Times change, and the world population is becoming increasingly diverse in terms of ethnic identity. This is especially true in the U.S., where people of many ethnicities and the merging of ethnic identities challenge old concepts of classification. Grasping the commonalities and differences between skin conditions common to specific ethnicities is absolutely critical to treating skin in an effective and truly modern way.
But here's the problem: it's difficult to even discuss the ethnicity of skin in correct, appropriately sensitive, and politically correct terms. The traditional language still applied to race — and in fact, the term "race" itself — is deeply rooted in Victorian and colonial social systems. In many cases, these concepts are no longer applicable.
These questionable terms include Caucasian. For instance, skin therapists will generally classify individuals of Latino/Hispanic heritage as Caucasian, since the other choices are Asian and African-American/Black. But the fact is that nearly all Latinos in the U.S. possess mixed genetic heritage, including Native American in the case of Latinos from Mexico and much of the Americas, or Afro-Caribbean heritage in the case of Latinos from Cuba, Puerto Rico, and the Dominican Republic. These non-European genetic components are present in many Latinos in tandem with their Iberian (European Spanish) heritage, and their skin tones will range from milky-fair to deeply, richly pigmented. Why is this important to discuss with the client? A Latino skin may appear as "white" as a Northern European skin, but in fact will respond with hyperpigmentation and will be slower to recover from cutaneous trauma than a Nordic/Celtic skin, precisely because of the non-"Caucasian" aspects of the client's genetic content. For instance, before prescribing microdermabrasion or any other invasive or ablative service, it's crucial to have a clear picture of the client's ethnic complexities. And, it is not politically incorrect to ask! In fact, it's essential in order to deliver insanely great service.
Skin color is visible to the eye, but unseen genetic factors play a crucial role in how the skin will respond to various treatments and products. For example, recent studies1 have confirmed that Asian skin is more prone to sensitization from topically applied chemicals; this is attributed to a thinner Stratum Corneum (SC) layer and a higher sweat gland density, which provides easy access to the dermis. For obvious reasons, this is an important consideration prior to selecting a hydroxy acid peel or treatment product for an Asian client. It also indicates that the same treatment protocol may not be suitable for a similar skin condition on an ethnically diverse group of individuals. The importance of doing a thorough consultation prior to treating the client cannot be underestimated. For example, if you are doing a consultation on an Asian client, you might probe deeper on the subject of sensitization — and examine for hot, tight, reddened areas – prior to determining the appropriate treatment. Now that we know why these differences are important in the skin care practice, let's take a closer look at what distinctions can be made.
Moving Beyond Myths
It's important to set aside preconceptions and explore the latest science. Much research is currently underway regarding non-Northern European skin, since the so-called "ethnic" market is booming. For instance, there is a common belief that African-American hair and skin are more resilient and tougher than those of Caucasians. In fact, the wave-pattern of African-American hair makes it fragile, and African-American skin heals more slowly from trauma than other more lightly pigmented complexions. This misinformation may extend to the African-American client as well, who may believe that she does not need sun protection, or that her skin will "never age" because of her pigmentation. All of this indicates opportunities for education on both sides of the therapist/client relationship.
The Anatomy of Color
The color of our skin is the net result of many different components, including UV exposure. When we look at our skin, we are viewing it through a semi-tinted epidermis that covers the dermis. Color is the combined effect of several factors: Brown tones are attributed to melanin pigment, while the yellow tone is due to the carotenoids that are found in many of the foods (e.g. carrots) we eat. The red and blue tones are attributed to oxygenated and deoxygenated blood of capillaries, respectively. Altogether these colors contribute to the color of our skin. What varies amongst different groups is the brown melanin component of our skin.
Treating hyperpigmentation has been the focus of many research studies and product launches in the past decade, and is of particular interest to African-American, Latino, and Asian clients. It's no surprise that hyperpigmentation disorders become more pronounced as we age — and so it's not unusual for a client with deep pigment who has neglected sun-protection in her youth to suddenly find blotching and uneven coloration an issue after the age of 40. There are numerous products on the market to treat hyperpigmentation; many are less than ideal for clients that are prone to sensitization and hyperpigmentation. I always recommend that one steer clear of hydroquinone-based products as they can be irritating to the skin (stimulating post-inflammatory hyperpigmentation) and the safety of hydroquinone is highly questionable (hence it is banned almost every where but in the U.S!).2 Kojic acid is also an ingredient I find to be irritating to the skin and would avoid. Look for brightening products with non-acidic forms of stabilized vitamin C, (Magnesium Ascorbyl Phosphate-MAP, Tetrahexyldecyl Ascorbate, and Ascorbyl Glucoside), whitening peptides (Oligopeptide-34), Niacinamide, Phytic acid, and anti-inflammatory agents (white tea, green tea, and licorice) for maximum results.
Keloids are a bulbous and disfiguring form of scarring attributed to hyperactive fibroblasts and sluggish collagenase enzymes. It's been known for some time that African-American skin exhibits more tendency to keloids than Caucasian skin.3 This is the basis of the decorative scarification practices which have been part of some African cultures for eons. Today, we now know that many Asian skins also exhibit this tendency. The potential to develop keloid scars most certainly must be taken into account prior to doing any radical exfoliation, microdermabrasion, extractions, or the like on African-American skin.
Individuals with light brown skin, such as Latino and Asian individuals, are more prone to developing melasma, or the mask of pregnancy. Hormones alone, whether they are from pregnancy or birth control pills, are not enough to trigger melasma. Exposure to the sun is a critical requirement for this pigmentation disorder. This is an important consideration in the skin care center when prescribing sunscreens for your clients. For more sensitive Asian skin, I would always recommend a physical sunscreen made of zinc oxide or titanium dioxide versus a chemical sunscreen to avoid potential irritation issues. And remember to avoid any sunscreens with alcohol, lanolin, fragrance, or colorants.
Scarring, pigmentation, and enhanced sensitization are the primary issues that are more pronounced in non-Northern European skin. A common concern is Pseudofolliculitis barbae or "razor bumps," a chronic condition seen commonly in African-American men who shave, but also seen in African-American women who experience excess hair and use shaving or tweezing as a means for hair removal. This is common in individuals with extremely curly beard (or, in the case of women, leg) hairs, which grow back at an oblique, dagger-like angle after shaving. The body recognizes this ingrown hair as a foreign body and triggers an inflammatory response that includes redness, itchiness, and a raised area that resembles a pimple that can fill with pus. Often, the repeated inflammation leads to permanent darkening of the area (e.g., around the collar). In severe cases, keloids may form, so be cautious when using strong acid peels that may irritate or inflame the skin.
Inflammation, medical procedures, exposure to chemicals (e.g. fragrance, glycolic acids, etc.), and medications may also cause hyperpigmentation. Any trauma to the skin, whether it be a wound or acne, or the result of a medical procedure (e.g. laser hair removal) can induce post-inflammatory hyperpigmentation (PIH), which can be a problem for skin of color. Look for anti-inflammatories in the products you prescribe: green tea, white tea, licorice, oatmeal, chamomile, allantoin, and aloe are all good choices.
The topic of sebum production variations among the different ethnic skin types has resulted in contradictory studies. Some report no difference in the amount of sebum produced while others state African-American skin generally has larger sebaceous glands and secretes more sebum while Asian skin has significantly more sebum than light-pigmented Caucasian/Northern European skin.3 The latter study supports the observation that there is a higher incidence of acne among Asians. When treating an Asian client for acne, remember to avoid products that are too harsh or that may trigger cascade reactions in skin that is predisposed to sensitization. Similarly when treating African-American skin for excess oil or acne, bear in mind keloid scarring and inflammation that can lead to PIH.
Several small scale studies4 have been undertaken to determine any difference in trans epidermal water loss (TEWL) and penetration of topical agents in Caucasian, African-American, and Asian skin. The assumption being that TEWL reflects the integrity of the barrier function of the SC. This could have implications for not only levels of hydration in skin but skin sensitivity due to enhanced penetration into the skin. The results showed that skin permeability was highest in Asians, then Caucasians, followed by African-American skin – which supports the notion that Asian skin is in fact more sensitive to topical agents.
The world has become a smaller place, and so our clients' ethnic composition becomes more complex — many, many strands of ethnicity now come together in the world's emerging population. In response, our treatment of skin must reflect greater awareness and greater understanding of this growing diversity. In addition to conducting a thorough client skin consultation and skin analysis, research your products and treatments carefully to ensure you have considered not only your client's skin condition, but have factored in any underlying predispositions that may be associated with their genetic skin type.
Working with an increasingly diverse clientele offers a tremendous opportunity to the skin therapist to expand and deepen skills and understanding. In any major U.S. city, you may encounter clients who bring together Vietnamese and African-American; Native-American, Mexican, and Irish; Sephardic North African and Italian – you name it! In this way, the world comes to you as a skilled therapist. Use this richness to learn everything there is to know about skin. Like the song says — we are the world!
A.V. Rawlings, Ethnic Skin Types: Are there Differences in Skin Structure and Function? in IFSCC Magazine vol 9, no. 1/2006 p.3-13.
(2) Howard, D. L. (2009) Hydroquinone: Is the Cure worse than the Problem? GCI Magazine p. 58-62
(3) Asian Skin: Its Architecture, Function and Differences from Caucasian Skin. C&T vol 117, no. 9. Sept 2002. P. 57-62.
(4) F. Kompaore, et al. In vivo evaluation of the SC barrier function in Blacks, Caucasians, and Asians with two noninvasive methods. Skin Pharmacol 6: 200-207 (1993)