Acne-prone skin is a condition that affects many professional skin care clients. Yet, both consumers and estheticians are sometimes disappointed with results of treatment. There are some very important factors in acne development and treatment that are frequently forgotten or overlooked. Keeping these in mind can make a big difference in treatment success.
1. Don’t forget that acne is a genetic condition. The basic tendency to develop acne and comedones is genetic. Retention hyperkeratosis causes skin cells to accumulate inside follicles instead of desquamating as normal skin does. This cell buildup mixes with excessive sebum produced by the sebaceous glands. This oiliness factor is also genetic. The blockage caused by this clumping of dead cells and solidified sebum obstructs the follicle, preventing its aeration. Propionibacterium acnes (P. acnes) bacteria, which exist normally in every follicle, are anaerobic, meaning they only survive in the absence of oxygen. These bacteria are normally fairly harmless and, even though they are in every follicle, their numbers are kept low because oxygen penetrating the follicle helps to eradicate them. However, when follicles are impacted, oxygen cannot penetrate to keep bacteria levels in check.
The blunder occurs when clients and estheticians forget that this is a genetic and ongoing battle. Once the skin is clear from the treatment, clients often believe that the condition is cured. They forget that it is chronic and will reoccur, so they stop treatment.
Solution. Constant management of this condition using a mild leave-on keratolytic on a daily basis, such as benzoyl peroxide (BPO) or hydroxy acids, will help clear the skin; however, use of these agents must be continued to battle genetically induced recurrence of cell buildup. Quality and consistent education about the importance of continuous treatment is vital.
2. Treat beyond what you can see. Both estheticians and clients are understandably focused on the current appearance of the skin. They forget that microcomedones, which are not visible to the eye, are constantly forming and reforming inside the lower follicles. For every visible pimple or clogged pore, there are many new microcomedones forming under the skin’s surface. These will eventually become a comedo, papule or pustule. Unless treated, clearance will never be achieved or maintained.
Solution. Make sure the client is not just spot-treating visible blemishes. All areas of the face must be treated with a mild keratolytic at home every day. Although spot-treating does help dry up current lesions, keratolytic treatment, such as a BPO or alpha hydroxy acid (AHA) and beta hydroxy acid (BHA) gel, should be applied daily to all acne-prone areas of the skin. Teach clients to apply a small amount of keratolytic product all over the face, avoiding the eye area, and then to spot-treat individual blemishes. This helps constantly flush out follicular debris to prevent new impactions, therefore preventing new inflammatory lesions from forming.
3. Remember hormonal factors. Sebaceous glands are stimulated by the male hormone dihydrotestosterone, which occurs in both men and women. Excess sebum production contributes to follicle inflammation, as well as comedo development. Hormonal factors cause excessive androgen (male hormone) production—these factors can also be genetic, or can be caused from hormonal imbalances during natural cycles and periods of stress, as well as medically related hormonal conditions.
Solution. Chronic hormonal acne can be treated medically. Estheticians can help skin topically by developing programs to keep follicles constantly clear using daily keratolytics and by avoiding external clogging that can be caused by various fatty
skin care products.
4. Don’t be afraid of BPO.
BPO is an amazing ingredient that sloughs debris from the follicle and kills acne bacteria. Consumers sometimes are shy about it because, at one point, they likely overused it, and it caused dryness and irritation, which commonly occurs from using too much product or applying it too frequently.
Solution. The trick in using BPO is to apply a very small amount to all acne-prone areas, gently massage until it penetrates, and then spot-treat raised lesions. If the skin is ultra-sensitive or redness develops, have clients use the BPO gel every other night and on the alternate night, use a noncomedogenic hydration fluid. So one night they flush the follicles and the next night they hydrate.
Sometimes BPO gel medication will act more aggressively if the surrounding skin care products are too irritating or dehydrating. Plan your clients’ entire program so they have a balance between proper hydration and proper use of the BPO product. In most cases, 2.5% concentration is high enough to be effective. Using a gel with a 10% concentration of BPO is often unnecessary and certainly can be more irritating to skin. Estheticians sometimes express worry about BPO causing free-radical damage. Although it is a peroxide, the application is controlled to benefit the skin. The possible damage does not outweigh the benefit.
5. Don’t recommend or use comedogenic skin care products and makeup. Fatty emollients and other oily ingredients used in skin care and cosmetic products can cause or worsen the development of comedones. Substances that cause comedo formation are known as being comedogenic. The oily substances in these products penetrate the follicles, causing the same effect as sebum does from the inside of the follicles. Some of these ingredients are also irritating to the follicle walls, causing inflammation and swelling that can further obstruct the air flow in the follicle. It is almost always the vehicle or spreading agent of the skin care product or foundation that contains these clogging ingredients. The comedogenic ingredients are very often found in products for mature and dry skin.
Solution. Make sure you only use and sell tested noncomedogenic products for your clients with problem skin. Look for products that are labeled both noncomedogenic and dermatologist-tested. This testing is elective and expensive, and not all companies choose to have it done. Double-check the client’s makeup to make sure it has also been properly tested for comedogenicity. This is especially important for foundations, powders and blushes.
6. Don’t ignore at-home care. Unfortunately, this happens too often. The esthetician diligently performs extractions, and uses peels and treatments to help the skin, but fails to recommend or design a home-care program for the client. Home care is the single most important factor in successful acne treatment. Having a program approach to both at-home care and the overall treatment plan makes a tremendous difference in treatment success.
Solution. Sit down with your client and design a program coordinating daily home care using a proper cleanser; toner; BPO or AHA treatment; noncomedogenic sunscreen; and hydration and makeup products. These should be available for purchase in your spa’s retail area. Coordinate in-clinic peels, extraction treatments and other related services to boost and accelerate the effects of great home care.
7. Don’t underestimate the importance of compliance. Teenagers are frequently guilty of this, but adults are, too. The failure to perform daily care consistently will not deliver results.
Solution. Try to keep the regimen as simple as possible while still being effective. Teach your clients a “three minutes, morning and night” method so they understand it does not take a lot of time to treat their skin at home. Another compliance problem is cleaning the face, but not using the medication, or using medication and not using sunscreen every day. Emphasize to your client that the key word is “program,” and sticking to one is the only way to achieve and maintain acne clearance.
8. Don’t fail to educate. When you look at all the other factors discussed here, many have one thing in common—client education.
Solution. Take the time, especially during the first visit, to provide a thorough consultation to inform your client specifically about how and why acne occurs, and the need for consistent care. Continue to be a cheerleader for your clients each time they visit your skin care facility.
Mark Lees, PhD, is an award-winning speaker, clinical skin therapist and product developer specializing in acne, sensitive and aging skin, and is the author of Skin Care: Beyond the Basics (Milady, 2011), The Skin Care Answer Book (Milady, 2010), and the newly-released acne book, Clearing Concepts (2013). He is a member of the 2014–2015 Skin Inc. Editorial Advisory Board and can be contacted at firstname.lastname@example.org or on Facebook.
Editor’s note: This article is based on Lees’ upcoming class by the same name, taking place during the Advanced Education Conference Program during Face & Body® Midwest at McCormick Place in Chicago, on March 22, 2014. Register today! www.FaceandBody.com/midwest/register.