Aging remains an enigma and the visible modifications that slowly appear in aging skin are provided by a gradual reduction in the size and number of cells and a decrease in the rate of many organic functions. Skin aging is the result of a programmed multistep, time-dependent continuous phenomenon at the cellular and molecular level.1,2 Little attention has been given to the issue of appearance in the elderly until recently. Skin functions that decline with age are cell replacement, injury response, barrier function, chemical clearance, sensory perception, immune and vascular responsiveness, thermoregulation, sweat production, sebum production, and vitamin D production.3 Successful aging is characterized by good mental health, adaptative psychosocial functioning, and life satisfaction.4 In the United States in 1998, the older population (65 years or older) represented 12.7% of the total: approximately one in every eight Americans. Since 1900, the percentage of Americans older than 65 years of age has more than tripled (4.1% in 1900 to 12.7% in 1998), and the number has increased eleven times (from 3.1 million to 34.4 million). By 2030, the estimate is that there will be approximately 70 million senior citizens, more than twice the number in 1998. People over 65 years of age are expected to represent 13% of the population in the year 2000 but will be 20% by 2030. The 40 million “baby boomers” born in the United States between 1946 and 1963 are approaching that stage of life in which, unfortunately, youthful good looks are becoming more of a memory than a reality. They obviously cannot remain forever young, but cosmetic innovations through scientific research are progressing very rapidly. Patients are able to significantly delay the visible aging process by practicing preventive skin care and taking advantage of the many chemical treatments available for facial rejuvenation.5 Cutaneous aging provides a visible model of the interaction between endogenous and exogenous (UV light) factors. Recently, much interest has been directed toward defining the aging processes in the skin, aiming to highlight areas such as environmental changes and their influence in skin aging and carcinogenesis.6,7 Clinically detectable, age-associated cutaneous changes result from two independent processes: chronologic aging and actinic irradiation (Fig 1). Several lines of evidence suggest that these two processes have different biologic, biochemical, and molecular mechanisms.8 Understanding these events at all these levels has unfortunately not been paralleled by clinical and therapeutic advances about common, troublesome skin problems of old age, such as cancer, xerosis, and pruritus. These conditions remain major causes of morbidity and are yet poorly explained.6,7 The main skin functions include protection, excretion, secretion, absorption, thermoregulation, pigmentogenesis, accumulation, sensory perception, and regulation of immunological processes; all of these functions are altered with the passing of time. Physiological changes include impairment of the barrier function, decreased turnover of epidermal cells, reduced numbers of keratinocytes and fibroblasts, and a reduced vascular network particularly around hair bulbs and glands, leading to fibrosis and atrophy, decrease of hair and nail growth, retardation in vitamin D synthesis, decline of Langerhans’ cells density, and impairment of the immune response.9–12 There is also a decrease in the function of Meissner’s and Pacinian corpuscles. Increased production of free radicals is observed and cutaneous permeability to chemical substances also changes, while water-binding capacity of the stratum corneum is reduced.8,13–15 Epidermal changes associated with aging involve the flattening of its underside, a reduction in the number of Langerhans’ cells and of melanocytes, and a decline in the number of synthesized melanosomes, leading to reduced pigmentation. Dermal changes are represented by a reduction in collagen and elastic fibers, fibroblasts, mast cells and macrophages, and dilation of the lymphatic channels. The most affected cells in the senescence process are keratinocytes and fibroblasts. The dermal–epidermal junction is flattened and the number of hair follicles decrease with age, although their structure remains unchanged.10,11,16–20 Colorimetric measurements show that elderly skin is darker than young skin even in areas not exposed to the sun. Epidermal atrophy and increased transparency From the Sector of Dermatology, HUCFF-UFRJ and School of Medicine, Universidade Federal do Rio de Janeiro, (MRS and SCSC) and the HUPEUERJ and Sector of Dermatology, School of Medicine, Universidade do Estado do Rio de Janeiro, (SCSC) Rio de Janeiro, Brazil. Address correspondence to Marcia Ramos-e-Silva, MD, Rua Sorocaba 464/205, 22271-110-Rio de Janeiro, Brazil. E-mail address: ramos.e.silva@dermato.med.br.
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