By 2044, more than half the U.S. population will be made up of people with skin of color, or Fitzpatrick skin types IV through VI, according to the Skin of Color Society.1 With this in mind, aesthetic experts point out that there are key considerations and important nuances when it comes to treating skin of color patients.
According to Desmer Destang, DDS, MD, an aesthetic practitioner in St. Lucia and Trinidad, who lectures around the world about treating patients of mixed ethnicities, skin of color patients often have different aesthetic desires and goals than Caucasian patients.
“A lot of Caucasian patients have wrinkles, which are more centered around collagen loss and fibroblast cells,” she elaborated. Conversely, skin of color patients tend to be less concerned with wrinkles or a clinically evident decrease in skin quality.
“In skin of color, the majority of patients’ cosmetic issues are going to be more focused on melanocytes,” Dr. Destang noted. “Many patients are mixed so we don’t see black and white. We just see more or less melanin. As skin of color patients age, what you get is more hyper-melanosis of the skin. That is the number one issue you will see, especially in parts of the world like ours where we have a high UV index,” she said.
The key cosmetic concern among patients with darker skin types goes back to the melanocyte cells, which are the primary cell of focus in skin of color.
Patients with acne or something as simple as an insect bite or cut get a lot of skin reaction that manifests clinically as post-inflammatory hyperpigmentation (PIH), Dr. Destang reported. “Acne is one of the biggest problems that you’ll find due to the PIH that comes with it. Even if we clear the acne beautifully, these patients are often left with several months, sometimes six to nine months, of dark spots that take forever to change and fade.”
Dr. Destang also commonly manages uneven skin tone. She explained that the distribution of melanin cells in darker skin is slightly different. Darker skin patients tend to get more uneven skin tone around the mouth and eyes.
To treat this indication, Dr. Destang uses the gold-standard hydroquinone for treating uneven skin tone, but she is a big proponent of something rarely used in the U.S. for pigmentary disorders – mandelic acid – an aromatic alpha hydroxy acid derived naturally from bitter almonds.
“Glycolic acid is the number one alpha hydroxy acid that most U.S. doctors know. However, because the molecular size is so small it burns through the skin a lot faster. It is more of an irritating hydroxy acid, meaning that when you are trying to use glycolic acid in conjunction with other cosmeceuticals, like hydroquinone, to create a more even skin tone, there are some patients where the complete opposite happens,” Dr. Destang said. “We have moved away from using glycolic acid in our skin conditioning protocols to achieve a more even skin tone and to fade discoloration.”
Mandelic acid has larger molecules and is not as irritating to the skin. Its rate of penetration is not as severe as glycolic acid, so the safety profile is better, she said.
“We get almost no reactionary hyperpigmentation with the protocols I use,” Dr. Destang shared.
Mandelic acid also works well to treat rosacea. “Rosacea is generally seen as a condition on fair skin, but dark skin can also get rosacea. It can be either rosacea in the cheek area or rosacea associated with acne,” she said.
Arisa Ortiz, MD, director of Laser and Cosmetic Dermatology and assistant clin- ical professor of dermatology at UC San Diego, treats skin of color patients with pigmentation issues using oral tranexamic acid.
“I have seen the most dramatic response in my patients to oral tranexamic acid,” she reported. “I don’t necessarily think that topical application has the same response. I use it in combination with bleaching creams, peels and low energy lasers like a superficial 1927 nm low energy, low density device. On average, it is about a six-month course of treatment, then I have them come off it and we reassess.”
Oral tranexamic acid at the recommended dose for melasma patients increases stroke risk, similar to the increased risk seen in patients on birth control, so she doesn’t recommend tranexamic acid if patients have other risks for clotting.
Like their Caucasian counterparts, darker skin patients suffer the effects of gravity and age.
“With age, the supporting ligaments of the face are not as strong,” Dr. Destang began. “We see alterations in the facial structure, which are centered around changes in muscles, muscle tone and underlying bone absorption.”
Botulinum toxin indications are similar across the spectrum, with many skin of color patients wanting treatment for forehead lines. But they tend to get fewer periorbital lines, or crow’s feet.
“There is less of a request for lip fillers among skin of color patients because we often already have volume in our lips,” Dr. Destang expressed. “However, I get a very high number of requests to treat the nasolabial folds. In this demographic, what you find is the folds tend to be slightly bigger, which means we use more volume of filler to treat the lines compared to Caucasian patients.”
Dr. Ortiz is seeing more patients wanting jawline slimming, which involves treating the masseter with neurotoxin to get a narrower, ovalized appearance.
“It is a very common request in Asia, where some patients have a more squared-off jawline. They want a more oval shaped face because it is perceived to be more beautiful,” Dr. Ortiz noted. Neurotoxin injections are used to relax the masseter, atrophying the muscle to reveal a slimmer jawline. “It is the same technique that we use for treating TMJ, or jaw clenching."
Hair Removal in High Demand
Dr. Destang said patients come into her clinic daily for removal of facial hair, body hair and underarm hair, but there is some- thing providers need to keep in mind when treating these patients.
“The hair in darker skin is very curly com- pared to light skin. Therefore, you have ingrown hairs and laser bumps from these curly hairs that are trying to pop through the skin. What happens is the follicles can become infected and patients can get PIH as a result of excessive hair removal. Thus, successful hair removal becomes not only a matter of removing the hair, but also avoiding leaving unsightly dark spots that are difficult to cover even with makeup,” Dr. Destang said.
Dr. Destang uses laser-based hair removal, but for darker skin, providers need to modify the amount of energy they use, as well as the wavelength they use to target the skin.
“We use the 1064 nm Nd:YAG, which is a long-pulsed laser that has the capability of penetrating into the skin without doing too much damage to the cells that produce melanin. The other laser wavelength that is really good for darker skin types is the 810 nm diode,” Dr. Destang said. Conversely, the 755 nm alexandrite laser is not recom- mended for darker skin, she added.
Rhinoplasty dos and don’ts
Asian-Indian noses are very interesting, according to Debraj Shome, MD, a board certified facial cosmetic surgeon and director of The Esthetic Clinics in Mumbai, India.
According to Dr. Shome, “Asian-Indian noses are supposed to be in between Caucasian noses and African American noses. They are neither as flat and large as African American noses, nor as pointed and fine as the Caucasian nose.” There are important considerations when surgically augmenting the Asian-Indian nose.
“Most Asian-Indians have skin color that is between Fitzpatrick IV and VI, which means we have more melanin in our skin,” Dr. Shome said. “While the aging of skin of color is much better than with Caucasian skin, it also means that surgery or any scars can leave pigmentation behind and scar healing can be more difficult than with Caucasian skin.”
Ultimately, surgeons have to keep in mind that the nose is not only critical for beauty, but also for form and function. So, post-surgery, the nose needs to transmit air through the nasopharynx and oropharynx, as well as look good.
“Sacrificing one for the other is something that should never be done. You have to be conservative. Less is actually more. Do not excise too much cartilage or too much tissue to try and create a very, very fine or refined nose because that may in turn lead to problems breathing and changes in the structure of the nose later in life,” Dr. Shome explained.
It is also important to consider that the darker skin on top of Asian-Indian noses is thick. “Thick skin is like a thick carpet that doesn’t allow you to see the underlying structure of the nose in as much detail as you would like,” he noted. “With the thick skin, it is almost impossible to get a very thin, refined nose because you might not be able to see the contours of the nose that well,” he said. “So, realistic expectations are important. Balancing the facial features is important. And, trying to understand that people should look like a better version of themselves and not like someone else or some other race is also important in ethnic rhinoplasty.”
Dr. Shome uses external rhinoplasty or internal rhinoplasty, depending on the patient. External rhinoplasty often is better for complex cases because it allows the surgeon to raise the skin and see the structures of the nose.
Threads for lifting and reshaping
Dr. Destang often uses threads in her skin of color patients. “The threads I use for my darker population are thicker threads that I get directly from Korea. The reason I do that is because the dermis in darker patients is actually thicker than for Caucasians so I need more robust and thicker threads to give me that same level of lift,” she advised.
Black skin would have the thickest dermis. Indian skin tends to be sort of in between and Caucasian skin is usually, but not always, thinnest, according to Dr. Destang.
Dr. Destang discourages use of fillers for liquid rhinoplasty procedures in skin of color patients. Her reasoning? “Similar to Asian patients, a lot of skin of color patients have more of a flatter nose bridge. Many of them are getting treated with filler to augment the nose bridge, which is being taught in a lot of educational programs. I have stopped doing this in recent years because the volume of filler needed to augment these noses is high. Physicians who are doing this have to be careful because filler in the nasal area could migrate and cause quite a bit of inflammation in the infraorbital area.”
Dr. Ortiz agreed that augmenting the nasal bridge with fillers is not a good idea. “I personally caution against it because it is very high risk for blindness. It is not that it is difficult to do, but it is too risky,” she said.
Instead, Dr. Destang uses threads to augment noses in darker skinned patients. She said the results are absolutely beautiful.
“Using the technique that I do for nose augmentation, we are able to build the nose bridge and the tip by knowing the correct entry points for the threads.”
The main concern when treating skin of color with energy-based and/or laser devices is the higher risk of PIH and hypopigmentation, according to Dr. Ortiz.
There are precautions that providers can implement to decrease the risk.
When using non-ablative resurfacing devices, providers should decrease setting density, Dr. Ortiz indicated. “I think it is a common misconception to decrease your fluence, but your fluence actually determines your depth of penetration, while your density determines the aggressiveness,” Dr. Ortiz clarified.
Dr. Ortiz said that anecdotally she likes to use one application of a high potency steroid immediately after treatment to decrease inflammation, which might also lessen hyperpigmentation risk.
“Another thing to consider is which wave-length to use. The more superficial wave-lengths are going to be more absorbed by the epidermis, so there will be more melanin absorption,” she pointed out.
Microneedling, especially microneedling in conjunction with radiofrequency (RF) is safe for any skin type, and works well to manage acne and treat acne scars.
“Microneedling has the ability to harmonize how the fibroblast cells work, how the melanocytes work and how the keratinocytes work,” Dr. Destang said. “Skin of color patients will have almost no worry about whether or not they are going to have any reactionary hyperpigmentation or darkening of the skin because microneedling has the ability to harmonize all of the cells.”
Dr. Ortiz recommends using fractional RF or RF microneedling with silicone-coated needles. The technology preserves the epidermis by delivering heat into the dermis only. “But of course, it is technique dependent. You need to make sure that the needles are fully in the dermis before you fire. If they are not fully depressed into the dermis and you kind of lift it off a little bit, then you might be firing more superficially than intended,” Dr. Ortiz said.
The latest in RF microneedling technology was just launched in late February. Potenza from Cynosure (Westford, Mass.) is the first FDA-cleared four-mode RF microneedling system allowing practitioners to deliver a variety of customized treatments on single device.
The device’s modes, including monopolar or bipolar delivered at either 1 MHz or 2 MHz frequency, enables practitioners to deliver both shallow and deep treatments from a single system. According to Cynosure, the treatment is safe for all skin types, anywhere on the body and any time of year.
Using combinations of newer nonsurgical technologies that tighten or even lift skin, new-age fillers that do a better job of lifting and options like threads, Dr. Shome said he has decreased surgical facelifts at his practice to less than 20% of patients. This combination approach, also called the liquid facelift, tends to last longer in darker skin types because degradation of the newly formed collagen is less.
1. https://skinofcolorsociety.org/impact-ethnic- skin-centers-united-states/