Aesthetic Management of the Aging Hand

The Clinical Problem ( Fig. 37.1 )

The hand is a major organ of the body. It is a sensory organ that has locomotor function and is used as a means of communication and assessing social status. The features of an aging face are in many ways similar to the features of an aging hand. Both show degenerative features in the skin as well as a reduction in the volume and consistency of tissue. Both are prone to the ravages of sun exposure. In the hand, skeletal joint changes in the form of arthritis can cause functional restriction, as well as deformity. Despite the hand being an important aesthetic unit in its own right, rejuvenation of the face, breasts, and trunk frequently takes priority for most patients.

Skin changes to the hand occur naturally over the passage of time but can be influenced by sun exposure, occupation, and genetics. In intrinsic aging, the skin may feel dry, develop fine wrinkles, and appear smooth and pale. Pigmented lesions usually arise from photo-aging of the skin. The epidermis thins, with flattening of the dermoepidermal junction, keratinocytes are less proliferative, and the skin can feel dry and rough. Dermal and epidermal thinning combined with less active or fewer melanocytes make the skin appear paler and shiny. The underlying vessels can be disrupted with minor trauma, presenting with ease of bruising due to capillary fragility. The skin on the dorsum of the aging hand is more prone to shear forces, and minor trauma can break the integrity of the skin in older adults. Surprisingly, though, such wounds invariably heal well.

In vasospastic disorders, botulinum toxin has been used to enhance the blood supply to the digits by blocking release of autonomic neuromuscular transmitters within the digital vessels , subsequently improving the appearance of the skin. Even in the absence of disease, there is small muscle atrophy and fat volume reduction naturally in the hand, both to the dorsal and palmar surfaces, appearing as guttering between the metacarpals and generalized wasting with skin wrinkling and thinning ( Fig. 37.2 ). Arthritic changes or nerve entrapment resulting in reduced muscle activity can also contribute to this appearance.

Other lesions such as actinic keratosis and basal papillomas are commonly seen in photo-aging, as are variants of malignancy, from Bowen disease to full squamous cell carcinomas.