@aestheticsgroup
@aestheticsjournaluk
Aesthetics
aestheticsjournal.com
Diagnosing Adverse Events in Skin of Colour Dr Emmaline Ashley and Dr Amiee Vyas discuss the importance of recognition and management of aesthetic adverse events in patients with skin of colour Within the field of aesthetic medicine, there has recently been a growing recognition of a gap in clinician knowledge around skin of colour (SOC).1 This is partly due to a historical bias in Western medicine’s approach to dermatology, where white skin was considered the standard and default, and darker skin tones were relegated to being a curious footnote. This has led to a glaring lack of representation of SOC in the traditional medical curriculum and research journals.2 In fact, dermatology textbooks depict most skin diseases with images of light skin, with many textbooks containing no photographs of common concerns – like acne or dermatitis – in darker skin tones.3 Consequently many clinicians are not well-equipped to treat SOC, and our patients lack confidence that their skin concerns can be competently handled.2 To gain this trust, research suggests that patients with SOC disproportionately approach clinicians of the same race for treatment, if given a choice.4,5 A survey by the Black Aesthetics Advisory Board (BAAB) revealed the ongoing existence of knowledge gaps and myths concerning facial aesthetic treatments in SOC, and the need for clinicians to recognise nuances when approaching treatments in order to prevent and reduce the risk of adverse events in this patient population.5 Seven out of 10 black patients said they had difficulties finding a practitioner confident in treating their skin.5 Clinicians have a responsibility to be aware of these nuances, to avoid treating SOC homogenously, and recognise there is a wide spectrum of diversity within these groups.6 In this article, we summarise SOC nuances and how to recognise common and important complications when they present in patients with SOC.
Considerations in skin of colour Anatomy and physiology Skin colour and its response to sun exposure, as well as other superficial phenotypic differences, have long been used to classify people into different races.7 While it is acknowledged that these classifications are largely arbitrary, they are still used as the basis of broad racial and ethnic categorisations for SOC – including African and Afro-Caribbean, Asian and Pacific Islander, Latinx or Hispanic, South Asian and Middle Eastern.7 Most clinicians will be very familiar with Fitzpatrick skin typing – a classification system based on skin’s reaction to UV exposure.8 However, as the field of aesthetic medicine has expanded, there is growing recognition that the Fitzpatrick Scale is an oversimplified and outdated system to categorise SOC, lacking both consistency and understanding
of variation and photosensitivity in darker skin types.7,9 Broadly speaking, the unique colours and tones inherent in our skin are a consequence of the density and distribution of melanin pigment, haemoglobin, bilirubin, and carotenoids.8,10 All skin types have the same number of melanocytes: in darker skin melanocytes are highly active producing more melanin in a wider distribution.10 Melanosomes in SOC tend to be larger, more individually dispersed, and degrade more slowly than light skin.10 While the thickness of the stratum corneum is the same in all types of skin, the cells of the stratum corneum in SOC are more compact with more layers and greater intercellular cohesion.10 Additionally, the lipid content of darker skin tones has been described to be higher than lighter counterparts, while ceramide content is lower.10 The data on differences in transepidermal water loss and water content are inconclusive.10 In the dermis, evidence suggests that fibroblasts are larger and exist in greater number in SOC.10 This may explain why there is a greater propensity for hypertrophic and keloid scar formation.7 Additionally, collagen fibres are smaller and more compact in comparison to lighter skin tones, where they are larger with propensity for fibre fragmentation.10 There has not been a demonstrable difference in the elastin content between skin types.10 Additionally, there is huge diversity and variability between and within ethnic groups, and studies discussing the differences in anatomy and physiology thus far are small and methodologically flawed.7,10 It is therefore difficult to draw definitive conclusions, and is an area of expanding research and interest. Cultural considerations Clinicians should be aware of cultural practices relevant to the skin health of our SOC patients. This includes cultural stigmas, including concepts like ‘colourism’. Colourism is still prevalent in many communities – the misconception within people of the same ethnicity that lighter skin tones are preferable to darker ones.11,12 This may lead to the use of commercial and non-prescribed skin lightening or bleaching treatments, often found under-the-counter in beauty supply stores. The practice of skin bleaching is a public health concern affecting many SOC communities throughout the world and is harmful beyond the skin potentially causing systemic complications.7,11,12 Clinicians should also have familiarity with traditional beauty products and practices. For example, hair pomades popular in some African and Afro-Caribbean communities may contain mixtures of petrolatum or different oils, which can lead to seborrheic dermatitis of the scalp
Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021
