Evaluation of a Neck Cream Developed to Enhance Nitric Oxide Availability in Aging Skin – Updated by CC

September 2023 | Volume 22 | Issue 9 | 7210 | Copyright © September 2023


Published online August 3, 2023

doi:10.36849/JDD.7210

Deanne Mraz Robinson MD FAADa, Joely Kaufman MDb, Alessia Giannini BAc, Syed Minhaj Rahman c,d, Mitchell Wortzman PhDe, Diane B. Nelson RN MPHe

aModern Dermatology, Westport, CT; Assistant Clinical Professor of Dermatology, Yale, New Haven, CT;Founder DMR Research, PLLC, Ridgefield, CT; Chief Medical Officer, Ideal Image, Tampa, FLbSkin Research Institute, Coral Gables, FLcDMR Research, Westport, CTdCollege of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NYeskinbetter science, LLC, Phoenix, AZ

Abstract
Background: To meet the unique needs of aging skin of the neck, a new neck cream that enhances nitric oxide availability has been developed to visibly improve signs of aging and overall quality of skin. Methods: The primary objective of this dual center, open label clinical trial was to assess the efficacy and tolerability of the new neck cream applied twice daily over 12 weeks in aging women with mild-to-moderate lines and wrinkles of the neck (Group 1, N=26). A second group with mild-to-moderate lines and wrinkles and photodamage of the neck and décolleté (Group 2, N=10) applied the neck cream (AM/PM) in combination with a double-conjugated retinoid/alpha hydroxy acid (AHA-Ret; PM) to both the neck and décolleté over 12 weeks. Results: Group 1 demonstrated significant improvements from baseline in the neck of 21% (P=.007) for wrinkles and lines, 27% (P=.004) for skin texture, and 26% (P=.003) for skin tone at 12 weeks. Significant improvements were also observed at 4 and 8 weeks. In Group 2, significant improvements were observed from baseline in the neck and décolleté areas with a 34% (P=.01) improvement in photodamaged skin in the décolleté area. The neck cream was well tolerated with few mild and transient adverse events. Conclusion: A new neck cream formulated to enhance nitric oxide availability to the skin when applied alone or in combination with AHA-Ret provided statistically significant improvements from baseline in skin appearance of the neck and décolleté, most notably in lines and wrinkles, skin texture, and skin tone. J Drugs Dermatol. 2023;22(9): doi:10.36849/JDD.7210

INTRODUCTION-updated by CC

It is well known that regions of human skin exposed to the environment can incur significant damage due to sun, wind, and indoor and outdoor pollutants. The pathological effects of skin exposure to sunlight have been studied extensively and are well documented.1-3 In general, the areas most exposed to the environment are the skin of the face and neck. These regions are much less protected by clothing compared to skin on other exposed parts of the body.4 In addition to being more vulnerable to environmental insults and oxidative stress, skin on the neck is thinner and especially prone to signs of aging due to the biomechanical properties of repetitive movement and extensibility, which increases its susceptibility to wrinkles and sagging. The presence of fewer sebaceous glands, especially in women, as well as less collagen and subcutaneous fat leads to less oil production, less moisture, loss of volume, and increased skin laxity.4,5 Further, the neck region is often neglected in terms of a lack of application of moisturizer and sunscreen.5
In addition to environmental insults at the surface of the skin, internal cellular processes are associated with aging that lead to diminished levels of nitric oxide (NO) within the skin.6-8 NO plays a vital role in maintaining homeostasis in the skin by increasing microvascular delivery of nutrients and oxygen to cells, including fibroblasts, and NO contributes to maintenance of the protective barrier function of skin as well as wound healing and tissue regeneration.7,9-13 The extensive microcirculatory system is located next to the reticular dermis within the dermis layer.14-16
 
Aging is associated with deficits in NO availability, that contribute to a 40% reduction in blood flow to the skin.10,11 As a result of reduced delivery of nutrients and oxygen, cells function less efficiently, making them more vulnerable to accelerated skin aging.11 NO synthases (NOS) produce NO from the oxidation of arginine, and increases the bioavailability of NO to the skin.7 Arginine is the sole substrate for intrinsic and extrinsic NO production in skin. Accordingly, production of NO by NOS largely depends on adequate availability of the substrate arginine from dietary sources.7,17 As we age, the enzyme arginase is upregulated resulting in the degradation of arginine, the downregulation of NO production, and endothelial dysfunction.6,17 Arginase activity limits the availability of arginine to support NO generation.
To meet these unique needs for aging neck skin, a new neck cream (NC) has been developed to enhance NO availability to the skin and to visibly improve signs of aging and overall quality of skin. The NC is comprised of a complex of amino acids including adenosine, carnosine, arginine, and a proprietary complex stabilizer (NOw Complex) as well as additional targeted ingredients (Table 1). These targeted ingredients help in firming the skin by supporting collagen, skin hydration and the skin’s barrier function, and defending against free radicals. An ex vivo study was conducted to evaluate changes in NO levels following application of the NC. Skin tissue was obtained from a female donor (59 years, Fitzpatrick Skin Type [FST] II) following abdominoplasty. The study occurred within 72 hours of the collection of the skin. NC or saline (15 mL) was applied to the surface of the tissue (N=4 per group). After 48 hours, test materials were removed from the tissues and total nitrate/nitrite protein concentration was determined using a standard ELISA assay.  Tissues treated with NC demonstrated a significant increase in total nitrate/nitrite concentration compared to tissues treated with saline (P<.05; Figure 1), confirming that the NC supports NO availability in human skin.  
 

OBJECTIVES

The study's primary objective was to evaluate improvements from baseline in the appearance of the neck area following twice-daily (AM/PM) application of the NC over 12 weeks. A secondary objective of the study was to evaluate complementary use and improvements from baseline in a subset of participants in the appearance of the neck and décolleté areas following twice-daily (AM/PM) application of the NC and once-daily (PM) application of a double-conjugated retinoid/AHA cream (AHA-Ret) 12 weeks.

MATERIALS AND METHODS

Study Design
This dual-center, open-label study conducted by two board certified dermatologists, evaluated twice-daily (AM/PM) application of the NC to the neck area only in female participants with mild-to-moderate lines and wrinkles (Group 1) over 12 weeks. A second group of participants (Group 2) enrolled with mild-to-moderate lines and wrinkles and photodamage of the neck and décolleté areas. Both Groups 1 and 2 applied the NC twice daily (AM/PM) in combination with application of a double-conjugated retinoid/AHA cream (AHA-Ret; PM) to both the neck and décolleté over 12 weeks (Group 2).
Study Population
Eligible participants were females, 35 to 65 years of age with FST I-VI with no known medical conditions that could interfere with their participation in the study. Each agreed to minimize exposure to sunlight and use a sunscreen prior to going outdoors at least once per day. Participants with mild (minimum score of 3)-to-moderate (maximum score of 6) lines and wrinkles of the neck only based on a 10-point grading scale: (0 [no wrinkles], 1-3 [fine wrinkles], 4-6 [fine-to-moderate-depth wrinkles, moderate number of lines], and 7-9 [fine-to-deep wrinkles, numerous lines, with or without redundant skin]) were eligible to participate in Group 1 of the study. In addition, participants determined to have mild-to-moderate lines and wrinkles and photodamage of the neck and décolleté areas based on the following 10-point grading scale were eligible to participate in Group 2 of the study: (0 [no pigmentary changes, brown spots, patches, or discoloration; no wrinkles], 1-3 [mild amount of hyperpigmentation, visible brown spots, patches, or discoloration; fine wrinkles and number of lines], 4-6 [moderate amount of hyperpigmentation, visible brown spots, patches, or discoloration; fine-to-moderate-depth wrinkles, moderate number of lines], and 7-9 [Severe amount of hyperpigmentation, visible brown spots, patches or discoloration; fine-to-deep wrinkles, numerous lines with or without redundant skin]).
Exclusion criteria included dermatological disorders (eg, severe acne vulgaris, severe Poikiloderma of Civatte); autoimmune diseases; moderate-to-severe laxity and platysmal banding; current or recent use to the neck or décolleté areas (within prior 2 weeks) of any cosmetic product containing AHAs, peptides, growth factors, skin lightening/brightening agents; current or recent use (within prior 4 weeks) of any prescription or non-prescription retinoids/retinols or other vitamin A derivatives, hydroquinone, or any product that, in the investigator’s opinion, would interfere with the study. Participants who had undergone chemical peels, microdermabrasion, microneedling, neuromodulator injections, or like procedure within the prior 3 months; dermal filler injections, non-ablative laser resurfacing or like treatment/procedure, radiofrequency, and/or ultrasound within the prior 6 months; pregnant, lactating, or planning a pregnancy during the study were excluded from participation in the study.
Study Methods
Investigators assessed parameters at baseline, 4, 8, and 12 weeks. Assessments of lines and wrinkles (Groups 1 and 2) and photodamage (Group 2) were based on the respective 10-point grading scales. Evaluation of skin texture, skin tone, and erythema (Groups 1 and 2) were assessed using a 6-point grading scale (0 [None] to 5 [Severe]). Eligible participants provided written informed consent and were assigned a washout period if needed. Images were captured using Canfield Imaging Systems (Canfield Scientific Inc. Parsippany, NJ). Distance and lighting were consistent from image to image. All participants completed self-assessment questionnaires at baseline, 4, 8, and 12 weeks, and Adverse Events (AEs) were captured throughout the study period. Participants were provided with a moisturizer, cleanser, and a mineral-based sunscreen (SPF 56).
The study was conducted under approval by an Independent Review Board (Advarra, Columbia, MD) and in accordance with Good Clinical Practice (GCP) Guidelines.
Statistical Analysis 
Endpoints were analyzed as mean least squares (LS) improvement and mean LS percent improvement from baseline to each timepoint. Mean percent improvement over time was based on the adjusted means (LS Means). Adjusted means were calculated using a general linear model, considering individual values at baseline for each variable.

RESULTS - Updated by CC

Demographics Thirty-six (36) participants were enrolled (Group 1, N=26; Group 2, N=10), and 34 participants completed the study. Two participants terminated early, one was lost to follow up and one withdrew consent. The mean age of participants was 54 years in Group 1, and 50 years in Group 2. Most participants enrolled were FST IV and II (44% and 28%, respectively), and the majority of participants in Group 1 and Group 2 presented with moderate neck lines and wrinkles at baseline (73% and 60%, respectively).
 
Efficacy
In Group 1, participants demonstrated significant mean visible improvements from baseline at 12 weeks in the appearance of the neck area with a 21% (P=.007) improvement in lines and wrinkles, 27% (P=.004) in skin texture, and a 36% (P=.0003) improvement in skin tone (Figure 2). A 24% improvement from baseline in the appearance of erythema of the neck area was also observed at week 12 (P=.18). Early, significant, visible improvements were also observed in Group 1 in skin texture and skin tone, respectively, at 4 weeks (17%, P=.0005; 22% P=.0004) and 8 weeks (22%, P=.005; 38%, P<.0001). Digital photography demonstrating visible improvements of neck skin from baseline through week 12 are shown for Group 1 (Figure 3).  In Group 2, significant mean visible improvements from baseline were observed in the neck area at 12 weeks with a 27%
 
(P=.003) improvement in lines and wrinkles, 36% (P=.0001) in skin texture, and 36% (P=.002) in skin tone (Figure 4A). Early, significant visible improvements in the neck area of Group 2 were also observed at 4 weeks in skin texture (13%, P=.03) and skin tone (22%, P=.008) and at 8 weeks in lines and wrinkles, skin texture, and skin tone (22%, P=.004; 28% P=.001; and 41% P=.001, respectively). Significant mean visible improvements were observed from baseline at 12 weeks in the décolleté area of 34% (P=.01) in photodamage and 30% (P=.002) in lines and wrinkles (Figure 4B). Visible improvements from baseline through week 12 are shown for Group 2 (Figure 5).
Participant Satisfaction
Participants in both Groups 1 and 2 reported high levels of satisfaction throughout the study period. In Group 1, 96% of participants reported that the skin on their neck looked less crepey and saggy, firmer and tighter, and felt more hydrated. In Group 2, 100% of participants reported that the skin on their neck and décolleté looked less crepey and saggy, was hydrated, felt firmer and tighter, and looked brighter.
Tolerability
The NC alone and in combination with the retinoid/AHA (AHA-Ret) cream was well tolerated with few mild, transient reports of localized irritation including dryness and flakiness, redness, and itching possibly related to the study product (n=5, Group 1; n=3, Group 2).

DISCUSSION

Formulated to enhance NO availability to the skin, the NOw Complex is comprised of adenosine, carnosine, and arginine amino acids along with a proprietary stabilizing ingredient to supplement and support skin’s natural process of NO generation, essential for microvasculature integrity and delivery of nutrients in the skin. Results from an initial exvivo study demonstrated that application of the NC significantly increased levels of NO vs saline in human skin tissues. These results suggest that, when topically applied, the new NC supports an increase in NO levels in the skin by direct enzymatic action through NOS.7,17 Twice-daily application of the NC resulted in statistically significant visible improvements of the neck, including lines and wrinkles, skin texture, and skin tone by week 12 of the study. In addition, significant improvements were observed as early as 4 weeks in the appearance of lines and wrinkles, skin texture, and skin tone. Application of the NC in combination with a double-conjugated retinoid/AHA cream (AHA-Ret) provided complimentary benefits in improving the appearance of photodamaged skin of the neck and décolleté. AHA-Ret has been previously shown to cause less irritation than other
 
topical retinoids, including retinol and tretinoin.18 In this study, application of the NC alone and in combination with AHA-Ret was well tolerated.

CONCLUSION

A new NC formulated to enhance NO availability to the skin provided statistically significant improvements from baseline in several measures of skin appearance of the neck and décolleté, most notably in lines and wrinkles, skin texture, and skin tone. Improvements were observed as early as 4 weeks when applied alone or in combination with a double-conjugated retinoid/AHA cream (AHA-Ret).
Participants reported high levels of satisfaction with both product regimens throughout the study period. Both study products were well tolerated with few mild and transient adverse events. This study supports the use of a tolerable and effective new NC when used alone or in combination with a double-conjugated retinoid/AHA cream (AHA-Ret) in the evening to improve visible signs of skin aging and overall quality of skin in the neck and décolleté areas.

DISCLOSURES

Deanne M. Robinson MD is an investigator and consultant for skinbetter science, LLC; Joely Kaufman MD is an investigator and consultant for skinbetter science, LLC; Mitchell Wortzman PhD and Diane B. Nelson RN MPH are employees of skinbetter science, LLC. Alessia Giannini BA and Syed Minhaj Rahman have no conflicts of interest to declare.

REFERENCES

  1. Kligman AM, Grove GL, Hirose R, et al. Topical tretinoin for photoaged skin. J Am Acad Dermatol. 1986;15:836-859.
  2. Kligman LH. Topical retinoic acid enhances repair of ultraviolet damaged dermal connective tissue. Connect Tissue Res. 1984;12:139-150.
  3. Zelickson AS, Mottaz JH, Weiss JS, et al. Topical tretinoin in photoaging: an ultrastructural study. J Cutaneous Aging Cosmet Dermatol. 1988;1:41-47.
  4. Shadfar S, Perkins SW. Anatomy and physiology of the aging neck. Facial Plast Surg Clin North Am. 2014;22:161-170.
  5. Kim E, Cho G, Won NG, et al. Age-related changes in skin bio-mechanical properties: the neck skin compared with the cheek and forearm skin in Korean females. Skin Research and Technology. 2013;19:236–-241.
  6. Pourbagher-Shahri AM, Farkhondeh T, Talebi M, et al. An overview of NO signaling pathways in aging. Molecules. 2021; 26:4533.
  7. Gad MZ. Anti-aging effects of l-arginine. J. Advanced Research 2010;1:169- 177.
  8. Adler BL, Friedman AJ. Nitric oxide therapy for dermatologic disease. Future Sci. OA 2015;1:FSO37.
  9. Cals-Grierson MM, Ormerod AD. Nitric oxide function in the skin. Nitric Oxide. 2004;10:179-193.
  10. Ryan T. The ageing of the blood supply and the lymphatic drainage of the skin. Micron. 2004; 35:161-171.
  11. Bentov I, and Reed MJ. The effect of aging on the cutaneous microvasculature. Microvasc Res. 2015; 100:25-31.
  12. Bruning RS, Santhanam L, Stanhewicz AE, et al. Endothelial nitric oxide synthase mediates cutaneous vasodilation during local heating and is attenuated in middle-aged human skin. J. Appl. Physiol. 2012;112:2019-2026.
  13. Del Rosso JQ and Kircik L. Spotlight on the use of nitric oxide in dermatology: What is it? What does it do? Can it become an important addition to the therapeutic armamentarium for skin disease? J Drugs Dermatol. 2017;16(Suppl 1):s4-10.
  14. Sanchez B, Li L, Dulong J, et al. Impact of human dermal microvascular endothelial cells on primary dermal fibroblasts in response to inflammatory stress. Frontiers in Cell and Developmental Biology. 2019;7(44).
  15. Charkoudian, N. Skin blood flow in adult human thermoregulation: how it works, when it does not, and why. Mayo Clin. Proc. 2003; 78:603-612.
  16. Gutterman DD, Chabowski DS, Kadlec AO, et al. The human microcirculation: regulation of flow and beyond. Circ Res. 2016; 118:157-172.
  17. Johnson JM, Minson CT, Kellogg DL Jr. Cutaneous vasodilator and vasoconstrictor mechanisms in temperature regulation. Compr Physiol. 2014;4(1):33-89.
  18. Bruch-Gerharz D, Ruzicka T, Kolb-Bachofen V. Nitric oxide in human skin: Current status and future prospects. J. Invest. Dermatol. 1998;110:1-7.
  19. McDaniel DH, Mazur C, Wortzman MS, Nelson DB. Efficacy and tolerability of a double-conjugated retinoid cream vs 1.0% retinol cream or 0.025% tretinoin cream in subjects with mild to severe photoaging. J. Cosmet Dermatol. 2017;1-7.

AUTHOR CORRESPONDENCE

Deanne Mraz Robinson MD FAAD [email protected]
Close Menu