Facial Anatomy & Fitzpatrick Skin Types

The Growing Need for Inclusive Practices in Medical Aesthetics

The landscape of medical aesthetics is undergoing a significant transformation, driven by the increasing diversity of the global population and a parallel rise in the demand for cosmetic procedures across all ethnic groups.¹ Projections indicate a substantial demographic shift, with populations of African and Asian descent constituting over 80% of the world’s inhabitants.⁶ This evolving demographic profile directly influences the demand for aesthetic interventions, necessitating a departure from the historical focus on predominantly Caucasian patients.² The medical aesthetics market itself is experiencing robust expansion, fueled by heightened consumer awareness, continuous advancements in technology, and the growing interest from diverse populations seeking to enhance their appearance.³ Notably, between 2016 and 2019, the United States witnessed a significant increase of over 900,000 aesthetic procedures performed on Hispanic, African American, and Asian American individuals, underscoring the escalating demand within these communities.⁴

Historically, the development and application of cosmetic procedures, along with the associated research, have largely centered on individuals with Caucasian skin.² This historical bias has resulted in a relative paucity of data and understanding regarding the specific needs and responses of individuals with skin of color to various aesthetic treatments. Consequently, there is a growing recognition of the importance of comprehending the nuances involved in treating diverse skin types to ensure both the safety and efficacy of medical aesthetic devices.⁴ The increasing demand from a multi-ethnic population presents both an ethical imperative and a significant opportunity for practitioners and the medical aesthetics industry to adopt more inclusive practices. This necessitates a concerted effort to invest in research that encompasses diverse skin types, provide comprehensive training to practitioners, and develop technologies and treatment protocols that are tailored to the unique characteristics of all patients seeking aesthetic enhancements.

Understanding the Foundation: Skin Type and Ethnic Variations

The Fitzpatrick Scale: A Clinical Tool

The Fitzpatrick skin type (FST) classification system, a cornerstone in dermatological practice, was developed in 1975 by dermatologist Thomas B. Fitzpatrick.¹¹ Initially designed to categorize the skin tones of White patients based on their tendency to burn or tan upon sun exposure, it has since been expanded to include a broader range of skin colors.¹¹ The primary purpose of the FST remains to assess an individual’s skin type, particularly in relation to ultraviolet (UV) radiation sensitivity and the associated risk of skin cancer.¹⁴

Furthermore, the scale plays a crucial role in guiding treatment decisions within dermatology, particularly for procedures involving phototherapy, UV therapy, and laser technology, where appropriate dosages and settings are often determined based on a patient’s Fitzpatrick skin type.¹⁵ In the realm of medical aesthetics, considering a patient’s FST is a routine aspect of care delivery, informing the selection of suitable treatments ¹⁶ and helping both patients and practitioners understand which aesthetic procedures might be most appropriate.¹⁷

The Fitzpatrick scale encompasses six distinct skin types, each characterized by specific features and reactions to sun exposure.¹¹ Type I describes very fair white skin that invariably burns and never tans. Type II includes fair skin that burns easily and tans minimally. Individuals with Type III skin have darker white to light brown skin that sometimes burns but gradually tans. Type IV is characterized by light brown skin that rarely burns and tans easily. Type V encompasses brown skin that seldom burns and tans darkly with ease. Finally, Type VI denotes deeply pigmented brown or black skin that never burns and always tans darkly.¹¹ This classification provides a valuable framework for understanding the spectrum of UV sensitivity and potential responses to various dermatological and aesthetic treatments.

Despite its widespread adoption and clinical utility, the Fitzpatrick scale has certain limitations, particularly in its ability to fully represent the vast spectrum of skin colors and ethnic diversity.¹¹ Originally, the scale primarily included skin types I through IV, with the inclusion of types V and VI in 1988 aiming to better represent the skin tones commonly found in people of color.¹⁸ However, the scale has faced criticism from dermatologists for its subjective nature and its initial development based on a predominantly White patient population.¹¹ The reliance on terms like “burn” and “tan” may not adequately capture the effects of UV radiation on darker skin tones.¹¹ Moreover, it is inaccurate to directly correlate lighter FSTs with White individuals and darker types with skin of color, as skin type and race are distinct concepts, and significant variations exist within racial groups.¹⁸ For example, individuals of Japanese descent, often considered people of color, may self-report their FST as type II.¹⁸ The Fitzpatrick skin type classification system is inherently subjective, and while it remains in use, it may not always accurately reflect an individual’s risk of developing skin cancer or their response to specific treatments.¹⁵ While the later addition of Types V and VI expanded the scale to include skin tones associated with people of color, it still does not fully encompass the heterogeneity observed within and across different racial groups.¹⁸

Beyond the Fitzpatrick Scale: Nuances of Race and Ethnicity in Skin Physiology

While the Fitzpatrick scale provides a useful classification based on UV reactivity, understanding the deeper physiological differences in skin across races and ethnicities is crucial for optimizing medical aesthetic treatments. One of the most apparent distinctions lies in melanocyte activity and melanin production.² Although the actual number of melanocytes, the cells responsible for producing melanin, is similar across individuals with light and dark skin, the melanocytes in darker-skinned individuals produce significantly greater quantities of melanin.² Furthermore, in darker skin, the melanosomes, which are organelles within keratinocytes that contain melanin, hold a higher concentration of melanin and degrade at a slower rate.² Studies have indicated that Black skin can produce twice as much melanin as White skin, and this pigment is more evenly distributed throughout the epidermis.⁶ Research also suggests that melanocyte cells in Black skin are larger and more active compared to those in White skin.⁶ This increased melanin production in darker skin provides a greater degree of natural photoprotection against UV radiation.¹⁹

Beyond pigmentation, there are notable variations in the structure and function of the stratum corneum, the outermost layer of the skin, across different ethnicities.² While the thickness of the stratum corneum may not differ significantly, ethnic skin often contains a greater number of cell layers within this layer.¹⁹ Histological analyses have revealed that ethnic skin tends to exhibit increased desquamation (shedding of skin cells) and a higher lipid content, but a decreased level of ceramides, which are crucial for maintaining the skin barrier.¹⁹ Darker skin often retains characteristics of younger skin for a longer duration, and its skin barrier function is reportedly stronger.⁷ In contrast, Asian skin has been reported to share similarities with Caucasian skin in terms of water loss and tends to have the weakest barrier function, along with lower natural moisturizing levels compared to both Caucasian and African skin.⁷ Black skin, while having a higher sebum content and a more compact stratum corneum with approximately twenty cell layers compared to sixteen in White skin, also exhibits lower ceramide levels, leading to increased transepidermal water loss (TEWL).⁶ Studies comparing skin barrier properties among different ethnic groups have also noted variations in TEWL, skin lipid levels, pH, and the size of mast cell granules.²⁰

A particularly important consideration when treating skin of color is the increased propensity for post-inflammatory hyperpigmentation (PIH).⁹ Individuals with darker skin tones, specifically those classified as Fitzpatrick skin types IV to VI, are more susceptible to developing PIH following any cutaneous injury or inflammation, including that resulting from aesthetic procedures.²³ This heightened risk is attributed to a more labile and exaggerated response of melanocytes in darker skin to such stimuli.¹⁹ Consequently, even minor skin irritations or procedures can trigger an overproduction of melanin, leading to noticeable hyperpigmentation.²³

Furthermore, research has identified differences in collagen structure and fibroblast activity across ethnicities.² Black skin, for instance, has been found to contain a greater number of fibroblasts, which are cells responsible for producing collagen, and these collagen fibers tend to be smaller in diameter compared to those in White skin.² Additionally, Black skin exhibits a higher number of macrophages, immune cells involved in the inflammatory response.² These variations in cellular composition and collagen structure may contribute to the differences observed in wound healing processes and the increased likelihood of keloid formation in individuals with darker skin.²

Finally, while overall rates of skin sensitivity may be similar across ethnic groups, the specific triggers and manifestations can vary.⁶ For example, African skin has been noted to have an increased size of mast cell granules, which could potentially lead to a greater release of histamine and other inflammatory mediators, thus increasing sensitivity.⁷ Despite this, skin sensitivity rates are similar across ethnicities, but the factors initiating a reaction can differ.⁷ Asian skin, for instance, may exhibit greater sensitivity to environmental chemicals, possibly due to a thinner skin barrier and a higher density of sweat glands.⁷ Studies have also indicated a higher degree of skin reactivity in Asian individuals compared to those of Black and White descent.²⁵

Medical Aesthetic Devices and Diverse Skin Types: A Comprehensive Overview

Laser and Light-Based Therapies: Wavelengths, Energy Levels, and Skin Pigmentation

Laser technologies in medical aesthetics operate on the principle of selective photothermolysis, where specific wavelengths of light energy are preferentially absorbed by targeted chromophores within the skin.¹ These chromophores can include melanin, hemoglobin, or water, depending on the laser’s wavelength and the intended treatment.²⁶ However, in individuals with darker skin tones, melanin, the pigment responsible for skin color, can act as a competing chromophore.¹ Because laser devices often target areas of contrast in skin color, the abundance of melanin in darker skin can lead to the laser energy being absorbed by the epidermis, increasing the risk of overheating and potential complications such as burns, blistering, and post-inflammatory hyperpigmentation.¹ The depth of laser penetration is also determined by its wavelength, with longer wavelengths reaching deeper layers of the skin and shorter ones working more superficially.²⁶ Therefore, understanding how different wavelengths interact with melanin is crucial for successful and safe laser treatments on diverse skin types.²⁶

When treating darker skin types with lasers, it is often recommended to utilize longer wavelengths, such as the 1064 nm Nd:YAG laser and certain diode lasers.⁹ These longer wavelengths have a lower affinity for melanin compared to shorter wavelengths like those used in Alexandrite or Ruby lasers, allowing them to penetrate deeper into the skin and target structures like hair follicles or blood vessels with less absorption by the epidermal melanin.⁹ For instance, the Nd:YAG laser is often the preferred choice for laser hair reduction in individuals with more pigmented skin due to its reduced risk of burns and post-inflammatory pigmentation.⁹ Similarly, diode laser technology has been shown to be safe and effective for hair removal across all skin types.¹⁷ By bypassing the superficial melanin, these longer wavelengths significantly minimize the risk of epidermal damage and subsequent pigmentary changes in darker skin.⁹

In addition to wavelength selection, careful adjustment of energy density (fluence) and pulse duration is essential for ensuring safety when treating darker skin with lasers.⁹ Lower fluence settings help to reduce the overall amount of heat delivered to the skin, thereby minimizing the risk of overheating and subsequent complications like hyperpigmentation or even hypopigmentation.⁹ Furthermore, utilizing longer pulse durations, which deliver the same total amount of energy over a more extended period, allows the skin to dissipate the heat more effectively, preventing excessive temperature buildup in the melanin-rich layers.⁹ This approach helps to strike a delicate balance between effectively treating the targeted condition and minimizing the potential for adverse pigmentary changes in patients with darker skin tones.¹⁹

Advancements in laser technology have led to the development of devices that offer more versatile treatment options for a wider range of Fitzpatrick skin types, including darker tones.⁹ For example, the Fraxel Dual laser, a non-ablative fractional laser that combines 1550 nm and 1927 nm wavelengths, has been shown to be safe and effective for skin resurfacing across all skin types, although the settings must be carefully tailored to the individual patient’s skin type and specific needs.⁹ Similarly, picosecond lasers, which deliver energy in ultra-short pulses, have demonstrated clinical success in treating various medical and cosmetic skin conditions across all skin types with a reduced risk of unwanted side effects compared to older laser technologies.²⁷ The Quanta Pico Discovery laser is also indicated for use on all Fitzpatrick skin types.¹⁶ These newer technologies often allow for greater customization of treatment parameters, enabling practitioners to minimize the risk of adverse effects while still achieving the desired aesthetic outcomes in patients with diverse skin tones.

Radiofrequency and Ultrasound Devices: Considerations for Different Skin Structures

Radiofrequency (RF) and ultrasound-based devices are often considered safer alternatives to some laser treatments for individuals with darker skin tones because their energy delivery mechanisms are not primarily dependent on melanin absorption.¹⁶ RF energy works by delivering electromagnetic waves that generate heat in the deeper layers of the skin, stimulating collagen and elastin production for skin tightening and contouring.¹⁷ Ultrasound devices, on the other hand, use sound waves to create thermal or mechanical effects in the subcutaneous tissues, leading to skin tightening and fat reduction.²⁹ Because these energy modalities do not primarily target melanin, they are often described as “color-blind,” which significantly reduces the risk of epidermal damage and post-inflammatory hyperpigmentation that can occur with some laser treatments in darker skin types.¹⁷ Treatments like VirtueRF and radiofrequency microneedling are suitable for all Fitzpatrick skin types.¹⁶ The Vivace® Microneedle RF device, for example, is specifically cleared by the FDA as a safe and effective solution for skin rejuvenation in patients with higher Fitzpatrick skin types.²⁸

Microneedling, especially when combined with radiofrequency energy (RFMN), has emerged as a particularly safe and effective skin rejuvenation technique for individuals with darker skin tones.¹⁶ RFMN involves the use of fine needles to create controlled micro-injuries in the skin, which triggers the body’s natural healing response and stimulates collagen and elastin production.²⁸ Simultaneously, radiofrequency energy is delivered through the insulated microneedles into the deeper dermal layers, further enhancing collagen remodeling and skin tightening while largely sparing the epidermis from thermal damage.²⁸ This targeted energy delivery minimizes the risk of post-inflammatory hyperpigmentation, making RFMN a valuable option for addressing concerns like acne scarring, wrinkles, and skin laxity in patients with higher Fitzpatrick skin types.²⁸

While RF and ultrasound technologies are generally considered safer for darker skin, it is important to acknowledge that variations in skin structure across different ethnicities, such as differences in stratum corneum thickness, hydration levels, sebum content, and collagen density, might influence the optimal treatment parameters and the overall response to these energy-based devices.² For instance, Black skin has a more compact stratum corneum and may have different moisture-retaining qualities compared to Asian or Caucasian skin.⁶ These structural differences could affect how the skin absorbs and conducts thermal energy. Therefore, while the risk of pigmentary complications might be lower with RF and ultrasound, practitioners should still take into account the individual patient’s ethnic background and skin characteristics when determining the appropriate treatment parameters to achieve optimal and predictable results.⁷

Injectable Treatments (including HA fillers, neuromodulators, and biostimulators): Anatomical and Physiological Factors

Injectable treatments, including dermal fillers, neuromodulators like botulinum toxin, and biostimulatory agents, are generally considered safe and effective for individuals across all Fitzpatrick skin types.³⁰ Unlike laser and light-based therapies, these treatments do not directly target melanin and therefore carry a minimal risk of causing pigmentary changes.³⁰ However, achieving optimal aesthetic outcomes with injectables necessitates a thorough understanding of the diverse facial anatomies and varying aesthetic ideals prevalent across different racial and ethnic groups.³¹ Facial structures, including bone contours, fat pad distribution, and muscle anatomy, can exhibit significant variations among different ethnicities.⁷ Furthermore, aesthetic preferences for facial features, lip fullness, and even body contours like breast and buttock proportions can differ considerably across cultures and ethnicities.² Therefore, practitioners must consider these factors when planning and administering injectable treatments to ensure natural-looking and harmonious results that align with the patient’s individual preferences and ethnic background.³²

The way in which the face ages can also vary significantly across ethnicities, and understanding these distinct aging patterns is crucial for guiding the placement of injectable fillers to address the specific concerns of each patient.² For instance, while Caucasian skin may exhibit prominent fine lines and wrinkles due to photoaging, individuals with skin of color might experience less wrinkling but more issues with dyschromia (pigmentation irregularities) or volume loss leading to sinking and sagging.² Research on facial aging in White patients is well-documented, but there is less information available on how injectables affect aging in Black skin.¹⁰ Therefore, practitioners should tailor their treatment strategies based on these observed differences, for example, by addressing volume loss in areas of sinking and sagging in skin of color or targeting fine lines and wrinkles in lighter skin types.²³

Stimulatory dermal fillers, which work by prompting the body to produce its own collagen, may offer particular advantages for individuals with skin of color.²³ It has been observed that skin of color may exhibit a more pronounced or “reactionary” collagenesis response to these types of fillers compared to those with lighter skin.²³ As sinking and sagging are often more prominent concerns in aging skin of color than fine lines and wrinkles, the enhanced collagen production stimulated by these fillers could lead to more noticeable and satisfying skin tightening and overall rejuvenation in this patient population.²³

While generally safe, practitioners should be aware that patients who are taking immunomodulatory or immunosuppressant medications might have a higher risk of developing complications following dermal filler injections, such as granulomas (inflammatory nodules) or infections.³¹ A thorough medical history is therefore essential to identify such patients, and careful consideration should be given to the risks and benefits of proceeding with filler treatments in these individuals.³¹

When considering the equivalency between Chinese and Caucasian populations for the treatment of chin retrusion with hyaluronic acid (HA) dermal fillers, several factors support the rationale. First, skin thickness plays a role, with both Chinese and Caucasian individuals exhibiting variations within a range that responds similarly to volumizing treatments such as HA fillers.

Regarding Fitzpatrick skin types, both populations typically fall within the moderate ranges of the Fitzpatrick scale. Fitzpatrick’s classification ranges from type III to IV in Chinese and from type I to IV in Caucasian population which ensures comparable reactions to HA injections.

Most of the studies and Population Review include various types of populations without distinction. For instance, in the study by (Ogilvie, et al. 2020), the results include 85.8% of Caucasian, 12.5% of Asian descent and 0.8% of African descent. Similarly, the results from (Beer, 2021) include 34.9% of Fitzpatrick types I/II, 52.1% for type III/IV, and 13% for type V/VI. However, the safety and performance results are not stratified by type of population and are globally described.

This mixed-population approach in clinical studies suggests that the treatment responses are comparable across ethnic groups, safety profiles do not show significant ethnic variation, and the performance endpoints are achieved regardless of ethnic background. Furthermore, subgroup analyses in studies like (Marcus, et al. 2022) have shown comparable responder rates across different Fitzpatrick skin types, i.e. Types I-III: 79.7%, Type IV: 87.5%, and Types V-VI: 78.9%.

These findings indicate that while anatomical differences exist between populations, the clinical response to HA fillers remains consistent. This is particularly relevant when considering that:

• The overlapping Fitzpatrick skin types (III-IV) between Chinese and Caucasian populations show similar response rates
• Treatment protocols and injection techniques are standardized across populations
• Safety monitoring shows consistent patterns regardless of ethnicity

Detailed comparisons based on the literature research (SOTA and Population Review) regarding facial anatomical differences, clinical outcomes, and safety profile are summarized in the following tables, demonstrating how anatomical variations between populations relate to clinical outcomes and safety profiles.

• FACIAL ANATOMICAL DIFFERENCES (Chinese vs. Caucasian)

Anatomical Feature	Chinese	Caucasian	Clinical Significance	Citation
Chin Retrusion (female)	-6.6mm	-3.1mm	Affects baseline severity	Gu, et al. 2011
Mandibular Shape Variance	Reference	0.5-0.78mm (±0.32-0.55) difference	Affects injection planning	Metzger, et al. 2011
Facial Width	Wider at all measured points	Reference	Affects treatment area	Machard, et al. 2016
Soft Tissue Thickness	Thinner	Thicker	Affects injection depth	Jia, et al. 2016
Mandibular Plane Angle	30.4° (female)	23.5° (female)	Affects injection approach	Wirthlin, et al. 2013

Notable anatomical differences exist between Chinese and Caucasian populations, characterized by:

Mandibular and Chin Characteristics:

• Different degrees of chin retrusion (Gu, et al. 2011)
• Variations in mandibular shape and angles (Metzger, et al. 2011), (Wirthlin, et al. 2013)

Facial Structure:

• Different facial width proportions (Machard, et al. 2016)
• Variations in soft tissue thickness (Jia, et al. 2016)

However, despite these anatomical differences, the clinical performance and safety data below demonstrate that:

• Treatment effectiveness is comparable between populations
• Safety profiles are similar
• Patient satisfaction rates are consistent
• Response to HA filler treatment shows no clinically significant population-based differences

This suggests that while anatomical differences exist, they do not significantly impact the clinical outcomes when proper injection techniques and individualized treatment approaches are employed.

Chemical Peels and Microdermabrasion: Depth of Treatment and Skin Sensitivity

When considering chemical peels for individuals with skin of color, it is generally recommended to opt for superficial peels as they carry a lower risk of triggering post-inflammatory hyperpigmentation (PIH), a significant concern in darker skin types.⁹ Superficial peels typically utilize milder acids such as glycolic acid at concentrations ranging from 20% to 50% or salicylic acid at concentrations between 20% and 30%.³⁰ These agents primarily target the stratum corneum and stratum spinosum, the outermost layers of the skin, causing less inflammation compared to medium or deep peels.³⁰ As patients with more melanin in their skin tend to be at higher risk for PIH, superficial peels are often the preferred choice to achieve skin rejuvenation benefits with a reduced likelihood of adverse pigmentary changes.⁹ However, it is important to note that even superficial peels are not entirely without risk in this population.³⁰

Medium and deep chemical peels, which involve a more aggressive exfoliation reaching into the dermis, pose a significantly higher risk of complications in individuals with skin of color.³⁰ The deeper level of injury can disrupt the normal skin structure, potentially leading to hypopigmentation (loss of skin color), disfiguring scarring, and prolonged post-inflammatory erythema.³⁰ Therefore, these types of peels should be used with extreme caution in darker skin types and only by experienced practitioners who are well-versed in managing the potential complications in this population.³⁰ It is highly recommended to perform a test spot in an inconspicuous area, such as along the jawline or under the chin, about one week prior to a full-face treatment to assess the patient’s skin reaction and suitability for a medium or deep peel.³⁰

Microdermabrasion, a mechanical exfoliation technique that removes the superficial layer of dead skin cells, is often considered a gentler alternative to chemical peels and lasers.⁸ However, individuals with Fitzpatrick skin types III to VI, which include medium to dark skin tones, still have a higher risk of experiencing dyspigmentation (abnormal changes in skin color, including both hyper- and hypopigmentation) with this procedure compared to those with lighter skin.¹⁸ While microdermabrasion might be a suitable option for some, practitioners should still exercise caution and consider the individual’s skin type when recommending this treatment to minimize the potential for adverse pigmentary outcomes.¹⁸

Microneedling and Other Collagen-Stimulating Devices: Safety and Efficacy Across Skin Tones

Microneedling is a minimally invasive procedure that has become a popular and generally safe option for skin rejuvenation across all Fitzpatrick skin types, including skin of color.⁹ The technique involves creating controlled micro-injuries in the skin using fine needles, which stimulates the body’s natural wound healing process and promotes the production of collagen and elastin.⁹ A significant advantage of microneedling for individuals with darker skin tones is that it does not rely on heat or light energy that could be absorbed by melanin, thus significantly reducing the risk of post-inflammatory hyperpigmentation (PIH) compared to some laser treatments and chemical peels.⁹ This favorable safety profile makes microneedling a valuable alternative for addressing various skin concerns, such as acne scarring, fine lines, and improving overall skin texture, in diverse populations.³⁰

Fractional radiofrequency microneedling (FRNM) is an advanced form of microneedling that combines the benefits of micro-needling with the delivery of radiofrequency (RF) energy into the skin through the microneedles.²⁸ Often, the needles are insulated, allowing the RF energy to be primarily released in the deeper dermal layers while sparing the epidermis from significant thermal damage.²⁸ This targeted delivery of RF energy further enhances the stimulation of collagen and elastin production, leading to more pronounced improvements in skin texture, firmness, and the appearance of scars and wrinkles.²⁸ Similar to traditional microneedling, FRNM carries a minimal risk of post-inflammatory hyperpigmentation because it does not rely on direct heat or light absorption by melanin in the epidermis, making it a safe and effective option for skin rejuvenation in patients with higher Fitzpatrick skin types.²⁸ Devices like Vivace® Microneedle RF have been specifically found to effectively treat various skin concerns in patients with darker skin tones, including acne scarring and wrinkles, while minimizing the risk of complications like PIH and scarring.²⁸

The combination of microneedling with subcision, a technique used to release the fibrous bands that tether depressed scars, has also demonstrated significant success in treating acne scarring in individuals with skin of color.³⁰ Subcision involves inserting a needle under the skin to break up these fibrous bands, thereby releasing the tension and allowing the skin to regain its normal contour.³⁰ When performed in conjunction with microneedling, which stimulates collagen production to further improve the texture and appearance of the scars, this combined approach has shown high rates of improvement in patients with Fitzpatrick skin types III-V, with minimal and short-lived side effects.³⁰ This makes microneedling with subcision a valuable tool in the treatment of acne scarring in diverse populations.

Clinical Considerations for Tailoring Treatments

Pre-Treatment Assessment: Identifying Risk Factors and Setting Realistic Expectations

A comprehensive pre-treatment assessment is of paramount importance when considering medical aesthetic procedures for patients with diverse skin types.¹⁶ This assessment should begin with eliciting a thorough skin care history, including the patient’s current skincare regimen, any previous aesthetic treatments they have undergone, and their skin’s typical reactions to various products and procedures.¹⁹ Accurately determining the patient’s Fitzpatrick skin type is another crucial step, as it provides valuable insights into their potential sensitivity to UV radiation and their inherent risk of pigmentary changes.¹⁶ Furthermore, understanding the patient’s natural skin type in terms of hydration (normal, dry, oily, or combination) can further guide the selection of appropriate treatment modalities and post-procedure care.¹⁹ This initial evaluation allows the practitioner to identify potential risk factors, such as a history of post-inflammatory hyperpigmentation or keloid formation, and to tailor the treatment plan accordingly.¹⁹

During the pre-treatment evaluation, it is also vital to inquire about the patient’s medical history, specifically noting any prior instances of keloid or hypertrophic scarring, as individuals with darker skin tones have a higher predisposition to these types of abnormal scarring.¹⁸ The presence of comorbid inflammatory cutaneous diseases, such as eczema or psoriasis, should also be considered, as these conditions might increase the risk of adverse reactions or interfere with the healing process.³⁰ Additionally, a history of cutaneous herpes simplex virus or herpes labialis, particularly in the area to be treated, is an important consideration, as certain aesthetic procedures can trigger an outbreak.¹⁸ In such cases, prophylactic antiviral medication may be necessary. Recent history of surgery or radiotherapy in the treatment area should also be noted, as these factors can alter the patient’s skin.³⁰

Finally, a thorough discussion with the patient to understand their specific cosmetic concerns and aesthetic goals is essential.² Aesthetic ideals and what constitutes beauty can vary significantly across different ethnic and cultural backgrounds.² For example, patients with skin of color may prioritize addressing hyperpigmentation and achieving an even skin tone, while others might be more focused on reducing wrinkles or improving skin texture.⁹ Understanding these individual goals is crucial for tailoring the treatment plan and ensuring patient satisfaction.² It is important to move away from a universal standard of beauty and embrace the diversity of aesthetic ideals across different populations.²

Customizing Treatment Parameters: Adjusting Device Settings for Optimal Outcomes and Safety

When utilizing laser devices on patients with diverse skin types, particularly those with darker tones, it is crucial to adjust the treatment parameters to minimize the risk of adverse effects and optimize outcomes.⁹ This often involves selecting longer wavelengths, such as the 1064 nm Nd:YAG laser, which are less absorbed by melanin in the epidermis, thus reducing the risk of overheating and pigmentary changes.⁹ Additionally, using lower energy densities (fluence) and, even more importantly, lower density settings are necessary to further minimize the risk of overheating the skin and causing hyperpigmentation or hypopigmentation.⁹ Longer pulse durations are also preferred for patients with skin of color, as they deliver the same amount of energy over a more extended period, preventing rapid overheating and minimizing the risk of hyperpigmentation.⁹ Understanding how different laser wavelengths interact with the patient’s skin is fundamental for treatment success.²⁶

For chemical peels, the selection of the appropriate peeling agent and its strength should be carefully determined based on the patient’s skin tone and sensitivity.⁹ Patients with more melanin in their skin generally tend to tolerate more superficial peels better, as deeper peels carry a higher risk of post-inflammatory hyperpigmentation.⁹ Superficial peeling agents like glycolic acid (20% to 50%) and salicylic acid (20% to 30%) are often considered safest for all skin tones as they primarily target the stratum spinosum and have a lower side effect profile.³⁰ In contrast, deeper peels are generally safer for lighter skin tones.⁹ Pre-treating the skin with melanogenesis inhibitors such as topical hydroquinone or retinoids can also be considered to further minimize the risk of PIH in patients with skin of color undergoing chemical peels.³⁰

While microneedling and radiofrequency microneedling are generally considered safe for skin of color, the depth of needle penetration and the energy levels of the RF can be adjusted based on the individual’s skin thickness, the specific area being treated, and the particular skin concerns being addressed.²⁸ For instance, the depth of the needles can be varied from 1.5 mm to 2.5 mm depending on skin thickness and the area being treated, with a reduced depth often used on the second pass.²⁸ Similarly, the power level of the RF energy can be adjusted to achieve the desired level of collagen stimulation.²⁸ This customization allows for optimized treatment outcomes while maintaining a good safety profile across diverse skin types.

The Importance of Patch Testing in Diverse Skin

Performing a patch test is a critical safety measure, especially when utilizing laser-based treatments on individuals with skin of color.⁴² Before proceeding with a full treatment, it is essential to apply the laser to a small, inconspicuous area of the skin using the intended settings.⁴² This allows the practitioner to observe how the patient’s skin reacts over a period of 24 to 48 hours to assess for any adverse effects, such as excessive redness, blistering, or hyperpigmentation.⁴² If an unfavorable reaction occurs, the laser settings can be adjusted or an alternative treatment can be considered.⁴² Patch testing is particularly crucial when treating darker Fitzpatrick skin types and when addressing a new anatomical area, as skin sensitivity can vary across different parts of the body.⁴² Consulting the manufacturer’s guidelines for specific devices is also important when performing patch tests.⁴² By taking this precautionary step, practitioners can significantly reduce the risk of widespread adverse reactions and ensure a safer treatment experience for their patients.⁴²

Navigating Potential Complications

Hyperpigmentation and Hypopigmentation: Mechanisms, Risk Factors, and Management

Post-inflammatory hyperpigmentation (PIH) stands as a primary concern when performing aesthetic procedures on individuals with skin of color.⁹ This heightened risk stems from the increased activity of melanocytes in darker skin tones, which are more prone to producing excess melanin in response to any inflammation or injury to the skin.²³ Whether the inflammation is triggered by innate factors like acne or as a result of aesthetic interventions such as laser treatments or hair removal, PIH remains a significant potential complication.²³ Even when using longer laser wavelengths, which are generally safer for darker skin due to their deeper penetration and reduced absorption by melanin, the risk of hyperpigmentation is still present if treatment parameters are not appropriately tailored.⁹

While hyperpigmentation is a more frequently encountered issue in skin of color, hypopigmentation, or the loss of skin color, can also occur, particularly with aggressive treatments or the use of inappropriate laser settings.¹⁶ Certain lasers can have negative effects on darker skin, leading to both hyper- and hypopigmentation.¹⁶ The higher concentration of melanin in darker skin can cause it to absorb more energy, potentially leading to damage that results in either a lightening or darkening of the treated area.⁴³ Additionally, some treatments for keloids, such as corticosteroid injections and cryotherapy, also carry the risk of causing hypopigmentation at the treatment site.³⁸

To mitigate the risk of PIH, especially in patients with skin of color, pre-treatment with topical agents that inhibit melanin production, such as hydroquinone (4% used twice daily) or topical retinoids like tretinoin (used 2 to 4 weeks prior to the procedure), can be considered.³⁰ Emphasizing the importance of diligent sun protection both before and after any aesthetic procedure is also crucial, as UV exposure can exacerbate hyperpigmentation and make any pigmentary changes more noticeable and potentially permanent.³⁸

When PIH does occur, various management strategies can be employed to help lighten the affected areas.³⁰ These may include the continued use of topical melanogenesis inhibitors like hydroquinone or retinoids.³⁰ Prescription-strength corticosteroid creams can help to ease itchiness associated with conditions like keloids.³⁸ Gentle chemical peels using agents like glycolic or salicylic acid can help to exfoliate the superficial pigmented layers of the skin.³⁰ In some cases, laser treatments, such as pulsed-dye lasers, can be used with appropriate settings to target the excess melanin and help fade hyperpigmentation, although caution is necessary to avoid further inflammation.³⁸ The choice of treatment for PIH will depend on the severity and persistence of the hyperpigmentation, as well as the individual patient’s skin type and response to treatment.

Keloid and Hypertrophic Scarring: Predispositions and Prevention Strategies

Individuals with darker skin tones, particularly those of African, Asian, and Hispanic descent, have a higher predisposition to the formation of keloids.⁷ Keloids are a type of raised scar that occurs when scar tissue continues to form even after the skin healing process has ended, resulting in thick, irregular scarring that extends beyond the borders of the original wound.³⁸ This increased susceptibility is likely due to genetic factors and inherent differences in collagen production within these populations.⁴⁰

Aesthetic procedures that cause more inflammation or place tension on the skin during the healing process may increase the risk of keloid formation in predisposed individuals.³⁹ Even minor injuries to the skin, such as insect bites, acne, injections, body piercings, burns, hair removal, and even minor scratches, can potentially trigger keloid growth in susceptible individuals.³⁹

For individuals identified as being at high risk for keloid formation, several prevention strategies can be implemented.³⁸ These include meticulous wound care to keep the area clean and moist.³⁹ The use of silicone sheeting or gel applied to the healing wound can also be beneficial in reducing the risk of keloid development.³⁸ Pressure dressings or garments can be effective, especially for preventing hypertrophic scars in burn patients, and pressure earrings are sometimes used after ear piercing to reduce keloid risk.⁴⁰ In some cases, corticosteroid injections into the wound site after a procedure may also be considered as a preventive measure.⁴⁰ It is important for individuals prone to developing keloids to avoid unnecessary surgeries or cosmetic procedures in keloid-prone areas of the body.⁴¹

Other Adverse Events: Recognition and Management in Diverse Patients

Mechanical dermabrasion, a skin resurfacing technique, carries a higher risk of dyspigmentation (abnormal skin color changes) in individuals with Fitzpatrick Skin Types III to VI.¹⁸ This underscores the importance of considering the patient’s skin type even with non-laser based resurfacing methods.¹⁸

While darker skin is more prone to hyperpigmentation, individuals with very light skin (Fitzpatrick Types I and II) may experience prolonged redness or skin irritation after certain laser treatments.¹⁶ Practitioners should be aware of this potential for increased sensitivity in lighter skin types as well.¹⁶
It is also crucial to recognize that dermatological conditions can present differently in skin of color compared to lighter skin types.¹⁹ This variation in presentation can sometimes lead to misdiagnosis or delays in treatment, highlighting the need for healthcare professionals to have adequate training and experience in diagnosing skin conditions in diverse populations.¹⁹ For example, fungal infections like tinea versicolor may be difficult to notice on white skin but cause very noticeable hypopigmentation on darker skin tones.¹⁹ Similarly, conditions such as dyschromia, alopecia, and seborrheic dermatitis are found much more frequently in skin of color compared to white patients.¹⁹ Even common conditions like acne may present with specific characteristics in darker skin that complicate standard management.¹⁹ The lack of adequate representation of darker skin tones in medical educational materials can further contribute to diagnostic challenges.⁴⁴

Addressing Bias in Medical Device Design and Evaluation

A critical area of concern is the potential for racial bias in the design and evaluation of medical devices.⁵¹ A prominent example of this issue is the pulse oximeter, a widely used medical device that has been shown to provide inaccurate readings in individuals with darker skin tones.⁵¹ Studies have consistently demonstrated that pulse oximeters tend to overestimate oxygen levels in patients with darker skin pigmentation, potentially leading to delays in the recognition and treatment of hypoxemia.⁵¹ This inaccuracy can have serious clinical consequences, as it may result in these patients being less likely to receive necessary supplemental oxygen or timely medical intervention.⁵⁵

To address this and other potential biases, it is crucial for medical device manufacturers to include diverse populations in their testing and validation processes.⁴⁶ Regulatory bodies should also establish clear, standardized methods for evaluating potential bias in medical devices to ensure accurate and equitable performance across all users.⁵¹ The FDA, for instance, has issued a discussion paper outlining an approach to improve the performance evaluation of pulse oximeter devices, taking into consideration skin pigmentation, race, and ethnicity.⁵¹ Furthermore, involving individuals from diverse backgrounds in the design and development process of medical devices, as well as engaging with communities through participatory research approaches, can help identify and mitigate potential biases and ensure that devices are more inclusive and meet the needs of all users.⁵² Creating diverse design teams and systematically identifying sources of bias are important steps towards ensuring equity in medical technology.⁵²

Facial and Body Anatomical Variations Across Ethnicities and Their Impact on Treatment Planning

Significant anatomical differences exist in facial structure across various racial and ethnic groups, including variations in nose shape, cheekbone prominence, jawline definition, and overall facial proportions.⁷ For instance, East Asian populations often have wider and shorter noses with a greater distance between the inner corners of the eyes compared to Caucasians.³³ African Americans tend to exhibit shorter and wider noses with narrower jaws compared to Caucasians and Koreans.³³ These anatomical variations extend to other facial features as well, such as forehead height and slope, lip projection, and chin prominence, all of which can differ significantly among various ethnic groups.⁷ These inherent anatomical differences must be carefully considered when planning medical aesthetic treatments to achieve harmonious and natural-looking results that respect the individual’s ethnic identity.³³ A standardized approach based solely on Caucasian facial features may not be appropriate or desirable for individuals from other racial and ethnic backgrounds.³³

Aesthetic preferences for facial features also vary widely across cultures and ethnicities.² What is considered aesthetically pleasing in one culture may differ significantly in another. For example, in some Asian cultures, a smaller face and double eyelids are often seen as attractive, while many African cultures may emphasize fuller lips and curvier body shapes.³⁴ Even within Malaysia, preferences for facial shape and nasal width-to-length ratio have been found to be associated with ethnicity among Malay, Chinese, and Indian women.³⁵ Therefore, aesthetic treatments should aim to optimize the patient’s existing ethnic traits rather than attempting to impose a Westernized or singular ideal of beauty.³⁴ Practitioners must engage in open communication with their patients to understand their specific aesthetic goals within their cultural context.³⁴

Furthermore, aesthetic ideals for breast and body contours also exhibit ethnic diversity.³⁶ Significant ethnic differences in preferences for upper- and lower-pole breast proportions have been reported.³⁶ Similarly, preferences for buttock size and shape, as well as the waist-to-hip ratio, vary among different ethnic groups, highlighting the need for personalized treatment approaches in procedures like breast augmentation and body contouring.³⁶ Non-Caucasians generally prefer larger buttocks than Caucasians, and there is consensus on the ideal waist-to-hip ratio, although other factors also contribute to the aesthetic evaluation of buttocks.³⁶

Best Practices and Guidelines

Providing culturally competent and clinically effective care to patients with diverse skin types in medical aesthetics necessitates a multifaceted approach. It is paramount to prioritize a thorough initial consultation that includes a detailed skin assessment, a comprehensive understanding of the patient’s medical history, and a clear discussion of their specific aesthetic goals.⁹ This comprehensive evaluation forms the foundation for developing a safe and effective treatment plan tailored to the individual’s unique needs and characteristics.⁶¹

Recognizing the inherent variations in skin physiology and aesthetic preferences across different ethnicities, clinicians must tailor treatment plans and adjust medical device parameters accordingly.⁹ This includes carefully selecting laser wavelengths, energy densities, and pulse durations based on the patient’s Fitzpatrick skin type to minimize the risk of pigmentary complications.⁹ For chemical peels, the choice of peeling agent and its strength should be adjusted based on the patient’s skin tone and sensitivity, often favoring superficial peels for darker skin types.⁹ For microneedling and radiofrequency microneedling, the depth of needle penetration and the energy levels can be customized based on skin thickness and the specific concerns being addressed.²⁸

Educating patients on proper pre- and post-treatment skincare is also vital for enhancing treatment outcomes and preventing complications, particularly hyperpigmentation.⁶ This includes emphasizing the critical importance of consistent, broad-spectrum sun protection and recommending appropriate skincare products that support healing and maintain results.⁶

Clinicians treating patients with skin of color should be particularly aware of the increased risk of post-inflammatory hyperpigmentation and keloid formation.⁹ Implementing preventive strategies is essential, such as using appropriate device settings, considering pre-treatment with melanogenesis inhibitors for procedures that carry a higher risk of PIH, and advising patients on meticulous wound care to promote optimal healing and minimize the risk of abnormal scarring.⁹

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