Chapter 2: Evaluation of the Ethnic Skin Patient Presenting for Cosmetic Procedures

INTRODUCTION

Based on the United States 2000 census data, it is estimated that 50% of the population will be comprised of persons of color by 2050.¹ Ethnic skin, also referred to as skin of color, is primarily composed of Fitzpatrick skin types IV-VI and encompasses many racial and ethnic groups, including but not limited to African Americans, Asians, Hispanics, and Native Americans. Cosmetic procedures have become increasingly popular among these darker-skinned racial and ethnic groups. However, currently the majority of the cosmetic surgical literature is limited to the treatment of nonethnic skin.

A fear of increased pigmentary and scarring complications has made dermatologists and cosmetic surgeons in the United States hesitant to perform elective procedures on persons of color. However, by appreciating the influences of structural and functional differences, such as increased melanin, follicular reactivity, and fibroblast reactivity, on ethnic skin dermatoses,^2,3 these fears can be replaced by a unique skill set to effectively and comfortably treat this patient population. Treatment of ethnic skin patients also requires knowledge of adverse reactions in darker skin, modification of surgical techniques, unique racial differences, and awareness of cultural issues specific to these patient populations.⁴ In addition, an understanding and accepting of the norms of different cultures are imperative for the cosmetic surgeon to better treat persons of color who desire cosmetic surgery.

The treatment of common conditions in patients with skin of color can be multi-modal. This section will focus primarily on the initial evaluation of the ethnic skin patient presenting for cosmetic procedures.

STRUCTURAL AND FUNCTIONAL DIFFERENCES IN ETHNIC SKIN TYPES

There are various differences observed in the biology of ethnic skin and hair. These differences are important to consider because they may influence presentation of skin and hair disorders, along with the effects and tolerability of therapeutic interventions.

Melanin

Melanin is the major determinant of color in the skin. The most clinically apparent difference between lightly pigmented and darkly pigmented skin is the amount of epidermal melanin. There is no difference in number of melanocytes between different skin types,⁵ but the concentration of epidermal melanin in melanosomes is double in darker skin types compared to lightly pigmented skin types.⁶ It is important to remember that epidermal melanin content is twofold greater in chronically photoexposed skin regardless of ethnicity.⁷ In addition, melanosome degradation within the keratinocyte is slower in darkly pigmented skin when compared to lightly pigmented skin. Therefore, although the increased melanin provides protection from the harmful effects of ultraviolet radiation (skin cancer and photoaging), it also makes darkly pigmented skins more vulnerable to postinflammatory dyspigmentation.

Stratum Corneum

The stratum corneum is the outermost layer of skin functioning as the principal barrier tissue to prevent water loss from the body and provide mechanical protection. It ...