MANAGING DARKER SKIN TONES

I am Dr. Mélissa Badof, and I practice aesthetic medicine at my office in Reims, France. I first discovered aesthetic medicine more than five years ago, when I experienced a dermatologic concern myself. This prompted me to pursue further training and obtain several university diplomas, which now allow me to offer a diverse range of treatments. I also developed a particular interest in darker skin phototypes, as I believe that treating these patients requires an understanding of their specific skin characteristics.

It is therefore essential to define what constitutes a darker skin phototype according to the Fitzpatrick classification: phototypes IV through VI. However, skin pigmentation can vary considerably within a single phototype. A patient’s ethnic background should systematically be documented during history-taking, as it may influence the therapeutic approach.

The aging process in darker skin phototypes differs from that in lighter skin. The number of melanosomes, rather than melanocytes, determines how light or dark an individual’s complexion is. Higher skin phototypes therefore provide greater protection against UVA radiation and, consequently, extrinsic aging.

Because Black skin is thicker, older individuals with darker skin tend to exhibit expression lines rather than skin laxity. Wrinkles in pigmented skin are thus more closely associated with intrinsic aging, clinically manifesting as deepening nasolabial folds, marionette lines, and glabellar lines. Atrophy of the midface, including the tear trough region, occurs later.

Understanding these physiologic characteristics allows us to adapt our approach in aesthetic medicine. Treatment outcomes are generally longer-lasting. Care must also be taken to avoid overly superficial injections in darker skin phototypes, as these may cause localized lightening or even yellowish discoloration of the overlying skin.

Dyschromia is a major concern among patients with darker skin phototypes. I will discuss residual hyperpigmentation following acne, scarring, postinflammatory pigmentation, and melasma. Inflammation stimulates melanocytes, resulting in hyperpigmentation. How should this understanding of skin physiology inform our approach to treatment?

Darker skin is more sensitive to chemical peels, with a greater risk of burns, and treatment outcomes also depend on the depth of the pigmentation. Superficial peels should therefore be used initially, with close monitoring of the skin’s response. A grayish appearance and erythema indicate the need for immediate neutralization, as they reflect involvement of the dermal-epidermal junction.

Initial peels should be performed using low concentrations and short application times. The peeling agent should then be rinsed off with water or a buffered solution, followed by the application of a moisturizer. Medium-depth peels may also be used, but require heightened vigilance from the practitioner. Deep peels, however, are strictly contraindicated in patients with darker skin phototypes. Suitable peeling agents include glycolic acid, salicylic acid, mandelic acid, and trichloroacetic acid. Pretreatment skin preparation is essential to optimize outcomes and minimize complications.

If acne is responsible for the hyperpigmentation, it must be treated first, and an alpha-hydroxy acid (AHA) cream should be prescribed for morning application before the peel is performed. Patients should be instructed to discontinue all potentially irritating cosmetic products. They may experience only limited desquamation, but this does not indicate that the peel has been ineffective. Caution must therefore be maintained at the next session, with gradual increases in both the concentration of the peeling agent and the application time.

The before-and-after photographs show a patient with acne scarring whom I have treated with only one peeling session so far, targeting hyperpigmented spots following electrolysis sessions for excessive hair growth.

Before and after one peeling session: improved skin radiance is already apparent.

An equally delicate case involved a patient with Fitzpatrick skin phototype IV who had a scar in the glabellar region following an accident. I performed a combined treatment consisting of a superficial peel and one session of intense pulsed light (IPL) at low settings to address the inflammatory component.

Managing patients with darker skin phototypes can be complex and requires an understanding of skin physiology to tailor aesthetic treatment appropriately. Nevertheless, as with lighter skin phototypes, a combination of treatments is often necessary to optimize the anticipated outcomes.