydration, diseased state and sleeping habits, though the main factor responsible for extrinsic aging is UVR.

6. Exposure to UVR is the primary factor of extrinsic skin aging, it accounts for about 80% of facial aging.

7. IR radiation and heat can lead to macrophage recruitment like UVR.

8. Even in indoor conditions, particulate matter (PM2.5) exposure levels were positively associated with skin aging manifestation.

9. Smoking provokes elastosis, telangiectasia, skin roughness, and premature wrinkles on facial skin due to the vascular constriction of nicotine.

10. Sleep deprivation is associated with increased signs of intrinsic skin aging (fine lines, uneven pigmentation, reduced elasticity), with much slower recovery rates.

11. Cooking processes that lead to higher levels of Advanced Glycation End Product (AGEs) include grilling, frying, and roasting.

12. Among US population 75% consumed less fruit and 87% consumed fewer vegetables than recommended.

13. Higher intakes of vitamin C and linoleic acid and lower intakes of fats and carbohydrates are associated with better skin-aging appearance.

14. In order to lowering the skin damage, cleansings with neutral pH and pH close to 5.5 are recommended.

15. 30-70% of patients with DM, both type 1 and type 2, will present with a cutaneous complication of DM at some point during their lifetime.

16. Obese-diabetes patients have decreased stratum corneum hydration, increased trans-epidermal water loss, higher skin AGEs and decreased dermal collagen fiber density compared with normalweight subjects.

17. Type I and III skin collagen is thought to decrease by as much as 30% in the first five years after menopause.

18. Africans from the African continent show delayed signs of aging compared to Caucasians. Darker skin types are better protected regarding sun exposure due to the higher melanin content in their skin.

19. The skin parameters of hydration, trans-epidermal water loss, sebum, microcirculation, pigmentation, and thickness are generally higher in men but skin pH is higher in women.

20. There is no proven effective product that completely eliminates the symptoms of skin photoaging, but there are products and treatments that can visibly reduce or slow down these symptoms.

Abbreviations: Luteinizing Hormone (LH); Follicle Stimulating Hormone (FSH); Adrenocorticotropic Hormone (ACTH); Growth Hormone (GH); Transforming Growth Factor Beta (TGF-β); Matrix Metalloproteinases (MMPs); activator protein-1 (AP- 1); Glycolsaminoglycan (GAG); Reactive Oxygen Species (ROS); 4-Hydroxy-2-Nonenal (HNE); Particulate Matter (PM2.5); Transepidermal Water Loss (TEWL); Glycation End Products (AGEs); National Health and Nutrition Examination Surveys (NHANES); Dutch Healthy Diet Index (DHDI); Principal Component Analysis (PCA); Carboxymethyl Lysine (CML); dermal White Adipose Tissue (dWAT); Peroxisome Proliferator-Activated Receptor γ (PPARγ); Hypothalamic-Pituitary-Adrenal (HPA) Glucocorticoid Receptors (GRs); Nuclear Receptor Subfamily 3 Group C Member 1 (NR3C1); Pulsed Electromagnetic Fields (PEMFs); Multipolar Magnetic Pulse (MP)2; Sun Protection Factor (SPF); Epidermal Growth Factor (EGF); Cytoplasmic Transduction Peptide (CTP); Ferric- Reducing Activity Of Plasma (FRAP); Sodium-Dependent Vitamin C Transporters (SVCTs); Matrix Metalloproteinase-1 (MMP-1); Epithelial/Epidermal Growth Factor (EGF); Insulin-Like Growth Factor (IGF-1); Nuclear factor erythroid 2-related factor (Nrf2); Collagen type I a 1 (Col1A1); basic Fibroblast Growth factor (bFGF).

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Citation: Mohiuddin AK. Skin Aging and Modern Age Anti-Aging Strategies. Austin J Womens Health. 2019; 6(1): 1034.

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