matrix components.23 Scarring has not been studied in all SOC types, and the evidence for fibroblast differences is limited to Black skin.28
Choice of appropriate cosmetic procedures is crucial to avoid iatrogenic dermal injury with resultant hypertrophic or keloid scars in higher-risk individuals.26 Racial/ethnic variations in stratum corneum structure and function have been reported; however, data are limited.27,28
The consulting physician can minimize epidermal and dermal injury through careful treatment selection, along with the use of pre- and post-treatment actions to optimize cosmetic outcomes in SOC.24,25,26,28,29
Section 2: Preventative Actions Before the Procedure
Previously published surveys and algorithms confirmed more than 90% of clinicians recommended sun avoidance before, during, and after facial cosmetic treatments.5-9 Sun exposure is a major contributor to undesirable post-inflammatory pigment changes. Despite the importance of sunscreen, there are few commercially available sunscreens designed for SOC. A recent report indicates people with SOC are less likely to use sunscreen and are less likely to receive sunscreen recommendations from a dermatologist.30 There are few cosmetically elegant sunscreens developed for SOC.4 To protect the face from visible light, a broad-spectrum, preferably tinted sunscreen (and/or one rich in antioxidants and free radical quenchers) with an SPF of 30 or higher is recommended for at least 4 weeks prior to aesthetic procedures.31
Sun exposure or skin trauma can trigger herpes simplex virus type 1 (HSV-1) flares. If a patient has ever had a cold sore, assess symptom frequency, prior location of the lesions, prior use of antiviral medication, and identifiable triggers, especially whether lesions were provoked by previous procedures. Reactivation following cosmetic procedures occurs, but reliable data on the incidence of reactivation is inconsistent. Reports of HSV-1 reactivation following dermal filler injections are uncommon. A case series of 138 patients in 6 centers in the US found that 2 patients (1.45%) developed herpes-like infections within 2 weeks of dermal filler treatment.32 When outbreaks occur, they are seen in the area injected with filler, usually the lips or nasolabial folds.33
Compared to the risk with fillers, ablative procedures have a higher risk of HSV-1 infection. In a 500-patient study, postoperative HSV-1 infection was seen in 7.4% of patients following an ablative laser procedure, regardless of prior history.34 Prophylaxis for patients undergoing ablative laser resurfacing procedures should be considered with or without a history of HSV-1.34 If there is a history of HSV-1, careful lip examination for early infection or healing lesions is necessary. Aesthetic treatments should be delayed until the skin is fully healed.35,36 In patients at risk, the expert panel recommends a 5-day treatment course with antiviral therapy, starting one day prior to the procedure.
Patients who demonstrate hyperpigmentation in response to skin trauma can be treated for 2 or more weeks with bleaching agents. Hydroquinone or a similar agent may be necessary for select patients for the prevention and treatment of PIH.16,17,37
Depending on the planned procedure, individual patients may need instructions about withholding anti-inflammatory drugs, retinols, and tobacco for days or weeks peri-procedurally to reduce bleeding risks, minimize skin irritation, and optimize wound healing.
Section 3. During the Procedure
All patients
For all patients, makeup removal and skin cleansing are required to prepare the skin. Available cleansing agents include isopropyl alcohol, chlorhexidine, or hypochlorous acid (HOCl). Isopropyl alcohol is inexpensive and easy to obtain, but it is flammable and can irritate the skin. Chlorhexidine is an effective cleanser, but it can be toxic to the eyes and ears.38,39 Stabilized HOCl is highly active against bacteria, viruses, and fungal organisms without the oto- or ocular toxicity of chlorhexidine.40 HOCl had dose-dependent favorable effects on fibroblast and keratinocyte migration compared to povidone iodine and media alone.40 It also increases skin oxygenation at treatment sites, which may aid healing. There is evidence that HOCI may reduce the risk of hypertrophic scars and keloids as it reduces inflammation and the risk for infection.40
Local anesthesia and pain management can be customized depending on the procedure and added at the discretion of the treating physician. Specific recommendations to minimize risks during laser and injection procedures are discussed below.
Laser Wavelength
With the right preparation and an experienced provider, patients with SOC can safely undergo laser and light-based treatments for hair removal, pigment abnormalities, skin resurfacing, and skin tightening.16,37 Laser outcome studies remain scarce in patients of African ancestry or those with SPT V or VI. Published studies for acne and facial rejuvenation in East Asian patients have reported a 55% incidence of PIH after ablative lasers; by 6 months later hyperpigmentation decreased to an 11% incidence.19 A provider can minimize risks with proper wavelength selection. Shorter wavelengths increase the risk for permanent pigment changes and scarring due to melanin acting as a competing chromophore. Skin containing high amounts of melanin absorbs energy more efficiently than fair skin, but the absorption coefficient of melanin decreases
Choice of appropriate cosmetic procedures is crucial to avoid iatrogenic dermal injury with resultant hypertrophic or keloid scars in higher-risk individuals.26 Racial/ethnic variations in stratum corneum structure and function have been reported; however, data are limited.27,28
The consulting physician can minimize epidermal and dermal injury through careful treatment selection, along with the use of pre- and post-treatment actions to optimize cosmetic outcomes in SOC.24,25,26,28,29
Section 2: Preventative Actions Before the Procedure
Previously published surveys and algorithms confirmed more than 90% of clinicians recommended sun avoidance before, during, and after facial cosmetic treatments.5-9 Sun exposure is a major contributor to undesirable post-inflammatory pigment changes. Despite the importance of sunscreen, there are few commercially available sunscreens designed for SOC. A recent report indicates people with SOC are less likely to use sunscreen and are less likely to receive sunscreen recommendations from a dermatologist.30 There are few cosmetically elegant sunscreens developed for SOC.4 To protect the face from visible light, a broad-spectrum, preferably tinted sunscreen (and/or one rich in antioxidants and free radical quenchers) with an SPF of 30 or higher is recommended for at least 4 weeks prior to aesthetic procedures.31
Sun exposure or skin trauma can trigger herpes simplex virus type 1 (HSV-1) flares. If a patient has ever had a cold sore, assess symptom frequency, prior location of the lesions, prior use of antiviral medication, and identifiable triggers, especially whether lesions were provoked by previous procedures. Reactivation following cosmetic procedures occurs, but reliable data on the incidence of reactivation is inconsistent. Reports of HSV-1 reactivation following dermal filler injections are uncommon. A case series of 138 patients in 6 centers in the US found that 2 patients (1.45%) developed herpes-like infections within 2 weeks of dermal filler treatment.32 When outbreaks occur, they are seen in the area injected with filler, usually the lips or nasolabial folds.33
Compared to the risk with fillers, ablative procedures have a higher risk of HSV-1 infection. In a 500-patient study, postoperative HSV-1 infection was seen in 7.4% of patients following an ablative laser procedure, regardless of prior history.34 Prophylaxis for patients undergoing ablative laser resurfacing procedures should be considered with or without a history of HSV-1.34 If there is a history of HSV-1, careful lip examination for early infection or healing lesions is necessary. Aesthetic treatments should be delayed until the skin is fully healed.35,36 In patients at risk, the expert panel recommends a 5-day treatment course with antiviral therapy, starting one day prior to the procedure.
Patients who demonstrate hyperpigmentation in response to skin trauma can be treated for 2 or more weeks with bleaching agents. Hydroquinone or a similar agent may be necessary for select patients for the prevention and treatment of PIH.16,17,37
Depending on the planned procedure, individual patients may need instructions about withholding anti-inflammatory drugs, retinols, and tobacco for days or weeks peri-procedurally to reduce bleeding risks, minimize skin irritation, and optimize wound healing.
Section 3. During the Procedure
All patients
For all patients, makeup removal and skin cleansing are required to prepare the skin. Available cleansing agents include isopropyl alcohol, chlorhexidine, or hypochlorous acid (HOCl). Isopropyl alcohol is inexpensive and easy to obtain, but it is flammable and can irritate the skin. Chlorhexidine is an effective cleanser, but it can be toxic to the eyes and ears.38,39 Stabilized HOCl is highly active against bacteria, viruses, and fungal organisms without the oto- or ocular toxicity of chlorhexidine.40 HOCl had dose-dependent favorable effects on fibroblast and keratinocyte migration compared to povidone iodine and media alone.40 It also increases skin oxygenation at treatment sites, which may aid healing. There is evidence that HOCI may reduce the risk of hypertrophic scars and keloids as it reduces inflammation and the risk for infection.40
Local anesthesia and pain management can be customized depending on the procedure and added at the discretion of the treating physician. Specific recommendations to minimize risks during laser and injection procedures are discussed below.
Laser Wavelength
With the right preparation and an experienced provider, patients with SOC can safely undergo laser and light-based treatments for hair removal, pigment abnormalities, skin resurfacing, and skin tightening.16,37 Laser outcome studies remain scarce in patients of African ancestry or those with SPT V or VI. Published studies for acne and facial rejuvenation in East Asian patients have reported a 55% incidence of PIH after ablative lasers; by 6 months later hyperpigmentation decreased to an 11% incidence.19 A provider can minimize risks with proper wavelength selection. Shorter wavelengths increase the risk for permanent pigment changes and scarring due to melanin acting as a competing chromophore. Skin containing high amounts of melanin absorbs energy more efficiently than fair skin, but the absorption coefficient of melanin decreases
