We are living in an era in which most of our clients enter through our doors with a plethora of concerns regarding their skin, especially photo damage, wrinkles and fine lines. Sometimes clients’ conditions are perplexing to even the most experienced skin care professional. How do we approach our clients and their concerns? What methods are we going to use in order to perform a complete assessment? How will we carefully plan a program of management to gain a realistic result? No two are exactly alike; neither are their expectations. We must be able to align reality with the condition of their skin and we must understand how any treatment is going to affect it. Obviously, the age of the client can make a difference. So will their history and lifestyle.

There are many variables to consider: premature wrinkles, excessive environmental and sun exposure, inflammatory diseases, age, and living/working environment. All of these add valuable information as to how we will approach their skin. It all begins with understanding the primary and secondary causes of a condition and the accumulative circumstances surrounding it. Inevitably, lifestyle, nutrition, and overall health provide valuable insight about what the underlying causes of skin conditions might be. The epidermis and dermis are complex. Employ your knowledge, experience and willingness to explore outside the box to identify the best new paradigms that support a long-term care program.
Be mindful that numerous skin conditions arise from dysfunction within the stratum corneum – the barrier function – that is responsible for a balanced climate within the skin. When you see dry, cracked, flaky, and irritated skin, they are telltale signs that something is amiss in the rainforest of the stratum corneum.
Our clients may show various levels of aging. Exposed skin ages quicker than covered skin. Abnormalities such as actinic keratosis, dischromias, solar lentigines, seborrheic keratosis, and unsightly imperfections are all clues to earlier sun exposure. Furthermore, these preventable conditions are reduced when the client is educated at an earlier age. Moreover, with an insightful skin care program, the skin will correct to variable degrees, depending upon the intensity of the condition.
Skin conditions may also be a result of moving away from one’s original cultural region. For example, if one moves from Ireland to the south of France along the Mediterranean, the skin and body will require time to adapt to its new location. If the move is from Maine to Arizona, there are major climatic discrepancies. There are other considerations such as light and darkness affecting our circadian rhythms, the local environment (sea level or mountain), local food sources, social changes and more all contribute to the well-being of an individual. The skin will often reflect these variations.

Understanding Treatment Options: Exfoliation And Peels
Our topic explores exfoliation and peels. In order to understand exfoliation, we must first be aware of the relationship between water and enzyme balance and the natural desquamation process that is greatly influenced by the health of the skin barrier. The second consideration is the wound healing progression that is essential to the skin reaching homeostasis after any disruption to the epidermal/dermal regions. The greater the disruption, the longer it takes to heal.
It is important to realize that what may have been a modality that worked years ago, skin peeling and too many exfoliating agents (chemical or mechanical) may not be the first choice in 2014, given the amount of new research and technologies that shed a new light on the effects of our treatment choices.
Prior to performing any treatment, it is essential that we fully understand the role of the skin and the potential risk for our client. There are several considerations to contemplate when choosing a treatment. Whenever we select a modality, it is essential that we are aware of how it will affect the cell and systems within the skin.

The Epidermis
The epidermis is the primary location for skin barrier defense and contains numerous systems that all work in harmony with one another.1 The acid mantle, the corneocytes (stratum corneum – SC), and the bilayer lipid barrier function as the first three lines of defense. Additionally, the immune system and the melanocytes are also part of the protective system of the epidermis.
The epidermis is constantly being renewed through mitotic cells at the basal layer that divide and produce differentiating keratinocytes that journey to the top of the skin. The spinosum layers must have strong cell-to-cell linkages maintained by the desmosomes. Moreover, at the spinosum layer, new keratinocytes are injected with packets of melanosomes into the cytoplasm near the nucleus via the dendrites of the melanocytes.
The Keratinocytes
The skin is a self-renewing and self-repairing system that requires full-functioning, biologically active differentiating keratinocytes. Keratinocytes regulate cell-to-cell communication, turning on and off a variety of cellular activities. Differentiation is a significant and amplifying
process, accompanied by compelling changes in lipid composition within the cell membrane during the building of the stratum corneum.2 Keratinocytes are responsible for communicating with the immune system, the melanocytes, and the fibroblasts.
Keratinocytes are the most important cells in the epidermis and have a cycle of 10 to 15 days from mitosis to the stratum corneum.3 Their significance has come to the forefront of research and confirms that healthy skin requires a functioning barrier defense that does not become overly compromised through poor choice of treatments or overexfoliation. Moreover, optimum function and life cycle of the keratinocyte is age dependent.

The Stratum Corneum
The stratum corneum consists of flattened cells called corneocytes embedded in a matrix of lipids, primarily cholesterol (25 percent), free fatty acids (25 percent), ceramides (40 percent), and cerebrosides. Corneocytes are hydrophobic (water repelling) cells and must remain compact. The stratum corneum is a biosensor. It is subject to changes in external humidity, meaning that it continuously signals and regulates the breakdown of protein structures (filaggrin), DNA/lipid synthesis, and initiation of inflammation.4 Lipid membranes act as a barrier to the movement of water and electrolytes, block entry of microorganisms, and provide strength and resistance to external mechanical trauma that surround them.5 The outermost cells desquamate in order to allow for cell renewal within the stratum corneum.
The stratum corneum is a two-compartment system of corneocytes embedded in a lipid-rich extracellular matrix. The anticipated role of a keratinocyte in the granulosum is to transform its cytoplasmic and nucleic material into bundles of hardened protein (keratin) to become a corneocyte.6 Lamellar bodies (Odlund), located within the granulocytes, direct several functions within the spaces between the corneocytes in the stratum corneum where the bilayer barrier is formed.7 The lamellar bodies manufacture both lipids and enzymes that export through the granular cell membranes out into the extracellular spaces between the corneocytes, forming lipid bilayers. These bodies are sometimes referred to as a “brick and mortar” concept, the bricks being the corneocytes and the mortar being depicted as the lipids bilayers that act as a reservoir of water for the skin.

The Acid Mantle
At the very top of the stratum corneum is the acid mantle. The acid mantle is the first line of defense. It contains microflora living within an acid environment pH of 5.5. It is imperative for hindering external pathogenic organisms, both bacterial and fungal, from colonizing on the skin surface. The mantle is made up of: sudoriferous (sweat) glands lactic acid and amino acids; the sebaceous glands (sebum) containing free fatty acids secreted from; and the amino acids and pyrrolidine carboxylic acid (PCA – natural moisturizing factor NMG) produced during the cornification process.8
The oil and water properties of the acid mantle help regulate transepidermal water loss (TEWL). It also has the capacity to neutralize alkaline substances. Interruption of the mantle or its pH balance may interfere with its function and can send repercussions to the cells and systems below its surface.9 When there is an increase in the pH, there is susceptibility for bacteria, infection, damage, and disease. The repetitive use of high alkaline soaps or detergents can also strip the mantle for up to 16 hours.

Wound Healing
The complex signaling that exists between platelets, fibroblasts, epidermal cells and immune cells plays a huge role in the wound healing process. The signaling amongst the keratinocytes is of particular significance during this process. The wound healing process is generated in precise stages and is dependent upon the degree and depth of the wound. Simply, the pathway is described.10

1. Inflammatory Phase (one to three days) – The first 48 hours, white blood cells migrate from capillaries to clear damaged tissue and debris.
2. Lag and Proliferative Phase (three to five days) – New blood cells made as part of the granulation tissue.
3. Fibroblastic Phase (five to 20 days) – New epithelial cells migrate to restore the epidermis. Myofibroblasts contract the wound margin and scar while collagen reorganizes (Myo means muscle).
4. Maturative and Remodeling Phase (28 days to two years)

Recent research reveals that thermal procedures (laser, intense pulsed light, or Fraxel®) that were once thought to stimulate the growth of normal new collagen may actually be creating fibrotic tissue by a stress response caused by hyperthermia to a specialized protein molecule that synthesizes collagen (Heat shock protein HPS47).11

Chemical Exfoliation
Chemical exfoliation involves the use of destructive compound agents that control wound the skin by dissolving the desmosome bonds in the stratum corneum, forcing the skin to slough prior to the normal cycle of the natural desquamation process (des means against, squama means cell). Depth of penetration is dependent upon the type of chemical, the pH of the product, timing, and overall application protocol. Normal pH of the skin surface may be 5.5 to 6.5. Any applied agent that falls below or above that range can easily cause irritation.
The mechanism of action during the application of a chemical peeling agent is to control wound. Depending upon the depth and type of peeling agent, there is an immediate interruption of the biological activity of the keratinocytes. Signaling begins to occur throughout the epidermis, including messages to the fibroblasts, that something has occurred, causing the cells to go into an immune response. The acid mantle and the skin barrier have been interrupted. Table 1 (page 94-95) provides an overview of peeling agents and enzymes.

“It is important to realize that what may have been a modality that worked years ago, skin peeling and too many exfoliating agents (chemical or mechanical) may not be the first choice in 2014, given the amount of new research and technologies that shed a new light on the effects of our treatment choices.”

Choosing a Treatment Plan
When we hear the term rejuvenation, many things come to mind. It is a word used in most marketing materials and conversations. Most everyone wishes to appear younger and live at a level of optimum health and vitality. When a client comes for a consultation, common practice is to recommend procedures such as microdermabrasion, a chemical peel, or even laser (thermolysis). According to the 2012 annual report for minimally invasive procedures by The American Society of Plastic Surgeons,13 1.1 million peels were performed, as well as 974,000 microdermabrasion procedures. These figures are mostly likely greater since they may not reflect independent skin practitioners in a non-medical environment where statistical data is not captured. This data also tells a greater story regarding trends within the industry. Sometimes these modalities are “oversold” to the consumer since they have been the “go-to” treatment choice for many years.

Do not perform unless well-educated in procedures.

1. Adhere to patient safety and precautionary measures.
2. Client should not be using Retin-A, Accutane, or other strong exfoliants.
3. Thoroughly cleanse skin.
4. Defat (degrease) with prepping solution.
5. Apply with miniature fan brush or 2×2 gauze.
6. AHAs must neutralize.
7. Beta peels cannot neutralize. Apply recommended number of layers. The more layers, the stronger the peel.
8. Combined peels: Lactic/salicylic acid must neutralize.
9. Results also dependent upon pH of product.
10. Apply post peel agents as prescribed.
11. Thoroughly instruct patient on post care and home care regimen. Hydration is critical.
12. Post treatment will vary according to each peel and the client’s skin.

DISCLAIMER: All exfoliating agents have risk potential and must be thoroughly understood and properly used by licensed skin care professionals. Formulations may vary depending upon the manufacturer. A health intake form and thorough skin analysis is mandatory. Informed release documents should be read and signed by the client/patient prior to treatment. Both verbal and written post-care recommendations should be provided to the client. Home care is mandatory.

 Resources

1. Barrett-Hill, Florence (2010). An Epidemic of Exfoliation. http://www.youtube.com/watch?v=q0XyX3bnjx8
2. Prausnitz, Mark KR., Elias, Peter M., et al. Skin Barrier and Transdermal Drug Delivery. Medical Therapy. https://www.dermascope.com/wp-content/uploads/2014/03/Prausnitz-Derm-Book-Chapter-2012-693.pdf
3. Barrett-Hill, Florence (2013). Advanced Skin Analysis – Skin physiology. The course. www.pastiche.net.nz
4. Ibid – Prausnitz, Elias
5. Ibid – Elias p. iii
6. Ibid, Elias – p. 1
7. Elias, P., Feingold, K. (2006). Skin Barrier. Taylor and Francis. p. 5
8. Barrett-Hill, F. (2013). pH and Skin Cleansers. http://www.beautymagonline.com/index.php/sample-pages/1205-ph-cleansers-3
9. Chiller, Katarina, Selkin, Bryan A, Murakawa, George J. (2001). Skin Microflora and Bacterial Infections of the Skin. http://www.nature.com/jidsp/journal/v6/n3/full/5640052a.html
10. Setterfield, MD, Lance (2013). The Concise Guide to Dermal Needling – Expanded Medical Edition. Acacia Dermacare, Canada. pp29-31
11. Ibid – Setterfield. p. 35
12. Panel of experts: Candace Noonan, Aesthetician-Educator, David Waggoner, Aesthetician-Educator, Michael Pugliese, Aesthetician-Educator, Florence Barrett-Hill, Aesthetician-Educator
13. American Society of Plastic Surgeons 2012 Statistics Report. http://www.plasticsurgery.org/Documents/news-resources/statistics/2012-Plastic-Surgery-Statistics/full-plastic-surgery-statistics-report.pdf
14. Zani, Alexandra J. (2005). Chapter 13: Exfoliation and Peels. Advanced Professional Skin Care – Medical Edition by Peter T. Pugliese, MD. The Topical Agent, Bernville, PA
15. Zani, Alexandra J. (2008). Advanced Skin Rejuvenation. Beauty New Zealand. pp 29- 33
16. Setterfield, MD, Lance (2013). The Concise Guide to Dermal Needling – Expanded Medical Edition. Acacia Dermacare, Canada. p119
17. Ibid – Setterfield. p118
18. Ibid – p118

Alexandra J. Zani is an international educator, researcher and author with a background in cell biology and medical technology. Zani has spent many years as a practitioner in the aesthetics industry. Her passion for education resulted in receiving numerous advanced certifications both in the United States and abroad. Zani earned an instructor license for aesthetics/cosmetology, is NCEA Nationally Certified, certified in Oncology Esthetics®, and the Pastiche Method® of Skin Analysis. She is a member of the International Association for Applied Corneotherapy (IAC). Zani presents education for advanced aesthetic technology including microcurrents, LED, and non-ablative laser. She is a specialist in the anti-aging sciences, including the effects of nutrition, lifestyle, and the mind/body connection.

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