Robert Kronemeyer

Technologies ranging from microneedling to picosecond domain lasers provide new solutions for treating dermatoses in skin of color, said Monica Li, MD, in her presentation on aesthetic considerations in patients of color at the American Academy of Dermatology (AAD) Virtual Meeting Experience (VMX).

“This is an important topic because the patient and population demographics in North America are changing,” said Li, a clinical instructor in dermatology and skin science at the University of British Columbia in Vancouver, Canada.

AAD recently released statistics advocating for proper skin care for all skin colors based on US Census Bureau predictions that by 2044, no single racial group will dominate the population.

“This trend in real-world clinical practice calls for greater knowledge, competence, and management by dermatologists to better serve the aesthetic dermatologic needs for those with darker skin phototypes,” Li said. “As an increasing number of patients of color come to our dermatology practices, clinicians also must appreciate differences in patient needs, outcomes, and management approaches compared to fairer skin types. This recognition requires awareness and education.”

These pigmentary skin conditions include melasma, benign pigmented epidermal and dermal skin lesions, plus common conditions like postinflammatory hyperpigmentation (PIH) and striae.

As with any patient, irrespective of skin tone, a thorough and comprehensive history is necessary. “This includes a prior history of PIH or keloid scarring from other treatments or skin diseases,” Li said. “By being mindful of these complications, clinicians can implement strategies to try to prevent them in the first place.”

Li does not believe there is a specific device for preferential use in skin of color; however, awareness of an increased risk of certain adverse events (AEs) in this population, such as PIH, is crucial. “Patients who [are at] risk for PIH need to be very strict about sun protection and avoidance at least 1 month before treatment,” she said.

Microneedling is relatively safer to use in darker skin types. “This collagen induction therapy has been shown to be safe and effective for all skin types for scars and striae,” Li said.

Picosecond domain lasers have seen positive safety results in skin of color, according to Li. “These lasers produce more of a photomechanical effect than a photothermal effect that is traditionally delivered by previous generations of lasers,” she said. “A more photoacoustic effect reduces the delivery of heat energy to the targeted site and surrounding skin, thus potentially reducing the risk of dyspigmentation.”

In addition, radiofrequency (RF) technologies and high-intensity focused ultrasound (HIFU) can benefit patients of color when used under the right circumstances. “But these two treatment modalities used in isolation often do not necessarily target pigmentary concerns or scars because of their different mechanisms of action,” Li said. “There may also be different therapy techniques when it comes to treating skin of color.”

Recent technological advancements show that fractional lasers might also be safe for this population, if used with care. “However, it requires more advanced knowledge and experience because fractioned lasers deliver thermal energy,” Li said. “Settings that are overly assertive can lead to adverse outcomes.”

Most laser and other light-based devices require longer intervals between treatments for skin of color than those with lighter skin phototypes: every 6 to 8 weeks vs 3 to 4 weeks, respectively. “This ensures that there is no residual inflammation that can drive adverse effects like PIH,” Li said.

To increase the safety of various aesthetic modalities, Li recommends testing for potential AEs using small spot treatments before proceeding with the full face, neck, or chest.

“You should also be more conservative with treatment parameters,” she said. “It is always OK to start low and go slow, to hopefully prevent or at least curb some of the adverse events. If they do occur, they may be of less intensity.”

For laser systems, larger spot sizes and lower fluences are generally advised.

Recognizing AEs promptly is important, “so if they occur, management is instituted as soon as possible,” Li said. “For instance, we know that typically PIH happens around week 3 to week 4 after a treatment. Therefore, timely follow-up is needed.”

Addressing immediate posttreatment inflammation with topical medications can lessen PIH, along with topical skin lightening agents.

“Going forward, I am hopeful for more clinical trials and more research and development in evolving technologies and devices that can be used safely and effectively across the skin spectrum,” Li said. “More importantly, increased knowledge and experience amongst colleagues ultimately will improve aesthetic dermatology care for patients of both light and dark skin tones.”

Li is a consultant and speaker for Candela Medical.

1. Li M. Let there be Light: Aesthetic considerations in ethnic skin using lasers and devices. Presented at: 2021 American Academy of Dermatology Virtual Meeting Experience (AAD VMX) annual meeting; April 23-25, 2021 (Virtual).

2. Taylor, SC. Skin of color boot camp: what every dermatologist should know about the patient with dark skin tones. Presented at: 2018 American Academy of Dermatology 2018 annual meeting; Feb. 16-20, 2018, San Diego, California.

3. Colby S, Ortman J. US Census Bureau Report No. P24-1143. Projections of the size and composition of the U.S. population: 2014 to 2060. March 3, 2015. Accessed April 12, 2020. https://www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf

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Physicians must learn how to tailor treatments and assess skin of color risk to best serve the POC patient population. Doing so will deliver positive outcomes and drive patient satisfaction.

Laser Considerations for Skin of Color

Simply observing symptoms can often help a patient receive a hair loss disorder diagnosis. However, observation alone is less helpful in evaluating treatment methods.

“It is important for a dermatologist to be able to quantify how much hair has been lost or gained,” said Jerry Shapiro, MD, a professor of dermatology at the NYU Grossman School of Medicine, New York, New York, who spoke on managing hair loss disorders at Maui Derm Live.

 The in-person dermatology continuing medical education (CME) conference in Hawaii was held concurrently with Maui Derm Connect, a virtual CME conference, January 25-29, 2021.

“Because of the tools now available to quantify, we now have a more scientific approach to determine how much [hair] gain or loss the patient has had from their treatment protocol.”

Trichometrics/numerics are key to measuring the efficacy of treatment modalities for hair growth. The 3 devices most effective to confirm success or failure in the office setting, according to Shapiro, are the Folliscope (LeadM Corporation), FotoFinder (FotoFinder Systems), and artificial intelligence with Vectra (Canfield Scientific Inc.).

“These are easy and accurate devices to use,” Shapiro told 

. “Patients also appreciate them because they like to know their numbers and whether those numbers have gone up or down or are the same.”

Scarring alopecias are a group of disorders characterized by a final common pathway of replacement of follicular structure by fibrous tissue. They present clinically as loss of follicular ostia and the histopathology is obliteration of the hair follicle.

“There are no placebo-controlled, double-blinded, randomized studies of therapeutics for scarring alopecias, and no evidence-based medicine,” Shapiro said.

One of these conditions is primary cicatricial alopecia, which involves preferential destruction of follicular epithelium with sparing of interfollicular dermis. Clinical indications are hyperkeratosis, erythema, a positive pull test, and symptoms includes itching, burning, and pain.

Discoid lupus erythematosus, another type of scarring alopecia, presents with lesions often localized to the scalp and can be treated based on the extent of disease. For milder cases, an ultra-potent topical steroid might be combined with intralesional triamcinolone acetonide (IL-TAC). If improvement occurs, treatment can continue as needed. But with no improvement, 3 other options are hydroxychloroquine, isotretinoin, and topical tacrolimus 0.3% twice a day+ corticosteroid twice a day + 5% minoxidil solution twice a day (TCM).

For more severe forms, beginning therapy comprises hydroxychloroquine 200 milligram (mg) twice a day, along with perhaps an ultra-potent topical steroid and/or IL-TAC and/or prednisone. With improvement, medications can be tapered to the lowest effective doses.

Assessment of clinical features of classic lichen planopilaris, a third type of scarring alopecia, may be enhanced through trichoscopy. Erythema and hyperketatosis can also be quantified and hair density quantified at target areas.

However, because of the risk of koebnerization with classic lichen planopilaris, “a hair transplant should be considered only after at least 2 years have passed with no disease activity,” Shapiro said. For rapidly progressive disease, oral prednisone can be given tapered for the first 8 weeks to bridge therapy.

Milder cases of classic lichen planopilaris can be stabilized with a treatment regimen of IL-TAC 10 mg/ml monthly + TCM twice a day. Treatment may continue as needed.

For more severe disease, a regimen of IL-TAC 10 mg/ml monthly + TCM twice a day + doxycycline 100 mg twice a day or hydroxychloroquine 200 mg twice a day is appropriate.

An increasingly common hair-loss condition is frontal fibrosing alopecia (FFA), which is irreversible and a trichologic emergency that requires immediate attention. “We do not know why we are seeing so many more cases,” Shapiro said. “Fortunately, there are treatments that can halt FFA by creating follicular rescue, so that no more hairs are lost.”

Aggressive management of FFA is necessary, including cortisone injections, topical tacrolimus, cortisone lotions, topical minoxidil, doxycycline, hydroxychloroquine, pioglitazone (Actos, Takeda Pharmaceuticals), and low-dose naltrexone. Finasteride or dutasteride, types of 5-alpha-reductase inhibitors, may also be used.

“Patients can start seeing a positive effect usually in 3 months,” Shapiro said. “There is also a low likelihood of [adverse] effects.”

Platelet rich plasma (PRP) is an adjunctive modality for treating androgenetic hair loss or alopecia areata. “Patients usually need 3 treatment sessions, spaced 1 month apart, followed by a hair count to determine if they have improved,” Shapiro said. “Photographs may not be sufficient to quantify the amount of improvement, so meticulous quantification is key to PRP treatments.”

Therapy can continue as long as improvement is observed. However, 2 downsides of PRP are pain and expense for some patients.

A game changer for managing alopecia areata is the use of oral Janus kinase (JAK) inhibitors, according to Shapiro. “They can also be used to treat certain forms of scarring hair loss,” he said. “Overall, JAK inhibitors have the highest chance of success for alopecia totalis or universalis.”

Shapiro favors the JAK inhibitor tofacitinib at a dose of 5 mg, twice a day. Newer JAK inhibitors, such as baricitinib (Olumiant, Eli Lilly and Company), have also proven to be effective.

“Patients, though, need to be monitored for [adverse] effects; namely the immune system through a complete metabolic panel, a complete blood count, and testing of triglyceride and cholesterol levels,” Shapiro said.

Women who use an intrauterine device (IUD) containing hormones/levonorgesterol are at risk of significant telogen effluvium upon insertion or removal.

Future therapies being developed for follicle neogenesis include an autologous dermal sheath cup, dermal papilla cell injections into the scalp, and hair farming/cloning.

Shapiro is a consultant/investigator for the following companies: Samumed, Incyte, Applied Biology, Eirion Therapeutics, RepliCel Life Sciences, Regen Lab SA, Keeps.com, Cassiopea, Pfizer, and Almirall. He also is an investigator for the non-approved uses of the medications naltrexone and pioglitazone.

Shapiro J. Maui Derm 2021. Dr. Jerry Shapiro Discusses The Management of Hair Loss Disorders in 2021. Presented at Maui Derm Live, January 25-29, 2021. Maui, Hawaii.

Trichometric analysis helps evaluate whether treatment is working for patients experiencing hair loss and what adjustments need to be made to the regimen.