Managing Complications From Cosmetic Procedures

Within the last 10 years, cosmetic procedures have increased significantly in popularity. The American Society of Plastic Surgeons (ASPS) estimated that $16.5 billion was spent on cosmetic procedures alone in the United States in 2018.¹ According to the 2018 ASPS survey of its members, a total of 15.9 million minimally invasive cosmetic procedures were performed.¹ This survey also showed a slight increase in procedures performed among patients with skin of color from 2017 to 2018. In 2018, 15% of chemical peels, 20% of botulinum toxin type A injections, and 19% of soft-tissue fillers, laser hair removal, and microdermabrasion were performed by ASPS members among patients with skin of color.¹ While these treatments may not differ significantly among Fitzpatrick skin types, certain procedures can cause disfiguring skin changes if not performed correctly.

While most patients will visit a board-certified plastic surgeon or dermatologist for these procedures, many will also seek treatment from nonphysicians for a lower cost. In doing so, individuals increase their risk for complications and adverse reactions from improperly performed cosmetic procedures. A recent study by Rossi et al² showed a higher number of adverse events, specifically burns and discoloration, occurred from procedures performed by nonphysicians, with improper technique cited as the most common reason for these reactions. 

Knowledge on cosmetic concerns among patients with skin of color is vital for dermatologists with aesthetic practices. However, many patients who go to a spa or attempt to address their cosmetic concerns at home and experience an adverse reaction will ultimately show up in a dermatologist’s office. Thus, all dermatologists should be aware of and know how to recognize, treat, and prevent these adverse reactions.

Areas of Cosmetic Concern and Complications 
Uneven skin tone. The number one concern among patients with skin of color, regardless of ethnic origin or geographical location, is uneven skin complexion.^3,4 Discoloration is associated with distress and high mental health burden among patients with skin of color.⁵ Topicals are the mainstay of treatment for discoloration, although lasers and oral medications are under investigation for the treatment of hyperpigmentation and melasma.⁴ Chemical peels have resurfaced as a popular treatment for discoloration due to its efficacy⁴ as well as hype on social media.

Each of these therapies are safe and effective among patients with skin of color. However, those with darker Fitzpatrick skin types can experience further discoloration and burns with improper administration and use of these therapies. Hydroquinone, for example, is standard of care for hyperpigmentation and known to cause pigmentary changes with long-term use. While the majority of providers are known to taper patients off of hydroquinone to avoid pigment alterations, hydroquinone is easily accessible online. Misuse of this product, both within and outside the United States, is not uncommon and can result in further discoloration in patients.^6-8 

Chemical peels also present a concern for dermatologists, as some patients may attempt these at home or at spas with unlicensed technicians. Certain acids, such as trichloroacetic acid, can cause discoloration and burns if used at higher concentrations in darker skin types.⁴ Lower concentrations are safe among patients with skin of color; however, chemical peels are available with concentrations up to 35% for sale on Amazon, eBay, and other consumer websites. Essentially, anyone can purchase chemical peels or lightening agents and attempt to use them based on instructions available on Google, blogs, Facebook, or other social media sites, with limited or no education on the safety and adverse events of this product.

Benign skin growths and keloids. Another common concern among patients with skin of color are benign skin growths.³ The majority of these can be excised with minimal complications in an office; however, patients with skin of color have a higher risk for keloid formation.⁸ Careful attention to how a patient who presents with a benign growth heals and whether they have had past or current keloids is necessary to reduce the risk of additional keloid formation. 

It is safe to assume the majority of patients with benign skin growths will seek medical treatment. However, concerns around cost and lack of access to a dermatologist may result in patients using home remedies they found on the internet for their growths. There are plenty of recipes for treating skin tags, with ingredients ranging from lemon juice and apple cider vinegar to tea tree oil and garlic. One such website is associated with a television doctor and includes recommendations for warts, skin tags, and other benign lesions.⁹ Although most patients may not experience any adverse reactions to these remedies, several are known allergens, such as garlic¹⁰ and lemon,¹¹ that can cause contact dermatitis and burns.

Glabellar lines and volume loss. Overall concerns regarding wrinkles are not as common among individuals with darker Fitzpatrick skin types. Instead, most patients seek treatment for frown lines and forehead creases. Patients who present with these concerns often want to look “less mean” or “angry” by reducing the appearance of glabellar lines. Another common concern is volume loss.¹² 

Similar to lighter skin types, injectables to improve the appearance of glabellar lines can be used, as well as fillers for volume loss. The majority of injectables are safe among patients of all skin types. However, technicians or providers who are inexperienced in treating patients with skin of color could perform the procedure incorrectly and cause complications. 

When administering soft-tissue fillers in patients with skin of color, it is important to avoid multiple puncture techniques. Clinical trials, according to an article that reviewed techniques for fillers among patients with skin of color by Burgess and Awosika,¹³ showed 13% of patients with skin of color who were administered hyaluronic acid (HA) fillers with multiple puncture techniques experienced hyperpigmentation compared with 2% of patients who were administered HA fillers with linear threading techniques. In addition, slightly longer injection times were associated with hyperpigmentation, while slower injection time decreased incidence of pigmentary changes and clinical bruising, with occasional subsequent hemosiderin deposition in black patients with HA fillers. The use of cannulas for injection of fillers minimizes needle entry and bruising to the skin. Notably, HA fillers are not associated with keloid formation or hyperpigmentation scarring.¹³

Pearls for Treating Complications 
In addition to recognizing erythema, burns, and pigmentary changes caused by poorly performed aesthetic procedures, dermatologists should conduct a thorough exam and history in which they not only address pigmentary changes, but also assess healing potential and risk of keloid formation. Some patients may be embarrassed to admit they sought treatment at a spa or from an uncertified technician and may be reluctant to share this information. Building a rapport with patients from the initial meeting can help encourage them to disclose all relevant information, such as where they received a certain procedure and how they got their injury, in order to information treatment decisions.

Techniques for preventing keloids should be employed in patients with a high risk of keloid formation. Such techniques include using topical treatment methods, corticosteroid injections into keloid lesion, cryosurgery, or excision for smaller lesions, while larger keloids will require more extensive and complex protocols. Additionally, awareness of patients’ risk for keloids should be considered when administering injectables, although evidence suggesting injectables cause scarring is limited.¹³ 

Dyschromia can be treated with a combination of lightening agents, sunscreen, sun avoidance, and chemical peels containing lactic acid, salicylic acid, or glycolic acid.¹³ For pigmentary changes caused by HA fillers, hyaluronidase may be needed to dissolve the filler and resolve postinflammatory discoloration.¹³ Among patients with persistent dyschromia that is caused by hemosiderin deposition, neodymium-doped yttrium aluminum Garnet (Nd:YAG) lasers may be considered to treat discoloration.¹³

Furthermore, dermatologists should keep up-to-date on the literature related to aesthetic procedures and complications in patients with skin of color to ensure all patients receive appropriate care, as well as education related to anatomical differences and proper techniques when administering injectables to prevent complications.

Conclusion
Education on concerns, treatment considerations, and complications among patients with skin of color is vital to any practicing dermatologist. Regardless of expertise with aesthetic procedures, all dermatologists should be aware of how to manage and treat complications among patients with darker skin types. As more patients with skin of color seek cosmetic treatment and more beauty salons and spas start to take of advantage of this growing market, the more dermatologists will need to compete to ensure patients are getting the best care from board-certified physicians and help patients who present to their clinic with burns, scars, or discoloration caused by providers who do not understand the unique needs of patients with skin of color. n

Dr Burgess is the founder, medical director, and president of the Center for Dermatology and Dermatologic Surgery in Washington, DC. She is also an assistant clinical professor of dermatology at Georgetown University and The George Washington University.

Disclosure: The author reports no relevant financial relationships.

References
1. American Society of Plastic Surgeons. 2018 Plastic Surgery Statistics Report. https://www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf. Updated March 2019. Accessed November 7, 2019.

2. Rossi AM, Wilson B, Hibler BP, Drake LA. Nonphysician practice of cosmetic dermatology: A patient and physician perspective of outcomes and adverse events. Dermatol Surg. 2019;45(4):588-597. doi:10.1097/DSS.0000000000001829

3. Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis. 2007;80(5):387-394.

4. 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(7):20-31.

5. Taylor A, Pawaskar M, Taylor SL, Balkrishnan R, Feldman SR. Prevalence of pigmentary disorders and their impact on quality of life: a prospective cohort study. J Cosmet Dermatol. 2008;7(3):164-168. doi:10.1111/j.1473-2165.2008.00384.x

6. Jha AK, Sinha R, Prasad S. Misuse of topical corticosteroids on the face: a cross-sectional study among dermatology outpatients. Indian Dermatol Online J. 2016;7(4):259-263. doi:10.4103/2229-5178.185492

7. Dadzie OE, Petit A. Skin bleaching: highlighting the misuse of cutaneous depigmenting agents. J Eur Acad Dermatol Venereol. 2009;23(7):741-750. doi:10.1111/j.14683083.2009.03150.x

8. Viera MH, Caperton CV, Berman B. Advances in the treatment of keloids. J Drugs Dermatol. 2011;10(5):468-480.

9. Dr. Nandi. A complete guide to removing moles, warts, skin tags, & more. https://askdrnandi.com/17-natural-remedies-for-removing-moles-warts-skin-tags-more/. Accessed November 7, 2019.

10. Chiriac A, Chiriac AE, Naznean A, Podoleanu C, Stolnicu S. Self-medication garlic-induced irritant skin lesions - case series. Int Wound J. 2017;14(6):1407-1408. doi:10.1111/iwj.12818

11. Matthews MR, VanderVelde JC, Caruso DM, Foster KN. Lemons in the Arizona sunshine: the effects of furocoumarins leading to phytophotodermatitis and burn-like injuries. Wounds. 2017;29(12):E118-E124.

12. Burgess CM. Cosmetic procedures in patients of color: what every dermatologist should know. Presented at: The Skin of Color Update; September 7-8, 2019; New York, NY. 

13. Burgess C, Awosika O. Ethnic and gender considerations in the use of facial injectables: African-American patients. Plast Reconstr Surg. 2015;136(5 suppl):28S-31S. doi:10.1097/PRS.0000000000001813

Within the last 10 years, cosmetic procedures have increased significantly in popularity. The American Society of Plastic Surgeons (ASPS) estimated that $16.5 billion was spent on cosmetic procedures alone in the United States in 2018.¹ According to the 2018 ASPS survey of its members, a total of 15.9 million minimally invasive cosmetic procedures were performed.¹ This survey also showed a slight increase in procedures performed among patients with skin of color from 2017 to 2018. In 2018, 15% of chemical peels, 20% of botulinum toxin type A injections, and 19% of soft-tissue fillers, laser hair removal, and microdermabrasion were performed by ASPS members among patients with skin of color.¹ While these treatments may not differ significantly among Fitzpatrick skin types, certain procedures can cause disfiguring skin changes if not performed correctly.

While most patients will visit a board-certified plastic surgeon or dermatologist for these procedures, many will also seek treatment from nonphysicians for a lower cost. In doing so, individuals increase their risk for complications and adverse reactions from improperly performed cosmetic procedures. A recent study by Rossi et al² showed a higher number of adverse events, specifically burns and discoloration, occurred from procedures performed by nonphysicians, with improper technique cited as the most common reason for these reactions. 

Knowledge on cosmetic concerns among patients with skin of color is vital for dermatologists with aesthetic practices. However, many patients who go to a spa or attempt to address their cosmetic concerns at home and experience an adverse reaction will ultimately show up in a dermatologist’s office. Thus, all dermatologists should be aware of and know how to recognize, treat, and prevent these adverse reactions.

Areas of Cosmetic Concern and Complications 
Uneven skin tone. The number one concern among patients with skin of color, regardless of ethnic origin or geographical location, is uneven skin complexion.^3,4 Discoloration is associated with distress and high mental health burden among patients with skin of color.⁵ Topicals are the mainstay of treatment for discoloration, although lasers and oral medications are under investigation for the treatment of hyperpigmentation and melasma.⁴ Chemical peels have resurfaced as a popular treatment for discoloration due to its efficacy⁴ as well as hype on social media.

Each of these therapies are safe and effective among patients with skin of color. However, those with darker Fitzpatrick skin types can experience further discoloration and burns with improper administration and use of these therapies. Hydroquinone, for example, is standard of care for hyperpigmentation and known to cause pigmentary changes with long-term use. While the majority of providers are known to taper patients off of hydroquinone to avoid pigment alterations, hydroquinone is easily accessible online. Misuse of this product, both within and outside the United States, is not uncommon and can result in further discoloration in patients.^6-8 

Chemical peels also present a concern for dermatologists, as some patients may attempt these at home or at spas with unlicensed technicians. Certain acids, such as trichloroacetic acid, can cause discoloration and burns if used at higher concentrations in darker skin types.⁴ Lower concentrations are safe among patients with skin of color; however, chemical peels are available with concentrations up to 35% for sale on Amazon, eBay, and other consumer websites. Essentially, anyone can purchase chemical peels or lightening agents and attempt to use them based on instructions available on Google, blogs, Facebook, or other social media sites, with limited or no education on the safety and adverse events of this product.

Benign skin growths and keloids. Another common concern among patients with skin of color are benign skin growths.³ The majority of these can be excised with minimal complications in an office; however, patients with skin of color have a higher risk for keloid formation.⁸ Careful attention to how a patient who presents with a benign growth heals and whether they have had past or current keloids is necessary to reduce the risk of additional keloid formation. 

It is safe to assume the majority of patients with benign skin growths will seek medical treatment. However, concerns around cost and lack of access to a dermatologist may result in patients using home remedies they found on the internet for their growths. There are plenty of recipes for treating skin tags, with ingredients ranging from lemon juice and apple cider vinegar to tea tree oil and garlic. One such website is associated with a television doctor and includes recommendations for warts, skin tags, and other benign lesions.⁹ Although most patients may not experience any adverse reactions to these remedies, several are known allergens, such as garlic¹⁰ and lemon,¹¹ that can cause contact dermatitis and burns.

Glabellar lines and volume loss. Overall concerns regarding wrinkles are not as common among individuals with darker Fitzpatrick skin types. Instead, most patients seek treatment for frown lines and forehead creases. Patients who present with these concerns often want to look “less mean” or “angry” by reducing the appearance of glabellar lines. Another common concern is volume loss.¹² 

Similar to lighter skin types, injectables to improve the appearance of glabellar lines can be used, as well as fillers for volume loss. The majority of injectables are safe among patients of all skin types. However, technicians or providers who are inexperienced in treating patients with skin of color could perform the procedure incorrectly and cause complications. 

When administering soft-tissue fillers in patients with skin of color, it is important to avoid multiple puncture techniques. Clinical trials, according to an article that reviewed techniques for fillers among patients with skin of color by Burgess and Awosika,¹³ showed 13% of patients with skin of color who were administered hyaluronic acid (HA) fillers with multiple puncture techniques experienced hyperpigmentation compared with 2% of patients who were administered HA fillers with linear threading techniques. In addition, slightly longer injection times were associated with hyperpigmentation, while slower injection time decreased incidence of pigmentary changes and clinical bruising, with occasional subsequent hemosiderin deposition in black patients with HA fillers. The use of cannulas for injection of fillers minimizes needle entry and bruising to the skin. Notably, HA fillers are not associated with keloid formation or hyperpigmentation scarring.¹³

Within the last 10 years, cosmetic procedures have increased significantly in popularity. The American Society of Plastic Surgeons (ASPS) estimated that $16.5 billion was spent on cosmetic procedures alone in the United States in 2018.¹ According to the 2018 ASPS survey of its members, a total of 15.9 million minimally invasive cosmetic procedures were performed.¹ This survey also showed a slight increase in procedures performed among patients with skin of color from 2017 to 2018. In 2018, 15% of chemical peels, 20% of botulinum toxin type A injections, and 19% of soft-tissue fillers, laser hair removal, and microdermabrasion were performed by ASPS members among patients with skin of color.¹ While these treatments may not differ significantly among Fitzpatrick skin types, certain procedures can cause disfiguring skin changes if not performed correctly.

While most patients will visit a board-certified plastic surgeon or dermatologist for these procedures, many will also seek treatment from nonphysicians for a lower cost. In doing so, individuals increase their risk for complications and adverse reactions from improperly performed cosmetic procedures. A recent study by Rossi et al² showed a higher number of adverse events, specifically burns and discoloration, occurred from procedures performed by nonphysicians, with improper technique cited as the most common reason for these reactions. 

Knowledge on cosmetic concerns among patients with skin of color is vital for dermatologists with aesthetic practices. However, many patients who go to a spa or attempt to address their cosmetic concerns at home and experience an adverse reaction will ultimately show up in a dermatologist’s office. Thus, all dermatologists should be aware of and know how to recognize, treat, and prevent these adverse reactions.

Areas of Cosmetic Concern and Complications 
Uneven skin tone. The number one concern among patients with skin of color, regardless of ethnic origin or geographical location, is uneven skin complexion.^3,4 Discoloration is associated with distress and high mental health burden among patients with skin of color.⁵ Topicals are the mainstay of treatment for discoloration, although lasers and oral medications are under investigation for the treatment of hyperpigmentation and melasma.⁴ Chemical peels have resurfaced as a popular treatment for discoloration due to its efficacy⁴ as well as hype on social media.

Each of these therapies are safe and effective among patients with skin of color. However, those with darker Fitzpatrick skin types can experience further discoloration and burns with improper administration and use of these therapies. Hydroquinone, for example, is standard of care for hyperpigmentation and known to cause pigmentary changes with long-term use. While the majority of providers are known to taper patients off of hydroquinone to avoid pigment alterations, hydroquinone is easily accessible online. Misuse of this product, both within and outside the United States, is not uncommon and can result in further discoloration in patients.^6-8 

Chemical peels also present a concern for dermatologists, as some patients may attempt these at home or at spas with unlicensed technicians. Certain acids, such as trichloroacetic acid, can cause discoloration and burns if used at higher concentrations in darker skin types.⁴ Lower concentrations are safe among patients with skin of color; however, chemical peels are available with concentrations up to 35% for sale on Amazon, eBay, and other consumer websites. Essentially, anyone can purchase chemical peels or lightening agents and attempt to use them based on instructions available on Google, blogs, Facebook, or other social media sites, with limited or no education on the safety and adverse events of this product.

Benign skin growths and keloids. Another common concern among patients with skin of color are benign skin growths.³ The majority of these can be excised with minimal complications in an office; however, patients with skin of color have a higher risk for keloid formation.⁸ Careful attention to how a patient who presents with a benign growth heals and whether they have had past or current keloids is necessary to reduce the risk of additional keloid formation. 

It is safe to assume the majority of patients with benign skin growths will seek medical treatment. However, concerns around cost and lack of access to a dermatologist may result in patients using home remedies they found on the internet for their growths. There are plenty of recipes for treating skin tags, with ingredients ranging from lemon juice and apple cider vinegar to tea tree oil and garlic. One such website is associated with a television doctor and includes recommendations for warts, skin tags, and other benign lesions.⁹ Although most patients may not experience any adverse reactions to these remedies, several are known allergens, such as garlic¹⁰ and lemon,¹¹ that can cause contact dermatitis and burns.

Glabellar lines and volume loss. Overall concerns regarding wrinkles are not as common among individuals with darker Fitzpatrick skin types. Instead, most patients seek treatment for frown lines and forehead creases. Patients who present with these concerns often want to look “less mean” or “angry” by reducing the appearance of glabellar lines. Another common concern is volume loss.¹² 

Similar to lighter skin types, injectables to improve the appearance of glabellar lines can be used, as well as fillers for volume loss. The majority of injectables are safe among patients of all skin types. However, technicians or providers who are inexperienced in treating patients with skin of color could perform the procedure incorrectly and cause complications. 

When administering soft-tissue fillers in patients with skin of color, it is important to avoid multiple puncture techniques. Clinical trials, according to an article that reviewed techniques for fillers among patients with skin of color by Burgess and Awosika,¹³ showed 13% of patients with skin of color who were administered hyaluronic acid (HA) fillers with multiple puncture techniques experienced hyperpigmentation compared with 2% of patients who were administered HA fillers with linear threading techniques. In addition, slightly longer injection times were associated with hyperpigmentation, while slower injection time decreased incidence of pigmentary changes and clinical bruising, with occasional subsequent hemosiderin deposition in black patients with HA fillers. The use of cannulas for injection of fillers minimizes needle entry and bruising to the skin. Notably, HA fillers are not associated with keloid formation or hyperpigmentation scarring.¹³

Pearls for Treating Complications 
In addition to recognizing erythema, burns, and pigmentary changes caused by poorly performed aesthetic procedures, dermatologists should conduct a thorough exam and history in which they not only address pigmentary changes, but also assess healing potential and risk of keloid formation. Some patients may be embarrassed to admit they sought treatment at a spa or from an uncertified technician and may be reluctant to share this information. Building a rapport with patients from the initial meeting can help encourage them to disclose all relevant information, such as where they received a certain procedure and how they got their injury, in order to information treatment decisions.

Techniques for preventing keloids should be employed in patients with a high risk of keloid formation. Such techniques include using topical treatment methods, corticosteroid injections into keloid lesion, cryosurgery, or excision for smaller lesions, while larger keloids will require more extensive and complex protocols. Additionally, awareness of patients’ risk for keloids should be considered when administering injectables, although evidence suggesting injectables cause scarring is limited.¹³ 

Dyschromia can be treated with a combination of lightening agents, sunscreen, sun avoidance, and chemical peels containing lactic acid, salicylic acid, or glycolic acid.¹³ For pigmentary changes caused by HA fillers, hyaluronidase may be needed to dissolve the filler and resolve postinflammatory discoloration.¹³ Among patients with persistent dyschromia that is caused by hemosiderin deposition, neodymium-doped yttrium aluminum Garnet (Nd:YAG) lasers may be considered to treat discoloration.¹³

Furthermore, dermatologists should keep up-to-date on the literature related to aesthetic procedures and complications in patients with skin of color to ensure all patients receive appropriate care, as well as education related to anatomical differences and proper techniques when administering injectables to prevent complications.

Conclusion
Education on concerns, treatment considerations, and complications among patients with skin of color is vital to any practicing dermatologist. Regardless of expertise with aesthetic procedures, all dermatologists should be aware of how to manage and treat complications among patients with darker skin types. As more patients with skin of color seek cosmetic treatment and more beauty salons and spas start to take of advantage of this growing market, the more dermatologists will need to compete to ensure patients are getting the best care from board-certified physicians and help patients who present to their clinic with burns, scars, or discoloration caused by providers who do not understand the unique needs of patients with skin of color. n

Dr Burgess is the founder, medical director, and president of the Center for Dermatology and Dermatologic Surgery in Washington, DC. She is also an assistant clinical professor of dermatology at Georgetown University and The George Washington University.

Disclosure: The author reports no relevant financial relationships.

References
1. American Society of Plastic Surgeons. 2018 Plastic Surgery Statistics Report. https://www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf. Updated March 2019. Accessed November 7, 2019.

2. Rossi AM, Wilson B, Hibler BP, Drake LA. Nonphysician practice of cosmetic dermatology: A patient and physician perspective of outcomes and adverse events. Dermatol Surg. 2019;45(4):588-597. doi:10.1097/DSS.0000000000001829

3. Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis. 2007;80(5):387-394.

4. 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(7):20-31.

5. Taylor A, Pawaskar M, Taylor SL, Balkrishnan R, Feldman SR. Prevalence of pigmentary disorders and their impact on quality of life: a prospective cohort study. J Cosmet Dermatol. 2008;7(3):164-168. doi:10.1111/j.1473-2165.2008.00384.x

6. Jha AK, Sinha R, Prasad S. Misuse of topical corticosteroids on the face: a cross-sectional study among dermatology outpatients. Indian Dermatol Online J. 2016;7(4):259-263. doi:10.4103/2229-5178.185492

7. Dadzie OE, Petit A. Skin bleaching: highlighting the misuse of cutaneous depigmenting agents. J Eur Acad Dermatol Venereol. 2009;23(7):741-750. doi:10.1111/j.14683083.2009.03150.x

8. Viera MH, Caperton CV, Berman B. Advances in the treatment of keloids. J Drugs Dermatol. 2011;10(5):468-480.

9. Dr. Nandi. A complete guide to removing moles, warts, skin tags, & more. https://askdrnandi.com/17-natural-remedies-for-removing-moles-warts-skin-tags-more/. Accessed November 7, 2019.

10. Chiriac A, Chiriac AE, Naznean A, Podoleanu C, Stolnicu S. Self-medication garlic-induced irritant skin lesions - case series. Int Wound J. 2017;14(6):1407-1408. doi:10.1111/iwj.12818

11. Matthews MR, VanderVelde JC, Caruso DM, Foster KN. Lemons in the Arizona sunshine: the effects of furocoumarins leading to phytophotodermatitis and burn-like injuries. Wounds. 2017;29(12):E118-E124.

12. Burgess CM. Cosmetic procedures in patients of color: what every dermatologist should know. Presented at: The Skin of Color Update; September 7-8, 2019; New York, NY. 

13. Burgess C, Awosika O. Ethnic and gender considerations in the use of facial injectables: African-American patients. Plast Reconstr Surg. 2015;136(5 suppl):28S-31S. doi:10.1097/PRS.0000000000001813

Pearls for Treating Complications 
In addition to recognizing erythema, burns, and pigmentary changes caused by poorly performed aesthetic procedures, dermatologists should conduct a thorough exam and history in which they not only address pigmentary changes, but also assess healing potential and risk of keloid formation. Some patients may be embarrassed to admit they sought treatment at a spa or from an uncertified technician and may be reluctant to share this information. Building a rapport with patients from the initial meeting can help encourage them to disclose all relevant information, such as where they received a certain procedure and how they got their injury, in order to information treatment decisions.

Techniques for preventing keloids should be employed in patients with a high risk of keloid formation. Such techniques include using topical treatment methods, corticosteroid injections into keloid lesion, cryosurgery, or excision for smaller lesions, while larger keloids will require more extensive and complex protocols. Additionally, awareness of patients’ risk for keloids should be considered when administering injectables, although evidence suggesting injectables cause scarring is limited.¹³ 

Dyschromia can be treated with a combination of lightening agents, sunscreen, sun avoidance, and chemical peels containing lactic acid, salicylic acid, or glycolic acid.¹³ For pigmentary changes caused by HA fillers, hyaluronidase may be needed to dissolve the filler and resolve postinflammatory discoloration.¹³ Among patients with persistent dyschromia that is caused by hemosiderin deposition, neodymium-doped yttrium aluminum Garnet (Nd:YAG) lasers may be considered to treat discoloration.¹³

Furthermore, dermatologists should keep up-to-date on the literature related to aesthetic procedures and complications in patients with skin of color to ensure all patients receive appropriate care, as well as education related to anatomical differences and proper techniques when administering injectables to prevent complications.

Conclusion
Education on concerns, treatment considerations, and complications among patients with skin of color is vital to any practicing dermatologist. Regardless of expertise with aesthetic procedures, all dermatologists should be aware of how to manage and treat complications among patients with darker skin types. As more patients with skin of color seek cosmetic treatment and more beauty salons and spas start to take of advantage of this growing market, the more dermatologists will need to compete to ensure patients are getting the best care from board-certified physicians and help patients who present to their clinic with burns, scars, or discoloration caused by providers who do not understand the unique needs of patients with skin of color. n

Dr Burgess is the founder, medical director, and president of the Center for Dermatology and Dermatologic Surgery in Washington, DC. She is also an assistant clinical professor of dermatology at Georgetown University and The George Washington University.

Disclosure: The author reports no relevant financial relationships.

References
1. American Society of Plastic Surgeons. 2018 Plastic Surgery Statistics Report. https://www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf. Updated March 2019. Accessed November 7, 2019.

2. Rossi AM, Wilson B, Hibler BP, Drake LA. Nonphysician practice of cosmetic dermatology: A patient and physician perspective of outcomes and adverse events. Dermatol Surg. 2019;45(4):588-597. doi:10.1097/DSS.0000000000001829

3. Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis. 2007;80(5):387-394.

4. 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(7):20-31.

5. Taylor A, Pawaskar M, Taylor SL, Balkrishnan R, Feldman SR. Prevalence of pigmentary disorders and their impact on quality of life: a prospective cohort study. J Cosmet Dermatol. 2008;7(3):164-168. doi:10.1111/j.1473-2165.2008.00384.x

6. Jha AK, Sinha R, Prasad S. Misuse of topical corticosteroids on the face: a cross-sectional study among dermatology outpatients. Indian Dermatol Online J. 2016;7(4):259-263. doi:10.4103/2229-5178.185492

7. Dadzie OE, Petit A. Skin bleaching: highlighting the misuse of cutaneous depigmenting agents. J Eur Acad Dermatol Venereol. 2009;23(7):741-750. doi:10.1111/j.14683083.2009.03150.x

8. Viera MH, Caperton CV, Berman B. Advances in the treatment of keloids. J Drugs Dermatol. 2011;10(5):468-480.

9. Dr. Nandi. A complete guide to removing moles, warts, skin tags, & more. https://askdrnandi.com/17-natural-remedies-for-removing-moles-warts-skin-tags-more/. Accessed November 7, 2019.

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