My nursing career started in 1988 at the School of Nursing at Royal Liverpool Hospital. I was the only black person in my year group of more than 100 students. Over the intervening years, the proportion of nurses from the Black, Asian and Minority Ethnic (BAME) community has grown to one in five, which more closely matches the community we serve.1 However, there is still an evident lack of knowledge when it comes to treating darker skin types, particularly in the aesthetic field.
A gap we need to fill
During my initial training as a nurse, skin colour and the effect it can have on diagnosis and treatment was never mentioned. This omission has continued in most of my subsequent training as a midwife, health visitor and for the last 10 years in my role as an aesthetic nurse.
For example, I was taught that a person presenting with a myocardial infarction would display a number of physical symptoms, including changes to skin appearance, but these skin colour changes were described with a white person in mind. For a person of colour, the majority of these symptoms would be the same, however the way they presented could be dramatically different. For example, whilst a person with white skin may well go either pale grey or blue in appearance, what would the appearance to a person of colour skin look like? For Fitzpatrick V and VI the skin will not look blue but will likely be ashen.2 In addition, colour changes in darker skin tones are not as apparent as in white skin for those that are ill or in shock.
The lack of information and training on skin colour also extended to descriptions on how skin disorders present. This gap in my knowledge began to take on added relevance as I moved into the aesthetics field.
My initial aesthetic training was conducted by a well-recognised and established UK training company, but throughout my time with them there was no mention of how we were to recognise and diagnose complications in people of colour. As I practise in a part of the country where the proportion of BAME patients significantly exceed the national average; I was keen to gain a greater insight.
When I asked trainers how a vascular occlusion due to dermal filler would present in a person of colour, they were unable to give clear guidance or provide evidence. As we know, vascular occlusion, if untreated, can lead to skin necrosis and tissue death so early identification is crucial to avoid long-term damage of skin.
I appreciate that for certain treatments, uptake is lower from BAME patients. Therefore, there will be fewer examples of complications from which we can all learn. However, this should not stop us from striving to improve. There needs to be a better understanding how adverse reactions appear in darker skin tones to prevent mismanagement or a delay in management.
Other areas for improvement when it comes to aesthetic training is facial assessment, which is currently focused on that of the Caucasian face. Therefore, when advising and conducting restorative work we usually base our knowledge on that example. Can we apply this knowledge to people of different ethnicities? People of colour age differently, have different facial characteristics, so we need to understand the structure and functional difference of black and brown skin, in order to treat appropriately.
Gaps in our knowledge and experience will significantly increase the chances of problems occurring. Knowledge gaps can be filled through specific training on skin and ethnic background variations; how skin of colour responds to treatments, facial structure differences and appropriate treatment options, potential complications and how to avoid them. Practitioners need to actively seek this information and training out, and if they find it is unavailable, encourage training providers and companies to focus on this. They should also share their case studies and help educate others based on their own experiences. As practitioners, we also need to seek out and promote images that showcase a wider variety of what represents the aesthetic ideal, acknowledging that what defines beauty and youth will vary across skin colours and ethnicity.
Get to know diverse skin colours and ethnic face variations
We live in a diverse society and this needs to be reflected in our training and training material. As we improve our knowledge, not only will we be able to treat our existing patients with skin of colour better and achieve better outcomes, but we will be able to broaden the appeal of our treatments to include the whole of our diverse society.
1. NHS, CNO Black and Minority Ethnic (BME) Leadership, <https://www.england.nhs.uk/nursingmidwifery/delivering-the-nhs-ltp/cno-black-and-minority-%20%20ethnic-bme-leadership/>
2. My American Nurse, Color awareness: A must for patient assessment, 2011.