Aesthetic Practices Treating More Dark-Skinned Patients

“We have entered a new era of dermatology in several respects,” said Susan Taylor, M.D., assistant clinical professor of dermatology at Columbia University College of Physicians and Surgeons in New York.

Dr. Taylor helped found the Skin of Color Center at St. Luke’s Roosevelt Hospital Center in New York almost a decade ago. Now, similar centers are popping up in cities around the country, including Detroit, Miami, Boston, and Washington D.C., to name a few. Scientific advances have been made in the understanding of skin pigmentation and dyschromias, such as the elucidation of the proteaseactivated receptor 2 pathway and its role in pigmentation. In addition, there is now much greater knowledge about the pathogenesis of pseudofolliculitis.

In darker-skinned patients, common cutaneous diseases such as acne vulgaris display histological and clinical differences compared with Caucasians, and the effect of therapeutic agents may vary significantly. The biggest concern in treating acne in darker-skinned patients is how to prevent and treat post-inflammatory hyperpigmentation (PIH). She and her colleagues have been pioneers in examining this issue and they have found that combination therapy may be the key.

They conducted a communitybased trial comparing three different topical therapeutic regimens. All patients received combination clindamycin 1%, benzoyl peroxide (BPO) 5% topical gel containing glycerin and dimethicone. The patients were randomized to receive this combination therapy in addition to either a tretinoin microsphere (RAM) gel at concentrations of either 0.04% or 0.1% or adapalene (AP) gel 0.1%. The investigators observed a trend toward better resolution of hyperpigmentation in the patients who received the clindamycin- BPO topical gel in combination with RAM gel 0.04%.

“Topical antibiotics and retinoids are combined now in products, so you can mix and match and customize for people of color. We didn’t have that in the past,” said Pearl Grimes, M.D., director of the Vitiligo and Pigmentation Institute of Southern California and a clinical professor of dermatology at the University of California in Los Angeles. “You have more choices now in regard to the agents you choose. If you go back 20 years ago you have substantially fewer providers who were truly comfortable in treating ethnic skin. As we go into 2009 we have far more providers who are comfortable with treating darker skin. That has occurred because we lecture more on it and there are centers that focus on darker skin.”

CLINICIANS NEED TO BE INCLUSIVE

As part of this new era in aesthetic dermatology, clinicians need to be inclusive and comfortable treating all skin types, Dr. Grimes said, adding that lasers in particular must be used with caution.

“You have to look at the morphology of darker skin,” Dr. Grimes told Aesthetic Dermatology News. Darker skin has more dermis, so the effects of aging on in the skin are not as pronounced as in lighter skin. The greater melanin content also reduces the risk of sunburn and skin cancer. But darker skin has some disadvantages. With more melanin, trauma to the skin can lead to dark spots, so patients are more likely to experience hyperpigmentation.

“Another problem with dark skin is you are more likely to develop keloids and hypertrophic scars,” Dr. Grimes said. “You have to be careful with fractional lasers. I think if you look at the data, the fractional laser in people of color works better for acne scars but, with some of the new lasers, there is a risk of dyschromias.”

While laser resurfacing in patients with olive or darker skin complexions has been associated with the potential risk of pigmentation problems, new studies show that adjusting the density and energy parameters during fractional laser resurfacing procedures may significantly reduce the incidence of discoloration.

In a study published in Lasers in Surgery and Medicine (2007;39:381-385), Chan et al reported that decreasing the number of passes made by the laser device over the skin and removing less skin in each treatment session may be a more important issue in reducing PIH when treating Asian patients. Air cooling was an important safety factor, especially in small anatomical sites like the perioral area.

In this retrospective study, 37 Asian patients underwent a total of 119 treatment sessions. The patients were divided into two groups: a skin-rejuvenation group and an acne-scarring group. The skin-rejuvenation group received a low-energy/high-density treatment. The acne-scarring group received a high-energy/low-density treatment. All patients had full facial treatment. Patients with acne scarring who received a high-energy but low-density treatment had a lower generalized PIH rate than the skin-rejuvenation group.

“Lasers are just a wonderful addition to the armamentarium that we use to treat skin of color, but we need to go a lot further. This patient population is now seeking out treatment and they need more centers,” said Eliot Battle, Jr., M.D., co-founder of Cultura Cosmetics Medical Spa and assistant clinical professor of dermatology at Howard University Hospital in Washington D.C. “People fly all over the world to see us. We get patients from Istanbul and India, and it makes no sense for people to travel so far.”

COLOR BLIND LASERS

As clinicians become increasingly comfortable treating skin of color, more individuals will be able to get treatment in their own communities and not have to travel for appropriate care, Dr. Battle said. This situation is improving daily, he said, adding that more than 200 dermatologists recently attended a course in New York on treating skin of color.

Dr. Battle helped pioneer what he calls the development of “color blind lasers.” He and his colleagues conducted research that led to a new generation of lasers that can be used safely and effectively for hair removal, skin rejuvenation, and skin tightening in all patients regardless of skin color or ethnicity.

Most new fillers, including autologous fat injections, are safe and effective for all skin colors, he said. These fillers can be especially effective treatments for improving the midface, an area where people of color facially age the worse. Moreover, new research involving natural oils and organic ingredients found in African plants is leading to the creation of products that expand treatment options in darker-skinned people