Whether managing a clinical dermatology practice or a spa, proper skin analysis is vital when seeing clients, especially if they are new. Old-fashioned or insufficient analysis can involve skipping steps, guessing, “eyeballing” clients, or simply using the latest trends, even when not applicable. However, this type of incomplete analysis carries with it multiple negatives:
- Inadequate or wrong services and treatments may be provided to the client, including post-appointment homecare
- Serious or even deadly skin conditions that warrant medical intervention may be missed
- The professional is unable to connect skin conditions to the client’s lifestyle, environment, genetics, and bodily systems
- It contributes to the perception of dermatological treatments as frivolous and not serious
Every clinic and spa are different in how they are set up and their budgets for equipment, but the basics of skin analysis should be observed consistently for every appointment, just as they would be for seeing a patient for a cardiac stress test or colonoscopy.
Remember that, as the owner, manager, or professional, one may be performing correct analysis, but it is also necessary to ensure all staff who analyze clients’ skin in the facility are doing so according to predetermined protocols. Let’s take a look at proper skin analysis methodology, as well as some instruments used in the process to improve the results.
Proper skin analysis starts with a thorough intake procedure. New clients obviously need a full workup, while those who have not been to the clinic or spa in some time need updating akin to a new client. The chart for regular clients should be reviewed at the start of each appointment, and it should be asked of the client whether they have made any changes to the factors listed below. Of course, implicit is the idea that records for each client are meticulously maintained, so any professional stepping in can understand the client’s history, conditions, previous treatments, and ongoing concerns.
Intake should include, at a minimum, questions about the client’s:
- Genetic history, particularly dermatological problems
- Nutrition and hydration, including special diets, water and caffeine intake, and over-the-counter nutritional supplements
- Lifestyle (exercise, stress, sun exposure, smoking, and so forth)
- Medical history (significant conditions, surgeries, allergies, over-the-counter and prescription medications, and so forth)
- Cosmetic history (previous procedures, reactions, homecare regimens, and so forth)
- Skin type (client’s perspective – to be confirmed with analysis)
- Skin’s intrinsic characteristics (related to genetics)
- Skin’s extrinsic characteristics (related to lifestyle)
- Treatment risk factors (allergies, sensitivities, previous reactions, medication interactions, lifestyle, and so forth)
While merely glancing at a client’s complexion will not always accurately reveal skin type (and should not be used as a substitute for thorough analysis) and makeup may also conceal the real skin type, it is worth taking a quick look before a formal analysis during the intake process. The cleansing process prior to analysis (see below) can temporarily mask inherent dryness or oiliness that surfaces several hours after cleansing.
Some professionals prefer to conduct intake during the analysis, but it is usually best to only ask additional questions during the analytical process, at least for new clients. Armed with the knowledge from a proper intake first, professionals can better assess the various elements required and are less likely to miss valuable information during analysis. Also, performing intake and examination simultaneously means note-taking and recording may be difficult unless there is an assistant who can transcribe.
Be sure to ask the client about any concerns they may have related to issues such as aging, homecare regimens, changes to the skin, or recent problems. For a new or long-absent client, simply asking, “What brings you in today?” can provide a wealth of insight and help guide the treatment once analysis is complete. Sometimes clients think they want one treatment (because it is trendy or a friend had it) when their concerns and analysis point to a different line of care.
PREPERATION FOR SKIN ANALYSIS
Once intake has been completed, the skin should be prepared for analysis. Makeup must be thoroughly removed so the skin can be seen clearly. Most clients can benefit from a towel or wrap to cover the hair. Cover the client’s eyes with eye pads to prevent them from being irritated by bright light and to help them relax.
There are four essential elements of the skin to measure when doing an analysis. It is key to understand these first before discussing the hands-on analytical process and instrumentation (see below).
This is a measure of the amount of free water in the epidermis. Hydration tells the professional about the client’s overall hydration throughout the body. It also indicates how effective the skin is functioning as a barrier system.
Lipid levels are how much sebum is produced, which can change with age, hormones, environment, diet, and the like. Assessing lipid levels properly is a must in treating many skin conditions, including eczema, rosacea, contact dermatitis, and essential fatty acid deficiency.
Assessing melanin is important when deciding on treatments involving heat and abrasion, as well as some chemical treatments. Melanin varies widely depending on DNA and ethnic origin of the client.
Erythema is redness of the skin at the superficial level. Understanding what causes this redness is key, as it is indicative of the density of vessels in the vascular mat. This can be used to predict post-treatment flushing and redness, as well as to analyze skin damage within supportive connective tissue. It is always more preferable to estimate vascularity through thorough analysis than to take a guess, make a quick opinion, or ask the client.
From analyzing the above four elements, professionals in a clinic or spa can then determine the client’s skin type. It helps clients to understand which skin type they have when, for example, they purchase skin care products outside the clinic or spa setting. The four skin types used today were developed by Helena Rubenstein in 1910 and are still very accurate.
Skin type is largely determined by how much oil the skin produces, which changes over time, particularly with age but also with environment, stress, diet, hormones, medical conditions, and medications. Clients can also have elements of both dry and oily skin, such as those with essentially oily skin but dry skin on the surface. Treating that type of dryness requires a different approach than managing a truly dry skin profile. This is a perfect example of why thorough skin analysis should be a precursor to any treatment.
Dry skin is naturally lacking in oil throughout. Comedones are absent, and the surface will often be patchy, red, or irritated. Clients may complain their face feels “tight.” Usually, the skin’s proper pH is also off, which can be restored with the use of mild washing and toning products. Good moisturizers for day and night, preferably with a humectant component, are essential with dry skin to assist the skin in its barrier function and to improve its feel and appearance. Dry skin can also be tackled from within with improved hydration and nutrition, and the client’s environment should be controlled to the degree possible, as well (for example, harsh interior heating or a dry climate).
Oily skin is basically the opposite of dry skin, although clients with oily skin can also have surface dryness. This skin type is prone to acne breakouts and may appear shiny with enlarged pores. Genetics, stress, and hormones are all key factors in precipitating oily skin. The key with this type of skin is to control excess oil without stripping the skin. Treating surface bacteria may also be helpful. Moisturizers, sunscreens, and makeup should be oil-free.
This is by far the most common skin type, with a large subset of this population having mostly dry skin with an oily T-zone. Different products may need to be applied where excess oil is a problem, such as a scrub or partial mask.
Sensitive skin is more easily irritated by a host of factors, including but not limited to sun exposure, environmental pollutants, skin care products, makeup, and certain dermatological treatments. Most clients know when they have sensitive skin because they have observed unpleasant reactions to many products and situations, but it helps to get at the underlying cause of the sensitivity, as this can sometimes be mitigated.
During skin analysis, dermatologists and aestheticians will often uncover various skin conditions that can be treated in the clinic or spa setting or at home. These include acne, milia (whiteheads), blackheads, fine lines and wrinkles, rosacea, dehydration, sun damage, loss of elasticity, discoloration, and lesions.
Depending on the credentials of the professional, these conditions may be addressed in the moment, later with a homecare routine, or through referral to a medical specialist.
Throughout the analytical process, the professional should approach the face methodically, first looking at the overall skin, then focusing on specific areas, making sure to work around the entire face and neck. Touching the skin is also important, to feel for elasticity and texture.
It usually helps to turn the client’s face to one side and then the other for optimum viewing. It is necessary to use strong light to see sufficiently, but there are multiple devices available today to assist in viewing the skin for analysis.
SKIN ANALYSIS DEVICES
There are several types of skin analysis devices, each with its own uses and benefits.
Virtually every dermatologist and aesthetician commences with a magnifying light, also known as a “mag light,” “mag lamp,” or “loupe.” This gives a good start to seeing things that are hard to view with the naked eye. Sometimes, it helps to reposition the lamp to get a good view of an area.
Magnifying lamps help prevent guesswork, and they eliminate shadows and color distortion. They also make life infinitely easier for the professional by preventing squinting, neck strain, and back problems.
Newer magnifying lamps offer many features, such as reduced weight, improved stability, adjustable arms and lamp heads, one-touch or hands-free positioning, dimmable LED lights that last 50,000 hours, and multiple magnification levels.
When selecting a magnifying lamp, look for one with a durable but ergonomic arm design, with a head that can be easily repositioned and self-tightening knobs. While there are lamps with fluorescent or halogen lighting, LED lighting has become the new standard, as it provides far superior color rendering.
If portability is important, there are models that can be mounted on a rolling stand for ease of use. Look for lamps that have a reputation for stellar customer service, should something go wrong, from an FDA-approved company.
The diopters of the lamp determine the instrument’s magnification. Diopters are fixed, so if different levels of magnification are needed, select a lamp that allows for choosing from several replaceable lenses, much like changing the eyepiece on a telescope or the lens on a camera.
The diopter of a lens is the reciprocal of its focal length. The higher the number of a magnifying lamp’s diopters, the thicker the lens and the more it is curved. Also, the higher the number of diopters, the greater the magnification.
It is simple to convert given diopters to the lamp’s magnification: divide the diopter by four and add one. For example, a three-diopter magnifying lamp (the most common strength) gives 175% magnification:
The distance from the lens center to the point where the rays of light meet is the focal length of the lamp, and it is where the subject comes into perfect focus. The focal length of the lamp is the working distance between the lamp and the client’s face. The greater the magnification, the shorter the working distance, which must be considered to allow room for hands, tools, and the like.
So, think carefully about how much magnification is really needed, since it will affect the working distance and the ability to work comfortably. If high magnification (above 175%) is rarely needed, consider getting a lamp with interchangeable diopters for those few occasions when needing to go higher (about 225% or five diopters).
A Wood’s lamp is another common tool used by both dermatologists and aestheticians. It is a handheld device that uses completely safe, long wave, ultraviolet light to help detect bacteria and fungi on the surface of the skin, as well as certain skin conditions.
Bacteria like pseudomonas species, propionibacterium acnes, and corynebacterium minutissimum, as well as fungi, will light up as a different color (luminesce) under a Wood’s lamp, usually appearing greenish, alerting the professional to their presence. A Wood’s lamp can also be used to diagnose:
- pityriasis versicolor
The normal wavelength of a Wood’s lamp is 320 to 450 nanometers; however, newer models with a specific wavelength of 395 nanometers are being used to detect tumors, like basal cell carcinoma and actinic keratosis.
It is particularly essential that all makeup, moisturizers, and perfume residue have been removed from the client’s face and neck before using a Wood’s lamp to ensure proper results and eliminate false positives. The room should also be dark enough for the professional to detect a difference between normal violet light and fluorescence on the skin that could indicate a problem area.
When purchasing a Wood’s lamp for a practice or spa, consider the following features:
- ergonomic design for frequent use
- white bulbs additional to the ultraviolet bulb(s)
- long bulb life
- wavelength suitable for clinical use
- magnifying element (for example, five diopters with 225% magnification)
- reasonable working distance (focal length) for the professional’s needs (about eight inches)
- easy on and off switch
- voltage options to suit the working environment
- return policy and long-term warranty
A professional may wish to invest in a dermascope, a small skin microscope resembling an otoscope. These instruments are used primarily for further evaluation of suspicious skin lesions.
With the magnification of a dermascope, a professional can quickly determine if a lesion is melanocytic (pigmented by melanin) and if it necessitates a referral outside their facility or an in-house biopsy. A dermascope may also be handy in identifying small psoriatic patches on the skin.
Dermascopes have come down in price since first introduced to the market, and they are no longer the sole purview of dermatologists. In fact, they have increased the ability of professionals of all types to identify problematic lesions, so the right next steps and treatment can be commenced. It takes some practice to use a dermascope properly but, in the right hands, this tool is invaluable.
There are a range of dermoscopes available on the market today, so it is essential to shop around based on use. Those who refer clients outside their facility for lesion follow-up will likely prefer a small scope that provides basic magnification. There are even smartphone dermascope attachments.
For dermatology practices, more sophisticated systems may be appropriate, including those with associated camera and video systems, perfect for telemedicine. This type of dermascope offers superior optics with adjustable magnification and field of view and usually includes a built-in scale for measuring lesions and tracking their growth. A removable reticle plate makes cleaning easier.
A new frontier of skin analysis tools involves full-face analysis. These instruments allow the client to place their face in a module for viewing the entire face at once. Some systems rotate around the client’s face, much like a panoramic dental x-ray.
Images from the analysis are transmitted to a camera or video system and can be helpful for both the professional and client.
Full-face skin analysis, like traditional skin analysis with a magnifying lamp and Wood’s lamp, can identify and color map issues like:
- fine lines and wrinkles
- spots and areas of discoloration
- ultraviolet damage
- subsurface melanin
- vascular conditions
Some offer a magnifying loupe element and aging simulation. Before and after imaging can be helpful in assessing the success of various treatments. Some practices use this type of imaging in helping clients decide on invasive procedures.
These systems are still in the clinical trials phase, awaiting FDA approval, and they are not considered standard skin analysis devices yet. But they present an exciting opportunity for skin analysis in the future.
Once a skin analysis has been performed, a follow-up depends on the findings and the type of facility. Treatments, referral to a specialist, and homecare are all options. With a proper skin analysis, professionals will never doubt they are following up correctly. Skin analysis is the basis on which all other beauty and dermatology actions are based, so performing a correct and thorough analysis is key.
Richard Merrill is a 15+ year award-winning beauty industry expert specializing in salon and spa sales and marketing. Licensed aesthetician, makeup artist, educator, and consultant, his experience in the industry is vast, making him a great resource for assisting to build a salon and spa business. For more information, visit richardmerrillconsulting.com.