An update on cosmetic procedures in

people of color
Part 1: Scientific background,
assessment, pre-procedure preparation

J AM ACAD DERMATOL
APRIL 2022
Quinonez et al
 Introduction
• Increasing nonsurgical cosmetic procedures in last 20 years
• Cultural preferences, structural and biological differences in skin of
people of color (POC)
• Gaps in knowledge about appropriate selection and execution of
nonsurgical cosmetic procedures in POC
• Favorable outcome and optimal cosmetic results
 Introduction
• American Society for Aesthetic Plastic Surgery : 32% cosmetic procedures on
racial or ethnic minorities in 2017
• Darker skin tones (FST IV-VI)
• Asian, African, Middle Eastern, Latinx or Hispanic, Pacific Islander, indigenous
• Intrinsic and extrinsic aging, dyschromia, scar formation, hypertrichosis
• Optimal formulation of treatment plan
• Anticipation and management of potential complications
 Melanocytes and melanosomes
• Basal layer melanocytes  melanosomes
 distributed within keratinocytes
• No racial differences in number of
melanocytes
• Size, number, distribution, density of
melanosomes in keratinocytes  skin
color
• Melanosomes in POC : larger, distributed
through all layers, higher concentration
at basal epidermal layer, more melanin
 Eumelanin
• Eumelanin, an insoluble brown or black melanin, predominates in
POC
• UV filter in Malpighian layer: average of 13.4 SPF in darker skin
• Abe et al., physiologic factors affecting skin susceptibility to UVR and
irritants in 101 Japanese women  darker complexion with less
severe reactions to UVR
• Photoprotective effects : delayed or decreased rhytids in POC
• Increased epidermal melanin  increased dyschromia in POC
Abe T, Arai S, Mimura K, Hayakawa R. Studies of physiological factors affecting skin susceptibility
to ultraviolet light irradiation and irritants. J Dermatol. 1983;10(6):531-537
 Fig : Differences between Eumelanin and Pheomelanin Fig: Pheomelanin and Eumelanin
(Source: Melanoma — Epidemiology, Risk Factors, and the Role of Adaptive (Source: Fitzpatrick dermatology
Pigmentation, Horrell E et al, 2015) in general medicine, 7E)
 Stratum corneum
• Inconclusive data on racial differences in stratum corneum
• Equivalent SC thickness but a more compact SC in Black
• Evaluation of tape stripping in Black versus : more stripping for removal of SC in
Blacks
• More compact SC barrier : barrier function, less cutaneous irritation and
propensity for contact dermatitis
• Reduced skin fragility and delayed visible signs of aging

Chu M, Kollias N. Documentation of normal stratum corneum scaling in an

average population: features of differences among age, ethnicity and body site.
Br J Dermatol. 2011; 164(3):497-507.
 Fibroblasts and collagen
• Larger, multinucleated, higher quantities of fibroblasts in Black women
• Collagen fibers smaller, closely stacked and surrounded by proteoglycans in
dermis
• Fiber fragments more in dermis of Black individuals
• Delayed dermal volume loss in POC  later appearance of rhytids
• High efficacy of radiofrequency skin-tightening procedures
• Increased propensity for keloid or hypertrophic scars due to basilar and dermal
damage
Hypertrophic scarring following abdominoplasty in Postinflammatory hyperpigmentation of the face
a 47-year-old Black woman (ie, acne-related
 Hair

• African descent have coiled kinky type hair

(greater follicular curvature)
• Asian and White populations: straight hair
• Asians: fastest growth rate and largest hair
diameter
• African descent: slowest growth rate and smallest
hair diameter
• Follicular curvature and hair curl pattern:
pseudofolliculitis barbae
 Biological differences in POC
Intrinsic and extrinsic aging:
• Skin barrier function, sebum production, dermal collagen and elastin, UV and
visible light, pollutants, chemical exposure
• FST IV to VI: delayed photoaging (photoprotective melanin)

• Late presentation of rhytids and volume changes in POC

• Less dramatic facial aging in FST V – VI

Photoaging in individuals of African and Hispanic ethnicities to illustrate differences in photoaging across ethnic backgrounds
A. A 46-year-old Hispanic woman with periorbital and perioral subcutaneous volume loss (arrows) and solar lentigos (ellipse). (Courtesy of Oma N. Agbai)
B. A 50-year-old non-White Hispanic woman with static rhytids of the forehead and glabella. (Courtesy of Rebecca L. Qui~nonez)
C. A 75-year-old Black woman with bitemporal volume loss (red arrow), mild periorbital and perioral volume loss (black arrows), skin laxity of the chin and
anterior aspect of the neck (white arrows), and perioral hyperpigmentation (ellipse). Notably, there was a near absence of static rhytids despite her
advanced age. (Courtesy of Cheryl Burgess)
• A study of 38 African or African Caribbean and White northern European
men and women aged 18 to 30 years:

o Decreased elasticity of skin, with residual deformity, inability of skin to revert

to original state upon stretching in White skin
o Higher elastic properties of skin of Black individuals
o Decreased collagen I and III immunostaining in papillary dermis of photo-
exposed skin of Whites
o Ability to return to its original position following deformation and high
elasticity in both groups of photo-protected skin after long-term sun exposure

Langton AK, Graham HK, McConnell JC, Sherratt MJ, Griffiths CE, Watson RE.
Organization of the dermal matrix impacts the biomechanical properties of skin.
Br J Dermatol. 2017;177(3):818-827.
• A study of 3267 women :

o Black women: least-severe facial aging, severe facial aging at 60-79 years

o White women: most-severe facial aging, moderate-to-severe facial aging 40-

59 years

o Asian and Hispanic women: facial aging around 50-69 years

Alexis AF, Grimes P, Boyd C, et al. Racial and ethnic differences

in self-assessed facial aging in women: results from a
multinational study. Dermatol Surg. 2019;45(12):1635-1648.
 Skin classification
Fitzpatrick Skin Types :
• Ability to get tanned or burnt after
exposure to UVR
• Gold standard for phototherapy
• Measure skin’s immediate response
to UV exposure
• No prediction of skin’s response to
procedures
• Assessment of suitability of laser
treatment
• Selection of optical settings in POC
 Skin classification
Roberts Skin Type Classification System (RSTCS)

• 4 part scale to assess and assign numerical value to patient’s phototype,

hyperpigmentation, photoaging, scarring capability
• Anticipate short and long term effects of cosmetic procedures
• Individualize procedure recommendations
• Assess patient’s past medical history, ancestral background and history
regarding scarring and pigmentary changes
• Hector Leal Silva, MD: for evaluating
the risk or degree of post procedure
PIH based on the color of patient’s
palmar creases

• Classifies individuals into 4 groups

(based on a scale of 0-3)

• Darker the palmar creases, the Pigment in a recent abdominal scar matching the

greater the incidence of PIH pigment in the palmar creases of the same subject

Jalalat S, Weiss E. Cosmetic laser procedures in Latin skin. J

Drugs Dermatol. 2019;18(3):s127-s131.
Rossi AM, Perez MI. Laser therapy in Latino skin. Facial Plast
Surg Clin North Am. 2011;19(2):389-403.
low risk for PIH: (A) Score 0 (Null) and (B) Score 1 (Low)
Retrospectively classified as high risk of PIH, exhibiting malar hypermelanosis
secondary to one single aggressive photo-rejuvenation IPL treatment
 Evolving cosmetic needs with chronologic age in POC
• Dermatosis papulose nigra, seborrheic keratoses in African descent
o DPN may develop during adolescence
o Number and size increasing with age

• 30s – 40s : dyschromia (chemexfoliators), early glabellar line (neuromodulators)

• 50s : volume loss and skin laxity

• More frequent and complex treatments in 60s – 70s

• Careful patient selection and discussion of realistic expectations

Dermatosis papulosa nigra in a 55-year-old Latinx man. Seborrheic keratoses in a Black woman.
 Pre-procedure Management
Cosmeceutical agents and melanogenesis inhibitors :

• Cosmetic procedures stimulate melanocyte activity  hyperpigmentation

• Delay or prevent dyschromia, scarring, rhytids
• Pretreatment with melanogenesis inhibitors
• Hydroquinone (4%) : OD for 6 weeks pre-procedure
• Topical retinoids : adjunctive or pre-procedure therapy for dyschromia and facial
rejuvenation
 Pre-procedure Management
• Azelaic acid, kojic acid, licorice extract, ascorbic acid, niacinamide,
tranexamic acid in combination
• Decrease activity of melanocytes, pigment production and transfer
• Reduce risk of postprocedural hyperpigmentation and treat underlying
pigmentary disorders
• Retinol or retinoid or peptides : diminish signs of photoaging and textural
changes
• Careful selection of treatment type, timing, dosing, formulation and
combination
 Photoprotection
• Education on benefits of routine sunscreen application  reduce
dyschromia, skin cancer, photoaging

• Tinted sunscreens with iron oxide and pigmentary titanium dioxide 

protection against VL + UVR
- More effective in prevention of hyperpigmentation

• Mineral sunscreens (inorganic filters as zinc oxide, titanium dioxide 

white, gray, violaceous cast on dark skin)
- Use of micronized sunscreen formulation (no VL protection)
 Medical considerations
• Patient’s complete history (oral medications)

• Attention to photosensitization, phototoxic medications (thiazide

diuretics, CCB, anticoagulation therapy, tetracyclines, OCP, hormonal
agents)

• Increased risk of procedural bleeding, delayed wound healing, PIH,

cutaneous eruptions
 Common photosensitizing medications
• Antibiotics: Tetracyclines, Fluoroquinolones (eg, ciprofloxacin), Sulfonamides
• NSAIDs: Ibuprofen, Naproxen, Ketoprofen, Celecoxib
• Diuretics: Frusemide, Bumetanide, Hydrochlorothiazide
• Retinoids: Isotretinoin, Acitretin
• Hypoglycaemics: Sulfonylureas (eg. glipizide, glyburide)
• Antipsychotics, Phenothiazines (eg. chlorpromazine, fluphenazine), Thioxanthenes
(eg, chlorprothixene)
• Targeted therapies: Vemurafenib (50%), Dabrafenib, Imatinib, Vandetanib
• Other drugs: Amiodarone, Diltiazem, Quinine, Quinidine, Hydroxychloroquine, Enalapril,
Dapsone, Voriconazole
• PDT photosensitisers: 5-aminolevulinic acid, Methyl-5-aminolevulinic acid, Porfimer sodium
• PUVA photosensitisers: Methoxsalen (8-methoxypsoralen), 5-methoxypsoralen, Trioxsalen
• Common photosensitising topical agents: Sunscreens (Benzophenones, Para-aminobenzoic acid
(PABA), Cinnamates, Salicylates), Fragrances, Musk, 6-methyl coumarin, 5-fluorouracil (oral and
topical), Coal tar
 Cultural considerations: is our notion of beauty the same?

• Beauty standards influence the type of cosmetic procedure sought

• Different in all parts of the world
• Cultural awareness to better understand and guide patients

• Different facial morphology:

- African face : increased nasal width, short nasal length, wide oral width with
large lip volume, long forehead, short ears
- Asian face : large intercanthal width, small eye fissure length, small oral
width, large mandibular width
 Cultural considerations: is our notion of beauty the same?

• Even skin tone is a desired feature for POC

• Selection and use of OTC topical products, natural remedies, cosmetics
Skin-lightening agents, ‘‘bleaching agents,’’ used by Asian and Black communities
• Encourage patients to communicate openly about their use of cosmeceuticals
and review their ingredients for their safety
• Bleaching agents containing high-potency corticosteroids : adversely affect post-
procedure wound healing
• Country of origin of the product : not all regulating institutions have the same
standards
 Conclusion
• Patient population becoming more diverse
• Increasing numbers of dermatologists integrating noninvasive
cosmetic procedures into their practices
• Education regarding cosmetic needs in patients of all ethnic and racial
backgrounds
• Structural, functional, biological and morphologic differences
between POC and non-POC
• Comprehensive understanding before initiating cosmetic procedures
Thank you