Chapter 6

Wise judgment and clinical thinking – Daily implementation in cosmetology issues

Cosmetology presents us with numerous facts, recommendations, instructions and products – which are meant to optimize our work. We tend to adopt them willingly, with quite a bit of hope and expectations. They quickly become part of our credo, part of our work routine and of who we are – as practitioners. Is this the right approach for working in this important profession of ours?

We make numerous daily decisions that pertain to purchasing products, to the most appropriate treatment, or to purchasing equipment and devices. In the world of cosmetology, we have been accustomed to receiving a lot of information that was given to us in training, the press, and brochures – as unquestionable. Without checking whether it is logical, why were we actually instructed to do it, whether the promises we were given can be achieved. Let us observe a few assumptions that took root in our line of work, and attempt to reexamine them with a fresh and more critical perspective.

 

The necessity of galvanic facial machines

An example of a consensus that we were taught at cosmetology school is the necessity of using a galvanic facial machine. How many of you have truly studied what it does and know what the therapeutic benefit we get from it is? Such questions, which I have asked cosmetologists, have elicited a variety of responses that indicate that this device’s role is not clear. The situation among “experts” is not much different: Chemists have also not provided reasonable answers after being asked further questions based on their answers. How is treatment with a galvanic facial machine actually meant to help the skin? We got a variety of answers. Including: “removing lipids from the skin”. What lipids, I asked? Lipids are an essential part of the skin’s structure. There is a variety of lipids in the epidermis, with various important roles that the skin can’t function without. Which of them do we want to “remove”? Have any of you witnessed the extraction of these lipids? (Science does not confirm this theory, by the way). How can the device differentiate between the lipids we want to remove – provided that we decided which ones – and those we don’t? Let us assume that the lipids are sebum, and that the galvanic facial machine can identify sebum, which contains several types of lipids, and differentiate between them and the lipids in the skin’s structure: Why remove sebum? Will a one-time removal of sebum at the skincare clinic change the rate at which sebum is secreted in the skin? Will the client, upon leaving the skincare clinic, not continue to secrete sebum at the same rate? And are we not familiar with numerous and much simpler methods to absorb sebum – assuming that the galvanic facial machine does it, while identifying and “ignoring” the other lipids? (You can also think about “oil absorbing” facial masks in the same manner. Sebum will continue to be secreted, at the same rate, once the mask is removed from the patient’s skin).

Ion infusion

Another response I get regarding the galvanic facial machine is “ion exchange”, or “ion infusion”. “What ions?” I ask. Most of the respondents don’t have an answer to this. Why infuse ions? And which ones, exactly? Is “ion infusion” a treatment goal? Can anyone explain what ions we infuse and why? What change in the skin’s appearance/functionality will we get after infusing these ions? The client does not come to us for “ion infusion” (which is a means, not a goal). The client comes to us for more beautiful skin (goal), acne-free skin (goal), or an improvement in hyperpigmentation (goal). Ion infusion is not a treatment goal, however this was the answer I got from numerous respondents, which indicates that for them it is a goal and not a means. There were other answers pertaining to a change in the “skin’s charge”, without explaining why it’s necessary, about “ingredient infusion” that the ions enable, supposedly the ions “pull” the applied ingredients with them (this is completely unfounded). Another explanation I got was “gel infusion” with the galvanic facial machine, which also constituted a sufficient and complete answer for many. “What’s the purpose of gel infusion?” I ask. Is gel infusion a treatment goal? Or is it more appropriate to call it a means? Once we understand that so far we’ve referred to “gel infusion” as a goal even though it is not, I ask again – what do we want to achieve with gel infusion? We “infuse gel” as a routine treatment using ultrasound as well, without examining why we do it. At a stretch, we may consider it as a way to “infuse moisture” into the skin. However, if we recall the skin’s structure and its water reservoirs, we’ll see that the source of the water (moisture) in the skin is not external. The skin’s water content is a property of the skin’s structure. The client’s skin may indeed look more beautiful after “infusing gel” with a galvanic facial machine or ultrasound, due to the resulting edema. However, this is a temporary effect, and we need to know exactly what we get as a result of “gel infusion” to decide whether the device we purchased to infuse gel justifies the necessity of its purchase. As a rule, in order to develop clinical thinking and to make the right decisions about devices and products, we always have to ask “why”, to use our prior knowledge about the skin, and to continue asking “why” until we reach an explanation that seems reasonable to us.

Products for the skincare clinic versus products for at-home use

One of the widespread beliefs among cosmetologists is that it’s important to give clients products from the same series we used to treat her at the skincare clinic, since there is some “continuity” between the products we used at the clinic and the products the client will use at home. This belief causes some of us to place the cosmetic treatment in contrived “drawers”, to spend more money, and – more importantly – to sometimes miss out on the excellent result we could have achieved. We are all familiar with the plethora of series, sometimes made by the same manufacturer, where one series (characterized by a uniform color and design for the entire series) is meant for acne, another for anti-aging, one for anti-aging for a younger age bracket, one for renewal of mature skin, one to treat red skin, one for hyperpigmentation, one for rehabilitation… and the list goes on. In each of the series there are products used to treat at the skincare clinic and products, with the same design, colors, and series name, for at-home use. Many of us tend to purchase the entire series of products, thinking that we can’t mix or combine products from a different series – even if it’s the same manufacturer – with another series, so as not to disrupt the “continuity” and the “synergy” between all these products… Have we asked ourselves – why do we think there is a connection between the brands that we used at the skincare clinic (beyond a similar name, colors, and design) and the brands we give for at-home use? Do these brands really “speak the same language”, a secret language, which other products cannot understand? Or will the skin not be able to understand “two languages” of two different series? Why can we not use products from a different series or by another manufacturer, that contain the active ingredients the skin requires? Do we choose to act automatically and without thinking, since we don’t really know what active ingredients there are in the products included in the series? Or have we chosen to give up understanding what is actually happening in the client’s skin while it is being treated, at the clinic and at home, and we leave this role, of understanding the treatment – up to the manufacturer?

Exercising professional judgement

The easiest way is to act automatically: To purchase entire series, to follow the dictated treatment protocols without making any adjustments, and without combining products from different series. It saves us from thinking, and gives us the feeling that we gave the perfect treatment. In practice, it’s everything but a perfect treatment. It’s complicated, expensive, feels like a programmed and unimaginative robot, and mostly – it distances us from acting like a professional cosmetologist. The wise cosmetologist understands, similar to a doctor, that what affects the skin’s appearance and behavior can only be properly described in terms of active ingredients and concentrations. Not by brand names and colors. She properly diagnoses the skin, understands what procedures must be conducted at the skincare clinic, what ingredients are necessary for the skin and in what order when the client is with her, and what the client needs to do at home – what ingredients and concentrations they must use, how frequently, and how to apply them. She purchases products – regardless of the manufacturer – according to their necessity in the treatments she conducts, and with a complete understanding of the active ingredients in the product. She has a complete understanding of the change she caused during the treatment at the clinic, and the change she must cause using products for at-home use. She uses this understanding to match products to the client (which can be from a variety of manufacturers, or a variety or series) and will be able to predict, with high likelihood, what the result will be. Just as a doctor doesn’t prescribe “series” and doesn’t avoid combining drugs by Pfizer with drugs by Novartis for the same patient, the intelligent cosmetologist does not have to adhere to series or to a pre-written treatment protocol, which is meant to be suitable for all clients “of the same type”. At this point, the cosmetologist will say – “But I don’t have the same knowledge as a doctor”. True, which is why you don’t practice medicine. But the knowledge that makes it possible to act independently, with a free hand and with therapeutic strength – does not belong to the field of medicine but to the field of cosmetology. And it is not beyond the cosmetologist’s reach. It’s simple, comprehensible, and clear. We just have to decide to give up the automatic, and to adopt a more professional skin treatment approach.

The penetrability of compounds to the dermis

At cosmetology school we were taught that we only treat the uppermost layer of the skin. Other professionals in the industry (and even some of the doctors) make the occasional claim that “products that are applied to the skin do not penetrate the dermis”. This claim, even if it was made by a doctor, stems from a lack of basic knowledge about the skin’s structure and the effects of the active ingredients. For dozens of years, scientific studies have shown the activity of compounds, such as vitamin A, vitamin C, and others – on the dermis and their ability to change its structure and content. Vitamin A, which acts throughout all layers of the skin, induces collagen production by fibroblasts. It does this by binding to receptors in fibroblasts. These established studies show an increase in collagen density as a result of applying retinol to the skin. If we remember the basic fact that collagen is found in the dermis, and that the cells that produce it are also found in the dermis, and that the effect on receptors found in these cells require reaching the dermis – we can ask again: Do active ingredients reach the dermis? The same goes for vitamin C, which affects the fibroblasts (in the dermis), biomimetic peptides – which bind to receptors in fibroblasts and thus affect the production of new collagen and hyaluronic acid, and additional familiar active ingredients.

We have to remember something else: The main barrier to the penetration of an active ingredient is the stratum corneum. An active ingredient that can penetrate this tight and dense layer, continues its journey in the skin, via diffusion, in a relatively easy way, inside a very soft and penetrable medium. The inner layers of the skin are not a true barrier to the continued penetration of the active ingredient inward. Vitamins, biomimetic peptides, and additional ingredients – meet the requirements for penetrating through the stratum corneum and do indeed reach the various layers of the skin, including the dermis.

By the way, the focus on “penetrating the dermis” and presenting any brand as penetrating the dermis should not impress the cosmetologist too much. Not every active ingredient should penetrate the dermis. There are a variety of sites of action in the skin – starting with the stratum corneum (the classic site of action of hydroxy acids, NMF, etc.), continuing in the different layers of the epidermis, where antioxidants work, ingredients that accelerate skin metabolism, anti-inflammatories, melanin suppressors and more, and ending in the dermis, where we want to influence the function of fibroblasts with ingredients such as retinol, vitamin C, biomimetic peptides and also some of the ingredients that also work in the epidermis such as antioxidants, anti-inflammatories. The penetration of the ingredient into the dermis is not the “highlight” of the product or treatment, many ingredients are not necessary in the dermis, some of them – it is better that they don’t get there…

Familiarity with compounds’ sites of action, mechanisms of action, and with their diverse effects – will help us understand the variety of benefits we can achieve when treating our clients, and enable us to understand why we can generate such beautiful and visible results, by using the right knowledge.

Nano-technology products

One of the terms cosmetologists love is “nano-technology product”. “Penetrable products”, “particle size reduction”, are expressions that will easily convince us that these products are at the forefront of technology, and the latest in any conceivable cosmetic treatment. Many of us believe that a serum, unlike a cream, has “smaller sized molecules”. And therefore “the serum is more penetrable”. Let us think about this from a few possible directions. Is the serum, as a whole, or any cream, as a whole, supposed to penetrate the skin? Or does the cream, or the serum, constitute a carrier that delivers active ingredients to penetrate the skin? Knowing that the specific active ingredients are supposed to penetrate and not the entire product – do we know which active ingredients are in the product? What is their natural molecular size, and does their size need to be reduced? (Vitamins, biomimetic peptides, amino acids, minerals, fatty acids, alpha and beta hydroxy acids, and more – do not require any size reduction to penetrate the skin. They are already penetrable due to their size). Did we bother to verify – what exactly was made smaller, what was its previous size, and was it even necessary to change its size? And another question: Is it even possible to decrease the size of this ingredient and to still maintain its action? Numerous ingredients will lose their characteristics and properties if we remove even one atom from the molecule. Do we know what change is reasonable to make? Have we checked what change was conducted and to what component? There are many other questions we haven’t thought about and that we haven’t asked the manufacturer, but the ones we already asked are enough to conduct a clearer and more accurate conversation with the sales representatives. We must not be impressed by long and fancy words that have a scientific ring to them. Scientific truths, provided that they are understood by the person explaining, can be conveyed in a very simple, clear, and comprehensible manner. As Einstein said: “If you can’t explain it simply, you don’t understand it well enough”.

Caviar, gold

Many ingredients are presented to us as being active and even “scientifically proven”.. In practice, there isn’t a single scientific study (or any clinical logic) that proves their action. There are no studies that demonstrate the activity of gold or caviar on the skin, or additional ingredients such as: diamonds, pearls, DNA. This doesn’t prevent writers from claiming that “recent clinical studies” have proven the ingredients’ activity. It is our duty as skincare practitioners to ask to review these “clinical studies” before we allocate a portion of the skincare clinic’s budget to these magical ingredients. After all, cosmetology offers powerful, scientifically proven ingredients. And we should focus on these when planning a results-driven treatment.

Stem cells

Another trend is creams containing “stem cells”. It undoubtedly sounds impressive. They create a magical atmosphere of science and futurism. With the most basic knowledge of biology (or simple logic), it’s possible to encounter some absurdities pertaining to the subject. Here are a few basic reminders:
A. Cells do not grow in cream. They need a growing environment suitable for cells, and cream is not such an environment. Even if they were first grown in a suitable environment, In a petri dish in the lab, they’ll be destroyed as soon as they’re placed in the cream.
C. Cells do not “penetrate the skin”. A sentence that is ridiculous to even write… It’s like writing that we can’t enter our home through the keyhole. Molecules that are smaller by thousands of orders of magnitude, like proteins, do not penetrate the skin.
C. Have we asked ourselves why would we even want to penetrate stem cells to the skin? Does anything come to mind? Do we know how stem cells act in the body? What’s needed to stimulate them to action? What is this activity? And if we don’t know, why do we think that a cream that contains them (assuming that they “penetrated”) will work?
D. Another reminder: Penetrating another living creature’s cell into our body would lead to rejection, akin to a transplanted organ being rejected unless immune system suppressants are taken. For the simple reason that we have an immune system that’s in charge of identifying foreign entities, including cells that are not our own.
E. Certain manufacturers clarify that these ingredients are actually growth factors that were produced from stem cells. Remember that growth factors are mostly proteins, and proteins do not penetrate the skin due to their size.
F. Even if the growth factors had penetrated, we must humbly remind ourselves that we don’t know a lot about them. Their role is complicated and complex, dependent on the skin’s needs and the events occurring in the skin at any moment. We are not all the same and growth factors cannot necessarily “be applied twice per day” as if we are all identical creatures who undergo the same events. Giving a growth factor “cocktail” only because there are growth factors in the skin, some of which may heal in a specific amount and in certain opportunities, is akin to giving a medication cocktail on a regular basis, to everyone. There’s no doubt that at a certain time, a specific drug in the cocktail will suit a specific person for a certain period of time. Even the amount isn’t exactly suitable, and the other ingredients that were given may be harmful.

Transdermal treatment/cream

The word “transdermal” has migrated from medicine to cosmetology, without it even being relevant to our line of work. Transdermal means through the skin, into the circulatory system. Transdermal delivery means that a substance that was applied to the skin passes directly into the circulatory system, without it being distributed through the skin. This is in order to administer a systemic medication, without swallowing the drug. In other words: The opposite action of what we want to happen when we topically apply substances. As cosmetologists and skincare practitioners, we want to penetrate the substance into the skin, not into the bloodstream. The word transdermal, like other impressive words (nanotechnology, biotechnology, etc.) is used extensively in the market, but it doesn’t reflect an understanding of its meaning.

What age is the cream meant for?

Another question the sales representatives occasionally get asked about products is “what age is it meant for?”. We should become accustomed to matching products not to age but to the goal we want to achieve. To the change we want to create in the skin. Active ingredients affect the skin not according to age but according to the active ingredient’s capability, to its properties. Again, we must know what active ingredient(s) there are in a product, and what these ingredients are capable of doing, and then conclude what goals we can achieve by using the product. After examining the active ingredients, we will be able to find a variety of uses for numerous products. And instead of buying many types of products, since we thought that each one is suitable for a different age, buy fewer types and adapt the product – perhaps with different instructions for use – to a variety of purposes. A 1.5% concentration of retinol, for example, can be suitable for a 16-year-old with acne (minimizing sebum secretion, exfoliating); for a 20-year-old (or any other age) with enlarged pores – to minimize the size of the pores; for a 25-year-old (or any other age) with post-acne scars, for a 40+-year-old to improve the appearance of the skin and treat the signs of aging, and for any age – to balance sebum secretion, or combined as one of the products used to treat hyperpigmentation. Knowing and understanding what the active ingredients can do and the composition of our products, will enable us to always give a solution, even if we have sold out of the specific product we wanted to give. We can use our knowledge and understanding to give an alternative product and achieve similar results.

Use of exfoliating agents in the summer

A final issue I will discuss in this chapter is using peeling agents, both at the skincare clinic and selling to clients for at-home use, during the summertime. Many of us believe that peeling shouldn’t be conducted in the summertime and that clients shouldn’t be given the same skin renewal products, containing hydroxy acids/retinol, during this season. This attitude is very understandable, we don’t want to cause more harm than good. However, we should also remember that we can also avoid sweeping generalizations here and address each client according to her unique circumstances and habits. Some clients’ daily routines enable them to avoid exposure to the sun, and they can commit to not spending time outdoors (at the pool, beach, nature walks, etc.) and to use sunscreen whenever they leave the home. If we are indeed convinced that this specific client will stand by her word, there is no reason not to give her the right treatment. Recall that several countries have 7-8 straight months of sunshine, and even their brief winter has many a sunny days. It makes more sense to weigh the circumstances individually, and see which peeling agents and at what concentrations (if we’ve already decided) we can use this time. We can change the instructions for use and/or the frequency, of course. Any logical change in the treatment parameters that will make it possible and safe even during the summertime. However, when it comes to exfoliating products there are no instructions for use, or concentrations, or products, or circumstances, that are suitable for a client who spends time in the sun at the beach or the swimming pool. Not even if she sits under a parasol. Ingredients at a peeling concentration are only suitable for individuals who we know with certainty will limit their sun exposure to running errands, going to and from work, on a route that doesn’t involve prolonged driving in the sun. Only in these instances will we use peeling agents at an active concentration, while individualizing the ingredient, the concentration, and the instructions for use, which may differ to what we gave in the winter.

Exercising judgement

Make sure you don’t confuse means and goals. Goals can be defined in terms of a change in the skin. Goal is: “smoother skin”, “even skin tone”, “acne healing”. Is a “state-of-the-art product” or “nanotechnology product” a goal? Or a means? If you can achieve the treatment goal with products, even if they don’t contain nanotechnology (assuming we have made sure that it is more than words), then the goal has been achieved. Nanotechnology products aren’t “better”, they aren’t “more promising”. Ensure that you’ve understood, and asked, which ingredient has been made smaller, and why is it necessary to do so? Ensure that the answer is logical and clear, and consistent with your knowledge and understanding. And if it isn’t understood, demand a simpler and more understandable explanation.
We have to remember that our clients come to us to attain skin that looks and functions better. Not in order to get “infusion treatment”, obtain “biotechnology products”, “transdermal products” and additional terms that impress us and which the client (and some of us) doesn’t understand. Let us focus on understanding the real ways we can change the skin. We’ll choose knowing and not blindly following gimmicks and slogans, and thus we’ll guarantee professionalism and a level of results that doesn’t fall short of what a doctor is capable of achieving.

We’ve discussed several examples, out of several dozen (!) of exercising treatment-related logic and a fresh perspective on topics we viewed as “closed” to additional discussion. Topics that we acted on automatically out of routine, and without needing additional explanation from the “experts” who presented us with the knowledge. As a matter of fact, cosmetology is rich in these kinds of assumptions, beliefs that are unfounded, devices that aren’t useful, and courses of action that we’ve become accustomed to without asking why we do them. At the same time, our pretensions and ambitions are rising. Our clients require us to work magic and quickly improve the skin’s appearance, health, and functionality. In order to deliver these results, most of which are indeed attainable, we have to get used to thinking like skin researchers and doctors within our skincare clinics, to acquire knowledge, exercise clinical thinking, challenge, demand explanations, be creative, and stop the habit of functioning on autopilot. Most of the material presented to you (in training, catalogs, lectures) – requires critical thinking, filtering and applying clinical logic before you decide whether it deserves to be called “established facts”. The better we are at judging and choosing, the more our ability to achieve accurate, fast, and safe therapeutic results will improve.

 

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