There is a demand for compounded pharmaceuticals in dermatology because they can offer medications for patients that are not commercially available. Dermatologists’ skincare products or cosmeceuticals can be cleansers, toners, moisturizers, serums, and masques that hold active ingredients such as retinoids, alpha-hydroxy acids, polyhydroxy acids, skin lightening, antiacne, growth factors, peptides, and vitamins. Medically based skincare products target three cellular components that contribute to aged skin: keratinocytes, melanocytes, and fibroblasts. Instituting the correct routine will slow the progression of aging and work towards reversing the extrinsic and intrinsic aging changes. In aesthetic practice, using cosmeceuticals in combination with cosmetic procedures is a new treatment ideal for skin rejuvenation. Pre-treatment with cosmeceuticals can prime the skin for procedures, and post-treatment can reduce complications.

Favorite topical agents that can address the signs of hand photoaging include tretinoin, a-hydroxy acid, vitamin C, other antioxidants, a-lipoic acid, pentapeptide, and cutaneous growth factors. Retinoids by reducing the rate of melanin transfer can correct pigmentary abnormalities and stimulate collagen production in the dermis.

Actinic Keratosis is a frequent epidermal change seen on the dorsal surface of the hands. It is typical to appear red scaly patches that may bleed or peel. Multiple treatment options include topical agents such as 5-fluorouracil or imiquimod. The best treatment approach begins in the office with a program that attends to all the significant issues in the epidermis and dermis and continues with an at-home regimen to keep up and expand these results. The use of sunscreen when they are outdoors is paramount. In addition, the daily use of an antioxidant (such as a cream or serum having vitamin C or green tea extract) and the nightly use of a low-strength retinoid along with a ceramide-containing moisturizer will keep the quality of the epidermis while continuing the stimulation of collagen synthesis begun in the office with through laser treatments and/or fat.

Electroporation or (no-needle mesotherapy) device seeks to do the same as injection mesotherapy such as skin rejuvenation, and whitening. It uses a pulsed low-frequency current, whose intensity is adjusted by the operator. It delivers a particular waveform that ionizes the molecules in the active ingredients used in the treatment and creates tiny channels in the skin for the elements to travel down. Ingredients in water-soluble molecules permeate the skin’s natural lipid barrier and then cascade through the tissue beneath via minute channels to penetrate the surface up to 9 -10cms and introduce 90% of the active ingredients being administered. This pain-free option is said to offer a practical mesotherapy alternative for needle-phobic.

Before the peel, Prof. Moawad prescribes MSI skincare production such as bleaching agents, tretinoin, sunblock, and moisturizer at least 4-6 weeks before chemical peel of the hands especially those patients with pigmentation or dark skin.

Chemical peeling is often used to treat sunspots, age spots, and the dull texture of hand skin. Generally, fair-skinned, and light-haired patients are ideal candidates for chemical peels. Darker skin types may also experience good results depending upon the type of skin problem encountered.

The skin is thoroughly cleansed with an agent that removes excess oils at the treatment time. A chemical solution is applied to the skin that causes it to “blister” and eventually peel off. Prof. Moawad may recommend a superficial or medium chemical peel to hand. He favors the medium-depth peel, the combination peel, and repeated lighter peeling regimens. He will select the proper mix of chemicals such as glycolic acid, salicylic acid, lactic acid, TCA, PCA, Phytic acid, or Jessner’s solution. Prof Moawad will individualize the strength of these chemical agents to match your skin type and degree of sun damage offering his patients more than ten programs.

Most patients experience a warm to the somewhat hot sensation that lasts about five to 10 minutes, followed by a stinging sensation. A deeper peel may need pain medication during or after the procedure.

Depending upon the type of peel, a reaction like a sunburn occurs following a chemical peel. Superficial peeling usually involves redness, followed by scaling that ends within three to seven days. Medium-depth and deep peeling may result in swelling and the presence of water blisters that may break, crust, turn brown and peel off over seven to 14 days.

Following any skin peel, you must avoid any exposure to the sun. Your new skin is susceptible to injury. Prof. Moawad will prescribe a good home skincare treatment program that includes cleansers, moisturizers, and sunscreens with or without anti-aging or bleaching agents to make sure adequate healing and keep up the result of your peel.

Following a chemical peel, your new hand skin will be tighter, smoother, and maybe slightly lighter than it was before surgery. The results of chemical peels may also be enhanced by new laser/light-based rejuvenation techniques

Lentigines, or brown age spots, are the most common skin alteration. I can treat it with specific lasers whose melanin. I can use a broad spectrum of wavelengths because melanin has a range of absorbance. The most common device is the frequency-doubled Q-switched Nd: YAG (532 nm). A single-pass may be performed, and the pulses stacked over flat SK. The spot size must be small enough to treat only the desired area regardless of the specific device used in all laser treatments.

Treatment with fractionated devices is a more aggressive approach to rejuvenating the epidermis—one that could more significantly improve the skin’s overall texture. Using fractionated technology to selectively wound small columns of skin, enabling the skin to heal from side to side, can eliminate lentigines. In addition to removing the age spots, fractional CO2 laser y has the benefit of improving the overall quality and texture of the hand skin.

Fractional radiofrequency (FRF) deliver energy creates zones of affected skin adjacent to unaffected areas. The treated areas result in thermal damage in the deep dermal collagen, stimulating wound healing, dermal remodeling, and new collagen, elastin, and hyaluronic acid formation. The unaffected areas serve as a reservoir of cells that promote and accelerate wound healing. FRF improves wrinkles and skin laxity reduction. The most common sequence effects are erythema and edema, which are transient (few days). You may use a topical anesthetic cream before the treatment to minimize pain. In a new approach, Prof Moawad offers his patients FRF to make tiny holes into the skin to overcome the stratum corneum to enhance PRP and /or nanofat. The results are doubles, and you will enjoy both the rejuvenating effect of the FRF resurfacing system and the regenerative effect of growth factors and stem cells present in PRP and/or nanofat.

Monopolar radiofrequency is a minimally invasive procedure to tighten and lift the skin, giving natural results with minimal risk and recovery time. Monopolar radiofrequency deliver a high-frequency electric current—tissue resistance to electrical current, resulting in volumetric heating to the deep dermis and underlying tissue. The resulting heat leads to immediate collagen contraction and a delayed wound healing response, with new collagen formation up to 4 to 6-month post-treatment. Although the results of RF are not as dramatic as surgery, over 90% of patients obtain noticeable tightening of the treated areas.  Radiofrequency is a very versatile procedure that can be used on any area of the body – including the hands.

The basis of microneedling (MN) relies on physical injury. It has been proposed that the trauma generated by needle penetration in the skin induces dermis regeneration. This results in the deposition of collagen by fibroblasts. The technique of microneedling has been well-exploited to increase the penetration of drugs across the skin barrier, including macromolecular biopharmaceuticals and drugs such as minoxidil, tretinoin, and L-ascorbic acid, vitamins, and hyaluronic acid (Mesolift), platelets rich plasma (PRP), and nanofat (vampire facelift) and even botulinum toxin microinjection (mesobotox) into the deep layer of skin and subcutaneous tissue. Microinjections and microneedling are successful in skin rejuvenation.

In today’s active, outdoor lifestyle, it is not just time aging us anymore. Sun exposure damages the skin, breaking down cells, hardening lines, and leaving age spots and blemishes every day. Coupled with dehydration, stress anxiety, and exposure to smoke and pollution, it is no surprise that people are looking for ways to make their skin look younger and more revitalized. The Mesolift is a Mesotherapy approach to treat aging, sun-damaged, and wrinkling of the skin involving hands. This minimally invasive treatment delivers vitamins, minerals, and amino acids directly into the skin to nourish and rejuvenate, promote the production of collagen and elastin, and stimulate your metabolism.

The platelet-rich plasma (PRP) has been applied in androgenic alopecia in both males and females successfully. Although platelets rich plasma (PRP) microinjection is new in aesthetics, Platelets have essential growth factors that, when secreted, handle tissue regeneration and rejuvenation, increase collagen production, recruit other cells to the site of injury, induce cell differentiation and extracellular matrix formation. It has an anti-inflammatory effect that will speed up healing time and ease recovery time after the CO2 laser hand resurfacing procedure. With PRP therapy, we stimulate long-term collagen growth, eliminating skin wrinkles, and rejuvenating the hand skin.

Newly prominent age- and UV-related veins, tendons, and bones can be addressed through re-volumization. We can reduce tissue laxity, wrinkles, prominent blood vessels, and bony prominences by plumping the hands. I can safely use several acceptable fillers and a collagen stimulant in the hands. Volume loss in the hands is addressed with a filler such as fat, hyaluronic acid products, or calcium hydroxylapatite (Radiesse). The injection of these materials is straightforward. First, the skin is tented between the fingers of the noninjecting hand. The hyaluronic or Radiesse is then injected in a bolus fashion, avoiding injecting into a vein or a tendon. The bolus is then gently massaged medially toward the wrist until it is flat. The next injection can occur at the next metacarpal space until the entire syringe is emptied. Fillers are not used in all patients because of the high cost, the necessity of repeat injections, and the possibility of an allergic reaction.

The results of hand rejuvenation by structural fat grafting are more prolonged than those of other rejuvenation methods, perhaps because of a stenting effect of the metacarpals that occurs with new blood vessels formation. A single fat transfer can produce a fuller and more youthful hand can lower the appearance of enlarged veins, and can improve the aesthetic of the skin and fingers without creating unintended side effects. Because fat serves as a filler and has the regenerative potential to improve the quality of soft tissue and skin on the dorsal side of the hands, Prof. Moawad prefers fat grafting to dermal filler, and he thinks it is more cost-effective.

• Fat extraction may be performed under conscious sedation or without if the patient wants to be awake. Local anesthesia was achieved with tumescent anesthesia at the donor site with nerve blocks at the receiving sites
• Fat is harvested from any area below the umbilicus to the knees by a blunt cannula attached to a 10 mL syringe. I selected the blunt cannula to cut the risk of injury to the small vessels.
• Harvested fat then centrifuged, cleansed, and transferred to 1 mL syringes connected to the cannula for injection into the receiving site.
• For each patient, six surgical accesses were made through a 16-gauge needle. The first access was positioned at the center of the wrist, such that the incision could be concealed by wearing a wristwatch after surgery. This access provided easy entry to the entire dorsum. Five added accesses were made in the interphalangeal folds, enabling fat transfer to the radial and ulnar aspects of the fingers to the most distal phalanx. These accesses also allowed full coverage of the dorsum, thereby simplifying retrograde and intertwined fat grafting over the dorsal surface of the hand.
• All patients underwent fat grafting in the superficial fatty layer of the hand, which was accessed by inserting the injection cannula at once below the skin and above the tendons and dorsal veins. The grafting technique consisted of tunneling and linear retrograde threading. I made several tunnels to maximize contact between the grafted fat and the receiving site to encourage nutrition, respiration, stability, integration, and uniformity of the fat graft.
• Approximately 15 mL (range, 10–20 mL) of centrifugal fat was injected into the dorsum of each hand, and each aspect (radial and ulnar) of the hand received 0.5 mL of fat. I took care to fill the dorsum, the intercarpal spaces, and the radial and ulnar aspects of the fingers to the distal phalanx of each finger. Immediately after fat grafting, the hands appeared just slightly overfilled.
• The surgical accesses were taped closed, and the massage was performed to adjust any irregularities in fat placement and do proper distribution and filling. The procedure lasted an average of 20 minutes per hand (range, 10–30 minutes per hand). All patients received a single dose of antibiotics during the procedure.
• Patients were instructed to elevate their hands for two days post-operative and avoid manual activity for one week. I will; inform patients that considerable edema and a bluish tint might be observable in the hands for 3 to 4 days post-operative. I will place a conveniently shaped Reston foam pad over the back of each hand to protect the area without restricting mobility. This dressing has been shown to cut waviness in the skin surface, improve comfort during recovery, and reduce blood loss and bruises. The dressing was removed ten days post-operative

Vein removal is often unnecessary after volume restoration, making before prominent veins invisible. However, if bulging or prominent veins stay a cosmetic problem, they can be treated with sclerotherapy or surgical or laser removal. Sclerosing agents such as polidocanol are preferred used in MSI.

Conclusion

A multi-modal approach to hand rejuvenation must be applied with caution. Everyone must be evaluated for the type of system (or sequence of processes) that would benefit them most. For example, if a course is chosen that includes a light alpha-hydroxy peel followed by an IPL treatment. Then volume restoration is contemplated. I should examine the patient at each step to ensure that healing is adequate and that the desired results have been achieved before proceeding further. A combination approach involves a higher risk of complications and a higher possibility of optimal outcomes. In summary, the combination of a superficial peel, laser treatment, and volume restoration combined with (and only when combined with) a well-planned at-home care program can result in beautiful, youthful appearing hands, regardless of patients’ age.

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