It is 8:30 a.m. and you just turned on the lights to your office when that proverbial phone call rolls in. "I think you have burnt me! I have blisters all over my legs and I could not sleep all night long. I cannot believe you did this to me."
Your stomach sinks and your mind goes into frenzy. You start thinking, "Did I really burn her? Will she have pigmentation changes… scars? Am I going to be sued? What should I do?"
This gut wrenching feeling coupled with all of its uncertainty is guaranteed at some point in the career of a laser professional. After all, if you do enough treatments, eventually someone will experience a complication. It does not mean that you did anything wrong, but what you do now certainly separates a good laser technician from a true professional.
To know how to proceed, we first need to discuss thermal injury of the skin. The skin is comprised of three main layers: The epidermis, the dermis, and the hypodermis or subcutaneous tissue. For the laser practitioner, understanding skin composition is essential for properly determining optimal treatment settings as well as how to address complications. Let us discuss the latter.
When a burn occurs, the practitioner must first determine the level of trauma experienced by the client. Just like layers of the skin, there are three degrees of burns. A first degree burn – like a sunburn – exists when the thermal trauma is limited to the epidermis. A second degree burn – manifested by superficial blisters – is more severe, and is defined as thermal injury to the depth of the dermis. The most severe burn is that to the third degree, where the thermal injury is so deep that damage occurs to one's nerve endings within subcutaneous tissue.
The First Step
Your response will certainly depend upon the level of injury – which means that you must see the client. And by see, the client should return to your office so that you can see the injury in person! As you undoubtedly know,
photographs can be highly misleading and sole reliance upon your client's impressions is nothing more than a wonderful way to provide a great disservice. So take a look!
During your phone conversation, remain relaxed and reassure the client that you are an industry professional with proper training and certification – and that the next step is for you to see the affected area so that the best treatment options can be explored. Reiterate the importance of quick attention so that the healing process can begin properly and that certain activities, depending upon the complication, may need to be limited until the condition resolves.
But sometimes this request can be a lot easier said than done, I know! Maybe your client is adamant about the inconvenience of returning to your office or is too frustrated to see the value of visiting your clinic in the near future. If this is the case, the best advice is to have the client seek a consultation from a qualified physician most convenient to wherever the client is currently located. Remember, a complication is best treated after a trained professional sees the condition first hand. All too often the client's perspective is much different from the complication that is really at hand.
So what is next? Do not drive yourself too crazy with excessive worry. Remember, the skin is an amazing organ that heals impressively well, especially with contained, isolated trauma of the sort laser hair removal treatments may cause. And most injuries look much worse than they really are, particularly with darker skin types, whose melanin composition is markedly superficial. So just hang tight until the client arrives, armed with the confidence that you can take the appropriate next steps.
The client arrives and you inspect the affected areas. Take pictures and promptly place them in the client chart that same day. Do you see:
- Blistering of the skin
- Crusting of the skin
- Well-defined circular or rectangular marks that match up perfectly with your spot size or hand piece
- Red whelps or an itchy rash
Swelling or maybe just pronounced perifollicular edema
- Lingering erythema
- Any pain, discomfort, or soreness
Your general observations will likely lead to fairly easy conclusions. After examining the treated area, start by asking what the client experienced directly following the appointment. If the client now in fact has a burn, the skin would have done just that following the treatment… burn! For example, if the client reports that they did not feel any burning sensation following the treatment and at the following consultation you determine that the blisters the client had referred to are actually whelps with a pronounced itchy rash, you know you likely have a histamine reaction on your hands and not a thermal injury.
But if a burn is the leading conclusion, continue the discussion by seeking pretreatment activity. Did the client experience recent sun exposure from a weekend jaunt to the beach, begin a new tanning regime at a local salon, or maybe visit a dermatologist and received a photosynthesizing medication? Ask for information on any changes in an at-home skin care regimen to the affected area – perhaps she is using a new tretinoin anti-aging solution or a simple glycolic acid pad that is being used twice daily? You want to explore all the variables so that proper adjustments can be made for future appointments and, of course, to grow professionally and continue to refine your own skills set to provide the best balance of safety and efficacy in all of your treatments.
So how do you know that you have a burn? If crusting of the skin is notated or well-defined reddish burn marks are identical to your laser's spot size, but no blisters are present, the thermal injury is likely limited to the epidermis and you have a first degree burn. With a sense of relief, you can inform your client of the importance of avoiding additional stimulus to the affected areas such as hot baths, showers, or prolonged sun exposure. And just like the typical sunburn, a full resolution is expected within a few weeks, with topical preparations such as sunscreen, hydration serums, and hydrocortisone creams helping to alleviate minor irritation, protect and soothe the skin and relieve minor itching.
If during your examination you discern superficial blisters or notate a breach of the epidermal barrier from a popped blister or separated epidermal tissue, you most likely have a second degree burn. Unlike a first degree burn, second degree burns must be treated much more aggressively. Chance of secondary post-treatment infection is certainly possible, and its occurrence is almost synonymous with excessive collagen coagulation – or scar tissue for short. In addition, pigmentation changes, albeit usually temporary, are to be expected.
The Healing Process
To mitigate further complication and to enhance the healing process, the use of silver sulfadiazine one percent, applied up to four times a day for the first four to five days, or until the wound begins to scab over, is an effective way to reduce the chances of infection while aiding the healing process and granulation of new tissue.
If your client is allergic to sulfanilamide (an ingredient in silver sulfadiazine), an excellent choice is a triple antibiotic ointment combined with a topical non-steroidal medication.
Additional consideration must be given to those with diabetes, HIV, AIDS or whose trauma is experienced in susceptible areas of the body to easy infection – such as bikini area treatments. In these cases, oral antibiotic should be considered to further mitigate chances of infection.
Certain short-term lifestyle changes may be necessary. Of paramount importance, avoidance of prolonged sun exposure is essential. The client should discontinue swimming, baths, or activity that results in constant friction upon the affected area. In addition, heightened consideration for workplace contamination must be considered, especially for warehouse or industrial professionals, as well as medical professionals in clinical settings.
Once the client is provided with the most appropriate information, it quickly becomes a "wait and see" exercise. Continue to follow up with your client, ensuring steady progress while also ruling out possible infection – as usually manifested by continued drainage, swelling, and/or localized pain. Infection must be treated immediately with continued wound care and follow-up visits.
Once the site heals and at least three weeks of time as lapsed, you will likely be confronted with short-term pigmentation change that should be further addressed. Darker areas, or the occurrence of post-inflammatory hyperpigmentation (PIH), can be treated with skin lighteners, conservative application of chemical exfoliants, and continued sun avoidance.
Lighter areas, or hypopigmentation, can be treated with UVB light – or sun exposure. Make sure, however, to distinguish true hypopigmentation from one's natural skin color, which only looks lighter only because of the surrounding tanned skin.
With the passage of time, the vast majority of burn cases resolve quite nicely – free of further complication, pigmentation change, and the election by the client to resume the normal course of laser treatment.
In The Treatment Room
So now that we know the basic steps of how to address a burn, are there ways a practitioner can discern whether or not a burn is taking place during a treatment?
It is tough. Certainly there are the clear examples – severe burning of darker skin types leading to an almost immediate graying appearance or client feedback, with indication of a burning sensation by saying something like, "It is burning - it did not feel like this last time." Remember, if ever in doubt, turn the fluence down and/or pulse duration up, use a longer wavelength or more aggressive cooling. You can always treat more aggressively later.
The less clear examples are more common. Usually, the client will not experience a burning sensation throughout the course of treatment. The aggressive cooling modality is masking the otherwise developing burning sensation. As a consequence, it is not until the client begins to check out or begin the drive home that the increasing burning sensation becomes overly apparent. With that said, if a client reports a burning sensation post-treatment that is becoming more and more pronounced, you should take immediate steps to mitigate further complication.
Have the client return to a treatment room and begin cooling the affected area by use of a Zimmer, cold compress, or cold running water if feasible. Never apply ice directly on the skin as additional injury may result. If ice is the most convenient cooling method, place ice in a plastic bag and lay a 4x4 over the affected area. Keep moving the ice pack every 15 to 30 seconds. Ideally, you will continue to cool the skin as long as the burning sensation is evident – which could last several hours. Silver sulfadiazine as appropriate should also be applied, pictures taken, and post-treatment considerations reviewed. Usually, you will not know what you have until the next day – so patiently follow up with the client in the morning to assess any complication.
With this understanding, you are armed with the fundamental methods by which to address burns. And you no longer need to fear that proverbial phone call, but rather can take assurance that you can effectively make the best out of an otherwise challenging situation.
Prevention is key. It begins before a burn ever occurs. There are many more questions to be answered, and I invite you to attend the upcoming conference sponsored by DERMASCOPE Magazine to learn more! I will answer such questions as: Do you have proper operating protocols and procedures in place? Do you have professional training and certification? Insurance? What are the right laser systems for the job? Should you issue a refund or pay for doctor's bills? Do you need to report this to a state or federal agency? What about charting requirements and consent sheets? And what happens if the client demands compensation?
Robert E. Logue is a Texas state-approved instructor, as well as registered laser hair removal professional. Having overseen tens upon tens of thousands of laser hair removal treatments, Logue is an expert in the safe and effective removal of unwanted hair through laser and IPL machines. He has certified hundreds of laser professionals throughout the country. Logue earned a degree in economics from the UNC Chapel Hill and a law degree from Washington and Lee University.