While energy-based aesthetic devices are constantly evolving and improving to satisfy consumer demand for nonsurgical therapies, not all patients are able to take advantage of what seems to be the ever-expanding menu of technological advancements. Patients with darker skin types request the same energy-based solutions everyone else does, but not all of these treatments suit all Fitzpatrick skin types. Therefore, it is up to the physician to choose – and use – technology wisely.
In 1995, Vivian Bucay, M.D., a dermatologist in San Antonio, Texas, began using the ablative CO2 laser to treat acne scarring in patients with skin of color. “It can be done, but it is all about preparing the patient and setting expectations,” she noted.
However, as soon as Dr. Bucay acquired a long pulsed 1064 nm Nd:YAG laser, which had been proven safe for laser hair removal in darker skin types, the dozens of African-American patients with pseudofolliculitis barbae (mainly police officers who had to shave daily) who sought treatment convinced her there was a significant unmet need for skin of color.
Today, patients with skin of color learn about the newest technologies online and assume they can have them all, but this is not always true, said Jeanine B. Downie, M.D., director of image Dermatology® P.C. in Montclair, N.J. “So, you have to guide them through the reality, as well as available options. Patients come to us to be the doctor. We don’t ask them what we should do, instead we tell them what is possible.”
Whether it is pigment busters, wrinkle smoothers or fat fighters, Dr. Downie’s patients with skin of color are asking more questions than ever.
According to the Skin of Color Society, more than half of the U.S. population will have skin of color by 2050. The widely used Fitzpatrick skin type classification system includes six categories, based on the skin’s appearance and reaction to sun exposure (Table 1).1 Phototypes range from I (ivory white skin that burns easily) to VI (dark brown or black skin that tans easily without burning).”
As Douglas Wu, M.D., Ph.D., a dermatologist in San Diego, Calif., explained, Caucasians generally have phototype I (marked by red hair and fair skin) and II, Asians and Hispanics typically have types III and IV, Southeast Asians and Indians have type V and African-Americans have types V and VI.
Beyond what’s visible
“As a society, everybody has skin of color to some degree,” said Dr. Bucay. “We are such a mixed population now. When you look at somebody, you can’t necessarily tell their ethnicity.”
Many of Dr. Bucay’s patients are Hispanic or Asian, with skin type IV, which responds unpredictably and pigments easily. In addition, Hispanic skin displays the broadest variety of skin tones because it can include Spanish ancestry mixed with any indigenous population of the Americas, she pointed out.
“If one is uncertain about a patient’s skin type, I suggest inquiring about their background in a culturally sensitive manner with questions like, “Was your mother dark skinned?” said S. Manjula Jegasothy, M.D., founder of the Miami Skin Institute and clinical associate professor of dermatology at the University of Miami Miller School of Medicine.
And, even if patients have fairer skin, Dr. Jegasothy suggests examining their palms. “If the creases are darker than their skin type, this means that they tend to tan more easily and may also be prone to hyperpigment more easily from certain laser procedures.”
Similarly, Dr. Bucay asks patients how their skin heals after cuts, burns or bug bites. “If they get post-inflammatory hyperpigmentation, I need to proceed with caution,” she said. A history of keloids also raises red flags.
“Ethnic skin types need to be treated in a very special way,” said Dr. Wu, whose personal practice is around 40% Asian and Hispanic.2 “While fair skin types mainly develop lines and wrinkles with age, patients with skin of color worry mainly about age-related pigmentary changes,” he expressed. “So, when resurfacing or applying any laser to an Asian patient, or an ethnic patient in general, pigmentation needs to be the primary concern.”
Nearly all lasers are capable of treating skin of color safely when used correctly, Dr. Wu indicated. “The key is to adjust the density and fluence so that they are appropriate for the skin type you are treating.”
Nevertheless, the two technologies that have emerged as largely appropriate for treating darker skin types are, broadly, fractionated lasers and picosecond lasers, Dr. Wu stated. The untreated skin that fractional lasers leave between microscopic columns of thermal injury facilitates healing while reducing side effects, he explained.
Commonly used non-ablative fractional wavelengths generally span the low infrared range: 1440 nm, 1540-1555 nm and 1927 nm. Ablative laser wavelengths, which can also be fractionated, include 2940 nm (Er:YAG) and 10,600 nm (CO2). Less common are fractionated 1064 nm or frequency-doubled 532 nm Nd:YAG lasers and fractionated picosecond lasers, he said.
Additionally, the ultra-short picosecond pulses carry sufficient energy to destroy melanin while minimizing collateral damage to surrounding tissues.
With fractional lasers, Dr. Wu said that treating Asian patients generally requires cutting density in half. He also recommended maintaining or slightly reducing fluence, rather than gradually increasing it as one would with lighter-skinned patients. With these adjustments, skin of color typically requires more treatment sessions than lighter skin types for optimal results, he added.
In Dr. Wu’s practice, commonly treated indications include discrete benign facial pigmentation – mainly solar lentigines, moles and freckles. “In this situation, spot lasers such as picosecond devices, can be used very effectively to remove these lesions in a very small number of treatments.”
For removing tattoos, picosecond lasers have proven superior in all skin types, said Dr. Wu. While previous-generation nanosecond fractionated lasers had approximately a 20% risk of PIH or hypopigmentation, the risk for picosecond lasers is less than 5%, he reported.3
Still, Dr. Wu recommended reducing fluences to avoid hypopigmentation in darker skin. For example, he recently treated a 23-year-old African-American woman with a black tattoo using the 1064 nm PicoWay picosecond Nd:YAG laser from Candela (Wayland, Mass.), with a non-fractionated 5 mm spot size and 1.4 J/cm2 fluence at 5 Hz. She underwent two treatments one month apart and minor residual hypopigmentation resolved completely after three months.