Practitioners discuss the key considerations around treating darker skin types with lasers for skin rejuvenation
Whether you attend conferences, talk amongst colleagues or scour social media, it’s safe to say that lasers are a hot topic. We have seen a significant rise in their usage over the last five years1 and some practitioners believe lasers are the ‘holy grail’ for many a skin concern. However, there seems to be one area that some still shy away from; treating skin of colour.
The UK is one of the most multicultural and diverse countries in the world2 but despite this, there still seems to be apprehension amongst practitioners when treating patients darker than Fitzpatrick Type III. As well as anecdotal evidence, a study published in the Journal of Drugs in Dermatology in July this year concluded that knowledge gaps and myths concerning facial aesthetic treatment in individuals with skin of colour do still exist.3
The following month, a study was published in JAMA Dermatology, reporting that if a clinic has a dermatologist with specific expertise in skin of colour then it improves the experience of black patients seeking dermatology solutions.4
To further support this, founder of the Black Skin Directory and aesthetician Dija Ayodele told Aesthetics, “Whilst awareness is improving, laser treatments are still poorly misunderstood within the skin of colour demographic. The main confusion is around its suitability and safety for darker skin tones. Communication and education from brands and practitioners alike should be clearer and be more inclusive by featuring pictures of patients with these skin types so that skin of colour patients are aware of the benefits of laser treatment. It’s not just the patients that are apprehensive, it’s the practitioners too, and I think there needs to be a lot more support and training out there for those who are looking to treat skin of colour.”
This article will explore the key considerations of treating skin of colour for skin rejuvenation purposes using lasers. It will discuss common complications, detail treatment techniques, and discuss why, when used appropriately and in conjunction with other modalities, it can be a strong addition to any clinic with a diverse patient base.
“Practitioners are mainly cautious in treating ethnic patients with lasers primarily due to the risks associated with the procedures, and rightly so. There are much higher risks of scarring and hyper and hypopigmentation in darker skin types due to the increased melanin content.5,6 Practitioners need to be particularly wary of this,” explains Dr Vishal Madan, consultant dermatologist and a laser and Mohs micrographic surgeon.
“This is despite the advent of newer devices and technologies which claim the risks are lower when treating patients of colour. Although technology has gotten better, there are still natural risks with treating skin with high melanin. The higher the skin’s melanin, the higher the chance of complications and pigmentary alteration that can arise as a result of heating it,” he adds.
Consultant dermatologist Dr Justine Hextall reiterates this point, noting, “I think practitioners’ apprehensions are entirely appropriate. There are few published studies in the treatment of skin types V and VI with laser therapies and these are obviously the groups most at risk for post-inflammatory hypo or hyperpigmentation.”
Whilst skin rejuvenation using lasers amongst Caucasian patients is a common offering, the practitioners interviewed agree that often in darker skinned patients, rejuvenation falls under textural and dermatological concerns, as opposed to fine lines and wrinkles.
Dr Madan explains, “Generally speaking, skin of colour patients don’t come into clinic with requests of treating fine lines and wrinkles. They age in a different way to Caucasian patients and they don’t have as many deep rhytids. It’s usually dermatologic concerns such as pigmentation and scarring that they want to address.”
Consultant dermatologist, Dr Mukta Sachdev, who is currently practising in India, adds, “Everyone’s concept of skin rejuvenation is very different. Some may consider it to be treating wrinkles, whilst others may be looking for textural improvement. It’s important to find out what the patient’s motives are as that will help guide the practitioner for the most suitable treatment options.”
So, when would lasers be suitable for patients of colour looking to improve the skin? Dr Madan believes that lasers are often the last resort when other modalities have failed. He says, “I personally would not advise someone to have laser as the first option, particularly in skin of colour. You have to build a patient’s tolerance to laser and first explore other treatments out there that are less invasive.”
Dr Hextall says that she would caution any practitioner trying to treat pigmentary issues in skin of colour without carefully looking at the alternative options, considering pre-treatment regimes and patch testing the skin. Dr Sachdev agrees, “No one does just one treatment anymore. If the patient is suffering with pigmentation, for example, and they aren’t pleased with the topical results, then we would make the decision to move them onto a laser, something like the Q-switched Nd:YAG laser, as there are studies to suggest that it is generally safer in skin of colour.”7,8
Whilst aesthetic practitioner Dr Ifeoma Ejikeme would opt for chemical peels, dermal fillers and botulinum toxin for generic skin rejuvenation in patients with darker skin, she says lasers absolutely have a place when treating more uncommon skin conditions. “I choose not to treat general ageing concerns with laser because there are much less invasive modalities out there. However, I believe they are very beneficial for treating keloid scars, ochronosis and deep acne scarring,” she explains.
Dr Madan adds, “My expertise is in treating acne scarring and this actually doubles as a rejuvenation treatment because the scarring will respond to fractional CO2 laser, which then gives skin tightening as a byproduct. It’s really important to examine the skin and the patient’s history. For example, if a patient comes in with boxcar scarring due to acne which they have said has not responded to microneedling, I would then decide to offer fractional ablative laser. The rejuvenation can sometimes come as a secondary option to a larger underlying condition.”
All practitioners interviewed highlight that a multi-modal approach is preferable for skin rejuvenation and sometimes safer amongst the darker Fitzpatrick types. Dr Sachdev says, “Nowadays, practitioners are aware of utilising a combination approach but when done effectively laser can offer extremely good results for many indications that topicals cannot treat alone.”
Dr Madan explains that he likes to divide the complications associated with laser in skin of colour into two categories; immediate and long-term.“The immediate complications are generally expected and reversible, these include hyperpigmentation, erythema, milia formation or folliculitis as a result of using occlusive topicals after treatment.9 The long-term complications are the ones that can be much more difficult to manage.
These primarily include scarring and hypopigmentation. Prolonged hyperpigmentation is uncommon, especially if you use suitable protocols, but does still exist. There is also the risk of the activation of herpes simplex virus (HSV), which is also fairly rare but should not be overlooked.”10
Dr Hextall adds, “Skin of colour is prone to post inflammatory pigmentary change, be that an increase or decrease in pigmentation. The problem with inducing this change is it can take months to settle and sometimes can be permanent. Remember that many treatments such as intense pulsed light target melanin. The darker the skin, the more melanin and therefore the greater the absorption of the light, therefore energy levels have to be reduced. I cannot overstate the importance of a patch test before any laser treatment in any skin type.”
Dr Ejikeme also reiterates that whilst post-inflammatory hyperpigmentation is often an adverse event that patients will express concern about, it is relatively easy to prevent in most cases. She says, “The key thing is to have a good protocol in place, to recognise it quickly and begin a treatment effectively. The most concerning is hypopigmentation.”
Dr Ejikeme further explains, “The laser needs a chromophore, or end point, to be absorbed. If the end point is something that looks very similar to a melanocyte, then the laser will put a signal through to that point and will consequently penetrate heat at a level that will damage and sometimes destroy the melanocyte, thus, causing pigmentary change.” Dr Madan advises to not perform such treatments on mild acne scarring, active acne, or if someone has very dark skin with a history of keloid scarring.5,9
To aid in prevention of the aforementioned complications and understand when to recommend laser treatment, both Dr Sachdev and Dr Ejikeme agree that there are lots of other classification scales that can be more beneficial than the common Fitzpatrick scale. “The problem with the Fitzpatrick scale,” Dr Ejikeme explains, “is that that it focuses primarily on skin colour. In actual fact we need to take into account genetic makeup and heritage to truly understand how a patient may react to a laser treatment.”
Dr Sachdev adds, “There is the Taylor Hyperpigmentation Scale,11 the Obagi Skin Classification12 and the Roberts Skin Type Classification System,13 all of which have applications for darker skin types. The most recent, published in 2011, is the Genetico-Racial Skin Classification14 and this encompasses all races, from Nordic to African. It incorporates the concept of interracial marriages too for those patients who have mixed racial descent – helping to predict how a particular patient will react to a treatment can give us warning signs that one needs to be extra careful when treating.”
Dr Ejikeme adds, “You need to ask your patients, no matter what their skin colour is, about their family history. Find out where their parents are from and where their grandparents are from. We need to know how the skin is going to react to the treatments. For example, a Japanese woman who appears to be a Fitzpatrick type II, could tan as dark as a type IV. Not being aware of this could be calamitous for her.” Dr Ejikeme continues, “Finding out information such as this can then help determine how long you should pre-treat the patient for and what strength of products you should be using. In the example mentioned above, you would treat this patient as a type IV to account for any eventuality.”
“Before treatment, if the patient is potentially a risk for post-inflammatory hyperpigmentation, I always perform a patch test on a small area of the body, usually the inner arm or behind the ear and assess the response in a couple of weeks,” says Dr Sachdev.
“You need to make sure that you test in a place that has some exposure to the sun as testing an area that doesn’t have any exposure can be misleading when you come to do the treatment. For example, you could come to treat the whole face and then realise that sun exposure provokes a completely different response,” she explains. Dr Madan also believes that patch tests are a good way to manage patients’ expectations. He says, “Whilst it is important to understand that a patch test does not always guarantee a safe treatment, it will help to set the patient’s expectations as they will be able to see the associated downtime and that they may also get a bronzing effect after treatment. If the patient is concerned with the results of the patch test, it’s generally a good indicator that they may not be suitable for treatment.”
As well as this, all practitioners advise to incorporate a pre-treatment plan using topicals for up to eight weeks prior to laser treatment, regardless of the concern being targeted. Dr Madan adds that SPF is also incredibly important for treatment success. “It’s so important to start patients of colour on a strict sun care regime six to eight weeks prior to treatment. I would also start them on a pigment-lightening regime and would slowly build the use from twice weekly to three times per week then every day. The use should then stop one week before treatment, however sunblock use should be continued. This would be suitable for any indication on darker skin when using ablative lasers. If there is a history of HSV the prophylaxis should be used to reduce risk of reactivation,”10 he explains.
In regards to the treatment itself, Dr Sachdev believes that it’s not a case of having the best laser, it’s more the experience of the operator. “The practitioner should be comfortable in using different techniques, just as they would when administering filler,” she explains, adding, “Practitioners should identify what technique is most suitable for the patient – for example a stamping or in motion technique. They should ensure that they are not too aggressive with the treatment and the settings should not be too high. It’s not a cookbook recipe, it needs to be patient dependent and that’s where experience kicks in.” Dr Sachdev recommends to start 10-20% lower fluency in darker skin than the company recommendation. “This is simply from a safety standpoint until you get comfortable with the device. Then you can up the settings,” she says.
Dr Madan agrees with this advice, and adds, “Lowering the fluence is very important. Generally, I would say that if you offer your Caucasian patients the same treatment in three sessions, you should do it in six for the darker skin types. But saying this, don’t ever sell a package. You may do just one session and get the results that you are happy with. The patient can then choose if they want to come back for another one or not.”
Dr Hextall adds, “At the time of treatment skin cooling before, during and after the procedure is incredibly important. You can do this with cold gel packs, by spraying the skin with cooled mineral water after a procedure and you can also apply a cold mask that contains antioxidants and hyaluronic acid, taking advantage of increased absorption of topical products. As well as this, long pulse durations facilitate efficient epidermal cooling and are therefore associated with fewer adverse events in darker skin types. You should look out for unwanted skin reactions as you treat. Listen to the patient, if they say it is more painful than usual, don’t plough on, stop. I frequently stop during treatment and observe the skin. If I am at all concerned, I will immediately cool the skin and re-consider my settings. If in doubt, stop. If there is an issue, cool the skin, consider topical anti-inflammatory creams and if necessary, bring the patient back daily.”
As well as this, Dr Hextall says that post-procedure treatments and support is just as important as the treatment itself. She shares, “In my experience, it isn’t the complication that is the issue for most patients, it is the lack of support afterwards that usually triggers the complaint. This is about being contactable, making sure the patient can be seen daily if needed and has a very clear monitored treatment plan in place to reduce further damage.”
Whilst all practitioners agree that it comes down to the knowledge and experience of the handler, they reiterate the importance of checking studies and efficacies of the devices used on skin of colour.
Dr Sachdev uses a number of devices and technologies in her clinic, including the eTwo by Candela Medical, a selection of Alma devices, amongst many others. She says, “I think that all of the companies today are very clued up and very aware of the concerns amongst skin of colour patients. Now it is common for each company to give recommendations of the setting that can be used for each skin type. But it’s important that you have proof that your device works for that indication, so ask the company for any clinical trials or supporting literature. In pigmentation for example, you need to know the absorption spectrum. This all works on the theory of selective photothermolysis.”
Dr Hextall uses the M22 platform by Lumenis with the erbium-doped non-ablative fractionated laser, ResurFX. She says, “This is my device of preference because it emits energy in a customisable train of pulses, allowing for tissue cooling between pulses. It delivers peak energy safely to the target, while protecting vital epidermal structures like melanocytes, thus reducing the risk of post-inflammatory pigmentation. The multiple filters allow for very specific targeted treatment.16 Because the fractional laser in ResurFX is not targeting melanin, it is able to deliver the heat required to stimulate mild collagen production and improve pigmentation.”
Dr Madan is the only practitioner interviewed that prefers to use a fractional CO2 laser – his choice is the KLS Martin surgical laser – and this he explains is down to personal preference and experience. He says, “Fractionated Erbium:YAG (Er:YAG) lasers are generally considered safer, but if you are experienced in CO2 resurfacing I think the results you get are far superior. If you are new to the field, however, I would choose the Er:YAG over CO2. It is more suitable for those who are less experienced because of the favourable safety profile.”
Dr Madan adds, “Fractional non-ablative lasers are appropriate in types V and VI, although the results have not been to mine or my patients’ satisfaction. I believe that you need to explain to the patient that because you are not doing a treatment that is ablating the skin, you may not see the results that you want. The main advantage with the CO2 laser is that you can be as superficial or as deep as you like.”
Both Dr Sachdev and Dr Madan recommend to always under-promise and over-deliver to help manage patient expectations. Dr Madan shares, “My practice is primarily surgical so often, by the time patients have come to me, they have explored all of their options. They come with high hopes and unfortunately their hopes have to be brought down. Explain to them that you can achieve 20-30% improvement but never promise more than 50% improvement. Then if you achieve 60% improvement, that’s fantastic!”
Dr Sachdev suggests, “Continuously re-evaluate results with images throughout. Often patients will forget what their concerns looked like before, so this is a really important tip. Also remember that every patient is an individual and each case needs to be evaluated as so. There really is no gold-standard approach or a superior device.” Being honest when a treatment is beyond your remit is also a key factor, Dr Ejikeme highlights.
She states, “Know when not to treat. I think practitioners are getting better at saying no, but you should also explain this to patients sensitively.” Dr Ejikeme concludes, “The patient shouldn’t be made to feel as though it is their fault you are unable to treat them. Simply state the treatments that are available for their presented concern and outline would be the best, even if you don’t offer it. Your patient will come back to you for the treatments that you do well and respect you more for referring them to someone who can treat them.”