The client is checking out: She just completed her seaweed wrap, or maybe a cellulite treatment. She smiles, pleased that she's taking steps to improve her skin's appearance. As she grabs her wallet, the front desk associate asks whether she could use another tube of sunblock. "No, thanks," the client says. "I don't really use it." She's 35. Her face is showing the beginnings of fine lines, a few dark patches here and there. Either she doesn't notice, or she figures that's what comes with normal aging. But it's not age, and it's not normal. It's sun damage. People who regularly go out in the sun unprotected can develop early wrinkles as well as "tough, leathery skin, making them look older than they are," according to the American Association of Dermatologists. Age spots and scaly growths aren't just cosmetic nuisances—they can develop into skin cancer. "I'm surprised our culture of sun worship hasn't changed more," observes esthetician Mary Napolitano, owner of Napolitano Day Spa in Seattle. "Every magazine you pick up has an article about skin cancer. Many people don't even wear sunglasses, which provide such easy protection!" Napolitano's comments are supported by a study sponsored by the American Cancer Society that found that the number of days adolescents and teens spend at the beach have been increasing, rising from an average of 6.7 days per person in 1998 to 10.3 days in 2004; days spent at the pool remained at 18 days. More than two-thirds of respondents agreed with the statement, "I look better when I have a tan," and more than half agreed, "I feel healthy when I have a nice tan." However, "healthy" is not a word the AAD associates with a tan. "A suntan is actually the result of skin injury," the organization notes. "Tanning occurs when UV rays enter the skin and it protects itself by producing more pigment or melanin." Dermatologist David Bank, founder and director of The Center for Dermatology, Cosmetic and Laser Surgery in Mt. Kisco, New York, sees the tanning trend reflected clinically. "When I was growing up, whoever had the darkest tan at the end of the day won," he laments. "The move in the right direction now is that the depth or darkness of the tan no longer seems to be the ideal. While we still see teens and preteens coming in after vacation with some color, it's more of a light tan."
Seasons in the Sun
Kathi Jones, owner of Persona Day Spa in Houston, believes the generational shift will grow increasingly visible. "Overall, we are seeing a younger population concerned with maintaining good skin care," says Jones, a medical practitioner. "Women in their 30s refer to their mothers—'My mom has those deep lines in her forehead'-and ask how we can help them avoid following in that hereditary path." Particularly for the populations of warm climates, Napolitano says sun damage becomes noticeable as early as the teens and 20s. According to the AAD, Florida receives 150 percent more ultraviolet rays than Maine. The sun's harmful effects are also elevated by wind and reflections from water, sand, and snow. As people reach their 30s and 40s, lines may appear deeper, and wrinkles may even begin. Jones says at that age, spa clients come in wanting solutions to crow's feet and frown and forehead lines.
science of skin damage The sun produces both visible and invisible rays, with the invisible rays causing most of the problems, according to the AAD. Known as ultraviolet-A (UVA) and ultraviolet-B (UVB), these rays are responsible for suntans, sunburns and lasting sun damage. The AAD maintains that there is no such thing as "safe" UV light: "Even on cloudy days, UV radiation reaches the earth and can cause skin damage." That's why the organization recommends that people check the weather section of their local newspapers to find out the UV index on any given day. "When ultraviolet radiation strikes the skin, it creates damage at multiple levels," explains Bank, whose book, Beautiful Skin: Every Woman's Guide to Looking Her Best at Any Age, includes advice regarding sun exposure. "It can damage the cells of the epidermis, changing the DNA in the cells and the way the cells reproduce themselves. Subsequent generations of cells may not replicate normally. Eventually, that's how you get a cancerous skin cell or, in a less drastic consequence, the cells take on a damaged look and develop into what we identify as sun damage." If the damage goes deeper than the epidermis, it can create breaking and fragmenting in the collagen and elastin, Bank continues. "This causes the skin to lose suppleness and elasticity," he says.
Serious Conditions
Complexions are graded from 1 through 6, with 1 the fairest skin and no ability to tan—think red hair, green eyes and freckles—and 6 the darkest African-American skin. "The darker the skin type, the more melanin in the skin," says Bank. "Melanin is our built-in sunblock. Someone with Type 1 skin exposed to 15 minutes of ultraviolet light will have little to no melanin in the skin to act as deflector and shock absorber. Virtually 100 percent of those rays will get into the skin, whereas only five to 10 percent will get past the melanin in Type 6 skin. "Nevertheless, for Type 6 the risk is not zero percent; even people with very dark skin can get skin cancer and should watch the spots and moles on their body." According to the Skin Cancer Foundation, the three types of skin cancer are:
* basal cell carcinoma. Representing more than 800,000 new cases each year in this country, basal cell tumors occur most often on the face, ears, neck, scalp, shoulders and back. With a low rate of metastasis, basal cell is not usually life-threatening but can be difficult to eliminate when not treated promptly. Typically, basal cell appears as an open sore, a reddish patch, a shiny bump, a pink growth or a scar-like area.
* squamous cell carcinoma. The second most common form of skin cancer with about 200,000 new cases estimated to be diagnosed this year in the U.S., squamous cell cancer typically remains localized and can be removed without serious results. Still, a small percentage of cases spread and become life threatening. Tumors appear most frequently on the face, neck, bald scalp, hands, shoulders, arms and back; the rim of the ear and the lower lip are particularly susceptible, as are spots where the skin has suffered burns or scars. Tumors appear thick, rough and shallow.
* melanoma. The most serious form of skin cancer, melanoma still is extremely curable if treated early. In 2007, ACS expects about 60,000 new cases to be diagnosed. ACS lists the "ABCDEs" of melanoma: asymmetry—a mole different on one side from the other side; border—an uneven border; color—most melanomas are black or brown, but some appear skin-colored, pink, red or purple; diameter—bigger moles are more likely a cause for concern; and evolving—any change in a mole is suspicious. Although heredity may play a role, the sun is the major culprit. The Skin Cancer Foundation attributes 90 percent of all skin cancers to sun exposure. "Data show that even one severe sunburn can increase your lifetime risk of melanoma two- or three-fold," says Bank. "That's pretty distressing news. Even so, we want people to go out and live their lives and not worry too much. It's just very important to prevent sunburn." An esthetician with any question about a mole or skin condition should refer the client to a dermatologist. "We see a lot of patients whose spa professional noticed something that didn't look right," Bank notes. "We give kudos to estheticians and massage therapists for being observant and doing the best to help their clients—and they may have saved a life. I tell patients, 'I'd rather have you come in nine times for me to tell you it's fine than have you not come in the tenth time when it's a melanoma."
sunscreen recommendations The AAD recommends applying sunscreen 20 minutes before going outside, even during winter and on cloudy days, and reapplying every two hours. The association suggests a minimum protection of SPF 15 for daily use. Jones feels it's part of the spa's responsibility to drive home the importance of using a sunblock formulated with either zinc oxide or titanium. "We must promote healthy lifestyle practices," Jones remarks. "For that reason, we don't suggest simply limiting sun exposure; rather, we never support any tanning in the sun. I advise clients to wear SPF 45 plus a hat with a big rim so they're protecting the sides of their face." Jones clues clients into sun-protective clothing lines, which offer densely woven fabrics that provide the best protection in hats and other clothing. A 2003 British medical report on the effectiveness of sunblock products concluded that sunscreens are not as effective as they could be, primarily because they are not applied strictly according to the manufacturer's directions. According to the report, people tend to apply the products less thickly than instructed and miss some spots completely. Key sites like the neck, temples and ears can go dangerously naked. Bank says this problem can be addressed by layering products with SPF protection. He tells patients: 1. Start your day with a gentle, mild cleanser recommended by your spa professional or dermatologist. 2. Next, apply a moisturizer that has an SPF and may offer other benefits as well. 3. Consider other products that have SPF, such as glycolics and skin care lines formulated with antioxidants like vitamin C, vitamin E, grapeseed extract and green tea.
Clients can carry this too far and irritate their skin, Bank cautions. "Theoretically SPF 60 make-up cream on top of sunblock may cause skin to break out or get red," he notes. "The best block you can achieve is about 98 or 99 percent. You can't get to 100 percent. So having additional ingredients like antioxidants—a different type of 'player' on the baseline—helps to block the damaging effects."
spa therapies Advice is not the only way the spa is able to come to the aid of the sun-challenged client. When her clients come to Jones with that question about how to fend off the ravages of aging, the spa holds a wealth of options:
* botox. Jones says Botox treatments can help, and even prevent, the appearance of frown and forehead lines, "Botox relaxes the muscles," she explains. "But you have to keep doing it. Then over time, a face that doesn't form a frown cannot develop the crease between the eyebrows. Even someone who already has those lines can smooth them out, sometimes completely." While Botox lasts about three months, Jones says that clients getting regular injections can space them out longer, up to as much as six months.
* fillers. Whereas Botox paralyzes the muscle, other injected fillers add volume or "plump up" the skin. Collagen itself used to be the filler of choice, but allergic reactions to collagen have driven the development of newer fillers like Restylane, Juvederm, Captique, Radiesse, Cosmoderm and Sculptraare. "We're seeing people coming in younger for fillers," says Jones. "Some of these are naturally occurring products in the body, so there's no allergy testing required."
* exfoliation. "Removing the dead skin cells affects the dermis, or top layer, where the collagen and elastin live," explains Bank. "Exfoliation sends messenger signals to the cells in the lower layers that they must increase their rate of replication. This actually hastens repair because, when done repetitively, it can stimulate skin cells to increase turnover, which, in turn, can cause damaged cells to revert back to their normal programming. It's been published in scientific journals that even relatively mild exfoliation techniques can have beneficial effects."
* peels. When performed with proven active ingredients, peels can help people in the 30-60 age range win the battle against sun-produced dark areas, lines and wrinkles, according to Bank. "Active ingredients like glycolic acid can be applied safely in lower concentrations like 20 to 30 percent by a trained esthetician," he says. "It's not a deep peel, but it can provide nice improvement to the skin's appearance. Beta-hydroxy acids can be used in lower strength." Bank mentions Jessner's Solution as a mild peeling agent that can lighten areas of hyperpigmentation and treat sun damage.
* microdermabrasion. Jones offers microdermabrasion along with a light chemical peel, but reinforces the mandate to wear a daily sunscreen as well.
* intense pulsed light (IPL) technology. Both Jones and Napolitano offer IPL, also referred to as "photo therapy" or "light energy," to stimulate collagen production. At Napolitano Day Spa, it's called Photo Rejuvenation; at Persona Day Spa, it's the FotoFacial Skin Rejuvenation service. Jones says it not only helps to repair fine lines but also treats brown spots, capillaries, diffused redness in the skin and textural changes that result from sun damage. "Our service can reverse the effects of sun damage," adds Napolitano, who has about 20 clients taking the regimen of eight weekly treatments and then one treatment every two months.
* lasers. While lasers are effective, Bank stresses that the more potent the treatment, the greater chance for misuse. "Stay up on the regulations in your state and, if a spa therapist is permitted to do laser treatment, make sure that the technician is highly trained," he emphasizes.
* home maintenance. "Put together a good home care skin routine for your client," Bank advises estheticians. "Many products have been shown to prevent, retard and reverse sun damage, beginning with retinol about 20 years ago. Spa professionals can sell these products with confidence to reverse sun damage and help complexions look more smooth, bright and even."
Once they get their skin looking smooth and fit, it's inevitable some clients will want to finish it off with a nice tan. To serve that population without promoting sun exposure, spas may want to carry a self-tanning line or offer a spray-tanning service. "We began offering an airbrush tanning service," says Jones. "Clients put on a disposable bra and panties, and our massage therapist applies the product. It can last up to seven days." Research at this time indicates that both self-tanners and airbrush services are completely safe. The future looks bright for the over-sun-drenched client. "There's a ton of money being poured into research and development to come up with lasers and other devices that can improve the health and appearance of the skin while having no down time," Bank reports. "Right now we can offer super-mild procedures with no down time, or we can do deep chemical peels with results that knock your socks off but require quite a bit of down time. The race is on to find the product that will maximize results."
Seasons in the Sun
Kathi Jones, owner of Persona Day Spa in Houston, believes the generational shift will grow increasingly visible. "Overall, we are seeing a younger population concerned with maintaining good skin care," says Jones, a medical practitioner. "Women in their 30s refer to their mothers—'My mom has those deep lines in her forehead'-and ask how we can help them avoid following in that hereditary path." Particularly for the populations of warm climates, Napolitano says sun damage becomes noticeable as early as the teens and 20s. According to the AAD, Florida receives 150 percent more ultraviolet rays than Maine. The sun's harmful effects are also elevated by wind and reflections from water, sand, and snow. As people reach their 30s and 40s, lines may appear deeper, and wrinkles may even begin. Jones says at that age, spa clients come in wanting solutions to crow's feet and frown and forehead lines.
science of skin damage The sun produces both visible and invisible rays, with the invisible rays causing most of the problems, according to the AAD. Known as ultraviolet-A (UVA) and ultraviolet-B (UVB), these rays are responsible for suntans, sunburns and lasting sun damage. The AAD maintains that there is no such thing as "safe" UV light: "Even on cloudy days, UV radiation reaches the earth and can cause skin damage." That's why the organization recommends that people check the weather section of their local newspapers to find out the UV index on any given day. "When ultraviolet radiation strikes the skin, it creates damage at multiple levels," explains Bank, whose book, Beautiful Skin: Every Woman's Guide to Looking Her Best at Any Age, includes advice regarding sun exposure. "It can damage the cells of the epidermis, changing the DNA in the cells and the way the cells reproduce themselves. Subsequent generations of cells may not replicate normally. Eventually, that's how you get a cancerous skin cell or, in a less drastic consequence, the cells take on a damaged look and develop into what we identify as sun damage." If the damage goes deeper than the epidermis, it can create breaking and fragmenting in the collagen and elastin, Bank continues. "This causes the skin to lose suppleness and elasticity," he says.
Serious Conditions
Complexions are graded from 1 through 6, with 1 the fairest skin and no ability to tan—think red hair, green eyes and freckles—and 6 the darkest African-American skin. "The darker the skin type, the more melanin in the skin," says Bank. "Melanin is our built-in sunblock. Someone with Type 1 skin exposed to 15 minutes of ultraviolet light will have little to no melanin in the skin to act as deflector and shock absorber. Virtually 100 percent of those rays will get into the skin, whereas only five to 10 percent will get past the melanin in Type 6 skin. "Nevertheless, for Type 6 the risk is not zero percent; even people with very dark skin can get skin cancer and should watch the spots and moles on their body." According to the Skin Cancer Foundation, the three types of skin cancer are:
* basal cell carcinoma. Representing more than 800,000 new cases each year in this country, basal cell tumors occur most often on the face, ears, neck, scalp, shoulders and back. With a low rate of metastasis, basal cell is not usually life-threatening but can be difficult to eliminate when not treated promptly. Typically, basal cell appears as an open sore, a reddish patch, a shiny bump, a pink growth or a scar-like area.
* squamous cell carcinoma. The second most common form of skin cancer with about 200,000 new cases estimated to be diagnosed this year in the U.S., squamous cell cancer typically remains localized and can be removed without serious results. Still, a small percentage of cases spread and become life threatening. Tumors appear most frequently on the face, neck, bald scalp, hands, shoulders, arms and back; the rim of the ear and the lower lip are particularly susceptible, as are spots where the skin has suffered burns or scars. Tumors appear thick, rough and shallow.
* melanoma. The most serious form of skin cancer, melanoma still is extremely curable if treated early. In 2007, ACS expects about 60,000 new cases to be diagnosed. ACS lists the "ABCDEs" of melanoma: asymmetry—a mole different on one side from the other side; border—an uneven border; color—most melanomas are black or brown, but some appear skin-colored, pink, red or purple; diameter—bigger moles are more likely a cause for concern; and evolving—any change in a mole is suspicious. Although heredity may play a role, the sun is the major culprit. The Skin Cancer Foundation attributes 90 percent of all skin cancers to sun exposure. "Data show that even one severe sunburn can increase your lifetime risk of melanoma two- or three-fold," says Bank. "That's pretty distressing news. Even so, we want people to go out and live their lives and not worry too much. It's just very important to prevent sunburn." An esthetician with any question about a mole or skin condition should refer the client to a dermatologist. "We see a lot of patients whose spa professional noticed something that didn't look right," Bank notes. "We give kudos to estheticians and massage therapists for being observant and doing the best to help their clients—and they may have saved a life. I tell patients, 'I'd rather have you come in nine times for me to tell you it's fine than have you not come in the tenth time when it's a melanoma."
sunscreen recommendations The AAD recommends applying sunscreen 20 minutes before going outside, even during winter and on cloudy days, and reapplying every two hours. The association suggests a minimum protection of SPF 15 for daily use. Jones feels it's part of the spa's responsibility to drive home the importance of using a sunblock formulated with either zinc oxide or titanium. "We must promote healthy lifestyle practices," Jones remarks. "For that reason, we don't suggest simply limiting sun exposure; rather, we never support any tanning in the sun. I advise clients to wear SPF 45 plus a hat with a big rim so they're protecting the sides of their face." Jones clues clients into sun-protective clothing lines, which offer densely woven fabrics that provide the best protection in hats and other clothing. A 2003 British medical report on the effectiveness of sunblock products concluded that sunscreens are not as effective as they could be, primarily because they are not applied strictly according to the manufacturer's directions. According to the report, people tend to apply the products less thickly than instructed and miss some spots completely. Key sites like the neck, temples and ears can go dangerously naked. Bank says this problem can be addressed by layering products with SPF protection. He tells patients: 1. Start your day with a gentle, mild cleanser recommended by your spa professional or dermatologist. 2. Next, apply a moisturizer that has an SPF and may offer other benefits as well. 3. Consider other products that have SPF, such as glycolics and skin care lines formulated with antioxidants like vitamin C, vitamin E, grapeseed extract and green tea.
Clients can carry this too far and irritate their skin, Bank cautions. "Theoretically SPF 60 make-up cream on top of sunblock may cause skin to break out or get red," he notes. "The best block you can achieve is about 98 or 99 percent. You can't get to 100 percent. So having additional ingredients like antioxidants—a different type of 'player' on the baseline—helps to block the damaging effects."
spa therapies Advice is not the only way the spa is able to come to the aid of the sun-challenged client. When her clients come to Jones with that question about how to fend off the ravages of aging, the spa holds a wealth of options:
* botox. Jones says Botox treatments can help, and even prevent, the appearance of frown and forehead lines, "Botox relaxes the muscles," she explains. "But you have to keep doing it. Then over time, a face that doesn't form a frown cannot develop the crease between the eyebrows. Even someone who already has those lines can smooth them out, sometimes completely." While Botox lasts about three months, Jones says that clients getting regular injections can space them out longer, up to as much as six months.
* fillers. Whereas Botox paralyzes the muscle, other injected fillers add volume or "plump up" the skin. Collagen itself used to be the filler of choice, but allergic reactions to collagen have driven the development of newer fillers like Restylane, Juvederm, Captique, Radiesse, Cosmoderm and Sculptraare. "We're seeing people coming in younger for fillers," says Jones. "Some of these are naturally occurring products in the body, so there's no allergy testing required."
* exfoliation. "Removing the dead skin cells affects the dermis, or top layer, where the collagen and elastin live," explains Bank. "Exfoliation sends messenger signals to the cells in the lower layers that they must increase their rate of replication. This actually hastens repair because, when done repetitively, it can stimulate skin cells to increase turnover, which, in turn, can cause damaged cells to revert back to their normal programming. It's been published in scientific journals that even relatively mild exfoliation techniques can have beneficial effects."
* peels. When performed with proven active ingredients, peels can help people in the 30-60 age range win the battle against sun-produced dark areas, lines and wrinkles, according to Bank. "Active ingredients like glycolic acid can be applied safely in lower concentrations like 20 to 30 percent by a trained esthetician," he says. "It's not a deep peel, but it can provide nice improvement to the skin's appearance. Beta-hydroxy acids can be used in lower strength." Bank mentions Jessner's Solution as a mild peeling agent that can lighten areas of hyperpigmentation and treat sun damage.
* microdermabrasion. Jones offers microdermabrasion along with a light chemical peel, but reinforces the mandate to wear a daily sunscreen as well.
* intense pulsed light (IPL) technology. Both Jones and Napolitano offer IPL, also referred to as "photo therapy" or "light energy," to stimulate collagen production. At Napolitano Day Spa, it's called Photo Rejuvenation; at Persona Day Spa, it's the FotoFacial Skin Rejuvenation service. Jones says it not only helps to repair fine lines but also treats brown spots, capillaries, diffused redness in the skin and textural changes that result from sun damage. "Our service can reverse the effects of sun damage," adds Napolitano, who has about 20 clients taking the regimen of eight weekly treatments and then one treatment every two months.
* lasers. While lasers are effective, Bank stresses that the more potent the treatment, the greater chance for misuse. "Stay up on the regulations in your state and, if a spa therapist is permitted to do laser treatment, make sure that the technician is highly trained," he emphasizes.
* home maintenance. "Put together a good home care skin routine for your client," Bank advises estheticians. "Many products have been shown to prevent, retard and reverse sun damage, beginning with retinol about 20 years ago. Spa professionals can sell these products with confidence to reverse sun damage and help complexions look more smooth, bright and even."
Once they get their skin looking smooth and fit, it's inevitable some clients will want to finish it off with a nice tan. To serve that population without promoting sun exposure, spas may want to carry a self-tanning line or offer a spray-tanning service. "We began offering an airbrush tanning service," says Jones. "Clients put on a disposable bra and panties, and our massage therapist applies the product. It can last up to seven days." Research at this time indicates that both self-tanners and airbrush services are completely safe. The future looks bright for the over-sun-drenched client. "There's a ton of money being poured into research and development to come up with lasers and other devices that can improve the health and appearance of the skin while having no down time," Bank reports. "Right now we can offer super-mild procedures with no down time, or we can do deep chemical peels with results that knock your socks off but require quite a bit of down time. The race is on to find the product that will maximize results."
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