Considerations When Treating Cosmetic Concerns in Men

of Color
Olabola Awosika, MD, MS,* Cheryl M. Burgess, MD,†‡ and Pearl E. Grimes, MDx

BACKGROUND Men of color include a diverse population encompassing individuals with Fitzpatrick skin
Types IV through VI. Yet, there is a paucity of data describing the cosmetic concerns of this population.

OBJECTIVE To review the basic science of advantages and disadvantages of skin of color and pathophysi-
ology, incidence, and treatment of disorders of cosmetic concern in men of color.

METHODS A MEDLINE search was performed for publications on sex and racial differences in basic science
of skin, common disorders in men of color, and evidence-based treatments.

RESULTS There are intrinsic differences in skin and hair of darker-complexioned men, particularly in His-
panics, African Americans, Asians, and Afro-Caribbeans. Advantages of darker skin include increased photo-
protection, slowed aging, and a lower incidence of skin cancer. However, the increased content of melanin is
associated with myriad dyschromias including melasma and postinflammatory hyperpigmentation (PIH).
Additional common skin conditions of concern in men of color include pseudofolliculitis barbae, acne keloi-
dalis nuchae, and keloids.

CONCLUSION A skin color conscious approach should be administered in caring for the cosmetic concerns
of men of color that is cognizant of differences in biology of the skin and hair, associated PIH of disorders, and
cultural/social practices among this population.

The authors have indicated no significant interest with commercial supporters.

S kin of color patients encompass a diverse

population varying in racial/ethnic background,
cultural practices, and preferences in aesthetics and
treatment concerns.1 This population includes African
Americans, Hispanics, Asians, and multiracial
individuals, of whom are projected to represent more
than half of the US population by 2044, according to
the US Census Bureau.2 Given the rapid growth of this
population and the unique presentation of
dermatologic conditions in these individuals,
dermatologists must become competent in their
understanding of the differences between skin of color
patients and their white counterparts.3,4 Moreover, the
paucity of information regarding men in this group
warrants further summary of the issues specific to men
of the skin of color population. Here, the authors
review the biological differences in skin and hair,
epidemiology of disorders, and necessities for care
pertinent to these men.
Basic Science
Advantages and Disadvantages of Ethnic Skin
Myriad morphologic and physiologic differences
characterize the skin of men of color. Such changes are
associated with cutaneous advantages and dis-
advantages (Table 1). Understanding the biological
aspects of the benefits and shortcomings of skin of
color are pertinent for management of conditions in
darker-skinned male patients.

*Department of Dermatology, The George Washington Medical Faculty Associates, Washington, DC; †Department of
Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC; ‡Department
of Dermatology, Georgetown University School of Medicine, Washington, DC; xDivision of Dermatology, University of
California, Los Angeles, California

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· ·
ISSN: 1076-0512 Dermatol Surg 2017;43:S140–S150 DOI: 10.1097/DSS.0000000000001376

S140

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TABLE 1. Dermatologic Issues in Men of Color
Advantages Disadvantages
Enhanced photoprotection Hyperpigmentation
Slowed aging Hypopigmentation
Low incidence of skin cancer Keloids and hypertrophic
scars
Fragility and sensitivity
of manipulation of hair
In particular, pigmentary differences, due to the
amount and distribution of melanin in the epidermis,
are a hallmark feature of skin of color. Although
melanocytes do not vary in number across racial
groups, the aggregation and size of melanosomes
within melanocytes and keratinocytes are the cause of
the variation in skin hues in skin of color. In lighter-
skinned patients, such as Caucasians and Asians,
melanosomes tend to be smaller and aggregated, and
less in number in the basal layer of the epidermis.4–6
Darker-skinned patients tend to have larger, dense,
nonaggregated melanosomes with an increased num-
ber of basal layer melanosomes.4,5
The increased melanin content of darker skin is pro-
tective against the carcinogenic and photoaging effects
of ultraviolet (UV) radiation, providing an inherent
sun protection factor (SPF) of 13.4 in Fitzpatrick skin
Types (FSTs) V and VI.4,7–9 Hence, Hispanic, Asian,
and black patients experience a lower incidence of skin
cancer and often experience photoaging later in life in
comparison with white subjects.4 In concordance,
melanoma development is inversely correlated with
pigmentation in skin.10 However, darker-skinned
patients are found to develop melanoma most often in
less pigmented areas of skin, such as the palms and
soles. In addition, this population is more susceptible
to pigmentary disorders, developing post-
inflammatory hyperpigmentation (PIH), melasma, or
uneven skin tone secondary to UV radiation, cutane-
ous injury, and the lability of melanocytes.4,11
Another consideration in ethnic skin types is the dif-
ference in cellular components of the dermis. In an
analysis of the dermis, Montagna and Carlisle12 found
greater quantity of fibroblasts in black female facial
skin compared with white female facial skin. Black
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AWOSIKA ET AL
individuals were also demonstrated to have fibroblasts
that were larger, often multinucleated, and composed
of closely packed smaller collagen fiber bundles run-
ning parallel to the epidermis. These findings are of
particular interest because fibroblast hyperreactivity
and decreased activity of collagenase enzyme is
thought to result in keloid formation.13 Keloidal
fibroblasts have increased expression of cytokines,
such as transforming growth factor beta 1 (TGF-b1),
which leads to increase synthesis of Type I collagen.13
Thus, enlarged and numerous fibroblasts found in
black individuals, which may be suggestive of
increased activity in these fibroblasts, may explain the
increased incidence of keloids in this population.4
Hair Characteristics
The structural elements of hair across racial groups
are similar in amino acid composition and types of
keratin.14,15 However, intrinsic properties of hair do
vary across skin of color patients and in comparison
with their white counterparts. In particular, signifi-
cance in structural variation, including shape and
diameter, has led to classification of the human hair
by ethnic origin into the 3 following major groups:
Caucasian, Asian, and African.16 On cross-sectional
analysis, African hair has the longest major axis of the
3 groups, leading to its elliptical, flattened shape.17,18
Hair of African populations is characterized by tight
coiling, random reversals in hair direction, and
curving of the hair follicle. By contrast, the round
nature and large cross-sectional area of Asian hair
manifests as a tertiary structure that is wavy, helical,
or straight.18,19 Caucasian hair is the smallest in
cross-sectional area. In addition, electron microscopy
has demonstrated an increased tendency for African
hair to form knots, longitudinal fissures, and breaks
along the hair shaft.20 These findings are virtually
absent in Caucasian and Asian hair, which appear to
shed rather than break. Furthermore, the total hair
density and number of terminal hair follicles has been
found to be significantly lower in patients of African
descent.21 These differences make the hair of African
origin more fragile and sensitive to manipulation.19
In particular, disorders of the scalp and hair in darker-
skinned patients result from the difference in structural
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 TREATING COSMETIC CONCERNS IN MEN OF COLOR

integrity of the hair shaft and follicle. For the men of

this population, the curvature of the hair follicle is the
causative factor in the development of pseudofollicu-
litis barbae (PFB).4,22,23 Close shaving results in curved
hairs puncturing the epidermis after a few millimeters
of growth (extrafollicular penetration), leading to
a neutrophilic inflammatory response. The con-
sequences of this disorder on cultural practices and
lifestyle are further discussed in the following section.

Disorders of Concern in Male Skin of Color

Pseudofolliculitis Barbae

Pseudofolliculitis barbae, colloquially referred to as

“razor bumps” or “ingrown hairs,” affects patients
with tightly curled hair in the bearded area. It has been
observed in Hispanic and Middle Eastern men.
However, it is most prevalent in men of African
ancestry, estimated to affect 45% to 83% of African
American men.24,25 Pseudofolliculitis barbae became
a prominent social issue among military men in the
1960s to 1970s due to the large recruitment of African
American men and the strictly enforced grooming
code of clean-shaven faces, particularly in the Air
Force and Army.24,25 In 1974, the National Medical
Association made a public statement opposing the
maltreatment of black men with PFB in the military
due to persistent harassment and discrimination.25
Today, PFB continues to have serious socioeconomic
implications for affected men in employment arenas,
where clean-shaven faces are strictly enforced or
encouraged.
As previously stated, PFB is a chronic foreign-body
reaction to hair re-entry. Growth of shaved coarse,
curly hairs result in extrafollicular penetration or
transfollicular penetration (distal tip of the hair pierces
the follicular wall beneath the skin’s surface) of the
upper dermis.19,22 Clinically, PFB presents as peri-
follicular or follicular papules on the neck and cheeks
of men, after repetitive shaving of these areas (Figure
1).22,23 Inflammation leads to sterile pustule forma-
tion, which may develop into abscesses. Potential
sequelae of severe cases include hypertrophic scarring
and keloids. The most commonly affected areas for
this disorder are the bearded areas of the face and
Figure 1. Pseudofolliculitis barbae—multiple papules in
beard area.
anterior neck, whereas the moustache and posterior
neck are usually spared.22 Patients may complain of
accompanying pruritus and pain, with PIH being the
most commonly reported associated feature (docu-
mented in up to 90%).24
The mainstay of treatment for PFB is avoidance of
shaving, with discontinuation of shaving for at least 1
month documented as curative in most cases.22
However, this approach is often impractical for life-
style and work environments. An alternative therapy is
trimming facial hair with clippers, while maintaining
0.5 to 1 mm of facial hair length.22 Notably, contrary
to previous beliefs, recent studies have demonstrated
that PFB is not exacerbated by multiblade, preshave,
and postshave hydrating regimens.26,27 In particular,
in a 2013 study, patients who practiced daily pre-
shaving and postshaving regimens with emphasis on
moisturization were found to have more improvement
in itching and equivalent decrease in papule count
compared with patients who decreased frequency of
shaving or had no preshaving and postshaving

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regimen.26 Hence, for patients who prefer clean
shaves, the following steps have been recommended
with success: (1) wash face with warm water and
gentle cleanser before shaving to soften hairs and
release ingrown hairs; (2) apply a generous amount of
shave gel/foam for improved razor glide and reduced
friction; (3) shave daily (with a technologically
advanced multiblade razor) if possible using light
strokes in the direction of hair growth; and (4) use an
after-shave product with moisturizing agents to
hydrate skin.26 For severe PFB, topical application of
tretinoin treats concomitant PIH and hyperkeratosis
(removing the thin layer of skin covering the embed-
ded hair shaft). In addition, low potency topical cor-
ticosteroids or topical/oral antibiotics (particularly
tetracycline on a standard acne regimen) may be used
to reduce inflammation associated with papule or
pustule and abscess formation, respectively.22,26
For recalcitrant cases of PFB, common treatments
include eflornithine hydrochloride cream to slow hair
growth or hair removal with electrolysis or light and
laser therapy.19,22,23 However, electrolysis is the least
effective of these methods as it is difficult for the straight
electrolysis needle to target the curved follicle of tightly
coiled hair.16 For laser and light-based therapy, intense
pulsed light and alexandrite, diode, and neodymium:
yttrium-aluminum-garnet (Nd:YAG) lasers have all
been approved for hair removal in darker skin types.19
In particular, the 1,064-nm Nd:YAG is the preferred
laser for hair removal in PFB because of its low inci-
dence of adverse events in this patient population.22,28 In
addition, the longer wavelength of the Nd:YAG laser
allows deeper penetration, resulting in follicular
destruction and sparing of the epidermis.
Acne Keloidalis Nuchae
Acne keloidalis nuchae (AKN), or folliculitis keloidalis
nuchae, is another chronic condition most prevalent in
African American men. It rarely affects white men but
does impact Hispanic and Asian populations. The
prevalence of the disease has been estimated at 4.7% in
South African boys, 9.4% at a Nigerian hospital, and
0.5% to 13.6% in African Americans.29–32 There is
a 20:1 ratio of disease occurrence in men compared
with women.33
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AWOSIKA ET AL
Men often associate the development of AKN with
exposure to unclean barber instruments.34 However,
lesions are often sterile, and the exact etiology of the
disorder is unknown.16,22 Proposed etiologies include
mechanically induced folliculitis resulting in scar for-
mation or pathogenesis similar to PFB or primary
cicatricial alopecia.30,35,36 Like PFB, AKN presents as
a chronic disorder of hair follicles; however, papules
tend to be fibrotic, dome-shaped, and localized to the
nuchal and/or occipital area of the scalp (Figure 2).23
Usually, patients experience a prodrome of pruritus
for hours to days before onset.29 Several inciting fac-
tors for PFB have been identified, including friction
from shirt collars or sports helmet. However, in
a Nigerian study, the most common precipitating
factor was a haircut at the barbers in 90% of the
patients.29 Acne keloidalis nuchae may be further
aggravated by close haircuts and injury to papules
resulting in bleeding, which raises concern for trans-
mission of blood-borne pathogens when unsterilized
hair clippers are shared.34 In severe, long-standing
cases, hairless fibrotic, keloid-like plaques with tufted
hairs may arise from coalescing papules.22,23,30
For AKN, preventive measures are also the primary
mode of treatment. Patients should avoid mechanical
irritation from short haircuts and culprits of increased
friction in the affected area, such as tight helmets, shirt
collars, and self-manipulation.22,23 Early disease can
be successfully managed with potent topical steroids
and topical retinoids.30 Mild to moderate disease is
usually treated with intralesional steroids, with cau-
tion for side effects such as hypopigmentation and
Figure 2. Acne keloidalis nuchae—papules in nuchal area,
scalp, and neck area.
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 TREATING COSMETIC CONCERNS IN MEN OF COLOR

atrophy. For more advanced presentations, systemic
treatment with tetracycline derivatives is useful in
reduction of inflammation.22 In addition, there has
been 1 case reported of a 27-year-old Caucasian man,
with both AKN and keratosis follicularis spinulosa
decalvans, who demonstrated rapid improvement of
scalp inflammation within weeks of starting iso-
tretinoin at 0.25 mg/kg daily.37 Surgical excision and
laser therapy, with long-pulsed Nd:YAG laser, have
also shown benefit.22,30 Esmat and colleagues38 dem-
onstrated significant reduction of papule count, pla-
que size, and sclerosis in 16 patients after 5 sessions of
long-pulsed Nd:YAG laser treatment of AKN. Early
intervention, however, is most important in the pre-
vention of advanced disease and success of
treatment.30
Keloids and Fraternity Branding
Keloids are a disfiguring disorder, carrying a signifi-
cant burden on quality of life in affected individuals.
Patients of African, Hispanic, and Asian descent are
more susceptible to formation of keloids compared
with Caucasians, with incidence ranging from 2.2% to
16%.39,40 There is no difference in incidence of keloi-
dal scars in men and women.41 However, there is
a predilection for development between the ages of 10
and 30 years.42
Clinically, keloids present as raised scars extending
beyond the margins of the original wound. These
firm lesions are usually hyperpigmented with
a smooth surface and may grow large enough to
cause deformity or limit mobility of joints.13,23 They
often occur in areas of tension, such as the sternum,
and may take on the shape of inflicted wounds, such
as fraternity branding (Figure 3). Notably, frater-
nity branding has become more fashionable in
western countries, with reports of up to 5% of
adolescents at an inpatient hospital showing some
form of branding or scarification.44 In the authors’
experience, there has been an influx of young male
patients of color presenting with formation of
keloidal scarring at branding sites. Hence, it is per-
tinent to counsel prevention, including avoidance of
trauma and surgical/cosmetic procedures such as
piercing, tattooing, or branding, in patients with
skin of color with personal or family history of
keloids.

Keloids often occur secondary to inciting factors,

such as acne, infection, tattoos, and burns.43 After
one of these insults to the skin, an abnormal wound
healing response takes place, leading to the formation
of a keloidal scar. This response is due to a multifac-
torial process, including increased collagen turnover,
growth factor expression, and alteration of apopto-
sis.13 In particular, TGF-b, connective tissue growth
factor, and platelet-derived growth factor are all
factors implicated in the pathogenesis of keloidal
scars.13 As noted previously, the characteristic of
larger, multinucleated fibroblasts in darker-skinned
patients, may explain the increased propensity for
keloids in this population. In addition, a genetic
predisposition for the development of keloids in skin
of color patients has also been proposed with several
descriptions of autosomal dominant and recessive
inheritance.23 Figure 3. Keloid from branding.

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For treatment of keloids, multiple modalities exist
with varying success and side effects. Intralesional
triamcinolone acetonide is a mainstay of treatment;
however, side effects include hypopigmentation,
atrophy, and telengiectasias. Interferons have shown
efficacy as monotherapy and in reduction of recur-
rence when used in combination with surgical exci-
sion.13,23 However, interferon injections are
associated with pain at injection site and influenza-like
illness. Sustained scar flattening has also been achieved
with 5-FU and bleomycin alone, with respective rates
of 88% and 92% in treated patients.13,45,46 Cryo-
therapy has less efficacy, with 67% to 73% of patients
reporting substantial flattening, and is associated with
pain and hypopigmentation or hyperpigmentation.
Laser therapy with argon, CO2, and pulse dye has
shown variable results, with tendency toward recur-
rence (in more than 90% of patients).13 Alternatives to
injections and lasers include silicone-based occlusive
and pressure dressings which are noninvasive methods
well-tolerated in younger patients who are unable to
bear the pain of more aggressive therapies. Other
therapies for consideration include radiotherapy and
intralesional bleomycin, etanercept, or botulinum
toxin. Surgical excision of keloids alone is not rec-
ommended due to high recurrence rates, ranging from
55% to 100%.13,42,47 However, this recurrence may
be minimized by adjunct use of the aforementioned
Figure 4. Postinflammatory hyperpigmentation. (A) Macular areas of hyperpigmentation caused by acne vulgaris. (B) After
treatment with tazarotene gel and hydroquinone.
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AWOSIKA ET AL
therapies, including corticosteroid injection, brachy-
therapy, or pressure dressings. Given the recalcitrance
of keloids, a multitherapy approach generally yields
the best results. In addition, consideration for change
in pigmentation should be addressed, as the lightening
effects of some modalities may be preferable in deeply
pigmented scars.
Postinflammatory Hyperpigmentation
and Melasma
Hyperpigmentation remains a primary concern
among patients of color and common sequelae of all
the aforementioned disorders. Pigmentary disorders in
general have a wide prevalence across the world,
ranging from 9% in African Americans to 22.8% in
Afro-Caribbean, Caucasians, Indians, and Chinese in
Jamaica.39,40
Postinflammatory hyperpigmentation and melasma
are 2 pigmentary disorders of major concern that
affect men with skin of color. Postinflammatory
hyperpigmentation manifests as dark macules or
patches usually resulting from overproduction and
transfer of melanin to keratinocytes secondary to
increased inflammatory processes (Figure 4). Such
inflammatory conditions include acne vulgaris, atopic
dermatitis, psoriasis, and drug eruptions. Although
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 TREATING COSMETIC CONCERNS IN MEN OF COLOR
the exact mechanism is not completely understood,
studies have demonstrated prostaglandins E2 and D2,
interleukin (IL)-1, IL-6, and tumor necrosis factor–
alpha to have melanocyte-stimulating properties.4,48
Melasma is a complex condition characterized by tan-
brown hyperpigmented patches often affecting the
forehead, cheeks, nose, and chin areas (Figures 5 and
6). Contributory factors in the pathogenesis of this
condition include genetic influences, sun exposure,
and topical irritants such as mustard, used in India.49
Men represent 10% of the melasma population, and
low testosterone levels have been reported in this
group of patients.50
Treatments for melasma and PIH often overlap.51
Although cures are possible for PIH, most cases of
melasma are chronic. Initial therapy should focus on
addressing any underlying inflammatory dermatoses.
Topical therapy with photoprotection (usually SPF of
30 or higher) and topical lightening agents should then
Figure 5. Melasma—hyperpigmented patches of the fore-
head and nose.
S146 DERMATOLOGIC SURGERY
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be implemented. Hydroquinone is usually the depig-
menting agent of choice due to its efficacy and fairly
safe profile. The most frequent side effects of hydro-
quinone in the United States include skin irritation and
contact dermatitis, with exogenous ochronosis
occurring more commonly in Africa and Asia due to
unregulated and prolonged use of hydroquinone.52 In
fact, extensive review by Simmons and colleagues52
demonstrated as few as 37 cases being reported
between 1983 and 2014 in the United States. Other
common topical agents with established efficacy and
safety in skin lightening for darker-skinned patients
include tretinoin, azelaic acid, ascorbic acid, and kojic
acid.53,54 Emerging agents under consideration for
depigmentation in skin of color include tranexamic
acid, undecylenol phenylalanine, flutamide, Rumex
occidentalis, and cysteamine.55
Resurfacing procedures, such as chemical peels or
laser therapy, have also been useful in improving
melasma and PIH in instances of more severe
cases.56,57 There have been few studies evaluating the
efficacy and safety of laser therapy alone or in com-
bination with chemical peels for dyschromia.48 Nota-
bly, Vachiramon and colleagues58 demonstrated
that low-fluence Q-switched Nd:YAG 1,064-nm laser
combined with glycolic acid peeling led to temporary
reduction of melasma in men. However, the transient
benefits did not justify the experienced side effects of
dyspigmentation. For chemical peels alone, superficial
chemical peels are preferable given the increased risk
of worsening dyschromia and hypertrophic and
keloidal scarring with deep chemical peels.59 Superfi-
cial peels, which penetrate through the stratum cor-
neum into the papillary dermis, include glycolic acid
20% to 70%, salicylic acid 20% to 30%, b-lip-
ohydroxy acid 10% or lower, tretinoin 1% to 5%, and
Jessner’s solution.60 Retinoids should be discontinued
1 to 2 weeks before to prevent complications, such as
excessive erythema, worsening PIH, or desquamation
post-treatment.59 Skin prep with hydroquinone 4% or
higher for 2 to 4 weeks reduces epidermal melanin,
which is of particular importance for treating dys-
chromias. In addition, patients should be encouraged
to wear sunscreen daily for maximal effects. For FST V
and VI, patients who do not demonstrate improve-
ment with superficial peels, combination peeling with

Figure 6. Melasma: severe hyperpigmented patches of the forehead cheeks. The patient was treated with hydroquinone 6%
and 10% creams and a series of 3 salicylic acid 20% peels. (A) Before treatment. (B) After treatment with hydroquinone and
chemical peels.
salicylic acid 20% to 30% and low strength tri-
chloroacetic acid (TCA) may be implemented. Tri-
chloroacetic acid is a medium depth peel most
efficacious for treatment of photodamage and mel-
asma in skin Types I to III.59 Hence, combination
peeling with TCA and salicylic acid may be adminis-
tered in all skin types, but TCA at higher strengths
should typically be reserved for use in FST I to IV.
Signs of Aging
Concerns for aging in patients of color vary signifi-
cantly from their white counterparts given biological
differences in aging. Skin of color patients, particularly
African Americans, experience increased skin laxity
more frequently than perioral rhytides during the
aging process, compared with Caucasians.61 This skin
sagging is caused by primary arcs converting into
straight lines.62 In addition, fat atrophy first becomes
most apparent in the cheek and temple of darker-
skinned patients, eventually resulting in a sunken
appearance in these areas. In blacks, there is greater
tendency toward mid- and lower-face aging,
including increased prominence of the nasolabial
folds from sagging of the malar fat pads.63,64 For
men in particular, hyperkinetic motion of the face,
including frowning, laughing, and smiling, leads
to forehead lines and glabellar scowl. A recent
study of self-reported signs of aging in multiple
ethnic groups showed slowed signs of aging in
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AWOSIKA ET AL
African American men compared with other racial
ethnic groups, including Caucasians, Hispanics, and
Asians.65
For all patients of color, dermatosis papulosa nigras
(DPNs) and seborrheic keratoses are benign epidermal
proliferations that increase in number and size as
patients grow older, often representing photoaging in
this population.66 Dermatosis papulosa nigras, par-
ticularly, may arise in the first decade of life and affect
more than 40% of darker-skinned patients by the third
decade. Removal of DPNs and seborrheic keratoses is
also of interest in this population because it results in
dramatic improvement of youthful appearance and
increased patient self-confidence. The current main-
stay of treatment for these lesions in patients of color is
electrodessication with or without curettage.28,67
Cryotherapy is not recommended given results of
variable pigmentation.68 Topical hydrogen peroxide
in a 40% solution is an emerging therapy for sebor-
rheic keratoses and DPNs currently under investiga-
tion in Phase 2 and 3 studies for safety and efficacy in
FST V and VI.69,70
Reversing signs of aging, other than DPNs, can be
accomplished through soft tissue augmentation and
neuromodulators. However, in the male patient of
color, clinicians should be aware of both defining
characteristics of the male face (such as well-defined
jaw lines) and varying perceptions of what constitutes
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 TREATING COSMETIC CONCERNS IN MEN OF COLOR
beauty in different ethnic/racial groups, when treating
these signs of aging.61,62,71 Enhancement of ethnic
features should be the goal of treatment opposed to
emulation of Western ideals of beauty.63 In addition,
preference for fillers which stimulate elastin, collagen,
and skin tightening should be given, as these fillers
have been found to be more effective in skin of color.
When using stimulatory fillers, such as calcium
hydroxylapatite and poly-L-lactic acid, skin of color
patients require fewer sessions to achieve the desired
correction. This is likely due to decreased thinning of
elastin and collagen bundles at baseline and after
treatment.72 There is also a decreased need for the
excess use of filler when botulinum toxin is used 2
weeks before soft tissue augmentation, allowing for
less need to correct folds and creases.61
Skin tightening, using infrared, radiofrequency, and
ultrasound-based technologies, can also be used alone
or in conjunction to botulinum toxin or fillers. At the
wavelengths of noninvasive skin tightening devices,
water opposed to melanin is the target chromophore
and makes these devices theoretically safe in all skin
types.28,66 Moreover, when using skin tightening
devices, the epidermis is spared from injury by
directing maximum absorption of energy to the dermis
which leads to induction of collagen contraction and
remodeling. Specifically, for skin of color, skin tight-
ening may be used to reverse skin laxity of the jowls
and nasolabial folds in older patients.66 Most studies
into safety and efficacy of skin tightening in skin of
color have been investigated in Asian patients, with
reports of infrared light demonstrating moderate to
good improvement in 81% of patients and physician
assessed improvement of 50% or more in patients
receiving radiofrequency.66,73,74
When treating darker skin types for signs of aging, side
effects, including dyschromia and keloid formation,
must be considered during the use of therapies for
cosmetic enhancement. Although electrodessication is
a fairly safe modality for DPN removal, treatment of
a single lesion to gauge inflammatory response may be
warranted given variable propensity for PIH after
treatment.48,67,75 For skin tightening, in particular,
lack of expertise when operating devices may lead to
postinflammatory pigment alteration and disfigure-
S148 DERMATOLOGIC SURGERY
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ment, such as hypopigmented scarring in patients of
color.28 Of interest, when using hyaluronic acid fillers,
slightly longer injection times and multiple puncture
techniques have been associated with increased rates
of PIH.76 In addition, caution should be taken to
reduce bruising when performing injections, as it
increases the incidence of hemosiderin deposition,
thereby leading to persistent dyschromia.63 Of further
concern is the increased propensity of skin of color
patients to develop keloids in comparison with their
white counterparts. Because of the composition of
fibroblasts in skin of color patients, keloids occur 3 to
18 times more often.62 Although keloid formation
secondary to the use of fillers has not been reported,
dermatologists should proceed with caution when
using them in patients with a history of keloids and
hypertrophic scars.61
Conclusion
As the skin of color population continues to grow in
the United States, dermatologists must stay abreast of
the dermatologic interests of these patients and the
prevalence of disorders specific to various ethnic/
racial groups. In concordance, as men show more
interest in dermatologic care, the men of the skin of
color population must be of priority to practitioners
in terms of their needs, primary concerns, and skin
ailments. Treatment approaches should take into
account associated PIH of disorders and cultural/social
practices regarding shaving and hair care practices. In
addition, knowing the difference in biology of the
skin and hair for these patients is helpful in guiding
dermatologists’ understanding of presentation of dis-
ease and potential resistance to treatment. Overall, the
unique population of men of skin of color is a diverse
group necessitating cultural competence and a skin
color conscious approach by dermatologists.
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Address correspondence and reprint requests to: Cheryl M.
Burgess, MD, Department of Dermatology, The George
Washington University School of Medicine and Health
Sciences, 2311 M Street, NW Suite 504, Washington, DC
20037, or e-mail: cheryl.burgess@ctr4dermatology.com