THE AUSTRALIAN SOCIETY OF DERMAL CLINICIANS

Written by Kiera Nikolakakis Interprofessional Practice & Providing a Holistic Approach A skin condition is usually just the surface/visible evidence of an internal health issue. With inflammatory skin conditions like atopic dermatitis and acne vulgaris, which are commonly seen within our scope of practice, we are able to create patient care plans to help manage the condition. However, more and more research suggests that where skin inflammation has risen there is potentially also gut inflammation. This could be due to an imbalance between the good and bad bacteria in the gut and can either be a mixture of a normal amount of good bacteria, but an over abundance of harmful bacteria, or not enough good bacteria and a normal to high amount of harmful bacteria. The following is an analogy we can use to make it easier to help our patients understand that it is more than just what is showing on the surface of their skin: “When it comes to gut dysbiosis and inflammatory skin conditions, think about how bees make honey. The gut is like the bee. The bee needs the right nutrients from the pollen in order to make honey. Similarly, the gut needs to have a nutrient and bacterial balance for the skin to perform its functions properly.” It is always important to remember that this research is in its infantile stages, and the exact mechanisms of the gut microbiota's influence on various inflammatory skin conditions are yet to be entirely and comprehensively understood. Looking after the gut can assist our patients in achieving the most desirable results from our clinical treatments and prescribed home care routine. Dermal Clinicians are highly trained and experienced in treating the external manifestation of inflammatory skin conditions, however, it is vital that we educate our clients on internal health, including root-causes of a condition and the benefits of practising a holistic approach when treating the skin. We want our patients to understand how lifestyle factors and diet have the potential to both negatively and positively impact skin health and conditions. It is therefore important that we are able to educate our patients on why we are recommending they see other healthcare professionals, and how this will assist in further determining and fixing the root cause of their skin conditions. Implementing inter-professional collaboration and respecting other healthcare providers’ perspectives in healthcare can help improve the patient's outcome. The treatment of inflammatory skin conditions is complex due to its multifaceted nature. Dermal Clinicians can go as far as educating patients on how the diet can impact the skin, and what the gut-skin axis is. We can provide our patients with information on how the results of our clinical treatments and home care regimes can be enhanced by treating the underlying causes of a condition by referring to additional yet complementary healthcare professionals in which the gastrointestinal tract and dietary nutrition are within the scope of practice. This includes such healthcare professionals like a: ● Gastroenterologist ● Dietician ● Nutritionist ● Naturopath Generalised and Common Suggestions for Balancing the Gut Microbiome It is now understood that there are some lifestyle and nutritional factors which ultimately affect the gut microbiome. The following are some generalised and common themes that have arisen from these published studies: Sleep Recent studies have actually shown that poor sleep quality or fragmented sleep correlates with poor microbiome diversity. In contrast, good sleep patterns are positively associated with a healthy, diverse gut microbiome. Antibiotics Inappropriate or overuse of antibiotics can significantly affect the gut microbiome, causing changes in the gut microbiota composition and leading to gut dysbiosis. This can be by causing an overgrowth of harmful bacteria or can lead to antibiotic-resistant bacteria and therefore the spread of these bad bacteria. Diet Put extremely simply, there are foods that support a healthy gut microbiome and foods that can lead to (or contribute to) gut dysbiosis when consumed in mass abundance. An example of food ingredients that support a healthy gut microbiome is prebiotics & probiotics. I’m sure we have all heard of prebiotics and probiotics by now – but what do they actually do? Prebiotic-rich ingredients include (but are not limited to) legumes, whole grains, garlic and onion, which ultimately serve as food for probiotics. Probiotics naturally contain good bacteria, in which they possess multiple ways of keeping the body healthy, like aiding in removal of excessive bad bacteria to aid in balancing and re-establishing the gut microbiome colonisation. On the other hand, a diet rich in refined carbohydrates has been shown to have an effect on the gut microbiome, being a contributing factor in gut dysbiosis. This includes foods and ingredients such as white bread, sugar, white pasta, and white rice. The above are just a few of the many complex factors involved in gut dysbiosis. These are just some examples to help our clients understand and make their own connections to what might be causing their skin inflammation whilst seeking the appropriate advice and care. Reviewed by the Education Sub-Committee of the Australian Society of Dermal Clinicians. References (for both part one & part two): Barko, P. C., McMichael, M. A., Swanson, K. S., & Williams, D. A. (2018). The gastrointestinal microbiome: A review. Journal of Veterinary Interna Medicine, 32(1), 9-25. https://doi.org/10.1111/jvim.14875 De Pessemier, B., Grine, L., Debaere, M., Maes, A., Paetzold, B., & Callewaert, C. (2021). Gut-skin axis: Current knowledge of the interrelationship between microbial dysbiosis and skin conditions. Microorganisms, 9(2), 353. https://doi.org/10.3390/microorganisms9020353 Duan, H., Yu, L., Tian, F., Zhai, Q., Fan, L., & Chen, W. (2020). Antibiotic-induced gut dysbiosis and barrier disruption and the potential protective strategies. Critical Reviews in Food Science and Nutrition, 62(6), 1427-1452. https://doi.org/10.1080/10408398.2020.1843396 Ellis, S. R., Nguyen, M., Vaughn, A. R., Notay, M., Burney, W. A., Sandhu, S., & Sivamani, R. K. (2019). The skin and gut microbiome and its role in common dermatologic conditions. Microorganisms, 7(11), 550. https://doi.org/10.3390/microorganisms7110550 Faits, T., Walker, M. E., Rodriguez-Moraro, J., Meng, H., Gervis, J. E., Galluccio, J. M., Lichtenstein, A. H., Johnson, W. E., & Matthan, N. R. (2020). Exploring changes in the human gut microbiota and microbial-derived metabolites in response to diets enriched in simple, refined, or unrefined carbohydrate-containing foods: a post hoc analysis of a randomized clinical trial. American Journal of Clinical Nutrition, 112(6), 1631-1641. https://doi.org/10.1093/ajcn/nqaa254 Lee, S-Y., Lee, E., Park, Y. M., & Hong, S-J. (2018). Microbiome in the gut-skin axis in atopic dermatitis. Allergy, Asthma and Immunology Research, 10(4), 354-362. https://doi.org/10.4168/aair.2018.10.4.354 Olvera-Rosales, L-B., Cruz-Guerrero, A-E., Ramirez-Moreno, E., Quintero-Lira, A., Contreras-Lira, A., Contreras-Lopez, E., Jaimez-Ordaz, J., Castaneda-Ordaz, J., Castaneda-Ovando, A., Anorve-Morga, J., Calderon-Ramos, Z-G., Arias-Rico, J., & Gonzales-Olivares, L-G. (2021). Impact of the gut microbiota balance on the health- disease relationship: The importance of consuming probiotics and prebiotics. Foods, 10(6), 1261. https://doi.org/10.3390/foods10061261 Salem, I., Ramser, A., Isham, N., & Ghannoum, M. A. (2018). The gut microbiome as a major regulator of the gut-skin axis. Frontiers in Microbiology, 10(9), 1459. https://doi.org/10.3389/fmicb.2018.01459 Sanchez-Pellicer, P., Navarro-Moratalla, L., Nunez-Delegido, E., Ruzafa-Coztas, B., Anguera-Santos, J., & Navarro-Lopez, V. (2022). Acne, microbiome, and probiotics: The gut-skin axis. Microorganisms, 10(7), 1303. https://doi.org/10.3390/microorganisms10071303 Seo, Y, S., Lee, H-B., Kim, Y., & Park, H-Y. (2020). Dietary carbohydrate constituents related to gut dysbiosis and health. Microorganisms, 8(3), 427. https://doi.org/10.3390/microorganisms8030427 Sinha, S., Lin, G., & Ferenczi, K. (2021). The skin microbiome and the gut-skin axis. Clinics in Dermatology, 39(5), 829-839. https://doi.org/10.1016/j.clindermatol.2021.08.021 Smith, R. P., Easson, C., Lyle, S. M., Kapoor, R., Donnelly, C. P., Davidson, E. J., Parikh, E., Lopez, J. V., & Tartar, J. L. (2019). Gut microbiome diversity if associated with sleep physiology in humans. PLoS ONE, 14(10), e0222394. https://doi.org/10.1371/journal.pone.0222394 Thursby, E., & Juge, N. (2017). Introduction to the human gut microbiota. Biochemical Journal, 474(11), 1823-1836. https://doi.org/10.1042%2FBCJ20160510 Wilmanski, T., Rappaport, N., Diener, C., Gibbons, S. M., & Price, N. D. (2021). From taxonomy to metabolic output: What factors define gut microbiome health? Gut Microbes, 13(1), Article 1907270. https://doi.org/10.1080/19490976.2021.1907270

Written by Kiera Nikolakakis The prevalence of inflammatory skin conditions has dramatically increased over the past few decades. There is emerging research on the connection between the microbiome of the gastrointestinal tract and inflammatory skin conditions. This leads to suggest that where there may be skin inflammation present – this may be an indication of inflammation within the gut lining and dysbiosis of the microbiota. What is the ‘Gut Skin Axis’? Our skin and gut are home to trillions of microbes that create the microbiota. Research suggests that the microbiome of both the skin and gut are directly linked which is known as the “gut-skin axis”. This is due to the immunological and metabolic processes of the gut, known as the gut microbiota, one of the main influences of the ‘gut-skin axis’. Essentially, dysfunction of the gut microbiome disrupts the skin microbiome which emerging research is now linking to inflammatory skin diseases commonly seen in Dermal Clinicians; practice such as atopic dermatitis and acne. What is the Gut Microbiome? The Gastrointestinal Tract contains all of the major organs of the digestive system including the intestines. It’s fascinating that this houses a multitude of species essential to survival such as varying fungi, viruses, protists, archaea and primarily bacteria. This collectively forms the gut microbiome. The complex array of biological and metabolic functions held in the gut microbiome as well as environmental factors, such as diet and lifestyle, modulates the phenotype of the host. Good bacteria help with the metabolism of nutrients from some of the foods that our intestines can’t manage to completely digest, which in turn aids with nutritional absorption, improving the body's immune function whilst also supporting the integrity of the intestinal wall. Connecting Gut Health to the Skin An abundance of bad bacteria can contribute to skin health problems. Similar to the gut, the skin also has a microbiota, made up of a large variety of diverse organisms. Dysbiosis is the imbalance of gut bacteria, which we now know also disrupts the skin's ability to efficiently perform vital functions like temperature regulation, protection and the ability to retain water. Dysbiosis of the gut alters the skin microbiome, essentially leading to exacerbating influence on inflammatory skin conditions. The skin is constantly regenerating itself via epidermal cell turnover, which is an essential function in maintaining a state of homeostasis. Although it is difficult to find a definitive cause-and-effect relationship between the gut microbiome and inflammatory skin conditions, research now shows that the gut microbiome affects both the cutaneous microbiome and homeostatic balance. This is an important concept to understand and consider as Dermal Clinicians when treating and educating patients with inflammatory skin conditions. Essentially, bacteria are in the driver’s seat and the skin is in the passenger’s seat. The microbiome is one of the prime controllers of the immune system, supporting cutaneous homeostasis. The skin microbiome has recently gained a lot of attention. Research suggests that some inflammatory skin disorders are now linked to the gut-skin axis. This includes research on: Atopic Dermatitis Atopic dermatitis is a chronic inflammatory skin condition with a multifactorial pathogenesis. This involves an altered innate and adaptive immune response, dysfunction in epithelial cells of the epidermis, multiple potential inherited gene mutations, as well as environmental risk factors. However, studies have also now suggested that atopic dermatitis is associated with the gut microbiome. The microbiome is made up of a multitude of opportunistic organisms. In terms of the gut microbiome, those with atopic dermatitis can have higher levels of species like Faecalibacterium prausnitzii, Clostridium, and Escherichia (in infants) and lower levels of Akkermansia, Bacteroidetes, and Bifidobacterium. In terms of the skin microbiome, there is a decrease in the diversity of bacteria and an increased abundance of s.aurus, which is a form of pathogenic bacteria. These distinct microbiota characteristics show a correlation between a dysfunctional gut microbiome and atopic dermatitis. Acne Vulgaris We all know that acne is a very common skin condition and over the years has been largely researched with a wide variety of causes that vary in each individual. There are now studies on the skin and gut microbiome (and more specifically, gut dysbiosis) as one of the causative factors of the condition. Cutibacterium acnes (c.acnes) is a type of bacteria found in those with acne, but is also found in the microbiota of non-affected, healthy skin. However, in acne skin, there is a pattern of some particular c.acnes strains, indicating a change in the skin microbiome of those with acne. In terms of the gut microbiome, there has been a large number of studies that link gut dysbiosis to this inflammatory skin condition, however, many different types of gut dysbiosis have been observed. As practising Dermal Clinicians, it is imperative to understand that not all individuals with acne vulgaris have gut dysbiosis, however, it is just one of the possible causative factors of the condition and must be initially considered and investigated. How Dermal Clinicians can Educate on the ‘Gut-Skin Axis’ It may be best practice for Dermal Clinicians to share this research with their patients, and encourage them to do their due diligence in seeking support from other appropriate allied health or medical practitioners who specialise in clinical investigation and treatment of gastrointestinal dysbiosis as a part of their scope of practice. Written by Kiera Nikolakakis. Reviewed by the Education Sub-Committee of the Australian Society of Dermal Clinicians.

Put November 26 & 27 in your diaries now. Stay up to date with SKINCON updates by following our Instagram and Facebook pages. Innovations and Emerging Trends in Dermal Science and Therapy SKINCON 2022 is the return of the largest educational event for the Australian Society of Dermal Clinicians. This year's conference will be a hybrid experience. This will include an in-person event in Melbourne as well as live-streamed and on-demand (online) access. We provide opportunities for our attendees to connect and learn in a way that suits their needs and preferences for when, where, and how they can undertake professional development. The event is for all Dermal Clinicians, Dermal Therapists, Dermatology, Cosmetic Nurses, Beauty Therapists, and Allied and Medical Professionals with a special interest in skin health and management. We look forward to the opportunity to catch up with colleagues old and new for this exciting event. Have you seen the lineup of speakers, presentations, and activities for SKINCON22? Click on the link to see the full agenda, speaker biography, and topic overview information. SKINCON22 covers all bases with interprofessional education, clinical practice updates, and presentations providing insight, tips, and tricks for your businesses. Interprofessional education presentations Vitiligo - Updates in diagnosis, differentials, and management strategies - Dr. Desmond Gan (FACD) Integrated facial aesthetics is the new black: Aesthetic harmony or aesthetic conflict - Dr. Naveen Somia (FRACS, Ph.D.) Body Dysmorphia - Dr. Toni Pikoos (Clinical Psychologist) Hair loss and hair transplant surgery - Dr. Bevin Bhoyrul (FACD) Skin Changes in Menopause - Chiza Westcarr (Nutritional Medicine Practitioner & Dermal Clinician) Clinical Practice Updates Combination therapies for body contouring. Microwave technology, lymphatic drainage & Electrical muscle stimulation (EMS) - Sally Shakespeare (Dermal Clinician) Acne Scarring Protocol with Ablative Fractional Technology - Vera Koslova-Fu (Dermal Clinician) Updates in LASER: Research & Clinical Guidance - Professor Greg Goodman (MBBS & FACD) Scar Management: Integrated patient care in a plastic surgery setting - Sofia Ververakis (Dermal Clinician) Successful outcomes with melanin-rich skins - Sarah Hughes (Clinical Educator and Dermal Therapist) The Science of Skin Inflammation and Managing Risk with Lasers - Vivian Gardiner RN Can we still rely on the Fitzpatrick scale? - Taneesa Williamson (Dermal Clinician) Importance of standardising assessment methodology - Jennifer Byrne (Dermal Clinician) Biostimulatory fillers and impacts on skin health - Dermocosmetica Interactive Case Study Workshop - Sunday the workshop will focus around collaborative case discussions with input from a panel of experts. Participants will explore assessment techniques, differential diagnoses and case management strategies. Practice Management Beyond the science: The art of connecting, creating and maintaining loyal customers in their clinical practice - Rochelle Akhaven (Head of Sales and Education Advanced Skin Technology) Virtual Consultations: COVID, Learnings, and future business practice applications - James Vivian (Business Owner and Dermal Clinician) HR Advice and Careers in the Dermal Sector - Sally Gardiner (HR online) It's all about choice - learning when, where, and how it suits you. This year you can choose how you wish to join SKINCON with an option to attend in person, join our live-streamed event, or access content on-demand. Where is the in-person event? The in-person event is being held in Melbourne at United Co. which is located at 425 Smith St, Fitzroy VIC 3065. For information on travel, parking and accommodation options near the venue you can view the information on the conference website. On-demand & Virtual Access with Eventee With in-person and virtual conference passes you will be provided with access to the virtual event live-streamed on the 26th and 27th as well as access to content on demand before or after the event. The virtual event is accessed through our Eventee app which can be used on a computer or through your mobile phone with apps for iPhone and Android devices. You will receive an invite to the event to begin networking and exploring content 7 days before the event. Get your conference pass now! Professional development and education may be a tax deduction and the ASDC offers options to spread repayments using our PayPal checkout options. **Terms and Conditions Apply All in-person passes provide access to on-demand content. For all inclusions click on the purchase your pass link below Scientific Plenary Pass - Saturday 26th of November Workshop Pass - Sunday 27th of November Weekend Pass - Saturday 26th & Sunday 27th November Virtual (on-demand pass) - includes access to on-demand and live-streamed presentations. ASDC members are eligible for a 35% discount. Ensure you are logged in to the website with your member profile when purchasing tickets to activate. Not a member, not a problem you can join from the events page to take advantage of the discounted conference entry as well as all of the other benefits of ASDC membership. Student pricing available **must be able to provide evidence of enrolment. We look forward to seeing you virtually or in person in Melbourne. The Australian Society of Dermal Clinicians Events Management Team Thank you to our sponsors and exhibitors

Put November 26 & 27 in your diaries now. SKINCON 2022 is the return of the largest educational event for the Australian Society of Dermal Clinicians. This year's conference will be a hybrid experience. This will include an in-person event in Melbourne as well as live-streamed and on-demand (online) access. The mission is to provide opportunities for our attendees to connect and learn in a way that suits their needs and preferences for when, where, and how they can undertake professional development. The event is open to Dermal Clinicians, Dermal Therapists, Dermatology, Cosmetic Nurses, Beauty Therapists, and Allied and Medical Professionals with a special interest in skin health and management. We look forward to the opportunity to catch up with colleagues old and new for this exciting event. Theme: Innovations and Emerging Trends in Dermal Science and Therapy The theme for the 2022 SKINCON is 'Innovations in Dermal Science and Therapy This topic will stimulate discussion with presentations on new technologies, techniques, case management in various clinical settings, controversies, and best practices as well as what is on the horizon for the dynamic and growing sector of skin health and management. You will hear from experts in their fields including Dermatology, Plastics, Dermal Clinical Practice & Research Topics include updates in LASER guidelines and protocols Pigmentary conditions assessment and treatment Hair loss & treatments Menopause and skin changes Bio-stimulatory fillers and dermal therapies Integrated approaches to dermal therapy Updates in education To see the agenda & speakers as they are updated click to enter the event It's all about choice - learning when, where, and how it suits you. This year you can choose how you wish to join SKINCON with an option to attend in person, join our live-streamed event, or access content on-demand. Where is the in-person event? The in-person event is being held in Melbourne at United Co. which is located at 425 Smith St, Fitzroy VIC 3065. For information on travel, parking and accommodation options near the venue you can view the information on the conference website. On-demand & Virtual Access with Eventee With in-person and virtual conference passes you will be provided with access to the virtual event live-streamed on the 26th and 27th as well as access to content on demand before or after the event. The virtual event is accessed through our Eventee app which can be used on a computer or through your mobile phone with apps for iPhone and Android devices. You will receive an invite to the event to begin networking and exploring content 7 days before the event. Get your conference pass now! All in-person passes provide access to on-demand content Scientific Plenary Pass - Saturday 26th of November **Choose to add on the networking drinks from 5.30-7.30 pm Workshop Pass - Sunday 27th of November Weekend Pass - Saturday 26th & Sunday 27th November **Includes networking drinks and breakfast workshop Virtual (on-demand pass) - includes access to on-demand and live-streamed presentations. ASDC members are eligible for a 35% discount. Ensure you are logged in to the website with your member profile when purchasing tickets to activate. Not a member, not a problem you can join from the events page to take advantage of the discounted conference entry as well as all of the other benefits of ASDC membership. Student pricing available **must be able to provide evidence of enrolment. We look forward to seeing you virtually or in person in Melbourne. The Australian Society of Dermal Clinicians Events Management Team Thank you to our sponsors and exhibitors

The Australian Society of Dermal Clinicians often receive queries from Dermal Clinicians, Dermal Therapists, employer groups as well as those thinking of entering into the profession particularly around the questions "What will I/should I get paid?" As the peak professional body representing Dermal Clinicians and Therapists, we aim to provide general guidance and information regarding industry pay rates based on previous data collected. This guidance includes information regarding the issues or considerations that may be involved in the determination of what 'a fair wage' is to inform workplace negotiations and discussions. Following is a discussion of award/s members may be covered by as well as the implications that employment setting and job description or duties can have when determining whether you will be paid under a particular award. Also, provided is information about the industry average according to ASDC commissioned industry research and how this compares to other allied and health professions. "Money grows on the tree of persistence" (Japanese Proverb) There are many variations on the saying "If you want to earn more, you must learn more". Generally speaking, increasing your education through recognised tertiary study provides benefits to you as an individual as well as to employers. In many cases formalised tertiary education can also result in increased earning capacity. Within the Dermal Science and Therapy industry sector, we have a fairly unique and perhaps problematic situation where advanced skills and techniques can be gained from non accredited industry training or short courses as well as qualifications from accredited tertiary institutions. Putting other debates and discussions aside for either approach, here we discuss the monetary ramifications that arise from either approach to expanding your scope of practice. These need to be carefully considered and individual counsel sought. Employers and individuals may utilise formal qualifications as well as the job description, duties and setting, to determine the most applicable industry/profession categorisation. Categorising a profession can inform whether there is a relevant industry award or alternatively negotiate a fair wage based on industry average. Industry categorisation also relates to Australian and New Zealand Standard Industrial Classification (ANZSIC) codes used by the Australian Bureau of Statistics and business industry codes (BIC) codes used by the Australian Taxation Office. Guidance as a starting point can be obtained by reference to award documents as well as consulting associated government and independent departments that relate to workplace relations such as the Fair Work Ombudsman. The Journey of the Dermal Therapy Profession: Implications and Misconceptions. To completely understand the conundrum or questions around "what does a dermal clinician or therapist get paid?" requires a little journey through our history. Twenty years ago, dermal therapy education was a postgraduate qualification for professional beauty therapists. The dermal therapy industry was naturally viewed as a progression or advancement of the knowledge and skill of beauty therapy. Between 1999-2001 the first offering of a dermal therapy university qualification and the present day, there have been developments that can complicate matters and the question of what does a dermal clinician or therapist get paid? This includes the emergence of qualifications within vocational and higher education sectors and the offering of dermal therapy procedures within a variety of different clinical settings. You can find dermal therapy practitioners in hair and beauty clinics, medi-spas and laser or cosmetic clinics, medical practices as well as newer areas such as community health settings and outpatient hospital services. ​ There has also been an evolution to increase the scientific rigour and evidence base paradigm of university education programs. In recent times we have seen the increasing professionalisation of dermal clinicians as practitioners and their professional body, the Australian Society of Dermal Clinicians. These developments have led to increasing recognition of Dermal Therapy as an emerging allied health profession. However, this is a road still being travelled. According to the Australian Council of Professions, a profession is: ​ "A disciplined group of individuals who adhere to ethical standards and who hold themselves out as, and are accepted by the public as possessing special knowledge and skills in a widely recognised body of learning derived from research, education and training at a high level, and who are prepared to apply this knowledge and exercise these skills in the interest of others". (Australian Council of Professions, 2021) ​ And a professional: ​ "Is a member of a Profession. Professionals are governed by codes of ethics and profess commitment to competence, integrity and morality, altruism, and the promotion of the public good within their expert domain. Professionals are accountable to those they serve and to society". (Australian Council of Professions, 2021) The Allied Professions of Australia (AHPA) define an allied health profession as: ​ "University qualified practitioners with specialised expertise in preventing, diagnosing and treating a range of conditions and illnesses. Allied health practitioners often work within a multidisciplinary health team to provide specialised support for different patient needs". (AHPA, 2021). Awards that may apply to the dermal therapy industry Those that can perform beauty services have Certificate through to Advanced Diploma qualifications and are covered under the Hair and Beauty Industry Award 2010 [MA000005]. The highest level to be paid as a beauty therapist is a level 6 with a Diploma of Beauty Therapy. Obtaining further non-formalised qualifications such as product or equipment training or even further diploma qualifications does not necessarily change the level any further within this award. Many employers do pay above award rate for years of experience, performance on the job and revenue generated through increased skills the individual has obtained over time. Dermal Clinicians with government accredited higher education qualifications including a Bachelor Degree or Post Graduate Certificate/Diploma may be covered under an award, or they may have to rely on negotiating their own rate of pay. Many professions do negotiate their salaries and not all job descriptions are covered under an award. This doesn't mean that the employer doesn't have guidance as to fair minimum rates or conditions, or that there isn't an award that may be applicable to individual situations. Professions including medical professionals, nurses, pharmacists, paramedics, engineers, bankers and architects all have industry or occupational awards that may cover them to refer to. However, they may also work outside these awards. Dermal Clinicians may fall under different awards depending on their education, workplace and job description or duties. They may also not be covered by an award as the company they are employed with has an enterprise agreement. In these situations, guidance from the Fair Work Ombudsman is recommended. A Dermal clinician with university qualifications, who identifies as an allied health professional may be covered under the Health Professionals and Support Services Award 2020 [MA000027]. In identifying as an allied health professional they perform a role in health assessment, therapeutic management of skin and working in clinical environments that align with descriptors within the classifications and descriptors of this award. There are other awards that may be reviewed as also applicable dependent on work duties including the hair and beauty award and the miscellaneous award. One of the common questions we get asked is if whether Dermal Clinicians can be covered by this award if their title is not on the list of health professions? The Fairwork Ombudsman has provided this response as clarification. The Health Professionals and Support Services Award provides a list of common health professionals in Schedule B. However, health professionals that still fit within the definition of the term under clause 4.2 and within a classification definition under Schedule A may still be covered by this award even if not specifically referred to or listed under Schedule B. Schedule B is an indicative list. It’s not exhaustive ​ Interpreting Health Pressionals and Support Services Award 2020 [MA000027] You can click here to be taken to a PDF of the Health Professionals and Support Services Award 2020 [MA000027]. Clicking on this link will provide you with information about definitions for categories, levels, roles and duties that will influence where you as an individual sit within this framework. As an individual, you need to be familiar with and stay up to date with changes to the award over time and if you have particular queries or concerns you can seek advice from the Fair Work Ombudsman. As some general advice regarding interpreting the levels and pay points the first thing to consider is the length of your degree or any recognised tertiary postgraduate qualifications you may hold. Then the number of years of clinical practice and your level of independence clinically including duties within your role. It is important to read each of the level descriptors as this will describe what your practice looks like for someone who is considered new to practice all the way through to highly specialised and independent. Within our industry, many graduates of Dermal Therapy or Clinical Aesthetics degrees already have significant years of clinical experience and this may require some negotiation with your employer. Industry Average Pay Rates for the Dermal Therapy Sector All of this information has related to what rights you have regarding minimum standards for wages and conditions. You might be asking though what is the industry average? What are most employers paying their dermal health professionals? According to an ASDC commissioned research project with Victoria University in 2017, there were several findings that impacted the average hourly rate of Dermal Clinicians Therapists. In 2017, the average pay rate for those working in the dermal therapy sector was $33-35 per hour. There was variance based on the clinical setting with those in medical settings being paid a higher rate than those working in beauty settings. The study had 82 respondents, 61.33% with a bachelor degree and 13.33% with an advanced diploma in Dermal Therapy. The remaining percentage either had no formal qualification, had trained overseas or identified as having a qualification other than dermal therapy-specific qualifications such as nurses working in the dermal therapy sector. Other findings reported in this survey of industry pay rates included: Increased years of experience resulted in higher rates of pay. It was reported that those with several years of experience were able to earn up to $45 per hour in some work settings. Postgraduate study also related to a higher average pay rate. At the time this research was carried out, respondents reported that pay increases were expected in the next 12 months but didn't necessarily occur on an annual basis. The ASDC aim to update this information with another survey over the next twelve months and will provide this information when available on the member portal via the ASDC website Comparing Dermal Health Professionals with other Health and Allied Health Professions Average Pay. The table below provides a summary of the hourly pay rate for comparison of professions working in the dermal sector and allied health. This comparison indicates for those with AQF 7 (bachelor) qualifications that there is a high similarity in both award and industry average pay rates. These figures are based on a full-time hourly rate (not casual or penalty rates) for entry-level (early graduates) and those with 2 years of experience only. All awards indicate higher pay rates based on increasing autonomy and duties. This table is for indicative comparison only. The rates included were correct at the time of analysis in January 2022 and are subject to change. The Grey Area There are grey areas where it is important to seek your own advice and counsel regarding your specific situation and negotiating a fair wage. ​ 1. Working whilst still a student of a dermal therapy program. We encounter situations where students are working in roles very similar or the same as qualified Dermal Clinicians but are not as yet qualified themselves. In this situation, your highest qualification as a beauty therapist may determine your award whilst a student, however, you may be performing a role outside the descriptor of a beauty therapist. ​ 2. When you hold post-graduate qualifications but don't hold an undergraduate degree (Bachelor). In this situation if you have for example a beauty therapy diploma and then a post-graduate program in dermal therapy you may fall outside descriptors in both the Hair and Beauty Industry and the Health Professions and Support Services Awards and this may require some negotiation with your employer and independent counsel as to how best to proceed. ​ 3. Just because you hold a qualification doesn't automatically dictate you are performing in that role. You may have a job role that requires you to perform techniques, skills or duties that are aligned with the role of a beauty therapist, as well as those of a dermal therapist or dermal clinician. In this situation, you may have to negotiate with your employer and seek independent counsel as to how best to proceed. Things you may want to consider in your negotiations are how many years of experience you have, your level of autonomy, the percentage of time performing duties in either role, the overall position description and the revenue that you generate for the business. You may also move into an entirely new role including business management, education and training or sales. ​ 4. If you gain a postgraduate qualification covered under another award. Dermal Clinicians that then go and complete post-graduate qualifications for example in Nursing would be advised to consult with nursing professional bodies about where you fit into the nursing award. Other post-graduate qualifications in health sciences may still be covered under the Health Professions award, whilst postgraduate qualifications in entirely different disciplines altogether may relate to another award due to distinct change in role. For the employers out there: Getting the most out of your University Graduate ​ Industry research and employment trends indicate that Dermal Clinicians are an extremely valued asset within many clinical settings and are remunerated accordingly, but we also occasionally hear some sad stories. Stories where graduates are being severely underpaid, under-utilised and undervalued for the education they hold. As an employer, if you employ a Dermal Clinician you are getting a lot more than someone who can do a great treatment and provide high-quality patient-centred care. Dermal Clinicians can Educate. Service that doesn't stop in the treatment room. In their university training many Dermal Clinicians are required to develop and facilitate education programs that can be offered to patient groups, peers in the workplace (within their scope) and also written materials for patient education around skin problems and management. Dermal Clinicians, OHS and risk mitigation: Employing a Dermal Clinician may cost a little more but your insurance costs could be lower. Dermal Clinicians are trained in developing risk assessments, standard operating procedures and clinical governance procedures such as audits. This documentation may provide your business with safer overall operations, reducing the risk of adverse events and also ensuring timely and appropriate management when or if they do occur. Dermal Clinicians are trained to ensure treatments are performed for maximum efficacy and lowest risk to the patient and the workplace. Dermal Clinicians are Evidence-Based and adhere to Best Practice: Better outcomes, happy clients, busy clinic, happy employer. During their education, Dermal Clinicians are trained to develop patient care plans and treatment protocols based on current evidence and best practice. This provides your clients/patients with the best and safest care currently available. They are trained in research design and protocols and have performed independent and group research during their studies so that they can implement this in their clinical practice and learn from observations over time. Dermal Clinicians may also develop clinical studies and publish their findings at conferences or industry publications. Dermal Clinicians are Allied Health Professionals: This means collaboration... Inter professional management of skin diseases and disorders, including wound management and healing are central to to the knowledge of Dermal Clinicians. They have the knowledge and training to facilitate multifaceted patient care by liaising with medical and other health and allied health professionals for better patient outcomes. This may mean referring out when required or appropriate but this network will also mean referrals coming in if you support your Dermal Clinician. Disclaimer The information in this document is of a general nature only and is not, and is not intended to be, advice. Before making any decision or taking any action, you should consult with appropriate accounting, tax, legal or other advisors. No warranty is given as to the correctness of the information contained in this publication, or of its suitability for use by you. To the fullest extent permitted by law, Australian Society of Dermal Clinicians Inc. (ASDC) is not liable for any statement or opinion, or for any error or omission contained in this publication and disclaims all warranties with regard to the information contained in it, including, without limitation, all implied warranties of merchantability and fitness for a particular purpose. ASDC is not liable for any direct, indirect, special or consequential losses or damages of any kind, or loss of profit, loss or corruption of data, business interruption or indirect costs, arising out of or in connection with the use of this publication or the information contained in it, whether such loss or damage arises in contract, negligence, tort, under statute, or otherwise References 1. Australian Council of Professions (2021). What is a profession? retrieved from https://www.professions.org.au/what-is-a-professional/ 2. Allied Health Professions Australia (2021). Defining Allied Health. retrieved from https://ahpa.com.au/what-is-allied-health/ 3. Drummond. E., Turvey. A., A., Joneidi. S., Cowling. S., Iacovangelo. V. & Bello. T. (2017). The Wage Levels of Dermal Therapy Graduates in Australia. Department of Research, Victoria University, College of Health and Biomedicine, Victoria, Australia (Student Research Project, Unpublished 4. Payscale (2021). Average Beauty Therapist Hourly Rate in Australia retrieved from https://www.payscale.com/research/AU/Job=Beauty_Therapist/Hourly_Rate 5. Payscale (2021). Average Registered Nurse Hourly Rate in Australia retrieved from https://www.payscale.com/research/AU/Job=Registered_Nurse_(RN)/Hourly_Rate 6. Payscale (2021). Average Physiotherapist Salary in Australia retrieved from https://www.payscale.com/research/AU/Job=Physiotherapist/Salary 7. Payscale (2021). Average Speech Pathologist Salary in Australia retrieved from https://www.payscale.com/research/AU/Job=Speech_Pathologist/Salary 8. Payscale (2021). Average Dietician Salary in Australia retrieved from https://www.payscale.com/research/AU/Job=Dietitian/Salary 9. Payscale (2021). Average Osteopath Salary in Australia retrieved from https://www.payscale.com/research/AU/Job=Osteopath/Salary

Introducing two ASDC Members presenting at the NSS Conference The Non-Surgical Symposium is a collaborative event between the Australasian Society of Aesthetic Plastic Surgeons (ASAPS) and the Australasian Society of Cosmetic Dermatologists (ASCD). The event is open to all medical practitioners, nurses, dermal clinicians, and practice staff in the aesthetic medicine industry. The NSS is held between June 3-5 on the Gold Coast. This year the event is a hybrid and you have the opportunity to attend in person or virtually. Dermal Clinicians and Therapists this year have another reason to attend. This year we have at least two Dermal Clinicians up on the presenter podium. As evidence-based allied health professionals presenting is an important aspect of clinical practice and presenting at these events is a great opportunity. This year the ASDC awarded funding as part of the research and education grant for the successful applications of an abstract for presentation in person on the Gold Coast. The expression of interest for abstract submission was open to all Dermal Clinicians and Therapists however the research and education fund is only available to ASDC members. Throughout the history of the Australian Society of Dermal Clinicians, we have always had strong ties with the Australasian Society of Aesthetic Plastic Surgeons. Twenty-three years ago several ASAPS members were among the group that established the first Bachelor's Degree level qualification in dermal science and therapy. They lobbied for this qualification to up-skill their practice staff performing skin and non-surgical cosmetic therapies with the emergence of advanced technologies. The ASDC has an affiliate agreement with ASCD and focuses on creating opportunities for collaboration, particularly in ongoing education and research. The Non-Surgical Symposium has traditionally been a great opportunity to come together to learn from and network with medical, nursing, and allied health professionals within the aesthetic medicine sector. Dermal Clinicians are speaking at this year's conference If you would like to attend the Non-Surgical Symposium, there is still time. Members should go to the member portal for information on how to attend and the link to register as an ASDC member. Recognition, referral, reward, revenue and retention in the management of pigmentation - A regional dermal clinician's perspective Whitney Gunn , BHSc (Dermal Science) Disclosures Owner of Do You Even Skin & Consultant Dermal Clinician Full Member of the Australian Society of Dermal Clinicians, research and education grant funding was provided to assist with travel expenses for this presentation by the Australian Society of Dermal Clinicians. Purpose – The early identification and management of sun damage and suspicious lesions in rural areas are challenging due to access to medical professionals and cost. Presented in this case study is a value-based health model integrating the skills and knowledge of Dermal Clinicians to improve client outcomes. Introduction – On the south coast of NSW, hyperpigmentation is prevalent due to the coastal location and the outdoor lifestyle. Therefore, sun, hormone, and inflammatory induced hyper-pigment as well as suspicious pigment, are regularly identified. In regional communities, wait times and price points of seeking medical advice can hinder the likelihood of early recognition and positive treatment outcomes. However, utilising dermal clinicians in the early recognition and management will lead to ongoing revenue within a value-based care model. As tertiary qualified skin professionals, Dermal Clinicians have the knowledge to differentiate the different types of hyper pigment and to refer appropriately. Method – A case study and model of valued-based health care demonstrating how integrating a Dermal Clinician along with medical practitioners in a community in regional NSW improves patient satisfaction and outcomes. Results – Dermal Clinicians and their knowledge and skills are a valuable resource as an emerging health workforce to assist with skin health. Utilising these tertiary qualified skin professionals within an allied health practice brings excellent reward and patient retention in long-term skin health management. This, in turn, leads to more significant revenue for the business. Skin tightening in an integrated model of care in a plastic surgery setting: An intervention ladder-based approach Sofia Ververakis, BHSc (Dermal Science) Disclosures Dermal Clinician employed with Re. Plastic Surgery. Full Member of the Australian Society of Dermal Clinicians, research and education grant funding was provided to assist with travel expenses for this presentation by the Australian Society of Dermal Clinicians. Purpose – This review will explore the scope of the Dermal Clinician and investigate evidence-based clinical interventions and outcomes for skin tightening when working in an integrated,multi-disciplinary, plastic surgery setting. Introduction- The clinical scope of the Dermal Clinician, although clearly defined and accredited, holds some ambiguity in multi-disciplinary practice. As AHPA-affiliated allied-health professionals, dermal clinicians are trained to provide clinical care in multi-disciplinary settings, both collaboratively and autonomously. With skin health at the centre of their work, the dermal clinician holds specialised knowledge in the assessment, prevention, and management of various skin conditions, both clinical and cosmetic. The multidisciplinary clinical approach of the dermal clinician follows a patient-centred and value-based care model, focused on wholistic patient management and improved patient outcomes. In the management of skin laxity, the scope of the dermal clinician allows for the use of non-surgical and minimally invasive interventions. Practice is evidence-based, and intervention selection is supported by clinical reasoning and medical intervention tools. The purpose of this review is to explore the scope and applicability of the Dermal Clinician when addressing a patient with concerns of skin laxity. Method - A search was conducted on both PubMed and Cochrane library to source viable, current, and high-level evidence relevant to the research topic and evaluated themes. A search strategy was formulated and reviewed. Search terms used were “non-invasive” and “skin tightening”, or “neocollagenesis” or “facial rejuvenation.” Evidence considered was exclusive to Meta-analyses, Systematic Reviews and Randomised-controlled Trials as each is of Level I or II standards (NHMRC), presenting as the gold standard for assessing evidence as clinical practitioners. Results were collated and reviewed, providing a strong and reliable body of evidence. Results -A total of 31 studies were found, each outlining non-invasive interventions, effective in the treatment of skin laxity and collagen degradation. Each of the proposed modalities works through varying mechanisms of action but ultimately result in changes to the structure of the dermis and epidermis. Results show improvements in skin tightness and overall texture and support the concept of combination therapy, exploring how the use of multiple modalities can yield superior results when addressing patients with concerns of skin laxity. The academic literature provides evidence and support for treatment programs designed and utilised by the dermal clinician in both independent and multi-disciplinary settings. Conclusion - The scope of the dermal clinician is such that they are of the skillset, knowledge, and ability to improve the effects of skin laxity successfully and independently. By taking a patient-centred approach and utilising clinical reasoning as well as assessment and intervention tools, the dermal clinician provides a standard of expertise and care that is of value to the integrated plastic surgery practice. There is still time to register As an ASDC member log into your portal to use the ASDC registration link

You have probably all now seen or heard about the story on A Current Affair that aired January 11, 2021. The story focused on adverse events resulting after procedures including cool sculpting and LASER. An incident was highlighted where horrific burns and long term consequences resulted from improper and inappropriate use of a Cryo chamber. The story whilst shocking was not informed by consultation with professional bodies that can speak for those that were targeted by this story. Of concern there were claims made the medical profession seeks regulation to have “medical” procedures only in the hands of medical (AHPRA regulated) practitioners. Should these procedures be performed only by medical professionals? The Issue is not whether medical or non medical professionals should be performing the treatment. Rather the question is do they have the depth of knowledge, level of critical thinking and relevant training and experience required to assess risks, prevent or manage any complications associated with these procedures. This includes energy devices, skin penetration procedures and medical grade cosmeceutical skin products. There are “non medical” health professionals that have completed 3 or 4 year health science degrees as skin health professionals. Specifically they have specialisation in performing non surgical minimally invasive ‘medical?’ procedures on the skin. This requires expert knowledge of the mechanism of various technologies and energy devices as well as tissue interactions to achieve desired outcomes and prevention of skin damage. It also requires proficiency during their study by completion of many clinical hours under supervision in performing techniques so that treatments are safe for the Australian public. Medical professionals whilst definitely qualified to understand risks and to manage the complications are not, as part of their medical degree taught extensively about skin or performing non surgical procedure using these technologies. Both nurses and doctors should, and do, undertake appropriate post graduate training. These medical specialisations have their own challenges with recognition and regulation of what education and training allows them to use titles such as cosmetic physician, surgeon or nurse. Is regulation required? In Australia there is a who dares can attitude among a small number of both medical and non medical practitioners that damages the reputation of the vast majority of practitioners who are ethical, patient centred and apply evidence based practice. The ASDC agree regulation is required. This is common ground between medical and non medical professions. It’s required to protect the public from unscrupulous providers of substandard short course education. It’s required to protect against companies that don’t concern themselves with who has the device or product they sell, or if they have the education and training required to use it safely. It’s also required for those very, very few non medical and medical individuals who practice outside their scope or dance along the margins because “nothing says they can’t”. To say that the industry is not regulated at all is not accurate. There are professional bodies that align with dermal (skin) science and therapy performing aesthetic/cosmetic procedures. Members of these organisations are provided with guidance and expectations regarding scope of practice, continuing education, use of titles and information about practice based on current evidence and best practice. Educational institutions that offer bachelor level qualifications have to demonstrate to accrediting bodies they have processes to ensure curriculum is robust, evidence based and complies with all industry, government, profession and institution based regulatory requirements. The ASDC are an affiliate member of Allied Health Professions Australia (AHPA) in recognition of their status as an emerging health profession that is evidence based and meets the benchmark standard of representing university qualified allied health professionals. The problem does not lie in medical or not medical. The real problem is a lack of regulation and recognition of the duration, depth, level and relevance of education required to operate in this specialisation and how this relates to scope of practice The problem lies in a current lack of recognition and protection for emerging health professions that are trained to manage skin health and the most common skin conditions. Beautician and Beauty Parlour title is it obsolete? The problem also lies in the continued use of antiquated titles such beautician and beauty parlour. These terms are used to cover everything from beautification procedures to minimally invasive non surgical cosmetic procedures. These terms are often used in a quite derogatory manner especially in instances such as the A Current Affair story but examples were also noted with industry classifications during COVID-19. The government currently lumps everyone from Cert III qualified beauty therapists to University qualified Dermal Clinicians under the same categorisation. These terms “beautician and beauty parlour” have no relevance and should not be applied to those that perform non surgical cosmetic/medical procedures whether this be in dermal therapy, cosmetic clinics or other medical and healthcare settings. It’s time that categorisation and descriptions of the "beauty/cosmetic" industry are updated. The titles dermal clinician, dermal therapist must receive Industry endorsement, be accepted, respected and consistently used so that they are only used by those endorsed to use them through recognised education and training. The importance of non-medical (allied health) skin health professions With the health problems facing Australia in the years to come and projected potential shortages in the medical workforce, allied health is going to play a larger role in preventative health reform and management of common conditions related to their scope. Dermal Clinicians play an important role in the early detection of skin disease and disorder, assisting Australians to age well and healthily. Dermal clinicians can manage common skin conditions to prevent further deterioration and subsequently assist with improving mental health caused by the burden of skin disease and disorders. The government has a 10 year reform plan that integrates allied and medical health services. https://www.health.gov.au/resources/publications/australias-long-term-national-health-plan The ASDC response to treatment warnings by Australian doctors. The ASDC are lobbying government for greater recognition and respect for what Dermal Clinicians and Dermal Therapists can do and the education and expertise we hold. We are lobbying for regulation that respects the education and expertise that is required to both manage and perform these procedures. We are lobbying for this to be based not only on medical or not medical education, but who is most qualified in that area of specialisation. Just like in many other health areas where there is overlap in scope of practice. You wouldn’t want a GP or nurse doing your X-ray, performing spinal manipulation or compounding your medications because they are medically trained. Medical professions definitely understand the risks and can manage complications associated with these, but all these ‘dangerous’ procedures are performed by trained experts in these specialisations. We will be lobbying government to ascertain if government regulation is being revisited. We will be working to develop consensus and understanding with other stakeholders in these discussions should this be the case. We will continue on our path to being recognised as a self regulating allied health profession and ordinary member of AHPA by 2024. What part can industry play in preventing these adverse events? If you aren’t a member of the ASDC or other professional bodies become one. This is an important way to stay informed and to seek advice. If you are considering taking on a new device or procedure or have a “medical grade” device or product, ask yourself the following questions. What is the worst that can go wrong? Are my employees/am I adequately trained to prevent this from happening? Can a wide range of people be treated safely and effectively by using clinical reasoning to adapt treatment when required? Do we know when not to perform the procedure and why? If something does go wrong are we educated and trained to manage this ourselves? If the answer is no to any of those questions don’t perform the procedure, it’s not in your scope of practice. Refer to someone who can that has the qualification and expertise required. If you are looking for a dermal Clinician or therapist contact the ASDC. Info@dermalclinicians.com.au Post edited 15/1/2021 to amend title beautician and beauty parlour title obsolete. The ASDC advocate that all skin health practitioners have a place in client management relevant to qualifications and scope of practice. We advocate for cross referral among skin practitioners who perform services related to education and training. This heading was not intended to anyway demean those that use the title beautician. Rather to highlight re-classification (government) of the beauty and cosmetic sector is required so that the public understand titles currently used in relation to education and scope of practice. On behalf of the ASDC General Committee

By Sofia Ververakis, a 4th Year Victorian University Dermal Science Student. As the world constantly evolves and requires us to connect in different ways, Tele-health has become an integral part of Medicine, Allied Health and Clinical Practice. In society today our ability to travel freely is uncertain, telehealth and resources such as the SSE Algorithm allow patients to take control over their health and keep in contact with medical professionals in a private and professional fashion. As part of our final year at Victoria University we, a group of Dermal Science undergraduates, endeavoured to create a tool that assists people of various locations and communities to readily access the information required to perform a Skin Self-Examinations. This topic was of particular importance to us since, as Australians, we hold the highest skin cancer rate globally and are commonly reminded that early detection is key in reducing the incidence of this disease. Our intention is to make this resource accessible and easy to use, therefore we have chosen to create a flowchart that provides the user with instructions on how to conduct a skin self-examination and analyse their lesion, as well as when to contact a medical professional. Additionally, the reverse side of the pamphlet contains educational information for the patient containing the characteristics of melanoma, as well as an instructive step-by-step description of a Skin Self-Examination (SSE). We envision that our tool will be distributed to all medical practices, where they can be used to identify which patients are at risk of skin cancer or to be used as a tool at home for those who would like to conduct routine Self Skin Examinations. The algorithm would be available in 2 forms: Physical form: a professionally printed, 2-page A4 pamphlet Online: accessible electronically via email as a PDF. Being available online bridges the gap for clients that would otherwise have to travel far or incur costs to visit a clinic. Contact details are provided for relevant services, linking patients to their nearest medical facility. Our vision for this resource is to assist all citizens in accessing and connecting with the appropriate medical professionals needed to detect and maintain cancerous and non-cancerous lesions.

The human skin, identified as being the largest organ by both weight and magnitude, is made up of multiple conjoined strata’s and is accountable for numerous fundamental processes such as percutaneous water loss, temperature conservation and immune protection. Intriguingly, the skin is also the initial projection of the physiological signs of ageing, a process described as a succession of complex biological developments that have the potential to damagingly affect the skins external presentation, as well as its functional and mechanical practices. Considering this, researchers declare that modern society’s necessity of beauty to be a youthful façade, expounds the great efforts being undertaken to guarantee the preservation of a youthful appearance. This information reiterates the significance of understanding the mechanisms that underly the ageing skin as it will ensure the suitable and safe use of interventions and modalities. Intrinsic and extrinsic ageing It is critical to consider the two individual developments of skin ageing, intrinsic ageing and extrinsic ageing. Intrinsic ageing: Also termed chronological ageing or physiological aging, is a series of biochemical molecular amendments instrumental of one’s genetic predisposition. It is hypothesised these alterations are consequential of the shortening of telomeres, the diminishment of antioxidant enzyme activity and lessened elastin gene expression. Extrinsic ageing: Also recognised as photoaging. Extrinsic ageing has the ability to imbricate intrinsic ageing. Extrinsic ageing is marked as a biochemical means that is successive of external factors such as mechanical, lifestyle and environmental bearings, for instance; accumulated exposure to ultraviolet radiation (UVR), pollution or cigarette smoking. It is important to remark, divergent to most bodily organs, the ageing skin is subject to both intrinsic and extrinsic ageing advances. Alterations of the ageing epidermis The epidermis, whilst also yielding cutaneous hydration, is liable for the body’s defence against environmental and external insults and as the skin moves through the ageing processes, this strata undergoes various modifications: Amplified skin vulnerability, fragility and transparency: It is proposed this is credited to the 6.4 per cent per decade decline in epidermal thickness resultant of amplified apoptosis toward the granular layer, cytological atypia and increased keratinisation. Pigmentation, guttate amelanosis and solar lentigo lesions: Research has testified this is due to the 20 per cent per decade diminution in the number of effective melanocytes within the basal layer in aggregation with a significant growth in the size of melanocytes. Xerosis, dermatitis, eczema and associated pruritus: This is attributed to trans epidermal water loss (TEWL) inclusive of the insufficient morphological and functional qualities of sebaceous gland cells. Post preliminary hypertrophy the size of the sebaceous gland cells regress and consequently their secretory output perishes, eventually succeeding a reduction in sebum formation and surface lipid levels. Decreased desquamation and altered immune function, skin infection, pathological disease and delayed wound healing: This is said to be consequential of the striking attenuation in Langerhans cells and the decrease in mitotic cell activity and re-epithelisation. Alterations of the ageing dermis The dermis offers a sturdy, flexible and supportive layer to the epidermis and remarkably displays the most extreme and dramatic reformations instrumental of skin ageing: Reduced skin strength and resilience and a thin, lax and wrinkly skin surface: This is hypothesised to be consequential of dense bundles of fragmented, disorganised and insoluble collagen and elastin conformations. Studies profess this is indebted to downgraded collagen synthesis and degradation due to weakened fibroblast activity, in addition with the upregulation of collagen degradation enzymes, such as matrix metalloproteinases (MMP) via the assembly of reactive oxygen species (ROS). Skin pallor and sallowness: This is affirmed to be successive of lessened vascularity resultant of a loss of vertical capillary loops. Telangiectasia: This is avowed to be momentous of the thinning of dilated vessel walls. The Dermal Clinician and treatment and management options of the ageing cutaneous Skin protection: UVR protection through routine and consistent use of protective sunscreens in aggregation with reduced exposure to UVR is proposed to be vital in protecting the cutaneous from gross variations that are linked with cumulative sun exposure. Skin care: Throughout cutaneous maturation the skin’s protective barrier can become compromised, though daily administration of a gentle skincare regimen can restore, repair and maintain the integrity of the barrier. Topical antioxidants can potentially assist in lessening UV-induced oxygen free radicals and skin impairment accompanied with UVR. Such antioxidants include, L-ascorbic acid, ferulic acid, alpha lipoic acid and coenzyme Q10. Alpha hydroxy acids (AHA) such as ascorbic acid, glycolic acid, lactic acid, citric acid and malic acid can recover the skins elasticity and overall exterior through encouraging epidermal thickness, mounting collagen production, cultivating perfusion of the dermis and increasing moisture retainment in the epidermis. Topical tretinoin can intensify epidermal thickness, diminish keratinocyte atypia, modify distribution melanin granule dispersal and increase collage and fibroblast activity in the dermis. Chemical peeling solutions: It is hypothesised chemical peels have the potential to expose a smoother skin surface through the craft of an orderly wound to stimulate regeneration. Dermabrasion and microdermabrasion: This involves the stimulation and production of new collagen through the replacement of abraded skin post treatment. Non-ablative therapies: This encompasses initiation of a thermal injury to the papillary and upper reticular dermis to promote a wound healing response and encourage fibroblast activation, regeneration of subsurface collagen and neocollagenesis. To summarise, skin ageing is a complicated progression and it is crucial to not only postulate a vaster understanding of the underlying physiological and biological developments correlated with cutaneous ageing, but to also ruminate the psychological considerations for ageing patients in order to accelerate the undertaking of holistic treatment and management approaches to ensure healthy ageing skin. References Bonifant, H., & Holloway, S. (2019). A review of the effects of ageing on skin integrity and wound healing. British Journal of Community Nursing, 24(3), 28- 33. doi:10.12968/bjcn.2019.24.sup3.s28 Ilankovan, V. (2014). Anatomy of ageing face. British Journal of Oral and Maxillofacial Surgery, 52(3), 195-202. doi:10.1016/j.bjoms.2013.11.013 Kazanci, A., Kurus, M., & Atasever, A. (2016). Analyses of changes on skin by aging. Skin Research and Technology, 23(1), 48-60. doi:10.1111/srt.12300 Limbert, G., Masen, M. A., Pond, D., Graham, H. K., Sherratt, M. J., Jobanputra, R., & McBride, A. (2019). Biotribology of the ageing skin—Why we should care. Biotribology, 17, 75-90. doi:10.1016/j.biotri.2019.03.001 Longo, C., Casari, A., Beretti, F., Cesinaro, A. M., & Pellacani, G. (2013). Skin aging: In vivo microscopic assessment of epidermal and dermal changes by means of confocal microscopy. Journal of the American Academy of Dermatology, 68(3), 73-82. doi:10.1016/j.jaad.2011.08.021 McDonald, R. B. (2019). Biology of Aging. London, England: Garland Science. Naylor, E. C., Watson, R. E., & Sherratt, M. J. (2011). Molecular aspects of skin ageing. Maturitas, 69(3), 249-256. doi:10.1016/j.maturitas.2011.04.011 Roenigk, H. H. (2000). Treatment of the aging face. Dermatologic Therapy, 13(2), 141–153. doi: 10.1046/j.1529-8019.2000.00022.x Sadick, N. S., Karcher, C., & Palmisano, L. (2009). Cosmetic dermatology of the aging face. Clinics in Dermatology, 27(3), S3-S12. doi:10.1016/j.clindermatol.2008.12.003 Tobin, D. J. (2017). Introduction to skin aging. Journal of Tissue Viability, 1(26), 37- 46. doi:10.1016/j.jtv.2016.03.002 Tortora, G. J., & Derrickson, B. H. (2015). Principles of Anatomy and Physiology. Hoboken, NJ: Wiley Global Education. Trojahn, C., Dobos, G., Lichterfeld, A., Blume-Peytavi, U., & Kottner, J. (2015). Characterizing Facial Skin Ageing in Humans: Disentangling Extrinsic from Intrinsic Biological Phenomena. BioMed Research International, 1-9. doi:10.1155/2015/318586 Villaret, A., Ipinazar, C., Satar, T., Gravier, E., Mias, C., Questel, E., … Josse, G. (2018). Raman characterization of human skin aging. Skin Research and Technology, 25(3), 270-276. doi:10.1111/srt.12643 Wong, R., Geyer, S., Weninger, W., Guimberteau, J., & Wong, J. K. (2015). The dynamic anatomy and patterning of skin. Experimental Dermatology, 25(2), 92-98. doi:10.1111/exd.12832 Zegarska, B., Pietkun, K., Giemza-Kucharska, P., Zegarski, T., Nowacki, M. S., & Romańska-Gocka, K. (2017). Changes of Langerhans cells during skin ageing. Advances in Dermatology and Allergology, 3, 260-267. doi:10.5114/ada.2017.67849 Zouboulis, C. C., & Makrantonaki, E. (2011). 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Acne scarring is the most common ramification of Acne Vulgaris and research declares 95 per-cent of acne sufferers will extant with various degrees of consequent acne scarring. Acne scarring emanates from the damage caused to the skin during the healing of active acne lesions and has the ability to induce overwhelming psychological, psychosocial and physical distress due to its bodily disfigurement. Successful treatment and management of acne scarring remains a challenge, however research advises early intervention is vital due to the correlation between the severity of acne scars and the duration between initial development of acne lesions and the commencement of acne treatment. The pathogenesis of acne scarring The subsequent scarring ensuing the inflammation accompanying Acne Vulgaris progresses from an exchange of numerous mechanisms, such as inflammation, granulation tissue formation and matrix remodelling. The formation of Acne scars transpires when an inflammatory lesion associated with Acne Vulgaris erupts into the sebaceous follicle and principates a perifollicular abscess. Typically, the inflammatory reaction is compressed, and the abscess is repaired with no supplement scarring, however, if encapsulation is defective, multichannel fistulous tracts will advance, and scar formation will befall. The type of scar that is formed is governed by the extent, the depth and the hosts response to the inflammation. It is also noteworthy to consider that some patients are more susceptible to the development of acne scarring as they encompass an altered inflammatory cell profile and consequently encounter an extended inflammatory response at the follicle culminating in collagen disruption and destruction. Classification of acne scarring Acne scars are established based on their tissue response to inflammation. Mostly, there are two categories of acne scars, those which are resultant from amplified tissue formation and those which are produced by deficient tissue formation. Hypertrophic and keloidal scars are associated with excessive collagen deposition and decreased collagenase activity. Specific to hypertrophic scars, they exhibit erythematous, raised, firm lesions in conjunction with thick hyalinised collagen bundles within the original site of injury. By comparison keloidal scars depict as red or purple papules and nodules with dense collections of hyalinised acellular collagen in whorls that proliferate outside of the original wound margin and often grow without retreat. Both hypertrophic and keloidal scars commonly display on the back, shoulders, trunk and jawline. In contrast, atrophic scars are more collective and are affiliated with the destruction of collagen and elastin due to inflammation in the deep dermis. Atrophic scars commonly appear on the face and primarily present as erythematous lesions that become hypopigmented as time advances. Atrophic scars are further divided into three sub-groups contingent on the depth, shape and degree of collagen lost. Ice-pick scarring (less than 2mm): Narrow, deep and sharply demarcated “V” shaped epithelial tracts that extend vertically into the deep dermis or subcutaneous layer. Credits to 60-70 per-cent of Acne scars. Rolling scarring (4-5mm): Undulating “M” shaped tracts resultant from dermal tethering of the dermis to the subcutis. Attributes to 15-20% of Acne scarring. Boxcar scarring (1.5-4mm): Oval or round, shallow or deep, sharply demarcated “U” shaped epithelial tracts that extend into the dermis, however they do not taper at the base. Responsible for 20-30 per-cent of Acne scars. It is crucial to establish the type of scarring present in order to generate and tailor a befitting treatment plan for patients. Whilst other deviating descriptors have formerly been used to classify Acne scars, they are subjective and therefore research advocates that Clinicians comply with the sanctioned nomenclature to ensure unity of terminology and allow for treatment contrasts across a variation of studies. Interprofessional Practice and how Dermal Clinicians can aid in the management and treatment of acne scarring The treatment of Acne scarring exposes as a challenge for both Clinician and patient, despite there being an abundance of treatment and management selections available there is no guaranteed uniform modality to completely and dependably remove scars, thus, research instructs when treating Acne scars the goal should be to give the skin a more acceptable physical appearance. Considering this, as Dermal Clinicians, when treating post-acne scarring patients it is imperative to educate and impart realistic expectations whilst also residing within our scope of practice. The ways in which Dermal Clinicians can work interprofessionally to aid in the treatment and management of acne scars are outlined below: Ablative lasers The epithelium, papillary dermis and reticular dermis are removed to stimulate re-epithelialisation, extracellular collagen synthesis and remodelling Non-ablative lasers Using thermal production, the skin is resurfaced to promote collagen remodelling in the dermis Fractional resurfacing Microscopic thermal wounds are created to induce dermal remodelling and re-epithelialisation Chemical peels A controlled wound healing process is engendered which results in the elimination of dead cells to prompt re-epithelialisation and increase collagen and elastin production Skin Needling Microchannels in the dermis are formed to initiate and increase collagen and elastin production Dermabraison The epidermis and part of the dermis is removed via either a rotating motorised hand piece with a wire brush or a diamond tipped handpiece to promote re-epithelialisation and re-pigmentation Radio-frequency (RF) A skin injury is created to encourage a wound healing response in order to inspire the remodelling of dermal collagen Subcision Fibrotic adhesions are loosened in order to form a gap for future collagen deposition in successive wound healing Isotretinoin Prevents post-acne scar formation Topical retinoids Motivates collagen formation, elastin fibres and dermal collagen synthesis Soft Tissue Augmentation Soft tissue volume is replaced, and collagen production is encouraged Punch Excision Scar tissue is excised via a punch biopsy to promote a controlled wound healing process Radiotherapy Prevents recurrence of post-acne scar formation by decreasing fibroblast activity and encouraging cellular apoptosis Considering the above information, it is essential to remark that research recommends in order to maximise patient clinical outcomes that Dermal Clinicians execute a combination of these therapies whilst working interprofessionally alongside other medical specialists in the treatment of post-acne scarring. References Pandey, A., Swain, J.P., & Minj, A. (2015). Assessment of Microneedling Therapy in the Management of Atrophic Facial Acne Scars. Journal of Evidence Based Medicine and Healthcare, (57), 8911. https://doi-org.wallaby.vu.edu.au:4433/10.18410/jebmh/2015/1256 Basta-Juzbašić, A. (2010). Current therapeutic approach to acne scars. Acta Dermatovenerologica Croatica: ADC, 18(3), 171–175. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=mnh&AN=20887698&site=eds-live Cohen, B. E., Brauer, J. A., & Geronemus, R. G. (2016). Acne scarring: A review of available therapeutic lasers. Lasers in Surgery & Medicine, 48(2), 95–115. https://doi-org.wallaby.vu.edu.au:4433/10.1002/lsm.22410 El-Domyati, M., Abdel-Wahab, H., & Hossam, A. (2018). Microneedling combined with platelet-rich plasma or trichloroacetic acid peeling for management of acne scarring: A split-face clinical and histologic comparison. Journal Of Cosmetic Dermatology, 17(1), 73–83. https://doi-org.wallaby.vu.edu.au:4433/10.1111/jocd.12459 Forbat, E., & Al-Niaimi, F. (2016). Fractional radiofrequency treatment in acne scars: Systematic review of current evidence. Journal Of Cosmetic And Laser Therapy: Official Publication Of The European Society For Laser Dermatology, 18(8), 442–447. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=mnh&AN=27592504&site=eds-live Forbat, E., Ali, F. R., & Al, N. F. (2017). The role of fillers in the management of acne scars. Clinical & Experimental Dermatology, 42(4), 374–380. https://doi-org.wallaby.vu.edu.au:4433/10.1111/ced.13058 Frith M, & Harmon CB. (2006). Acne scarring: current treatment options. Dermatology Nursing, 18(2), 139–142. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=c8h&AN=106466765&site=eds-live Goodman, G. J. (2011). Treatment of acne scarring. International Journal Of Dermatology, 50(10), 1179–1194. https://doi-org.wallaby.vu.edu.au:4433/10.1111/j.1365-4632.2011.05029.x Gozali, M. V., Bingrong Zhou, & Dan Luo. (2015). Effective Treatments of Atrophic Acne Scars. Journal of Clinical & Aesthetic Dermatology, 8(5), 33–40. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=afh&AN=102705642&site=eds-live Hession, M. T., & Graber, E. M. (2015). Atrophic Acne Scarring: A Review of Treatment Options. Journal of Clinical & Aesthetic Dermatology, 8(1), 50–58. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=afh&AN=100415112&site=eds- Levy, L. L., & Zeichner, J. A. (2012). Management of acne scarring, part II: a comparative review of non-laser-based, minimally invasive approaches. American Journal Of Clinical Dermatology, 13(5), 331–340. https://doi-org.wallaby.vu.edu.au:4433/10.2165/11631410-000000000-00000 Magnani, L. R., & Schweiger, E. S. (2014). Fractional CO2 lasers for the treatment of atrophic acne scars: a review of the literature. Journal Of Cosmetic And Laser Therapy: Official Publication Of The European Society For Laser Dermatology, 16(2), 48–56. https://doi-org.wallaby.vu.edu.au:4433/10.3109/14764172.2013.854639 Pavlidis, A. I., & Katsambas, A. D. (2017). Therapeutic approaches to reducing atrophic acne scarring. Clinics in Dermatology, 35(2), 190–194. https://doi-org.wallaby.vu.edu.au:4433/10.1016/j.clindermatol.2016.10.013 Phothong, W., Wanitphakdeedecha, R., Sathaworawong, A., & Manuskiatti, W. (2016). High versus moderate energy use of bipolar fractional radiofrequency in the treatment of acne scars: a split-face double-blinded randomized control trial pilot study. Lasers In Medical Science, 31(2), 229–234. https://doi-org.wallaby.vu.edu.au:4433/10.1007/s10103-015-1850-2 Qian, H., Lu, Z., Ding, H., Yan, S., Xiang, L., & Gold, M. H. (2012). Treatment of acne scarring with fractional CO2 laser. Journal of Cosmetic and Laser Therapy, 14(4), 162–165. https://doi-org.wallaby.vu.edu.au:4433/10.3109/14764172.2012.699679 Qin, X., Li, H., Yu, B., & Jian, X. (2015). Evaluation of the efficacy and safety of fractional bipolar radiofrequency with high-energy strategy for treatment of acne scars in Chinese. Journal of Cosmetic and Laser Therapy, 17(5), 237–245. https://doi-org.wallaby.vu.edu.au:4433/10.3109/14764172.2015.1007070 Simmons, B.J., Griffith, R.D., Falto-Aizpurua, L.A., & Nouri K. (2014). Use of radiofrequency in cosmetic dermatology: focus on nonablative treatment of acne scars. Clinical, Cosmetic and Investigational Dermatology, 335-339. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=edsdoj&AN=edsdoj.b29b37ba431f468783746276bd0840cb&site=eds-live Sobanko, J. F., & Alster, T. S. (2012). Management of acne scarring, part I: a comparative review of laser surgical approaches. American Journal Of Clinical Dermatology, 13(5), 319–330. https://doi-org.wallaby.vu.edu.au:4433/10.2165/11598910-000000000-00000

Wounds and Diabetes Mellitus The human skin embodies a crucial and imperative barrier against environmental perils, and what’s more, when cutaneous injury emerges the human body commences a sequence of coordinated molecular progressions. Though, in some disastrous instances non-healing chronic wounds may advance where an anatomical and functional outcome is not achieved within a timely means and the wound remains in a self-perpetuating inflammatory phase. There are innumerable influences that can delay wound healing, one of the most frequent being chronic disease, more specifically Diabetes Mellitus. Diabetes Mellitus is one of the most widespread metabolic disorders worldwide and concerns approximately 383 million people globally. The World Health organisation delineates Diabetes Mellitus as a chronic endocrine condition identified by hyperglycaemia consequential of insulin deficiency, insulin resistance, glucagon secretion, or potentially an aggregation of all three. Normal cutaneous healing To entirely comprehend the fundamental mechanisms of chronic wounds associated with Diabetes Mellitus, a reconsideration of the well-regulated developments of physiological wound healing is elemental. Haemostasis: Initially succeeding cutaneous injury, the extra-cellular matrix stimulate and unite circulating platelets, which then withstand adhesion and accumulation. The impaired tissue and the aggregated platelets activate coagulation pathways to secure the fibrin platelet clot, which eventually formulates a framework for the migration and proliferation of additional participating cells in the wound healing progressions. Inflammation: The inflammatory phase is a central reaction to anatomical injury and comprises the cessation of tissue and the clearing of cellular, extra-cellular and pathogen debris. In standard cutaneous wound healing inflammation is resolute after one to two weeks, though in chronic wounds, this phase becomes extended and intensified. Proliferation: Throughout the proliferation stage, re-epithelisation launches as the keratinocytes and the epithelial cells proliferate and migrate. Simultaneously, angiogenesis also takes place to postulate oxygen, nutrients and hydrate the matrix for cellular activity. Remodelling: To finish the developments of normal cutaneous wound healing, contraction and remodelling undergo, where collagen synthesis and lysis ensue, and collagen fibres are reorganised in small parallel bundles along tension lines to form a scar. The end of the wound healing phases is signified by apoptosis of vascular cells and myofibroblasts, finally transfiguring the granulation tissue into a collagen filled scar. Diabetic Foot Ulcers Diabetic Foot Ulcers, a chronic wound, are the most disastrous extensive impediment of Diabetes Mellitus. For the sufferer, Diabetic Foot Ulcers extant with neuropathic pain, skin discolouration, occasional haemorrhage, reduced mobility, sleep troubles, leakage and malodour, and in more catastrophic cases, they may lead to amputation or mortality for the patient. Emergent research has affirmed up to 4% of Diabetics cultivate a Diabetic Foot Ulcer annually, with at least 25% of Diabetics presenting with one Diabetic Foot Ulcer throughout their lifespan, these statistics convert to 16 million Diabetic Foot Ulcers per annum. Even more to this, Australian studies have confirmed one limb is amputated every three hours due to Diabetic Foot Ulcers, and a total of 8% of all Diabetic fatalities being credited to Diabetic Foot Ulcers. Furthermore, owing to Diabetic Foot Ulcers necessitating long-standing wound management and being one of the most common reasons for hospitalisation they are associated with substantial health care costs and burden, further indicating the requirement and importance for greater understanding and awareness. The pathophysiology of Diabetic Foot Ulcers Diabetic Foot Ulcers are consequential of both ischemia and neuropathy, which fundamentally deteriorate a patient’s skin integrity and lead to a cascade of consequences, such as hindered wound healing. Diabetic Foot Ulcers extant due to sensory, motor and autonomic neuropathies associated with Diabetes, devastatingly, this culminates a loss of protective foot sensation, foot deformity due to abnormal weight bearing, reduced sweating and amplified skin dehydration, causing hyperkeratosis, also known as callus formation. Subsequent to this, once a callus has formed, the continual weight bearing compression causes subcutaneous haemorrhage beneath the callus, and finally, a Diabetic Foot Ulcer develops. The newly formed Diabetic Foot Ulcer is vulnerable to secondary infection owing to the Diabetic’s already compromised immune system and the lessened blood supply to the lower limbs which creates an ischaemic environment. The damaging effects of Diabetic Foot Ulcers on patients Both former and developing studies have indicated sufferers of Diabetic Foot Ulcers regularly display concerning psychological and social issues, such as; Depression Anxiety Mood disorders Embarrassment and low self-esteem due to stigma Isolation Stress and apprehension Decline in social activities Restricted employment, and Financial difficulty To evade patient non-concordance and provide support for the sufferer’s mental and physical wellbeing, research endorses the implementation of a patient centred management plan that encompasses the imparting of knowledge and education to both the sufferer and their family, caregiver and significant others. Treatment and management of Diabetic Foot Ulcers Essentially, although challenging and tedious, the aim of Diabetic Foot Ulcer treatment is to achieve swift wound closure and prevent catastrophic consequences such as amputation and fatality. The treatments which are currently available comprise of; Hyperbaric Oxygen Chamber: Heightens the local distribution of oxygen to ischaemic tissues and the site of the wound Debridement: The elimination of whole superficial debris and the peri wound callus necrotic, hyperkeratotic and pestiferous tissues and external bodies to expose healthy feasible tissue that can then heal Wound off-loading: Reduces vertical plantar pressure and plantar shear stress, this can be succeeded through the employment of bed rest, a wheel chair, crutches or via surgical approaches Low Level Laser Therapy (LLLT): Encourages and enables swift wound contraction and healing through stimulation of neovascularization and collagen remodelling Dressings Human amniotic: Averts the gathering of threatening bacteria and moderates’ pain and damage to fluids and proteins within the body Antibiotic Therapy Stem Cell Therapy Revascularisation: Restores blood flow to the foot Human Growth Factors Further to this, research has also summarised numeral ways for Diabetic Mellitus patients to inhibit the advancement of Diabetic Foot Ulcers, these include; Regular and systematic screenings and risk assessments Properly controlled blood glucose levels, blood pressure and lipid profile Weight management through a healthy diet and amplified physical activity Smoking cessation To conclude, it is well acknowledged in medical literature that the treatment of Diabetic Foot Ulcers is to be approached interprofessionally to extant successful and effective outcomes. Diabetes Mellitus and Diabetic Foot Ulcers are both multifaceted and complex inhibitions and their management necessitates collaboration with a range of specialists and Allied Health Professionals, including the Dermal Clinician. References Abolghasemi, V., & Mesri, M. (2019). Update on New Therapies of Diabetic Foot Ulcers: A Systematic Review. Journal of International Translational Medicine, (1), 61. https://doi-org.wallaby.vu.edu.au:4433/10.11910/2227-6394.2019.07.01.13 Feitosa, M. C. P., Carvalho, A. F. M. de, Feitosa, V. C., Coelho, I. M., Oliveira, R. A. de, & Arisawa, E. Â. L. (2015). Effects of the Low-Level Laser Therapy (LLLT) in the process of healing diabetic foot ulcers. Acta Cirurgica Brasileira, 30(12), 852–857. https://doi-org.wallaby.vu.edu.au:4433/10.1590/S0102-865020150120000010 Haesler, E., Frescos, N., & Rayner, R. (2018). The fundamental goal of wound prevention: Recent best evidence. Wound Practice and Research: Journal of the Australian Wound Management Association, (1), 14. Retrieved from https://search-ebscohost- com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=edsihc&AN=edsihc.559373188177885&site=eds-live Jeyaraman, K., Berhane, T., Hamilton, M., Chandra, A. P., & Falhammar, H. (2019). Mortality in patients with diabetic foot ulcer: a retrospective study of 513 cases from a single Centre in the Northern Territory of Australia. BMC Endocrine Disorders, (1), 1. https://doi-org.wallaby.vu.edu.au:4433/10.1186/s12902-018-0327-2 Levy, N., & Gillibrand, W. (2019). Management of diabetic foot ulcers in the community: an update. British Journal of Community Nursing, 24, 14–19. https://doi-org.wallaby.vu.edu.au:4433/10.12968/bjcn.2019.24.Sup3.S14 Lindsay, E. (2019). Diabetic foot ulcers, the Legs Matter Campaign and much more! British Journal of Community Nursing, 24(6), 40–41. https://doi-org.wallaby.vu.edu.au:4433/10.12968/bjcn.2019.24.Sup6.S40 Mathur, R. K., Sahu, K., Saraf, S., Patheja, P., Khan, F., & Gupta, P. K. (2017). Low-level laser therapy as an adjunct to conventional therapy in the treatment of diabetic foot ulcers. Lasers In Medical Science, 32(2), 275–282. https://doi-org.wallaby.vu.edu.au:4433/10.1007/s10103-016-2109-2 McIntosh, C., Ivory, J. D., Gethin, G., & MacGilchrist, C. (2019). Optimising Wellbeing in Patients with Diabetic Foot Ulcers. EWMA Journal, 20(1), 23–28. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=c8h&AN=137071464&site=eds-live Moore, E., Charlwood, N., & Ahmad, M. (2018). The use of debridement in the healing of diabetic foot ulcers. British Journal Of Nursing, 27(20), 12–14. https://doi-org.wallaby.vu.edu.au:4433/10.12968/bjon.2018.27.Sup20.S12 Schaarup, C., Pape-Haugaard, L., Jensen, M. H., Laursen, A. C., Bermark, S., & Hejlesen, O. K. (2017). Probing community nurses’ professional basis: a situational case study in diabetic foot ulcer treatment. British Journal of Community Nursing, 22, 46–52. https://doi-org.wallaby.vu.edu.au:4433/10.12968/bjcn.2017.22.Sup3.S46 Schreml, S., Szeimies, R. M., Prantl, L., Karrer, S., Landthaler, M., & Babilas, P. (2010). Oxygen in acute and chronic wound healing. The British Journal Of Dermatology, 163(2), 257–268. https://doi-org.wallaby.vu.edu.au:4433/10.1111/j.1365-2133.2010.09804.x Subrata, S. A., & Phuphaibul, R. (2019). A nursing metaparadigm perspective of diabetic foot ulcer care. British Journal of Nursing, 28(6), 38–50. https://doi-org.wallaby.vu.edu.au:4433/10.12968/bjon.2019.28.6.S38 Sulistyo, A. A. H. (2018). Management of Diabetic Foot Ulcer: A Literature Review. Journal Keperawatan Indonesia, (2), 84. https://doi-org.wallaby.vu.edu.au:4433/10.7454/jki.v21i2.634 Yu, J., Lu, S., McLaren, A.-M., Perry, J. A., & Cross, K. M. (2016). Topical oxygen therapy results in complete wound healing in diabetic foot ulcers. Wound Repair And Regeneration: Official Publication Of The Wound Healing Society [And] The European Tissue Repair Society, 24(6), 1066–1072. https://doi-org.wallaby.vu.edu.au:4433/10.1111/wrr.12490 Zhao, R., Liang, H., Clarke, E., Jackson, C., & Xue, M. (2016). Inflammation in Chronic Wounds. International Journal Of Molecular Sciences, 17(12). Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=mnh&AN=27973441&site=eds-live Zielinski, M., Dalla Paola, L., & Lázaro Martínez, J. L. (2018). Meeting report: Go beyond: A multidisciplinary approach for the management of diabetic foot ulcers. Wounds International, 9(3), 44–49. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspxdirect=true&db=c8h&AN=131918866&site=eds-live

Acne vulgaris is the most common inflammatory dermatological disease which disturbs the pilosebaceous unit. Acne is distinguished by non-inflammatory lesions in the form of comedones; or inflammatory lesions in the manifestation of papules, pustules, nodules and cysts. However widespread acne may be globally, the comprehensive pathogenesis of acne is complex, multifactorial and still unidentified. Formerly, it has been proposed the progression of acne is due to four factors; the production of additional sebum, the interference of keratinisation within the infundibulum of the hair follicle, the colonisation of the pilosebaceous duct by Propionibacterium acnes and the discharge of inflammatory mediators into the skin. Yet, emerging and continuing research encompassing the pathogenesis of the chronic inflammatory disorder is still advancing. Propionibacterium acnes (P. acnes) For an extended time, it has been thought P. acnes, fostered on the skin of most humans, donates considerably to the pathogenesis of acne, though, it has been conjectured that not all who harbour P. acnes suffer from acne, as P. acnes, located within the pilosebaceous unit bestows in both acne sufferers and healthy individuals. Henceforth, evidence and research is continuously emergent surrounding the role of P. acnes in acne advancement, with one study implicating that certain P. acnes strains may be linked to healthy individuals, whilst other P. acnes strains may be closely related to acne sufferers. Studies have also inferred that P. acnes may be significant in the adaptive immune response of acne. In biopsy tests of inflammatory acne lesions Interleukin 17 (IL-17) cells were discovered in perifollicular infiltrates and resultant of P. acnes being an inducer of IL-17 and IFN-y from CD4 T-cells a consensus was drawn that acne may possibly be a T-helper type 17 (Th17) mediated condition, where Th17 cells could possibly contribute to either the homeostasis or the pathogenesis of acne vulgaris. Considering these findings, it is imperative to note that the P. acnes strain and its correlation to the development of acne is controversial and not yet wholly understood or recognised. Inflammation A noteworthy expanse of histological, immunological and clinical research indicates inflammation is significant in all stages of the acne lesion, including the instigation, propagation and resolution. Recent findings indicate inflammation and follicular epithelial hyperproliferation are present in the microcomedo, prior to the the comedo formation, which tests the categorisation of non-inflammatory and inflammatory acne lesions and the consensus that inflammation is only extant in the delayed phases of acne vulgaris lesions. Research has also demonstrated that uninvolved skin from acne patients contains raised levels of CD3+ and CD4+ T-cells in the perifollicular and the papillary dermis in accumulation with amplified macrophage activity, similarly to that of papular lesions. Additionally, in the regression period of acne lesions an excessive level of T-cells, macrophages and leukocyte antigens are found to be existing, suggesting that delayed hypersensitivity reactions are significant in the inflammation of acne. Hormones An upsurge in androgen levels inspires sebum production via the binding of receptors on sebaceous glands and pilosebaceous ducts, and research has exhibited that acne prone skins have higher levels of androgen receptors and increased testosterone and 5a-dihydrotestosterone activity. This discovery further supports the proposed correlation between acne development and those possessing high levels of androgens, which is seen in puberty, Polycystic Ovarian Syndrome and Congenital Adrenal Hyperplasia, whilst conversely, those with deficient androgens are said to not develop acne. Interestingly, endocrine interrupting chemicals which are widely used in industrial, pharmaceutical and personal care products, have the potential to inhibit synthesis of natural hormones, and studies suggest contact with these chemicals can result in raised androgen levels and henceforth are also capable of promoting the progression of acne. Sebum composition Emerging evidence also indicates that it is not the amount of sebum secreted rather the alterations in the components and composition of sebum lipids which correlates with the occurrence and the development of inflammation and acne. Sebum is composed of a mixture of non-polar and polar lipids consisting of triglycerides and free fatty acids (57.5%), wax esters (26%), squalene (12%) and cholesterol and cholesterol esters (4.5%) and research has indicated that certain molecules found within the composition of sebum are cytotoxic and irritant and therefore provoke reactive follicular hyperkeratosis and the formation of comedones. This concept is further supported by the mechanism of antiacne compounds which have the ability to reduce acne lesions through inhibition of proinflammatory lipids. Diet and Environmental Factors Exposome factors involving nutrition, medication, occupational aspects, pollutants, climatic, psychosocial and lifestyle influences are also said to contribute to the development of acne due to their capabilities to interact and generate a chronic inflammatory response within the pilosebaceous unit and therefore affect the skins natural barrier and microorganisms. In conjunction with the Exposome factors, examinations have also hypothesised that the Western Diet of hyperglycaemic carbohydrates and dairy proteins are fundamental contributors in the progression of acne due to their ability to upregulate the insulin-like growth factor (IGF-1) and alter the composition of sebum. It is also interestingly noteworthy that acne is absent in populations which consume less insulinotropic Palaeolithic diets which could be due to the lower insulin-like growth factor (IGF-1). Interprofessional practice and the role of Dermal Clinician’s in the management of Acne Research affirms that acne necessitates systemic treatments in the form of Oral Antibiotics (Benzoyl Peroxide Antibiotics, Clindamycin and Crythromycin), Oral Hormone Antiandrogens and Oral Retinoids (Isotretinoin). Though, due to the collective cases of antibiotic resistance and the major adverse effects of these medications, such as Xerosis and skin irritations, an increased demand for alternative therapies in the management of acne has become apparent. As Dermal Clinicians there are a number of ways we can work interprofessionally to aid in the support, treatment and management of acne sufferers, some of these involve; Photodynamic Therapy, which can destruct sebocytes and reduce inflammation via the application of 5-aminolevulinic acid and the use of Red Light. Non-Ablative Radiofrequency which can be used to denature bacteria and diminish sebaceous glands through heating of the dermis and subcutaneous tissue via the use of radio waves. Fractional Radiofrequency, which entails the use of microneedles to target the mid dermis and reduce inflammation of acne lesions. Laser, which can reduce sebaceous gland activity and inflammation through Thermal coagulation of the sebaceous glands and the associated hair follicles. IPL, which can treat inflammatory lesions and cause destruction of the sebaceous glands by targeting the blood cells using heat and energy generation. In addition, through selectively targeting the chromophores melanin and water, IPL devices can also be used to treat post inflammatory pigmentation and atrophic scarring linked with acne. LED can photoactivate endogenous porphyrins in P. acnes. Chemical Peeling Preparations can be used for antibacterial, anti-inflammatory, keratolytic and comedolytic effects, these are achieved through the manipulation and creation of a controlled and managed injury to the skin, which promotes regeneration of the epidermal layer of the dermal tissues. It is vital to note, depending on the severity of the acne, these modalities and alternative treatments alone may not achieve complete resolution of the condition. Therefore, it is recommended for best clinical outcomes that Dermal Clinicians work interprofessionally alongside other medical specialists and in some cases, treatment and management can be undertaken in conjunction with the administration of topical or systemic medications. References Agak, G. W., Kao, S., Ouyang, K., Qin, M., Moon, D., Butt, A., & Kim, J. (2018). Original Article: Phenotype and Antimicrobial Activity of Th17 Cells Induced by Propionibacterium acnes Strains Associated with Healthy and Acne Skin. Journal of Investigative Dermatology, 138, 316–324. doi: 10.1016/j.jid.2017.07.842 Bergler-Czop, B. (2014). The aetiopathogenesis of acne vulgaris - what’s new? International Journal Of Cosmetic Science, 36(3), 187–194. doi:10.1111/ics.12122 Beylot, C., Auffret, N., Poli, F., Claudel, J.-P., Leccia, M.-T., Del Giudice, P., & Dreno, B. (2014). Propionibacterium acnes: an update on its role in the pathogenesis of acne. Journal Of The European Academy Of Dermatology And Venereology: JEADV, 28(3), 271–278. doi:10.1111/jdv.12224 Chen, X., Wang, S., Yang, M., & Li, L. (2018). Chemical peels for acne vulgaris: a systematic review of randomised controlled trials. BMJ Open, 8(4), e019607. doi:10.1136/bmjopen-2017-019607 Cong, T.-X., Hao, D., Wen, X., Li, X.-H., He, G., & Jiang, X. (2019). From pathogenesis of acne vulgaris to anti-acne agents. Archives Of Dermatological Research. doi:10.1007/s00403-019-01908-x Contassot, E., & French, L. E. (2014). New insights into acne pathogenesis: propionibacterium acnes activates the inflammasome. The Journal Of Investigative Dermatology, 134(2), 310–313. doi:10.1038/jid.2013.505 Das, S., & Reynolds, R. V. (2014). Recent advances in acne pathogenesis: implications for therapy. American Journal Of Clinical Dermatology, 15(6), 479–488. dDoi:10.1007/s40257-014-0099-z Gollnick, H. P., Bettoli, V., Lambert, J., Araviiskaia, E., Binic, I., Dessinioti, C., … Dréno, B. (n.d.). A consensus-based practical and daily guide for the treatment of acne patients. Journal of the European Academy of Dermatology and Venereology. doi: 10.1111/jdv.13675 Gollnick, H. P. M. (2015). From new findings in acne pathogenesis to new approaches in treatment. Journal Of The European Academy Of Dermatology And Venereology: JEADV, 29 Suppl 5, 1–7. doi:10.1111/jdv.13186 Kurokawa, I., & Ohyama, M. (2015). Revisiting the dogma of acne pathogenesis. 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