Complementing cultural perceptions of beauty

Perceived beauty goes beyond numeric values and divine proportions. In fact, beauty in the beholder’s eyes is a collage of geographic, ethnic and demographic influences, according to research published in the March issue of Journal of Craniofacial Surgery.

Researchers from universities in Germany and the United States generated computerized images of a model's face. The nasal characteristics and lips and chin projection in the images could be altered. They then sent a survey with the modifiable images to more than 13,000 plastic surgeons and lay people in 50 countries, who, according to the paper’s abstract, could virtually create the faces they felt were esthetically ideal and pleasing.

The researchers found people’s perceived ideal appearances of the nose and projections of the lips and chin depended greatly on their backgrounds, cultures, places of residence and occupations.

The cultural effect on perceived beauty is so powerful that dermatologists have created skin of color academic departments and organizations to address cultural and ethnic influences on skin health and perceived appearance. With this knowledge, they hope to better address a melting pot of patients’ concerns and aesthetic goals.

One of the great mistakes of dermatology in the United States is the lack of understanding skin of color concerns and treatments, says Maritza Perez, M.D., director of cosmetic dermatology at Mount Sinai St. Luke’s, New York. Dermatologists who care for patients the same way - regardless of their race, culture and ethnicity - could do more harm than good, she says.

Understanding cultural nuances, perceptions

Taking optimal care of patients from all walks of life involves consideration of a patient’s race, ethnicity, language, social status, religion, sexual orientation, occupation and more, says Roopal V. Kundu, M.D., founder and director, Center for Ethnic Skin, Northwestern University, Feinberg School of Medicine, Chicago.

“We have to all be on the same page in terms of understanding dermatologically what is problematic to the patient; then, how to best treat them,” Dr. Kundu says.

To truly understand a patient’s needs, concerns and how to best treat that patient, dermatologists have to look at the biology and pathophysiology of the skin, hair and nails.

“We must incorporate the biological structure and function differences that we see in different skin types, ethnicities and races,” Dr. Kundu says.

That’s compounded by the cultural skin and haircare practices, she says. What are the basic things that people are doing, which could impact their conditions?

To illustrate her points, Dr. Kundu refers to African haircare practices and how those can come into play when a dermatologist tries to connect with a patient with a scalp or hair issue.

“They’re very distinctive and unique, compared to the general Caucasian haircare practices. (The dermatologist should understand) the norm for African hair is to shampoo every week or every two weeks. If you give them a regimen to wash every day, you’re not going to connect to that patient and you’re not going to provide them a feasible option or treatment that they can abide to,” Dr. Kundu says.

On a biological level, the dermatologist would have to understand the nuances of African-American versus Caucasian hair.

“The hair is curlier. The hair follicle, itself, is curved, and it’s drier and has more complex knots that it naturally makes,” she says.

Next: Treating acne

A look at acne

Andrew F. Alexis, M.D., M.P.H., director of the Skin of Color Center, at St. Luke’s Roosevelt Hospital, Mount Sinai Health System, New York, says the most important message to get across to dermatologists regarding acne in darker skin versus lighter skin types is the presence of postinflammatory hyperpigmentation (PIH).

“When the pimples resolve, dark spots remain. And those dark spots can persist for several weeks to several months - sometimes longer than a year - depending on the severity and where they’re located,” Dr. Alexis says. “… Dark spots are frequently the driving force for patients to see the dermatologist - more so than the acne. The way I put it is it’s equal or sometimes even more important to the patient than the acne.”

There are important nuances to treating acne patients, typically with Fitzpatrick skin types V and VI, Dr. Alexis says. Managing both the acne and hyperpigmentation is an important treatment goal. And while managing the acne, you want to avoid irritation.

“Any irritation induced by the prescription treatment can induce more dyspigmentation,” he says.

Pigment is a bad word

Many cultures with darker skin types perceive lighter, even skin tones as more beautiful. Many Caucasians, on the other hand, try to darken their skin in the sun.

Wendy Roberts, M.D., a dermatologist in Rancho Mirage, Calif., says dermatologists should be aware of misperceptions that can affect patients’ skin health and beauty. One common misunderstanding among darker skin types is they don’t think they need sunblock. By the same token, hyperpigmentation and skin darkening is not something people of darker skin types typically want, she says.

“This is an area where we can really help educate our patients and the public that they are related,” Dr. Roberts says.

People of skin of color, who span Fitzpatrick types IV through VI, react differently to the sun than lighter skin types, according to Dr. Perez.

“They burn, but the first thing they do is tan. And they respond with hyperpigmentation to every inflammatory stimuli of the skin,” Dr. Perez says. “In the Caucasian patient you see more precancerous lesions and deep wrinkles, whereas in the patient of skin of color, you see more loss of volume and discoloration as a manifestation of sun damage.”

When it comes to Asian and Indian patients, Dr. Roberts says, commercialized beauty is all about skin color.

 “Far East Asians want to have flawless skin - no brown spots on their skin,” Dr. Kundu says. “It’s very normal in Far East Asia to see people walking around with umbrellas. We will see people present to us in terms of wanting to do cosmetic procedures to remove their freckles. What we see in Far East Asians is Hori’s nevi, which is a variant of freckles. Not having those is a sign of being youthful and beautiful.”

Next: Skin-lightening options

Skin-lightening agents

As a result, there’s a huge market for skin lightening products and services, Dr. Roberts says.

“Because of that pressure to be ‘fair and lovely,’ women are often seeking hydroquinone to lighten the face, neck, chest, even bodies. It’s important for dermatologists to be aware of hydroquinone abuse,” Dr. Roberts says.

Dermatologists should encourage the use of hydroquinone alternative treatments, such as non-hydroquinone bleaching agents, cosmeceuticals that lighten pigmentation, chemical peels and emerging lasers and devices, according to Dr. Roberts.

“Asian, African-American and East Indian skin is a little more sensitive and prone to atopic and contact dermatitis, specifically. You want to avoid aggressive product use or peeling, because that could result in increased pigmentation,” Dr. Roberts says.

Dermatologists should also help to dispel cultural myths. Many with skin of color use homeopathic remedies to treat pigment problems. And those treatments tend not to work, according to Dr. Perez.

“There is the belief among Hispanics that cocoa butter helps with hyperpigmentation. It doesn’t help hyperpigmentation and can be an occlusive that causes acne and inflammation,” she says. “They think that lemon bleaches (the skin). Lemon just causes phytophotodermatitis, when skin with it is exposed to the sun.”

Dermatologists should be aware that Hispanic patients are culturally sensitive to melasma, according to Dr. Roberts.

“While we may see a woman with melasma and think she just has melasma, she may have low self-esteem because her face is perceived to be dirty,” Dr. Roberts says.

Next: Appropriate treatment is crucial

Understanding the pigmentary concerns is one thing. Properly treating them and not creating pigmentary problems for other dermatologic problems is another.

Know that all people with skin of color will respond to inflammation with hyperpigmentation, Dr. Perez says. Any medication or other treatment that causes a little transient irritation in a Caucasian patient has the potential of inflaming and leaving hyperpigmentation in skin of color.

Dermatologists can use similar treatments and devices to treat pigmentation and other issues in skin of color, but there are nuances, experts say.

“There are certain lasers you cannot use in skin of color because the melanin in the skin will be absorbing the energy and will cause blistering and sequelae - either as hyperpigmentation or scarring,” Dr. Perez says. “You’re not going to use an ablative lasers, like the CO₂ laser, in a patient with skin of color because if you ablate with a CO₂ laser and coagulate too much the healing process might cause severe scarring and hyperpigmentation in skin of color.”

For hair removal on skin of color, dermatologists should use a longer wavelength, such as a 1,064 nm, according to Dr. Perez.

When using fillers to treat loss of volume and more, the idea is to avoid inducing inflammation, Dr. Perez says.

“The recommendation is do the least amount of point-needle access. For every pinpoint needle, you can get inflammation leading to hyperpigmentation,” she says.

Skin-tightening procedures are useful and effective in skin of color because of these patients’ tendency to lose volume with age and sun exposure, according to Dr. Perez. She says either Thermage (Liposonix) or Titan (Cutera) work well to tighten skin of color.

Be cautious when using chemical peels on skin of color, Dr. Perez says. To avoid inflammation, dermatologists should turn to salicylic acid, glycolic acid or fruity acid peels for discoloration.

“You have to start out at low percentages and time it well,” she says. “Trichloracetic acid peels, which are very caustic, are not indicated in skin of color.”

Dermatologists can become more culturally competent by listening and learning, according to Dr. Kundu.

“I think, on an individual level, it’s being very direct and asking the patient what is bothersome to them and understanding maybe there is a cultural influence as to why that’s important to them,” Dr. Kundu says. “Other things are from learning … reading journals and (attending) conferences. I think (cultural competence) needs to be part of our educational system … because we have a beautiful, wonderful melting pot in America.”

Disclosures: Dr. Alexis is a consultant for Amgen and Galderma and is a consultant and investigator for Allergan. Dr. Perez is a speaker for Cutera. Dr. McMichael is a consultant for Allergan, Galderma, Guthy-Renker, Procter & Gamble and Johnson & Johnson. She also is a researcher for Allergan and Procter & Gamble. Drs. Kundu and Roberts report no relevant financial interests.