October 2010

Lisa Kind - Editor

Esthetic Endeavors | by Judith Culp


Treatments and Diverse Clients

The population base in the United States is shifting as more cultures are merging.

Did you know that in 1990, the US Census Bureau identified six races and 23 sub-types but just ten years later, in 2000 they identified six races and 67 sub-types?

The world and our client base are changing. So, why would this be of concern to us as estheticians?

Consider this scenario: A client who appears to be a Fitzpatrick III with a nice summer tan comes into the clinic for an AHA or BHA treatment. We do the treatment, following all of the manufacturer’s suggested guidelines and it seems to go well. The client gets a little pink, but nothing out of the norm. We do some extractions, a nice mask and check the client out when the service is complete.

A few days later, the client comes back into the clinic complaining about skin discoloration. We note some brown areas – post-inflammatory hyperpigmentation. Why would the client, who is only a Fitzpatrick III, hyperpigment? The answer lies in what we did not know – the client, although fair, is of mixed heritage, part Puerto Rican, and her skin reacted like that of a higher Fitzpatrick.

The challenge to us as estheticians is in the field of skin analysis. The subtle blends of a client’s heritage may make their skin react in a manner we do not expect when we are performing services.

The Fitzpatrick scale was developed back in 1975 and does not take clients with heritage blends into consideration. It only describes how skin will respond to UV exposure – inflammation, or the lack of it or a tan. It does not take into consideration two new areas that medical and clinical professionals now need information on: insult and injury.

While estheticians should not be causing injury, we certainly want to be aware of how a client heals. We also want to be aware of how a client’s skin responds to what it perceives as insult. What is the risk of post-inflammatory hyperpigmentation?

The medical community is ahead on this as aesthetic procedures make it critical for dermatologists and plastic surgeons to be able to identify client risk factors. Since Asian skin can be very reactive, it is not surprising a system called the Kawanda Skin Classification system was one of the first to advance on the Fitzpatrick Scale back in 1986. This system was specifically developed to deal with Japanese patients.

The next attempt at dealing with heritage related risk factors was the Lancer Ethnicity Scale developed in 1998. Lancer used the Fitzpatrick scale and added ethnicity to it. The Lancer scale has proven to be helpful to estheticians as it brought out the issues of heritage and better helped us identify how these clients might respond.

Dr. Lancer’s research and development triggered a flurry of research and new scales to better attempt to deal with multiple cultures. Each had a different approach. The Goldman World Classification system deals with burning, tanning and post-inflammatory pigmentation.

The Willis and Earles scale is for those of African only descent. It evaluates skin tone, UV response and pigmentation. Another scale, the Taylor Hyperpigmentation Scale, focuses on dyschromia.

In 2006, the Roberts Skin Classification System was released, using a complex seven-point evaluation system to determine how the client’s skin will probably respond to inflammation, insult or injury. It makes use of the Fitzpatrick Scale, the Glogau Scale of Photoaging, a scale to evaluate tendency to pigmentary issues, and a scale to evaluate risk of scarring.

While estheticians cannot use these in the same manner in which a physician would, we can still make use of the techniques. We can take a complete client history, including standard medical and lifestyle questions. We can establish their Fitzpatrick and add questions regarding ancestry to our questionnaire.

We want to do a thorough evaluation of the skin through the magnifying light, observing skin tone, texture and signs of photoaging. In addition, we can ask the magic revealing question: When you have a skin injury, does it go from pink to red and then fade away OR does it go from pink to red to brown. If they say it goes brown, we know we have a client who is at risk for post-inflammatory pigmentation.

We can evaluate this information to determine if we think the client is appropriate for the treatment, and if so, whether we need to use a more conservative approach. A good guideline for estheticians might be if the client has heritage that is in a higher Fitzpatrick range than her skin appears, treat her as the next higher level of Fitzpatrick. If she appears to be a Fitzpatrick IV but has African ancestry, treat her as a Fitzpatrick V.

Using this approach, which is in essence what the medical community does, allows us to protect the client and minimize the risk of post-inflammatory pigmentation that can take months or longer to clear.

Judith Culp, a CIDESCO Diplomat has been in the esthetics industry since 1980. A CPCP permanent makeup technician for over 18 years she served a 4-year term as a Director for the Society of Permanent Cosmetic Professionals, two years as their president. She is president of Culp Enterprises Inc. and CEO of NW Institute of Esthetics. Judy Culp is available for consulting. For more information visit www.estheticsnw.com.