Chapter 3

The cosmetician and the treatment given by the doctor:
how to combine the two

Our clients are often treated for the same problem by a dermatologist as well. The challenge for the cosmetologist is how to integrate in the medical treatment that the client is already receiving without adversely affecting the results or the skin’s condition, without irritating it, and preferably also being able to intensify the treatment outcome. The ability to do this is conditional upon a full understanding of the doctrine of the active ingredients and the known ways to bring about a change in the skin.

Numerous skin conditions that bother our clients are the bread and butter of dermatologists and cosmetologists as well. It is also what both parties earn a living from. The cosmetologist sometimes “takes a step back” when her client, let’s say in the case of acne, decides to receive medical treatment. She may settle for extracting comedones and monitoring the skin’s condition, giving soapless soap with acids or a facial toner, and to “let the medication do its thing”. A similar approach may be adopted in cases of medical treatment for additional conditions: hyperpigmentation, various types of dermatitis, and more. This stems in part from the belief that the drugs are a magical solution, the ingredients we do not have access to and they (along with the doctor’s knowledge) are the more tested solution to the problem. The reality is that in most cases, the cosmetologist can improve the results of the medical treatment and help the client undergo it with minimal side effects or irritation, when irritating active ingredients are given. Another fact is that some of the ingredients that are available to the doctor are also available to you at the cosmetic clinic. Some of the medical products have equivalent cosmetic products – a different ingredient that does the same thing. And there are numerous cosmetic ingredients that have no equivalent drug, and that give the cosmetologist a wide variety of treatment options, which are not available to the doctor.

Integrating Properly

To integrate wisely in a doctor-prescribed treatment requires knowing the variety of ingredients available to the doctor, their effect on the skin and their mechanism of action, the concentrations that generate a change, and what happens to the skin at each concentration. It’s also necessary to know the nature of the skin problems we and the doctor are treating and the known ways to affect them. When we are familiar with the skin problem we and the ,doctor are treating and the product the doctor prescribes, we have the tools to do our part in several ways: A. We can check whether the product the doctor gave addressed all the needs and the various manifestations and causes of the disease. This is not always a given. If we assessed that a need was not met – we can give a product that supplements the treatment. B. If the doctor gave a product that we know will create discomfort in the skin: irritation, dryness, visible peeling, inflammation, etc. – we can prepare for the situation in advance and provide our patient with the right solution. The esthetic needs or comfort of the treatment are not always taken into consideration by the doctor. C. Sometimes the skincare clinic is equipped with devices or technology that are not available at the doctor’s clinic. The devices may be effectively integrated in the medical treatment, providing that it is done the right way.
When selecting the products that we give in combination with the medical treatment, we must ensure that we don’t repeat what the doctor is doing. When our client receives antibiotics from the doctor, we won’t choose our own product that has an anti-bacterial action. This need has already been met by the doctor. There’s no point in giving a hydroxy acid peel for rejuvenation to someone who is taking a prescription drug with retinoic acid for the same goal. However, it is possible, and preferable, to supplement prescription drugs with complementary products – according to the skin’s condition and needs. We will see examples of this later.

Integrating in Hyperpigmentation Treatment

Let’s take a few examples of the judgement we must exercise when treating hyperpigmentation. A common and standard dermatologist-prescribed treatment for hyperpigmentation is the Kligman’s formula cream, also called “triple combination”. A Kligman’s formula prescription may contain three or more of the following six ingredients: tretinoin, hydroquinone, hydrocortisone, glycolic acid, kojic acid, ascorbic acid. The first three are the main ingredients, which make up the original Kligman formula. The doctor will also determine what concentration of each ingredient our client will receive. The doctor will give the patient a prescription that includes the ingredients and concentrations he saw fit to prescribe, and the pharmacist will prepare it. The cosmetologist must be familiar with this prescription, which is the foundation of the medical treatment for hyperpigmentation, the role each ingredient plays, and the effects of different concentrations of each ingredient. Hydroquinone, for example, is an extremely effective melanin suppressor. It will appear in every Kligman’s formula prescription. The doctor will usually prescribe 4% to 10% and sometimes more. Suppressing melanin production is only part of what’s needed to treat hyperpigmentation, so the doctor will also add retinoic acid (in the same prescription) as a peeling agent that boosts the hydroquinone’s penetrability. Most will also contain hydrocortisone (a topical steroid), to calm the inflammation. It’s important to verify with the client which Kligman’s formula she received, in other words, what ingredients did the doctor prescribe and in what concentrations, to know how to handle the treatment in this case. What we can contribute, and what the doctor has already addressed. If we use invasive therapeutic device, such as IPL, plasma pen, fractional RF etc, we have to take into account that the application of irritating ingredients (such as retinoic acid) must be stopped at least 4 days before undergoing the treatment at our clinic, and the treatment should be resumed at least 4 days after, on calmed and restored skin. Melanin inhibitors, in contrast, must be given throughout the IPL treatment, to prevent hyperpigmentation due to the irritation we created. Another topic is the irritation that may accompany the treatment with the Kligman’s formula cream. Certain clients will experience irritation due to the high concentrations of the cream’s active ingredients. We must know what’s in the cream, examine our client’s reaction and if needed, supplement the treatment with anti-inflammatory and antioxidant ingredients (on its own, inflammation may create or exacerbate hyperpigmentation). Retinoids are effective ingredients that are part of the Kligman’s formula prescription, however it’s important to remember that they harm the efficacy of the skin’s barrier. This is exactly why they make a good peel and boosts the penetration of active ingredients. This is why we, at the cosmetic clinic, can focus on rehabilitating the corneal layer using products that mimic the hydro-lipid barrier (hydro=contains water and hygroscopic substances, lipid=contains different types of fats and oils. The cornea contains both types of compounds). Our clients are sometimes prescribed Esomed, which is a drug whose active ingredient is hydroquinone, 2% or 4%. By itself, as a monotherapy, Ezomed is not sufficient for the treatment of hyperpigmentation. Its penetrability is poor, and often doctors add some form of topical retinoid to the treatment with Esomed. It should also be noted that the comprehensive and effective treatment for hyperpigmentation will always also include exfoliating ingredients that accelerate skin cells turnover and help lighten the existing spots. The melanin suppressors do not lighten the spots that has already formed but prevent the formation of further excess pigment. If the client uses Esomed without an accompanying peeling agent, we can give them such a product. On its own, Esomed can be used as a melanin inhibitor for IPL treatments for hyperpigmentation. In many brands, the treatment is separated into products containing only melanin suppressors and those containing only exfoliants. The separation helps us use the right family of compounds when we need it.

Integrating in Acne Treatment

With acne treatment, the issue is even more complex and fascinating. Acne is actually no less than four different pathologies: hyperkeratinization, excess sebum production, bacterial infection, and inflammation. Each of the four pathologies requires treatment, and there are separate therapeutic products the cosmetologist and doctor can use (although many compounds help with more than one pathology). Sometimes the doctor prescribes a specific therapeutic product, which upon our examination of the client’s condition – does not meet all the needs. For example, a teenager with acne involving papules and comedones, who was prescribed antibiotics. The pathology of bacterial infection is indeed addressed with medication, although the problems of hyperkeratinization (manifesting in comedones and also in the actual papules) and of excess sebum production – were not addressed. Antibiotics do not peel and do not decrease sebum production. They only address the bacterial infection. We must choose the therapeutic product that will address the other two pathologies that are clearly involved here. In this case, we can choose from among the variety of therapeutic ingredients available to a cosmetologist, those that will peel (like alpha and beta hydroxy acids), but in fact the ideal choice is those that will both peel and decrease sebum production – like retinoids or azelaic acid. If, on the other hand, the doctor prescribed a product that peels and decreases sebum production – like tretinoin for example, and there is also a bacterial infection and/or inflammation, there are various products available to the cosmetologist that have anti-inflammatory or antibacterial properties. Their importance increases in light of the fact that the treatment with retinoids irritates the skin, and anti-inflammatories address this properly. When our client is prescribed retinoids, we must also consider rehabilitation of their stratum corneum using suitable ingredients since we know that they may suffer from dehydration (a condition we commonly encounter). Remember that dehydration exacerbates acne, and we must place an emphasis here on compounds from the NMF group and not on oily compounds, since the problem is the water content in the skin and not the oil content.
In recent years we have been encountering increasingly more clients who prefer to shorten the process and take Roaccutane. If our patient receives this medicine, I recommend not to combine a therapeutic product from our clinic that contains peels, azelaic acid, retinoid, benzoyl peroxide or any irritating or drying ingredient. It is recommended to put emphasis on ingredients that help in rehabilitation of the cornea and helping the client maintain healthy skin and adequate water content. When the treatment with Roaccutane is finished, we usually ask – at what point can we give irritating or peeling products – to (for example) treat scars. An answer I often hear is “after six months”. So, in medicine, and in therapeutic cosmetology, there are no cookie-cutter solutions that suit everyone. Each client reacts differently to treatment with Roaccutane, and according to their condition after the treatment, we will decide on what products to give them and when. There are clients whose skin, after six months of treatment with Roaccutane, is still oily, healthy and functioning well, and there is no problem giving them therapeutic products that include hydroxy acids at a peeling concentration. However, others complete the treatment with extremely dehydrated and irritated skin that requires rehabilitation. We won’t know how long we’ll need to rehabilitate the skin and when it will function better, until we start. Maybe the level of sebum secretion in the skin will decrease, maybe it will return at some point to function as oily skin, maybe some of its characteristics will change under the influence of the drug.
Since acne treatment involves treating four different pathologies, and there are various medical products to treat them, the cosmetologist must know more to understand how to make the combined treatment successful (cosmetologist combined with the doctor). She must know all the available medical products at the doctor’s disposal, and the specific pathology of the disease they are targeting. To reiterate, this is so as not to repeat the action the doctor performed and to address the possibility that the doctor did not cover all four components of the problem. Fortunately, there is a fairly rich variety of available ingredients for cosmetic use in treating acne. A cosmetologist who studies this variety and learns it, will be able to significantly improve the treatment outcomes she provides, and to differentiate herself from others. Knowledge in this field transforms some cosmetologists into “magicians” of acne treatment, with results that do not fall short of those with Roaccutane treatment.

A combination of skills and knowledge

There are numerous other skin conditions where we work in tandem with the doctor, whether he’s aware of this or not. Skin renewal, for example, an indication we haven’t discussed, is a broad field for cosmetic treatments, such as IPL treatments or additional technologies, different types of peeling treatments and products for at-home use. Our clients, in an effort to achieve the best results and as quickly as possible, want both medical and cosmetic solutions. The doctor has access to certain compounds which the cosmetologist is forbidden from using, and others that are permitted for cosmetic use but up to a limited concentration. However, when we want to change the skin’s appearance we work exactly like the doctor: We set goals, understand exactly what is occurring to the skin – what the problem is and what we want to change, we know which products or procedures can affect the condition and at what dosage – and we develop a treatment plan. Sometimes the doctor can improve the outcomes of our plan of action, or vice versa – we can improve the outcomes of the medical treatment. The cosmetologist who works in accordance with a scientifically based approach, is not afraid of integrating in the medical treatment, and she does not step aside. On the contrary – she sees the situation as an opportunity to cause a faster and more effective change in the client’s skin together with the doctor.


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