Working within the law
First and foremost, licensure is critical. Each state has differing regulations surrounding which treatments can be performed by an aesthetician. In many states, if a licensed aesthetician works under the supervision of a physician, their ability to perform additional treatments expands. It is of the utmost importance that each licensed individual, as well as the location where they are employed, are clear on the limitations of licensure. Most states have one level of aesthetic license, while there are a few that do have master aesthetician status. That said, even in those states where the "master" portion is available, it does not allow that individual to perform medical tasks. In a medical setting, it is not unusual to find that medical professionals, like nurses or medical assistants, also have aesthetic licensure.

Understanding patient and client expectations
The mindset of the person coming in for treatment at each type of location is equally as important. When coming into a medical location, typically a dermatology or plastic surgical practice, the consumer is referred to as a patient; the expectation is one of having something treated. They are often looking for guidance and direction from the physician. This guidance often translates into being referred to the aesthetician for treatment. These patients are also more likely to believe and follow any diagnosis and direction given. Whether being checked for suspicious moles or lesions or looking for relief from a condition like seborrheic dermatitis, acne, or eczema, they come with a goal in mind and they want answers.

These statements are also true when scheduling patients for peels or other mildly invasive treatments, like microneedling, dermaplaning, or microdermabrasion at a medical practice. Some of these types of treatments may be available at a medical spa, although at lower percentages and within stricter guidelines. The patient at a medical practice will often have higher expectations of the outcomes they can achieve.

Conversely, the client coming into a medical or destination spa is usually seeking relaxation and pampering along with a desire for visible results from treatment.

There are more limitations on what types of treatments are available. These limitations can be based on the differing licensure guidelines from state to state; peels may be allowed, but there might be limitations on the types of acids that can be applied and the level of pH that is acceptable. Limitations can also be a function of the fact that people may be on vacation where they will likely have sun exposure and may not want, or would not be safe to experience, visible peeling or skin redness during their resort stay. The types of treatments offered in these settings are more facial-based. The spa client may also request hand and foot massages, waxing, eyebrow microblading, or body treatments that would rarely be offered in a medical setting.

Hiring for long-term success
Licensed aestheticians can work in many settings, yet personality types and career goals play a role in who will be happy and successful in either a medical practice or a spa environment.

The clinical environment of a medical practice appeals to some more than others. This type of work setting for an aesthetician comes with built-in referrals from the physicians in the practice. Self-promotion is not typically necessary outside of building good relationships with those treated. The aesthetician in the clinical setting will also likely be treating patients as directed by the physician and will be using different types of modalities that would not be present in a spa. This reason is why many aestheticians prefer working in a clinical setting – they have the opportunity to consult with a physician on their patients and the treatments they plan to perform or outcomes they have achieved.

Working in a medical facility usually provides the aesthetician with benefits such as paid time off and health insurance. Another perk that can be of value to some aestheticians more than others is the opportunity to take advantage of free treatments such as injectables. Drug company representatives traditionally bring fillers and neurotoxins to practices for the physicians to use and assess; these assessments are often performed on staff who are interested. In some plastic surgery practices, procedures can be performed at a greatly reduced or no cost to employees.

The spa environment is quite different from a medical practice. The aesthetician that would find long-term happiness and success in this setting may likely also be interested in body work, relaxation techniques, and other wellness opportunities – such as essential oils, reiki, mindfulness, and massage. The client coming to a spa is still looking for visible skin improvement, but would also like to have relaxation as part of their experience. Spa aestheticians, whether working independently or as an employee, still typically spend a good amount of time in self-promotion and working for referrals. If someone is skilled, their name will travel by word of mouth, but they will still benefit from outside promotion. The personality type of a spa aesthetician typically enjoys an independent working style. They have their own personal room that is their domain and enjoy putting their own personal impression on that space.

There is also a hybrid situation where a spa has a medical director and combines some medical practice procedures and techniques into the spa environment. There will still be some devices and procedures that would be limited in these businesses, but medical spas can be a good choice for aestheticians who are either trying to decide which setting works best for them or those that just want a bit of both in their work day.

The value of a physician's presence
Many skilled aestheticians that choose to work in a spa or medical spa setting can become frustrated with limitations put on them by state regulations. There truly may be many clinicians that could safely and effectively perform more dramatic treatments than are allowed under their licensure. That said, there are good reasons that some treatments are limited to those working within a medical practice. Medium depth peels and some microneedling, among other procedures, have the potential to reach below the dead epidermal layers that aestheticians are licensed to treat. When these treatments penetrate more deeply or cause potential microinjury to the skin, the chances of complications increase – sometimes dramatically and without warning. In these instances, it is critical to have a physician on-site to assist. Additionally, at a medical practice there would be medications available, like strong steroids, in the case of dramatic histamine responses. Having a back-up physician available if a patient were to have a negative response to a treatment is immensely important. Just as aestheticians pay for insurance they may never use, it is the accident that happens without warning that makes it important to have that insurance. Keeping that in mind can minimize frustration for those who would like to perform treatments that are outside of their licensure.

Patient events at medical practices versus spas
Skin health businesses often hold events or workshops for their patients/clients. These events may highlight a skin condition, a new treatment available, or any number of other relevant topics. These events differ dramatically between the medical practice and the spa. In a physician's office, these events are often sponsored by representatives of drug companies that would like to highlight a particular product, whether that product is a neurotoxin, injectable, laser, or microneedling pen. The event is often focused around the physician and the drug representative doing a demonstration of one of these drugs or devices. The practice will typically run a promotion simultaneously that offers special discounts on that particular drug or procedure. At these events, it is not uncommon for there to be a raffle for attendees to win free services in the future. Even in an event setting, the medical practice still remains a clinical setting and most portions of the event are centered on the medical procedures.

Events at spas are decidedly different. There is usually an atmospheric and experiential feeling to the location in preparation for an event. Lighting, candles, and aroma may all be tied into the focus of the event. A spa will often partner with businesses in the area to co-market the event and there is usually a stronger social media presence in the lead-up to the event to raise awareness and increase attendance. The specials at these events may include exclusive facial packages, color matching for makeup lines, and massage specials. Spas, like medical practices, also often have a raffle during an event, yet the raffle is more commonly a gift basket of products rather than a coupon for a free service.

The future
Aestheticians' understanding of skin and its function continues to expand along with the product and procedure offerings available. Regardless of which type of environment an aesthetician chooses to work in, staying informed, attending continuing education classes, and always seeking new information is critical to staying on the cutting edge of the skin care industry. There is a bright and exciting future in skin care for those who choose to participate. It is an incredibly rewarding field that allows the licensed professional with many opportunities to improve people's lives.

Since 2007, Sandy Newton, C.M.A., L.E. has been working side-by-side with and managing the practice of Dr. Jennifer Linder, Mohs skin cancer surgeon, dermatologist, and chief scientific officer for PCA SKIN. Newton is passionate about skin cancer education and speaks daily to patients and skin health professionals about the importance of proper product and daily sunscreen usage. She has been featured on television to share the importance of skin cancer prevention. In 2013, Newton joined the PCA SKIN education team to more widely share her dermatology experience and her expertise with PCA SKIN daily care and professional treatments.