Dark skin is always a challenge for skin practitioners, and yet a wide variety of complicated skin conditions such as pigmentation disorders including post-inflammatory hyperpigmentation and melasma, keloid and hypertrophic scars, as well as pseudo folliculitis barbae (PFB), occur more frequently in people-of-color than Caucasian skin types.
Maritza Perez, MD in New York is among a small number of well-known physicians who specialize in treatments for patients of color. With over 15 years of experience, she is also recognized as one of the top authorities on how lasers and other cosmetic treatments can be best performed on skin of color patients. Like most other aesthetic physicians Dr. Perez prefers using Nd:YAG 1064 nm lasers on darker skin. YAG is the most widely recognized modality for safe and efficacious treatment of Fitzpatrick IV-VI in any laser clinic or medspa.
By George J. Hruza, MD
Xu LY et al. Histopathologic study of hidradenitis suppurativa following long-pulsed 1064-nmNd:YAG laser treatment.
Arch Dermatol 2010Sep 20; [e-pub ahead of print]. (http://dx.doi.org/10.1001/archdermatol.2010.245)
Aggressive treatment with hair removal laser such as Nd:YAG 1064 nm may have a positive effect on lesions of HS. Hidradenitis suppurativa (HS) is very resistant to both medical and surgical management — exacerbations, recurrence, and progression are the norm.
The observation that HS (aka Acne Inversa) may be related to follicular occlusion has led to attempts to treat HS with hair removal lasers. In this prospective, controlled clinical and histologic study,20 patients with Hurley stage II HS (skintype, Fitzpatrick III or VI) underwent treatment with a long-pulsed 1064-nm Nd:YAG laser.
Diet, exercise and healthier living may make us feel younger but too often our skin tells the true tale of our age, despite our best efforts to mitigate the damage to our skin that can make us look much older over time. Aging skin, with its “loose” feel, sagging, fine lines, enlarged pores, sallow complexion, and creases — is caused by many factors, including too much sun with too little sunscreen, wind, cold and pollution, plus cigarette smoke, stress, poor nutrition, facial contortions, and alcohol, among other things.
While many people still opt for invasive techniques like surgical face lifts, aggressive resurfacing, or deep chemical peels to combat the signs of aging skin, many are now turning to minimally invasive procedures to rejuvenate facial skin and take years off that image in the mirror. According to the American Society of Plastic Surgeons, minimally invasive cosmetic procedures for the face increased considerably in 2010, with laser skin resurfacing treatments increasing by one-third over the prior year.
One key reason that the number of these procedures has increased so dramatically is the development of high-energy, extremely accurate lasers which have enhanced the ability of physicians to improve sun-damaged skin, scars, wrinkles, brown spots and other conditions with minimal to no downtime.
New laser skin resurfacing techniques can take years off your appearance and you can see a significant improvement in the look and feel of your skin. You will see fewer wrinkles. Laser skin rejuvenation can be done in one to just a few treatments, depending on the technology, and patients are able to return quickly to their normal activities.
1. Fractional Non-ablative Lasers. This multiple treatment approach requires no preparation for the patients, who simply get a topical anesthetic and feel light pressure during this safe and gradual laser procedure that stimulates the body to replace aged and photo-damaged skin. It also shrinks the pores and is the first and only laser approved for treatment of the discoloration of melasma. It can be used throughout the body. Although there is some redness, most go right back to work.
2. Fractional Ablative Lasers. These are less aggressive than CO2 resurfacing and result in much less patient down-time. The physician tailors the skin resurfacing procedure to each person’s unique needs. The technology can be used on light, medium and deep settings depending on the amount of improvement and the number of days for complete rehabilitation along with the number of treatments desired. It does not have the previous CO2′s high risk of discoloration, long healing times and prolonged erythema. It still offers some skin tightening benefits which increases with a second or third treatment. The results can be quite dramatic.
3. Erbium Lasers. One of the latest tools available for the treatment of wrinkles, acne scars, aged and sun-damaged skin, the Erbium is a cool light laser that resurfaces the skin. This method results in less post-procedure redness, less swelling and faster healing time and much less risk of side effect than with other strong laser skin resurfacing methods. The Erbium laser can be used on the face, neck, chest and hands. You can expect up to a several days of down-time from this procedure depending on the depth of the peel. People say how smooth and fresh their skin looks and feels.
Using one or more of these new laser skin rejuvenation methods, healthy, active adults can now look as young as they feel.
Effectively treating vascular and pigmented lesions — from common facial telangiectasias to more challenging hemangiomas — relies on identifying the appropriate tools and then honing one’s technique to achieve the best results. However, more often than not, patients want to make the most of their sessions by undergoing concomitant facial resurfacing to improve wrinkles and texture changes related to repeated sun exposure, according to William F. Groff, D.O., who practices alongside aesthetic laser pioneer, Richard Fitzpatrick, M.D., at the La Jolla Cosmetic Surgery Centre, in La Jolla, Calif. In these cases, Dr. Groff tells Cosmetic Surgery Times, a combination of two or more lasers is often the best approach. Here, Dr. Groff offers tips and perspective on wrinkle and vascular and pigmented lesion treatment strategies that result in patients whose post-procedure appearance is ultimately the best form of marketing.
RESULTS DELIVERED The most common facial lesions that patients request treatment for are wrinkles, telangiectasias and solar lentigines according to Dr. Groff, who adds that these are followed in frequency by rosacea, melasma, cherry angiomas and spider angiomas.
“Facial telangiectasias, cherry angiomas and spider angiomas are fairly easy to treat if you have the right tools,” says Dr. Groff. They can all be treated very safely and effectively with pulsed dye lasers (PDLs) in just one or two sessions. “PDL has a long track record and is certainly considered the gold standard, so if the practitioner wants to treat both vascular and pigmented lesions, the PDL is one unit that can be counted on to deliver reliable, predictable and safe results. We have about 20 lasers in our practice and the PDL is probably the safest. The chance of having a problem or complication is extremely rare.”
Dr. Groff’s technique for facial telangiectasias comprises the use of a Candela V-beam Perfecta PDL, using the 10 mm spot size with 7.5 to 10 J/cm2. “I would usually use a 6, 10 or 20 ms pulse duration [depending on the size of the vessels], and it could take anywhere from one to three sessions at the most,” he explains. Larger vessels require treatment with longer pulse durations. David J. Goldberg, M.D., J.D., adds that, “A variety of other lasers and light sources can also be successfully and safely used to treat such vascular lesions. Among the more popular wavelengths besides the 595 PDL are the 532, 940, 980 and 1064 nm wavelengths.” Dr. Goldberg is director of Skin Laser & Surgery Specialists of NY/NJ, and clinical professor of dermatology/director of laser research at the Mount Sinai School of Medicine in NYC.
There is a high demand for facial laser resurfacing in Dr. Groff’s practice and almost every person who comes in for resurfacing has brown spots and telangiectasias. “But no matter what kind of fractional resurfacing device you use, most telangiectasias and some brown spots remain.” To get the best results, Dr. Groff recommends using a combination of lasers. “There’s not one box that does it all and does it all the best,” he says.
For a patient who has facial telangiectasias, solar lentigines and wrinkles, Dr. Groff recommends using the PDL to remove the capillaries, the PDL or Q-switched alexandrite to remove the lentigines, then immediately treating with fractional CO2 resurfacing all in one session. “The results are much better than if you use any of these technologies alone,” he says. “Dr. Fitzpatrick and I have been doing these combination treatments for years, and we’ve never had any complications from combining lasers in one session. Our results are excellent and patients appreciate not having to come back for separate treatments, which would incur more social downtime. There’s a synergistic effect where the results are much better when these treatments are done at the same time, in comparison to doing them separately,” he adds.
Taking the synergistic effect one step further, Dr. Groff recommends pretreating with BOTOX around the glabella, the forehead and the crow’s feet area one to two weeks before performing fractional resurfacing. “If you do this, those muscles are relaxed so they’re not contracting and etching lines into freshly resurfaced skin,” he explains.
STACKING TREATMENTS In the majority of these cases, patients who are seeking resurfacing and treatment for telangiectasias also want to be rid of the vertical upper lip “smokers’ lines” that are commonplace among women over the age of 40. “The gold standard for erasing these lines is still traditional multiple pass CO2 laser resurfacing in combination with erbium laser resurfacing. So even though fractionated CO2 will soften the lines, if the patient wants those lines to be gone you still need multiple pass CO2 and erbium laser resurfacing,” he explains. “In our practice, if we’re going to resurface a woman’s facial skin, we’ll use a fractional CO2 over the entire face with the exception of the upper lip where we’ll perform traditional multiple pass CO2 and erbium resurfacing in addition to using the PDL and the Q-switched alexandrite laser to address the telangiectasias and brown spots, respectively. We use these lasers back to back in the same treatment session. That’s really the way to get the best results,” Dr. Groff says. With regard to these challenging upper lip lines, Dr. Goldberg adds that, “Although fractional nonablative lasers do not typically lead to improvement of upper lip lines, many clinicians have also seen great results from ablative fractional lasers emitting 2790, 2940 and 10,600 nm wavelengths.”
For pigmented lesions, Dr. Groff opts for Candela’s TriVantage, a Q-switched alexandrite laser, which delivers energy through a fiber optic cable, giving it a homogeneous result with less variation from pulse to pulse. “We consider this laser the workhorse of our practice. It’s fast and extremely effective,” he says. The TriVantage offers Q-switched 1064 nm and 532 nm wavelengths, as well as a 755 nm wavelength, so, in addition to treating pigmented lesions, it is also effective for tattoo removal of many colors. “Previously removing multicolor tattoos meant using multiple lasers, but with the TRiVantage we’re able to remove all colors except for white, yellow and fluorescents,” he says.
People of African, Asian, Latin and Native American backgrounds know that their skin, hair and nails are subject to conditions that do not affect lighter skinned people. “While most of these are not serious, they may be disturbing, troubling or unsightly,” says Joshua Fox, MD, a leading dermatologist, founder of Advanced Dermatology and an official spokesperson for the American Academy of Dermatology and the American Society of Dermatologic Surgery.
“Fortunately, your dermatologist is well acquainted with these conditions and can help people with dark skin to diagnose and treat their concerns early and quickly,” says Dr. Fox. He offers the following listing of the top skin conditions faced by people of color and how it differs from lighter-skinned individuals.
1. Acne – Many dark skinned women suffer from acne vulgaris, sometimes combined with hyper pigmentation, or skin darkening in spots or patches, which occurs in response to the outbreak of acne. Unlike fairer-skinned individuals, the discoloration plays an integral role in treatment. Surprisingly, these patients are more bothered by the discoloration than the acne itself. Treatments may include topical skin lightening creams for dark spots, sunscreen and topical, prescription acne medications.
2. Dermatosis Papulosa Nigra – These brown or black raised spots, which commonly affect African American women and people of Asian descent, may look like moles or flattened warts. They are always benign, never lead to skin cancer and are not harmful. However, some people do have them removed for cosmetic reasons. Typically, up to 50 percent of Dermatosis Papulosa Nigra patients have a family history of the condition, and up to 35 percent of adult blacks in the United States have it. They are easily removed with minimal to no marks.
3. Eczema – Very common among those with brown skin, eczema is an itchy, irritating rash that can occur in skin of any type or color. However, according to the National Eczema Society, it is found twice as often in black skin. When it does occur, differences in the structure of black from Caucasian skin can cause related problems including excessive pigmentation and a thickening of the skin that can also cause changes in skin color. “Because eczema is harder to identify in dark skin, and is often confused with psoriasis or fungal infections, getting the right diagnosis and treatment can be difficult,” Dr. Fox says. “Once the correct diagnosis has been made, topical medicines are quite helpful.”
4. Keloids – Scar tissue caused by abnormal healing of the skin occurs frequently in individuals with brown skin. Any time dark skin is injured, the risk of keloids is dramatically increased. According to Skin & Aging magazine, up to 16% of black and Asian people suffer from keloids. Keloids can develop immediately following an injury or take a long time to grow. Sometimes they itch, are painful and burning or feel tender to the touch. Treatments include cortisone and other injections, radiation therapy, pressure dressings, silicone gel applications and several types of lasers are extremely helpful. Keloids can also be removed via traditional or laser surgery.
5. Traction Alopecia – This hair loss condition is caused by damage to the hair follicle from constant pulling or tension over a long period of time. It is most common in African Americans who braid their hair tightly, but can also be caused by over processing of the hair through dyes, bleaches or straighteners. According to the National Institutes of Health, some 17% of African-American schoolgirls (6-21 years) and more than 30% of women (18-86 years) suffer from traction alopecia. While this condition can be reversed if diagnosed early, it can lead to permanent hair loss if it is undetected for a long period. These people – mainly women – should change to looser, gentler hair styles and should see a dermatologist. Unfortunately, no medical treatment is available to reverse late-stage traction alopecia; hair grafts, transplants or wigs have been identified as the only practical solution.
6. Melanoma — Those with brown skin often have a false sense of security when it comes to skin cancer. “While increased skin pigmentation offers some protection against the sun’s harmful UV rays,” Dr. Fox says, “melanoma can and does occur,” unlike in the lighter-skinned individual, it occurs especially on the palms, soles, fingers and toes, nails and mucous membranes (such as the mouth or nose). “A new dark mark or a mark that changes in size, shape or color in these areas should be seen by a dermatologist immediately. Even people with dark skin should always use a sunscreen when spending extensive time in the sun,” he says.
7. Pigmentation – Women with brown skin, particularly those of African and Latino descent, have a high incidence of hypertension, diabetes and heart disease and thus take medications for those medical problems. These, as well as other commonly used medications (LIST MEDICATIONS THAT CAN CAUSE PROBLEMS) can cause various types of allergic reactions that frequently lead to hyperpigmentation, or dark patches. While the dark spots can fade over time, women should seek treatment early. Procedures such as chemical peels and skin bleaching, designed to lighten the darkened areas, can help, as can diligent use of sunscreen. The new Fraxel™ is the first laser approved for treatment of melasma – a type of pigmentation disorder of the face.
8. Vitiligo – Skin gets its color from pigment cells. When those cells are damaged or destroyed, they no longer produce pigment, causing white or colorless spots to appear. The spots can grow larger over time and eventually blend together so that large portions of the skin have no color at all. While no one knows why this occurs, many suspect it is related to problems within the autoimmune system. Vitiligo also may be hereditary. While people of any skin color can develop Vitiligo, it is most obvious and therefore debilitating on dark skin. One common treatment is PUVA — a repigmentation therapy involving the drug psoralen combined with exposure to UV light. A simpler, newer and equally efficacious treatment is narrowband UVB light treatment. The newest laser treatment though is that of the Excimer laser 308nm which markedly shortens the number to treatments and spares unwanted streaks. This process help increase the amount of pigment cells at the skin’s surface. Other treatments include prescription-strength corticosteroid cream, light/laser treatments and, in rare instances, skin grafting.
Imagine the astonishment as Ponce de Leon, the Spanish explorer credited with discovering the legendary Fountain of Youth in 1513, teleports to present time. He would the manifestation of disappearing wrinkles, shaving bumps, spider veins, tattoos, scars, acne, hair removal and the effects of similar aesthetic rejuvenations, not with an elixir but with light.
Nearly 500 years later, people still clamor to be ever-young, ever-beautiful and ever-healthy, and aesthetic and surgical lasers help enhance their appearance, self-esteem, personal comfort and quality of life. And thus, they are willing to pay for the benefits of LASER treatment.
We have over 25,000 medical spas on the U.S., and more physicians are adding aesthetic services to their practice every month. Many surveys indicate that patients prefer a medical rather than a spa environment to receive laser procedures, and therefore doctors of many specialties will offer various non-invasive light-based treatments to their own patients in years to come. Lasers are main stream of aesthetic medicine.
Medical tourism is a growing trend when it comes to plastic and cosmetic surgery. Some Americans believe that they can get the same cosmetic procedures for a lower cost outside the U.S.
Brazil, Chile, Venezuela and Colombia are the most popular destinations among American medical tourists. An interesting fact: some of the better surgeons were actually trained in Cuba. There are a lot of excellent doctors in Latin America and the equipment they use is often comparable to that available in the laser clinics in the U.S. You just have to do your own research to avoid complications.
Importance needs to be placed on researching the doctor’s credentials and experience because you want a doctor who is qualified and will take good care of you. As far as the cost… These days you can get excellent deals within a reasonable driving distance from your home. Plastic surgeons and medical spas in the U.S. is a very saturated business. There is a lot of competition and a lot of top notch experts in both surgical and non-invasive procedures. Give them a chance at a free consult before you board an airplane! Guess where the Swiss are going to save money on cosmetic surgery? The U.S.!