Creating New Exfoliation Services to Smooth the Way in Rough Economic Times

Exfoliation is perhaps the most results-driven service in our playbook. The effects of exfoliation are literally visible and tangible, and this immediacy makes it very appealing to today’s time-crunched, cash-crunched consumer who demands delivery on every marketing promise. “You will see results next time,” is simply not good enough anymore. Exfoliation is a service (or array of services) that you can book with confidence in delivering a measurable wow factor after a single session. For this reason, offering and promoting upgraded ex-foliation services may be an excellent method for new customer acquisition, including men who have historically responded favorably to the mechanical concept of lifting and removing dead skin cell debris for a clearer, more vibrant baseline. 
Before beginning, it is important to check basic health facts with your client. Be sure that the client has not recently waxed, has no evidence of sunburn, or had any form of laser/light based treatment within the last 72 hours. If they have, exfoliation will need to be delayed. Examine the skin for any open acneic lesions; those clients who have recently taken Accutane will need to wait a minimum of six months before undergoing any form of exfoliation. Topical forms of vitamin A, however, only require discontinuing application the day of, and up to a few weeks before exfoliation, depending on the form used and its concentration. Check with the client to determine if he/she is living with diabetes, HIV/AIDS, or any other immunosuppressive condition – as these conditions drastically affect cutaneous healing. Be sure to ask female clients if they are pregnant or plan to initiate a pregnancy soon. These questions are highly personal and highly confidential, but they are very important.

Offer Exfoliation Options

Some skin therapists may hesitate when it comes to selecting a form of exfoliation for their clients. One size does not fit all – that is never the case in skin care. It is important to incorporate a variety of exfoliants for the wide array of different skin conditions presented by a diverse client base. Identify what concerns are top of mind for the majority of your clients right away. In the treatment room, you will initiate the benefits of exfoliation with highly active ingredients and techniques which are best performed by a professional. To truly optimize your program results, you should not only reevaluate your back bar and menu, but also reevaluate the retail shelves. Does your current retail selection offer clients assistance in their exfoliation goals? The retail products offered need to embrace the pre-treatment preparation and conditioning of the skin, as well as the post-treatment recovery. Due to the high level of ingredients and technology used during treatment, it will require customizing and individualizing the client’s current home care product regimen to optimize the benefits of the professional treatment. Be sure to discuss products currently used during your pre-treatment consultation and skin analysis and conclude the treatment with recommendations that will best accommodate before and after the professional exfoliation process. Before a treatment, consider prescribing chemical and physical exfoliants or a combination of both to prepare the skin by removing excess corneocyte build-up. Exfoliants may also be used post-treatment as a maintenance product at home. For some clients, simply prescribing hydrating boosters or masks to return the skin back to a state of health is another option. Consider the needs of the client or the goal of the exfoliation treatment to help determine if a mask or serum is used versus exfoliation pads or a fine powder that could be used if the client’s skin is on the sensitive side.
The American Society of Plastic Surgeons (ASPS) has recently reported that in the United States, 14.6 million cosmetic plastic surgery procedures were performed in 2012.1 This includes both minimally invasive and surgical procedures and represents a five percent increase in comparison to 2011. That increase, according the ASPS President Gregory Evans, M.D., is due to the significant rise in minimally invasive procedures. Chemical peels and microdermabrasion are two of the top five minimally invasive procedures. Without a doubt, the market for professional exfoliation persists, even though overall spa and salon bookings may be trending down in a struggling economy. Gone are the days of extreme skin peeling and ablative treatments. Consumers want those same results but in new treatments, procedures and ingredients that accomplish results without social downtime.
As a professional skin therapist, it is your job to analyze and determine what form of exfoliation is going to best suit the needs of your client. Take into account the client’s main skin concern and lifestyle. Make sure to talk to him/her about waxing and tanning before any exfoliation procedure and what is currently happening with his/her skin. Also discuss timing regarding any planned cosmetic surgeries or other procedures offered by other professionals.
Many factors will determine which exfoliant is going to accomplish the results that you need and is best for your client’s skin. By staying current regarding the newest uses of exfoliation agents and how they work, you will be equipped to master the art of skin peeling or exfoliation. As always, you must be educated and trained in emerging research and science, as well as contemporary applications and techniques, in order to ensure optimum treatment results and the safety of your client’s skin.

Let’s Get Physical

Physical or mechanical exfoliation literally breaks up the keratinized protein which accumulates on the skin’s surface, lifting and whisking away dry, dull cell debris to reveal softer, fresher skin beneath. Products and techniques for physical exfoliation include the use of a scrub, a gommage and an exfoliation device that uses various technologies, including microdermabrasion, ultrasound, brushes and dermaplaning. By contrast, chemical exfoliation is the use of topical ingredients such as enzymes, alpha hydroxy acids (AHAs), beta hydroxy acids (BHAs), trichloroacetic acid (TCA), or specific vitamins such as retinol or its derivatives. These topical applications dissolve cell debris for a pristine, glowing skin finish.
Examining the skin of your client and taking his/her health history into consideration will help to determine which form of exfoliation to use, along with indications of what ingredients are best suited. Let us start with a gommage, popular throughout Europe and Asia. This diverse form of exfoliation is used to erase or peel off dead skin. Gommages are widely available in cream or gel-based formulas. It is ideal for skin that is not showing great signs of laxity or excess slackness. The product is applied to the skin and then massaged or manipulated in ways that allow a peel-off motion, or eraser-like surface peelings to occur. Plant extracts like cellulose, grains and proteolytic enzymes such as bromelain (pineapple) or papain (papaya) are the most common type of ingredients found in gommage formulations.
Scrubs are self explanatory and work just the way they sound. The mild loosening action of a scrub relies upon ingredients such as tiny beads of jojoba, corncob, rice bran or polyethylene. Other scrubs utilize sugar and salt crushed nut shells like walnut and apricot – the latter, however, may be abrasive and its sharp, extremely hard edges may create microscopic scratches which actually irritate the skin. Oil absorbing scrubs may contain clays such as kaolin or diatomaceous earth. The vigor of the scrub must be gauged to the sturdiness of the skin. Sensitized and genetically sensitive skin – including skin which has recently been resurfaced or waxed is prone to flushing or inflammation – benefits from choosing a microfoliant approach, wherein the scrubbing particles are extremely small and smooth edged (versus jagged and sharp), such as particles made from rice husks. Microdemabrasion, ultrasound, brushes and dermaplaning can be termed both physical forms of exfoliation and mechanical exfoliation. Mechanical exfoliation is the use of a tool or machine to safely remove cellular buildup upon the skin.
Microdermabrasion is excellent for skin showing signs of sun damage and may be used to polish and smooth the skin. All microdermabrasion systems employ the use of pressurized suction. This suction can be combined with corundum crystals or with varied grades of diamond tips for a crystal-free application. Microdermabrasion works by removing the top layers of the epidermis consisting of dead skin cells. Medical grade crystals found in dermatologists’ and cosmetic surgeons’ offices can increase the depth of exfoliation, allowing for deeper removal.

Just Add Water

Today, manufacturers are combining microdermabrasion machines with water and/or serums in what is being called hydro microdermabrasion. While traditional microdermabrasion may deplete moisture from the skin, hydro microdermabrasion machines ideally help infuse moisture and humectant ingredients into the skin, reducing redness, soreness, flaking, and other commonly experienced aftermath. With either process, it is important that microdermabrasion is not used on inflamed pustules, open acneic lesions, sensitive skin showing signs of telangetasia, or rosacea.
Ultrasound or ultrasonic is another form of mechanical exfoliation that uses sound waves to create cavitation, or openings within the corneocytes. These spaces help break skin cell particles apart, resulting in tiny openings or crevasses which allows the product to penetrate, resulting in a deeper cleanse, exfoliation or hydration of the skin. This form of technology may be combined with cleansers or chemical exfoliants. While ultrasonic is safe for all skin types (except open or inflamed acne), it is important to check to be sure that there is no contraindication to the use of electrical modalities.
The use of a brush or brush machine can enhance the results of a cleanser or scrub. Other uses of brushes include assisting the removal of cream or clay masks. Brushes may even be used on the body for what is called dry brushing. This can be used before exfoliation and helps to encourage removal of toxins by stimulation of the lymphatic system.
Dermaplaning, a highly skilled procedure using a small surgical blade, gently removes the uppermost layer of skin. This method requires superb technical control and precision by the skin care professional. Dermaplaning is useful in the reduction of the appearance of scars and helps to even out irregular skin tone. In addition to exfoliation, dermaplaning is also a depilatory technique used to remove superfine, soft vellus hair, or peach fuzz, such as the downy hairs around the nape of the neck, on the forearms of many women, or similar hair growth in the small of the back above the tailbone. In some cases, dermaplaning may be used more aggressively than microdermabrasion. In all cases, great care will be needed to prevent damage and to ensure proper recovery of the skin.

Hungry Natural Enzymes

For those skin conditions for which physical exfoliation is contraindicated, or for skin in need of deeper exfoliation, the use of enzymes, vitamins, acid-free smoothing agents, or other active ingredients will often hold the answer. Enzymes are excellent for all skin types. They are especially useful when targeting acneic skin in need of extractions, dry, sensitive skin, or as a complement to chemical peels. This growing category of skin exfoliants is derived mainly from a variety of fruits and vary in potency. Enzymes do not rub the skin like mechanical exfoliation methods, nor do they loosen dead cells from skin surface like chemical peels; technically, enzymes accelerate the natural exfoliating process of skin by nibbling or gently eating away at the keratinized protein layer which forms a hard coating on an aged cell. With this nibbling action in mind, proteolytic enzymes such as bromelain, papain and pumpkin are ideal for mature skin which is experiencing a natural slow down of cell turnover, resulting in skin that feels dry and rough and looks lifeless and dull.
Since enzymes are not acid pH-dependent like AHAs and BHAs, they are versatile in being used at higher pHs (six to eight) or in conjunction with hydroxy acids. Most enzymes are activated by water. Activation by water makes enzymes effective in maintaining hydration within the skin.

Anti-aging Powerhouses

Vitamin A (retinol) is used to treat a variety of conditions such as acne, aging and photo-damage. Retinol is the main form of retinoid used in exfoliation. Due to the skin’s ability to convert retinol to retinoic acid, this makes retinol a potent anti-aging agent. While retinol specifically can cause irritation, other retinoids or synthetic derivatives of vitamin A (such as retinyl palmitate, retinaldehyde or hydroxypinacolone retinoate) can deliver similar benefits and effects without irritation. Caution should always be exercised with clients who are or may be pregnant, or planning a pregnancy, when prescribing this group of active ingredients.
Acid-free smoothing agents use state-of-the-art technology to accelerate cell renewal and promote natural exfoliation without any irritation or causing flaking of the skin. Unlike hydroxy acids that are pH dependent, acid-free smoothing agents can accelerate cell turnover without impacting the skin’s own natural pH. Ingredients such as urea, glucosamine HCL (hydrochloride), hibiscus extract, and rosa moschata seed oil (rosehip seed oil) are just a few examples of ingredients which deliver the key benefits of AHAs and other forms of exfoliation, without skin drying side effects. In fact, prolonged use of acid-free smoothing agents has been found to not only increase cell renewal and turnover rates, but can also improve firmness and surface texture.

Chemical Peels

Chemical exfoliation, or chemical peels, when done properly, can offer the professional skin therapist some of the most powerful nonsurgical ingredients for skin improvement. Chemical peels may use acids, enzymes and other active agents to optimize results. The use of any acid requires the ultimate level of understanding, education and experience. The results that are possible with these acids place the chemical peel into the realm of being an art form. There are a variety of acid formulas on the market which are developed for aesthetic use, as well as those available only in a medical setting. Each acid has its own advantages and requires a specific knowledge and understanding of its properties.
When selecting a chemical peeling agent, in addition to considering the overall condition of the skin and any related concerns, using the Fitzpatrick classification will help determine what agent is used and the depth of peeling. All human skin has the potential to burn, especially when creating inflammation with a chemical agent. Extremely fair skin, such as that of Northern Europeans of Celtic and Nordic descent, will endure and recover from a deep chemical peel treatment better than someone who has deeper pigmentation or the potential of reactive pigmenting. This contradicts the assumption that darker skin is somehow tougher than pale or light skin. Actually, the opposite is true. Richly pigmented skin may produce reactive hyperpigmentation, even keloiding and scarring, in response to cutaneous injury, including chemical injury. Recent history is filled with first person accounts of mercury based lightening, bleach and fade creams which deeply disfigured and destroyed the skin health of individuals with melanin-dense skin, aspiring for lighter skin color.
Individuals possessing Native American, Latino, Asian, African and Afro-Caribbean, Indigenous Aboriginal Australian, Maori New Zealander and other Pacific Islander heritage, as well as any combination of these backgrounds, can present as a fair or light color complexion but could respond to deep peeling with inflammation and a darkening of pigmentation. This may apply to skin which is generally considered Caucasian skin, such as Mediterranean and Middle-Eastern, contrary to incorrect assumptions made by many skin care professionals and even consumers themselves.
Proper preparation of the client and the skin will be important in the outcome of a treatment. This can be the defining difference between an average peel treatment and a great peel treatment. Preparation will differ, depending upon the client in regards to the formulaic composition of the peel and the client’s objectives and expectations for the treatment. During the use of any chemical peel, it is critical to closely watch the skin for unusual signs of erythema, heat, rashes or swelling. A clinical stopping point of any chemical acid solution will be if the skin presents a white frost or blanche effect. When structuring your treatment, it is best to plan on the conservative side to avoid extreme reactions. With this in mind, it is highly recommended that newly licensed skin therapists, or therapists who are not fully versed in this area of practice, observe the procedure many times in the treatment room as it is performed by a skilled, advanced therapist. Once they are comfortable observing different skin concerns, they can begin to build their own skill-set or under your belt.

The Acid Test

Today’s array of chemical peels still relies on familiar acid ingredients like glycolic, salicylic, lactic and trichloroacetic (TCA). What is changing is the ways in which these ingredients are used and formulated. Anhydrous, or non-water formulas, are evolving to minimize the amount of injury, pain and ultimately the downtime a client might experience. Manufacturers are blending or creating proprietary mixtures of acids and active ingredients that allow for simplified application, offering the best predictability of results and allowing for a multifunctional approach in making chemical peels more target specific. Some of the newer formulas on the market today do more than just exfoliate; these formulas can affect the skin on a cellular level, not only exfoliating the skin but also evening out the pigmentation distribution in the process. Some chemical formulations can even produce effects similar to what can be achieved with lasers.
Salicylic acid, used primarily in the treatment of acne due to its lipophilic nature, can also offer anti-inflammatory benefits and can be an excellent choice when targeting hormonal hyperpigmentation or sensitive skin.
Lactic acid, due to its molecule structure, can exfoliate the skin in a manner similar to the action of glycolic acid, but without burn risk or irritation. Lactic acid, being a humectant,will also improve hydration within the skin. Recent studies have demonstrated that a five percent lactic acid solution not only stimulated stratum corneum sloughing, but also increased skin hydration and helped to reduce hyperpigmentation.
Glycolic acid, having the smallest molecular size, allows for absorption into the epidermis quickly. For some clients, this can cause damage such as hypopigmentation. While glycolic can be used for treating acne, it is better used for treating fine lines and texture concerns.
Trichloroacetic acid (TCA) is a synthetic chemical based on acetic acid and chlorine. Concentrations of TCA can safely provide superficial exfoliation while higher concentrations of 30 percent and above provide more of a medium depth peel, capable of reaching the papillary dermis. When TCA is combined with other hydroxy acids such as lactic acid, a more effective resurfacing is achieved than if used alone.
Jessner solutions are a blend of salicylic, lactic and resorcinol. This blend can effectively target a range of skin concerns such as acneic, sensitive and even irregular pigmentation. Modified Jessner solutions are generally lactic, salicylic, and either citric acids or other botanical extracts.
There are additional acids and hydroxy acids used to also exfoliate the skin. These formulas may include plant or fruit extracts like lotus flower, kojic acid, acetic acid, mandelic (derived from bitter almonds used to target pigmentation), tartaric (derived from grapes), and malic (derived from apples).

The Magic is in the Mix

Any of the previously discussed ingredients, methods or technologies may be used to provide a brilliantly effective, yet safe exfoliation treatment for your client. The real challenge is one of design. As a professional skin therapist, you must design a treatment that addresses the full spectrum of the client’s skin condition, from his/her present health status to his/her cultural heritage (if possible). While it may not be possible to collect every nuance of information you would ideally like to obtain, the more knowledge you have, the better your client’s treatment will be. Then you must use all of your skill, sharpened and kept contemporary by your advanced ongoing education, to design a treatment which simultaneously will protect the client’s skin, address his/her skin care concerns, and produce the desired results. Safety is your primary concern. Remember that we are always treating a whole person, not simply the skin. However, it is your responsibility as a skin care professional to ensure that the state boards where you currently practice allow for your ingredient combination and formulation. It is equally important to check with the manufacturers of all products to determine if the mixing or blending of exfoliants is applicable. All of these concerns must be researched in advance and are an important aspect of your treatment design. Again, this is why no exfoliation treatment is one-size-fits-all; requirements vary from state to state, country to country, and client to client!

More Than Just Face Value

The value of an exfoliation treatment does not stop at the face. Each of the discussed exfoliants may be used to exfoliate other areas such as the chest and hands, in particular where photodamage is seen and felt by many clients, as well as the feet, upper arms, back, and other areas in need of polishing and refining. Exfoliation on the chest and back can be especially helpful for clients experiencing post-inflammatory hyperpigmentation due to acne. The joy of wearing a tank top, swimsuit or low cut blouse must not be taken for granted or underestimated.
Exfoliation, specifically in the form of sophisticated chemical peels, is perhaps the single most innovative element to add to your service menu. Begin by educating yourself and your team about the benefits, ingredients, products, techniques and potential risks. Then, educate your clients – and uncover a powerful new skill set for your business!

Resources

1 The American Society of Plastic Surgeons (ASPS) http://www.plasticsurgery.org/news-and-resources/14-million-cosmetic-plastic-surgery-procedures-performed-in-2012.html

Whitney Johnson, global education developer for The International Dermal Institute (IDI), is a skin care educator and researcher who brings an extensive background in medical spa, medical skin care, protocol development and laser procedures to her current role. A licensed skin therapist and massage therapist, Johnson also holds numerous continuing education certificates in chemical peels, laser and light therapies, is an NCEA candidate, and has served on the editorial board for the PCI Journal. She works at IDI world headquarters in Carson, Calif.