Photoaging

Over the past few decades, there has been an increase in sun exposure through increased leisure time and outdoor activities. Years of people trying to acquire the ‘healthy tan’ have produced high rates of prematurely aged skin. Cumulative sun exposure is the greatest factor in aging skin, and is responsible for a large portion of the unwanted esthetic effects, including many of the wrinkles which may be treated with filler substances. Glogau has developed a systematic classification of patient photoaging types. Depending upon the degree of sun exposure, these generalizations apply at different ages and to different degrees in patients with more pigmented skin.

Glogau type I patients have early photoaging changes, and are usually in their 20s or 30s. These patients generally have no rhytides at all, even when the face is animated during speaking or expression. Early photoaging, if present, may include mild pigmentary changes causing a disruption in the homogeneity of skin color. These patients generally wear no make-up foundation at all, as they do not require it for either rhytides or pigmentary alterations.

Glogau type II patients are usually in their late 30s or 40s. These patients have early to moderate photoaging changes, and chronic ultraviolet damage to the elastic fibers impairs the inherent ’snap back’ quality of the skin. These patients are without wrinkles while the face is at rest, but wrinkles begin to appear as expression lines when the face is in motion, appearing parallel to the melolabial fold, corners of the mouth, lateral canthal areas, and over the zygomatic arch and malar eminences. Early solar lentigines begin to appear and patients frequently utilize make-up foundation to conceal the pigmentary irregularities. As these patients only have wrinkles while the face is in motion, they most aptly demonstrate the effects of the underlying musculature on the skin, a critical consideration when contemplating the use of botulinum toxin.

Patients classified as Glogau type III have advance photoaging changes, and are typically in their 50s or olde Damage to the cutaneous elastic fibers becomes moi severe, and the wrinkles produced by facial movement eventually persist even at rest. These may present as wrinkles radiating outwards from the lateral canthi, inferiorly from the lower eyelids onto the malar cheeks, parallel to the oral commissures, and outward from the upper and lower lips. Advanced photoaging results in obvious pigmentary dyschromias, telangiectasias, and visible keratoses. Patients commonly wear heavy make-up foundation to conceal these changes.

Glogau type IV patients have severe photoaging changes and are usually in their 60s or 70s, but may be younger in the most severe cases. Wrinkles gradually spread to cover the majority of facial skin, and these patients may not have any unlined skin remaining on their faces. The dermis becomes engorged with thick debris, rendering a thickened, coarse quality to the skin. Pigmentary dyschromias are present as a yellow-gray sallow color of the skin, and patients have often had prior cutaneous malignancies. Glogau type IV patients are not able to wear makeup, as the uneven facial surface often causes the make-up to have the texture of ‘cracked mud.’