PCA In The News - Combining

Combining Modalities For Enhanced Results
By Margaret Ancira, as seen in Dermascope � Oct 2005

Skin care professionals are continuously searching for new and advanced ways to achieve results for their clients. Exciting novel ingredients, advanced product delivery technology, new machines and treatment modalities are becoming available at record speed. With so many choices, it is difficult to identify the best and safest ways to expand your services. One option is combining modalities already present in your practice. Many skin care professionals are currently performing microdermabrasion, but often have not been able to achieve the type of dramatic results desired by their clients. Using microdermabrasion in conjunction with gentle chemical peels can be a great way to boost your results and your business. However, it is imperative to thoroughly understand each of these modalities before performing combined treatments. If your clients are properly screened and common sense safety guidelines are followed, combined modality treatments can deliver excellent results for your clients.

Getting Personal
It is extremely important to conduct a thorough consultation before treating any new client. This becomes more critical when performing advanced treatments, as there is a greater possibility of complications. Your evaluation should include a visual analysis of the skin to determine any active conditions as well as an examination with a Wood's lamp or Skin Scanner to illuminate any dehydration, impacted follicles or underlying deposits of pigmentation. Have the client also share personal information by filling out a written profile. This personal history helps reveal any allergies, sensitivities or past reactions that may impede a successful treatment. It is also very helpful to understand the common predispositions in different hereditary skin types.

Over generations, our skin evolves to accommodate our current environment while still retaining the genetic information of our ancestors. Our skin cells 'remember' the evolutionary defense mechanisms of previous generations. For this reason, it is helpful to detail all facets of a client's hereditary background to avoid possible reactions and avert complications. Those individuals whose ancestry originated from equator regions of the world have a greater predisposition to produce excess melanin or hyperpigmentation. This is due to the high intensity of UV exposure in these regions. The skin 'learns' that protecting itself from injury and cancer from UV rays is its prime objective. Therefore, the melanocytes of people from equator regions are more easily stimulated by other types of inflammation (e.g. peels, microdermabrasions, etc). Conversely, if a client's ethnic background is from an arctic or polar region of the world, their response will be quite different. These people are generally not as susceptible to hyperpigmentation, although aggressive treatments or over-stimulation may trigger hypopigmentation. These clients are generally more resilient and are oftentimes better candidates for combined treatments.

Mixing It Up
Before combining modalities it is essential to understand the technical aspects, function and expectations of each individual treatment. Any treatment is only as safe and effective as the technician's knowledge of the application, whether it is a topical product or a mechanical device. Protect yourself and your client by taking advantage of any manufacturer's training offered when you begin to use a new modality, and stay informed through continuing education seminars offered at industry meetings and online courses. These will not only refresh your existing base of knowledge, but expand it by introducing "pearls" from other practitioners and industry experts on new ways to enhance the treatment experience and results for your clients.

Microdermabrasion is a modality that helps to eliminate excess stratum corneum cells which in turn improves and refines surface texture. This is achieved by 'bombarding' the skin's surface with inert crystals, most commonly corundum/aluminum oxide. Microdermabrasion will not help to dissipate any pigmentary disorders that exist below the surface. It is effective in helping to minimize the appearance of hyperpigmentation by removing the melanin-filled, keratinized cells on the surface. When performed more aggressively, this modality can be used for scar revision and collagen stimulation. Protocols where microdermabrasion is utilized in this vigorous manner are not conducive to combining modalities.

Superficial chemical peels are very effective when used alone. The primary function of a chemical peel is to either loosen the bonds between the cells allowing them to exfoliate more easily, or to perform a controlled burn of the surface layers to reveal the healthier, smoother skin below. Once again, if peel solutions are being used in this more aggressive manner (which should only be performed by a medical professional), combining modalities should not be considered.

There is a wide array of solutions available today. TCA, salicylic acid, lactic acid and glycolic acid are each often used on their own at varying percentages. These types of treatments do have benefits, but straight acid applications are generally too aggressive to be used in conjunction with microdermabrasion. What you need to consider is how to create a treatment that is well-rounded and balanced. Microdermabrasion tends to be drying and does cause some inflammation and surface activity on the skin. When using a solution in conjunction with microdermabrasion, you want to choose one that will compensate for this dryness and not cause unwelcome irritation. Superficial chemical peels that are formulated with a combination of many beneficial strengthening, hydrating and healing agents are ideal choices.

The mild abrasion and removal of impacted keratinized skin cells that occurs when microdermabrasion is performed create a more porous and 'open' skin surface. Anything you apply following microdermabrasion will have an increased penetration of approximately 50%. This is a very important piece of information when approaching the combining of modalities. If a layer of a superficial chemical peel is applied following a pass of microdermabrasion, the peel's penetration will be enhanced. If you choose your solution wisely, these increased benefits will mean more markedly visible results. On the other hand, if you do not follow safety guidelines, it can result in complications.

The following is an example of a safe and easy combined modality treatment:
• Cleanse the skin with a gentle gel cleanser designed to remove debris and excess sebum from the skin. Lather and rinse.
• Tone the skin with an alcohol-free, AHA toner to continue to degrease and prep the skin. Ask your client "On a scale of one to ten, ten being extremely irritating, how does your skin feel?" If your client rates higher than a four with simply an AHA toner, combining treatments may not be appropriate.
• Fan the skin until completely dry.
• Perform one pass of gentle microdermabrasion using a circular motion.
• With a cotton pad, brush the crystals from the area of treatment.
• Tone the skin (some choose to wash again and tone the skin at this point). Once again, ask your client, "On a scale of one to ten, ten being extremely irritating, how does your skin feel?" Your client will feel more activity because of the 50% increase in penetration mentioned earlier. In order to safely proceed with applying a chemical solution the client should not rate higher than a five or six at this point.
• Apply one even layer of your selected gentle chemical exfoliation solution.

Note: It is generally only appropriate to apply one layer of solution. If clients are extremely resilient and rate below a four on the scale of one to ten after applying the first layer of peel solution, applying two layers may be appropriate.
• Fan the skin and continue to ask the client's level of sensitivity on a scale of one to ten, as described in step 2.
• You may now apply topical vitamin preparations to enhance the benefits of your treatment.
• Always end your treatment with a cooling cream to balance the pH of the skin and a broad-spectrum sun protection moisturizer.

Clients are always eager to see results fast, and may pressure a skin care professional to accelerate the process by combining modalities. This is when expertise needs to curb enthusiasm and you as the expert need to explain that combined modality treatments are not for everyone. Through careful consultation and skin analysis, you will be able to determine who the right client is for combined modalities treatment and paired with adequate training in the correct application of combined modalities, you and your client will witness firsthand the dramatic and visibly satisfying results that can be achieved!