This article will help the skin care professional recognize: common skin disorders, when to refer to a dermatologist, and treatment options for certain skin conditions.

ACNE

How to Recognize
Acne is the most common skin problem that afflicts 90 to 95 percent of the population at some point during a lifetime. Dermatologists classify acne by severity, ranging from Grade 1 to Grade 4.
Grade 1: Presence of open comedones (blackheads), some closed comedones (whiteheads), erythematous papules and pustules, but no cysts. Usually less than 25 lesions on the entire face; upper trunk is not affected. Minimal risk of scarring.
Grade 2: Skin may appear bumpy due to more open comedones, closed comedones, erythematous papules and pustules. About 25 to 50 visible lesions are present. Also involves chest and back.
Grade 3: Very erythemic, inflamed skin with many open and closed comedones, and many inflammatory papules and pustules, usually about 50 to 75 lesions at each body site. May have one cyst or nodule.
Grade 4: Also known as cystic acne, or the worst type of acne vulgaris. This most disfiguring acne presents with multiple nodules, cysts, and severe scarring. Open and closed comedones, inflammatory papules and pustules are also present.

How to Treat
Simple, consistent home care is a good start to treating acne, which may begin in elementary school. At first, it is best to try not to treat acne aggressively, since irritating the skin surface could trigger further breakouts. Formulations should include ingredients that clean pores, kill the propionobacterium (p.acnes) bacteria, and calm inflammation. These include benzoyl peroxide; hydroxy acids such as glycolic, lactic, and malic; salicylic acid; willow bark extract; azelaic acid; and sulfacetamide. Aesthetic treatments may include deep pore cleansing facials, extractions, high frequency and antimicrobial masks, as well as enzyme treatments, microdermabrasion (for non-inflamed acne only), and superficial chemical peels. Prescription treatments include topical antibiotics, retinoids, and oral antibiotics with anti-inflammatory activity. Under physician supervision, one may benefit from a light or laser series which may be combined with aminolevulenic photodynamic therapy (PDT). Oral hormone modulating drugs and/or isotretinoin are among the last-resort of acne treatment options.

When to Refer
Patients with Grade 1 can benefit from a professionally recommended home skin care program along with facials that incorporate extractions and deep pore cleansing treatments. Acne Grades 2 to 4 may also receive aesthetic treatments, but should also be seen by a dermatologist for further evaluation and possible prescription topical and oral medical treatment. The worse the acne condition, the greater the risk of self-esteem issues, and poorer quality of life.

ROSACEA
How to Recognize
A widely mis/self-diagnosed skin condition which appears in the 30s and later years. Rosacea is characterized primarily by transient flushing that eventually becomes persistent flushing, inflammatory papules and pustules with visible blood vessels (telangiectasias), mainly across the cheek and nose area. Comedones are rare. Burning or stinging of facial skin, raised red patches, appearance of scaly, rough skin, facial swelling are all present to varying degrees in rosacea. Eye problems such as burning or itching, and rarely, styes on the lids, will occur. Thickening of the nasal skin occurs in rhinophyma (irregular nodularities and enlargement on the nose). A family history of rosacea, a tendency to flush or blush when drinking alcohol, eating spicy or hot foods and beverages, or when exposed to extreme temperatures strongly indicates this disease.

How to Treat
Rosacea rarely clears up without treatment, and left untreated, could become worse. Treating rosacea should leave out harsh cleansers and exfoliating scrubs which could trigger a flare, and begin with gentle, consistent home care. Professional and topical pharmaceutical products that contain azelaic acid, metronidizole, clindamycin, and sulfacetamide are quite effective in treating rosacea, but oral therapy is usually required. Aesthetic treatments include calming, soothing facials and mild superficial chemical peels. Also effective under physician supervision are Intense Pulsed Light or laser therapy, including LED phototherapy treatments combined with or without PDT of 415nm, 570nm, or 650nm lasers.

When to Refer
The symptoms of rosacea may also mimic other common skin problems. It is therefore always better to refer to a dermatologist for proper diagnosis, and depending on the severity, prescription medical treatment.

ATOPIC DERMATITIS (AKA ECZEMA)
How to Recognize
The National Institute of Health estimates that 15 million people in the U.S. have some form of dermatitis, which may appear during infancy and occurs in both children and adults. Eczematous dermatitis is characterized by the “itch that rashes” and appears as irregular scaly and/or crusted patches of irregular shape and margin. Atopic dermatitis is noncontagious, and may ruin the quality of life in a household due to poor sleeping by the afflicted person. In children and adults, it is typically found on the face, neck, and the insides of the elbows, knees, and ankles. This disease may “bubble up” with small blisters and ooze, which usually indicates infection. Atopic dermatitis-types may suffer from fish scale (ichthyosis) skin and allergies; about half develop asthma.

How to Treat
The most important factor is to stop the itch and help prevent scratching. Hydrocortisone ointment alternating with antibiotic ointment each two to three times daily is an effective non-prescription regimen. Ice cold compresses will rapidly calm the itch. Non-prescription antihistamines such as diphenhydramine, loratadine, and fordcetirazine give good relief and are non-addicting. Topical products that contain ingredients such as mineral oil, petrolatum, glycerin, beeswax, bisabolol, safflower seed oil, and lanolin are especially soothing. Oral supplements such as flax (linseed) oil and borage oil help increase lipid levels in the skin. Counter irritant anesthetics such as pramoxine, menthol, camphor, and methylsalicylate rapidly relieve the itch with intermittent use. Applying tar oil for 10 minutes then obtaining 20 minutes of mid-day sun provides significant relief.

When to Refer
When over the counter therapy fails and the client has persistent itching sites, or when infection is suspected (by the appearance of oozing), refer to a dermatologist. Even though the scaling and roughness appears as dry skin, itching indicates the more serious atopic dermatitis. If the condition is left uncontrolled, stunting of growth and mental functions can occur, so no child should be forced to endure “itchy, dry skin.”

HYPERPIGMENTATION – SUN DAMAGE OR HORMONAL IMBALANCE?
How to Recognize
Localized hyperpigmentation on sun exposed areas include freckles (ephelides), moles (nevi), and splotchy tan or dark lentigos are all due to excessive sun exposure. Tanning is the skin’s protective mechanism against damaging sun exposure; there is no such thing as a “safe” tan.
Brown patches that appear on the cheeks, bridge of the nose, forehead, and upper lip could be an indication of a deeper problem, one caused by a combination of hormonal imbalance and sun or heat exposure, called melasma. Women account for 90 percent of melasma conditions. The most common races affected are darker-skinned races, Fitzpatrick classes IV and V, such as Hispanics, Asians, and Indians – although it can occur in lighter Fitzpatrick types as well.

How to Treat
It is absolutely essential to enforce daily sunscreen with at least SPF 30 when treating melasma, preferably one with broad spectrum, reflective protection such as zinc oxide or titanium dioxide. Two morning applications 30 minutes apart provide the best coverage. Topical depigmenting products that contain azelaic acid, arbutin, kojic acid, 20 percent ascorbic acid, retinol, and salicylates are effective in lightening the skin, especially when used in combination of two or more. Aestheticians should avoid causing excessive irritation to the skin surface. Thus, try a series of gentle superficial chemical peels instead of microdermabrasion, or a series of light treatments using 650nm (red) or 833nm infrared laser or LED lights. It’s better to use non-heat types of treatments when working on melasma; however, physician supervised procedures including Fraxel or prescription products with four percent hydroquinone plus tretinoin daily are very helpful.
Clients with melasma must also take precaution against sun exposure by wearing a hat of cloth, leather, or felt material with a four to five-inch brim around the head; straw hats are usually not woven tightly enough to stop UVA penetration. Aggressive photoprotection must be a daily routine for these types.

When to Refer
Because hyperpigmentation may indicate serious glandular disease or even cancer, it is best to have an official diagnosis from a dermatologist. A potassium hydroxide scraping under the microscope and a Wood’s light (UVB) examination usually provide the correct diagnosis. A skin biopsy may be necessary to differentiate treatable melasma from other untreatable skin diseases
and conditions.

ACTINIC KERATOSES
How to Recognize
These premalignant keratoses (AKs) appear on light exposed places such as face, head, arms, and neck. AKs most commonly appear on Fitzpatrick skin types I through III, middle-aged, or older. In America, 50 percent of 60-year olds are afflicted with AKs. Left untreated, 2.7 to 16 percent progress to squamous cell carcinoma, a life-threatening form of skin cancer.
The typical lesion is a scaly, rough, usually reddish-brown or erythematous macule or papule, or patches up to several centimeters in diameter. They are rarely yellowish brown, minimally scaly macules. The most dramatic AK lesion is the cutaneous horn, which can be small to several centimeters in size, and a straight, curved, or twisted-shaped horn. Actinic cheilitis are AKs appearing as diffuse, scaling patches of the lower lip. They also may range from bright red to violet colored multiple papules resembling a skin disease known as lichen planus.

How to Treat
AKs must be treated under physician supervision. Options include cryosurgery, surgical excision, curettage (scraping) with or without electrosurgery (heat generated by an electrical current), and topical prescription medications. Lasers, chemical peels, dermabrasion and PDT are also effective for most cases. Topical prescription retinoids may be prescribed for prevention as well as the anti-inflammatory, diclofenac. Due to the risk of premalignant deterioration, regular re-examination is necessary, two to three times per year by the dermatologist.
After treatment for AK, the patient must practice consistent sun safety using broad-spectrum sunscreen with at least SPF 30, applied twice daily 30 minutes apart in the morning. As well, it is important to remember to protect lips with SPF 30 or higher lip balm. Avoid midday (10a.m. to 4p.m.) sun exposure and wear UV-rated clothing to protect other body sites.

When to Refer
Always refer to a dermatologist to correctly identify and diagnose AK when you see any questionable lesions described above, or one that is growing, causing itching or tenderness, or is inflamed on your client.

CONCLUSION
It is very important, as an aesthetician and skin care professional, to communicate with your client whenever you see or feel something unusual in the skin you are treating. Many times there is no cause for alarm, but there may be cause for concern, enough to bring to a dermatologist’s attention, since many skin conditions and disorders can look similar. An established referral relationship with a trusted dermatologist is one of the best ways to ensure your clients receive the best options in treatment care.

Dr. Carl R. Thornfeldt is President, CEO, and Chief Scientific Officer of Episciences, Inc. He is a practicing dermatologist with 24 years of skin research experience, 21 U.S. patents granted, and over 19 scientific publications in the area of treatment of skin diseases and conditions, including chapters in five dermatological textbooks. Along with these accomplishments, he has also spent nearly two decades focusing on researching the skin barrier and cutaneous inflammatory conditions. Dr. Thornfeldt received his M.D. from the Oregon Health Sciences University, and completed his dermatology residency at University Hospital, San Diego, Calif.