The skin is what patients are looking at day in and day out. The filled, expressionless face which inspired the term ‘overdone’ is a far cry from what patients want, and the message from a lot of practitioners about caring for the ‘canvas’ is hitting home. Many beauty trends are seeing 20-45-year-olds looking at holistic, convenient and safe ways of reaching their goals to achieve good skin health and quick results, with little to no downtime.1
Skin boosting treatments have become the go-to in many aesthetic clinics in the UK. In the cosmetic and beauty industry, this term often refers to serums within a beauty regime, such as those containing concentrates of retinol and alpha hydroxy acids (AHAs), or antioxidants like vitamin C. However, in the aesthetics industry, this term describes injections of hyaluronic acid (HA), multivitamins, minerals, amino acids and antioxidants into the skin.2 Also known as skin revitalisers or injectable moisturisers, these mixtures aim to increase hydration, elasticity, vitality and turgidity, thus providing more youthful skin.3
This article will discuss some main injectable skin boosters available to practitioners, as well as the active ingredients and benefits they confer on the skin. These skin boosters are examined due to the active ingredients and the differences between them, as opposed to similarities.
Skin and the ageing process
By knowing the structure and function of the skin, we can see that the ageing process is multifaceted, and no single determinant can be identified as the ‘culprit’. The genetic predisposition of an individual, coupled with biological, socio-economic and psychological factors, are a few determinants which affect a person’s ageing process and the appearance of their skin. However, the most detrimental factor is exposure to UV light.4
An aged epidermis:5
- Is thinner, although the cell numbers remain the same
- Appears wrinkled and weather-beaten
- Is paler and dry
- Suffers from pigmentation
- Bruises easily
- Has multiple capillary angiomas
This is the result of several changes in the epidermis, dermis and hypodermis as we age. The number of melanocytes decreases, but those remaining increase in size, giving rise to pigmented areas known as lentigos or liver spots.5 There are also changes in the connective tissue in all three layers of the skin, but most notably in the dermis.5 This affects the integrity of the skin, with reduced collagen and elastin giving the skin a weathered look, known as elastosis.5
The capillaries within the dermis also become fragile, and blood supply is reduced in some areas. There can also be entangling of the vessels, resulting in cherry angiomas.5
The connective tissue and matrix within the dermis and its connectivity to the epidermis reduces, which affects the texture and hydration of the skin.5
The lessening of secretions from the sebaceous glands also adds to the drying effect of the skin, and the number of adipocytes within the hypodermis reduces. This causes its connectivity to the deep fascia to drop, giving the appearance of sagging, lax skin.4,6,7
For the skin to appear healthy, hydration is paramount, as well as a supported extracellular matrix. By adding moisture and structure, we can facilitate the function and therefore skin health through the addition of skin boosters.5
A range of skin boosters
There is a wide range of products available on the market, with some companies claiming additional nourishment and hydration all the way through to bio-remodelling and revitalisation of the skin, hence the names injectable moisturisers and revitalisers. Almost all are based on the molecule HA and some are poly-component, containing amino acids, antioxidants, vitamins and minerals, to name a few.
Some of the most common brands include Belotero Revive which contains HA with amino acids, vitamins, minerals and antioxidants. Juvéderm Volite, Profhilo and Restylane Skinboosters are all based on HA, whilst SuneKOS and Teosyal Puresense Redensity 1 have been formulated with HA and six amino acids.5 Other skin booster brands include Hydro Deluxe by Neauvia, the PhilArt range by Croma Pharma, as well as Pure+ Stylage Hydro and Hydromax by Prollenium, but there are others available.
HA is typically associated with moisturisers and dermal fillers. However, when the rheological properties are modified, we are given a new perspective on this ingredient. HA is a hydrating molecule that is known as the ‘most hydrophilic water molecule in nature’. Its effect is one of efficiently moisturising, drawing and retaining moisture in the deeper structures of the skin – an essential component for boosters.6
An in-vitro study on human fibroblasts analysed the repair, refill and stimulant activities of intradermal injectable HA on fibroblast activity, as well as the capacity to induce extracellular matrix activity of components such as collagen type I and elastin.8 The study demonstrated that fibroblast activity was up by 4.7% and collagen and elastin gene expression increased to 9.7% and 14% respectively. This added weight to the many claims that these skin boosters can enhance skin health, vitality and overall appearance.8
Belotero Revive uses the properties of HA and further adds to the integrity of the skin’s extracellular matrix using the humectant glycerol. This is an ingredient that draws water such as HA and glycerin to itself, helping with hydration for the skin. In a study carried out and supported by Merz, known as the BELOVE study group, a small cohort of individuals involving Caucasian 25 females aged between 31-44 years had Belotero Revive treatments over a set number of weeks. It was demonstrated that the overall viscous-elastic properties of the skin, as well as hydration and radiance, had markedly improved after three to four weeks.9
Another well-known product is Juvéderm Volite. It consists of 12 mg/ml of HA and 0.3% lidocaine.10 This Juvéderm products is HA engineered with Allergan’s patented Vycross technology to provide hydration and smoothness to rough, dry and fatigued skin by means of multi-intradermal injections. A prospective study of 131 subjects noted that Volite safely and effectively improved skin smoothness for up to six months and hydration lasted up to nine months.11
Of the common skin boosters, Profhilo, also known as a bioremodeller, contains a mixture of low- and high-molecular weight HA, and purports to have one of the highest concentrations at 64mg/2ml in the skin booster market. Profhilo has been shown to be well tolerated and appears to ‘bio-remodel’ aged skin.12
A literature review on human fibroblasts studying the effects of high and low molecular HA in the skin (Profhilo) and its effect on skin remodelling techniques showed that when administered as per a five-point plan, it displayed positive aesthetic results in terms of the skin vitality and overall health. It does not simply hydrate and nourish, but remodels via its fibroblast activity that stimulates aged skin.13
The Restylane Skinboosters range is primarily based on HA. To make the HA last longer, for several months or a year, degradation is delayed by cross-linking the HA molecules.14,15 The Restylane Skinboosters form small ‘reservoirs’ of moisture beneath the skin’s surface that gives long-lasting hydration and radiance. There are two products in the range, Vital and Vital Light, which are based on different HA concentrations. Vital contains 20mg of HA/3mg of lidocaine for areas where the skin is thicker, such as the mid-face, temples, hands and decolletage.15,16 Whilst Vital Light contains 12mg of HA/3mg of lidocaine to treat areas where the skin is thinner like the perioral and periocular regions and neck.16,17
SuneKOS uses the advantages HA has to offer and combines it with a specific mix and concentration of amino acids including glycine, proline, lysine, alanine, valine and leucine.18,19 The product focuses on the regeneration of the ageing extracellular matrix by means of promoting gene expression for elastin and collagen IV and VII.18,19 Interestingly, the additional rhetoric is that SuneKOS’s unique mixture of amino acids supports the longevity of HA by reducing hyaluronidase activity in the skin.13 The literature for this is still under publication, and if it proves significant, it will add huge value to its brand and formulas. SuneKOS can be injected via micro boluses or via cannula over the face, forehead and neck.
Teosyal Puresense Redensity 1 is based on a myriad of ingredients including non-cross-linked HA, amino acids, vitamins, minerals and antioxidants. The product contains 15mg/ml of HA (a mix of crosslinked and non-crosslinked high molecular weight HA). Its degree of modification with BDDE is 5.5%, as well as a dermo-reconstructing complex containing 14 essential nutrients; vitamin B6, zinc, copper, three antioxidants and eight amino acids.20
Considerations for treatment
Skin booster treatment tends to last for up to a year, although this depends on which product you use and also how many treatments are administered.13 Downtime can vary depending on the brand but is usually minimal and the skin should return to normal within five to 20 minutes.21 For those with sensitive skin, patients may experience swelling or redness in the treated areas, but it should subside in a few days and last no longer than two weeks, but again, is dependent on the product used.21
Other potential complications include small, slightly raised bumps, brusing, pain or tenderness and itching.21 As with any treatment, practitioners should conduct a thorough medical history in the consultation and note any medical conditions as this may impact the suitability of the treatment. Patients should receive instructions for aftercare post-treatment.
Some contraindications include:22
- Pregnancy/breastfeeding
- Exposed/cracked/infected skin
- Any autoimmune disease
- Certain medication for acne taken within three months prior to treatment
- Medical allergies
In my clinical experience, practitioners can use skin boosters in conjunction with fillers, anti-wrinkle treatments and regular facials for patients that would like to smooth as well as hydrate the skin.
An alternative treatment
Skin boosters are a valuable addition to the aesthetics industry, enhancing the skin’s nutrition, hydration and overall health. The numerous active ingredients work on varying degrees of physical and chemical properties. Humectants, HA’s hydrophilic nature and induction of fibroblast activity, as well as the increased gene expression brought about by amino acids and the protective effects of antioxidants, help nourish the skin. Most are based on some form of lightweight HA, making it a key component for boosters.
Additions of specific ratios of amino acids and properties of standalone components such as antioxidants offer comfort to clinicians and patients alike. However, clinicians should read the literature to support the physicochemical properties of a particular skin booster, their patients’ needs and overall experience in delivering the right treatment.
