Pigmentation Disorders

NAPLES, Fla. — Vitiligo, keloids, acne keloidalis nuchae, and hair and scalp concerns are among the challenges dermatologists face when treating darker skin, Dr. George Cohen said.

Black skin is prone to adverse pigmentary or hyperproliferative responses to cryotherapy, lasers, and chemical skin treatments. Because of these and other concerns in a growing population of patients with skin types IV through VI, Dr. Cohen suggested dermatologists learn more about recognition and treatment of these important differences.

"We are a more diverse society. Become culturally competent and learn as much as you can," Dr. Cohen said at the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons. Respect, inquire, and do not make assumptions—those are the three pillars of cultural competence, he said.

Cultural competence is not only good for patients; it can be good for your practice as well. "Access and acceptance are good for us—this creates more demand for services," said Dr. Cohen, of the department of dermatology and cutaneous surgery at the University of South Florida in Tampa.

Vitiligo

Vitiligo is the prototypic pigmentary challenge for patients with skin of color, Dr. Cohen said. Although the etiology is not completely understood, it may be related to the immune system. The challenge for dermatologists is that "some people respond to some things some of the time, so we don't always know who is going to respond," Dr. Cohen said.

The myriad of treatments available for vitiligo include:
- Narrow-band UVB therapy.
- Targeted laser treatment with the XeCL Excimer (308 nm).
- Topical steroids.
- Calcineurin inhibitors.
- Surgery.
- Depigmentation (using medications or 694-nm Q-switched Ruby laser).
- Makeup.

Unfortunately, "none of these work perfectly," he said.

Photos courtesy Dr. George Cohen

He cited the case of a patient with vitiligo who tried steroids, psoralen and UVA (PUVA), and other treatments to no avail. "He was desperate. He came to me with his family and asked: 'Doctor, can you make me one color?' I told him we can only make him one color—white—that is all we are able to do.

"Sometimes you cannot repigment the patient, and you have to know how to judiciously offer depigmentation. Some might say I robbed him of his culture. I say, no, I didn't, I robbed him of a disfiguring condition," said Dr. Cohen.

More research is clearly warranted to improve treatment options for vitiligo, such as studies to assess the biology of melanocytes, he said.

Keloids

Keloids are another challenge in skin of color patients. The therapeutic approach depends in part on the extent of the patient's condition. For example, a single keloid on the earlobe would be treated differently than more widespread presentation.

Again, more research is warranted on optimal treatments, Dr. Cohen said, because studies in the literature are contradictory and provide no consensus.
Acne keloidalis nuchae, "the keloids' cousin," most often occur in black men, he said. These nuchae can advance to plaque and form tumors, "and at the very least will need intralesional therapy." One clinical tip is to make an incision only within the keloid, he said.

If a patient presents with an acne keloidalis tumor, simply excise it. Once you get hemostasis, dress the wound with petroleum jelly only, and let it close by the magic of second intention

"I monitor these people. If I see any evidence of regrowth, I treat with triamcinolone early and often," he said.

Hair and Scalp Challenges

Hair and scalp concerns are common in patients with skin of color, Dr. Cohen said. A scalp biopsy is recommended to determine or confirm a diagnosis and to guide the course of clinical treatment.

These presentations can have a great psychosocial impact. "Do not underestimate the effect on patients," he said. Know your limitations and the limitations of therapy, and make sure you communicate those effectively to the patient. Otherwise, both the patient and provider can become frustrated.

Be honest with genetically-susceptible patients who present with scarring on the scalp from physical insult. In this population, scarring results when fibrous tissue replaces hair follicles. "Let them know up front that creams and other nonsense are not going to work," he said.

Contrary to popular belief, Dr. Cohen said, hair transplants are an option in patients with skin of color. "Hair transplants in black patients are not scary— I've been doing them for years and never had keloids," he said.

Black hair is heterogenous, so not everyone has curved follicles. If a skin of color patient has straight follicles, standard hair transplant procedures—for example, with 4-mm donor grafts—would be an option.

Dr. Cohen said that he did not have any relevant financial disclosures.

NAPLES, Fla. — Vitiligo, keloids, acne keloidalis nuchae, and hair and scalp concerns are among the challenges dermatologists face when treating darker skin, Dr. George Cohen said.

Black skin is prone to adverse pigmentary or hyperproliferative responses to cryotherapy, lasers, and chemical skin treatments. Because of these and other concerns in a growing population of patients with skin types IV through VI, Dr. Cohen suggested dermatologists learn more about recognition and treatment of these important differences.

"We are a more diverse society. Become culturally competent and learn as much as you can," Dr. Cohen said at the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons. Respect, inquire, and do not make assumptions—those are the three pillars of cultural competence, he said.

Cultural competence is not only good for patients; it can be good for your practice as well. "Access and acceptance are good for us—this creates more demand for services," said Dr. Cohen, of the department of dermatology and cutaneous surgery at the University of South Florida in Tampa.

Vitiligo

Vitiligo is the prototypic pigmentary challenge for patients with skin of color, Dr. Cohen said. Although the etiology is not completely understood, it may be related to the immune system. The challenge for dermatologists is that "some people respond to some things some of the time, so we don't always know who is going to respond," Dr. Cohen said.

The myriad of treatments available for vitiligo include:
- Narrow-band UVB therapy.
- Targeted laser treatment with the XeCL Excimer (308 nm).
- Topical steroids.
- Calcineurin inhibitors.
- Surgery.
- Depigmentation (using medications or 694-nm Q-switched Ruby laser).
- Makeup.

Unfortunately, "none of these work perfectly," he said.

Photos courtesy Dr. George Cohen

He cited the case of a patient with vitiligo who tried steroids, psoralen and UVA (PUVA), and other treatments to no avail. "He was desperate. He came to me with his family and asked: 'Doctor, can you make me one color?' I told him we can only make him one color—white—that is all we are able to do.

"Sometimes you cannot repigment the patient, and you have to know how to judiciously offer depigmentation. Some might say I robbed him of his culture. I say, no, I didn't, I robbed him of a disfiguring condition," said Dr. Cohen.

More research is clearly warranted to improve treatment options for vitiligo, such as studies to assess the biology of melanocytes, he said.

Keloids

Keloids are another challenge in skin of color patients. The therapeutic approach depends in part on the extent of the patient's condition. For example, a single keloid on the earlobe would be treated differently than more widespread presentation.

Again, more research is warranted on optimal treatments, Dr. Cohen said, because studies in the literature are contradictory and provide no consensus.
Acne keloidalis nuchae, "the keloids' cousin," most often occur in black men, he said. These nuchae can advance to plaque and form tumors, "and at the very least will need intralesional therapy." One clinical tip is to make an incision only within the keloid, he said.

If a patient presents with an acne keloidalis tumor, simply excise it. Once you get hemostasis, dress the wound with petroleum jelly only, and let it close by the magic of second intention

"I monitor these people. If I see any evidence of regrowth, I treat with triamcinolone early and often," he said.

Hair and Scalp Challenges

Hair and scalp concerns are common in patients with skin of color, Dr. Cohen said. A scalp biopsy is recommended to determine or confirm a diagnosis and to guide the course of clinical treatment.

These presentations can have a great psychosocial impact. "Do not underestimate the effect on patients," he said. Know your limitations and the limitations of therapy, and make sure you communicate those effectively to the patient. Otherwise, both the patient and provider can become frustrated.

Be honest with genetically-susceptible patients who present with scarring on the scalp from physical insult. In this population, scarring results when fibrous tissue replaces hair follicles. "Let them know up front that creams and other nonsense are not going to work," he said.

Contrary to popular belief, Dr. Cohen said, hair transplants are an option in patients with skin of color. "Hair transplants in black patients are not scary— I've been doing them for years and never had keloids," he said.

Black hair is heterogenous, so not everyone has curved follicles. If a skin of color patient has straight follicles, standard hair transplant procedures—for example, with 4-mm donor grafts—would be an option.

Dr. Cohen said that he did not have any relevant financial disclosures.

NAPLES, Fla. — Vitiligo, keloids, acne keloidalis nuchae, and hair and scalp concerns are among the challenges dermatologists face when treating darker skin, Dr. George Cohen said.

Black skin is prone to adverse pigmentary or hyperproliferative responses to cryotherapy, lasers, and chemical skin treatments. Because of these and other concerns in a growing population of patients with skin types IV through VI, Dr. Cohen suggested dermatologists learn more about recognition and treatment of these important differences.

"We are a more diverse society. Become culturally competent and learn as much as you can," Dr. Cohen said at the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons. Respect, inquire, and do not make assumptions—those are the three pillars of cultural competence, he said.

Cultural competence is not only good for patients; it can be good for your practice as well. "Access and acceptance are good for us—this creates more demand for services," said Dr. Cohen, of the department of dermatology and cutaneous surgery at the University of South Florida in Tampa.

Vitiligo

Vitiligo is the prototypic pigmentary challenge for patients with skin of color, Dr. Cohen said. Although the etiology is not completely understood, it may be related to the immune system. The challenge for dermatologists is that "some people respond to some things some of the time, so we don't always know who is going to respond," Dr. Cohen said.

The myriad of treatments available for vitiligo include:
- Narrow-band UVB therapy.
- Targeted laser treatment with the XeCL Excimer (308 nm).
- Topical steroids.
- Calcineurin inhibitors.
- Surgery.
- Depigmentation (using medications or 694-nm Q-switched Ruby laser).
- Makeup.

Unfortunately, "none of these work perfectly," he said.

Photos courtesy Dr. George Cohen

He cited the case of a patient with vitiligo who tried steroids, psoralen and UVA (PUVA), and other treatments to no avail. "He was desperate. He came to me with his family and asked: 'Doctor, can you make me one color?' I told him we can only make him one color—white—that is all we are able to do.

"Sometimes you cannot repigment the patient, and you have to know how to judiciously offer depigmentation. Some might say I robbed him of his culture. I say, no, I didn't, I robbed him of a disfiguring condition," said Dr. Cohen.

More research is clearly warranted to improve treatment options for vitiligo, such as studies to assess the biology of melanocytes, he said.

Keloids

Keloids are another challenge in skin of color patients. The therapeutic approach depends in part on the extent of the patient's condition. For example, a single keloid on the earlobe would be treated differently than more widespread presentation.

Again, more research is warranted on optimal treatments, Dr. Cohen said, because studies in the literature are contradictory and provide no consensus.
Acne keloidalis nuchae, "the keloids' cousin," most often occur in black men, he said. These nuchae can advance to plaque and form tumors, "and at the very least will need intralesional therapy." One clinical tip is to make an incision only within the keloid, he said.

If a patient presents with an acne keloidalis tumor, simply excise it. Once you get hemostasis, dress the wound with petroleum jelly only, and let it close by the magic of second intention

"I monitor these people. If I see any evidence of regrowth, I treat with triamcinolone early and often," he said.

Hair and Scalp Challenges

Hair and scalp concerns are common in patients with skin of color, Dr. Cohen said. A scalp biopsy is recommended to determine or confirm a diagnosis and to guide the course of clinical treatment.

These presentations can have a great psychosocial impact. "Do not underestimate the effect on patients," he said. Know your limitations and the limitations of therapy, and make sure you communicate those effectively to the patient. Otherwise, both the patient and provider can become frustrated.

Be honest with genetically-susceptible patients who present with scarring on the scalp from physical insult. In this population, scarring results when fibrous tissue replaces hair follicles. "Let them know up front that creams and other nonsense are not going to work," he said.

Contrary to popular belief, Dr. Cohen said, hair transplants are an option in patients with skin of color. "Hair transplants in black patients are not scary— I've been doing them for years and never had keloids," he said.

Black hair is heterogenous, so not everyone has curved follicles. If a skin of color patient has straight follicles, standard hair transplant procedures—for example, with 4-mm donor grafts—would be an option.

Dr. Cohen said that he did not have any relevant financial disclosures.

PHOENIX — Educate darker skinned patients who seek treatment for acne scars that there is no remedy to make the scars completely disappear.

"Depending on the patient's skin type, the sensitivity of their skin, and how aggressively you treat them, the risk of hyperpigmentation can be relatively modest, or well over 50%. The expected degree of improvement, on the other hand, even with multiple modalities and multiple treatments, is 40%-50%. I think it's very important to explain that," said Dr. Murad Alam at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago, said that clinicians face certain challenges in treating acne scars in patients of color, including the risk of exacerbation of active acne, risk of focal or diffuse hyperpigmentation or hypopigmentation, risk of nodularity or surface texture change, and risk of minimal effect.

To mitigate risks, Dr. Alam considers oral antibiotics in patients who have any degree of active acne, "even if they get one or two acne pimples once in a blue moon," he said. "If the acne is more than very mild, you may wish to target that as the primary goal and defer treatment of the acne scarring until the acne is under good control."

If the acne is mild, "you can start oral antibiotics at least 1 month before the acne scarring intervention, so they do have something on board to reduce the risk of an acne flare," he said. "You may also consider pretreatment with bleaching agents. I'm personally not that convinced that pre-treatment is that helpful, but post-treatment with bleaching agents is of definite efficacy in mitigating postinflammatory hyperpigmentation."

As for treatment, nonablative resurfacing with mid-infrared lasers, including 1320-nm, 1450-nm, and 1540-nm devices, has been shown to be effective in patients with lighter skin. "This heating process causes collagen remodeling, and can have a modest effect on so-called rolling scars, which can be quite disfiguring," he said.

Another option is ablative resurfacing with non-CO2 fractional lasers such as the 1550-nm laser. "This is one of the most gentle devices in this category, but even so you have risks of postinflammatory hyperpigmentation," Dr. Alam said. "I like to err on the side of being very modest with regard to fluences. It's much better to do more treatments than to push each individual treatment at the risk of having pigmentary abnormalities."

A more aggressive approach is ablative resurfacing with CO2 fractional lasers, which "should be restricted to patients who are of lighter skin type. If they do choose this [modality], they need to understand the significant risk of postinflammatory hyperpigmentation. I would say that virtually every patient of skin of color who undergoes this treatment will have some degree of postinflammatory hyperpigmentation. In some cases they might consider that worth it if it makes their scarring better and if it can be managed after treatment so it eventually goes away."

Perhaps the most beneficial treatment for acne scars in patients of color, Dr. Alam said, is subdermal manipulation.

In one procedure, known as subcision, clinicians insert a needle with a sphere-like tip, often an 18-guage Nokor needle, underneath the skin. "By debriding the underside of the skin, you can cause some of the acne scars to float upward," he explained. "You want to ensure very good hemostasis before doing this—lidocaine with epinephrine—because you want to avoid bruising during the procedure. If done properly, this can result in modest improvement of rolling scars, and it can be done repeatedly."

Dermal fillers can be used as an adjunct. About a month after subcision procedures Dr. Alam considers collagen for fine defects, hyaluronic acid for medium defects, and calcium hydroxylapatite for deeper defects.

The best way to develop a treatment plan for acne scarring, he said, is to assess the patient's commitment to improvement and their tolerance for adverse events.

"How much annoyance and disfigurement are they willing to tolerate?" Dr. Alam asked. "If both of these are low, you might wish to restrict yourself to subcision with or without fillers, because if done properly, that almost eliminates the risk of adverse events like hyperpigmentation, and it does provide some modest improvement with relatively little cost."

If the patient is highly committed to achieving improvement but is wary of adverse events, "then you might consider subcision and fillers, followed by nonablative laser or repeated low energy non-CO2 fractional laser treatments."

In those rare patients with a high tolerance for adverse events, he said, consider CO2 fractional laser treatments "at very modest settings."

Dr. Alam said that he had no relevant financial conflicts.

PHOENIX — Educate darker skinned patients who seek treatment for acne scars that there is no remedy to make the scars completely disappear.

"Depending on the patient's skin type, the sensitivity of their skin, and how aggressively you treat them, the risk of hyperpigmentation can be relatively modest, or well over 50%. The expected degree of improvement, on the other hand, even with multiple modalities and multiple treatments, is 40%-50%. I think it's very important to explain that," said Dr. Murad Alam at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago, said that clinicians face certain challenges in treating acne scars in patients of color, including the risk of exacerbation of active acne, risk of focal or diffuse hyperpigmentation or hypopigmentation, risk of nodularity or surface texture change, and risk of minimal effect.

To mitigate risks, Dr. Alam considers oral antibiotics in patients who have any degree of active acne, "even if they get one or two acne pimples once in a blue moon," he said. "If the acne is more than very mild, you may wish to target that as the primary goal and defer treatment of the acne scarring until the acne is under good control."

If the acne is mild, "you can start oral antibiotics at least 1 month before the acne scarring intervention, so they do have something on board to reduce the risk of an acne flare," he said. "You may also consider pretreatment with bleaching agents. I'm personally not that convinced that pre-treatment is that helpful, but post-treatment with bleaching agents is of definite efficacy in mitigating postinflammatory hyperpigmentation."

As for treatment, nonablative resurfacing with mid-infrared lasers, including 1320-nm, 1450-nm, and 1540-nm devices, has been shown to be effective in patients with lighter skin. "This heating process causes collagen remodeling, and can have a modest effect on so-called rolling scars, which can be quite disfiguring," he said.

Another option is ablative resurfacing with non-CO2 fractional lasers such as the 1550-nm laser. "This is one of the most gentle devices in this category, but even so you have risks of postinflammatory hyperpigmentation," Dr. Alam said. "I like to err on the side of being very modest with regard to fluences. It's much better to do more treatments than to push each individual treatment at the risk of having pigmentary abnormalities."

A more aggressive approach is ablative resurfacing with CO2 fractional lasers, which "should be restricted to patients who are of lighter skin type. If they do choose this [modality], they need to understand the significant risk of postinflammatory hyperpigmentation. I would say that virtually every patient of skin of color who undergoes this treatment will have some degree of postinflammatory hyperpigmentation. In some cases they might consider that worth it if it makes their scarring better and if it can be managed after treatment so it eventually goes away."

Perhaps the most beneficial treatment for acne scars in patients of color, Dr. Alam said, is subdermal manipulation.

In one procedure, known as subcision, clinicians insert a needle with a sphere-like tip, often an 18-guage Nokor needle, underneath the skin. "By debriding the underside of the skin, you can cause some of the acne scars to float upward," he explained. "You want to ensure very good hemostasis before doing this—lidocaine with epinephrine—because you want to avoid bruising during the procedure. If done properly, this can result in modest improvement of rolling scars, and it can be done repeatedly."

Dermal fillers can be used as an adjunct. About a month after subcision procedures Dr. Alam considers collagen for fine defects, hyaluronic acid for medium defects, and calcium hydroxylapatite for deeper defects.

The best way to develop a treatment plan for acne scarring, he said, is to assess the patient's commitment to improvement and their tolerance for adverse events.

"How much annoyance and disfigurement are they willing to tolerate?" Dr. Alam asked. "If both of these are low, you might wish to restrict yourself to subcision with or without fillers, because if done properly, that almost eliminates the risk of adverse events like hyperpigmentation, and it does provide some modest improvement with relatively little cost."

If the patient is highly committed to achieving improvement but is wary of adverse events, "then you might consider subcision and fillers, followed by nonablative laser or repeated low energy non-CO2 fractional laser treatments."

In those rare patients with a high tolerance for adverse events, he said, consider CO2 fractional laser treatments "at very modest settings."

Dr. Alam said that he had no relevant financial conflicts.

PHOENIX — Educate darker skinned patients who seek treatment for acne scars that there is no remedy to make the scars completely disappear.

"Depending on the patient's skin type, the sensitivity of their skin, and how aggressively you treat them, the risk of hyperpigmentation can be relatively modest, or well over 50%. The expected degree of improvement, on the other hand, even with multiple modalities and multiple treatments, is 40%-50%. I think it's very important to explain that," said Dr. Murad Alam at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago, said that clinicians face certain challenges in treating acne scars in patients of color, including the risk of exacerbation of active acne, risk of focal or diffuse hyperpigmentation or hypopigmentation, risk of nodularity or surface texture change, and risk of minimal effect.

To mitigate risks, Dr. Alam considers oral antibiotics in patients who have any degree of active acne, "even if they get one or two acne pimples once in a blue moon," he said. "If the acne is more than very mild, you may wish to target that as the primary goal and defer treatment of the acne scarring until the acne is under good control."

If the acne is mild, "you can start oral antibiotics at least 1 month before the acne scarring intervention, so they do have something on board to reduce the risk of an acne flare," he said. "You may also consider pretreatment with bleaching agents. I'm personally not that convinced that pre-treatment is that helpful, but post-treatment with bleaching agents is of definite efficacy in mitigating postinflammatory hyperpigmentation."

As for treatment, nonablative resurfacing with mid-infrared lasers, including 1320-nm, 1450-nm, and 1540-nm devices, has been shown to be effective in patients with lighter skin. "This heating process causes collagen remodeling, and can have a modest effect on so-called rolling scars, which can be quite disfiguring," he said.

Another option is ablative resurfacing with non-CO2 fractional lasers such as the 1550-nm laser. "This is one of the most gentle devices in this category, but even so you have risks of postinflammatory hyperpigmentation," Dr. Alam said. "I like to err on the side of being very modest with regard to fluences. It's much better to do more treatments than to push each individual treatment at the risk of having pigmentary abnormalities."

A more aggressive approach is ablative resurfacing with CO2 fractional lasers, which "should be restricted to patients who are of lighter skin type. If they do choose this [modality], they need to understand the significant risk of postinflammatory hyperpigmentation. I would say that virtually every patient of skin of color who undergoes this treatment will have some degree of postinflammatory hyperpigmentation. In some cases they might consider that worth it if it makes their scarring better and if it can be managed after treatment so it eventually goes away."

Perhaps the most beneficial treatment for acne scars in patients of color, Dr. Alam said, is subdermal manipulation.

In one procedure, known as subcision, clinicians insert a needle with a sphere-like tip, often an 18-guage Nokor needle, underneath the skin. "By debriding the underside of the skin, you can cause some of the acne scars to float upward," he explained. "You want to ensure very good hemostasis before doing this—lidocaine with epinephrine—because you want to avoid bruising during the procedure. If done properly, this can result in modest improvement of rolling scars, and it can be done repeatedly."

Dermal fillers can be used as an adjunct. About a month after subcision procedures Dr. Alam considers collagen for fine defects, hyaluronic acid for medium defects, and calcium hydroxylapatite for deeper defects.

The best way to develop a treatment plan for acne scarring, he said, is to assess the patient's commitment to improvement and their tolerance for adverse events.

"How much annoyance and disfigurement are they willing to tolerate?" Dr. Alam asked. "If both of these are low, you might wish to restrict yourself to subcision with or without fillers, because if done properly, that almost eliminates the risk of adverse events like hyperpigmentation, and it does provide some modest improvement with relatively little cost."

If the patient is highly committed to achieving improvement but is wary of adverse events, "then you might consider subcision and fillers, followed by nonablative laser or repeated low energy non-CO2 fractional laser treatments."

In those rare patients with a high tolerance for adverse events, he said, consider CO2 fractional laser treatments "at very modest settings."

Dr. Alam said that he had no relevant financial conflicts.

PHOENIX - When performing laser hair removal in patients with Fitzpatrick skin types IV-VI, keep in mind that darker skin contains more melanin in the epidermis, which acts as a competing chromophore, "so the risk for epidermal injury is higher," Dr. Andrew F. Alexis said.

Other tips to remember when treating this patient population include the melanocytes' tendency "to be labile in response to injury and inflammation, so there is an increased risk of dyschromia," Dr. Alexis said at the annual meeting of the American Society for Laser Medicine and Surgery. "This can manifest as hyperpigmentation or hypopigmentation following laser hair removal procedures."

He went on to note that fibroblasts in the dermis "are also more reactive to injury, so there is an increased risk of hypertrophic scars and keloids when performing surgical or some cosmetic procedures. In addition, having curved follicles [which are primarily seen in people of African descent] is associated with an increased prevalence of a number of follicular disorders."

His guidelines for performing laser hair removal safely on skin of color include longer wavelengths, lower fluences, longer pulse durations, and increased epidermal cooling.

"You want longer wavelengths because we're trying to maximize the ratio of follicular bulb temperature to epidermal temperature," explained Dr. Alexis, director of the Skin of Color Center at St. Luke's & Roosevelt Hospitals, New York, and assistant professor of dermatology at Columbia University.

"Using wavelengths in the near infrared range, we are at a lower point on the melanin absorption curve and therefore are compromising some efficacy, but this is the range that is considered safest for darker skin types," he noted.

A review found that the long-pulsed 1064-nm laser had the lowest incidence of adverse events in dark-skinned patients, followed by the long-pulsed 800-nm or 810-nm diode laser (J. Drugs Dermatol. 2007;6:40-6).

"For patients with type IV or V skin, the diode laser is appropriate, as long as you are using long pulse durations," he said, "but for the darker skin types, particularly type VI, the 1064-nm Nd:YAG laser is the best choice for safety reasons."

In one study, researchers used a 1064-nm laser with contact cooling to treat pseudofolliculitis barbae in 37 patients with skin types IV, V, and VI. They found that the highest fluences tolerated by the epidermis were 50 J/cm2 for skin type VI and 100 J/cm2 for skin types IV and V (J. Am. Acad. Dermatol. 2002;47:263-70).

In another study, researchers used a 1064-nm laser with contact cooling for hair removal in 36 patients with skin types I-VI (Dermatol. Surg. 2004;30:13-7). Patients underwent three consecutive treatments at 4- to 6-week intervals. For skin types V-VI, investigators used a 30-millisecond pulse duration and a fluence of 30-45 J/cm2 on the face and 35-50 J/cm2 on nonfacial sites. Six months post treatment, the mean facial hair reduction ranged from 41% to 46%, while the mean hair reduction on the body ranged from 48% to 53%.

Based on the results of these and other studies, and from his own clinical experience, Dr. Alexis recommends a pulse duration of 100 milliseconds or 400 milliseconds when using a 810-nm diode laser and a duration of 20-30 milliseconds when using a 1064-nm Nd:YAG laser with contact cooling.

One recent study used a 1064-nm Nd:YAG laser with lower than traditional fluences for treating 22 patients with skin types IV-VI who had pseudofolliculitis barbae (Dermatol. Surg. 2009;35:98-107). Patients underwent five weekly treatments on the neck with a fluence of 12 J/cm2 and a pulse duration of 20 milliseconds and a spot size of 10 mm. At 4 weeks follow-up, the papule count had been reduced by a mean of 91% and dyspigmentation by a mean of 60%.

In another recent development, researchers studying a novel diode laser with a fluence of 5-10 J/cm2 used at a repetition rate of 10 Hz found that it resulted in less pain, faster treatment, and fewer adverse events compared with one pass of a high-fluence diode laser at 25-40 J/cm2 in Fitzpatrick skin types I-V (J. Drugs Dermatol. 2009;8:s14-7).

Options for epidermal cooling include cold gel, contact cryogen or forced air, and post treatment with ice packs for 10-15 minutes. Devices for contact cooling feature either a sapphire tip or chilled copper plate. Regardless of which type of contact cooling chosen, Dr. Alexis suggested "using a slower treatment speed in order to ensure adequate cooling before delivering pulse."

Dr. Alexis said that he had no relevant financial conflicts.

PHOENIX - When performing laser hair removal in patients with Fitzpatrick skin types IV-VI, keep in mind that darker skin contains more melanin in the epidermis, which acts as a competing chromophore, "so the risk for epidermal injury is higher," Dr. Andrew F. Alexis said.

Other tips to remember when treating this patient population include the melanocytes' tendency "to be labile in response to injury and inflammation, so there is an increased risk of dyschromia," Dr. Alexis said at the annual meeting of the American Society for Laser Medicine and Surgery. "This can manifest as hyperpigmentation or hypopigmentation following laser hair removal procedures."

He went on to note that fibroblasts in the dermis "are also more reactive to injury, so there is an increased risk of hypertrophic scars and keloids when performing surgical or some cosmetic procedures. In addition, having curved follicles [which are primarily seen in people of African descent] is associated with an increased prevalence of a number of follicular disorders."

His guidelines for performing laser hair removal safely on skin of color include longer wavelengths, lower fluences, longer pulse durations, and increased epidermal cooling.

"You want longer wavelengths because we're trying to maximize the ratio of follicular bulb temperature to epidermal temperature," explained Dr. Alexis, director of the Skin of Color Center at St. Luke's & Roosevelt Hospitals, New York, and assistant professor of dermatology at Columbia University.

"Using wavelengths in the near infrared range, we are at a lower point on the melanin absorption curve and therefore are compromising some efficacy, but this is the range that is considered safest for darker skin types," he noted.

A review found that the long-pulsed 1064-nm laser had the lowest incidence of adverse events in dark-skinned patients, followed by the long-pulsed 800-nm or 810-nm diode laser (J. Drugs Dermatol. 2007;6:40-6).

"For patients with type IV or V skin, the diode laser is appropriate, as long as you are using long pulse durations," he said, "but for the darker skin types, particularly type VI, the 1064-nm Nd:YAG laser is the best choice for safety reasons."

In one study, researchers used a 1064-nm laser with contact cooling to treat pseudofolliculitis barbae in 37 patients with skin types IV, V, and VI. They found that the highest fluences tolerated by the epidermis were 50 J/cm2 for skin type VI and 100 J/cm2 for skin types IV and V (J. Am. Acad. Dermatol. 2002;47:263-70).

In another study, researchers used a 1064-nm laser with contact cooling for hair removal in 36 patients with skin types I-VI (Dermatol. Surg. 2004;30:13-7). Patients underwent three consecutive treatments at 4- to 6-week intervals. For skin types V-VI, investigators used a 30-millisecond pulse duration and a fluence of 30-45 J/cm2 on the face and 35-50 J/cm2 on nonfacial sites. Six months post treatment, the mean facial hair reduction ranged from 41% to 46%, while the mean hair reduction on the body ranged from 48% to 53%.

Based on the results of these and other studies, and from his own clinical experience, Dr. Alexis recommends a pulse duration of 100 milliseconds or 400 milliseconds when using a 810-nm diode laser and a duration of 20-30 milliseconds when using a 1064-nm Nd:YAG laser with contact cooling.

One recent study used a 1064-nm Nd:YAG laser with lower than traditional fluences for treating 22 patients with skin types IV-VI who had pseudofolliculitis barbae (Dermatol. Surg. 2009;35:98-107). Patients underwent five weekly treatments on the neck with a fluence of 12 J/cm2 and a pulse duration of 20 milliseconds and a spot size of 10 mm. At 4 weeks follow-up, the papule count had been reduced by a mean of 91% and dyspigmentation by a mean of 60%.

In another recent development, researchers studying a novel diode laser with a fluence of 5-10 J/cm2 used at a repetition rate of 10 Hz found that it resulted in less pain, faster treatment, and fewer adverse events compared with one pass of a high-fluence diode laser at 25-40 J/cm2 in Fitzpatrick skin types I-V (J. Drugs Dermatol. 2009;8:s14-7).

Options for epidermal cooling include cold gel, contact cryogen or forced air, and post treatment with ice packs for 10-15 minutes. Devices for contact cooling feature either a sapphire tip or chilled copper plate. Regardless of which type of contact cooling chosen, Dr. Alexis suggested "using a slower treatment speed in order to ensure adequate cooling before delivering pulse."

Dr. Alexis said that he had no relevant financial conflicts.

PHOENIX - When performing laser hair removal in patients with Fitzpatrick skin types IV-VI, keep in mind that darker skin contains more melanin in the epidermis, which acts as a competing chromophore, "so the risk for epidermal injury is higher," Dr. Andrew F. Alexis said.

Other tips to remember when treating this patient population include the melanocytes' tendency "to be labile in response to injury and inflammation, so there is an increased risk of dyschromia," Dr. Alexis said at the annual meeting of the American Society for Laser Medicine and Surgery. "This can manifest as hyperpigmentation or hypopigmentation following laser hair removal procedures."

He went on to note that fibroblasts in the dermis "are also more reactive to injury, so there is an increased risk of hypertrophic scars and keloids when performing surgical or some cosmetic procedures. In addition, having curved follicles [which are primarily seen in people of African descent] is associated with an increased prevalence of a number of follicular disorders."

His guidelines for performing laser hair removal safely on skin of color include longer wavelengths, lower fluences, longer pulse durations, and increased epidermal cooling.

"You want longer wavelengths because we're trying to maximize the ratio of follicular bulb temperature to epidermal temperature," explained Dr. Alexis, director of the Skin of Color Center at St. Luke's & Roosevelt Hospitals, New York, and assistant professor of dermatology at Columbia University.

"Using wavelengths in the near infrared range, we are at a lower point on the melanin absorption curve and therefore are compromising some efficacy, but this is the range that is considered safest for darker skin types," he noted.

A review found that the long-pulsed 1064-nm laser had the lowest incidence of adverse events in dark-skinned patients, followed by the long-pulsed 800-nm or 810-nm diode laser (J. Drugs Dermatol. 2007;6:40-6).

"For patients with type IV or V skin, the diode laser is appropriate, as long as you are using long pulse durations," he said, "but for the darker skin types, particularly type VI, the 1064-nm Nd:YAG laser is the best choice for safety reasons."

In one study, researchers used a 1064-nm laser with contact cooling to treat pseudofolliculitis barbae in 37 patients with skin types IV, V, and VI. They found that the highest fluences tolerated by the epidermis were 50 J/cm2 for skin type VI and 100 J/cm2 for skin types IV and V (J. Am. Acad. Dermatol. 2002;47:263-70).

In another study, researchers used a 1064-nm laser with contact cooling for hair removal in 36 patients with skin types I-VI (Dermatol. Surg. 2004;30:13-7). Patients underwent three consecutive treatments at 4- to 6-week intervals. For skin types V-VI, investigators used a 30-millisecond pulse duration and a fluence of 30-45 J/cm2 on the face and 35-50 J/cm2 on nonfacial sites. Six months post treatment, the mean facial hair reduction ranged from 41% to 46%, while the mean hair reduction on the body ranged from 48% to 53%.

Based on the results of these and other studies, and from his own clinical experience, Dr. Alexis recommends a pulse duration of 100 milliseconds or 400 milliseconds when using a 810-nm diode laser and a duration of 20-30 milliseconds when using a 1064-nm Nd:YAG laser with contact cooling.

One recent study used a 1064-nm Nd:YAG laser with lower than traditional fluences for treating 22 patients with skin types IV-VI who had pseudofolliculitis barbae (Dermatol. Surg. 2009;35:98-107). Patients underwent five weekly treatments on the neck with a fluence of 12 J/cm2 and a pulse duration of 20 milliseconds and a spot size of 10 mm. At 4 weeks follow-up, the papule count had been reduced by a mean of 91% and dyspigmentation by a mean of 60%.

In another recent development, researchers studying a novel diode laser with a fluence of 5-10 J/cm2 used at a repetition rate of 10 Hz found that it resulted in less pain, faster treatment, and fewer adverse events compared with one pass of a high-fluence diode laser at 25-40 J/cm2 in Fitzpatrick skin types I-V (J. Drugs Dermatol. 2009;8:s14-7).

Options for epidermal cooling include cold gel, contact cryogen or forced air, and post treatment with ice packs for 10-15 minutes. Devices for contact cooling feature either a sapphire tip or chilled copper plate. Regardless of which type of contact cooling chosen, Dr. Alexis suggested "using a slower treatment speed in order to ensure adequate cooling before delivering pulse."

Dr. Alexis said that he had no relevant financial conflicts.