East Asian patient concerns

There are both unique nuances and cultural considerations to rejuvenating the skin of East Asian patients, according to  Annie Chiu, M.D., founder and owner of The Derm Institute in Hermosa Beach, Calif. Primary common concerns are more centered around skin texture, pore size and evenness of pigment, she says. While these patients can vary in presentation of pigment in their skin, they are generally skin type 3 or higher, making them more prone to hyperpigmentation than more fair-skinned individuals.

Avoid irritation

She notes that East Asian skin can be hyperreactive.

“These patients can look like lighter skin types, but can have a greater tendency then you expect for hyperpigmentation,” she says. The increased melanocytes in the skin can be easily activated with trauma, inflammation or heat, says Dr. Chiu who spoke on cosmetic dermatologic concerns among East Asians at the Skin of Color Seminar Series (SOCSS) in New York City in May.

“Therefore, you need to be careful when employing treatment modalities that may be irritating, whether it be topical medications or lasers,” Dr. Chiu says. 

When treating with peel modalities, the use of less inflammatory peel ingredients such as salicylic acid or lactic acid, versus the more inflammatory glycolic acid, should be considered for more predictability. 

Co-managing such patients with topical bleaching products containing hydroquinone is also an option, as a way to both prevent and pretreat possible unexpected postinflammatory changes.

In addition, “sun protection and proper broad-spectrum sunscreen is critical whenever you undertake any sort of resurfacing procedures on these patients,” Dr. Chiu says.

Because East Asian skin can be more sensitive, products like retinoids and hydroquinone to treat melasma and hyperpigmentation will cause excessive irritation.

“Consequently, I tend to start my patients on an every-other-day regimen, making sure they are not too irritated, using only tiny amounts, perhaps mixed with a moisturizer,” Dr. Chiu says. “If tolerated, I will then increase the amount of topical retinoids and hydroquinone.”

Treatment considerations

“When treating using lasers, you may want to consider a test area. This also holds true for deeper chemical peels,” Dr. Chiu says. You may also consider products that inhibit pigment, including vitamin C, hydroquinone and kojic acid, both pre- and post-procedure, she adds.

Laser procedures are not recommended for patients that are tanned or who are going to be in the sun, and should be used with great caution in melasma.

“These factors increase the likelihood of having an adverse effect, and I often see Asian patients who have worsened pigment because of incorrect treatment with intense pulsed light (IPL) by a medical spa,” Dr. Chiu says.

Next: Aging nuances

Aging nuances

Dr. Chiu notes that East Asian skin ages differently.

“Because these patients have slightly more pigment, they typically present with less photodamage, less fine rhytids and less thinning of the skin,” Dr. Chiu says. As a result, loss of volume or even dynamic wrinkles “can occur at a slightly later age,” Dr. Chiu says.

Dr. Chiu believes that compared with other populations, East Asians are more likely to first seek cosmetic procedures like chemical peels and lasers, and skincare, in general, to address texture and pigment, instead of asking for injectable treatments such as neuromodulators and fillers, “but are open to these suggestions, if you demonstrate expertise,” she adds.

Injectable aversions, education tips

Currently in the U.S., East Asians as a group are not as enthused about injectables, such as soft tissue fillers and neuromodulators.

“I think part of this is the perception that doctors will make them look more round, as they may already have wider faces or look not like themselves or not of their ethnicity,” Dr. Chiu says. “Still, if these patients have concerns that we can correct, I educate them on injectables and allow them to make their own decision.”

When using injectables, dermatologists should consider treatment beyond the usual glabella, crow’s feet and horizontal forehead lines.

“Often, the first area East Asians seek neuromodulators treatment is for facial contouring, like treatment of the masseters to soften a squared appearing jawline,” Dr. Chiu says. “Further contouring of the temporalis muscle can also give patients the oval or heart-shaped face they desire.

Unlike Caucasian patients, who typically first have fat and bone loss laterally, “volume corrections in the lateral midface should be used only in small volumes, due to the genetic tendency toward an increased bizygomatic distance in East Asians,” Dr. Chiu says. “The key is not to make the Asian face look wider. Instead, medial cheek fat pad correction with dermal fillers, softening of the perialar crease, and lifting the base of the nose to address central bony retrusion can achieve a refreshed, softened and more youthful appearance without widening the face.”

Classic training for the pattern of injection with fillers for midfacial correction is to start with most of volume laterally on the zygomatic arch, according to Dr. Chiu.

“However, this model is very much based on a Caucasian face, which is typically more narrow and thin,” she says. “In contrast, East Asians already have an increased bizygomatic and bitemporal width. They are usually actually more flattened in the midface, due to skeletal structural differences in the central facial midline between East Asians and Caucasians.”

East Asians have more flattened midfacial bone structures (glabella, nasal bone, nasal spine and medial maxilla) to begin with, and “with age, fat pad loss and descent is most acute in the medial maxilla, where you notice medial cheek flattening, which compounds medial retrusion of the entire face,” Dr. Chiu says.

Correction of the medial cheek fat pad helps soften the lid-cheek junction, and provides the face a less flattened profile. 

Slight central nasal retrusion also occurs because the nasal spine and pyriform margins becomes more flattened with age.

“Adding just a little bit of filler deep under the alar base and on the pyriform margins can help bring some lift to the midline,” Dr. Chiu says. “This sometimes allows the face to appear thinner and more lifted.”

Likewise, Caucasians are associated with the deep nasolabial folds with age. But in East Asian skin, the nose flattens and “the nose gives the appearance of sitting deeper in the face because of a deepened perialar recess,” Dr. Chiu says. “Hence, when you soften the perialar grooves right by the nares, this midline area of the face is brought forward.”

Body sculpting

East Asians can also enter cosmetic procedures through routes of body sculpting.  As a population, they may have a lower body mass index (BMI), “but are concerned about localized fat in areas like the middle of the lower abdomen and upper arms, so are open to treatments like cryolipolysis,” Dr. Chiu says.  

Cultural awareness

Dr. Chiu believes it is important for dermatologists to recognize cultural differences, in both how the skin behaves and subjectively in how different cultures want their skin to appear cosmetically.

“We need to respect that,” she says. “I think that naturally all practitioners are most comfortable with whatever we see the most of. Sometimes, though, all of us need to take a step back and consider treatment addressing different cultural subtypes and concerns, whether it is African American or Hispanic or East Asian, to become experts.”

Communication

Dr. Chiu also says that dermatologists should not assume that they know a patient’s ethnic background.

“Nowadays, everyone is so mixed that it is always best to talk to the patient about what ethnic backgrounds they have, especially when it comes to resurfacing procedures,” she says.

By being cognizant of the few parameters that might be more specific to a particular culture, “you will be able to provide the expert and personalized cosmetic and dermatologic care that every patient truly deserves,” Dr. Chiu says.

Dr. Chiu says that if dermatologists are good at what they do, continue to push their skills and not treat every patient in a cookie-cutter manner, “results usually speak for themselves. I find in the East Asian community that word of mouth is actually much more effective than marketing online or review sites like Yelp, because often this type of marketing is less inclusive of different cultural examples. When people see their friends of similar ethnicity looking great, they will trust whoever performed the procedures because they now believe you understand how to treat their ethnic skin type and concerns.”

However, there needs to be “more trainings, talks and more published papers on handling these different types of patterns and cultural differences in cosmetic corrections, so that we can continue to be experts leading the noninvasive cosmetic field,” Dr. Chiu says.

Disclosure: Dr. Chiu serves as a consultant for Allergan, Galderma and Merz.