Skin health and ageing is affected by numerous factors. Genetics and ultraviolet (UV) light from the sun have a significant impact on our skin. However, there are a number of other, often overlooked aspects of our lifestyle that affect how well our skin ages and its aesthetic appearance into older age. Collectively, this group of factors is known as the skin exposome.1
The skin exposome incorporates nutrition, stress, smoking, sleep and pollution, in addition to environmental factors; all of which work together to determine the health of our skin (Figure 1).1
Skin ageing is a common concern of patients presenting to our clinics; helping them protect their skin exposome through good nutritional choices is another way we can improve skin health, alongside more traditional non-surgical treatments and skincare regimens.
Researching the microbiome
The gut microbiome is a fascinating area of study that examines the impact of the trillions of organisms that reside in our large intestine and the impact they have on numerous aspects of our health, from our weight to our mood.2 Recent research has suggested that the gut microbiome may play a key role in maintaining healthy skin and preventing the signs of skin ageing.2
One study has shown that different types of gut bacteria can influence the production of collagen – the key scaffolding protein in the skin – by activating specific enzymes.3 Another has suggested that certain species of bacteria act in an anti-inflammatory capacity; we know that inflammation can accelerate skin ageing, thus bacteria could be useful in reducing this.4 Additionally, there is evidence suggesting that gut bacteria can influence the production of certain hormones that are involved in skin health and can even influence skin barrier function.5
In my experience, I have seen diet as the most effective way to optimise our gut microbiome, eating foods that support the growth of good gut bacteria and strengthen the gut microbiome.6 Aesthetic practitioners are well-placed to offer their patients lifestyle advice which may improve their skin health, and this includes diet.
In my view, optimising patients’ diets should be the first port of call for improving skin health through nutrition. Studies have shown that an antioxidant-rich diet, full of colourful fruits and vegetables, contributes to better skin ageing, thus good nutrition should be at the heart of a holistic approach to skin health.7,8
An effective way to promote gut health is through eating plenty of prebiotic-rich foods and those that contain good gut bacteria (probiotic foods), including sauerkraut, live yoghurt, kefir, kimchi and kombucha.6 It is also important to advise patients to eat a variety of foods, aiming for 30 different plants per week as this has been shown to improve the diversity of gut bacteria.9 Whilst patients may find this advice daunting, this includes spices and herbs too.
Our skin is primarily composed of proteins, thus protein is an essential part of a skin-friendly diet; lean protein sources such as salmon, chicken, eggs or vegetarian/vegan sources like chickpeas and tofu are crucial. As such, low protein diets can impair wound healing because the skin does not receive sufficient protein.10 Finally, healthy fats like olive oil, nuts, seeds and avocados are all rich in omega 3 fatty acids which help support the skin barrier for smooth and supple skin.11
As well as a balanced diet, patients should be advised to minimise refined sugar such as sweets, cakes and biscuits. As these foods can cause blood sugar levels to rise quickly, they can contribute to accelerated skin ageing.12 Sugar causes compounds called advanced glycation end products (AGEs) to be produced in the skin, which cause collagen fibres to stiffen and hastens the appearance of skin wrinkling, also known as ‘sugar sag’.12
It is also important to remind patients to be mindful of alcohol intake. A study of more than 3,000 women across the globe found that those who drank more than eight alcoholic beverages per week had an increase in upper facial lines and loss of mid-face volume, as well as more prominent blood vessels in the skin.13
After appropriate diet adjustments are made, supplementation is another option practitioners can offer to their patients. It is important to remember that when it comes to long-term health, diet plays a central role and supplements should be considered in addition to, rather than instead of, a balanced diet.
Probiotics are supplements in the form of tablets or drinks which contain live bacteria to support the gut microbiome. When choosing a probiotic to offer patients, look for species such as lactobacillus acidophilus, bifidobacterium bifidum and lactobacillus rhamnosus GG.14 These have been found to strengthen the skin barrier, increase skin hydration, reduce inflammation and oxidative stress, all of which are key factors in maintaining youthful-looking skin.14 The effects of probiotics on skin ageing is still being studied, and more research is needed to fully understand their benefits.
Collagen supplements have grown in popularity for their potential benefits for skin and hair support.15 There is some research to suggest that they may help with skin ageing.15 Collagen is an essential structural protein in the skin, and levels start to decline as early as our 20s.15 Collagen is disrupted by smoking, high sugar diets and UV light.15 Lack of collagen contributes to the appearance of wrinkles, fine lines and sagging skin.15
A study has looked at the impact of collagen supplements on skin health, but this should be reviewed with caution as it was funded by supplement manufacturers. It has, however, shown reduction in wrinkle depth and greater skin hydration after a period of eight to 12 weeks.15 When choosing a collagen supplement, consider dipeptide collagen fragments, which appear to have more rapid results.16 Marine and animal-derived supplements are available, and while results of the two are comparable, certain studies have shown that the marine option may be able to achieve slightly enhanced results.17,18 Other studies have not demonstrated that liquid collagen supplements (which are often more costly) exhibit a superior advantage.16
Due to their cost, collagen supplements should be cautiously considered, and patients advised to discontinue use if they do not see benefits after a period of three months. Collagen supplements can be used in the post-procedure period to assist wound healing, however, the benefits of this is as yet unproven.19
Vitamin C is a gold-standard antioxidant with numerous benefits when applied topically on the skin.20 There is some evidence that vitamin C supplements can help support healthy skin ageing and wound healing.20 This may be beneficial after cosmetic procedures such as chemical peels or surgery, but topical vitamin C is still primarily recommended over a supplement for optimal results.20 Doses higher than 1000mg per day are not recommended, as vitamin C can turn into a pro-oxidant at higher levels.20
Many different formulations of vitamin C exist, but early evidence suggests some superiority of liposomal vitamin C over standard vitamin C, as the encapsulation increases the delivery to the skin.21 As vitamin C is required for all phases of wound healing, it can be considered for use in the post-procedure or post-operative phase.21
Nicotinamide (niacinamide or vitamin B3) is another popular supplement, taken for antiageing effects.22 A clinical study examining 386 patients has demonstrated its role in the potential mitigation of risk of skin cancer at a dose of 500mg twice per day in individuals deemed high risk who have a past history of non-melanoma skin cancer.22 Its protective effects are thought to be down to it reduction of UV radiation-induced DNA damage, and its ability to encourage DNA repair.22
This supplement can affect liver enzymes and cause flushing as an unpleasant side effect, but non-flush varieties are available.22 As yet, although the role of nicotinamide as a photoprotective supplement is promising, definitive evidence that it can influence skin ageing is lacking.
There are special considerations for patients following specific diets. Early research suggests that individuals who follow a vegan or vegetarian diet may have poorer outcomes from minor surgical procedures and facial rejuvenation procedures.23,24
Although the mechanism behind this is not entirely clear, it may be due to a lack of protein, omega 3 or B12 in the diet, all of which are required for proper wound healing and collagen production.25 Therefore, optimising protein intake, consideration of algae-derived omega 3 supplements at a dose of 500mg EPA/DHA per day and B12 supplements 10mg per day could all be considered pre- and post-procedure to support recovery.25
Optimising skin health
Despite the widespread marketing of nutraceuticals for skin health and ageing, the most important influence is, in fact, our diet. Optimising diet should be a key step in a holistic approach to skin ageing, alongside an effective skincare routine with diligent sun protection and cosmetic treatments where appropriate.
The relationship between gut health and skin ageing is an exciting area for further research. Whilst there may be a role for supplements, particularly those following specific diets or following procedures or cosmetic interventions, they should not replace a balanced diet.