The New Age Spa Institute 1870 Busse Hwy, Des Plaines, IL 60016 847-759-0900 www.newagespainstitute.com Sensitive or Sensitized

SKIN PHYSIOLOGY

The skin is made out of three major layers: Dermis Subcutaneous

Photo courtesy of Google Images

Each layer plays an important role and it goes through many chemical reactions and physiological changes.

Human skin is a beautiful yet very complex organ. Each layer undergoes through different stages in developing the top protective layer of our skin.

The epidermis, the top most layer of skin, is only 0.1 to 1.5 millimeters thick. It is made up of five layers (starting from the deepest):

• Stratum germinativum (basal) • Stratum spinosum (spiny) • Stratum granulosum (granular) • Stratum lucidum (clear) • (horny)

Working together, these layers continually rebuild the surface of the skin from within, maintaining the skin’s strength and protecting the internal organs of human’s body.

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Basal Layer The process of cell regeneration begins in the basal layer of the epidermis. This layer comprises of small round cells called basal cells, which are considered the stem cells of the epidermis. Stem cells are biological cells that divide during process of cell mitosis and differentiate into specialized cells. Stem cells are self-renewing and producing new cells. The cells continually divide during the process of regeneration and push the older cells towards the top of the skin. This process is called Cell Turnover and it begins in the layer of stratum germinativum. The name germinativum refers to constant renewal or germination of new cells. There are various cells located within basal layer, but estheticians should have an understanding of at least two: • Melanocytes •

Melanocytes play important role within the skin. They are specialized cells in which biosynthesis of melanin takes place, simply – melanocytes produce enzyme called melanosome, which in turn produces melanin (pigment). DNA predetermines the natural color of the skin: the higher the activity of melanosome, the darker the skin tone. The same understanding of melanocytes comes to play on daily basis. When our skin is exposed to sun – melanocytes start producing pigment. The idea is to produce a tan and prevent the skin from . Sunburn leads to internal inflammation of the skin; trauma caused to cells, which causes cell damage, permanent dilation of capillary walls, weakening of connective tissue, and severe dehydration leading to sensitivities. Not to mention hyperpigmentation! The activity of melanocytes within our skin allows for either nice, even tan OR creates almost immediate burning of the skin. The Fitzpatrick Type 1 almost immediately, versus Fitzpatrick Type 5 or 6 can be exposed to sun for longer period of time without visible damage. Freckles, age spots, melasma or white discoloration on the skin are all associated with melanocytes. Basal layer also contains other cells that play predominant role in the formation of the top layer of the skin: keratinocytes. Those cells undergo a transformation during the process of keratinization and turn into keratin (skin is made out of soft keratin). present in the top layer of the epidermis give the skin protection and prevent invaders from damaging the lower layers. Basal layer also contains Merkel cells, which are thought to be responsible for sensation via touch receptors. Langerhans cells are present in the basal layer and are directly responsible for the production of T-cells (immunity of the body). Basal layer contains live cells and is one (1) cellular layer in thickness.

Spiny Layer This layer is located right above the basal layer. It is also known as stratum spinosum, because the cells are being held together with tiny spiny projections. In this layer cells have migrated from the basal layer and are changing in shape and maturity. Keratinocytes have begun production of keratin, a tough, protective protein that makes up a large part of the structure of the skin, hair, and nails. Cells from this layer are pushed upwards to stratum granulosum where once again they are undergoing changes. Spiny layer is the thickest layer of the epidermis and contains live cells that are at the end of their living cycle.

Granular Layer Within the layer of stratum granulosum a process known as keratinization takes place, during which squamous cells undergo a change of becoming harder and stronger and are turning into soft keratin. This layer is impermeable to penetration of anything, except for the substances of the tiniest molecular size, which give this layer a name of “waterproof layer” of the skin. The waterproof component is due to special lamellar granules that are present within the granular cells and those secrete sheets of fatty substances. Those fatty substances are deposited into the spaces between

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the cells of stratum granulosum, forming a waterproof sealant. The main job of this sealant is to protect the lower layers of epidermis by not allowing penetration from the outside invaders.

Clear Layer The layer of stratum lucidum is named for its translucent appearance under a microscope. It is a thin, clear layer of dead cells of specialized keratin, known as eleidin. This intermediate form of keratin is made of very small granules. Stratum lucidum is only found in the areas of thick skin, mostly noticeable on the palms of the hands and soles of the feet.

Horny Layer In this layer of the skin cells complete their migration. During the process of cell turnover cells change shapes, flatten, bond together, then eventually become dehydrated and die. Stratum corneum is made up of over 95% of dead cells held together by intercellular cement. Increased external pressure or friction can cause thickened areas in the stratum corneum known as corns or calluses. In the average adult, it takes nearly a month for the stratum corneum to be completely replaced. This process is known as natural desquamation (exfoliation) of the skin. The replacement process (cell turnover process) generally slows with age. The top layer of epidermis is protected by hydrolipidic film (HLF) a combination of lipids, sweat and dead cells that has an important job of providing an invisible, protective layer on the skin.

Dermis This layer also referred to as True Skin is located under the epidermis. Over 70% of the dermis is comprised of collagen and elastin tissue (connective tissue) that provides structural support to the skin. Collagen is responsible for holding hydration in versus elastin corresponds to elasticity of our skin. Capillaries, sensory nerves, sebaceous glands, sudoriferous glands, lymph, arrector pili muscle, hair follicles, GAGs and other substances are housed in the dermis. Healthy dermis provides stable support and nourishment through capillary diffusion to epidermal layer of the skin.

Subcutaneous This layer of adipose tissue is located under the dermis and separates the skin from underlying organs. It acts as a cushion, and gives our skin nice contour. As we age this layer shrinks, especially on the face.

As estheticians we are directly working with the Stratum Corneum (outermost of the epidermis), but it is imperative to know and understand all layers of the skin.

Sensitive skin A skin type or condition? Up to 90% of the population perceives their skin as sensitive. But do they really have sensitive skin? Sensitive skin affects millions of people, but the exact definition varies depending on whom you ask.

We are all born with a skin type that has been assigned to us as a biological makeup of our bodies during the time of conception. And yes, it’s true - we are all born with the same size pores on our faces. If we were to compare two newborns together, we would notice that the sizes of their pores are the same. They will continue to be the same for several years, until the time they hit puberty. At this time our bodies undergo many hormonal changes, and this is when the sebaceous glands (regulated by the Androgen hormone) start producing more or less sebum. This change in hormones will be directly related to teenage for some teenagers, while others will only experience an occasional breakout. During puberty we also start to notice the changes in the oil production of the skin. For those with higher production the pores stretch, become filled with excess sebum, and their skin starts showing the characteristics of an oily skin type. For those whose bodies are not producing

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enough sebum the pores are going to stay small, filling up with sebum in few areas of the face only (such as chin, nose etc.). There will also be those individuals in between.

Commonly known skin types: • Oily • Combination Oily • Combination Dry • Dry

Yet there are some individuals that claim to have sensitive skin as a type. Can this be possible? It’s up to the esthetician to understand the difference in what may be the cause of this sensitivity. Is this skin truly sensitive or is it sensitized?

A true sensitive is caused by a genetic predisposition. Someone who is truly sensitive is born with this condition and tends to be prone to blushing, asthma, and allergies. This skin is considered more delicate with a lower amount of pigment, a thin epidermis, and blood vessels close to the skin surface, hence the occasional appearance of redness. This genetic predisposition is found in those who have very fair skin and are usually of Northern European ancestry. This genetically pre-disposed sensitivity of the skin has nothing to do with oil production and it can affect anyone with oily or dry skin types. The skin of someone who is genetically sensitive may appear without any visible outside irritations, but will react quickly to touch, product or to both.

This skin type is generally thinner, lacking dermal hydration and without proper internal lubrication making the sensory nerves react quicker to any stimuli, whether it’s touch or a product resulting in symptoms typical for sensitive skin: itching, burning, redness, , stinging. Many times sensitive skin type cannot be seen with the naked eye as it resides deeper within the skin. According to some doctors there are also four distinct types of sensitive skin due to skin condition— acne, rosacea, burning and stinging, and contact dermatitis (allergies and irritants) — and they all have one characteristic in common: inflammation.

Sensitized skin, on the other hand, is not genetic and it can affect any person of any racial background or skin color. Symptoms for sensitive and sensitized skin do have a lot in common (itching, burning, redness, flushing and stinging). The difference is that sensitive skin is a skin type, and sensitized skin is a skin condition. As estheticians we cannot change sensitive skin, because it is a skin type and genetic. We can perform calming treatments, but the skin type will always be sensitive. On the other hand, we can help the skin condition of sensitized skin by using products and treatments to rebalance the skin, making the skin less reactive.

Different factors play into sensitized skin causing our skin to react in a sensitive manner. Our level of sensitization can vary due to environmental assaults, products (including harsh exfoliation and irritating ingredients), aging, and lifestyle. For example, the climate we are exposed to in our home, cars, and during air travel, changes daily, meaning our level of sensitization changes.

In this class we will talk about many different types of sensitized skin and various factors leading to this sensitivity.

What causes sensitized skin? Environmental Assaults The fastest rising factor contributing to sensitized skin is environmental assault, as the epidermis (top layer of skin) is constantly exposed to assault from the sun, extreme weather and pollution.

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The Sun Exposure to the sun causes water to evaporate from the skin, making it dehydrated and more prone to sensitivity. Summer activities, such as swimming, can also cause skin irritation, as chlorine in pools and salt in ocean water are abrasive and drying.

Pollution On average, our skin is exposed to an estimated 6 million chemicals, and roughly 2,800 of these have sensitizing properties. Extensive exposure to Nitrogen oxides (from road traffic, industrial heating units, etc.) and volatile organic compounds (from hydrocarbons and waste) contributes to the steady rise in sensitized skin cases.

Cold Weather and Low Humidity Cold winds and low temperatures can dry out skin, depriving it of balanced levels of oil that keeps skin lubricated. Without these oils, skin becomes dry, and is more prone to sensitivity because of the lack of protective oils. This goes for forced air heating as well. Warm, dry air acts like a sponge, soaking up moisture from everything it touches.

Aging Scientists agree that there is a sharp decline in the stratum corneum lipids as we age (lipids are fats that are essential for the structure and function of living cells). Meaning by the time we reach age 40, our skin will almost certainly be dry and/or dehydrated. Without these protective lipids, skin is left exposed and defenseless against external aggressors, and the chances for reaction to the environment increase.

Ingredients Certain ingredients in cosmetic can cause irritation and exacerbate skin sensitivity. More importantly, these ingredients can be found in skin care ingredients that claim to help treat sensitized skin! Some ingredients that can sensitize skin include fragrances, D and C colors, preservatives, and lanolin, parabens, fragrances, harsh exfoliation (benzyl peroxide, AHA, BHA), soaps, mineral oil, bentonite or kaolin.

Lifestyle An essential fatty acids (EFA) deficiency can result in skin problems such as chronic itching, dryness, scaling and thinning, and can lead to an imbalance in prostaglandins, which are necessary to control inflammation. The lack of “good” fats in our diets is also linked to the increase in the percentage of the population that suffers from psoriasis, eczema and dandruff. Individuals surviving on diet sodas and fat-free food items are missing out on vital, skin-friendly essential fatty acids (EFA) and fat- soluble vitamins. Fat-free foods often substitute sugar with artificial sweeteners that can cause skin sensitivity. Smoking can also have a drying effect on skin, as smoking inhibits the body’s ability to provide oxygen and nutrients to skin. Smoking drains the skin of vitamin C and creates inflammation of blood vessels – smoking is somewhat like suffocating the skin from the inside. In addition excessive intake of alcoholic beverages and certain medications (such as antihistamines) can also contribute to dehydrated and irritated skin.

Over-cleansing Excessive bathing, showering, scrubbing, or the use of harsh soaps that dissolve the protective layer of oil commonly causes the loss of existing oil. without a protective medium or using dull razors can also weaken the skin's barrier function, leaving it exposed to environmental assaults. Chlorine exposure leads to dry-out external layer of the skin.

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Over-exfoliating The top layer of stratum corneum is covered with a film known as hydrolipidic film. The HLF’s main job is the protection of our skin. With repeated exfoliation this film is stripped off and is the cause of redness and irritation, and that in turn causes sensitized skin.

Treating Sensitized Skin When skin is healthy, a sensitized skin condition is minimized. Professional skin treatments coupled with the right lifestyle choices are great ways to begin treating sensitized skin. An effective sensitized treatment will include gentle cleansing, soothing and anti-inflammatory based products, and hydration and pressure point massage techniques to help increase the skin's natural protective barrier while repairing previous environmentally-induced damage. The "less is more" rule should be followed during any professional sensitized skin treatment and at-home regime. Essential oils of lavender, sandalwood and eucalyptus are ideal for hydrating and healing sensitized skin.

The home care routine, and the wearing of sunscreen anytime skin is exposed to daylight will heavily influence the success of treating a sensitized skin. Utilizing physical SPF instead of chemical SPF (which can sometimes increase irritation) is imperative in treating sensitive skin. Proper skin care techniques will also help ease skin sensitization. Do not use hot water when cleansing, don't use excessive or abrasive movements, and stay away from artificial fragrances or colors. In addition, take note of what triggers the redness in the skin. Certain foods such as artificial sweeteners or spices can bring about the flush look. Also be aware of hormones, stress levels, physical activity, adrenal shifts and alcohol and nicotine intake.

SENSITIVE SKIN SENSITIZED SKIN A type A condition

Permanent condition, part of DNA. Temporary condition caused by harsh Doesn’t matter what skin type: oily or dry. exfoliants, abusive products, lifestyle, environmental factors, medicine and medical Skin may look normal but reacts quickly to: conditions. - product - touch Regardless of the skin type, all may be - both: product and touch sensitized.

Skin looks: red, irritated, may be present.

As estheticians with proper care and As estheticians we cannot change the sensitive treatments, we can help to rebalance sensitized skin. skin.

Proper protocols for sensitive or sensitized skin during professional treatments: Gentle chemical exfoliation with enzymes designed for sensitive skin. No physical exfoliation (including brushes and physical scrubs) is allowed. Less heat is recommended during the treatment (instead of hot towels use warm towels). Steam should be applied about 18 inches away and should not be left on for too long. No stimulating massages are allowed (use acupressure or MLD) The should be based on calming ingredients only, paying attention to hydration of the skin. Avoid tightening and stimulating masks. Supply the skin with a mask that provides hydration. No electrotherapy is recommended during the treatment

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Reducing redness and sensitivity is the goal of the treatment.

Important Rules to Remember when performing a treatment for Sensitive Skin • Do not treat the skin during a flare-up. • Do not contradict the client’s dermatologist. • Keep touch from a mild to moderate speed and pressure.

In Case of Flare-Up or Irritation during a facial No matter how careful we are, sometimes a client may develop an irritation during a facial. The most important thing to remember is stay calm, and act quickly.

What to Do: • Remove product immediately. • Use cool distilled water with gauze or cotton. • Work quickly and gently. • Apply a Soothing Product/ Soothing Mask

ROSACEA and sensitivity of the skin Rosacea, a type of sensitive skin, is a chronic skin condition involving inflammation of the cheeks, nose, chin, forehead, or eyelids. It may appear as redness, defined spider-like blood vessels, swelling, or skin eruptions similar to acne. Rosacea is a vascular skin disorder and involves swelling of the blood vessels. It may be associated with other skin disorders (acne, seborrhea) or eye disorders (blepharitis, keratitits). Symptoms • Redness of the face in discrete areas or covering the entire face • A tendency to flush or blush easily • Increased number of spider-like blood vessels (telangiectasia) on the face • A red, bulbous nose • Acne-like skin eruptions (may ooze or crust) • A burning or stinging sensation of the face • Irritated, bloodshot, watery eyes

Causes • Repeated exposure to Rosacea triggers (alcohol, wind, sun, etc.) • Low levels of stomach acid • Constipation • Food allergies • Nutritional deficiencies (especially of B vitamins) • Hormone imbalance • Reaction to synthetic hormones

Treatment There is no known cure for Rosacea. The goal is to identify and avoid possible triggers, and to reduce flare-ups. Keeping a symptom diary helps to identify specific triggers, and you may be able to see a pattern of what makes Rosacea worse. Use this information to avoid future flare-ups. Here are some steps that may help:

• Avoid sun exposure. Use physical SPF every day. • Avoid prolonged exertion in hot weather. • Try to reduce stress. Try deep breathing, yoga, or other relaxation techniques. • Limit spicy foods, alcohol, and hot beverages.

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Trigger factors vary from person to person. Other triggers may include wind, hot baths, cold weather, specific skin products, exercise, or other factors. Antibiotics taken by mouth (examples: tetracycline, minocycline, or doxycyline) or applied to the skin (such as metronidazole) may control skin eruptions. Other medications (isoretinol or Accutane), which are similar to vitamin A, are stronger alternatives that a doctor or dermatologist might consider. Rosacea is not acne and will not improve with over-the-counter acne treatment. In severe cases, laser surgery or photo-facial may help reduce the redness. Rosacea is not medically dangerous. It is not curable, but can usually be controlled with treatment.

Ingredients, vitamins and minerals shown to benefit Rosacea clients: • Burdock (improves detoxification, helps to improve the skin tone) • Green tea • Licorice • Kojic acid (has anti-inflammatory properties and assists with reduction of redness) • Alfalfa (good source of chlorophyll, which has detoxifying properties) • Nettle and rosemary (improves the skin tone, nourishes the skin, promotes healing) • Azelaic acid (derived from wheat, rye and barley; has antimicrobial properties that slows the growth of skin bacteria and is effective at reducing skin redness and papules and pustules associated with Rosacea) • Chamomile • Red clover (powerful blood cleanser) • Rose hips (anti-inflammatory properties aid in relieving inflammation in skin irritations) • Selenium (an essential trace mineral, it is also a powerful antioxidant that helps to support skin health) • B vitamins (reduce flushing and promote cell production and repair) • Zinc (reduces the facial redness and irritations)

Rosacea clients need to be treated as sensitive skin type any time they come in for a facial treatment. A calming and hydrating facial would be recommended. Avoid scrubs or any other forms of physical exfoliation. Products designed for sensitive skin types would work best as they are calming and use less irritating ingredients.

Good rules to remember with rosacea are: • Less manipulation • Less heat • Less steam

Oncology patients: Sensitivity of the skin and the right approach with esthetic treatments Clients undergoing cancer therapies and those in the recovery process will have skin that appears sluggish, devitalized and sallow. Many times, their skin will be sensitive. All people with cancer, whether in treatment or recovery, can receive some form of therapy, especially in the spa environment that has been prepared for oncology esthetics. Be aware that temporary restrictions may be placed on those people who are undergoing radioactive radiation therapy, however restrictions usually only last for a week. Providing oncology patients with vigorous and strong spa (during cancer treatments when the body needs all the strength it has to hear and recover) can lead to unnecessary trauma caused on the skin. Soft touch spa treatments can begin immediately after surgery if the client chooses to go ahead with them. Estheticians must touch their clients with gentleness, be considerate of how their clients, and help them to remove any thoughts of fear. Spa treatments must be given in nonaggressive and light applications. Strengthening the lymphatic and circulatory systems to help increase oxygen delivery to the cells is beneficial. This will lead to a healthier look of the skin.

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UNDERSTANDING CANCER: Cancer is the term given to a group of diseases caused by uncontrollable growth and spread of abnormal cells. These abnormal cells do not conform to any rules of regular cell growth - they clone each other, and spread without regard to the needs of the body.

Types of cancer: Carcinomas - this term refers to cancers that affect the skin, mucous membranes, glands and internal organs.

Leukemias - this term refers to cancers that affect blood-forming tissues.

Sarcomas - this term refers to cancers that affect muscles, blood vessels, connective tissue or bones.

Lymphomas - this term refers to cancers that affect the lymphatic system.

The original tumor is known as as primary tumor. It is a term frequently used when working with cancer patients.

Skin cancers are primary tumors located on the skin and are often caused by over-exposure to UV rays. They may appear as bumps, areas of various discoloration, rough skin or sores. Estheticians are not licensed to diagnose any skin disorder, including skin cancer, and the client needs to be referred to a physician.

Differentiation is the process of normal cells going through physical and structural changes to develop and form different tissues in the body. The cancer cell’s structure and function are different from that of the originating parent tissue. The more closely a cancer cell looks and acts like a normal cells from the parent tissue, the more differentiated the cell.

Differences between cancer cells and normal cells: Cancer cells are cells originating from normal cells but due to different factors are damaged. They can grow immensely to damage other cells in process. One of the main difference between cancer cells and normal cells is the growth: Cancer cells will not be alike the normal cells. They have a tendency to multiply incorrectly and progress to spread to a larger area. Those cells don’t have the immunity power of normal cells.

Normal cells are more in balance to produce a more normal level of cell activity. They have a built-in blood vessel system and produce immunity and strength for the human body. Cancer can be classified into three different stages of development: • Stage 1 - when cancer cells look alike like normal cells. In other words these are a slow growing cell which doesn’t show much symptoms of a cancer infection. A cancer infection if identified in this stage can be cured. This is also termed as early stage. • Stage 2 - when cancer cells starts to appear different from normal cells. These are fast growing cells and are in the growing stage. If proper treatment is given at this stage, the disease can be cured. A cancer if unidentified in stage 2 could be termed as a stage where hope of curing is less or rare. A complete cure if guaranteed is only during the initial stages. • Stage 3 - when cancer cells are found to be immensely growing and are in the final stages of growth.

Tumors are classified as either: • BENIGN (non-cancerous) or • MALIGNANT (cancerous) 9

Both types involve abnormal cell growth. Carcinogenesis is the process by which a normal cell is transformed into a malignant one. Skin cancer lesions (or tumors) can be seen more frequently by estheticians in their line of work as they deal primarily with the face, neck and hands. Estheticians are not licensed or qualified to diagnose a cancerous lesion.

Cancer’s origin continues to be unknown and is constantly being studied, yet no one quite knows the exact cause yet. Each year we know more about this devastating condition. Most cancers are not hereditary; fewer then 10% of cancers are linked to hereditary factors.

Additional causes of cancer: Environment: cancers can be caused by exposure to chemicals such as asbestos, tobacco, cigarette smoke (lung cancer); plant products such as medicine and teas (oral cancer); and hormones (vaginal, breast, uterine cancer).

Viral elements: include those that can alter the DNA leading to changes in the cell, which cause a mutation in the cell.

Age and Immunity: the very young, the elderly and individuals with immune-comprised systems are more at risk.

Spa Treatments for Cancer Patients Touch therapies, which include facials, , or any other therapies that require you to touch clients, play an important role in helping clients acknowledge the physical effects of stress and anxiety. The power of touch releases stress and gives an experience of relaxation, thus providing your client with newfound energy to fight the disease. Some clients have their immune systems compromised more than others and understanding their special needs and expectations is mandatory.

Treatment Considerations: Sanitation: fungal, bacterial infections are more prone in immunosuppressed clients. Using gloves is required. Products should be in tubes, or bottles with pumps. Jars that require dipping into are more prone to problems. Over 60% of clients who are immunosuppressed will encounter an infection if their skin has been damaged from radiation therapy, or from IV therapy insertion sites. Before clients come to your spa/salon, especially clients undergoing cancer therapies or who are in recovery, the facility must be immaculately clean and immaculately sanitized.

Precautions include: • Detailed sanitation of cart or wherever products are kept during use • Detailed sanitation of products being used • Detailed sanitation of countertops, sink, esthetician’s chair, doorknobs • Laundering of sheets, gowns and blankets – not leaving laundry overnight • Hand washing and wearing gloves

Client Intake Form: this form needs to be filled out and carefully reviewed each time client comes for a treatment. Here are examples of some questions that should be asked: Do you have any incisions - if so, where? Do you have any IV lines? (If so, product application and massage are to be avoided in this area. The risk of blood clots in this area may be increased. Stay at least 6” away from the device. Some client’s are on blood thinners, so they are more prone to bruising or bleeding) Do you have any restrictions when lying on your back; if so what position is the most comfortable for you?

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Do you have any side effects that require attention? Are you suffering from bruising, inflamed areas on the skin or skin reactions?

Room Setup for immunosuppressant clients: to make sure you have a treatment room that is able to comfortably service your clients, consider each of the following: Have a stable stepstool that allows easier access to bed or adjustment bed that can be lowered for clients. If your clients have any breathing problems, fear or anxiety, this must be addressed before the service. Begin the treatment by guiding them through slow breathing exercises and by lightly touching and gently massaging their feet – this will allow clients to relax. Oncology patients tend to get cold – make sure to have additional blankets just in case.

Facial Therapies - regular facials of a deep cleansing treatment of the face includes toning, steaming, exfoliating, massaging and moisturizing. Facial treatments provided to oncology patients should concentrate on gentle touch, sincere approach and care. This treatment is not about deep- cleansing, exfoliation and extractions – this treatment is about providing the client with tender loving care that relieves stress and delivers positive energy to mind, body and skin. Hydration of the skin is the key.

Steps that need to be altered / avoided when treating an oncology patient: • Exfoliation - only with light enzyme treatment. No physical exfoliation. • Gommage - not recommended; it can cause further damage to fragile and sensitive skin. • - provides hydration. Do not use toners containing alcohol or fragrance. Those may be to irritating to the skin. • Steam - can be used if no respiratory issues are of a concern. Steamer should be about 18” away from the face. • Ozone - not advised as it produces free radicals (can help kill bacteria, germs but not recommended for patients with comprised ). • Extractions - not recommended. The skin may be too sensitive; it may lead to irritation of the skin. Creating an infection is also at risk. This may also be too painful for sensitive skin. • Massage - oncology esthetics massage (using light effleurage with the palms of hand toward the heart at all times), acupressure massage if permitted by the doctor. No deep tissue or vigorous massage can be performed. Only light pressure massage movements are recommended (depending on the lymph node removal and sensitivity of the skin). Manual Lymphatic Drainage Massage can be performed only with the doctor’s written permission. • Serums - can be used to treat skin conditions for overall rejuvenation providing they are not exfoliating or too irritating to the skin. • Mask - hydrating masks are better then clay. Gel is advised for additional hydrating purposes and cooling and soothing effect. • - can be used to moisturize, hydrate and condition the skin • Sun Protection - a mandatory step to protect the skin from UV damage, and help prevent further development of skin cancer. Physical sunscreen is recommended for oncology patients over chemical sunscreen.

Additional therapies that are allowed: LED Reflexology Meditation Chromatherapy (color therapy) Sound therapy Music therapy

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Treatments/ Products to avoid: Chemical peeling Microdermabrasion Oxygenating Facials Electrotherapy (HF, galvanic, faradic, ultrasound) Acupuncture treatments Electrolysis , sugaring, Aromatherapy oils Heavily fragranced

Post Inflammatory Hyperpigmentation: Treating Acne and Post-Inflammatory Carefully Acne is one of the most common skin diseases in America. The American Dermatologist Association estimates that 60 million Americans have active acne. Acne can be tricky to deal with, because of the inflammation and infection. After acne is under control, clients may have scarring and post- inflammatory hyperpigmentation.

What is Post Inflammatory Hyperpigmentation? Post inflammatory hyperpigmentation, or PIH, is the medical term given to discoloration of the skin that follows an inflammatory wound. It is the skin's natural response to inflammation. PIH presents itself as a flat area of discoloration on the skin (macule) ranging from pink to red, purple, brown or black, depending on your skin tone and depth of the discoloration.

PIH develops when a wound, rash, , or other stimuli causes skin inflammation, which triggers the skin to produce too much melanin. Melanin is the protein in the skin that gives the skin its color. The excess melanin darkens and discolors the wounded area. This discoloration remains even after the wound or rash has healed. PIH is very common among acne sufferers. It can occur in all skin types, although it is more common in darker skin tones. It affects both men and women equally. Luckily, PIH is not a true scar.

PIH and Acne A post inflammatory hyperpigmentation macule often is the remnant of an inflamed acne lesion. PIH macules can follow relatively minor and papules, in addition to more serious lesions. However, the more inflamed a breakout, the larger and darker the PIH macule tends to be. Picking increases the chance of developing post-inflammatory hyperpigmentation. PIH macules can be a range of colors; however, the skin will not be pitted or depressed. It may look like a discolored freckle on the skin, or it may present as a larger, dark discoloration of the skin. PIH macules may look shiny, or like "new skin." Post-inflammatory hyperpigmentation affects males and females. However, the Hampton University Skin of Color Research Institute indicates that patients of certain races and ethnic groups are more likely to experience it. These include African-American, Asian, Native American and Hispanic individuals. Caucasians may also notice changes in pigmentation due to acne, but are in a lower risk group.

Treating PIH Most acne sufferers are relieved to learn that post inflammatory hyperpigmentation is not scarring. PIH will fade away over time, even without treatment. It can take three to 24 months for PIH to fully fade, although in some cases it may take longer. The length of time it takes for PIH to fade depends on how dark the PIH macule is compared to your skin tone. The bigger the contrast between the macule and your natural skin tone, the longer it will take to fade.

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Treatments There are treatment options available to help fade post inflammatory hyperpigmentation more quickly. However, acne should be under control before beginning any treatment for PIH. Otherwise, each new pimple could cause another PIH macule, reducing the effectiveness of treatment.

There are numerous medications and treatments used to treat PIH caused by acne. A topical cream that contains 4 percent hydroquinone may be appropriate for some patients. Other topical applications may employ use of a corticosteroid, tretinoin, tazarotene, adapalene or azelaic acid. Other in-office treatments may include a series of laser treatments, microdermabrasion or chemical peels. Microdermabrasion kits and chemical peels marketed for home use may exacerbate PIH. Whatever treatment option is chosen, estheticians must understand that improvement will take time and be able to explain it to the client. Think in terms of months rather than weeks. Also, many dermatologist recommend using a broad-spectrum sunscreen daily. The sun may darken the discolorations and increase fading time. Exposure to the ultraviolet rays can make post-acne spots darker and more pronounced. Use a sunscreen with a sun protection factor of at least 30 and apply it to all areas of the skin exposed to the sun at least 20 minutes before going outdoors. As estheticians we need to remember that clients with PIH can be on topical medications that can make their skin more sensitized and dehydrated, or they can be undergoing laser treatments. Treating them as sensitive clients is recommended.

Pre- and Post-Op Patients: Treating them as Sensitive Clients In this day and age, clients are looking to more advanced treatments to help with anti-aging. With the growing demand for medical cosmetic procedures clinical skin treatments are a way to bridge the gap between the doctor’s office and the spa. As estheticians, our pre and post care roles are to assist the client in the healing process. This means that we need to make sure the skin is in the best condition possible before a procedure to help ensure successful results, as well as to encourage a faster healing response to whatever procedure is used. There are specific treatments designed to help minimize “downtime” and encourage healing.

Some Common Cosmetic Procedures: • Cosmetic Surgery • Laser Resurfacing • Chemical Peels • Injectables • Microdermabrasion Always consult with a doctor before performing a skin treatment on a pre-or post-op patient.

Common Cosmetic Surgeries: • Traditional Face Lift (Rytidectomy) - tightens the jaw line and neck • Eye Lift () - tightens the upper and lower eyelids. • Forehead Lift (Transblepharoplasty) - tightens the forehead and raises the brow • Nose Surgery (Rhinoplasty) - changes the shape of the nose. • Facial Implants - increase prominence of cheek and chin areas

The client will be under the doctor’s supervision for the first two weeks. Begin facial treatments only with WRITTEN PERMISSION from the doctor. The time period varies, depending on the physician.

LASER RESURFACING Laser is actually an acronym for “Light Amplification by the Stimulated Emission of Radiation.” Dermatologists have used lasers effectively for many years to resurface the skin, diminishing sun damage, aging, wrinkles, and acne scarring. Physicians use an intense, pulsating beam of light to achieve a controlled vaporizing of the outer layer of the epidermis. Due to the growing demand and advanced research, laser technology is rapidly changing. 13

Lasers have a broad range of surgical applications, including improving skin texture, increasing collagen production, and removing port wine stains, birth marks, freckles, scars, tattoos, and hair. There are two types of lasers, Non-Ablative and Ablative.

Non-Ablative Laser - Known as the ‘non-burning’ laser, rejuvenates the skin without causing . The benefits of non-ablative laser skin surgery are reduced healing time, less risk of infection and less time spent in the doctor’s office. The procedure is done by a physician or nurse (depending on state) on an outpatient basis and can take anywhere from two minutes to two hours to complete. There is generally no downtime, or less than one day.

Another use of the non-ablative laser is for long lasting permanent . This is because the laser is able to reach below the first layer of skin and kill the root of the hair in the hair follicle. The only drawback of non-ablative hair removal is that it does not work with light hair on light skin and it cause depigmentation in dark skin. It works best on people who have dark hair on white skin. Non- ablative laser work on light skinned clients. Hypopigmentation can be caused on clients with dark skin (Refer to Fitzpatrick Scale).

Ablative Laser - Extreme heat penetrates the surface of the skin into its deepest layers. To ablate means to remove, destroy, or vaporize. Doctors only can perform these procedures. Downtime, depending on the procedure, can last anywhere from 1 week to 3 months.

Common types of lasers: What Type What it is used for CO² Skin rejuvenation, wrinkle reduction Nd: YAG Hair removal, vascular, lesions, skin rejuvenation Er: YAG Wrinkle reduction, skin rejuvenation Diode Hair removal Pulsed Dye Vascular lesions, psoriasis Alexanderite Tattoo removal, hair removal, pigmented lesions Ruby Tattoo removal, hair removal, pigmented lesions

MICRODERMABRASION (Machine-Assisted) Microdermabrasion is a skin exfoliating treatment. With machine-assisted microdermabrasion, exfoliation is accomplished with tiny crystals propelled through a closed vacuum system. Simultaneously, dead cells are suctioned back into a waste compartment. Client can expect skin sensitivity post-microdermabrasion treatment and should pay special attention to hydration and nourishment of the skin. Daily application of SPF is required.

CHEMICAL PEELS Physicians also use many of the same peeling chemicals that are used in the salon; however, medical strength peels are stronger. There are three basic types of peels offered by physicians: superficial, medium, and deep peels. Estheticians can administer AHA/BHA peels, but all others need to be performed by physicians and nurses. Downtime is usually 1 day to 6 weeks depending on the strength of the peel. Daily application of SPF is required.

Alpha or Beta Hydroxy Acids (superficial) These are the mildest forms of chemical peels available and include salicylic, glycolic, lactic, or other fruit ads. These peels produce smoother, brighter looking skin. Mild peels can be used to: • Treat mild wrinkling • Treat areas of dryness • Aid in control of acne 14

• Smooth rough skin • Improve texture of sun damaged skin

Jessner’s Peel (deep superficial to medium, depending on how many layers applied) Jessner’s produces keratolysis and protein removing the stratum corneum and the epidermis. This peel solution has been clinically used for over a century and performed by a physician. It’s a light chemical cosmetic peeling treatment. Jessner’s is used for: • Dry acne lesions • Reducing acne scarring • Clearing the skin of blackheads • Smoothes fine lines • Reduces light wrinkles • Lightens pigment disorders

Trichloroacetic Acid (TCA) Peel (medium) These peels can be used in many concentrations of 20-50 percent TCA. TCA peels penetrate the dermis and therefore offer more dramatic results than the milder peels. The upper layer of skin is destroyed with this type of peel and sheds to reveal a new skin layer. TCA peels are used to: • Smooth fine surface wrinkles • Remove superficial blemishes • Correct pigment problems

Phenol Peel (deep peel) This is the strongest of the chemical peel solutions and produces a deep peel with the most striking results. Phenol peeling is an alternative to ablative laser resurfacing. Phenol peels would be used to treat: • Wrinkles • Acne scarring • Sun damage

INJECTABLES There are many different materials that can be injected into the skin. Injectables fall into two categories: Dermal Fillers-these are materials that are injected into the skin to add volume and plump lines. Among many dermal fillers, the most popular include collagen, hyaluronic acid, and silicone. (Botox) - this is one of the most popular injectables. Botox has been proven to smooth facial lines by preventing the muscles from contracting. Target areas include horizontal forehead lines, crow’s feet, and frown lines between the brows.

Most Commonly Used Facial Fillers The U.S. Food and Drug Administration (FDA) protects consumer’s health by assuring the safety and effectiveness of drugs and medical devices. The agency does this by requiring manufacturers of drugs and devices to perform rigorous scientific testing and reporting. Many procedures today have brand names. But a brand name being advertised doesn't always ensure FDA approval. The American Society of Plastic Surgeons offers the following list of FDA approved and cleared brand name procedures and treatments that will help a consumer make informed decisions about the many options available. The most common substances for improving facial imperfections approved by FDA are: • Botulinum Toxin - The cosmetic form of botulinum toxin is a popular non-surgical injection that temporarily reduces or eliminates frown lines, forehead creases, crow’s feet near the eyes and thick bands in the neck.

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• Hyaluronic Acid - Hyaluronic acid filler acts like an inflated cushion to support facial structures and tissues that may have lost volume or elasticity due to normal aging. It also brings water to the surface of skin to keep it looking fresh and supple. • Polylactic Acid - Polylactic acid is a synthetic substance that stimulates your own body's collagen production, with results appearing gradually over a period of a few months. • Calcium Hydroxylapatite - Calcium hydroxylapatite is used to fill the moderate-to-severe creases such as nasolabial folds, marionette lines and frown lines. It's also used to enhance fullness of the cheeks and other facial contours. • PMMA (polymethylmethacrylate) - PMMA is considered a semi-permanent filler, and is most often used to treat medium-to-deep wrinkles, folds and furrows, particularly nasolabial folds. It can also be used to fill out pitted scars and to augment thin lips.

This information is presented for educational purposes only. The ASPS does not recommend or endorse the brand names products and technologies in this section. www.plasticsurgery.org

Facial Filler Brand Name BOTULINUM TOXIN Botox, Dysport HYALURONIC ACID Elvess, Hydrelle, Hylaform, Juvaderm, Perlane, Prevelle, Restylane POLYLACTIC ACID Sculptra CALCIUM HYDROXYLAPATITE Radiesse PMMA (POLYMETHYLMETHACRYLATE) Artefill

Estheticians approach to facial treatments Pre- and Post-Injection Facial treatments and many advanced facial treatments can be done on the same day as the injectable, BEFORE the injectable has been administered into the skin. Facial treatments SHOULD NOT be provided post-injection for at least 10-14 days. Due to many facial fillers available on the market, always ask for doctor’s written permission for facial treatments provided less then 10 days after injection.

Precautions for all Post-Op Facials • Use caution with heat: • Do not use hot water or hot towels. • Do not use steam or infrared lamps too close to the skin. • Aggressive exfoliation is not recommended immediately following surgery.

Pre-Op Skin care treatments and recommendations Most surgeons will provide patients with a list of vitamin supplements that should be taken for at least 4 weeks prior to the surgery or treatment. Commonly suggested antioxidants that contain vitamins A, C, and E to help enhance healing and minimize infection as well as guard against ultraviolet radiation and free radical formation. Do not take Vitamin E one week prior to surgery as it can impair the blood’s clotting mechanism.

Post-Op Skin Care The post-op client will be under the doctor’s supervision for the first two weeks. They will be instructed to use a thick, clear topical ointment similar to petroleum jelly over the whole are that was treated. This is to ensure that the area stays moist and does not form a scab. The surgeon wants the skin to rebuild regular tissue-not scar tissue that always forms under a scab. The client will be taking oral antibiotics to help prevent the possibility of infection. Once the dressings are removed and the surgeon’s WRITTEN PERMISSION is obtained, facial treatments can begin. This will be anywhere between 11-14 days post-surgery.

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Important points of the Post Surgery Facial: • Promote healing with the use of emollient creams blended with healing plant extracts, • Use water-binding products and barrier creams to help to replace lost lipids. • Use caution with heat. Only mild heat is appropriate to help increase circulation and skin hydration. • Most exfoliants are not recommended immediately following surgery for about 3 months. The type of exfoliant will be based on client skin assessment emphasizing what is appropriate according to the client’s rubefactor (degree of sensitivity)

Fitzpatrick Skin Type Classification The Fitzpatrick Skin Type Classification system was developed in 1975 by Harvard Medical School dermatologist Thomas Fitzpatrick, MD, PhD. This system classifies complexions and their tolerance of sunlight. It is most commonly used classification to asses person's skin type by their response to sun exposure in terms of the degree of burning and tanning. This system is used by many skin care professionals to determine how someone will respond or react to facial treatments. This classification is also used to determine the strength of chemical exfoliation. Although individuals with Fitzpatrick skin type V or VI don’t easily when exposed to UV rays, the same individuals may have severe hyper- or hypo-pigmentation complications when provided with medium or deep chemical peels.

Fitzpatrick scale focuses on potentials for: • Irritation • Burns • Hyperpigmentation

For example, Fitzpatrick skin type I clients have a greater tendency toward irritation, but less, theoretically, for developing hyperpigmentation, if it is not triggered. The Fitzpatrick skin type VI client will not be as easily irritated and will have a high tendency toward pigmentation.

Skin Type Skin Color Characteristics I White; very fair; red or blond hair; blue eyes; Always burns, never tans freckles II White; fair; red or blond hair; blue, hazel or Usually burns, tans with green eyes difficulty III Cream white; fair with any eye or hair color; Sometimes mild burn, gradually very common tans IV Brown; typical Mediterranean Caucasian Rarely burns, tans with ease skin V Dark brown; Middle Eastern skin types Very rarely burns, tans very easily VI Black Never burns, tans very easily

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