In the aesthetics specialty, injectables are commonly considered the bread and butter of the industry, however, devices are also becoming increasingly popular among patients. According to business consulting and market research company DelveInsight, the global energy-based aesthetic device market is estimated to be valued at US $4.96 billion by 2026.1 This highlights that patients could be investing their money into treatments which are considered less painful and less invasive, while still delivering those all-important results.
Despite energy-based treatments being available for all patients regardless of skin type, practitioners may need to take some precautions for skin of colour (SOC) patients.2 Due to having higher melanin production, SOC patients may be provided with specific pre-treatment and post-procedure care to avoid complications such as post-inflammatory hyperpigmentation (PIH).3 Using the Fitzpatrick classification, we are referring to SOC as those patients with skin types IV-VI, whilst lighter skinned patients fall into I-III (Figure 1).4
Aesthetics spoke to aesthetic practitioners Dr Rehanna Beckhurst, Dr Ifeoma Ejikeme and Dr Yusra Al-Mukhtar to discover their advice for treating SOC patients with devices and what practitioners should be aware of before treatment.
Differences between SOC and white skin
The physiology and anatomy of SOC and white skin differs, causing patients to present to practitioners with contrasting concerns. Dr Al-Mukhtar explains, “The collagen density tends to be higher in SOC people compared to white skin, meaning they are less likely to suffer with issues like fine lines and wrinkles.5,6 Instead, their main concerns are usually scarring, acne, pigmentation or textural issues such as enlarged pores. For lighter skinned patients, the concerns are likely to be thin, crepey skin, lines and wrinkles and wanting to improve skin texture.”
Another key difference is the melanocyte activity between the skin types, with eumelanin being more present than pro-melanin in melanin rich skin, Dr Ejikeme states. “Melanin is a protective mechanism,” she says, “Therefore it is produced, distributed and increased in the skin in response to skin stress. This stress can be caused by prolonged pressure, scrubbing the skin, heat and sunlight, which encourages the body to trigger this protective mechanism and increase pigment. As a result, this presents itself as uneven skin tone, darkening of the skin, discolouration, PIH, or in extreme cases, hypopigmentation.”5,7
Dr Beckhurst notes that PIH is the main concern to be aware of when treating SOC patients, as well as the risk of keloid and hypertrophic scarring. “In my consultations, where possible, I ask my patients about their ethnic background, as it isn’t just the colour of the skin which determines how the skin will react, but also its response to UV radiation, according to Fitzpatrick skin types.” She continues, “In my clinic, scarring is one of the main concerns SOC patients face due to being more prone to PIH, melasma, age and sunspots, leading to a darkening of the skin and marks. Therefore, I make sure to always conduct a thorough examination of the patient’s skin before advising treatments.”
Dr Ejikeme reiterates the importance of understanding that pigment production is ultimately a protective mechanism. She notes, “The goal for practitioners when treating is to try and calm the pigment producing cells, so there isn’t an exaggerated response. It is also important to note that if there is a mild response such as some PIH, this is normal, and it should settle itself down. Therefore, when I’m thinking about treating skin, I always start preparing it by using specific products or altering my process to avoid overstressing the skin.”
Potential complications
All the practitioners agree that PIH is the main complication to avoid when treating SOC with devices such as radiofrequency microneedling, laser and high-intensity focused ultrasound. Dr Al-Mukhtar reiterates that PIH can be a long-term complication if not treated appropriately. “In essence, PIH is the skin’s response to a wound. It causes the skin to be angry and inflamed, so the skin deposits more melanin in response to the heat trauma it is experiencing. PIH can most commonly occur after treatments like microneedling or CO2 laser,” she notes.8
Dr Beckhurst agrees, highlighting that dark spots can also occur as a reaction to the injury on the skin. She says that hypertrophic scarring is also riskier in SOC patients and should be managed accordingly.
Furthermore, Dr Ejikeme believes that although complications can occur in melanin rich patients, they are rare and can usually be rectified. She notes, “Hypopigmentation and PIH are our main concerns, but if you pick the right treatment option, these are rare. If they do happen, it’s relatively straightforward to address them. Despite this, it’s important to advise your patient to use SPF regularly, avoid direct sunlight and continue using the skincare products recommended by their practitioner to maintain results.”
Before treatment
All three practitioners conduct a thorough medical history and skin assessment during their consultations, as well as advising a skincare regime before treatment, including the use of SPF 50.
Dr Beckhurst recommends vitamin C pre-treatment, and rarely prescribes hydroquinone cream to her SOC patients unless they are suffering from PIH. She explains, “I try to avoid prescribing hydroquinone creams if the patient has no clear history of PIH, because if used long-term or not used strictly, it can cause dyschromias. I will only advise hydroquinone if I want to hasten the rate of PIH on the skin. Therefore, I advise using a vitamin C serum from PCA Skin (C&E advanced), as well as PCA Skin Pigment Bar and Pigment Gel Pro to inhibit tyrosinase and melanogenesis. I also recommend the PCA Skin Vitamin B3 to even out skin tone and hydrate the skin.”
Dr Al-Mukhtar chooses to put her patients on a skincare regime using either prescription tyrosinase inhibitors alongside a retinoid to reduce the activity of the melanocytes, improve collagen density and mitigate the risk of PIH prior to an energy-based treatment.
On the other hand, Dr Ejikeme notes that it is important to consider whether you are going to cause an exaggerated stress response to the skin, further causing inflammation. If so, she recommends regulating the pigment producing process beforehand. “In my clinic, I use a number of different options including Obagi products to regulate pigment. There are lots of different ones on the market, but the one you choose will determine the amount of inflammation you’re intending to cause post-treatment,” she notes.
Dr Ejikeme reiterates that if you are intending to carry out a mild treatment after which you don’t think there will be any pigment production or inflammation, she recommends the patient use a consistent broadband sunscreen. If the treatment is mild/moderate such as microneedling, she uses products to optimise the skin such as vitamin C, arbutin and SPF. Lastly, for resurfacing treatments, she would use tretinoin and SPF, as well as hydroquinone for two to four weeks prior to treatment.
Choosing your device
When choosing a new device for your clinic, Dr Al-Mukhtar advises checking that it has been tried and tested on SOC and to ensure they provide clinical data to back this up. “In the past, devices were trialled on Fitzpatrick skin types I-III, including skincare,” she says. “With the conversation surrounding diversity becoming more topical, practitioners and patients are advising company manufacturers to test their products on SOC.”
Dr Al-Mukhtar uses the Secret Pro radiofrequency microneedling and CO2 combination device by Cutera, for epidermal and dermal focused skin rejuvenation applications. This particular device allows her to tailor her treatment specifically for SOC patients. She comments, “The device has the option of using semi-insulated needles rather than just the non-insulated option, which allows me to prevent unnecessary heat and trauma to the epidermis and deliver energy to the deeper dermal tissues, which is the aim with SOC patients. This mechanism of action helps reduce incidence of melanogenesis (new pigmentation), which is a priority. To further reduce risk, the Secret Pro also allows me to tailor my target depth within 0.1mm increments, depending on skin type and treatment indication.”
Furthermore, Dr Beckhurst uses a similar technique when treating SOC with radiofrequency, choosing to use insulated needles and a lower energy output with the Gentlo device from Beamwave Technologies. She explains, “Gentlo gives me a choice of needles (insulated or non-insulated). For darker skin types, I use insulated needles as they deliver radiofrequency from the tip at a deeper depth. In lighter skin types, we aren’t as concerned about upsetting melanocytes and increasing melanin production, but in darker skin, we want to bypass those layers and deliver radiofrequency at a deeper level, targeting collagen production safely.”
Dr Al-Mukhtar notes that she adapts her protocol based on the patient’s concern, goals and skin type, by changing the energy, depth, and needle size. She states that she might add additional CO2 into her treatment if necessary. “In the past, CO2 laser was completely avoided in SOC patients with Fitzpatrick skin types III-V,” she says, “However, with advancements in the efficiency of the technology available to practitioners, we can tailor the treatment to suit SOC. This means we can alter the depth of the CO2, and the amount of skin coverage meaning we can deliver a fraction of the laser so that it is fractionally ablative rather than fully ablative. By ensuring we spend time preparing the skin pre-treatment by prescribing melanin inhibitors such as hydroquinone, we can then deliver a more controlled, lower energy output of the CO2 10,600 nm, avoiding unnecessary trauma to the skin. The advancements in technology have enabled us to offer our SOC patients gold-standard CO2 resurfacing treatments, which they might previously have been told wasn’t suitable for them."9
Dr Ejikeme prefers to use different devices depending on the patient’s condition. She reflects, “I like to use the Secret Pro device for any radiofrequency microneedling procedures too. For laser hair removal, I use the Nd:Yag laser by Fotona because I believe it is the safest modality for SOC.”
After treatment
Dr Beckhurst reiterates that post-treatment skincare (the same products used in pre-treatment) is advised, as well as regular follow-up appointments to catch any complications early. She says, “I try to make it clear to patients that our main concern is PIH occurring, so I advise vitamin C and SPF, alongside topical skinboosting enzyme products to slow down melanin production by inhibiting tyrosinase. We also give my patients a courtesy call two days post-treatment to see how they are, and then a follow-up one or two weeks later depending on how the call goes. We then have an additional radiofrequency microneedling treatment booked in for six weeks’ time after the original to maintain results.”
Similarly, Dr Ejikeme offers post-procedure care to all patients regardless of skin colour to maintain results. “When patients come for their treatment and the skin seems hyperactive, I may give 1% hydrocortisone after treatment to reduce hyperpigmentation. For all treatments we do, everybody would get an emollient and SPF 50,” she adds.
Dr Al-Mukhtar reinforces the point that protecting the skin post-treatment is vital. She notes, “Aftercare is not one size fits all approach – it depends on the patient’s previous history of treatments, what skincare they’ve been on and reactions to previous devices. The number one thing I would say is that patients need to protect their skin after treatments and keep it hydrated. Applying sun protection is pivotal in preventing further hyperpigmentation and dark spots. Once the healing has completed after an energy-based treatment, I will follow up with tyrosinase inhibitors and a retinoid again to improve the results and reduce the risk of PIH.”
In the past, SOC patients may have been reluctant to seek out energy-based treatments due to a higher risk of PIH and other skin complications. Dr Al-Mukhtar adds that with appropriate pre- and post-care, practitioners can offer patients treatments that they might have been reluctant to have previously. If melanin production is managed, SOC patients can be treated without the additional fear of complications.
Treat SOC with caution
Dr Ejikeme concludes that practitioners should be confident in treating all ethnicities and make expectations clear to patients before treatment. She says, “Patients with melanated skin are not a uniform group. From African and Middle Eastern to Indian and Southeast Asian, every group has a different skin tone and concern. Therefore, make clear to patients the results they can expect from your treatment. There must be a match between what you think you can achieve and what the patient wants. If you achieve this, you can get great results and happy patients!”
Dr Beckhurst advises practitioners to refer patients to other colleagues if they are unsure of how to treat. “Always treat SOC patients with caution! If you are unsure, refer to a practitioner who specialises in SOC, especially if there is something in a patient’s medical history which raises concerns such as if they had complications from treatment before. If in doubt, always refer.”
