Statistics in the industry of cosmetic medicine continue to reveal a positive trend in regard to growth. The growth trend in regard to performing services on clients who have ethnic skin is significant. In the medical field, the statistics show that more than 1.3 million cosmetic plastic surgery procedures were performed on ethnic patients in 2004, an increase of 44 percent since 2000.

Resurfacing Techniques in the aesthetic industry include the following:

• Chemical – application of various acids to achieve epidermal necrosis
• Physical – controlled mechanical skin injury, such as microdermabrasion

What is Skin Resurfacing?
By definition resurfacing is an intentional controlled tissue wound and subsequent exfoliation whose purpose is to remove specific surface imperfections and improve overall skin appearance. In the aesthetic industry, the most effective methods include microdermabrasion (a.k.a. physical exfoliation) and chemical peels. The physical exfoliation options available depend upon the laws in the state you are working in, as well as the medical supervision you may or may not have in your facility. Most aestheticians today are aware of microdermabrasion treatments for a physical peel, yet the knowledge and training of how to approach exfoliation for ethnic clients is few and far between. This is complicated by the early manufacturing deficiencies of microdermabrasion systems, some of which are still being utilized today throughout the industry. Looking through operators manuals of early models of microdermabrasion systems, routinely shows a list of contraindications that often include ethnic skin. Does this mean you cannot perform microdermabrasion treatments on ethnic skin? A decade ago that may have been true. Today there are better engineered microdermabrasion systems and with proper training you can get excellent results performing this type of treatment on your ethnic clients.
The reason early models of microdermabrasion systems avoided working on ethnic skin had to do with the inability to separate the vacuum and crystal flow. The basic concept of performing microdermabrasion (or physical exfoliation) is to increase the depth of the peel in a progressive manner through a series of treatments. An effective first exfoliative treatment is one that prepares the client's skin for the reception of progressively increased treatments.

Crystal-based microdermabrasion systems have been clinically proven to stimulate dermal tissue over non-crystal systems (Am J Derm March 2007). Microdermabrasion systems can progressively increase the depth of peel by increasing one, some, or all of the following: vacuum (a.k.a. suction), crystal flow, and/or number of passes over the same area. Understanding that not every client's skin is the same, allows the skin care professional to alter the course of a client's treatment specific to their skin. This is based upon the client's skin condition, the treatment protocol available, and the training obtained. If you have a client that has a history of telangiectasias (couperose) or if you suppose that their skin may develop post-inflammatory hyperpigmentation (PIH), then increasing the vacuum or suction during the course of the series of treatments is inappropriate. Maintaining a consistent low vacuum pressure with a microdermabrasion system that has independent vacuum and crystal flow allows the operator to increase the depth of the peel by increasing the crystal flow and/or the number of passes. Older technology does not allow the operator to do this as the vacuum and crystal flow are directly linked and cannot be operated independently. Thus increasing the depth of the peel during the course of a progressively increasing series of exfoliation treatments becomes more difficult if not impossible.

Pigmentation
Pigmentation is defined at the cellular level and is interrelated through three cellular components consisting of melanocytes, melanosomes, and keratinocytes. Keratinocytes originate in the basal layer, move upward toward the surface of the epidermis, and slough off through a natural exfoliation process. This sloughing process can be accelerated by the use of exfoliants such as AHA, salicylic acid, tretinoin, microdermabrasion, TCA, Levulan, and retinol.
Melanocyte variation does not determine the color of skin, rather it is the distribution of melanosomes produced by the melanocytes. There are approximately 2,000 epidermal melanocytes/mm2 on the head and forearms and approximately 1,000 epidermal melanocytes/mm2 on the rest of the body. These differences are present at birth.
All people have approximately the same total number of melanocytes; it is the distribution of melanosomes in the keratinocytes that correlates with skin color.

Fitzpatrick Skin Classification and Analysis
While there are several models available to categorize pigment distribution and the correlating sun sensitivity in skin, the Fitzpatrick model has been the most accepted in the aesthetic industry. This classification provides identification of fair to black skin, based on the concentration of melanin and is a necessary step to provide safe effective treatment. There are many methods utilized in the industry that can assist in accurately predicting the Fitzpatrick skin type of a client. One method of accomplishing this is to ask your client about sun exposure and their history of burning when exposed to the skin. See a typical worksheet on facing page.

Ethnic versus Non-ethnic Skin
So why are there differences in skin color if we all have approximately the same number of melanocytes? In Fitzpatrick skin types I to III, the melanosomes are small and aggregated in complexes, and in types V and VI there are larger melanosomes that are distributed singly within keratinocytes. This distribution of melanosomes and melanin in ethnic skin provides a level of protection, which is a primary property of skin pigment. This level of protection of melanin is to absorb and scatter energy from UV light in order to protect the epidermal cells from damage. The degree of protection corresponds directly to the degree of pigmentation. Increased melanin in the skin also offers significant prevention of photo-aging, which is one of the primary cosmetic concerns in Fitzpatrick skin types I to III

Pigmentary Changes in Ethnic Skin
Historically, the ability to perform microdermabrasion treatments on ethnic skin was limited due to lack of training and lack of manufacturing and engineering of early models. As the depth of the treatment increased, so also did the increase in trauma, and correlating blood flow to the area of treatment. Skin responds to trauma much like all other human tissue, with an inflammatory response. Ethnic skin can sometimes respond to this type of treatment by increasing the stimulation of melanocytes, primarily due to the inflammatory response in the tissue. The key to exfoliatiation described in this article is to proceed with moderate increases over the course of the treatment protocol. Although hypopigmentation can occur, hyperpigmentation is most common.

Chemical Peels
When you choose chemical over physical exfoliation, you need to know about the specific peels to which you have access. It is important to choose a peel that you have "control" of during a service. An example of a peel that you would have no control of after application would be a TCA peel. Subsequently, they are not recommended for use on ethnic skin. You can count on a chemical peel to break down and lift away dead skin cells through a controlled injury. The strength of your peel will be responsible for how much injury occurs. Our bodies go into defensive mode to try and heal the injury initiating a rush of restorative support to the tissue. The body's response can reduce fine lines, decrease melanin content, and scarring as well as improving acne conditions.
Another reason many skin care professionals are hesitant to treat ethnic skin with exfoliation is the variability (and sometimes lacking) post-treatment procedures. Any ingredient that has a potential to cause significant irritation or dryness when applied to the skin can cause pigment alteration in ethnic skin. Following an exfoliative procedure such as microdermabrasion or chemical peel it is critical to apply moisturizer and sunscreen, regardless of the skin type you are working with. Removal of the stratum corneum leaves underlying tissue starved for hydration and extremely susceptible to UV rays. The stratum corneum layer provides protection that keeps moisture in and helps protect against UV rays. When removed by exfoliation, the underlying tissue becomes suddenly exposed to these elements and can become dry and/or sunburned quickly if not
treated appropriately.
When dealing with ethnic skin types, extra care must be taken to ensure that the skin stays hydrated. Choosing peel ingredients that are effective yet gentle on the skin is a must. Staying away from harsh peels or products containing resorcinol or benzoyl peroxide will help to ensure positive results in an ethnic client. Moisturizers are extremely important to your ethnic clientele. Darker skin will appear gray or have an "ashy" appearance when not properly hydrated and some studies show that ethnic skin has a greater risk of trans-epidermal water loss than lighter skin tones. Proper care before and after an exfoliative procedure is just as important as the peel you choose for this particular client, so don't slight client care by skipping over this important step. Sunscreen is still necessary for ethnic clients and it is important when using a reflective sunscreen to make sure it is micronized. Micronization will ensure that the reflective ingredients do not cosmetically alter the natural skin's color.
Above all, moderation is the key when dealing with ethnic skin. Many clients are looking to have skin care procedures done, but can't find an aesthetician who knows how to balance treatments effectively. Being too aggressive with darker skin will increase the risk of systemic side effects without necessarily increasing the benefits. One example of being too aggressive would be performing microdermabrasion and a chemical peel during the same session. If you have an effective microdermabrasion system and an effective chemical peel, they will be effective on any skin type without compromising the integrity of the skin. The risk of post-inflammatory pigmentation problems increase as the intensity of your services also increase. Be confident in knowing that there are procedures available to effectively treat a darker skin care client. Unfortunately, today's society likes to promote the "more is better" mentality, so much of the time. If you steer clear of that mind set, you can successfully build a clientele from a market that is anxious for results.

Tim Hamilton has been involved in clinical medicine for over 20 years. He has a BS in Biology, a masters of science in human genetics and attended University of South Carolina School of Medicine. He owns Grace Medi-Spa and Grace Medical Equipment, Inc, located just outside of Charleston, SC. He teaches continuing education programs throughout the Southeast. His website is www.gracemedicalequipment.com.

Colleen Large is the product manager for Grace Medical Equipment. She is a founding member of the South Carolina Esthetics Association under which she teaches continuing education. She is a licensed aesthetician in S.C. and Md., as well as a licensed aesthetic instructor in S.C.