CPD Article: Treating Patients with Skin of Colour
The aesthetics industry has evolved significantly in recent years, embracing inclusivity and acknowledging the unique needs of individuals with different skin tones.1 However, despite some advances, aesthetic medicine training and clinical trials have remained largely centred around Caucasian skin, leaving significant gaps in knowledge and clinical training when it comes to treating patients with skin of colour.2-6 In addition, treatments and products have been developed with a narrow focus, often overlooking the unique needs of patients with skin of colour. This limitation can result in misdiagnoses, ineffective treatments, and an overall lack of trust in aesthetic practitioners.3,7
The need for aesthetic professionals to broaden their understanding and expertise in treating patients with darker skin tones has never been greater.8 It is essential that practitioners recognise the structural and functional differences in skin of colour and adapt their treatments accordingly.9 Without proper knowledge, there is an increased risk of adverse effects, particularly hyperpigmentation and scarring, which are more prevalent in these patient groups.10 Furthermore, cultural competence is equally critical – understanding beauty ideals, patient concerns, and historical experiences with the medical field can strengthen the practitioner-patient relationship and enhance treatment outcomes.7,11-13
Physiological considerations in skin of colour
Understanding the physiological characteristics of skin of colour is key to delivering safe and effective aesthetic treatments.7 One of the most important factors to consider is the increased activity of melanocytes, which are responsible for pigment production.14-15
Black skin has more melanin than white skin.7 In fact, some studies have shown that black skin produces twice as much melanin as white skin and they are more evenly distributed with the epidermis.7,16
While this provides some natural protection against UV damage, it also makes individuals with darker skin more susceptible to post-inflammatory hyperpigmentation (PIH).17-18 Any form of trauma, including aggressive exfoliation, chemical peels, or laser treatments, can lead to excessive melanin production, resulting in persistent dark marks.10
Additionally, wound healing in skin of colour presents distinct challenges.4 The heightened response of fibroblasts can lead to excessive collagen production, increasing the likelihood of keloid and hypertrophic scarring.19-21 Treatments such as dermal fillers, microneedling, or laser resurfacing must be carefully adjusted in line with each patient’s individual needs to minimise unnecessary inflammation.6-7 In some cases, alternative treatment strategies may be required to avoid triggering unwanted skin reactions.
Another consideration is the structure of the dermal-epidermal junction, which differs slightly in darker skin tones.17,22 In addition, there may be increased skin sensitivity and a higher likelihood of irritation from active ingredients found in some skincare products or active ingredients. For example, retinoids and high-potency exfoliants may cause greater irritation in darker skin than in lighter complexions.23 Consequently, treatment protocols should prioritise skin barrier protection and hydration to maintain optimal skin health and prevent adverse reactions.
Another significant distinction between highly pigmented and lighter skin is the rate of trans-epidermal water loss (TEWL).7 The skin’s primary role is to act as a barrier, preventing excessive water evaporation through the outermost layer, the stratum corneum. Research indicates that while melanin-rich skin tends to have a higher sebum production and a denser stratum corneum7 – comprising around twenty layers of cells compared to approximately sixteen in lighter skin – it also has lower ceramide levels. This reduction in ceramides contributes to increased moisture loss, making individuals with more pigmented skin more susceptible to xerosis, particularly in colder climates. As a result, conditions such as dry, flaky, or ashy skin are more commonly observed in these populations.7
Common dermatological conditions and treatment challenges
Many skin conditions present differently in patients with skin of colour, making accurate diagnosis and effective treatment more challenging for practitioners who are not familiar with these variations.7,24-26 For instance, eczema does not always exhibit the typical redness seen in Caucasian skin but instead may appear as brown, purple, or grey patches.27 Similarly, psoriasis often presents as dark brown or violaceous plaques rather than the classic erythematous appearance.28 The risk of misdiagnosis is significant, as these conditions may be mistaken for post-inflammatory hyperpigmentation or other disorders.
Acne is another common concern among patients with darker skin, often complicated by the presence of hyperpigmentation.7,29 Unlike Caucasian patients, where the primary concern may be inflammation and active lesions, individuals with skin of colour frequently experience residual dark spots that persist long after the acne has resolved. This means that a comprehensive treatment plan should address both acne control and pigment correction, incorporating products and procedures that reduce inflammation while minimising the risk of PIH.
Hyperpigmentation disorders such as melasma and vitiligo can also be more pronounced in darker skin tones and can have significant psychological and social impacts. Treatments for these conditions require a cautious approach, as aggressive interventions can worsen pigmentation irregularities. Laser therapy, for instance, must be carefully selected to avoid exacerbating pigmentation issues, while chemical peels should be performed with gentler acids that do not trigger an inflammatory response.
Modifying aesthetic treatments for skin of colour
While many aesthetic procedures can be safely performed on patients with darker skin types, modifications are often necessary to reduce the risk of adverse effects.30 Chemical peels, for example, should be chosen with caution, avoiding highly aggressive exfoliants such as phenol or high-strength glycolic acid, which may cause excessive irritation. Instead, practitioners can opt for milder alternatives like mandelic or lactic acid, which provide exfoliation without inducing inflammation.31
Laser treatments require particular attention, as inappropriate settings can lead to burns, hyperpigmentation, or hypopigmentation.32 Proper cooling techniques and cautious energy settings are essential when performing laser hair removal or resurfacing treatments on patients with skin of colour.33
Injectable treatments, including dermal fillers and neurotoxins, must also be administered with care.5-6 While these procedures are generally safe, practitioners should be mindful of vascular differences in darker skin and use conservative techniques to prevent complications such as vascular occlusion. Ensuring that patients are well-informed about potential side effects and expected outcomes is an important aspect of treatment planning.
The Importance of sun protection
One of the most common misconceptions about skin of colour is that it does not require sun protection.7,15,34 While melanin provides some degree of natural sun defence, it does not eliminate the risk of photodamage, premature ageing, or skin cancer. Unfortunately, due to a lack of targeted education and marketing, many individuals with darker skin tones do not use sunscreen regularly. Studies have shown that skin cancer in Black patients is often diagnosed at a more advanced stage, leading to poorer outcomes. Therefore, it is crucial for aesthetic practitioners to educate their patients on the importance of daily sun protection and recommend broad-spectrum sunscreens suitable for darker skin.
Cultural competency and inclusive aesthetic practice
Beyond clinical knowledge, cultural competence plays a vital role in aesthetic medicine. Understanding the beauty standards, preferences, and concerns of diverse patient populations fosters a more inclusive and supportive environment. Patients should feel comfortable discussing their aesthetic goals without fear of being dismissed or misunderstood. This requires practitioners to actively educate themselves on the unique experiences of individuals with skin of colour, as well as the historical context that has shaped their relationship with the beauty and medical industries.
Inclusivity should also extend to marketing and branding efforts. Clinics that feature diverse models in promotional materials, showcase a variety of treatment results, and engage with diverse audiences on social media can help build trust and accessibility. Additionally, practitioners who lack direct experience treating skin of colour should establish referral networks with experts who do, ensuring that all patients receive the highest standard of care.
Conclusion
Providing safe and effective aesthetic treatments for patients with skin of colour requires a commitment to education, adaptability, and inclusivity. By understanding the physiological differences, recognising variations in skin condition presentations, and modifying treatment protocols accordingly, practitioners can improve patient outcomes and foster trust. Cultural competence is equally critical in ensuring that all patients feel seen, valued, and confident in the care they receive. Continuous professional development, including attending conferences and engaging with resources such as The Black Skin Directory and Skin of Colour Training UK, can help practitioners stay informed and improve their expertise in this vital area of aesthetic medicine.
References
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