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The A-Z of Cosmetic Dermatology In Blacks (Part 1)

Introduction
Cosmetic surgical and non-surgical procedures are popular options for many people who are unhappy with their physical appearance. This desire to improve perceived physical flaws and reverse the signs of ageing is fuelled by our society’s increasing emphasis on aesthetics. This has contributed to the growth in the cosmetic industry, especially in the field of cosmetic medicine.1

In 2006, nearly 11.5 million cosmetic surgical and non-surgical procedures were performed in the USA, with non-surgical procedures accounting for 83 percent of these procedures.2 Thus, since 1997, there has been a 446 percent increase in the total number of cosmetic procedures performed in the USA, with the greatest increase observed in non-surgical procedures (747 percent increase). Table 1 and 2 lists the top five non-surgical and surgical procedures performed in both men and women in the USA in 2006.

The majority of cosmetic procedures are undertaken by women (representing 92 percent of cosmetic clients in 2006 in the USA).2 Furthermore, people aged 35-50 had the most procedures performed in the USA in 2006.2 Given this data, it is not surprising that the cosmetic medical client is typically portrayed as a middle-aged Caucasian woman. However, the ‘face’ of cosmetic medicine is slowly changing, with ethnic minorities now increasingly seeking these procedures. In 2006, ethnic minorities accounted for 21.7 percent of all cosmetic procedures performed in the USA. Hispanics led this group accounting for 9.7 percent; African-Americans 6.6 percent; Asians, 4.7 percent; and other non-Caucasians, 0.8 percent.2 Furthermore, in a survey of 1000 American households, 25 percent of non-white Americans indicated that they would consider cosmetic surgery for themselves, now or in the future.2

There are several reasons accounting for the rise of the ‘ethnic cosmetic market’. First, the range of cosmetic products available now accommodates for a more diverse clientele. Second, more minority doctors are entering specialties like dermatology and are promoting an awareness of skin of colour. Third, the demographics of many Western countries is changing, with non-Caucasians becoming an increasing proportion of the population (Table 3).3 Thus, the cosmetic industry now recognize the potential revenue that can be generated from this ethnic market and are employing novel marketing strategies to directly target this group. In light of the aforementioned data, it is important that both ethnic minorities and their physicians be aware of the specific challenges that skin of colour may present, when choosing cosmetic dermatological procedures. This article provides an introductory overview of cosmetic dermatology in an A-Z format and addresses some important issues pertinent to black people, who may be considering undertaking cosmetic dermatological procedures.

Ageing in blacks
The process of ageing is associated with several physical changes to our body. In particular, ageing of the face, especially in Caucasians is associated with the development of wrinkles, pigmentary changes and loss of elasticity of the skin. Other important factors contributing to the changes in an ageing face include the loss and or redistribution of facial fat, changes in facial musculature and in the underlying cartilage and bone. Due to an increased amount of melanin pigment in the skin, black people are less likely to exhibit signs of ‘photo-ageing’, such as the development of facial wrinkles, lending truth to the old adage ‘black don’t crack’. Nonetheless, facial ageing still does occur in blacks, although often it takes a different format, such as the redistribution of facial fat leading to hallowing under the eyes, and deepening of the nasolabial folds.4 Addressing these particular areas with the use of non-surgical and surgical rejuvenation techniques may improve some of the signs of ageing in blacks.

Body Dysmorphic Syndrome (BDS)5
This is an under-recognized disorder characterized by a pre-occupation with an imagined or a slight defect in physical appearance. These pre-occupations are excessive, causing clinically significant distress and impairment of function. Typical areas of concern include acne, scarring, perceived pigmentary problems of the skin and hair problems (either excessive amount or loss of hair). Studies indicate that BDS is common in clients seeking dermatological procedures. Thus, it is likely that some clients seeking cosmetic dermatology may suffer with BDS and for this reason, physicians offering these services should be cognizant about this disorder. This ensures that the appropriate treatment is given to individuals suffering from BDS.                                                                                        [ back to top ]

Chemical Peels6

Overview
Skin resurfacing is the process by which damaged layers of the skin are removed, thereby promoting growth and re-generation of new skin with improved surface characteristics. The process of removing away the damaged layers of the skin can be done in several ways:

• Chemicals (Chemical peels)
• Mechanical (Microdermabrasion)
• Irradiation of the skin with a laser beam (laser resurfacing)

The technique of skin resurfacing using chemicals, is a suitable primary or adjunctive therapy for managing a range of dermatological conditions including :

• Acne vulgaris
• Smoothing uneven skin tone
• Correction of dark blemishes on the skin following skin diseases (Post-inflammatory hyperpigmentation)
• Melasma
• Scarring
• Pseudofolliculitis barbae (shaving bumps on the chin)

Chemical peeling agents
A range of chemical peeling agents, have been documented to have a good safety profile in individuals with dark skin. In general, chemical peeling agents remove away the superficial or deep layers of the skin and depending on the depth to which they strip away the skin can be sub-classified as superficial, medium-depth or deep chemical peeling agents. In general, superficial and medium-depth peeling agents are the treatment of choice for dark skinned people. Deeper peeling is associated with damage to the underlying dermis, with subsequent scarring and increased pigmentation of the skin. There are several other factors, which will determine the depth of injury produced by the agent and the treating physician should be fully cognizant of these issues. This includes:

• Concentration of the chemical peeling agent
• Amount of chemical peeling agent used
• Amount of pressure used when applying the chemical peeling agent on to the skin
• The duration of time the chemical peeling agent is in contact with the skin

The site of body the chemical peeling agent is applied to (in general, chemical peels are applied to the head and neck region, other sites produce less impressive and predictable results. Furthermore, due to the sensitivity of the neck region, only superficial peels should be performed on the lower third of the neck).
The range of chemical peeling agents available for individuals with dark skin includes:

1. Alpha-hydroxy acids
   This range of chemical peeling agents are a family of naturally occurring acids that includes:
   • Glycolic acid-present in sugar cane
   • Lactic acid-present in sour milk
   • Malic acid-present in apples
   • Citric acid-present in oranges
   • Tartaric acid-present in grape
2. Beta-hydroxy acids
   This group of chemicals includes salicylic acid, a naturally occurring substance found in the bark of the willow tree. As a chemical peeling agent, salicyclic acid is excellent for managing acne, and dark blemishes in dark skinned individuals.
3. Trichloroacetic acid (TCA)
   This is an inorganic compound, which is mixed with distilled water to create the desired concentration. This agent can be used alone, or in combination with glycolic acid or salicylic acid and is of use in the treatment of acne scarring and uneven facial pigmentation
4. Jessner’s solution
   This is a combination of resorcinol (a skin lightening agent), salicyclic acid and lactic acid in ethanol. This agent is used for managing uneven skin tones.

Procedural aspects-Medical History
Prior to undertaking a chemical peel, your dermatologist should discuss with you about the most appropriate type of chemical peeling agent. Furthermore, the expected results and potential complications should also be discussed with you in detail. A test spot should be performed by applying the chemical peeling agent to a small area of the skin, to observe how the skin reacts to this agent. In addition, the dermatologist should also obtain a detailed medical history from you, including:

• The presence of a history of delayed wound healing and/or scarring
• Ethnicity
• Medications-including oral contraceptive pills and other hormonal agents
• History of herpes infection-a positive history may necessitate the use of prophylactic oral antiviral medication, to prevent the development of a herpetic infection during and after the chemical peel

Procedural aspects (Pre and post peel care regime)
Your dermatologist should provide you with appropriate advice regarding optimum care of the skin prior to and following the chemical peel. This will include the use of a gentle cleansing agent, moisturizing agents, skin lightening preparations and sunscreens, over a specified period prior to the chemical peel. Furthermore, a post-peel regime should be written down for each client. Broadly speaking, clients are advised to avoid application of water to their face for 24 hours following the chemical peel. Thereafter, normal activities can be resumed, with emphasis on gentle cleansing of the skin and the use of bland moisturizing lotions and sunscreens.                                                                             [ back to top ]

Procedural aspects (The procedure)
Superficial and medium-depth chemical peels are performed in the dermatologist’s consulting office and usually do not require any anesthesia. Prior to applying the chemical peel, the dermatologist will remove excess oils from the skin, a process termed ‘defatting’. This ensures that there is even penetration of the skin by the peeling agent. During ‘defatting’, acetone or isopropyl alcohol is applied on to cotton balls or gauze and used to wipe the face until no yellow colour residue is seen on the cotton balls or gauze. Thereafter, a cotton-tipped applicator, sponge, cotton pad, cotton swab or brush is used to apply the peeling agents to the pre-specified site. Depending on the type of chemical peeling agent used, the skin may be subsequently sprayed with water or a neutralizing solution. During the procedure, slight stinging may be noted. The whole process may take approximately 10 minutes. Depending on the dermatological problem being treated, a series of chemical peels may be required at regular intervals in order to achieve the desirable result. The main complications of chemical peels in dark skinned individuals are pigmentary changes to the skin and scarring. These complications can be reduced by having this procedure undertaken by a dermatologist who is trained in performing this procedure in skin of color and also by the performance of a test spot prior to undertaking the procedure.

Choosing a Dermatologist
Worldwide, there are many individuals, including both physicians and non-physicians, who offer cosmetic dermatological services. Thus, it is important that potential clients choose their practitioners wisely, prior to undertaking a cosmetic dermatological procedure. In my opinion, medically trained individuals, who have completed a nationally recognized dermatological training program, and are, certified in dermatology are the best placed to offer cosmetic dermatological services to blacks, as they understand best the potential complications that may occur in those with pigmented skin. Additional qualifications that may be of help include sub-specialty training in the field of cosmetic dermatology/dermatology surgery and demonstration of an understanding of issues pertaining to skin of colour. I would encourage potential black cosmetic dermatology clients to research their individual physician and be forthright in addressing all their concerns with their physician, prior to undergoing any cosmetic procedures. In particular, I would encourage you to ask the physician about his or her experience in managing and treating black skin. Further information about dermatologists in your country may be available from your national dermatological association, for example the American Academy of Dermatology in the USA and the British Association of Dermatologists in the UK.

Ethics7
Maintaining high standards of ethical practice is a requirement within the field of medicine, and this is especially relevant in the field of cosmetic medicine. In general, the majority of physicians take seriously their moral obligation to uphold sound ethical judgments at all times. Nonetheless, there may be a small minority who may not feel obligated to be compliant with these ethical standards. For this reason, as a potential cosmetic medical client, it is important to be vigilant about these issues and be prepared to have a dialogue with your physician if any problems arise.

Final point
This is the first part of a series of articles, addressing cosmetic dermatological procedures in blacks. Please join us over the next few months to learn more about:

• Non-surgical facial rejuvenation techniques (soft tissue fillers & botox)
• Laser hair removal
• Microdermabrasion

Send your comments about part 1 of this article to comments@blackhealthmatters.com.

By Dr. Ophelia Dadzie

Scientific References                                                           [ back to top ]