Skin Types in a Changing World
Written by Susan Etter
The United States is no longer the melting pot that it once was. These days, it is more like an organic, herbal-infused smoothie in a blender. The mixing of various ethnicities and multiple heritages that belong to each individual make it much more difficult to classify someone into one of six Fitzpatrick Skin Type categories. It has long been said that you cannot judge a book by its cover. While that may be an overused adage, it certainly applies in the business of laser/intense pulsed light treatments.
Once a month, our staff participates in a conference call with a number of colleagues who handle laser/intense pulsed light claims on our policies. From an insurance standpoint, we have always been most concerned with treatments on Skin Types V and VI because this skin has a harder time healing and will more likely have issues if not treated properly. Problems resulting from treating these skin types were also more common due to the fact that until the last few years there have only been a few machines manufactured that were intended to treat them. However, insurance companies have recently discovered a different concern: misdiagnosis of the skin type.
Many of the claims we see result from the misdiagnosis of those middle skin types that may be harder to distinguish between than the extremes of Skin Types I or VI. We find that there are many cases of Skin Type IV being treated as a III, V being treated as a IV, and III being treated as a II. When in doubt, a good rule of thumb is to treat the skin as the higher skin type and then increase the settings if the client responds well, bearing in mind that the skin on a cheek will respond differently than on a forearm on the same person.
Some technicians insist that intense pulsed lights are safer than lasers. However, it does not matter what type of machine you use; if you use the wrong settings, you will still injure your client regardless.
For each insurance policy that we write, we review the client intake/medical history form provided to clients. These forms generally include Fitzpatrick Skin Typing questions.
The majority of the incoming forms include only the shortest form of the following:
Which describes your skin type? Please circle one.
- Always burn, never tan
- Always burn, sometimes tan
- Sometimes burn, tan somewhat
- Rarely burn, tan with ease
- Moderately pigmented, tan very easily
- Deeply pigmented, never burn
Is this really enough to go on? At first glance, and based on the above, I would be a Type II. I am, as appearances go, pretty light with naturally dirty blonde hair and blue eyes. Most of my body turns red if I spend more than 30 minutes in the sun. I invest in SPF 50 sunscreen every year, and am pleasantly surprised if I can see my tan line at the end of the summer. Based on other Fitzpatrick questionnaires, I have come up with scores that move me to a Type I or even Type III. That seems to be a pretty big range. One score indicates that I would be an excellent candidate for laser/intense pulsed light hair removal and the other says that I have no business trying to get rid of any hair using that method.
Let us dig a little deeper. For all intents and purposes, I am 75 percent Irish and 25 percent Native American. My body hair color varies widely from head to toe and, after a sebaceous cyst removal, I now know that I can form a keloid scar. Does that change the way you would classify and subsequently treat me? It should.
State laws around the country vary greatly in regards to laser/intense pulsed light treatments and who is qualified to perform them. Some states feel that only doctors are qualified to operate these machines. Some states will allow nurses, some states allow aestheticians, and some states allow other professionals to operate machines if they obtain a laser technician certification. Our experience shows that it is not so much the degree of the technician we need to be concerned about, but more so with the training involved before becoming qualified. As with any skill, training, technique, and practice go hand in hand in becoming a master of your craft. Laser and intense pulsed light manufacturers are happy to send a representative to your facility to provide one day of training on your newly purchased machine. Since knowing the ins and outs of how to operate that device is all important, this is a great resource. A number of new laser and intense pulsed light technicians seem to think this is enough training to start working on the general public. Our experience shows this not to be the case. Some centers are expanding so quickly that perhaps it would seem imprudent that they skip training.
Regardless as to what the state regulates for training prior to starting to work with lasers and intense pulsed lights, each technician needs to spend time in both didactic and hands on training including: types of lasers, the physics behind how they work and the use for each type; laser safety for both the client and the technician; an in-depth discussion of dermis layers, skin types, and tissue interactions on both old and new skin; contraindications for treatment related to medical history, drug interactions, and even vitamin/supplement interactions and; hands on training, including use of various laser types and work on a range of skin types.
It is a bit terrifying to see that a number of machines now come with the option to basically push one button and have the laser itself decide the settings. This is akin to the future of self-driving vehicles. Technology is great, but do not let it to do all the thinking. Perhaps, if a technician is not comfortable adjusting the setting themselves, it is a sign they may need more training.
The other item that has become apparent from our claims is that the states where less training is required have a much higher frequency of claims – typically burns or hyper/hypopigmentation – than those states that force their technicians to go through hours and hours of training. Those performing these services certainly do not intend to harm their clients; most just do not know any better. That, coupled with the changing demographics of the world in which we live, should be enough for the industry as a whole to shift the way they analyze clientele and work towards becoming more comfortable with fine tuning their craft.
Susan Etter joined the Underwriting Team of Professional Program Insurance Brokerage (PPIB) in spring of 2010. She has a 16-year background in insurance. During her time at PPIB, she has developed a strong knowledge of the issues that face MediSpa, Beauty and Body Art businesses. From this expertise, she is becoming a well-known speaker and writer within these industries, advising ways to develop a successful business and implement procedures to increase loss control and prevention. Etter manages the Underwriting Department at PPIB, and is on the Marketing and Business Development Team. Prior to working for PPIB, she managed a number of independent retail insurance agencies.