Gaining and Retaining Skin of Colour Patients

Diversity and inclusivity are not just buzzwords in beauty and aesthetics; they represent the ideals of the rich multicultural society we live in and they set the standard that clinics and practitioners should embody in order to serve the needs of the entire population. Professionals need to be able to tailor their approach to ensure they understand and can meet the skincare demands of darker skin-toned patients who sometimes present with different priorities to Caucasian patients.1,2 The top five patient concerns according to race are outlined in Figure 1. 3 This article will explain why it is crucial to examine the needs and expectations of your skin of colour patient, and how by doing so, you deliver strategic advantages to your practice and positively enhance your bottom line. The confidence factor In a 2017 survey, my website, Black Skin Directory, found that 92% of 125 women of colour surveyed felt ‘they were unable to’ or ‘found it a challenge’ to find a skincare professional they felt confident could treat black skin safely.4 Instead, they turned to unverified internet sources, beauty magazines, family and friends, rather than professionals such as dermatologists or aesthetic practitioners,5 thus creating a void between patient and practitioner. While we appreciate this wasn’t

the largest of surveys, qualitative feedback we receive from the general public on a weekly basis confirms the extent of the problem. The consequence of being unable to access qualified professionals is two-fold. Firstly, the skin of colour patient misses out on expert advice and treatments. Secondly, the practitioner is unable to access or treat this demographic and subsequently retain their custom. The patients’ lack of trust in the ability of practitioners to treat their skincare concerns creates a lose-lose scenario for both parties. Invisible patients Gaining and Retaining Patients One of the main challenges faced by skin of colour patients is that of visibility, representation with Skin of Colour and inclusion in the aesthetics industry. In 1976, communications professor George Gerbner coined the term ‘symbolic annihilation’ to Aesthetician and specialist website founder describe the absence or underrepresentation Dija Ayodele discusses why it can be difficult to of some groups in the media, based on defining factors such as sex and race.6 These groups are attract darker skin-toned patients and how to omitted from mainstream advertising, thereby overcome these challenges to secure long-term making them invisible. Research shows that if a person of colour doesn’t see a representation patient loyalty of themselves in media, their engagement will be low and the assumption is that their needs will not be met.7,8 If we extend this same idea to the aesthetic industry, where to a large extent, marketing and imagery is heavily geared towards Caucasian skin tones with much less representation of skin of colour, we can see how skin of colour patients are left behind. A recent article from online platform R29, highlighted the lack of diverse representation in the visual marketing of skincare, especially on social media. This inadvertently and incorrectly sends out a message that these brands do not cater for people with skin of colour.9 Black Skin Directory research also revealed that skin of colour patients attached importance to the racial background of a practitioner, and expressed some desire to be treated by a professional of the same/similar heritage. The main reason cited was that a doctor of the same cultural background would appreciate and be able to treat the nuances of black skin more sympathetically than a white doctor.4,10 This fact was also evident in the 2018 Oakland Men’s Health Disparities Project undertaken by researchers from Stanford University and the University of California which revealed that, “Nearly 65% of black respondents and 70% of white respondents reported that a doctor of the same race would understand their concerns best.”11 But with research pointing to an unconscious racial bias in the hire of black and minority ethnic (BME) professionals12, even up to senior posts within the NHS, skin of colour patients are even

Skin of Colour Patients Caucasian Patients less likely to see a reflection of themselves in the ethnic make-up of professionals and provision of services. Only

Acne Acne 57% of BME applicants achieve success in securing a

Dyschromia Unspecified dermatitis or eczema consultant role, compared to 77% of Caucasian doctors.13 This is particularly important when you consider that,

Seborrheic dermatitis Actinic keratosis especially within dermatology, doctors have to achieve

Atopic dermatitis Viral warts the position of consultant before they can practice as a qualified dermatologist. That said, overall, patients will be

Unspecified dermatitis or eczema Sebaceous cyst more inclined to see practitioners who can demonstrate their knowledge and experience in treating diverse Figure 1: The top five patient concerns according to race. Information obtained from an analysis of nationally representative data from the US from 1993 to 2009.3 caseloads, regardless of their ethnic background.

Myths and misconceptions One of the consequences of patients not seeking dermatology and skin opinions from professionals has been the propagation of myths about treatment options for skin of colour patients. These long held misconceptions, passed down through generations, create a hurdle for professionals to overcome in order to attract skin of colour patients. Myths such as darker skin tones don’t burn in the sun or get skin cancer, so therefore do not require sunscreen protection,14 have resulted in a higher melanoma mortality rate for skin of colour patients, even though the initial incidence rate is lower. The evidence shows that skin of colour patients present with skin cancer at a much more advanced, untreatable stage, than white patients.15 Darker skin tones tend to present more concerns with dyschromia16 and the use of home remedies such as applying cocoa or shea butter to treat skin scars and stretch marks is a long-held myth, even when studies have indicated that nut butters cannot lighten or fade discoloration.17,18 Conversely, hydroquinone, a powerful ingredient confirmed to fade discolouration and safe for skin of colour patients when used as medically prescribed,19 is viewed with much apprehension due to its overuse in the skin bleaching phenomena,20 especially from people of West African descent, and also from Asia.21 Therefore, it is good practice to approach the topic with care and offer additional advice to reassure the patient when prescribing or suggesting its use for treatment. There has also been much confusion about the types of devices that are safe for skin of colour patients. In the early days of laser hair removal, it was accepted that it was unsuitable for darker skin tones due to the way in which the device targets melanin. However, the latest technological advances have opened up laser hair removal for skin of colour patients, with devices such as the ND:Yag laser providing effect hair removal without damaging dark skin.21

Embracing diversity Seeing as inclusion and representation are key factors in attracting skin of colour patients, ensuring your clinic speaks to a diverse audience is key. For example, an audit of your marketing materials may quickly reveal your diversity narrative. Do you have skin of colour imagery and typical concerns detailed in your brochures and on your website? It is insufficient to assume that skin of colour patients will resonate with your clinic message if you do not directly draw them in through your content. It may even be beneficial to include a specific page on your website covering your approach to skin of colour patients. This is an immediate signal to new patients that you are aware of their needs and also boosts your search engine optimisation ranking. Furthermore, it’s worth keeping records of patient ethnicity data.22 Some patients like to know how many skin of colour patients you have treated, and this data can be a valuable marketing tool in attracting other skin of colour patients. From our survey, 70% of respondents cited a practitioner’s experience in treating skin of colour patients as a key deciding factor when choosing a skincare professional.4 If your clinic has an active social media account such as Instagram, and you have the budget available, working with prominent skin of colour ‘influencers’, such as Patricia Bright, Freddie Harrel or Chanel Ambrose, can garner exposure to the large skin of colour audience. Influencers are seen as credible and authentic social media personalities who have the ability to persuade their audience on the merits of your offering.23 It is crucial to not only look at personalities with high followers, but also those who have high engagement rates, thus providing a superior return on investment. You could even choose to work with ‘microinfluencers’ such as makeup artist Stacy Wodu or fashion model Irene Agbontaen, who admittedly have smaller audiences, but nevertheless are trusted and remain relevant without a heavy price tag! In the main, the decision on whether you work with a large influencer or microinfluencers comes down to cost but also style, expertise in subject matter, previous collaborations and brands they may have worked with in the past.24 Additionally, the brands you choose to use in your clinic will have an impact on your ability to attract, treat and retain patients with skin of colour. It is advantageous to select a brand with extensive clinical data up to Fitzpatrick VI. They will be able to provide skin of colour trial data, as well as before/after imagery, that you can display in clinic on your retail shelves and use during consultations.25

Education is key Continuously educating the demographic is key to combat ingrained myths surrounding treatment of skin of colour patients. It is incumbent on professionals to send the right messages to reassure these patients that safe, evidence-based treatments and products exist. Sharing your expertise by writing a blog, or making contributions to magazines and newspapers such as Pride,26 The Voice,27 or Black Beauty & Hair28 which have a large skin of colour readership, can raise your profile to a more diverse audience. You can further expand your blog by including skin of colour case studies of your patients. Pictures speak a thousand words, so clear before and after images can set you apart, reinforce your expertise and secure patient loyalty. Likewise, up-to-date education for the practitioner is also important. Some studies have pointed to inadequate levels of skin of colour training amongst dermatology personnel29,22 and there are a number of conferences and training courses dedicated to skin of colour, where you can learn and network with colleagues who are experienced in treating skin of colour patients. For example, award-winning training provider Dalvi Humzah Aesthetic Training hosts a skin of colour course in the UK, and further afield there is the larger Skin of Color Update conference in the US.31 Making the time to refresh your knowledge is reassuring to your patients, so make sure you shout about it your digital newsletter, social media and in your clinic. Cultural competency is important in maintaining a positive relationship with skin of colour patients. Within aesthetic practice, the faces of celebrities like Angelina Jolie or Elizabeth Hurley have long been used as the ‘golden ratio’ of beauty. In today’s diverse world, is it ethical to infer to a skin of colour patient that these celebrities are the standard of beauty to emulate? Rather, develop a portfolio of images that cover all skin tones, including darker skin toned examples such Halle Berry, Priyanka Chopra or Jourdan Dunn.

Summary The skin of colour demographic is burgeoning, with excellent spending power upwards of £300 billion a year30 and by understanding skin of colour patients’ unique needs and tailoring your approach, it is possible to increase your patient numbers as well as retain them in the long term. There are distinct nuances in darker skin, so ensuring that your service provision is well thought out to be inclusive and diverse at all levels, from imagery and social media to product selection and the knowledge, you can make a notable difference that sets you up for increased success with skin of colour patients.

Dija Ayodele is a London-based aesthetician, British Beauty Council Advisory Board member and founder of the award-winning Black Skin Directory, which connects skin of colour patients with expert skincare professionals. She specialises in skin rejuvenation techniques for skin of colour at her Kensington clinic.

REFERENCES

1. Alexis A.F. & Barbosa V.H, Skin of Colour – A practical Guide to Dermatologic Diagnosis and Treatment. (New York: Springer, 2013), p. 301 2. Torjesen, I., ‘Cosmetic needs differ for skin of color patients’, Dermatology Times, 2018. 39(6) <http:// www.dermatologytimes.com/article/unique-treatment-approaches-skin-color> 3. Davis SA et al., ‘Top dermatologic conditions in patients of color: an analysis of nationally representative data’, J Drugs Dermatol, 2012. 11(4) <https://www.ncbi.nlm.nih.gov/pubmed/22453583> 4. Black Skin Directory, Skincare for all (UK: Black Skin Directory, 2017) <https://www.blackskindirectory. com/our-vision> 5. Alexis A.F. & Barbosa V.H, Skin of Colour – A practical Guide to Dermatologic Diagnosis and Treatment. (New York: Springer, 2013). 6. Gerbner G. & Gross L. (1976). Living with television: The violence profile. Journal of Communication, 26, 172-199. 7. Dhesi, N., ‘The Importance of Diverse Advertising’, Huffington Post, 2017 <https://www.huffingtonpost. co.uk/neel-dhesi/advertising-diversity_b_15380586.html> 8. Vinjamuri, D., ‘Diversity in Advertising Is Good Marketing’, Forbes, 2015 <https://www.forbes.com/sites/ davidvinjamuri/2015/12/11/diversityinadsisgoodmarketing/#3fa30a464248> 9. Kilikita, J., ‘Why are Global Skincare Brands Excluding People of Colour on Instagram?’, Refinery29, 2019 <https://www.refinery29.com/en-gb/lack-of-diversity-beauty-instagram> 10. Hardy, A., I’m black and my doctor should be too, Tonic, 2017 <https://tonic.vice.com/en_us/article/ ezx9zz/im-black-and-my-doctor-should-be-too> 11. Torres, N., Research, Having a black doctor led black men to receive more effective care. Havard

Business Review, 2018 <https://hbr.org/2018/08/research-having-a-black-doctor-led-black-men-toreceive-more-effective-care> 12. Kline, R., ‘Diversity and inclusion are not optional extras if the NHS wishes to improve’, HSJ, 2018 <https:// www.hsj.co.uk/equality-and-diversity/diversity-and-inclusion-are-not-optional-extras-if-the-nhs-wishes-toimprove/7023599.article> 13. Campbell, D., ‘White NHS doctors ‘more likely to be promoted than minorities’, The Guardian, 2018 <https://www.theguardian.com/society/2018/nov/04/white-nhs-doctors-more-likely-to-be-promotedthan-minorities> 14. Wu et al., Racial and Ethnic variations in incidence and survival of cutaneous melanoma in the US, 19992006, JAAD, 2011. 65(5) < https://www.ncbi.nlm.nih.gov/pubmed/22018064> 15. Krishnaraj Mahendraraj et al., Malignant Melanoma in African–Americans, A Population-Based Clinical

Outcomes Study Involving 1106 African–American Patients from the Surveillance, Epidemiology, and

End Result (SEER) Database (1988–2011), Medicine (Baltimore), 2017. 96(15) <https://www.ncbi.nlm.nih. gov/pmc/articles/PMC5403065/> 16. Kundu R.V. and Patterson S., Dermatologic Conditions in Skin of Color: Part I. Special Considerations for

Common Skin Disorders. American Family Physician, 2018. 87(12) <https://www.aafp.org/afp/2013/0615/ p850.html> 17. Osman H. et al., Cocoa butter lotion for prevention of striae gravidarum: a double-blind, randomised and placebo-controlled trial. BJOG, 2008, 15(9) <https://www.ncbi.nlm.nih.gov/pubmed/18715434> 18. Buchanan K. et al., Prevention of striae gravidarum with cocoa butter cream. Int J Gynaecol Obstet. 2010, 108(1) <https://www.ncbi.nlm.nih.gov/pubmed/19793585> 19. Desai, SR., Hyperpigmentation Therapy: A Review. The Journal of Clinical Aesthetic Dermatology. 2014, 7(8) 20. Benn, ETK et al., Skin Bleaching and Dermatologic Health of African and Afro-Caribbean Populations in the US: New Directions for Methodologically Rigorous, Multidisciplinary, and Culturally Sensitive

Research. Dermatol Ther (Heidelb), 2006, 6(4) <https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC5120641/> 21. Khan C., Skin lightening creams are dangerous - yet business is booming. Can the trade be stopped?

The Guardian, 2018 <https://www.theguardian.com/world/2018/apr/23/skin-lightening-creams-aredangerous-yet-business-is-booming-can-the-trade-be-stopped> 22. Battle EF, Hobbs LM, ‘Laser-assisted hair removal for darker skin types’, Dermatol Ther (2004), pp.177-83. https://www.ncbi.nlm.nih.gov/pubmed/15113285 23. The difference between an influencer and a micro-influencer (and which is best for your brand) <https:// www.smalltalksocial.com/blog/the-difference-between-an-influencer-and-a-micro-influencer> 24. Chalmers, A.M., Are you optimising your cosmeceutical range? Aesthetics Journal, 2017 https:// aestheticsjournal.com/feature/are-you-optimising-your-cosmeceutical-range 25. Pride Magazine <http://pridemagazine.com> 26. The Voice Newspaper <https://www.voice-online.co.uk> 27. Black Beauty & Hair <https://www.blackbeautyandhair.com> 28. Buster, KJ et al., Dermatologic health disparities. Dermatol Clin. 2012 30(1) <https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3742002/> 29. Pandya, AG et al., Increasing racial and ethnic diversity in dermatology: A call to action. JAAD, 2016, 74(3). 30. Amoah, L., To tap into the ‘black pound’, brands must embrace cultural transformation. Campaign

Live, 2018 <https://www.campaignlive.co.uk/article/tap-black-pound-brands-embrace-culturaltransformation/1496325> 31. Skin Of Color Update 2019, New York <https://skinofcolorupdate.com/>

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