Laser Success in Patients With Skin of Color: From Consultation to Procedure Options

Dr. Eliot Battle, co-chair of the Skin of Color Update conference and CEO/Founder of Cultura Dermatology & Plastic Surgery, has a distinguished history of establishing safe and effective laser techniques in patients with skin of color. During his recent lecture at the 2023 Skin of Color Update conference, he shared with the audience his personal pearls and suggestions for establishing a thriving laser practice, especially with patients with skin of color. To start, Dr. Battle emphasized the shifting demographic in US cities toward skin of color. As such, in 2023, it is essential in an aesthetic practice that uses lasers to be able to treat patients with darker skin. He emphasizes that in treating a patient’s skin color, the physician is really treating the culture of their skin. It is important to treat each patient uniquely and to take into account the skin’s culture including: skin color, ethnicity and race, health history, sun exposure history, water and food intake, medications, pregnancies,  and stress. Since you don’t know the patients DNA, it’s important to treat conservatively.  Some practitioners putlasers in skin of color too much confidence in having the right laser and don’t consider the patient’s skin culture when determining safe laser parameters.  There is an exponential growth of laser induced side effects in patients with skin of color from practitioners not treating conservatively and using aggressive parameters.

Getting Started

To start, it is important that your skin of color patients see themselves in your office. It is paramount to have a diverse staff, to have before and after pictures that are diverse, to have displays and wall pictures as well as marketing materials that demonstrate diversity. In essence, the practice must be cosmetically appealing to all demographics. This is important to assess and continue to reassess. The geographic location of the practice is also important, and you want your patients to feel proud. When hiring new staff or providers, it is crucial to observe their behaviors. While qualifications are important, Dr. Battle emphasizes hiring by “behaviors, not just resumes”.

The Consultation

In the initial consultation, it is important to gain the patient’s trust. By sitting down and facing the patient at eye level patients feel that their provider listened to them. They feel that you spent 7 minutes more than you actually did. Providers who do this are viewed as more compassionate and have higher patient satisfaction ratings. Upon entering the room, if a patient asks Dr. Battle how he is, he responds with an open-ended statement like, “I’m doing the best I can in this crazy world we live in, how are you doing?”.  Most people believe the world is a bit crazy and it breaks the ice, so you can start building rapport with patients. In most cases, patients can’t measure a physician and practitioner’s skill and knowledge level. As such, they infer the quality of the provider and practice based on what they observe, including staff and physician manners, politeness, style and habits, and interest in the patient. Dr. Battle emphasizes employing the Platinum Service – “Treating patients how they want to be treated”.

During the consultation it is important to embrace and connect with the patient. This is done by using kindness and compassion when introducing yourself, followed by creating a conversation that connects you with your patient. After this, it is important to tell the patient about your career and your company’s history in order to further establish trust. When discussing lasers, focus on education as the cornerstone of the consultation, explaining in layman’s terms what lasers do and what they are used for. It is important to not lock yourself into an exact number of treatments by employing the phrase “a minimum us…” or providing a range of treatments.

Before Treatment

It is imperative to take pretreatment photographs. This allows you to document changes for patients to observe. By using UV light, you can enhance the appearance of epidermal pigmentation. By using polarizing light, you can enhance vascular involvement. These features will also provide further trust in your patient. Computerized skin analysis will also assist in identifying problems and is the best platform for discussing patient’s cosmetic concerns and pricing.

Laser Therapy on Skin of Color

Patients with skin of color are more difficult to treat with laser therapy. It is difficult to assess exact risk as we don’t know the DNA of the patient, and even if we did, we don’t fully understand the influence on melanin. In essence, melanin competes for laser light targeting both blood and melanin chromophores. Melanocytes are more susceptible to cold and heat induced injury, and skin or color has increased incidence of scarring and pigmentary changes from thermal injury, inflammation, and irritation. Minimizing epidermal pigment absorption increases safety for patients with skin of color. These measures include using longer wavelengths, non-pigment absorbing parameters (microsecond Nd:YAG, RF, Ultrasound), minimizing epidermal heating by using longer pulse durations, maximizing epidermal cooling, and using fractional technology also increases safety.

Practitioners using lasers must become laser experts in order to reduce risk. This can be obtained through study and practice, by gaining training and expertise, joining organizations, and always treating conservatively. Dr. Battle emphasizes that when providers start to push parameters, patients experience complications. Inconsistent laser treatments must be avoided in patients with skin of color.  The clinician’s own judgement must also be used as opposed to solely relying on the laser manufacturer’s parameters.  In laser hair removal on Skin of Color, the Nd:YAG wavelength is by far the safest option. Diode wavelength options offered to increase safety include longer wavelengths (1060 diode), longer pulse durations, suction technology, scanning technology, and fast motion technology.

Laser hair removal is an important procedure in treating skin of color.  Darker skin types have higher incidence of hair disorders including hypertrichosis, hirsutism and pseudo-folliculitis barbae and most conventional methods like shaving, plucking waxing cause irritation leading to post-inflammatory hyperpigmentation.

For pigmented lesions, it is important to consider a ‘top-down and bottom-up’ approach. For top down, patients are prescribed topical exfoliants, vitamin C, retinoids, broad spectrum sunscreen, topical bleaching creams, and topical steroids. For bottom-up, patients are offered lasers and energy based devices. With the appropriate expertise, there are numerous lasers on the market that are safe for skin of color to treat unwanted hyperpigmentation, including fractional lasers, microsecond Nd:YAG, picosecond, Q-Switched nanosecond, fractional microneedling RF.  When making a laser selection, it is important to choose your wavelength based on the depth of the target.

This information was presented by Dr. Eliot Battle during the 2023 Skin of Color Update conference.  The above highlights from his lecture were written and compiled by Dr. Jacob Beer.

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