Chiza Westcarr from Advanced Skin Technology debunks some common myths in skin therapy and shares her insight into managing pigmentation across a multi-ethnic patient base.

The face of today’s cosmetic client is difficult to define. The ‘typical’ patient can span across genders, multiple age groups and – perhaps the most important when it comes to distinguishing between treatment modalities – various ethnic backgrounds.

LYTERA_Packaging_Secondary+Primary_10.25.12“I have been with Advanced Skin Technology (AST) for the past 10 years and, in that time, there has been significant diversification in the ethnic mix of patients looking for solutions to skin concerns,” explains Chiza Westcarr, Global Clinical Education and Development Manager at AST. “The diversification of modern-day Australia is reflected in cosmetic patients.”

What does this mean for clinicians? According to Westcarr, it calls for a deeper understanding of common skin concerns and possible treatment options for different ethnicities, as well as an understanding of why certain skin conditions are more prevalent in certain ethnicities.

“When I provide training, I make a point of reminding clinicians that Australia has a disproportionately large Caucasian population living in an environment that is not designed for Caucasian skin,” Westcarr says. “Caucasian skin is ill-equipped to handle these conditions and, as a result, there is a manifestation of skin cancer, actinic damage and accelerated ageing not seen in higher Fitzpatrick phototypes. In contrast, higher Fitzpatrick phototypes might be acne prone, have pigmentation concerns, there might be concerns of dull, lifeless skin or sensitivity, but the visible manifestations of ageing are very different.”

“Despite the fact that Australia is indeed a melting pot, medical practitioners and clinicians alike are still very hesitant, even nervous, about treating higher Fitzpatrick phototypes for fear of causing PIH or worse,” Westcarr adds. “There needs to be an understanding of the nuances associated with treating higher Fitzpatrick phototypes combined with an understanding of the mechanisms behind certain skin concerns before going ahead with treatment. For example, despite all Fitzpatrick phototypes possessing the same number of melanocytes, higher Fitzpatricks produce larger, denser UV absorbing melanosomes (pigment packages). So while it may seem counterintuitive, thicker skin is more common in Caucasian patients with a lot of sun-damage, as hyperkeratosis is a way for the skin to protect itself.”

Practitioner education is key in ensuring all patients are offered comprehensive and effective solutions tailored to their Fitzpatrick phototype and cosmetic concerns. AST offers courses through the Medical Aesthetics Institute, providing comprehensive generic education on all aspects of skin, ranging from skin physiology and skin conditions right through to ingredient technology and chemical peels.

In these classes Westcarr shares some insight (and debunks some common myths) to help optimise the results of cosmetic intervention across a multicultural clientele. She says adequate preparation, assisted recovery and researching alternatives to hydroquinone for higher Fitzpatrick phototypes are all must-dos in the effective management of common skin concerns.

“There needs to be due diligence on the part of the clinician, and it is vital to understand the nuances of treating ethnically diverse patients for effective and long-term results,”

Westcarr says. “Best practice should involve adopting protocols that are less invasive, with less irritation, because every patient, from every ethnic background, deserves to have the best care.”

Preparation & recovery

There are certain ‘non-negotiables’ around patient preparation of a higher Fitzpatrick phototype before undergoing any form of cosmetic procedure, including peels, laser therapy and micro-needling.

“Anyone coming in for any treatment needs effective preparation, and the basics every Chiza-Westcarrpatient should be on include Vitamin A, alpha hydroxyl acids (AHAs), antioxidants and sunscreen,” Westcarr explains. “As well as this, those patients with a Fitzpatrick phototype higher than III should be on tyrosinase inhibiting (TI) serum. Patients with a Fitzpatrick phototype of III to IV should be on a TI serum for two weeks prior to treatment, and those patients with a phototype higher than this should be using the serum for three to four weeks prior at least.”

For the best treatment outcomes in any skin treatment, it’s important the practitioner knows how long to wait – and why – between prepping, performing the actual treatment and then the aftercare.

“There are three phases of wound healing,” Westcarr explains. “There is the inflammatory phase, where the cells involved in the initial stage of the wound healing process are recruited; the proliferative phase, where keratinocytes, fibroblasts and melanocytes are activated to increase repair and restore skin function; and the remodelling phase, where the structurally weak matrix that has been initially laid down in the proliferative phase is replaced and reinforced by collagen Type I, which is of greater tensile strength.”

“Depending on the treatment performed, for example following chemical peels and non-ablative laser or microneedling, the inflammatory phase might last four to five days, and aftercare is essential – focusing on barrier protection, repair and hydration using soothing and calming ingredients such as hyaluronic acid (HA), niacinamide and essential fatty acids,” Westcarr adds. “Vitamin A and other actives can be re-introduced around day five onwards (depending on when the proliferative phase kicks in, characterised by flaking and the disappearance of redness and discomfort).”

Why hydroquinone shouldn’t be the go-to therapy in higher Fitzpatrick phototypes

Hydroquinone has always been the gold standard in the management of skin pigmentation. Even in higher Fitzpatrick phototypes, where it should be more cautiously applied, hydroquinone is often the go-to solution for many doctors in treating pigmentation because the results are typically predictable and fast. According to Westcarr, this reliance upon hydroquinone to achieve results in treating pigmentation in higher Fitzpatrick phototypes long term can be detrimental to the long-term health of the patient’s skin.

“Many medical practitioners prescribe hydroquinone, alongside tretinoin and a steroid and sunscreen, because it affords quick results and predictable outcomes,” Westcarr explains. “While it might work to successfully address pigmentation in the short term, there are a range of long-term use issues in higher Fitzpatrick phototypes when using hydroquinone.”

“Hydroquinone has been shown to be cytotoxic to the melanocyte, with risks including confetti-like dyspigmentation and exogenous ochronosis in higher Fitzpatrick phototypes, hyper/hypopigmentation, dermatitis and skin irritation and – arguably the most frustrating – the occurrence of rebound pigmentation, which results from taking a break from its use due to tachyphylaxis,” Westcarr adds.

Advancements in cosmeceutical technology means hydroquinone no longer needs to be the only treatment option when it comes to managing pigmentation. According to Westcarr, there is a plethora of tyrosinase inhibitors that are effective in managing pigmentation in all Fitzpatrick phototypes, including Lytera, AST’s number-one selling pigment management product.

“There are many alternatives to hydroquinone that can be used long term with no associated irritation – because of this, consumers who have done their homework are often interested in, and visit clinics enquiring about, a hydroquinone alternative,” Westcarr says. “Lytera targets all the pathways of melanin production and has been clinically tested against hydroquinone (4%) over a period of 12 weeks – the results have been compelling.”

“Lytera combines Vitamin A, alongside tyrosinase inhibitors, melanin transfer inhibitors, skin calming agents and photoprotectants,” Westcarr adds. “It can be used alone or, for best results, in conjunction with a Vitamin A serum, sunscreen and a cleanser to produce results comparable to those achieved with 4% hydroquinone without the irritation. Lytera can be safely used ongoing and long term, with a very satisfactory outcome.”

What you may not know about using peels to treat pigmentation

Chemical peels can be a good option in reducing pigmentation across most skin types, as Westcarr explains.

“Traditional peels (both toxic and caustic) were designed to annihilate or create maximum destruction to the skin’s layers, which would ultimately result in remodelling and repair. These peels were associated with a high risk of post-inflammatory hyperpigmentation (PIH), and even hypopigmentation, in patients with higher Fitzpatrick phototypes,” says Westcarr. “It’s best to be cautious, and I recommend using metabolic peels and salicylic acid peels to achieve the best results in patients at risk.”

“For example, lactic acid and Vitamin A peels allow for the increased proliferation of keratinocytes and the stimulation of fibroblasts to produce collagen without the downtime and irritation associated with caustic peels,” Westcarr adds. “Often, practitioners are hesitant to use salicylic acid for fear of causing PIH, because it is heat-inducing, but salicylic acid is actually anti-inflammatory, and a series of salicylic acid peels can be the ideal solution to specific skin concerns in higher Fitzpatrick phototypes, so long as the skin is prepped correctly.”

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