target the dermis and induce neocollagenesis, minimizing rhytides.7-9 The disadvantage of IR laser for nonablative skin rejuvenation has been that it induces ...
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FOCUS-ON: SCALING
A QUANTITATIVE AND COMPREHENSIVE GRADING SCALE FOR RHYTIDES, LAXITY, AND PHOTOAGING Macrene Alexiades-Armenakas MD PhD Assistant Clinical Professor, Yale University of Medicine, New Haven, CT; Private Practice, Dermatology and Laser Surgery, New York, NY
Prior Global Classification Schemes In the past, grading scales were devised to assess clinical outcomes from ablative technologies, grouping the various aspects of skin aging into broad but useful classification schemes. The most widely used include the Glogau and Fitzpatrick wrinkle assessment scales.1,2 These well-accepted grading scales were primarily developed and used in evaluating ablative technologies, such as chemical peeling or carbon dioxide laser resurfacing, which result in global improvement in all aspects of skin aging.1,2 On the other hand, these scales were not intended to individually or independently assess each of the diverse aspects of the aging skin, but rather to group findings together into stages of progression. Since those scales were devised a decade ago, nonablative technologies have emerged and rapidly evolved in an effort to minimize risk and speed recovery in the face of acceptable cosmetic improvement. Nonablative laser resurfacing technologies typically target specific aspects of skin aging but not all, making broad groupings of clinical findings less useful in assessing their efficacy. In addition, patients seeking nonablative treatments often do not fall neatly into any one global category, displaying certain aspects of skin aging but not others. By not separating the various facets of skin aging from each other, but rather placing them into broad groups, the Glogau and Fitzpatrick schemes are less easily applied to assessing efficacy of nonablative modalities.1,2 Thus, a comprehensive grading scale is needed that individually grades the multiple, distinct categories of skin aging, allowing for quantitative assessment of nonablative and other modalities that target individual aspects of the aging skin.
Categories of Skin Aging Aging of the skin may be classified into 2 main types, intrinsic aging and aging due to environmental factors.4 Intrinsic aging is attributable to genetic factors and telomere shortening. Telomeres, the terminal sequences on chromosomes, shorten with each successive cell cycle until the critical length is reached and cycle arrest or apoptosis occurs.5 Intrinsic aging is characterized by laxity and deep rhytides.4,6 Aging due to environmental damage is predominantly caused by ultraviolet (UV) damage. UV exposure induces DNA mutations, reactive oxygen species, melanogenesis, inflammatory cytokines, angiogenesis, immunosuppression, and extracellular matrix degradation.4 This type of skin aging is termed “photoaging” or “photodamage” and is characterized by dyschromia, elastosis, fine rhytides, erythema, telangiectasia, textural changes, and keratoses.3,5 Thus, skin aging is multifaceted, has multiple etiologies, and consists of multiple categories, each manifested by distinct clinical findings, which occur independently from each other depending upon the etiology. Nonablative Therapeutic Categories Nonablative systems may be classified into 3 main groups––IR lasers, IPL, and RF devices––each of which target certain categories of skin aging, but not all. Among the IR wavelengths (720-1,000,000 nm), the near IR lasers (1320, 1450, and 1540 nm) have largely been employed. These lasers target the dermis and induce neocollagenesis, minimizing rhytides.7-9 The disadvantage of IR laser for nonablative skin rejuvenation has been that it induces only dermal changes and is of limited benefit for patients with photoaging who have both epidermal and dermal changes. IPL (500-1200 nm) primarily targets pigment and vascular structures, improving dyschromia and erythema-telangiectasia, while inducing minimal improvement in rhytides.5 RF devices generate electrical energy that delivers a uniform volumetric heating effect into the deep dermis, generated by the tissue’s resistance to the current flow, which induces collagen contracture and primarily improves laxity.10 Thus, different classes of nonablative technologies have emerged typically targeting subcategories of skin aging. A grading system assessing these individual categories of skin aging is thus necessary to accurately evaluate the efficacies of nonablative modalities.
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Current Comprehensive Grading Scale A comprehensive grading scale is presented here which separates the individual categories of skin aging and allows for quantitative analysis of changes within each category as well as overall (see page 733, Table 1).3 This grading scale may be used to assess the efficacy of nonablative or other laser resurfacing technologies and cosmetic treatment modalities for their clinical impact on each individual aspect of the aging skin, providing a more quantitative analysis of each category, as well as overall improvements. The grading scale was tested in a study of a nonablative combination devices incorporating the 3 main classes of nonablative rejuvenation.3 In the Quantitative Analysis of Grading accompanying study, a combination of the 3 main The quantitative analysis of each category of skin aging as nonablative modalities, radiofrequency (RF), infrared (IR) well as overall scores are presented here and employed in the laser and intense pulsed light (IPL), is assessed in a series of accompanying study.3 For each patient, the pre- and post28 patients for the treatment of rhytides, laxity, and treatment scores for each category are recorded, as are treatphotoaging using this comprehensive grading scale. The ment number and final date of follow-up. Pretreatment scores quantitative effects of the combination system on each indiare recorded at baseline on the date of the first treatment. vidual aspect of aging of the skin, rhytides, laxity, and the Posttreatment scores are recorded the date of final follow-up. multiple parameters of photoaging, overall improvement, and Patient mean % improvements may be calculated using the 2006-Journal of Drugs in Dermatology (JDD). All Rights Reserved. patient satisfaction are reported.3 This© document following formulae each of the categories of skin aging, contains proprietary information, images and marksfor of JDD. No reproduction or use of any portion of the contents of these materials may be made without the express written consent of JDD. If you believe you have obtained this copy illegally, please contact JDD immediately.
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JOURNAL OF DRUGS IN DERMATOLOGY SEPTEMBER 2006 • VOLUME 5 • ISSUE 8
including rhytides, laxity, elastosis, dyschromia, erythematelangiectasia, keratoses and texture.
Improvement per Patient Score difference = posttreatment score – pretreatment score. Patient % improvement = score difference/pretreatment score. Patient % improvement per treatment = patient % improvement/treatment number.
Improvement per Category
Patient mean % improvement per individual category = Mean (Patient % improvements). This is calculated separately for each category. Patient mean % improvement per individual category per treatment = Mean (Patient % improvements per treatment). Patient mean % improvement per category overall = Mean (Patient mean % improvements per individual category). The patient mean % improvement per category overall per treatment = Mean (Patient mean % improvement per category per treatment).
Improvement Overall Mean % improvement overall = mean (patient % improvement) for each category. Mean % improvement overall per treatment = mean (patient % improvement per treatment). Overall mean % improvement = mean (means % improvement overall). Overall mean % improvement per treatment = mean (means % improvement overall per treatment).
FOCUS-ON: SCALING
of photoaging, including dyschromia, elastosis, erythematelangiectasia, texture, and keratoses, as well as patient satisfaction, is a necessary tool for evaluating nonablative and other cosmetic modalities. The application of the current comprehensive grading scale to the assessment of nonablative technologies is illustrated in the accompanying study.3 For example, a patient with advanced skin laxity but lacking advanced rhytides or other findings of photoaging would not fit into a Glogau or Fitzpatrick category aptly, but may be assessed for this category independently. Conversely, patients with significant findings in all categories of aging may also be comprehensively evaluated such that the differences in efficacies of treatment on each individual category may be assessed (Figures 4 and 5, pages 736). The quantitative analyses of these changes demonstrate that the percent improvements in each category may be calculated. The accompanying study demonstrates that a scale of the type developed herein is needed in order to accurately assess the individual and independent categories of skin aging that are variously affected by nonablative laser resurfacing. This scale permits the quantitative analysis of the individual categories of skin aging, as well as of overall improvement, thereby making it facile and applicable in the efficacy assessments of a wide range of current cosmetic therapeutic modalities.
References
1. Glogau RG. Aesthetic and anatomic analysis of the aging skin. Semin Cutan Med Surg. 1996;15(3):134-8. 2. Fitzpatrick RE, Goldman MP, Satur NM, Tope WD. Pulsed carbon dioxide laser resurfacing of photo-aged facial skin. Arch Dermatol. 1996;132(4):395-402. 3. Alexiades-Armenakas MR. Rhytides, laxity and photoaging treated with a combination of radiofrequency, diode laser, and pulsed light and assessed with a comprehensive grading scale. J Drugs Dermatol. 2006;5:731-738.
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Patient Satisfaction Patients answer on a yes/no scale as to overall satisfaction.
% Patient Satisfaction = Number of patients answering Yes/Number of patients answering No x 100.
The above formulae provide the quantitative degree of improvement in each category as well as overall, and serve to control for interpatient variability in response to a given treatment.
4. Rabe JH, Mamelak AJ, McElgunn PJS, Morison WL, Sauder DN. Photoaging: mechanisms and repair. J Amer Acad Dermatol. 2006; 55(1):1-19. 5. Vaziri H, Benchimol S. From telomere loss to p53 induction and activation of a DNA-damage pathway at senescence: the telomere loss/DNA-damage model of cell aging. Exp Gerontol. 1996; 31:295-301. 6. Lavker RM. Cutaneous aging: chronologic versus photoaging. In: Gilchrest BA, Ed. Photodamage. Cambridge: Blackwell Science: 1995;123-35.
Discussion 7. Bitter P, Campbell CA, Goldman M. Nonablative skin rejuvenation The grading scale presented here enables the assessment of using intense pulsed light. Lasers Surg Med. 2000;12;16. efficacy of nonablative as well as other technologies in the 8. Goldberg DJ. Non-ablative subsurface remodeling: clinical and multiple distinct and individual categories of skin aging, histologic evaluation of a 1320 nm Nd:YAG laser. J Cutan Laser including rhytides, laxity, and the multiple aspects of phoSurg. 1999;1:153-7. toaging. Prior wrinkle assessment scales in common use, 9. Ross EV, Sajben FP, Hsia J, et al. Nonablative skin remodeling: including those of Glogau and Fitzpatrick, were designed priselective dermal heating with a mid-infrared laser and contact marily to evaluate ablative technologies, which result in globcooling combination. Lasers Surg Med. 2000;26:186-195. al improvements in all categories of aging.1,2 These prior 10. Kelly KM, Nelson JS, Lask GP, et al. Cryogen spray cooling with scales, while widely used and easily applicable to ablative nonablative laser treatment of facial rhytides. Arch Dermatol. technologies and chemical peeling, do not allow for the indi1999;135:691-4. vidual and independent measurement of each aspect of aging 11. Alexiades-Armenakas MR. Laser skin tightening: non-surgical needed for the evaluation of current nonablative modalities, alternative to the face-lift. J Drugs Dermatol. 2006;5:295-6. which typically target subsets of categories, but not all. A grading scale individually assessing© each category of skin 2006-Journal of Drugs in Dermatology (JDD). All Rights Reserved. aging, including rhytides, laxity, and multiple parameters Thisthe document contains proprietary information, images and marks of JDD. No reproduction or use of any portion of the contents of these materials may be made without the express written consent of JDD. If you believe you have obtained this copy illegally, please contact JDD immediately.
