Distinguishing Between Skin Diseases Aestheticians Need to Recognize
Friday, 28 June 2013 06:28

Distinguishing Between Skin Diseases Aestheticians Need to Recognize

Written by   Christine Heathman C.M.E., L.M.T.

My career in specialized skin care transcends over 25 years of functioning behind the chair recognizing skin diseases and performing professional clinical skin care treatments. During this time, I have seen some of the most challenging facial conditions which would cause a majority of aestheticians to either panic or refuse. Embracing the difficulty of severe skin problems is what I love, therefore, I have built my career on this. I encourage aestheticians to expand their learning curve to recognize the most common skin diseases to provide a clinical remedy appropriate to the client's condition and your skill.

I have worked with prestigious institutions such as Bothin Burn Unit in San Francisco, The University of Utah, and the Institute of Facial Surgery in Salt Lake City. Also, because of past referral associations and earning the trust of dozens of physicians and medical professionals, I understand many skin diseases and my license boundaries. Thus, I acquire excellent results from my clients' treatments, resulting in higher patient satisfaction.

Acne
Acne is the pleomorphic disease par excellence. Its conditions are multifarious and expressive. Acne flourishes in adolescence, beginning in the prepubescent stage and subsides in most cases when the threshold of early adulthood is entered. Hardly anyone makes the trip through adolescence without coming in contact with acne lesions consisting of comedones or pustules. The prevalence of this occurrence is close to 100 percent in this puberty phase, however, when asked of adults, only 10 percent who experience this period actually recall the event.
Acne is not an endocrine disorder. The general belief is that there are not usually deficiencies, excesses or imbalances. However, normal circulating levels of androgens from the gonads and adrenals are absolute requirements. The fact remains that without a source of androgens, the sebaceous glands will remain small. In addition, adrenal glucocoricosteriods play a collaborative role. They potentate the effects of androgens and have an influence over the end organ sensitivity where they influence the capacity of the follicle to form comedones.
While acne typically first appears during adolescence, hormonally influenced acne in women usually begins in the early-to-mid 20s and can persist well into adulthood. The cause of hormonal acne is most often linked to androgens and while most women with acne have normal levels of this hormone, some may have a more serious medical condition for which acne is just one symptom. This is important to note for aestheticians who come in contact with women suffering from acne. If a client shows absolutely no response during the process of eliminating the 13 established aggravating factors, then the individual should be advised to seek medical testing.
Acne affects millions of individuals. This skin disease is still the most common dermatologic condition treated by dermatologists in the United States, however, more and more men, women and teenagers are seeking successful alternative acne treatments from aestheticians. Traditional medical treatments assist in getting acne under control and help improve the appearance of the skin to prevent the development of scars and psychological damage. A new generation of skin therapists, namely aestheticians, have been very successful combating acne without drugs by working with the body's natural circadian rhythm and immune system to heal and control future lesions as new cells generate healthy skin.
The identification of multi-factorial pathogenesis of acne has a direct affect on treatment management considerations which now include the use of combination therapy to act on the different pathogenic factors. Treatment today by the medical profession still includes systemic therapies that involve oral antibiotics; hormonal therapy, such as birth control pills (Accutane); and in some instances, nutritional modalities with vitamins. Topical therapies successfully administered by aestheticians utilized for the management of acne include, but are not limited to: benzoyl peroxide, alpha hydroxyl acids (AHAs), botanicals, oxygen therapy, sulfur, resorcinol, jessners, TCA, enzyme, et cetera.
Acne is an inflammatory disease of the pilosebaceous unit with a multi factorial pathogenesis. True acne is a follicular eruption that originates as a comedo; if the comedo erupts and inflammatory reaction ensues, it forms papules, pustules or cysts.
acneNot all acne lesions are alike and learning to recognize and understand each lesion type will aid in effective management of this disease of the pore. The technique of acne grading is based on palpation and inspection of the skin, assessing the grade, and manifesting the stage (acute/chronic) the client falls into.
Without reservation, controlling the inflammatory response is crucial and must be the number one priority of the skin care professional. Not only must the professional understand the type of acne the client has inherited, but they must also comprehend how the body is genetically predisposed to inflammation. Genetically, one could inherit a non-inflammatory acne response. In each case, acne must be assessed via a skin analysis intake form and properly treated on an individual basis with respect to age, skin type, genetics, lifestyle, chronic, acute, grade, et cetera.
It is clearly unrealistic for the skin care professional to categorize all acne conditions into one category. This is called lazy aesthetics and there is no room for any aesthetician or physician who generalizes the acne condition. Individual cases vary and evaluation will depend on the inflammatory response. Diagnosis of the acute/chronic nature will be contingent on lesion count and duration of infection. The determination of the acne grade and the severity forecast lies in the family history. All clients must fill out an acne questionnaire intake form, making sure to answer all questions regarding family history. Facial lesion counting can be a reliable method for evaluating efficacy of your treatment. For years it has been reported that lesion counts were used to determine therapeutic utility in clinical investigations. Today, lesion counting is used also as a litmus to determine the progress of the acne client. An increase or decrease of acne lesions is integral for monitoring how the client is responding to a specific treatment.
Aestheticians working in spas, medical spas and skin care clinics can offer the acne sufferer many new options available to beautify and increase the health of the skin to reduce and control the acne disease.
Acne, under the care of an aesthetician, is generally void of any drug considerations, unless working alongside a medical doctor who also maintains control over the acne client. An experienced aesthetician will always use a holistic and preventative approach to acne, identifying the factors that aggravate the condition and taking time to control the disease with scheduled clinical management and home maintenance remedies.
The recommended topical therapies used by aestheticians can include benzoyl peroxide, anti-inflammatory agents, anti-aging peptides, antioxidants, alpha hydroxy acids (AHAs), beta hydroxy acids (BHAs), jessner peels, trichloroacetic acid (TCA) peeling agents, enzymes, keratolytic agents, lymphatic drainage, nutrition, supplements and ultrasonic facial treatments.

Rosacea
Often mistaken for acne vulgaris, rosacea is a chronic disorder of the facial pilosebaceous units, coupled with an increased reactivity of capillaries to heat, leading to flushing, blushing, and ultimately a vaso-dilation condition called telangiectasia (small blood vessels). Rosacea is an extremely common disease that is underreported and often improperly treated. It progresses slowly in stages and in its early forms, is rarely recognized by skin practitioners and, all too often, missed by dermatologists as well. The key to correct diagnosis is the skin history of the client, especially in the early stages of rosacea. Rosacea usually starts on the skin, but if left untreated, many cases will progress after decades to affect the eyes in some form.
Previously called acne rosacea, this disease is unrelated yet quite often coexists with acne. Although acne may have preceded the outbreak of rosacea by years, rosacea may and usually arises de novo – without any preceding history of acne or seborrhea. Rosacea presents itself as a sensitive or inflamed skin that shows telangiectasia near the skin's surface that can become pustular, which leads it to being mistaken for acne.
Rosacea is a persistent neurovascular disorder of unknown origin and can be triggered by an indication of blushing or flushing. Occurring with equal frequency in persons with global skin color, flushing and blushing can be difficult to discern clinically due to skin pigment influences.
boy-acneFlushing is an unpleasant and sudden intense diffuse reddening of the face (and other areas of the neck and chest) that is an exaggeration of the normal vasodilatatory response to hypothermia or other factors. It is caused by a precipitatous extensive facial vasodilatation leading to increased cutaneous blood flow. Flushing may be precipitated by dietary factors, alcohol, drugs, environment and hormonal change, or it can appear for no apparent reason. Flushing is also more widespread than blushing, extending in a diffused fashion from the hairline to involve the neck and upper anterior chest. The aesthetician should be aware of this and know how to identify it.
Rosacea is a skin disease involving the sebaceous follicle. This primary oil factory of the skin contains a tiny hair anchored within its complicated environment. Although the sebaceous gland is the responsible perpetrator for acne, this is not the case of rosacea other than it hosts a very interesting resident called the demodex skin mite.
The demodex mite is found on the face and produces an enzyme called lipase. Lipase breaks down sebum on the skin's surface and is found in all rosacea sufferers. It occurs when the skin heats up to 99 degrees Fahrenheit or higher, and appears to be the cause of inflammation in papules and pustules. Luckily, this condition can be controlled by cleansing the skin twice daily with a lipid soluble cleanser containing AHAs.
Before any home care or clinical treatment can be initiated, detailed questioning via a skin analysis intake form is essential for comprehending the many faces of rosacea. It is always a challenge to extract precise information from any client; however, in the case of rosacea, it can be even more challenging regarding their blushing and flushing tendencies. Clients are often unaware of the associations until you begin to ask specific questions.
Start with basic everyday issues such as sweating, exercise, embarrassment, sunlight sensitivity, diet, drugs, et cetera, as well as subjective discomforts from skin care topical products and medications. Follow a specific list and dispel all misinformation such as coffee and other suspected culprits and fine tune the process of elimination. Record all diet concerns, environmental factors, skin care products and/or treatments, et cetera that might irritate rosacea. Use this time to educate your client so they can manage their skin condition based on your assessment discovery. As a skin care professional, it is imperative that you teach your client how to take back control of the disease and begin the journey back to healthy skin with clinical treatments and a proven home care routine.
Skin affected by rosacea is in trauma and out of balance. When tissue repairs itself, it requires more amino acids for cell proliferation. Peptides are organic chemical compounds composed of one or more basic amino acid groups and one or more acidic carboxyl group. Therefore, select a peptide product that contains palmitoyl-pentapeptide-3 and other peptides with a low molecular weight in the amino acid chain. Peptides are non-irritating and more stable than vitamin C and retinol, making peptides an integral step in treating rosacea skin. Not only do peptides have the capability to reduce the inflammation associated with rosacea, they also reduce the aging factors that compound rosacea sufferers linked with photo-damaged skin.
It has been established that rosacea clients can have sensitive skin and be misled that topical agents such as cleansers and AHAs could affect this hyper-reactive condition. This hypersensitivity link has not been convincingly demonstrated nor has it been proven. Rosacea patients are not especially prone to stinging after an application of 10 percent lactic acid. In fact, clinical studies of this disease in relationship to these acids are reassuring because rosacea can readily accommodate to irritating agents. Because rosacea is photodermatosis, it is absolutely imperative that a ratio of at least 30 SPF and protective makeup (such as a camouflage base) is part of the daily treatment program to protect against the environment. Furthermore, when selecting sun protection for skin suffering with rosacea, it needs to be a formula that does not hold inflammation heat in the skin. Be aware that not all SPF products are good for rosacea; many can irritate the condition.

Psoriasis-Vulgaris-on-shinPsoriasis Vulgaris
Psoriasis can be challenging for any patient, physician and aesthetician. The word psoriasis is New Latin from the Greek words: psor (itching) iasis (condition). Epidemiology is early age onset, with peak incidence at age 22.5 and late incidence at around age 55. Textbooks invariably and appropriately describe it as a chronic dermatitis. In spite of intensive research, we know that psoriasis involves excessive rapid turnover of epidermal cells and is an inherited disorder with the genetic mechanism being complex. If one parent has psoriasis, then eight percent of the offspring will inherit the disease. If both parents have this condition, then 41 percent of their offspring will by chance inherit the disease.
The principal abnormality in psoriasis is an alteration of the cell kinetics of the keratinocytes. The major change is the shortening of the cell cycle that results in 28 times the normal production of epidermal cells. The epidermis and dermis appear to respond as an integrated system, for example, changes in the germinative zone of the epidermis and the inflammatory changes in the dermis possibly trigger epidermal transformation.
Triggers cause a major factor in eliciting lesions, as rubbing and scratching stimulate the psoriatic proliferative process. Stress is also a major factor in flare-ups, affecting both adults and children. Drugs known to trigger psoriatic episodes can include systemic glucocorticoids, oral lithium, antimalarial drugs, systemic interferon and B-adrenergic blockers. Alcohol is also a recognized trigger factor.
Identification of the classical psoriasis presentation is sharply demarcated – scaling plaques of the scalp, elbows and knees are easy. It can also appear in ways that baffle even the most experienced medical professional and certainly the aesthetician. Psoriasis may present difficulties when it affects only the palms, soles or fingernails. It may begin to resemble such disorders as seborrheic dermatitis, eczema, dry-skin dermatitis, atopic eczema, or hand dermatitis. Many dermatologists have learned to view stubborn seborrheic dermatitis of the scalp with suspicion, due to its prosperity to develop into classical psoriasis years later. Aestheticians should also maintain steadfast observation, recording on their clients' intake form any changes that could affect aesthetic treatment options.
The duration of lesions that are present for months are identified as indolent, but may be of sudden acute onset activity brought on by several identified psoriasis triggers. These psoriasis lesions are salmon-pink papules with sharply marinated plaques marked with silvery-white scales that are lamellar, loose and easily removed by scratching.
Psoriasis is an equal opportunity skin condition, affecting as many males as females and range between one and a half to three percent of the Caucasian. A low incidence of occurrence does take place in darker global skin types of African, Japanese, Eskimo and South American Indian descendants. It is recommended to always inquire of your client's ethnic background and to make sure the information is recorded on their skin analysis intake form. Being forewarned of genetic predispositions of any condition will provide insight into treatment management.
Individuals with newly developed psoriasis often become disenchanted with their treatment and switch physicians or seek alternative therapies in hope of finding a cure that includes licensed aestheticians and nutritionists. While there is no cure, treatment usually offers significant temporary relief and sometimes clears up the rash.
Due to the dynamics of the disease, aestheticians are limited in clinical treatment options. There are new, safe, gentle clinical remedies available that can provide relief and help manage the psoriasis lesions to smooth skin and reduce inflammation, augmenting most medical psoriasis topical treatments.
Since psoriasis is a disorder requiring long-term treatment, therapy should be simple. More than 90 percent of psoriatics require only topical therapy. One very effective treatment for your clients suffering from psoriasis is the use of a 30 percent acid protease peel that mimics cathepsin D (the skin's natural enzyme that controls exfoliation and cellular turnover). This high-tech ingredient is gentle, self-neutralizing, can be used on the most sensitive of skins, increases skin penetration of other psoriasis topicals, and is extremely safe. Thirty percent acid protease works on one cell at a time, releasing the desmosomes and corneodesmosomes to induce the shedding of the squames at the outer layer of the epidermis at a rate that is balanced by the mitotic development of new cells at the basal layer.
Lactic acid formulations have always been part of a successful psoriasis treatment plan. Many of my clients experience a significant difference in managing and reducing new and old plaque lesions in addition to keeping fresh ones from emerging. I successfully use lactic acid in clinical applications with continuance of home care, which includes mild peels along with treatment creams and serums. For over 50 years, AHAs have been substantially documented, stating their features and benefits as to how they re-educate skin cells to facilitate and reestablish normal desquamation activity. Lactic acid is the most diverse choice among all the professional topical exfoliants due to its unique ability to combat a wide variety of skin problems and co-exist amicably with other actives. The power of this agent provides the skin care specialist with more options for successful treatment with less irritation on the skin.
Smooth, supple and moist skin results from a complex interaction between three major skin elements: lipid production, natural water content, and the presence in varying amounts of special substances called natural moisturizing factors (NMFs). Produced by the body, NMFs are substances that act to attract and hold on to water at the skin's surface. They are thought to work by binding water in place or by helping the skin's cellular proteins arrange themselves so that they better absorb and hold on to the water.Psoriasis-Vulgaris-on-elbow
NMFs consist primarily of amino acids or their derivatives such as pyrrolidone carboxylic acid (PCA) and urocanic acid (UCA), combined with lactic acid, urea, citrate and sugars. These compounds are collectively present at high concentrations within the cell and may represent 20 to 30 percent of the dry weight of the subcutaneous (SC). The importance of the NMF lies in the fact that its constituent chemicals, particularly its PCA and lactic acid salts, are intensely hygroscopic. Lactic acid, as well as being a component of the NMF, is also a member of the class of AHAs, which exert specific and unique benefits on skin structure and function, particularly cell renewal.
It is important for the aesthetician to note that systemic therapy is generally a medical option born out of a psoriasis sufferer's desperation and should be reserved for patients whose severe psoriasis fails to respond to all exhausted topical treatment alternatives. Aestheticians should have all medications reported on their intake form, as all drugs potentially can cause photosensitivity and other contraindications.
By avoiding foods that trigger incidences, managing nutritional intake can also be of great benefit. Since psoriasis is a metabolic disease, a cleansing juice fast for about two weeks is always desirable in the beginning of treatment. Carrots, beets, cucumbers and grapes may be used for juices. Juices made with citrus fruits should be avoided.

eat-wellAfter the juice fast, the client should adopt a diet of three basic food groups, namely: seeds, nuts, grains, vegetables and fruits. Plenty of organically grown raw vegetables and fruits are recommended. In this regimen, breakfast may consist of fresh fruit such as apples, grapes, pears, peaches, pineapples and a handful of raw nuts or a couple of tablespoons of raw seeds. A large bowl of fresh green vegetable salad and sprouts may be eaten for lunch, and dinner may consist of steamed vegetables and whole wheat.
It has been recommended that all animal fats (including milk, butter, and eggs) be avoided or have a reduced intake. Refined or processed foods as well as foods containing hydrogenated fats or white sugar, condiments, tea, coffee, alcohol and tobacco should also be avoided or consumed in moderation.
Lecithin has proved effective in the treatment of psoriasis; vitamins A and B6 also help. The patient can take three tablespoons of granular lecithin daily along with all nutrients needed to help the liver produce its own lecithin. Nutritionists also recommend the intake of of vitamins C, E and B-complex.
The client information intake form on psoriasis contains mainly background information and aims treatment for control rather than cure. Also, since treatment varies with severity and location of disease, routine printed treatment instructions are not feasible. Treatment is often complicated and it is wise to write out specific treatment instructions for each individual.
Medical topicals used for psoriasis are corticosteroids, tars and anthralin, in addition to a few miscellaneous agents of limited usefulness such as salicylic acid and phenol. Corticosteroids are the most popular topicals because they neither stain nor stink; however, they are expensive. One major disadvantage is that the control they achieve is usually transient and daily applications are generally needed. In certain areas, atrophy from the more potent fluorinated corticosteroids becomes a limiting factor. There is a considerable difference in the efficacy of fluorinated corticosteroids in psoriasis. Resolutions of lesions can be accelerated by the use of phototherapy. However, tars are some of the better medical agents for treating psoriasis. In fact, in the United States, coal tars are chiefly used.

Vitiligo
Vitiligo is a chronic disease. Its course is highly variable but rapid onset is followed by a period of stability or a characteristically slow progression. As a skin disorder, vitiligo occurs when the melanogenesis (melanin production) in the body fails to produce melanin. Normal skin color is composed of a mixture of four biochromes, however, it is the total amount of melanin pigment that is the principal determinant of skin color. Melanin is a complex molecule responsible for the pigment in the skin, hair and eyes. This molecule works to protect by reducing the penetration of ultraviolet rays into the skin and subsequently into the nuclei of cells where DNA resides. It is important to note that both dark and light skins have the same number of melanocytes (cells responsible for melanogenesis); however, the difference in how the cells respond fluctuates greatly in the varying global skin types.
Principal theories have been identified regarding the destruction of melanocytes in vitiligo sufferers. The autoimmune theory holds that selected melanocytes are destroyed by certain lymphocytes that have somehow been activated internally.
VitiligoVitiligo is a disorder that affects one to two million Americans. It is equal in both sexes, appears in all races and looks as if to be an inherited disease. The obvious manifestations are asymptomatic white spots on the skin.
Treatment of the loss of pigment in the skin is prolonged, difficult, and requires a sustained effort by the client and the physician. Most physicians incorrectly advise their clients that there is little hope or a need to treat the condition. This advice is misguided and discouraging for the client. The cosmetic disfigurement of vitiligo has a substantial impact on a person's social, emotional and professional relationships.
Vitiligo is caused by the destruction of pigment cells. Vitiligo develops in half of the clients it affects before the age of 18 years and in one-fourth of the clients before the age of 8 years. Depigmentation begins most frequently on the hands, feet or face and may spread to involve most of the integument. Eventually, the process leaves the client spotted and disfigured. A few fortunate clients lose all of their pigment and acquire a pleasing, uniform, white appearance. In 20 percent of clients, vitiligo develops after severe sunburn or after notable tanning. A similar percentage first observes the depigmentation after severe emotional or physical stress.
For many clients, the depigmentation is asymptomatic, but about 10 percent acquire a dermatitis with mild pruritus before the loss of pigment occurs. Routine light microscopy of skin biopsy specimens from ordinary non-inflammatory vitiligo shows that the epidermis appears normal; only a few lymphocytes are visible in the dermis. In the skin where there is inflammatory vitiligo, edema and a lymphocyte infiltrates in the epidermis, as well as in the dermis. At the border are pigment cells that often are two to three times normal size and have increased numbers of dendrites. It is thought that these enlarged cells are in a pre-morbid state.
Electron microscopic findings in normally pigmented skin also show that Langerhans cells (immune cells in the epidermis) are affected. Their cytoplasm has vacuoles, increased quantities of endoplasmic reticulum, and a notably folded cytoplasmic membrane. The findings are less prominent in depigmented skin. The studies have resulted in the scientific belief that all three cell types: keratinocytes, Langerhans and melanocytes are involved in vitiligo.
Although there has been significant research in the cure of this disease for decades, vitiligo is managed and never cured. Aestheticians can provide significant emotional and aesthetic support to help reduce the clinical effects of this chronic disease.
Firstly, all vitiligo sufferers must wear sun protection. The dual objective is for the protection of the skin from acute sunburn reaction and limitation of tanning of normally pigmented skin. Full spectrum sun protection of SPF 30 should be part of a daily routine with intermittent reapplication when exposed to long-term environmental conditions.
As a licensed master aesthetician, I also recommend to vitiligo sufferers the use of a self-tanner in the depigmented areas of the skin. The dihydroxyacetone (DHA) ingredient in self-tanning formulations provides new color in the depigmented areas. Applying an AHA prior to the self-tanner product will increase color intensity. This is not a permanent solution and the individual must maintain DHA therapy with continued application every four to five days.
Another remedy I use with my clients who suffer from vitiligo is camouflage cosmetic therapy. This beneficial therapy is the application of camouflage makeup and it is an important physical protection which gives the skin a natural, even skin tone. The tripwire for pigmentation disorders is inflammation and this condition is exacerbated by environmental influence (vitiligo, hyperpigmentation, melasma, freckles, age spots, brown spots, lupus, et cetera).
The inorganic ingredient of a great camouflage product is titanium dioxide, which provides a natural, essential form of sun protection. In addition to rendering an effective barrier from solar damage, camouflage makeup supports the patient with immediate visual cosmetic improvement by minimizing the discoloration. Patients not only benefit from the instant concealment but can also continue to be treated successfully while undergoing therapy for pigmentation. Powder mineral makeup is not a sufficient barrier of protection and should not be used alone, however, it can be applied as a finishing product after the initial application of a camouflage cream.
Last but not least, you need to provide continued professional skin care treatments and continuance of care formulations designed to augment the skin's immune system. Persistence in the cosmetic improvement of vitiligo is the only acceptable method in managing this very challenging skin condition.
In conclusion, there are thousands of variable skin diseases aestheticians should gain knowledge of in their pursuit of continuing education, providing the point of difference in their clinical treatments and client management. It is important to remember that education should be first and foremost in your pursuit of aesthetic skill set, followed by product information, working with established educators, and credible product formulators to guarantee your future success in aesthetics.

Christine Heathman 0510As a licensed master aesthetician who has practiced clinical skin care for over 25 years, Christine Heathman C.M.E., L.M.T. is an aesthetic pioneer and nominated Legend in American aesthetics. She is a powerful speaker, world-wide lecturer, educator, author of several skin manuals, has written hundreds of skin science editorials, selected to the editorial board of a leading skin journal and is an innovator in the research and development of unconventional and progressive skin care and protocols used in the most prestigious skin care and medical clinics all over the world. Owner and CEO of GlyMed Plus, a professional only skin care line, she has appeared several times on the popular health care program, The Doctors. Heathman has remained loyal to the professional, applying her extensive knowledge and experience to facilitate American aesthetics and remains a commanding and authoritative influence in the skin care industry today.

 

 

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