Three practitioners discuss how you can make skin of colour patients feel confident seeking filler treatment in your clinic
“Black people have never been treated fairly, and aesthetics is no different,” says Sharron Brown, aesthetic nurse prescriber and secretary for the British Association of Cosmetic Nurses (BACN). This is a sentiment reflected throughout the industry, with last year’s survey by the Black Aesthetics Advisory Board (BAAB) showing that there was a lack of knowledge, training and literature on treating skin of colour patients (SOC). In addition, 7/10 black patients said they had difficulties finding practitioners who were confident in treating their skin type, and 86% said aesthetic brands needed to be more culturally aware.1
With injectables remaining a hugely popular aesthetic treatment,2 Aesthetics spoke to Dr Simi Adedeji and Dr Tijion Esho, alongside Brown, to find out how practitioners can appropriately consult, assess, and treat SOC patients using dermal fillers.
Knowing the anatomical differences between Caucasian skin and SOC patients is integral to a successful treatment, according to Dr Adedeji. Dr Adedeji explains that the signs of ageing are different depending on your skin tone, as with darker skin there is less wrinkling and less laxity, and often volume loss will occur later in life than in Caucasian skin. In terms of specific features, she explains that SOC lips have a ratio of 1:1 rather than 1:1:6 and have a greater projection. “Noses also have fundamental differences,” she says, “Because black patients tend to have a wider nose, the bridge is flatter with a less pointy tip, and in general it’s a lot shorter than Caucasian noses.”
Knowing the anatomical differences between ethnicities helps to manage patient expectations, says Dr Adedeji. “We’ve all been there as practitioners where a patient brings you an image of someone famous and says, ‘I want this nose’ or ‘I want these lips’. Because SOC patients are anatomically structured differently to Caucasian patients, it’s not realistic for everyone to be able to get the same results from fillers. A black patient won’t be able to get a tiny, pointed nose with non-surgical interventions – it just isn’t possible because of the structural differences. So, if they come into your clinic requesting a Caucasian look for example, it’s important to be able to tell them what a realistic outcome of the treatment would be and explain why this is the case,” she adds.
“You don’t have to be a practitioner with a darker skin tone to treat SOC patients, you just need to be knowledgeable on it!”
Dr Simi Adedeji
Filler treatments are something often not spoken about by people of SOC, says Dr Adedeji, and so going for a consultation can cause feelings of shame and guilt, greater than Caucasian patients. She explains, “Many black patients don’t view aesthetics as being for them and I have had patients who worry that getting work done betrays their heritage and culture. For example, I have one woman who’s been coming to me for years and never has she told a soul that she has any work done, because she feels that she would be massively judged by her community for it. This isn’t uncommon, because there’s a huge push in black culture about accepting who we are and embracing our culture/heritage, so aesthetics may be viewed by some as going against that. Because a lot of SOC patients that present to clinics will be experiencing negative feelings around the experience, it’s even more important to make the patient feel confident and at ease.”
Dr Esho also emphasises the importance of practitioners making a conscious effort to understand the needs and wants of different communities. He says, “I do find that SOC patients are more nervous when presenting to clinic, but as I’m a black doctor I think patients feel more comfortable to discuss this with me, as they know I will automatically be empathetic and understand these concerns. For non-black practitioners this may be more difficult, and so ensuring that you understand these concerns prior to consultation can help alleviate worries that a patient may or may not tell you. Understanding what preconceived issues a patient group may have will help to increase the ability to reassure the patient, and therefore gives a better outcome for the consult and subsequent treatment.”
Dr Adedeji emphasises that individuals with SOC have melanosomes and more active melanocyte cells, which create dark marks if the skin is pierced or damaged. “Black patients are more prone to certain complications, for example keloid scars or hypertrophic scars,” she says, “Because of this, practitioners need to make sure they’re gaining a comprehensive overview of the patient, medically and personally, before they agree to filler treatment. For example, it’s important to ask them how their body reacted when it experienced any other kind of trauma, such as any kind of body piercing or vaccine injection. If this sort of treatment left them with scarring, then it’s usually not appropriate to be giving them fillers.”
Dr Adedeji adds that when taking history from patients, it’s important to use terminology that they will understand. She explains, “Once I asked a patient whether she’d ever had any keloid scarring and she said no, but she did say that she’d had some small, raised bumps – which is exactly what keloid scars are! As practitioners we sometimes forget that patients don’t speak our language, and this could potentially lead to missing something vital. I also always ask patients to show me exactly what they’re talking about, so I can assess and diagnose it myself. Doing this can prevent SOC patients from potentially having to experience complications and negative effects.”
In terms of choosing what dermal filler to use, Brown has no preference based on a patient’s skin colour. She says, “As with anything in aesthetics, there isn’t a one-size-fits all approach. The important thing is knowing how to assess the patient correctly, and that practitioners are educated in anatomy, physiology and how the skin may react in various ways.”
Dr Adedeji advises that when it comes to choosing what products or treatments to offer in your clinic, practitioners should take into consideration whether the company itself presents as being inclusive. She says, “As a practitioner, I don’t want to align myself with companies that don’t align with my ethos. There are a lot of brands that I think about using in my clinic, but when I look into their promotional materials, they have no black or SOC patients, or if they do, they’ll just have the odd one just thrown in. If a patient researches the dermal filler you’re using and is unable to find any examples of people who resemble them on their website, they’re not going to feel confident that this product will work for them and are unlikely to trust you to treat them using it. Even though it may well be perfectly fine, there’s no way for them to know this! You should only endorse what reflects you and your values, so clinics need to think carefully about using a brand/range that only uses Caucasian models.”
All three practitioners agree that aesthetic marketing needs to be more inclusive of all skin types, but are conscious of ensuring this doesn’t result in SOC patients feeling separated from other ethnicities. “This reduces the risk of black patients being made to feel like ‘the other’,” says Brown. “If you make a big song and dance about being able to treat black and Asian patients, then it singles them out as a separate group to everyone else. So, while we absolutely need aesthetic marketing to be inclusive of all ethnic groups, it shouldn’t become a different strategy altogether,” she adds.
Dr Adedeji agrees, noting that SOC should be integrated into all usual clinic campaigns. She says, “If you’re making an advert, don’t just have Caucasian models in the advert. If you’re posting images on Instagram, make sure you’re showing a diverse range of patients with different skin tones and colours. If you want to attract SOC patients to your clinic, they need to be able to see that you are inclusive and have experience in treating SOC.”
Dr Adedeji advises that before and after images in your marketing can be a great way to showcase to patients that you can offer them good results. She comments, “What they need is to look at these images and be able to see themselves in the people that you’re showing. If they go on your Instagram and all they can see are Caucasian lips, noses, cheeks, how can they feel confident that you’re going to treat them effectively? There’s no evidence of you doing so! People like to recognise themselves in what they see, so ensuring that you show a variety of skin colours on your feed will help to reassure SOC patients that you know how to treat them and can also show what sort of outcomes they can expect.”
“Understanding what preconceived concerns a patient group may have will help to increase the ability to reassure the patient, and therefore gives a better outcome for the consult and subsequent treatment”
Dr Tijion Esho
Dr Esho agrees, noting, “If we as black people don’t see us, we don’t feel it’s for us and that’s very important for practitioners and clinics to understand if they want to attract black patients.” As such, he encourages clinics to also ensure that they have diverse clinic staff in order to be able to appeal to people of different ethnicities. He says, “Being proactive in making sure your website and social media is inclusive can be hard as it needs to become a subconscious process to work long term. Making sure you have people on your team that reflect different cultures and listening to their thoughts can help, and if that isn’t possible, I would recommend consulting companies with services that specialise in this area, for example the BAAB or the Black Skin Directory.”
Brown notes that this inclusion into marketing can also help to normalise the concept of black patients getting fillers. She says, “The more it’s spoken about and shown, the less we will have the stigma that I mentioned earlier. Promoting SOC injectables can make the whole thing less taboo and make patients realise it’s perfectly normal and fine to do – they’re not the only ones from their community who are getting procedures!”
Brown urges fellow aesthetic practitioners to expand their knowledge base to have the correct information to include all skin types. She says, “While there is a definite lack of resources out there on treating people with skin of colour, there are definitely resources such as the British Association of Dermatology Skin Diversity Sub Comittee and an upcoming book by Dija Ayodele from the Black Skin Directory. It’s just a case of researching! Other useful resources are search engines such as, Google Scholar and PubMed which are completely free for people to use, there are studies and articles available. I also urge more practitioners to write articles, present case studies and conduct trials, so that we can get more information out there.”
Dr Adedeji agrees that practitioner education is paramount and believes that more training courses should integrate SOC into their curriculum. She says, “You don’t have to be a practitioner with a darker skin tone to treat SOC patients, you just need to be knowledgeable on it! Something I’m very passionate about is making SOC more mainstream in aesthetic training and education. For practitioners entering the industry, this is the best way to equip them with the correct knowledge needed to be able to treat patients with darker skin tones in the most effective way. Again, this doesn’t mean that there has to be completely separate courses that single different skin colours out, but rather it just be incorporated into the existing programmes.”
While he also believes that practitioners should conduct research, Dr Esho advises that the best thing you can do is not to shy away from treating black patients, so that you can gain the necessary experience. He notes, “Practice makes perfect! The more immersed a practitioner becomes in seeing black patients the better they will be at understanding the concerns, expectations, and anatomical differences. There’s only so much a book can show. As with anything in aesthetics, practical experience is invaluable!”
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