medical esthetics - sdss · medical esthetics i n s t r u c t i o ... the philosophy of the...

CE Activity provided by:

National Coalition of Estheticians, Manufacturers/Distributors & Associations (NCEA)

MEDICAL ESTHETICS

I N S T R U C T I O N S1. To reinforce your learning and retain the information, highlight or underline

the answers to each of the (30) Study Objectives.2. Take the Three (3) Self-Assessment Tests, and then attach the tests to the CE

Registration Form. Total test scores must be 75% or higher in order to obtain your CE Certificate.

3. Complete the CE Registration (Section A) and Course Evaluation (Section B).4. Section C - Enclose a check or money order payable to NCEA:

N C E A Member Price: $ 3 4 . 9 5 Non Member Price: $ 5 4 . 9 55. Mail completed CE Registration Form, payment, & three tests to:

N C E A CE Program, 484 Spring Avenue, Ridgewood, NJ 07450-4624.

G E N E R A L PURPOSE STATEMENT To provide the skin care professional with a review of Medical Esthetics. The COA h a s

approved this activity for 3 CEs and is good through July 1st, 2015.

LEARNING OBJECTIVESAfter completing this interactive medical esthetics CE activity, the skin care

professional will be able to:1. Evaluate the role of the esthetician in medical esthetics and formulate a job

d e s c r i p t i o n .2. Describe medical esthetic procedures for cosmetic and medical indications.3. Understand scope of practice and increased responsiblities in a medical setting.4. Summarize the differences of working in a spa vs. a medical esthetics practice.

Medical Esthetics - COA-Approved for 3 CEs i©2011 NCEAAll rights reserved.

MEDICAL ESTHETICS

Section A - CE Registration:

PRINT CLEARLY (Illegible forms will not be processed)

Name: ______________________________________________________________

Address: ____________________________________________________________

City: ___________________ State: ________ Zip: _____________ + ____________

Tel: _________________________________ Fax: ___________________________

Email: ______________________________________________________________ *Delivery Method used to send CE Certificate

Are you NCEA Certified? ___Yes___No If yes, NCEA Certified# _________________License# ________________________ State of Issue _____________________

Type of License:

Esthetician ___ Cosmetologist ___ Teacher ___ Medical Professional ___

Other ___ Please specify: ______________________________________

Section B - Course Evaluation:1. Did this CE activity's learning objective relate to its general purpose? ___Yes ___No

2. Was the interactive format an effective way to present this material? ___Yes ___No

3. Was the content relevant to your skin care practice? ___Yes ___No

4. What type of setting do you currently work in? ___________________________________

5. How long in minutes did it take you to read the article_______, study the material_______,

and take the self-assessment tests_______?

6. Suggestions for future topics__________________________________________________

___________________________________________________________________________

Section C - Payments and Discounts:The fee for this CE Activity for NCEA Members: 34.95 Non Members: $54.95

(Check or money order payable to NCEA)

*We offer special discounts for 6 or more CE Activities that are for institutional use..

Call (201) 670-4100 Ext 5, for visit www.NCEA.tv more information.

Medical Esthetics - COA-Approved for 3 CEs ii©2011 NCEAAll rights reserved.

Medical Esthetics

“Sally called me today to ask me what it’slike working in a medical setting. She wastelling me a little bit about a position in amedical practice, but she needed to get somemore information on what was expected of her,”said Joan. “What type of practice it is?” askedLoraine.

“She didn’t know..., she was just so excitedabout the prospect of working with a physician,I don’t even think she asked what the positionpaid!” exclaimed Joan.

“Well, she really needs to find out more...likewhat her job description will entail, and if allher time is going to be spent seeing patients, orif she will have administrative tasks also...”“And does she even know if her license allowsher to do theses types of services? Several stateregulatory boards do not recognize theesthetician license if the facility is not licensedby the same board,” said Joan.

Sally needs to understand that working in amedical practice or medical spa is different thanworking in a traditional salon or spa–and thatshe shouldn’t think that she can call herself alicensed medical esthetician (because there is nosuch license currently). She also needs toconsider if she is cut out for this type of work,because it is different, “ said Loraine.

“What should I advise her to do? I knowthat Sally really wants this job,” asked Joan.

“Well, she graduated from school only acouple of months ago right? So she doesn’t even

have enough skin experience to meet the NCEAcertification candidate application requirements.But, she could negotiate with the physician toinclude continuing education and gettingNCEA Certified as part of her training. There isno profession like medical that understands theimportance of continuing education. Once shefinds out about the type of practice, she shouldjoin a professional organization that has annualmeetings and opportunities for her to networkwith other like-minded individuals. Going tospa shows is okay, but she really needs toadvance her career and most of the medical skincare associations offer CEs as part of theprogram they offer,” said Loraine.

Once she is NCEA Certified, then she canstart to do some reading on books that arespecifically in this area such as:

Steven H. Dayan, MD, FACS & Terri A. Wo j a kMastering Medical Estheticswww.trueuniversityesthetics.com

Pamela Hill (Several books)www.pamelahillinstitute.com

Susanne S. Warfield (Several books)www.pcijournal.com

Medical Esthetics - COA-Approved for 3 CEs 1©2011 NCEAAll rights reserved.

StudyObjectivesHighlight/underline theanswers to the followingquestions as you read:

1. What crucial roledoes an estheticianplay in a medicalsetting?

2. What is an importantfactor in deciding towork in a medicalsetting?

3. What may determinethe use of patient vsclient terminology?

4. What is the purposeof developing a jobdescription?

5. What administrativeduties might youexpect to do?

6. Who has the ultimateauthority on care ofthe patient?

7. To treat acneeffectively, what mustthe physician/estheticiando?

8. What syndrome canlead to acne?


O v e rview of Medical EstheticC a reer Opport u n i t i e sToday’s esthetician enjoys a broad range of career options

upon graduation and obtaining their licensure, if re q u i re d .Some of these careers include working in makeup for thefilm or television or stage; cosmetic and equipmentcompanies offer numerous opportunities; sales andmanagement positions, to trainer and educator positions.The traditional choice might be in a salon or spa setting,medical speciality practice, wellness or medical spa setting.To determine exactly what "medical esthetics" means, wewill first examine the licensure re q u i rement. Simplyp u t – t h e re is none. Currently there is not a "medicalesthetician," "paramedical esthetician" or "clinical esthetician"license anywhere in the United States.

Highly motivated estheticians have sought advancededucation and have helped to define the emerging role of theesthetician in a medical office. These estheticians havebecome an increasingly important and recognized adjunct tothe physician.

Among the cosmetic services available today, the larg e s ti n c rease has been in nonsurgical pro c e d u res, such asm i c rodermabrasion and chemical peels. This clearlyindicates the increased value of an esthetician to the medicalp rofession. This demand has resulted in a larger number ofphysicians offering cosmetic treatments, treatments beforeand after surg e r y, and a wide array of skin care pro d u c t s .Estheticians not only help with skin therapy before and afters u rg e r y, but they also play a less-celebrated, although cru c i a lrole in managing their patients’ comfort and well-being.

Use of Esthetician Titles

It is the position of the NCEA that:1. Estheticians represent themselves according to their

licensed title, as designated by their state licensing board or regulatory agency.

2. Estheticians must not promote themselves or allow any employer to market them otherwise.

One of the most important factors indeciding whether to work in a medicalsetting is: Do you like it? Specifically, areyou comfortable dealing with patients thathave had surgical procedures or medicalproblems on a daily basis? Not that themedical setting you’re likely to choose willbring you into contact with a great deal ofblood and disease, but your "clients" willall be "patients" and all of them will have amedical or esthetic concern. The use of theterminology–"client" or "patient" may alsobe confusing. As more physicians turn toself-pay cosmetic services to coveroverheads, the use of the term "client" isgrowing. The thought process being thatthe self-pay "patient" needs to be treateddifferently. The philosophy of the practiceor setting will determine the usage ofpatient vs client.

While working in a dermatology orplastic surgery practice, there will still beserious medical issues, or pre and post-opsurgical care. Some plastic surgeonsperform reconstructive surgery to repairthe trauma of accidents or thedisfigurement of diseases such as cancer,burn survivors or genetic defects. Anddermatologists treat skin cancer various,sometimes disfiguring rashes andinfections as well as various diseases thataffect the skin.

If you cannot stand the sight of blood orif you find illness or disfigurementoverwhelming, then you probably shouldconsider an esthetician career path otherthan a clinical setting. On the other hand,most of us can get used to the sights andthe situations that are likely to come up indermatology or plastic surgery, and if youenjoy helping others and if you appreciate

the privilege of working intimately withpeople who depend on you, the rewards ofworking as an esthetician in a medicalsetting can be tremendous.

One area that hasn't been touched on atall is the medical spa environment.

Definition of a Medical Spa

It is the position of the NCEA that:

A medical spa is a facility that during allhours of business shall operate under theon-site supervision of a licensed healthc a re professional operating within theirscope of practice, with a staff thatoperates within their scope of practice asdefined by their individual licensingboard if licensure is re q u i red. The facilitymay offer traditional, complimentary,and alternative health practices andt reatments in a spa-like setting.

Working in this type of facility may takeyou in several different directions. Thisdepends on the philosophy of the owner,services rendered, supervising physician orcorporate vision of what a medical spa is.Be sure to fully explore the different typesof medical spas and services. Don't assumethat all medical spas are the same, offer thesame types of services, or have the samephilosopy.

Formulating Your Job Description

The job description of an esthetician in amedical setting will vary greatly, andthoroughly exploring your position andwhat is expected of you with youremployer is essential.


The purpose of doing this is three-fold:first, it will clarify the position to yourself;second, it will help you communicate it toothers; and finally, you’ll use it as the basisfor fulfilling the position.

A detailed list of your duties andresponsibilities, such as the direct workyou’ll do with clients/patients, your role ina marketing, educating, and theadministrative work you’ll do (yes, there isalways paperwork).

Dermatology, Plastic Surgery orMedical Spas

If you are serious about considering acareer in medical esthetics, there are severalpaths open to you. While a number ofmedical specialties can use the services ofan esthetician, the choice may come downto dermatology, plastic surgery related sub-specialties, or a medical spa. These are theareas that deal most directly withappearance, and offer the greatest numberof opportunities for the esthetician.

Dermatology

Dermatologists are physicians whospecialize in diseases of the skin, in treatingdiseases, injuries and conditions that affectthe skin, hair, and nails. Their trainingconsists of a minimum of four years ofcollege, four years of medical school,generally a year of internship in generalmedicine and two to four years ofspecialty residency in dermatology. A f t e rcompleting their re s i d e n c y, dermatologistsa re eligible to take their boards. Somedermatologists go on to subspecialize. Theymay specialize in cosmetic dermatology,

dermatologic surgery or in micrographicsurgery or MOHS, which is a technique forskin cancer treatment.

Plastic Surgery

Plastic surgery is another medicalspecialty most likely to use the services ofan esthetician. The word “p l a s t i c” comesf rom the Greek word that means to mold.Plastic surgery literally molds, orremolds, the human body. There are twobasic forms of plastic surgery: cosmeticand re c o n s t ru c t i v e / restorative.

Surgery is considered strictly cosmeticwhen it is performed solely for aestheticpurposes, to make the patient look better.Among the more frequently performedcosmetic procedures are rhytidectomy(facelifts), rhinoplasty (nose surgery), chinsurgery, eyelid surgery (blepharoplasty)and breast augmentation or reduction.While this kind of surgery may not bedeemed medically necessary, it may bevery necessary for patients general wellbeing. In fact, the psychological dimensionsof cosmetic surgery are sometimes almostas important as the physical ones; thepayoff of this kind of surgery in terms ofenhanced self-confidence, socially andprofessionally, can be tre m e n d o u s .Estheticians are particularly sensitive to therole that physical appearance can play in apersons life.

R e c o n s t ructive surg e r y, of course, is quited i ff e rent, although often the object is similar.Burn survivors, trauma patients, patientswho have had major cancer surg e r y, andpatients born with deformities often needre c o n s t ructive surgery to re s t o re functionsthat have been lost or to allow normalfunction that was absent at birth.


Quite fre q u e n t l y, however, the surgery alsoserves to re s t o re a “normal” or near“normal” appearance. While many plasticsurgeons perform both kinds of surgery,others specialize in one or the other. For theesthetician, the choice may come down tothe kinds of patients you enjoy workingwith. Patients requiring reconstructivesurgery have emotional needs that can bequite different from those of the patientwho has elective cosmetic surgery. For thereconstructive surgery patient, estheticsmay play a secondary role to the primarypurpose for their surgery, usually therestoration or preservation of function.

P reoperative skin care, helping the skinheal postoperatively, and using makeup tominimize the cosmetic effects of the surg e r yplay a vital role in restoring patients’confidence and well-being. And noteveryone is comfortable dealing with peoplein pain or discomfort on a daily b a s i s .

On the other hand, reconstructive surgerycan literally transform people’s lives, andbeing a part of that kind of work can beextremely fulfilling. For certainreconstructive procedures, the estheticaspects can be absolutely central. Surgeryfor burn survivors and abused women, forinstance, can go far towards restoring thedamaged tissue and the contours that mayhave been lost, but it is rare that theappearance of the skin can be completelyrestored by surgery alone.

The skilled use of makeup and a skin careregimen can frequently do what no surgicalprocedure can accomplish by restoring theappearance to what it was before theaccident.

Client/Patient Services

This section of the job description willoutline the services you’ll perform,including both the treatments you’ll offerand the skin care education you’ll helpprovide. Don’t be exhaustive. Simply listthe type of services that you you will beexpected to perform. This is where havinga clear understanding of your scope ofpractice will be highlighted.

Note:

As a NCEA Certified Professional youmust maintain your license as issuedby your state regulatory board (orregulatory board of your province).The NCEA Certification does notauthorize or qualify a NCEA CertifiedProfessional to exceed the scope oflicensure granted in the state/provincein which you practice.

Client/Patient Evaluation and Education

You are a skin care expert and you canassume that you’ll play an important rolein educating patients on proper skin caretechniques, sun protection, home care etc.The esthetician in a plastic surgeon'spractice will typically advise the patient inthe weeks before surgery about whatcosmetics to use, sun-avoidance and howto get the skin and underlying tissues inthe best possible shape. The doctor mayalso delegate to the estheticianresponsibility for educating the patientabout the pre-operative skin care which,may include oral and topical medicationapplication.

In a dermatology practice, theesthetician may be responsible for


obtaining the patient’s skin care history,including a complete list of the pro d u c t sand any other topicals the patient used.Follow up on the medical treatments asp rescribed by the physician. Becauseestheticians working in a medical practicemay spend more time with patients thanthe physician, the esthetician is particularlywell positioned and qualified to questionthe patient about their skin care concerns.

In all settings–spa or medical–the historyshould also include information about pastservices, oral and topical medications,history of past pro c e d u res such as chemicalexfoliations etc, and past cosmetic surg e r i e s .Knowing what the physician or youremployer expects of you, is an extre m e l yimportant part of your job description.

Home-Care Instruction and Patient Followup

As an esthetician you know that home-c a re is in an integral part of any tre a t m e n tsuccess, and providing thorough instru c t i o nto the client is particularly important.Estheticians working in medical practicescan also expect to learn special techniquesfor cleansing the skin, how-to recognize preand post-operative complications, and willhave to learn about medications specific tothe physician specialty. You may needspecific product and equipment training,and also to learn the protocols of the facilitythat you end of working in. Whendiscussing use of technologies and pro d u c t s ,be sure to review your state license scope ofpractice and the NCEA Code of Ethics of thep rofession. Do not perform pro c e d u res oruse devices, unless you have satisfied yourethical obligations and have assure dcoverage through your liability c a r r i e r.

Administrative Responsibilities

Although it will be the most re w a rd i n gpart of your day, not all of your time will bespent with patients. You’ll also undertake acertain amount of administrativeresponsibilities, although precisely whatthese will be will depend on the nature andsize of the type of facility. Large medicalpractices or spas may have a full-timem a n a g e r, receptionist or even a patientc o o rdinator who may take on some of thesere s p o n s i b i l i t i e s .

Administrative duties can be dividedinto two categories: general administrationand administrative tasks related specificallyto the services that you provide. Generaladministrative tasks may be to help outwhen necessary in routine functions suchas scheduling, answering phones, andperhaps filling in for the receptionist onoccasion. The administrative tasks relatesolely to your esthetic services such asmaintaining proper patient chartsincluding: Health Insurance Portability andAccountability Act (HIPAA) forms,informed consent and signed release forms,client care and recommended homecareforms. These specific duties can carryheavy penalty for non-compliance at thestate and federal level.

The medical setting does carry moreresponsibility and training of protocols,due to the nature of the setting. Ten daysafter hiring, you should receive thenecessary training and education in orderto be in compliance.

There are various ways you can achieveindependence in a medical practice and therelationship you could have working witha physician. Always remember: it is thephysician who has the ultimate authority in


the care of the patient. The types ofprocedures that would be performed in amedical practice by the esthetician varywidely. However, there is a distinctdifference between a treatment performedin a medical practice as opposed to a salonor spa environment.

Working in a dermatology practice youare dealing with diseases of the skin suchas acne, atopic dermatitis, psoriasis, etc. Inthe plastic surgery practice you are dealingwith the pre and postoperative care of thepatient. These can include lymphaticdrainage, wound care, and advising thephysician on the psychological status of thepatient in regards to the outcome of thesurgery. The esthetician may also have theopportunity to work with trauma patientsor burn survivors which can be veryfulfilling work in helping to reduce theanxiety caused by the incident. The use ofesthetic treatments in a medical practicecan go a long way in restoring the elasticityof damaged tissue and thorough the skillfuluse of makeup help to restore the selfimage of the patient.

Acne Treatments in a Medical Setting

No matter what age it occurs, there isnever a good time for an acne breakout.Too often, patients want an immediateappointment at the medical office, or theycall by phone to find out what actions theycan take to get rid of or decrease thebreakout.

To treat acne effectively, the estheticianand physician must work together andminimize the underlying causes. Clientsshould be on a stable skin care regimenthat maintains a good balance of oil and

hydration levels so that breakouts do notoccur. However, this regimen may changedepending on the weather, the season, andfor some women, the point in theirmenstrual cycle.

Women can have naturally occurringhigh levels of testosterone or a conditioncalled polycystic ovary syndrome; both canlead to increased bouts of acne. Polycysticovarian syndrome is a conditioncharacterized by the accumulation ofnumerous cysts (fluid-filled sacs) on theovaries associated with high levels of malehormone, chronic anovulation (absentovulation), and other metabolicdisturbances. One of the most importantcharacteristics of polycystic ovarysyndrome is hyperandrogenism, theexcessive production of male hormones(androgens), particularly testosterone, bythe ovaries. This accounts for the malehair-growth patterns and acne in womenwith polycystic ovary syndrome.

Androgen production can be reduced orblunted by taking hormone modulators.Many women notice that their acnebreakouts are less severe when they aretaking birth control pills. This is becausebirth control pills cause testosterone levelsto drop. These male hormones areresponsible for the development of themale reproductive system and secondarymale sexual characteristics such as voicedepth and facial hair. Testosterone isnormally produced by the testes in largequantities in men, but it also occursnormally in smaller quantities in women. A side effect of testosterone production inboth sexes is that it increases oil productionand the frequency of acne breakouts.


Self Assessment Test 1

1. To treat acne effectively, patients should be on a skin care regimen that:a) Removes all oil from the skinb) Does not include a sunscreenc) Maintains a balance of oil and hydrationd) None of the above

2. Androgen production can be reduced by taking ____________ ____________.3. HIPAA stands for the ____________ ____________ ____________

____________ ____________ ____________.4. A patient’s skin care history may include: (check all that apply)

a) Oral and topical medicationsb) Past surgeriesc) Relationship statusd) Skin care products

5. Helping the skin heal postoperatively, and using makeup to minimize cosmetic effects of the surgery play a vital role in restoring patients’ ____________ and ____________.

6. Dermatologists specialize in diseases of the:a) Skin, hands and feetb) Skin, hair and nailsc) Skin, bones and nailsd) Skin, lymph and bones

7. Many women notice their acne breakouts are less severe when taking birth control pills. True or False?

8. The largest increase in nonsurgical procedures have been in:a) Rhytidectomiesb) Laser and light therapiesc) Microdermabrasion and chemical peels d) Acne and Atopic Dermatitis


S p i ronolactone is an effective treatment for polycysticovary syndrome. Spironolactone is a diuretic, which meansthat it increases the amount of urine passed, causing thebody to lose water and salt. It helps treat medicalconditions, such as heart, liver, or kidney disease. And italso (sometimes quite effectively) blocks the release ofexcess hormones like testosterone. However, patients musttake spironolactone re g u l a r l y, because if they stop therapy,the hormone production goes back up. In this sense,s p i ronolactone is not a cure, only a temporary relief. A l s o ,s p i ronolactone can negatively affect a male fetus, andt h e re f o re cannot be given to pregnant women or womenthinking of becoming pregnant. For patients ons p i ronolactone, it is also important that they are followedclosely by a physician, so that blood pre s s u re and potassiumlevels (which are affected by the drug) can be monitored.

Light-Based Therapies for Acne

Laser light in the red to blue spectrum may be effectiveat killing the bacteria that causes acne by decreasing theinflammation associated with acne. The laser works not byheat but by activating a protein that is released by thebacteria P. acnes to become a killer protein. The protein thendestroys the bacteria and the surrounding inflamed acnecells. Injury is limited to only the acne lesions, and thenormal skin is not affected. Lasers alone, or lasers used incombination with a topically applied solution (calledphotodynamic therapy), have proven highly successful andsoon may be the treatment of choice for the control ofmoderate to severe acne.

Photodynamic Therapy

Photodynamic therapy (PDT) is combination of atopically applied drug called aminolevulinic acid (ALA)plus laser light therapy. The ALA is applied to the patient’sface and allowed to sit for up to eight hours, after whichthe remaining acid is gently removed. Immediatelyfollowing the treatment, the esthetician's role is to advisethe patient that for the next 48 hours sun avoidance ismandatory.


9. What doesspironolactone treat?

10. How does red lightwork on acne?

11. What is PDT?12. What ethics define

“Scope of Practice?”13. Why should AKs be

watched closely?

14. List four OTClightening agents.

15. What four agents canbe used to treatmelasma?

16. Why should lasertreatment ofpigmentation bealternated?

1 7 . What medications havebeen used to tre a tro s a c e a ?

18. Which laser has beeneffective in treatinghemoglobin?

19. What esthetictreatments causeexcessive heat to begenerated?


NCEA Code of Ethics1.29.08 Revision

Client RelationshipsEstheticians* will serve the best interests of their clients at all times and will provide thehighest quality service possible.Estheticians will maintain client confidentiality, keep treatment and documentation records,and provide clear, honest communication.Estheticians will provide clients with clear and realistic goals and outcomes and will notmake false claims regarding the potential benefits of the techniques rendered or productsrecommended.Estheticians will adhere to the scope of practice of their profession and refer clients to theappropriate qualified health practitioner when indicated.

Scope of PracticeEstheticians will offer services only within the scope of practice as defined by the statewithin which they operate, if required, and in adherence with appropriate federal laws andregulations.Estheticians will not utilize any technique/procedure for which they have not hadadequate training and shall represent their education, training, qualifications and abilitieshonestly.Estheticians will strictly adhere to all usage instructions and guidelines provided byproduct and equipment manufacturers, provided those guidelines and instructions arewithin the scope of practice as defined by the state, if required.Estheticians will follow, at minimum, infection control practices as defined by their stateregulatory agency, Centers for Disease Control & Prevention (CDC) and OccupationalSafety & Health Administration (OSHA).

ProfessionalismEstheticians will commit themselves to ongoing education and to provide clients and thepublic with the most accurate information possible.Estheticians will dress in attire consistent with professional practice and adhere to the Codeof Conduct of their governing board.

*For the purpose of the NCEA Code of Ethics, the use of the term “Esthetician” applies to alllicensed skin care professionals as defined by their state law.


Sample Job Description

Position: Esthetician

Requirements: Esthetician will maintain state-issued licensure (if required) and NCEA Certified credential during employment, and adhere to the NCEA Code of Ethics.

Responsibilities:

1. Coordinates patient care with the physician, including but not limited to the use of oral and topical medications, pre-and postoperative care, and various patient compliance concerns.

2. Provides new patients with complimentary consultations regarding skin are services.3. Serves as a liaison with the patient coordinator during the pre- and postoperative

phase of patient surgery/treatment to ensure understanding of the outcome.4. Maintain treatment rooms and workstations in compliance with OSHA standards,

specifically the Bloodborne Pathogen Act, Hazards Communication Standard, American National Standards Institute (ANSI) and Federal Laser Product Performance Standard (FLPPS) for laser hazard safety.

5. Seek advice of physician on treatment protocols and advice physician of patient noncompliance.

6. Maintains and insure HIPAA compliance and current patient records detailing treatment procedures, products, medications and education information.

7. Maintains equipment or proper operations, including cleaning and maintenance schedules are manufacturer, state and federal requirements.

8. Overview and updates office personnel telephone procedure on handling scheduling, confirming appointments, wait listing and cancellation policies and patient followup (when required).

9. Participates and attends in-service programs and staff meetings.10. Assists with orientation and training of new office personnel, including but not

limited to product educations, sales procedures, skin care services, and another related protocols.

11. Coordinates any correspondence/brochures to patients regarding their skin caretreatments, product usage, and home care instructions.

12. Tracks outside referral sources and send thank you letters and/or post-consultation letters if referred by another physician or facility

13. Maintains inventory system for professional and retail products.14. Orders and stocks medical supplies/sundries as needed for maintaining treatment

room and retail shelves.


Patients are told to wear a hat and committo staying in an area with no sunlight orf l u o rescent lights. If the patient is exposed tolight, the reaction becomes much more severeand they could have an unexpected week ortwo of additional downtime.

Treatments for Pigmentation

Actinic Keratoses (AKs) are also knownas solar keratoses that are precancerouslesions. These raised lesions are usuallypink or brown and often have a white scaleon the top. They are rough to the touch andthe size is usually between 2-6 mm. Theyare usually present in areas of excessivesun exposure, such as the face, neck, scalpand hands. Since these are precancerouslesions, the patient, the esthetician and thephysician should all watch these lesionsclosely to be aware of any changes in color,shape and size. Physicians may treat AKsby cutting them out or freezing them withliquid nitrogen which makes them sloughoff. There are topical agents containing 5 -fluorouracil, which will cause the lesion tobecome red and inflamed and then fall off.Photodynamic therapy can also be used tophoto sensitize actinic keratoses beforeusing a light source to burn them off.

Solar lentigines, also known as old agespots or liver spots, appear as flat, oval,evenly pigmented macules in areas ofchronic sun exposure. Solar lentigines areamong the most common benign lesions ofthe skin. The most commonly affected areasare the backs of the hands, shoulders, back,and face.

Solar lentigines are made up ofcollections of highly active melanocytes(cells that cause pigmentation) producingdense melanin pigment in their associated

keratinocytes. The features of solarlentigenes are mostly limited to theepidermis, and although there is a greatdeal of melanization of the epidermis, thenumber of melanocytes does not changewith skin color. A solar lentigo is focus ofhighly active melanocytes that results in anarea of hyperpigmentation. No treatment isnecessary for solar lentigines. However, ifcosmetic removal is desired, treatments forsolar lentigines include topical agents suchas a freezing with liquid nitrogen, applyingh y d roquinone for bleaching, laser tre a t m e n t sand chemical peels. Multiple applications ofliquid nitrogen using short freeze times areused to avoid the chances ofhypopigmentation in the area.

Melasma

Melasma (also known as chloasma whenp resent in pregnant women) is a tan or darkfacial skin discoloration, usually located onthe sides of the face, forehead and chin.Although it can affect anyone, melasma isparticularly common in pregnant women,and those who are taking oralcontraceptives or on hormone re p l a c e m e n tt h e r a p y. It is also prevalent in men andwomen of Native American descent (on thef o rearms) and in men and women ofGerman/Russian Jewish descent (on thef a c e ) .

Ultraviolet exposure stimulates anincrease in the levels of melanin present inmelasma. Melasma may be a permanentcondition, but it may go away afterpregnancy or with the discontinued use ofhormone therapy. Pigment lighteningagents are limited and work better inconjunction with in-office treatments.


Laser treatments are not always the bestoption for treatment.

Use of prescription strength (4% &higher) hydroquinone can result inlightening of the solar lentigines as well asmelasma, but the results usually take fromsix to eight weeks. The concentration andduration of therapy are usually limited bythe adverse effects, which consist ofirritation, depigmentation, and ochronosis.(bluish-black discoloration of tissue)Patients should only use hydroquinone foreight weeks at a time and then take eightweeks off, repeating the process until thedesired outcome is reached.

T h e re are many skin-lightening agents inskin care preparations available to patientso v e r-the-counter (OTC), such as kojic acid,licorice root, bearberry extract,h y d roquinone (less than 4%) and azelaicacid. These agents have been shown top roduce some improvements, but they workbest when paired with in-office tre a t m e n t sto enhance the results.

Other topical products such as tretinoinor other vitamin A products, have shownfavorable results in lightening facial solarlentigines.

Phenol and trichloroacetic acid peels(TCA) 25%-35% have been used to tre a thyperpigmentation. However, the adversee ffects may include post-inflammatorypigmentation, (PIH), hypopigmentation,scarring, persistent erythema, and withphenol, cardiac arrhythmias (irre g u l a rheartbeats). This is why the use ofp ro g ressive exfoliation treatments asopposed to aggressive peeling treatments arem o re commonly used today. Theset reatments take time, and clients re q u i remultiple treatments along with the skin-lightning agents to obtain results.

For more-sensitive skin types andFitzpatrick skin types IV through VI, lacticacid peels of 30% to 40% are commonly usedat 2-week intervals for a series ofa p p roximately 6 to 10 treatments.

For lower Fitzpatrick skin types (skintypes I-III), who can tolerate a stro n g e rt reatment, the Jessner’s peel isrecommended. Jessner’s peels should bespaced 4 weeks apart owing to the longerhealing time, with a series of 3 to 4t reatments recommended.

If the patient is sensitive to chemicalexfoliation treatments, micro d e r m a b r a s i o nmay be used, although the results are notsignificant.

Laser treatments for pigmentation aredone in the office and can be completed inminutes with minimal discomfort to theclient. Patients who are Fitzpatrick I to IIIcan expect the best outcome, because theskin tone is lighter in color, pigmentedlesions starkly contrast to those fair skintypes. In the event that a fair-skinned patienthas a suntan, these patients should becounseled to return after their tan dissipates.

Skin types IV, and occasionally V, can bet reated, however, they are at increased risk ofepidermal injury. The skin pigment in theseskin types compete with the pigment in solarlentigines, absorbing a significant amount ofthe laser energ y. There f o re, darker- s k i n n e dpatients are treated more conservatively andoften re q u i re multiple treatments. However,they can expect a modest and cosmeticallysatisfactory improvement.

Skin preparation is not necessary otherthan removing all topical preparations. Useof a parallel cooling device may be helpful ind a r k e r-skinned patients by providing addedp rotection to the epidermis.

Immediately after laser treatments, the


pigmented area may appear ash-like, with ac i rc u m f e rential area of redness. Patientsmust avoid makeup for six to twelve hoursafter the treatment and should not exposethe area to the sun. Rare l y, a blister mayform; however, this is more likely in ad a r k e r-skin or tan-skin patient. Should ablister form, patients are instructed to notp u n c t u re it. If it ru p t u res, then a topicalantibiotic ointment is re c o m m e n d e d .Permanent hyper- or hypo-pigmentation,and permanent scarring are possible, butr a rely encountered.

Most patients feel comfortable re t u r n i n gto their routine schedule within a few hours.Over the subsequent week, the lesiontransiently becomes darker and ultimatelyfades. Occasionally, the lesion will slough offin the second week.

Subsequent treatments are spaced two tofour weeks apart and are necessary to furtherfade the lesion. Most people are satisfied aftert h ree treatments. Results continue to impro v eover the next three months.

The esthetician’s role is important in thet reatment of pigmentation becausecombination treatments seem to be moste ffective. Laser treatments can be alternatedwith chemical peels or micro d e r m a b r a s i o nat two week intervals. This is especiallybeneficial because with laser treatments, thepigment most often gets darker before itlightens; a superficial peel orm i c ro d e r m a b r a s i o n can speed up thep rocess of sloughing off the excess pigmenton the epidermis. Recommending skin carep roducts is of the utmost importance whent reating pigmentation. The client canactually make their pigmentation worse ifthey are not using a proper sunscreen. The use of skin lightening agents canenhance the results.

Rosacea

The word rosacea is derived from theLatin word rosaceus, meaning “rosy.”Rosacea is a chronic disorder of thepilosebaceous unit (consisting of the hairshaft, the hair follicle, the sebaceous glandand the erector pili muscle), characterizedby vascular dilation of the central face,including the nose, cheeks, eyelids, andforehead. Because there is currently nocure, the goal of current therapies is tocontrol the symptoms. Thirteen millionAmericans and over 45 million peopleworldwide are affected by rosacea.

The initial therapy should consist ofclient education, emphasizing the use ofsunscreens and mild cleansers and theimportance of avoiding irritants. The use ofsunscreens is particularly important to helpprevent further damage to the skin.Physical sunscreens, tend to be the bestchoice. Rosacea patients are extremelysensitive to topical agents and manychemical sunscreens can be irritating. Zincor titanium oxide are typically the broad-spectrum sunscreens of choice, and Zinc isalso anti-inflammatory. Sunscreen can bepaired with a gentle cleanser that containsno fragrance. Also, for those with rosacea,only mineral-based makeup should beworn because of its anti-inflammatory andsun-protective qualities.

If basic home care and trigger avoidanceis not enough, topical antibiotics are thefirst choice to relieve the inflammatorylesions of rosacea. Topical metronidazolecan be used with or without oral antibioticsto decrease the lesion counts by as much as60%. Azelaic acid , sulfacetamide,clindamycin, erythromycin and benzoylperoxide have been used with varyingamounts of success.


These agents should be used for at leastfour to six weeks before assessing theresults.

When symptoms of rosacea persist, astronger topical treatment, such as tretinoincream, can be used. Patients need to buildup tolerance to tretinoin, since it can causeslight irritation at first because of itschemical exfoliating properties. Treatmentwith this medication starts with applying itat bedtime two to three times per weekuntil the skin becomes accustomed to it,and then increasing the frequency tonightly.

If the disease is resistant or if symptomsof nodular rosacea or ocular symptomsoccur, oral antibiotics in combination withtretinoin can be used. Oral antibiotics thathave shown to be useful are tetracycline,erythromycin and minocycline. These aremedications commonly used to treat acne.

Lasers have been used with greatsuccess in rosacea. Intense pulsed light hasalso been used with success to treat theredness associated with rosacea. Theselasers have filters that bracket the visiblelight spectrum, so the emitted light energyis absorbed superficially in the epidermisand dermis. The KTP laser is a beamgenerated by a neodymium:YAG laserwhich is directed through a potassiumtitanyl phosphate crystal to produce abeam in the green visible spectrum; usedfor photoablation and photocoagulation.The KTP laser is particularly effective attreating rosacea because of its ability toattract to hemoglobin.

When treating rosacea with lasers,individual red lesions are often treated firstwith a small diameter hand piece. The laseris then passed over the affected area threetimes in a “painting” motion with a larger

diameter hand piece on a lower energysetting. This method of treatment isintended to even out redness and blend inthe skin tones. Patients may appear slightlyred or flushed after treatment, but theformation of purpura (a purplishdiscoloration) is uncommon. An ice pack isgiven to cool the area, and the rednessusually resolves within a couple hours.Blister formation and permanent scarringare rare and avoidable with proper patientselection and low-energy laser settings.Most patients feel comfortable returning toregularly scheduled activities that day.Improvement from flushing, pain, and thedeep redness of rosacea can be expectedwithin a week. To attain stable control ofthe rosacea, most patients prefer a series ofthree treatments. This seems to provide aplateau in symptoms for several months inmost patients, after which time patientsmay return for maintenance treatment.

The most important role the estheticianhas in treating these patients is to educatethem on how to control their symptoms.

Skin care treatments may be done onthese patients, but they must be done withextreme caution. Many esthetic treatmentsstimulate circulation and increase skintemperature, which is the last thing arosacea patient needs. For this reason,steaming, facial massaging, use ofultrasound, radio frequency and othertreatment modalities that will causeexcessive heat in the skin, should beavoided. Simple exfoliation treatments likea lactic acid for drier skin types or asalicylic exfoliation for those that have thepresence of breakouts, may be used. Thesetreatments tend to help calm down rosaceabreakouts.



1. Laser light in which spectrum may be effective at killing p.acnes?a) Red to Yellowb) Blue to Violetc) Red to Blued) Orange to Yellow

2. Photodynamic therapy can be used to photosensitize actinic keratoses.True or False?

3. When treating melasma, more sensitive skin types and Fitzpatrick Skin Types IV - VI should be treated with:a) Jessner’s peelsb) Glycolic peelsc) Salicylic peelsd) Lactic peels

4. The patients who can expect the best outcome with laser treatments of melasma are:a) Fitzpatrick types I through IIIb) Fitzpatrick types IV through VIc) Fair skin with a suntand) None of the above

5. The most effective approach an esthetician can use for hyperpigmentation is to use a __________________ of treatments.

6. A cooling device may be helpful to:a) Freeze the skin prior to laserb) Protect the epidermis from overheatingc) Dry up acne lesionsd) Protect the dermis from heating

7. Blister formation and permanent scarring are rarely __________________ after laser treatment of pigmentation.


Severe cases of rosacea and those with inflammationshould only be treated by a physician, unless there aredirect instructions by the physician for the esthetician.However, to rid the skin of red undertones, laser treatmentsare required.

Lasers & Light Therapy

The word laser is an acronym for Light AmplifiedStimulated Emission of Radiation. Light that we see withthe naked eye is called visible light, which is a combinationof multiple colors that are blended together. Visible light ismost evident when looking at a rainbow. Here, eachcomponent of the visible light is seen as one of theindividual primary colors, red, orange, yellow, green, blue,indigo, and violet. Each color in the visible light spectrumhas a corresponding wavelength, from 400 nanometers nm(violet) to 700 nm (red).

Intense Pulsed Light (IPL) is a light therapy device thattargets several wavelengths across the electromagneticspectrum. Lasers emit collimated and coherent light,meaning it is a single wavelength of light that is focusedand directed. Incoherent light is scattered. For example, ifyou were to shine a flashlight at a wall, the entire areawould light up. This is because the light that comes from aflashlight is composed of multiple wavelengths that are notcollimated or coherent.

Lasers and IPL devices can improve superficial brownspots and red discolorations. When the darkly pigmentedcells of the skin absorb the laser light, energy is released inthe form of heat, which causes destruction of the cell. In thecase of spider veins or broken capillaries, the energy isabsorbed by the red blood cells and the heat is transferredto the wall of the blood vessel, which is then destroyed. Inboth of these methods, little energy is dissipated to thesurrounding tissue, and therefore the skin surface remainsunharmed because the energy emitted is attracted to colorwithin the skin.


20. What does LASERstand for?

21. What is a differencebetween laser andIPL devices?

22. Why is a patient’snatural skin colorimportant?

23. What protectiveequipment must beworn?

24. What is a “controlledburn?”

25. Which laser targetswater in the skin?

26. What post-op roledoes the estheticianhave in ablative lasert re a t m e n t s ?

27. How does thefractionated laser work?

28. Which laser causesrapid epithelizationwithin 24 hours?

29. What is micro-resurfacing?

30. What does it take tohave a fulfillingcareer in medicalesthetics?


For more information regarding lasers and light therapy: • NCEA’s 42-Hour Laser Light Curriculum Outline • Recertification Section - Lasers and Light Therapy

Available from www.ncea.tv

Protocols for Laser & Light Therapy

Pretreatment

During the pretreatment evaluation, it isimportant to consider the patient’s naturalskin color. In general, a greater contrastbetween the patient’s base skin color andthe existing discoloration will yield a betterresult.

For example, a patient with a faircomplexion will generally have a betterresult and fewer complications thansomeone with a darker complexion. This isbecause someone with a darkercomplexion, the light being absorbed bythe melanin within area being treated willalso have a higher risk of be absorbed bythe melanin in the surrounding tissue.Patients must not tan or use self-tanningcreams before treatment.

Immediately pretreatment, all makeupand moisturizers must be removed fromthe face. A topical anesthetic is generallynot needed and is best avoided because itmay affect the efficacy of the laser/ IPLtreatment.

Treatment Process

All individuals in the room must wearp rotective goggles throughout the pro c e d u re ;as inadvertent exposure of the eyes to thelaser beam can cause complicationsincluding blindness. After the skin has beencleansed of all makeup and debris, a topicalw a t e r-based gel is applied. This facilitatesmovement of the hand piece and may havesome cooling effects. Devices may also beused to pump cool air against the skin tocool the skin during the treatment.

It is important to protect the outermostlayers of the skin, because as the energy or

fluence increases, so does the depth of thelaser beam. Some laser energy will bescattered as it penetrates the superficialskin, and it will be absorbed by superficialcompeting chromophores in the top layerof the skin (epidermis) and living tissue ofthe skin (superficial dermis). Thisabsorption results in heat, and it is crucialthat these structures are protected so thatthey are not damaged.

When treating red blood vessels ortelangiectasias, near complete resolution isoften expected. Most patients are thrilled tosee the red blood vessel that they have beencovering with makeup for the last ten yearssuddenly gone; however, it can take morethan one treatment for the vessel to impro v e .

As a rule of thumb, patients shouldexpect three treatments, each separated byfour to six weeks, to achieve a desired re s u l t .It is rare for a telangiectatic vessel to re m a i nbeyond a series of treatments, although onoccasion, this may occur. If this does occur,the vessel can be directly cauterized orinjected with a sclerosing agent, which re a c t swith the walls of the vein causing the veinsto seal off.

On the other hand, after treatment of sun-induced brown spots, the treated area maybecome darker for approximately one weekb e f o re it begins to lighten. Typically by thesecond week, the treated area begins tolighten significantly. Three to five laser/ IPLt reatments, each separated by four to sixweeks, are usually recommended. The finalresults are impressive, and patients aredelighted that they no longer must wearmakeup to cover up the spots. Similar to thet reatment of red blood vessels, there is littleto no pain or downtime associated with thep ro c e d u re, and most people return to theirdaily activities right after the pro c e d u re.


After Treatment

After the treatment, many patients likehaving a cold pack placed on the skin for 15to 20 minutes. This can be soothing and candraw away some of the heat from the skin.The face is usually a bit red, but thistypically resolves quickly, usually within 15to 20 minutes. Wearing sunscreen ismandatory because these lesions will re t u r nif they are overexposed to the sun. To p i c a ls u n s c reen and mineral makeup can typicallybe applied immediately after the tre a t m e n t .

Most patients are comfortable getting thist reatment done on a lunch hour or in themiddle of a busy day. Intense pulsed lightand laser treatment for pigmentation is oneof the best rejuvenation treatments available.This is one area in which today’s availablemodalities have a huge advantage overp reviously used methods for skinre j u v e n a t i o n .

The treating physician may re c o m m e n dthat the patient see the esthetician form i c rodermabrasion treatments or chemicalexfoliations between treatments to enhancethe results. The microdermabrasion or peelscan assist in sloughing away the pigmenteda reas on the surface of the skin.

Complications

Poor outcomes and complications arerare if proper protocols and precautions arefollowed. If the energy used is too high orif the pulse widths are too short (meaningthat too much energy is absorbed by theskin too quickly) blisters may form on theskin. This indicates too much heat wasabsorbed superficially. The wound must becared for with topical ointments until itheals. These wounds may become hyper-pigmented temporarily, but to prevent

permanent scarring and hypopigmentation,certain precautions, such as the use ofsunscreen, must be exercised.

Almost universally, hyperpigmentationwill resolve over time with bleachingagents and sunscreen. Uneven pigment canalso be covered with camouflage makeup.If a blister develops, it is important that itnot be disrupted, and the patient see thephysician. If the blister breaks open, it mustbe cleansed three to four times a day with agauze pad or cotton tip applicator andperoxide, followed by a clean dressing.Patients must not smoke during thishealing period, and the wound should notbe covered with cosmetics.

After it has re-epithelized, the woundmust be treated to prevent scarring. Use ofa topical steroid or a steroid injection maybe necessary if keloids (hard, raised scarsthat are usually slightly pink or white) arerecognized. However, this outcome is rare.

The Esthetician’s Role in MedicalAblative Laser Treatments

Lasers that improve wrinkles and finelines work by heating the water content inthe skin to a boiling point therebyvaporizing the skin cells.

This laser treatment results in a“controlled burn,” which is limited to theouter layers of the skin. When this occurs,it is called ablative because the outer layersof skin are being destroyed or “ablated”. Ifthe treatment is aggressive, the underlyingskin is left raw, uncovered, andunprotected. The skin typically becomesred (erythematous) and weepy followingthe procedure. It is therefore important tokeep the skin clean and protected with anemollient.


Skin regeneration can take up to sixmonths, depending on the depth of theprocedure. As the wound heals, new skinregenerates by collagen formation. There isa thickening of the dermis and theepidermis, excess dead skin cells areremoved, and superficial brown spotsgreatly improve.

Contraindications for Ablative Laser

Treatments for darker skin tones:Fitzpatrick skin types IV -VI, those who scareasily or anyone prone to keloid scars,smokers, those using nicotine patches andeven those in proximity to secondhandsmoke can have altered healing becausesmoke is a vasoconstrictor. Those with anactive herpes infection, pre g n a n c y,i s o t retinoin use within the past year, andthose who have undergone electrolysis, maybe contraindicated for treatment.

The Carbon Dioxide Laser

In the early 1990s, the carbon dioxide(C02) laser was the most popular laser forskin resurfacing. It provided outstandingresults. The carbon dioxide laser uses along wavelength 10600 nm, which isabsorbed by the water in the skin. Thisablative resurfacing rejuvenates the skin bydestroying the outermost (and the mostphotodamaged) layers of the skin.

During this ablative therapy, the layersof the epidermis and the dermis arevaporized down to the level of the upperreticular dermis. Heat travels locally in acontrolled manner to the deeper dermalreticular layers. The generated heatchanges the shape of dermal protein suchas collagen, which shrinks as it tightens.This is usually a one-time procedure and is

one of the most aggressive treatments forrejuvenating aged, photodamaged skin.Although the occurrence of adverse effectsis higher with a more aggressive lasertreatment, most patients ultimatelyappreciate their “new skin” that appearsthe way it did decades earlier.

The major problem with the C02 lasertreatments, however, is the extendedrecovery time needed. Some patients mayappear “red” or “pink” for months, andsome patients may develop areas ofhypopigmentation (this has been seen inapproximately 20% of patients whenmultiple passes of the C02 laser wereperformed). In the end, the extendedrecovery needed for this treatment inaddition to the substantial risk forcomplications, such as hypo-pigmentationand scarring, have resulted in the deeperablative therapies falling out of favor withmost clinicians.

The Esthetician’s Role

The esthetician’s role is involved andintense with these patients because these arepatients that are attuned to their skin andwill want a lot of advice. Some physiciansrecommend six to eight weeks ofm i c rodermabrasion and superficialexfoliations peels performed by anesthetician to pre p a re the skin for theresurfacing laser pro c e d u re. It is importantto counsel patients and pre p a re them for theintense treatment they are about to underg o .It must be made clear to the patient that theycannot smoke or expose their skin to the sun.After the treatment, some patients needmany hours of care and reassurance from themedical staff .

Understanding the post-tre a t m e n tp rotocols is necessary, as is identifying any


concerns so that a physician or nurse can benotified of potential adverse effects as soonas possible. During the ensuing six-monthhealing time, the skin will need attentivec a re. Most patients will be excited andi n t e rested to learn how to take proper care oftheir “new” rejuvenated skin, and they willbe motivated to work with the esthetician tokeep the skin in a healthy state.

Fractionated Ablative Lasers

One of the largest breakthroughs infacial rejuvenation treatments in the lastfew years is the advent of fractionated laserresurfacing (Fraxel™, Reliant Technologies,Palo Alto, CA; Active Fx™, Lumenis,Yokneam, Isreal. The laser beam isfractionated by a special difractionatedmicrolens, so that it is evenly distributedfrom the hand piece to the skin. Islands ofuntreated, intact skin are targeted evenlythroughout the treatment field, and theresult is rapid healing. The Fraxelfractionated C02 laser was the first laser toreceive FDA approval for skin resurfacingand treating melasma, pigmented lesions,crow’s feet (periorbital rhytids), and softtissue coagulation.

During Treatment

Patients are usually given a prescriptionfor medication to ease any discomfort oranxiety prior to the procedure. After theskin is cleansed with alcohol, a topicalanesthetic is applied to the skin for 60 to 90minutes. The anesthetic must be cleansedoff thoroughly (with alcohol) prior tobeginning the laser treatment because if theskin is not properly cleansed, it can causedeep dermal burns. Most patients willexperience some burning and discomfort

during the treatment, although if the patientis properly pre p a red for the pro c e d u re thediscomfort is usually minimal.

After Treatment

The physician or esthetician will apply athick layer of occlusive ointment andsupply the patient with a cooling compresspost-treatment. The patient must beinstructed to avoid direct sunlight to theface for at least four weeks following thetreatment. The patient may take ananalgesic, such as ibuprofen, fordiscomfort, should gently cleanse the skinwith tepid water, and apply the occlusiveointment recommended by the physicianafter cleansing. After the surface of the skinhas healed, it may be cleansed with agentle cleanser followed by a hydratingserum containing hyaluronic acid orvitamin B5. The patient must be educatedon the importance of wearing a zinc-oxidebased sunscreen and mineral makeup.

Non-Ablative Fractionated

The Pixel® 2940 Er:YAG (Alma Lasers,Inc, Israel) laser module was specificallydeveloped to capture the same superioraesthetic results of an ablative techniqueand also the comfort, short recovery, andmild adverse effect profile of a non-ablativemodality. Such technology allows deeppenetration of energy that denatures(changes the structure of) collagen andstimulates a wound response. The resultshave been reliable and predictable andtreatments produce mild to no painrequiring no anesthesia. The hand-piececan be adjusted to fit the desiredaggressiveness of the treatment, thepatient’s response, and the skin’s


sensitivity. Rapid epithelization is typicallyinduced within 24 hours and erythema andedema rarely last more than one to twodays. There is considerable skin protectionwhen using this laser, and there is areduced risk of scarring and heat-relatedcomplications. Complete healing isachieved quickly, and there is essentiallylittle to no downtime. Several treatmentsare usually done at intervals of three tofour weeks to maximize benefits; however,in clinical practice, most patients arecompletely satisfied after only two to threetreatments.

After the laser treatment series iscomplete, the skin’s texture anddiscolorations (dyschromias) generallyimprove. One can expect to see asignificant improvement in epidermal anddeeper dermal dyschromias, indicating thatthis technology is effective without thedowntime common to medium-depth peelsand ablative laser treatments. The efficacyof the treatment is comparable to othermodalities used for dyschromias, such asintense pulsed light and visible light laser.


The esthetician frequently takes care ofthese patients both before and after thelaser procedure. Patients may beundergoing chemical exfoliations andmicrodermabrasion treatments and thenbegin requesting treatments that areslightly more aggressive than simpleepidermal treatments. For patients seekingmore aggressive treatments, it is importantto refer them to the physician once thetreatments performed by the estheticianhave reached outside scope of theirpractice. Patients should be educated on

the importance of daily sunscreen use andlaser treatments, and many of thesepatients return to the esthetician tomaintain the benefits of their treatment.Some return visits may be simply to get arecommendation regarding a topicalproduct with natural skin lightening effectssuch as kojic acid, bearberry, or retinol.

Erbium:YAG Laser Resurfacing 2940 nm

For patients who want an improvementbut do not want the significant amount ofdowntime or risk that comes with C02 lasertherapy, there is another option: theerbium:YAG laser or Er:YAG laser. One ofthe greatest benefits of the erbium laser isthat it allows adjusting the strength of thetreatment from a mild resurfacing to adeeper treatment. The treatment can thusbe adjusted to the patient’s desire.

The Er:YAG laser has a shorterwavelength 2940 nm than does the C02l a s e r. It produces energy in the mid-infrare dinvisible light spectrum, and this energy is10 to 15 times better absorbed by water inthe skin than is the energy from thetraditional C02 lasers. This has severalconsequences for the client, because thislaser energy is so well absorbed, it instantlyvaporizes skin and tissue so precisely thatthe surrounding skin is hardly affected.

The Er:YAG laser does not “burn” theskin like the C02 laser does, so the amountof pain and the number of adverse effectsexperienced by the patient are gre a t l yreduced, while the degree of precision andc o n t rol is significantly enhanced. Only a fewm i c rons of thickness are removed with eachpass. The healing process lasts only one ortwo weeks, so this pro c e d u re is suitable forrelatively young, working patients who


cannot aff o rd significant down time. The pro c e d u re also will be of interest to

patients who have had their facial skinresurfaced by another method and wouldlike to improve their condition further orresurface delicate skin surfaces like the neckor hands. The higher safety profile ofE r : YAG lasers allows the clinician to tre a tpatients with darker skin colors–Fitzpatricktypes IV–VI.

Low-level Erbium Laser Treatment

Despite the lower morbidity associatedwith standard short-pulse Er:YAGtreatment, patients and physicians are inconstant search for less invasive techniques.The concept of micro-resurfacing is anattractive option. Generally speaking, low-level erbium ablative therapy can be doneon patients with all skin colors and in thosewho want mild improvement in their skintexture and tone without significantdowntime. Those with thin fair skin color,multiple skin discolorations, and fine linestend to respond best to low level erbiumlaser treatments. The treatment iscontraindicated in pregnancy (as are alllaser and light treatments), in patients withan active herpetic breakouts, in patientswith a history of hypertrophic scarring orkeloid formation, and with patients whohave taken isotretinoin within the last year.Non-smokers will achieve better resultsthan will smokers.


Similar to the esthetician’s role in C02laser resurfacing, in Er:YAG laser tre a t m e n t ,the esthetician is involved both before andafter treatment, but more care is usuallyneeded after treatment. During the first

week after the laser treatment, theesthetician often guides the aftercare byrecommending the appropriate cleanser.Care must be taken with patients who haveoily or acne prone skin to avoid irritationand future breakouts. If the skin is nothealing, becomes ulcerated or if the patientcontinually complains about pain oritchiness, the esthetician shouldcommunicate these concerns to the nurse orphysician. Counseling after treatment isessential, especially regarding theimportance of wearing sunscreen. Many patients undergoing Er:YAG lasertreatments become motivated regularclients of the esthetician because their skinis in better condition and they will needcontinued help to care for it.

Conclusion

Working within a medical facility can bea fulfilling career choice for estheticians.Understanding your role and yourlimitiations, can ensure full support andteamwork with your physician.



1. Lasers emit _______________ and _______________ light in a _______________ wavelength.

2. Visible light is seen as:a) Greenb) Bluec) Oranged) All of the above

3. IPL is a light therapy device that targets _______________ wavelengths.4. After laser treatment, many patients like applying a:

a) Mud maskb) Topical antibioticsc) Cold packd) Vitamin A

5. To prevent post laser hyperpigmentation, the patient’s daily use of _______________ is mandatory.

6. An ablative or C02 laser can vaporize down to the level of:a) Stratum corneumb) Papillary dermisc) Upper reticular dermisd) Stratum germinativum

7. C02 lasers require more patient downtime than the Er:YAG laser.True or False?

8. Which lasers uses a difractionated microlens so that the beam is evenly distributed?a) C02 lasersb) Fractionated lasersc) IPLsd) Er:YAGs


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