Dr. Eliot Battle discusses key fundamentals that underlie the art of safely and effectively treating skin of color using energy-based devices.
Eliot Battle, MD, is CEO & Co-Founder of Cultura Dermatology & Plastic Surgery, Washington DC
“It’s very important for all of us to learn how to treat skin color,” said Eliot Battle, MD, who presented “Fundamentals of Laser Treatments on SOC – What Every Dermatologist Should Know,” at the 41st ASLMS Annual Conference on Energy-Based Medicine & Science.
“We always hear that in 2050, over half the world is going to be brown skin. But if you look at the demographics today, in the majority of cities, we have well over 60% of skin of color patients.”
As the demand for dermatologic treatment within this population of patients grows, so does the need for dermatologists to develop specific skin of color expertise, said Dr. Battle.
In pursuit of that expertise, dermatologists should follow these 5 guiding principles, he said:
- Use the right laser or device with the appropriate wavelength, for the skin color you are treating.
- Always treat conservatively because we don’t know the DNA of the patient.
- Become an expert not only in technology, but in really understanding the nuances of skin of color.
- Choose treatments that are proven to consistently be safe and effective on skin of color like laser hair removal, treating pigmented lesions, texture improvement, skin tightening, and body contouring.
- Success comes from minimizing heating of the epidermis by minimizing pulse stacking, the number of passes, and fluence levels.
More Than Color
“My first take home message for this conference is, white is not white, brown is not brown.”
According to Dr. Battle,if five people have the same skin color but have varying heritage (for example, African, South Asian, Japanese, Brazilian, and Italian), their skin won’t react the same way.
“Every patient is unique and their skin color is not the only consideration when treating the skin. Patients need to be treated as the unique person they are. Our skin color, although a vary important criteria, is not the only one. The same skin color is different. People will react differently with lasers because our DNA is different.”
Often asked how he treats African Americans, his answer is always the same—one at a time, Dr. Battle says, because each one of us has a different mixture of ethinicities and history of sun expsoure, health, and medication.
“‘African American’ is not an ethnicity. It’s a title. Each of us is an unique mixture of African, European, Caucasian, American Indian, Latin, Mediterranean, and Asian DNA. So it’s not just color. It’s much more than that.”
And it makes safely treating skin of color more difficult than treating lighter-skinned patients, said Dr. Battle.
“Each patient is unique and science hasn’t advanced enough to understand how different DNA impacts the skin, but we know it does. We don’t fully understand the genetic influences of melanin. In skin of color, melanocytes, our cells that make pigment, are more susceptible to cold and heat injury than lighter skin. And there’s an increased risk of scarring with patients with skin of color.”
The key to safe treatment is becoming an expert with treatments that are proven to be safe and work on skin of color, said Dr. Battle.
“If you can focus on hair removal, dark spots, texture improvement, you’ve got the majority of patients who are seeking your expertise. Throw in acne, body contouring, and skin tightening and you really have a large basket of treatments you can do to any patient, regardless of skin color or ethnicity.”
A Word of Caution
To perform safe and effective treatments on patients with skin of color also means knowing what to avoid, said Dr. Battle.
“We’re not good at treating vascular lesions, like capillaries and blood vessels, on skin of color. We’re not good at resurfacing skin of color. Imagine if I took away my top layer of the skin—it’s a dice roll that my skin is going to repigment evenly.”
While the IPL device is great for treating lighter skinned patients, its frequency of causing side effects makes it less safe when used on darker skin, particularly Fitzpatrick skin types V and VI, said Dr. Battle.
“If I could take away the IPL device from practitioners treating skin of color, I will remove probably 80% of the side effects we see when patients come to us from other practices.”
I also don’t always trust the device treatment parameters provided by manufacturers, said Dr. Battle.
“To get FDA approval you need a couple of dozen patients, not enough data to make treatment recommendations. I generally treat more conservatively than the manufacturer’s recommendations.”
To safely treat skin of color with lasers and energy-based devices, “You minimize epidermal absorption of the laser light by using longer wavelengths and using non pigment-absorbing parameters like microsecond pulse durations, radio frequency devices, and ultrasound. You minimize epidermal heating by using longer wavelengths, longer pulse durations, lower fluences, and maximize cooling. Heat is your enemy, cold is your friend.”
And, anything that causes irritation, erythema, or edema should be minimized as those can lead to post inflammatory hyperpigmentation, said Dr. Battle.
In terms of test spots, side effects may not be apparent until 48 hours or more when treating skin color, said Dr. Battle. So when evaluationg test spots, wait at least two days prior to evaluating the patient to make sure that you’re using the right parameters.”
Another option is to treat so consevatiely you don’t need to do test spots.
Treatment Tips
Overall, safe and effective energy treatments on skin of color require some guiding principles, said Dr. Battle.
“Again, heat is my enemy, cold is my friend. We need to cool the skin by taking heat from it. Excessive epidermal heating causes epidermal thermal injury (side effects). So we have to always keep the epidermis under 45 degrees Celsius. One way we can assist is by using longer pulse duration. The slower I pour the bucket of energy (longer pulse duration), the slower my skin absorbs it, allowing it to heat up slower, making cooling more efficient. It’s easier cooling a slow heating object than a fast heating one.”
Dark spots are one of the biggest reasons skin of color patients seek out aesthetic dermatologic treatments, said Dr. Battle.
“To treat dark spots [or] pigmented lesions, there are four major devices that we use consistently: fractional lasers using low energy, low density; microsecond Nd:YAG lasers; Picosecond and Q-switched nanosecond lasers; and now the new kid on the block is a fractional microneedling radiofrequency device.”
With fractional lasers, wavelength determines penetration depth. For water-absorbing wavelengths, the shorter the wavelength, the deeper the laser beam penetrates into the skin. The 1927 nm wavelength is shallow; 1540 nm wavelength goes much deeper, said Dr. Battle.
“My favorite fractional device is the1540 nm wavelength, but we all can have our preferences. I also like the 1927 nm diode wavelength. It’s just a matter of becoming an expert with the fractional laser you have.”
For laser hair removal, the Nd:YAG is the go-to for skin of color patients, said Dr. Battle.
“We’re great at laser hair removal. The Nd:YAG laser has proven over time to be the best wavelength to treat skin of color for laser hair removal. We can safely treat anyone, any color, any ethnicity with the Nd:YAG wavelength. We have to use lower fluences, longer post durations, maximize cooling, accurate overlapping. But again we can treat anyone.”
Switching the parameters of a long-pulsed Nd:YAG to a shorter microsecond pulse duration, offers treatment versatility, said Dr. Battle.
“A microsecond is 1 millionth of a second and a millisecond is 1 thousand of second. So the millisecond pulse duration laser is dramatically different than the microsecond pulse duration lasers. The millisecond is the pulse duration we use for hair removal. [It’s the] same device, just by changing the pulse duration, using a much shorter microsecond pulse duration, the laser light bypasses the epidermis and allows us to safely treat dermal issues. We can use it to improve texture, complexion, and even small capillaries, which makes it an effective device to improve melasma.”
The new kid on the block, fractional microneedling radiofrequency devices that have been FDA approved for skin tightening are also being used to improve texture, acne scarring and pigmentation in skin of color patients, said Dr. Battle.
They use small pins to penetrate the skin and when treating skin of color “the pins are coated (epidermal sparing) so they’re not heating the epidermis. It’s only heating down deep in the dermis where the target is. You’ve got to be accurate with your placement. You have to minimize stacking the pulses and keep the handpiece flush to the skin. But we get consistent results improving acne scarring, texture, tightening, and complexion on skin of color.”
