Micropigmentation Training Manual New - Ananta Institute

First Platform to Permanent Make

!

A N A N T A INSTITUTE OF ADVANCED

DERMAL THERAPIES AND AESTHETICS

PRESENTS

THE ART OF MICROPIGMENTATION


Welcome to your training and to the new and exciting adventure into the world of micropigmentation as you enter your career in one of the most rewarding yet challenging professions in the Beauty industry. A career in Permanent Make Up is not only exciting, varied and financially lucrative, but it is also incredibly fulfilling. Being a skilled technician, you have the power to make a positive difference every single day both to the lives of your clients and to yourself, by advancing your own personal journey of growth and development. In order to be successful in this highly competitive industry, you need to learn from the best. Our highly progressive training course will equip you with the knowledge, skills and support that you need to excel in Micropigmentation as well as providing you with national accreditation.

Teaching for us means sharing knowledge, experience and a genuine passion to an art that we have dedicated our lives to. It means supporting you to develop technical skills and trying to get the best out of you. While some students learn quickly, others will need more time; you should not compare yourself to your colleagues during the first few weeks of your learning as everyone learns at different rates. It may be the case that you haven’t been in a classroom situation for a very long time, or you may be a perfectionist who becomes frustrated when you cannot grasp something new immediately and you have to start out as a beginner. During this course you will go through a rollercoaster of emotions and it is totally normal. We are here to offer you guidance and support and to help you become the very best technicians in the world. Work hard, be patient and embrace the team spirit of learning with others to become colleagues and not competitors.

We would like to thank you for choosing to train with us and have no doubt that this first platform to permanent make up will provide you with the foundations to build a long, skilled and successful career in this wonderful industry.


Training Course Code of Conduct 1. Leave your ego outside the door! It’s easy to become frustrated

and angry when you can’t be perfect at something that initially may appear to be very easy, but listen to your trainers and be totally open to their suggestions. Don’t take offence or critique as it’s purely to help you be the very best you can be. Don’t be afraid to ask for help when you need it.

2. Our experienced trainers will not let you do anything on a client if they don’t feel that you’re ready. If you aren’t ready, watch the trainer take over, and use any free moment to practice on the mats provided – practice really does make perfect.

3. IIt is essential that you have up to 120 hours of practice out of the classroom. If you haven’t got to grips with the fundamental theory of Permanent Make Up, you’re not ready to work in a practical environment where knowledge of hygiene and legislation is vital.

4. Safety is paramount.

5. The models on the course are real people and you should treat them with the same respect, courtesy and understanding that you would a regular client in your own clinic. If you feel nervous, if an issue arises that you feel uncomfortable with (such as they are bleeding a lot or you can’t get the colour in) or if there is something that you need to say to your trainer that may be inappropriate for your client to hear, ask to speak to your trainer privately and do not have the conversation in front of the model.

6. Whilst a totally sterile environment cannot be achieved, it is essential that: a. Hands are washed before entering the classroom and sanitizer is used b. Coats and bags are left in the communal area c. Hair is tied back and out of your face d. Gloves are worn at all times when working with models/on skin e. No food or drink is bought into the classroom f. No jewelry is worn g. There is no smoking permitted on the premises h. Mobile phones may only be used in the communal break-out area

7. Please note also that swearing, discriminatory and offensive language/behavior will not be tolerated.

8. While we provide you with the tools and methods to start your own brilliant business in Permanent Make Up, it is forbidden to plagiarize or copy any material from this training manual.


9. Have fun and make the most of the opportunity to learn with some of the very best and most experienced Permanent Make Up trainers!

Contents Health and Safety …

1. The Importance of Hygienic Practices 2. Infection 3. Sanitation and Sterilisation 4. Waste Disposal


5. Workplace Hygiene Checklist 6. First Aid (inc. Needle Stick Injury)

Pre-Procedure … 1. Preliminary Consultation 2. Patch Test 3. Contraindications 4. Consent Forms and Eligibility 5. Client Questions 6. Does it Hurt? 7. Pre-Procedural Advice 8. Contra-actions and Allergic Reactions

Main Theory … 1. Anatomy

a. The Skin b. Inflammation and Healing c. Conditions and Disorders d. The Skeletal System: Bones of the Skull e. The Muscular System: Muscles of the Face f. The Eye g. The Eyebrows h. The Lips

2. Colour Theory 3. Fitzpatrick Skin Type 4. Anaesthetic

Eyebrow Treatments …

1. Trolley Checklist a. Treatment Checklist

2. Predrawing (General) 3. The Art of Microblading

a. Design Considerations b. Preparation and Procedure c. Troubleshooting d. Aftercare

Additional Material for Micropigmentation Qualification …


1. Additional Health, Safety and Security in the Clinic/Salon a. Risk Assessments b. Compliance

2. Quality Management a. The Importance of Quality Management b. Client Satisfaction Surveys

Appendix A: Medical History and Consent Forms Appendix B: Pre-Procedural Advice Appendix C: Aftercare Advice Appendix D: Risk Assessment

What is Permanent Make Up?

Permanent Make Up (Micropigmentation) is a cosmetic tattooing technique which implants minute amounts of pigment into the outer layers of the skin, most commonly using safety regulated cartridges or a single acupuncture needle. The pigments consist of organic and inorganic minerals in a glycerin base, all specifically selected for their hypo-allergenic qualities. It is sometimes described as a ‘cosmedic’ procedure, owing to the fact that it can be used to create perfectly realistic hair-by-hair brows, beautifully shaped lips and add


definition to the eyes for cosmetic purposes but also as a treatment for medical reconstruction and enhancement, providing that finishing touch to reconstructive surgery after, for example, breast cancer or breast surgery where the areola has been removed/distorted.

The Stages Involved

• Preliminary Consultation • Patch Test • Pre-Drawing • Procedure • Retouch • Annual Retouch

We would recommend that the client is seen for a preliminary consultation prior to starting the procedure. This time should be spent listening to what the client wants to achieve and for you to decide firstly whether your client is a suitable candidate for

treatment (for example, a lip treatment will not be suitable for darker skin tones as we will later discuss) and also whether you believe that you can successfully manage your clients expectations and that what they desire is appropriate. If there is any chance that the final outcome of the treatment is not an improvement, we would never recommend carrying out the procedure. A consultation will also allow for you to give the client a patch test (usually a small dot of pigment behind the ear) to ensure that when they come for their treatment, they have no allergy to the pigment.

The next stage is carrying out the actual treatment which will be discussed in more depth later during this course pack, but in essence is comprised of the initial pre-drawing and then the actual cosmetic tattooing procedure. When you are still in the early stages of your Permanent Make Up career, it is important that you allow yourself enough time to carry out your treatment so that you do not feel under pressure or rushed. We generally recommend



that you block out a 2 hour interval for the initial treatment to make sure that you achieve the optimum results. As a beginner, it should certainly not take you any time shorter than 2 hours, and you may find that you require a longer period of time to produce the desired outcome.

The client will be required to return after 4-8 weeks (depending on the treatment method) to complete the process, otherwise known as their retouch. The process will not necessarily be finished until the client has had this retouch, as some skins will not sufficiently retain the pigment from the initial session. Moreover, it is advisable to start off ‘lighter’ in the first treatment as it is much easier to intensify and add to the colour in the second treatment than to remove a colour that is too dark for the client. Any minor shape changes or additions can be made at this stage. Some clients may even need 2 retouches, although this is not common for experienced technicians. To keep the colour looking fresh and fabulous, we would suggest that on average, your client returns every 12 months for a yearly retouch, but if it is correctional/medical work that has been carried out, this time period may vary.


Health and Safety 1. The Importance of Hygienic Practices (p8) 2. Infection (p8) 3. Sanitation and Sterilisation (p9) 4. Waste Disposal (p10) 5. Workplace Hygiene Checklist (p11) 6. First Aid (inc. Needle Stick Injury) (p12)


1. The Importance of Hygienic Practices

Effective use of hygiene practices are necessary in the salon to prevent cross-infection. We are surrounded by ‘germs’. Some germs are harmless, some are even beneficial, but others present a danger to us because they cause disease. Cross-infection occurs when microorganisms capable of causing disease and/or infection are transferred through personal contact or by contact with infected tools that have not been properly cleaned and sterilised.

Contraindication - A contraindication is a reason to not carrying out a service. When you carry out your consultation it is important to check for any type of contraindication or signs of infection. If a contraindication is evident or suspected, advise that your client goes to their GP and gets written confirmation that it is safe to carry out the treatment (attach this letter to their client record card).

Contra-action - A contra-action is an adverse reaction to a treatment or product. This can happen even when all the necessary safety precautions have been taken. It is important that contra-actions are recognised and dealt with appropriately.

2. Infection

Infection occurs when the body becomes contaminated by micro-organisms, these usually include bacteria, fungal or viral causes. The reaction to the infection will depend on its cause and the part of the body which is infected. The general signs of infection are inflammation, swelling and pus. Secondary infection can occur if bacteria penetrate an existing injury or compromised skin that is already infected by a viral or a fungal infection.

The germs which cause disease are usually spread by:

• Unclean hands • Contaminated tools/instruments • Sores and pus • Discharges from the nose and mouth • Shared use of items such as towels and cups • Close contact with infected skin cells • Contaminated blood and tissue fluid

Infectious diseases that are contagious are a contraindication to beauty treatments and clients presenting with a contraindication of this nature should be referred for medical attention. Clients with skin disorders that have caused the skin to crack and inflame should also not be treated as they are more susceptible to secondary infection.


Hygiene practices must always be strictly adhered to for every service offered as sometimes people have a contraindication they are not aware of. If hygiene practices are not followed there could be a risk of contamination from blood-borne viruses such as Hepatitis B and C, and HIV/Aids.

3. Sanitation and Sterilisation

Refers to any procedure undertaken in the salon to remove contamination and reduce the risk of infection. Specific methods are required to ensure effective sanitisation of tools, equipment and implements have taken place. As a permanent make up practitioner, you have a duty of care and it is absolutely imperative that you provide a clean and sanitised environment and equipment for your client.

Sterilisation is the total destruction of all micro-organisms. It is very difficult to maintain sterile conditions as once the items have been exposed to the air they are no longer classed as sterile. Articles that have been cleaned, sterilised and stored hygienically are safe to use on clients.

Methods of Cleaning Tools and Equipment:

• Disinfectant inhibits the growth of disease-causing organisms (except spores) using chemical agents. Disinfectants only reduce the number of organisms however this is usually sufficient for maintaining hygienic conditions. Most are used for wiping down work surfaces and equipment. Disinfectants should only be used under manufacturer's instructions and following the correct COSHH guidelines. Do not use directly on the skin

• Antiseptic is a diluted disinfectant designed for safe use on the skin. It prevents the multiplication of microorganisms by making the conditions unfavourable for growth

• UV Light Radiation is a method of sterilisation that can be used but has limitations. The object being sterilised must be turned regularly as only the surface being exposed to the light rays will be effectively treated. If there is debris or product residue on the instruments this will act as a barrier to the light penetration so effective sterilisation will be slowed down. The UV light must be contained within a closed cabinet as the light is dangerous especially to the eyes. Records of usage should be kept as the ultra violet light source will decrease in its effectiveness over time and new bulbs will need to be installed (follow manufacturer's guidelines)


• Glass Bead Steriliseri can be used for

sterilising small metal tools such as scissors and tweezers. The heat from the beads transfers to the objects effectively killing off microorganisms. All tools must be cleansed before placing in the unit to remove dirt and debris. It is important to follow the correct timing guidelines from the manufacturer's instructions to ensure efficient sterilisation has taken place

• Autoclaveii is the most effective method for killing bacteria and their

spores, however it has its limitations as the temperature needed for this level of effectiveness is 121 -134 °C. It works similar to a pressure cooker using high pressure steam to cleanse the objects. Due to the higher levels of heat it is only suitable for certain objects and these should be cleansed before being placed in the autoclave. Always ensure you have been trained in its use and follow manufacturer's instructions when using equipment of this nature

4. Waste disposal

Disposal of waste should be in a sealed bin lined with a durable polythene bin liner. The bin should be cleaned regularly with disinfectant (this should only be done in a well-ventilated area) following manufacturers’ guidelines to ensure no risk from potential hazards.

Hazardous waste must be disposed of following the correct COSHH procedures, and the member of staff responsible for the disposal must be fully trained.

Clinical contaminated waste usually by blood and tissue fluid should be disposed of as recommended by the environment agency in accordance with the controlled waste regulations.

Any sharp implements that have been used to penetrate or pierce the skin should be placed in a sharps box. The local environmental health department will be able to


advise you on disposal arrangements. All disposable waste matter following


application is contaminated as it will contain blood and tissue fluid. There is a risk of transfer of blood borne infections such as Hepatitis B and C, and HIV.

All staff should be trained in the risks of handling this waste. The waste should be placed in an orange sack which indicates its level of risk and should be kept separate from all other general waste.

Yellow bags are now provided to medical establishments as they are classed as clinical waste and are hazardous.

Orange bags are generally provided to salons as they are classed as a potential hazard. However, both are disposed of in the same way.

Your local environmental health office can give up to date guidance on disposal of such waste.

5. Workplace Hygiene Checklist

To maintain acceptable levels of hygiene:

• Maintain high standards of personal hygiene • Wash hands before and after every treatment using a detergent

containing chlorhexidine which is recognised medically as an effective ingredient for skin sanitation

• Follow all health and safety policies identified during your work place induction and regular work place reviews

• Check all equipment is in good repair and fit for purpose, identify any concerns by labelling and isolating equipment and report to manager for follow up action

• Regularly clean all working surfaces with an appropriate cleaning solution following manufacturers’ guidelines

• Cover any cuts on yourself or client with a suitable waterproof dressing • Ensure all tools have been effectively sterilised or disinfected according to

their manufacturer's instructions, for example using Trigene solution and an autoclave to disinfect callipers, tweezers, metal sharpeners

• Prevent the risk of cross infection by checking for contraindications during the consultation


• Use where possible disposable products and dispose of correctly following use • All gowns and towels should be washed at a minimum of 60 °C and clean

towels and gowns provided for each client. The dirty laundry should then be placed in a covered laundry bin

• Waste should be placed in correct bags or sharps containers depending on their nature and disposed of in accordance with local government legislation. Pigment caps and all contaminated usable items, including the barrier film wrapping should be disposed of in the yellow waste bags

6. First Aid

It is imperative that as a semi-permanent make up practitioner, you know basic first aid techniques acquired through a relevant course (such as those run by St. Johns Ambulance or at local colleges etc.) Many people are nervous prior to their procedure and allergies, although rare, can occur. You should know how to deal with fainting and blackouts, panic attacks, heart palpitations and anaphylaxis, as well as cuts, burns and sprains.

For Needle Stick Injuries you must react immediately, as diseases such as HIV/Aids and Hepatitis are transmitted through the blood. You should remove your gloves and squeeze the injured area hard so that it bleeds, and then run the area under cold water. You should apply a disinfectant such as neat Dettol and put a plaster on the broken skin. The needle cartridge should be changed and gloves should be reapplied. You may wish to carry out a risk-assessment on your client and visit the doctor if you feel you need.

All practitioners should have had a Tetanus and Hepatitis B vaccination prior to entering the industry.

Pre-Procedure 1. Preliminary Consultation 2. Patch Test 3. Contraindications 4. Consent Forms and Eligibility 5. Client Questions 6. Does it Hurt? 7. Pre-Procedural Advice 8. Contra-actions and Allergic Reactions


1. Preliminary Consultation

The preliminary consultation is used to understand what your client wants to achieve and to determine whether they are a suitable candidate for Micropigmentation. Their colourings will be assessed as well as any contraindications they may have that will prohibit them from having the treatment. It is during this consultation that you should be able to answer any questions that your client has and they should be given a patch test. Either at this point, or at the beginning of their procedure the client should be given a consent form to sign, giving you permission to carry out the treatment.

2. Patch Test

A patch test should be given to the client at least 24 hours prior to them having their treatment to help determine whether they have an allergy to either the pigment or anaesthetic. If the client comes to the clinic, a small dot of pigment and anaesthetic should be applied to an inconspicuous part of their body, for example behind the ear. If you are posting their patch test to them, you may wish to send a cotton bud that has some of the pigment and anaesthetic on it which they can rehydrate and apply to themselves.

3. Contraindications

As has previously been mentioned, a contraindication to micropigmentation is a condition that serves as a purpose for a person not undergoing the semi-permanent make up treatment. If your client admits to having one of these conditions, you should not carry out the treatment. This list below is not exhaustive, but these are the most common contraindications preventing a client from having treatment. You should also check with your insurance company as they may put exclusion clauses in your public and product liability insurance relating to certain conditions.

Auto-immune conditions (these require doctors consent prior to

treatment) Antabuse (must be finished course of medication)

Insulin dependent

diabetes Epilepsy

Haemophilia

HIV/Aids

Hepatitis B and

C

Pregnancy and

Breastfeeding Problems

with skin healing


Roaccutane – Must allow 6 months after completing the course before having

treatment Lupus

Undergoing chemotherapy – Need doctors consent prior to

treatment \ Keloid scarring

4. Consent Forms and Eligibility

Your client must declare their medical history and give their signed consent to you carrying out the treatment before you begin. They should also:

• Be over the age of 18 • Not be pregnant of breastfeeding • Have obtained a doctors written consent if they are currently

undergoing chemotherapy or suffer from an immune condition • Be aware that they will not be able to give blood for one year following

their treatment • Be aware that if they are to have an MRI, it should be made aware that

they have permanent make up

See Appendix A for an example medical history and consent forms that should be given to the client.

5. Client Questions

Here are typical answers that we give to our clients frequently asked questions:

How long will my Permanent Make up last?

The majority of clients require 2 initial permanent make-up treatments after which you will require at least one treatment per year to ensure that your make-up stays fresh and fabulous looking for the whole year.

What factors may affect the results?

Pigment implantation is partially affected by differing skin types and by the following: • Medication • Natural skin overtones • Skin characteristics (dryness, oil, sun damage, thickness and or colour) • pH balance of the skin


• Scarring from previous surgery

How long will a treatment take?

Depending on the treatment, we recommend at least 2 hours for each new procedure to ensure that the client receives a detailed and personalized consultation and treatment.

Is it permanent?

Micro-pigmentation procedures can leave residue pigment in the skin permanently. However, it cannot be truly classed in the same category as a tattoo for in many cases the pigment will fade and may even disappear completely.

If the procedure was classed as semi-permanent this would imply that the skin will return to its pre-tattooed stage at some point (this usually would not be the case). The procedure would only be truly classed as semi-permanent if the penetration of pigment only affected the epidermal layers. The layers of the epidermis are constantly renewing themselves so therefore any pigmentation implantation to this level only, would be desquamated out of the skin within a 4 -6 week period.

Traditional tattooing procedures are practiced using inks and dyes which are dissolved in a wetting agent and implanted at a deeper level into the lower reticular layer of the dermis. Micro-pigmentation procedures implant iron oxides into the upper reticular layer of the dermis, therefore there may be a degree of colour visible in the skin for a lifetime. However the degree of colour will usually fade and maintenance procedures are required every 12-18 months to ensure clarity of colour and design. Clients should be informed that the procedure will leave a degree of pigmentation in the skin that is likely to fade over time.

NB. There is an exception to this rule when discussing lip tissue type 1 in comparison to the vermilion border or peri-oral skin. Due to the vascular nature of lip tissue type 1, infused pigment will usually only last about 2-3 years maximum before they need re-treating. The vermilion border and peri-oral skin are more likely to retain pigment and therefore a definite lip line may become apparent as the body of the lip tissue pigment colour fades.

Any area of enhancement can have colour changes as the pigments fade over time, although this is more obvious in eye and eyebrow procedures. Reviewing the clarity and colour every 12 -18 months will ensure the client is satisfied with the overall results and allow for any changes that need to be made.


6. Does it Hurt?

Remember that pain is experienced at differing levels with each individual client and that it is felt as a result of causing damage to the tissues of the body. During the permanent cosmetic procedure, pain can be derived in a number of ways:

• The continuous rapid needle penetration damages the tissue and may present itself as a sharp/scratchy pain

• Stretching the skin. While it is necessary to stretch the skin for good practice, it could cause the client some discomfort, especially as the tissue has been damaged

• The anaesthetics and cleansers used are chemical irritants and can cause what some may consider to be a painful sensation, especially when used around the eyes for example.

It is likely that your client will experience some level of pain, and while you should use anaesthetics to minimize this, your client should not be deluded into thinking that this is a pain-free procedure, nor should they be made to worry that this painful sensation is abnormal. You may wish to mention to your client that she will be more sensitive during her period and also that it is normal to experience pain more on one side of the body than the other because of the positioning of our nerve endings.

You will minimize the pain by:

· Application of anaesthetic (although by law the client must buy their own anaesthetic and apply it themselves)

· Scheduling appointments around the monthly cycle

· Working accurately and with speed · Giving necessary breaks at clients request · Use cooling antiseptic products

throughout the treatment to ease discomfort

· Adopting the correct stretching technique

7. Pre-Procedural Advice


See Appendix B for standard document of pre-procedural advice.

8. Contra-actions and Allergic Reactions

Certain contra-actions are expected in the first week following micro-pigmentation procedures:

· Inflammation - erythema, swelling and increased skin temperature on and around the treatment site is expected for the first 72 hours post treatment. Severe swelling and blistering within in this timescale would indicate allergic reaction to the healing balm. Once application of this product is ceased symptoms would begin to disappear

· Pain - lips are the most sensitive regarding pain and this symptom can last up to 2 weeks post procedure. Eyelid procedures can cause discomfort for around 72 hours post treatment in line with the normal inflammatory response period. Eyebrows are usually a little tender post procedure but are not generally painful

· Peeling/Flaking Skiniii - increased shedding of

the skin will occur following trauma, this is all part of the natural healing process. However prolonged dryness beyond 2 weeks on the eyebrow and eyelid area is not normal and the client should visit their GP. Lips can require the application of moisture balm for up to a month post procedure as they do not contain sweat or sebaceous glands to provide natural lubrication to the area

· Bruising - this can commonly affect the eyelids and lips but is only superficial and normally subsides within 3-5 days


· Herpes Simplex Type 1iv - herpes

outbreak will only occur if the client is already carrying the virus. It would normally manifest itself around day 3 post procedure. The client should be advised to use topical anti-viral creams as a precautionary method for a week following micro-pigmentation enhancement to the lips. However some GP's will prescribe a course of oral anti- viral medication pre and post treatment (Acyclovir). Acyclovir is an antiviral drug. It slows the growth and spread of the herpes virus so that the body can fight off the infection. Acyclovir will not cure herpes, but it can lessen the symptoms of the infection

· Impetigov - impetigo is a skin infection

caused by the bacterium Staphylococcus aureus or Streptococcus pyogenes and causes fluid-filled spots or blisters. The bacterium enters into a cut or opening in the skin and is a common secondary infection following on from herpes simplex. Good hygiene and aftercare practice can minimise the chances of contracting this infection

It is not possible to predict whether a client is likely to be allergic to pigments which may be Organic, Inorganic, Synthetic Organic or Synthetic Inorganic. You should always ask for the safety data sheets on any pigment range which you are using from the manufacturer to prove that the pigment is from a sterile source and the ingredients are safe to be introduced into the human body. Please note that these approved ingredients may vary from one country to another. If you are using monodose pigments, they should not be reused. If you are using multi use bottles of pigment please ensure that they are used within their 'use by' date and once opened kept as clean as possible with regular wiping over.

Allergy testing pre-treatment is mandatory. However it does not guarantee that a reaction will not take place at a later date even if the result is negative. There have been reports of delayed reactions occurring up to 2 years following the procedure. Your client should be made aware of this prior to procedure.


True allergic reaction symptoms to iron oxide pigments would not usually manifest themselves until 3 months and up to 2 years post procedure. The following symptoms on the treatment site following several years could be observed:

· Swelling · Blisters · Pain · Burning sensation · Urticaria · Flakiness/scabbing · Oozing lymph

vi

Allergic reaction of this nature is rare however if you suspect your client has pigment allergy they should be referred to a dermatologist immediately.

Note: All British insurance companies covering micro-pigmentation presently insist on sensitivity testing for pigment prior to treatment. Please refer to your insurers for their patch testing guidelines.

Main Theory 1. Anatomy

a. The Skin b. Inflammation and Healing c. Conditions and Disorders d. The Skeletal System: Bones of the Skull e. The Muscular System: Muscles of the Face f. The Eye g. The Eyebrows h. The Lips

2. Colour Theory 3. Pigments 4. Fitzpatrick Skin Type 5. Anaesthetic


1. Anatomy

As a permanent make up practitioner, it is essential that you have an in depth knowledge of the anatomy of the face, the way certain parts of the face will typically and atypically react to treatment and also conditions and disorders that are known to affect it. You must have an understanding of this before you can learn the main theories of permanent make up.

a. The Skin

Skin is made up of 3 main layers a thin epidermis at the surface a thicker dermis beneath, and below that a fatty layer known as the subcutaneous layer.

The epidermis is made up of 5 layers of cells, these are structured like a brick wall. New cells are constantly being formed in the bottom most layer and they push the older cells towards the surface. As the cells get pushed upwards, they become flat, hard and eventually die (keratinisation), forming a dead layer at the surface.

The cells on the surface of the epidermis are like overlapping tiles and are constantly being shed (desquamation).

vii

These cells contain the protein Keratin, the same substance that the scales of reptiles and feathers of birds are made of. Keratin makes the skin waterproof and tough and adds to its protective function. The epidermis contains a dark pigment called melanin, ethnic skins contain higher levels of melanin than Caucasian skins. Oriental skins have an additional pigment called carotene which gives their skin a yellowish tone. Although Caucasian skins do not have such high levels of melanin, the amount is increased by the action of ultra-violet light on the skin stimulating the pigment producing cells melanocytes into producing more protective pigment.

The dermis is composed of a network of tough connective tissue fibres, blood, lymph capillaries and sense organs. Towards the bottom of the dermis there are sweat glands from which narrow sweat ducts run to the surface of the skin.


Projecting out of the skin are hairs, each hair projects from a hair follicle, and its root is situated deep in the dermis. Opening into the hair follicles are glands which produce oil, they are known as sebaceous glands, the oil they produce is known as sebum, this keeps the hair supple and helps make the skin waterproof.

A muscle runs from the side of each hair follicle to the base of the epidermis, when this muscle contracts it causes the hair to stand upright, when it relaxes the hair lies flat, it is known as the erector pili muscle and is important in temperature control.

Below the dermis is a layer of cells containing fat which varies in thickness from one part of the body to another. This layer is known as the subcutaneous layer, the fat in this layer acts as insulation to preserve body heat and acts as a cushion to protect underlying bones and organs.

The 5 layers of the epidermis are known as:

Stratum Germinativum (Germinating Layer) - This is a single layer of soft cuboid cells. These cells divide to form new cells which push the adjacent ones nearer the surface. The cells also divide to repair surface damage to the skin. Smaller cells called melonocytes are also present in this layer, they produce granules or melanosomes. These contain the yellow, brown or black pigment melanin which is the main pigment agent in skins.

Stratum Spinosum (Prickle Cell Layer) - This layer contains living cells with spiny outgrowths which form bridges between the cells. This layer receives the pigmentation caused by melanin production from the melanocytes situated within the germinating layer.

The Stratum Germinativum and the Stratum Spinosum together form the living layer of the epidermis known as the Malpighian layer.

Stratum Granulosum (Granular Layer) - This is an area where a lot of change takes place in the cells. The nuclei of the cells break down leading to the death of the cells. Keratin is produced in this layer and the cells become harder and flatter.

Stratum Lucidium (Clear Layer) - This is a very shallow layer in facial skin but is thicker on the soles of feet and palms of the hands. The Stratum lucidium will-



form protection against friction. The flattened cells in this layer are completely filled with keratin and are translucent in appearance.

Stratum Corneum (Horny Layer) - This is the outer layer of the epidermis and consists of flat dead cells of keratin. The cells are constantly being shed (desquamated) from the surface of the skin.

The Dermisviii

The average thickness of the dermis is 3 mm and it is made up of 2 regions:

The Papillary Layer - This region interlocks with the epidermis in series of ridges sometimes referred to as the dermal papillae. This layer is continuous around each hair follicle forming a connective tissue sheath. The papillary layer contains a network of blood capillaries to supply the needs of the living cells in this region. The papillary region is made up of collagen fibres, with non-elastic protein fibres and some yellow elastic fibres.

The Reticular Layer - This lies beneath the papillary layer and is made up of a dense network of collagen fibres that are arranged in layers and between which there are many elastic fibres. This arrangement allows the skin to stretch but return to its original form when the stretching forces are removed. A jelly-like ground material of mucopolysaccharides absorbs considerable amounts of water making the skin turgid or taut.

Dermal Cells

There are 3 main types of cells in the dermis:-

1. Mast Cells - when the skin is damaged they secrete histamine which results in dilation of the blood vessels, increasing blood flow and aiding healing.

2. Leucocytes - These cells are white blood corpuscles which can deal with bacteria or foreign material present in the skin, which could lead to infection.

3. Fibroblasts - these are involved in collagen fibre production as well as producing the ground material of the dermis.


"

Pain receptors

Through the varied nerve endings in the skin any changes in the external or internal environment can be relayed to the brain. In addition to the above there are motor nerve endings responsible for secretion of sweat, raising of the hairs and dilation of blood vessels.

Skin's Blood Supply

Blood supplies the skin cells with nutrients, oxygen and hormones and removes waste materials or products from the capillary networks. Tissue fluid is formed which bathes the cells and through this fluid the cells exchange materials. In the skin there are 2 plexuses, a dermal plexus, which runs parallel to the skins surface and from this plexus small vessels extend to form papillary networks around the hairs and glands. These then join to form the sub-papillary plexus just below the papillary layer of the dermis and from these the capillary network of the upper part of the dermis is formed.

Temperature Regulation

Blood carries heat and through the large surface area of the skin heat can be readily lost. If our internal temperature falls below normal and heat needs to be conserved then constriction of the arterioles will occur to reduce blood flow into the capillary networks of the papillary layer. Conversely if the temperature rises above normal then dilation of these same vessels occur to increase blood flow. Heat is lost from the skin through radiation, conduction and by being used in the evaporation of sweat.


Glands of the Skin

There are 2 main types of glands in the body exocrine and endocrine. Exocrine glands have a tube or duct which takes the secretion from the gland and passes it through a pore either into or onto the body surface. All glands of the skin are of this type. Endocrine glands have no duct (ductless) but are surrounded by blood capillaries. Their secretions pass directly into the blood stream and the blood is the transport medium. Hormones are produced in endocrine glands.

Sweat Glands

There are 2 types in our body:

Eccrine - these are the most numerous of the whole skin being concentrated in the palms of hand and soles of feet. They are formed prior to birth and so their number is fixed. They produce a watery secretion, made up of 98% water 2% sodium chloride (salt) with traces of urea and also lactic acid. They secrete throughout the life of the individual and daily up to 1 litre of sweat can be lost in insensible perspiration. The main purpose of sweating is to cool the skin. The sweat when it evaporates from the skin surface uses the heat of the skin to change its state. Sweat production increases with temperature rise in the environment, nervous tension or physical activity.

Apocrine Glands or Odoriferous - these glands are found only in certain body areas i.e. armpits, pubic region and the nipples. They produce an oily secretion which can even be "milky" in colour. It is these glands that can give rise to unpleasant body odours as our resident bacteria attack the fat in the secretion. Gland development takes place at puberty and the secretion is under nervous as well as hormonal control. They differ from eccrine glands in that they are normally associated with hair follicles and open above the level of the sebaceous gland.

Sebaceous Glands - Found in all areas of the skin except soles of feet, palms of hand or between the fingers and toes. They are most numerous in the scalp, forehead, nose and beard areas as well as on the back between the shoulder blades.

The outer epidermis of the skin is concerned mainly with

protection: Protection against invasion by micro-organisms:

· The dead stratum corneum acts as a physical barrier when intact, due to the dead cells not providing any food or moisture for micro-organisms to live on

· The "acid mantle" (pH 5.5) formed by the combined secretions of sebum and eccrine sweat produce unfavourable conditions for bacteria to reproduce in

· The fungicidal properties of sebum helps prevent fungal growth


Protection against ultra-violet rays:

· Melanocytes present in the basale layer of the epidermis produce the pigment melanin, which prevents ultra-violet rays of the sun from penetrating into the dermis beneath

Protection against undue water gain or loss:

· The cells as they flatten and die on leaving the stratum spinosum layer become impregnated with keratin. This protein along with the physical properties of the dead cells forms a waterproof barrier

Repair:

· The stratum basale or germinative layer can replace and repair damaged areas of the skin. Normal epidermal loss due to friction is also replaced by cell division in this region. Excess friction as on the soles of the feet and palms of the hands can lead to a greater increase in the thickness of the stratum lucidium and stratum corneum for protective purposes

Additional Functions of the Skin:

· Acts as a sense organ through its complex network of nerve endings. The skin can detect changes in the environment both favourable and unfavourable and by communication with the nervous system the correct action can be followed

· Synthesis of vitamin D through the action of the ultra violet rays of the sun on steroids present in the upper skin layers

· Storage depot for water and fat

b. Inflammation and Healing

Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the body to remove the injurious stimuli and to initiate the healing process.

When tissue cells become injured they release a number of chemicals that initiate the inflammatory response. Inflammation is characterized by 5 distinct signs, each of which is due to a physiological response to tissue injury. The area becomes painful (dolar), swelling occurs (tumor), vasodilation causes redness (rubor) and temperature increase within the tissues (calor) as pain and swelling intensify impairment of function occurs (functio laesa).

It is important to understand how the skin reacts to inflammation following the superficial wounding caused by micro-pigmentation. With this understanding you will be able to advise

http://en.wikipedia.org/wiki/Blood_vessel

http://en.wikipedia.org/wiki/Pathogen


your clients on aftercare during the expected downtime period following micropigmentation treatment.

Acute Skin Inflammation Following Micro-Pigmentation

Acute inflammation is a short-term process, usually appearing within a few minutes of the cell trauma being induced by micro-pigmentation.

Damage occurs from the initial trauma to the cells and tissues, where the local network of ruptured blood vessels bleed into the tissue spaces and the cell walls rupture. Cellular damage occurs leaving dead and dying cells disrupted by the trauma. Within seconds and up to 10 minutes after the initial trauma local blood vessel constriction occurs. This vasoconstriction minimises blood loss from the area and initiates clotting (haematoma).

and cause stimulation of surrounding pain receptors (dolar).

However, the resulting hypoxia causes tissue necrosis at the primary injury site. This triggers the lysosomes (waste disposal unit within a cell) found within the dead and damaged cells to start to leak digestive enzymes through their ruptured membranes. These enzymes act as inflammatory mediators causing surrounding arterioles and capillaries to dilate (calor and rubor)

Pain receptors are specialised nerve endings located throughout the body in most body tissues. Once the nerve endings are stimulated by these chemicals they begin firing the nerves that are connected to them and send pain signals to the spinal cord and brain.

As blood vessels dilate, they become more permeable and within a few hours exudation increases. As the vessel walls enlarge the speed of flow decreases due to vessels being packed with cells. The stasis of blood allows leukocytes to move along the endothelium and escape through the capillary wall, along with plasma and


other circulating defensive substances such as antibodies, phagocytes, and fibrinogen to the site of the injury. The


arrival of these specialised cells (antibodies, phagocytes) lead to the engulfing of dead cells, foreign material or infectious agents.

As fluid moves out of the capillaries, stagnation of flow and clotting of blood in the small capillaries occurs at the site of injury. This process is caused as fibrinogen produces fibrin which forms a mesh of fibres creating a collection site for red blood cells (haematoma) and also traps micro-organisms preventing their movement further from the injury site. This increased collection of fluid into the tissue spaces causes it to swell (tumor). This expansion of chemical activity in surrounding tissues produces the zone of secondary injury.

Normally, lymphatic vessels drain the area of excess fluid and cells. However following trauma within the tissues the lymph vessels become blocked. The excess fluid and cells collect in the spaces between the tissues around the site of the trauma and oedema occurs. As fluid and cells try to occupy a limited amount of space, the pressure caused on nerve endings is perceived as pain.

A large number of lymphatic channels lie directly beneath the skin.ix

Oedema which is the swelling or natural splinting process of the body has 2 basic components. The first is a liquid, which can be evacuated by the circulatory system and the second is comprised of proteins which have to be evacuated by the lymphatic system.


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The lymph vessel diameter and the flow of the lymph system being decreased causes the swelling to occur in the first 24 hours following micro-pigmentation.

Within 12 hours of injury macrophages move in to digest tissue debris to clear the way for peripheral cells to begin the process of mitosis. Fibrocytes also move into the area to start the process of fibroplasia. Tissue repair overlaps the inflammatory process and within 48 to 72 hours the haematoma is sufficiently diminished to allow for this new growth of tissue.

As the damaged skin within the epidermal layers begins to regenerate, the deeper soft tissues will replace damaged cells with scar tissue. The fibroblasts release collagen, elastin and reticulin fibres forming a mesh network to reconnect tissues.

Over the next 3 day’s mitosis continues and all around the injured area capillary loops develop (angiogenesis). These sprouting vessels originate from pre-existing vessels and appear as minute red granules, hence the name granulation tissue. As the circulation is increased by these additional blood vessels replacing damaged ones, more oxygen and nutrients become readily available to these cells to aid in speeding up the healing process. When circulation is increased it automatically increases lymphatic flow with the movement


of tissue fluid between the 2 systems, allowing the excess build up of lymph to be drained reducing swelling.

Inflammation is the important first stage of healing damaged tissue. Healing cannot occur until inflammation has come and gone. Therefore we cannot prevent inflammation, however we can speed up the processes involved by application of cold therapies following micro-pigmentation for the first 72 hours following treatment.

Whenever trauma occurs to the surface of the epidermis the protective barrier will be impaired, the application of micro-pigmentation treatment will cause a burn, cut or puncture wound to the area infused with pigment.

The epidermis will protect this impairment by the formation of a scab, the size and extent of this scab will be in relation to the trauma caused (scab in picture is not caused by PMU treatment).

x The scab may be minute and

clearer in colour if only lymph vessels has been disturbed, however if capillary damage was involved there will be droplets of blood also in the scab formation.

When treating more mature clients or clients with more sensitive skin, there is a higher tendency to bruise and tear the skin resulting in a greater inflammatory response. This will result in a slightly longer healing process.

The healing process can differ from one client to another; there are several factors to consider such as:

• Age • Health of client • Client lifestyle

As a rule the older you are (once passed 25 years) the slower the expected healing rate. Remember the superficial tissues will display signs of healed skin long before the internal layers have completed the full healing process. The following is a general guideline to expected healing rates:

For Eyeliner and Brows

• 0 - 40 4 weeks • 40 - 60 4 weeks • 60 onwards 6 weeks

Lip procedures

• Full 6 week healing period required whatever age of client


Common Skin Conditions

Papule xi– Small, solid raised area of unbroken skin which often

develops into a pustule.

Pustule xii

– Consists of a small collection of pus which is visible through a raised portion of the epidermis.

Vesicle – Small blister raised above the skin’s surface and containing Serum (a pale yellow liquid similar to blood plasma). Vesicles usually disappear without forming a scar.

Bulla – Blister more than 0.5cm in diameter and is similar to a vesicle but larger.xiii

Nodulexiv

- Small round swelling which extends both above and below the surface of the skin.

Tumor – Swelling of the skin larger than a nodule, consisting of hard or soft tissue.


Weal – White raised area of the skin containing fluid surrounded by a red area. A weal may appear and disappear quite quickly e.g urticaria (see urticaria image)

Bruise xv

-Area of unbroken skin discoloured by blood from dam-aged blood vessels in the dermis.

Scales xvi

– Flakes of easily detached Keratin, eg. scales of dry skin / psoriasis.

Skin Tag xvii

– These are common in the neck of the elderly, but can also be found in the areas of skin folds such as underarms, beneath breasts, eyelids and groin areas. They are small growths of fibrous tissue which stand away from the skin. Sometimes they are pigmented black or brown which makes them more obvious. A doctor may remove them if they prove to be a nuisance or a therapist qualified in advanced electrolysis.

Milia xviii

– This is a small sub-epidermal cyst containing keratin and producing a small white papule. They are common on the face of all age groups. In adults the contents are easily expressed after cutting the overlaying epidermis with a cutting-edge needle.


Xanthomas xix

– Yellow plaques around the skin of the eyelids, these are thought to be connected with certain medical conditions such as high cholesterol, diabetes and blood pressure disorders.

Allergies – Abnormal reaction of sensitivity of the body tissue to an individual substance which does not affect the majority of people.

Urticaria xx

– A skin reaction following contact with an allergen. Erythema combined with raised skin weals and intense itching (pruritis). The condition usually subsides over time with no trace following removal of the allergen, Antihistamines can relieve symptoms.

Keloid Scar xxi

– Overgrowth of abnormal scar tissue, characterised by an excessive build up of collagen fibres. The scar is raised, red and ridged in appearance and sensitive to UV exposure. More common in black skins. Skins with a tendency towards keloid formation should avoid procedures where the skin is pierced or damaged leading to the laying down the scar tissue. Some medical treatments are available to reduce scaring however results vary and are limited.


Pigmentation Disorders

Macule xxii

– Small abnormally coloured area of skin which is level with the skin’s surface so may be seen but not felt e.g. Freckle. The Macule may be darker or lighter than the surrounding skin. A macule larger than 1cm is called a Patch.

Freckles (Ephelides) xxiii

– Small brown macules, common on blonde or red haired people.

Lentigenes (Liver Spot)xxiv

- Hyper-pigmented areas of skin larger than freckles in childhood lentigo simplex can occur. In adulthood Actinic lentigenes can develop due to UV exposure.

Chloasma xxv

– Patchy pigmentation usually found on the cheek area, nose and forehead, lower arms, back of hands and chest. Stimulation occurs from exposure to UV light and is more common in women and darker pigmented skins. The condition is common in pregnancy usually disappearing shortly after the birth, but can also be triggered by the use of oral contraceptives. There is thought to be a connection with raised levels of oestrogen triggering the melanin production.


Dermatosis Pupulosa Nigra xxvi

– Commonly known as flesh moles, these raised pigmented papules are benign growths that are commonly seen on black skins. Common sites are forehead, cheeks, neck, upper chest and back.

Leuoderma (Vitiligo) xxvii

- Patches of un- pigmented skin that can occur anywhere on the face or body due to an autoimmune trigger which causes the breakdown of melanocytes in certain areas of the skin. Once the pigment has been lost the patches are permanent. If vitiligo occurs in areas that are hairy, the pigment in the hair is also affected causing the hair to grow through white.

Albinism xxviii

- The skin is unable to produce melanin and the hair and eyes lack colour. Hair is usually white blonde in appearance and eyes will be pink and extremely sensitive to light. There is no effective treatment for albinism, however protection from UV light for skin and eyes is essential.

Pre-Malignant Skin Conditions

Cutaneous Horn – Warty looking growth protruding from the skin. Found in the elderly, and can indicate malignant change in lower layers. Excision and histological examination are advised.


Keratonacanthoma xxix

- Rapidly growing skin tumour on sun exposed areas. Grows up to 20mm within weeks. Characterised by a central horny plug. This lesion can spontaneously heal.

Solar Keratosis xxx

- Found on sun exposed areas on older clients. Red, scaly, lesions that have been entirely sun induced. Slow growing.

Actinic Cheilitis xxxi

– Grey, scaly areas on lower lip or corners of mouth which are the result of sun exposure or smoking. Can lead to squamous cell carcinoma.


Dysplastic Naevi xxxii

– Inherited trait, multiple large naevi that carry risk of becoming malignant. Irregular shape, size and pigmentation. Regular mole checks needed.

Bowens Disease xxxiii

– Red, scaly plaque that expands out in a circular fashion. Usually found in the elderly, common on lower part of leg. Can develop into squamous cell carcinoma.

Malignant Skin Conditions

Basal Layer Carcinoma xxxiv

- Also known as a rodent ulcer, these are usually seen in the elderly and starts as a spot that fails to heal. Caused by sun exposure but are very slow growing.


Squamous Cell Carcinoma xxxv

- Aggressive growth that generally affects the over 60's. Caused by sun exposure and is twice more common in men. It has the potential to spread.

Malignant Melanoma xxxvi

- Increasing cases due to our obsession with tanning. Common site is legs for women and backs for men. They can occur from an existing mole, and these should be checked for irregular pigmentation or changes in colour and size.

c. Conditions and Disorders

Sebaceous Gland Disorders

Acne Vulgaris xxxvii- This disorder is due to

overactivity of the sebaceous glands causing the follicles to become blocked with a plug of sebum and keratin. Since many sebaceous glands are located on the face, chest and back, these are the most common sites for the disorder. The disorder usually starts at puberty, when increased Androgen production from the sex organs and adrenal glands causes increased sebum production. A keratin plug blocks the follicle and the sebum behind builds up. Black heads


(comedones) are formed by the oxidation of sebum and bacteria may become active in the follicle, producing pus and resulting in inflammation.

Acne usually affects more men than women, and may be affected by such things as diet, stress, weather, premenstrual tension etc. Acne is usually at its worst between 14-18 years, and diminishes and eventually disappears in the early twenties. Treatment involves frequent washing to remove the sebum; the use of chemicals which have a 'peeling' effect and may help to unblock the follicles; antibiotic ointments or pills on a long term basis e.g. Oxytetracycline; ultra-violet radiation in doses which induce erythema and peeling; dietary restriction if the client feels certain that foods are involved (no scientific evidence for this) ; oral contraceptive therapy i.e. oestrogen's to reduce sebum production, but not recommended for males; dermabrasion techniques; vitamin A therapy (trials show that the sebaceous glands diminish in size).

Acne Rosacea xxxviii- Sometimes just called

Rosacea, it is often associated with excess sebum production. Rosacea is usually confined to the 'flush' areas of the forehead, nose, cheeks and chin. Unlike Acne Vulgaris, there is no blockage of the ducts leading to comedones, but inflammation occurs around the sebaceous glands producing papules and pustules. Treatment with low dose long term antibiotics can alleviate symptoms and aid control of the disorder.

Comedones xxxix- A buildup of excess sebum

and keratinised cells blocking the entrance to a follicle. The blockage becomes oxidised giving it a black appearance at the mouth of the follicle. These can become infected leading onto papules and pustules. Common sites are the T zone and chest and back areas.

Seborrhoea xl- Excessive production of

sebum from the sebaceous glands. This condition is usually triggered at puberty when the androgen based hormones trigger enlargement of the sebaceous glands. Follicle openings enlarge and the skin of the face, chest, back, scalp and hair become greasier. This condition usually progresses onto the production of comedones, papules and pustules.


Steatomas/Sebaceous Cysts/Wens xli

- Localised collection of excess sebum, caused by blocked or malfunctioning sebaceous gland. The pocket containing the excess sebum becomes distended and a lump appears often visible above the skin. The cyst can become unsightly dependant on its location. Sebaceous cysts can become infected and would then require treatment with antibiotics under medical supervision. Doctors can remove cysts under local anaesthetic. If the cyst occurs on the upper eyelid it is known as a chalazion or meibomian cyst.

Vascular Skin Disorders

Dilated Capillaries xlii

- Superficial capillaries that have become weakened and stretched causing blood to pool in them. They appear as small red interconnecting lines on the surface of the skin. Common on cheeks, across the bridge of the nose and on thighs in females. Cosmetic camouflage products can be used to disguise or treatment with laser or advanced epilation can successfully remove them.

Erythema xliii

- A reaction in the skin caused by dilation of blood capillaries, it can be localised or generally apparent over the skin surface. It is usually caused by injury, inflammation or stimulation to the skin surface. The skin will appear red. Mild erythema is an expected contra-action following treatments which cause mild trauma to the skin surface. In cases of extreme erythema, the cause if apparent should be noted on the clients record card and the client should be referred to a medical practitioner.

Vascular Naevi - Permanent dilation of blood capillaries which alters the skin pigmentation in the area affected. More commonly known as birth marks. Currently only certain laser treatments operated medically can be used to lessen the appearance of vascular naevi.


Spider Naevi xliv

- Centrally dilated blood vessel with smaller capillaries radiating out from it. Commonly seen on cheeks, upper body, arms and neck. Usually occur following injury to the skin which results in dilation of the capillaries due to weakened capillary walls. Cosmetic camouflage products can used to disguise or treatment with laser or advanced epilation can successfully remove them.

Naevi Vasculosis - Red or purplish raised area which appears on the skin at birth. Caused by a collection of dilated capillaries. Treatment is not usually necessary as most disappear before the age of 6.

Capillary Naevi xlv

- Port-wine stains are red or purple marks, often on the face. They are caused by a localised area of abnormal blood vessels thought to be formed during the foetal stage of development. Treatment with lasers can give good results although complete clearance is rare. Treatment in early childhood is best. Camouflage creams are an alternative treatment.

Cellular Naevi Disorders – Most of these malformations are benign but some can be more sinister in nature. They occur when changes within a cell result in skin malformations.

Junction Naevi xlvi

– Localised mass production of melanocytes causes smooth or slightly raised pigmented areas ranging in colour from pale brown to black. These can occur on any area of the body (benign).


Dermal Naevi xlvii

– Smooth dome shaped nodules ranging from skin tone to dark brown, can contain hairs. Commonly found on the face (benign).

Hairy Naevi xlviii

- Raised mole varying in size and depth of colour, found generally anywhere on the skin. The hairs should be cut not tweezed as tweezing may encourage coarser growth of hair over time. These can be surgically removed for cosmetic reasons.

Seborrhoeic Keratosis xlix

- Very common in middle age, commonly affecting trunk & face. Raised brown, rough, scaly patch that can exceed 2 cm in length. There is no risk of malignant change.

Disorders of Keratinisation

Psoriasis l- Affects about 2% of the

population in NW Europe. It is a chronic skin disease of unknown cause and is believed to be inherited. It is thought to be connected with a fault in metabolism resulting in increased division of cells in patches of skin. It is silvery scales and is commonly seen on the scalp, elbows and knees, but can affect any area of the body, including the nails, where it leads to pitting and Onycholysis. It may be mistaken on the


scalp for severe dandruff, but the scales are thicker, harder, silvery and dry and if the scales are removed, the skin beneath is red. Treatment may involve the application of steroid ointments, coal tar preparations, ultra violet therapy etc.

Dermatitis li- Contact Eczema, more

commonly known as Dermatitis, is due to the epidermis becoming sensitised to substances with which it is in contact. Repeated contact produces inflammation and blistering. The skin becomes red, swollen and studded with minute blisters which burst and form crusts.

This reaction may occur at first contact with the irritant and the irritation is limited to the area of contact, or there may be no visible irritation at first contact, but subsequent contact may provoke irritation in other areas other than the area of contact. If a substance is suspected to be causing allergic contact dermatitis it can be tested by applying it to an area of unaffected skin under a patch of adhesive tape. The patch is removed after 48 hours, or earlier if severe irritation develops. A positive reaction consists of erythema, sometimes with oedema and blistering.

There are 2 types of contact dermatitis:

Irritant contact dermatitis lii- caused by prolonged contact with

chemicals or repetitive wet work which leads to irritation of the skin causing it to become inflamed.

Allergic contact dermatitis liii

- Sensitising chemicals trigger allergic reaction. The reaction is usually delayed and the skin would need to be exposed to the sensitising chemical at least on one previous occasion for the sensitivity to be triggered at a later date. Once this sensitivity has developed you will be allergic to the trigger for life.

Causes of Allergic Contact Dermatitis in Beauty Therapy • Persulphate salts – bleaching agents, oxidising agents • Hydrogen peroxide – oxidising agent • Paraphenylenediamine (PPD) – lash and brow tints • Perfumes Preservatives – products and cosmetics • Detergents – shampoo, soaps • Nickel – tools, equipment, jewellery • Latex gloves



Eczema: Tissue Reaction

This is a form of Dermatitis affecting the upper Dermis and epidermis causing intense itching and the development of a weeping rash, with erythema and oedema. Eczema is a dry skin condition, which is not contagious but comes in many forms. In mild cases of eczema, the skin is dry, scaly, red and itchy. In more severe cases there may be weeping, crusting and bleeding. Constant scratching causes the skin to split and bleed and also leaves it open to infection. Eczema affects people of all ages but is primarily seen in children. It often clears in their teens however it can recur again in later life.

Atopic eczemaliv

is a genetic condition based on the interaction between a number of genes and environmental factors. In most cases there will be a family history of either eczema or one of the other ‘atopic’ conditions i.e. asthma or hay fever.

Seborrhoeic eczemalv

tends to affect the scalp, face, torso and flexures in both adults and children or babies. It bears no special relationship to the sebaceous glands. It may appear as redness and scaling of the scalp or face, especially in the eyebrows and on the side of the nose. A similar rash may appear behind the ears, or as small red scaly patches on the body especially over the sternum and between the scapulae, or in body folds producing red moist patches of broken skin. Treatment involves anti-dandruff or tar preparations for the scalp, and steroid ointments for the face and body.


Discoid eczemalvi

is very distinct with ‘coin shaped’ discs of eczema. Hydrocortisone ointments are usually prescribed to control flare up's.

Gravitational eczemalvii

also known as varicose or stasis eczema and asteatotic eczema also known as eczema cracquelée, usually affects older people. Weight management is important to relieve pressure on the deeper circulatory vessels supplying the lower limbs and improving circulation improves the condition. Topical steroid creams may be prescribed to relieve superficial skin symptoms.

Eczema sufferer's do not produce as much sebum, and will be less able to retain water. The protective barrier (acid mantle) is therefore compromised. Gaps open up between the skin cells because they are not sufficiently plumped up with water. Moisture is then lost from the deeper layers of the skin, allowing bacteria or irritants to penetrate more easily. Some everyday substances contribute to breaking down the skin. Soap, bubble bath and washing- up liquid, for example, will remove oil from anyone’s skin, but if you have eczema your skin breaks down more easily, quickly becoming irritated, cracked and inflamed. Because it is prone to drying out and is easily damaged, skin with eczema is more liable to become red and inflamed on contact with substances that are known to irritate or cause an allergic reaction.

Bacterial Skin Conditions

Bacteria are minute single celled organisms. COCCI are small round bacteria which may be arranged in bunches (STAPHYLOCOCCI) or in long chains (STREPTOCOCCI). Our skin is inhabited by large numbers of bacteria, many are harmless. The 2 above are mostly responsible for skin infections, they may cause disease if they enter the hair follicles or broken skin. The most common bacterial infections of the skin are Boils, Carbuncles and Impetigo.


Boilslviii

– A boil is a deep abscess formed in a hair follicle due to staphylococcal infection. It begins as an under inflamed papule which rapidly develops into a painful pustule. Pus is later discharged from the head of the boil. Removal of the core of pus leaves a cavity which heals with a scar. Predisposing factors are poor general health, chronic illness such as diabetes and the rubbing of the skin, especially at the back of the neck by the pressure of a collar. Boils should be treated by frequent local heat. No cosmetics should be applied to the area and contact with the area should be avoided. If infection becomes severe antibiotics are usually prescribed medically.

Carbuncleslix

– These are formed when several adjacent follicles are simultaneously infected by staphylococci and are in effect a group of boils, which develop several heads. Severe inflammation of the surrounding area that occurs and medical advice should be sought.

Impetigo lx– Rapidly spreading bacterial infection of the surface of the skin.

Staphylococci and Streptococci are usually both present. The infection usually starts with red macules, which quickly form small vesicles filled with serum. Often seen in children and is very contagious. Treatment is medical based usually prescribing antibiotic cream and or oral antibiotics. Conjunctivitis – Inflammation of the eye. Bacterial infection caused by irritation by grit or powder. i.e. eye cosmetics entering the eye. The condition is highly infectious. No cosmetics should be applied to the area. Bacterial eye ointments are usually prescribed by a GP.

Paronychia lxi

– Bacterial infection of the tissue (nail wall) surrounding the nail. Inflammation resulting in swelling, redness and pus occurs. Client should be referred to their GP for treatment.


Styes (Hordeola) lxii

- Bacterial infection of an eyelash hair follicle. A large red painful pus filled lump appears along the lid line. Treatment usually requires antibiotics in topical form. Note -Prescribed antibiotics can cause temporary light sensitivity.

Fungal Infections

Fungi which attack the skin, causing various types of ringworm, consist of a series of finely branching threads known as mycelium. The threads secrete a digestive juice containing a keratin splitting enzyme. The fungus uses keratin for its nutrition and may attack the epidermis, hair or nails but does not invade any living tissue. Any part of the skin, including that of the face, may be affected.

Tinea Corporis (Body Ringworm) lxiii

– This type of ringworm affects the trunk, face or limbs. It is characterised by circular scaly lesions which spread outwards and then heal from the centre leaving a ring. Some papules and pustules may develop. Medical attention is necessary and no cosmetic service should be offered if ringworm is suspected. Treatment is given by the drug Griseofulvin taken orally or topically applied anti-fungal creams.

Tinea Pedis (Athletes Foot) lxiv

- Affects skin between the toes, skin becomes blistered, moist inflamed and itchy. Very contagious. Treatment usually requires keeping skin of feet as clean and dry as possible, with regular applications of anti-fungal ointment and or anti-fungal powders. Shoes should be cleaned inside where possible and anti-fungal powder sprinkled in regularly.


Tinea Capitis lxv

- Ringworm patches affecting the scalp, hair is also affected due to the keratin levels. The patches feel spiky due to the remaining hair shaft protruding through the surface. Medical treatment should be sought.as this will spread rapidly due to high keratin content of hair. Anti-fungal topical lotions will normally be prescribed and all brushes and combs etc. should be regularly sterilised to prevent cross infection.

Tinea Ungium lxvi

- Ringworm of the nails, affects the nail plate causing them to discolour thicken and eventually if left untreated break down. Treatment of nails affected can be lengthy, up to 6 months for finger nails and 18 months for toe nails.

Viral Infections

Many viral infections cause a skin rash eg Measles, German measles, chicken pox as a symptom of the disease. Few viruses cause only a skin rash or infection as the only symptom. Viruses can only grow in living cells in the lower layers of the epidermis.

Warts - A wart is a growth of the epidermis caused by the virus invading the lower layers of the epidermis, causing the cells to multiply quicker and resulting in a thickened area of horny layer of the epidermis.

Common Warts lxvii

- Firm papules with a roughened surface. They may occur singly of merge into large' masses. They are common on the back of the hands, and often cluster around the nails. They may also be found on the face. They are not painful and most disappear within 2 years. Treatment may be considered unnecessary, unless the warts are unsightly. Application of wart 'paints' bought from a chemist usually make the warts disappear, or the doctor may freeze them for 30-60 seconds with carbon dioxide snow or liquid nitrogen.


Plantar Warts lxviii

- Occur on the sole of the foot, and the weight of the body causes them to grow inwards, so they may be painful. Treatment may involve wart 'paints', freezing or cauterisation i.e. burning out.

Plain Warts lxix

– Small, flat - topped and often occur in groups. Treatment again involves the use of wart 'paints', freezing or cauterisation.

Filiform Warts lxx

– Often occur on the face and can be dealt with by cauterisation. Transmission of warts is by contact with an infected person or object e.g. walking in an infected area, from manicure equipment, makeup etc.

Cold Sores (Herpes Simplex) lxxi

– This is a blistering of the epidermis, commonly around the lips. They usually start as irritable or tingling vesicles which crust over and disappear in 7-14 days. The lesions tend to recur every few months. The virus may lie dormant along a nerve and erupt when activated by such things as sunlight, menstruation, high body temperature etc. It is believed that 95% of humans acquire this virus in early childhood and retain the virus in their lips and saliva for life. Transmission involves contact with an infected person or object e.g. kissing, cups, towels, lipstick etc.


Herpes Zoster (Shingles) lxxii

– Very painful condition caused by the virus attacking sensory nerve endings. The virus lies dormant following chicken pox and may remain dormant for years only being triggered when the immune system is low. The skin becomes red, and blistered along the affected line of the nerve. The blisters crust leaving dark purplish/pink pigmentation

Hepatitis B - Hepatitis is a virus that is transmitted by contaminated blood and blood products, saliva, semen and vaginal secretions e.g. from contaminated syringes and needles, dental and medical instruments, tattooing, acupuncture, ear-piercing, electrolysis, sharing razors etc. Some people may be carriers of Hepatitis B i.e. do not show symptoms of the illness, but can transmit it to healthy people. A break in the skin is necessary for transmission. The symptoms usually appear about 3-6 months after infection and include abdominal discomfort, nausea, mild fever, enlarged liver, jaundice. There is also a relationship between Hepatitis B and Liver cancer. 1% of patients die from Hepatitis B. Prevention of infection is concerned with the safe handling of blood, body fluids and infected equipment so the same precautions should be taken for AIDS.

Acquired immune deficiency syndrome (AIDS)

Cause: HIV (Human immunodeficiency virus formerly HTLVIII) Transmission: Contact with infected blood or semen or vaginal secretions. A break in your skin is necessary for transmission. The incubation period can be weeks to years.

Symptoms: After a few weeks, you may develop 'flu / glandular fever symptoms i.e. swollen glands, fatigue, fever, dry cough, aching limbs etc. Then months to years later, patient succumbs to strange illness's which are usually rare in humans e.g.

• Kaposi's sarcoma - A form of skin cancer producing mole-like spots on skin, even on the feet. 20% of British patients develop this illness

• Pneumocystis - A rare form of pneumonia • Cryptospiridiosis - A rare cause of diarrhoea normally carried by cattle • Toxoplasmosis - A disease affecting the brain

HIV enters white blood cells called T-Iymphocytes. HIV contains a strand RNA, so when the virus infects a T-cell, the viral RNA is injected into the T-cell and then converted by the T-cell to Viral DNA which is then incorporated into the host DNA. The T lymphocyte then begins to produce new viruses, which then attack more T lymphocytes. The T-cells are no longer able to perform their function (activating B cells to produce antibodies) so the body succumbs to a wide range of diseases which will eventually kill the patient.


d. The Skeletal System: Bones of the Skulllxxiii

The skull consists of 22 bones; 8 form the cranium and 14 form the facial bones. The bones of the cranium protect the brain and provide muscle attachment points for muscles of the skull. The muscles of facial expression and mastication are attached to the external facial bones.

Frontal Bone – 1 cranium bone that forms the forehead and upper parts of the eye sockets. 2 frontal sinuses are situated one above each eye towards the midline.

Parietal Bone – 2 cranial bones that form the roof of the cranium. At birth the fusion with the drontal bone is incomplete, we recognise this as the anterior fontanel.

Occipital – 1 cranial bone that forms the back of the cranium. This bone articulates with the atlas of the cervical vertebrae (C1) forming a condyloid joint.


Temporal – 2 cranial bones that form part of the sides of the cranium. Situated above the ears and below the parietal bones.

Sphenoid – 1 cranial bone that internally forms the upper floor base of the cranium, serves as a bridge between the focial bones and the cranium.

Ethmoid – 1 cranial bone which forms part of the eye socket, roof of the nasal cavity and part of the nasal septum.

Lacrimal – 2 small facial bones found medially within the orbital cavity (eye sockets).

Turbinate – Facial bones (layered) that are located either side of the outer walls of the nasal cavities.

Vomer – 1 facial bone at the back of the nasal septum (divides the nasal cavity).

Palatine – 2 facial bones that form the anterior portion of the roof of the mouth.

Zygomatic arch – 2 facial bones either side of the face forming the cheekbones. Used as an attachment for muscles of mastication.

Maxilla - 2 facial bones that form the upper part of the jaw and contain the upper teeth. The maxillae have maxillary sinuses which open into the nasal cavity.

Mandible - Facial lower jaw bone, the only freely moveable bone of the skull (hinge joint) contain the lower teeth.

Mastoid - Facial bone situated on the lower edge of the occipital bone, a lump behind the entrance to the ear.

Nasal - Nasal bones extend forward from the base of the frontal bone, they are short and in 2 pieces. Cartilage forms the base of the nose structure.


e. The Muscular System: Muscles of the Facelxxiv

Sterno-Cliedo Mastoid – These muscles run up each side of the neck from sternum and clavicle bones up to the mastoid process. They have an individual action and turn the head side to side. Because this muscle provides a lot of head movement it can become tense with repetitive strain i.e. desk work.

Splenius Capitus – Originates from the occipital bone and runs down both sides of back of the neck connecting to the cervical vertebrae and upper thorax. They extend the neck to hold the head upright. They are easily fatigued from repetitive strain injuries such as desk work etc.

Massester – This muscle runs downwards from the zygomatic arch and backwards to the angle of the jaw (mandible) – around the cheek area. It lifts the mandible and exerts pressure on the teeth when eating. As it is the muscle of mastication, it holds tension from the clenching jaw.


Temporalis – It extends from the temples at the sides of the head to the mandible. It raises the jaw and draws it backwards, as in chewing. It aids mastication. Tempromandibular joint dysfunction syndrome causes this muscle to become over contracted and inflamed.

Corrugator – This muscle is found below the inner corners of the eyebrow. It draws the eyebrows together making you frown. Overuse of this muscle forms vertical expression lines between brows.

Mentalis – This muscle is found on the chin, running from lower lip over the centre of the chin. It raises the lower lip causing the chin to wrinkle. It will give a facial expression of doubt.

Depressor Labii - This muscle runs downwards from the lower lip. Depresses lower lip either on one side or as a whole.

Platysma – This thin muscle is found at the front of the throat and sides of the neck. It pulls down the lower jaw and lower lip. It causes the skin of the neck to wrinkle.

Frontalis – This muscle is found at the forehead (frontal bone) and runs vertically along the forehead to the occipital region. Joining the occipitalis via the epicranial aponeurosis (connective tissue sheath). This muscle raises the eyebrows and wrinkles the forehead. Giving a surprised facial expression. Horizontal expression lines form on the forehead from over contraction of this muscle. Concentration of massage moves in this area can be soothing to a stressed area.

Obicularis Oculi – This muscle surrounds the eyes (sphincter) and closes the eyelid when winking. Overuse of this muscle forms vertical expression lines between brows.

Risorius – This muscle extends diagonally from the corners of the mouth. It draws the mouth corners outwards and is used when smiling. It is used to produce slight smile expression and assists the zygomaticus in producing a wide smile and grinning.

Buccinator – This muscle is found inside the cheeks forming the greater part of the cheek area. Fibres run forwards from the jaw bones to the angle of the mouth. It is used to compress food against teeth during mastication and for blowing and whistling actions.

Zygomaticus – This muscle runs down the cheeks from the zygomatic arch towards the corners of the mouth. It raises the corners of the mouth when smiling/grinning. Laugher lines form from repetitive use of these muscles over time.

Orbicularis Oris – This muscle surrounds the mouth and closes it. It produces a small opening when whistling and is used to pucker the lips when kissing.


f. The Eye

The Eye

Eyeballs sit within the bony sockets (orbits) of the skull and they are enveloped in a membrane called the Capsule of Tennon, which allows them to move freely. The sockets are lined with orbital fat that protect and cushion the eyeballs. The eyeball movement is activated by 4 rectus and 2 oblique muscles that allow movement in different directions.

The cornea is a transparent lens situated on the outer anterior portion of the eye. It is about ½ mm thick and consists of 5 layers:

• Epithelium (surface layer) • Bowman’s membrane • Stroma • Descemet’s membrane • Endothelium layer

The cornea acts as a barrier preventing germs, dirt and other harmful material from entering the inner eye. The lens focuses the entry of light into the eye, when light strikes the cornea, it bends, or refracts the incoming light onto the lens. The surface epithelium layer regenerates quickly, so if any superficial damage occurs although sight will temporarily be damaged, the eye will recover fully.


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However if damage occurs to the endothelium layer, the resulting oedema may become permanent which will affect the corneal transparency and in turn could permanently affect vision

Conjunctiva - The conjunctiva is a mucous membrane covering the outer epithelium covering of the cornea and lining the inner surface of the eyelids. Mucous membranes are the connection between the outer surfaces of skin and the internal lining of orifices. They are highly vascular, and coated with mucous secretions which protect the body openings from foreign particles.

The Iris – (coloured part of the eye) controls the amount of light entering the eye via the pupil. The pupil changes size in response to light levels.

• bright light - muscles contract causing the pupil to constrict • dim light - muscles dilate allowing more light into the eye

The Lens - Is a transparent structure of about 5mm thick with a diameter of about 9mm and is positioned directly behind the iris. The lens focuses the light that passes through the pupil onto the retina. The curvature of the lens is controlled by the nervous system through a system of muscles surrounding the lens. When we focus on objects at different distances we alter that curvature to allow for clearer vision.


The Vitreous Humour – The vitreous humour is a clear, thick, substance comprised mainly of water that fills the centre of the eyeball giving it volume and shape. It connects with the retina.

The Retina – The retina is a light-sensitive layer of tissue, when we look at something we transfer that image onto the retina, which serves much the same function as the film in a camera. Light striking the retina triggers nerve impulses that are sent to various visual centres of the brain through the fibres of the optic nerve.

The retina hosts several layers of neurons interconnected by synapses. The only neurons that are directly sensitive to light are the photoreceptor cells (rods and cones):

• Rods aid vision in dim light and provide black-and-white vision. • Cones aid daytime vision and the perception of colour.

There is a third, rarer type of photoreceptor called the photosensitive ganglion cell. It is important for reflexive responses to bright daylight.

The Macular – The macular is found at the centre of the retina, and allows us to see detail. It has a diameter of approximately 1.5mm.

The Fovea – The fovea is a small pit of around 0.3mm near the centre of the macula which has the highest concentration of cone cells and is free of rod cells.

The Optic Nerve - The optic nerve connects to the back of the eye near to the macula, it is the nerve that transmits visual information from the retina to the brain. The photoreceptor cells of the retina are not present in the connecting part with the optic nerve. As a result this creates a blind spot in our field of vision at the point on the retina where the optic nerve leads back into the brain. This is not normally noticeable because the vision of one eye overlaps with that of the other.

The Eyelid

The eyelid a thin fold of skin that covers and protects the eye from local injury, the blinking of the eyelid aids tear film maintenance, by distributing the protective and optically important tear film over the cornea. Eyelids also aid the flow of tears by their pumping action on the conjunctival sac and lacrimal sac.

The levator palpebrae superioris muscle contracts (voluntarily or involuntarily) to "open" the eye. The eyelid has a row of eyelashes which protect the eye from dust and foreign debris, as well as from perspiration. The eyelid is made up of several layers; from superficial to deep. These are: skin, subcutaneous tissue, orbicularis oculi, orbital septum, tarsal plates and palpebral conjunctiva. The meibomian glands lie within the eyelid and secrete the lipid part of the tear.


The skin of the eyelids is relatively thin and has more pigment cells (in diseased persons these pigments may cause a discolouration of the lids). It contains sweat glands and hairs, and numerous sebaceous glands.

The eye lashes are situated on the margin of the eyelid and are arranged in 3 to 5 rows. They vary in each individual regarding colour, length, thickness and curvature.

The sensory nerve supply to the upper eyelids is from the infratrochlear, supratrochlear, supraorbital and the lacrimal nerves from the ophthalmic branch (V1) of the trigeminal nerve (CNV).

The skin of the lower eyelid is supplied by branches of the infratrochlear at the medial angle, the rest is supplied by branches of the infraorbital nerve of the maxillary branch (V2) of the trigeminal nerve.

The eyelids are supplied with blood by 2 arches on each upper and lower lid. The arches are formed by connecting vessels from the lateral palpebral arteries and medial palpebral arteries, which branch off from the lacrimal artery and opthalmic artery.

The Lacrimal Apparatus

The lacrimal gland produces tears which are excreted through ducts to cleanse, moisten and lubricate the cornea and eyelids. Tears collect in the corners of the eye. If excessive tears collect (crying) they spill out onto the cheeks. However, daily normal secretions produced for protection purposes deal with any over secretion by collecting at the nasal canthus (lachrymal lake) and are then filtered through the lachrymal puncta that are situated at the medial wet line of the eyelids.

The puncta are openings of the lachrymal canals, which are small channels leading to the lachrymal sacs and onto the naso-lacrimal duct. The naso-lacrimal duct empties behind the nose into the naso-pharynx and down the throat.

The lacrimal puncta are visible by pulling up (upper lid) or down (lower lid) on the eyelids. They appear as 4 tiny holes.

The obicularis occuli muscle is a ring of muscle (sphincter) which surrounds the orbit and eyelid area, it has 3 distinct sections - the lachrymal, palpabrae, and orbital portions. The facial nerve (7th Cranial nerve) innervates the obicularis occuli muscle. The obicularis occuli allows the eyelids to be closed, and the blinking action of the lids, the levator palpebrae muscle lifts the upper eyelid when opening the eye (the levator palpebrae is innovated by the 3rd cranial nerve).


The Eyelashes (Cilia)

These are part of the eyes protective function. The slightest contact with the lashes will trigger the blink reflex causing the eyes to close.

The margin of the eyelid which contains the lashes is the connection between the external lid and the conjunctiva lining the internal lid. It is slightly thicker in depth to the skin of the rest of the lid, which means pigmentation insertions between the rows of eyelashes can be slightly deeper in this area to allow for good colour retention.

g. The Eyebrows

The Eyebrows

Eyebrows give protection to the eyes from sweat and sunlight. They cushion the protrusion of underlying bone known as the supraorbital ridge (as the supraorbital ridge is absent in the lateral third of the orbital rim, brow ptosis usually begins here).

Eyebrows are also important to human communication and facial

expression. 4 muscles insert into the skin of the eyebrows to control

eyebrow movements:

• Frontalis: elevate the brows • Orbicularis oculi: closes the eyelids and draw the brows towards the eyes • Corrugator superiocili: pulls the nasal eyebrow inferiorly and

medially, producing vertical glabellar wrinkles • Procerus: pulls the eyebrow inferiorly.

The eyebrow sits along the supraorbital ridge through its attachment to the under surface of the eyebrow fat pad.

h. The Lips

The Lips

The lips surround the entrance to the oral cavity and to accomplish a multitude of functions, lips require a complex system of muscles and supporting structures. Lips serve as the opening for food intake and aid in the articulation of sound and speech. Human lips are a tactile sensory organ, and one of our erogenous zones.

The upper lips are the "Labium superius oris" and the lower lips are the"Labium inferius oris. The juncture where the lips meet the surrounding skin of the mouth area is the vermilion border, and the coloured area within the borders is called the vermilion zone.

http://emedicine.medscape.com/article/1520068-overview

http://emedicine.medscape.com/article/1288447-overview

https://en.wikipedia.org/wiki/Vermilion_border

https://en.wikipedia.org/wiki/Vermilion_border

https://en.wikipedia.org/w/index.php?title=Vermilion_zone&action=edit&redlink=1


The vermilion border of the upper lip is known as the cupid's bow. The fleshy protuberance located in the centre of the upper lip is a tubercle and is known by various terms including the procheilon, tuberculum labii superioris, or the labial tubercle. The vertical groove extending from the procheilon to the nasal septum is called the philtrum.

The skin of the lip, is very thin compared to facial skin. With Caucasian skin colour, the lip skin contains fewer melanocytes. Because of this, the blood vessels appear through the skin of the lips, which leads to their notable red colouring. With darker skin colour this effect is less prominent, as in this case the skin of the lips contains more melanin and thus is visually darker.

The skin of the lip contains no hair follicle, sebaceous or sweat glands. Therefore it does not have the usual protection layer of acid mantle which keep the skin smooth, inhibits pathogens and regulates warmth. For these reasons, the lips dehydrate faster and become chapped more easily.

Blood Supply

The facial artery supplies the lips by its superior and inferior labial branches.

The main cause of brow ptosis is the result of gravitational pull with age, the lateral brow is the most commonly affected due to the absence of the supraorbital ridge laterally. However, medial eyebrow ptosis can occur with atrophy of the eyebrow fat.

Sensory Nerve Supply

· The infraorbital nerve is a branch of the maxillary branch. It supplied not only the upper lip but much of the skin of the face between the upper lip and the lower eyelid, except for the bridge of the nose

· The mental nerve is a branch of the mandibular branch (via the inferior alveolar nerve). It supplies the skin and mucous membrane of the lower lip and labial gingiva (gum) anteriorly

Muscles Acting on the Lips

· The muscles acting on the lips are considered part of the muscles of facial expression and are supplied by the facial nerve. The muscles acting on the lips are:

o Sphincters of the oral orifice o Buccinator o Orbicularis Oris

· Lip evelvation: o Levator labii superioris o Levator Labii superioris alaeque nasi o Levator anguli oris

https://en.wikipedia.org/wiki/Cupid%2527s_bow

https://en.wikipedia.org/wiki/Tubercle

https://en.wikipedia.org/wiki/Procheilon

https://en.wikipedia.org/wiki/Nasal_septum

https://en.wikipedia.org/wiki/Philtrum

https://en.wikipedia.org/wiki/Melanocytes

https://en.wikipedia.org/wiki/Blood_vessel


o Zygomaticus minor o Zygomaticus major

· Lip depression: o Risorius o Depressor anguli oris o Depressor labii inferioris o Mentalis

2. Colour Theory

The colour wheel shows us the different colours of the spectrum and it demonstrates how we can mix colours to create another colour. As a permanent make-up artist you will find that you will develop further skills in colour matching to the client’s skin type without the need of colour swatches, but you will always need to know the basics.

There are 3 different colour types:

· Primary colours: o Red, Yellow, Blue o These are pure, they cannot be recreated from any other colour combination

· Secondary colours: o Orange, Purple, Green o Created by mixing 2 of the primary colours together

· Tertiary colours: o Tones found between the primary and secondary colours


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Complementary colours:

Complementary colours are two colours on opposite sides of the colour wheel. The complementary colour of a primary colour (red, blue or yellow) is the colour you get by mixing the other two: Red + Blue = Purple Blue + Yellow = Green Red + Yellow = Orange


Skin Colour All skins have either a warm tone or a cool tone. As a permanent makeup artist you need to know that:

• RED will add fullness and warmth to your client • BLUE will add depth and darkness to your clients as it becomes

a dense cool colour • YELLOW is a combination of warm and cool tones. It has little

density but it does have extreme intensity

Colour theory is an integral part of the permanent make up procedure. This is because a colour inserted into the skin may change as it mixes with the clients natural undertones. A clients undertones can be described as ‘warm’ or ‘cool’. 85% of the worlds population are cool and if you are in doubt, you should assume that they are a cool undertone. Skin undertones are decided by their ethnicity and genes and can be categorised into 6 groups which we refer to as the Fitzpatrick scale.

Skin colour is dependent on the amount of melanin present. There are 2 types of melanin that may influence our pigment colour selection for permanent make up procedures:

Pheomelanin - these are red to yellow tones of melanin that are found in the hair, lips, nipples and the skin. They are found in light and dark-skinned people, but more commonly in females than males, which is why the body colour of females tends to appear slightly more pinky or red. Redheads have a lot of pheomelanin in their skin. Yellow tones in pheomelanin also determine the pigmentation of a golden-haired person.

Eumelanin - these are brown to black tones of melanin found in the hair and skin.

These colour undertones will ultimately affect the selection of pigment as certain colours will look better or worse on each individual skin tone.

3. Pigments

Pigments – Iron Oxides There seems to be much confusion over the use of Organic and Inorganic pigments used for permanent cosmetic makeup application.

There are 2 types of pigment colour ingredients used for permanent cosmetic makeup. 1. Iron Oxides (Inorganic) 2. Lakes (Organics)

Over 95% of the major permanent cosmetic makeup pigment manufacturers use both Organic and Inorganic cosmetic colorants in their pigment. Permanent cosmetic application involves piercing the skin with single or multiple sterile needles utilizing various insoluble opaque oxides, lakes and iron oxide pigments to create a semi- permanent or permanent design or decoration.


Why Use Iron Oxides and Lakes? Iron oxides used for permanent makeup pigments are essential because iron is the most stable and the most common of all of the elements. It’s nontoxic and has a variety of colours available to technicians. Iron oxides have been one of the most commonly used coloring agents for cosmetics for over a century. They have also been used in natural minerals, not only for permanent cosmetics, but for traditional cosmetics, foods, medications, religious ceremonies and skin protection. Iron oxides are inert, innocuous and non-reactive. In other words they are safe, harmless and inactive.

Colour Ingredients

Color ingredients are regulated by the Federal Food and Drug Administration (FDA). Most pigments used in manufacturing are dry colorants that are ground into a fine powder and added to a vehicle (matrix) of a relatively neutral or colorless material that acts as a binder. A colorant can be both a pigment and a dye depending on the vehicle it is used in. A soluble dye with metallic salts results in a lake pigment, other colorants are iron oxides. Iron oxides have various colors which are classified into three major color groups: yellow iron oxide, red colcothar and black iron oxide. The following table shows the details of the chemical ingredients of each group, being mindful that each group does not consist of a single component, but of a mixture.

Color tone depends on the temperature, concentration, pH, and radius of the particle when manufactured. For example; different tones of yellow can be produced from yellow iron oxide using these properties. At present, iron oxides are the most commonly used pigment for coloring cosmetics such as foundation, blush, lipstick and eye shadow. Various skin colors are produced by mixing these three groups of iron dioxide in different ratios.

ORGANIC Certified colors are organic and are also known as metal salts. They are called “lakes” and are listed on ingredient labels as “D & C” (Drug and Cosmetic).

INORGANIC Non-certified colors are inorganic synthetics. They include; zinc oxide, iron oxides, carmine, mica and ultramarine colors. They are less intense in color than certified colors. Zinc oxide and iron oxide help with opacity, meaning that they provide a solid color that is not transparent. They are used extensively in cover-up makeup products such as foundation. In most powders the ingredients include talc, zinc oxide, titanium dioxide and others.

Chemical name Chemical formula

Yellow iron oxide Ferric oxide, hydrate FeO(OH)

Colcothar Ferric oxide Fe2O3

Black iron oxide Ferrous ferric oxide Fe3O4 (Fe2O3/ FeO)


How Are Pigment Colours Made?

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1. Synthetic organic tattoo pigments are more intense in color than inorganic pigments.2. Give a wider range of colors3. Some are removable by laser Although a number of color additives are approved for use in cosmetics, none is approved for injection into the skin. Using an unapproved color additive in a tattoo ink makes the ink adulterated. Many pigments used in tattoo inks are not approved for skin contact at all. Some are industrial grade colors that are suitable for printers’ ink or automobile paint.

Organic Based Vegetable Pigments Our main concern and focus has always been people’s allergies to vegetable and fruit dyes as so many people have developed life threatening allergies to nuts including peanuts, fruits and berries. If a technician used a brown pigment made from any type of peanut, green made from kiwi, blue or red pigment made from berries and the client had severe allergies to these foods they could have a life threatening reaction go into anaphylaxis and die. Vegetable Pigments can be very dangerous when used for permanent cosmetics.

4. Fitzpatrick Skin Type


As a micropigmentation practitioner we may observe a client’s skin tone by the Fitzpatrick Skin typing. Fitzpatrick skin typing is a method that looks at and considers the following when determining a clients skin colour:

• Client’s skin colour • Hair colour • Eye colour • Ethnicity • An individuals reaction to unprotected sun exposure


Bizarrely the clients determined Fitzpatrick skin typing may differ from their Lip Fitzpatrick skin colour. It is not unusual for a person of dark skin to have lighter colour lips. This should not however be confused by a V or VI type who has areas on their lips which are lighter or geographical in appearance. These clients are generally NOT suitable for lip procedures.

The Fitzpatrick Scale:

· Type I Pale white; blond or red hair; blue eyes;

freckles Always burns, never tans

· Type II White; fair; blond or red hair; blue, green or hazel

eyes Usually burns, tans minimally

· Type III Cream white; fair with any hair or eye color; quite

common Sometimes mild burn, tans uniformly

· Type IV Moderate brown; typical Mediterranean skin

tone Rarely burns, always tans well

· Type V Dark brown; Middle Eastern skin

types Very rarely burns, tans very easily

· Type VI Deeply pigmented dark brown to

black Never burns, tans very easily


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5. Anaesthetic

Anaesthetic can be used not only to make the client more comfortable during their procedure but also to achieve more accurate results, as without anaesthetising the area, the client may try to contract their muscles resulting in pigment being implanted in the wrong area. A topical anaesthetic should generally be applied both before and during treatment for maximum efficacy, depending on whether it is suitable for broken or unbroken skin. It is also important to let the client know that they may still feel discomfort, although it will be greatly reduced.

The amount of anaesthetic that you will need to use will be dependent on the individual. Clients with higher metabolisms, for example may process the anaesthetic more quickly and therefore require more of it throughout the procedure.

It is incredibly important that you are aware of the national guidelines regarding the use of anaesthetics, and any use of prescription anaesthetic deemed to be used inappropriately or illegally will result is prosecution.

Please note that the client must purchase the anaesthetics that will be used herself.

Use of Topical Anaesthetic

If choosing to use topical anaesthetic creams to numb the area, they should be applied 30 minutes before commencement of treatment. Below is a quick guide on how to use a product, but you must follow manufacturers recommendations.

Prescription only medicine (client will need to obtain from GP), cream is usually applied thickly to treatment area and covered with cling film. It can take 30-60 minutes for this cream to effectively numb the area. The anaesthetic contains 2 medicines called lidocaine and prilocaine that belong to a group of medicines called local anaesthetics. Application of this


cream will reduce pain on the skin, however you may still experience feelings of pressure and touch.

It is common for the skin to look paler for a short time following the application of the cream, some people may experience erythema and slight swelling.

Topical Anaesthetic cream should not be used if you are allergic to any of the following ingredients:

• Lidocaine • Prilocaine • Polyoxyethylene hydrogenated castor oil • Carbomer 974P • Sodium hydroxide • Purified water

GP permission should be sought before use on the following clients suffering with:

• Anaemia • Rare inherited illness called glucose-6-phosphate dehydrogenase deficiency • Methaemoglobinaemia (affects blood pigment levels) • Atopic dermatitis

Or using the following medications:

• Sulphonamides (a large group of synthetic bacteriostatic drugs that are effective in treating infections caused by many gram-negative and gram- positive microorganisms. They are used in treating many urinary tract infections)

• Other local anaesthetics • Mexiletine or amiodarone (treatment for uneven heart beat)

The above information should be checked at the consultation stage of treatment. Numbing cream or Emla cream is not recommended for use close to the eye area and never during any eye procedure. If using around the mouth area ensure ingestion of product does not take place.

Topical Numbing can be purchased without a prescription. The cream will numb the area within 30 minutes of application. The Numbing creams and gels may keep the area numb for up to 30-45 minutes after application. When applied to the eye area if reaction occurs be sure to remove and flush the eye with saline.


It is usual to see slight flushing of the skin in the treated area due to widening of the small blood vessels (erythema).

Some clients may experience:

• Swelling (oedema) of the skin in the treated area • Itching of the skin in the treated area • Blistering of the skin at the site of application may occur very rarely.

If this happens the gel should be removed from the skin immediately

Use of Emla cream is not recommended as not only will it cause a skin irritation it may also inhibit the effectiveness of micro-pigmentation treatment.

Topical anaesthaesthic should not be used if you are allergic to any of the following ingredients:

• 4% w/w of tetracaine • Purified water • Sodium chloride • Potassium phosphate • Xanthan gum (E415) • Sodium hydroxide and sodium methyl and propyl-p-hydroxybenzoates

(E217 & E219)

GP permission should be sought before use on the following clients suffering with: • Epilepsy • Allergies to local anaesthetics • Heart conditions

Those using the following medications:

• This medicine is not known to affect other medicines

Aspirin or NSAIDS: Clients are often tempted to take pain reducing medication before treatment. Aspirin and NSAIDS have anti-coagulant properties and therefore will affect the clotting mechanism and result in a higher current than necessary being used which will cause more trauma and increase the risk of bleeding or bruising.


Skin Factors Affecting Absorption:

• Medication - including anti-inflammatory medications, steroids and various others.

• General Health • Sun Exposure • Topical Cosmetic Creams including Retin A, AHA's and Various

Acids now found in modern day skin creams. • Lasering • Sun damaged skin • Scarred skin • Life Style • Drugs and Alcohol • Age • Natural Skin properties • Chemotherapy • Alopecia • Exfoliating Skin conditions (psorisis or eczema for example)


Eyebrow Treatments 1. Trolley Checklist

a. Treatment Checklist 2. PreDrawing (General) 3. Stretching Technique 4. Eyebrow Procedure

a. Design Considerations and Brow Predrawing b. Preparation and Procedure c. Troubleshooting d. Aftercare

1. Trolley Checklist

For the system that you are using see the supplementary manual provided. Trolley set up should ensure that the surface is wiped according the approved H&S Exec Guidelines. On the working trolley ONLY include disposable single use consumables for micropigmentation, including tissues, wipes and cotton buds (out of their box in preparation). Any other components of the treatment should be covered in disposable plastic sheeting or be stainless steel such as tweezers and scissors and be fully sterilisable, preferably sonically cleaned and then autoclaved. As a rule keep your trolley clear of anything that you won't actually need during the procedure. Creams and pigments including approved anaesthetics can be decanted into disposable pigment cups prior to beginning the procedure.

On the second tier of your trolley you should have your consumables such as gloves, plastic covers, yellow bags and sharps bin, an approved spray cleaner and a small jar to keep instruments clean and immersed in Barbicide or another equivalent sterilising fluid. Remember before replacing any used tweezers or scissors in the barbicide they should be thoroughly cleaned and scrubbed with an appropriate antibacterial cleanser and water.

Treatment Checklist

· Hands must be washed before and after treatment using antibacterial soap using clinical handwashing techniques. Any cuts or abrasions on hands should be covered with sterile dressing. Any equipment coming into contact with the skin should be sterile/sterilised before use

· Check all electrical safety precautions and machine settings follow manufacturer's instructions eg. Micropigmentation unit, Magnifying lamp etc.


· Working area must be prepared to meet all H&S legislation requirements

· PPE in place for client and therapist - gloves, mask and apron, caps, glasses should be worn by therapist

· Couch protected with clean disinfected couch cover, covered with disposable body roll

· Decontaminate all surfaces with isopropyl alcohol or other hospital grade appropriate disinfectant. Placed protective coverings such as plastic wrap or barrier wrap on all equipment and surfaces. If you fail to do so you risk of the transfer of contaminated blood-borne pathogens on fixtures, phones, door handles, pigment bottles, and machines.

Client Preparation

Following the consultation and full explanation of the treatment procedure the client should be instructed with the following guidelines before treatment commences:

· Client will need to remove piercings if obstructing treatment site area

· Their hair will need to be covered with a disposable head cap

· The client should be positioned at the head of the treatment couch ensuring you have good access to the procedure area

2. Predrawing

Why is the Predrawing so important?

If you can’t draw great brows, eyeliners and lips, how can you expect to permanently tattoo them into the skin? Predrawing is key to achieving the best results, and you need you need to master this before progressing onto the main procedure.

· The Predrawing is your template. Without this you won’t be able to achieve perfect pigmentation results.

· The drawing allows you to determine what the client wants and what suits her. Your client may tell you she wants something but means something else totally different. Drawing is not permanent, so it allows you to adapt the shape until you are both happy.

· Predrawing is also a great sales pitch. If a client is just with you for an initial consultation and you are able to draw perfect make up that she falls in love with, you’ve won yourself a PMU client. Even if she can’t immediately book up to have the treatment done, she won’t forget the way that you made her look and feel with your skilful Predrawing.

· The Predrawing is essential for insurance purposes. The client agrees to this


drawing and as a technician you transform it into Permanent Make Up, documenting the agreed shape by taking pictures both before and after. Some clients will change their mind about the shape after the procedure, but providing you have taken photos of the Predrawing, you can always prove that this is what she agreed to.


Generally speaking, the Predrawing along with the initial consultation allows you to find out more about your clients wishes and expectations, to build confidence and to map out the rest of your treatment to ensure good results. The most challenging part of the Predrawing combined with the consultation will be finding the balance between listening and making professional suggestions in an empathetic yet authoritative manner. This will of course depend on the personality of your client. You should therefore be perceptive to other aspects of your clients personality before beginning the Predrawing: how she dresses, her style, how she acts and her general appearance. This is all very important and will make you more likely to meet her demands rather than spending hours and hours blindly getting the drawing correct. Her individual style and the psychology behind how this make up will make her feel is so important, as in theory it’s semi-permanent.

The Art of Microblading

The History Of Microblading It’s currently the hottest trend in the world of permanent makeup, but what is the history of Microblading and from where exactly did it originate? It may come as a surprise to hear that Microblading is not a new invention at all, but rather an extension of ancient artisan techniques. Whilst opinions as to the definitive origins of this popular trade differ slightly, it is believed by many that Microblading as we know it today, whilst originating in Asia, derived from methods of manual hand tattooing techniques adopted as far back in history as the Ice Age, over 5,000 years ago. In 1991 tattoos which had been produced by fine incisions made to the skin and pigmented with charcoal, were discovered on the famous ‘Ötzi’ Iceman in the Italian Alps. Microbalding has come a long way since the days when vegetable dye was injected under the skin to form tattoos and has been adopted by many on a global scale, popularised by the talents of international artists and renowned trainers, whose years of experience, skills and knowledge are highly sought after by those who are new to the dynamic and exciting world of permanent make up. Due to the intricate nature of the technique, where a specially designed blade comprised of ultra-fine needles is used to implant cosmetic grade pigments into the skin, the technician is able to design volumised brows that enhance and compliment facial features, with understated subtlety, or if desired impactful on trend statement runway replicas.

What Is Microblading

Also known as Brow Embroidery, Feathering, Feather Touch Etching and Micro-Strokes, Microblading is an art which allows the design and crafting of simulated precision perfect hair strokes and subtle volumised coverage to existing brows, using fine deposits of cosmetic grade pigments which are manually implanted into the dermal layer (upper reticular layer) of the skin. In essence it’s a highly skilled manual process of cosmetic tattooing, which uses a specially designed handheld Microblade and uniquely engineered needles to create fine strokes


which penetrate the skin. Cosmetic pigment is then implanted into the ultra-fine incisions, which has been colour matched to existing hairs. Technicians are able to subtly transform brows into statement facial features using a selection of needles which collectively form a variety of shapes such as slopes and half circles (often referred to as ‘U’), which are natural looking to the eye and capture the elegance and bespoke precision of hand drawn penmanship through free flow motion. Microblading is a manual process which relies on artistry and hand pressure of the technician to control the depth of the strokes. In the past this discipline has been favoured by technicians who believed that the process offered more control than popular machine procedures, resulting in the precise and consistent replication of hair strokes that blend seamlessly with hairs already present in the eyebrows. The method was embraced my many who favoured hand held microblading over PMU devices, which historically struggled to cope with the bend load created by downward pressure and needle size variations, however it is important to note that with the introduction of Nano Needle Technology both variations are now able to offer the customer customised crisp strokes which can be implemented to fill in gaps occurring in natural brows, create fuller of more structured brows and reshape or add definition to existing eyebrows. Microblading however is still a very popular and sought after treatment and makes an excellent introduction to Permanent Makeup. It can be used as a stand-alone procedure or to compliment a PMU device, however those undertaking a course in this discipline should always seek to develop their skills and knowledge through further training.

Contraindications

It is paramount that as a Microblading Technician you are able to explain the contraindications that prevent or restrict micropigmentation treatments and demonstrate how to effectively recognise them, whilst explaining the importance of and reasons for not naming specific contra-indications when referring clients to medical practitioners. Please take time to research the following and provide written evidence of actions you would take to deal with the following contraindications; Contra-indications which restrict Epilepsy, Injectables, Inflamed and infected skin conditions and disorders, Contagious diseases,Moles in the treatment area, Medication causing a thinning or inflammation of the skin (e.g. Steroids, Acutane, Retinols, Retin A, Renova and active skincare ingredients such as alpha or beta hydroxyls), Pigmented naevi,Medium/deep chemical peels, Under the influence of alcohol or recreational drugs, Herpes simplex, Pregnancy/Nursing Mothers, Clients with botox, fillers or implants. Contra-indications which prevent Hyper-pigmentation, Recent facial surgery (within 6 months), Recent dermabrasion, chemical peels or AHA treatments, Allergies (to metals i.e. nickel, latex, numbing creams and pigments etc.), Haemophilia, Hypertrophic scars, Body dysmorphia, Sunburn in the area, Keloid scars or prone for keloid formation, Diagnosed scleroderma, Pink eye, Psoriasis in the area to be treated.

Contra-indications requiring medical referral Insulin controlled diabetes, Blood thinning medication (i.e. Warfarin), Chemotherapy / Radiotherapy

High blood pressure, Heart disorders, HIV, Hepatitis, Under 18 Clients who suffer from auto-immune disease disorders (the body will be used to removing foreign substances and may break down pigments more rapidly), Organ transplant


patients (due to a compromised immune system), Blood disorders such as sickle cell anaemia, haemophilia etc. and those taking large doses of aspirin, Coumadin, Heparin or Cortisone, Clients suffering from Lupus. Contra-actions As a Microblading Technician it is imperative to be aware of contractions which may occur during treatment and what actions should be taken if they occur. Please take time to research the following and provide written evidence of actions you would take to deal with the following contra-actions should they arise;

Excessive erythema Corneal abrasion Burning / blistering Migration of pigment Excessive discomfort Oedema Reactions leading to bruising Hives Allergic reaction to treatment Needle stick injury Dizziness Stinging Nausea Anaphylaxis Excessive pain

Sensitivity and Patch Tests It is important to always patch test the client in advance of their treatment following manufacturers’ instructions Technicians need to be aware of how to perform an onsite scratch test, in the event that they are required to carry one out.

Procedure

6 key overview steps:

1. Trolley set up 2. Consultation (to include numbing cream application, scratch test and pre-treatment photograph) 3. Brown Design 4. Application 5. Post Treatment Consultation and Aftercare (post-treatment photograph) 6. Re-booking of touch up appointment (4-6 weeks)

Design Consideration:

It is important to take into consideration the client’s skin types, face shape, width of the face, skin colouring / undertones and facial structure when designing brows. Before you begin the process remember that adequate [LED full spectrum white] lighting is key to the success of your working environment, as you need to be able to view skin tones and structures in minute detail. Wearing a headlamp will also be highly beneficial. 1.Locate the central point in between both brows, by asking your client whilst seated on the bed to look straight ahead at the tip of your nose. Using the callipers mark onto the forehead where the centre point between the eyebrows should be, using the central point of each pupil as a guideline.

2.Next measure from the inner corner of one eye to the inner corner of the other eye making a note of the measurement.

3.To find the correct location for the starting point of each brow measure (1.5cm / proportionate to face shape) from the centre line mark. (point 1). In essence from the outer point of your nose to the inner corner of your eye is where your starting point should begin.

4.Using the measurement you took from in between the eyes make a mark measuring from the allocated start of the brow to the highest point (point 2). This


measurement can also be obtained by asking the client to look straight ahead and measuring from the outer corner


the nose and marking above the centre point of the client's pupil where the brow arch should sit. 5.Extending the callipers outwards, position the bar from the outer corner of the nose to the outer corner of the eye. This is where the brow will end (point 3). If your client’s face is long or oval, lengthen the central point outwards slightly towards the temples.

6.Repeat the steps on the other eye. 7.Comb through each brown to separate all individual hairs, then remove any excess hair with sterile tweezers or eyebrow razor.

8.Start to draw your brow outline and placement of hair strokes. 9.Consult with the client on the proposed brow design and mapped shape making adjustments as necessary until the client is happy.

10.Start to microblade and make your first pass on each brow, working slowly to build a foundation structure of hair like strokes using the pattern you have mapped, before wiping away with pencil and saturating with pigment. Leave the pigment on for at least 1 minute before wiping away and reapplying numbing cream. Repeat the second pass and then re-evaluate the eyebrows for any extension of strokes or added strokes prior to finishing the procedure.

11. Be sure to add healing balm after the procedure to ensure cleanliness and protection of the area.

Ombre Brows: Follow same procedure outline as above, but select single point needle or nano NT needle with machine and use pendulum technique. Starting at the tail work slowly moving the needle at a 90 degree angle back and forth to implant colour. Apply anesthetic for up to 5 minutes to further numb the area. Be sure not to remove predrawing at this as you work. Once colour is implanted you may wipe the area clean and sit the client up and redraw to ensure symmetry of the brows as you move throught the procedure. Do up to 2-3 passes to build colour ensuring to keep the work softer with less passes in the front to create the Ombre Effect.

During the procedure: 1. If the skin is cut or punctured, immediately remove the gloves, bleed the wound. 2. Wash the area with soap and water. 3. Pour 70% isopropyl alcohol directly on the wound. 4. The practitioner must never touch hair, glasses etc.during the procedure.

After procedure:

1. Place use needles in a sharps container. These containers can be purchased through a medical supplier from the health Department. The collector is made from puncture resistant material but it is not completely puncture proof. Appropriate care must be taken transporting to avoid the possibility of injury. These bins must be disposed of at appropriate health Department disposal area.

2. Dispose of used casings, tips, pigment caps, immediately in leak proof container.

3. Remove blood and bodily fluids contaminated clothing in a manner that avoids contact with the skin.


4. Remove glasses. Do not touch anything with bloody gloves.

5. Wash hands, or arms and face at the sink with an antiseptic soap.

Stretching Techniques:

Stretching techniques are very personal and unique to each technician. There are many variables to consider:

1. Right and left handed technician 2. Side of the hands 3. Device being used 4. The positioning of the procedure to bed 5. The width of the procedure bed 6. Fit of the gloves used 7. The texture of the glass used

When it corrects stretching techniques are used the placement of pigmented is more accurate and the retention of pigments will be better. The skin should be stretched firmly like the skin of a drum, with the three point stretching technique to ensure consistent results.

Eyeliner Procedure:

During an eyeliner procedures the eyeliner is placed in the skin exactly sure ordinary pencils would be applied. It can also be used to feel any gas in the lash hairline.

Important points:

-The line should be as close as possible to the natural line. -If the client request a thick line just add on be low for a bar of the first line until the desired thickness is reached or select a fuller needle at consultation time. - Perform stretching technique properly and work on closed eyes. - Never use alcohol around the eyes only damp gauze to clean the area or damp cotton pads. - If client request wings, it is advisable to work in stages - Never close off the corners of the eyes or join the lines together - Never tattooed eyeliner in the wet tissue or wet line - The smudged look is achieved by placing a lighter coloured line beneath the first dark one at the lash line. - Never use black colour alone on and eyeliner procedure. Always mix a little dark brown in with the black pigment to prevent blue eyeliner. - Never perform an eyeliner procedure on a client who has glaucoma, the pressure used during the procedure could potentially cause a client to go blind.

Needle Selection:

Top eyeliner is designed to go between the lashes as on top of the lashes. The client can determine the thickness of the line. Fine to medium line is three prong cluster needle, For thick line use five from cluster needle. For lash enhancement techniques use a three microneedle or work from the tip of a three prongs cluster.


Procedure:

1. Prepare in the workplace area maintaining infection control and workplace health and safety standards on the highest level.

2. Set up your machine, where disposable gloves during the preparation, and invite the client to inspect all disposable and unopened machine parts and needles.

3. Gently wipe around the area with damp cotton wool only. Do not use alcohol and around the eyes.

4. Take before photo. 5. If you are performing upper and lower eyeliner procedures, start on the other line first. 6. Shake the pigment well before using. Place pigment into disposable cup. 7. Apply Celluvisc to the eye to protect the eye. 8. Stretch the skin of firmly to insure the colour is implanted in a straight line. Stretching

also assists in minimizing pain. 9. Use etching technique from the outside corner toward the inner eye, follow con two up of

the eyelashes. Remember that the machine is always held at 90° angle. 10. Once the scheme is broken, it is time to apply procedural anaesthetic. Use micro brush

for the application. Wait 2 to 3 minutes before continue tattooing. 11. Over the area three times keeping eyes closed. 12. White excess pigment from in the area after each passing. 13. When the line is straight and even, you can continue to the lower eyeliner. 14. Keep rechecking work during the procedure, comparing it to the other eye so that both

sides are even. 15. Rinse the eyes with eye wash and clean the corners with damp cotton tips. 16. A cold compress or a cold pack in a clean freezer bag may be applied for client comfort. 17. Take after photos. 18. Apply healing balm and rebook client for their retouch and provide aftercare instructions.

Lip Procedure:

- Always choose dark intense colours during lip procedures as the lip might lose up to 70% of its intensity

- Advise the client to use lip exfoliator before procedure as this will remove the dry flaking skin and allow for better retention and penetration of the colour.

- Remember that a cold sore sufferer, even if they have only experienced a single outbreak in their entire life should go online seen one week prior to procedure all I take anti-viral medication.

- A client should not bleach their teeth until the epidermis is completely healed. - Some lips pull blue tones when certain shade of red are used. This is because many

dark red contain blue or similar colour. This can cause the lips to heal blue black. This can be avoided by adding a few drops of orange or red orange to your preferred colour.

- If the client request a very natural lip colour, you must advise them that this colour will not last as long as a brighter colour.

- A client should not have it permanently blind procedure until a minimum of six months post collagen and fat transfer injections on the lips.

- Do you not ever connect to the corners of the lips, as you risk colour migration. Colour


migration in can also occur if the area is overworked, and if the area has wrinkle lines extending from the lips.

- At the cupids bow never overstretched the skin, as it will distort the draw line. As in any procedure continually recheck your work.

Procedure: 1. Prepare in the workplace area maintaining infection control and workplace health and

safety standards on the highest level. 2. Set up your machine, where disposable gloves during the preparation, and invite the

client to inspect all disposable and unopened machine parts and needles. 3. Gently wipe around the area with damp cotton wool and over the lips with alcohol

swab. 4. Take before photo 5. Apply topical numbing cream, and allow 30 minutes whilst doing consultation. 6. Design and draw the lipline. Should never be tattooed without a clear guideline to

follow. If the client prefers to draw the lip line by herself, this is fine but always measure and check the symmetry and balance.

7. If the client is totally satisfied with the lip line and shape, take another photo. 8. Use xylocaine jelly on a cotton role inside the mouth to improve numbing. 9. Stretch the lip firmly, first work on the bow as this part will swell first. Continue from

the outer corners and connect the line at the bow. Don’t forget to hold the machine at a 90° angle.

10.Apply numbing, wait 2 to 3 minutes for anaesthetic to take effect. 11. Go over the area, using very precise etching technique. Check the line and used

pointillism if necessary. 12. Started to fill the lips by using pendulum technique. Continue to numb lips if required. 13. Place a balance line to the lower lip at the centre of the lower lip using acting

technique to define it. 14. After the skin is broken apply anaesthetic. 15. After the balance line is in place, work from the outside of the live it to the centre of

your balance line in using action technique. 16. Continue to fill the lips using pendulum technique and apply anaesthetic as required. 17. If you find that the corners of the lip are not taking the pigment use pointillism to finish

them. 18. Sit your client up and check your work that it is clean and symmetrical. 19. Apply healing barn and icepack to reduce swelling. 20. Rebook client for retouching appointment and provide after-care.

Aftercare

Eyebrows: There may be slight swelling. It will subside within a couple of hours. You may apply an icepack to the area to reduce swelling.


First Day: Rinse the eyebrows with warm water and neutral soap without stretching skin. Circle gently on the eyebrows until clean skin is felt under the fingertips. After rinsing apply a thin layer of our healing balm antiseptic cream. The first rinsing process should be done half hour after the treatment. This should be repeated 4-5 times the first day. Then apply the balm twice a day for a period of 14 days. Use a clean cotton tip to apply. It is important to keep the area clean and dry during the healing process. Do not rub or traumatize the pigmented area. Do not use soaps cleansers or moisturisers in the pigmented area until the area is completely healed. To prevent infection do not touch the pigmented area with fingers. DO NOT PICK OR PEEL ANY CRUST that may have formed on the pigmented area. The pigment will be removed along with the crust. No swimming in chlorine or in the ocean for 7-10 days or until the procedure are has healed. NO sauna or spa for 7-10 days or until the procedure area has healed. When the area has healed, apply sun block to prevent fading of the pigment color. Apply a thin coating of Vaseline to the area with a clean cotton tip to the area before bathing. Eyeliner: (As Above + the following) Do not use eyelash curler or mascara for a period of 7 days. When you resume use of mascara purchase a new tube. If you wear contact lenses, we advise you to arrange transport home. The contact should not be replaced for a minimum of two hours. Lip Procedures:(As Above + the following) Avoid wiping the lips when eating. Do not rub or traumatize the pigmented area. Avoid licking the lips and eating, greasy, spicy, oily, citrus food or juice until the healing process is complete. This will impede the healing process. Be careful when cleaning teeth. Toothpaste can pull pigment colour out of the lip vermillion. For the first few days drink through a straw. Do not use soaps cleansers or moisturisers in the pigmented area for at least 5 days. Do not use lipstick, lipbalm or lip gloss until the area is completely healed.


Additional information for your Qualification:

5. Additional Health, Safety and Security in the Clinic/Salon a. Risk Assessments b. Compliance

6. Quality Management a. The Importance of Quality management b. The Importance of Quality Management

1. Additional Health, Safety and Security in the Clinic/Salon a. Risk Assessments b. Client Satisfaction Surveys

Risk assessments are a legal requirement to ensure that both you, your team and your clients are protected against any potential risks in the best possible way and for you to provide a safe environment for everyone that enters your clinic.

Please see Appendix D for an example risk assessment.

Risk assessments minimise hazards and risks by identifying them, evaluating them and then putting in place procedures to deal with alleviate them. They should also be regularly updated and it is your duty to do this within your clinic/salon. Current systems in place should constantly be reviewed.

There are a number of ways that you can manage the procedure for risk assessments: - Review policy - Keep documentation - Planned and spot checks - Determine the level of risk - Justify and suggest preventative measures - Record findings - Nominate staff to implement changes - Notify remaining staff - Make sure that implemented changes have truly reduced/eradicated the

risk that a situation poses

Health, Safety and Security isn’t just confined to the control of hazardous substances, reporting of diseases etc that we explored earlier in this manual. To be operating in a safe workplace you should also consider PAT testing for all electrical equipment, other fire hazards and precautions, the correct insurance for yourself and your customers (compulsory liability insurance), building insurance and the space that you are working in, correct code of conduct and manual handling. To ensure a secure workplace, you should consider data


protection, stock control systems and procedures, the secure storage of personal belongings of your staff/clients, emergency evacuation procedures, data protection of private information and point of sale security.

c. Compliance

Laws and National Legislations are put in place to ensure that you are adhering to standard Health, Safety and Security practises and that you are providing the same workplace previously discussed. Keeping up-to-date with these laws and complying with them is of the greatest importance. Keeping in line with the industry code of practice not only builds your professional reputation as a service provider, but also fulfils your license to practice requirements (insurance and policies) and helps you avoid accidents that could result in big legal claims and/or close of your business.

Compliance with such legislations is the key to a healthy business and a happy workforce. It is also your duty to manage, monitor and support others to ensure compliance of Health and Safety. Be sure to monitor any changes in the law, invest in continual staff training and take external advice from a qualified source if necessary. You must make these compliance points easily accessible to visitors/staff and can present them in the form of leaflets or posters, conduct regular staff meetings and be open to suggestions from colleagues.

2. Quality Management a. The Importance of Quality Management

A great and well respected business relies not only on the correct Health, Safety and Security measures being taken but also exceptional customer care. The beauty industry as a whole is exceptionally competitive. To be at the top of this industry you need not only to meet your client’s expectations but exceed them, and this is not just confined to the tattooing. The client should be made to feel comfortable, valued and always informed of what is going on from the moment they make contact with your company to the moment they leave and should have some element of control during their procedure.

As a manager/team leader it is important that you set a good example to your team in regards to offering the best possible customer service. Frequent staff meetings are also essential so that changes made based on client reviews can be quickly and smoothly implemented and adhered to by everyone. Quality management also extends to the quality of the working environment that you provide for your team, and how happy and secure they are within their positions. Similar surveys and meetings should be carried out with them also.

You should listen to your individual clients and the needs of the market as a whole. Negative feedback, although not necessarily the best reflection of the current service that you are offering, should not solely be taken as a bad thing. We can learn valuable lessons from this feedback so that the service offered can be improved for future clients, leading to a positive impact on our reputation as service providers and indeed an increase in sales and turnover. As a manager you should not be too proud to change systems within the salon/clinic in order to improve the service that you offer.



There are many different methods that can be adopted to review the overall client service experience as part of quality assurance. Frequent inspections can be carried out, practical observations can be made, a client suggestion box can be made available to the client and reports on turnover can be analysed. Sampling is a fair method to extract such data and the percentage of clients that return to you for their annual retouch is also very telling.

There are also governing bodies that aim to regulate companies and maintain client satisfaction by supplying standards-related services such as the ISO, BSI and CEN. You should also see the relevant national and European industry standards as well as overall industry policy and procedure.

Quality management can be measured in a number of way: - Review of sales/turnover - Meeting set goals and targets in specific timeframes - Staff turnover - Employee happiness - Number of sick days/holidays - Monitoring trends - Data gathering

b. Client Satisfaction Surveys

One of the most effective ways to collect data to evaluate client satisfaction is by conducting a client satisfaction survey to give to each of your clients. This survey should be in the form of a questionnaire and cover every part of your clients experience with your company, from communications to booking an appointment, through to the actual procedure itself and the quality of aftercare provided. Appropriate questions should be asked that can be easily measured and realistically responded to. Answers may arise that surprise you or that you may not have considered; the customer invariably has a different experience during the treatment to the technician. Health and safety issues may also arise that will protect your business in the long run, and may even instigate the creation of new legislation to protect the industry as a whole.

Once the surveys have been reviewed, changes to company policy/procedures should be implemented and goals and targets should be set and achieved. Feedback and frequent appraisals should be given to members of your team. Turnover can be measured and surveys can be repeated to assess the effectiveness of these changes. You will find that as you respond to the client’s feedback your relationship with them will grow as will loyalty. As previously mentioned, this is an effective way to exceed your client’s expectations and make your company successful.

Typical ways to improve your business will be to review the quality of work provided, personal appearance and professionalism, the qualifications of staff, hygiene and sterilisation, general ambience, communications , time management, reliability and aftercare, although this list is by no means exhaustive. You can also make your customers



feel more valued by setting up loyalty schemes, exclusive offers, birthday promotions and running special events. Investment in ongoing training is also essential to keep up-to-date with industry demands, maintain a competitive edge and for self-improvement.

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http://4.bp.blogspot.com/-4HEUqvwk9GU/U81nqXZsI_I/AAAAAAAABAU/zbBjI806Shg/s1600/chloasma1.jpg xxvi

http://doctorv.ca/wp-content/uploads/2013/02/dermatosis_papulosa_nigra.jpg xxvii

https://www.vitiligosupport.org/vitimages/vitiligo1.jpg xxviii

http://api.ning.com/files/JWZijwmckpPaK- Ifoc6CWCO*YnsVkpes3qY9ydPNVuWjwyPel3La5gESx5ZOocFKwW0xZS06jHq7q8PkSIMm- IjalliPSG8N/albinism3.jpg?width=194 xxix

http://m.patient.media/images/om2336a.jpg xxx

http://images.medicinenet.com/images/slideshow/skin_cancer_s2_actinic_keratosis.jpg xxxi

https://www.dermquest.com/imagelibrary/large/025210HB.JPG xxxii

http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/health_tools/birthmarks _slideshow/dermnet_photo_of_atypical_nevus.jpg xxxiii

http://www.nhs.uk/Conditions/Bowens-disease/PublishingImages/bowens- disease_342x198_M1200082.jpg xxxiv

https://mypearlpoint-production.s3.amazonaws.com/nci_media/CDR0000579043.jpg xxxv

http://www.sigmaaldrich.com/content/dam/sigma-

http://www.franceneir.com/dev/photosProduits/23B.jpg

http://healthool.com/wp-content/uploads/2013/07/flaky-skin.jpg

http://www.drdeborahmd.com/sites/drdeborahmd.com/files/styles/medium/public/health-

http://cdn1.medicalnewstoday.com/content/images/articles/162/162945/eczema.jpg

http://theatticofjulie.com/wp-content/uploads/2014/08/2010-July-leg-wound-22.jpg

http://www.greenmedinfo.com/sites/default/files/ckeditor/Sayer%2520Ji/images/skin_light

http://silver-botanicals.com/assets/images/illustrations/structure-of-the-epidermis.jpg

http://www.softchalk.com/lessonchallenge09/lesson/ImmuneSystems/Blood_009002.jpg

http://www.softchalk.com/lessonchallenge09/lesson/ImmuneSystems/Blood_009002.jpg

http://www.doctorschierling.com/uploads/8/2/1/1/8211021/89410.jpg?366

http://people.rit.edu/grhfad/DLP2/DLPdict/nodule.jpg

http://www.skincaretalk.com/images/8/8e/8ed60a7a_vbattach5021.jpeg

http://2.bp.blogspot.com/-H5eskBP98l4/VYY6r-

http://static1.squarespace.com/static/51831984e4b0580e0004a8c6/t/52295e3ee4b05116fdbe2837/1378442

http://www.hxbenefit.com/wp-content/uploads/2011/12/Xanthelasma.jpg

http://media.clinicaladvisor.com/images/2011/03/24/foodallergy_uticaria_154333.jpg

http://www.burnsurvivorsttw.org/pictures/Scar2A.jpg

http://wallpaper.pickywallpapers.com/ipad/ultimate-freckles.jpg

http://images.medicinenet.com/images/image_collection/skin/lentigines.jpg

http://4.bp.blogspot.com/-4HEUqvwk9GU/U81nqXZsI_I/AAAAAAAABAU/zbBjI806Shg/s1600/chloasma1.jpg

http://doctorv.ca/wp-content/uploads/2013/02/dermatosis_papulosa_nigra.jpg

http://www.vitiligosupport.org/vitimages/vitiligo1.jpg

http://www.vitiligosupport.org/vitimages/vitiligo1.jpg

http://api.ning.com/files/JWZijwmckpPaK-

http://m.patient.media/images/om2336a.jpg

http://images.medicinenet.com/images/slideshow/skin_cancer_s2_actinic_keratosis.jpg

http://www.dermquest.com/imagelibrary/large/025210HB.JPG

http://www.dermquest.com/imagelibrary/large/025210HB.JPG

http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/health_tools/birthmarks

http://www.nhs.uk/Conditions/Bowens-disease/PublishingImages/bowens-


http://www.radpro.eu/companies/Gulmay/gulmay%20images/patient%20care/squamous_cell_carcinoma.jpg xxxvi

https://upload.wikimedia.org/wikipedia/commons/6/6c/Melanoma.jpg

http://www.radpro.eu/companies/Gulmay/gulmay%2520images/patient%2520care/squamous_cell_carcinoma.jpg


xxxvii http://www.dermedonline.com/images/home06.jpg

xxxviii http://nbdskin.com/wp-content/uploads/2014/04/rosacea-female.jpg

xxxix http://healthh.com/wp-content/uploads/2014/11/comedonal-acne-pictures-2.jpg

xl http://hardinmd.lib.uiowa.edu/pictures22/dermnet/seborrheic_dermatitis_248.jpg?pid=371

xli https://i.ytimg.com/vi/9xKYKyn3oMM/maxresdefault.jpg

xlii http://www.annalotan-usa.com/uploadimages/fragile.jpg

xliii http://amaprod.silverchaircdn.com/data/Journals/INTEMED/11987/ibr10011f1.png

xliv https://s-media-cache-ak0.pinimg.com/736x/69/02/6a/69026a9cc4da4c719d199df86a53b0d6.jpg

xlv https://upload.wikimedia.org/wikipedia/commons/3/3d/Capillary_haemangioma.jpg

xlvi http://m.patient.media/images/dis57.jpg

xlvii http://www.dartmouth.edu/~thabif/weeklyClinic111300/22DermalNevus.jpg

xlviii http://1.bp.blogspot.com/- SWhRIMsRLy4/Ta2DDobXsHI/AAAAAAAAAO0/FXpx5WzADcY/

s1600/congenital+melanocytic+nevus2.png xlix

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/dermatology/dermatologic- signs-of-systemic-disease/images/dermatologic-signs-fig2_large.jpg l http://www.nhs.uk/Conditions/Psoriasis/PublishingImages/psoriasis_332x163_136810224.jpg

li http://img.medscape.com/news/2014/dt_141022_eczema_800x600.jpg

lii

http://missinglink.ucsf.edu/lm/DermatologyGlossary/img/Dermatology%20Glossary/Glossary%20Clinical%20I mages/Contact_Derm_3-6.jpg liii

http://commonsensealternatives.com/wp-content/uploads/image/eczema_irritantcontact.jpg liv

http://www.dermexpert.co.uk/wp-content/uploads/2014/07/eczema-.jpg lv

http://skincarebylouisa.com/wp-content/uploads/2012/03/seborrheic-dermatitis.jpg lvi

http://www.eczemaexpert.org/wp-content/uploads/Nummular-eczema2-500x327.jpg

lvii http://www.hxbenefit.com/wp-content/uploads/

2011/03/stasis-dermatitis-pictures.jpg lviii

http://www.dermishealth.com/images/skin-boil.jpg lix

http://healthool.com/wp-content/uploads/2014/07/carbuncle-pictures-6.jpg lx

http://www.nhs.uk/Conditions/Impetigo/PublishingImages/impetigo_342x198_C0175679.jpg lxi

http://doctorv.ca/wp-content/uploads/2013/04/100_9843-e1365272203879.jpg lxii

http://img.medscapestatic.com/pi/meds/ckb/77/40677tn.jpg lxiii

http://usercontent1.hubimg.com/9084018_f260.jpg lxiv

http://i.ytimg.com/vi/OrOcTlv24Oo/maxresdefault.jpg lxv

https://www.onlinedermclinic.com/dz_images/1/0/10210978264e470fb816979.jpg lxvi

http://pic.pimg.tw/mulicia/1342923375-1100158586.png?v=1342923376 lxvii

http://www.bupa.co.uk/~/media/Images/HealthManagement/Topics/wart-427x240.ashx lxviii

http://sicknessnhealth.com/wp-content/uploads/photo-jun-25-18-36-08.jpg lxix

http://www.colaz.co.uk/images/skin-wart2.jpg lxx

https://www.studyblue.com/notes/note/n/infections-and-infestations/deck/9827792 lxxi

http://www.nhsdirect.wales.nhs.uk/assets/images/encyclopaedia/Coldsore.jpg lxxii

http://www.herpeszostertreatment.net/wp-content/uploads/2014/06/HerpesZoster.jpg lxxiii

http://oerpub.github.io/epubjs-demo-book/resources/704_Skull-01.jpg lxxiv

http://hair-and-makeup-artist.com/wordpress/wp-content/uploads/2012/06/Facial-Muscles.jpg

http://www.dermedonline.com/images/home06.jpg

http://nbdskin.com/wp-content/uploads/2014/04/rosacea-female.jpg

http://healthh.com/wp-content/uploads/2014/11/comedonal-acne-pictures-2.jpg

http://hardinmd.lib.uiowa.edu/pictures22/dermnet/seborrheic_dermatitis_248.jpg?pid=371

http://www.annalotan-usa.com/uploadimages/fragile.jpg

http://amaprod.silverchaircdn.com/data/Journals/INTEMED/11987/ibr10011f1.png

http://m.patient.media/images/dis57.jpg

http://www.dartmouth.edu/%257Ethabif/weeklyClinic111300/22DermalNevus.jpg

http://1.bp.blogspot.com/-

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/dermatology/dermatologic-

http://www.nhs.uk/Conditions/Psoriasis/PublishingImages/psoriasis_332x163_136810224.jpg

http://img.medscape.com/news/2014/dt_141022_eczema_800x600.jpg

http://missinglink.ucsf.edu/lm/DermatologyGlossary/img/Dermatology%2520Glossary/Glossary%2520Clinical%2520I

http://commonsensealternatives.com/wp-content/uploads/image/eczema_irritantcontact.jpg

http://www.dermexpert.co.uk/wp-content/uploads/2014/07/eczema-.jpg

http://skincarebylouisa.com/wp-content/uploads/2012/03/seborrheic-dermatitis.jpg

http://www.eczemaexpert.org/wp-content/uploads/Nummular-eczema2-500x327.jpg

http://www.hxbenefit.com/wp-content/uploads/2011/03/stasis-dermatitis-pictures.jpg

http://www.dermishealth.com/images/skin-boil.jpg

http://healthool.com/wp-content/uploads/2014/07/carbuncle-pictures-6.jpg

http://www.nhs.uk/Conditions/Impetigo/PublishingImages/impetigo_342x198_C0175679.jpg

http://doctorv.ca/wp-content/uploads/2013/04/100_9843-e1365272203879.jpg

http://img.medscapestatic.com/pi/meds/ckb/77/40677tn.jpg

http://usercontent1.hubimg.com/9084018_f260.jpg

http://i.ytimg.com/vi/OrOcTlv24Oo/maxresdefault.jpg

http://www.onlinedermclinic.com/dz_images/1/0/10210978264e470fb816979.jpg

http://www.onlinedermclinic.com/dz_images/1/0/10210978264e470fb816979.jpg

http://pic.pimg.tw/mulicia/1342923375-1100158586.png?v=1342923376

http://www.bupa.co.uk/%257E/media/Images/HealthManagement/Topics/wart-427x240.ashx

http://sicknessnhealth.com/wp-content/uploads/photo-jun-25-18-36-08.jpg

http://www.colaz.co.uk/images/skin-wart2.jpg

http://www.studyblue.com/notes/note/n/infections-and-infestations/deck/9827792

http://www.studyblue.com/notes/note/n/infections-and-infestations/deck/9827792

http://www.nhsdirect.wales.nhs.uk/assets/images/encyclopaedia/Coldsore.jpg

http://www.herpeszostertreatment.net/wp-content/uploads/2014/06/HerpesZoster.jpg

http://oerpub.github.io/epubjs-demo-book/resources/704_Skull-01.jpg

http://hair-and-makeup-artist.com/wordpress/wp-content/uploads/2012/06/Facial-Muscles.jpg

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