Patients of color make up a growing market for aesthetic dermatology. Physicians must learn how to tailor treatments and assess skin of color risk to best serve this emerging patient population. Doing so will deliver positive outcomes and drive patient satisfaction.
Technologies ranging from microneedling to picosecond domain lasers provide new solutions for treating dermatoses in skin of color, said Monica Li, MD, in her presentation on aesthetic considerations in patients of color at the American Academy of Dermatology (AAD) Virtual Meeting Experience (VMX).1
“This is an important topic because the patient and population demographics in North America are changing,” said Li, a clinical instructor in dermatology and skin science at the University of British Columbia in Vancouver, Canada.
AAD recently released statistics advocating for proper skin care for all skin colors based on US Census Bureau predictions that by 2044, no single racial group will dominate the population.2,3
“This trend in real-world clinical practice calls for greater knowledge, competence, and management by dermatologists to better serve the aesthetic dermatologic needs for those with darker skin phototypes,” Li said. “As an increasing number of patients of color come to our dermatology practices, clinicians also must appreciate differences in patient needs, outcomes, and management approaches compared to fairer skin types. This recognition requires awareness and education.”
These pigmentary skin conditions include melasma, benign pigmented epidermal and dermal skin lesions, plus common conditions like postinflammatory hyperpigmentation (PIH) and striae.
As with any patient, irrespective of skin tone, a thorough and comprehensive history is necessary. “This includes a prior history of PIH or keloid scarring from other treatments or skin diseases,” Li said. “By being mindful of these complications, clinicians can implement strategies to try to prevent them in the first place.”
Li does not believe there is a specific device for preferential use in skin of color; however, awareness of an increased risk of certain adverse events (AEs) in this population, such as PIH, is crucial. “Patients who [are at] risk for PIH need to be very strict about sun protection and avoidance at least 1 month before treatment,” she said.
Microneedling is relatively safer to use in darker skin types. “This collagen induction therapy has been shown to be safe and effective for all skin types for scars and striae,” Li said.
Picosecond domain lasers have seen positive safety results in skin of color, according to Li. “These lasers produce more of a photomechanical effect than a photothermal effect that is traditionally delivered by previous generations of lasers,” she said. “A more photoacoustic effect reduces the delivery of heat energy to the targeted site and surrounding skin, thus potentially reducing the risk of dyspigmentation.”
In addition, radiofrequency (RF) technologies and high-intensity focused ultrasound (HIFU) can benefit patients of color when used under the right circumstances. “But these two treatment modalities used in isolation often do not necessarily target pigmentary concerns or scars because of their different mechanisms of action,” Li said. “There may also be different therapy techniques when it comes to treating skin of color.”
Recent technological advancements show that fractional lasers might also be safe for this population, if used with care. “However, it requires more advanced knowledge and experience because fractioned lasers deliver thermal energy,” Li said. “Settings that are overly assertive can lead to adverse outcomes.”
Most laser and other light-based devices require longer intervals between treatments for skin of color than those with lighter skin phototypes: every 6 to 8 weeks vs 3 to 4 weeks, respectively. “This ensures that there is no residual inflammation that can drive adverse effects like PIH,” Li said.
To increase the safety of various aesthetic modalities, Li recommends testing for potential AEs using small spot treatments before proceeding with the full face, neck, or chest.
“You should also be more conservative with treatment parameters,” she said. “It is always OK to start low and go slow, to hopefully prevent or at least curb some of the adverse events. If they do occur, they may be of less intensity.”
For laser systems, larger spot sizes and lower fluences are generally advised.
Recognizing AEs promptly is important, “so if they occur, management is instituted as soon as possible,” Li said. “For instance, we know that typically PIH happens around week 3 to week 4 after a treatment. Therefore, timely follow-up is needed.”
Addressing immediate posttreatment inflammation with topical medications can lessen PIH, along with topical skin lightening agents.
“Going forward, I am hopeful for more clinical trials and more research and development in evolving technologies and devices that can be used safely and effectively across the skin spectrum,” Li said. “More importantly, increased knowledge and experience amongst colleagues ultimately will improve aesthetic dermatology care for patients of both light and dark skin tones.”
Li is a consultant and speaker for Candela Medical.
1. Li M. Let there be Light: Aesthetic considerations in ethnic skin using lasers and devices. Presented at: 2021 American Academy of Dermatology Virtual Meeting Experience (AAD VMX) annual meeting; April 23-25, 2021 (Virtual).
2. Taylor, SC. Skin of color boot camp: what every dermatologist should know about the patient with dark skin tones. Presented at: 2018 American Academy of Dermatology 2018 annual meeting; Feb. 16-20, 2018, San Diego, California.
3. Colby S, Ortman J. US Census Bureau Report No. P24-1143. Projections of the size and composition of the U.S. population: 2014 to 2060. March 3, 2015. Accessed April 12, 2020. https://www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf