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To Exfoliate or Not to Exfoliate, That is The Question

Exfoliation is the name of the Skin Rejuvenation Game. Whether treating acne or aging skin, professional exfoliation is of primary importance in determining any treatment's direction.
Indeed, chemical and physical professional exfoliation has a most illustrious history from wine and milk baths( tartaric and lactic acid) to pumice polishing (microdermabrasion) and the blunt knifelike instrument called a strigils, used by the ancient Egyptians for scraping the skin (the forerunner of dermaplaning).

Though the skin exfoliates naturally as a function of a living organ, it slows down incrementally as we age. Exfoliation can be the application of a topical solution or a physical debriding, both of which induce the epidermis to thin out it's tightly compacted layers of stratum corneum cells. Skin has the amazing dual function of respiration and elimination, yet it's primary raison d'etre is to repair itself, for therein lies the defense of the human organism from infection and disease. When the skin is asked to do more quickly what it does best, it does so more efficiently as evidenced in the healthy
re-epitheliation of stratum corneum and increased tensile strength in the dermis via collagen and elastin rebuilding. What a marvelous organ we study!

All professional exfoliation assists this natural process regardless of the technique employed, but the more aggressive the exfoliation the more dramatic the cellular revival. In this article I will be discussing the various types and degrees of both chemical and physical exfoliation.

Professional exfoliation is divided into two avenues, chemical and physical exfoliation and when used intelligently, are not exclusive of one another. A combination approach can be utilized to effect a more profound outcome as well as avoiding the potentiality of irritation, scarring or abrasion.

Exfoliation should be approached with caution. Picture a white picket fence where the client is gingerly trying to balance while crossing from one side (photo-damaged skin) to the other (a vibrant, youthful looking complexion). The esthetician's job is to design an at home and in clinic protocol for the client that will provide the highest level of results without falling off either side of the fence; one side of which is dermatitis, the other side being no measurable improvement at all.

Treatment should begin with an assessment of the client's long term as well as short term goals. In this respect, a "menu of facial treatments" is obsolete. As professionals, it is for our training and experience to which the client turns to interpret their emotional rendering of their complexion's predicament in unbiased and clinical terms, ultimately to prescribe a professional solution with honest and accurate descriptions of immediate and long-term treatment results.

I. Chemical Exfoliants

A. Enzymes: Chemical ingredients creating proteolytic activity, causing dead skin cells to be digested by the process of hydrolysis.

1. Pancreatin: Powerful and pungent mixture of enzymes(amylase, lipase and protease) derived from bovine or porcine pancreas, effective for all skin types except rosacea and extremely sensitive. Use with caution.

2. Papain: Extremely effective enzyme from papaya. Available in powder with activating fluid, paste, cream, masque, and cleanser. Highly effective green papaya available from some companies. Useful on all skin types.

3. Bromelian: Another fruity enzyme derived from pineapple. Higher reactivity than papain though useful for all skin types. Commonly found mixed with papain. Check for food allergies.

B. Herbs, flowers, plants: Herbs used in skin care must either be reduced to powder when used as a scrub or mixed with activator or masque base and then kept warm after application with hot towel compresses or steam.

Steeping herbs (distilled, boiling water poured over dry herbs, left to brew for 3-20 minutes and then strained ) then using the tea is another method for utilizing their multifaceted properties and hundreds of beneficial active substances.

Excellent herbs, flowers or plants for skin care are chamomile, lavender, ribwort, sage, marigold, ginseng, irish moss, aloe vera, horsetail, comfrey root, arnica, borage, calendula, chickweed, cleavers, burdock root, licorice root, sarsaparilla, and pau d'arco (as well as some Chinese and Ayurvedic herbs). Used in an exfoliative peel, herbal professional products are typically combined with resorcinol or salicylic acid.

C. Acids: Broad category of acidic products which exfoliate by dissolving the intercellular cement between the epidermal stratum corneum. Depth of exfoliation is in direct relationship to prior home care product usage, preparatory measures, type of acid used, percentage, Ph, layers or coats, duration of contact and post procedural care.

1. AHA's or Apha Hydroxy Acids:

a. Glycolic Acid: Derived from sugar cane, this AHA has the smallest and shortest molecular chain and is thus more effective as well as more potentially irritating. Microdermabrasion or dermaplaning can precede application with cautionary tactics such as using partially neutralized solutions and avoiding low Ph values.

b. Lactic Acid: Derived from sour milk, lactic acid is next in line for effectiveness with a slightly longer chain and and larger molecular size thus rendering it slower with less chance of irritation. It is uniquely hydrating and anti-inflammatory and useful for mature or dry, sensitive skin. Excellent delivery system when combined with antioxidants such as vitamin C and green tea.

c. Citric, Malic, Tartaric Acids: Derived from fruits such as lemons, apples and grapes, respectively. Milder AHAs, they are typically integrated into retail products for their gentle exfoliating and skin brightening abilities.

2. Salicylic Acid: This beta hydroxy acid is excellent for all skin types but is especially effective for thick, oily skin or acne complexions. It liquifies sebum, kills bacteria, acting as a "rotorooter" deep within the pores. Percentages range 1% in OTC up to 30% in professional exfoliating formulas. This is an excellent choice prior to extraction.

3. Trichloroacetic Acid: TCA is an analogue of acetic acid. It is a more aggressive exfoliant and at higher percentages, produces a peel. TCA is professional strength at 20 % to 50%. Some skin care lines are incorporating it at lesser percentages in their retail products for graduated exfoliative peeling. Safe for ethnic skin, it is an excellent choice for acne, hyperpigmentation, blemished complexions and fine lines.

4. Jessner's Solution: This exfoliative solution is a unique cocktail 14% each of Lactic Acid, Salicylic Acid and Resorcinol. The addition of Resorcinol to the already discussed acids in this formula create the an esthetic advantage unparalleled in esthetic strength chemical peels. Historically used for acne, warts, calluses, rough or dull skin, eczema, psoriasis and corns, resorcinol has antiseptic and a disinfectant properties which help clear the skin of acne and prevent infection. The formula is utilized for light to medium peels delivering dynamic exfoliation resulting in a 5-7 day turnaround time.

5. Jessner's Solution combined with TCA: This is a designer peel utilizing TCA 20% - 30% after a preliminary application of Jessner's. It is as effective as 40% TCA with a much greater safety margin. "Frosting" is more evenly distributed and "hot spots" can be controlled, lessening the incidence of post-inflammatory dyschromia or scarring.

6. Baker Gordon Phenol Formula
Phenol 88%
CO2 plus TCA 35% : Physician Executed.

II. Physical Exfoliant Methods

Physical exfoliation is a manual procedure executed with or without an implement. Mechanical exfoliation, as it is sometimes referred, is the calculated debridement of skin cells with a predetermined purpose ranging from very superficial exfoliation to controlled "wounding." This subsequently creates the phenomenon of rapid cellular repair, thereby increasing collagen and elastin in the reticular and papillary layers of the skin.

Superficial physical exfoliation can be achieved simply by the using a towel, esthetic wipe, cotton pad, gauze sponge, natural or synthetic sponge, manual, battery powered or electric brush. The mechanical motion coupled with texture removes the loose top layers of dead skin cells. Using a chemical exfoliant in conjunction with the physical exfoliation method quickens your intent, shortens your time investment and enhances end results.

I. Manually Executed Physical Exfoliants

a. Gommage: Paraffin or wax in a cream which, after drying is "rolled" off the skin in small sections thus lifting off the top layer of skin.

b. Propylene beads: Suspended in a cleansing or emollient product such as a scrub.

c. Natural abrasive scrubs: Pumice, seeds, ground nut shells, herbs, cornmeal, etc. in a cleansing or emollient formula. With the exception of granulated sugar, table salt and sodium bicarbonate, natural source ingredients are not recommend as they are irregular in shape and can cause microscopic cuts in the skin.

d. Microdermabrasion scrubs: Crystals such as magnesium oxide are suspended in a cream or waxy product for more aggressive exfoliation.

II. Implement Executed Physical Exfoliants

a. Microdermabrasion: A stream of crystals ( sodium chloride, sodium bicarbonate, or aluminum oxide) is directed over the complexion in one to three passes with steady, even pressure. The vacuum action of the machine creates a mild edema as it raises small sections of the skin to work on as well as collect used crystals for disposal. Newer tools use a single diamond-tipped wand instead of a stream of particles issued from a vacuum. This is a highly technique dependent treatment which, delivered without training and experience, can bruise the skin, cause post-treatment breakouts, dermatitis or post-inflammatory hyperpigmentation. It should never be done on the eyelids and care should be taken on the lip area lest it trigger herpes simplex.

b. Skin File: This is a skin resurfacing tool made of stainless steel and finely crushed cosmetic diamonds that resembles a dental tool. Available in three grit sizes: Fine, Medium, and Coarse, it gives the esthetician control over the exfoliation process. Indicated for hyperpigmentation, acne scarring, and stretch marks as well as general refinement of the skin's texture.

c. Dermaplaning: A skin resurfacing procedure performed with a surgical blade to remove the top layers of the epidermis. This refining treatment also removes fine hair from the face and is therefore excellent for those clients using a retinoid who are no longer facial waxing candidates. It improves the texture of the skin as well as making adjunct therapies and home care products more effective.

III. Deeper Procedures

a. Ablative Lasers: Vaporizing the stratum corneum with a laser-generated beam of energy, this controlled wounding creates a rapid healing of the skin evidenced by a refined epidermis and a restructured dermis akin younger, healthier skin. Benefits are visible reduction of fine lines and lessening of gesture related lines. It can be combined with other procedures such as a facelift and performed over the entire face or used in specific areas such as perioral and periorbital. Infection, herpes simplex (pre and post treatment oral anti viral medications and antibiotics are recommended), sustained redness, hypopigmentation, and scarring are possible side effects. The carbon dioxide and erbium: YAG lasers are the most commonly used resurfacing lasers though new fraxel technology is now being incorporated with the
carbon dioxide laser.

Though the carbon dioxide laser is more effective than the erbium, it has a longer recovery time as well as a greater chance of adverse reactions. Physicians sometimes incorporate both lasers in the same procedure to reduce risks, utilizing the erbium where lines are the lightest and skin is the thinnest.

b. Dermabrasion: A procedure that removes fine wrinkles, planes gesture lines and minimizes scars, dermabrasion utilizes a high speed rotating brush to remove the epidermis. Possible complications are permanent pigmentary changes, herpes simplex, skin thickening and infection. Physician domain.

c. Dermaplaning: A handheld instrument called a dermatome has an oscillating blade that shaves off surface layers of skin surrounding ice pick acne scars or other three dimensional scarring. It can be used in conjunction with other procedures to customize treatment areas Performed by physician. Same possible risks as dermabrasion.

Summary

To some degree all exfoliation thins stratum corneum and induces a rapid and therefore more efficient cellular recovery in the papillary and reticular dermis. Generally speaking, the deeper the exfoliation, the greater the risk, the longer the downtime, the better the result.

One aspect of exfoliation, whether physical or chemical, needs to be addressed. One cannot strip the skin of it's protective barrier and jeopardize it's acid mantle without consequences. A surgeon wouldn't repair a heart valve, then wake the patient up, tell them they are fixed and send them on their way! The repair is only half finished for the incision must be sutured, fluids and antibiotics administered and attentive care given under close supervision in intensive care. So too, hydration, nourishment and protection is the second half of exfoliation and equal in importance. Additionally, the client must be educated on how to care for their baby tender skin in the following days or weeks.

Very simply, for this is not the purview of this article, hydration should be both hydro and lipid. Look for products containing ingredients such as water, Na-PCA, glycosaminoglycans i.e. hyaluronic acid, allantoin, glycerin or squalene.

Addressing lines related to muscle movement can only be achieved by deep chemical peels, the purview of the physician. To tell a client that multiple superficial, light or medium chemical peels can come close to a deep chemical peel is erroneous information. However, do not assume that the lighter solutions of chemical peels are fail-safe, for even a low percentage alpha-hydroxy acid can create dermal destruction if administered improperly. What is a favorable "frost" in a medium or deep chemical peel can be uneven epidermolysis in esthetician strength peels that can lead to crusting within 48 to 72 hours, signifying a potential dermal injury.

It is important to remember that deeper is not always desirable or indicated. A brighter, more lively complexion can be achieved in spa settings with pureed papaya, mango, avocado, pineapple, pumpkin, pomegranate, tomato, apple, or apricot thickened with glycerin and or kaolin, tapioca or plain organic yogurt.

The value of keeping charts on every client can not be overstated. These should include a treatment sheet for each appointment, preferably with the SOAP assessment. Digital before and after photos chronicle the resolution of skin care concerns. A health history, as well as a Fitzpatrick sun-reactive and Glogau photoaging assessment should be taken at the first appointment and changes noted at each new appointment. A facial diagram with suspected skin cancers should be kept along with persistent follow-through with scheduling an annual skin cancer checkup. Originals of signed client releases for stronger procedures are kept as well as personal notations for reference during appointments. This personal touch not only enhances customer loyalty, it makes a strong statement about your professionalism. An esthetician exhibiting ethical responsibility in their profession and practicing it clinically as aligned with medical disciplines will be a successful esthetician, regardless of their setting.

References

Salvador Bello, Jaclyn BSN, RN, CNOR, RNFA. (2008 July/September Volume 28 Number 3).
Treatment Options for Sun-Damaged Skin. Plastic Surgical Nursing. Retrieved from http: //www. nursingcenter. com/ prodev/ce_article.asp?tid=818696

Bisaccia, Emil MD, FACP, Scarborough, Dwight A. MD, Ara, Collette, MD, Khan, Azim, MD, Torres, Omar, MD (2003, Oct 15 Volume 11) Exploring the Options for Treating Perioral Signs of Aging. Skin & Aging. Retrieved from http://skinandaging.com/article/2100

Arndt, Kenneth A. MD, Dover, Jeffrey S MD, FRCPC, Munavalli, Girish MD, Weiss, Robert MD (2007, Sept 15 Issue Number 9) 9th Annual Laser Surgery Issue: Spotlighting New Technology. Skin & Aging. Retrieved from http://skinandaging.com/article/7741

Scarborough, Dwight MD, Saap, Liliana MD, Bisaccia, Emil MD (2006, Oct 15 Issue Number 10_2006) Exploring Aesthetic Interventions: The Gold Standard in Facial Resurfacing: The CO2 Laser and Future Directions. Skin and Aging. Retrieved from http://skinandaging.com/article/6271

Rubin, Mark G. (1995) Manual of Chemical Peels, Superficial and Medium Depth. Phildelphia, PA, Lippincott-Raven.

Pugliese, Peter T. MD (1996) Physiology of the Skin, A scientific guide for the skin care professional. Illinois, Allured.

Castleton, Virginia (1973) The Calendar Book of Natural Beauty. New York, Harper & Row.

About the Author

Cheryl Bryant Rushing is a licensed aesthetician with over 30 years of experience.  She is former publisher and contributer to the American Society of Esthetic Medicine and has written an informational newsletter for her international clientele since 1990.  Her most recent published article appeared in the Jan 2010 "Dermascope."

Stepped On Nail Today?

Today I stepped on a rusty nail (approximately six hours ago) and the nail seems to have went deep. I immediately cleansed the wound with an NaCl irrigation and then cleansed it with hydrogen peroxide. I placed a gauze sponge over it and then bandaged it. Since the pain has increased (gradually). Now it is difficult to walk without a severe hobble. The puncture site is stiff and a bit swollen. I am also diabetic. I am wondering what I should do next. I am regular on Tetanus vaccine.

So far you have described a normal reaction. I see no emergency situation from what you said.
If you have circulatory problems along with your diabetes, you must elevate the foot as much as possible, stay off it for a few days.
You will want to see your regular doc tomorrow just to be on the safe side or to get him to say you you should be off your feet for work purposes. but a visit to the ER would be excessive, I think.

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