This dark spot is often referred to as post inflammatory hyperpigmentation (PIH).
The acne and PIH are important concerns for skin of color clients. An acne lesion often causes emotional distress; the appearance of an acne lesion often leads to feelings of poor self image and lack of confidence. PIH only exacerbates these feelings as the site of trauma from the acne lesion continues to be marked and evident for weeks and sometimes months after the acne lesion is healed in skin of color.
Whether it is a comedo, pustule or another type of lesion, acne is a common disease involving the sebaceous gland. It is important to identify the origin and development of the acne lesion(s) to determine the recommended professional treatment and home care regimen.
For example, a comedo, a blackhead, is a combination of keratinized and lipid materials congested in the follicle as a result of a change in the cell turnover cycle and pattern. As such, it is best cared for with an ingredient like an alpha hydroxy acid (AHA) to aid in the exfoliation of the keratinocytes. A pustule is similar to a comedo, it is a combination of not only keratinized and lipid materials, but also proprionibacterium acnes (p. acnes) congested in the follicle. It is best cared for with an ingredient that will oxygenate the follicle, like benzoyl peroxide, and change the environment of the congested follicle so that the p. acnes cannot proliferate and induce greater trauma and inflammation to the skin causing greater PIH.
Understanding the pathogenesis of acne and ingredient use and benefits will allow the skin care professional to create the most effective professional treatment and home care regimen for successfully addressing acne in skin of color.
Post Inflammatory Hyperpigmentation (PIH)
Epidermal PIH is the response of the epidermis to inflammation and trauma and can be addressed by an aesthetician. Epidermal PIH can be detected by a Wood’s Lamp. With progressive and serial professional treatments and a dedicated home care regimen, PIH can be resolved. For dermal PIH, aestheticians should follow the NCEA Code of Ethics and “refer clients to the appropriate qualified health practitioner”.¹
PIH is the release and oxidation of many products, including fatty acids to chemical messengers like arachidonic acid to prostaglandins, that change the immune and melanocyte cells as a result of the stimulation. Melanocytes respond by producing melanosomes containing melanin (skin color pigment) and the end result is the transfer of melanosomes to the keratinocytes creating the PIH.
This PIH is created when the melanosomes are stimulated through trauma, inflammation, and heat. An inflamed acne lesion or an overly stimulated and picked at acne lesion will create the PIH marking the spot of a healed acne lesion.
Working In Tandem with a Partnership Commitment
While acne is a disease and PIH is a condition, both disease and condition can be cared for by a skin care professional. The key to working with skin of color is to find the balance between aggressive early intervention and gentle treatments to avoid irritation and greater inflammation.² An early start caring for the acne lesion will help reduce the amount of trauma, inflammation, and heat to the skin resulting in the degree of PIH.
This balance is most successful when a partnership is formed between a dedicated skin care professional and a compliant client working with great patience. Torrie Jakes, Louisiana Licensed Aesthetician, finds “the main ingredient in any hyperpigmentation regimen is patience.” Creating the formula for success is patience plus commitment, resulting in the sum, achievement of the goal.
During a consultation, having a client join you, the skin care professional, in signing a commitment agreement can encourage the partnership structure. This commitment holds no financial or legal value. Its sole purpose is having the client understand the joint goal of achieving healthy, balanced, beautiful skin and committing to the same agenda as the skin care professional in working with acne and skin of color.
Sample Skin Care Commitment for Working with Acne in Skin of Color
I, _____________________________________________________________________ ,
commit to working with _______________ of (Business Name) ____________________
to address my acne and skin care concerns. I agree to follow the recommended home
care regimen to optimize the benefits of my professional treatments. I agree to
arrive on time for my regularly scheduled professional treatments and to follow a
series of professional treatments as advised by my skin care professional to meet
the goal of achieving healthy, balanced, beautiful skin.
Signature of client _______________________________________Date _____________
Signature of skin care professional __________________________Date _____________
Clients seek results and the expertise of a skin care professional. With results comes dedication from a client. Helping the client trust in your professional expertise will help them be a more compliant client, a long term key to patient success. Ensuring clients are diligent with their home care regimens will allow the good results to continue in the treatment room with progressive and serial treatments.
Ingredient Use and Benefits in Home Care and Professional Treatment Regimens
The combination of both home care and professional treatment regimens is successful with the right combination of ingredients in the products. A noncomedogenic home care regimen founded on products that are for more sensitive skin, a characteristic of skin of color, should contain gentle exfoliation and skin brightening ingredients. The basic regimen should consist of a cleanser, a hydrator or a moisturizer, a melanocyte suppressant product and a sun protection product. Added to this regimen are specialty ingredients or products featuring these specialty ingredients formulated to target the acne lesion or brighten the skin and reduce the degree of PIH.
Sukhi Bingham/Johal, Owner of Spa Manjoh, Westwood Village, Calif. advises skin care professionals to work slowly and gradually on clients with skin of color. By progressively introducing clients to specialty ingredients, clients experience good results with little irritation. Bingham/Johal says, "Clients want quick results, yet quick, aggressive treatments with high concentrations of performance ingredients in a low pH can cause even more problems as the skin of color clients have sensitive skin and are not prepared for such aggressive treatments". Working progressively with a good home care regimen and using a mid range product to a more aggressive product leads to better results with less irritation and trauma to the skin and most importantly less risk of inducing PIH.
In designing progressive professional treatments and home care regimens, specialty ingredient use is most important. A few acne specialty ingredients include benzoyl peroxide, salicylic acid and AHAs. Benzoyl peroxide works by oxygenating the hair follicle where the proprionibacterium acnes (p. acne) can only survive in an oxygen free environment. Benzoyl peroxide will deliver oxygen to the hair follicle preventing the growth of the p. acne bacteria therefore reducing the amount of inflammation and trauma resulting in PIH. Benzoyl peroxide is best used as a spot treatment or as a specialty ingredient in the basic home care regimen.
Salicylic acid, often classified as a beta hydroxy acid (BHA), derived from wintergreen and birch bark, is lipid-soluble and therefore able to penetrate the congested follicle and exfoliate the skin with its keratolytic and antimicrobial actions. Like lactic acid, it is an excellent ingredient for use as a specialty ingredient an SPF product should be recommended for collaborative use with salicylic acid as this ingredient will exfoliate the skin and leave it more susceptible to trauma and PIH.
Lactic acid, an AHA, derived from sour milk, has a large molecular structure and while it is as effective as glycolic acid, another AHA, derived from sugar cane, it does not penetrate as deeply and is therefore better able to exfoliate the skin where the PIH damage resides. Lactic acid is another excellent ingredient for use as a specialty ingredient. As it is an AHA, the skin care professional must recommend collaborative use of an SPF product with an AHA product.
A few skin brightening ingredients include azelaic acid, vitamin A, vitamin C, and kojic acid. Originally developed as a topical acne treatment, azelaic acid inhibits tyrosinase used for melanin production. It does not have a depigmentation effect on normally pigmented skin. By using this specialty ingredient in a home care regimen, skin of color clients will observe skin lightening and especially the reduction of PIH.³ When used with an Alpha Hydroxy Acid (AHAs), the benefits of these combinations in ingredients leads to an exponentially greater result. As this is a skin lightening ingredient and especially if used in collaboration with AHAs, use of an SPF product is highly recommended. Azelaic acid is a specialty ingredient that may be used in a cleanser, hydrator, moisturizer or specialty melanocyte suppressing product.
Vitamin A is an antioxidant and is known for its ability to exfoliate and improve the appearance of fine lines and wrinkles. It is also good for its ability to increase collagen production and elastin formation. Most importantly for skin of color clients, vitamin A is known to aid in pigmentation concerns. It is often used as a specialty ingredient.
Vitamin C, also an antioxidant and a tyrosinase inhibitor, is a specialty ingredient with a variety of uses. As an independent antioxidant ingredient or as a specialty ingredient, vitamin C serves many purposes. It does tend to be more photosensitive and like melanocyte suppressing ingredients, should be stored with care in a dark and cool environment as this ingredient is more prone to quick oxidation.
Kojic acid inhibits the activity of tyrosinase. It is known to be irritating and for this reason should be used with great care. As it is a skin brightening ingredient, it is imperative to use an SPF product to maintain the skin brightening benefits.
Hydroquinone is a skin-bleaching ingredient recognized by the United States Food and Drug Administration (FDA). It is often considered the most effective specialty ingredient. The over-the-counter (OTC) use is limited by the FDA to 2 percent, however; caution should always be used as there is an adverse effect, exogenous ochronosis. This condition is a darkening of the area treated by hydroquinone, the opposite effect of the goal of lightening the PIH. For this reason, many skin care professionals prefer to use skin brightening ingredients until their clients are accustomed to working with a skin care professional experienced in working with this ingredient.
As with all home care regimens, the use of a sunscreen is always important. Sun exposure will reverse the benefits of the skin brightening ingredients and will only stimulate not suppress melanocyte activity. A minimum SPF 15 product should be used on a daily basis and should the client be exposed to sun and outdoor activity, it is highly recommended to be in the sun in the early morning and the late evening while wearing a hat and using sun protective clothing and coverings with a SPF 30 product applied to the skin.
From home care to professional treatments, clients will find that using a home care regimen prior to, during, and after professional treatments will allow the skin care professional to work with greater success by optimizing the professional treatments with less irritation to the client and visible results in the reduction of acne lesions and PIH.
For optimum results, perform a professional exfoliation treatment every 12-14 days to ensure the collagen has reached its optimal level of stimulation and to ensure the skin is not overly exfoliated and therefore irritated leading to trauma and PIH. Pamela R. Springer, Licensed Educator and Founder of The Skin & Makeup Institute of Arizona, Peoria, Ariz., shares her success in the professional treatment room. Depending on the severity of the acne in skin of color clients, Springer says, “my most successful treatments are when the client is committed to weekly or bi-weekly treatments. These treatments vary and are conducted by rotating mild to moderate exfoliation services.” Professional serial lactic acid and salicylic acid exfoliation treatments are excellent for skin of color clients.4
In working with acne in skin of color, progressive combinations of specialty ingredients and aggressive early intervention and gentle treatments will help you in working with this specialty. Partnering with your clients will ensure a committed professional treatment and home care regimen for the successful achievement of healthy, balanced and beautiful skin of color.
Austine Mah is an Asian American who successfully works with skin of color, especially her own. She is an accomplished methodologist and facilitator, dedicated to advancing the understanding of therapeutic skin treatments through continuing education. Technically knowledgeable, Austine extends her commitment to excellence and awareness from treatment room to home care. She regularly consults, educates and writes for the aesthetic industry. Learn more about Austine at www.austinemah.com.
¹ National Coalition of Estheticians, Manufacturers/Distributors and Associations. 15 June 2006.
² Callender, Valerie D. (2004) Acne in ethnic skin: special considerations for therapy. Dermatologic Therapy 17 (2), 184-195.
³ Rodriguez Prieto, M.A., P. Manchado Lopez, I. Ruiz Gonzalez, and D. Suarez. Treatment of lentigo maligna with azelaic acid. Int. J. Dermatol. 32:363-364, 1993.
4 Grimes, Pearl. (1999) The safety and efficacy of salicylic acid chemical peels in darker racial-ethnic groups. Dermatologic Surgery Jan; 25 (1):18-22.