The Last Word: Biological Ageing in Aesthetics

By Dr Natalia Spierings / 26 May 2023

Dr Natalia Spierings debates why consultant dermatologists are well-placed to offer aesthetic treatments and the potential impact on biological ageing

Human beings are deeply concerned with their appearance. As a dermatologist, I see the struggles of those who suffer with skin issues daily and, thankfully, I have the privilege of helping many of them whilst seeing the impact an improvement in their appearance can have on their day-to-day lives.

A study published in 2021 of 624 patients found that the majority requested ‘rejuvenation’ rather than ‘correction’ as the goal of seeking treatment.1 In another study of 72 patients, almost one-third had experienced a major life event in the preceding year and were seeking treatments to positively impact their appearance, with over a quarter stating that ‘pressure to look younger in the work setting’ was the most important factor in their decision-making.2

Though these reasons are valid, clinicians often have conflicting or mixed views about treating these patients. I’m sure that any reader of this journal is happy to perform a myriad of treatments to improve patient appearance, I would be surprised if there was not a moment where we stopped and thought: ‘Hold on, I am a practitioner, trained to diagnose and manage diseases, as well as promoting the active prevention of disease. Should I be performing aesthetic treatments? Is this what I spent years in medical school and training to do?’

Many consultant dermatologists in the UK do not perform any aesthetic treatments at all, and there is an air of superiority to this: we will leave other healthcare professionals to provide these ‘trivial’ services while we treat ‘real’ skin diseases and ‘help’ people. So should consultant dermatologists be performing aesthetic treatments, or instead focus on diagnosing and treating skin diseases?

Dealing with disease

I believe that dermatologists should offer evidence-based aesthetic treatments to patients and be the leaders in aesthetic medicine, but how do I justify this when the waiting list for skin cancer treatment is extensive? There is a shortage of dermatologists globally, and in 2007 it was noted that the median waiting time for a neurotoxin injection for wrinkles with a dermatologist in the US was eight days, compared with a waiting time of 26 days for evaluation of a changing mole.3 It is currently not documented what these statistics are for the UK. However, this is almost certainly due to financial reasons, but it still begs the question: should dermatologists be doing aesthetic treatments at all, when there is an increase in actual disease for us to deal with? What if there is evidence that aesthetic treatments provide benefits to patients beyond psychosocial ones? What if ‘looking young’ was not only important for an individual’s mental health and self-esteem as they grow older, but also vital to biological health?

Predicted age vs. biological age

It is agreed that individuals can age slowly or rapidly. Although many people ‘look their age’, we can probably all name someone in middle or late adulthood who appears to be ageing more slowly (or more rapidly) in terms of physical appearance.

Determining someone’s ‘rate of ageing’ is tricky; it is difficult to assess ageing by quantitative means. For example, noting down parameters that are associated with ageing, such as blood pressure and physical strength and then combining these mathematically with actual age. This creates a figure that estimates the biological age of the individual.

Is there another way to assess the rate of ageing for an individual that could be more reliable? Borkan et al. controversially proposed that it may be possible that the difference between visually estimated age and actual age is a useful indicator of biological age in adulthood.4 The query raised was: are those who look old for their stated age biologically older when evaluated in terms of physiological functioning? If a 70-year-old looks 50, are they physiologically younger and vice versa? The answer seems to be yes.

Increasing longevity

Biological or intrinsic age can be correlated with physical appearance. Those who look old are, in fact, older as measured by physiological losses. The most compelling evidence comes from a longitudinal study of 1,086 adult males receiving annual check-ups at the Baltimore Gerontology Research Center over a 20-year period.5 They found that men who looked older visually were found to be biologically older on many key parameters (like blood pressure, cholesterol, type 2 diabetes, arthritis) and the younger looking participants lived longer.5

Is it possible that ‘youthful looks’ are not only associated with good health but also contribute to longevity? Is it possible that appearance can become a matter of life and death? If this is the case, if we ‘artificially’ change someone’s appearance to look younger, does the relationship between apparent age and biological age still hold?

I think this is the billion-dollar question that as far as I am aware has not been conclusively answered. Does it justify my work as a consultant dermatologist doing aesthetic treatments? Perhaps this is how I rationalise what I do, but it is an intriguing question that may never have a clear answer.

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