When a client visits you, it’s important to consider all that you see and do not see. Skin care curricula have emphasized the importance of skin examinations before each service. However, the value of this information-gathering process is largely missed. The fact is that very few estheticians know how to use the information they collect during a skin examination, which really only gives you a third of the story.
A superficial, external examination can help you treat a topical symptom, but it does not adequately uncover the root cause of any condition and it does not give you the full picture of what is happening at the cellular level. For decades, estheticians have been trained to devise treatment protocols on what they see. Unfortunately, we now know that this mode of evaluation and treatment only produces marginal, short-term results. What’s missed is everything that’s not seen. And this leaves gaps in the reasons why certain skin conditions have emerged.
The most important thing to remember when speaking of the skin and its many layers is that it is not autonomous. It’s connected to every part of the body and in turn, every part of the body is connected to it. External factors that affect the skin also affect all of the organs and systems of the body. Internal factors that affect the systems and organs also affect the skin. And emotional factors that affect a person’s outlook or influence his or her decisions and lifestyle will affect the entire body including the skin.
To fully understand all that’s happening, it’s necessary to use an inclusive, three-pillar evaluation, looking at all external, internal and emotional issues that may be involved with the client’s skin and body health. Through this comprehensive evaluation, a wellness roadmap can be created to offer an effective, long-term solution. This is what Inclusive Health® is all about. It’s an advanced way of offering complete esthetic care and wellness. It features a multidisciplinary approach that offers a blend of high-tech and high-touch treatments, augmented with proven alternative methods and the best of holistic care and medicine. Inclusive Health® is a collaborative effort among spa professionals, which includes the doctor, esthetician and lifestyle practitioner.
With the client at the epicenter, an esthetician’s job is to become a super sleuth. The body communicates all of its needs; we simply have to be astute enough to listen. The only way esthetics professionals can do this is if they let go of preconceived notions on skin evaluation gleaned from formulaic teachings—most of them are largely ineffective and purposeless in real-world esthetics and do nothing more than waste time and create useless paperwork. An insightful and thorough evaluation depends on knowledge. Estheticians must know the components and functions of skin and how cells, organs and systems work in concert.
When examining a client’s skin, there are two things you need to keep in mind: every treatment plan must begin with water; and every condition has a root cause, which can benefit from water. As a Chinese proverb says, “Water always has a source, and trees always have roots.”
Water Loss Reflects Cellular Aging Skin physiology must begin with an examination at the cellular level. Skin is a water gauge. The skin is also the largest and only visible organ of the body, and it reflects the aging processes—including water loss—that occur throughout the body. Next to oxygen, water is the most important substance you need, and almost everything we know about aging tells us the decline in function over the years is a story of water loss. At birth, we lose the ability to hold on to water. On average, man is about 60% water. While a 15% decrease in water may not seem like much, it makes a dramatic, visible difference.
When I see dry, thin, sagging skin, I know that the problem doesn’t stop there. The damaged, water-deprived fibers and cells and the gel-like substance in which they are all embedded, tell me that similar situations exist in the cells of the heart, the muscles, the liver, the walls of the blood vessels, and the joints. Water makes skin pliable and smooth. Each and every cell of the body is connected. In other words, if water is lost from the epidermis, those cells will withdraw water from somewhere else. It comes from the fluid circulating around the cells, then from an adjacent cell or from the dermis beneath it, and eventually from other tissues or cells of other organs. I learned in my years of caring for very sick patients that while the body may have a survivor mechanism that keeps water in the cells of most of the vital organs, if there is a lack of water on the skin, chances are there’s a shortage elsewhere in the body as well.
Water is essential to life and to every cell. It’s what keeps them functioning well, renewing properly, and it maintains immunity. Without adequate water, cells disintegrate—they simply cannot cope with all that they are designed to do in addition to their own maintenance. The structures that support skin stiffen and skin layers thin out and flatten. Blood vessel walls become porous and friable—they leak like old water pipes. When this happens, nutrients cannot be delivered effectively, waste cannot be excreted properly, there is chronic inflammation and the skin’s barrier loses its resilience, which leads to even more water loss and damaged cells.
Water loss can create a vicious cycle. This is why, with regard to skin and wellness evaluations, it’s the first thing that should be examined and corrected. To keep healthy water at optimal levels, common thought is to drink more water. The truth is that there really is little scientific evidence to support the “eight glasses, eight times a day” recommendation. According to The Cellular Water Principle®, in order to put water back into the cells and keep it there, the body needs to be flushed with nutrients to strengthen cell membranes and connective tissue so they hold in the good water. Hydrated cells function, heal and renew well, and keep the skin barrier function intact.
Identifying Skin Types and Conditions For a thorough and complete skin analysis, I believe that the standard system base on the oil and moisture content of the skin is best. This system encompasses the most important factor in skin health - its ability to hold moisture. Of course, there are conditions beyond the basic type of skin that affect is care so I modify the basic skin types with “special concerns”. These include acne, pigmentation, hormonal aging, and sensitivity.
When people think of skin type, they typically mean how oily or dry the skin is. Oil is actually a white, fatty, sticky substance secreted by the sebaceous glands. Except for the lips and eyelids, which have no hair follicles or sweat glands, sebaceous glands empty sebum into the upper part of the hair follicle. As the oil emerges from the follicle opening, or pore, it lightly coats the skin, mixing with the structural lipids within the stratum corneum, creating a kind of protective barrier that keeps water within the layers, helping the skin stay moist and soft.
When the sebaceous glands are overactive (usually in response to hormonal stimulation), the excess sebum can make skin look shiny and feel greasy. When sebaceous glands are under active or harsh chemicals or overzealous scrubbing remove the natural lubricant, moisture is lost and the skin becomes dry.
Using sebum and structural lipids, or oil, as primary criteria, the skin types are broadly categorized as oily, dry, or normal/combination. It is normal for pores to be more abundant on the nose and chin, and so there is more oil secreted in these areas, the so called T-zone. There are fewer pores on the cheeks and around the eyes, so these areas normally tend to be drier.
Keep in mind skin types may change with different life situations-such as pregnancy and menopause, or if you move to a more dry or humid climate and you may need to make changes in the way you care for it. With aging-and especially for women after the hormonal shifts of menopause-most people, though certainly not all, will notice that their skin is drier.
Normal Skin Normal skin has pores that are medium-size. There may be more pores along the nose and chin, and these areas may be oilier than the cheeks. Blackheads and pimples are infrequent and if they do occur they are more prominent in the T-Zone area. Normal skin tolerates extremes in temperatures well, however adjusting the moisturizer in hot and cold climates works well for normal skin.
Dry Skin Pores are small and fine, even across the nose and chin. There may be flaky areas where there are fewer pores, and the skin is thin over the cheeks. It may be so transparent and delicate that small blood vessels can be visible, especially across cheek bones and chin. Skin looks smooth, but it feels rough when you run your fingertips across it. There’s tightness to the skin’s texture within a half hour after cleansing especially without a moisturizer. There may be very fine superficial lines etched on cheeks and under eye area. That’s because the normal creases in the skin are more obvious when there isn’t enough moisture to soften them. Moisturizing creams and lotions disappear quickly in to skin.
In a sense, dry skin is like a dry sponge. It’s rough, hard, and has little cracks in it. When the sponge is soaked in water, it becomes plump, soft, and smooth, and those little cracks disappear.
Dryness is caused by lack of either sufficient sebum or structural lipids or both. This occurs because oil glands are not producing enough sebum, or aging has taken a toll on the production of structural lipids within and outside of the skin cells.
When dryness doesn’t improve despite following the appropriate regimen for dry skin, or if it gets worse, suggest a physical checkup. Dry skin can be a warning sign of a health problem such as a thyroid condition.
Oily Skin The pores are noticeable and skin looks shiny at times, and it feels oily, especially along the nose and across the forehead and chin. The overall skin tone is more likely to be sallow. When it comes to aging, oily skin has far fewer lines than dry or normal skin types. As skin ages, deeper lines, rather than fine wrinkles, will predominate. Oily skin tolerates cold and wind very well, but hot, humid weather may make it glisten with oil. Foundation disappears after about and hour or two, and moisturizing lotions and creams tend to sit on the surface if they are too rich.
It’s generally assumed that people with oily skin are more prone to acne. I find that in adults, acnes happens in all skin types.
Regardless of skin type, breakouts may occur and some people’s skin is easily irritated. Three of the most common problems are acne, environmentally stressed skin (which I call city skin), and disease.
Common Skin Conditions Acne. Starts with a tiny pale dot of oil in the pores. Nearly everyone can see this along the sides of the nose, for instance. When that trapped sebum is exposed to the air, it turns black. Blackheads, or comedones, and whitheads surface in areas where there are more oil glands, such as the sides of the nose and the middle of the chin. These breakouts can occur at any time, but they are especially common in women in the days before menstruation begins when estrogen levels are low and there is more male hormone, or androgen, in circulation.
When that oil mixes with dead skin cells and harbors bacteria, you get red, inflamed breakouts. That is acne. And despite what you have heard, oil or sebum alone doesn’t cause it. Nor is acne a “teenage” problem only.
Adults who never had trouble with breakouts during their teenage years can still develop acne later in life. When you’re under stress, your body is producing more adrenaline or epinephrine. The same glands that produce these hormones also produce dehydroepiandrosterone (DHEA), which stimulates the sebaceous glands in the skin to produce more sebum.
Women going through menopause sometimes develop acne because of the hormonal imbalance that occurs as a result of the decrease in estrogen. There is more of the male hormone androgen circulation than the female hormone, and androgen stimulates sebaceous gland activity. Excess sebum is one of the conditions that contribute to acne. The typical acne lesion is raised, red, and sometimes even feels lumpy. In extreme cases, a cyst is formed that can lead to scarring.
But sebum alone doesn’t cause acne, so modifying oil production alone won’t cure it. Therefore, I suggest following the regimen that addresses your skin type and then adding to it products that address the acne. They may be an antibacterial agent to destroy the acne-causing bacteria, a more powerful exfoliating agent to help shed the accumulated skin cells in the pore or follicle, and a drying agent to remove the excess sebum. Fighting inflammation, which is part of every regimen, is especially important for people prone to breakouts, because the combination of bacteria, oil, and skin cells can trigger a destructive inflammatory response.
Environmentally Stressed or City Skin Living in an urban area, exposes skin to greater environmental toxins from pollution and smog, also a heightened stress level arises from coping with the logistics of daily life. Living in a very sunny part of the country, also contributes to more sun exposure. In the city, busy work schedules often mean meals of fast foods or high-fat restaurant meals and fewer fruits and vegetables. This kind of diet also contributes to skin problems.
Also, despite the fact that cities are crowded, people work long hours and often live alone. This 24/7 lifestyle contributes to isolation, which takes its toll on the skin and the entire body.
Hormonally Aging SkinSome dermatologists feel that the skin of people over forty should be treated differently. They say “mature skin” is a type in and of itself. I believe all adults have “mature” skin, and all of my products and the alternatives I suggest are for people of every age. However, women’s skin is affected by the shifting balance of hormones just prior to, during, and after menopause.
Women who never had breakouts in their lives may find they now get pimples, as they have less estrogen to suppress the sebum-stimulating androgen circulation in their bodies. For the same reason, they may have more facial hair and they may perspire more. Also, because the sin thins so much with age, women past menopause may have more visible sun damage, such as brown spots and fine, dilated blood vessels, and increasingly sensitive skin. In fact, older won need to be even more watchful of the sun and weather extremes, such as cold and wind.
Although most physicians assume that only women have menopausal skin, I believe that men also have a shift in hormones in middle age. So men might find that the menopausal skin program works well for them.
The Big Picture The aging signs you see in your clients are a reflection of the events taking place on a microscopic level. It’s important to understand this concept, because what you’re going to do to reverse and repair your client’s aging skin will take place first in the cells of these layer and will take at least five weeks to become noticeable. To recap, here are just a few of the normal changes that typically begin at about age 20 to 25 in healthy individuals.
- The individual skin cells that are being made are larger and their shape is more irregular. They also develop more slowly.
- There are fewer layers of dead cells on the surface.
- There is a decrease in the water-holding molecules surrounding the collagen and elastin that keeps them pliable and moist.
- There is a decrease in the water-holding molecules that surround the developing skin cells and the dead cells of the skin’s top layer.
- The pigment-producing cells become 20% less dense every 10 years. At the same time there is an increase in melanin production in small areas, which is the cause of age spots.
- The immune cells of the skin that help protect it, the Langerhans’ cells, diminish by half between young adulthood and old age, and they are further diminished by sun exposure.
- The cells called fibroblasts that produce collagen and elastin become less active and are decreased in number.
- The collagen fibers that give skin its resiliency become thicker and more brittle and decrease by about 1% a year.
- Elastin fibers that give skin its elasticity become loose and break easily. There are also fewer of them.
- The ground substance that holds the collagen and elastin fibers together thins.
- Blood vessels that carry nutrients and remove cellular waste from the skin diminish. Those that remain may become dilated and their walls may thicken. They tend to twist and break.
Rogue Molecules Now that we know all of the pieces and parts, a discussion of why they deteriorate or age is in order. About 300 theories have been suggested on aging. The most likely theory is that cells lose their ability to reproduce because of accumulated damage. That damage can be influenced or even caused by several forces such as intrinsic, extrinsic/environmental, or hormonal influences. In addition, the deleterious wake some systemic diseases cause and the state of the person’s immunity are also factors. In any case, at the top of the list, cellular damage occurs because of free radicals, which are destructive, rogue molecules.
Free radicals are unstable molecules or parts of molecules within cells. There is still no evidence in human studies that getting rid of free radicals before they cause too much damage will actually extend life, but many experiments have shown that curtailing their unruly behavior can slow age-related changes.
Free radicals are powerful destroyers because they break up other molecules and this creates even more free radicals. A molecule consists of bundles of atoms that have a certain number of electrons in their outer shells. They’re in balance and humming along, performing their tasks. But in doing some of those jobs, the molecules lose electrons. To restore balance, they bombard other molecules in hopes of stealing the much-needed electron. So while one free radical manages to rebalance, or neutralize itself, other destructive free radicals are created. The damage accumulates and the cells begin to malfunction and age.
Free radicals are created as a natural byproduct of the body’s metabolism. They also occur when there is uncontrolled inflammation in the body or anything that creates a disturbance in the cell like cigarette smoke, pollution, heat, radiation or ultraviolet light. Alcohol, iron excess and high-fat diets also create free radicals.
Any molecule can become a free radical, but the most common is oxygen. Free radicals destroy protein, fats in the cell walls and DNA at the cell’s core. Virtually any part of the cell is easy prey, but the most susceptible are polyunsaturated fatty acids. Disturbing this important component of the cell ultimately affects the cell’s integrity.
Luckily, nature has provided us with antioxidants, which neutralize free radicals and even prevent them. As you can see, a comprehensive treatment plan for total well-being is necessary to keep the body healthy and skin as well. Skin care programs that only rely on surface treatments will fail at producing lasting and profound results. Internal recommendations such as supplements, fruits, vegetables, good fats and minerals are necessary to treat the skin in addition to topical solutions. If you saturate the body with nutrients from the inside, the cells in the entire body will benefit—cellular water will be restored and free radicals will be neutralized.
Mind and Body Connection Nobody is perfect. We all have crutches or “flaws” that can affect skin at the cellular level. The key is for our clients to recognize the influence their emotions have so they can correct them, control them or seek help. Stress can flare skin conditions like acne. Emotional distress can make us lose sleep, which is key to health and vitality and normalizing cortisol levels. Loneliness can cause people to choose poor habits like smoking, binge eating or drinking, and even excessive tanning, which has been shown to be addictive for some. These activities are counterproductive to any skin care regimen and lasting results.
The goal for estheticians is to treat what they see and to consider everything they don’t see. And this begins with a thorough Inclusive Health® evaluation that explores external, internal and emotional factors. With this inclusive approach, I guarantee that you’ll never look at skin the same way again. You’ll be able to see that skin is not autonomous. Everything is indeed connected. Recognizing this fundamental fact is half the battle.
Comprehension Review- The most important thing to remember when speaking of the skin and its many layers is that it is not autonomous
- The skin is also the largest and only visible organ of the body, and it reflects the aging processes—including water loss—that occur throughout the body
- The stratum corneum’s keratinized corneocytes (dead skin cells), lipids, and natural moisturizing factors work in synergy to provide an efficient barrier against water loss and promote water retention
- Skin comprises about 16% of your total body weight. Every square inch of your face contains about 65 hairs, 100 oil glands, 650 sweat glands, 78 yards of nerves and 19 yards of blood vessels
- The skin consists of two layers, the epidermis and the dermis. Although technically not part of the skin, the hypodermis, also known as the subcutaneous layer or superficial fascia is situated beneath the dermis
- An easy way to remember the epidermal layers is with mnemonics: “Cher Likes Getting Skin Botoxed”¬—stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, stratum basale
- The total epidermal renewal time is between 59 to 75 days assuming 19 days for the reproduction of germinating cells, 26 to 42 days migration time through the stratum malpighii and 14 days through the stratum corneum until final desquamation
- The dermal papillae help join the skin layers together. They, along with the rete ridges or rete pegs are akin to the tongue-and-groove joints that you might find in woodworking
- The desmosomes are cell adhesion proteins and linking proteins. Hemidesmosomes are similar in form to desmosomes, but instead of linking cell to cell, the hemidesmosomes attach basal cells to the underlying basement membrane zone
- The basal layer is the germinating layer where new skin cells are “born.” This layer contains merkel cells, sensory cells and melanocytes, pigment cells
- The stratum spinosum contains Langerhans’ cells, which have octopus like arms. They attach themselves to antigens that invade damaged skin and alert the immune system to their presence
- The stratum granulosum (granular layer) is about one to three cells deep and is the highest layer in the epidermis where living cells are found
- The stratum lucidum (clear layer) is a dead, translucent layer and it lies above the stratum granulosum. It contains eleidin, a clear substance that eventually becomes keratin
- While the stratum corneum is relatively thin, it is also very tough. Its resilience is primarily because of its keratin protein composition, which is resistant to water and many chemicals
- The dermis makes up about 90% of the skin, and it gives skin its structure. It contains supportive collagen and stretchy elastin, which are crucial to younger- and smooth-looking skin
- Beneath the dermis is the hypodermis, which is used mainly for fat storage. It is the energy depository for the body, it insulates the body and offers cushioning protection
- Free radicals are unstable molecules or parts of molecules within cells. Free radicals are powerful destroyers because they break up other molecules and this creates even more free radicals
- If you saturate the body with antioxidants and nutrients from the inside, the cells in the entire body will benefit—cellular water will be restored and free radicals will be neutralized.
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