Danger at Your Local Salon
By Ginny Graves, Health magazine
Just 36 hours after getting a pedicure at an upscale nail salon near her home in Lafayette Hill, Pennsylvania, Jamie Joffe, 38, had a fever of 101 degrees and a very scary-looking toe—“It was about five times its usual size, and there was greenish goo oozing out from under the nail,” she recalls. Joffe went to the emergency room, where they diagnosed her with a staph infection, probably from scissors or a cuticle pusher contaminated with the bacteria. “The doctor made an incision and drained all this stuff out of it,” she says. “If I hadn’t gotten the infection treated quickly, it could have spread to the rest of my body.”
After taking antibiotics for 10 days, Joffe was fine, but the experience left her with more than a scarred toe. “I still get pedicures, but I now bring my own tools and watch what they’re doing very carefully,” she says. “I had no idea you could get so sick from a pedicure.”
Most of us aren’t aware of the potentially ugly side of manicures, pedicures, Botox injections, haircuts, or waxing. “We assume that if a salon is operating it must be safe, but that’s not true,” says Shelley Sekula-Gibbs, M.D., a clinical assistant professor of dermatology at Baylor College of Medicine, who has studied salon infections and salon safety. “There’s lots to worry about, including poorly trained technicians and dirty or illegal instruments.”
Each state has its own rules for salon safety, but even those with the strictest standards, like California and Texas, can’t scrutinize the businesses as carefully as they’d like. “Each of our 18 inspectors is responsible for 3,500 to 4,000 shops, which means most salons get inspected only about once every six years—unless we get a complaint,” says James Jacobs, a supervising inspector with the California Bureau of Barbering and Cosmetology. “About 75 percent of the salons we inspect have violations. Sometimes they’re minor, like a nail file being re-used when it should have been tossed. But lots of times they’re real health hazards, like filthy foot spas.”
That’s bad news because, like hospitals, salons can harbor dangerous infection-causing bacteria and viruses, including methicillin-resistant Staphylococcus aureus (MRSA) and hepatitis B. That means it really is buyer beware, and the onus is on you to protect yourself. Here’s how to make sure all your beauty treatments are totally safe.
At the nail salon
Trouble spot: Foot spa
There’s nothing more relaxing than soaking your feet in a tub of warm, bubbling water—or is there? In 2000, 110 women who had pedicures at the same northern California salon were infected with a nasty bacteria, Mycobacterium fortuitum; some of the women had dozens of boils and were on antibiotics for months. Afterward, scientists from the California Department of Health Services took swabs from 30 whirlpool foot spas in 18 nail salons around the state and found potentially dangerous bacteria in all but one.
Since then, California has required nail salons to follow specific cleaning and disinfection procedures for their foot spas, but not all states have the same requirements—and not all salons follow the rules. In fact, 27 California salons were put on probation for foot-spa violations in the first six months of 2008 alone, says Kevin Flanagan, spokesman for the California Bureau of Barbering and Cosmetology.
Other foot-spa worries: warts and fungal infections. “Both spread on wet skin,” says Carolyn Jacob, M.D., director of Chicago Cosmetic Surgery and Dermatology.
Wash your hands and feet with antibacterial soap before any procedure, and ask your technician to wash her hands.
Ask to see the foot-spa-cleaning log, Flanagan says. Salons with the highest standards drain all the water, scrub the residue from the walls, and run a cycle of disinfectant for 10 minutes between every client—a procedure that’s particularly important for older machines with pipes that can harbor standing water, a haven for bacteria. Many salons are switching to pipeless foot spas, which don’t have a place for water and bacteria to build up; they still should be disinfected between clients and at the end of the day, and filtration screens should be periodically removed and cleaned.
Don’t shave your legs the day of your pedicure because even a small cut can offer an entry point for minuscule bacteria and other infection-causing bugs. “See a doctor if you have a suspicious spot that won’t go away or gets worse after a pedicure,” says Oliver Zong, a New York City podiatrist. If your aesthetician has a cut on her hands, reschedule your appointment, ask for a different technician, or ask her to wear gloves—a practice some salons employ automatically.
Trouble spot: Mani and pedi instruments
You wouldn’t poke yourself with a sharp instrument at home without making darn sure it was clean, so don’t let someone working on your nails do it, either. The most dangerous tool in the salon is the Credo blade, a razor-like device that’s used to shave off calluses. It’s illegal in most states, but pedicurists routinely violate the rules, as Stacy Nartker, 25, of Kalida, Ohio, discovered when she received an inch-long gash on her foot from a Credo blade. “I didn’t need stitches, but I hobbled around for a few days afterward,” she says.
Nartker got off easy, according to inspector Jacobs. “People have had tendons cut because a manicurist slipped while shaving a callus on the heel,” he says.
Even legal instruments, like cuticle cutters and scissors, have the potential to transmit staph infections, hepatitis B and C, and, yes, HIV if they’re contaminated with even microscopic drops of blood from an infected person, says Sonia Badreshia-Bansal, M.D., a dermatologist in private practice in Danville, California. Far more common than serious bugs are annoying ones like fungal infections that can be picked up from contaminated tools, files, brushes, and cuticle instruments. “The best way to treat fungus is with a topical antifungal cream, but some require a prescription-strength oral medication,” she says.
Ask how the salon disinfects its instruments. The most foolproof device is an autoclave, which sterilizes metal tools overnight. At a minimum, implements should be disinfected between clients; they should be washed in soap and water, then soaked in disinfectant in a covered container. “The solution should say bactericidal, fungicidal, germicidal, or virucidal on it,” Flanagan says. Clean tools should then be stored separately from used ones. Items that can’t be disinfected—nail-buffer blocks, nail brushes, emery boards—should be thrown away immediately after being used. To be supersafe, bring your own.
Just say no to razor-edge cutters and cuticle cutters. “Using a Credo blade is actually considered minor surgery—not something you want performed in a nail salon,” Dr. Sekula-Gibbs says. It’s easy to slice the skin with cuticle cutters, too. “Cuticles actually serve an important purpose, providing a protective barrier to microbes that could seep under your nails with water and cause an infection,” she explains. If your cuticles are too long, have the aesthetician gently push them back—or do it yourself at home with your own tools.
Avoid pedis and manis if you’re diabetic or if your immune system is compromised because of chemotherapy or a recent bout with a serious illness like breast cancer. “You’re much more susceptible to all sorts of infections if your immune system isn’t functioning well,” says Vincent DeLeo, M.D., chairman of dermatology at St. Luke’s Hospital, Roosevelt Hospital, and Beth Israel Medical Center.
At the hair salon
Trouble spot: Chemicals and relaxers
In 2007, doctors at Chicago’s Sumner L. Koch Burn Center reported that a young woman had received chemical burns while getting highlights at her local salon. She was hospitalized and received skin grafts, and was left with two 3-centimeter bald patches at the top of her head.
Although such severe injuries are rare, the Food and Drug Administration (FDA) says that hair straighteners and dyes are among the top consumer complaints and can cause everything from itchy, raw skin to trouble breathing. “I’ve had patients who have had allergic reactions—their faces and eyelids swell or they break out in hives—after salon hair treatments,” Dr. DeLeo says.
If you feel a burning sensation on your scalp while you have color on your hair, alert your stylist and have her wash the chemicals off ASAP. Also, make sure your technician is paying attention when wielding hot blow-dryers, curling irons, and flat irons.
“Have your stylist test any chemicals on the inside of your elbow the day before you get your hair done to make sure you’re not allergic,” says Dr. DeLeo.
Trouble spot: Combs and brushes
Even at top hair salons, stylists toss used combs and brushes back in the drawer at their stations. It seems innocent enough, but those styling tools can carry fungal infections (ringworm and dandruff, for instance), as well as lice. “We regularly see outbreaks, especially of lice, that are spread through hair salons—and not just low-end places,” inspector Jacobs says.
If you can see that the stylists are using combs and brushes on client after client, bring your own during your next visit. “That’s what I do,” says Zoe Draelos, M.D., editor of the Journal of Cosmetic Dermatology. “I don’t want to catch anything, particularly dandruff. Who wants a crusty, scaly scalp?”
Trouble spot: Shampooing sink
Having someone else shampoo your hair is a true pleasure of a salon visit. In rare instances, though, tilting your head back can cause a tiny tear in an artery in your neck, triggering a stroke.
Tilting your head backward into a sink while shampooing can alter blood flow to the brain, but researchers at the University of Medicine and Dentistry of New Jersey reported that using a support, such as a towel, minimizes the problem.
Be sure you know the signs of stroke—sudden numbness or weakness of the face, arm, or leg on one side of the body; confusion or trouble speaking or understanding; trouble walking; dizziness or loss of balance or coordination; difficulty seeing in one or both eyes; a sudden, severe headache—and get medical help immediately. To prevent permanent damage, the anticlotting drug t-PA must be given within three hours of a stroke’s onset.
At the waxer
Trouble spot: Hot wax
Three years ago, Kathleen Croissant, 50, of Westlake, Ohio, had her eyebrows waxed before a black-tie event. The wax felt very hot the moment it was applied, but the aesthetician assured Croissant that the temperature of the wax pot was carefully controlled. After the wax was removed, Croissant’s skin started oozing and scabs began to form. “It was obvious that I’d been burned,” she says. “I had to go to a formal event with scabs on my eyebrows—and to this day the skin is crepey and wrinkled.”
Burns are actually fairly common during body waxing, according to inspector Jacobs. Even though wax pots are supposed to be temperature controlled, he says, it’s easy for them to overheat if they’re plugged in all day.
The other serious wax-related woe: infection, particularly if the aesthetician double dips the waxing sticks. “I’ve cultured wax, and there’s often bacteria in it,” Dr. Sekula-Gibbs says. “Since people have everything from staph to herpes to viral warts on their skin, double-dipping the sticks is a no-no—especially during a bikini wax.”
Waxing can also leave little red bumps called folliculitis on the skin, says Shelly Holmstrom, M.D., assistant professor of obstetrics and gynecology at the University of South Florida in Tampa, who has seen many clients with folliculitis from bikini waxes: “It happens when bacteria get in your hair follicles and cause a little localized infection.”
If the wax feels too hot, say something right away,” California Bureau of Barbering and Cosmetology inspector James Jacobs says. “Even fairly minor burns on the face can leave permanent scars.”
Don’t use numbing products before waxing: Absorbing too much lidocaine-containing cream can be dangerous (particularly if you cover it with, say, plastic wrap). Plus, you can’t tell if the wax is too hot if your skin’s numb.
Make sure your technician has a license for waxing; a hairstylist, for instance, is not automatically licensed to wax.
To avoid infection, ask for a new wax stick with every application. And if you’re lying on a table for a bikini wax, be sure a clean towel or clean paper is beneath you.
To prevent folliculitis, wash the freshly waxed area gently with soap and water, apply a dab of antibiotic ointment, and keep it as clean and dry as possible, Dr. Holmstrom says.
Don’t get waxed if you’re using an antiwrinkle or acne treatment containing retinol; get tweezed instead. “The chemicals in Retin-A and similar products make your skin sensitive, so the wax can actually pull a layer off,” Dr. Vincent DeLeo says.
For a bikini wax, make sure the aesthetician wears disposable gloves.
At the medi-spa
Trouble spot: Injections
In 2006, a woman in Salinas, California, died after receiving injections of fake Botox (it was cooking oil) from a hairdresser who was not licensed to do the treatment; the stylist was later charged for causing the death.
Although serious side effects from cosmetic injectables are extremely rare, counterfeit products have caused the most serious problems. “It’s a big issue because there is only one real Botox cosmetic currently approved by the Food and Drug Administration (FDA), but there are lots of cheaper fake and foreign products,” says Julius Few, M.D., spokesman for the American Society for Aesthetic Plastic Surgery and director of the Few Institute for Aesthetic Plastic Surgery in Chicago. “When considering a cosmetic filler, it’s extremely important to make sure you’re getting something that’s FDA-approved.”
There can even be trouble with real Botox: If diluted incorrectly before being administered, its effectiveness can be reduced. “Botox comes as a powder and is mixed with a saline solution, so it could be overdiluted by someone trying to stretch profits,” says Bruce Cunningham, M.D., director of the division of plastic and reconstructive surgery at the University of Minnesota. “I hear patients say, ‘The Botox I got at the spa lasted only three months instead of the usual six.’ That may be because it was diluted.”
Cosmetic injections are considered extremely safe, but they can cause side effects, like bruising, redness, lumps, and bumps. Most are temporary, but some, like droopy eyelids and a frozen expression, both of which can happen with Botox, can be upsetting. “An under-
standing of dynamic facial anatomy—what the muscles do when you talk and express emotions—can make the difference between a natural-looking outcome and something that’s just plain bizarre,” says Richard D’Amico, M.D., president of the American Society of Plastic Surgeons. “The farther you get from a plastic surgeon’s or dermatologist’s office, the more likely you are to have less-knowledgeable or inexperienced people doing the procedure.”
Make sure your initial appointment is with a physician. A nondoctor may not know the ins and outs of where a filler versus Botox would work best, says Alan Gold, M.D., president of the American Society for Aesthetic Plastic Surgery.
Check the credentials, training, and expertise of the person doing the injections. (In one state, a physician’s assistant with a day of training may be licensed.) Someone experienced in cosmetic fixes will know that the hyaluronic acid in Restylane and Juvederm, for example, can be dissolved by injecting a substance called hyaluronidase if something goes wrong—they’ll also know that some people are allergic to hyaluronidase.
Beware of prices that sound too good to be true. According to a recent analysis in the Wall Street Journal, the average price for Botox is $363; injectable fillers range from about $390 for collagen to $557 for Restylane, a hyaluronic acid. Prices can be much higher in urban areas, however.
Look at the product, Dr. Gold says: Make sure that the package is unopened and the brand name and manufacturer are the same as what you were promised. Allergan, for example, has put a hologram on its Botox packaging to foil counterfeits.
Find out the spa’s emergency procedures. “You should be told what could go wrong and how quickly a doctor can get there,” says Hannelore Leavy, executive director of the International Medical Spa Association and the Day Spa Association.
Ask about ongoing training. With new Botox-like products expected to reach the market in the next year, the situation will soon be more complicated. “All the new products disperse differently in the tissues, so you’ll need to inject each one somewhat differently,” Dr. D’Amico says. “People performing these procedures are going to need to understand the differences.”
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