Director of the Ethnic Skin Care for the University of Miami
Department of Dermatology and Cutaneous Surgery
University of Miami, Miller School of Medicine

Driven by a passion for treating pigmentary disorders, Heather is an internationally recognized expert in skin of color. She tells us about skincare challenges in skin of color patients.

 

 

 

 

BEHIND THE BUSINESS WOMAN
About your career and the people who inspired you: Increasing diversity in medicine has always been a passion for me. I always knew I wanted to go to medical school and decided to study dermatology as I enjoyed the fast pace and the wide scope of practice. Dermatology is one of the most varied medical specialties in that it offers tremendous opportunities ranging from medical dermatology to surgical dermatology in a diverse patient population.

Expanding research and knowledge in dermatologic diseases unique to skin of color has been my passion. Along my journey two people have contributed to shape this passion, Dr. Eliot Battle who taught me everything about lasers in skin of color and Dr Pearl Grimes who taught me about pigmentary disorders in skin of color. These two inspiring leaders armed me with invaluable insights from a technical, academic and patient care standpoint. These esteemed mentorships helped me to become a recognized specialist in skin of color at the University of Miami.

 

SKINCARE CHALLENGES IN SKIN OF COLOR

The #1 dermatology complaint in patients with skin of color is hyperpigmentation.  Treatment of hyperpigmentation in skin of color is very challenging. Pigment needs to be approached differently depending on its cause. For melasma, it is about education and helping the patient to understand that melasma is a chronic condition that can be managed effectively with the right products. For post-Inflammatory hyperpigmentation, managing the cause of the hyperpigmentation, which for many women is adult acne, is just as important as treating the dark spots.  For the uneven skin tone seen in aging skin, it is about a comprehensive skincare approach. And for all types of hyperpigmentation, it is about really effective sun protection.

What are the key challenges in skincare treatments for skin of color?

The two major challenges we face in treating hyperpigmentation in darker skin tone is EFFICACY & PATIENT EDUCATION. In terms of product efficacy, many of the product studies done in the past to treat hyperpigmentation focused on skin types I-III so when the product was used on skin Type VI skin, it did not work as well as would be expected. In terms of education, it is important for patients to understand that sun protection is critically important.  I often explain to patients that “One day in the sun without sun protection can take away the benefits from months of treatment”. Broad spectrum sun protection against UVA and UVB is critical and, interestingly, even visible light (blue light in particular) has been proven to have great impact on pigmentation in darker skinned patients ^1,2.

What is your way to approach to Hyperpigmentation?

Pigment needs to be approached differently. For melasma, I really focus on educating the patient. For post-Inflammatory pigmentation, I make sure to address the cause of the hyperpigmentation, which for many patients is adult acne. For uneven skin tone associated with aging, it is about a comprehensive skincare approach.

• When you talk about melasma, you need to think about it as a chronic condition. There is no “cure” for it so it is critical to set appropriate expectations with patients. When patients have melasma, they might have it for 20-30 years and patients can be very emotional.  Melasma needs to be managed with special care as it has significant impact of the quality of life of patients. It is a team approach with the dermatologist and the patient working together to get the best results and there is no “miracle cream”.
• When you deal with post-inflammatory hyperpigmentation, it is about managing both the hyperpigmentation and the underlining cause, which is often acne. It is about making patients understand that they have to treat their acne first and foremost.
• When it comes to uneven skin tone associated with aging, it is about the importance of adopting a comprehensive skincare regimen including sun protection, exfoliation, retinoids and skin brighteners to improve the overall appearance of the skin.

What have been the most exciting skincare innovations for skin of color in the past 2-3 years?

1. We are starting to see more studies specifically in darker skin patients (skin types 4,5,6) so that when the product comes to the market, we have more confidence that it is going to work in darker skin patients.
2. Combining multiple ingredients to address pigmentation at different points in the pathway has been a new and effective approach to treating hyperpigmentation. Many companies are trying to combine ingredients that inhibit pigment at different steps of the melanogenesis in an effort to approach the efficacy of the gold standard hydroquinone. One ingredient alone is great but not enough to approach the powerful efficacy of the hydroquinone so you need today to combine actives to approach its efficacy ^{3, 4}
3. Oral therapy will become more mainstream in the near future with oral therapies containing ingredients like polyphenols, Polypodium Leucotomos or tranxenamic acid for example ^5,6,7.
4. Combining skincare with procedures like chemical peels and even at home treatments is also a new trend where brands are embracing a comprehensive approach to treating hyperpigmentation.

If you could create one Skincare product for darker skin, what it be?

The goal for all of us is to get something as effective as hydroquinone. Hydroquinone is highly effective but is not designed for long term use.  Many things we are talking about, such as melasma, require a long-term approach. Patients cannot be on daily hydroquinone from age 30 to 80! The perfect alternative would be to be as effective as hydroquinone without the side effects associated with long term use.  In addition a product with low irritation potential and, of course, one that is cost effective would be best.

This is obviously challenging to develop but pigment has become a new area of interest in dermatology and for the industry. People are trying to find new ingredients or combination agents. There is exponential growth in this field and we are getting closer than ever.

Are there any promising evidence-based skincare ingredients on the horizon for skin color ?

As a pigment expert, when people were coming to me 10 years ago, I only had three things at my disposal: vitamin C, azelaic Acid and hydroquinone. Today, I have many more options and particularly some combination agent formulations that have been tested against hydroquinone ^{3, 4}.

What does the future of skincare for skin of color look like?

The future of skincare is about Inclusive Beauty which has already become a reality thanks to women like Rihanna. Her make-up line of products is a reflection of the reality of the world we live in. The skin of color is no longer a trend, it is becoming the norm with every type of person being represented.

 

VIEW ON SKINCARE EDUCATION

You told us about Education as being PARAMOUNT. Are you using social media to try to disseminate validated messages to patients/consumers with darker skin tone?

Education is the role that physicians should play on social media. Delivering short informative videos or posts about common simple things in dermatology can be so helpful.  Every day in the office, dermatologists hear patients say “I did not know this!”. Today, patients have access to a lot of information and are much better educated about skin. Thanks to the internet and social media they have become more proactive about seeking treatment for things that bother them and that they would have suffered about in silence in the past. Education is great, but the risk is a false sense of security because patients cannot diagnose themselves. This is an opportunity for physicians, they need to step in and be more vocal on social media about seeing a board certified dermatologist for their skincare concerns.

What is inspiring you to contribute to advancing the knowledge and the education on the topic?

My personal passion is to expand research and knowledge in dermatology in skin of color.  I lecture regularly because there is a real unmet need in this area. I am driven by it because I am dedicated to an area of dermatology that only a small (but growing) group of dermatologists are focused on. It is really something that is an unmet need even though skin of color research is finally becoming more prominent.   From an industry standpoint, there is still room for growth.  Although there is now an interest in creating products to treat hyperpigmentation, for many companies, it might end up being only one product out of the hundreds of products that a company offers.  So there continues to be a need for more research and this is what is driving me.

Definition of healthy skin in darker skin

Healthy skin in darker skin types has an even skin tone. The texture should be smooth and overall there should be a radiant glow.  This is the goal that women of color are looking for in their skincare products.

Any final thoughts? Sunscreen & Sunprotection.

Often times patients concerned about hyperpigmentation overlook one of the most important factors in achieving an even skin tone…sun protection.  For all of my patients, I recommend a daily sunscreen-preferably one with added antioxidants.  As a dermatologist in Miami, I also talk about avoiding sun exposure during peak hours.  Exercising outside should be done in the early hours or the late evening.  Even as early at 8 a.m., the UV index in Miami is already very high.  Wide brimmed hats and sun protective clothing also make sun protection so much easier.  These sound like straight forward tips but sometimes hearing this directly from the dermatologist improves compliance and leads to better long-term results.

 

BIBLIOGRAPHY:

1. Mahmoud BH et al, Impact of Long-Wavelength UVA and Visible Light on Melanocompetent Skin. JID 2010
2. Castanedo and al, Near-visible and UV photoprotection in the treatment of melasma: a double-blind randomized trial. Photodermatol Photoimmunol Photomed 2014;30:35-42 .
3. Makino ET et al. Development and clinical assessment of a comprehensive product for pigmentation concerned populations. J. Drugs Dermatol 2016; 15 (12): 1562-1570.
4. Draelos Z et al. Dyspigmentation, skin physiology, and a novel approach to skin lightening. J. Cosmet Dermatol 2013; 12 (4):247-53.
5. Del Rossario, Eunice et al. Randomized, placebo-controlled, double-blind study of oral tranxenamic acid in the treatment of moderate to severe melasma. Journal of the American Academy of Dermatology 78.2 (2018): 363-369.
6. Middelkamp-Hup MA, Pahak MA, Parrado C et al. J Am Acad Dermatolog 2004 Dec ; 51(6)/910-8.
7. Woolery-Lloyd, Martin, Caperton, Poster AAD 2012