Debunking the myths of laser treatments for darker skin

Dr. BattleThere are two myths that Eliot Battle Jr., M.D., would like to dispel about using lasers to treat skin of color:  

Myth:  Lasers are not safe for skin of color                                                             

It’s been almost 20 years since Dr. Battle and Harvard University researchers first published research demonstrating how practitioners can safely treat skin of color.

“I still have patients who come into my office and tell me their dermatologist or laser center told them that it is not safe to treat skin of color with lasers,” says Dr. Battle, who is CEO and co-founder of Cultura Dermatology and Laser Center in Washington, D.C. He recently spoke on laser treatments for ethnic patients at the Skin of Color Seminar Series held in New York City in May.  

Myth: Focus solely on skin color when considering laser treatments

Skin color is just one criteria practitioners should consider. The patient’s ethnic mixture, sun exposure and health history are key factors that should be taken into consideration.

“A person who has been raised in the northern United States with shorter summers will react differently than a patient raised in the south. Similarly, a patient raised in the Caribbean will react differently than a person raised in Africa or in the United States, based on the sun’s impact to their skin,” he tells Dermatology Times.

Health history is also an important component.

“For example, the skin changes of patients with diabetes will impact how lasers react to the skin,” Dr. Battle says. 

However, despite major advances in laser technology over the past 20 years to improve the safety and efficacy of treating patients with skin of color, “we are seeing a disproportional number of side effects within that group,” he says.

Two reasons for this disconcerting statistic are the exponential number of darker skin patients receiving cosmetic treatments, coupled with the lack of appropriate training for practitioners.

Know the skin's culture

“Regardless of the color of our skin or ethnicity, we all have the same number of melanocytes in our skin. Melanin is packaged in organelles called melanosomes. The size of the melanosome, how they are packaged (individually or in membranes) and where they are dispersed in the epidermis help determine our skin color, which greatly impacts laser-skin interactions,” Dr. Battle says.

Ethnicity and sun exposure affect how melanin is dispersed in the skin. Lighter skin or “melanin-deprived” patients have smaller melanosomes which are packaged together in membranes around the basal layer of the epidermis. Darker skin, or melanin-enhanced patients, have larger and more numerous melanosomes that are dispersed throughout the layers of the epidermis.

What truly needs to be evaluated, though, is what Dr. Battle calls the “skin’s culture,” which includes ethnicity, health history and sun exposure. Patients with skin of color often have a diverse mix of ethnicities, and how this mix may affect cosmetic treatments is not yet fully understood.

“In other words, white is not white and brown is not brown,” he says.

Melanocytes are more susceptible to cold- and heat-induced injury making it more difficult to safely treat patients of color.

“Epidermal melanin competes for most laser wavelengths, resulting in an increased risk of thermal-induced side effects, like pigmentary changes and scarring,” Dr. Battle says.

He opts to treat these patients more conservatively than the manufacturer’s recommendations. Because of the frequency of inconsistent results, he does not use vascular lasers, intense pulsed light (IPL) or resurfacing lasers on patients with skin of color. Increasing safety is a priority, so Dr. Battle strives to minimize epidermal pigment absorption, minimize epidermal heating, and minimize epidermal erythema, edema and irritation

“Every patient you treat is a unique individual with unique DNA, so you need to be cautious,” he says.

More than vanity  

For the past 15 years, laser hair removal has been the most popular noninvasive cosmetic procedure performed at his center, with a minimum of eight sessions, spaced about one month apart. It is part vanity treatment, part medical treatment and part quality of life treatment.

Patients with tight curly hair have an increased risk of hair bumps or pseudofolliculitis barbae (PFB). “Even with the most meticulous hair removal methods such as shaving, plucking, depilatories, waxing and threading, patients with curly hair often acquire PFB. Laser hair removal has been an excellent treatment option for PFB,” Dr. Battle says.

Of the three FDA-approved laser hair removal wavelengths to treat skin of color - 805-nm, 1060-nm and 1064-nm - Dr. Battle believes the 1064-nm Nd:YAG wavelength is the safest.

There are many 1064-nm laser manufacturers, but Dr. Battle favors Cynosure, Cutera and Candela, while for the 805-nm diode laser, it is Lumenis, followed by InMode, Solta and Alma.  His choice for the 1060-nm laser is Lumenis, which is relatively closely comparable to the Nd:YAG.

“Because of the large spot size of the Lumenis LightSheer Infinity 1060-nm laser for large areas like legs and backs and arms, we often gravitate toward that laser,” he says.

However, it is not just the wavelength that needs to be evaluated. “The mode of cooling is as important,” Dr. Battle says. “Most lasers cool by contact, cryogen spray or air cooling, each with its own nuances.”

Complexion blending                                 

Treating pigmented lesions is the second most popular cosmetic laser procedure at Dr. Battle’s practice.

“At my practice, we call it “complexion blending,” which helps to eliminate unwanted dark spots to even out the patient’s skin color and tone,” Dr. Battle says. “Its popularity is approaching hair removal because our dark spots can originate from anything: hormonal issues like melasma to acne to any form of scar or injury to the skin.”

The safest lasers and devices to treat pigmented lesions on skin of color are low-fluence, high hertz, microsecond Nd:YAG lasers, according to Dr. Battle.

“I personally like Cutera, Cynosure and Quanta,” he says. For low-energy, low-density fractional lasers, his favorites are Solta’s Fraxel and Clear and Brilliant Primea, and Palomar’s Icon and low-fluence Q-switched lasers.

Like with hair removal, treating patients for pigmented lesions requires multiple treatments of about four to eight sessions at four to six week intervals.

Dr. Battle combines a top-down approach by using products and prescriptions, including bleaching creams and chemical peels with lasers.  “We are not trying to blast the dark spots away, but just gently nudging the spots, which is why the parameters we use involve low-fluence, low energy and low density,” Dr. Battle said. 

One of the exciting new approaches of treating pigmented lesions is using a low-fluence Q-switch laser, either an Nd:YAG or an Alexandrite in the picosecond pulse-duration mode. Options include PicoSure (by Cynosure), Enlighten (by Cutera), Picoway (by Syneron) and Discovery Pico Plus (by Quanta).

“There is still a need for the nanosecond laser, however,” Dr. Battle says. “But the picosecond appears to provide us with increased safety in treating skin of color.”

Melasma treatment approach

Although there is no cure for melasma, combining a top down and bottom up approach “really improves a patient’s complexion and meets their expectations,” Dr. Battle says.

Long-term maintenance of melasma is critical, so patients must be willing to continue a home regimen, which includes gentle exfoliating, bleaching cream and “becoming sunscreen addicts,” Dr. Battle says. “Patients also need to occasionally come to the office for additional laser or peel treatments.”

Sun protection should be strongly encouraged in these patients who have a 6.7 times higher incidence of  melasma without sunscreen, he said.

Identify lesions first

Permanent improvements in pigmented lesions caused by sun damage and freckles can be achieved with laser treatments, but first, a proper diagnosis must be made prior to initiating treatment.

“Many dermatologic conditions and issues in skin of color can mimic benign everyday lesions, so if you do not know what you are treating, do not treat until you have a definitive diagnosis,” he said. 

Skin computerized analysis using visible, ultraviolet (UV) and polarizing light filters can aid in appropriately identifying lesions. “UV light enhances the appearance of epidermal pigmentation and polarizing light enhances vascular markings,” Dr. Battle says.

Preventative and reparative

Laser treatment has also been successfully used to improve skin texture due to scars or enlarged pores.

Fractional microneedling UV devices like InMode’s fractora and INTRAcel have been shown to be effective in treating acne scarring in skin of color. “These procedures spare the epidermis from thermal heating by coating the epidermal part of the pins/needles and delivering the RF energy directly into the dermis,” Dr. Battle says.  The typical treatment protocol is two to four sessions, spaced six weeks apart.

“Patients can expect to see probably a 10% to 20% improvement in acne scarring for each treatment. There is also an improvement in active acne and post-inflammatory hyperpigmentation,” he says.

Skin tightening still elusive

Skin tightening with laser is still the Holy Grail. “We are not as consistent in achieving patient satisfaction as we should be,” Dr. Battle said.

While any form of infrared or RF energy devices have been proven to be effective to a degree, ultrasound using the Ultherapy laser is probably the gold standard. Dr. Battle’s practice uses the Cutera Titan or InMode Forma laser - often in conjunction with either kybella injections or Coolsculpting (Zeltiq) to minimize fat prior to tightening the skin. After four to six treatments spaced six weeks apart, patients can expect a 20% to 40% improvement in skin tightening.

Most body contouring devices are also safe to treat patients with skin of color. “Apoptosis can be obtained through cryolipolysis, RF and lasers, because our fat cells are sensitive to extremes of temperatures,” he says. 

Train first, treat second

For all indications, Dr. Battle recommends that practitioners take appropriate education courses, particularly courses that include hands on training. 

“It is the practitioner’s responsibility to use the right laser or device and to become an expert not only with technology but on the nuances of treating skin of color,” he says.

CONSERVATIVE TREATMENT IS BEST

Dr. Battle recommends choosing only laser treatments with proven success and to stand strongly by the Hippocratic Oath of doing no harm.

“Treat more conservatively because you probably do not know the DNA of the patient you are treating,” he says. ƒ

Disclosures:  Dr. Battle reports no relevant financial disclosures.