Professional exfoliation is the process by which skin care professionals use manual exfoliation methods, enzymes, chemical peels, or machines to clarify and beautify the surface of the client's skin. Exfoliation is commonly used to diminish blemishes; reduce pigmentation; lessen textural scarring; soften the appearance of wrinkles; replace dull skin with a healthy, glowing complexion; clear cellular build-up; and open pores, reducing and preventing ingrown hairs.

Professional exfoliation removes dull, unhealthy surface cells, which are replaced by healthy new ones. It also allows skin care products to work more effectively because they are able to efficiently penetrate the skin.

SKIN TYPE
Normal skin is well-hydrated with adequate lipid levels, small pore size, and minimal breakouts.

Dry skin lacks adequate sebum production, has small pores, is prone to fine lines due to the dryness, can be sensitive, and appears thin. Dry skin is often dehydrated, meaning that the skin is lacking moisture.

Oily skin has excessive levels of sebum production, larger pores, and appears thick and shiny. It is prone to clogged pores and breakouts and is less likely to develop wrinkles.

Combination skin is perhaps the most common condition treated by skin care professionals. The skin is dry in some areas, while oily in others. Pores are often larger in
the T-Zone.

Mature skin lacks firmness and elasticity. Skin tends to be loose and thin, displaying fine lines and wrinkles, and may be crepe-like in areas, especially around the eyes.

FITZPATRICK SKIN TYPE
Some stronger exfoliation methods are not recommended for darker Fitzpatrick skin types due to the potential for keloid development and post-inflammatory hyperpigmentation. As a general rule, the lower the Fitzpatrick type, the more resilient the skin. The higher the Fitzpatrick type, the more sensitive the skin.

Today, it is very common for clients to have mixed ethnicities, causing professionals to use a point system to determine the client's Fitzpatrick skin type and
sensitivity levels.

Questionnaires have been developed assigning points to each answer to help the professional determine a more accurate Fitzpatrick classification. Questions include: What are your natural hair, eye, and skin colors? How long does it take for your skin to burn when exposed to the sun?

SENSITIVITY LEVEL
A client consultation form should ask if and where clients have areas of sensitivity. Their sensitivity can be related to current product use as products that are too harsh and abrasive can cause the skin to become irritated. It can also be the result of skin conditions like rosacea, eczema, and psoriasis; diseases such as fibromyalgia; or even cancer treatments. Knowing the cause of the skin sensitivity can influence the exfoliation method that is chosen.

CLIENT CONCERNS AND SKIN CONDITIONS

Aging
Aging skin delivers a unique set of challenges. As people age, the skin thins and bone density decreases while dryness, pigmentation, and wrinkling increase, creating several obstacles. Clients may visit the spa concerned with their increasing crow's feet and dehydration levels. At the same time, the professional may also observe ultraviolet damage and a few breakouts. Luckily, the professional can address these concerns and have several exfoliation choices available. The best choice may end up being a treatment plan that incorporates several of the options available. The final choice will depend on client compliance levels and the downtime they are willing to incur, which can last from a few days to two or more weeks.

Sagginess
Sagging skin lacks elasticity and support due to decreasing collagen and elastin levels and weakening facial muscles. Treatment plans
include chemical peels, Fraxel laser treatments, and other modalities that initiate the collagen remodeling process.

Sensitivities
Sensitive skin conditions require additional education to truly understand the condition before attempting to beautify the skin. If the client has an impaired skin barrier, the skin care professional may choose to restore it before concentrating on active exfoliation methods. A client with rosacea can benefit from trichloroacetic acid-based peels blended with anti-inflammatory ingredients. Salicylic acid is a great choice for clients with papulopustular rosacea (subtype 2) as this acid has been shown to reduce Demodex mite populations, a common contributor to subtype 2 breakouts. These treatments consist of superficial levels of exfoliation (in the upper epidermis) with minimal downtime.

Dryness
Dry patches or dehydrated skin can occur at any age and may have multiple sources. However, since these conditions are caused by a lack of sebum and/or water, both conditions can benefit from professional exfoliation, which will allow for deeper product penetration of ceramides and humectant ingredients. Beneficial exfoliants can range from enzymes to chemical peels and usually result in minimal or no downtime.

Lackluster
Dull, grayish-toned skin can indicate two issues. If the skin is dull-looking due to cellular buildup, an exfoliation is in order. If the skin is dull and gray, it may be sluggish and in need of a detoxification with circulation stimulation. In this instance, a mild enzyme exfoliation or a very superficial chemical peel combined with an oxygenating treatment might be the cure for the client's concerns.

Hyperpigmentation
Hyperpigmentation may be epidermal or reside in the dermis. If the pigment is epidermal, a mild exfoliation using an enzyme, microdermabrasion, or a mild chemical peel can produce wonderful results. Long-term treatment success relies upon client compliance. The skin care professional can exfoliate the pigment, but the client needs to be diligent with the application of a pigment-suppressing product and wear sunscreen daily to achieve long-term success. Downtime is minimal or non-existent with this level of exfoliation. If the pigment lies in the dermis, stronger and more aggressive exfoliation methods, including mid-depth chemical peels, IPL, or other laser light therapies targeting pigmented chromophores will be necessary. Downtime, due to redness and flaking, can last from three to seven days.

Scarring
Uneven texture resulting from textural scaring requires more active treatments, such as laser therapies, microneedling, or higher percentages of trichloroacetic acid-blended peels. The length of downtime depends on the treatment program. A series of microneedling treatments may not incur any downtime. A strong laser treatment or deep chemical peel may incur a week or more of downtime.

Acne
Breakouts are a skin concern for all ages. One of the main contributors to acne is hyperkeratinization. The type of exfoliant chosen may vary depending on the type and the grade of the acne.

Hormonal acne can be addressed with enzymes or chemical peels. Advise clients that they will experience a short-lived breakout while the skin purges and a series of enzyme or chemical peels will be required to express all congestion. Discuss the importance of balancing hormone levels to develop a long-term solution. The client should consider visiting a physician to test their hormone levels.

Teenage acne may best be addressed with enzyme exfoliants as teenagers will not want to experience any downtime.

Grades one to two acne can be treated with an enzyme or a mild alpha hydroxy acid, beta hydroxy acid, or trichloroacetic acid chemical peel with little-to-no downtime. Microdermabrasion or dermaplaning is possible as long as there are no active pustules. Disturbing active pustules may spread bacteria.

Grades three to four acne should incorporate a treatment plan in conjunction with a physician. This client may need antibiotics to help get the skin condition under control. The skin care professional can still exfoliate the skin, but should do so with caution. Antibiotics will increase sensitivity levels, leaving the professional with fewer options.

Mild alpha hydroxy acid, beta hydroxy acid, trichloroacetic acid peels and enzymes can still be part of the treatment plan, but microdermabrasion or dermaplaning is not advised.

CLIENT COMPLIANCE

Chemical peels require a short period of downtime, where a client must avoid heat and ultraviolet exposure. It is vital that the client complies with the professional's aftercare advice If the skin care professional applies a peel and, after the treatment, the client takes off for a trip to the beach or a tanning session, they will most likely burn, blister, and possibly develop post-inflammatory hyperpigmentation.

ALLERGIES AND MEDICAL CONDITIONS

Be sure to check the client's consultation form for allergies or any medical conditions that contraindicate certain exfoliation methods. For example, the skin care professional should remember that aspirin is a salicylate; avoid salicylic acid peels or products. Furthermore, they should review all ingredients in the exfoliation product for potential allergen concerns. Common examples are citrus, honey, and mushroom. Be sure to narrow down the specific allergen. When in doubt, patch test prior to exfoliating, allowing a minimum of 48 hours for potential reactions to surface.

Do not perform microdermabrasion on a client with bacteria or fungus present as it will spread to other areas of the face or body. Moreover, open lesions should
always be avoided.

Electric machines are a contraindication for clients with epilepsy, metal plates, pacemakers, heart conditions, high blood pressure, and pins in the body, and
pregnant clients.

THE MECHANICS OF EXFOLIATION

Healthy skin cells shed microscopically throughout a 28-day cycle instead of one big flaking session each month. Unfortunately, most client's skin is not in a healthy state. Sometimes cell turnover gets interrupted due to an impaired acid mantle. Even though cells are turning over underneath the surface, they build up on top of the skin. This condition is referred to as corneocyte cohesion and results in hyperkeratinization. Professional exfoliation methods are required to remove this build-up.

EXFOLIATION METHODS AND DOWNTIMES

Mechanical Exfoliation
Both scrubs and gommage are possibilities for a client who needs minimal exfoliation and does not want to experience any downtime.

Scrubs exfoliate the skin using plant kernels or sugar to manually smooth the surface of the stratum corneum. If incorporating a scrub in a client's professional exfoliation, take caution as to the quality of the ingredients used so the skin is not irritated or torn.

Gommage exfoliation leaves the skin soft and smooth. The skin care professional applies a paste-like exfoliant to the face or body and allows it to dry. The exfoliant combines the use of an enzyme that dissolves dead surface cells with mechanical exfoliation in the form of rubbing. It should not be used on thin, dry, acneic, or sensitive skin types with dilated capillaries.

Exfoliating mitts or brushes are often used in spa treatments to provide a pre-exfoliation prior to body services. They gently remove dead surface cells and can be used for all skin types.

Enzymatic Exfoliation
Enzymes are protein molecules that break down larger molecules into smaller ones. Enzyme exfoliation is appropriate for all skin types and is a good choice for the client who does not want any downtime.

Pumpkin enzymes are excellent for breakout-prone skin because they purge congestion without residual flaking. Bromelain, which comes from pineapple, and papain, which is derived from papaya, are proteolytic enzymes, or proteases, that break down and digest keratin proteins in the keratinocyte cells, helping them to slough off.

Exfoliating Peptides
Exfoliating peptides are chemical compounds that induce exfoliation within the skin.

Passionfruit is a biomimetic peptide that is synthetically created to mimic the natural function of an enzyme. It is great for firming the skin without residual flaking. The exfoliation will be very superficial without downtime.

Hexanoyl Dipeptide-3 Norleucine Acetate is a peptide that stimulates cell regeneration by degrading desmosome bonds, allowing cells to slough more readily.

Chemical Exfoliants
Alpha hydroxy acids are milk or fruit acids that work by dissolving small fibrous bonds, or desmosomes, that hold epidermal cells together. Once the bonds are dissolved, natural exfoliation is easier. Alpha hydroxy acids are mild exfoliants that exfoliate superficially with little-to-no downtime. They can be used on many types of skin conditions and have additional benefits. For example, glycolic acid penetrates quickly and degreases the skin and lactic and malic acids are hydrating. Mandelic acid addresses pigment, tartaric acid is a great antioxidant, and citric acid is a pH adjuster.

Beta hydroxy acids are keratolytic; they dissolve surface skin cells. Salicylic acid is the most commonly recognized form of beta hydroxy acids and are perfect for clients with rosacea and acne. Most salicylic peels come in concentrations varying between 10 to 20 percent. Natural sources of salicylic acid are willow tree, wintergreen oil, and sweet birch. Salicylic peel can be applied with gauze, a cotton square, glycolic wand, or a fan brush. Peels are usually timed, then removed with cool wated. They are superficial peels' penetration is layer and time dependent. Depending on the percentage and application method, salicylic acid has minimal downtime.

Poly hydroxy acids are considered less irritating than alpha hydroxy acids as their molecules are larger, so they penetrate the skin gradually, layer by layer. Lactobionic acid is one of the new generation peels. It is a poly hydroxy acids formed by oxidation of milk sugars. It is an excellent peeling agent for sensitive skin types, providing superficial levels of exfoliation. It is so gentle that it can be combined with other modalities.

Retinoids promote cellular turnover and can be used on all skin types. Many blended peels use a retinoid in the form of retinol, retinaldehyde, or retinoic acid in their formulas. The amount of exfoliation and downtime experienced by the client, if any, depends on the form and percentage of retinoid used. A 0.1 percent retinol would provide minimal exfoliation while a 0.1 percent retinoic acid will provide far more exfoliation. Downtime on most retinoid treatments is minimal, with perhaps one to three days of light to moderate flaking.

Trichloroacetic acid is synthesized in a laboratory by combining three molecules of chlorine with acetic acid. This acid acts as chemical cauterant, dissolving cells. Trichloroacetic acid peels can come in percentages as low as five percent, which is very superficial with no downtime, and go to 100 percent, which is very aggressive with substantial downtime. This type of peel can be used for a variety of skin types and conditions, depending on the percentage used.

Phenol is another chemical cauterant that is more commonly used in medical settings. Low percentages of phenol act to numb the skin or area being treated. In some states, aestheticians may use phenol in peels up to a 10 percent level. Other states will allow its use up to 2 percent. Some states ban the ingredient from aesthetic use altogether. Flaking and downtime can occur with levels that are 10 percent and above. Today, phenol is rarely the sole or primary ingredient in a peel. It is usually found in blended peels as a flaking or numbing agent.

Blended peels are very popular in the industry today. It has been determined that a peel blended with multiple acids induces less inflammation than a single agent peel. Blended peels are used on many skin conditions. Downtime is dependent on the formula.

Machine-Assisted Exfoliation
Microdermabrasion is a machine-assisted superficial exfoliation of the stratum corneum only. It requires multiple treatments to achieve results; however, there is no downtime. Microdermabrasion also stimulates circulation. Clients with couperose, rosacea, or acne are contraindicated to this treatment.

Epidermal leveling, or dermaplaning, involves using a scalpel to remove superficial stratum corneum cells. Epidermal leveling also has the added benefit of removing vellus hair. Because dermaplaning does not stimulate circulation, skin care professionals may consider it for a sensitive client. Acne lesions are a contraindication for this treatment.

There are many factors that contribute to the best selection of exfoliation for each client. Each client's skin is unique due to their own individual concerns. It is important to factor in skin type, Fitzpatrick skin color, sensitivity level, and any allergies or medical conditions along with the client's concerns, their ability to comply with the suggested treatment plan, and their preferred downtime to select the best exfoliation method for today's treatment.

Brenda Linday is a licensed aesthetician, licensed aesthetic instructor, and certified aesthetic consultant with over 12 years of experience in the medical aesthetic industry. She offers consulting services to medical and aesthetic companies desiring to build strong sales and education teams. She also develops educational and engagement-marketing content for employees, contractors, practitioners, and industry distributors around the world. Linday's passion is to share her wealth of knowledge with other like-minded professionals who believe that education is key to building lasting relationships with clients, making each clinician more successful by increasing client satisfaction.