History and exam
Key diagnostic factors
common
age >40 years
By the fourth decade, wrinkles mostly appear with animation of the face; by the fifth decade, expressive lines result in permanent creases; and by the sixth to seventh decade, the whole facial skin may be covered with wrinkles.
Gravitational lines become more obvious between the ages of 40 and 50 years, and occur throughout the face and neck.[17][Figure caption and citation for the preceding image starts]: 30-year-old woman with mild wrinkles showing few wrinkles at restFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
[Figure caption and citation for the preceding image starts]: 50-year-old woman with photo-aged skin showing advanced wrinkles, discoloration of the skin, actinic keratoses, and dynamic forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
[Figure caption and citation for the preceding image starts]: 80-year-old woman with severe wrinkles, photoageing, and gravitational forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
chronic sun exposure
The face, neck, and dorsum of hands and forearms are affected by the damaging effects of UV exposure.
The major environmental factor contributing to photoageing and secondary wrinkle formation is sun exposure causing photodamage to the epidermis and dermis.
The clinical skin signs of photodamage are dyschromia, yellow hue, wrinkles, telangiectasia, leathery appearance, and cutaneous malignancies. [Figure caption and citation for the preceding image starts]: 50-year-old woman with photo-aged skin showing advanced wrinkles, discoloration of the skin, actinic keratoses, and dynamic forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 80-year-old woman with severe wrinkles, photoageing, and gravitational forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
smoking
Smoking results in the formation of deep wrinkles in the facial expression lines and flexion creases of the neck.
lines on face
Wrinkles are most noticeable in skin on exposed areas of the body (i.e., face, neck, dorsum of hands).
Commonly manifest as horizontal forehead lines, glabellar lines between the eyebrows, lateral canthal lines ('crow's feet'), nasolabial folds, upper lip lines, lower radial lip lines, lines at the corner of the mouth, vertical lines at the corner of the mouth that run downward to the chin ('marionette lines'), a labiomental crease, cheek lines, and lines on the lower eyelids and in the preauricular area.
horizontal neck folds
Wrinkles are most noticeable in skin on exposed areas of the body (i.e., face, neck, dorsum of hands).
lines on dorsum of hands and wrists
Wrinkles are most noticeable in skin on exposed areas of the body (i.e., face, neck, dorsum of hands).
dynamic lines
Repetitious contractions of muscles responsible for facial expression pull directly on the overlying tissues, causing the skin to fold and develop dynamic lines.
Among the first lines to develop (by the third decade) are the horizontal forehead creases, caused by contractions of the frontalis muscle, and lateral canthal or 'crow's feet' lines, caused by contractions of the orbicularis oculi muscle. Glabellar frown lines develop at variable ages as a result of the pull of the procerus and corrugator muscles.[5] Chronic contraction of the orbicularis oris muscle induces folds and lines around the mouth, perpendicular to the vermilion border, which become more noticeable in the fifth decade. Forceful contraction of the zygomaticus muscles contributes to the formation of the nasolabial folds.[Figure caption and citation for the preceding image starts]: 50-year-old woman with photo-aged skin showing advanced wrinkles, discoloration of the skin, actinic keratoses, and dynamic forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 30-year-old woman with mild wrinkles showing few wrinkles at restFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 30-year-old woman with mild wrinkles showing moderate wrinkles on major facial activityFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
gravitational lines
Gravitational lines are wrinkles in the form of sagging folds, which become more obvious between the ages of 40 and 50 years, and occur throughout the face and neck.[17][Figure caption and citation for the preceding image starts]: 80-year-old woman with severe wrinkles, photoageing, and gravitational forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
deep wrinkles
Wrinkles resulting from intrinsic ageing are deep and often accompanied by skin laxity.
fine wrinkles
Wrinkles due to sun exposure (photoageing or photodamage) are usually fine and often accompanied by other signs such as dyschromia (liver spots, lentigines), dermal elastosis, erythema, telangiectasia, textural changes (leathery appearance), and actinic keratoses.[32][33][34]
Old, photoprotected skin may have increased laxity and fold accentuation, but it lacks signs of sun damage.[35][Figure caption and citation for the preceding image starts]: 50-year-old woman with photo-aged skin showing advanced wrinkles, discoloration of the skin, actinic keratoses, and dynamic forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 80-year-old woman with severe wrinkles, photoageing, and gravitational forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
Other diagnostic factors
common
skin laxity
Wrinkles resulting from intrinsic ageing are deep and often accompanied by skin laxity.
dyschromia
Wrinkles due to sun exposure (photoageing or photodamage) are usually fine and often accompanied by other signs such as dyschromia (liver spots, lentigines), dermal elastosis (advanced skin laxity), erythema, telangiectasia, textural changes (leathery appearance), and actinic keratoses.[32][33][34][Figure caption and citation for the preceding image starts]: 50-year-old woman with photo-aged skin showing advanced wrinkles, discoloration of the skin, actinic keratoses, and dynamic forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 80-year-old woman with severe wrinkles, photoageing, and gravitational forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
dermal elastosis
Wrinkles due to sun exposure (photoageing or photodamage) are usually fine and often accompanied by other signs such as dyschromia (liver spots, lentigines), dermal elastosis (advanced skin laxity), erythema, telangiectasia, textural changes (leathery appearance), and actinic keratoses.[32][33][34][Figure caption and citation for the preceding image starts]: 50-year-old woman with photo-aged skin showing advanced wrinkles, discoloration of the skin, actinic keratoses, and dynamic forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 80-year-old woman with severe wrinkles, photoageing, and gravitational forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
erythema
Wrinkles due to sun exposure (photoageing or photodamage) are usually fine and often accompanied by other signs such as dyschromia (liver spots, lentigines), dermal elastosis (advanced skin laxity), erythema, telangiectasia, textural changes (leathery appearance), and actinic keratoses.[32][33][34][Figure caption and citation for the preceding image starts]: 50-year-old woman with photo-aged skin showing advanced wrinkles, discoloration of the skin, actinic keratoses, and dynamic forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 80-year-old woman with severe wrinkles, photoageing, and gravitational forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
telangiectasia
Wrinkles due to sun exposure (photoageing or photodamage) are usually fine and often accompanied by other signs such as dyschromia (liver spots, lentigines), dermal elastosis (advanced skin laxity), erythema, telangiectasia, textural changes (leathery appearance), and actinic keratoses.[32][33][34][Figure caption and citation for the preceding image starts]: 50-year-old woman with photo-aged skin showing advanced wrinkles, discoloration of the skin, actinic keratoses, and dynamic forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 80-year-old woman with severe wrinkles, photoageing, and gravitational forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
textural changes
Wrinkles due to sun exposure (photoageing or photodamage) are usually fine and often accompanied by other signs such as dyschromia (liver spots, lentigines), dermal elastosis (advanced skin laxity), erythema, telangiectasia, textural changes (leathery appearance), and actinic keratoses.[32][33][34][Figure caption and citation for the preceding image starts]: 50-year-old woman with photo-aged skin showing advanced wrinkles, discoloration of the skin, actinic keratoses, and dynamic forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 80-year-old woman with severe wrinkles, photoageing, and gravitational forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
actinic keratoses
Wrinkles due to sun exposure (photoageing or photodamage) are usually fine and often accompanied by other signs such as dyschromia (liver spots, lentigines), dermal elastosis (advanced skin laxity), erythema, telangiectasia, textural changes (leathery appearance), and actinic keratoses.[32][33][34][Figure caption and citation for the preceding image starts]: 50-year-old woman with photo-aged skin showing advanced wrinkles, discoloration of the skin, actinic keratoses, and dynamic forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 80-year-old woman with severe wrinkles, photoageing, and gravitational forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
Risk factors
strong
genetic susceptibility
The role of genetically programmed chronological ageing is controversial. However, evidence can be found in the literature that human ageing has a hereditary component, and that the age of onset and rate of progression of skin ageing largely depends on genetic factors.[8][9] Intrinsic ageing is an inevitable, genetically programmed process, of unclear underlying mechanism, for which no prevention is available.[10] Moreover, the natural ageing process first appears as invisible changes at the level of the DNA. Intrinsic genetic factors influence the shape and location of facial wrinkles.
age >40 years
As in all tissues and organs, the skin undergoes characteristic alterations with advanced age. Morphological changes associated with chronologically aged skin result in cutaneous laxity and fine wrinkling, and become evident primarily on the face.
By the fourth decade, wrinkles mostly appear with animation of the face; by the fifth decade, expressive lines result in permanent creases; and by the sixth to seventh decades, the whole facial skin may be covered with wrinkles.Histological changes of the chronologically aged skin include progressive thinning of the epidermis, flattening of the dermal-epidermal junction, and dermal atrophy.[5]
Subcutaneous tissues (fat, muscle, bone) also demonstrate progressive atrophy with age, causing the overlying skin to hang from points of deep attachments and contributing to further accentuation of skin folds. Gravitational lines represent the combined influence of atrophy and gravity on aged skin. They become more obvious between the ages of 40 and 50 years, and occur throughout the face and neck.[17]
[Figure caption and citation for the preceding image starts]: 30-year-old woman with mild wrinkles showing few wrinkles at restFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 50-year-old woman with photo-aged skin showing advanced wrinkles, discoloration of the skin, actinic keratoses, and dynamic forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 80-year-old woman with severe wrinkles, photoageing, and gravitational forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
white skin
The likelihood of photoageing and chronic actinic damage depends on skin type. People with white skin (skin types I to III on the Fitzpatrick classification) consistently exhibit greater risk for developing the long-term effects of sun exposure.[4]
hyperdynamic muscular activity
Muscular facial activity is a major force responsible for facial ageing and wrinkling. Repetitive contractions of muscles responsible for facial expression pull directly on the overlying tissues, causing the skin to fold and develop dynamic lines.
Among the first lines to develop (by the third decade) are the horizontal forehead creases, caused by contractions of the frontalis muscle, and lateral canthal or 'crow's feet' lines, caused by contractions of the orbicularis oculi muscle. Glabellar frown lines develop at variable ages as a result of the pull of the procerus and corrugator muscles.[5] Chronic contraction of the orbicularis oris muscle induces folds and lines around the mouth, perpendicular to the vermilion border, which become more noticeable in the fifth decade. Forceful contraction of the zygomaticus muscles contributes to the formation of the nasolabial folds.
[Figure caption and citation for the preceding image starts]: 50-year-old woman with photo-aged skin showing advanced wrinkles, discoloration of the skin, actinic keratoses, and dynamic forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 30-year-old woman with mild wrinkles showing few wrinkles at restFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 30-year-old woman with mild wrinkles showing moderate wrinkles on major facial activityFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
chronic sun exposure
The major environmental factor contributing to photoageing and secondary wrinkle formation is sun exposure. Photoageing does not accelerate the normal ageing process, but the effects of ultraviolet (UV) radiation superimpose upon those of ageing, and many of the skin alterations that decline with age show an accelerated decline in photodamaged skin.[18] The face, neck, dorsum of hands, and forearms encounter additional damaging effects due to UV exposure.
Actinic damage caused by UV-A and UV-B injury to the dermis and epidermis results in the impairment of skin collagen and elastin organisation, and accentuates wrinkling over the sun-exposed areas of the body.[19]
[Figure caption and citation for the preceding image starts]: 50-year-old woman with photo-aged skin showing advanced wrinkles, discoloration of the skin, actinic keratoses, and dynamic forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 80-year-old woman with severe wrinkles, photoageing, and gravitational forces affecting the skinFrom the personal collection of Dr Dimitrios Dionyssiou; used with permission [Citation ends].
smoking
Cigarette smoking has been established as an independent risk factor for the development of facial wrinkles and is a significant exogenous factor in the accelerated ageing of both sun-exposed and protected areas of skin.[1][11][12] The cumulative tobacco dose has been shown to significantly influence both the number of elastic fibres and the percentage of the area these fill in the reticular dermis.[11] The more a person smokes, the greater the risk of premature wrinkling.[27][28] Smoking results in the formation of deep wrinkles in the facial expression lines and flexion creases of the neck.
weak
pollution
Exposure to air pollution may start a cascading process that results in the formation of free radicals. Free-radical damage causes wrinkles by activating metalloproteinases that break down collagen.
low socioeconomic class
Investigations have found that people of low socioeconomic class are associated with higher perceived age and increased facial wrinkling.[29]
low BMI
Investigations have found that people with a low BMI are associated with higher perceived age and increased facial wrinkling.[29]
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