Editor’s note: This article has been excerpted from the new Physiology of the Skin, Third Edition book by Zoe Draelos, MD, and Peter T. Pugliese, MD, which was released in February 2011 by Allured Books. The book can be purchased online at www.AlluredBooks.com.
There are two basic methods of altering the surface of the skin: chemical and physical. Chemical alterations are accomplished by applying acids to the skin causing the cells of the stratum corneum to separate and slough off. Superficial chemical peels using glycolic and salicylic acid make the skin smooth and soft by this mechanism. Another mechanism of removing the stratum corneum cells is to physically rub, blast or grind them off. This physical type of removal is used in microdermabrasion and dermabrasion.
Dermabrasion
Dermabrasion was first developed as a medical procedure to improve the appearance of scarred skin and was later adapted to photoaged skin. It was originally done with a wire brush that literally ground off the surface of the skin. This procedure was quite bloody and painful, but was successful in improving severely scarred skin by smoothing the surface of the skin. The healing time was prolonged, taking weeks for the scabs to resolve and months for the redness to improve. In addition, sometimes the treated skin became lighter than the untreated skin as it healed, making skin color an issue. Dermabrasion could not be used on people who had deeply pigmented skin.
This rather aggressive dermatologic procedure has been refined through the introduction of new equipment. Modern dermabrasion equipment resembles a hand-held rotary motor drill with a small diamond-coated bit that is used to grind off the skin. The small diamond pieces are sharp, but can be easily controlled as the bit is moved over the surface of the skin. Dermabrasion was the standard treatment for deep wrinkles of the face from severe photodamage until the carbon dioxide (CO2) laser was adapted for dermatologic use. For a time, dermabrasion was rarely done, but it is making a resurgence, especially for wrinkles on the upper lip that do not respond to many other modalities.
The concept of dermabrasion was adapted for use by skin care professionals with the invention of the microdermabrasion machine. The microdermabrasion machine removed the top layer of stratum corneum physically, but did not enter the living part of the skin like medically administered dermabrasion did. This made the procedure safe to use without the possibility of bleeding or scarring.
Microdermabrasion theory
Microdermabrasion operates on the premise that encouraging exfoliation of the skin is desirable. The word “micro” is used to separate this procedure from true dermabrasion, where the deeper layers of the skin are removed. By using a motorized brush system or bombarding the skin with high-speed particles, it is possible to remove desquamating corneocytes, and make the skin smoother and softer with a better color. It is important not to go any deeper into the skin than the first few layers of stratum corneum to avoid scarring and other problems. Microdermabrasion can be used by trained skin care professionals because it does not enter the living layers of the skin; any procedure that enters the living layers of the skin and causes bleeding should be performed by a physician.
Microdermabrasion improves the appearance of several aspects of the skin, such as increased pigment, which may be contained in the outer corneocytes. This pigment may make the skin look freckled due to the presence of lentigenes, the medical term for brown spots, and scaling brown growths, known as seborrheic keratoses. Microdermabrasion can remove the skin scale that contains the pigment, making the skin more evenly colored. However, it is possible for the lentigenes and seborrheic keratoses to reappear as the skin cells again produce irregular pigment, making the improvement temporary.
There is some evidence that repeated microdermabrasion can have a longer-lasting impact on the amount of ground substance in the skin responsible for holding water. The minor skin injury induced by microdermabrasion may cause wounding that encourages the skin to heal. This healing can stimulate the replacement of skin structure and improve the appearance of photoaged skin. Controlled wounding is the reason both dermabrasion and laser resurfacing improve skin appearance. This same effect is seen to a much lesser degree with microdermabrasion, especially if the procedure is repeated every two to four weeks.
In addition, as the skin ages, the bonds between the cells do break easily, and dead skin can accumulate. This is why exfoliation produces a benefit in mature skin. Microdermabrasion can return the skin exfoliation process to a normal rate if performed on a recurring basis. Between treatments, exfoliant-containing moisturizers with alpha or beta hydroxy acids can be used to maintain the result until the next microdermabrasion session.
Microdermabrasion is a valuable technique for the esthetician to master. It can be used in both young and old clients. Treatments result in improved skin texture, smoothness, pigmentation and possibly function, however microdermabrasion must be properly and safely performed.
Methods of performing microdermabrasion
There are a variety of different microdermabrasion machines that can be purchased. The typical machine blows out a particle and then sucks it up with a vacuum, making for a closed system. This is important because neither the client nor the skin care professional want to breathe the residue. Substances that can be used to bombard the skin and remove desquamating corneocytes include aluminum, silica—or sand—and baking soda particles. Aluminum was the first particle introduced in microdermabrasion machines, but is not used much presently because inhalation of aluminum is not safe. The particle can determine the aggressiveness of the skin removal, as well as the force by which the particle hits the skin.
Microdermabrasion machines come in several different models: those designed for unsupervised skin care professionals and those designed for use by medically supervised skin care professionals. Many machines have a key that allows the force at which particles hit the skin to be increased. Increased force makes for a deeper, more aggressive microdermabrasion. This can make the treatment produce more noticeable results, but also increases the risk of problems, such as wounding and scarring. It is best to use the machine in the safe range at all times, and schedule more frequent microdermabrasion treatments to produce more dramatic results.
The microdermabrasion particulate is blown out on the skin though a wand, known as the handpiece, which emits the particles that are then collected by a vacuum suction device to prevent inhalation and the particles from covering the entire treatment room. Because the old particles contain pieces of removed skin and cannot be reused, they must be either discarded or sterilized. The use of contaminated particles can spread disease and is not an acceptable practice. The handpiece area that makes contact with the client’s face must also be thoroughly cleaned after each use.
The handpiece is moved over the entire face to achieve the microdermabrasion. The length of time the handpiece is left in one location and the number of times the handpiece is moved over a given location are also factors in determining the depth of the microdermabrasion. Some areas of the face, such as the central face, can be treated more aggressively, while the lateral areas of the face along the jawline tend to be more sensitive and should be treated more gently. The amount of dead skin removed from each area of the face may need to be tailored for the expectations and skin needs of each client.
Selecting a machine with various power adjustments provides the flexibility that the skin care professional needs to customize client treatments. The machines that operate within the physician-supervised realm may be too aggressive, producing irritation and other medical problems. More is not necessarily better when it comes to microdermabrasion. Key elements to consider in selecting a machine are ease of use, expense of consumable materials such as the particulate, ease of handpiece sterilization and versatility. A comfortable machine to use will provide many years of service.
Infusion microdermabrasion
One of the newest additions to microdermabrasion is the infusion system. Infusion microdermabrasion involves the same principles as traditional microdermabrasion, but after the desquamating corneocytes have been removed, liquid is applied to the surface of the skin automatically by the machine. Because the skin is more permeable once the skin cells have been removed, the absorption of the substances applied to the skin is greater. This is good in that increased efficacy may be obtained, but bad in terms of increased incidence of allergy if the client is allergic to one of the ingredients in the infusion.
Common substances used after microdermabrasion for infusion include vitamins and antioxidants. Vitamin C is a popular infusion ingredient, but must be formulated as an acid to have biologic activity, and may cause stinging and burning. Vitamin E is also sometimes used in combination with other vitamins creating an anti-aging cocktail. These vitamins may be used with antioxidants, such as green tea, blueberry extract and ginkgo, to improve the appearance of the skin. Infusion microdermabrasion does not offer a clear benefit over manually applying materials to the skin immediately following the procedure. It is a new trend, and the skin care professional will need to determine if the added expense provides benefit to clients.
Uses and misuses of microdermabrasion
Microdermabrasion may provide noticeable improvement in clients’ skin texture, but there are other uses of microdermabrasion that are less effective. Microdermabrasion is very good at improving skin radiance and providing a smooth surface for even cosmetic application. Some have advocated its use to treat stretch marks. Indeed microdermabrasion can make all skin surfaces smoother, including stretch marks, but it does not eliminate stretch marks, which are scars, and no currently available treatment can eliminate scars. Be sure to understand the best uses of the technique so you can advise your clients properly, and do not overpromise results where they cannot be achieved. This will result in an unhappy client.
Microdermabrasion can temporarily lighten some brown spots on the face. Be aware that if the lesion is a skin growth, it will become brown again before the next treatment. It is also risky to treat pigmented growths on the face, as they may be precancerous or cancerous growths. In general, aggressively treating brown spots on the face to lighten them should be avoided. Ask the client to seek advice from a dermatologist before proceeding with specific spot treatments.
Some skin care professionals have also tried to treat the common condition of cellulite with microdermabrasion. This too is fraught with problems. Since cellulite is a condition related to the structure of the deeper dermis and subcutaneous fat, a surface treatment cannot produce results. Microdermabrasion only works on the surface of the skin, not deeper tissues. Keep this in mind when identifying conditions for treatment. You cannot achieve results if the problem is deeper that your microdermabrasion tool can reach.
Microdermabrasion has been advocated for the treatment of acne scars. Indeed, medical dermabrasion was first developed as an acne scar treatment. Acne scars are defects in the dermis; any scar is a defect in the dermis, because only dermal injury results in scarring. The epidermis can completely regenerate, which is why epidermal wounds are less likely to scar. Because the microdermabrasion equipment should not enter the viable epidermis or dermis, dramatic improvement in acne scarring is not possible with this technique. Indeed, acne scars may feel and look smoother after microdermabrasion, but they will not disappear. Again, be careful in explaining the anticipated results to your client.
Selecting the microdermabrasion client
The most important issue is to select a microdermabrasion client who has realistic expectations. Sure, everyone would like to have all discolorations, wrinkles and acne scars removed with one microdermabrasion treatment, but you know this is impossible. Be sure your client has been properly educated about the realistic result and make sure they are listening to your instructions. Some people seem to have difficulty grasping reality, and they make poor clients.
Be wary of the clients who have seen many different skin care professionals and come to your facility stating that they heard from friends that you are the best. You may be able to please a client, but someone who has been dissatisfied with numerous others may leave your facility dissatisfied as well. Listen to what prospective clients are telling you and watch for danger signs. Follow your instincts. If the client makes you uncomfortable and is looking for unrealistic results, take note and tailor your treatments accordingly.
The best clients are those with a realistic, positive outlook, and who are not looking for miracles. They are comfortable with their self-image and are not trying to seek esthetic procedures for some other need. Clients who have recently divorced or broken up with a boyfriend may be looking to improve their appearance to attract another companion. These are challenging clients because microdermabrasion will not find them a companion; it will only temporarily smooth their skin. Try to select clients who will have a positive experience at your facility and spread the word to their friends.
Avoiding problems with microdermabrasion
Problems can be avoided with microdermabrasion simply by carefully selecting clients and using the machine within specified operating parameters. Do not turn up the speed or suction higher than recommended. Do not continuously re-treat areas to remove more skin. Read the instructions for the recommended operation of your machine, and follow these directions to the letter. Clients wishing more dramatic results from more aggressive treatments should be referred to a dermatologist for consultation.
You should also be aware that microdermabrasion can result in the spread of disease if the equipment is not properly disinfected. Flat warts are a viral infection of the skin appearing as small pink lumps on the face, are highly contagious and could be passed client to client if the handpiece is not properly sterilized. The skin care professional can also contract flat warts on the hands by touching this client. If you notice any type of viral infection on a client’s face, do not perform the microdermabrasion and contaminate your equipment. Insist that this client see a dermatologist before providing additional treatments.
The presence of other facial infections, such as a herpes virus-induced fever blister should also preclude microdermabrasion treatments. The liquid present in the blister is highly contagious and could be spread to the hands of the skin care professional or to other clients. In general, if the client has any open facial wounds or scabbing, microdermabrasion should not be done. The wound could become infected or the infected wound could spread disease to your client’s entire face, to your hands or to other clients. Delay the microdermabrasion procedure until the client experiences complete healing in order to stop a problem before it occurs.
Microdermabrasion in skin of color
Microdermabrasion is a versatile procedure. It can be performed on people of all ages, sexes and skin colors. However, special care must be taken when using microdermabrasion in clients of color. Deeply pigmented clients, such as African-Americans, Asians, Hispanics and Indians, have the tendency for the skin to darken once irritated, which is unattractive and undesirable. When performing microdermabrasion on skin of color, be sure to care for the skin gently. Do not dial up the speed of the machine; use it on a lower setting at first until you better understand your client’s skin. Although microdermabrasion can smooth skin of color, it cannot lighten pigmented areas or skin color. Do not attempt to use microdermabrasion for this purpose.
Microdermabrasion off the face
Microdermabrasion can be used on any dry-skin area. It is not recommended for use around the moist areas of the body, such as the eyes, nose, mouth or genitalia. It can be used to smooth the backs of the hands, the décolleté and the neck. Skin in this area is not as forgiving, however, and can be easily scarred. Use a gentle setting on low power when performing microdermabrasion off the face. It is always possible to go back with a more aggressive treatment later when you are more familiar with the client’s skin.
Because the skin off the face is thicker, the results are not as dramatic. Areas where skin scale collects, such as the anterior shins and the tops of feet, can be nicely smoothed with microdermabrasion, but the scale will recollect quickly. Even with this type of benefit, most microdermabrasion is performed on the face.
Easily incorporated
Microdermabrasion is a versatile, safe procedure that can be rewarding both for the skin care professional and the client. The procedure can be easily incorporated as part of a professional skin care routine.
Zoe Draelos, MD, is a practicing board-certified dermatologist and a Fellow of the American Academy of Dermatology (AAD) with a research interest in cosmetics, toiletries and biologically active skin medications. She is in private practice in High Point, North Carolina, and is a consulting professor of dermatology at Duke University in Durham, North Carolina. In 1988, she founded Dermatology Consulting Services, serves on eight journal editorial boards and functions as the editor in chief of the Journal of Cosmetic Dermatology. She is also a member of the 2010–2011 Skin Inc. magazine advisory board.
Peter T. Pugliese, MD, earned a Bachelor of Science degree from Franklin and Marshall College in Lancaster, Pennsylvania, and in 1957, a Doctor of Medicine from the School of Medicine at the University of Pennsylvania in Philadelphia. Since 1972, he has been engaged in the study of skin physiology, and is a member of the AAD, the Society of Investigative Dermatology, the Society of Bioengineers of the Skin, the American Chemical Society and the Society of Cosmetic Chemists. He has written more than 60 scientific papers, has published four books and is a member of the 2010–2011 Skin Inc. magazine advisory board.
