Chapter 2

The clinical approach to cosmetic treatment

Active ingredients in cosmetic products are like raw materials in an artist’s hands. The wise cosmetologist who understands the ingredients’ mechanism of action and capabilities – will be able to achieve beautiful treatment results. In other hands, the same ingredients will not result in any change to the skin, and may even do damage. In this and the following chapters we will present the knowledge and the treatment approach that will enable us to properly manage the skin treatment and get optimal results from the active ingredients.

When the dermatologist plans the treatment for a skin problem, he observes the clinical manifestation of the disease (how it looks externally), questions the patient, and then prescribes medication. What enables the doctor to assign the treatment is the in-depth knowledge that he acquired about the disease, how it behaves, how the course of the disease can be affected, what active ingredients can do this, and how. Without all these knowledge components, he will not be able to treat the skin effectively. We are not surprised when the dermatologist usually achieves the therapeutic goal. We know that he acquired knowledge and tools that enable him to do so. We are surprised, however, and sometimes frustrated, when we grapple with skin conditions that do not respond to any treatment we’ve tried.

The skin’s behavior is complex and affected by numerous factors. Even dermatologists don’t always succeed in the first or second treatment attempt. Sometimes there’s a lot of trial and error until the right product is matched for the specific patient. The situation is similar in cosmetology. There are stubborn skin conditions that are slow to improve, even with the best care. There will always be a certain degree of uncertainty, which is a good thing: We always need to be vigilant and to think and investigate every case and not be overly confident, because nothing is guaranteed. However, we must acquire the knowledge and the approach that are necessary for solving problems the same way doctors do. It’s the maximum we can do to ensure that we achieve the best results for each specific case.


The Systematic Treatment of Skin Conditions

Treating any skin problem (or skin condition) requires three components:
A. A comprehensive understanding of the skin problem (causes, how the disease manifests);
B. An understanding of how to affect the manifestation and course of the disease;
C. A familiarity with active ingredients that are capable of achieving this. A familiarity with the active ingredients means understanding their effect on the skin – what they change in the skin. With a large portion of them, the ingredient’s mechanism of action must also be understood – how it causes the change and at what concentration.
These three points need to guide us when treating any skin condition: dry skin, mature and lackluster skin, hyperpigmentation, skin that is loose and lacks elasticity, enlarged pores, comedones, acne, etc. In order to demonstrate this systematic approach to managing the treatment of skin conditions – let us take cane treatment as an example, and address it according to the stages mentioned above.

A – A comprehensive understanding of the skin problem. Acne is a conditions resulting from three main factors: *Excess sebum production; *The difficulty of sebum drainage through the pores and its accumulation in the sebaceous gland ducts; *Proliferation of the P. acnes bacteria inside the sebum and the development of infection and inflammation. (I will mention that there are additional and less common reasons that researchers have raised, which we will not address now).

B – An understanding of how to affect the manifestation of the disease. By understanding the actual disease and its manifestation, we can deduce that affecting one or more of the causes of the disease can result in an improvement of the condition or even to a cure. We can cause an improvement using: * Balance and control over skin cells turnover. *Balancing the skin’s excess oiliness and causing it to secrete less sebum; *Calming the inflammation; *Treating the infection caused by P. acnes using ingredients with an antibacterial effect.

C. A familiarity with active ingredients that are capable of achieving this. The table below presents the active ingredients that can affect the manifestation of acne, divided according to their actions. Because acne involves several factors (Hyperkeratinization, bacterial infection, an accumulation of sebum and residual cells in the ducts, inflammation…) we must have a very good understanding of which active ingredients do what. We also have to know at what concentration/s. There are certain ingredients that perform a specific action at concentration X, and a different action at concentration Y.

Familiarity with mechanisms of action

Every medication and therapeutic cosmetic ingredient that affects the skin has a mechanism of action. A mechanism of action is simply how the ingredient causes the effect. For example, the alpha hydroxy acids break the adhesion between the epidermal cells and enable them to shed. The concentration required to generate such peeling glycolic and lactic acid is 8% and higher. The salicylic acid also breaks the adhesion between cells, but concentrations between 1% and 2% will suffice for daily use in order to achieve exfoliation. The salicylic acid is fat-soluble, unlike the alpha hydroxy acids, so it is especially suitable for treating acne: It dissolves well in the oily environment of the pores (or the comedones) and effectively peels the walls of the duct. Salicylic acid is also an anti-inflammatory from the aspirin family. This is another benefit in treating acne that is characterized by inflammation. Let’s look at some additional active ingredients: Sulfur creates a mild keratolytic effect but mainly lowers sebum secretion. It balances the skin’s oiliness. By understanding the ingredient’s capabilities you will be able to deduce where and in what conditions it should be used (not just for active acne but also for healthy but very oily skin, in order to balance it). Another ingredient that is standard in acne treatment is retinoids – vitamin A derivatives. As drugs, we know them as Retin-A, Retavit, Locacid, Adaferin, Adapalene, Tazarotene, and more. In cosmetology we mainly encounter retinol. What is its mechanism of action in treating acne? It binds to receptors in the cell’s nucleus and affects gene expression. What does this mean clinically? The most important effects of retinol on acne are: *It reduces sebum secretion; *It peels; *It improves and normalizes the shape of the pore duct (in some cases it bends and its shape is distorted, making it difficult to drain). * It helps treat post acne and skin texture problems. A familiarity with the different capabilities, mechanisms of action, and concentrations of active ingredients is a must for every wise and progressive cosmetologist who wants to achieve results. Every action that does not stem from this knowledge is akin to fumbling in the dark, or trial and error, or automatically implementing a treatment protocol that was once taught in a course. Theoretically, if all acne conditions and clients were identical to each other, perhaps we could use one treatment protocol and implement it without realizing what we are actually doing. However, acne comes in numerous and diverse forms and each person’s skin differs in its genetic characteristics, and each client differs in their daily routine and habits. Acne treatment is a complex and sophisticated solution that is customized to each client. To match the treatment to the specific acne we must be proficient in the knowledge mentioned above (understanding the disease, how to affect it, and knowing the active ingredients’ mechanism of action and the required concentration). Let’s see a few examples of implementing this knowledge to the various acne conditions.

How to Handle Different Disease Conditions

First, I will note that the entire discussion below focuses on products that are provided to the customer for use at home on a daily basis. It’s mandatory to equip the client with therapeutic products they can use daily (and not just soap. Soap cleanses, but does not treat. It is rinsed off the skin and does not leave behind any therapeutic ingredients).
Acne can manifest in numerous forms. It can involve numerous and inflamed pustules with red and purulent skin. In such a case we can consider starting the treatment with anti-inflammatories and anti-bacterial agents, to calm the skin and reduce the inflammation, and only then to use peels, which have the potential to irritate the skin and exacerbate certain acne conditions. In another case, where there are no papules/pustules but rather comedonal acne, there is no point in giving anti-inflammatories and anti-bacterial agents. The focus should be mainly on prolonged and consistent peeling of the skin, to enable proper drainage. Peeling will make it much easier for the cosmetologist to extract the comedones at the skincare clinic and much more tolerable for the client. Peeling can be conducted with a product that contains hydroxy acids, 10% and more, for topical application in the evening. Sometimes the acne is on the back. As you know, the back is a thick area and has a low penetrability to active ingredients. Here we will have to adjust a treatment plan and products that will allow effective penetration. A concentration of 10% glycolic or lactic acid may not be enough, and if we use a product whose active ingredient is azelaic acid, we choose a more concentrated and more penetrating product. The important point is that every acne condition is characterized by one or more (usually more than one) of the components mentioned above – hyper kretinization, excess sebum secretion, Accumulation of excess sebum in the follicles, Bacterial infection in papules/pustules, inflammation… And each has a different manifestation. We have to define what we are treating in each and every case – how does the acne manifest and what is the course of the disease in a specific client; we have to know how to affect these manifestations and how we can do this with the specific client. What ingredients will we use in this case (ingredients that we won’t necessarily use in another case).
Sometimes cosmetologists consult me and tell me that they gave a client “a lot of products” for at-home treatment, and even though the client uses them all, the treatment is not progressing. When we closely examine what each of the products contain, we see that they all do the same thing. For example, they are all HA peels, or they are all anti-inflammatories. Obviously, acne that involves several manifestations (inflammation, sebum drainage problem, etc.) cannot be eradicated with one type of action. You don’t wage a war with only an air force. You also have to deploy the navy and ground troops to be able to cope with all of the enemy’s forms of attack. We have to ensure that each of the causes of acne manifesting in our client have been addressed, without missing a single cause. And also without wasting time and money on products that aren’t helping. We may give a certain client a wonderful product but which is not suitable for their specific acne condition. Because the treatment isn’t progressing, we would erroneously think that the product isn’t working, and we may even stop buying it… But the source of the problem was matching the product to the acne condition and not the quality of the product. As we said, active ingredients are raw materials in an artist’s hands. We can only match the product to the client’s condition after becoming acquainted with all the players on the scene – all the active ingredients at the cosmetologist’s disposal, what they are capable of, and the concentrations required to achieve the desired outcome.

In Summary

The topic of our discussion is not treating acne but adopting a treatment approach that enables the right solution to the various skin problems and success in changing the skin’s appearance and functionality. We used acne treatment as an educational case, where we demonstrated the principles or approach to treating skin (there is still a lot to learn about treating acne that wasn’t mentioned here). To change the skin we must know it deeply. To treat a skin problem we have to know it comprehensively, all of its different manifestations, to know how to affect its course, and the ingredients that are capable of causing this change. Unfortunately, the clinical approach to skin care, and in particular the subject of active ingredients, are not studied in depth in cosmetology school. Therefore it’s necessary for the modern cosmetologist to acquire the knowledge, master it, and know how to apply it. Knowledge is what sets the doctor and the patient apart. Knowledge is also what sets the cosmetologist and the drugstore sales rep apart, and what will cause a client to come to the cosmetic clinic and not to settle for off-the-shelf products. To justify the client’s visit to the skincare clinic and purchasing the products you offer, you must cause a visible change in her skin’s appearance. We will make the change happen using the right knowledge and approach to treating skin.


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