Addressing Skin of Color Disparities in Cosmetic Dermatology

A recent study¹ found that patients with darker skin types, particularly phototypes 5 and 6, are often excluded from or missing in clinical trials evaluating the safety and efficacy of laser and light therapies in dermatology.

Elaine Kung, MD, FAAD, is a board-certified dermatologist, assistant clinical professor of dermatology at NYP-Weill Cornell Medical Center, and founder of Future Bright Dermatology in New York, New York, where she serves a diverse population of patients, treating dermatologic conditions and specializing in aesthetic procedures. Kung spoke with Dermatology Times® to discuss raising the standard of care for patients with darker skin types using energy-based devices and enhanced training opportunities.

Elaine Kung, MD, FAAD/Future Bright Dermatology

Dermatology Times: How has aesthetic and cosmetic dermatology historically missed the mark with respect to patients with skin of color?

Kung: When I was a resident in dermatology over 15 years ago, energy-based devices for aesthetic treatments were based on selective photothermolysis pioneered by Dr. Rox Anderson at Wellman Center for Photomedicine. This concept is characterized by delivering wavelengths of light over a specific duration to targets in the skin, such as pigment or oxyhemoglobin, to affect a desirable aesthetic outcome. Later, devices were engineered to fractionate CO2 and erbium laser pulses to lessen the risk and recovery time of using these machines to remove photodamage and improve collagen production.

The intense pulse lights, diodes, pulse dye, erbium, and CO2 devices that I alluded to above are not "color-blind" technologies. They carry the risk of hyper or hypopigmentation for people with medium or darker skin tones. However, in the last 10 years, energy-based devices have been made to be inclusive for people with medium to darker skin tones. Devices that target the skin beyond the basal layer of the epidermis are safer for people with darker skin. Therefore, Ultherapy (Ultrasound), Sofwave (Ultrasound), Thermage (Radiofrequency), and other Radiofrequency devices that target the dermis are safe for all skin colors.

This is important because a majority of the world is populated by people with medium to dark skin tones. It is estimated that 50% of the United States will be people of color by 2040.²

Dermatology Times: What new advances are on the horizon that are inclusive of skin of color?

Kung: As I have mentioned, there have been skin tightening devices that are safer to use on darker skin for the last decade. The most exciting advance in anti-aging is rejuvenating the muscle as well as the skin.

Lumenis Aesthetics launched triLift and BTL Aesthetics launched Emface to utilize muscle stimulation and radiofrequency to firm facial muscles and tighten the skin to create non-surgical face-lift like results.

Dermatology Times: How are these new advances groundbreaking and/or impactful to the field of dermatology?

Kung: I think these advances are impactful because they allow dermatologists to treat beyond the cutaneous layer. Aging involves loss of bone mass, muscle tone, subcutaneous fat in certain areas, collagen and elastin. TriLift and EMFACE allow us to target 2 of these aging structures.

Dermatology Times: From a patient perspective, how do these advances improve their dermatologic care?

Kung: We have the triLift in my clinic and my patients love that it treats many of their aging concerns without using large needles, cannulas, or a scalpel. The triLift protocol combines the powers of direct facial muscle stimulation and radiofrequency microneedling so it repositions facial tissues, increases dermal thickness, improves skin texture, and evens out skin tone. Initially, people are excited about firming their skin or lifting their jowls but found that fine lines, pore sizes, brown spots, and rosacea have improved as well. This global improvement with relatively little pain and downtime attracts a lot of patients.

Dermatology Times: What should dermatologists be cognizant of when it comes to implementing these advances in their own practices?

Kung: When rejuvenating facial muscles with muscle stimulation, it's important not to target muscle depressors, not to strengthen masseters for people with teeth grinding, jaw clenching, or temporomandibular joint (TMJ) pain, not to use the device on people with facial neuralgias or implantable devices near treatment areas.

Dermatology Times: Could you speak a little bit to that exposure and that training, and what dermatologists or aspiring dermatologists would really be cognizant of with regard to treating patients with skin of color? What expanded training suggestions do you have moving forward?

Kung: People's comfort level has to do with their exposure in practice. I'm in a unique position, because I trained at University of Chicago and have practiced in New York City, where I treat the colors of the human rainbow. It's because I've been in urban centers for the entirety of my career that I’ve been comfortable treating people of color because my exposure is reflective of the population I serve.

If the population isn't diverse enough, then residents would not reach a level of comfort with treating patients of color through their training programs. There are more and more conferences geared towards helping skin of color patients. I think that type of learning program has to be expanded so dermatologists can become more comfortable treating people of color.

For example, Lumenis Aesthetics ran workshops, which I've been a part of, where we talk about how to skin type someone and what machines we can use to target specific concerns. I think what's missing in these workshops is the actual, real-world live demonstrations on maximizing the use of these devices. If there are models of different ethnic groups, we can demonstrate how we can use these devices and what endpoints we're looking for during the treatment.

Dermatology Times: Is there anything else that you feel is really important for dermatologists and/or patients to know about this topic?

Kung: I think there are a lot of devices that are able to treat people of color. It's really just the comfort level of the users. The disparity of using laser and energy-based devices for people of color is not that the companies haven't developed a device for people of color.

For example, radiofrequency (RF) microneedling has now become more popular and more widely used. It can help improve skin tone and pigmentary issues, as well as skin texture and laxity. The RF energy that's delivered via the microneedles passes the epidermis without damaging the melanocytes in the skin’s basal layer. So those of us who treat patients with darker skin deem RF microneedling to be a “color-blind” technology.

I think we do have technologies available to treat people of color. The root of the disparity is the level of comfort with the user of these devices. I think partnership with aesthetic device companies to do clinical trials with broader demographic groups will help narrow this knowledge gap.

[Transcript edited for clarity]

Disclosures

Kung has received lecture fees for speaking at the invitation of a commercial sponsor (Lumenis).

References

1. Manjaly P, Xia E, Allan A, et al. Skin phototype of participants in laser and light treatments of cosmetic dermatologic conditions: a systematic review. J Cosm Dermatol. 2023. doi:10.1111/jocd.15739
2. Frey WH. The US will become “minority White” in 2045, Census Projects. Brookings. March 9, 2022. Accessed May 9, 2023. https://www.brookings.edu/blog/the-avenue/2018/03/14/the-us-will-become-minority-white-in-2045-census-projects/.