Health: Looking younger on prescription

A cream claimed to be a cure for wrinkles has just been launched in Britain, though it has been denied such a licence in the US. Can it work?

WRINKLES aren't a natural consequence of ageing any more; they are a medical condition known as "photodamage'. And, according to large advertisements in the medical press, the condition can be cured. Retinova, says its makers, the Ortho Division of Janesen-Cilag, "effectively repairs years of photodamage to skin". Women need no longer trawl cosmetics' counters for lotions to iron out wrinkles; they should simply visit their GPs for a prescription.

Licensed by the British Committee on the Safety of Medicines last autumn for use as a cream for skin damage, Retinova was originally developed as an anti-acne cream (known as Retin-A) and still has a licence only for that less profitable use in the US. It was developed by an American dermatologist, Albert Kligman, who said recently: "The wrinkle is a serious disease. Do you know anyone who gets up every morning and worries about illness? But everybody worries regularly about wrinkles."

In May this year, Ortho held a launch in Britain designed to inform patients and doctors that they need suffer wrinkles no longer. The cream, which costs pounds 13.75 for a 20g tube, is available on private prescription only.

But are wrinkles a medical condition? Should middle-aged or elderly women (for it is mainly women) occupy doctors' time seeking medical help for something many people would consider part of ordinary life? Medical opinion covers a spectrum of views. Some doctors see wrinkling as almost exclusively the result of over-exposure to sunlight, and believe it worthy of medical intervention. Others think wrinkles are a natural feature of ageing, influenced not just by the sun but by diet, smoking, lifestyle and heredity - and certainly not requiring costly medical treatment.

Christopher Griffiths, professor of dermatology at Manchester University, who has carried out much of the research on Retinova, insists, "Wrinkles are not a normal part of the ageing process. Some fine lines under the eyes are due to age, while some wrinkles are due to frowning or other expressions, but even these lines are likely to be deeper if you have been exposed to the sun. Just because wrinkling is not life-threatening does not mean we should not treat it. Few dermatological conditions are going to kill you, but we still treat them."

Ronald Marks, professor of dermatology at the University of Wales College of Medicine, Cardiff, agrees. "If you look at people who have always worked indoors, they have less damaged skin."

Dr Andrew Griffiths, consultant in dermatology at St Thomas's Hospital, London (no relation to Christopher Griffiths), acknowledges that this is a complicated area. "It is hard to draw up rules to distinguish between what is medical and what is cosmetic. Some people would try and make you feel guilty for treating wrinkles, but I do not see what is wrong with it. It is only controversial in the context of the rationing inside the NHS."

Ian Kennedy, professor of medical law and ethics at King's College, London, is opposed to medical intervention. "The emergence of this cream raises yet again the difficult question as to what extent we should satisfy the ambitions of people who do not want to appear to grow old. This is part of the pursuit of Shangri-la and is in the same category as bust lifts and bottom tucks. I can't see the case for it occupying the time of busy doctors faced with far more difficult cases."

But does Retinova actually work? Does its active ingredient, tretinoin (retinoic acid), a naturally occurring derivative of Vitamin A, deliver the goods?

Most doctors believe that it makes patients' wrinkles look less obvious. There is also general agreement that the cream causes mild dermatitis, or swelling of the skin. But that is where the consensus ends. Some doctors think that it is this swelling, and this swelling alone, which causes the wrinkles to disappear, by filling in the crevices. Others believe that the cream actually restores collagen (the structural fibres in the dermis) and puts elasticity permanently back into the skin.

Sam Shuster, emeritus professor of dermatology at the University of Newcastle- upon-Tyne, says: "It is scientific nonsense to think you can reverse major collagen defects this way. The cream produces dermatitis, which makes the skin swell and so the creases become less visible. That's all it does and as soon as you stop using it, this effect will disappear.

"I have used Retin-A on my scrotum (and show photographs of it when I lecture) to illustrate the point that oedema (fluid swelling) will obliterate wrinkles. If you had a drug that could put back the collagen that is lost in ageing (about one per cent a year), it would be a major drug, but this is not it. "

But Professors Griffiths and Marks both believe that Retin-A does more than merely cause swelling. "In carefully controlled studies, we have shown that retinoic acid induces the production of new collagen in the upper part of the dermis," says Professor Griffiths. "It causes changes to the skin at a molecular level"

Professor Marks's trial on 30 patients, published in the British Journal of Dermatology, showed an improvement in the treated group, "although the improvement was judged to be slight in most cases". He does not believe that the effect is due only to swelling (though that could partly account for it), because the effect persisted a month after the end of treatment.

Dr Malcolm Rustin, consultant dermatologist at the Royal Free Hospital in north London, thinks that the jury is still out on whether Retin-A switches on collagen synthesis, but believes that if people want to try it, they should be allowed to do so. "If people feel it does them some good, even if there is no scientific basis for it, then fine."

But the underlying mechanism is crucial in one specific way. If the cream treats the symptoms rather than curing the disease, patients who want to stay young-looking will have to continue using it for the rest of their lives. It is known that the cream thins the top layer of the skin (the stratum corneum), and thereby lets in more damaging ultra-violet light. While the manufacturers recommend that anyone prescribed it must also be given a sunblock and warned to stay out of the sun, nevertheless, this property could mean patients are at an increased risk of skin cancer. In 25 years of use, no increased incidence has been found, but the numbers using the product for that length of time are small.

What do the patients who are acting as guinea pigs think about the cream? Several seem quite pleased with the results, but do not consider them dramatic.

Mrs Patricia Rowlinson, aged 66, a former ancillary nurse, who lives in Droylsden, Lancashire, has been using it for three and a half months, as part of a trial being conducted by Professor Griffiths. "My face is quite lined. The doctors say it is due to sunlight, but I think it is stress," she says. "I think the fine lines underneath my eyes are better. I can't see any other change, but the doctors seem to think all the lines are improving. I might look 21 when I've finished."

Mrs Barbara Knott, a 61-year-old school welfare officer, from Bury, Lancashire, who is also taking part in Professor Griffiths's trial, has noticed a few minor changes, but again nothing spectacular. She is fighting the ageing process with some spirit, having had cosmetic surgery on her tummy and taken to bleaching her hair. "My skin was very sun-damaged. I blame the sunbeds and going abroad. I would lie in the sun for 12 hours," she says. "I'm finding my skin a lot softer now. And one or two brown spots on my hands are disappearing, but I wouldn't say the wrinkles are going."

Whatever the cream's efficacy, its promotion can only amplify the message that ageing is a shameful process and must be disguised at all costs. The scientists at Ortho would seem to have little time for the attitude of the Irish poet Joseph Campbell, who wrote:

"As a white candle

In a holy place,

So is the beauty

Of an aged face." !