Dr Amiee Vyas
In recent years, the importance of understanding different skin tones and how this impacts aesthetic treatments has become a growing priority. Historically, western medicine has taught dermatology with Caucasian skin as standard, the consequence of which is a huge gap in clinician knowledge of both skin of colour anatomy and how to recognise common conditions and clinical signs in all specialties. There is now greater awareness that inadequate knowledge has resulted in avoidable complications and dangerous misdiagnoses in this group. In this article, I will provide an introduction to how the standard of care that is provided to the ever-growing diverse patient population in the aesthetics industry can be raised.
The TREND-EF population projection for the UK suggests that, by 2051, the black and ethnic minority population will have increased from 8% to 21%, with the mixed group expected to grow between 148% and 249% and the Asian group between 95% and 153% (Rees et al, 2012). Therefore, it is more crucial than ever for clinicians to offer safe and effective treatments for a diverse skin palette.
Anatomy and physiology
There are fundamental differences in the anatomy and physiology of non-Caucasian skin, and this is an expanding area of research due to the vast variability within ethnic groups.
Skin colour is determined by the distribution and density of melanin, as well as haemoglobin, bilirubin and carotenoids (Zaidi, 2017; Gupta and Sharma, 2019). While all skin types have the same number of melanocytes, in darker skin, they have higher tyrosinase activity, producing more melanin and have a wider distribution of melanocytes throughout the epidermis and dermis (Zaidi, 2017). Furthermore, melanosomes tend to be larger, more dispersed and degrade slower than Caucasian skin. This explains why hyperpigmentation is a leading presenting complaint when these patients seek the help of clinicians. Another important difference is that, while the stratum corneum in skin of colour is the same thickness as all other skin types, it is also more compact with more layers and greater intercellular cohesion as the skin tone gets darker (Zaidi, 2017). Additionally, ceramide levels tend to be lower, but lipid content is increased compared to lighter skin (Zaidi, 2017). Dermal fibroblasts in skin of colour are larger and more numerous (Zaidi, 2017), likely contributing to the higher prevalence of keloid and hypertrophic scarring in this group (Taylor, 2002). Collagen fibres are also smaller, more compact and less prone to fibre fragmentation (Zaidi, 2017), which could account for the later presentation of rhytids and skin laxity in skin of colour patients.
Classifying skin colour
When classifying skin colour, the most widely used scale in the aesthetics sector is the Fitzpatrick scale. Based on the skin's reaction to ultraviolet (UV) exposure, this scale was originally created in 1975 (Gupta and Sharma, 2019). Skin types V and VI were added later to include people with darker skin. While helpful for quick reference, this scale is largely oversimplified and does not account for the variation in photosensitivity in darker skin tones (Taylor, 2002; Okoji et al, 2021). It is important to note that darker skin types can still burn. In my experience, it can be helpful to document the patient's ethnicity, their UV sensitivity—whether they are prone to burning, skin reactions or hyperpigmentation—and to document whether their skin is sensitive or sensitised.
There are many myths associated with darker skin, the most common of which are:
- Darker skin types do not require sunscreen
- Darker skin is stronger than white skin
- Darker skin does not age.
Presently, aesthetics and skin health professionals are all very aware that, while darker skin is relatively protected by a higher melanin content, it is still not enough to mitigate the risk of skin cancer. However, patients are still not all so well informed and may not be educated about sunscreens that do not leave a white cast on their skin. A simple way that they can be supported is by including sun protection factor (SPF) options suitable for all skin types in clinics.
While all skin types have the same number of melanocytes, in darker skin, they have higher tyrosinase activity, producing more melanin and have a wider distribution of melanocytes throughout the epidermis and dermis
While noting the differences in collagen structure in skin of colour (Zaidi, 2017), it is vital to remember that, due to the lower ceramide content, among other factors, irritation and dermatitis is common in this group and can lead to post-inflammatory hyperpigmentation (Taylor, 2002). Therefore, it is essential to take a slow and stepwise approach to skincare and treatments and ensuring that they are suitable for the patient before commencing a treatment plan.
Finally, clinicians need to understand the nuances of skin ageing in patients of colour. Although wrinkles and loss of skin thickness and elasticity tend to present later than in Caucasian patients, these signs can also present earlier, especially when combined with lifestyle factors such as high UV and oxidative stress exposure. Patients of colour may present with signs of ageing or hyperpigmentation, as well as changes in texture and hydration status (Chan et al, 2019). There are, therefore, many ways that the aesthetics treatment toolkit can be used to support these patients. Considering ideals of beauty is essential when treating patients of different ethnicities (Chan et al, 2019). The golden ratio does not universally apply to all ethnicities, and treatments should take into account the patient's desires, while also respecting and maintaining racial characteristics for optimal attractive and natural-looking results (Chan et al, 2019).
Cultural products and practices
Two major areas that should not be missed in the consultation are cultural practices and attitudes to skin tone. These can hugely vary across different groups and can contribute to various skin presentations.
Common cultural products include black soap made from the ash-derived alkali from agricultural waste and oil extracted from vegetable matter. It is very popular in West Africa or patients of West African descent and is often advertised and anecdotally described as gentle, suitable for sensitive and allergy prone skin and having medicinal properties, such as antimicrobial and anti-acne benefits. It is often used as an exfoliator, for skin toning and to fade scars. While traditional black soap can be beneficial against staphylococcal and streptococcal organisms, which are commonly seen in sub-Saharan Africa, and can be helpful for some patients, it is important to recognise that traditional recipes vary (Ogunbiyi and Enechukwu, 2021). This can result in inconsistent formulations and sensitivities arising. Patients of African descent may also use shea butter and mixed oils, including castor oil and coconut oil on the skin and hair.
Indian patients may also use mixed oils on the hair and skin. Coconut oil is comedogenic and mustard oil can contribute to hyperpigmentation. Furthermore, traditional scrubbing practices can result in post-inflammatory hyperpigmentation and wearing bindi accessories can result in dermatitis.
Colourism
Colourism is a form of prejudice and discrimination based on skin colour that occurs within and between non-Caucasian racial groups (Craddock et al, 2018). Colourism stems from colonial times, when the British and Europeans held higher status and wealth than the native populations that they invaded. Sadly, this perception has filtered through generations and continues to the present day. It favours those with lighter skin tones and negatively impacts individuals, particularly adolescents and young adults, in regard to life opportunities, including education/career progression and marriageability, as well as general wellbeing (Craddock et al, 2018). Although things are improving since the resurgence of the Black Lives Matter movement in 2020, colourism glamourising lighter skin tones still features in popular culture, media images and social media. Filters that lighten the skin tone on Instagram and Snapchat can be particularly problematic and feed into the extremely dangerous skin-lightening/skin-bleaching industry (Craddock et al, 2018).
The skin-lightening industry is problematic because of the implications on mental health, as well as the medical dangers it poses. By 2024, this global industry is projected to be worth US $31.2 billion (Craddock et al, 2018). It involves the use of topical applications and injectables, with the aim to lighten the skin tone. The skin-bleaching industry takes this a step further with the use of hazardous and banned ingredients, such as mercury and other heavy metals, and the misuse of pharmaceutical agents, such as hydroquinone and corticosteroids (Craddock et al, 2018). Under the counter sales of these products are common and affordable and risk, at best, permanent skin damage with post-inflammatory hyperpigmentation, contact dermatitis and ochronosis and, at worst, life-threatening conditions, such as skin cancer, renal failure, liver failure and permanent brain damage (Craddock et al, 2018).
The clinician's role and positive change
As clinicians, we must assess cultural practices and attitudes with empathy and have open, non-judgmental conversations with patients around these topics. We must sensitively investigate the impact of colourism on patients' mental and physical health, educate them on the risks and dangers of any existing practices and support them in reaching their goals under supervision. Counselling and expectation management will also be necessary throughout the treatment journey.
There have been many positive steps to improve both clinician understanding of diverse skin tones and patient safety in the world of dermatology, aesthetics and skincare. During the past year, global brands, such as Unilever and L'Oreal, have worked to improve their messaging in a positive way. While skin education and training has a long way to go, the gap in knowledge has been brought to the forefront and medical school curriculums have started to be amended. Within aesthetics, many cosmeceutical skincare, injectable and device brands have improved their training and support for treatments on darker skin types. Information and case studies have started to be shared more widely and progress is being made. My final advice to aesthetic practitioners is to always make informed decisions when selecting treatments, conduct in-depth research into the brands you align yourself with review clinical studies, white papers and the level of training and support that will be available to you so you can safely treat all skin types.