The Journal of the American Academy of Dermatology update for treating patients of color (POC) advances equity in cosmetic procedures and increases practitioner knowledge for skin of color (SOC).
Rebecca L Quiñonez, MD, MS, of the Dr. Phillip Frost department of dermatology and cutaneous surgery at the University of Miami Miller School of Medicine in Miami, Florida and colleagues authored the Continuing Medical Education article. They wrote that to give better care to POC, dermatologists need to understand scientific differences in skin color in relation to cosmetic procedures. They said providers also need fluency in the cosmetic issues that can be addressed in SOC, and understand what predicts success and risks of complications. Finally, Quiñonez and colleagues said dermatologists need to be aware of current recommendations for preparing SOC for procedures.
Skin of color has structural and functional differences
While studies have established there is no difference in melanocytes between non-POC and POC, the authors reported that POC have larger melanosomes that contain more melanin. The melanosomes occur in higher amounts at the basal epidermal layer and are found throughout all epidermal layers in POC.1
While white individuals have pheomelanin, a soluble red or yellow pigment, POC have eumelanin, an insoluble black or brown pigment that has photoprotective qualities. “Eumelanin serves as a UV filter in the Malpighian layer, the area consisting of both the stratum basale and stratum spinosum, which affords an average of 13.4 sun protective factor in patients with darker skin types,” the authors wrote.1 They said this protection can delay or reduce wrinkles, but also increase dyschromia.
Studies suggest that racial differences for stratum corneum are unclear due to small sample size and varying results, several suggest that SOC may be more compact and have greater density.2-5 “A more compact stratum corneum barrier might have implications regarding barrier function, cutaneous irritation, and propensity for the development of contact dermatitis,” the authors noted.1 The authors said further study is needed. In addition, this compactness may reduce skin fragility and delay aging.1
The skin of Black women has more fibroblasts, which are larger and multinucleated. Collagen fibers are smaller, surrounded by proteoglycans in the dermis, and stacked closely, the authors stated. They said fiber fragments were more prolific in SOC than white skin, which may account for delayed aging due to dermal loss. Radiofrequency skin-tightening procedures in POC is highly effective, perhaps because of fibroblast ability to produce collagen in SOC. “Larger, multinucleated, and numerous fibroblasts in POC have implications for the development of keloidal or hypertrophic scars due to basilar and dermal damage,” the authors wrote.1
POC have hair that has greater follicular curvature, and the authors said people of African descent have the slowest hair growth rates and smallest hair diameter. “Follicular curvature and hair curl pattern have implications for hair disorders, such as pseudofolliculitis barbae, for which patients often seek nonsurgical cosmetic procedures,” the authors said.
Quiñonez and colleagues said the wide variety of skin tones among POC, even among those of the same ethnic or racial group, makes racial or ethnicity-based skin color classifications unhelpful. While the authors said the FST scale is used to make decisions about laser treatments and optical settings selections in POC, they recommended using the Roberts Skin Type Classification System (RSTCS). This scale assesses patients’ past medical history, ancestral background, and scarring and pigmentation change history, and contains a full skin evaluation and can include a skin reaction test.1 The RSTCS helps providers prepare for the short- and long-term effects of cosmetic procedures and make individual recommendations in the full spectrum of POC.1
The authors reported that in addition to seeking treatment for aging, with chronological age come different demands for cosmetic procedures in POC. They noted that younger POC have been seeking cosmetic procedures perhaps due to social media, changing perceptions of what beauty is in the modern era, easily accessed, minimally invasive options, and more cultural acceptance of cosmetic procedures. They added that benign skin growths such as seborrheic keratoses and dermatosis papulosa nigra are reasons POC seek treatment.
For treatment management, the authors discussed the use of cosmeceutical agents and melanogenesis inhibitors for the special needs of SOC in pre- and postprocedure management, and the importance of photoprotection. “Given the reduced rates of regular sunscreen use in the Black population, education on the benefits of routine sunscreen application is paramount in reducing the risk of UV-related dyschromia, skin cancer, and photoaging in this population,” the authors emphasized.1
Finally, the authors commented on differing beauty standards for POC, noting that beauty standards differ worldwide. “Because POC are from diverse backgrounds, a considerable amount of cultural awareness is required to understand and better guide patients toward achieving their preferred beauty outcomes,” Quiñonez and colleague wrote. Healthy skin and even tone are universally desired, the authors said. This impacts the products POC use, some of which, like bleaching agents may impact postprocedure wound healing, so the authors stressed good communication between POC and providers. In addition, providers should check country of origin for products POC use because they are regulated differently.
Oma N Agbai, MD, of the department of dermatology at the University of California’s Davis School of Medicine in Sacramento, California and coauthor of the update told Dermatology Times® that POC at her clinic routinely share that medical providers have discouraged them from undergoing cosmetic procedures. She said this was due to the perceived risk of scarring or post-procedural hyperpigmentation. “The truth is that there are many procedural options for these patients, and an evidence-based cosmetic plan can be developed for each patient to optimize their cosmetic outcomes and minimize risk,” Agbai explained. “Examples of conditions in POC that have been treated successfully with cosmetic procedures include dyschromias such as melasma and post-inflammatory hyperpigmentation, photoaging, acne scarring, rhytids, volume loss, and skin laxity.”
Agabi said what is most significant about this update is that it brings the topic of SOC cosmetic dermatology into the forefront, because it was published as the first of a two-part CME article series in the Journal of the American Academy of Dermatology.
Agbai said 2 practical points from the update deserved to be highlighted. First, to reduce the risk of post-procedural hyperpigmentation, she said it is advisable to treat the patient with a topical melanogenesis inhibitor for 6 weeks before and after each procedure. “Examples of topical melanogenesis inhibitors include hydroquinone 4% cream, topical azelaic acid, and topical TXE,” she said.
Second, Agbai told Dermatology Times® that consistent photoprotection is crucial in managing hyperpigmentation disorders. “In recent years, protection against visible light, in addition to ultraviolet light, has been recommended, as visible light has been shown to exacerbate melasma. Topical iron oxide has been shown to have protective qualities against visible light, and can be found in tinted broad-spectrum sunscreens,” she said.
Agbai said because of this update, “dermatologists performing cosmetic procedures have an opportunity to expand their practice to address concerns of patients of all skin types more equitably. The key step is seeking out information, resources, and trainings that are readily available.”