|
 It is easy to see the aesthetic laser industry booming.
As a result, many physician's offices blending medicine and aesthetics are asking nurses to focus on procedures and practices not covered in nursing school.
Nurses, in fact, are very often the primary provider in a medical office performing aesthetic procedures such as laser treatments.
This is exciting because the aesthetic industry is providing a new job market for nurses. On the other hand, the lack of detailed education and understanding can have devastating effects on a patient.
Right now these nurses are trained by laser manufacturers or the physician for whom they work as few businesses provide training in medical aesthetics. Moreover, there are no standards for nursing education in this industry. While each state has its own standards of practice for laser procedures, a few allow non-medical people to perform laser treatments under a physician's supervision.
To provide the best care and achieve the best results from in-office procedures, it is important nurses first understand the pathophysiology of the skin, what exactly these laser treatments do to the skin, and what type of post-procedure care is most important for the best results.
Skin Pathophysiology
While you may have learned basic pathophysiology of the skin in nursing school, if you are not specializing in dermatology or plastic surgery you may need a refresher.
The skin consists of three distinct tissues: epidermis, dermis and subcutaneous fat. The epidermis contains four layers beginning with the most superficial: stratum corneum, stratum granulosum, stratum spinosum and stratum basale. The dermis is made up of two layers: papillary and reticular. The subcutaneous fat is the deepest layer.
The stratum corneum is a mixture of cells and lipids arranged like a wall made of bricks and mortar, with the bricks as skin cells and the mortar as lipid (oil) layers. Within the stratum corneum resides the cutaneous permeability barrier, the main function of which is to protect the deeper cells.
The three key lipids in this permeability barrier are cholesterol, ceramides, and free fatty acids. These are produced in the epidermis and the epidermal glands including the sebaceous gland.1-3 Skin in its normal, optimal healthy state is a 1:1:1 molar ratio of these three lipids. When this ratio is out of balance, disruption of the barrier occurs, making the skin more vulnerable to environmental insults and triggering a chronic inflammatory process.
Skin's Natural Response
Over the years, there has been a continual push in the medical aesthetic industry to find the best and latest way to reverse damage and age within the skin.
Lasers and peels have been very popular because they can cause collagen stimulation, tightening, and reduction of wrinkles, redness, pigments and scars. These seemingly positive reactions by the skin occur due to the skin's natural response as seen in wound healing. Lasers and peels injure the skin creating a controlled wound, though they do this in different ways.
Ablative lasers use heat to vaporize the surface of the skin. Non-ablative lasers use light to dissolve unwanted skin cells deeper in the skin while leaving the skin barrier intact. Chemical peels use chemicals to dissolve superficial skin cells.
The body's natural response to heal the "wound" is acute inflammation. This is necessary as a part of the body's normal healing response. However, this incredibly complex process can quickly become detrimental if the proper post-procedure care is not taken.
There are seven inflammatory cascades activated by insults to the stratum corneum. If the acute inflammation lasts for about 14 days, then it becomes destructive chronic inflammation. Each pathway represents a mechanism that, when triggered, releases matrix metalloproteinases (MMPs) into the skin. These enzymes are crucial to the remodeling of the supporting structures that provide tensile strength to the skin, vasculature and related tissues, but halts the healing process.
As the mechanisms each come to the end of their pathways, collagen and elastin are destroyed and the skin is more vulnerable to environmental assault, impacting desired outcomes. Again, just as in wound care, the same effect of chronic inflammation inhibiting wound healing in chronic wounds can take place in aesthetic procedures.
Skin Barrier
There are many potential complications if the skin barrier is not restored quickly following an aesthetic treatment.
When the barrier is compromised after an exfoliating or resurfacing treatment, the skin is exposed allowing as much as 1,000-fold increase in penetration from harmful microbes and pro-inflammatory UV radiation. Some treatment devices can cut through sebaceous glands, releasing bacteria and yeast into deep portions of the skin, which may result in infection.
After any resurfacing treatment, the calcium gradient of the stratum corneum must be restored to allow proper barrier repair. Gas exchange within the skin itself is imperative for proper healing and to prevent possible infection and scarring.
Oxygen is physiologically supplied and processed to skin cells via the bloodstream. After the oxygen is processed, the skin cells naturally release CO2. Some of this CO2 is then released back into the blood stream and respired, some diffuses into the environment through the skin and some interacts with molecules to produce acid. This acid can slow blood flow to the area.
In order to prevent a build-up of CO2, which leads to more acid production and increases the risk for microbial infection, a non-occlusive topical agent must be used to allow some of the CO2 to release into the environment.
Once a treatment procedure is complete, the skin barrier must be rejuvenated as quickly as possible to prevent activation of destructive chronic inflammation. If not, pro-inflammatory environmental insults penetrating the denuded epidermis will prevent the best possible cosmetic result.
Once the stratum corneum has been disrupted, use a product with barrier repair capabilities to help stop the progression to chronic inflammation while protecting the skin from the penetration of these insults.
Post-Procedure Products
Occlusive agents such as pure petroleum jelly (petrolatum) do not allow gas exchange nor renew the calcium gradient. It is known that petrolatum improves wound healing, but it does not return the skin to optimum health.
A post-procedure product with a group of multifunctional active ingredients that reduce inflammation and help repair the skin barrier without occluding the wound surface, will help provide maximal clinical results with minimal risk. Certain ingredients that provide some barrier repair functionality include petrolatum, glycerin, lanolin, bees wax, squalene, aloe, avocado, safflower and meadowfoam.
There are several products available on the market for use post-procedure. To ensure efficacy and safety look for a product in which the final, marketed formulation has been clinically tested.
Ask for the clinical studies from the manufacturer. Clinical studies should be double-blind, with treatment applied to one side of the face, and conducted by independent research organizations on the finished formula (not just testing on a specific ingredient).
Along with finding the right post-procedure product, it is important that this product be reapplied as often as necessary to keep the skin moist and clean at all times.
If ablative procedures have been done, the nurse may also recommend and teach the patient about using sterile technique when applying these products at home or else using a dressing.
Patient Education
Other mandatory steps patients must take to assure best results include avoiding direct sunlight and aggressive use of sunscreen with at least an SPF of 30.
As mentioned before, after these types of procedures skin is even more vulnerable to the environment. Without proper sun protection, the risk of hyperpigmentation is dramatically increased.
Patients should use sunscreens with anti-oxidant and anti-inflammatory properties as that will assist in reducing the inflammation as well. Photo-protective clothing such as hats will also be very beneficial.
Instruct patients to avoid touching, scratching or picking at the skin during the exfoliation process as this puts them at higher risk for infection and scarring. Depending on the aggressiveness of the procedure, patients may also need to avoid hot showers and strenuous exercise for the first few days following it.
Schedule a follow-up appointment(s) to track the progress so recommendations on the post-treatment care can be adjusted, and a regular skin care regimen can be initiated or resumed.
Assuring Best Outcomes
We've all heard about treatments gone wrong. While sometimes it is the skill level of the person performing a laser procedure, many times it is a lack of post-procedure care, instructions or compliance.
The most basic way to achieve the best results is to help return the skin to its optimal state as quickly as possible following a procedure.
It is a nurse's responsibility to follow the patient through the entire healing process after procedures such as lasers and peels.
References for this article can be accessed here.
Molly Johnson is a sales/clinical consultant for wound care and skin care with Episcience in Boise, ID. She has also worked in cardiac nursing and for 2 years worked as clinical research associate on asthma and cardiac clinical trials for drugs and devices.
|