Conference Coverage

Expert shares his approach for aesthetic treatments of ethnic skin



– The United States is more ethnically diverse than ever before, creating an added challenge for dermatologists to identify skin types in patients considering aesthetic procedures.

Dr. Ashish C. Bhatia, dermatologist

Dr. Ashish C. Bhatia

“Unfortunately, one’s ethnic background is not always clear,” Ashish C. Bhatia, MD, said at the annual Masters of Aesthetics Symposium. “There’s a lot more blending, a lot more difficulty figuring out what people’s ethnicity is and how their skin is going to respond to different treatments.”

When consulting with patients, Dr. Bhatia, director of dermatologic and cosmetic surgery at Oak Dermatology, outside of Chicago, determines their Fitzpatrick skin type and asks about their heritage. “Some people who are adopted don’t know their heritage,” he said. “We also ask about their history of keloids, hypertrophic scars, postinflammatory hyperpigmentation or postinflammatory erythema.”

He also makes it a point to ask patients about blemishes. “If they get pimples, how long do the marks last, and what do they look like?” is one question he asks patients. “That dialogue gives you a lot of useful information. If they get hyperpigmentation, that’s one thing. But many times, people just get postinflammatory erythema, which is often a lot easier to treat.”

In his clinical experience, challenges and risks of performing aesthetic procedures on ethnic skin include postinflammatory hyperpigmentation and hypopigmentation, depigmentation, keloids, and hypertrophic scars. He explained that patients with darker skin types have bigger melanin granules and melanosomes, and more of them are deposited into keratinocytes.

“There’s a complex interaction that occurs between the melanocytes and the keratinocytes, where they phagocytize the ends and take up the melanosomes,” said Dr. Bhatia, also of the department of dermatology at Northwestern University, Chicago. “There’s an opportunity to block tyrosinase to prevent the production of melanin, but once the melanin is produced, what we really worry about is where that melanin ends up. It may end up in the epidermis in the form of light brown pigment. You can see this enhanced if you look at it with a Wood’s light. But if it ends up in the dermis, you don’t get enhancement and clinically it’s more of a bluish-gray pigment. The deeper melanin is much more difficult to treat. Often the postinflammatory hyperpigmentation people get is a combination of these two.”

To reduce the risks of hyperpigmentation and hypopigmentation from procedures, he generally advises against the use of intense pulsed light (IPL), fractional ablative lasers, shorter-wavelength lasers, and cryotherapy. “It’s not to say you can’t use them, but you have to be very careful,” he said. For clinicians with less experience treating skin of color, he recommends using procedures that spare the epidermis and the dermal/epidermal junction altogether. “This includes lasers with longer wavelengths such as the 1,064-nm Nd:YAG, always using generous cooling to avoid injury or trauma to the dermal/epidermal junction and using longer pulse durations.”

Nonlaser procedures to consider using for darker-skinned patients include superficial chemical peels, radiofrequency (RF) microneedling with semi-insulated needles, microfocused ultrasound, and noninvasive RF procedures that spare or cool the epidermis. “You should never be afraid to do a test spot,” he said. Adjunctive therapies to consider using include hydroquinone and other tyrosinase-receptor blockers, and preprocedural preparatory formulas. “Always advise sun protection and avoidance and administer HSV [herpes simplex virus] prophylaxis as indicated,” he added. “Ample evidence exists to show that currently available fillers and neuromodulators are safe to use in darker skin types. The issue here is more with postinflammatory hyperpigmentation, which can occur from needle punctures, so small-gauge needles and linear threading versus serial puncture is preferred.”

Adjunctive postprocedure preventative therapies include hydroquinone and other tyrosinase-receptor blockers; high-potency topical steroids such as clobetasol twice a day for 3 days and tapering to once a day for 3 days before halting; and postprocedural recovery/healing formulas.

Dr. Bhatia said that hypopigmentation can be treated with UV therapy, with bimatoprost topically combined with needling or low-density fractional lasers, as well as with epidermal microsuction grafting such as the CelluTome Epidermal Harvesting System. Hyperpigmentation can be treated with tyrosinase inhibitors, retinoids, chemical peels, and with microdermal/dermal infusion.

As for cosmeceuticals, sunscreens are necessary for keeping skin tone even. Retinoids are also helpful for maintenance, “but irritation can lead to postinflammatory hyperpigmentation, so go slow,” he said. Hyperpigmentation can be treated with hydroquinone, azelaic acid (Finacea), as well as many other preparations.

“Don’t be afraid to treat these patients,” Dr. Bhatia concluded. “As you get more used to performing procedures on people with darker skin types, you discover the limits of what you can and can’t do. But in general, we can do a lot to make these patients happy.”

Dr. Bhatia reported having research and financial ties to numerous pharmaceutical and device companies.

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