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The appearance industry speaks to all age groups. Trendy fashions, makeup, and beautifully packaged skin potions splash their message across page after page of magazines and tabloids. Sound bites of beautiful airbrushed youthful images with convincing close ups pan across our media screen. Millions of dollars are spent to promote youth in a bottle or the latest breakthrough of anti-aging, or a remedy for acne. A total of over $7 billion are spent each year on cosmetics in North America.1 According to the American Society for Aesthetic Plastic Surgery, almost 9.5 million dollars was spent in 2010 for surgical and non-surgical procedures including fillers.
More over an excess of $20 billion is collectively spent annually on cosmetics, skin care, fashion, diet related products, and cosmetic surgery.
Amongst the glamor and glitter is also an undercurrent of social issues covertly tucked into the scaffolding under the stage of the fashion runway. It affects our younger generation who strive on a daily basis to find their place in the world. A 2008 report done by YWCA USA found that appearance focus for younger girls and women of color becomes an increasing problem. They will go to great lengths to achieve unrealistic physical beauty in order to feel confident, competitive, employment-worthy, and accepted by their peers. Alarmingly, it has escalated to the extent of endangering their health along with their emotional well-being. Many are either trying to surgically alter their appearance or drive behavior to extremes in order to slim their bodies to the point of smoking cigarettes, thinking that it will curb their appetite.3 Compounding this are the increasing health concerns regarding the fact that parents may outlive their children due to an epidemic of childhood obesity.4 This unembroidered health concern regarding our youth and their journey into adulthood amplifies into metabolic diseases that were unheard of two decades ago. Establishing one's place in the world is multi-faceted and challenging when making decisions for creating our future. There are mixed messages aplenty for all ages. Hard hit are our younger generations whose brains are not fully developed as the neurological pathways develop in the frontal lobes of the decision making part of their brain.5 What is perceived may not always be what is real. There are increasingly social stigmas that encompass their world. Having good role models close by is mandatory for their safe journey. Young women are not alone. The beauty industry can also instill insecurities in men.6 They too are challenged with mixed messages regarding what to wear, how to shave, and having muscles of steel and a hairless body. While our main focus in this article is the skin, I have opened with some thought-provoking social trends that prompt us to become mindful of what is perceived as beauty varies regionally and culturally. Fashion can certainly shape our external appearance. Our skin, nevertheless, is the billboard for our health. Positively there are beautiful aspects of this industry that play an essential role in the health and beauty of one's self-esteem and comfort level within society. Our overall internal health requires a mind/body/spirit synergy so that we continue to unveil our true self as the magnificent human beings we all are. This requires us to grow through good lifestyle, attitude, and the opportunities that allow everyone to live to their highest potential.
The Social Media As I follow several group discussions in the social media (such as LinkedIn© and Facebook©) an underlying theme emerges regarding the gaps in understanding the dermal sciences and the fundamental causes of skin conditions. Numerous queries request specific remedies for certain conditions – acne, pigmentation, rosacea, sensitive and aging. The questions continue regarding correct choice of products and machines. Overtly the discussions are very valuable since they additionally project the education inconsistencies for truly understanding the complexity of the skin and its responses in an ever-changing environment. While our role as an aesthetician involves preventative care of the skin, increased awareness of its disorders and their causes supports better decisions with the choice of in-clinic treatment and home care – including knowing when to recommend medical intervention.
Overview of the Epidermis Most underlying issues with the skin have to do with skin barrier disorders. The core function of the epidermal cells (particularly those in the stratum corneum (SC) or horny layer) is to construct a strong barrier defense to regulate and prevent transcutaneous water loss, invasion of external allergens/antigens such as bacteria, viruses, pollen, pollution, and through the action of the melanocytes, serves as a shield for excessive radiation.7 Corneocytes are hydrophobic (water repelling) cells that are the end result of the keratinocyte cycle. Between the layers of the SC (corneocytes) are stratified compartmentalized hydrophobic and hydrophilic lipid-enriched extracellular bilayers. They serve as a border between the external environment and the water-enriched human body.8 They can also be pathologically involved with a variety of diseases including psoriasis and atopic dermatitis.9 The acid mantle rests on top of the SC and is a mixture of resident microflora bacteria that have evolved and live in the acid pH of 5.5. It is the first line of defense and is formed by the sudiferous (sweat) and sebaceous (sebum) secretions.10
The Immune System There is a close association between the epidermal barrier function and the immune system. When there are defects in the barrier, it triggers the immune system to react by eliciting the release of several mediators including cytokines to repair the physical barrier. It also influences the innate and adaptive immune systems.8 The role of the SC and defense system within the epidermis is most insightfully described by one researcher as being similar to the dual barrier of a castle – a moat with a drawbridge and a portcullis (locked gate) with guards behind the gate.9 The moat contains water that surrounds the castle and is analogous to the SC deterring unwanted external invaders. The drawbridge covers the tightly closed gate that further protects everything inside the castle (dermal cells). When there is a breach – the drawbridge is down – invaders may cross (allergens/antigens). However, an intact gate (barrier) blocks any further access. The surface of the skin is consistently subjected to environmental intruders. An intact barrier results in little immune response. If intruders manage to get over the drawbridge (weakened barrier) and crash through the gate, they are met head on and become engulfed by the dendrites of the Langerhans. When the drawbridge is down as well as the gate open, (an impaired barrier) then there is a surge of response from the gatekeepers and special sentinels.
The Architecture of a Strong Skin Barrier Healthy cells work in synergy to build a healthy epidermis. The process of differentiation and keratinization within the epidermis is a strategic process whose purpose is to build a strong barrier defense system for the skin. Metabolically active, differentiating keratinocytes migrate upward from the spinosum layer into the granular layers. Their cellular contents begin to transform into hardened filaments (keratohyalin structures), making the cells less flexible. The granular layer is very important for synthesizing material for the SC. Cells at this layer produce membrane-coating lamellar granules called Odlund bodies that contain lipids and proteins. The lipid mixtures in the lamellar granules are made up of ceramides, cholesterol, free fatty acids and cholesterol sulfate.11 They are dedicated lipid-rich apparatuses that extrude their lipidic and enzymatic contents through the keratinocyte cell membrane out into the extracellular spaces where they come in contact with the water (natural moisturizing factors – NMF). The lipids then form two layers, one of oil and the other of water and are reorganized into multiple long sheets of lamellar structures.12 These structures play a dynamic role in barrier defense and controlling transepidermal water flow and maintaining proper hydration levels within the epidermis. Their strategic function is to govern skin permeability and water balance (NMF) within the skin.13 They are also the primary pathways for chemical penetration through the SC. Epidermal tissue must remain as impermeable as possible with the exception of allowing enough water to maintain hydration at the outer layers of the SC, as well as supporting the enzymatic processes that facilitate corneo-desmosomal degradation and desquamation. The water content supports skin flexibility and the ability to adjust to relative humidity (internal and external). The ability for the SC to maintain its water content is dependent upon (a) the thickness of the SC, (b) the organizational and compacting characteristics of the corneocytes that allow them to function properly, and (c) the presence of very hygroscopic (NMF) compounds largely found within the corneocytes.14
NMF – Multi-Function Qualities The NMFs are composed primarily of amino acids, PCA and other compounds. The hygroscopic properties of NMF greatly contribute to the corneocytes' ability to retain moisture.15 NMF also facilitates enzymatic processes, including the dissolution of the desmosomes.15 NMFs consist of amino acids that are not only responsible for the moisture content of the skin, but also for the osmolytic balance (transition of water across cell membrane) – i.e., NMFs correct imbalances in the osmotic pressure of the skin. Furthermore, the amino acids and the urea of the NMFs protect against ROS (reactive oxygen species – free radicals).15
Antioxidant Systems The skin has a network of enzymatic and non-enzymatic antioxidant systems that help combat oxidative injury from pollution, bacteria, ultraviolet rays (UVR), microorganisms, or chemical oxidants.15 The normal functioning of these systems is reliant upon a balance of lipid and protein systems that maintain the barrier function and are essential for skin moisturization.15 When there is oxidative stress within the lipid and protein structures of the cells, it degrades the barrier integrity. The skin begins to show signs of dryness with the increased water loss (transepidermal water loss - TEWL). Traditional terminology used to describe skin abnormalities – dry, lipid dry, oily, sensitive, or a combination of being both oily and dry – are not providing enough information. A key question here is to explore the underlying causes of the condition. A close examination of health history, family history of diseases such as cancer, lifestyle and race begins to uncover clues regarding your client's skin. Dryness and sensitivity in the skin, as in the case of dermatitis, psoriasis or abnormalities in the desquamation process, is an indicator that there are underlying issues concerning the skin's lipids/protein/enzyme/fluid balance within the bilayers. Be mindful that during your consultation, external observation must be surveyed more deeply since there may be a genetic link to one's skin type and future tendencies for developing disorders. The leading cause of a skin condition may be linked to a genetic component that began in the womb during early embryonic development with regulatory genes that orchestrate the assembly of the dermal components.16 For example, the development of transporters are called aquaporins (aqua = water; porins = pores or channels) – a family of integral water transporting proteins found in the skin. They are required for fluid balance, metabolism of skin lipids and regulation, differentiation and proliferation of the keratinocytes throughout the skin's physiology,17 and are very necessary for wound healing. Aquaporin-3 in particular transports glycerol, a humectant. In the event of an aquaporin-3 deficiency, there is a shortfall in the transport of glycerol. The consequence is dry skin with reduced hydration in the SC and decreased elasticity and impaired enzyme activity (biosynthesis).18 Additionally, aquaporins can also be affected by age and chronic sun exposure, and a defective osmotic equilibrium in the epidermis.19 The health and nutrition of the mother is paramount during the development of the fetus. Balanced nutrients such as protein; adequate amounts of essential fatty acids (omega 3 in particular); folic acid; vitamins A, B-complex, C and D; iron; calcium; chromium; zinc; folic acid and other nutrients.17
Acne Acne grades 1 through 4 may display a multitude of skin irritations including pustules, comedones, or painful, inflamed cysts. Acne is hormonally mediated and begins in puberty where hormone production and balance affects the skin and hair growth.20 It is a condition that must be understood from the physiological to the emotional aspect. The growing and changing body of a teenager particularly creates havoc within the follicle secretions, oftentimes escalating to excessive oil and full-blown breakout. While the degree of acne varies for many teenagers, it is part of the adolescent phase during the transition from youth to adult. As a result, there can be disturbances in the pH of the skin and the follicle with proliferation of bacteria. Severe irritation and inflammation are also signs that there are imbalances and disruption in the skin barrier function. Correction includes focus on a reduction of sebum lipids and related increase of the TEWL to avoid creating an environment that elicits the proliferation of propionic acne (P. acnes).20 Selection of skin care should be carefully assessed and directed for the treatment of acne. Heavy moisturizing substances should be avoided since they act as a breeding ground for P. acnes.21 Sometimes, the tendency is to use more aggressive substances to mop up the oil, discourage bacteria and control breakout. A first rule is to support the skin barrier and calming of irritation without adding more stress to the skin. When there is fire on the roof (the barrier), it requires attention. Education is a key factor for this individual.
The Important Role of Essential Fatty Acids Polyunsaturated essential fatty acids (EFAs) are a primary component for developing healthy cell membranes and the bi-layers for an intact barrier. Moreover, the brain is built from fatty acids and omega-DHA content.22 EFAs perform a multitude of functions within the cells. Therefore, it is important to note that essential fatty acids cannot be synthesized by the body and must come from food sources. Inadequate intake of omega-3 results in abnormalities in the skin barrier.23 There is a marked difference in healthy skin with organized lamellae (layers) between the corneocytes versus skin with essential fatty acid deficiency (EFAD) that causes disorganization and appears as undulations (furrows), resulting in ichthyosis (scaly skin). When the membrane becomes damaged (oxidative stress, disease, poor nutrition), it no longer functions correctly, which leads to acceleration of the aging process. Glycation is a prime example.
Caring for the Skin Barrier The SC contains signal functions that influence important controls within the epidermal layers.24 The horny layer has a direct influence of the regenerating process in the deeper layers of the skin. The normal function of the skin barrier declines with age, including lipid synthesis and the pH of the acid mantle. Choosing correct products for protecting the barrier is based on several factors, especially the age of the client, the biological age of the cells, lifestyle, and the extent of accumulated damage. The chemical and physical properties of a product greatly influence the integrity, regeneration and preservation of the horny layer. A key philosophy is to preserve the natural function of the epidermal layers at all times. Product choices should mimic the physical structures of the cells, be free of emulsifiers and contain appropriate active agents such as linoleic acid to support the skin in reactivating its own regeneration capability.24 Many cosmetic products can actually interfere with the natural TEWL process. Mineral oils and silicones form too much of an impermeable film on the skin. They can easily cause a lower TEWL that actually slows down the regeneration process. The client ends up experiencing dry skin upon discontinued use of these substances. There was not a clear understanding that the skin barrier began to experience disorder and lost its ability to regenerate. The perplexity of this situation is compounded with repeated use of inappropriate cosmetic or dermatological products. Moreover, the prescribing of corticosteroids for inflammations provide a temporary relief; however, they actually contribute to increased skin sensitivity and deterioration of the condition.24
Conclusion As members of the beauty industry, a large percentage of our mission is to support the well-being of our clients through professional and knowledgeable care. Take the steps needed to educate your client and teach preventative care of their skin!
References: 1 Beauty At Any Cost. http://www.ywca.org/atf/cf/%7B711d5519-9e3c-4362-b753-ad138b5d352c%7D/BEAUTY-AT-ANY-COST.PDF 2 2010 News Release – Demand for Plastic Surgery Rebounds by Almost 9%. Retrieved from http://www.cosmeticplasticsurgerystatistics.com/statistics.html#2010-NEWS 3 Wilson, A. (April 26, 2008) Smoking Doesn't Cause Weight Loss in Teenage Girls. Health Myths and Misconceptions. Retrieved from http://healthhubs.net/myths/smoking-doesnt-cause-weight-loss-in-teenage-girls/ 4 Warner, J. (April 9, 2010). Baby Boomers May Outlive Their kids: High Obesity Rates Set Younger Generation Up for Poor Health. WebMD Health News. Retrieved from http://children.webmd.com/news/20100409/baby-boomers-may-outlive-their-kids 5 Cloud, J. (Sept. 2, 2009) The Teen Brain: The More Mature, The More Reckless. Retrieved from http://www.time.com/time/health/article/0,8599,1919663, 00.html 6 The Body Project (2012) Women's Studies Program of Bradley University – Center for Wellness and Dept. of Sociology. Retrieved from http://thebodyproject.bradley.edu/ 7 Elias, P.M., Feingold, K.R. (2006) Chapter 1: Stratum Corneum Barrier Function: Definitions and Broad Concepts. Skin Barrier, Taylor & Francis Group, NY. p. 1 8 Jensen, JM, Proksch, E. (2006) Chapter 32: The stratum Corneum of the Epidermis in Atopic Dermatitis. P. 572 9 DeBenedetto, A., Kubo, A, et al (2012) Skin Barrier and Allergen Sensitization. J Inv Dermatol, Vol 132 p 949 10 Elias, P.M, Feingold, K. R. (2006). Skin Barrier. Taylor & Francis Group, NY, London. P. 78 11 Akemi IshidaYamamoto, M. Simon, M. Kishibe, et al. (2004) Epidermal Lamellar Granules Transport Different Cargoes as Distinct Aggregates. J Inv Derma 122, 1137-1144; Retrieved from http://www.nature.com/jid/journal/v122/n5 12 Svane-Knudsen, V., Halkier-Sorensen, L., et al (2000) Stratum corneum barrier lipids in cholesteatoma. Acta Otolaryngol Suppl. 543: 139-42. Retrieved from http//www.ncbi.nlm.nih.gov/pubmed/10909003 13 Barrett Hill, F. (2004) Advanced Skin Analysis. Virtual Beauty, New Zealand. 14 Thiele, J.J. (2006) Chapter 23: The Epidermal Antioxidant Barrier. Skin Barrier. Taylor & Francis, NY. p. 379-381 15 Lautenschläger, H. (2007) Applied corneotherapy and skin care: guidelines for the anti-aging treatment. Ästhetische Dermatologie (3), 8-16 16 Nathanielsz, P. (2009). The Prenatal Prescription. Pennington Biomedical Research Center – Division of Education. https://www.pbrc.edu/training-and.../ppt/Prenatal_Prescription.ppt 17 Boury-Jamot, M., Daraspe, J. et al (2009) Skin Aquaporins: Function in Hydration, Wound Healing, and Skin Epidermis Homeostasis. Handbook of Experimental Pharmacology, Vol 190, III, 205-217, DOI: 10.1007/978-3-540-79885-9-10 Retrieved from http://www.springerlink.com/content/u82v27l241174u72/ 18 Hara-Chikuma, M. and Verkman, A.S. (2005) Aquaporin-3 functions as a glycerol transporter in mammalian skin. Biol. Cell 97, 479-486. 19 Dumas. M., Sacik, NS, et al (June 2007). Hydrating skin by stimulating biosynthesis of aquaporins. J Drugs Dermatol. (6) Suppl):s20-4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17691206 20 Lautenschläger, H. (2009) Skin care for the adolescent skin. Kosmetik international (10), 20-23. 21 Lautenschläger, H., Klein, E. (2006) Acne caused by too many different moisturizing factors in creams? Letters to the editor, Kosmetische Praxis (3), 4 22 Weatherby, Craig (2010, June 1) Did Humans Evolve on Fishy Diets? Retrieved from http://vitalchoice.com/shop/pc/articlesView.asp?id=1039 23 Elias, P.M, Feingold, K. R. (2006). Skin Barrier. Taylor & Francis Group, NY, London. P. 78 24 Lautenschläger, H. (2000). Regeneration of the skin barrier. Kosmetik International (8), 100-103
Alexandra J. Zani is an international educator and author with a background in biology and medical technology. She is a licensed cosmetologist/aesthetician, NCEA nationally certified, and an independent technical and scientific advisor for postgraduate studies in the medical spa industry, including cosmeceutical development. Zani presents education for advanced aesthetic technology including microcurrents, LED and laser. She is a specialist in the anti-aging sciences, including the effects of nutrition, lifestyle and the mind/body connection. Presently, Zani facilitates post-graduate aesthetics education, is a technical writer, and a founding member of the International Organization of Continuing Education Providers (IOCEP). She is a contributing author for textbooks and industry publications. Alexandra is co-author with E.A. Ordonez, M.D. of a newly released book Eat to be Free.
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