significantly as wavelengths become longer.41,42 Fitzpatrick phototype VI, the darkest skin, absorbs up to 4 times as much energy with a 694 nm ruby laser as with a longer wavelength laser such as the 1064 nm neodymium:yttrium aluminum-garnet (Nd:YAG) laser.41,42 Longer wavelengths penetrate more deeply into the dermis with less tissue damage and are not efficiently absorbed by melanin. Even with longer wavelengths, lasers do create skin inflammation, which can lead to PIH. Although hyperpigmentation is more common, over-treatment with lasers can disrupt melanin production and reduce melanocyte populations, leading to longstanding or permanent areas of hypopigmentation. A test spot may be necessary prior to more extensive laser use to assure treatment has the desired effect.43
Laser Treatment Techniques
Besides wavelength selection, additional laser treatment practices will minimize skin injury. Patients with SOC require more conservative treatment, with lower fluences and longer pulse duration. For certain procedures, such as laser hair removal, a more conservative approach will require a greater number of sessions. For laser resurfacing, lower treatment densities are recommended.16 Epidermal cooling with slower treatment speeds and pauses between passes while resurfacing will reduce skin heating and resultant skin injury.16
Injection Techniques
As with laser procedures, physicians who are well acquainted with available cosmetic toxins and fillers are best equipped to use cosmetic injections in the service of patients with SOC. Injection of botulinum toxin is the most widely used cosmetic procedure in the US. This practice has been safe and effective for correction of facial wrinkles in all ethnic groups.24
Historically, safety concerns and misconceptions related to facial aging in racial/ethnic populations with SOC have limited use of soft tissue fillers.37 Proper placement of filler depends on knowledge of anatomic differences among racial/ethnic groups and how aging affects population-specific features. Aging patients of Asian ancestry tend to be more concerned about pigment changes, including lentigines, seborrheic lesions, and mottled pigmentation than about volume loss.24 Among East Asian populations, a wider bizygomatic facial diameter is more common, thus if filler is desired it is important to avoid augmenting the maxilla and lateral zygoma.24 African American individuals tend to have a less prominent malar eminence. With age, African American patients tend to lose volume in the midface, an area in which volume restoration may be desired.24 Among Hispanic populations, skin mottling, jowl formation, and infraorbital hollowness have been reported as leading facial aging concerns.24 Accumulation of mid-face fat, leading to exaggeration of the nasolabial folds has been reported in Hispanic patient populations.24
Clinical trials of soft tissue fillers have included diverse patient populations with SOC, but data specific to individual racial/ethnic groups are relatively limited.44 In an investigator blinded study, 150 (predominantly African American) patients with SPT IV to VI had facial filler using either small or large particle hyaluronic acid. Patients reported good cosmetic effects with both fillers. Changes in pigmentation occurred in 17 patients; 6% of those who received large particle HA, and 9% of those who received small particle HA. Pigmentation changes were more likely to occur in SPT V and VI. Within 3 months, most pigment changes resolved. Three patients noted hyperpigmentation for longer than 3 months. There was no hypertrophic scarring nor keloid formation. Three patients had injection-site mass formations, 2 of which were infectious in nature. The authors concluded variable-particle HA fillers are effective and well tolerated in patients with SOC.44
Proper injection techniques for SOC can reduce the risk of PIH. Serial and rapid filler injections may contribute an increased risk for PIH and bruising. Injecting sub-dermally with longer, slower injection times will decrease the risk of PIH.44 Cosmetic providers should be aware of skin thickness variability among facial areas in SOC, which affects optimal injection depth. To avoid vascular injury, large filler volumes should be avoided in areas with less collateral circulation, such as the glabella.44,45
Section 4: Post-Procedural Care
All patients
Following cosmetic laser/other energy-based treatment, nonenergy treatment, or injectables, all patients should be counseled to continue adequate sunscreen containing SPF of at least 30.30,37 All patients require gentle skin care with nonirritating cleansers and fragrance-free gentle moisturizers.
Cosmetic procedures, especially those that are more invasive, put patients at risk of infection. HOCl has been shown to be effective in preventing infection, and in reducing hypertrophic and keloid scarring after surgical procedures.40,46 It is available as a solution, skin spray, and as a gel. HOCl has antimicrobial and antibiofilm activity. Use of HOCI solution has been associated with a lower risk of wound infection than povidone-iodine. It increases oxygenation at wound sites, which may enhance healing.40,46 Additional studies to investigate the use of HOCL in post-procedure treatment and scar management in patients with SOC are warranted.
More invasive procedures also increase the risk for PIH. Although most cases of PIH resolve over the course of several months,16,17 post procedure bleaching agents, such as hydroquinone 4% cream, can be continued for 2 weeks or longer on a case-bycase basis.
Laser Treatment Techniques
Besides wavelength selection, additional laser treatment practices will minimize skin injury. Patients with SOC require more conservative treatment, with lower fluences and longer pulse duration. For certain procedures, such as laser hair removal, a more conservative approach will require a greater number of sessions. For laser resurfacing, lower treatment densities are recommended.16 Epidermal cooling with slower treatment speeds and pauses between passes while resurfacing will reduce skin heating and resultant skin injury.16
Injection Techniques
As with laser procedures, physicians who are well acquainted with available cosmetic toxins and fillers are best equipped to use cosmetic injections in the service of patients with SOC. Injection of botulinum toxin is the most widely used cosmetic procedure in the US. This practice has been safe and effective for correction of facial wrinkles in all ethnic groups.24
Historically, safety concerns and misconceptions related to facial aging in racial/ethnic populations with SOC have limited use of soft tissue fillers.37 Proper placement of filler depends on knowledge of anatomic differences among racial/ethnic groups and how aging affects population-specific features. Aging patients of Asian ancestry tend to be more concerned about pigment changes, including lentigines, seborrheic lesions, and mottled pigmentation than about volume loss.24 Among East Asian populations, a wider bizygomatic facial diameter is more common, thus if filler is desired it is important to avoid augmenting the maxilla and lateral zygoma.24 African American individuals tend to have a less prominent malar eminence. With age, African American patients tend to lose volume in the midface, an area in which volume restoration may be desired.24 Among Hispanic populations, skin mottling, jowl formation, and infraorbital hollowness have been reported as leading facial aging concerns.24 Accumulation of mid-face fat, leading to exaggeration of the nasolabial folds has been reported in Hispanic patient populations.24
Clinical trials of soft tissue fillers have included diverse patient populations with SOC, but data specific to individual racial/ethnic groups are relatively limited.44 In an investigator blinded study, 150 (predominantly African American) patients with SPT IV to VI had facial filler using either small or large particle hyaluronic acid. Patients reported good cosmetic effects with both fillers. Changes in pigmentation occurred in 17 patients; 6% of those who received large particle HA, and 9% of those who received small particle HA. Pigmentation changes were more likely to occur in SPT V and VI. Within 3 months, most pigment changes resolved. Three patients noted hyperpigmentation for longer than 3 months. There was no hypertrophic scarring nor keloid formation. Three patients had injection-site mass formations, 2 of which were infectious in nature. The authors concluded variable-particle HA fillers are effective and well tolerated in patients with SOC.44
Proper injection techniques for SOC can reduce the risk of PIH. Serial and rapid filler injections may contribute an increased risk for PIH and bruising. Injecting sub-dermally with longer, slower injection times will decrease the risk of PIH.44 Cosmetic providers should be aware of skin thickness variability among facial areas in SOC, which affects optimal injection depth. To avoid vascular injury, large filler volumes should be avoided in areas with less collateral circulation, such as the glabella.44,45
Section 4: Post-Procedural Care
All patients
Following cosmetic laser/other energy-based treatment, nonenergy treatment, or injectables, all patients should be counseled to continue adequate sunscreen containing SPF of at least 30.30,37 All patients require gentle skin care with nonirritating cleansers and fragrance-free gentle moisturizers.
Cosmetic procedures, especially those that are more invasive, put patients at risk of infection. HOCl has been shown to be effective in preventing infection, and in reducing hypertrophic and keloid scarring after surgical procedures.40,46 It is available as a solution, skin spray, and as a gel. HOCl has antimicrobial and antibiofilm activity. Use of HOCI solution has been associated with a lower risk of wound infection than povidone-iodine. It increases oxygenation at wound sites, which may enhance healing.40,46 Additional studies to investigate the use of HOCL in post-procedure treatment and scar management in patients with SOC are warranted.
More invasive procedures also increase the risk for PIH. Although most cases of PIH resolve over the course of several months,16,17 post procedure bleaching agents, such as hydroquinone 4% cream, can be continued for 2 weeks or longer on a case-bycase basis.
