Increasingly, patients with ethnic skin are seeking out cosmetic procedures to provide epidermal and color improvement to their skin. According to the American Society for Aesthetic Plastic Surgery, 11.7 million cosmetic procedures were performed in 2007. Of these, procedures on ethnic patients comprised 21%, an increase from 14% in 1997. Hispanics account for 9%, African Americans 6%, Asians 5%, and all other non-Caucasians 2%. Among ethnic minorities, the most frequently requested procedures were Botox, wrinkle fillers, chemical peels, and microdermabrasion.1 Based on the 2000 U.S. Census and interim data, the U.S. Census Bureau has projected an increase in the percentage of Asians, Hispanics, and African Americans from 30.6% to nearly 50% by 2050.2 As this portion of the population increases, the cosmetic dermatologist will need to better understand the unique needs of patients with darker skin types.
Pigmentary disorders are one of the most common dermatologic conditions seen in African Americans, Hispanics, and Asians.3 These include postinflammatory hyperpigmentation, hypopigmentation, and melasma. Acne is the most common dermatologic diagnosis seen in blacks and Hispanics at 27.7% and 20.4%, respectively. In a study of African female acne, biopsies of acne lesions showed a high degree of histologic inflammation compared to clinical inflammation which may explain the frequency of postinflammatory hyperpigmentation in darker skinned individuals.4 Other causes include many inflammatory diseases from papulosquamous disorders to vesiculobullous disorders. For darker phototypes, care needs to be exercised so that therapies utilized to treat dyschromia and epidermal texture do not create more problems.
Current medical treatment for dyschromias such as postinflammatory hyperpigmentation and melasma include prescription therapies such as retinoids, hydroquinone, azelaic acid, and alpha-hydroxy acids. However, these therapies often require many months of diligent usage to realize improvement and concentrations need to be titrated slowly to try to prevent development of an irritant dermatitis. In patients with skin of color, irritant dermatitis can easily lead to postinflammatory hypopigmentation or hyperpigmentation. Hydroquinone, which is commonly used for bleaching, can also cause an allergic contact dermatitis. The clinician and patient need to be watchful of these side effects and stop the treatment when this occurs.
When medical therapies are insufficient, more aggressive treatments, such as in-office superficial chemical peels and microdermabrasion may be added to augment the results. However, special skill and care need to be exercised when using these resurfacing agents in patients with darker skin as they are more likely to develop posttreatment dyschromias.
Ablative resurfacing techniques include chemical resurfacing, mechanical resurfacing, and laser resurfacing. These modalities cause controlled skin injury to a known depth. Superficial resurfacing procedures extend from the epidermis to the papillary dermis while medium depth procedures extend to the upper reticular dermis and deep depth procedures extend to the mid reticular dermis. Healing from these procedures results in new skin growth with improved surface texture and pigmentation. Superficial chemical ...