Dr Loredana Nigro explores how lifestyle amendments and topical formulations can help prevent or improve rhytids on the neck
The lines on the neck, also known as necklace lines or transverse neck lines, are regularly perceived by patients as a negative sign of ageing and ways to reduce the appearance of lines are often reported by consumer media.1,2 The lines commonly present as horizontal overlapping skin folds and can be seen in patients of any age, as there is some congenital occurrence. They are progressive in nature and there is a strong correlation between age and rhytid depth.1
In clinical practice, I find the reasons patients present for progressive conditions such as neck rhytids are multifactorial – including financial, social and life-event drivers. For instance, we often see patients present when they have self-observed a significant, rapid negative change, such as during periods of accelerated visible ageing around the peri-menopause. In many cases, an earlier preventative adjuvant therapy regime would delay the requirement for intervention.
Although there are several in-clinic treatment approaches for this concern, such as dermal filler and botulinum toxin injections, energetic stimulation radiofrequency, micro-focused ultrasound and lasers to name a few,3-10 there are also out-of-clinic recommendations and lifestyle factors that patients can adopt to either complement treatment approaches or prevent further damage.
Neck lines are caused by the intrinsic skin and tissue changes associated with ageing. As with most facial lines, the main pathology is loss of collagen, along with elastin.11 However, the specific histology of the neck indicates greater propensity for structural degradation and permanent changes, including (when compared to the cheek) sparser adnexa in the reticular dermis and a thinner, stiffer stratum corneum, adhering to a more compliant and mobile dermis. Increases in extensibility, viscoelastic effect, and transepidermal water loss all drive earlier physical failure, compared to the face.1
An important structural component of the skin is the extracellular matrix (ECM), which is composed of glycosaminoglycans (GAGs), proteoglycans (PGs), collagen fibres and other large molecules.
Together, these form a super-structure, which facilitates the biochemical function and structure of the skin as an organ. Degradation of the ECM is a key result of both chronological skin ageing and photoageing.2
Other contributing effects leading to the presentation and increasing severity of neck lines include gravity, skin laxity, body fat fluctuations, and the action of the platysma muscle. The causative factors often lead to co-occurrence of Poikiloderma of Civatte, a common skin condition that presents as red-brown skin with prominent hair follicles that mainly affects the skin on the sides of the neck.11
Patient awareness of visible neck ageing in women often coincides chronologically with menopause – this is likely due to accelerated collagen loss. Research has suggested that women lose an average of 30% of Type I and III collagen in the five years following menopause, which naturally increases the severity of neck lines that may have been present but unobtrusive.12
Menopause in women and general ageing in both sexes is also associated with bony atrophy, which degrades and reduces the supporting structure of the jawbone, structurally deepening visible lines.12 The neck can be seen as a drape from the mental protuberance to the clavicles and, following bone resorption, the drape begins to sag, deepening existing lines and increasing intradermal shear forces.13
The condition of the neck can be classified according to its severity of presentation. The appropriate treatment approach will be determined by the class of neck line, which include:
0 – None: No transverse neck lines
1 – Minimal: Superficial transverse neck lines
2 – Moderate: Moderate, effaceable transverse neck lines
3 – Severe: Deep, non-effaceable transverse neck lines
4 – Extreme: Non-effaceable transverse neck furrows with redundant skin
As with many conditions involving structural degradation of tissue, surgery may provide the only practical solution for the most serious and extreme cases, for example where redundant skin is present.14
Multimodal, less-invasive approaches can help minimal to severe presentations. If practitioners incorporate a combination of less invasive treatments with the below adjuvant therapies, I believe optimum results can be achieved.
In addition to injectables and energy-based treatments, a number of topical and other adjunctive therapies are available, with demonstrated efficacy (Table 1).3-10 A key objective, particularly in younger patients, and patients entering menopause, is prevention.
A regime of treatments that mitigate the damaging effects of photoageing is also very important.
While budgets vary, patients concerned about necklines should be encouraged to include
lifestyle modifications and topical barriers and antioxidants from as early in life as possible
The key to prevention of neck lines is preservation and support of structured collagen and elastin. Lifestyle modification to address these biochemical and physical impacts can mitigate collagen degradation, structural failures and the formation of lines.
Smoking, excessive alcohol consumption, lack of sleep, inflammatory diet, and extended and unprotected sun exposure can all contribute to premature ageing and structural decline of the neck skin and tissue, through elevating levels of free radicals and reactive oxygen species.15 A significant problem susceptible to lifestyle modification, which is becoming more prevalent particularly in younger adults is ‘text neck’ or ‘tech neck’ – a syndrome of musculoskeletal pain, arthritis and disability related to awkward smartphone use.16 This is a newer structural driver of skin damage and can likely exacerbate neck lines in younger patients.16
UV damage due to sun exposure can affect skin tissue and subsequently play a large part in the ageing process of the neck. Patients should be mindful that not all clothing forms an effective sun protection barrier, and I recommend that when in the sun, all patients should regularly reapply sun protection to the entire face area, neck and decolletage. Research also shows the degrading impacts of high energy visible (HEV) light. Blue light – ubiquitous in our modern existence of computers, tablets and smartphones – is shown to negatively impact pro-collagen I. Suspected to damage collagen through reduction of cutaneous carotenoids, its higher wavelength means deeper penetration (1mm against 0.2-0.4mm for UV wavelengths).17-19 Regular use of a full spectrum barrier is therefore recommended, even when spending a lot of time indoors.20 For all patients, I recommend an antiageing sun protection product which specifically mitigates UVA, UVB, IR and HEV light.
As mentioned, menopause and associated hormonal changes are extremely detrimental to collagen levels, elastin levels, and overall skin quality, including the neck area.21 Adjuvant therapies to mitigate menopause, include hormone replacement therapy, biophotomodulation or photodynamic therapy (PDT) with red/ near infrared (NIR) irradiation, and topical applications that will help build the ECM.22,23
A variety of effective topical treatments exists to improve the appearance of transverse neck lines – which can work in isolation and provide a beneficial adjuvant effect to the multi-modal approaches discussed above. Topical formulations or regimes comprise various combinations of synergistic ingredients; what I personally deem to be the most relevant components are described below. Evidence is becoming available of their efficacy in revision of existing lines, along with preventative functions relating to collagen and elastin maintenance.3,24 Manufacturers may provide specific application instructions that have been developed in conjunction with the product chemistry, and I generally recommend that these should be followed.
NAG is a monosaccharide amide, which is demonstrated to increase hyaluronic acid production and to moderate uneven pigment. Application of NAG supports structure, integrity, growth and repair of the ECM. NAG supports the competence of the neck skin superstructure, preserving the adherence of the dermis and stratum corneum.24
This is an ester of citric acid which is shown to increase dermal collagen with high efficacy.24 Ongoing replacement of dermal collagen is key to maintenance of the ECM and slowing or preventing progression of neck lines.24
Antioxidants improve the health, structure and integrity of the dermal ECM, and so support collagen and elastin maintenance. Vitamins are common components of topical formulations – vitamin B3 regulates cell regeneration and metabolism, vitamin C upregulates the production of collagen types I and III, and vitamin E has demonstrated anti-inflammatory and anti-proliferative effects. Vitamin C and E in combination have been shown to have synergistic benefits in terms of antioxidative protection. Pro-amino acids such as palmitoyl glycine also reduce inflammation and increase procollagen production.25
Vitamin A and derivatives such as tretinoin are antioxidants which upregulate collagen synthesis, and suppress the effects of collagenase, directly supporting the health of the ECM matrix through metabolic effects. Polypeptides can imitate matrix components, and stimulate dermal metabolism, including collagen synthesis, and certain botanical extracts (including polyphenols and stem cells extracts) have been demonstrated to provide similar metabolic upregulation.25 Pigmentation modulators and acid peels can also stimulate exfoliation, collagen biosynthesis, skin tautness, and eradication of effaceable lines.25
This can be applied directly to the skin in ultra-small particle formulations (also known as nano-HA), which allows deep penetration of the product into the dermal matrix, which has been shown to significantly improve the appearance of fine lines as per a minimal presentation of transverse neck lines.26
While conducting my research, I found many studies documenting the general benefits of topical treatments on skin rhytids, but I could only find one study that purely focussed on treating the neck with topicals. This 2015 study (P=42) recorded the effect of a multi-ingredient topical cream over a 12-week daily application profile, without any additional multi-modal therapies. The cream comprised 8% N-acetyl glucosamine, 4% tri-ethyl citrate, along with various antioxidants and anti-inflammatory agents (vitamin E, palmitol glycine and swiss apple stem cell extract).27
In my clinic, we treat each patient as their individual presentation and circumstances dictate. However, Table 1 reflects my own clinical decision-making process, which should factor in the treatments available, the classification of the neck lines, and of course the patient’s budget when deciding upon an appropriate combination regime. While budgets vary, patients concerned about neck lines should be encouraged to include lifestyle modifications, topical barriers and antioxidants from as early in life as possible.
Transverse necks lines present as a progressive condition, and therefore a regular intervention regime which supports the maintenance and rejuvenation of the skin and underlying ECM matrix is key to management. Particular care should be taken to consider the increased support requirements of metabolically significant life changes such as peri-menopause. The neck is a difficult area to treat and is an aesthetically sensitive part of the body. While surgery may be indicated for the most serious cases, there are a range of non-invasive procedures which can improve the area. Adjuvant to the available remediation therapies, a daily regime incorporating full-spectrum barrier protection, appropriate lifestyle choices, and supporting topical applications (including matrix builders, antioxidants and cell regulators) will minimise the emergence or worsening of this unwanted sign of ageing. To adequately address all issues, in-clinic and home care should be considered on an ongoing basis.
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