Report on Chemical Peels to DOL                                               October 16, 2014

Report submitted by:

Anne Martin, CIDESCO Diplomate, Master Aesthetician and Lic.Aes. Instructor;

Sylvia Garcia, Chair, Spokane Community College, Department of Cosmetology and Aesthetics, Master Aesthetician, Lic. Instructor;

Context

A bit of context for the need for law change in Washington State: estheticians are increasingly being hired by doctors, medical spas and clinics. We cost less than nurses and ARNPs, and our subject expertise is skin. In 2008 the cosmetic industry was a $60 billion industry; in 2011 it had increased by 5.3% ... in a recession no less! The call for estheticians to work in these medical spas and laser clinics is sounding louder as the industry responds to the demands of aging baby boomers.

Currently, in Washington, estheticians are required to have 600 hours of education from a licensed school, and then take a state exam given by our governing body, the Washington State Department of Licensing (DOL), to earn an esthetics license. Embedded in that 600 hours is the scope of practice that permits use of lasers. Granted, this work has to be delegated or supervised by a physician (a condition imposed upon estheticians by the Medical Quality Assurance Commission). But, and here’s the rub: no 600-hour school curriculum can fit into it even the most rudimentary instruction on lasers, let alone the in-depth teaching that would prepare estheticians for laser work.

How does laser training happen now? It relies on the business that does the hiring, with no training consistency required. Typically, that education consists of the representative who sold the laser equipment offering two to four hours of training. And then that trained individual usually carries out the training on the next hire, etc. ... a little like playing telephone. Some estheticians or their employers opt to pay for private classes; some pay to go out of state to recognized laser schools, for more thorough and longer training. A good training idea, but it comes at an economic loss to this state. A colleague who operates a laser clinic, with two physicians on board for oversight, reckons she has spent over $25,000 sending her estheticians out of the state for training over the last several years.

To address the laser dilemma, and to raise educational standards in our remarkably advancing esthetic profession, the Northwest Aestheticians’ Guild first presented the idea of tiers in stakeholder workshops held over a span of three to four years and sponsored by DOL. We had carefully considered the idea of a single 1200-hour license and then discarded it, because we thought there will always be those who prefer to practice  traditional esthetics, sans lasers and medium-depth peels, and we wanted room at the table for all. Moreover, we believe it is important in this economic climate to avoid putting smaller schools under such pressure as to double their training to the point that they go out of business. Choice, then, was strongly supported: for schools, as to which tier they would offer (if not both), and estheticians, as to which they would study. Our belief is that the workplace demands will help potential students make the decision as to which tier best suits their goals and answers the marketplace needs.

When offering our proposal, we kept laser and medium-depth peels within scope for the new 1200-hour master esthetician license; the added hours will more broadly and safely educate, while producing work-ready estheticians. And we raised educational standards with the 750-hour esthetician, while defining laser and medium-depth peels as beyond scope of practice.

This new esthetics law belongs to everyone. From its inception, many have worked hard to craft the ideas into a truly viable proposals for law; for that work, they should be justifiably proud.

This good law, soon to be signed into law by our governor, accomplishes the following:

  •  Increases current esthetician 600-hour training to 750-hour to meet the needs of new technology and allow students additional practice and theory while in school;
  •  Prohibits the use of lasers and medium-depth peels for the 750-hour esthetician;
  • Specifies that injections are beyond the scope of practice for all estheticians;
  • Creates a master esthetician license that requires 1200 hours of training, a standard which is in line with several other states; notably Utah with 1200 hours, Kansas with 1000 hours and Nevada with 900 hours; 
  • Stipulates that the master esthetician can operate lasers and perform medium-depth peels (while still adhering to the MQAC rules for laser operation);
  • Automatically grandfathers into the 750-hour esthetician license all currently licensed estheticians;
  • Provides five avenues for current licensees to qualify for the master esthetician license during grandfathering;
  • Gives until January 1, 2015, for estheticians to qualify for the master esthetician under grandfathering

The Law

RCW 18.16.020  

(27) "Practice of esthetics" means the care of the skin for compensation by application, use of preparations, antiseptics, tonics, essential oils, exfoliants, superficial and light peels, or by any device, except laser, or equipment, electrical or otherwise, or by wraps, compresses, cleansing, conditioning, stimulation, superficial skin stimulation, pore extraction, or product application and removal; temporary removal of superfluous hair by means of lotions, creams, appliance, waxing, threading, tweezing, or depilatories, including chemical means; and application of product to the eyelashes and eyebrows, including extensions, design and treatment, tinting and lightening of the hair, excluding the scalp. Under no circumstances does the practice of esthetics include the administration of injections. 

29) "Practice of master esthetics" means the care of the skin for compensation including all of the methods allowed in the definition of the practice of esthetics. It also includes the performance of medium depth peels and the use of medical devices for care of the skin and permanent hair reduction. The medical devices include, but are not limited to, lasers, light, radio frequency, plasma, intense pulsed light, and ultrasound. The use of a medical device must comply with state law and rules, including any laws or rules that require delegation or supervision by a licensed health professional acting within the scope of practice of that health profession.

WAC (Washington Administrative Code-308.20)

(4) For esthetics:

Theory in the practice of esthetics services and business practices (750 hours):

(a) Care of the skin compresses, massage, facials, wraps, masks, exfoliation, use of electrical or mechanical appliances or chemical compounds;

(b) Temporary removal of superfluous hair of the skin by means including tweezing, waxing, tape, chemicals, lotions, creams, sugaring, threading, mechanical or electrical apparatus and appliances;

(c) Sanitizing and disinfecting of individual work stations, individual equipment and tools and proper use and storage of linens;

(d) Diseases and disorders of the skin of the face, neck and hands;

(e) Safety including proper use and storage of chemicals, implements and electrical appliances;

(f) First aid as it relates to esthetics; and

(g) No more than twenty-five percent of skills training using mannequins.

(5) Master esthetics (450 additional hours):

Theory in the practice of master esthetics and business practices includes all of subsection (4) of this section and the following:

(a) Exfoliation and medical esthetic procedures;

(b) Laser, light frequency, radio frequency, ultrasound, and plasma practices;

(c) Medium depth chemical peels;

(d) Advanced client assessment, documentation, and indications/contraindications;

(e) Pretreatment and post-treatment procedures;

(f) Lymphatic drainage and advanced facial massage;

(g) Advanced diseases and disorders of the skin; and

(h) Advanced theories; alternative, touch, and spa body treatments.

Background                                                                                           

The use of chemical peels, termed chemoexfoliation, to rejuvenate skin is one of the most effective tools available to the licensed Aestheticians, and, in stronger forms, to medical professionals.

The goal of chemical peeling is to remove a predictable uniform thickness of damaged skin. Normal healing and skin rejuvenation follow, while complications such as scarring and pigmentary changes, (found in deeper, physician applied peels), are minimized.

The concept of using a chemical agent to resurface the skin for purposes of improved appearance dates as far back as ancient times. In fact, it has been reported that Cleopatra routinely bathed in sour goat's milk to help beautify her skin. Unbeknownst to her, the lactic acid (an alpha hydroxy acid, as is the more well-known glycolic), contained in the milk was the active ingredient providing her with a rejuvenating peel.

The modern era of chemical peeling began at the turn of the century when George Miller MacKee, a dermatologist, began using phenol to treat facial scars. Over the ensuing decades, peeling was popularized by lay operators rather than by physicians. At the time, formulas were considered closely guarded secrets. But eventually, these procedures began to attract widespread attention because of the remarkable results that were achieved. To delineate peel indications and limitations, while improving safety and efficacy, scientific investigation was undertaken by medical researchers who legitimized peel use of various strengths for cosmetic enhancement of the face.

Currently, a number of categories of chemical peeling agents available can be found. These range from mild formulations, available over-the-counter, to light superficial, superficial, medium, and deep chemical agents. When used in the proper setting with appropriate technique, these products have proven very successful in improving quality and appearance of facial skin.

Peels

(Note: though the word peels is used in Aesthetics, the more accurate language for this typical and well known Aesthetic service is rapid exfoliation. However, because the term peels is ubiquitous in the profession, as well as being very familiar to the general public as an Aesthetic service, the term is appropriate to use for the sake of clarity).

Peels are characterized as either timed or layered.

Timed refers to the length of time the peel is on the skin (recommended by the manufacturer). Typically, these range from 30 seconds to 10 minutes, whereupon they are neutralized by either water or an alkaline solution.

 Layers refers to the number of solution layers applied, typically 3-4 in Aesthetic practice, (or more as recommended by the manufacturer).

Aesthetic level peels, using either time or layers, prompt either a light superficial, or superficial action on the skin that promotes cellular rejuvenation, which improves skin texture and color.

  • Light superficial (aka light) peels affect only the outermost layer of the epidermis: these have the same effect as strong scotch tape being pulled from the skin.  Epidermal growth is stimulated through qualitative regenerative changes.
  • Superficial peels affect parts, or all, of the epidermis through break-down challenges, which in turn prompt qualitative changes and improvements in the skin through epidermal regenerative repair.  

These peels are within scope for both the 750 hour and the Master Aesthetician licensee.

All timed and layered peels are designed to reach certain depths in the skin. Depth is determined by:

  • The level of penetration into the skin;
  • The nature of the skin break-down;
  • The skin’s inflammatory response

Note: that depth is affected not only by the type pf peel used, but also the concentration of the agent. Typically, that concentration is made stronger:

  • by lowering the pH and raising the percentage in a given product;
  • by a tweaking of either;
  • by raising the number of payers applied to the skin    

These guidelines are what a manufacturer uses when they specify the effect/outcome and, especially, depth of their peels.

Medical level services are based on depth, and considered (true) peels; these wound tissue beyond the epidermis into the papillary or reticular layer of the dermis, and so prompt a more involved regenerative repair. These peels are categorized as medium and deep, which are indicators of skin depth reached.

  • Medium depth peeling is the use of a chemical agent to wound skin through the papillary dermis.  These products are typically sold only to a physician's office.
  • Deep peels reach to the reticular dermis and are only sold to, and only administered by, a physician.

Note: In Aesthetics, medium depth peels are beyond the scope of the 750 hour Aesthetician, and within scope for the Master Aesthetician, but only when working under the supervision of a medical professional.

Peel Regulation Using Depth, versus pH/Percent

When considering regulation for Aesthetic practice, it was tempting to use pH and percentage as other States have done.

The pH:

  • signifies a scale ranging from O to 14, to measure the acidity-(O)-or the alkalinity-(14)-of the solution;
  • skin measures as slightly acidic, with a pH of 5.5 (with slight variances to either side).     

 Percentage:

  • refers to the amount of the particular peeling agent in the product.      

However, we believe there is an inherent problem when relying upon pH and percentage:

  • it is possible for a practitioner to combine peels by applying one type of peel just before the application of another;
  • though each peel may be within scope of practice, when used together they can potentiate one another;
  • thus, the combining of peels may result in reaching a depth that is categorized as medium depth peel;
    • o   for 750 hour Aestheticians, this is a depth that is beyond scope;
    • o   for Master Estheticians, this depth requires the supervision of a medical provider.

It is also true that regulating by pH and percentage can be a Herculean task, and ultimately, a fractured process because:

  • each type of peel manufactured by the many commercial/medical companies may need to be approved if not specified exactly in existing Rules;
  • new peels come on the market frequently, which begs the question: how can the State respond to each new one?
  • the answer: it would necessitate Rules workshops to respond to anything that was not listed in Ruels.       

Better, then, to regulate by depth, which:

  • uses common medically accepted standards;
  • offers clarity of scope to the Esthetician;
  • is most coherent when definitions are needed by the State licensing agency.

To successfully and safely offer peels, now and as always, the professional expectation of an Aesthetician is to:

  • be comprehensively educated in pre and post-care of the client;
  • choose the correct peel for the individual skin and its challenges;
  • be appropriately educated in the product;
    • o   understand action of peel ingredients;
    • o   realize that pH and percentage are but guidelines to the true safety objective, which is fully understanding the depth the peel reaches;
  • scrupulously follow the manufacturers’ directions;
  • understand and follow scope of practice as it applies to peel applications    

Examples of Peel Depths by Products

Note: We’re including this information as a partial and general guideline, for DOL and Inspectors, of the many peel combinations and variations. It is not an exhaustive or comprehensive list. With all the variable pH and different percentages and chemical exfoliants etc., on the market and in general use, the use of depth , rather than pH, peel name, and percentages to determine scope is clearly the most efficient.

Peel Depths

Light Superficial: 750 hour and Master Aesthetician; affects outer layer of epidermis

  • o   TCA up to 10%
  • o   PCA’s Sensi 6%
  • o   PCA Ultra Peel One 10%
  • o   Jessner’s 1-3 layers
  • o   Glycolic single layer up to 30%, pH 3 (vary), for up to 10 minutes
  • o   Beta Hydroxy acids
  • o   Lactic, tartaric, malic single layer (see Glycolic)

Superficial: 750 hour and Master Aesthetician; affects epidermis

  • o   TCA 10-20% (per manufacturer)
  • o   Jessner’s 4+ layers
  • o   Glycolic single layer 40-50%, pH 3, (can vary) for up to 20 minutes

 Medium: Master Aestheticians under supervision of a Medical professional only; affects to the papillary dermis

  • o   TCA 25-40%    
  • o   TCA plus Jessner’s
  • o   TCA plus Glycolic
  • o   Glycolic 50-70%

Deep: Physician only; affects to the reticular dermis

  • o   Phenol
  • o   Baker Gordon
    • o   Un-occluded
    • o   Occluded

 

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Sources:

Medical Depth Chemical Peels by Gary D. Monheit, M.D., U of Alabama Assoc. Professor at Dermatology Department. (note: Our report is reprinted verbatim from Dr. Monheit’s synoposis , with additional language and editing).

Chemical Exfoliation from ASCP

 Medscape Reference Drugs, Diseases and Procedures (website).  (note: Our report is reprinted verbatim, with additions and editing).