Our hands are constantly on show: grabbing the house keys, closing the front door, waving hello to a neighbour. All these activities involve the hands, the second most seen body part after the face.

With the increased attention on facial rejuvenation, it follows that the rest of the visible body is also under scrutiny. Ageing is no longer only measured by crow’s feet and saggy jowls, but also by the appearance of the hands, with a growing number of patients complimenting their facial treatments with neck and décolletage care, followed by hands.

A helping hand

If you want to know the age of a woman, looking at her hands is one of the most exacting ways of establishing her age. Take this example shared by one of the experts interviewed for this article describing how one of her patients decided to start a hand rejuvenation protocol.

On a transatlantic flight, her patient was seated next to a gorgeous woman. Exquisite: hair beautiful, face smooth. It was impossible to guess her age. Halfway through the flight, she noticed a lot of people walking down the aisle — all staring at the woman in repose — her resting face perfect, yet clutching the blanket under her chin with veiny, wrinkly, spotted, thin-skinned hands. The contrast was startling.

The beauty of the hands is mandatory in many cultures, especially in Asia. From ancient times, beautiful hands have been considered an influential factor in determining the elegance and grace of a woman. In China, the hand is literally the second face: as only the face and the hands of a woman were allowed to be uncovered. The beauty of the hands is considered almost as important as the beauty of the face. The fingers need to be slender and long with small knuckles. The texture of the skin should stay smooth and bouncy. No lines or wrinkles permitted. Chapped, patchy skin, loss of skin tone, and apparent veins are completely unacceptable. With our growing whitening obsession, sun-spots are also banned.

Western women tend not to look at their hands so closely, and this only becomes an issue when they are in their mid-forties. Ageing women will complain and say that their faces look better than their hands. They mainly complain about sun-spots and the the loss of volume with visible veins and the tendency to get what are described as ‘bony’ hands.

Hands are affected by both intrinsic and extrinsic ageing. Intrinsic factors cause a decrease in skin elasticity and thickness, while extrinsic ageing — caused mostly by sun exposure — affects the epidermal and dermal layers, and manifests as pigmentary spots, wrinkling, and pre-malignant lesions. Both intrinsic and extrinsic factors affect soft tissue, and therefore, the volume of the hands. As a result of the loss of volume, veins and tendons become more visible.

According to our panel, hand treatments in US and UK-based practices can vary from 10 to 30 to even 50% of the total treatments carried out in one practice, and the number is only set to grow.

Three factors might explain the large discrepancy in the figures between practices. First the location of the practice (north versus south) plays a role: where winter is cold and long, the rate of hand treatments tends to be lower. In contrast, in places where the sun shines most of the year, women tend to follow facial treatments with those for their hands.

Second, fashion also plays a role, with many women aged 50 plus not worried about ‘skinny’ and ‘bony’ hands, as it often goes with the rest of their skinny and fit body.

The third factor is age: practices with a younger clientele typically see less demand for hand treatments. Despite this, our panel of physicians reported a strong increase in the number of hand treatments within the last 5 years (up to 100% in some cases). For instance, one of our experts told us that 50% of her patients who do facial peels and laser resurfacing will include their hands in the same session.

Hand treatments also have a great patient return rate: patients who have been treated for hand ageing will keep coming back for more. They like the results and can’t live without it anymore.

An interesting fact about hand treatments is that it tends to be in demand among repeat patients: it’s not often an entry-level treatment. Most women who come for hand treatments have already been addressing their face for years and want their hands ‘to match’ their youthful looks. As women who want to correct their hands are cosmetic-medicine savvy, it is important to chose the right treatments for them.

Putting your hands in the right hands

Hands can be difficult to treat; they are trickier to treat than the face. Hands are very delicate, so a careful and gradual approach is needed. They are described as ‘dependent’, which means they are at a lower point below the heart, compared to the face. The dermis is thinner on the dorsum of the hand than it is on the face, and there are fewer adnexal structures and superficial dermal vessels, making the healing reservoir more limited. During the course of the healing process, pigmentary changes occur more frequently because the hands have less capacity to replace the epidermis. Hands can also swell and react with oedema for months after being treated. Our panel of experts urge patients to seek treatment from highly experienced physicians: only very experienced injectors should treat the hands.

Popular treatments for the hands include peels, resurfacing lasers, and dermal fillers. In many practices, volumising dermal fillers remain the gold standard for the hands. Many of our experts believe that calcium hydroxylapatite-based products, such as Radiesse, are a ‘hit’ that provide instant results with no downtime and are relatively affordable for the patient. Recently, one of our experts has been using polycaprolactone-based fillers to rejuvenate the back of the hands with good results. A five-patient prospective pilot study of a polycaprolactone-based dermal filler for hand rejuvenation suggests these dermal fillers are safe, well tolerated, and effective for hand rejuvenation; offering a potentially valuable addition to the current treatment armamentum¹.

According to some of our experts, more communication directly to patients from companies/clinics might help this growing segment. Patients in general are still largely unaware of the effectiveness of hand treatments compared to those for the face and neck. Radiesse is approved by the FDA for the correction of moderate to severe facial wrinkles and folds around the nose and mouth, so securing FDA-approval for use on the hands is likely to help grow business.

Many of our experts also use stabilised hyaluronic acid such as Restylane Skinboosters to improve the quality of the skin of the back of the hands. Restylane Skinboosters has been shown to improve skin elasticity and hydration, reduce skin surface roughness, and even-out imperfections^2, 3.

One of our experts is pioneering the technique of combining a bio-revitalisation technique using stabilised hyaluronic acid Restylane Skinboosters with growth factor (GF) gel needling in a procedure called GF gel needling lift. The synergy of the injection of light dermal filler plus the skin needling with growth factors make the treatment much more powerful. First, the doctor injects the Skinbooster, followed by the application of a topical growth factor serum in combination with a skin needling treatment. The automated DermaPen needling device with 1.5 mm needles is used under topical anaesthesia. The topical serum used here contains a potent mix of various growth factors and is the sterile AQ Solutions Recovery Serum. The serum, which is deeply infused in the skin, further encourages collagen and elastin production. The GF gel needling lift works well to improve overall skin quality and help combat loss of skin elasticity on hands, neck, and chest. It also makes the back of the hands look much less ‘bony’ and softens the impression of visible veins and tendons. If performed regularly, it will also help to slow down the skin’s natural ageing process over time. Three sessions in 6–8 week intervals are recommended.

Loss of volume is not the only thing that patients want to correct. When it comes to hands, patients are also keen to remove their dark spots. Sun-spots and pigmentation problems are addressed by many of our experts with intense pulse light (IPL) used alone or in combination with other treatments, such as chemical peels. According to our experts, combining IPL with a salicylic-retinoic acid peel in a series of four to six treatments gives good results to treat pigmentation on the back of the hands. IPL devices target both dyspigmentation and vascularity, resulting in an overall improvement of photodamage, lentigines, telangiectasias, and epidermal pigment.

Q-switched lasers (694 nm) are also highly popular to treat pigmentation. In an ongoing study conducted by the University of Zurich, investigators estimate that physical therapy with a Q-switched Ruby laser system is more effective in the removal of solar lentigines than a topical chemical therapy with a hydroquinone-containing bleaching cream⁴.

Another treatment mentioned is cryotherapy to freeze age spots, which experts note works especially well on fair skin. One of our experts uses the CryoPen and recommends not freezing too aggressively, but using it more superficially (two cycles of 2 seconds or so only) combined with a topical anti-pigment regimen and, of course, sun protection.

Complete daily regimen

The use of topical treatments has been strongly recommended by our panel. Tretinoin or other retinoids are largely prescribed by doctors to improve the skin of the hands and prevent further damage. Also prescribed, but not as common, is hydroquinone.

Protecting the hands with sunscreen is mandatory. So much about hands is about sunscreen: SPF 30 and ideally higher such as SPF 50. It is important to remember to apply often as hands are washed  so frequently.

For many doctors, anti-ageing face creams work well for the hands and there is no need for specific anti-ageing hand creams. ‘Everything I put on my face, I put on hands,’ is what one of our experts recommends. However, specific highly moisturising hand creams are ‘a must’ as the dorsal skin of the hand has typically less sebaceous glands.

One of the top choices is Dermatopics Intensive Hand Cream, only sold in doctors’ offices, which has a smooth silky feeling. Anti-ageing serums such as SkinMedica TNS serum has also been mentioned as a great anti-ageing cream to use in the morning.

Some physicians recommend a complete skincare regimen for the hands to prevent and correct the damage already done. Products mentioned for this purpose were Skinceuticals Phloretin CF Gel, rich in antioxidants, to provide an environmental protection against UVA/UVB radiation as well as a brightening action, and Jan Marini’s non-greasy SPF30–50 as a sun block. And at night, Medik8 White Balance Click Serum to correct pigmentation and La Roche-Posay Redermic R to treat wrinkles and uneven skin tone. Then NeoStrata Bionic Face Cream was also said to work well as an overnight hand mask treatment.

Hand in glove: Asia-inspired care

Sun protection for the hands is a given, but what about wearing gloves to protect our hands or even treat them?

Protective gloves in some circumstances, such as gardening and outdoor sports, is highly recommended by our panel. Skin protection with gloves during domestic duties and regular use of a moisturiser immediately after, is of upmost importance. The American Academy of Dermatology (AAD) recommends wearing gloves when doing yard work or playing any outdoor sports. Golfers should consider wearing gloves on each hand to protect them. Usually golfers only wear one glove and it creates a big discrepancy between both hands with the hand without the glove looking more aged than the one with a glove. Using cotton gloves with moisturiser over night or during morning coffee is also a great idea, according to our experts.

Do not forget the nails either. More and more doctors recommend not trimming back the cuticles. Another big ‘no-no’ is cleaning fingernails with sticks, as it may lead to infections and nail problems.

The finishing touch

Treatments for the hands can only grow in the future. As women invest more time and money in ageing gracefully, treating the hands is about to become the mandatory finishing touch along with treating both the neck and décolletage. When you think about age groups, remember women in the sixty plus range: they have younger-looking faces, which they are keen to match to younger-looking hands.

The future is no doubt about combining treatments to obtain better results and treat the multiple ageing signs that show on the hands. Combining resurfacing treatments with fillers is set to become a standard protocol, as well as fillers with non-ablative radiofrequency treatments. Adding some growth factors or stem cells to rejuvenate the skin from within will also become a winner.