Why Skin Should Always Come First

The number of practitioners turning to the field of medical aesthetics is quickly increasing. But it’s not just about injectables – a “skin first” approach is necessary if you want to be truly successful.

Unlike conventional medicine, aesthetics is a growing, fast-moving sector, where innovation and advancement is a regular occurrence. Yet aesthetic medicine is also at risk of becoming synonymous with injectable treatments, namely botulinum toxins and dermal fillers.

Many practitioners new to the industry are eager to train in these particularly exciting treatments, and understandably so given the immediacy of the results. Yet what is often neglected, especially by those new to training, is the very first step of any aesthetic treatment plan: skin rejuvenation.

Injectable treatments can have a visibly profound effect, but if the condition of the client’s skin is sub-optimal then the result of the injectable treatment will also be lacking. This means dissatisfied patients.

Here at Harley Academy, we believe in the concept ‘skin first, injectables second’. Just as an artist would first carefully prepare a high-quality canvas before starting their masterpiece, the same can be said when treating our patients’ skin. The result is a longer-lasting, more vivid painting.

So, how can you embody ‘skin first’ as a practical philosophy?

Treating the Canvas

First, when consulting any client, the skin should be assessed, with the initial aim of improving the overall condition. One way to do this is with skin analysis tools. These range from a fairly simple Wood’s Lamp to more advanced devices, such as VISIA and OBSERV. These tools may allow you to see damage that is not visible to the naked eye, and pinpoint where improvements can be made. These kinds of devices can also be useful if you want to assess the progress of a treatment, and show these improvements to your client.

However, assessment devices can be expensive. They are also unnecessary if you have a solid understanding of skin and the ability to recognise dermatological conditions. These “skin first” skills will equip you with the tools you need to evaluate your client’s skin type and tone. Above all, listen to your client. When they talk about their concerns are they just talking about dynamic lines and volume loss, or are they talking about looking “tired” and generally “aged”? If their concerns are broad, it’s likely that a deeper skin analysis will help you both to develop a more holistic treatment plan together.

Before considering taking a needle to the face, the following treatments can be considered:

Skincare

The high street is saturated with ineffective and expensive skincare products. As a practitioner, you must have sufficient knowledge of the serums and creams that do work and be able to advise your clients on skincare regimes that will effectively address their concerns.

Not only can cosmeceuticals be the mildest first step in improving the condition of your client’s skin, but by providing products that are highly tailored to the client’s skin condition you can build trust. No patient wants to feel as though injectables are being used as a scattergun option. When recommended proportionally and in conjunction with skincare the right injectables can also become a much more effective, individualised treatment option.

Chemical Skin Peels

Chemical peeling has come a long way since its induction in dermatology in the early 1950s when phenol was used in the treatment of acne scars. Peels can provide safe and successful results (as long as recommended protocols are followed). They can improve the skin by using a chemical solution, which results in controlled damage at a certain level of the skin – superficial, medium or deep. By simultaneously removing dead cells and encouraging the production of new skin cells, peels can result in visible improvements in conditions such as sun damage, sun spots, rosacea, spots and acne, fine lines and wrinkles, mild scars and skin texture. At Harley Academy, we offer chemical peel training to safely learn how to carry out the procedure.

Hydroxy Acids

Both alpha and beta hydroxy acids are used in chemical peel treatments to exfoliate or peel. Alpha hydroxy acids (AHAs) are fruit acids and can be found in various fruits, corn, sugarcane and sour milk. Examples include malic acid, lactic acid, citric acid and glycolic acid. AHAs help with age spots and pigmentation, and the reduction of fine lines and wrinkles.

Beta hydroxy acids (BHAs), unlike AHAs, are oil soluble, meaning they can get deep into the pores and cut through any clogging oil. They are also ideal for treating acne and blackheads, as they have antibacterial and anti-inflammatory properties. The most common BHA is salicylic acid; this occurs naturally in willow bark and sweet birch.

Different solutions can be used depending on the depth of skin you wish to reach. For superficial peels, hydroxy acids, most commonly glycolic acid, is used, but also lactic, mandelic, resorcinol and retinoic acid. Combination solutions are also an option; Jessner’s solution is a well-known exfoliator, which is a combination of resorcinol 14%, salicylic acid 14% and lactic acid 14%.

For medium-depth peels, TCA (trichloroacetic acid), which is a relative of vinegar (acetic acid), is widely used as a single ingredient peel and in combination. TCA is water soluble and does not penetrate easily in lipid-rich sebaceous skin. Therefore, prior to use, superficial peeling is beneficial, to increase the permeability of the stratum corneum and remove oils from the skin’s surface. Medium-depth peels can have incredible results, even after a single use.

Lastly, for deeper peels, many practitioners use phenol or combination peels. Phenol can penetrate the skin quickly and causes denaturation and coagulation of proteins at a specific depth in the dermis. Phenol peels are very intense and should not be considered lightly. They are not just a Level 7 procedure, but should only be performed by medical practitioners under general anaesthetic. Finding out more about chemical peel solutions and their use in combination opens up a wide range of peeling treatments, that can be added to a practitioner’s repertoire.

Learn how to perform peels of any depth on our cosmetic dermatology courses.

Mesotherapy

Developed in 1950s France by Dr Michel Pistor, mesotherapy is a non-surgical technique involving injections of ‘medications’ directly into the dermis in order to restore a healthy and youthful appearance.

Mesotherapy allows chemicals to penetrate where topical creams cannot. A range of ingredients can be chosen for mesotherapy.

A typical cocktail may include a host of vitamins, minerals and other antioxidants, dependant on the treatment concern. The injection of mesotherapy products promotes skin rejuvenation by increasing both hydration and fibroblast activation, re-establishing skin tone and elasticity.

Mesotherapy is manually administered or managed using a mesotherapy gun or small syringe, and several micro-injections are carried out in covering the treatment area.

Depending on the aesthetic concern, different techniques are used and the depth of injection required is also variable. In younger skin, the treatment aims to keep fibroblasts active and maintain a client’s youthful appearance. In older skin, the treatment aims to aid hydration, reduce anti-radical action and combat against the effect of oxidative stress.

Mesotherapy results are progressive and incremental and clients will need several sessions, usually two to three weeks apart. Although the product is injected, it is delivered superficially, meaning it is less invasive than botulinum toxin and/or dermal fillers. The treatment is a great option for clients who care to take a more holistic option in treating problematic areas.

Microneedling

A popular treatment amongst today’s aesthetic clientele is microneedling due to its minimally-invasive nature and noticeable results.

The German dermatologist Ernst Kromayer was the first recorded person to use microneedling, in 1905. He experimented with dental burs attached to motorised flexible cord equipment and used this technique to treat scars and hyperpigmentation.

There are numerous micro-needling devices available to clinicians, including rollers and pens, making it easier and safer to perform this treatment. Microneedling works by administering controlled injury to a chosen depth.

A device with small needles is rolled over the face to create controlled punctures, forcing the skin to react to the trauma and regenerate. This process induces collagen production. The production of collagen is essential to skin rejuvenation because collagen acts as the scaffold of the skin, giving it strength and elasticity.

After a micro-needling treatment, skin goes through four phases:

1. A clotting phase; to stop the bleeding to close and protect the wound;

2. Inflammation phase; to kill bacteria, debride damaged tissue and release chemical factors that encourage fibroblasts, epithelial and endothelial cells to divide;

3. Proliferative phase; where immature granulation tissues containing plump active fibroblasts form which quickly produce type III collagen (this collagen fills the defect left by an open wound);

4. Finally, the maturation phase; where the type III collagen is largely replaced by type I.

Microneedling can also be used in combination with other treatments, such as platelet-rich plasma (PRP) treatments and laser therapies. Learn how to carry out this procedure with the microneedling training course offered.

A Place for Injectables

Of course, many clients who firstly begin with skin rejuvenation treatments, such as chemical peels and microneedling, will eventually go on to request dermal filler and botulinum toxin procedures. As much as non-invasive skin treatments are continually improving in terms of the results that can be achieved, they will always have their limitations, and this is where injectable treatment comes in. However, this will never mean that skin rejuvenation will take a back-seat; using a combination of skin rejuvenation treatments and techniques, alongside injectables, promises the best results.

Skin First

There will be practitioners who have adopted the ‘skin first’ mentality, but this does not mean their clients have. There will always be some clients that are adamant they want – or indeed need – an injectable treatment. But as ethical practitioners, we must always explain the importance of ‘skin first’. As stated by the GMC, in their document on Good Cosmetic Surgical Practice:

“If you believe the intervention is unlikely to deliver the desired outcome or to be of overall benefit to the patient, you must discuss this with the patient and explain your reasoning. If, after discussion, you still believe the intervention will not be of benefit to the patient, you must not provide it. You should discuss other options available to the patient and respect their right to seek a second opinion.”

Saying no to clients will always be an awkward hurdle, but moral duty must always prevail. Be confident in your approach, refine your toolkit, always think ‘skin first’ and you may be able to find the right treatment for every patient.

Download the latest Harley Academy course prospectus to find out more about our cosmetic dermatology training.

Article last fact-checked: 11 January 2023