Procedures to Proceed and Avoid With Skin of Color

Seemal Desai, MD, dermatologist at Innovative Dermatology in Plano, TX, shared invaluable insights on procedures for patients with skin of color, specifically addressing pigmentary disorders, in the session “Therapies and Procedures to Avoid and to Use in Skin of Color” at the 2024 Winter Clinical Hawaii Dermatology Conference.¹

Seemal Desai, MD (Photo courtesy: Innovative Dermatology)

Acne and Post-Inflammatory Hyperpigmentation

Desai highlighted the challenge faced by patients with darker skin types facing post-inflammatory hyperpigmentation resulting from acne. He emphasized the effectiveness of chemical peels as a cost-effective and impactful solution. He stressed the importance of patient preparation to optimize results.

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"Remind all of your chemical peel patients to discontinue any topical retinoids at least 7 days prior to coming in for the treatment,” Desai said. He continued to share the need for patients to pre-treat with hydroquinone for several weeks before the chemical peel to prime their skin.

Sharing his preferred chemical peeling agents, Desaisaid, "On this list I've listed glycolic acid, salicylic, and trichloroacetic acid (TCA)." He challenged the traditional understanding of TCA,stating, "TCA does not become medium depth until it's in concentrations close to 20%.At lower concentrations, TCA actually works as a superficial chemical peel."²

Melasma Treatment

Transitioning to melasma, Desai introduced mandelic acid as an effective addition to chemical peels. He referenced a study supporting the efficacy of mandelicacid 40% in treating melasma. The concept of "chemical peel cocktails" or sequential chemical peels was introduced, where multiple ingredients are layered in 1 session, providing quick and efficient results.³

These are procedures done in less than 10 minutes in the office. Any one of us in this room can do this," Desai added.

Acne Scars and Dark Circles

Addressing acne scars, Desai recommended a combination of Jessner's solution and 20% TCA. He highlighted the synergy achieved by combining alpha (mandelic acid) and beta (salicylic acid) hydroxy acids in chemical peels.⁴Additionally, he shared a procedure involving 10% TCA with shallow depth micro-needling for treating infraorbital dark circles, showcasing impressive before-and-after images.

Vitiligo Evening of Skin Tone

For patients with patchy vitiligo desiring an even skin tone, Desai recommended techniques involving liquid nitrogen and/or or laser-assisted depigmentation. “This is one of my favorite go-to techniques,” he said."So many of you may have seen patients who come in with vitiligo, and you get their face better.Hands are so difficult to repigment, especially the fingertips and the dorsal hand. Some of these individuals just an evening of the skin tone, even if you can't bring back their normal color, they just don't want to be multicolored.That's where you can actually use simple liquid nitrogen to destroy their normal pigment or laser assist.”

He stressed the significance of treating hands, considering their cultural importance in beauty.

Patient Counseling on Cosmetic Procedures

Desai provided guidelines for dermatologists when counseling patients with vitiligo on cosmetic procedures. A consensus highlighted the safety of laser hair removal and IPL for stable vitiligo, emphasizing the importance of low settings and cautious use to avoid heat-induced trauma.

“Patients with vitiligo should never undergo an ablative laser because that is bound to koebnerize and worsen the disease,” he said. “Try to always do test spots whenever you can. And if you have any laser or device induced depigmentation, treat very aggressively with the systemic dexamethasone along with the topicals in terms of laser hair removal and IPL. If your disease has been stable for at least a year,if you don't have new lesions or worsening of your vitiligo in a previous 12 months, then I think it's okay to do laser hair and IPL with the caveat that laser devices can cause a heat induced trauma to the skin and a theoretical koebnerization.”

Caution Against Counterfeit Skin Bleaching Products

Desai emphasized the need to counsel patients on safe skin-lightening agents and cautioning against counterfeit products. He presented examples of products with harmful ingredients like lead, arsenic, and mercury, stressing the dermatologist's role in advocating for evidence-based treatments.

“It's important that we, as dermatologists, advocate for the use of hydroquinone and asoleic acid and tranexamic acid and all the things we use as experts to help pigmentary diseases. We want to argue against using these counterfeit skin bleaching products that are actually causing toxicity and damage to our patients,” Desai concluded.

References

1. Desai S. Therapies and Procedures to Avoid and to Use in Skin of Color. Presented at: 2024 Winter Clinical Hawaii Dermatology Conference; January 12-17, 2024, Honolulu, HI.
2. Sarkar R, Bansal S, Garg VK. Chemical peels for melasma in dark-skinned patients. J Cutan Aesthet Surg. 2012;5(4):247-253. doi:10.4103/0974-2077.104912
3. Sarkar R, Arsiwala S, Dubey N, et al. Chemical peels in melasma: a review with consensus recommendations by indian pigmentary expert group. Indian J Dermatol. 2017;62(6):578-584. doi:10.4103/ijd.IJD_490_17
4. Puri N. Efficacy of modified Jessner's peel and 20% TCA versus 20% TCA peel alone for the treatment of acne scars. J Cutan Aesthet Surg. 2015;8(1):42-45. doi:10.4103/0974-2077.155082