- Risk Analysis for IPL and Sunbed Operators
- Cosmetic vs Medical Needling
- Hormones and the skin: An overview
It is still amazing that in the new millennium, Intense Pulsed Light technicians and sunbed operators are still taking risks with their clients when choosing appropriate settings for treatments or determining treatment suitabity. Specifically, the choice of energy settings with different types of skins, and in particular skins with a mixed genetic pool. The professional practice of determining potential outcomes when using light based therapies is called Risk Assessment.
Any skin care professional undertaking treatments or providing services using light based devices should be aware of the risks involved. These risks manifest themselves in burns or post treatment pigmentation problems and are usually caused by inappropriate energy settings or technique due to incorrect assessment of the Fitzpatrick skin tone and the individuals reaction to the light source.
In this age of technology, there is really no excuse for guessing likely reaction to light based devices, and with the more diverse cross-ethnicity in society, it is only too easy to make a mistake.
This cross-ethnicity is producing more skins that appear to be darker, but are carrying the MCR1 gene. It is here that there is more of a risk for unpredictable effects.
Professionalism & credibility
Photodermatological research has established that the most accurate method of determining the Fitzpatrick type and its reaction to various light sources is to measure the melanin content and erythema levels of the skin across a minimum of three areas of the body that represent minimal, moderate and maximum levels of sun exposure.
The technology to do this comes in the form of a device that measures the rate of absorption and reflection of specific wavelengths of light. This method of testing is universally recognised as the most accurate and consequently found in professional dermatological devices.
With this knowledge, we can assess the average rate that Melanogenesis occurs within a clients skin, and more accurately predict the response to the Intense Pulsed Light or sunbed, choosing energy settings/treatment duration accordingly.
For IPL, this should be undertaken before test patches or initial treatment is commenced, and in between treatments to monitor changing melanin levels. With the ability to measure the levels of Melanin and Erythema in the skin we are more readily able to monitor changes in between treatments and adjust device settings to avoid potential problems.
The use of devices to determine the rate at which Melanogenesis occurs within skin is also used to measure the efficiacy of sunscreens and suntanning equipment.
Proliferation of IPL technology
With the dramatic increased use of light based devices by skin care therapists, there understandably comes a corresponding increase in unsatisfactory outcomes.
These are commonly due to inadequate training and lack of the fundamentals required to perform these treatments safely and correctly. In fact, some users of IPL devices have received little more training than a day covering the device operation.
It is this considerable variation in standards of training from device marketers where the use of measuring devices can play a vital role in reducing risk.
Health insurance and accident compensation organisations in both New Zealand and Australia are reviewing a number of cases of inadequate consultation, risk assessment and test patch protocols that have resulted in unsatisfactory outcomes such as scarring and pigmentation issues.
Some of these may prove to be costly oversights for the practitioners who provided the treatments, particularly if investigations deem litigation appropriate.
Unsatisfactory outcomes from lack of correct consultation, risk assessment
and test patch analysis created these problems for IPL clients. Similar, but less concentrated
problems can occur from unmonitored sunbed use.
If the frequency of these instances increases enough to attract the attention of regional health authorities, there may be a likelihood that non-medically trained personnel will loose the ability to provide these light based treatments. This would be a disaster for professional skin treatment therapy.
With regard to sunbed systems, even more care should be taken when hiring out the sunbed. In the event of something going wrong, the operator can be sued if they did not provide adaquate consultation and expalined the risks involved in their use. An excellent article about the dangers is here.
Such are the dangers, the American Medical Association (AMA) passed a resolution in 1994 calling for a ban of the use of suntan parlour equipment for non-medical purposes. U.S Dermatologists have also urged the FDA to take action to discourage use of suntan parlours and suntan beds.
About the Author
Trudy Fleming is a renowned personality with more than 40 years of industry experience, both clinically and as an educator. She has a national and international profile as a trainer with a passion for learning and passing on that knowledge in an easy-to-understand format and manner. Trudy has an abundance of knowledge, passion and energy to impart to those wanting the best in light-based aesthetic education.
Article provided by The Fleming Institute of Aesthetic Technology
|Themes: Aesthetic Mesotherapy, Controversies in Aesthetic Medicine, Combination Therapy.
Skin health is influenced by numerous factors including lifestyle, environment, genetics, hormones, nutrition etc.Aging results in poor absorption of ingested skin nutrients and poor delivery to the target secondary to vascular and lymph insufficiency.Topical application of nutrients is a logical solution, but the natural barrier created by the skin has always limited success.
The majority of modalities used for skin rejuvenation incorporate the wound healing process.Conventional wisdom has leaned towards more is best.The biggest challenge is finding the balance between the degrees of injury (acceptable downtime) and effectiveness (best outcome).Darker skin types limit aggressive treatments.Ablative treatments, e.g. laser resurfacing and deep peeling, while aesthetically effective, may cause epidermal thinning, papillary dermis fibrosis and cicatricial healing.Fractional treatments minimize this effect, but there is still up to 20% coagulation of tissue and the ensuing necrosis stimulates cicatricial healing.Medical needling does exactly the opposite, which is ideal.
Preservation of the epidermis maintains environmental protection and minimizes downtime.There are no reported post treatment pigmentation issues, even with sun exposure.The procedure breaks down scar tissue, allowing reorganization.It can be performed on most areas of the body by individuals with minimal skills and requires minimal capital outlay.
Percutaneous collagen induction uses thousands of tiny needle pricks into the upper dermis to trigger the wound healing cascade.The upregulation of TGF-B3 through this process is thought to be the reason for natural collagen regeneration following needling, as opposed to scar collagen secondary to TGF-B1 and B2 associated with thermal injury.
Understanding the predictable phases of wound healing dictates optimum timing for treatment and modalities to obtain greatest success.Prolonging the inflammatory phase (day 1-5) will result in more growth factors.Photomodulation and lymph drainage are valuable from day 2-14 and then cosmetic rolling combined with Sonophoresis and micro-current are beneficial to assist maximum delivery of nutrients to cells.Collagenase peaks at around day 14 to reorganize collagen fibrils, converting collagen 3 to collagen 1 and it therefore makes no sense to reinjure the skin more frequently than every 30 days.
Collagen synthesis requires Vitamin A (e.g. Retinyl Palmitate, Retinyl Acetate, Retinol or Tretinoin), Vitamin C (e.g. Magnesium Ascorbyl Phosphate, L-Ascorbic Acid), key amino acids (proline & glycine), bioflavonoids, growth factors, selenium, silicon allied with magnesium and calcium, copper peptides, zinc and iron (co-factors), hormones and essential fatty acids (for cell function and membranes).Stem cell products and platelet rich therapy hold enormous promise.
Does depth of injury matter?
Prominent South African surgeon Dr Des Fernandes pioneered much of the work on needling and in 1996 he used a 3 mm roller.Treatments were painful and required IV sedation and analgesia.Further studies by Dr Fernandes and Dr Aust in Germany concluded that similar results could be obtained using a 1 mm roller.
|To gain some insight, a retrospective study on 44 patients was done using data from Visia Skin Analysis to provide objective numbers.While there are many variables (age, lifestyle, compliance, active ingredients and dose applied topically, duration of treatment etc.) the positive findings are encouraging in that they were obtained, for the most part, under least favorable conditions (compliance).
Methods: Measurements for brown spots, pores, wrinkles, evenness and UV spots were used to determine effectiveness of products alone vs. the use of rollers with 0.2 mm, 0.3 mm, 0.5 mm, 1 mm and 2 mm long needles combined with products.
All groups showed improvement in combined parameters with averageg ranging from 5-11%. Wrinkles and UV spots showed best improvement (7% -26% and -2% -16% respectively). The 0.5mm produced best results in the shortest time (wrinkles 26% & UV 16%).
About the Author
Canadian Skin treatment specialist Dr Lance Setterfield is the Medical Director of Acacia Dermacare and a member of the College of Physicians and Surgeons of British Clumbia and the Canadian Association of Aesthetic Medicine. He has a special interest in the field of anti-aging and cancer treatments.
Janine Tait of Tauranga, New Zealand has been a beauty, health and nutrition specialst for over 30 years. She has specialised as a skin therapist treating skin problems such as severe acne and eczema using organic plant based skin care products and nutritional advice.
Janine says: Giving nutritional advice is now an accepted part of a therapists recommendation for the clients home care program.
If beauty therapists and clinical aestheticians want to move towards involving nutrition in their clinic, Janine recommends that they start to increase their knowledge base by reading and taking courses in those related subjects.
The agony of adolescent acne, the irritation of pre-menstrual breakouts, the burden or bloom of our skin during pregnancy and the changes experienced at menopause. What do these skin conditions have in common? Sex hormones.
As therapists we are aware of the huge influence sex hormones have on the appearance of the skin. For men their influence is most apparent during puberty when acne strikes. For women, whose blood hormone levels are constantly fluctuating, their influence is experienced throughout their adult lives. Not only this, the difference we see between the skin of men and women is due to the dominant hormones of each sex.
What are hormones?
Hormones are chemical messengers that have specific effects on certain cells of the body. Hormones, which are produced by endocrine glands, are released into the bloodstream where they are carried to all parts of the body. But they will only effect cells that have specific receptors for that particular hormone. The tissue acted upon by each hormone is known as the TARGET TISSUE. The cells that make up these tissues have receptors in their cell membrane or within the cytoplasm to which a specific hormone attaches. The purpose of the receptor is to recognise the presence of the hormone. Once it is attached it then conveys the message to the nucleus, where the required action takes place through the regulation of the manufacture of proteins and enzyme synthesis.
Hormones can only have an effect if they are able to bond to a receptor. If they cannot bond it will not matter how high the hormone levels are, they will have no effect. The more receptors in a certain area the more sensitive that area will be to that particular hormone.
The skin contains receptors for several types of hormones:
- Oestrogenic Hormones Female-like effect
- Androgenic Hormones Male-like effect
- Progesterone A precursor hormone to both androgens and estrogens.
Many endocrine diseases and disorders effect the hormonal balance throughout our bodies. This can result in an imbalance of sex hormones, which can affect the appearance of the skin.
The effects of hormones on the skin
- Increases the rate of cell turnover in the basal layer of the epidermis.
- Reduces the size and activity of the sebaceous glands.
- Keeps sebaceous secretion thin and less fatty.
- Slows the rate of hair growth.
- Increases the action of the enzyme hyaluronidase, which produces hyaluronic acid.
- Keeps the skin metabolically active.
- It also appears to stimulate fibroblast activity however study is continuing into this area. (Fibroblasts contain oestrogen and produce hyaluronic acid.)
The influence of oestrogen is easily seen in womens skins. Its regulatory effect on the size and action of the sebaceous gland means that compared with men, women generally have finer pored and drier skins.
Oestrogen also stimulates the production of hyaluronic acid. Hyaluronic acid is one of the chief components of the base substance in the dermis and it enables the dermis to hold moisture. It provides the skin with its ability to resist stretching and keeps the skin firm and moist, giving it the smooth, soft feel we so often associate with the skin of a woman. Androgens, on the other hand, stimulate collagen production resulting in the stronger, coarser skin of a man.
The skin contains receptors for progesterone but its action on the skin is unknown. However, it has been shown that progesterone can interfere with the action of oestrogen receptors in the skin.
- Increase the rate of cell turnover in the basal layer of the epidermis.
- Increase the size and activity of the sebaceous glands.
- Increase collagen production through the stimulation of fibroblast cells to produce the proteins needed for collagen synthesis.
- Increase hair growth.
Males have a far higher level of androgen hormones than females and because of the effect the sex hormones have on the skin, this means there is a huge difference in the skin of the sexes. Because of the effect of the androgens the sebaceous glands are larger and therefore the pores appear larger. In the dermis, the androgens stimulate the action of the fibroblast cells, responsible for the production of collagen and elastin. Little is known about the effect of hormones on elastin production but much research has been carried out on their influence on collagen synthesis. This has shown that testosterone increases collagen production resulting in a very strong skin.
We can now apply these hormonal influences to the different stages our skin passes through during times of hormonal change.
Androgens increase the rate of cell turnover in the basal layer resulting in a thickening of the skin surrounding the opening of the pilosebaceous duct.
One of the most undesirable effects of hormones on the skin is acne. This can range from the odd spot to Grade IV acne. Even though the actual cause of acne is unknown some facts have been established. Acne in puberty is the result of defective sebum production, abnormal cornification (thickening) in the top of the pilosebaceous duct, abnormal microflora of the skin and inflammation as a result of the presence of this micro-flora.
The androgen hormones influence two of these. Androgens increase the rate of cell turnover in the basal layer resulting in a thickening of the skin surrounding the opening of the follicle. This increases the likelihood of blockages forming in this area. Androgens also increase the flow of sebum. However, we often observe acne conditions that show signs of lipid dryness. This could be due to the fact that an androgen dominance would negate the thinning, liquefying effect oestrogen would normally have on sebaceous secretions, resulting in a thick, viscous sebum that is more likely to block the pilosebaceous duct. Because of this the sebum would not be secreted onto the surface of the skin and the skin would appear lipid dry as a result.
This suggests that all acne sufferers have high levels of androgens circulating in their blood. But research shows that this is only true for 50-70% of women with acne. So not all acne sufferers have disturbed androgen levels. It is also interesting that not all people with hormonal imbalances get pimples. It seems that one factor that can determine whether or not a person will develop acne is their sensitivity to androgens and this sensitivity can be an inherited trait. Studies show that the same acne type will equally affect identical twins whereas this is not the case for non-identical twins. There are also racial tendencies with the Japanese being less affected than the Chinese and Caucasians more affected than Blacks.
To further complicate the issue, we must also consider that the ovaries and adrenal glands produce only 50% of our androgens. The other half is produced locally in tissue such as the skin. Weak androgens can be converted into stronger ones in the hair follicle. This results in an increased androgenic influence in the skin without high levels circulating in the blood. This also tends to be an inherited trait.
In summary, androgen hormones certainly contribute to the problem of acne by increasing the turnover of cells and the flow of thick, fatty sebum. However, the person must have inherited sensitivity to androgens in order for them to have this influence.
During the first half of the menstrual cycle the hormone oestrogen is dominant and it exerts its control over the sebaceous glands, limiting sebum production and ensuring that it is thin and less fatty. After ovulation the corpus luteum is formed in the ovary and starts to produce increasing amounts of progesterone making it the dominant hormone in the second stage of the menstrual cycle. The effect of progesterone on the skin is unknown even though we know that our skin cells do have receptors for this hormone. However, progesterone can interfere with the action of the skins oestrogen receptors and the regulating effect that oestrogen would normally have on the secretions of the sebaceous glands. This would result in an increase in the flow of thick, viscous sebum, explaining why women suffer from pre-menstrual breakouts.
The effect of progesterone on the skin is still unknown, but we do know it interferes with the regulating effect that oestrogen would normally have on the sebaceous glands.
Women often find that their skin can respond to pregnancy in a number of different ways. Some women find to their delight that their skin is radiant and glowing while others, to their despair, find their skin is unsettled and they develop pimples.
The dominant hormone during pregnancy is progesterone with the placenta churning out quantities ten to twenty times higher than normally experienced during a usual menstrual cycle.
The exact effect of progesterone on the skin is still unknown but we do know that it interferes with the regulating effect that oestrogen would normally have on the sebaceous glands. To further complicate the issue, whenever progesterone levels are high in our bodies, androgen levels are low. Perhaps these two conflicting influences explain why some women have wonderful skins during pregnancy and others do not. Obviously, more research is needed in this area.
Unless surgically induced, the hormonal changes at menopause often occur gradually. The menstrual cycle becomes increasingly erratic and ovulation occurs less and less. Eventually ovulation ceases completely.
At this time a number of things happen. Progesterone production stops because the corpus luteum, which is the source of this hormone, only forms if ovulation occurs. The ovaries production of oestrogen greatly diminishes and oestrone becomes the dominant oestrogen in the body.
Oestrone is formed by the conversion of androgens in the fatty tissue (peripheral oestrogen conversion). It is a very weak estrogen (twelve times weaker than oestradiol the oestrogen produced by the ovary). Because the ovary produces only minute amounts of oestradiol, the main source of estrogen available to the body is now oestrone and even the formation of this weak hormone drop to two-thirds of the usual level found in menstruating women. The net result of these changes is a much-reduced oestrogen and progesterone influence in the body.
Meanwhile, testosterone production by the ovary continues after menopause at much the same levels as in menstruating women. The effects of testosterone now become more apparent as normally oestrogen would balance out its effect. This unopposed testosterone often stimulates the hair germ cells causing facial hair growth. It can also cause acne to return or the development of seborrheic dermatitis.
The lack of oestrogen also causes a reduction in the action of the enzyme hyaluronidase, which produces hyaluronic acid. The low dermal GAGS (hyaluronic acid makes up a large percentage of these substances) mean that the skin becomes thinner and loses its supple texture. The skin can remain soft to touch but can feel less smooth. There is also a decrease in the reflection of light from the skin leaving the surface looking dull and dry. Stress can also disrupt the delicate hormonal balance, upsetting the menstrual cycle or even stopping it completely.
When Things go Wrong
Many endocrine diseases and disorders effect the hormonal balance of our bodies. This can result in an imbalance of sex hormones, which can effect the appearance of the skin in the following ways:
- Too much androgen causes the epidermis to become coarse and thick. The sebaceous glands enlarge and acne can develop. The hairline of both males and females can recede.
- Too little androgen results in a dull, thin epidermis that becomes finely wrinkled. The skin can become dry and there is no facial, pubic or axillary hair. The skin can have a pallor due to fewer blood vessels and decreased pigment levels.
- Too little oestrogen in women causes changes to the skin that are very similar to a lack of androgens but not to the same extreme. The skin will appear dull, thin and finely wrinkled with some loss of tone.
- Too much oestrogen causes pigmentation changes and the appearance of spider nevi.
Stress can also disrupt the delicate hormonal balance, upsetting the menstrual cycle or even stopping it completely. That stress can be emotional, as in the break-up of relationships, exams or moving away from home. Stress can also be physical, such as serious illness or extreme physical exercise. Often women who are involved in such physically demanding sports as triathlons or bodybuilding can develop acne conditions because of the effect this has on their bodies endocrine system.
As we know, the sex hormones can have a powerful effect on the skin and any upset in their delicate balance can have a dramatic effect on the appearance of the skin. Is there anything that we can do to positively influence these hormones and help our clients through their times of change?
Pugliese, P. (1996). Physiology of the Skin. Allured Publishing Corporation.
Trickey,R. (1998). Women, Hormones & Menstrual Cycle. Allen & Unwin.