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Handling Post-inflammatory hyperpigmentation, alpha hydroxy acids, Asian, Native American, ethnic, hypopigmentation

Contact Author Christine Heathman October 2012 issue of Skin Inc. magazine

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professional skin care client with post-inflammatory hyperpigmentation

Global skin of color is the ultimate future snapshot of your skin care clientele. Skin care professionals who ignore the phenomenon of the multitude of skin races are out of touch with the reality concerning the trends that will dictate their esthetic careers in the near future, and will miss the opportunity to learn how to work with this ever-increasing population successfully. Skin care professionals must prepare for this prospect, and learn to recognize what is appropriate and inappropriate concerning skin treatments, ingredients and products for skin of color.

There are significant differences between global skin types. Just look at the rainbow of skin colors that make up the millions of skin types and where they originate. Cosmetically speaking, black skin has a wide range of color variations from a creamy light coffee color to deep ebony black. Asian skin exhibits colors that range from a light yellow hue to a dark golden tan. Native American skin colors vary with respect to different tribes, and have coloring that ranges from light to dark red-brown. Even white skin is misinterpreted visually and put into inaccurate categories. Caucasian skin ranges greatly from milky alabaster white to dark olive tones.

Darker global skin types are much more reactive to topical agents such as alpha hydroxy acids (AHAs), beta hydroxy acids (BHAs), trichloroacetic acid (TCA) and many different ingredients, and are more sensitive to these constituents than Caucasian skin. Unfortunately, many skin care professionals misunderstand the darker global skin combinations and treat skin of color as if it were Caucasian, being overzealous in their procedures and recommending improper skin care products, triggering an inflammatory response leading to unwanted problems. This can result in devastating side effects, such as hypopigmentation and hyperpigmentation. These very avoidable mistakes not only affect the client cosmetically and emotionally, but destroy the trust between client and professional.

Understanding color distinction

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Melanocytes, melanin and pigmentation formulate the key color distinction of skin. The content of melanin within keratinocytes determines skin color, with deeply pigmented skin having the highest content of epidermal melanin. Melanin is a complex molecule responsible for the pigment in the skin, hair and eyes. This molecule works to protect by reducing the penetration of UV rays into the skin and subsequently into the nuclei of cells where DNA resides.

It is well-established that there are no racial differences in the number of melanocytes; however, the actual number of melanocytes does differ from one individual to another, and from one anatomical region of the body to another, with the head, neck and forearms having the highest number.

Racial and ethnic differences in skin color are due to the number, size and aggregation of melanosomes within the melanocyte and keratinocytes. Racial or ethnic differences in the size and aggregation of melanosomes within keratinocytes have been clearly established. In Caucasian global skin types, melanosomes are smaller in size than those in black skin and contain less melanin.

It has also been determined that melanosomes are larger, more oval and denser in dark-skinned individuals compared to lighter-skinned individuals. Similarly, not all white and Asian skin has small melanosomes, nor are the melanosomes always aggregated. Total melanin content is greater in people with darker skin compared to those with lighter skin.

The amount of melanin is the very basis of skin-typing classification, an important factor in cataloging skin history for UV radiation reaction. The increase of epidermal melanin content of darker-skinned individuals provides greater intrinsic photo protection. Simply put, higher melanin concentration translates into better photo protection from UV radiation and delays the clinical appearance of photoaging brought on by photodamage, especially in lighter skin types that are more prone to UV burn.

Melanosome groupings are also affected by sun exposure. Asian skin exposed to sunlight has a predominance of nonaggregated melanosomes, whereas unexposed skin has predominately consolidated melanosomes. The effects of UV and visible light on human skin include sunburn, suntan, phototoxic and photoallergic reactions, as well as post-inflammatory hyperpigmentation (PIH).

Post-inflammatory hyperpigmentation (PIH)

One of the most common pigmentation disorders of clients with darker skin is PIH, which is one type of pigmentation morbidity. PIH can be considered the default pathophysiologic response to cutaneous injury of darker global skin of colors. This response is the belief predicated on the labile response of melanocytes to irritation or inflammation. The common link to any pigmentation disorder is inflammation. Darker skin differs from Caucasian skin in its reactivity and clinical presentation. Although ongoing research continues to unveil aggravating factors, significant prudence in understanding this problem still remains to be practiced in the area of ethnic skin disorders to properly manage them.

The basis of pigmentation morbidity can occur as the result of cumulative exposure to UV light, making it a major culprit in melasma, solar lentigines and ephelides. Many medications, cosmetics and inflammatory skin diseases, in addition to adverse reactions to chemical peels, ingredients, pesticides, chemicals, detergents, heat, laser resurfacing, laser assisted hair removal and skin injuries can also be a source of pigmentation disorders.

PIH is caused by one of two mechanisms that result in either epidermal melanosis or dermal melanosis. These constituents of inflammation alter the activity of both immune cells and melanocytes. Specifically, these inflammatory components stimulate epidermal melanocytes, causing them to increase the synthesis of melanin and subsequently to increase the transfer of pigment to surrounding keratinocytes. This increased stimulation and transfer of melanin granules results in epidermal hypermelanosis.

Dermal melanosis occurs when inflammation disrupts the basal cell layer, causing melanin pigment to be released and subsequently trapped by macrophages in the papillary dermis, also known as pigmentary incontinence.

Accept the challenge

PIH is a universal response of the skin and can occur in lighter global skin categories, but is more common in the darker global skin types. This condition can occur at any age and takes place in both females and males. Inflammation is the trip wire to hyperpigmentation, and the skin you treat can have many levels of damage that require assessment to determine how you manage pigmentation disorders according to the information brought to light during the client’s skin history consultation.

Are you prepared to accept the challenges of working with skin of color? Beautiful skin, sex appeal, sophistication and good looks have always been a desire of all cultures. Always assess individual ethnic variability when developing a personal home care program and clinical treatment plan.

Christine Heathman is a licensed master esthetician, massage therapist and burn specialist with more than two decades of clinical practice and research at institutions such as Stanford University in Palo Alto, California, and the University of Utah in Salt Lake City. Honored in 2003 as an industry legend by the American Association for Esthetics, she believes the future of skin care is now.

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How-to: Pigment Treatment Protocol for Fitzpatrick Skin Type III

Editor's note: As always, Skin Inc. magazine recommends that skin care professionals obtain the proper training before offering any new treatments in their skin care facility.

This client is 50, of Japanese decent, and suffers from a post-inflammatory hyperpigmentation (PIH) condition. It is important to note that Asian skin is prone to sensitivities and irritation, and is genetically predisposed to scarring because the skin has a thinner stratum corneum. This unique global skin type is also at high risk for hyperpigmentation; therefore, careful selection of professional products is prudent. With skill and appropriate product selection coupled with depth of knowledge for the Asian global skin type, success can be achieved. Although many pigment injuries can take weeks and months to resolve, a minimum of eight treatments is recommended. This is a very stubborn and challenging skin condition, and you may not see improvement until the sixth treatment. Hyperpigmentation is a permanent injury to the melanocyte cell and can reappear in as few as eight days if treatment and professional products to treat the condition are suspended.

Skin must be pre-treated with home-care maintenance for up to 16 weeks, depending on skin of color type and pigment morbidity propensity. Also, it is very important to monitor your client, carefully examining the skin with a Wood’s lamp before each treatment. This will assist you in determining how much of the transient pigment is under control.

Cost: $95–125

Duration: 45 minutes

Contraindications: Contraindications of a chemical treatment on any skin type should always be a consideration when implementing application. Every esthetician who uses peeling modalities on a regular basis in their treatments must develop specific guidelines and techniques to avoid PIH, irritation and discomfort and understand all risks. Serious complications are extremely rare, usually only occurring after the deep chemical peels.

Supplies and equipment needed:

Soft, nonabrasive cloth

Cotton pad

4 x 4 gauze applicator

Large cotton-tip applicator

Products needed:

Creamy noncomedogenic cleanser

Hydrating rinsing mist

Salicylic exfoliating cleanser

AHA pre-treatment solution

Tyrosinase pigment cell clarifier

Gel lactic 30% solution

Gel cooling mask

Tyrosinase skin-bleaching fluid

Antioxidant serum

Retinol serum

Hydrating ceramide serum

Stem cell serum

Hyaluronic acid gel

Anti-inflammatory aloe cream

SPF 30 sunscreen

Camouflage makeup with SPF protection

Step 1: Remove all makeup from the facial skin using a creamy noncomedogenic cleanser. Using efferlauge strokes, cleanse skin and follow with a thorough removal of decayed dermal debris using clean, tepid water and a soft, nonabrasive cloth. Avoid too much irritation.

Step 2: Spray cleansed area with a hydrating rinsing mist.

Step 3: Apply a salicylic exfoliating cleanser to the entire face and chest. Remove cleanser with clean tepid water and a soft, nonabrasive cloth.

Step 4: Spray skin with hydrating mist to ensure all traces of cleanser have been flushed from the skin.

Step 5: Using a cotton pad, apply an AHA pre-treatment solution to the cleansed area. Do not scrub the skin; instead, gently and thoroughly saturate fatty acids on the skin surface. Allow fluid to dry thoroughly.

Step 6: Spread a generous amount of a tyrosinase pigment cell clarifier over the entire area. Be sure all areas to be treated are completely coated.

Step 7: Using a 4 x 4 gauze applicator, spread a gel lactic 30% solution evenly across pigmented facial zones. Leave this solution on the skin for no more than one minute. Neutralize the solution with cool water and thoroughly flush all traces of the product from the skin using clean gauze. After the third treatment in the series, graduate to lactic 50%, carefully following the instructions on the product. (Editor’s note: Before using these percentages of acids, you must confirm with your state’s rules and regulations that it is within your scope of practice to do so. It varies from state to state. Log on to for complete contact information for each state’s board.)

Step 8: Spray the skin again with hydrating rinsing mist.

Step 9: Apply a gel cooling mask for five minutes.

Step 10: Saturate a large cotton-tip applicator with tyrosinase skin bleaching fluid and apply on dark pigmented areas. Your goal here is to accelerate the lightening of the darker areas to match the normal value of the skin.

Step 11: Using the fingertips, coat skin with a generous amount of antioxidant serum over the bleaching fluid.

Step 12: Follow with an application of a retinol serum all over the face.

Step 13: Using the fingertips, spread a minimum of 3–5 drops of a hydrating ceramide serum over the entire affected facial area, including the neck. Wait two minutes before the next application step to stabilize the inner cellular substances of the stratum corneum. It is normal for the skin to feel some stimulation after this step and your client may remark that stinging is occurring. Stimulation from AHAs or any peeling agent subsides within a few minutes after applying cool or cold water to the skin during removal; however, in the event of persistent irritation (which is rare), application of an aloe cream or ice is recommended.

Step 14: Using the fingertips, apply a stem cell serum followed by an application of a hyaluronic acid gel over entire treated area.

Step 15: Spread a thin coat of a light anti-inflammatory aloe cream over treated skin.

Step 16: Apply a retinol cream over the entire face using your fingertips and gently massage it into skin until it disappears.

Step 17: Apply a generous amount of SPF 30 over the entire face and neck area.

Step 18: Complete the treatment by applying skin camouflage makeup with SPF protection. The client should avoid direct contact with sun, and always wear a hat or carry a parasol when outdoors.

A Global Service Outlook

By Linda Harding-Bond

As the world becomes smaller and new demographic markets emerge, the opportunities to work on a global clientele are increasing. If you want to attract a multicultural audience, you must have a global service outlook that will suit every ethnicity. Following is a cheat sheet for skin care professionals who want to attract and keep an ethnic clientele.

Smile. A smile is a universal welcoming signal that crosses all boundaries and immediately puts your client at ease. Initial chatting may be more expected among different ethnic groups, so bump up your charm a bit.

Interview your client. Every client’s skin is different, based upon how she lives her daily life, genetics, and what she uses on her skin. Don’t assume anything; just ask.

Don’t categorize your clients. Knowing the Fitzpatrick Classification Scale is not enough. Check skin for hyperpigmentation, which may indicate trauma, and will provide considerable information for you about what products can be used on the client’s skin.

Make the client comfortable. If your wraps and robes are skimpy and you have a plus-sized client, recommend that she forgo the wrap and just climb under the sheet. Also, if your client has a hairstyle that is not washable, offer her an additional headband or even a shower cap, especially if heavy steam is involved.

Cleanse, cleanse, cleanse. The more glamorous ethnic clients are often huge fans of cream-to-powder makeup formulations and pigment-rich eye shadows. Consider using makeup remover and work it into the skin first before cleansing. Never hesitate to perform a third gentle cleansing if necessary, but do not scrub the skin.

Use your loupe. Look past the color to the skin. I recently had a Latina client who had fine capillary activity and redness on her cheeks that was visible only under the loupe. It turned out that her father was Irish and suffered from rosacea. I modified her facial accordingly.

Be gentle. It is a common belief that the darker the skin tone, the rougher the skin can be treated. The opposite is true. Here’s the rule of thumb: If it causes pain to your client, it is probably causing hyperpigmentation, as well. Be gentle!

Avoid extractions during the initial facial. A good rule for the first facial is to provide clients with skin that is polished, luminous and smooth to the touch. They always return, and this is when you start focusing on in-depth cleaning.

Watch your time. Because there is such a dearth of information and skin care professionals who truly understand ethnic skin, many ethnic clients will have a myriad of questions. Add a minimum of five additional minutes to the normal amount of time you allow yourself for product recommendations when working with a new client with skin of color.

Check in later. This, of course, is customer service 101, but with your ethnic clients, you are certain to score huge points if you call them later in the week to see how their skin is doing after a facial. This is also a perfect way to offset concerns about possible skin reactions. Just be sure to allow yourself sufficient time to chat.

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