Acne Treatment Consent Form

WHAT IS ACNE?

Acne is an inherited disorder of the pores where dead skin cells shed much faster than normal. Normal pores shed approximately 1 layer of dead skin cells per day inside the pore. Acne-prone pores shed up to 5 layers of dead skin cells per day, causing buildup. This buildup forms a microcomedone, which is where all acne lesions begin. That microcomedone turns into blackheads or whiteheads under the skin; and if bacteria is present, it feeds on the dead skin cells and oil, creating inflamed pimples or pustules, and possibly cysts. This process can take up to 90 days.

HOW LONG IS THE CLEARING PROCESS?

Because it takes up to 90 days for acne to form, you may still have 90 days of acne that will surface. Our acne products and protocol will keep the new acne from forming that would surface 90 days from now. In most cases, the Face Reality Skincare Program will have your acne under control in about 3 to 6 months, depending on your type of acne. Some types of acne take longer to clear. Your Acne Expert will customize a home care routine that takes at least 5 things into consideration: acne type, skin type, skin color, skin sensitivity and environment. The biggest part of the clearing process is your commitment to applying your
home care routine as instructed and following recommended lifestyle where possible.

YOUR COMMITMENT THROUGH THE CLEARING PROCESS

• Use your customized routine of home care products exactly as directed
• Receive treatments and/or check-in with your Acne Expert every 2 weeks
• Follow any recommended adjustments to your home care routine as directed
• Follow lifestyle recommendations where possible, including diet, recommended supplements, stress management, and pore-clogging ingredients in skin, hair, and cosmetic products.

Your progress will be closely monitored by your Acne Expert who will make sure you have the best home care routine for your skin and will make adjustments, if necessary, to get your skin healthy and clear in the fastest way possible.

WHAT ARE ADJUSTMENTS TO HOME CARE?

During the first 6 to 8 weeks, your skin is assessed every 2 weeks to see if we can make your routine a bit stronger. We do not want your skin to get used to products, but we also do not want the routine to be so strong that your skin gets dry and irritated. This method will keep your skin on the path to clearing while maintaining optimal skin health. It’s important to know that if adjustments are not made, progress may stall. If, for some reason, you cannot make it in for a treatment, contact your Acne Expert to get the next set of instructions for home care adjustment.

TREATMENTS

Very mild corrective peels are used to boost the home care along with extractions of existing acne. If your skin is dry or irritated, we will opt for an enzyme treatment and extractions.

COST OF TREATMENTS

Acne Consultation & Treatment: $150

Acne Treatment: $120

Please note that changes to prices may change*

 

Lifestyle Choices That Can A ect Acne

Below are some lifestyle choices that can have an impact on your skin and your journey towards clear skin.

• Rest and Stress
  Get enough rest and reduce your stress. Stress stimulates the adrenal gland which promotes oil production that can lead to clogged pores in the acne prone individual.
  
  

• Fabric Softener
  Fabric softeners (liquid or dryer sheets) leave a waxy residue on pillowcases, towels, wash cloths, sheets, and any other fabric comes into direct contact with the skin. This residue can clog pores of acne-prone individuals. You can use anti-static dryer balls to reduce static cling.
  
  

• Detergent
  Detergents with fragrance can cause skin irritation. Fragrance-free detergents are a better choice. Remember to check the ingredient list of the detergent you choose and against Face Reality’s Pore- Clogging Ingredients handout.
  
  

• Pillowcases
  It is good practice to change your pillowcases often. Oil and other products (such as hair care) can leave build up and contribute to clogged pores.
  
  

• Water Softeners
  There is some evidence that water softeners can lead to acne, especially those containing high amounts of potassium chloride.
  
  

• Swimmers
  Swimming pool disinfectants contain iodides and chlorine which can remain in the water, causing skin problems for frequent swimmers. Consider applying a thin layer of petroleum jelly over your sunscreen before you get into the pool.
  
  

• Sun Exposure and Acne
  Although sun exposure causes desirable scaling and drying, it also damages the follicle, exacerbates dark spots, and causes skin cancer and premature aging. Always wear sunscreen, even if it’s overcast and/or raining.
  
  

• Beware of Hand Lotions
  If you are using a pore-clogging (comedogenic) hand lotion then leaning your face on your hands or sleeping on your hands, this could exacerbate your acne.
  
  

• Breakouts Around the Mouth Area
  Many lip balms, toothpastes, and even facial tissues have comedogenic ingredients in them. If you see breakouts around your mouth area, one of these products may be the culprit. We recommend petroleum jelly as a lip balm and toothpaste without SLS (sodium lauryl sulfate). Many well-known tissue brands are infused with things like coconut oil, isopropyl myristate, and SLS, all of which will clog the pores.
  
  

• Resist Picking or Squeezing
  Rub ice on pustules and pimples for a couple of minutes, twice a day.
  IMPORTANT: if you pick, squeeze, and break the skin, that scab will leave a red or dark mark that will be there for months longer than if you left it alone.
  
  
• Birth Control and Hormone Replacement
  Forms of birth control that contain low doses of estrogen can be higher in androgen hormones, and that combination may aggravate acne-prone skin. Certain forms of birth control are FDA approved to treat acne. Please speak with your doctor about the birth control method that will be best for you. You
  should also familiarize yourself with the benefits and risks of any birth control. Please see the Birth Control And Acne Simplified handout for more detailed information.
  
  Progesterone hormone replacements may exacerbate acne. If you have Polycystic Ovarian Syndrome, it can cause hormonal changes and breakouts.
  
  
• Prescription Drugs
  Prescription drugs that may exacerbate acne include some topical and oral steroids, anticonvulsants, thyroid medications, fertility drugs, Isoniazid, Imuran, Danazol, Gonadotrophin, Cyclosporin, Disulfiram, and drugs that treat ADD/ADHD.
  
  Other topical prescription drugs that must be discontinued at least 14 days prior to receiving a treatment or starting Face Reality Skincare active products include Azelex, Finacea, Retin-A, Tazorac, Differin, Clindamycin (Cleocin-T), Erythromycin (Erygel), Dapsone (Aczone). This includes any topical treatment from Proactiv or Curology, that is not benzoyl peroxide only.
  
  If you are taking oral Isotretinoin consult your Acne Expert for guidance on how long you must wait after discontinuing use prior to starting treatments and active products.
  
  
• Recreational drugs
  Recreational drugs that may exacerbate acne include marijuana, cocaine, and amphetamines (speed).
  
  
• Chemicals
  Coal tars (roofers), grease (mechanics, cooks, waiters), chlorinated industrial chemicals, and dioxin can exacerbate acne.

Foods

This is a guideline only. We are not asking you to eliminate foods or food groups completely; we do suggest you cut back and moderate some food types. The “May Aggravate Acne-Prone Skin” group has been a problem for many people who experience acne. We also know that some people have trigger foods such as citrus, but this is not across the board.

Face Reality Clear Skin Supplements

Diet, nutrition and lifestyle can make a big impact on your acne clearing outcome. Many nutrients have been well-researched and are associated with improving acne and supporting skin.

These two exclusive supplements were developed by Face Reality, the #1 professional acne brand, to provide powerful support for topical treatments and skincare regimens. Based on evidence-based research, they work to help clear skin from the inside out while supporting overall health.

Clear Skin Balance contains Omega-3s and a proprietary Antioxidant Skin Defense Blend that may clear, balance, and brighten skin while supporting overall health and wellness.*

Key benefits include:

• Helps to clear skin and support overall skin health*
• Helps to brighten skin and balance uneven skin tone*
• Provides antioxidant support*
• Supports immune health*

INGREDIENTS

• Omega-3 Fish Oil 1,000 mg: Omega-3 fish oil helps to clear and calm skin, supports a healthy skin barrier, and balance oil.* Sustainably sourced and molecularly distilled with a 2:1 EPA:DHA ration
• Vitamin D3 50 mcg (2,000IU): Supports immune health*
• Antioxidant Skin Defense Blend
  
  • Skin Brightening Complex 12 mg: Lutein and Zeaxanthin (from marigold) flowers, helps to brighten skin and improve overall skin tone*
  • Vitamin A 1600 mcg RAE: Provides antioxidant protection*
  • Vitamin E 15 mg: Helps to maintain healthy skin*

HOW TO USE

The recommended dose is 2 softgels per day. They should be taken with food, and preferably with a meal that contains fat for better absorption. You can also start with 1 softgel per day with food to ramp up more slowly if there are any concerns. After a week or two of no negative side effects, you can move to 2 softgels daily.

Clear Skin Restore contains the most bio-available form of Zinc and a proprietary Probiotic Gut-Skin Axis Blend to help clear skin while supporting overall health and wellness. Some people who experience acne breakouts have low levels of zinc in their body.*

Key benefits include:

• Helps to clear skin, and reduce the severity of blemishes and breakouts*
• Supports overall skin health*
• Supports microbiome balance and gut health*
• Supports immune health*

INGREDIENTS

• Zinc Monomethionine 30 mg: This highly bioavailable form of zinc helps with oil control and clearing skin, and supports immune health*
• Vitamin C 90 mg: Provides antioxidant protection, supports immune health, and is necessary for the body to produce collagen, which helps support healthy skin
• Niacin 100 mg NE: Supports cellular health*
• Probiotic Gut-Skin Axis Blend 6 Billion CFU: This proprietary blend of 4 strains of probiotics helps support breakout-prone skin, supports microbiome balance, and supports gut health*

HOW TO USE

The recommended dose is 1 capsule per day for the first 2-4 weeks. They should be taken with food to avoid any stomach upset by the zinc. Once you are past the 2-4 week acclimation period, you can take 2 capsules per day until you achieve clear skin. Once your skin is clear you can return to 1 capsule per day if you desire.

Foods More Often Associated With Exacerbating Acne & Inflammation

• Trans Fats
  • Cakes, pies and cookies
  • Biscuits
  • Breakfast sandwiches
  • Margarine (stick and tub)
  • Crackers
  • Microwave popcorn
  • Cream-filled candies
  • Doughnuts
• Overheated fats: baked foods/ fried at high temperatures
• Excess sugar
• Omega-6 oils (most vegetable oils) and not enough Omega-3s
• Known food sensitivities (examples: fruit, gluten)

Supportive Foods/Beverages

• Ceylon cinnamon
• Apple cider vinegar
• Green tea, especially matcha

Antioxidant “Helper”- Selenium Rich Foods

• Brazil nuts
• Pinto beans
• Halibut
• Wild–caught salmon
• Oats
• Navy beans
• Chicken
• Spinach

Foods/Beverages That May Provide Anti-Inflammatory Support

GENERAL

• Turmeric
• Ginger
• Green tea (especially matcha)
• Ceylon cinnamon
• Apple cider vinegar

FOODS HIGH IN OMEGA-3

• Fatty fish
• Salmon
• Sardines
• Atlantic mackerel
• Anchovies
• Herring
• White fish
• Omega-3 enriched eggs
• Walnuts
• Deep leafy greens: spinach, kale, watercress
• Blueberries
• Hemp seeds
• Mustard seed
• Brussel sprouts
• Winter squash
• Navy beans

FOODS HIGH IN VITAMIN B3

• Cremini mushrooms
• Tuna
• Chicken breast
• Fish (halibut, salmon, sardines)
• Leafy greens
• Asparagus

A well-balanced low-glycemic diet can support all aspects of health, including your skin.

Below is a list of ingredients that can be found in skincare products, makeup, and hair products that can clog your pores and may exacerbate acne. Always check the ingredients of any non-Face Reality products you use on your skin or hair, even if it says “Won’t Clog Pores” or “Non-Comedogenic” on the bottle.

Natural oils can be some of the worst offenders (like cocoa butter and coconut oil) and are found in many “organic” skin care lines. Other oils such as jojoba, olive, and lanolin are mildly comedogenic and can be a problem if formulated with other comedogenic ingredients. Some prescription products like the cream form of Retin-A, as well as many over-the-counter acne medications also contain pore clogging
ingredients. “Oil-free” products can be formulated with pore-clogging ingredients. The following list is meant as a guideline

• Acetylated Lanolin • Acetylated Lanolin Alcohol • Algae Extract • Algin • Butyl Stearate • Carrageenan • Cetyl Acetate • Cetearyl Alcohol + Ceteareth 20 • Chondrus Crispus   (aka Irish Moss or Carageenan    Moss) • Chlorella • Coal Tar • Cocoa Butter • Coconut Alkanes • Coconut Butter • Coconut Oil • Colloidal Sulfur • Cotton Seed Oil • D & C Red # 17 • D & C Red # 21 • D & C Red # 3 Plankton • Polyglyceryl-3 • Diisostearate • Potassium Chloride • Propylene Glycol Monostearate • Red Algae • Seaweed • Shark Liver Oil (Squalene) • Shea Butter • Sodium Laureth Sulfate • Sodium Lauryl Sulfate • Solulan 16 • Sorbitan Oleate • Soybean Oil (Glycine Soja) • Spirulina • Steareth 10 • Stearic Acid Tea • Stearyl Heptanoate • Sulfated Castor Oil • Sulfated Jojoba Oil

• D & C Red # 30 • D & C Red # 36 • Decyl Oleate • Dioctyl Succinate • Disodium Monooleamido PEG 2- Sulfosuccinate • Ethoxylated Lanolin • Ethylhexyl Palmitate • Glyceryl Stearate SE • Glyceryl-3 Diisostearate • Hexadecyl Alcohol • Hydrogenated Vegetable Oil • Isocetyl Alcohol • Isocetyl Stearate • Isodecyl Oleate • Isopropyl Isostearate • Isopropyl Linolate • Isopropyl Myristate • Isopropyl Palmitate • Isostearyl Isostearate • Isostearyl Neopentanoate • Wheat Germ Glyceride • Wheat Germ Oil • Xylene Kelp • Laminaria Digitata Extract • Laminaria Saccharina Extract (Laminaria Saccharine) • Laureth-23 • Laureth-4 • Lauric Acid • Mink Oil • Myristic Acid • Myristyl Lactate • Myristyl Myristate • Octyl Palmitate • Octyl Stearate • Oleth-3 • Oleyl Alcohol • PEG 16 Lanolin • PEG 200 Dilaurate • PEG 8 Stearate • PG Monostearate • PPG 2 Myristyl Propionate

STEP-BY-STEP

1. Cleanse: Using your cleanser and a little warm water, cleanse your face gently with your fingertips, avoiding the eye area. Rinse thoroughly with water.
2. Ice: Apply ice to inflamed breakouts using a slow circular motion without stopping for 1-2 minutes. Pat dry.
3. Tone: Pour a small amount on a (flat) cotton round and apply to face.
4. Serum: Apply 1 pump onto palm and apply with fingers to entire face (and/or back, chest). Apply every other day.
5. Hydrate and/or Moisturize: This is an optional step to add if you are dry. Apply for added moisture.
6. Apply Sunscreen: Apply liberally on face and neck at least 15 minutes before sun exposure. Re-apply hourly when in direct sun or after swimming/perspiring. Apply your noncomedogenic makeup; if desired.
   
   Optional Supplements: Clear Skin Restore & Clear Skin Balance

STEP-BY-STEP

1. Cleanse: Using your cleanser and a little warm water, cleanse your face gently with your fingertips, avoiding the eye area. Rinse thoroughly with water.
2. Ice: Apply ice to inflamed breakouts using a slow circular motion without stopping for 1-2 minutes. Pat dry.
3. Apply Advanced Acne Med Mask: Apply dime to nickel size amount to entire area avoiding eye and neck. Follow the below timed schedule for Week 1-2. You can opt to add hydraBalance Gel prior to the Advanced Acne Med if your skin is dry and dehydrated.
   
   
   
4. Cleanse: Using your cleanser and a little warm water, cleanse your face gently with your fingertips, avoiding the eye area. Rinse thoroughly with water.
5. Tone: Pour a small amount on a (flat) cotton round and apply to face.
6. Moisturize: Apply moisturizer all over face and neck, avoiding eye area. You can opt to add hydraBalance Gel prior to your moisturizer if your skin is dry and dehydrated.

Day 14 Instructions:

If you get to Day 14 before your next clinic appointment, you will proceed to Cleanse, Toner and use Advanced Acne Med all night (in the absence of dryness and irritation). Let Advanced Acne Med absorb and dry for at least 60 seconds before adding a moisturizer.

Advanced Acne Med Precautions

• Not on Eye or Lower Neck
  Do not use Advanced Acne Med on your neck or eye area. The tissue in the eye and neck area is delicate, and Advanced Acne Med will irritate the skin too much.
• No Eye Cream
  Do not use eye cream or moisturizer around the eyes or neck because the Advanced Acne Med will migrate through the cream and cause irritation and possible swelling.
• Eye Irritation
  Allow your Advanced Acne Med to dry before going to bed. If your eyelids get irritated, try changing your pillowcase more often. When you are wearing Advanced Acne Med all night, it will get on the pillowcase.
• Smile Lines
  This area tends to be the most sensitive area on the face and will be the first place you see irritation and dryness. You can put a very thin layer of Vaseline on this area to occlude it for a few days and then resume product use there.
• No Working Out
  Do not wear Advanced Acne Med when you expect to perspire, as in exercising, physical labor or getting hot in the sun. If you are wearing it, wash it off or it will irritate your skin.
• Will Bleach Fabric
  Advanced Acne Med will bleach fabric, so we suggest wearing a white shirt or T-shirt when using it. Use white pillowcases when you start wearing it overnight. Make sure to wash your hands with soap after using it to avoid bleaching towels.
• Allergic Reaction
  Allergies to benzoyl peroxide are rare but do occur occasionally. Dry skin does not constitute an allergic reaction; rather an allergy is characterized by itching, swelling or burning associated with a rash (similar to a mild case of poison ivy dermatitis). If an allergic reaction occurs, stop using Advanced Acne Med and contact us immediately.
• Use Consistently
  If you skip a day or two, or only spot treat, it gives a chance for acne to form. You must do your home care routine consistently to reach and maintain clear skin.
• Expect Some Dryness
  Expect your skin to get a bit dry while getting used to the Advanced Acne Med. This is normal; however, if your skin gets uncomfortably dry, please contact us so we can adjust your home care routine. Do NOT stop using your Advanced Acne Med until the next time you have an appointment— when in doubt, call us.

Remember!

• If anything tingles more than a “2” or stings/burns, do NOT use that product. Wash it off and contact us.
• Apply sunscreen every day whether you are going outdoors or not.
• You can use Ultra Gentle Gel Cleanser to remove your makeup, or you can find a non-comedogenic micellar water.
• Avoid perfumed or medicated shaving creams and aftershave lotions. Ask your Acne Expert for the Shaving Tips handout if you get shaving irritation.

YOUR INFORMATION

YOUR PRIMARY CARE PHYSICIAN:

LIFESTYLE CONSIDERATIONS

PRODUCTS CURRENTLY USING - PLEASE PROVIDE PRODUCT NAMES

An acne treatment may consist of surface cleansing, mild chemical peels or steam and exfoliation, application of antibacterial serums, corrective serums, and extractions. Treatments take approximately 20 to 45 minutes to complete and are designed to balance, hydrate, extract acne impactions, and prepare the skin for the home care routine. Implements and equipment used in this facility are disposable or properly sterilized according to the State Board of Cosmetology regulations.