In the aesthetic setting, skin care professionals may be exposed to a variety of excoriations, scars, waxing and laser burns, acne pustules, and tissue wounds that require careful consideration with regard to evaluation and aesthetic treatment, or the determination of immediate medical intervention.

Fundamentals of Wound Healing
Normal wound healing involves physiological responses that include trauma, bleeding, coagulation, contraction, initiation of inflammatory response, regeneration, migration, proliferation, synthesis of extracellular matrix proteins, and collagen deposition.
There are several variations in the types of healing and the aspects surrounding the regeneration of tissue. Wound healing time may vary as some wounds may take a year or longer to reach full maturation. Additionally, the original tensile strength may never be fully regained as multiple, systemic factors and circumstances surrounding the injury may delay the course of the intricate healing process, which is applicable to all types of wounds incurred.

Wound Catagories
Partial-Thickness Wounds: A partial-thickness wound is superficial and does not penetrate the entire dermis. The healing of this wound mainly occurs by epithelialization from remaining dermal elements. This wound displays less contraction than secondary healing in full-thickness wounds and minimal collagen production and scar formation. Examples of partial-thickness wounds include first-degree burns, cuts, lacerations, abrasions, chemical peels, and skin tears (excoriations v and extractions).
Acute Wounds: An acute wound is self-repairing and proceeds in a normal-healing pathway to functional and anatomical restoration. The course of healing for this wound is usually five to 10 days or within 30 days. Examples of acute wounds include surgical procedures and trauma-induced loss of tissue.
Chronic Wounds: Chronic wounds fail to transition through the normal phases of wound healing and are faulty in repair mechanisms. This affects the overall time, quality, and completeness of the wound remodeling. Examples of chronic wounds include pressure wounds, vascular wounds, and burns.
Complicated Wounds: Complicated wounds are considered a combination of a tissue defect and infection. This combination may represent a continual threat to the wound and the conditions of healing.

Phases of Wound Healing
Phase One – Hemostasis: Phase one, or hemostasis, starts with the formation of platelets and fibrin clots. This development helps to stop the bleeding of an injury. During this phase, there is a release of growth factors
and cytokines.
Phase Two – Inflammatory Stage: The second phase, the inflammatory stage, sees the involvement of platelets, mast cells, neutrophils, macrophages, and T-lymphocytes. Inflammation during this stage is the normal response to an injury as new framework develops for blood vessel growth. This phase also includes the instigation and removal of bacteria, cellular debris (phagocytosis), and wound debridement.
Phase Three – Proliferative and Granulation Stage: With the involvement of fibroblasts, endothelial cells, keratinocytes, myofibroblasts, and macrophages, phase three, the proliferative and granulation stage, starts the dermal restoration. This restoration includes the replacement of damaged dermal tissue with scar tissue. Although Type I collagen is the most abundant type of collagen in the dermis (approximately 80 to 90 percent), during the early stages of wound healing, fibroblasts actively produce Type III collagen, which may then account for 30 percent of the collagen in a healing wound. By week two, Type I collagen again becomes the principal collagen produced by fibroblasts. During remodeling, by week two, Type III collagen is replaced by Type I collagen to restore the normal dermal collagen composition. This phase also includes the angiogenesis of new capillaries and re-
epithelization instigated by keratinocytes. The tensile strength of a wound will not exceed 70 to 80 percent of the original skin.
Phase Four – Remodeling and Maturation Stage: Phase four sees the continued involvement of keratinocytes, myofibroblasts, and endothelial cells. While fibroblasts organize Type I collagen cross linking, wound strength gradually increases and wound contraction occurs. This contraction is accompanied by the dissipation of pink and purple coloration as capillary and fibroblast density decreases.
All wound-healing phases may vary in length, depending on the extent of the injury and the presence of infection.

Types of Wounds
The two potential wound types include open wounds and closed wounds. Open wounds consist of incisions by sharp-edged objects; lacerations, or tears in the skin; abrasions, or grazes of the epidermis; puncture wounds; or penetration wounds by a sharp object. Closed wounds consist of hematomas, or blood vessel damage and tumors, such as petechiae, purpura, and ecchymosis, and contusions.

Potential Skin Traumas in the Aesthetic Setting
Acne and Infection: The complications of acne extractions may include the risk of infection, incomplete extraction (possible re-infection), and potential scarring due to tissue trauma precipitated by forceful evacuation, causing rupture to the wall of the pustule. With regard to chronic pustulous acne, the immune response is greater, initiating increased swelling, inflammation, and pain due to the size and nature of the lesions. With larger inflammatory nodules and cysts, it is difficult to facilitate the drainage of white blood cells due to the depth and location of the infection and may require
dermatological care.
Blanching from a Chemical Peel: Trauma burns from a chemical peel or ingredients in the peel may cause blanching. Blanching is very different from the ‘frosting’ that occurs with certain advanced peels.
Hair-Related Trauma: Wounds from hair-related traumas include burns from hot wax or an allergy to an ingredient in the wax or the topical and systemic medications; eyelash tint and developer burns, where a tint is formed from the dyes and coal tar or a burn is produced from a hydrogen peroxide-based developer with chemical additives; and eyelash adhesive burns from formaldehyde, methacrylic acid, cyanoacrylate, and hair-bonding adhesives.
Equipment Burns: These traumas include contact burns from galvanic, faradic, ultrasound, steamer, IPL, and lasers.
Injury from Microdermabrasion: Trauma from microdermabrasions include frictional excoriations (scraping) and petechiae.
Cavernous Sinus Thrombosis: While this condition is rare, it is a potentially dangerous complication from a bacterial infection that spreads from the sinuses, teeth, nose, ears, or skin of the face. This area is known as the ‘danger triangle.’ This ‘triangle’ is a perimeter around the nasal dorsum and medial periorbital region. This area has a special blood supply to the nose and surrounding area through which vascular structures are connected to veins and arteries leading to the brain. It should be confirmed that during any aesthetic practice engaging extractions, gloves are to be worn without question due to the possibility of a scratch, excoriation, tear, or potential bleeding of the skin. Clients who have habitual behavior regarding chronic excoriations should be informed regarding all aspects of self-extractions.
Other potential skin traumas include scarring from tissue excoriation, skin tears from aggressive extractions, and chemical burns.

Factors That Affect Wound Healing
Age: This factor consists of reduced skin elasticity and collagen remodeling. Delayed wound healing is associated with an altered-inflammatory response, such as delayed T-cell infiltration into the wound area with alterations in chemokine (protein). This response also includes white blood cell production and reduced macrophage phagocytic capacity.
Immune System: The decreased functioning of the immune system effects the skin’s immune response and healing potential.
Alcohol Consumption: Clinical evidence has shown that exposure to alcohol impairs wound healing and increases the incidence of infection.
Infection: Infections prolong the inflammatory phase, disrupt the normal clotting mechanism, and prevent the development of new blood vessels and the formulation of granular tissue.
Medications: Anti-inflammatory, anti-coagulant, chemotherapeutic, and immunosuppressive drugs may interrupt cell division and/or blood clotting.
Diabetes: Hypoxia can increase the inflammatory response in a wound and prolong the injury by increasing the levels of oxygen radicals. Hyperglycemia can also add to oxidative stress, as can the development of advanced glycation end products.
Cigarette Smoking: Smoking impedes blood flow, reduces nutrient status, and de-oxygenates. Approximately, over 4,000 substances in tobacco smoke have been identified, with some showing a negative impact on healing. Most studies have focused on the effects of nicotine, carbon monoxide, and hydrogen cyanide from smoke.
Oxygenation: Oxygenation assists in angiogenesis, resistance to infection, and re-epithelialization. It is important for cell metabolism, energy production of adenosine triphosphate, enhancing fibroblast proliferation and collagen synthesis, and promoting wound contraction.
Sex Hormones: Aged males have been shown to have delayed healing of acute wounds. A partial explanation is that the female estrogens (estrone and 17β-estradiol), male androgens (testosterone and 5α- dihydrotestosterone), and their steroid precursor, dehydroepiandrosterone, appear to have significant effects on the wound-healing process.
Stress: The pathophysiology of stress results in the deregulation of the immune system, mediated primarily through the hypothalamic-pituitary-adrenals or sympathetic nervous system. Stress and chronic stress lead to anxiety and depression, which may have an impact on all factors involved in wound healing, due to depression of endocrine function and immunity.
Other factors that affect wound healing include sanitization and dehydration. It is important to note that many medications and health conditions may cause subclinical skin sensitivity. This sensitivity may create a pre-disposition to inflammation and various chemicals may produce unpredictable chemical burns and/or irritation.

Nutrient-Support Basics and Wound Healing
A compromised nutritional status may result in poor wound healing, no matter the type of lesion or wound. This list provides the most basic nutrients required for optimum healing. Individualized recommendations, nutritional advice, or the recommendation of vitamin supplements should be provided by a dietician, nutritionist, or health care provider.
Water: Water helps to replace fluids lost when a wound drains, assist the body to facilitate the uptake of blood and nutrients to the wound, and prevent dehydration, which can cause poor oxygen perfusion and prevent essential nutrients from being delivered to the wound site. Water is also the primary way that oxygen and nutrients are delivered to the wound itself. A lack of sufficient water can cause cell function to become disrupted. Dehydration causes delays in every aspect of wound healing.
Protein: Protein is required for all phases in wound healing, particularly collagen synthesis. Protein deficiency can impair capillary formation, fibroblast proliferation, and wound remodeling. It also helps to fight infection and increase the tensile strength of the tissue. Furthermore, the demand for amino acids increases during stress and injury, including the requirements for non-essential amino acids, glutamine and arginine.
Glucose Balance: Glucose balance is the major source of fuel used to create cellular adenosine triphosphate for angiogenesis and the deposition of new cells.
Glucosamine: Glucosamine enhances hyaluronic acid production.
Iron: A deficiency in iron can result in impaired collagen production because it provides oxygenation to the site of the wound.
Vitamin A: Vitamin A affects epithelial development and immune system function, enhances early inflammatory phase, and aides in the absorption of other fat soluble vitamins.
Low levels of vitamin A are associated with delayed wound healing.
Vitamin B Complex: Vitamin B complex aides in repairing cells and wound healing and reduces inflammation. It is also required for protein and DNA synthesis and the formation of red blood cells, which supply the wound with oxygen and nutrients.
Vitamin C: Vitamin C is important for capillary formation, enhances lymphocyte transformation, is necessary for collagen synthesis, and increases the absorption of iron from various sources. Vitamin C deficiencies have been linked to impaired immune response and increased susceptibility to infection, as well as abnormal collagen fibers, decreased strength of fibrous tissue, and impaired wound healing. Furthermore, acids such as citric, ascorbic, acetic, boric, and alginic have long been used as a topical application to promote recovery and stave off infection. The evaluation of a recent study showed that acidic environments created with the use of topical applications helps defend against wound infection while increasing antimicrobial activity. It also enhances the angiogenesis and epithelization processes and spurs the release of toxicity from bacterial-end products such as ammonia released by the enzyme urease.
Vitamin E: Vitamin E is an anti-inflammatory that aides in decreasing scar formation. Topical vitamin E has been widely promoted as an anti-scarring agent, however, clinical studies have not yet proved a role for topical vitamin E treatment in improving healing outcomes.
Zinc and Copper: Both zinc and copper are important for enzymes and the immune system. Zinc is required for DNA synthesis, cell division, and protein synthesis, while copper protects against reactive oxygen species and species of free radicals. Zinc deficiency contributes to the disruption of granular tissue formation.
Lipids and Fats: Fats provide essential fatty acids, the essential building blocks for wound and tissue repair. Essential fatty acids are a major component of cell membranes and the need for fatty acids increases after a trauma or injury. They also must be utilized through supplementation, as the body is unable to synthesize the required amount for healing. In addition to providing essential fatty acids, lipids and fats also provide energy for the body.
Probiotics: Probiotics balance the gastrointestinal tract and aide in healing and balancing the body’s microbiota.

The different aspects of wound healing play a decisive role in the manner in which many of the applications and procedures in the treatment room are approached. The client intake form also continues to be a cornerstone in determining if procedures should be performed based on previous history, medications, factors representing nutritional status, and more. Collaboration with a nutritional professional is becoming a viable and important relationship and verifies a progressive and thought-provoking alliance. The manner in which skin care professionals approach and provide care regarding the healing of an extraction or excoriation has become an increasingly important consideration. Invariably, a seemingly important factor that should be considered is the healing nature of the client. For example, do they bruise easily? If they receive a contusion, how long does it take to heal? The detailed information that a client shares may drastically impact ‘tissue sensitive’ services and the results those services provide, both to the client and the
professional expectations.

References
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Wong, V. W., Martindale, R. G., Longaker, M. T., & Gurtner, G. C. (2013). From germ theory to germ therapy: skin microbiota, chronic wounds, and probiotics. Journal of Plastic Reconstructive Surgery, 132(5), 854e-861e.

Erin Madigan-Fleck, NMD, CNHP, LMC, has over 30 years of experience in the aesthetic and natural health industries, and is licensed as a master cosmetologist and aesthetic instructor in Georgia. She is a nationally certified natural health professional, holds a bachelor’s degree in natural health, a master’s in holistic nutrition, and is a doctor of naturopathic medicine. She served her clinical residency at Progressive Medical Centers of America in Atlanta, Ga. Madigan-Fleck has written a complete course in holistic and integrative aesthetics and is currently working on a book to be released in 2015.