Aging hands, honestly.

The hand trial is small and unusually clean. Twenty-seven patients with multiple solar lentigines on the backs of both hands had lesions randomised to liquid nitrogen, a frequency-doubled Q-switched Nd:YAG (532 nm), a krypton laser or a 532 nm diode-pumped vanadate laser, with blinded observers grading photographs at 6 and 12 weeks. At 12 weeks the Q-switched Nd:YAG produced good, excellent or clear lightening in 89% of spots against 80% for krypton, 72% for the diode and 68% for liquid nitrogen; hypopigmentation was under 2% for all, textural change 2% for the Q-switched laser against 8% for krypton and 4% for cryotherapy, 25 of 27 patients (93%) said laser gave the best overall result, and only 8% rated the Q-switched laser most painful against 60% for the krypton (four-treatment hand trial, full results). A Zurich split-hand randomised trial in 11 patients, three sessions at weeks 0, 4 and 8, found the 694 nm Q-switched ruby "significantly more efficacious" than an ablative fractional CO2 laser for lentigines on the dorsum of the hands (p = 0.01) (ruby versus fractional CO2 trial). Across all sites, the 2025 systematic review of 41 trials in 3,234 patients aged 24–92 put Q-switched lasers at 36–77% success and picosecond lasers at 68–93%, concluded that "laser therapy appears more effective than other modalities, with an acceptable safety profile", and noted that cryotherapy carried the more severe side effects (lentigo systematic review). Strong — with the caveat that the hand-specific trials number 38 patients between them and the grade leans on the larger lentigo literature, whose biology is the same. Practicalities: a test spot in darker skin, because post-inflammatory darkening is the main risk and rises with skin type; a retinoid paused for a fortnight before; sunscreen for a month after; and a dermatologist's eye on every spot before the laser touches it, since a lentigo maligna treated as a lentigo is the one disaster on this page. The laser and IPL guide has the device physics.

Three open series and one randomised trial arm. In Japan, 31 patients with solar lentigines on the backs of the hands were treated with a 515 nm-filtered IPL at monthly intervals up to five times: 62% had more than 50% improvement and 23% more than 75%, no one stopped for side effects and "no patients showed hyperpigmentation or scarring" (IPL hand lentigo series). In Brazil, 23 patients with sun damage and lentigines had four sessions three to four weeks apart: investigators rated the improvement in lentigines and skin quality good to excellent in 100% and patients in 86.9% (20 of 23), with no significant side effects (IPL hand rejuvenation series). The largest series, 128 Japanese patients of mean age 58 treated with 560–1,200 and 515–1,200 nm filters, graded lentigines excellent in 45.3% and good in 14.8%, unchanged in 37.5% and worse in 2.3% — dark, flat spots cleared best, often after one treatment — while wrinkles were "effective" in only 25.0% after the first session (IPL in 128 Asian patients). The one randomised design used IPL as the light source for photodynamic therapy against the same IPL with placebo cream, three sessions six weeks apart in 37 patients with actinic keratoses on the hands: both arms "significantly improved photoaged skin", and the sensitiser added the keratosis clearance (PDT-IPL hand trial). The systematic review puts IPL at 74.6–90% success for lentigines and, with the pulsed-dye laser, "less associated with post-inflammatory hyperpigmentation" (lentigo systematic review). Moderate: consistent series in 182 patients and one trial arm, no head-to-head against the Q-switched laser on hands, and nothing for the crepe. Not on tanned or darker skin, where the broad spectrum burns the surrounding pigment; the laser and IPL guide has the settings and the skin-type limits.

The comparisons are all on hands. In the four-treatment randomised trial, liquid nitrogen produced good, excellent or clear lightening in 65% of spots at six weeks and 68% at 12 against 89% for the frequency-doubled Q-switched Nd:YAG, with textural change in 4% and 16% of patients rating it the most painful (four-treatment hand trial, full results). In Tehran, each hand of 25 women was randomised to cryotherapy or 33% trichloroacetic acid: cryotherapy "was more likely to produce substantial lightening" (p = 0.025) but was more painful and slower to heal, post-inflammatory hyperpigmentation was equal in both and was "the major complication", and results were significantly better in fairer skin types (cryotherapy versus TCA trial). In Boston, 99 lentigines in 13 patients randomised to cryotherapy, argon laser or low-fluence CO2 laser found cryotherapy superior to both older lasers (cryotherapy versus argon and CO2 trial). The systematic review gives cryotherapy 37–71.4% success and notes it "was linked to more severe side effects" than the lasers (lentigo systematic review), and DermNet's summary of all destructive methods applies most to this one: they "risk leaving pale or dark spots, which can be temporary or permanent" (DermNet). Moderate: randomised comparisons in 65 patients, effective in two thirds, beaten by the Q-switched laser on every measure but price. Its real value is that the person holding the canister is a dermatologist who has looked at the spot first — cryotherapy is also the standard treatment for the actinic keratoses that share the hand (extremity keratosis trial). Freeze lightly (two to five seconds), never on a tan, and expect a pale ghost where each spot was.

The controlled study is recent and small: 20 patients with hand lentigines (mean age 64.4, range 51–71) received three 15% TCA + 3% glycolic acid peels at four-week intervals on one hand, the other serving as the untreated control; 18 completed, mean pain was 3.8 on a 10-point scale, two blinded dermatologists correctly identified the after-treatment photographs in 16 patients (88%), and physician- and patient-graded improvement was significantly greater on the treated hand (split-hand peel trial). The stronger acid did less well against cold: 33% TCA lost to cryotherapy on the other hand in 25 women, though it hurt less and healed faster (cryotherapy versus TCA trial), and across the lentigo trials TCA peels achieved 12–46% success against 36–93% for the lasers (lentigo systematic review). Emerging: one blinded 18-patient trial and one comparison. The reason to consider it anyway is the reason the peelers give — a light peel evens the mottled background between the spots and softens fine crepe in one appointment, which the spot lasers do not do — and the reason to stop at "light" is the same tissue warning as for lasers: hand skin heals slowly, and medium and deep peels that are routine on a face scar on a hand. Skin of colour darkens after any peel here; a retinoid should be paused a fortnight before; and the chemical peel guide covers the acids, depths and the neutralising.

Ten patients with hand photodamage (skin types II–IV) were randomised to five treatments of a 1,550 nm fractional erbium-fibre laser on one hand at 8–9 mJ and 2,500 microscopic zones per square centimetre: patient and physician assessment at one and three months showed a mean 51–75% improvement in pigmentation and 25–50% in roughness and wrinkling, biopsies showed increased dermal collagen density, and side effects were transient redness and swelling with no scarring (fractional 1,550 nm hand study). A nine-patient series with five to six sessions found statistically significant improvement in wrinkling, pigmentation, texture and overall photodamage (23%) at six months, with histology showing fewer atypical keratinocytes, restored rete ridges, denser collagen and less solar elastosis (second 1,550 nm hand study). The ablative version, fractional CO2, was piloted in ten participants with three treatments to one hand at four-to-six-week intervals: at one month after the last, investigators rated wrinkles 26–50% improved, pigment 51–75% and texture 26–50%, participants rated texture higher, one had significant swelling after the first session, and there was "no long-term scarring or pigmentary alteration" (fractional CO2 hand pilot). For the spots specifically, the Q-switched ruby was significantly better than the fractional CO2 in an 11-patient randomised split-hand trial (ruby versus fractional CO2), and across sites the systematic review gives fractional CO2 8–23% lentigo success (lentigo systematic review). Emerging: 29 patients across three pilots, no controls, and encouraging histology. The practical rule from all three papers is conservatism — low densities, more sessions, no fully ablative resurfacing, because the hand's sparse follicles re-epithelialise slowly and the scarring that a face shrugs off is permanent here. The laser and IPL guide and the décolletage guide, another slow-healing site, have the device detail.

The Regensburg trial randomised the hands of 37 patients (mean age 68.8) with one to four mild-to-moderate actinic keratoses per hand to methyl aminolaevulinate cream or placebo, both followed by the same IPL illumination (λ ≥ 600 nm, 16.2 J/cm², three passes), three treatments at six-week intervals. Ten weeks after the last, complete keratosis clearance per hand was 54.5% with the sensitiser against 3.0% with placebo, the trial's second primary endpoint — new subepidermal collagen — was met, and "both treatment modalities significantly improved photoaged skin" (PDT-IPL hand trial). The larger comparison is against cold: 121 patients with 1,343 keratoses, 98% on the extremities, treated once on each side with MAL-PDT or cryotherapy and retreated at 12 weeks if needed, had 78% lesion reduction with PDT against 88% with cryotherapy at 24 weeks — inferior for clearance, "significantly better" for cosmetic outcome by the investigators, and preferred by the patients (PDT versus cryotherapy on the extremities). Emerging for the cosmetic claim — one 37-patient trial in which the rejuvenation was a secondary observation shared by the placebo arm, so the IPL may have done it — and established, with reimbursement in many countries, for the medical one. The reasoning for the reader with a rough, spotted hand: the keratoses have to be treated anyway, because up to 65% of squamous-cell carcinomas arise from them (actinic keratosis to SCC review), and field treatment of the whole back of the hand with a light source is the version that also lightens the lentigines and smooths the surface. Hands respond a little less than faces, so two or three rounds are usual; the sun-damage guide has the keratosis pharmacology.

The hand-specific literature is a single 2010 report of percutaneous collagen induction (medical needling) for hand rejuvenation in a plastic-surgery journal, without controls (collagen induction on hands); the microneedling guide grades the facial evidence, which is better, and the mechanism — new collagen in the dermis — is plausible for crepe on a hand with no trial to say so. Microfocused ultrasound has 67 studies in a 2025 narrative review, mapped to firmness, surface evenness, tone and glow, "with sustained effects beyond 6 months" — on the face, neck, décolletage, arms and abdomen, not the hand (microfocused ultrasound review); the dorsal hand's tendons a few millimetres down are the reason nobody has been keen to focus heat there. Radiofrequency microneedling, platelet-rich plasma, exosomes and microdermabrasion appear in the hand reviews as options — the 2016 fat-grafting review lists microdermabrasion and peeling agents as the "alternative options" fat outperforms (fat-grafting review) — and in the systematic review as seven "miscellaneous" studies, with the finding that satisfaction was lowest for the energy-based treatments (dorsal hand rejuvenation systematic review). Limited, then: not because they fail, but because no one has measured them on a hand. If a clinic proposes one, ask what it will change that the hand grading scale or a photograph can show, and compare the price per session with the fractional laser and the skin-booster rows, which have hand data for the same complaint.

The pivotal study was multicentre, single-blind and randomised 3:1: 114 subjects with moderate-to-very-severe volume loss received calcium hydroxylapatite mixed with lidocaine into the dorsum of both hands or waited three months as untreated controls, with effectiveness graded live by blinded investigators on the Merz Hand Grading Scale (12-month randomised hand trial). The posted results: mean grade 2.6 in both arms at baseline, 1.5 against 2.6 at three months; a one-grade-or-better improvement in 77.1% of treated hands against 5.2% of control hands and in 75.3% of treated subjects against 3.4% (p < 0.0001); a similar response under and over 60; the Global Aesthetic Improvement Scale at least "improved" in 97.6% at three months; and among those never retreated, responders still 73.6% of hands at nine months and 71.7% at 12, with the mean grade drifting from 1.3 back to 1.7 — the filler fading, not gone (trial results on ClinicalTrials.gov). A smaller controlled trial randomised 30 subjects 2:1 and found all 20 treated improved at least a grade at four weeks against none of the ten controls (30-subject controlled study); a 52-week series of ten women given 1.3 mL per hand had 80% of hands rated improved at nine months and 30–40% at 12 (52-week series). Safety from the same trial, in 113 treated: swelling 20.4%, bruising 18.6%, redness 8.0%, pain 6.2%, itching 3.5%, nodules or lumps 6.2%, "expected, minor, short-lived" (adverse-event table); and from the 256-person, two-year safety study of severe (grade 4) against moderate hands treated with up to 3 mL per hand and up to three retreatments: bruising 30.0% and 29.4%, swelling 24.6% and 21.4%, nodules 13.1% and 11.1%, erythema 15.4% and 6.3%, severe device- or injection-related events 1.5% and 0%, and no worsening of range of motion, dexterity, sensation or grip and pinch strength at 24 months (hand safety study). The one unusual question — it is radiopaque — was answered in 20 people X-rayed for two years: visible in 100% at one month and 83.3% at 24, "no bone obscuration" at any point (X-ray study). Strong. It is one of only two fillers with a regulatory indication for the hand (hand rejuvenation review), placed with a cannula into the structure-free superficial lamina and massaged flat. Diluted, it is also used for skin quality: in 15 women, both a deep-fat and a subdermal technique improved the grading and aesthetic scores, viscoelasticity and ultrasound dermal parameters over 24 weeks (diluted CaHA study), and a 40-woman series combined undiluted and diluted in the same session with satisfaction held to six months (dual-approach series). It cannot be dissolved, which is the argument for the hyaluronic acid row below in a first-timer; the filler guide covers the products.

The design is the fair one for a hand: each person their own control. Ninety-two subjects were randomised, 90 treated in one hand with a 20 mg/mL large-gel-particle hyaluronic acid with 0.3% lidocaine and the other hand untreated, a mean 2.1 mL at the first session and 1.13 mL at the touch-up; blinded evaluators scored both hands on the Merz Hand Grading Scale. Responders — one grade or better — were 85.9% of treated hands against 21.2% of untreated at week 12, significantly higher at weeks 16, 20 and 24 (p < 0.0001), at least 92.8% of subjects rated themselves improved on the aesthetic improvement scale at every visit, 84.5% would recommend it to a friend and 77.4% would repeat it (split-hand trial, open access). The posted counts: 73 responders of 85 against 18 of 85 at week 12 (difference 64.7 points, 95% confidence interval 53.3 to 76.1), 76 against 16 at week 16, 68 against 21 at week 20 and 63 against 25 at week 24; the treating investigators rated 83 of 84 treated hands improved at week 12 and none of the untreated (results on ClinicalTrials.gov). Tolerability from the subject diaries in the first week: swelling 75.0%, tenderness 75.0%, redness 71.6%, bruising 60.2%, pain 44.3%, itching 13.6%, impaired hand function 6.8%, "the majority resolved within 4 days"; treatment-related adverse events in 7 of 89 (7.9%), none serious (trial safety data). It became the first hyaluronic acid filler with a US hand indication in May 2018 on that study (approval announcement). The older comparisons agree: in ten women randomised to hyaluronic acid or human collagen in alternate intermetacarpal spaces, hyaluronic acid cleared the veins from view significantly better on blinded photographs at six months (hyaluronic acid versus collagen), and a 100-subject Chinese split-hand trial of a skin-quality hyaluronic acid gel over 15 months found clinically relevant differences on the hand grading scale in favour of treatment (Chinese split-hand trial). Strong. The trade against calcium hydroxylapatite: a little less lift per millilitre and a shorter run, against reversibility with hyaluronidase within a day if a lump, a vein or a regret needs it — which is why it is the sensible first hand filler. The filler guide has the rheology.

The placebo-controlled trial is small and clean: 30 women (mean age 53) received three monthly injections of 1.0 mL of a 20 mg/mL stabilised hyaluronic acid gel as microdroplets into the dorsum of one hand and 1.0 mL of saline into the other, with evaluators blinded. At three months every patient had improved on the Global Aesthetic Improvement Scale, patient scores were significantly higher for the treated hand from month one, biomechanical measurements showed significantly better hydration and elasticity than both baseline and the saline hand, maximum roughness and waviness improved against saline, all adverse events were mild, and the improvements were sustained to 12 months in the extension (skin booster versus saline trial). The earlier split-hand study in 15 volunteers compared a stabilised with a non-stabilised hyaluronic acid at weeks 0, 4 and 8: the stabilised gel produced significant improvement in elasticity and surface roughness at week 12 and higher hydration with lower water loss than the other hand, the blinded dermatologist rated it clinically superior, and by week 24 the effects "started to return back toward baseline" (stabilised versus non-stabilised study). The 100-subject Chinese trial of a hyaluronic acid gel for dorsal hand skin quality over 15 months adds the largest numbers, with clinically relevant differences on the hand grading scale and biophysical measures of elasticity, roughness and hydration in favour of treatment (Chinese trial). Moderate: three controlled studies in 145 people, all showing the same thing — a better surface for six to twelve months — and none of them showing a lift, because there is no volume in a microdroplet. The honest use is the hand whose complaint is crepe and dryness rather than veins, or the top layer of a two-part plan over a volume filler; expect to repeat it yearly, and expect the effect to be one that a photograph in good light shows and a photograph in bad light does not.

The technique dates from the structural fat grafting described in 2002: fat harvested with a blunt cannula, cleaned by centrifugation or decanting, and placed as minuscule parcels through many passes so each meets recipient tissue and survives, restoring "a slight fullness to atrophic subcutaneous tissue" and softening the exposed tendons and veins (structural fat grafting technique). The 2022 systematic review pooled ten studies and 320 patients (93.1% women): volumes of 10–39 mL per hand, most needing one session; some postoperative oedema "in nearly all patients", ecchymosis 7%, temporary dysesthesia 5.3%, cysts or irregularities 1.3%, infection 0.67%, no major complications; 97.6% self-reported satisfaction; and the frank verdict that "unpredictable graft resorption is the greatest drawback", with survival ranging from 30% to 83% in the literature — one 3D-scanned series retaining a mean 10.3 mL of 25.5 injected (about 40%) at eight months (fat transfer systematic review). The 2025 review found 11 studies and 303 patients, three small randomised trials (comparing preparation methods, not fat against filler), high satisfaction, and the same warning that "fat graft resorption may require multiple treatments" (2025 systematic review). The measured case: 3D surface scanning found 69% of the injected volume still present at six months in one hand (3D volumetric case). The long series: 65 patients over 12 years, 10–30 mL per hand, decanted rather than centrifuged, injected from the wrist above the deep fascia: 84% satisfied, 12% "somewhat satisfied" and needing a second graft, 4% dissatisfied, three cases of temporary swelling, no long-term complications (12-year fat grafting series). The rare harm is on record: an atypical mycobacterial infection of both hands after fat grafting in a 55-year-old, needing months of treatment (M. abscessus after hand fat grafting). Moderate: hundreds of patients, consistent satisfaction, no comparison against the fillers that have randomised controlled trials, and a durability that cannot be promised for any individual hand. It suits the person who has done the reversible trial with a filler, liked it, and wants it once; the regenerative aesthetics guide covers nanofat and the stem-cell claims.

Poly-L-lactic acid does not fill; it provokes. Reconstituted to five to eight millilitres and injected in 2–4 mL portions into the intermetacarpal spaces, it is cleared over months while the fibroblasts around it lay down collagen that thickens the tissue. The founding series treated 27 patients (mean age 65.9) in 109 sessions between 2004 and 2005, every hand treatment paired with a face or neck treatment, and reported that most were satisfied (PLLA hand series); the newer poly-D,L-lactic acid has a 2024 pilot on the dorsal hand (PDLLA pilot); and the hand reviews list it among the options without a controlled study to grade (hand rejuvenation review). Emerging: uncontrolled series, no blinded grading on the hand scale, and a mechanism that is slow, cumulative and cannot be reversed. The case for it is a gradual change that no one notices happening and a duration often quoted at two years; the case against is that the two fillers above have randomised blinded trials of over 100 people each and produce their result in the chair, and that the diluted calcium hydroxylapatite row does the biostimulation with better hand data. Nodules are the specific risk of any stimulator placed too superficially or massaged too little, and on a hand they are felt with every handshake. The regenerative aesthetics guide covers the biostimulator class.

The largest series is the argument for and against at once. One hundred healthy women (mean age 56.5) had sclerotherapy of dilated dorsal hand veins of 1–6 mm: the 20 treated with 0.5% sodium tetradecyl sulfate or 1.5% polidocanol failed in 16 (80%), while 3% polidocanol succeeded in 76 of 80 (95%); adverse events "common to sclerotherapy" — pain, bruising, oedema of various degrees, thrombosis of the treated veins — were observed in 90%, 14.5% of the successes developed microscopic new vessels (matting), and one patient had transient palsy of the superficial radial nerve after a vein on the thumb web was treated (100-patient sclerotherapy series). Foam versions are gentler: a retrospective review of 41 hand patients treated with 0.2% sodium tetradecyl sulfate or 0.5% polidocanol foam over a mean of 1.5 sessions found coagulum in 15.2% of sessions, induration, oedema and hyperpigmentation rare, no thrombophlebitis, ulceration or nerve events, and significant improvement in 63.2% at three months (foam sclerotherapy review); a telephone survey of 21 of 45 foam patients scored improvement 2.55 of 3 (foam sclerotherapy survey). The endovenous laser: 54 hands in 28 patients treated in the office with a 940 nm fibre under tumescent anaesthesia, on average four veins per hand; all but one vein cannulated, all 28 patients satisfied at up to 31 months, hand swelling in every treated hand for up to two weeks, one 3 mm skin burn (endovenous laser series). And the harm: acute ischaemia of a fingertip after elective sclerotherapy of a dorsal hand vein, reported by hand surgeons who note that as the procedure "grows in popularity", awareness of this "rare but potentially devastating complication" is essential (hand ischaemia case). Emerging: series without controls, a real effect, permanent, and a specific injury on record. The editorial position is in the safety section: the dorsal hand veins are the veins of the rest of your medical life, and a filler placed over them hides them in a blinded trial without removing them (vein-clearance scores with filler). If the reader still wants them gone, a phlebologist, the foam, the smallest effective concentration, the non-dominant hand first, and never both hands in one sitting.