Challenges of skin color

I've heard people described as Latin, Spanish or Hispanic in their background. How do you define people of color?

Dr. Woolery-Lloyd: There are two ways to define skin of color. Typically, skin of color is defined as Fitzpatrick skin types IV though VI. Another way to think of skin of color is the propensity to hyperpigment, because that is what we're often most concerned with, and that type of skin is the most common in Hispanic, Asian and black populations.

How do cosmetic concerns differ in patients with skin of color?

Also, for many of these patients, there is the concern with unwanted facial hair. Another common concern for these patients is scarring. This is something that I think still needs a lot of research. We have a long way to go in the treatment of keloids and hypertrophic scars.

Let's talk about both conventional and novel approaches to hyperpigmentation in people of color.

Dr. Woolery-Lloyd: Obviously the number one thing that I emphasize is sun protection. For the typical patient that comes into my office complaining of hyperpigmentation I really try to emphasize using a sunblock daily. Sometimes patients with skin of color don't like physical blockers, because the zinc oxide or titanium dioxide can leave a gray film or gray tint to the skin. Patients who complain of this problem would rather use chemical sunscreens. The great news is that our chemical sunscreens are improving, but I still think the gold standard is a physical blocker.

How do you manage hyperpigmentation caused by acne?

Dr. Woolery-Lloyd: I typically recommend a topical retinoid at night and a bleaching cream that contains hydroquinone, usually in the range of 6 percent to 8 percent. And I recommend a combination product with benzoyl peroxide and an antibiotic in the morning.

Now that's higher than conventionally available hydroquinone, which usually tops off at 4 percent. So how does one access 6 percent or 8 percent hydroquinone for their patients?

Dr. Woolery-Lloyd: I use a compounding pharmacy that specializes specifically in compounding hydroquinones. Not all local pharmacists - even if they're good at compounding - have the materials that are necessary to produce a stable hydroquinone product.

What should the expectations be in terms of time, point of efficacy and duration of treatment?

Dr. Woolery-Lloyd: An 8 percent hydroquinone works and works quickly. I usually tell patients that they should expect to see some improvement within two weeks and maximum improvement at around six weeks.

The other issue is that it is important to carefully explain to patients how to apply the product. For the patients that have diffuse hyperpigmentation, I explain to them that they can use the bleaching cream within a given cosmetic unit - but I also explain that it will lighten their normal skin. And if they see that happening, and if it becomes prominent, they need to hold the bleaching cream for five to 10 days until their normal skin repigments; then they can restart the treatment again.

In patients with just a few scattered macules I prefer spot treatment, but I explain carefully they have to stay within the borders of the pigmented areas.