Aestheticians frequently encounter clients with sensitive skin conditions. While a professional’s scope of practice does not allow them to treat eczema, rosacea, or psoriasis, they can provide treatments that supplement the care the client receives from their medical provider. By gaining an in-depth knowledge of each condition, its causes, and standard treatment options, professionals can combine empathy and understanding with superior skin health services to deliver first-rate therapies to this select group of clients.
Eczema, or dermatitis, is the name for a group of non-contagious skin conditions that present with symptoms of inflammation, pruritis (itchiness), and erythema (redness). Over 30 million Americans suffer from one or more forms of eczema which primarily appears on the hands, feet, face, and torso.
The most common form seen in the spa, atopic dermatitis, affects over 18 million Americans. It can present in infancy, teenage years, or adulthood. Individuals with a family history of atopic dermatitis, asthma, or hay fever have a higher risk of developing atopic dermatitis.
Symptoms include itchiness, redness, rash, dry or scaly skin, and open, crusty, or weepy lesions. If an infection develops from scratching, small pustules may form. Lichenification (skin thickening) can occur from excessive scratching and rubbing.
Contact dermatitis has two sub-classifications dependent on exposure to an irritant or allergen. Allergic contact dermatitis occurs with exposure to pollen, dust mites, or other allergens. Irritant contact dermatitis occurs with exposure to irritants like household cleaners. Symptoms include itchiness, redness, rash, swelling, bumps, and blisters. The best treatment for contact and irritant dermatitis is to avoid the offending agent.
The exact cause of eczema is unknown. However, genes and certain triggers are factors. Individuals with eczema have an immune system that over-reacts to outside stimuli producing inflammation. In turn, inflammation triggers the erythema, discomfort, and pruritis.
Researchers have discovered that some individuals suffering from eczema have a mutation of the FLG gene responsible for creating the protein filaggrin. Filaggrin is found in the granules in epidermal skin cells of the stratum granulosum. The epidermis acts as a barrier, inhibiting penetration of toxins, allergens, and bacteria. Filaggrin plays an essential role in the skin’s barrier function. Filaggrin attracts and binds structural proteins, forming tight bundles, flattening, and strengthening the cells to create a strong barrier. The breakdown of the filaggrin proteins leads to the production of molecules, including pyrrolidone carboxylic acid (PCA), that are part of the skin’s natural moisturizing factor which helps to maintain skin hydration. Filaggrin also assists with the maintenance of the slightly acidic pH of the skin (approximately 5.5) which is another essential aspect of barrier function.
Without adequate amounts of filaggrin, a weakened skin barrier can allow moisture to escape through transepidermal water loss. Additionally, bacteria, viruses, toxins, and allergens can penetrate with ease. The weakened barrier causes dry and infection-prone skin.
Research using probiotics to alter the skin’s microbiome is promising. A study discovered that parabens, commonly used as preservatives in skin care products, inhibit the growth of roseomonas mucosa (a gram-negative bacteria), suggesting that parabens might hinder the skin’s defenses against eczema.1
Prevention of Flareups
The best way to prevent flareups is to recognize and avoid the triggers.
The type and severity of eczema often determine the treatment. The medical provider determines the appropriate regimen based on the client’s condition. Knowledge of both clinical care and homecare remedies can help the aesthetician identify the best aesthetic regimens to complement the client’s current medical treatment.
A regular bathing and moisturizing routine using a gentle, soap-free cleanser and an emollient cream with humectant and occlusive ingredients is recommended to seal in the desperately needed hydration. Pat the skin dry with a towel (no rubbing) and apply moisturizer while the skin is slightly damp. Well-moisturized skin decreases dryness and keeps out allergens.
A 10-minute lukewarm bleach bath (using unconcentrated bleach) sounds harsh but can be calming and can prevent infection. The amount of chlorine is similar to the amount found in a swimming pool: approximately half a cup of bleach for a standard 40-gallon bathtub. The client should only utilize this therapy with their health care provider’s permission and must be sure to thoroughly rinse the skin with fresh warm water to remove all bleach residue.
Wet wrap therapies are beneficial for rehydration. They also help topical medication to penetrate more efficiently. To use this option, clients should apply moisturizer and any topical medications, followed by wrapping dampened gauze or cotton to the affected skin. Then, the client should follow the damp wrap layer with a dry cloth over the top of the dampened wrap and complete the process with nighttime clothing to keep the wraps in place. They should leave this on for several hours, staying moist, or overnight.
Many over-the-counter products – including gentle cleansers, mild steroids, moisturizers, petroleum jelly, mineral oil, and coal-tar-based products, amongst many others – are available to help prevent and control eczema flareups. Clients must be sure to read the labels and follow directions.
Clients should apply all topical over-the-counter and prescription medications as directed by the healthcare provider. Topical steroids reduce cutaneous inflammation. They also tighten and constrict the capillaries, which decreases erythema. They are not intended for long-term use; sensitive areas, including eyelids and genitals, should always be avoided. Topical calcineurin inhibitors (TCIs) can be used for extended periods to control symptoms and reduce flareups because they do not contain steroids. TCIs inhibit the stimulation of the inflammatory cascade, keeping eczema in check. Prescription-grade topical skin barrier medications made from lipids and ceramides help prevent transepidermal water loss and protect against irritants penetrating the skin’s barrier. Topical phosphodiesterase 4 (PER) inhibitors block the PDE4 enzyme, reducing inflammation both on and below the skin’s surface and can be used for extended periods.
Biologics are injectable drugs engineered from proteins derived from living cells or tissues. Biologics target the immune system to slow down its reaction, enabling the reduction of inflammation, redness, itchiness, and rashes.
Phototherapy, or light therapy, incorporates ultraviolet light to slow inflammation and mitosis. A hand-held device or a walk-in light source somewhat similar to a tanning booth may be used. Treatments take place in a doctor’s office several times a week and therapy can last weeks or months.
Immunosuppressant medications suppress the immune system, which reduces inflammation. They can be taken orally or by injection. Methotrexate, cyclosporine, and mycophenolate are three current medications used off label to treat eczema.
Rosacea is a chronic, but treatable, vascular skin condition that is estimated to affect 415 million people worldwide. It usually presents as redness in the central portion of the face when the patient is in their 30s. Left untreated, the condition worsens, resulting in more persistent redness and vascularity. Inflammatory pimples often develop and, in severe cases, the nose may grow swollen and bumpy from excess tissue. Up to 50% of patients have watery, bloodshot eyes that feel dry and irritated. Rosacea is most prevalent in people of northern or eastern European descent; however, all ethnicities can develop this condition.
Primary presentations on the central face include flushing, persistent redness, dilated capillaries, and papules and pustules. Secondary features include irritated eyes, burning or stinging, itchiness, dry skin, plaques, thickened skin, and edema.
Medical science is still looking for the cause of this condition. Knowledge of rosacea’s signs and symptoms enables the control of the condition with medical therapy and lifestyle changes while a search for the cure continues.
Facial redness presents because the client has an increased number of capillaries (which increases blood flow) that are closer to the surface of the skin. Eyelids may become red and swollen and styes are common. Crusts may accumulate around the eyelids or eyelashes and clients may notice visible blood vessels around the lid margins. Severe cases of ocular rosacea can result in corneal damage and loss of vision without medical intervention.
Clients must see a dermatologist or other qualified physician for diagnosis and appropriate treatment before their disorder becomes increasingly severe and affects their quality of life.
Groundbreaking studies funded by the National Rosacea Society focusing on the immune system discovered cathelicidin antimicrobial peptides (CAMPs) affect clients with rosacea differently than healthy individuals. CAMPs speed up physical repair but worsen rosacea symptoms. Researchers Dr. Yoshikazu Uchida and Dr. Peter Elias examined elements along the CAMP production pathway and found a lipid substance known as SP1 that is responsible for increased CAMP synthesis. They also discovered another lipid metabolite, C1P, that stimulates the production of other protective peptides which, in turn, decreases the number of CAMPs. New medications that can intersect the production of these protective peptides may lead to new rosacea therapies.2
Dr. Anna DiNardo and her research team discovered that mast cells play a role in the stimulation of certain types of cathelicidins, an enzyme involved in the immune system response that is over-produced in people with rosacea. Dr. DiNardo’s team determined that mast cells in mice exposed to PACAP – a neuropeptide, produced enzymes that triggered cathelicidin production. This chain reaction did not occur in mice bred to lack mast cells. Additional research is needed to discover if a mast cell stabilizer known as cromolyn sodium will decrease rosacea symptoms.3
Oral and topical medications treat the various signs and symptoms associated with the disorder. Rosacea-specific therapies are available in various formulations for each client.
Redness, papules, and pustules are treated with oral and topical therapy for immediate improvement, followed by long-term use of an anti-inflammatory for maintenance. Telangiectasias and rhinophyma are best addressed by lasers, intense pulsed light sources, or other medical and surgical devices. Ocular rosacea is treated with anti-inflammatory medications and recommendations from an ophthalmologist or optometrist.
The aesthetician must treat the skin very gently. Irritation and heat exacerbate the condition. Avoid the use of harsh chemical peels, scrubs, hot steam, microdermabrasion, or anything abrasive. Consider replacing the European massage with something lighter, like manual lymphatic drainage or pressure point, to minimize flushing due to stimulating circulation.
It is best to avoid aromatherapy or the use of any fragrances on sensitive skin. Consider using a cool spray in place of steam (found in multi-function machines) or adding a Lucas Championaire to the equipment arsenal. Mild chemical peels stimulate cellular renewal replacing damaged skin cells with healthy new ones. Incorporate calming, hydrating, and anti-redness ingredients into masks and serums.
Skin Care Routine
Gentle skin care products used daily will calm the skin. Clients should wash with a mild cleanser, rinse with lukewarm water, and blot dry. Suggest non-irritating skin care products as needed and a broad-spectrum mineral sunscreen with an SPF of 30 or higher.
Look for products with ingredients that address: inflammation, such as argan oil, niacinamide, linoleic acid, azelaic acid, ginger extract, bisabolol, green tea, lavender, jasmine, rose, tea tree, and thyme; barrier function, like niacinamide and linoleic acid; and redness, such as sulfur, caffeine, asparagopsis armata, and ascophyllum nodosum. Also, look for antioxidant-rich ingredients like argan oil, soothing and calming ingredients like aloe, hydrating ingredients like honey, hyaluronic acid, and glycerin, and healing ingredients like argan oil, lavender, jasmine, rose, tea tree, and thyme. A physical sunscreen that includes zinc oxide and titanium dioxide is a good idea, as well.
Avoid products with ingredients that sting, burn, or cause additional redness including: fragrances, peppermint oil, eucalyptus oil, drying alcohols, witch hazel, or foaming cleansers, which can be drying. Green-tinted makeup foundations can be used to counter redness, followed by a foundation with natural yellow tones. Avoid pink or orange hues.
Lifestyle and Environmental Factors
To supplement medical therapies, rosacea clients can improve their skin health by identifying and avoiding lifestyle and environmental factors that trigger flareups. Identifying these factors is an individual process because what causes a flareup in one person may not affect another.
More than 125 million individuals worldwide have psoriasis. Science is still searching for a cure, so patients must work to manage their symptoms. Psoriasis has several forms, with the most common being plaque psoriasis, which presents as a patchy, red rash with silvery, white scales. This form appears most often on the scalp, elbows, knees, and lower back. Psoriasis is an autoimmune disease that must be diagnosed by a physician.
Plaque psoriasis symptoms include flaking, inflammation, and thick, white, silvery, or red patches of skin.
An overactive immune system, the body’s defense against germs, causes psoriasis. It is a chronic skin condition. The body’s immune system mistakes healthy skin cells for damaged ones, then attacks them as if it were fighting an infection. The body responds to the attack by making new skin cells every few days instead of the usual 28 days. The newly formed cells build up on the skin’s surface and form a rash.
Psoriasis may be treated by using creams, steroids, biologics, laser, and phototherapy, amongst many other options.
Treatment options depend upon the level of the condition. A client is considered to have mild psoriasis, if it covers less than 3% of the body, moderate, when coverage ranges from 3% to 10%, and severe, if over 10%.
The client’s physician will determine the best treatment plan for each individual case. At-home treatments include:
- topical steroid creams to reduce inflammation and itching and slow the cell turnover rate
- moisturizers to hydrate and reduce itching
- salicylic acid to exfoliate, lifting scaly skin cells
- retinoids to reduce inflammation and normalize
- the cell turnover cycle
- calcipotriene or vitamin D (studies have shown that psoriasis patients are deficient in vitamin D)
- coal tar to slow the rapid cell turnover rate, calm inflammation, and reduce itching and scaling
- biologics (drugs made from living cells) like Humira and Enbrel to target the immune system
- prescription medications to target various
- psoriasis symptoms
- anthralin (a medication) to slow the cell turnover cycle
- occlusion methods (wrapping an area treated with cream) to improve product penetration
There are a number of natural remedies that may be helpful, as well. Exposure to sunlight may be useful, as UVB rays from the sun work like UVB phototherapy. Aloe is calming and tea tree oil is antibacterial – it will fight any infection from scratching. Oatmeal baths calm irritated skin and epsom salt baths remove dead skin. Studies show that turmeric in foods or taken as a supplement may cut down flareups.
Light therapy (UVB phototherapy): UVB penetrates the skin to slow the growth of skin cells in an affected area. Skin is exposed to a UVB light source for a set length of time on a regular schedule. Phototherapy can be administered in a medical office or at home. PUVA is a form of phototherapy that combines a medicine called psoralen with UVA light. Excimer laser is FDA-approved for treating chronic, localized psoriasis plaques by emitting a high-intensity beam of UVB light. Biologics can be taken at home orally or by injection or IV in a medical facility.
Aesthetic Therapies: Blue LED light therapy addresses the bacterial components associated with psoriasis, while red addresses the inflammation. Massage can relax the client; stress is a trigger for flareups. Superficial chemical peels can exfoliate surface plaque buildup as long as they are mild; salicylic acid is FDA-approved to treat psoriasis.
Climatotherapy: Dipping into the Dead Sea has been said to improve psoriasis. A combination of the salty water and abundant sunshine is believed to be healing. Recent studies report improvements in psoriatic skin after taking the Dead Sea plunge. Many clients report having no symptoms for months afterward.
Prevention or Management of Flareups
Researchers know that approximately 10% of the population carries the gene for predisposition but only 2% to 3% develop the disease, which leads them to believe that environment and lifestyle choices play a factor.
Just as with eczema, a regular bathing and moisturizing routine using a gentle, soap-free cleanser and an emollient cream with humectant and occlusive ingredients to seal in hydration is ideal. Clients should pat the skin dry with a towel (no rubbing) and apply moisturizer while the skin is slightly damp. They should use a physical broad-spectrum sunscreen with zinc oxide or titanium dioxide for UVA and UVB protection.
Armed with the knowledge of sensitive skin presentations, their causes, treatments, and suggested homecare, skin care professionals can deliver exemplary services and product recommendations to a select group of clients that need empathy, understanding, and a gentle touch. There is nothing more fulfilling than seeing an impact made on someone’s life.
1 Research funded by the U.S. National Institute of Allergy and Infectious Diseases (NIAID) and published May 3, 2018, in the journal JCI Insight.
2 “A novel therapeutic approach via modulation of sphingolipid signaling in rosacea.” National Rosacea Society. https://www.rosacea.org/grants/reports-on-completed-research.
3 “Mast cells play a direct role in the activation of certain types of cathelicidins.” National Rosacea Society. http://www.rosacea.org/grants/reports-on-completed-research.
4 National Eczema Association. https://nationaleczema.org.
5 National Roscaea Society. https://rosacea.org.
6 National Psoriasis Foundation. https://www.psoriasis.org.