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Saturday, 25 November 2006 09:30

Co-Managing Clients

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Some patient diseases – such as skin cancer or acne – are especially well-suited to co-management between a dermatologist and an aesthetician. The physician may see the patient, but typically it is for a shorter amount of time and the patient is usually referred to the aesthetician, who can educate the patient on medication use, make sure follow-up appointments are kept, and help the patient with the psychological aspect of the disease. Because aestheticians scrutinize the patient’s skin, they are also more likely than the nurse – or even the dermatologist – to notice and question potentially cancerous lesions.

Further, when the skin condition is hormonal or genetic in origin, it’s much more likely the patient will continue to see the aesthetician on a more regular schedule than the dermatologist. For instance, a patient with recurring acne may see the aesthetician monthly until controlled and then three or four times a year, but only need to see a dermatologist once or twice a year. As a result, the aesthetician should be able to bring drastic (or subtle) changes in the patient’s condition to the attention of the dermatologist quickly.
When co-managed correctly, patients leave the office educated about their disease and how to manage it properly, is happy, and will gladly speak about their experiences to their friends, and recommend potential clients/patients to the practice. In short, the dermatologist is there to get a patient’s disease under control and the aesthetician is there to educate the patient about disease management and prevention.
With more and more cosmeceuticals available, the need for aestheticians in a dermatologist’s office is growing. Oftentimes, the aesthetician knows about a cosmeceutical before the dermatologist. Take, for example, eczema. Most people with the condition know they need to moisturize, especially in the southwest and desert conditions of Las Vegas. Yet many patients feel “moisturizing” means drinking more water or taking a long bath. The aesthetician is invaluable in explaining what the condition truly entails, and what treatments are valid. The aesthetician can help the patient develop a long-term skin care regimen, and may be able to identify and suggest newer cosmeceuticals for a patient before he or she sees the dermatologist.
But what about harder to treat skin conditions, such as acne or skin cancer? With well over 500 cosmeceuticals on the market, patients with hard-to-treat acne are often depressed or embarrassed and confused about remedies. Most do not need to go on Accutane or other powerful antibiotics. In a co-managed practice, the aesthetician can educate the patient about specific courses of action, and if over-the-counter remedies fail, the dermatologist can prescribe something more potent. The team approach is what’s so important in managing these types of patients and skin disorders.
Acne is easily one of the top three conditions we see in our office. We tend to see more female adults ranging in age from their 20s to their 40s than we do teenagers. The most common statement we hear is that they never had bad acne when they were younger. Usually, those cases tend to be hormonal or stress-related. Women on oral contraceptives pose an additional concern when treating acne, as some antibiotics can interfere with the effectiveness of the birth control pill. Women who are pre-menopausal are developing severe acne for the first time in their lives, and their self-esteem plummets. Patients may benefit from glycolic treatments or retinoids, which should be a course of treatment before Accutane or heavy retinoids or antibiotics. A large number of acne treatments are sun-sensitive as well, and the peels that an aesthetician can do are invaluable for the patient.
Glycolic and TCA peels work very well on a number of more difficult-to-treat acnes, and can be administered by the aesthetician. Laser treatments and intense pulsed light (IPL) treatments definitely help calm down the inflammatory parts of acne. More and more treatments are being handled by IPL, which are administered by the physician. The aesthetician can help educate the patient about various options, including lasers, for
the treatment of their acne, but also alert them to what insurance will cover and what it will not.
With rosacea, the aesthetician can educate the patient about topical treatments. The aesthetician can work with the patient to educate them about avoiding spicy foods, coffee, tea or any other caffeinated product to avoid or reduce the outbreak of rosacea.
Oftentimes, the patient can be managed by the aesthetician alone, with minimal interaction with the dermatologist.
Aestheticians play an invaluable role in a co-managed office setting. For example, plantar warts tend to develop in the heels and balls of the feet, and tend to grow into the deeper layers of the skin because of the pressure on them while walking. They are usually caused by human papillomavirus and can be treated by over-the-counter salicylic acid in various formulations, cryotherapy, surgical excision, laser ablation and a host of other methods. Tape occlusion is probably one of the more common methods as well. In fact, 5-FU with tape occlusion is beginning to be shown as a highly effective treatment for plantar warts. Unfortunately for the patient, some of these treatments could result in scarring so caution must be used. Some types of warts – such as mosaic warts or multiple warts – may not benefit from surgical treatment or it’s too complex a procedure. Some therapy options for warts can be painful or cause blistering. Some can destroy pigment and are undesirable options for people with facial warts.
In the spa setting alone, an aesthetician may not have a lot of exposure to plantar warts, but the condition is more common in a co-managed setting. However, spa personnel should be familiar with recognizing the condition. In our office setting, the aesthetician can help the patient manage the condition more effectively by using their expertise in thinning the skin with glycolic agents. The thicker the skin, the more difficult it will be for the medication (5-FU) to get to the wart, prolonging the patient’s pain and recovery time. In the spa setting alone, when aestheticians come across the condition they should recommend the client see a dermatologist for medical treatment, but should be able to counsel the patient about the benefits of glycolic agent peels and how the cosmetic peel can speed recovery.
In the southwest, precancerous lesions are relatively common, especially conditions known as actinic keratosis (AKs, also called solar keratoses). AKs are precancerous lesions that, if left untreated, may become cancerous. The lesions tend to be a growth, with a sharp outline and are caused by excessive exposure to the sun. Most times, the aesthetician will see patients who have actinic keratosis for routine skin care treatments, and will notice the lesions to bring it to the dermatologist’s attention. About 93 percent of the patients in our practice who have this condition are caucasian. It’s invaluable to have someone on staff that is screening patients, looking for the obvious and subtle changes on a person’s skin.
Once the condition has progressed to the point of medical treatment, the dermatologist has an array of options. Studies have shown that glycolic acid treatments and peels help photodamaged skin and precancerous skin lesions. Glycolic treatments, however, tend to scare a lot of people with horror stories about their physical appearance and length of recovery. The Food and Drug Administration has approved Efudex, Carac, and Aldara for precancerous skin condition treatment, and Efudex and Aldara have been approved by the FDA for superficial basal cell cancer as well. (These medications are not glycolic peels and need to be prescribed by a physician.)
In combination with one of these medications, certain peeling agents can help minimize the inflammatory response most patients have, and the aesthetician is responsible for the peels. A large percentage of our patients are extremely pleased with the results from the combination therapy. They have significantly less inflammation and weeping of the skin during treatment. In our practice, the majority of basal cell cases are caucasian. Darker pigmentation helps to a point in preventing sunburn and developing these types of lesions, but no one is immune from the potential to develop AK. In our co-managed practice, there is a good symbiosis between the medical treatment and the aesthetic treatment.
Post-care for these patients is crucial, and the aesthetician is invaluable for this. They are responsible for the pre-education of the patient (in terms of what to expect during the medication/peel process), during treatment, and after treatment. With precancerous lesions, the patient has “down time” usually ranging from 1 to 3 weeks where they should not have direct sun exposure. The aesthetician is fully able to work with the patient one-on-one to try and ensure patient compliance and limit recurrences.
People with skin types 4-6, Latinos, Asians, and African Americans, tend to be extremely concerned about skin discoloration when undergoing dermatological treatments. People of color may feel they’re scarred, when in reality it’s a discoloration from treatment that the aesthetician can help treat. Aestheticians can educate the patient about microdermabrasion, retinoids, hydroquinones, glycolic peels, etc.
Aestheticians who have been in the field for three to five years or have furthered their education beyond initial certification could be well-suited to co-manage with dermatologists although proper training in a medical office is essential. In our practice, our aesthetician and nurse work with the newer aestheticians to teach them about potential drug interactions. The aesthetician will likely be spending more time with the patient than the dermatologist, and will see them for further follow-ups more frequently than the dermatologist. In this office, the aesthetician sees a number of cases of hyperpigmentation. Post inflammatory hyperpigmentation from a dermatologic procedure can be treated through product care and home care treatments. If the aesthetician cannot help control the problem, the referral back to the dermatologist for further evaluation is an easier transition for both the patient and the dermatologist.
Co-managing patients between the dermatologist and the aesthetician merges Eastern and Western philosophies, as Eastern philosophies tend to treat from the inner to the outer well-being, and Western philosophies tend to treat medically first, psychologically second. The different training each gives the patient yields a happier, more content customer.

Johnnie M. Woodson, M.D. is a Dermatologist specializing in general, surgical dermatology and dermatologic research in the Las Vegas area. He has been practicing in Las Vegas since 1994.Woodson is a graduate of the University of Michigan, Wayne State University School of Medicine and the dermatology program at The Los Angeles County/Martin Luther King Medical Center. Woodson is an Assistant Clinical Professor at the University of Nevada, School of Medicine, Director of Woodson Dermatology, and the Principle Investigator of Woodson Clinical Studies Group, Inc.He also specializes in cosmetic dermatologic surgery and ultraviolet light treatment.
Daphne L. Davis is an Aesthetician specializing in medical aesthetics with over 20 years experience. Davis is currently the Aesthetic Medical Director at Woodson Dermatology in the Las Vegas, Nevada area. Davis’s 19 year career began in 1988 as a Medical Assistant in an Encino, California dermatology practice where she is credited for establishing the dermatology office medical aesthetician department, which she directed for 9 years. Davis graduated from Yamano Beauty Collage, Los Angeles, California in 1996.

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