Treating diversity: Patients of color have unique cosmetic concerns

New York - Patients of color have a unique set of skin concerns, and those concerns need to be addressed while clinicians are treating patients, according to Andrew Alexis, M.D., M.P.H., a dermatologist at St. Luke’s-Roosevelt Hospital in New York.

"This is a rapidly growing segment of the population (in North America)," he says, referring to populations from Latin America, South America, Asia, Africa and the Middle East. "They are characterized as having skin types IV through VI."

Dr. Alexis says that 22 percent of patients who underwent cosmetic procedures in 2006 were individuals who came from racial or ethnic minorities, and that number is increasing every year.

"There are a number of important features of darker skin that have important clinical implications," Dr. Alexis says.

Increased melanin

One of the significant features in these populations is the increased amount of melanin in their skin, which gives these populations greater protection from ultraviolet radiation and developing skin cancer than the Caucasian population.

In addition, photo-aging incidence is also reduced compared to the Caucasian population.

Some research has shown that increased melanin provides a mean protective factor from ultraviolet B radiation that is almost four-fold higher in black skin compared to white skin (13.4 versus 3.4).

"However, the reactivity of the melanocytes is associated with an increased risk of hyperpigmentation and hypopigmentation, and an increased activity of the fibroblasts lends itself to increased risk of hypertrophic scarring and keloids in darker-skinned individuals," Dr. Alexis says.

Cultural differences

There are also cultural differences in the perception of beauty and cultural practices relating to skin and haircare, he says.

"These various cultural differences and practices can overlap with structural and functional differences to produce racial and ethnic variations in the prevalence and clinical presentation of dermatologic disorders," Dr. Alexis says.

Dyschromia

Dyschromia is a significant concern for darker-skinned individuals, with post-inflammatory hypopigmentation being the most common form of dyschromia. Melasma is likely the second most common form of dyschromia that prompts darker-skinned individuals to seek treatment.

"There are a variety of treatments (for dyschromia) with different mechanisms of action, and we typically combine more than one agent to increase efficacy," Dr. Alexis says.

Some of those agents include hydroquinone, glycolic acid or salicylic acid peels, and topical retinoids, with the latter working by dispersing epidermal pigment and increasing keratinocyte turnover.

Peels

Chemical peels and microderm-abrasion represent ways to remove epidermal melanin, Dr. Alexis says.

One of the newest therapies to emerge are fractional lasers to treat some disorders associated with hyperpigmentation.

"When using chemical peels in darker skin types, one has to be very careful to minimize the extent of epidermal injury," he says. "Otherwise, you will have a very high risk of inducing hyperpigmentation."

Superficial peeling agents such as glycolic acid can be used to treat hyperpigmentation. It’s imperative to stop the use of topical retinoids one week prior to a chemical peel.

Melasma can be managed via chemical peels and with the use of hydroquinone, Dr. Alexis says.

Fractional lasers

Fractional lasers represent a new treatment modality that can be used safely in patients with skin of color, but lasers, in general, have mixed and unpredictable results in melasma and, thus, should be reserved for cases refractory to conventional therapies.

"By minimizing the extent of epidermal injury, there is less down time and less risk for post-inflammatory hyperpigmentation," Dr. Alexis says.

Hydroquinone

One patient who presented with melasma and superficial acne scarring was refractory to all topical treatments, including hydroquinone products and chemical peels, but did have a clinical response to fractional laser treatment in combination with hydroquinone 4 percent cream.

"The key to doing this safely is using lower treatment levels, and prophylactic use of hydroquinone beginning two weeks prior to laser treatment," says Dr. Alexis, noting more studies are needed to determine optimal administration of fractional lasers in patients with skin of color.

Hirsutism

Hirsutism is a cosmetic concern of darker-skinned patients, and laser treatment can be a therapeutic option for this condition, according to Dr. Alexis.

"The key is to use longer wavelengths, longer pulse durations, and effective epidermal cooling," he says, noting a therapy like intense pulsed light for hair removal is not suitable in darker-skinned patients.

Specifically, the 810 nm diode and the long-pulsed 1064 nm Nd:YAG are safe to use and well-tolerated in darker-skinned individuals.

"We typically use lower fluences delivered over six to eight treatments to get results," Dr. Alexis says.

Loss of volume

While wrinkling may be less of a concern with darker-skinned patients than Caucasian patients in the aging process, darker-skinned patients experience volume loss in the face and loss of radiance, which are concerns in aging skin, Dr. Alexis says.

Dermal fillers are increasingly being used to correct wrinkles and volume loss in patients with skin of color. Studies to date have been shown that they are safe in darker skin types, and no cases of keloids following injectable fillers have been reported. DT