The history and developments of non-medical aesthetic therapies

The definition of non-medical aesthetic therapies.
The term ‘non-medical’ refers to therapies that are not involving, relating to, used in, or concerned with medical care, theory or practice.

So, in this case it refers to minimally invasive aesthetic therapies carried out by therapists who are not registered healthcare practitioners, but are professionally trained in the specific modalities of:

  • Chemical skin peeling
  • Cryolipolysis
  • Laser/IPL hair removal
  • Laser/IPL/LED for skin rejuvenation
  • Laser for tattoo removal
  • Mesotherapy treatments
  • Microneedling
  • Micropigmentation
  • Radio frequency
  • Ultrasound
  • Platelet rich plasma treatments (PRP)

These therapies can become medical in their own sense if used in a manner as to create higher risks and must be used by medical practitioners e.g. medium to deep chemical peels, Medical microneedling to a depth of 2.5mm, IPL for lesions etc.

 

The history and developments of non-medical aesthetic therapies

There has been a substantial growth of non medical therapies over the past number of years. Beauty therapists and medical practitioners have extended their skill set to address skin concerns of ageing, acne and pigmentation with advanced machines and therapies that give proven results.

  • Microneedling

Microneedling is a relatively minimally invasive procedure involving superficial and controlled puncturing of the skin by rolling with miniature fine needles. Over a short period of time, it has gained mass popularity and acceptance as it is a simple, cheap, safe, and effective technique requiring minimal training.

Traditionally used as a collagen induction therapy for facial scars and skin rejuvenation, it is also widely used now as a transdermal delivery system for therapeutic drugs and vaccines. Pens and Derma stamps became the clinic devices with Derma rollers being purchased for home use as a maintenance treatment. Many new machines have recently been launched with additional non-fractional microneedling devices delivering radio frequency (RF) and high intended focussed ultrasound (HIFU) waves to the deeper layers of the skin. 

  • Chemical Peels 

The chemical skin peel, the concept of a topical solution to trigger the skin’s wound healing process, can be traced right back to ancient Egypt some four thousand years ago.
Forward-thinking ancient Egyptians were reported to have used animal oils, salt and alabaster (a soft white mineral or rock, often used for carving) to regenerate skin for aesthetic purposes. In a nod to the distant future of non-surgical aesthetics we know today, the ancient Egyptians also depended on the lactic acid within sour milk as an active chemical agent for exfoliation.
Today, popular peels usually involve either alphahydroxy or betahydroxy acids, with deeper peeling agents used for specific conditions. While the science behind these chemicals is sophisticated, it’s surprising how direct the link is to the past. Alphahydroxy acid for instance forms the basis of many common treatments like the glycolic peel. AHAs include lactic, citric and tartaric acids – all of which have their roots in the age-old cosmetic use of sour milk, sour grapes and citrus juices. Betahydroxy acid peels like the salicylic peel are used to control acne – harking back to the ancient Indian practice of applying wintergreen, an aromatic plant high in BHA, to control skin oil.
Skin peels today are highly refined – absorption rates, penetration and after effects continue to improve. With ongoing efforts to minimise trauma while enhancing results, the skin peel is safer and more effective than ever. Many deeper and more complex treatments are the result of modern research – retinoic acid based peels and TCA for example are 20th century discoveries – but the basics of the skin peel remain unchanged and our debt to the past, and to the long chain of trial and error which got us here, remains.

  • Intense Pulsed Light 

IPL and Laser Hair Removal Machines have been around since the 90’s, they were primarily used for scientific purposes and then IPL evolved and made its transition into the Aesthetic Industry.

After this transition the equipment was expensive and only the wealthy could afford what they thought was ‘permanent’ hair removal treatments; the treatments were exceptionally painful and often were not successful.

The technology evolved into less expensive technology, more refined and resulted in less expensive machines. This allowed for laser hair removal equipment to move from high-end, high-brow clinics and clients only, to be affordable for the general aesthetic and beauty clinics.

Next was the de-regulation of Intense Pulsed Light Laser Hair Removal Treatment, which at the time was regulated by the Health Care Commission (HCC) now called the Care Quality Commission.
This de-regulation facilitated the IPL Technology to be produced and priced much more affordable in  comparison to previous years, along with cheap technology came cheap companies who can supply equipment with only a Chinese  training manual.

Note: regulation by (RQIA)  for laser and IPL equipment and clinics remains legislation  in Northern Ireland

Current working environments
Treatments are performed in salons, aesthetic clinics, medispa and medical environments.

Aesthetic therapies are now practised in skin clinics, beauty salons. Standards for working environments rely on the professionalism of the practitioner. With new standards being published from the Joint council of cosmetic practitioners (JCCP) this has lead the way for guidance to be provided in order to ensure that the clinic complies with the best health and safety advice in order to promote professionalism and safe practice. 

 

The roles of specialist practitioners: medical and non-medical
The roles of medial and non medical practitioner can mix comfortably with one another.  Medical practitioners can have clinical over site in the clinic and be on hand if a complicated  issue arises as well as giving treating the more complex skin issue.
  Non medical practitioners are specialised in their particular area and can deliver outstanding results as they become more experienced in the modality that they are practicing in constantly.

The difference between medical and non-medical treatments, surgical and non-surgical treatment

  • Non medical treatments

These are treatments that can be carried out by non registered health practitioners. They  cause minimum risk to the skin however specific training in their use is still needed to avoid more serious injury.
In essence, the difference between an ‘non medical  Practitioner’ and a ‘Medical Aesthetic Practitioner’ is accountability.
Medical Aesthetic Practitioners are qualified medical professionals and are registered with a governing body. 

  • Medical treatments


 The term “medical treatments” overlaps with nonsurgical treatment so can be inter-used when describing the use of injectables, deeper peels and more invasive treatments.  

  • Non surgical/ Medical aesthetics  

Non-surgical/ Medical aesthetic procedures do not require a surgical incision to be made and are usually considered minimally invasive. However, as with any medical procedure, these treatments may have some side effects, especially if they’re carried out by practitioners who are not properly qualified. 
Types of Non-Surgical Cosmetic Procedures
There are many types of non-surgical cosmetic procedures but some of the most popular treatments include:

  • Botulinum Toxin Injection
  • Dermal fillers 
  • Deep and medium Chemical peels 
  • Surgical treatments

 Surgical treatments require an anaesthetic and are carried out by specialised doctors and include face lifts, breast augmentation or liposuction.

Current dispensing models and regulation for the use of topical anaesthetic products

There are only a few topical anaesthetics available over the counter in a pharmacy, these include, EMLA, LMX-4 and Ametop. These products are ‘P’ medicines, which mean Pharmacy Only Medicine, and should be given under direction of the pharmacist direct to the user (client). It was always believed that professionals could purchase topical anaesthetic for application on their clients prior to any invasive procedure. 

Every council also have their own stance on the use of topical anaesthetics. Some are ok with us purchasing and using the product on our clients after a patch test, whilst others prefer the client to purchase and apply the product themselves. The MHRA also state that it is down to individual councils and our insurers to use the product safely and legally. However, the issue of using ‘P’ products only becomes an issue, when a client has a reaction or subsequently dies from the use of such. 

Can we use OTC (over the counter) topical anaesthetics legally? The law around this is simple, no we cannot. ‘P’ medicines should only be sold to the intended user. Whilst some councils and the MHRA turn a blind eye, it is a risk not worth taking. The best and safest solution is to speak to your client about pain tolerance and discomfort that may be associated with your treatment. If you have a prescriber, then they can prescribe cream specifically for them to use or the client can go and purchase this direct at their local pharmacy. The client should apply this to themselves 20-30 minutes prior to their appointment. The client should also sign to state that they purchased and applied the anaesthetic themselves and/or are happy for you to apply it, if it is for use on eyelids or other areas where they may struggle with the application. 

The role of clinical oversight within non-medical aesthetic therapies
This is were a registered prescriber will oversee other treatments in the clinic. They will take accountability for the treatments delivered from the Non prescriber. Thy must under their code of practice ensure that they are happy that the administrator  is adequately trained and is proficient in the modality that are performing. 

The Keogh Report and the HEE Qualification Standards
In 2013 the previous NHS England national medical director Sir Bruce Keogh’s review of the regulation of cosmetic practice was published (Department of Health and Social Care (DHSC), 2013). 
The review was requested by Andrew Lansley, the then Secretary of State for Health, following an insight into some of the problems and challenges within the sector, gained at the time of the Poly Implant Prothèse (PIP) implant crisis. Some well-crafted phrases, with powerful imagery, were introduced into the report that highlighted the impact of failings in non-surgical practice.
The review stated that a person having a non-surgical procedure has ‘no more protection and redress than someone buying a ballpoint pen or a toothbrush’. It also surmised that dermal fillers were a ‘crisis waiting to happen’.
Keogh’s report presented a picture of an area of practice without defined standards of training, and without efficacy or safety data for the treatments and products being provided. It was clear that patients were rarely supplied with adequate information about the procedure(s) they were offered and, in the event of a complication, they received very little in the way of support.
The initiatives proposed in the Government’s response to the review (DHSC, 2014) were designed to help develop and support ‘a high quality of care and an informed and empowered public’. In the first instance, Health Education England (HEE) was tasked with developing ‘appropriate accredited qualifications for providers of non-surgical interventions’.
The Government’s response stopped short of an agreement with the proposal that ‘all practitioners must be registered centrally on a register, that should be independent of a particular professional group or commercial organisation, and which should be funded through fees’ (DHSC, 2014). It did, however, suggest that ‘clinical involvement in certain non-surgical procedures was key to improving standards of practitioners who are not members of a regulated profession’.

The Joint Council of Cosmetic Practitioners (JCCP)
This body is the Joint Council of Cosmetic Practitioners (JCCP) and is representative of all professional disciplines including plastic surgeons, dermatologists, aesthetic doctors and nurses, dentists and beauty therapists. As such it marks a milestone in recognising and securing the role of beauty therapists and non-medical aesthetic practitioners within the medispa sector as well as in establishing a uniformity of qualification and practice across all disciplines providing aesthetic treatment. One of the government’s stipulations in commissioning the JCCP was that it must establish a voluntary register of practitioners which all professionals working within aesthetics should join, irrespective of other professional memberships. The resultant JCCP register is due to be ready for accreditation by the Professional Standards Authority in June 2017 and officially launched in November 2017.
Practitioners and training organisations will then most likely have 5 years to comply (this term is subject to final JCCP agreement).

Legislation 
While at present this is not a legal or statutory requirement, it is intended that membership of this voluntary register will be implemented in the strongest sense by way of industry selfregulation.
Membership of the register will not only represent a ‘kite mark’ for the public to source appropriately qualified practitioners and compliant clinical facilities but will also register courses and training providers for the guidance of practitioners looking for accredited education and training.
Supplier driven training, and that without the accreditation of an Ofqual awarding body, university or other accrediting organisation endorsed by the JCCP, will not be acceptable for entry onto the register.

Practitioner Registration 
The Register for practitioners will be for: 

1. Practitioners already registered with their professional statutory bodies ( Eg: GMC, NMC, GDC etc) and: 

2. Practitioners not registered with a statutory body – this includes ALL beauty therapists as no national statutory body exists. 

These practitioners must be able to demonstrate that they meet Level 4 and above educational and practice standards as described in the HEE Education and Training Framework as described below. To gain entry onto the register as an individual practitioner you will need a minimum qualification at Level 4 in each treatment genre you wish to provide and you will only be registered for the level of practice stipulated within the qualification framework . For example, to provide superficial chemical skin peels to the Stratum Corneum, a Level 4 qualification in chemical skin peeling will be required, while to peel down to the Dermal-Epidermal Junction will require a Level 6 qualification.

The Cosmetic Practice Standards Authority (CPSA)
The CPSa has been established to standardise protocols for best clinical practice across the aesthetics industry.
It will work in conjunction with the JCCP in order that the clinical and practice standards are integrated fully into the qualification standards.

The British Association for Cosmetic Nurses (BACN)
The BACN is the largest Professional Association for nurses carrying out cosmetic treatments in the UK. It operates under a strict Code of Conduct in order to ensure patient safety across all treatments undertaken by its members.
The BACN has a dual role:

  • To provide services and support to all of its Members
  • To promote and support patient safety in the area of Non-Surgical Aesthetic Treatments

The BACN is a ‘Not for Profit’ organisation owned by its Members and its Board is elected on an Annual Cycle.

National Institute for Clinical Excellence (NICE)
NICE gives  guidance, advice, quality standards and information services for health, public health and social care.they also provide resources to help maximise use of evidence and guidance.
Essential information for key groups including GPs, local government, public health professionals, social care professionals and members of the public is available from heir website 

BSI standards EN 16844:2017 The definition of non-medical aesthetic therapies 
This European Standard addresses the requirements for certain aesthetic non-surgical medical treatments:


  • treatments with resorbable injectables, botulinum toxin and micro needling
  • treatments with non-ablative fractional resurfacing and superficial peels, lasers and comparable energy based devices
  • treatments with fractional ablative lasers and comparable energy based devices and medium depth peels
  • other treatments such as deep chemical peels, full ablative lasers and thread lifts 

This European Standard provides recommendations for aesthetic non-surgical medical treatments, including the ethical framework and general principles according to which aesthetic medicine services are provided by all practitioners and stakeholders of the aesthetic medical field. These recommendations apply before, during and after the treatment.
 Any aesthetic medical treatment that goes deeper than the stratum corneum or which has, or claims to have, a biological effect beyond the stratum corneum (with or without instrument or devices) is included in the scope of this European Standard.
 Aesthetic surgical procedures covered by EN 16372 and dentistry ) procedures are excluded from the scope of this European Standard.
 Aesthetic non-medical treatments (tattooing and any treatment not affecting tissue deeper than the stratum corneum) which can be legally performed by non-physicians (e.g. tattooist, beauty therapists) are excluded from the scope of this European Standard.

NOTE: Some of the information supplied above may either become obsolete or changed according to new reviews post Brexit. We will do our best to update you as soon as changes take place. 


References 

Aaamed.org. (2021). Mission Vision and goals. [online] Available at: https://www.aaamed.org/past_present_future.php
Brody, H., Monheit, G., Resnik, S. and Alt, T., 2000. A History of Chemical Peeling. Dermatologic Surgery, [online] 26(5), pp.405-409. Available at:
 https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1524-4725.2000.00505.x

http://iplmachines.blogspot.com/2013/07/ipl-history-and-evolution.html

https://www.hee.nhs.uk
https://www.rcseng.ac.uk
https://www.gmc-uk.org
https://www.nice.org.uk

Aesthetic medicine has a  history only of decades. The average person who requests medical treatment is referred to as a healthy consumer. Their main aim is to improve their appearance. These patients are not the conventional patient from bygone years but now known as a “consumer patient” 
Aesthetic medicine is minimally invasive compared to cosmetic surgery which requires an aesthetic and includes face lifts, breast augmentation or liposuction.
The dilemma exists in that no matter how mimally invasive, the treatment still carries some risks. As a result some would say it is ethically more challenging when carrying out nonsurgical treatments than with conventional medicine.
Aesthetic medic e bridges the gap beteeen beauty and health.  A healthy  psycho- physical balance is important but  any potential patients may suffer from some form of psychosomatic disorder. It is important that the medical practitioner recognises this and initiates the proper treatment plan. Aesthetic consideration encompasses both nonsurgical and conventional medicine. Even sick patients want to look the best that can when they are getting better.

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