When it comes to procedures such as chemical peels, microdermabrasion, and laser therapies, fact is one size doesn’t fit all. And the final responsibility falls on the shoulders of the dermatologists; they should take special precautions when treating patients with darker skin.
In my current practice in Jeddah, I see at least few patients every day who are seeking treatment for pigmentary complications that have been caused by patient’s exaggerated genetic tendencies to pigment coupled with prior cosmetic procedures performed by other physicians. Some I can treat, and some are beyond repair.
If I were to sum up my clinical experience, I would tell all dermatologists that above all, be conservative and don’t be aggressive especially when dealing with ethnic skin. Follow special protocol while treating skin of color and take your time in taking the patient’s history and establish if they have pigmentation prone skin type. The most important part of talk with the patient is asking about reaction to prior procedures or surgeries and prior history of post-inflammatory hyperpigmentation (PIH).
Take your time and ask them about what they do, what their hobbies are, or if they spend a lot of time outdoors. And take into account the season. During warmer temperatures, consider superficial peels and be careful with lasers. Medium peels and laser resurfacing are more appropriate during cooler and cloudier seasons.
Special Precautions While Treating Skin Of Color:
Don’t perform chemical peels on patients who are using tretinoin. Never start with a high concentration fruit acid peel. Don’t do excessive layers. And don’t combine surgical procedures with peels in the same visit.
When performing microdermabrasion, don’t be too aggressive to avoid PIH, streaking, and scratch marks. Don't perform the procedure too close to the eyes. Avoid extremely sensitive skin and look out for pressure urticaria. Always start with the lowest strength and time interval.
With fillers, be careful with superficial placement since the colored material can be seen through the skin. Hyaluronic acid is safer, because it’s colorless and less risky to use. Be mindful that severe bruising can lead to hemosiderin deposition. Be sure that all your patients are using sunscreen.
For laser and light therapies, always do a test spot. Have a solid understanding of laser-tissue interactions. Be prepared if pigmentation problems develop, so that you can treat them early.
Aggressive and early intervention is crucial in treating side effects from cosmetic procedures.
· One of the keys to prevent hyperpigmentation is UV protection, whether it’s with sunscreens, cosmetics, antioxidants such as topical vitamin C and E, or systemic agents such as chloroquine, fish oil, or green-tea extract.
· Several topical agents can be used to treat hyperpigmentation e.g. hydroquinone, hydroquinone combinations, glycolic/retinoid/steroid combination, or antioxidants.
· Niacinamide is a great cosmeceutical skin-lightening agents that act as a vitamin exfoliant, reducing melanosome transfer.
· Soy-protease inhibitors and glutathione also have skin-lightening effects.
· Melanozyme, Melaplex, Lumixyl (oligopeptide), retinaldehyde, lactic acid, ferrulic acid, can be good alternatives to hydroquinone but always prescribe bleaching agents with a broad spectrum sunscreen.
My favorite method of treating pigmentary complications is to combine treatments. For instance, I combine peels with microdermabrasion; peels with laser; and fractional resurfacing with topical regimens. The procedures can be maximized with the topical regimens. The bottom line is watching out for the skin reaction and aggressive as well as early intervention for side effects.
There’s no way of predicting who will hyperpigment, unless you take a good history and remember two pearls to stay out of trouble: Be conservative, and don’t use aggressive techniques.