Treatment of photoaged skin. Efficacy, tolerability and costs of available agents.

Photoaging is a cumulative degenerative process induced by solar irradiation with well defined clinical and histological correlates. Because of its huge psychological impact, there is much demand for effective treatment. Many well constructed trials confirm the clinical efficacy of topical tretinoin for improving fine wrinkling and mild to moderate hyperpigmentation; coarse wrinkling and severe hyperpigmentation respond less well. Histological improvement is well documented, but the precise relationship to clinical response is not clearly established. Tolerability can be a problem. Optimal concentrations are not firmly established and vary between patients. Claims that topical isotretinoin is better tolerated than tretinoin need to be confirmed with well constructed trials. Despite many claims, there have been no adequate trials documenting the efficacy of fish cartilage polysaccharide extracts or alpha-hydroxy acids. Careful patient selection with consideration of alternative treatments such as chemical peeling, dermabrasion and surgery is important to successful management of photoaging.