A Five-Step Guide to Treating High Risk Clients
The wide range of treatment options delivered by experienced practioners works exceedingly well in transforming the appearance and enhancing the emotional well-being of the patients. However, some of these treatments can potentially cause significant side effects, especially when used aggressively on patients with skin disorders such as eczema, rosacea, and sensitive skin.
For example, a long-time patient of mine asked me if she should try dermaplaning to remove vellus hair on her cheeks. This patient is a 49-year-old Caucasian woman with blonde hair and fair skin. She has a history of basal cell skin cancer on her left forehead, and is currently dealing with mild symptoms of rosacea. She also had eczema as a child and has sensitive skin.
I asked a few questions and shared my opinions and thoughts about the risks and benefits of the procedure. I marveled at the amazing innovations in the field of anti-aging. Currently, a patient has the options of choosing simple treatments (e.g. facial, exfoliation, dermabrasion and dermaplaning) to light-based therapies such as laser, IPL and LED treatment. If still not satisfied, she can try microneedling, Botox and filler injections before considering surgery.
However, none of the above may be suitable if the patient has eczema, rosacea, or sensitive skin. In this short review, we will briefly introduce these three skin conditions to raise awareness and highlight the central pathologic mechanism of these issues. Lastly, we will provide a five step guide for practitioners to deliver the best care to this group of patients.
Eczema, Rosacea, and Sensitive Skin
Eczema is a common skin condition that affects 30 million Americans. People with eczema have an itchy, red rash commonly seen on the face, behind the knees, and on the flexor surface of the elbows. However, the rash can also be found on the trunk, hands, neck and scalp. The disease can be very itchy, which prompts uncontrollable scratching, inevitably leading to worsening of the disease. The good news is that the disease tends to improve as kids grow into adults. However, these adults may have sensitive skin that tends to itch, burn or sting easily.
Rosacea is another common skin disorder affecting seven million Americans. People with rosacea often have fair skin, and the disease usually first appears when people reach their 40’s. Initially, they present with a reddish complexion of the face. Over time, they can develop small broken blood vessels on their cheeks and nose. As the disease progresses, one can develop papules, and even pustules on the face. Aggravating factors include intense sun exposure, alcohol consumption, emotional stress, drinking hot beverages and eating spicy food.
Aside from these two common skin disorders, a large portion of Americans have sensitive skin. In one study, 40 percent of women reported having sensitive skin, as manifested by stinging, burning, and/or an itching sensation. Some of those individuals had asthma and eczema in childhood. The challenge with this group of patients is there may not be any specific telltale signs to make a diagnosis.
Stratum Corneum – The Key to Barrier Function
The common thread that links these three conditions is the concept of skin barrier. Anatomically, the skin barrier refers to the stratum corneum, the outermost layer of epidermis. This is a thin layer of dead skin that is only 10-40 μm in thickness. The thickness of the stratum cornea varies, depending on the anatomic location. For example, the stratum corneum on the eyelid is much thinner compared to the palms, back and bottom of the feet.
The stratum corneum is formed from layers of living cells in the basal layer of the epidermis. As the epidermal cells mature and migrate upward to the outer surface of the skin, these skin cells shed their nucleus and other cellular organelles, to form corneocytes. Wrapped around the corneocytes are fatty acids and phospholipids that bind the corneocytes together, forming the barrier in a “brick and mortar” arrangement.
An intact skin barrier serves multiple functions, such as regulating transepidermal water loss and blocking allergens, irritations, and bacteria from entering the living portion of the epidermis and dermis.
Various factors can disrupt the physical integrity of the stratum corneum and weaken the skin barrier. Those factors include cold temperature, dry ambient air, intense UV exposure from the sun, chemical ingredients (e.g., acid peels) or mechanical abrasions such as scratching, and treatments such as dermabrasion, laser resurfacing, and microneedling and dermaplaning.
Weakening of the skin barriers worsens eczema, rosacea and skin sensitivity. For example, a patient with eczema and a poor skin barrier will allow increased penetration of irritants into the living portion of the epidermis. The ensuing release of inflammatory cytokines can trigger an itch-scratch cycle, creating a vicious cycle that makes eczema worse. Disruption of the skin barrier in patients with rosacea can lead to inflammation and vasodilation. Clinically, patients will present with an increase in redness of complexion and increase in number and size of blood vessels on the face.
Routine facial treatments, such as cleaning with an astringent cleanser and/or toner or excessive exfoliation can weaken the skin barrier. Procedures such as dermaplaning, microneedling and dermabrasion definitely break the barrier.
Caution must be exercised when performing procedures in this group of patients. Otherwise, there is an increased risk of developing potential side effects ranging from rash, acne breakouts, flare ups of diseases, and worse yet, bacterial and viral infections. On a less severe note, your clients may look and feel better when they leave your office, but will have no improvement. The next time you see them, they may complain that your treatment did not work.
Five Steps To Ensure Optimal Care
• First, obtain a good medical history. This is a good practice for any healthcare provider. Aside from understanding the patient’s wishes, needs and concerns, inquiry about personal and family medical history will prompt you and your team to identify high risk patients. It is a good idea to simply ask if your clients have eczema, rosacea, and sensitive skin. Medication history is also helpful. For example, if a client is on anticoagulants such as Coumadin, Pradaxa, Xarelto, Eliquis, or aspirin, they have a higher risk of developing bleeding or bruising.
• Second, perform a thorough skin exam. The exam should be performed in a setting with good ambient lighting. Consider using a magnifier or loop if needed. In addition to visual inspection, palpate and feel the skin. Most of the time, your exam will be focused on the face, neck and chest area. If you suspect your client has eczema, look for rashes at the wrist, inner elbow and back of the knees to confirm your suspicion. A good skin exam helps you to better appreciate the texture and overall health of your clients’ skin, thereby helping you to formulate an optimal treatment course. On a subconscious level, your client will appreciate your service because they will appreciate your thorough exam.
• Third, design the appropriate treatment. In the field of medicine, the next frontier of advancement is to deliver personalized medicine based on genetic profiles. Although gene-based therapy may be decades away in the field of esthetic care, we should tailor an individual and appropriate treatment for each client. Instead of following preset protocols blindly, an experienced and knowledgeable esthetician uses the protocol and makes slight adjustments to enhance the outcome. In the case of dealing with patients with eczema, rosacea, or sensitive skin, it may be judicious to follow the principle of “less is more.” Specifically, consider reducing intensity, concentration, depth of penetration, frequency and duration of the treatment to prevent potential damage to the skin barrier.
• Fourth, spend the time discussing home care regimens. One of the great services you can provide is to educate your patients about an appropriate skin care routine. There is a large gap in basic skin care knowledge in the general public. Myths and misconceptions still prevail, and erroneous concepts can undo all the benefits of your treatment. For example, a patient raved about the cleanliness of her bar soap. Yet, she cannot understand why her skin is so dry and irritated. This example may be obvious to all of us, and yet, how many of us still prescribe complicated skin care regimens with astringent actives that are actually making skin worse, especially for clients with sensitive skin?
• Fifth, call your patients the next day. As a routine in our surgical practice, we often call our patients the next day after major surgeries. A quick call can be very reassuring to the patients and to me, the surgeon. This practice can be incorporated into the field of esthetic care, especially for clients with sensitive skin, rosacea or eczema. The purposes of the calls include providing assurance, addressing any lingering questions, repeating care instructions, and making sure your patients are happy with the outcome. Trust me, your patients will be pleasantly surprised by the call, and this extra care will set you apart from other estheticians. More importantly, your clients’ sincere gratitude will be rewarding for you and your team.
A large portion of Americans have sensitive skin, eczema and rosacea. Your next client may have one or all three of these conditions. Recognizing the signs and symptoms and tailoring your treatment accordingly are important steps in ensuring optimal results. As for my patient mentioned earlier, I told her that dermaplaning in the hands of trained practitioners can definitely remove vellus hair and transiently improve her appearance. She will need to share her medical information with her esthetician before the procedure so they can adjust her treatments as necessary. If she is worried, consider treating a small area of the face as a test. Most importantly, pay attention to any side effects the days after the procedure. Now, what would you do next time a similar client seeks your service?