Skin of Color

Approach to Treatment of Medical and Cosmetic Facial Concerns in Skin of Color Patients

In Collaboration With the Skin of Color Society

Cutis. 2017 December;100(6):375-380

Valerie D. Callender, MD

Victoria Barbosa, MD

Cheryl M. Burgess, MD

Candrice Heath, MD

Amy J. McMichael, MD

Temitayo Ogunleye, MD

Susan C. Taylor, MD

Facial concerns in skin of color (SOC) patients vary and can be a source of emotional and psychological distress. This article discusses 4 common facial concerns in SOC patients: acne, rosacea, facial hyperpigmentation, and cosmetic enhancement. Treatment recommendations are provided as well as management pearls.

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Practice Points

Treat acne in skin of color (SOC) patients early and aggressively to prevent or minimize subsequent postinflammatory hyperpigmentation (PIH) and acne scarring.
Vascular lasers and intense pulsed light may be used to address the vascular components of rosacea; however, the latter is not recommended in Fitzpatrick skin types IV to VI.
Hydroquinone is the gold standard for skin lightening and is often used as a first-line therapy for melasma and PIH.
Photoprotection is an essential component of therapy for hyperpigmented skin disorders.
Cosmetic procedures are gaining popularity in the SOC population. When treating SOC patients, consider the impact of ethnicity on aging and facial structure, the patient's desired cosmetic outcome, tissue reaction to anticipated treatments, and the patient's expectations for recommended therapies.

References

White GM. Recent findings in the epidemiologic evidence, classification, and subtypes of acne vulgaris. J Am Acad Dermatol. 1998;39(2 pt 3):S34-S37.
Halder RM, Grimes PE, McLaurin CL, et al. Incidence of common dermatoses in a predominantly black dermatologic practice. Cutis. 1983;32:388, 390.
Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis. 2007;80:387-394.
Davis SA, Narahari S, Feldman SR, et al. Top dermatologic conditions in patients of color: an analysis of nationally representative data. J Drugs Dermatol. 2012;11:466-473.
Perkins AC, Cheng CE, Hillebrand GG, et al. Comparison of the epidemiology of acne vulgaris among Caucasians, Asian, Continental Indian and African American women. J Eur Acad Dermatol Venereol. 2011;25:1054-1060.
Taylor SC, Cook-Bolden F, Rahman Z, et al. Acne vulgaris in skin of color. J Am Acad Dermatol. 2002;46(2 suppl):S98-S106.
Davis EC, Callender VD. A review of acne in ethnic skin: pathogenesis, clinical manifestations, and management strategies. J Clin Aesthet Dermatol. 2010;3:24-38.
Halder RM, Holmes YC, Bridgeman-Shah S, et al. A clinicohistologic study of acne vulgaris in black females (abstract). J Invest Dermatol. 1996;106:888.
Plewig G, Fulton JE, Kligman AM. Pomade acne. Arch Dermatol. 1970;101:580-584.
Kligman AM, Mills OH. Acne cosmetica. Arch Dermatol. 1972;106:893-897.
Halder RM, Brooks HL, Callender VD. Acne in ethnic skin. Dermatol Clin. 2003;21:609-615.
Callender VD. Acne in ethnic skin: special considerations for therapy. Dermatol Ther. 2004;17:184-195.
Winhoven SM. Postinflammatory hyperpigmentation in an Asian patient. a dramatic response to oral isotretinoin (13-cis-retinoic acid). Br J Med. 2005;152:368-403.
Sarkar R, Bansal S, Garg VK. Chemical peels for melasma in dark-skinned patients. J Cutan Aesthet Surg. 2012;5:247-253.
Alexis AF, Coley MK, Nijhawan RI, et al. Nonablative fractional laser resurfacing for acne scarring in patients with Fitzpatrick skin phototypes IV-VI. Dermatol Surg. 2016;42:392-402.
Culp B, Scheinfeld N. Rosacea: a review. P T. 2009;34:38-45.
Al-Dabagh A, Davis SA, McMichael AJ, et al. Rosacea in skin of color: not a rare diagnosis. Dermatol Online J. 2014:20. pii:13030/qt1mv9r0ss.
Del Rosso JQ. Advances in understanding and managing rosacea: part 1: connecting the dots between pathophysiological mechanisms and common clinical features of rosacea with emphasis on vascular changes and facial erythema. J Clin Aesthet Dermatol. 2012;5:16-25.
Jackson JM, Knuckles M, Minni JP, et al. The role of brimonidine tartrate gel in the treatment of rosacea. Clin Cosmet Investig Dermatol. 2015;23:529-538.
Patel NU, Shukla S, Zaki J, et al. Oxymetazoline hydrochloride cream for facial erythema associated with rosacea. Expert Rev Clin Pharmacol. 2017;10:104954.
Weinkle AP, Doktor V, Emer J. Update on the management of rosacea. Clin Cosmet Investig Dermatol. 2015;8:159-177.
Grimes PE. Skin and hair cosmetic issues in women of color. Dermatol Clin. 2000;19:659-665.
Taylor A, Pawaskar M, Taylor SL, et al. Prevalence of pigmentary disorders and their impact on quality of life: a prospective cohort study. J Cosmet Dermatol. 2008;7:164-168.
Davis EC, Callender VD. Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol. 2010;3:20-31.
Grimes PE. Melasma: etiologic and therapeutic considerations. Arch Dermatol. 1995;131:1453-1457.
Handel AC, Miot LD, Miot HA. Melasma: a clinical and epidemiological review. An Bras Dermatol. 2014;89:771-782.
Callender VD, Reid SD, Obayan O, et al. Diagnostic clues to frontal fibrosing alopecia in patients of African descent. J Clin Aesthet Dermatol. 2016;9:45-51.
Narang T, Sawatkar GU, Kumaran MS, et al. Minocycline for recurrent and/or chronic erythema nodosum leprosum. JAMA Dermatol. 2015;151:1026-1028.
Boyer M, Katta R, Markus R. Diltiazem-induced photodistributed hyperpigmentation. Dermatol Online J. 2003;9:10.
Pandya AG, Guevara IL. Disorders of hyperpigmentation. Dermatol Clin. 2000;18:91-98.
Taylor SC, Torok H, Jones T, et al. Efficacy and safety of a new triple-combination agent for the treatment of facial melasma. Cutis. 2003;72:67-72.
Bulengo-Ransby SM. Topical tretinoin (retinoic acid) therapy for hyperpigmented lesions caused by inflammation of the skin in black patients. N Engl J Med. 1993;328:1438-1443.
Grimes P, Callender V. Tazarotene cream for postinflammatory hyperpigmentation and acne vulgaris in darker skin: a double-blind, randomized, vehicle-controlled study. Cutis. 2006;77:45-50.
Jacyk WK. Adapalene in the treatment of African patients. J Eur Acad Dermatol Venereol. 2001;15(suppl 3):37-42.
Kircik LH. Efficacy and safety of azelaic acid (AzA) gel 15% in the treatment of postinflammatory hyperpigmentation and acne: a 16-week, baseline-controlled study. J Drugs Dermatol. 2011;10:586-590.
Lee HC, Thng TG, Goh CL. Oral tranexamic acid (TA) in the treatment of melasma. J Am Acad Dermatol. 2016;75:385-392.
Kindred C, Okereke U, Callender VD. Skin-lightening agents: an overview of prescription, office-dispensed, and over-the-counter products. Cosmet Dermatol. 2013;26:18-26.
Makino ET, Kadoya K, Sigler ML, et al. Development and clinical assessment of a comprehensive product for pigmentation control in multiple ethnic populations. J Drugs Dermatol. 2016;15:1562-1570.
Halder R, Rodney I, Munhutu M, et al. Evaluation and effectiveness of a photoprotection composition (sunscreen) on subjects of skin of color. J Am Acad Dermatol. 2015;72(suppl 1):AB215.
Castanedo-Cazares JP, Hernandez-Blanco D, Carlos-Ortega B, et al. Near-visible light and UV photoprotection in the treatment of melasma: a double-blind randomized trial. Photodermatol Photoimmunol Photomed. 2014;30:35-42.
American Society for Aesthetic Plastic Surgery. 2016 Cosmetic Surgery National Data Bank Statistics. https://www.surgery.org/sites/default/files/ASAPS-Stats2016.pdf. Accessed November 15, 2017.
Burgess CM. Soft tissue augmentation in skin of color: market growth, available fillers and successful techniques. J Drugs Dermatol. 2007;6:51-55.
Davis EC, Callender VD. Aesthetic dermatology for aging ethnic skin. Dermatol Surg. 2011;37:901-917.
Grimes PE, Arora S, Minus HR, et al. Dermatosis papulosa nigra. Cutis. 1983;32:385-386.
Lupo M. Dermatosis papulosa nigra: treatment options. J Drugs Dermatol. 2007;6:29-30.
Grimes PE, Shabazz D. A four-month randomized, double-blind evaluation of the efficacy of botulinum toxin type A for the treatment of glabellar lines in women with skin types V and VI. Dermatol Surg. 2009;35:429-435.
Burgess CM, Awosika O. Ethnic and gender considerations in the use of facial injectables: African-American patients. Plast Reconstr Surg. 2015;136(5 suppl):28S-31S.
Taylor SC, Kelly AP, Lim HW, et al, eds. Taylor and Kelly’s Dermatology for Skin of Color. 2nd ed. New York, NY: McGraw-Hill Education; 2016.
Taylor SC, Burgess CM, Callender VD. Safety of nonanimal stabilized hyaluronic acid dermal fillers in patients with skin of color: a randomized, evaluator-blinded comparative trial. Dermatol Surg. 2009;35(suppl 2):1653-1660.
Marmur ES, Taylor SC, Grimes PE, et al. Six-month safety results of calcium hydroxylapatite for treatment of nasolabial folds in Fitzpatrick skin types IV to VI. Dermatol Surg. 2009;35(suppl 2):1641-1645.
Hamilton TK, Burgess CM. Consideration for the use of injectable poly-L-lactic acid in people of color. J Drugs Dermatol. 2010;9:451-456.
Fabi SG, Goldman MP. Retrospective evaluation of micro-focused ultrasound for lifting and tightening of the face and neck. Dermatol Surg. 2014;40:569-575.
Harris MO, Sundaram HA. Safety of microfocused ultrasound with visualization in patients with Fitzpatrick skin phototypes III to VI. JAMA Facial Plast Surg. 2015;17:355-357.

The approach to the treatment of common skin disorders and cosmetic concerns in patients with skin of color (SOC) requires the clinician to understand the biological differences, nuances, and special considerations that are unique to patients with darker skin types.^1-3 This article addresses 4 common facial concerns in SOC patients—acne, rosacea, facial hyperpigmentation, and cosmetic enhancement—and provides treatment recommendations and management pearls to assist the clinician with optimal outcomes for SOC patients.

Acne in SOC Patients

Acne vulgaris is one of the most common conditions that dermatologists treat and is estimated to affect 40 to 50 million individuals in the United States.¹ Many of these acne patients are individuals with SOC.^2-4 A study of 2835 females (aged 10–70 years) conducted in 4 different cities—Los Angeles, California; London, United Kingdom; Akita, Japan; and Rome, Italy—demonstrated acne prevalence of 37% in blacks, 32% in Hispanics, 30% in Asians, 24% in whites, and 23% in Continental Indians.⁵ Blacks, Hispanics, and Continental Indians demonstrated equal prevalence with comedonal and inflammatory acne. Asians displayed more inflammatory acne lesions than comedones. In contrast, whites demonstrated more comedones than inflammatory acne. Dyspigmentation, postinflammatory hyperpigmentation (PIH), and atrophic scars were more common in black and Hispanic females than other ethnicities.⁵ This study illustrated that acne-induced PIH is a common sequela in SOC patients and is the main reason they seek treatment.^6,7

The pathogenesis of acne is the same in all racial and ethnic groups: (1) follicular hyperkeratinization and the formation of a microcomedone caused by abnormal desquamation of the keratinocytes within the sebaceous follicle, (2) production of sebum by circulating androgens, (3) proliferation of Propionibacterium acnes, and (4) inflammation. Subclinical inflammation is present throughout all stages of acne, including normal-appearing skin, inflammatory lesions, comedones, and scarring, and may contribute to PIH in acne patients with SOC (Figure 1).⁸ A thorough history should be obtained from acne patients, including answers to the following questions⁷:

What skin and hair care products do you use?
Do you use sunscreen daily?
What cosmetic products or makeup do you use?
Do you use any ethnic skin care products, including skin lightening creams?
Do you have a history of keloids?

Figure 1. Acne and postinflammatory hyperpigmentation in a patient with skin of color (Fitzpatrick skin type V).

It is important to ask these questions to assess if the SOC patient has developed pomade acne,⁹ acne cosmetica,¹⁰ or a potential risk of skin irritation from the use of skin care practices. It is best to take total control of the patient’s skin care regimen and discontinue use of toners, astringents, witch hazel, exfoliants, and rubbing alcohol, which may lead to skin dryness and irritation, particularly when combined with topical acne medications.

Treatment
Treatment of acne in SOC patients is similar to generally recommended treatments, with special considerations. Consider the following key points when treating acne in SOC patients:

Treat acne early and aggressively to prevent or minimize subsequent PIH and acne scarring.
Balance aggressive treatment with nonirritating topical skin care.
Most importantly, target PIH in addition to acne and choose a regimen that limits skin irritation that might exacerbate existing PIH.⁷

Develop a maintenance program to control future breakouts. Topical agents can be used as monotherapy or in fixed combinations and may include benzoyl peroxide, antibiotics, dapsone, azelaic acid (AZA), and retinoids. Similar to white patients, topical retinoids remain a first-line treatment for acne in patients with SOC.^11,12

Tolerability must be managed in SOC acne patients. Therapeutic maneuvers that can be instituted should include a discussion on using gentle skin care, initiating therapy with a retinoid applied every other night starting with a low concentration and gradually titrating up, and applying a moisturizer before or after applying acne medication. Oral therapies consist of antibiotics (doxycycline, minocycline), retinoids (isotretinoin), and hormonal modulators (oral contraceptives, spironolactone). Isotretinoin, recommended for patients with nodulocystic acne, may play a possible role in treating acne-induced PIH.¹³

Two common procedural therapies for acne include comedone extraction and intralesional corticosteroid injection. A 6- to 8-week course of a topical retinoid prior to comedonal extraction may facilitate the procedure and is recommended in SOC patients to help reduce cutaneous trauma and PIH.¹¹ Inflammatory acne lesions can be treated with intralesional injection of triamcinolone acetonide 2.5 or 5.0 mg/mL, which usually reduces inflammation within 2 to 5 days.¹¹

Treatment of acne-induced PIH includes sun protection, topical and oral medications, chemical peels, lasers, and energy devices. Treatment of hypertrophic scarring and keloids involves intralesional injection of triamcinolone acetonide 20, 30, or 40 mg/mL every 4 weeks until the lesion is flat.¹¹

Superficial chemical peels can be used to treat acne and PIH in SOC patients,¹⁴ such as salicylic acid (20%–30%), glycolic acid (20%–70%), trichloroacetic acid (15%–30%), and Jessner peels.

Acne Scarring
Surgical approaches to acne scarring in patients with SOC include elliptical excision, punch excision, punch elevation, punch autografting, dermal grafting, dermal planning, subcutaneous incision (subcision), dermabrasion, microneedling, fillers, and laser skin resurfacing. The treatment of choice depends on the size, type, and depth of the scar and the clinician’s preference.

Lasers
Fractional photothermolysis has emerged as a treatment option for acne scars in SOC patients. This procedure produces microscopic columns of thermal injury in the epidermis and dermis, sparing the surrounding tissue and minimizing downtime and adverse events. Because fractional photothermolysis does not target melanin and produces limited epidermal injury, darker Fitzpatrick skin types (IV–VI) can be safely and effectively treated with this procedure.¹⁵

References

White GM. Recent findings in the epidemiologic evidence, classification, and subtypes of acne vulgaris. J Am Acad Dermatol. 1998;39(2 pt 3):S34-S37.
Halder RM, Grimes PE, McLaurin CL, et al. Incidence of common dermatoses in a predominantly black dermatologic practice. Cutis. 1983;32:388, 390.
Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis. 2007;80:387-394.
Davis SA, Narahari S, Feldman SR, et al. Top dermatologic conditions in patients of color: an analysis of nationally representative data. J Drugs Dermatol. 2012;11:466-473.
Perkins AC, Cheng CE, Hillebrand GG, et al. Comparison of the epidemiology of acne vulgaris among Caucasians, Asian, Continental Indian and African American women. J Eur Acad Dermatol Venereol. 2011;25:1054-1060.
Taylor SC, Cook-Bolden F, Rahman Z, et al. Acne vulgaris in skin of color. J Am Acad Dermatol. 2002;46(2 suppl):S98-S106.
Davis EC, Callender VD. A review of acne in ethnic skin: pathogenesis, clinical manifestations, and management strategies. J Clin Aesthet Dermatol. 2010;3:24-38.
Halder RM, Holmes YC, Bridgeman-Shah S, et al. A clinicohistologic study of acne vulgaris in black females (abstract). J Invest Dermatol. 1996;106:888.
Plewig G, Fulton JE, Kligman AM. Pomade acne. Arch Dermatol. 1970;101:580-584.
Kligman AM, Mills OH. Acne cosmetica. Arch Dermatol. 1972;106:893-897.
Halder RM, Brooks HL, Callender VD. Acne in ethnic skin. Dermatol Clin. 2003;21:609-615.
Callender VD. Acne in ethnic skin: special considerations for therapy. Dermatol Ther. 2004;17:184-195.
Winhoven SM. Postinflammatory hyperpigmentation in an Asian patient. a dramatic response to oral isotretinoin (13-cis-retinoic acid). Br J Med. 2005;152:368-403.
Sarkar R, Bansal S, Garg VK. Chemical peels for melasma in dark-skinned patients. J Cutan Aesthet Surg. 2012;5:247-253.
Alexis AF, Coley MK, Nijhawan RI, et al. Nonablative fractional laser resurfacing for acne scarring in patients with Fitzpatrick skin phototypes IV-VI. Dermatol Surg. 2016;42:392-402.
Culp B, Scheinfeld N. Rosacea: a review. P T. 2009;34:38-45.
Al-Dabagh A, Davis SA, McMichael AJ, et al. Rosacea in skin of color: not a rare diagnosis. Dermatol Online J. 2014:20. pii:13030/qt1mv9r0ss.
Del Rosso JQ. Advances in understanding and managing rosacea: part 1: connecting the dots between pathophysiological mechanisms and common clinical features of rosacea with emphasis on vascular changes and facial erythema. J Clin Aesthet Dermatol. 2012;5:16-25.
Jackson JM, Knuckles M, Minni JP, et al. The role of brimonidine tartrate gel in the treatment of rosacea. Clin Cosmet Investig Dermatol. 2015;23:529-538.
Patel NU, Shukla S, Zaki J, et al. Oxymetazoline hydrochloride cream for facial erythema associated with rosacea. Expert Rev Clin Pharmacol. 2017;10:104954.
Weinkle AP, Doktor V, Emer J. Update on the management of rosacea. Clin Cosmet Investig Dermatol. 2015;8:159-177.
Grimes PE. Skin and hair cosmetic issues in women of color. Dermatol Clin. 2000;19:659-665.
Taylor A, Pawaskar M, Taylor SL, et al. Prevalence of pigmentary disorders and their impact on quality of life: a prospective cohort study. J Cosmet Dermatol. 2008;7:164-168.
Davis EC, Callender VD. Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol. 2010;3:20-31.
Grimes PE. Melasma: etiologic and therapeutic considerations. Arch Dermatol. 1995;131:1453-1457.
Handel AC, Miot LD, Miot HA. Melasma: a clinical and epidemiological review. An Bras Dermatol. 2014;89:771-782.
Callender VD, Reid SD, Obayan O, et al. Diagnostic clues to frontal fibrosing alopecia in patients of African descent. J Clin Aesthet Dermatol. 2016;9:45-51.
Narang T, Sawatkar GU, Kumaran MS, et al. Minocycline for recurrent and/or chronic erythema nodosum leprosum. JAMA Dermatol. 2015;151:1026-1028.
Boyer M, Katta R, Markus R. Diltiazem-induced photodistributed hyperpigmentation. Dermatol Online J. 2003;9:10.
Pandya AG, Guevara IL. Disorders of hyperpigmentation. Dermatol Clin. 2000;18:91-98.
Taylor SC, Torok H, Jones T, et al. Efficacy and safety of a new triple-combination agent for the treatment of facial melasma. Cutis. 2003;72:67-72.
Bulengo-Ransby SM. Topical tretinoin (retinoic acid) therapy for hyperpigmented lesions caused by inflammation of the skin in black patients. N Engl J Med. 1993;328:1438-1443.
Grimes P, Callender V. Tazarotene cream for postinflammatory hyperpigmentation and acne vulgaris in darker skin: a double-blind, randomized, vehicle-controlled study. Cutis. 2006;77:45-50.
Jacyk WK. Adapalene in the treatment of African patients. J Eur Acad Dermatol Venereol. 2001;15(suppl 3):37-42.
Kircik LH. Efficacy and safety of azelaic acid (AzA) gel 15% in the treatment of postinflammatory hyperpigmentation and acne: a 16-week, baseline-controlled study. J Drugs Dermatol. 2011;10:586-590.
Lee HC, Thng TG, Goh CL. Oral tranexamic acid (TA) in the treatment of melasma. J Am Acad Dermatol. 2016;75:385-392.
Kindred C, Okereke U, Callender VD. Skin-lightening agents: an overview of prescription, office-dispensed, and over-the-counter products. Cosmet Dermatol. 2013;26:18-26.
Makino ET, Kadoya K, Sigler ML, et al. Development and clinical assessment of a comprehensive product for pigmentation control in multiple ethnic populations. J Drugs Dermatol. 2016;15:1562-1570.
Halder R, Rodney I, Munhutu M, et al. Evaluation and effectiveness of a photoprotection composition (sunscreen) on subjects of skin of color. J Am Acad Dermatol. 2015;72(suppl 1):AB215.
Castanedo-Cazares JP, Hernandez-Blanco D, Carlos-Ortega B, et al. Near-visible light and UV photoprotection in the treatment of melasma: a double-blind randomized trial. Photodermatol Photoimmunol Photomed. 2014;30:35-42.
American Society for Aesthetic Plastic Surgery. 2016 Cosmetic Surgery National Data Bank Statistics. https://www.surgery.org/sites/default/files/ASAPS-Stats2016.pdf. Accessed November 15, 2017.
Burgess CM. Soft tissue augmentation in skin of color: market growth, available fillers and successful techniques. J Drugs Dermatol. 2007;6:51-55.
Davis EC, Callender VD. Aesthetic dermatology for aging ethnic skin. Dermatol Surg. 2011;37:901-917.
Grimes PE, Arora S, Minus HR, et al. Dermatosis papulosa nigra. Cutis. 1983;32:385-386.
Lupo M. Dermatosis papulosa nigra: treatment options. J Drugs Dermatol. 2007;6:29-30.
Grimes PE, Shabazz D. A four-month randomized, double-blind evaluation of the efficacy of botulinum toxin type A for the treatment of glabellar lines in women with skin types V and VI. Dermatol Surg. 2009;35:429-435.
Burgess CM, Awosika O. Ethnic and gender considerations in the use of facial injectables: African-American patients. Plast Reconstr Surg. 2015;136(5 suppl):28S-31S.
Taylor SC, Kelly AP, Lim HW, et al, eds. Taylor and Kelly’s Dermatology for Skin of Color. 2nd ed. New York, NY: McGraw-Hill Education; 2016.
Taylor SC, Burgess CM, Callender VD. Safety of nonanimal stabilized hyaluronic acid dermal fillers in patients with skin of color: a randomized, evaluator-blinded comparative trial. Dermatol Surg. 2009;35(suppl 2):1653-1660.
Marmur ES, Taylor SC, Grimes PE, et al. Six-month safety results of calcium hydroxylapatite for treatment of nasolabial folds in Fitzpatrick skin types IV to VI. Dermatol Surg. 2009;35(suppl 2):1641-1645.
Hamilton TK, Burgess CM. Consideration for the use of injectable poly-L-lactic acid in people of color. J Drugs Dermatol. 2010;9:451-456.
Fabi SG, Goldman MP. Retrospective evaluation of micro-focused ultrasound for lifting and tightening of the face and neck. Dermatol Surg. 2014;40:569-575.
Harris MO, Sundaram HA. Safety of microfocused ultrasound with visualization in patients with Fitzpatrick skin phototypes III to VI. JAMA Facial Plast Surg. 2015;17:355-357.

How to decide which ‘birthmarks’ spell trouble

Approach to Treatment of Medical and Cosmetic Facial Concerns in Skin of Color Patients

In Collaboration With the Skin of Color Society

References

Acne in SOC Patients

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