Development of skin aging scale by using dermoscopy

Skin Research and Technology 2013; 19: 69–74 Printed in Singapore
All rights reserved doi: 10.1111/srt.12033 © 2013 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd Skin Research and Technology Development of skin aging scale by using dermoscopy Burcu Isik1, Mehmet S. Gurel2, Asli T. Erdemir2 and Ozgu Kesmezacar3 2 1 Dermatology Department, Ordu University Research and Education Hospital, Ordu, Turkey, Dermatology Department, Istanbul Research and Education Hospital, Istanbul, Turkey and 3Public Health Department, Istanbul Research and Education Hospital, Istanbul, Turkey Background: Some features of skin aging that cannot be detected by the naked eye can be determined more easily by dermoscopy. Therefore, we aimed to measure skin aging with dermoscopy. Methods: The study was performed in Istanbul Training and Research Hospital, a tertiary care referral center. A total of 441 participants between the ages of 20–88 (mean 48.4  17.7) were separated into six groups according to their age. All participant’s facial sun-exposed areas were examined by dermoscopy in terms of telangiectasia, vascular changes, pigmentation changes, seborrheic keratosis, actinic keratosis, periorbital comedones and cysts, superficial- deep- criss-cross wrinkles as the signs of photoaging and scored with the help of dermoscopic photoaging scale (DPAS). The validity of the scale was assessed with DPAS by the evaluation of both the axillar and the gluteal regions, that were not sun exposed and photoaged, with DPAS. Results: The scale was found to be highly reliable as Cronbach’s a coefficient was 0.756. Skin aging of patients from every decade was compared clinically with Glogou photoaging scale and Monheit-Fulton photoaging index and significant correlation was calculated as 0.773 and 0.774, respectively. An increase in photoaging scores from young people toward elders according to their ages was observed and the same linear difference between their mean values was detected. Conclusion: DPAS is a reliable and valid diagnostic tool that can evaluate photoaged skin quantitatively by the help of objective criteria so can be used to evaluate the effect of preventive and therapeutic applications for skin aging. the main organ in which age-related changes are visible (1, 2). Skin aging is a complex process that composed of chronologic (intrinsic) aging associated with people’s genetics and extrinsic aging associated with ultraviolet (UV), alcohol, smoking, malnutrition, and adverse environmental conditions (2, 3). Dermoscopy is a simple, non-invasive, reproducible diagnostic tool that provides visibility of the morphological features that cannot be seen with the naked eye (4). Also some features of skin aging can be detected easily with dermoscopy (5–7). Measurement of skin aging with dermoscopy will give more reliable and objective results than the scales using clinical criteria. Prevention and treatment of skin aging can be measured with the dermoscopic photoaging scale (DPAS) and efficacy of many therapeutic application can be investigated. Materials and Methods S KIN IS Key words: skin measurement – skin aging – photoaging – dermoscopy – scale Ó 2013 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd Accepted for publication 10 November 2012 Devolopment stages of dermoscopic photoaging scale As a first step, clinical findings of 40 photoaged skin were examined for preliminary study. Mean age of the volunteers was 53.2 and they were 15 men and 25 women. Preliminary DPAS consisting of 12 criteria was developed with previous clinical photoaging scale criteria and our clinical findings from those 40 volunteers (Table 1). Study group In the second step, according to the power analyze results; minimally 65 healthy people from each decade were enrolled in the study without distinguishing gender and skin phototype. Volunteers above the age of 20 were separated into six groups according to their ages (20–29, 30–39, 69 Isik et al. TABLE 1. DPAS criteria DPAS evaluation criteria Clinic description (3, 8, 10, 16–19) Dermoscopic description (4, 20, 21) Yellowish discoloration (solar elastosis) and yellow papules White linear areas of scarring (skin atrophy) Ephelides/lentigo Abnormal, yellowish, nonfunctional elastotic material accumulation in the upper dermis, coarsening of the skin Irregular healing of easily torn, fragile skin More pronounced yellow pigmentation and yellow dots seen with dermoscopy than the naked eye assessment White, clear, irregular extensions Well-circumscribed, brown macules and patches Persistent pigmentation in the form of mottled hypo-hyperpigmentation Light-brown, intertwined, tight, pigment network Hypopigmented -hyperpigmented macules Telangiectases Actinic keratosis Senile comedones Ectatic vessels with atrophic walls Cutaneous neoplasms by the proliferation of keratinocytes with atypical cytology Deep wrinkles Periorbital, localized, non-inflamed, open and closed comedones Wrinkles not improved by stretching Superficial wrinkles Fine wrinkles improved by stretching Criss-cross wrinkles Deep, crossing lines 40–49, 50–59, 60–69, and above 70). People who had done face lift, botulinum toxin or filler injection, chemical peelings, and other facial rejuvenation applications in the last 12 months and had received systemic or topical retinoid therapy in the last 6 months were excluded. All participant’s sun-exposed facial regions were evaluated in terms of yellowish discoloration, diffuse erythema, white line, telengiectasia-vascular changes, pigmentary changes, actinic keratoses, senile comedones-cysts, and superficial- deep- criss-cross lines by dermoscopy (Fig. 1). DPAS criteria were separately evaluated by scoring every facial region as left malar, right malar, forehead, and chin (Fig. 2). The evaluation was made by yes or no policy. For example, if the criterion was positive on one facial part and negative on the remaining three, that means the sum is 1 point for that criterion (Table 2). Also patients’ demographic information, Glogou Photoaging Scale and Monheit–Fulton photoaging index scores, sunscreen using, skin phototype, sunburn history, chronic sun exposure, and smoking habits were asked and recorded to the study form (8, 9). Volunteers were informed about the study and they signed ‘informed consent form’. Control group Validity of the scale was evaluated by comparing the sun-blind and nonphotoaged axillar and 70 Irregular pigmentation in the form of hypopigmented macules between hyperpigmented patches Red lines showing different configurations €donetwork, prominent follicular Perifollicular, red pso openings surrounded by a white halo, pigmented ostia, brown-gray dots and globules Follicle openings with brown-black keratin plug in the middle, on periorbital region More obvious deep wrinkles seen by dermoscopy than the naked eye assessment More pronounced superficial wrinkles seen by dermoscopy than the naked eye assessment More obvious criss-cross wrinkles seen by dermoscopy than the naked eye assessment gluteal regions with DPAS. The evaluation and scoring was made similarly. In this way, they were compared in terms of dermoscopic findings on their sun-exposed and nonsun-exposed areas. Parallel scales Glogou photoaging scale and Monheit–Fulton photoaging index were used (8, 9). Results Total of 441 white people whose ages were between 20 and 88 were included in the study (Table 3). Skin phototypes of the volunteers were ranging from I to IV. Dermoscopic photoaging score reliability study Two independent researchers used DPAS on first 50 people (mean age of 41.6, 18 men and 32 women) without distinguishing their ages. External reliability of the scale was tested (Pearson product-moment correlation analysis r = 0.918; P < 0.01). According to the 12 criteria-DPAS scores of 441 people, Cronbach’s a coefficient was calculated as 0.756. It was seen that if ‘diffuse erythema’ was removed from the DPAS, there would have been more compliance between other findings (Table 4). Therefore, ‘diffuse erythema’ was not included in the final DPAS. Dermoscopic skin aging measurement (a) (b) (c) (d) (e) (f) (g) (h) (j) (k) (l) (m) Fig. 1. Skin aging findings examined by dermoscopy, (a) aktinic keratosis, (b) lentigo, (c) diffuse erythema, (d) hypo-hyperpigmented macules, (e) yellowish discoloration, (f) yellow papules, (g) senile comedones, (h) white line, (j) telangiectases, (k) superficial wrinkles, (l) criss-cross wrinkles, (m) deep wrinkles. TABLE 2. Patient evaluation chart DPAS criteria Forehead Right cheek Left cheek Chin Yellowish discoloration White line Lentigo Hypo-hyperpigmented macules Telangiectases Yellowish papules Actinic keratosis Senile comedones Deep wrinkles Superficial wrinkles Criss-cross wrinkles TOTAL DPAS score Fig. 2. Facial separation diagram for dermoscopic examination. Validity study between sun-exposed and sun-blind regions The DPAS scores of sun-exposed and sun-blind four regions were examined for validity. On the sun blind sides, only yellowish discoloration, telengiectasia, and superficial wrinkles were able to be scored. The findings were significantly different between sun-exposed and sunblind areas (P < 0.001). There was a moderate positive correlation between DPAS- Glogau scales (r = 0.773, 71 Isik et al. TABLE 3. Distribution of Fitzpatrick skin type Age groups Fitz 1 Fitz 2 Fitz 3 Fitz 4 N % 20–29 30–39 40–49 50–59 60–69 >70 Total 4 4 2 0 4 10 24 41 24 24 32 41 36 198 35 45 41 39 25 23 208 4 4 1 1 1 0 11 84 77 68 72 71 69 441 19.0 17.5 15.4 16.3 16.1 15.7 100.0 P < 0.001) and DPAS- Monheit-Fulton scales (r = 0.774, P < 0.001), respectively. One way ANOVA for difference between decades A significant difference (P < 0.001) between the groups and increased photoaging scores from youngs to elders were obtained. Comparison of the skin phototype by DPAS As a result of variance analysis, there was not seen any significant difference between the DPAS scores of different skin types (P  0.05). total DPAS scores of sun-exposed areas were examined, it was seen that people having sunburn history had higher photoaging scores (P = 0.006). Chronic sun exposure A proportion of 67.8% of persons included in the study had a chronic sun exposure history. When the total DPAS scores of sun-exposed areas were examined, it was seen that people having chronic sun-exposure history had higher photoaging scores (P < 0.001). Smoking A total of 37.2% of the volunteers had a smoking history. It was seen that smoking had caused yellowish discoloration independent of sun exposure (P = 0.000 < 0.05) and also had increased senile comedones (P = 0.045 < 0.05) and telengiectasia scores (P = 0.006 < 0.05) on sun-exposed skin. Discussion Using sunscreen Of 441 people, 9.8% expressed that they had been using sunscreens. When the total DPAS scores of sun-exposed areas were examined, it was seen that people using sunscreens had less photoaging scores (P < 0.001). Sunburn history A proportion of 39.2% of persons included in the study had a history of sunburn. When the Skin aging is a complex biological phenomenon concerning different components of the tegumentary system. Independent clinic and biological processes cause aging by affecting the skin simultaneously (10). Intrinsic aging occurs through time-dependent, slow, inevitable, and irreversible tissue damage. Extrinsic aging is a premature aging caused by preventable factors such as UV, chemicals, and smoking. Ultraviolet exposure is the main environmental factor for extrinsic aging and mostly affects fair-skinned TABLE 4. Cronbach’s alpha coefficients for internal DPAS integrity Findings of the survey Mean of the scale after the excluded finding Variance after the excluded finding Corrected total correlation Cronbach’s alpha after the excluded finding Yellowish discoloration Diffuse erythema White linear areas of scarring Lentigo Hypopigmented-hyperpigmented macules Telangiectases Yellow papules Actinic keratosis Senile comedones Deep wrinkles Superficial wrinkles Criss-cross wrinkles 20.60 21.46 23.53 21.39 20.72 20.73 23.32 23.67 23.67 22.04 19.78 22.14 59.864 72.435 70.072 68.485 69.191 66.489 67.776 72.875 72.461 56.757 50.471 60.204 0.418 0.080 0.434 0.356 0.368 0.274 0.424 0.298 0.331 0.663 0.594 0.712 0.739 0.774 0.741 0.743 0.743 0.755 0.737 0.751 0.750 0.700 0.713 0.702 72 Dermoscopic skin aging measurement people. The characteristic signs of photoaging is surface irregularity, atrophy, fine-coarse wrinkles, and dyschromia resulting leathery and pale skin (9, 11). Chemical, physical, medical, or surgical techniques are used for skin-aging treatment. However, to determine and evaluate the effectiveness of these treatments, objective measurement methods are needed. For this purpose, the photographic staging scales and clinical assessments are used to measure the skin aging quantitatively (5–7). On the other hand, all these scales remain insufficient in establishing all effects of skin aging, regional assessment, and effectiveness of treatments (9, 12–15). The ideal scale that would be used to evaluate the aging of the skin should be simple, easily applicable, non-invasive, capable of quantitative evaluation, and it can easily be used both in clinical and epidemiological studies. In our study, in the stages of developing DPAS, first, skin aging criteria were determined and after, they were tested by reliability and validity studies. DPAS has been able to detect the signs of photoaging before they become clinically visible. In many cases regarded as ‘premature photoaging’ and can be included in the second group of Glogau photoaging scale, it is seen that clinically nonvisible pigmentation disorders, early solar lentigines, and new telangiectasias that cannot be seen with the naked eye can easily be detected by dermoscopy. DPAS evaluates the face by separating it into four regions as forehead, right malar, left malar, and chin, so it can be used in the evaluation of treatment efficacy of regional rejuvenation procedures. In our study, there is no significant difference in sun-exposed area scores between skin types (P > 0.05). This may be caused by most of the participants having skin phototype II and III. There are numerous studies showing the role of smoking in extrinsic aging (16–18). In our study, similarly, a statistically significant difference was observed between the smokers and nonsmokers’ DPAS scores. In addition, smoking increased the development of telangiectasia and senile comedones on sun-exposed areas. Increased sun exposure correlates with higher wrinkle and pigmentation scores (16). Also increased DPAS scores associated with sun burn and chronic sun exposure was observed in our study. Skin aging significantly increases in 4th and 5th decades (5). In our study, the most important differences were observed in the fifth decade. In the study that photoaging in Asians evaluated, the most common finding in male sex is seborrheic keratosis and hyperpigmented macules in females (16). The most common findings observed in our study were telengiectasia (13.4%) and hypo-hyperpigmented macules (13.3%) in males and hypo-hyperpigmented macules (15.5%) in females. The scale we developed was used by two independent investigators and a very strong, right-way, positive correlation between variables were found (r = 0.918). The strong correlation between the researchers showed that this scale could be used without having a special education on dermoscopy or photoaging. Cronbach’s a coefficient was 0.756. Diffuse erythema has been removed according to the results of the statistical analysis. Therefore, final DPAS was generated with 11 item and maximal DPAS value was calculated as 44 points. During the measurement and evaluation with DPAS, only tool that has been needed is dermoscopy. DPAS is quick, easy to use, and applicable in any environment, and the numerical results can be calculated immediately. In the light of our findings, DPAS quantitatively can evaluate photoaged skin with the help of objective criteria. By using our scale, the results of protective and therapeutic applications for skin aging can be ascertained with numerical values and the efficacy of different treatment methods can be demonstrated. Acknowledgements There is no funding source that supported the work. 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