Twenty years ago, the aesthetician had only creams and lotions. These provided very little benefit for the skin compared with what is available today. These products were combined with an aesthetician's techniques and atmosphere to provide the customer with a luxurious feeling of being doted upon and pampered. Today we have access to a wide variety of effective chemical exfoliants such as alpha hydroxy acids (AHA) and beta hydroxy acids (BHA), as well as microdermabrasion and the ultrasonic spatula for physical exfoliation. But can we go a bit further? Which comes first, AHAs or BHAs? Can we combine these exfoliants without overstepping any boundaries? Should we consider combining chemical exfoliants with physical exfoliation treatments to increase their combined effectiveness?

Determining Which Type of Exfoliant to Use
For aestheticians, the old way of skin typing was all about the level of oils on the skin. Today, the Fitzpatrick scale is widely considered to be the gold standard in skin care. The Fitzpatrick scale helps determine what percentage of chemical exfoliant, pH, and formula you should use for any specific skin type. This system answers questions about genetic disposition (skin, eye, and hair color), ethnicity, and response to sun exposure. Through measuring the response to the sun's exposure, it also provides guidelines for post-inflammatory hyperpigmentation (PIH), which helps us to decide how aggressive we can be with the exfoliant.
The Fitzpatrick scale is the most reliable test in the field of aesthetics. Of course, skin typing like Rubin and Glogau may also be useful to aestheticians, but these scales are for determining the amount of damage the skin has already incurred. Since aestheticians cannot go deeper than the first few layers of the epidermis, they are limited with the types of chemical and physical exfoliation they can use.
The Glogau scale is for the classification of photoaging, while the Rubin classification determines pigmentation and texture. We can use these classifications to help guide our clients toward what is possible for us to accomplish in an attempt to repair the damage already done to their skin. We can then utilize the Fitzpatrick scale to determine what is necessary to halt any future damage.
The Fitzpatrick scale further helps us to set a client's expectations for what can be accomplished during our sessions in the treatment room. When a client consults an aesthetician, we may assume that they are hesitant or unwilling to take more drastic measures such as LASER, IPL, and plastic surgery. This is our best opportunity to explain what options we can offer and what benefits she can expect while in
our care.

Alpha Hydroxy Acids (AHAs)
AHAs are naturally occurring organic Carboxylic acids, which means that the carbon atom is attached to "an oxygen atom by a double bond, and to a hydroxyl group (OH). AHAs are water soluble.
Among AHA, glycolic acid is the "Top Dog" in the skin care industry. Due to its smaller molecule, it is believed to get deeper into the epidermis and work more quickly by melting the glue-like substance between the dead cells. Lactic acid is a larger molecule, which dissolves the anchors of the dead cells at a slower pace. Mandelic acid is another AHA which has been gaining popularity recently. The name is derived from the German word "Mandel" for "almond." Mandelic acid works a bit like salicylic acid in that it is water soluble, but because of the benzoic ring in the molecule, it is gentler.

It also possesses antibacterial properties. Another popular AHA is Tartaric acid. Tartaric acid (or the wine peel) is a white crystalline organic acid, which occurs naturally in many plants, particularly grapes, bananas, and tamarinds. Tartaric acid is one of the main acids found in wine. Malic and citric acids are also considered AHAs, but are currently less popular. All AHAs primarily promote desquamation by detaching the corneocytes from one another. They break the desmosomes, which are the intercellular "rivets" that bind corneocytes together. You should not see any flaking with AHAs unless the client has a lot of loose, dead skin.

Beta Hydroxy Acid (BHA)
BHA is an organic compound that contains a carboxylic acid functional group and hydroxyl functional group separated by two carbon atoms. In salicylic acid's instance, there is a benzoic ring (or aromatic ring) separating the hydroxyl and carboxylic group. BHAs are oil soluble, mainly because of the aromatic ring. Salicylic acid, being a BHA, is known to be helping to dissolve blackheads and resistant clogged pores. It also coagulates the protein in the cell, a little bit like frying an egg. The cells become very hard and it takes longer for the dead cells to flake off the skin. In cosmetics, the term "beta hydroxy acid" refers specifically to salicylic acid.
Many aestheticians like to use salicylic acid as a peel, but it is not recommended to use this with Fitzpatrick type IV, V, and VI. Salicylic acid at a higher percentage (more than five percent) can have a rebound effect and promote pigmentation. You can perform an AHA and a BHA at a higher percentage in the same session as long as you use the AHA first. Once you neutralize the AHA and dry the skin, you can apply the Salicylic acid. You should not use anything with an emollient afterwards, since BHA can react with the oil molecules of the product. Therefore, you can use Hyaluronic acid and mineral foundation before you send the client home.

pH, Concentration, and Formula
Having established that AHAs and BHAs primarily do the same work, how do we determine which one will work best in our treatment room? There are a myriad of formulas available, and all manufacturers will invariably expound their chemical exfoliation as the best for every situation.
Whenever it's time to choose a chemical exfoliant, we have to consider the pH, the concentration, and the formula. The pH factor is a scale of 0 to 14, 0 being the most acid and 14 being the most basic. Most states recommend not going under a pH of 3.. A rule to follow with any chemical exfoliant is that when the pH is less than 3, the exfoliant doesn't need to be neutralized. If it's less than 3, a neutralizer (solution of Sodium Bicarbonate) is recommended most of the time. Regardless of the chemical exfoliant used, following this basic guideline will help you avoid danger zones. Also, as the pH lowers, the time the chemical exfoliation is left on the skin should decrease. Of course, it is always recommended to follow the manufacturer's protocol. Be sure to read the entire protocol before you test any exfoliant.
The concentration is the percentage of the active exfoliant in the compound. For Glycolic acid, most states recommend a percentage of 30 percent. You can follow the same principle for any AHAs. Combinations are always acceptable but be careful to pay attention to the pH. There are also AHAs formulas with lower percentages of Salicylic acid. If the percentage of Salicylic Acid is too high, and if you are performing a chemical exfoliation, remember that you cannot use it on skin with Fitzpatrick type IV through VI without a high risk of triggering pigmentation.

Physical Exfoliation
Physical exfoliation is exfoliation using methods such as microdermabrasion (diamond or crystal), ultrasonic spatula, scrubs, and gommage to name a few. Microdermabrasion, specifically crystal microdermabrasion, is the most aggressive physical process. When the skin is vacuumed, crystals are projected on to the skin creating minute indentations. The crystals are not distributed evenly on the skin, and therefore can make varying concentrations of indentations across the treated areas. A diamond tipped microdermabrasion tool will provide a more controlled exfoliation being that you can go over the area as needed. Ultrasonic spatula works by vibrating the skin. A liquid is needed to make the connection between the spatula and the skin. No matter what the aesthetician elects to do, it is crucial that she NOT do a chemical exfoliation AFTER a physical exfoliation as aggressive as microdermabrasion. Always perform the chemical exfoliation prior to a microdermabrasion if you elect to do both in order to loosen any dead skin. Many estheticians use the following protocol: Chemical exfoliation, neutralization, then microdermabrasion. This sequence is considered to be safest.
Chemical and physical exfoliants are now part of the skin care industry. We, as sestheticians, want to be sure that we can utilize these more aggressive treatments while having the knowledge to know when to draw the line. Therefore, we need to educate ourselves about how aggressive a treatment can be used on each skin type. Our clientele have the right to expect us to offer the best and safest care and treatment available to us. Make sure that no matter what manufacturer you consider, they offer comprehensive training for each of their products. Then study these resources carefully, and don't be afraid to go back often and "sharpen the saw."

Johanne Clément has been a licenseda esthetician since 1995. In 2007, she started her own skin care business based in the Tampa Bay area in Florida. Clément is a national educator and demonstrator for Rose Skin Care Products. Her classes include workshops on Chemical Peels, and TCA/Jessner's Certification around the country. Her various curricula for these classes are being used by other educators to train students and licensed aestheticians in new techniques and technologies. Clément is currently working towards a degree in biochemistry and is involved in the research and development of formulas for several new products for different skin care companies. She received her NCEA certification in 2008 and believes that alla estheticians should be involved in the decision process along with the Board of Cosmetology for each state