1.3 Delegated Medical Procedures, Chemical Exfoliation & Advanced Esthetic Limits

1.3 Delegated Medical Procedures, Chemical Exfoliation & Advanced Esthetic Limits

Quick Answer: Wis. Admin. Code Cos 2.025 is Wisconsin's advanced-esthetics rule. Sub. (1) allows licensees to provide medical procedures only as directed, supervised and inspected by a physician. Sub. (2) names the delegated procedures — laser hair removal, microdermabrasion, chemical exfoliation, microneedling, and any treatment impacting a skin layer below the stratum corneum. Sub. (2)(c) caps cosmetic peels at AHA 30 percent or less and salicylic acid 20 percent or less, each at pH not less than 2.0. Sub. (2r) then carves microdermabrasion back out of supervision — but only if every one of its conditions is met.

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1. The Governing Line: The Stratum Corneum

Wisconsin does not regulate advanced esthetics by device brand or by marketing name. It regulates by depth. Cos 2.025(2) sweeps in "any treatment impacting a skin layer below the stratum corneum," which means a new modality invented tomorrow is already covered if it goes deeper than the dead outer layer.

The supporting definitions in Cos 1.01 do the technical work:

• "Exfoliation" (Cos 1.01(6s)) — the process whereby the superficial epidermal cells are removed from the skin.
• "Mechanical exfoliation" (Cos 1.01(11n)) — physical removal of surface epidermal cells by brushing machines, granulated scrubs, peel-off masques, or microdermabrasion.
• "Microdermabrasion" (Cos 1.01(11r)) — mechanical exfoliation using an abrasive material or apparatus to remove surface epidermal cells with a mechanical closed loop vacuum system.
• "Physician" (Cos 1.01(13t)) — a person licensed in Wisconsin to practise medicine and surgery.
• "General supervision" (Cos 1.01(7m)) — the supervising physician is available for direct communication and is physically located within 120 miles of the licensee.

That 120-mile figure is a favourite exam detail. Supervision in Wisconsin is not "a doctor somewhere on the paperwork"; it has a measurable radius.

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2. What Counts as a Delegated Medical Procedure (Cos 2.025(2))

              Is the treatment below the stratum corneum?
                              |
            +-----------------+------------------+
            | YES                                | NO
            v                                    v
  DELEGATED MEDICAL PROCEDURE          Cosmetic service, provided it
  - Laser hair removal                 stays inside the Cos 2.025(2)(c)
  - Microdermabrasion*                 acid and pH limits
  - Chemical exfoliation beyond limits
  - Microneedling
  - Anything below stratum corneum
            |
            v
  Requires a physician to direct,
  supervise and inspect (Cos 2.025(1))

  * Microdermabrasion escapes supervision under the
    Cos 2.025(2r) conditions - see section 4 below.

Cos 2.025(1) is the operative command: a licensee may provide these procedures only as directed, supervised and inspected by a physician who holds decision-making authority. Written protocols alone are not enough; the rule contemplates active physician involvement.

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3. Chemical Exfoliation Ceilings (Cos 2.025(2)(c))

Wisconsin sets two numbers and one floor, and the exam asks for all three:

Exceed either concentration ceiling, or drop below pH 2.0, and the service is no longer cosmetic chemical exfoliation — it is a delegated medical procedure requiring physician direction under Cos 2.025(1).

The reason the pH floor matters as much as the concentration ceiling is that free-acid activity, not label percentage, drives penetration. A 20 percent glycolic solution buffered to pH 3.8 is a mild superficial peel; the same 20 percent unbuffered at pH 1.5 is aggressive enough to reach living tissue. Wisconsin regulates both variables because either one alone is gameable.

Exam Trap: two ceilings, one floor. Candidates memorise "30 and 20" and forget that both acids share the same pH 2.0 minimum. A question offering "30 percent AHA at pH 1.5" is describing an unlawful service, not a lawful one.

Phenol, trichloroacetic acid (TCA) and resorcinol peels are not cosmetic exfoliation under any reading of Cos 2.025 — they are designed to reach the dermis and fall squarely inside the delegated-procedure category.

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4. The Microdermabrasion Carve-Out (Cos 2.025(2r))

This is the most commonly reversed fact in Wisconsin cosmetology study material. Microdermabrasion is listed in Cos 2.025(2) as a delegated medical procedure. Cos 2.025(2r) then permits it without physician supervision when all of the following hold:

1. The device is an FDA Class I aesthetic-grade device.
2. It uses a closed loop negative pressure system incorporating a tissue retention device.
3. It removes only surface epidermal cells.
4. Eye protection and gloves are used.
5. Microdermabrasion is not provided within 48 hours before or after a chemical exfoliation.
6. A pretreatment assessment is completed.
7. The client has given written consent describing the nature of the procedure, its risks, and the client's acknowledgment.

So the FDA Class I device, the closed loop, the written consent and the 48-hour separation are not conditions of supervised practice — they are the price of escaping supervision. Get one wrong and the service reverts to a delegated medical procedure that a physician must direct.

Cos 2.025(2m) operates the same way for a second group of services — dermaplaning, eyelash and eyebrow tinting, microblading, and electromagnetic or thermal procedures — which avoid the supervision requirement on the strength of documented training.

Why the 48 hours? Chemical exfoliation and mechanical abrasion both remove stratum corneum. Stacking them inside two days strips the barrier past the point where it can defend against water loss and microbes, producing prolonged erythema, post-inflammatory hyperpigmentation and, on compromised skin, scarring. The rule converts a judgement call into a bright line.

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5. Working the Boundary in Practice

Scenario A. A salon buys a diamond-tip microdermabrasion unit with an open exhaust that vents spent crystals into the room. It is not a closed loop negative pressure system with a tissue retention device, so Cos 2.025(2r) does not apply. The service is a delegated medical procedure and needs a physician to direct, supervise and inspect it.

Scenario B. A client had a 30 percent glycolic peel yesterday afternoon and wants microdermabrasion this morning. Fewer than 48 hours have elapsed, so the (2r) exemption is unavailable. Rebook.

Scenario C. An aesthetician wants to run a 40 percent glycolic peel at pH 3.0. The pH is fine; the concentration is not. Above 30 percent AHA the service leaves the cosmetic category regardless of pH.