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Decision 09HDC01350, 09HDC01064
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(09HDC01064, 2 November 2009
and
09HDC01350, 4 December 2009)
Beauty therapist ~ IPL (Intense Pulsed Light) ~ Hair removal
~ Informed consent ~ Rights 4(1), 7(1)
A practitioner of Chinese medicine who also provided beauty
therapy using intense pulsed light (IPL) was found to have breached
the Code of Health and Disability Services Consumers' Rights after
two complaints were received from women who experienced
blistering.
As the complaints were received close together, concerned the
same service provider, and raised similar issues, they were
investigated in tandem.
Complaint 09HDC01064
The first woman consulted the practitioner about IPL hair
removal treatments to her upper lip and lower leg. She was advised
that she would require six treatments, for which she pre-paid.
After her first treatment she was provided with an information
sheet "After Care for Light Treatment" in English and Japanese. She
was asked to read the sheet carefully. The practitioner, a director
of the clinic, went through the information sheet with the woman
and emphasised the importance of avoiding warm water and some foods
during the treatment programme.
The information sheet also warned that clients undertaking IPL
hair removal may develop red, swollen skin and blisters after the
treatment and that scabs may form. The skin in the treated area
would become darker but would peel off naturally in one week. The
sheet instructed clients not to rub any areas that became red and
irritated and to apply antibiotic cream if blisters developed.
The clinic also had a two-page document, headed "IPL permanent
hair removal procedure". This document outlined the treatment steps
to be undertaken by the IPL operator. Step 7 stated, "First test
the skin, then undergo immediate observation of the skin's
reaction, the appropriate response in this time is whether the skin
or the hair roots are red, sometimes there is a faint burnt
smell."
The practitioner was not a member of the Association of Beauty
Therapists NZ Ltd. He had studied Chinese medicine and medicinal
beauty in China, and had been providing beauty therapy treatments
at his clinic for 11 years. He had performed IPL hair removal for
over three years on nearly 1,000 clients and had had some formal
training.
The practitioner did not perform any pre-treatment skin tests on
the woman, but before each treatment he asked if she had
experienced any problems. The first four treatments were
uneventful, but the woman had some redness after the fifth
treatment and advised the practitioner of this. When the sixth
treatment commenced, she immediately experienced severe pain. Her
legs felt hot and prickly.
Within 36 hours of the treatment, blisters developed on the
woman's legs. She sought treatment for the blisters from a medical
clinic and telephoned the practitioner to advise him of this. He
asked her to call into the clinic so that he could look at the
blisters and offer assistance. However, the woman went to see a
dermatologist, who advised her that she had been given too much
energy during the procedure. This had led to prolonged erythema
(redness), blistering and possible scarring. The woman then
returned to the clinic for the practitioner to examine the scarring
to her legs. He agreed to fully refund her fees.
Complaint 09HDC01350
Another woman consulted the clinic about IPL hair removal
treatments to her lower legs. She was also advised that she would
require six treatments. She pre-paid, and was given the "After Care
for Light Treatment" sheet in English and Japanese, which she said
she read carefully and understood.
Again the practitioner did not perform any pre-treatment skin
tests, but before each treatment asked whether she had experienced
any problems. After the third treatment this woman's legs were very
painful and blisters appeared. At her fourth visit, she told the
practitioner about the blisters. She was advised that this was a
normal reaction and her skin would return to normal within a few
weeks. She arranged to have further treatments to her legs and
knees at extra cost. The remaining treatments were provided using
lower power and, although painful, caused no further problems.
A month after her final treatment this woman saw a television
programme about the other woman who had suffered skin blisters
following IPL treatment at this clinic. She returned to the clinic,
advised the practitioner that she had scarring to her legs and
asked for her fees to be refunded. He examined her legs, but was
reluctant to refund her fees.
She went to see a dermatologist a week later. The dermatologist
found areas of striped hyperpigmented scarring on the side of her
left calf, and a small area on her right calf. He advised her that
the operator had used too much energy during the procedure, but the
scarring would improve with time.
Conclusions
IPL treatment involves a risk to the consumer, and should only
be performed by those with appropriate training, expertise and
experience. The Association of Beauty Therapists NZ Ltd (the
Association) recognises this and advises its members that the
training and ongoing education in the use of IPL machines is the
responsibility of the machine distributors. The Association
Secretary, commenting on an earlier similar complaint[1] to HDC, advised that
the Association has a number of members who distribute IPL machines
and they conduct "extensive and continued" training to the beauty
therapy clinics they supply. The Association believes this training
and follow-up should be mandatory.
Although the information sheet provided to the two women in
these cases advises about the known associated risks of IPL, the
first woman was not given this information until after she had
agreed to the series of treatments and had had her first treatment.
Therefore, she was unable to make an informed choice about whether
to consent to the treatment.
Furthermore the clinic had appropriately provided policies and
procedures on IPL treatment which were not followed. It has a
14-step written procedure for the guidance of IPL machine operators
performing permanent hair removal treatment. This includes the need
to test the client's skin for sensitivity before starting
treatment, and to adjust the IPL energy according to the client's
skin and hair type. The IPL operator did not follow those steps for
either of the women in these cases.
As a director of the clinic, the practitioner should have been
aware of the policies, including the requirement to carry out skin
tests ― a requirement he did not follow.
In case 09HDC01064, the practitioner was found to have breached
the Code of Rights in relation to providing services of an
appropriate standard and obtaining informed consent. In 09HDC01350,
he was found to have breached the Code of Rights in relation to
providing services with appropriate care and skill.
Recommendations
It was recommended that the practitioner undergo further
training and review his procedures. He discussed the skill and
safety aspects of these cases with the clinic staff and directors,
amended the clinic procedure manual, and undertook further training
with the IPL machine supplier. He was also asked to apologise and
subsequently did so. The Ministry of Health and the Association of
Beauty Therapists were advised of the findings.
Use of title "Dr"
The matter of the practitioner advertising himself as "Dr" on
the clinic's website, on the basis that he studied Chinese medicine
and medicinal beauty in China, was also addressed. The practitioner
was advised that it is a serious matter for an unqualified person
to use a description that implies he or she is a registered health
professional. The IPL operator removed the title "Dr" from the
website.
The Ministry of Health was notified.
[1] 07HDC09713 (June 2008) available from HDC's
website, www.hdc.org.nz