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Milady’s Aesthetician Series:
Peels and Chemical Exfoliation
Edition: 2
Pamela Hill, R.N.
President, Milady: Dawn Gerrain
Publisher: Erin O’Connor
Acquisitions Editor: Martine Edwards
Product Manager: Philip Mandl
Editorial Assistant: Elizabeth Edwards
Director of Beauty Industry Relations:
Sandra Bruce
Senior Marketing Manager:
Gerard McAvey
Production Director: Wendy Troeger
Senior Content Project Manager:
Nina Tucciarelli
Art Director: Joy Kocsis
© 2010, 2006 Pamela Hill
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Library of Congress Control Number: 2009937737
ISBN-13: 978-1-4354-3866-8
ISBN-10: 1-4354-3866-3
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Printed in Canada
1 2 3 4 5 XX 10 09
Contents
xi
Preface
xii
About the Author
xiii
Reviewers
xiv
Acknowledgments
Chapter 1
1 INTRODUCTION TO PEELS AND PEELING
1
Key Terms
2
Learning Objectives
2
Introduction
3
Evolution of Skin Care
5
History and Origins of Peels and Peeling
6
Chemical Peeling
12
Training
15
Aesthetic Employment Opportunities and Considerations
26
Top Ten Tips to Take to the Spa
26
Chapter Review Questions
27
Chapter References
28
Bibliography
v
vi
Contents
Chapter 2
31 ANATOMY AND PHYSIOLOGY OF AGING AND
SOLAR DAMAGED SKIN
31
Key Terms
32
Learning Objectives
32
Introduction
33
Layers of the Skin
41
Aging Skin
46
Skin Cancers
48
48
49
Chapter References
51
Bibliography
Chapter 3
53 HEALING PEELED SKIN
53
Key Terms
53
Learning Objectives
54
Introduction
58
Wounds
64
Wound Healing Compromised
70
Normal Scarring
75
Conclusion
75
76
77
Chapter References
79
Bibliography
Contents
Chapter 4
83 FUNDAMENTALS OF SKIN CARE
83
Key Terms
84
Learning Objectives
84
Introduction
85
Cosmeceuticals
89
Cleansers
93
Alpha Hydroxy Acids
95
Vitamin C
97
Moisturizers
100
Sunscreens
102
Hydroquinone
104
Retinoids
107
Conclusion
107
108
109
Chapter References
110
Bibliography
Chapter 5
113 ASSESSING CLIENT’S SUITABILITY AND
PREDICTING PEEL EFFICACY
113
Key Terms
113
Learning Objectives
114
Introduction
114
Skin Condition
115
Skin Typing
125
Aging Analysis
133
Practical Application: Consultation
vii
viii
Contents
143
Selecting Peel Candidates
148
Conclusion
148
149
150
Chapter References
150
Bibliography
Chapter 6
153 UNDERSTANDING CHEMICAL PEELING
153
Key Terms
153
Learning Objectives
154
Introduction
154
Principles of Chemical Peeling
160
Types of Peeling Agents
165
Best Responses to Chemical Peeling
172
Contraindications for Chemical Peeling
177
178
179
Chapter References
180
Bibliography
Chapter 7
183 GLYCOLIC PEELS
183
Key Terms
183
Learning Objectives
184
Introduction
184
Glycolic Peels
206
When to Consult a Physician
207
Contents
208
209
Chapter References
209
Bibliography
Chapter 8
211 JESSNER’S PEELS
211
Key Terms
211
Learning Objectives
212
Introduction
213
Jessner’s Peeling
231
When to Consult a Physician
235
235
237
Chapter References
237
Bibliography
Chapter 9
239 TRICHLOROACETIC ACID PEELS
239
Key Terms
239
Learning Objectives
240
Introduction
243
Trichloroacetic Acid Peels
267
When to Consult Your Spa Physician
268
268
270
Chapter References
270
Bibliography
ix
x
Contents
Chapter 10
271 SALICYLIC ACID AND DESIGNER PEELS
271
Key Terms
271
Learning Objectives
272
Salicylic Acid Peels
282
Designer Peels
288
288
289
Chapter References
289
Bibliography
Chapter 11
291 PEELS IN YOUR PRACTICE
291
Key Terms
291
Learning Objectives
292
Introduction
292
Creating a Peel Business
303
Conclusion
303
304
304
Chapter References
304
Bibliography
307
Glossary
319
Index
Preface
Welcome to the second edition of Peels and Chemical Exfoliation. Today,
chemical peels continue to be a popular choice for clients, even with the
advent of techniques such as laser peeling and light therapy. Chemical
peels are tried and true: There is a wealth of information about them.
They have stood the test of time. When treating appropriate clients, clinicians have every reason to consider a chemical peel or a series of chemical
peels. If you are a skilled and knowledgeable aesthetician, one who understands and feels comfortable providing chemical peels, you can achieve
notable results for clients.
Before this book was published, little useful information had been
available to the clinical aesthetician and cosmetic nurse on the concepts
of peeling and the healing that follows. This book is intended for people
who are studying to become the best aesthetician they can be. It is written to provide the basic knowledge of aesthetics training, taking concepts to a practical level. Chemical peels can be technique dependent,
and the success of a peel is based on managing its variables. Your ability
to teach clients pre– and post–skin care aids in their success and yours.
Peels and Chemical Exfoliation takes the research, facts, and opinions,
and shapes them into a start-to-finish model for chemical peels.
This clinical handbook for chemical peeling is not a cookbook for
peeling but rather an educational tool. The chapters are organized to
provide essential, must-have information on chemical peeling. General
knowledge is built upon, and insightful hints and recommendations
allow you to optimize your knowledge and achieve the replicable results
that will ensure your success. The chapter texts are dedicated to the
peeling process from beginning to end. Each chapter has questions and
“Top Ten Tips to Take to the Spa,” which will help you well beyond
your training. The book will help you learn the basics of chemical peeling while acquiring the information that will allow you, the aesthetician,
to develop, refine, and redefine your skills.
xi
About the Author
Pamela Hill
xii
Pamela Hill, RN, CEO, received her diploma from Presbyterian/St. Luke’s
Hospital and Colorado Women’s College. She practiced as a registered
nurse for more than 20 years, with her initial emphasis on cardiac
surgery. She then moved into cosmetic surgery and medical skin care.
In 1992, Ms. Hill founded Facial Aesthetics®, a network of medical
skin care clinics, in association with John A. Grossman, MD. She has
been a pioneer in the medical spa industry, who has contributed to the
growth and development of this industry. As the president and chief
executive officer of Facial Aesthetics®, Ms. Hill has been proactive in
the evolution of the medical spa model and in the integration and union
of cosmeceuticals and nonsurgical skin care. She is the author of many
books and articles on various facets of the industry. In addition to her
leadership in the medical spa industry, Ms. Hill has been actively
engaged in the research and development of the successful Pamela Hill
Skin Care product line.
Reviewers
The author and publisher wish to thank the reviewers for their assistance and expertise in producing the second edition of this text. We are
indebted to them.
Darlene Battaiola
Butte, Massachusetts
Alan Bunting
Loxahatchee, Florida
Pat Cavenaugh
Carolina Beach, North
Carolina
Linda G. Cowin
Renton, Washington
Sallie Deitz
Bellingham, Washington
Patricia Heitz
Albany, New York
Celia G. Hines
Charlottesville, Virginia
Ruth Ann Holloway
Providence, Utah
Tracy Johnson
Flowery Branch, Georgia
Rose Policastro
Little Ferry, New Jersey
Sherry Taylor
Deerfield Beach, Florida
Ellen Thorpe
Mesa, Arizona
Karen Wackerman
Phoenix, Arizona
Janice Walters
Lakewood, Colorado
xiii
Acknowledgments
The Milady’s Medical Aesthetics Series is designed to provide books
to help aestheticians grow to a new level. As the president and CEO of
a multilocation medical spa, I know how important chemical peels are
to our industry, so I’d like to thank the aestheticians, nurses, and physicians’ assistants who strive each day to make a better place in our
world.
I’d also like to acknowledge the love of my life, my husband John.
Always at my side, he has been my best critic, my beacon of light, my
teacher, and my best friend. Without him this book would not exist.
Additional thanks go to those at Milady who believed in my message and supported me through this process.
Milady and I would like to thank the following for contributing to
this series:
Larry Hamill Photography, Denver, Colorado
Edit Viski-Hanka, and her entire staff at Edit Euro Spa in Denver,
Colorado, for allowing us to use their beautiful location for our photo
shoot.
Aesthetic Technologies for graciously allowing the use of the Parisian
Peel® Prestige™.
The models who participated in the photo shoot:
Jessica Anderson Barbour
Marnie Brooks
Tina Marie Castillo
Beverley J. Grant
Velma Guss
Alysa K. Hill
Patricia Iannacito
Rosalyn Kurpiers
Sandra D. Martinez
Connee McAllister
xiv
Julie O’Toole
Jeffrey Robison
Melissa Ryan
Kathryn Staples
Christian M. Sterling
Kavina Trujillo
Lawrence P. Trujillo, Jr.
Nina Tucciarelli
Karyn Turner
Phyllis Walsh
Acknowledgments
Patricia J. McIntyre
Polly McKibben
Barbara J. Miller
Susan Nathan
Janene T. Newell
Pamela Whatcott
Lisa Williams
Donna R. Wilson
Sandra Vinnik
Edit Viski-Hanka
Illustration credits
Figure 2–3: Provided by Getty Images.
Figures 2–8, 2–9, 2–10, 3–12, 3–13, 6–10, and 6–12: Reprinted with
permission from the Academy of Dermatology. All Rights Reserved.
xv
Introduction to
Peels and Peeling
Key Terms
5-flourouracil (5-FU)
acidic
alpha hydroxy acids
anatomy
Ayurveda
Blue Peel®
carbolic acid
carbon dioxide (CO2)
laser
career plan
chemical peeling
chemoexfoliants
Chi (or Qi)
collagen
continuing education
units (CEUs)
cosmeceutical
deep epidermal
wounding
dermaplaning
dyschromias
epidermal cells
erbium laser
exfoliation
Four Humors
glycolic acid
ground substance
Health Insurance
Portability and
Accountability Act
( HIPAA)
hepatitis
herpes simplex
Hippocrates
Hippocratic Oath
human
immunodeficiency
virus/acquired
immunodeficiency
syndrome ( HIV/
AIDS)
hypopigmentation
Jessner’s solution
keratolysis
lymphatic drainage
medispa
mission statement
necrosis
nonsurgical aesthetic
skin care
papillary dermal
wounding
partial-thickness
injury
peel depth
phenol
physiology
postinflammatory
hyperpigmentation
poultices
progressive
improvement plan
(PIP)
pyruvic acid
radio frequency (RF)
reflexology
resorcinol
Retin A®
salicylic acid
spa protocols
technique sensitive
telangiectasia
trichloroacetic acid
universal precautions
yin and yang
Chapter
1
1
2
Chapter 1
Learning Objectives
After completing this chapter you should be able to:
1. Describe the history of peels and peeling.
2. Discuss the value of clinical training for peeling.
3. Discuss variations in licensure regulations and insurance
requirements.
4. Name the career options available with peel training.
5. Understand the key points of professional ethics.
INTRODUCTION
The four levels of peeling
include very superficial, superficial, moderate, and deep.
L
ines, wrinkles, and sagging skin are a natural consequence of
the aging process (Figure 1–1). As our parents and grandparents will attest, these consequences were unsightly, yet a testament to their passage into the golden years, battle scars that marked
their survival through war, depression, and oppression. Of course, they
didn’t have the knowledge and technology that are available to us today.
Chemical peeling is basically
an accelerated exfoliation
induced by a chemical agent.
Superficial peeling agents cause
increased slough of the stratum
corneum, and deeper peels
cause necrosis and inflammation in the epidermis, papillary
dermis, or reticular dermis.1
Figure 1–1 This woman has many lines and wrinkles as a
result of the aging process.
Introduction to Peels and Peeling
These once irreversible consequences of the aging process can be managed now, if not completely reversed.
Thanks to advancements in nonsurgical skin treatments and the
desire not to have surgical treatment, the multibillion-dollar industry of
nonsurgical aesthetic skin care has come into existence. In this day
and age, the signs of aging are considered unwarranted and unwanted.
As a result of the needs of the baby boomers and their desire to maintain a youthful appearance, our industry has developed products and
refined services. Among the most popular—and common—services are
chemical peels and exfoliation.
Many of you are familiar with chemical peels and exfoliation, the
processes of using agents that exfoliate and peel the skin. With acidic
agents you can loosen and eradicate the outermost layer or layers of
skin, allowing newer and healthier skin to rise to the surface. These
agents are key to nonsurgical aesthetic skin care, especially in the host of
treatments offered in the spa or medispa environment.
Over time, different peels, each with different peel depths, have
been developed. While many are fairly benign and easy to use and sell,
some require more finesse. The deeper peels may cause injury or scarring. Depending on the particular peel, the downtime as well as the risk
of infection and scarring can be significant. Therefore these peels
require practice and knowledge to master. These treatments also come
with greatest potential for successful outcomes.
A thorough understanding of chemical peels is vital to your success
as an aesthetician. They have extensive appeal. Given the wide range of
treatment indications and their success in treating them, young and old
alike can benefit. With many positive attributes to sustain the market
desire, chemical peels and exfoliation are treatments that you will recommend often because of their successful outcomes for the treatment of
skin complaints, including dyschromias and fine lines. Just remember
that often these results do not come without risks. This point cannot be
emphasized enough and will be frequently repeated in this text.
nonsurgical aesthetic
skin care
Any noninvasive procedure that is
intended to improve overall skin health
and appearance.
exfoliation
The process of removing dead skin
cells from the outermost layer of the
skin; very superficial and superficial
peels are exfoliants rather than true
peels.
acidic
Any substance that has a pH less
than 7.0.
dyschromias
Discoloration of the skin.
cosmeceutical
Products that do more than decorate or
camouflage but less than prescription
drugs would do. The term was
originally coined by Dr. Albert Kligman.
Our society puts a high value
on the commodity of youth,
which to many means looking
younger and fitter. Progress
in medical science and
cosmeceutical research has
increased our ability to treat the
E V O L U T I O N O F S K I N CA R E
Skin care is nearly as old as civilization itself. No sooner had humans
banded together than they realized the benefits of enhancing their
appearance. Beginning with the Chinese, whose appearance and hygiene
were considered to be defining characteristics of their culture, skin care
has held a valued place in every civilization, from the Egyptian, Greek,
Romans, Indian, and African to the present day. From decorating and
celebrating to masking and concealing, every culture has placed a value
3
skin and generate excellent
nonsurgical results.
4
Chapter 1
yin and yang
Concept, originally developed in the
writings of Fu Xi, that describes the
harmony between nature and its daily
phenomenon.
Chi (or Qi)
Life energy, a concept from the Yellow
Emperor of China’s Han Dynasty.
According to Chi, nature has a delicate
balance and illness is an imbalance.
Hippocrates
Greek physician and “father of
medicine” associated with the
Hippocratic oath and the four humors.
Four Humors
Early medical concept that says that
the character of a man is determined
by the specific balance of the four
fluids running through the body: black
bile, yellow bile, blood, and phlegm.
Hippocratic Oath
Oath, created by Hippocrates, taken by
all physicians relative to the practice of
medicine. Its first rule is “Do no harm.”
Ayurveda
Indian theory, dating back to 2500 B.C.,
known as the science of living. It
defines the essentials seen as
necessary to health.
on beautiful faces and maintaining that beauty. Today, we use a much
more scientific and medical approach than civilizations in the past, approaches that not only enhance the appearance of our faces but also
improve it down to the cellular level.
Today, the medical and aesthetic arts have converged and today that
tie is stronger than ever. The Chinese were the first to understand medical
fundamentals, and many of their concepts are still relevant today. Traditional Chinese medicine dates back over 5000 years to the writings of Fu
Xi. His texts, called the trigrams, relied on the theories of yin and yang.
Yin and yang represent harmony between nature and its daily phenomenon. The Yellow Emperor of the Han Dynasty later wrote of the need for a
“positive physician–patient relationship.” The Chinese methods involving
Chi (or Qi), the balance of nature and imbalance of illness, are important
foundations on which contemporary western medicine was constructed.2
In ancient Egypt, various materials were commonly used to enhance
the skin’s appearance. Ancient Egyptians routinely used animal oils,
alabaster, and salts for this. Some Egyptian women even soaked in sour
milk, unaware that its lactic acid was the source of their positive results.
In addition, the Egyptians are credited for inventing the process of distillation, which they used to extract oils and other essences for use in
both ceremonial and aesthetic contexts.3
Simultaneously, physicians in the Greek Empire were making medical and aesthetic advancements of their own. Hippocrates developed the
Four Humors (blood, phlegm, yellow bile, and black bile), the balance
of which defined a person’s character. He also created the Hippocratic
Oath, which is taken still today by doctors and which requires that those
in attendance work cohesively (a point which has modern day relevance
for students who are reading this text). Concurrently, the Greeks also
used accessories and adornments to enhance their physical appearance,
including using pigments such as vermillion to enhance facial coloration.
From then on, many other cultures built on previous knowledge
and developed their own techniques in both medicine and aesthetics.
The Indian concept of Ayurveda, or science of living, became part
of the foundations of Western medicine. In Africa colorful decorations
of the body were offered as gifts to the gods. Different colors and their
use in varied combinations reflected equally varied meanings, many of
which are still celebrated today. Similarly, Native Americans wore elaborate beads and head dresses for hierarchical and aesthetic purposes.
Native Americans also were quite adept in herbal wound healing, a skill
they shared with their new neighbors, the European immigrants.
In Europe, frequent bouts with plague and disease were cause for
King Henry IV to issue the “Order of the Bathe,”4 which required all
men and women to bathe frequently. During the Renaissance, amazing
2900 BC
2500 BC
Fu Xi
creates the
Trigrams.
Indians
create
Ayurveda.
0
1000 BC
2000 BC
1500 BC
Egyptian civilization
uses animal oils, alabaster,
salts, and sour milk to
enhance their physical
appearance.
Distillation is also created.
500 BC
5
1500 AD
1000 AD
Hippocrates creates
the Hippocratic oath
and the four humors.
2000 AD
Victorian Era
ushers in
advances
in makeup
and dress.
King Henry IV
issues the
Order of
the Bathe.
Renaissance
begins.
Figure 1–2 Evolution of skin care. This time line depicts the progress of skin care.
breakthroughs in science and technologies of all kinds made medicine
more reliable and aesthetics more beautiful. During the Victorian Era,
elaborate gowns, head dressings, and make up made women stand out,
at least the very wealthy ones (Figure 1–2).
Some of the most remarkable advancements in medicine and aesthetics, however, have been made in the last 25 years. Understanding epidermal cellular migration, dermal collagen content, and advanced wound
healing have allowed the development of procedures and products that
can truly affect the skin. These advancements also created chaos and fragmentation in the retail skin product industry, the medical industry, and
the spa and skin-care industry. The skin health industry is further fragmented into those who treat skin disease and those who treat skin aging,
leaving consumers many choices. Combine these choices with the abundance of products and services that claim to fight the effects of aging, and
consumers may wonder where to go and for what.
HISTORY AND ORIGINS OF
PEELS AND PEELING
Chemical agents were first applied to the skin thousands of years ago
in ancient Egypt. As it turns out, the Egyptians were quite advanced
with regard to aesthetics. One of the earliest known treatments involved
Microdermabrasion
is invented.
Dermabrasion
is invented.
6
Chapter 1
poultices
An herb or other substance made into
a paste used to relieve congestion or
pain on the skin.
chemical peeling
The use of chemical agents to destroy
layers of skin.
carbolic acid
See phenol.
phenol (carbolic acid)
Highly corrosive acid used in peel
solutions that dissolves cells to make
room for newer and healthier ones.
resorcinol
Equal parts of hydroquinone and
catechol; a peeling agent with
similarities to phenol.
salicylic acid
Beta-hydroxy acid; a peeling agent
usually reserved for acne treatment.
chemoexfoliants
The use of chemical agents to exfoliate
the stratum corneum.
trichloroacetic acid
Chemical used in peel solutions that
dissolve aging cells to make room for
newer and healthier ones.
Peel solution for the skin that is
14% resorcinol, 14% salicylic acid,
and 14% lactic acid in ethanol.
alpha hydroxy acids
Mild organic acids used in cosmeceutical
products. AHAs “unglue” cells in the
epidermis, allowing keratinocytes to be
shed at the stratum granulosum,
providing skin with a healthier texture.
the application of abrasive tapes composed of alabaster, honey, and sour
milk. After removal of the tape, the tightened skin was then abraded
with finely ground sand. This was the earliest mask and microdermabrasion treatment! As was pointed out earlier, the Egyptians were also
using lactic acid when they applied milk to smooth their skin. Later,
Greeks developed facial peeling techniques using various combinations
of limestone, mustards, and sulfurs. Early facial peeling techniques
also included poultices treated with plant and mineral derivatives,
sanding techniques, application of various acids, and even burning
with fire.5
A German dermatologist, Dr. P. G. Unna, ushered in the modern
era of chemical peeling in 1882. Unna used carbolic acid, derived
from coal tar, as a means of peeling. In the early 1900s, phenol was discovered to treat acne scarring effectively. Later, phenol was used to treat
facial gunpowder wounds during the World War I.
Realizing the efficacy of phenol, Sir Harold Gillies first used chemical
peeling in an aesthetic context. Gillies used phenol to remove fine lines
under the lower eyelid. Over the years, the process was replicated and perfected. In 1941, Eller and Wolf suggested combining resorcinol paste
with phenol and afterwards using carbon dioxide cryotherapy to rejuvenate
the face. Soon afterwards, Dr. J. C. Urkov introduced salicylic acid as a
chemoexfoliant. In the 1960s, Drs. Baker and Gordon developed a
phenol-peeling agent, which smoothed deeper furrows, especially around the
mouth. Beginning in the 1980s and continuing to the present day, research
has continued on phenol and the variables used to create a positive result.6
In the latter half of the twentieth century, other chemicals, including,
trichloroacetic acid, Jessner’s solution, and alpha hydroxy acids, were
successful for use in aesthetic peeling and made their way into the marketplace. Formulas, concentrations, and specific techniques were all reviewed,
modified, and perfected to ensure safety and efficacy. Today, chemical peels
are performed routinely in spas, physicians’ offices, and medispas.7
CHEMICAL PEELING
Chemical peels are intended to remove the outermost layers of the skin.
To accomplish this task, the chosen peel solution induces a controlled
partial-thickness injury to the skin. The resulting wound healing
processes begin to regenerate necrosed epidermal tissues.8 When the
new skin replaces that which was removed, the skin will be healthier
and more youthful in appearance. Depending on their depth, peels
will reduce imperfections or damage caused by sunlight exposure, pigmentation irregularities, and fine wrinkles. We will explore this concept
7
Table 1–1 Peeling Agents
Retinoic acid (Retin A®)
Resorcinol
Salicylic acid ( BETA)
Alpha hydroxy acids (AHAs)
Trichloroacetic acid ( TCA)
Alpha keto acids (pyruvic acid)
Phenol
in greater details in the following chapters, but for now, it is important
for you to understand that chemical peeling is controlled wounding with
a predictable result.
Results from chemical peels can be controlled to an extent by the
amount of time, concentration, and type of the chemical peel used; pretreatment; the number of treatments; and application technique. These
variables determine the peel depth. Peel depth is your key to success.
Similarly, peel depth is the source of any complications. Great attention
should be paid to peel depths, which will be discussed in greater detail
later ( Table 1–1).
Separating Fact from Fiction
Because of the wide variety of peels, a great deal of misinformation has
been given about the processes and aftercare results. Many myths exist:
Lunchtime peels never scar. Peels are easy to do. Peels are for every skin
type. Peels replace facelifts. Peels take weeks to heal. Peels always leave
the skin red. Peels always risk hyperpigmentation. Peels are really painful. Peels are better (or worse) than other skin procedures. Statements
such as these foster misinformation for the public and an educational
challenge for the aesthetician. To eliminate the fiction, let us talk briefly
about realities.
Practitioners of so-called lunchtime peels carved out a niche for
themselves in the mid-1990s. These peels were superficial, and in reality,
these light peels should not scar. However, an exception to this rule can
be found. The risk for scarring increases if these peels are used in conjunction with dermaplaning (BioMedic, circa 1993) or dry ice. So
remember, the tools that you use need to be handled with respect. Simply
because the peel is billed as a light peel does not mean it could not be
harmful if used improperly.
partial-thickness injury
A wound that penetrates only the epidermis
or the upper layer of the papillary dermis.
These wounds tend to heal more quickly
and with less risk of scarring.
Retin A®
Topical vitamin A, also known as
tretinoin.
A chemotherapy agent that is given as
a treatment for some types of cancer;
used as a topical peeling agent; also
known as Efudex® when used on
the skin.
pyruvic acid
An alpha keto acid that has properties
of acids and ketones. Pyruvic acid is
a powerful peeling agent.
peel depth
The depth of skin injury by chemical
peeling agents.
dermaplaning
The use of a sharp surgical blade
to exfoliate the stratum corneum.
8
Chapter 1
postinflammatory
hyperpigmentation
Pigment that occurs in response to
skin injury.
necrosis
Death of cells when tissue is deprived
of blood supply.
collagen
An insoluble protein found in connective
tissues. Particularly, type I collagen
forms a network in the epidermis, and
it is credited with providing skin with
its tensile strength and firmness.
ground substance
Consists mainly of glycosaminoglycans
(hyaluronic acid, chondroitin sulfate,
and dermatan sulfate); involved in
maintenance and repair of dermis.
The notion that peels are easy to do is another misconception. Some
aestheticians and clients believe that when doing a peel the skin is
washed and the peel solution is put on and washed off. While simplified,
this is basically true. However, those in the know, realize that performing
a peel is so much more. The condition of the skin must be considered
as well as the home program, the clinical preparation of the skin, and the
technique and skills of the aesthetician. Peels are not easy to do and
require education and practice to ensure a positive outcome.
What about the idea that peels are for every skin type? Well, this
assumption is simply not true. The decision to perform a peel depends
on the indications that the client presents and the analysis of the age and
type of skin. When a peel is performed on a skin type or for an indication that is inappropriate, not only do you risk a poor result but also
you risk potential complications such as scars or postinflammatory
hyperpigmentation.
Peels do not replace facelifts. Even the most aggressive of peels (for
instance, phenol) will not provide benefits equal to a surgical facelift. If
your client has loose and sagging skin, guiding her or him in the right
direction—to a physician’s office—will be important. Remember, peels
are for skin quality; surgery is for skin quantity (i.e., too much skin).
Do peels make the skin red? Well, yes. Reddening is the normal
response of the skin when an irritant is applied. Nonetheless, how red
and for how long are the important questions. The answers are associated with the specific peel solution applied, the time it is left in place,
and the aftercare.
Benefits of Peeling
Figure 1–3 Chemical peels
are valuable for all skin types.
As you may already know by this point in your education, older and
dead skin cells cause the skin to appear dull and aged. Every day, our
skin undergoes the normal process of sloughing off older, dead skin
cells. In place of these dead cells, newer cells have traveled up through
the layers of skin. These new cells replace the dead cells and then ultimately suffer the same fate. However, as we get older, the time required
for the older cells to slough off increases, meaning that the older cells
stay in place longer (Figure 1–3).
Chemical peels accelerate the sloughing process in three different
ways. First, resurfacing the stratum corneum stimulates epidermal
growth, which makes the epidermis thicken. Second, chemical peels cause
necrosis, or destruction of damaged skin. Ideally, the damaged or dyschromatic skin will be replaced with healthier, normalized tissue by
means of the skin’s normal wound healing processes. Finally, deeper peels
will induce the production of new collagen and ground substance
within the dermis, which occurs as an inflammatory response to
wounding deeper basal layer and papillary dermis tissue. This entire
process is discussed in greater depth later in this text. Given that peeling can cause necrosis, you will want to do as little damage as possible
while still stimulating as much new tissue formation as possible. This
task is best accomplished with repeated superficial and medium-depth
peels.9
Peeling versus Other Treatments
The four levels of peeling include very superficial, superficial, moderate,
and deep. The first two categories can be defined as exfoliation, while
the second two categories are true peels. The peels that are associated
with very superficial peeling would include lunchtime peels, 20% glycolic
peels, and herbal designer peels. Superficial peeling is 30% to 50% glycolic
peels, salicylic peels, or Jessner’s peels. Moderate peels are defined as
TCA peels and 70% glycolic peels. The deep peel category is saved for
phenol or pyruvic acid peels, and typically these peels are performed by
physicians ( Table 1–2).
Each peel level is associated with the degree of skin injury. For
example, very superficial peels are acting only on the outermost layer of
skin, and moderate peels are wounding into the papillary dermis, resulting in pinpoint bleeding. An aesthetician is qualified to do the very
superficial and superficial peels. Some peels require some “downtime”
for the client to peel and heal. Healing times are directly related to peel
depth. Lighter peels or exfoliations simply cause the skin to have a light
flaking while deeper peels cause obvious peeling of the skin. The deeper
the peel, the longer the heal. Some peels, mostly those that are deeper,
can also pose a slightly higher risk of scarring, infection, and postinflammatory hyperpigmentation.
With most peels, the potential risks and results are directly related
to the depth of the peel. Interestingly, however, the repetitive nature of
the very superficial to superficial peels or exfoliation have the potential
to create enough minor injury to stimulate collagen remodeling in the
dermis and new collagen formation. For this reason and the minimal
healing associated with superficial and very superficial peels, they have
become popular with the public. This trend is not to discount the
moderate peels, especially TCA, which usually provides improvement
with one peel. The most popular TCA peel is known as the Blue Peel®
and was developed by Dr. Zen Obagi. This peel combines a blue dye
into the TCA to assist with application and observation of the peel. In
recent years, these peels have become well accepted and have few
complications.
The peels that create deep
epidermal wounding are
considered superficial peels,
papillary dermal wounding
is created by TCA or 70%
glycolic acid, moderate depth
peeling.
deep epidermal
wounding
Injury that reaches deep into the
epidermis, as with peeling solutions.
papillary dermal
wounding
Any injury to the skin that is sufficient
to cause bleeding.
glycolic acid
Alpha hydroxy acid derived from sugar
cane. It has a small molecular size
that allows for easier penetration into
the skin.
Blue Peel®
TCA peel solution that is combined
with blue color and acid penetration–
slowing or modifying agents.
9
10
Chapter 1
AHAs melt epidermal cells
Table 1–2 Comparison of Treatments
and exfoliate the skin. These
Treatment
What It Does
What It Does Not Do
Trichloroacetic
acid ( TCA) peels
Flatten scarring
Reduce rhytides
Correct photo damage
Improve hyperpigmentation
Reduce pore size
Eradicate all rhytides
Remove telangiectasia
Remove deep scarring
and glycolic
acid peels
Reduce rhytides
Reduce pore size
Dermabrasion
Flatten scarring
Reduce rhytides
Reduce pore size
Carbon dioxide
(CO2) laser
Remove some acne scarring
Remove coarse static rhytides
Reduce coarse dynamic
rhytids
Reduce pore size
Remove some acne scarring
Remove coarse static rhytides
Reduce coarse dynamic
rhytides
Reduce pore size
Flatten scars
Remove hyperpigmentation
Reduce fine dynamic rhytides
Reduce pore size
peels act differently on the skin
by causing separation of the
layers of the epidermal cells
(keratolysis) and then sloughing those necrotic cells off.
Erbium laser
telangiectasia
Dilation of a group of small blood
vessels.
epidermal cells
Cells found in the outermost layer
of skin.
keratolysis
Separation of the skin cells in the
epidermis.
Microdermabrasion
Microdermabrasion
Chemical peels have many of the same indications as those of microdermabrasion, including light acne scarring, dyschromias, rough texture,
and fine lines. Although microdermabrasion has less downtime, and
11
Figure 1–4 Medical microdermabrasion machine using crystals.
Photograph courtesy of Aesthetic Technologies®.
potentially fewer complications, it cannot match chemical peels with
regard to collagen stimulation and the number of treatments required
for improvement (Figure 1–4).
Carbon Dioxide (CO 2 ) Laser
Resurfacing lasers cause epidermal and papillary dermal injury. Two
major types of skin resurfacing lasers have been developed: the carbon
dioxide (CO2) laser and the erbium laser. The CO2 laser vaporizes
the skin, causing a thermal injury, which, in turn, causes additional
improvements in the dermis through collagen formation. Unfortunately,
because of the aggressive nature of CO2 laser, the skin is at great risk for
hypopigmentation.
The erbium laser causes an epidermal and papillary dermal injury.
However, this “lighter” laser does so with little thermal injury. Therefore the result is somewhat less than that of the CO2 laser resurfacing
procedure. The erbium laser also creates a slightly lower risk of
hypopigmentation.
Several lasers have been developed that now combine the effects of
erbium and CO2 laser. The benefit of these lasers is the ability to treat,
for example, the skin around the eyes with a lighter setting and other
areas with a more aggressive setting. These lasers are often used in conjunction with facial surgery such as blepharoplasty and facelift.
carbon dioxide (CO2)
laser
Aggressive type of laser used for skin
resurfacing that vaporizes skin and
causes thermal injury, allowing for
improved collagen production.
erbium laser
Type of laser that causes less thermal
injury than a CO2 laser while still
causing epidermal and papillary
dermal injuries.
hypopigmentation
The lack of melanin production.
12
Chapter 1
Laser treatments can be a preferred treatment to some deeper
chemical peels. Because the laser beam is small and easy to manipulate, it
allows the physician to treat specific areas intricately. The laser also has the
capability to be turned up or turned down and thus create a tailored injury
for the problem. No single “hammer” that works best to treat aging skin
has been found. In fact, a combination of peeling and other treatments
such as laser and microdermabrasion can provide the best results.
Intense Pulsed Light
Figure 1–5 Intense pulsed
light or Foto Facials® are
another treatment for solar
damage.
Intense pulsed light (IPL) therapy, also known as Foto Facial® or Photo
Facial®, is a light treatment. Using a broad spectrum of light energy
in a range of wavelengths, IPL therapy supplies high levels of light
power in millisecond bursts.10 This phenomenon treats colors—red and
brown. When alternated with a peeling treatment, such as glycolic, the
skin responds faster, and the result is more dramatic (Figure 1–5).
Radio Frequency Therapy
radio frequency (RF)
Frequency used with the newest
technology for promoting collagen
growth.
Radio frequency (RF) therapy has been shown to tighten the skin
effectively on the lower face and neck. Tightening the skin, not unlike
surgery, does not improve the quality of the skin, and therefore a skin
program that includes peeling and home therapies is appropriate.
technique sensitive
Results of a treatment that depend on
the aesthetician’s ability to administer
consistent results.
Facial Surgery
Facial surgery is directed at improving loose skin on the face and neck.
The objective of cosmetic facial surgery is not to improve the quality of
the skin. Therefore a program of clinical peels and therapeutic home
products is appropriate for an optimal result. Additionally, healing the
skin after surgery is helpful if the client has been on a preoperative skincare program that includes peels and home programs.
TRAINING
When it comes to performing peels treatments, it is obviously very
important for an aspiring aesthetician to have a mastery of the treatment
prior to certification. Less known, it is also very important to further
your training on the job. Because chemical peel treatments are
technique sensitive, aestheticians must understand the processes, concentrations, indications, and contraindications; the importance of home
products for the skin; and proper management of aftercare because all
are important factors for success.
Once you are on the job, the training process for peeling should not
be left to the individual aesthetician to figure out on his or her own.
Given that chemical peeling can be risky, the aesthetician must have the
necessary training. (Although state licensure does not generally depend
on peel training or theory, the qualified aesthetician will have advanced
training in this area.) This preparation will give the spa the confidence
necessary to allow the aesthetician to provide care to the client. If the
aesthetician is not trained, the spa must have a trainer available to teach
and mentor the new aesthetician in the use of these chemicals. Similarly,
new peeling agents and products will come on the market. It is to your
benefit to have practical experience prior to performing these peels on
clients.
On-the-job chemical peel training should take place in a dedicated
class that addresses theory and hands-on practice. The classroom work
ought to include a review of the anatomy and physiology of the skin,
the basics of wound healing, the indications and contraindications of
treatment, and the fundamentals of the at-home skin programs. The
course should require familiarity with spa protocols for chemical peels
and the variety of available treatments and programs available. Once
the student completes the classroom work and has passed the recommended examination, she or he can move to hands-on clinical training.
The review of anatomy and physiology should be specific to the
layers of the skin and the response to the application of peel solutions.
Additionally, the trainer should be able to tie these responses into
wound healing and the anticipated result of the treatment. Obviously,
all the conditions that reflect indications and contraindications should
be covered. This information may vary by facility and be based on predetermined policy and procedures. An in-depth discussion of these subject matters is discussed at length in this text.
In the spa, a training program should focus on how to observe for
skin injury, wound healing, and the benefits of chemical peeling. The
aesthetician should also be introduced to the specific solutions such as
glycolic acid, lactic acid, Jessner’s solution, TCA solutions, and phenol
solutions. The protocols will differ in each facility as to which peel solutions can be used by aestheticians, which solutions are to be used by
nurses, and finally, which solutions are to be used only by physicians.
Once the aesthetician is introduced to the theories of the solution, the
clinical education begins.
The ability to reproduce a treatment comes with practice, and therefore extra time should be built into this area of the training process. Ideally, an aesthetician ought to have his or her technique established prior
to ever performing the treatment on a client. The aesthetician should not
provide chemical peel treatments to clients until he or she has completed
a thorough clinical training program. Remember that completion of a
13
The safety of both the client and
the aesthetician are important.
Safety begins with understanding
and implementing universal
precautions and using the proper
safety equipment. The safety
equipment includes the use of
goggles for the client to protect
his or her eyes from any possible
splash of peel solution and goggles and gloves for the aesthetician. Typically, an aesthetician
will wear a lab coat or scrubs to
protect her or his clothing. In
addition, following the manufacturers recommended use of the
peel solution helps to ensure the
safety of the client.
universal precautions
Preventative actions taken to prevent
the transmission of infectious diseases;
they involve the use of protective
procedures and equipment, such as
gloves and masks.
anatomy
The study of the body and how its
structures work in relation to one another.
physiology
The study of body functions.
spa protocols
Any set of rules or guidelines
established by a spa to ensure safe
practice. These guidelines will vary
by location yet are expected to be
observed by aestheticians working
within the individual spa.
14
Chapter 1
training program does not always reflect competency. Therefore skill testing and observation of the aesthetician are critical for the safety of the
client.
Continuing Education
At some point in the near future, you will have completed your certification, and performing peel treatments will seem like second nature to
you. This is both a blessing and a curse. On the one hand, it indicates
your comfort level with the treatment. On the other hand, it may mean
that you are becoming too comfortable. You may be skipping steps
or be unfamiliar with advancements in the treatment. By taking advantage of continuing education opportunities, you improve your technique
and keep your knowledge base fresh. See Table 1–3 for a treatment
Table 1–3 Additional Aesthetician Skills
Clinical Skills
Communications Skill
Clarity
Education
Ongoing education is the most
Sales abilities
important thing you will do for
Safety Skills
your career. It is your annuity
for increased wages, improved
treatment results, and selfimprovement.
Wears protective gear
Understands machine
Charting
Understands the record
Makes appropriate notes
Ongoing training should be part
Takes pictures
of a yearly self-improvement
Products
plan. After you graduate from
school, plan to take at least one
Understands product lines
course a year to learn a new
Professionalism
subject that will add depth and
Appropriate to client
power to your resume.
Appropriate to peers
Score 1–10
Recommended
Improvements
evaluation. Continuing education is a professional obligation and privilege. Educational updates can be acquired in three ways: an annual recertification through the spa; continuing education units (CEUs) at
meetings and trade shows; and online study and education. Annual recertification at a spa usually has two phases. The first phase is self-managed
workbook reading and quizzes. These workbooks can be printed or put
on your intranet (an efficient way of managing the process). The second
phase is the clinical recertification. This recertification occurs when the
spa educator or physician observes the aesthetician treating clients. The
educator uses a score sheet to evaluate the aesthetician in all areas in the
treatment room, including the actual treatment, cleanliness of the room,
professionalism with the client, and so forth. If an aesthetician does not
achieve a passing score, then a problem-solving document called a
progressive improvement plan (PIP) should be implemented to help
the aesthetician improve his or her treatments.
Another approach to ensuring educational updates is by requiring
recognized CEUs. In some states, CEUs are required for licensure
renewal. Some spas also require each practicing aesthetician, registered
nurse, licensed practical nurse, or physician’s assistant to obtain a certain number of hours each year to maintain employment. CEUs can be
obtained at annual meetings of professional organizations or at meetings
held by product manufactures. These meetings are usually illuminating
and help the aesthetician stay current on the newest products and services. If aestheticians at the spa cannot attend the meeting, the returning
aesthetician should give a report and provide copies of any relevant
literature.
Finally, learning can take place through a variety of web sites on the
Internet that are dedicated to education. These sites provide recognized
CEUs or simple educational information.
A E S T H E T I C EM P L O Y M E N T
OPPORTUNITIES AND
CONSIDERATIONS
Considering the great demand to look younger and healthier, career
opportunities abound for the educated and skilled aesthetician or cosmetic nurse. Creating a career plan for success is the first step to realizing your dream. Many professionals in the area of self-improvement
recommend identifying the goal and working backward to achieve that
goal ( Table 1–4).
15
continuing education
units (CEUs)
Any certified training or event that is
intended to build or add skills.
progressive improvement
plan (PIP)
Administrative document intended to
record a problem and the actions taken
to correct the problem and prevent its
reoccurrence.
career plan
Action taken by an individual to set
goals and actions needed to ensure
that these goals are realized.
16
Chapter 1
Table 1–4 Career Opportunities
Medical Office
Plastic surgery
Dermatology
Family practice
Gynecology
Otolaryngologist (ear, nose,
and throat [ENT ])
Dentistry
Spas
Salon spas
Fitness club spa
Country club spas
Holistic spas
Day spas
Medispas
Resorts
Destination spas
Resort/hotel spas
Cruise ship spas
Administrative
Board Members
Writers
Instructors
Product Representatives
Test Proctors
Researchers
Using this technique, identify where you want to be and what you
want to be doing in five years. Then, create a list of objectives to achieve
the goal. Where you want to be and what you want to do encompasses
a lot, and is intentionally vague. For some, the goal in five years is to be
making a certain amount of money. For others, it might include a career
goal, and for yet others, it might mean a location. Set your goal, and
take baby steps to achieve it.
For example, if you are currently an aesthetician without medical
experience and you would like to be in a medical office as a chemical
peel specialist, identify objectives that will allow you to meet this goal.
Find out where to gain the training, expertise, and experience that will
allow you to be a valued employee in a medical setting. Identify internships or learning situations that will help you perfect your clinical skills.
Take communication courses that will help you learn how to communicate with clients, peers, and superiors in a medical setting. Talk to those
who are already practicing in a medical environment, ask questions, and
make connections. At the other end of the spectrum, suppose your goal
is to work in a resort and spa in Bali. Tailor your education toward
relaxing and exclusive peel treatments. Take sales courses that will help
you contribute to your employer’s goals and to your own. Learn the
basics of building a business. Create a professional resume. Practice
interviewing skills that will help you get the job. Even consider an
unpaid internship at a similar spa.
Once you have identified the steps needed to reach your goal, you
need to take the difficult steps toward achieving your goal. A big part of
this is marketing yourself. Marketing yourself to a business is an important skill in acquiring the right job. Whether you want to land a job at a
medical spa, a destination spa, or a holistic spa, the tactics you use to get
there will be the same. Remember, just as you are looking for the perfect
job, the employer is looking for the perfect employee. Not every opportunity will be a good match for you or the employer, and that is reasonable. Understanding the components of a good match is the key to
long-term success. By marketing yourself, you will have a sound understanding of what positions will be a good match for you personally.
Several components of marketing yourself should be addressed,
including your values, your integrity, your skills, and your needs. Before
looking for a job, it’s worthwhile to address each of these categories. This
exercise will help you ask potential employers the right questions, which
will assist in your own decision about the position. Consider, practicing
with a friend or enlisting the help of a professional career guide. Remember, you are interviewing the employer as much as the employer is interviewing you. To this avail, you must make sure that your goals and
values are synchronized with that of your potential employer.
While goals are huge on reaching your potential and a good match
is desirable in landing job, they are not the only important considerations. Matching goals are invaluable to landing a job, but unless there is
a value match, you won’t be happy in that job. You are then less likely
to keep the job.
Values are defined as “the abstract concepts of what is right, worthwhile or desirable.”11 With regards to employment, it is an alignment of
principles or standards. Before you even begin your employment match,
be prepared. Ask yourself what it is you aspire to. What principles will
you employ to meet that goal? Even more in depth, ask yourself in what
you believe. Make a list of these principles. While interviewing, ask questions about the business’s philosophies and goals (businesses should have
both financial and nonfinancial goals). Specifically ask about client care
philosophies. Then, discuss these values with which you can identify.
Important values to you may include being on time, following company
17
When seeking employment as
an aesthetician, compatible
goals and values will help you
get a job, perform optimally,
be successful, and remain in
the position. High attrition rates
are detrimental to both the
spa’s and the individual aesthetician’s long-term success.
18
Chapter 1
Your skills are important to an employer, but sometimes the position
is not exactly what we want. You may be underqualified or overqualified. You need to assess this aspect with your potential employer. Ask
questions about the specific skills needed, and respond with information about your skills and why you want to work for the company. If you
are underqualified but otherwise matched to the position, what training
will be available to help you become qualified? How quickly will that
training happen, and who will do the training? Could a pay raise be
expected once the training is complete? These are important questions to ask before committing to a position. What you hear at the
interview and what comes to pass in a job are not always the same.
Putting some of what would otherwise be a “handshake” deal in writing is in your best interest. This approach eliminates any future misunderstandings or hard feelings. If the employer is unwilling to provide a
written agreement, maybe the position is not a match.
mission statement
A written statement of a business’s
individual philosophy.
protocol, providing quality care to clients, or even volunteering at the
local women’s shelter. Think twice about taking a position in which your
values differ from those of the spa or employer. If you do, you are likely
to be unsatisfied with your choice, and that can be of detriment to your
personal career success.
Integrity is different from values. Integrity is defined as “uncompromising adherence to moral and ethical principles; honesty.”12 In other
words, it is the degree to which one employs her or his values. For
example, most spa people say that they put client care above all, including their profit margins; those with integrity will not cut corners to
achieve more money. On an individual level, you may believe in charity,
but integrity is actually donating your time and money to the cause.
Like values, an integrity match is vital to your successful match with an
employer. In this category, you will want to ask questions about client
care, such as how complications are handled, how unhappy clients are
handled, and how fee disputes are managed. Additionally, ask direct
questions about the ethical principles of the company. A written philosophy, usually known as the mission statement, should be available.
Then, consider if these ethical principles are similar or the same as your
own. They should be.
Once you have your credentials, your resume, and your marketing
plan, you are ready to go and get the job for which you are uniquely
qualified.
19
Medical Offices
As the medical and aesthetic industries continue to come closer together,
clients, aesthetic businesses, and aestheticians all benefit. Services become
more refined, client care goes to the next level, and opportunities abound
for those with the training and desire.
Whereas doctors’ offices were once about becoming well, today all
types of specialists from general practitioners to gynecologists to dermatologists are seeing the benefits of making their patients better instead of just
being well. The ease of administration, the results, and the profit potential
make adding an aesthetic component to their practices an easy decision.
For the aesthetician, this creates a special and desirable niche, what
has come to be known as the medispa, that is, aesthetic treatments done
in a clinical environment under the supervision of doctors and nurses.
Busy aesthetic medical offices are always looking for proficient aestheticians and cosmetic nurses. A physician will often be looking for an
employee who can multitask and can take on additional job responsibilities. Depending on the scope of the practice, you may have an opportunity that will allow you to learn more than simple aesthetics and to
expand your skills. Some medical offices even are willing to train aestheticians or cosmetic nurses.
Working in a medical office has many rewards; among them are prestige, advanced knowledge, complex treatments, and working with other medical professionals. Medical professionals—physicians, nurses, and physician
assistants, as well as residents and interns—are unlike any other professional
you will meet. The training of these professionals included life and death
issues, and their commitment to their clients is unlike any other. Mistakes
are not tolerated by physicians or nurses, or clients for that matter. This
type of environment can be an intense and intimidating place to work, but
the payoffs are worth the effort you put into the job. The ability to make a
difference in the life of a client is among the most meaningful of rewards.
To learn and become more skilled, to participate, and to bring visible
results to clients in need are some of the benefits of working in a medical
office. Working in a medical office requires expert skills, willingness to
learn, compassion, understanding, and professionalism.
The peels that are done in a medical office are more advanced, more
aggressive, and, as such, provide a better result compared with peels
that are performed in a salon setting. The care of the client undergoing
a peel requires advanced knowledge in skin anatomy and physiology,
wound healing, and wound care. The aesthetician is also expected to
know about the different peeling solutions, how they will act on the
skin, and the potential outcome. The aesthetician must have the ability
to talk with clients, explain procedures, and work alongside the physician. Acting as a representative for the physician, conveying important
medispa
A spa where doctors and nurses are
present doing medically indicated
procedures in addition to the typical
spa treatments.
Belonging to a professional
organization can be educational
and a great place to network.
However, finding a good fit is
important. The physician with
whom you are working usually
belongs to a professional organization. If associations for
ancillary staff are available, consider these organizations first.
“A code of ethics is a means
of uniquely expressing a group’s
collective commitment to a specific set of standards of conduct
while offering guidance in how
to best follow those codes.”13
20
Chapter 1
Figure 1–6 Medical spas are comfortable and also have facilities conducive
to more technical procedures. They may resemble a physician’s office.
information, and providing treatments to the client will make the aesthetician a valuable asset to the medical office and to the client.
Working in a medical office is not always easy. The challenging
aspects of working in a medical office include dealing with the politics
(though all offices seem to have politics), being the low person on the
totem pole (the aesthetician or cosmetic nurse often feels out of the loop
and unimportant), adhering to many new rules that seem to have little
or no apparent meaning, learning a new business sector, and building
the nonsurgical aesthetic business in isolation. Physicians are often busy
performing surgery or seeing clients and do not have the time to dedicate to the growth and development of the aesthetic arm of a business,
even though it is important to them. Physicians will be looking to the
aesthetician or cosmetic nurse to build the nonsurgical aesthetic side of
the business. Understanding all of the potential pitfalls of building a
nonsurgical aesthetic business will be important in this situation. Learn
how to maneuver through the landmines, and you will find this career
rewarding and financially profitable (Figure 1–6).
HIPAA and the Aesthetician
When working in a medical office, the aesthetician must understand all
of the laws and regulations that affect the practice. Among these rules
and laws is the HIPAA. Passed by Congress in 1996 and signed into law
in January 1997, its purpose is to protect the privacy of clients’ health
information. Uniform standards are now in effect across the nation
identifying how health information changes hands. Health information
is protected by stringent rules that apply to information in the chart, on
the computer or fax, and by spoken word. Seven categories of the law
are of concern: access to medical records, notice of privacy practices,
limits on use of personal medical information, prohibition on marketing, stronger state law, confidential communications, and complaints.14
Proper Handling of Medical Information
Access to medical records: clients are entitled to have copies of their
records and to have access to their medical records.
Notice of privacy practices: medical facilities are required to communicate with clients in writing about how their medical information will
be used and what the client’s rights are under the law.
Limits on the use of personal medical information: this section of the
law deals with insurance plans and how the client’s information is
communicated between insurance companies and medical
professionals.
Prohibition on marketing: this area involves restrictions on how a
client’s information can be used for marketing purposes.
Stronger state laws: The national law does not affect stricter state laws.
However, all states must abide by the national law.
Confidential communications: Clients can dictate where and how they
are contacted.
Complaints: All clients may file a complaint if they believe that their
privacy has been violated.
The following are a few basic tips to keep you out of trouble and
respect HIPAA laws:
• Do not talk about clients within earshot of other clients (especially
at the front desk and near or in the waiting area).
• Do not share information about the client with others, including the
client’s family.
•
•
•
•
•
Do not fax medical records.
Do not gossip about clients.
Do not leave charge tickets where other clients can see the name.
Do not make a computer screen available for the client to see.
Do not release information over the telephone.
Continued
21
22
Chapter 1
Proper Handling of Medical Information—cont'd
• Do not release copied information without a signed release by the
client.
• Take only the record for the client you are treating into the
treatment room.
• Chart immediately and file the chart; do not leave charts where
others can see them.
• Be an ethical professional, and consider how you would like to be
treated.
A Higher Standard of Professionalism
When we work in the medical office, more is expected of us by both the
client and the physician. We are expected to adhere to a higher level
of professionalism and customer service than is familiar to us in the
spa setting. You must train yourself to refrain from laughing, joking, and
loud behavior. Clients may think you are talking or laughing about them.
Additionally, this kind of “party” atmosphere does not reflect positively
on our image or our profession. In fact, this unprofessional activity may
negatively reflect on you in the eyes of the client. Your ethical conduct
should be present in your contact with clients, their charts or records,
and your communication with others about the client. The information
you must pass along about the client to colleagues or others involved
Health Insurance
Portability and
Accountability Act
( HIPAA)
A federal regulation that dictates
procedural protocols to protect client
privacy.
in their care should be complete but comply with Health Insurance
Portability and Accountability Act (HIPAA) regulations. The client list
of the medical spa belongs to the physician, and, according to the laws
of HIPAA, the information should never leave the medical office.
CLIENT LIST
Although you may believe that the client you meet and treat belongs
to you, the reality is this client belongs to the medical spa and physician.
Without the physician’s license, you would be unable to extend your
services. Therefore if and when you leave the employ of the spa, taking
a list of client names and telephone numbers to contact for your next
job is inappropriate and unethical. It constitutes poor judgment, and if
Continued
A Higher Standard of Professionalism—cont'd
23
lymphatic drainage
Drainage of lymphatic fluids.
you are a medical professional (registered nurse or physician’s assistant), your professional license may be at risk. This behavior will not
gain you points in the medical and professional community. If the physician for whom you are going to work asks you to do this, you should
be concerned. All you have is your reputation, not only in the eyes of
clients but also in the eyes of physicians and the medical community
reflexology
A system of massage in which certain
body parts are massaged in specific
areas to influence other body functions
favorably.
at large. You may some day require the referral of your current manager or physician, or need to work with them on some professional
level, such as a committee. Do not embarrass yourself by doing
something inappropriate or worse yet illegal.
Salons and Spas
Whereas physicians are more recently embracing aesthetic services, salons and spas have been doing so for decades. Rather than the sterile and
cold environments of the doctor’s office, salons and spas offer a sense of
well-being and luxury to the client. As treatments have become more
sophisticated and the tools have become more advanced, there exists the
opportunity to provide clients with treatments that may supplement
medical treatments (lymphatic drainage) or help to reduce the stress
(reflexology) caused by an extraordinarily busy world. Superficial and
light peels can also take place in a spa or salon setting. However, treatment should be appropriate to the setting. That is to say, the peel
should be limited in its aggressiveness and the need for potential physician oversight. TCA peels or even higher-percentage glycolic peels are
simply not appropriate for the spa or salon setting. The salon or spa
should consider light rejuvenative peels such as 30% glycolic acid with a
ph of 3 or more, lactic acid, or designer peels that have less potential for
complications and fall within the laws of the state. Because peels can be
popular, spas should have protocols in place about the types of peels
that can typically be provided. This precaution reduces the liability
exposure for both the aesthetician and the spa.
As the medical spa becomes more popular and many aestheticians
desire to work in them, other types of spas are looking for qualified and
valuable employees. Many different types of spas exist: salon spas, resort
spas, cruise ship spas, day spas, club spas, destination spas, and holistic
or mineral bath spas. Each type of spa has a different focus and requires
the aesthetician to understand the advanced treatments she or he will be
providing. Especially popular in resort spas and destination spas are body
The aesthetician must be properly licensed by the state in which
he or she plans to be working.
24
Chapter 1
treatments. Cruise ship spas are looking for employees with excellent customer service skills as well as extensive technical skills.
Spa directors expect their employees to be professional, educated,
and willing to work hard to build their clientele. Having some experience or education in marketing will give you an opportunity to excel and
build your clientele more quickly. As is the case in a medical spa,
acquiring advance education and refining techniques are important for
the aesthetician to be successful in the specific spa that he or she happens to have an interest (Figure 1–7).
License and Insurance
Figure 1–7 Traditional
spas offer nonmedicinal
treatments in a professional
and aesthetically pleasing
environment. Traditional spas
may be more luxurious and
have a retail focus.
Photograph courtesy of Edit
EuroSpa, Denver, Colorado.
Before you begin your employment, be sure to contact the
state board that recognizes your
license and find out what specific
implications should be noted
when you are working in a medical setting versus a spa setting.
Once you have completed this
task, the next contact should be
made to your insurance agent
to ensure that you have the
proper coverage for the procedures you will be doing.
Upon completing your aesthetic education, including that of peeling
and peeling agents, you will be tested and certified. Whether you are an
aesthetician, nurse, physician’s assistant, or medical assistant, you must
be licensed in each state in which you work. Your employer will request
confirmation of licensure, and this documentation will be kept in your
employee record. Many aestheticians like to keep their license hanging
in their treatment rooms for all to see. In some states, this posting is a
requirement. Unlicensed aestheticians should not be working in a medical setting (or at all for that matter), and the license should be obtained
before employment begins.
Once you begin to practice on clients, it is in your best interest to
be covered by insurance. Several types of insurance are necessary for a
spa business. For the aesthetician, the most important insurance policy
is the errors and omissions policy. This policy covers your actions when
treating clients. If something goes wrong, this policy will protect you.
When working in a medical office, the physician will sometimes have a
broad policy under which you are covered. This practice is also true in
the luxury spa. For you, as the individual aesthetician, getting proper
coverage is a fact-finding mission. First, find out from your employer
what the status of coverage for your position will be. Second, find a
reputable company, and have a consultation with one of its agents. Take
the agent’s counsel, and then consider a discussion with an attorney to
ensure that your best interests are served.
Liability Issues for the Aesthetician
Liability issues for the aesthetician are an important factor in preparing
for a career. The United States is a far more litigious society than ever
before. If something goes wrong, the client is always looking for someone to blame, and a lawyer will usually take the case. Whether a case
ever comes to settlement or trial, the stress of being blamed can be overwhelming, a situation in which no aesthetician should be caught.
Aestheticians face many potential liability risks. The most common
injuries at risk for lawsuits are scarring, burns, product reactions and
allergies, infections, and failure to keep information confidential. When
speaking specifically of chemical peels, the greatest risks of liability are
burns, infection, and scarring.
Burns that are caused by chemical peels can develop into deep
wounds and finally into scars. The burns caused by chemical peeling
are sadly the result of either a failure to understand the peel solution
or a failure to recognize an unusual circumstance. Regardless of the
cause, the safeguard is for the aesthetician to be well qualified. Nonetheless, bad things can happen. Having an understanding of wound
healing and wound care is important for the aesthetician so that he or
she can quickly recognize a problem and seek help once a problem is
determined.
Scarring is an obvious concern, especially in the medical spa. No one
is exempt from causing a scar, and as we know, even correctly performed
extractions can cause scarring. Although medical aestheticians are more
at risk, all aestheticians should be aware that each day they work they
might cause a scar. With aggressive treatments, the aesthetician needs to
follow protocol carefully and ensure that she or he is skilled in that treatment. As previously stated, being qualified and knowing when to ask for
help from the physician is important for the aesthetician. Knowing when
to ask for help is an important skill in and of itself, one that is directed by
protocol and experience.
Infection is most commonly the result of an aesthetician’s failure
to provide an adequate standard of care. Infections can occur for various
reasons: failure to properly clean and sterilize implements, including
extractors, microdermabrasion tips, makeup brushes, peel brushes, electrodes, tweezers, bowls, reusable masks, or anything else that touches
the skin; failure to wear gloves during treatments (including spa treatments); or failure to understand the sterilization and contamination process. The transmission of hepatitis C, human immunodeficiency
virus/acquired immunodeficiency syndrome ( HIV/AIDS), and
herpes simplex should be of concern to the aesthetician.
Regulatory Agencies
The agencies that regulate spas are not federal. Rules are implemented
on a state-by-state basis. Therefore you need to check with the licensing
agency in your state to determine any specific requirements related to
your job, aside from general licensure. For example, you might need a
certificate indicating that you have completed a course on chemical peels
to perform that treatment.
25
hepatitis
A condition caused by multiple viruses
defined as hepatitis A, B, or C. It is a
contagious inflammation of the liver,
with possible chronic consequences,
particularly with hepatitis C.
human immunodeficiency virus/acquired
immunodeficiency
syndrome ( HIV/AIDS)
Opportunistic infections that are
associated with a compromised
immune system.
herpes simplex
An infectious disease caused by herpes
simplex virus ( HSV-1), characterized by
thin-walled vesicles that tend to occur
repeatedly in the same place on the
skin’s surface.
26
Chapter 1
> > > Top Ten Tips to Take to the Spa
1. Aging baby boomers will be the thrust of your practice, and they
can be demanding.
2. Four levels of chemical peels have been developed; know and
understand them.
3. The origins of skin care date back over 5000 years. From the
beginning of time, people have wanted to improve their appearance.
4. Chemical peels accelerate the rate of cellular turnover and, as such,
improve the appearance of the skin. But too much exfoliation can
thin the skin.
5. Many organizations for skin-care specialists are available; find the
right one for you.
6. Know your state regulations before you start to practice.
7. Obtain insurance that covers and protects you.
8. Hold yourself to a higher standard of professionalism.
9. Understand and abide by HIPAA regulations.
10. Respect your physician.
1. What is nonsurgical aesthetic skin care? Why has it gained in
popularity in recent years?
2. How does peeling fit into today’s advanced skin-care programs?
3. True or False: The degree of peel depth has little bearing on
potential for side effects or consequences.
4. True or False: Peels are a controlled partial thickness injury to
regenerate irregular epidermal tissues.
5. Chemical peel results are controlled by:
a. Type of peeling agent
b. Number of treatments
c. Application technique
d. All of the above
6. True or False: All chemical peels are fairly easy to do, and
require little training.
7. Explain what postinflammatory hyperpigmentation is and how it
relates to peel procedures.
8. True or False: Over time, chemical peel results are equal to
those achieved by a facelift.
9. List the benefits of peel treatments.
10. What is technique sensitivity? How can an aesthetician
overcome it?
11. What areas of chemical peel training need to be emphasized on
the job? How do CEUs contribute to an aesthetician’s long-term
career goals?
12. What type of aesthetic career do you envision for yourself? Why?
13. Why are maintaining licensure and insurance requirements
critical to the long-term success of your aesthetic career?
14. Explain some ways that an aesthetician can circumvent liability
issues?
15. True or False: Leaving client treatment files in treatment rooms
is a HIPAA violation.
16. What is a medispa? How does it differ from a tradition spa?
17. What are some of the tools you can use to determine if a
particular spa will be a good employment fit for you?
18. Look at Table 1–3. What areas do you think you will need to
emphasize during your aesthetics education?
19. How does a chemical peel compare to some of the other aesthetic
treatments you will be providing?
20. True or False: Lunchtime peels have shorter downtimes with
results that equal that of typical peels.
Chapter References
1. Rubin, M. (1995). Manual of chemical peels: Superficial and
medium depth. Philadelphia: Lippincott, Williams & Wilkins.
2. D’Angelo, J., Dean, P., Dietz, S., Hinds, C., Lees, M., Miller, E.,
et al. (2003). Milady’s standard: Comprehensive training for
aestheticians. Clifton Park, NY: Thomson Delmar Learning.
3. Rubin. Manual of chemical peels.
4. D’Angelo et al. Milady’s standard: Comprehensive training for
aestheticians.
5. Ancira, M. A. (1998). Chemical peels: An overview, Plastic
Surgical Nursing, 19, 179.
6. Kuwahara, R. T. (2001, December 5). eMedicine: Specialties:
Dermatology: Surgical, Chemical Peels [Online]. Available:
http://emedicine.medscape.com.
7. Ancira, M. A. Chemical peels: An overview.
8. Kuwahara. eMedicine.
9. Rubin. Manual of chemical peels.
27
28
Chapter 1
10. Hinds, A. (2003, August). Not convinced yet? Aestheticians turn
the tide, washing in new opportunities [Online]. Available:
http://cosmeticsurgerytimes.modernmedicine.com
11. Webster’s college dictionary. (1992). New York: Random House.
12. Webster’s college dictionary.
13. Olson, A. (2004, March 11). Authoring a code: Observations on
process and organization [Online]. Available: www.iit.edu
14. United States Department of Health and Human Services. (2004,
March 9). Fact sheet [Online]. Available: www.hhs.gov
Bibliography
Ancira, M. A. (1998). Chemical peels: An overview. Plastic Surgical
Nursing, 19, 179.
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peels in clinical practice, Journal of Clinical Plastic Surgery, 27(4),
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29

1 - Milady - Cengage Learning

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