There is a growing trend amongst patients with skin of color for cosmetic and aesthetic procedures. The top reasons skin of color patients seek dermatologic care is acne, acne scarring, and hyperpigmentation. In this article, I discuss safe and effective cosmetic options for skin of color (SOC) patients. I refer to a recent article by Desai, Gill, and Luke (2023) called, Cosmetic Procedures in Patients with Skin of Color: Clinical Pearls and Pitfalls. I discuss the implications of the concepts in the article for Aspiring Dermatology Nurse Practitioners when it comes to treating and teaching patients about cosmetic options and how to avoid complications in SOC patients.
Skin of Color Considerations
Skin of color (SOC) refers to those from African descent, Latin descent, Asian and Pacific Islanders, Indians, Pakistanis, Middle Eastern groups, Native Americans, and Alaskans. SOC has higher levels of melanin which protects the skin from aging and sun damage (Desai et al., 2023). Utilization of the term race is discouraged as there is no one gene or trait distinct to a group of people. Furthermore, the majority of people share a common genetic pool and have a mixed racial background (Taylor et al., 2016).
SOC patients have distinct skin, hair, and nail characteristics; reaction patterns; and cultural practices that must be taken into consideration when diagnosing, treating, and evaluating care. In addition to acne and hyperpigmentation, patients with SOC may inquire about cosmetic treatment options for keloid scarring, dermatosis papulosa nigra, seborrheic keratoses, and solar lentigines.
Implement spot testing as a standard practice when treating SOC patients, and educate them on the importance of doing so when they receive care or use new products or try new treatments at home. When assessing your patient’s risk for PIH, look for darker pigment in the creases of the palms and fingers which can indicate a higher risk for PIH. This is an excellent clinical pearl to keep in mind when treating multiracial patients as Fitzpatrick Skin Type is not reliable (Desai et al., 2023).
Image courtesy of Mahogany Dermatology. All rights reserved.
Hyperpigmentation
Hyperpigmentation is the most common skin disorder in SOC. While patients of darker skin tones are more prone to getting hyperpigmentation, it can happen to anyone at any age, and on any part of the body. The most common cause of hyperpigmentation or post-inflammatory hyperpigmentation (PIH) is irritation and inflammation (Taylor et al., 2016). A disruption in the skin barrier increases the risk for irritation which can cause inflammation and ultimately hyperpigmentation. Common causes of irritation to the skin barrier are:
-Injury from trauma or the wrong cosmetic treatments and procedures
-Skin diseases associated with solid or fluid filled bumps
Patients may describe hyperpigmentation as the presence of uneven complexion or skin tone, blemishes, dark marks, dark patches, dark circles, and dark scars. Hyperpigmentation is not harmful, but the psychological stress can poorly affect quality of life. In fact, hyperpigmentation can be more distressing than the inflammatory condition. Dermatology nurse practitioners should remember it’s important to teach patients that treating the inflammation and identifying the source of irritation is critical to correcting the hyperpigmentation and getting the most out of their skin care regimen. We should also assess for psychodermatologic concerns and educate patients on how common it is and the treatment options when experiencing anxiety or depression associated with chronic skin, hair, and nail disorders.
Skin Phototyping
When we talk to our patients about cosmetic procedures, we want to emphasize the importance of protecting the skin barrier before and after treatment. Reducing sun exposure is the primary preventative practice in dermatology when it comes to reducing the risk of irritation, sun burns, aging, skin cancer, disrupting the skin barrier, and triggering inflammatory responses. When we talk about the skin’s reaction to sun exposure, we use a term called skin phototyping. Skin phototyping is a classification system used to (Gupta & Sharma, 2019):
-Describe how the skin responds to sun exposure
-Predict the risk of sun damage and skin cancer
-Calculate the initial therapeutic dose of UV light treatment
-Estimate how likely someone is to respond to a cosmetic procedure
Fitzpatrick Skin Type Classification. Image source DermNetz.org.
Fitzpatrick Skin Type Classification
Prior to the 1960s, skin color was used to determine ultraviolet (UV) radiation sensitivity. That methodology was replaced in 1975 by the Fitzpatrick Skin Type Classification which remains the most widely used skin phototyping scheme today. It is a self-reported measure of a person’s tendency to sunburn and ability to tan based on their ethnicity. FST uses a 6-part scale consisting of type I (light skin tones) to type VI (darker skin tones) where lighter skin tones are more likely to burn and tan poorly; and darker skin tones are more likely to tan, less likely to burn, and more likely to develop PIH. FSTs IV to VI represent darker skin tones.
Initially, FST was used to determine the initial dose of phototherapy in non-Hispanic white populations. Since 1975, it has gone through several iterations and a number of other classifications are in use today as FST has been criticized for its inconsistency, and inability to predict the risk of PIH after cosmetic treatment and determine the severity of skin cancer (Gupta & Sharma, 2019). Some proposed objective skin phototyping classification schemes used for cosmetic procedures are:
- Pigment protection factor
o Use of spectroscopy to measure sensitivity to burn and tan from sun exposure
o A reliable and consistent method that works well with darker skin tones
- Lancer ethnicity scale
o Considers ancestry (parents and grandparents)
- Fanous skin classification
o Considers ancestry
- Goldman world classification scale
o Considers ancestry and history of post-inflammatory hyperpigmentation
- Roberts’ hyperpigmentation scale
o Considers hypopigmentation, and the severity and duration of hyperpigmentation
You can use a chemical exfoliating agent to penetrate the epidermis (superficial), papillary dermis (medium), or mid-reticular dermis (deep) layers of the skin. Chemical peels allow you to trigger a controlled injury to the skin that removes upper layers of the stratum corneum (most outer layer of the epidermis) and renews the epidermis. The strength of the chemical peel depends on the exfoliant. Some commonly used superficial chemical peels are:
- Glycolic acid
- Lactic acid
- Mandelic acid
- Salicylic acid
- Trichloroacetic acid
Skin of color. When it comes to skin of color, superficial peels are the safest option. It is effective at treating acne, photodamage, hyperpigmentation, fine lines, and shallow scars. It may take multiple visits to yield the desired result, but it is also the least likely to cause irritation or inflammation. When assessing whether your patient is a good candidate for a chemical peel, ask about their history of scarring, keloids, inflammatory diseases, herpes, surgery, radiotherapy, and medications associated with hyperpigmentation (birth control or hormone replacement therapy) and photosensitizing medications like tetracyclines and non-steroidal anti-inflammatory medications (aspirin, ibuprofen, Aleve, etc.).
While superficial peels are the safest, exfoliants that penetrate the papillary dermis and mid-reticular dermis are more likely to cause hypopigmentation (lighter skin color), scarring, and post-inflammatory erythema. In a study that evaluated five popular chemical peels, the researchers found FST VI to be most at risk for developing crusting, PIH and erythema (Vemula et al., 2018). These side effects took about eight months to resolve and were less likely to occur during the winter.
I love the article by Desai et al. (2023) because they offer clinical guidance to help us prevent PIH as much as possible. When applying a chemical peel, they recommend:
- Patch test a week in advance
- Prime the skin with topical hydroquinone 4% or a retinoid 2-4 weeks in advance
- Consider the use of superficial peels to prevent hyperpigmentation
o Glycolic acid 20-50% with a neutralizing agent
o Salicylic acid 20-30%
- Apply the peel all at one time to prevent uneven exposure times to the exfoliating agent
- After the chemical peel, immediately treat the skin with triamcinolone 0.025% cream or ointment to reduce irritation and inflammation
- In between 3-week treatments, have patients apply a topical triple combination cream that includes hydroquinone 5%, tretinoin 0.05%, and hydrocortisone acetate 1%.
When you use medium peels like trichloroacetic acid and glycolic acid, you control how deeply the peel penetrates the skin making medium peels an ideal choice for melasma. Melasma, a common pigmentary disorder seen in SOC, can be difficult to treat or require a series of treatment over a long period of time depending on how deep the pigment is located.
I was just singing the praises of microneedling on my Instagram stories. I’ve had two sessions of microneedling with protein rich plasma (PRP). You can see my immediate results in the pictures attached to this article. Microneedling is the use of a handheld device that contains multiple small needles that penetrate the dermis causing controlled injury to the dermis which ultimately stimulates collagen and elastin.
Skin of color. Microneedling is a great option for skin of color patients who want to improve skin texture, firmness, acne, acne scarring, melasma, hyperhidrosis (excessive sweating) and who want to reduce their chance of developing PIH. In addition to PRP, there is microneedling combination options. It can be used to deliver tranexamic acid and lightening agents into the dermis. It can be combined with fractional radiofrequency to penetrate the dermis. Lastly, it is highly efficacious (by 96% in a recent study) at improving acne when combined with subcision which disrupts fibrous tissue below acne scars to improve skin texture (Desai et al., 2023). Side effects resolve in about two days and the best results are seen in rolling and boxcar scars compared to ice-pick scars.
Botox. Botox or bostulinum toxin (BoNT) is a popular injectable that can be safely used on SOC patients to treat wrinkles (rhytides). Clostridium botulinum (bacteria) produced the seven types of botox (serotypes A-G) used to minimize muscular activity by blocking acetylcholine. If you’re going to use injectables, it’s imperative that you understand facial anatomy and muscle mass which will help you determine the number of units to inject.
Skin of color. In our SOC patients, rhytides are not as common, however botox is a great option for those with sagging and double chin appearance which is a common complaint. A meta-analysis highlighted the importance of setting realistic expectations and letting anatomic variations determine the appropriate treatment. The literature shows a higher rate of eyelid edema, sensory disorder, and ptosis after botox injections to the glabellar (vertical frown lines between the eyebrows) and lateral canthal lines (Crow’s feet or the fine lines on the lateral corners of the eyes) in Asian and white patients (Desai et al., 2023).
Filler. When talking to your patients about the cosmetic options available for aging, focus on volume loss, and soft tissue redistribution as that is more common in SOC. Filler injections help to rejuvenate the skin. Hyaluronic acid is a popular filler to correct nasolabial folds, restore perioral lines (wrinkles around the mouth), and augment lips in FST IV, V, and VI.
Skin of color. Studies have compared high and low concentrations of popular fillers like Juvederm, Hylaform, and Captique with results yielding no increased risk of hyperpigmentation or scarring. Poly L-lactic acid has also been shown to be administered safely as long as consecutive treatments are spaced out to prevent overcorrecting. To prevent post-inflammatory hyperpigmentation in SOC patients, inject filler deep into the dermal plane to prevent bruising and hemosiderin deposition (hemorrhage in the subarachnoid space) (Desai et al., 2023). Additionally, administer the filler in a linear fashion instead of injecting multiple punctures.
Lasers
Laser is an acronym which stands for: light amplification by the stimulated emission of radiation. They are composed of a pumping system, lasing medium, and optical cavity. The beam of light emitted from a laser can be reflected, scattered, transmitted or absorbed once it reaches the skin. Chromophores (melanin, hemoglobin, and water), light-loving substances, absorb the beam of light. That light can be delivered using a continuous, quasi-continuous, or pulsed mode. The length of time it takes to deliver a beam of light (pulse duration) can be measured using milliseconds (long duration) or nano-seconds, ultra-short or picoseconds (short duration) (Taylor et al. 2016).
The beauty of lasers is the ability to direct a beam of light and selectively target chromophores without causing unwanted damage to adjacent tissue. This can be achieved by ensuring the pulse duration is equal or shorter than the time it takes for the target chromophore to cool down to half the initial heated temperature (thermal relaxation time) (Taylor et al., 2016). Lasers are commonly used to treat superficial wrinkles, acne scarring, and to improve texture, pigment, and vascular concerns (Taylor et al., 2016).
Non-ablative and Ablative Lasers
There are two types of lasers, non-ablative fractional and ablative fractional. Non-ablative fractional lasers use a shorter wavelength allowing the stratum corneum to remain intact. One example of a non-ablative laser is the 1550 nm and long pulsed 1064 nm Nd: YAG (neodymium-doped yttrium-aluminum-garnet) laser. The data shows the YAG laser is a safe and effective option for SOC patients as there have been fewer reports of adverse effects and permanent dyspigmentation (Desai et al., 2023).
Ablative lasers use longer wavelengths which result in more effective results, but pose a significant risk to SOC patients (FST IV-VI), require a longer recovery time, and can lead to permanent dyspigmentation. As Aspiring Dermatology Nurse Practitioners, we always want to emphasize safety. We have to explain to our SOC patients that a series of safe treatments is better than using stronger treatments one time and risk causing permanent damage or introducing new problems, especially when they are avoidable. It’s helpful to share your personal and clinical experience to show that safe can still be effective and yield the desirable results they are looking for. Patience on the part of both the NP and the patient is the key to healthy skin and happy clients.
Skin of color.Lasers can be safely used in SOC patients by trained professionals who receive the proper education and training for treating SOC, and select the appropriate device, wavelength, and parameters. Because SOC patients have more melanin, there is a chance the laser will heat both the target chromophore and the melanin causing the tissue to overheat. This may lead to blister formation, scar formation, or permanent dyspigmentation. To mitigate complications, it is recommended to use longer wavelengths, longer pulse durations, cooling devices, topical steroids, and conservative fluence (the number of energy particles emitted in a given period of time). Note, combining cooling with the use of pulsed dye lasers permits the use of higher fluences while preventing unwanted complications (Desai et al., 2023; Taylor et al., 2016).
The Skin Barrier
This article is in response to an inquiry about scar treatment. While these options are great, it’s important to have an appropriate skin care regimen for your skin type, goals, and lifestyle. A great skin care regimen is a consistent one that cultivates a skin barrier that reduces the risk of irritation, inflammation, and hyperpigmentation. It primes the skin barrier to absorb your skin care ingredients and sets you up to be in the best shape to optimize your cosmetic treatments. Even the best cosmetic treatments need the support of a great skin care regimen before and after care, and in between treatments. When it comes to scars, you want to be mindful to avoid scratching, picking, plucking, and popping the skin to reduce your risk of irritation, inflammation, and PIH.
References
Desai, M., Gill, J., & Luke, J. (2023). Cosmetic procedures in patients with skin of color: Clinical pearls and pitfalls. Journal of Clinical and Aesthetic Dermatology, 16(3), 37-40. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10027327/
Vemula S, Maymone MBC, Secemsky EA et al. (2018). Assessing the safety of superficial chemical peels in darker skin: A retrospective study. Journal of the American Academy of Dermatology, 79(3), 508-513.e2. https://doi.org/10.1016/j.jaad.2018.02.064
Kimberly Madison is a nurse practitioner with a passion for writing, entrepreneurship, education, and mentorship. I created this blog to share my journey as source of motivation and as a blueprint as you embark on your journey. Most importantly, I’m looking forward to increasing access to dermatology education and clinical training for aspiring and practicing nurse practitioners. I invite you to view the mission and vision statement on the homepage to see how we can best partner to make our dreams align.
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