Cosmetic needs differ for skin of color patients who may require different treatments, says Dr. Eliot Battle who addressed the use of old and new technologies for skin of color patients during this year’s Skin of Color Seminar Series meeting in New York City.
Eliot F. Battle, Jr., M.D.
If a Caucasian patient comes to my practice they will be looking for treatment for sun damage, wrinkles and capillaries, whereas, if it is a person of color, they will be looking for treatment for dark spots - dark spots from hair, dark spots from melasma, dark spots from scars, says Eliot F. Battle, Jr., M.D., CEO and Co-Founder, Cultura Dermatology and Laser Center, Washington, D.C.
Not only do people of color have different cosmetic needs than Caucasian patients, they require different treatments than Caucasian patients seeking treatment for the same condition, he said during a presentation at the Skin of Color Seminar Series held last month in New York City.
In a session entitled “Updates on New Technologies for Treating Aesthetic Concerns in Skin of Color,” Dr. Battle outlined how best to treat skin of color cosmetic concerns.
Unfortunately, despite massive advances in laser technology, physicians are seeing more side effects than ever before on patients of skin of color. They are being treated by practitioners who have limited experience with lasers or skin of color.
“There is still a great need for education to help our practitioners understand the nuances of skin of color and the nuances of which laser procedures are appropriate,” Dr. Battle says.
The Cultura Dermatology & Laser Center, for example, has more than 40 lasers, some of which are used for patients of all skin colors, but usually one laser will be used to treat a particular condition in skin of color, and another type will be used for Caucasian skin. Lasers can be used on all skin colors for hair removal, skin tightening, body contouring, texture improvement and to treat pigmented lesions from acne, traumatic and surgical scars or melasma which are dark symmetrical patches on the face.
“What we are not good at, and what I don’t recommend practitioners doing, is treating vascular lesions on skin of color,” Dr. Battle says. “We are also not good at any invasive resurfacing where you take away the top layer of the skin and hope it will heal back better, and intense pulse light(IPL) treatment is not safe on skin of color, outside of very light Skin Type IV patients.”
Whenever a laser is used in skin of color it is important to minimize redness, inflammation and erythema, because in skin of color any form of irritation can transform into hyper pigmentation and dark spots, he emphasises. “Skin of color is more sensitive and reactive towards irritation. So in Caucasians, irritation and erythema from laser treatment usually resolves. In skin of color, we have a much higher incidence to turn irritation, inflammation and redness into dark spots. As a result, we are more conservative and adopt common sense parameters rather than those recommended by the manufacturer. We need to try and stay under the erythema and inflammation threshold,” he said.
HAIR REMOVAL LASERS
For hair removal, there are only two wavelengths that are FDA-approved for skin of color â the diode and NdYAG. Diode lasers have evolved to treat skin of color more safely, whether from using suction, longer wavelengths (diodes now go up to 1060 nm), larger cooling plates that are often coupled with laser scanning or in-motion diodes which heat the dermis gradually through faster motion to offer greater protection of the epidermis. “Regardless of the advances in the diode wavelength, the NdYAG is by far the safest wave length. The diode lasers are definitely improving but they certainly do not touch the NdYAG lasers as being the gold standard in treating patients with skin of color, particularly Skin Type VI patients,” Dr. Battle said.
A top down (prescriptions, bleaching creams and spa treatments) and bottom up (lasers) approach should be taken for pigmented lesions and for dark spots, he said. “For skin of color, we have low fluence, micro-second NdYAG lasers and Q-switched nanosecond and picosecond lasers, and low energy and low density fractional lasers. All those [lasers] have the capabilities to treat skin of color and these devices also improve acne scars, surgical scars, stretchmarks and burn scars on top of improving complexion by treating dark spots. However, fractional lasers must be low energy and low density to avoid inflammation and erythema that can lead to hyperpigmentation,” Dr. Battle said.
In skin of color, it is important to use lasers that bypass pigment in the top layer, which is why many lasers that treat skin color are absorbed by water. “Water is mostly in the dermis and the water absorbs the light, turns it into heat and heats up the dermis shattering dark spots. We can also use much higher fluencies and much higher energies,” he said.
Melasma is difficult to treat in all patients and patients with skin of color are even more challenging because there is both a vascular and pigment component that must be addressed. Vascular lasers are mostly contraindicated in patients with skin of color. It requires multiple treatments, both using top down products, prescriptions and very gentle, non-irritating peels and bottom up treatments with minimal-heat, producing lasers, Dr. Battle said. Treatment has to be very gentle in both directions in treating melasma because aggressive treatment will trigger a rebound and often worsening of melasma.
Promising results are being achieved in using low fluence Q-switched nanosecond and picosecond lasers and low fluence micro-second Nd:YAG lasers. Radio frequency (RF) devices are getting a resurgence by using coated pins that penetrate the skin with the RF energy being delivered only at the bottom of the pins, thus sparing the epidermis from being heated. “Radio-frequency is color-blind, even though it causes heat, which can still cause erythema and inflammation, it is color-blind in terms of it is not absorbed by pigment,” he said
However, he warns: “If the patient is not willing to do a strong sun protection routine every day of their life, then there is no point treating it because 15-20 minutes in the sun unprotected will retrigger it.”
In terms of other conditions, radiofrequency or ultrasound can be used for tightening skin of any color, and although they are absorbed by pigment, infrared lasers have also been shown to be effective.
The Q-switched picosecond and nanosecond lasers have been shown to be effective for improving texture and complexion (skin rejuvenation) in skin of color.
When treating skin of color, it is most important to use the right device or laser, which means appropriate wavelength, safe parameters and aggressive skin cooling; become an expert both in technology and in the nuances of skin of color; choose treatments that work; manage patients expectations and treat conservatively to ensure no harm, says Battle. “The more I know the more conservatively I treat stay under the erythema and inflammation threshold.”
"Updates on New Technologies for Treating Aesthetic Concerns in Skin of Color,” Eliot Battle, M.D., Skin of Color Seminar Series. May 5-6, 2018, New York City