Cosmetic

If we accept that skin is healthy only if the individual is content with the way their skin looks, feels and functions, cosmetic and aesthetic considerations become part of skin health.

Currently in the UK cosmetic dermatology remains a relatively small proportion of a dermatologist’s work and most of what is done is as part of private practice. However in other countries, for example the United States of America, officebased dermatologists provide extensive cosmetic services with nurses providing significant support and education to patients and technical assistance to their medical colleagues. For many the march towards dermatologists doing more cosmetic work is an inevitable part of the modern age. If we accept the fact that skin health includes the psychological well-being which comes as part of feeling good about oneself, this shift may seem acceptable. However, in a national health service with limited resources, providing cosmetic care within that system is generally considered inappropriate. Indeed when dermatologists’ skills are at a premium in order to manage chronic skin disease and skin cancer, it may be considered immoral to use those skills for nondermatological disease procedures.

It can be a challenge to determine when a skin problem is ‘purely cosmetic’ and when it is a dermatological disease requiring treatment. For example, removal of a skin tag (which is harmless to physical health) may be seen as a cosmetic procedure and therefore not a treatment to be carried out as part of a national (public) health service. However, if the skin tag is exactly in a position which catches on a bra-strap and causes pain and discomfort each day, a case may be made for its removal. Likewise a skin tag on the neck may cause acute embarrassment and psychological damage for an individual and thus seeing its removal as part of a treatment process, is a relevant approach. The first example may seem more clear cut, but that is because priorities in health care are usually given to problems that give physical rather than emotional pain. It is easy to see that the line between cosmesis and treatment is blurred and often fraught with controversy.

The beauty industry focuses on the attributes of young looking skin and works hard to persuade a youth oriented world that those attributes are positive and desirable. These messages are so effective that individuals will go to considerable lengths to achieve younger looking skin. Table 1.2 gives some examples of beauty treatments with their intended outcomes, methods of working and possible side effects. In general youth enhancing treatments aim to reduce signs of ageing by smoothing and/or filling wrinkles and improving texture and colouring. Any nurses interested in working in the field of aesthetics would do well to read the latest Royal College of Nursing Guidance (2008) (Royal College of Nursing, 2008).

Table 1.2 Examples of cosmetic procedures.   Type of treatment How it works Outcome Possible side effects                   Botulinum toxin The toxin botulinum is produced by the bacteria Clostridium botulinum. A purified formulation of the toxin (tradename Botox) can be injected into facial muscles and cause paralysis by preventing the release of acetylcholine from motor nerve endings. It also controls sweating by blocking sympathetic nerve fibres. It is used particularly on the face to reduce frown lines and crows feet. The muscle paralysis means that the skin looks smoother. The effect will last for several weeks and individuals may opt to have treatments every 3–6 months. Bruising at the injection site; Eyelid droop if the botulinum toxin tracks down into the eyelid muscle. Headache.                     Exfoliation Physically removing the outermost layer of dead keratinocytes using a rough substance, either a cleanser or a rough cloth/sponge. This is a mild non-invasive treatment, easily carried out at home. The skin will appear ‘brighter’ and smoother. Soreness and discomfort especially for people who have very sensitive skin.                     Fillers A filler smoothes out the skin surface, usually by the injection of a substance into the skin. Substances such as collagen and hyaluronic acid are injectable and need to be redone to maintain effect as they are absorbed into the body over time. The skin will appear smoother. It can be used to reduce facial lines and can also be used on depressed acne scars Numbness; Allergic reactions; Bleeding and bruising.                     Laser resurfacing There are different methods of laser resurfacing. Non-ablative methods have fewer unwanted side effects and treat only the dermis without affecting the epidermis. Ablative methods are more effective but associated with more risk and a longer recovery time The skin is rejuvenated with fewer wrinkles, lines and blemishes. It may also be helpful in removing scars. Few side effects are associated with non-ablative methods. Ablative methods are likely to lead to erythema, swelling, soreness and potential for infection.                     Microdermabrasion A type of exfoliation using a variety of techniques including ‘crystal’ and ‘diamond’ microdermabrasion. Often carried out in spas but increasingly marketed to the home environment. As with exfoliation. Often a series of treatments will be recommended. As with exfoliation above.                     Peels Chemicals are applied to the skin surface to remove the top layers of skin, the extent of epidermal removal depends on the strength of the peel. Smoothes the skin surface and also improves skin tone. It may also be helpful in treating mild acne scarring A mild peel is described as being like sunburn and may cause skin scaling; a more severe peel will lead to blistering, swelling and considerable discomfort and possible skin infection. May lead to scarring.                     Retinol Creams containing retinol or pro-retinol (a form of vitamin A) are thought to increase levels of glycosaminoglycan and procollagen. This leads to greater skin strength and a reduction in the appearance of ageing. Reduces fine lines and wrinkles. Skin redness and soreness; increased sensitivity to sun exposure.                     Thread face-lift Threads with small ‘teeth’ on them are passed through subcutaneous fat just below the skin, with a needle. The threads are then pulled tight and secured with a suture. Sagging or wrinkled skin is smoothed out, but it will not change the shape of the face. The change is permanent but the skin continues to age so the effect lasts for about 5 years. Possible bruising; infection is a risk. If not carried out well facial asymmetry may result.