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The Asian Dermatologic Patient: Review of

Common Pigmentary Disorders and
Cutaneous Diseases
Stephanie G.Y. Ho, Henry H.L. Chan
Am J Clin Dermatol. 2009;10(3):153-168.

Abstract and Introduction

Abstract
The Asian patient with Fitzpatrick skin types III-V is rarely highlighted in publications on cutaneous disorders or cutaneous
laser surgery. However, with changing demographics, Asians will become an increasingly important group in this context.
Although high melanin content confers better photoprotection, photodamage in the form of pigmentary disorders is common.
Melasma, freckles, and lentigines are the epidermal disorders commonly seen, whilst nevus of Ota and acquired bilateral
nevus of Ota-like macules are common dermal pigmentary disorders. Post-inflammatory hyperpigmentation (PIH) occurring
after cutaneous injury remains a hallmark of skin of color. With increasing use of lasers and light sources in Asians,
prevention and management of PIH is of great research interest. Bleaching agents, chemical peels, intense pulsed light
(IPL) treatments, and fractional skin resurfacing have all been used with some success for the management of melasma.
Q-switched (QS) lasers are effective for the management of epidermal pigmentation but are associated with a high risk of
PIH. Long-pulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers and IPL sources pose less of a PIH risk but
require a greater number of treatment sessions. Dermal pigmentary disorders are better targeted by QS ruby, QS
alexandrite, and QS 1064-nm Nd:YAG lasers, but hyper- and hypopigmentation may occur. Non-ablative skin rejuvenation
using a combination approach with different lasers and light sources in conjunction with cooling devices allows different skin
chromophores to be targeted and optimal results to be achieved, even in skin of color. Deep-tissue heating using
radiofrequency and infra-red light sources affects the deep dermis and achieves enhanced skin tightening, resulting in
eyebrow elevation, rhytide reduction, and contouring of the lower face and jawline. For management of severe degrees of
photoaging, fractional resurfacing is useful for wrinkle and pigment reduction, as well as acne scarring.
Acne, which is common in Asians, can be treated with topical and oral antibacterials, hormonal treatments, and isotretinoin.
Infra-red diode lasers used with a low-fluence, multiple-pass approach have also been shown to be effective with few
complications. Fractional skin resurfacing is very useful for improving the appearance of acne scarring. Hypertrophic and
keloid scarring, another common condition seen in Asians, can be treated with the combined used of intralesional
triamcinolone and fluorouracil, followed by pulsed-dye laser. Esthetic enhancement procedures such as botulinum toxin type
A and fillers are becoming increasingly popular. These are effective for rhytide improvement and facial or body contouring.
We highlight the differences between Asian skin and other skin types and review conditions common in skin of color together
with treatment strategies.
Introduction
[1]

Population demographics have evolved in the 21st century such that over half the world's population is Asian. The US
[2]
Census 2000 reported that 4.2% of the US population was of Asian origin. Furthermore, this fastest growing group in the
[3]
US population is projected to double in size by 2050. The term Asian refers to people having origins from the Far East,
[2]
southeast Asia, or the Indian subcontinent. They are a diverse group with various skin phototypes ranging from Fitzpatrick
type III to V in the Chinese and Japanese to type IV and V in Indians and Pakistanis. We review cutaneous disorders that
are common or particular to skin of color (with particular emphasis on Asian patients) and discuss the management of these
conditions.

1. Photoaging in Asians
Ninety-five percent of the visible signs of aging are caused by sun exposure, which begins in infancy and continues
[4]
throughout life. Other intrinsic factors such as gravity and pollution also contribute to the cutaneous aging process.
Skin of color is differentiated by the amount and epidermal distribution of melanin. Szabo

[5]

established that although there

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are no racial differences in melanocyte density, darker skin has larger melanocytes producing more melanin and the
melanosomes are distributed individually in keratinocytes. The increased melanin and more dispersed melanosomes appear
[6]
[7]
to absorb and deflect UV light more efficiently, conferring significant photoprotection to skin of color. Tadokoro et al.
confirmed this by showing a close inverse correlation between melanin content in the skin and the amount of DNA damage
resulting from a given dose of UV radiation.
[8]

Despite this, Kotrajaras and Kligman reported that significant photodamage in the form of epidermal atypia and atrophy,
dermal collagen and elastin damage, and pigmentary disorders can occur in skin of color. Other investigators have similarly
[9,10]
[11]
observed that pigmentary changes occur with a greater incidence than skin wrinkling in Asians.
Chung
more recently
found both pigmentary changes and wrinkling to be major features of photoaging in Asians. However, moderate-to-severe
wrinkling becomes apparent only at about 50 years of age, which is a decade or two later than in age-matched
[4]
Caucasians.
Other cutaneous manifestations of aging ethnic skin include the development of benign cutaneous growths such as
[4,11]
dermatosis papulosa nigra, seborrheic keratoses, and the development of solar lentigines.

2. Disorders of Pigmentation
2.1 Post-Inflammatory Hyperpigmentation
[12]

PIH can be
Post-inflammatory hyperpigmentation (PIH) is a common pigmentary disorder in melanin-rich Asian skin.
considered the default pathophysiologic response to cutaneous injury in such individuals. Several factors contribute to the
development of PIH, including increased melanocytic activities, dermal melanophages, and hemosiderin deposition
secondary to hemorrhage. The severity of PIH is related to the degree of inflammation and extent of disruption of the
epidermo-dermal junction. It may be caused by endogenous inflammatory skin disorders or iatrogenic sources such as
[13]
lasers.
The high epidermal melanin content in Asian skin may act as a competing chromophobe for vascular and pigment
lasers, interfering with the absorption of laser energy that is intended for another target. With increasing use of lasers and
[14]
light sources in Asians, prevention and management of PIH is becoming increasingly important.
This will be discussed in
more detail in subsequent sections.
2.2 Melasma
Melasma is an acquired symmetric hypermelanosis involving sun-exposed areas commonly seen in Asian middle-aged
women. Genetics, UV radiation, pregnancy, hormonal therapies, and other phototoxic drugs are all thought to be contributing
etiologic factors and melasma remains a difficult condition to treat. Melasma was formerly classified histopathologically as
[15]
[16]
epidermal, dermal, or mixed type depending on the location of the pigment.
However, Kang et al.,
in a histopathologic
study of 56 Korean patients with melasma, suggested that there is no true dermal type and the dermal melanophages seen
in 'dermal-type melasma' may be due to undiagnosed acquired bilateral nevus of Ota-like macules or Hori's macules.
In a study comparing the histopathologic features of melasma with those of normal skin using several different
[16]
immunohistochemical stains, Kang et al.
reported that melasma skin had more melanin in the whole epidermis whereas
melanin is confined to the basal layer in normal skin. Increased numbers of melanocytes and widely dispersed melanosomes
in keratinocytes are also found in melasma lesions. These investigators proposed that increased activity of melanogenic
enzymes results in hyperactive melanocytes with increased synthesis and transfer of melanosomes, and decreased
degradation in keratinocytes. Sublethal laser damage to these labile melanocytes can increase the production of melanin
[16]
[17]
and lead to PIH.
This may explain why previous studies using a 510-nm pigmented lesion dye laser
and a Q-switched
[18]
(QS) ruby laser
for the management of melasma led to little improvement and worsening of pigmentation in some cases.
Recent studies have also indicated that intense pulsed light (IPL) can lead to manifestation of previously subclinical
melasma; for this reason, Wood's light examination or UV photography prior to IPL treatment of Asian skin is recommended.
[19,20]

Use of bleaching agents and sunscreens for at least 6 weeks, and preferably for 3 months, prior to any laser or light therapy
[14]
can help suppress the function of these hyperactive melanocytes and reduce the risk of PIH.
Even with such precautions,
[20]
a recent study in Taipei
that compared topical bleaching treatment only with bleaching plus IPL treatment for melasma
reported two cases of PIH in the IPL-treated group despite prolonged use of bleaching agents and sunscreens prior to
treatment.

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Combinations of hydroquinone with topical corticosteroids and tretinoin have been reported to be effective as first-line
[21,22]
treatment of melasma.
The limitations of topical treatment include the longer time required for effectiveness to become
apparent and patient compliance. Glycolic acid, salicylic acid, and trichloroacetic acid peels are also useful adjuncts to
[23-25]
topical treatments in the management of melasma in Asians.
[20]

Wang et al.
in Taipei showed that patients with melasma in the IPL-treated group achieved a significant improvement of
39.8% compared with 11.6% in the control group after four sessions of IPL and topical treatment. However, partial
repigmentation was noted 24 weeks later, suggesting the need for repeated treatments for maintenance. These investigators
suggested use of the lowest fluence to achieve minimal erythema, a recommendation supported by the findings of Negishi et
[19]
al.
This avoids excessive thermal injury to labile melanocytes and reduces the risk of PIH.
Ablative lasers such as carbon dioxide lasers and QS alexandrite lasers have been used with some success in the treatment
[26-28]
of melasma.
These lasers are thought to prevent the clonal expansion of hyperactive melanocytes located in the
epidermal basal layer. In addition, ablative lasers may increase the topical absorption of bleaching agents in patients with
impaired epidermal barrier function. However, the significant downtime and adverse effects associated with the use of
ablative lasers has made them unpopular.
Fractional skin resurfacing is a recent development in the management of melasma (figure 1). This involves the use of a
1540-nm laser that creates microscopic zones of thermal injury that are surrounded by normal skin. As the areas of thermal
injury are very small, lateral migration of keratinocytes to them occurs rapidly, leading to re-epithelialization of the epidermis
[14]
[29]

within 24 hours.
Rokhsar and Fitzpatrick
conducted a small study that evaluated use of fractional resurfacing (Fraxel ,
Reliant Technologies, Mountain View, CA, USA) in the treatment of melasma. In their ten subjects, using 6-12 mJ at
2
2000-3500 microthermal treatment zone (MTZ)/cm as treatment parameters, 60% reported 75-100% clearing of melasma,
30% reported <25% clearing of melasma, and one case developed PIH. No downtime was required for wound healing.

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Figure 1.

Treatment of melasma with fractional skin resurfacing: (a) pre-treatment; (b) post-treatment.
2.3 Freckles and Lentigines
Freckles and lentigines are common benign pigmented lesions seen in Asians. As the cultural trend in Asians moves
towards fair porcelain skin, these pigmented lesions can often present in dermatology outpatients as a cosmetic concern.
Freckles or ephelides occur in adolescence and are relatively uniform in distribution, size, and color. Histopathologically,
epidermal hypermelanosis without an increase in melanocyte number is seen. Lentigines increase in number and prevalence
with age. They tend to vary in size and color and are non-uniformly distributed. Histologically, the number of melanocytes
[30]
and epidermal hypermelanosis are increased and the epidermal rete ridges are elongated.
[31]

Anderson et al.
were the first to demonstrate the effectiveness of QS neodymium-doped yttrium aluminum garnet
(Nd:YAG) laser in the treatment of cutaneous pigmentation. However, studies using QS Nd:YAG, QS ruby, and QS
[30,32,33]
[33]
alexandrite lasers for pigmented lesions in Asians have reported a PIH risk of around 25%.
Chan et al.
compared
the use of different types of 532-nm Nd:YAG lasers in the treatment of facial lentigines in Chinese patients and found similar
effectiveness for the QS Nd:YAG and long-pulsed Nd:YAG. However, there was a higher risk of post-operative
hyperpigmentation with the QS device. It has been suggested that unlike the long-pulsed laser that causes tissue destruction
purely by photothermolysis, the QS Nd:YAG laser, with its high-energy nanosecond radiation, exhibits both photothermal and
photomechanical effects. The undesirable photomechanical effect induces damage to surrounding oxyhemoglobin as well as
[34]
target melanin, resulting in inflammation of superficial vessels, altered activity of melanocytes, and subsequent PIH.
Results from other studies also support the theory that long-pulsed devices are more suitable for Asian skin in reducing the
[30,35]
risk of PIH.
IPL sources emit a broad band of visible light from a non-coherent filtered flashlamp and produce photothermal effects
[36]
only.
There have been several studies confirming the effectiveness of IPL in the management of epidermal pigmentation
[35,37]
in Asians. Negishi et al.
conducted two studies that evaluated photorejuvenation using IPL. Results from the first study
2
involving 97 Asian patients (cut-off filter 550 nm, 28-32 J/cm , double-pulse mode of 2.5-4.0/4.0-5.0 msec, delay time
20.0/40.0 msec) showed that >90% of patients reported a reduction in pigmentation after three to six treatments at intervals
[35]
2
of 2-3 weeks.
The second study used IPL with an integrated contact cooling system (cut-off filter 560 nm, 23-27 J/cm ,
double-pulse mode of 2.8-3.2/6.0 msec, delay time 20.0/40.0 msec) and, in this study, 80% of the 73 patients evaluated had
[37]
[38]
a significant reduction in pigmentation after three to five treatments at intervals of 3-4 weeks.
Kawada et al.
evaluated
60 patients with solar lentigines and freckles and reported more than 50% improvement in 68% of these patients following
2
three to five IPL treatments at intervals of 2-3 weeks (cut-off filter 560 nm, 20-24 J/cm , 2.6-5.0 msec pulse duration in
double or triple pulses, delay time 20 msec). Freckles responded better than lentigines. Interestingly, post-operative PIH was
not seen in any of these studies, highlighting the advantage of IPL as a treatment choice for photorejuvenation in Asian
patients.
A treatment algorithm relating to use of lasers and IPL sources for the treatment of acquired pigmentary lesions in Asians
[36]
has been put forward by Chan
to help physicians weigh up issues such as cost effectiveness, clinical outcome, and
adverse events such as PIH. This author suggests IPL for patients who demand a low risk of PIH and who are amenable to
having several treatment sessions. A median approach using long-pulsed Nd:YAG may be considered if a faster outcome is
desired. An aggressive approach using QS lasers requires only one to two sessions, which make this approach the most
time- and cost-effective approach; however, it also carries the highest risk of PIH and necessitates a downtime period of 1
week.
Other means of reducing PIH in Asians include diascopy during laser therapy to compress and empty dermal vessels in
[39]
order to reduce the risk of dermal vascular damage and hemosiderin deposition. Kono et al.
recently compared the
efficacy and complications seen with use of the QS ruby laser and the 595-nm-long pulsed dye laser (PDL) delivered with a
compression method in the treatment of lentigines. The efficacy was similar in both groups but there was a much lower risk
of PIH in the group treated with the compression technique. Using a laser or light source with a shorter wavelength (350-500

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[4]

nm) confines the thermal injury to the epidermal layer and is another means of reducing the risk of PIH.
2.4 Nevus of Ota

[40]

Nevus of Ota is a dermal melanocytic hamartoma common in Asians and affects about 0.6% of the population.
Clinically,
nevus of Ota presents as a bluish hyperpigmentation along the distribution of the trigeminal nerve. QS ruby, QS alexandrite,
[41]
[42]
and QS 1064-nm Nd:YAG lasers have all been used to achieve good therapeutic results.
Watanabe and Takahashi
evaluated 114 nevus of Ota patients treated with a QS ruby laser and reported a good-to-excellent degree of lightening after
[43]
three or more treatment sessions. Kono et al.
confirmed these findings when they reviewed 101 nevus of Ota patients 12
months after they had been treated with a QS ruby laser and found that 56% reported over 75% clearing and 36% achieved
complete clearing. Hypopigmentation was seen in 17% of patients and hyperpigmentation in 6%. Studies comparing the use
of QS alexandrite with QS 1064-nm Nd:YAG lasers found the former to be better tolerated but the latter more effective after
[44,45]
three or more sessions.
The risks of hypo- and hyperpigmentation were similar in both treatment groups, with 15%
hypopigmentation and 3% hyperpigmentation reported at all treated sites. The risk of recurrence is estimated to be between
[43]
0.6% and 1.2%,
which has important implications when treating pediatric patients.
2.5 Acquired Bilateral Nevus of Ota-Like Macules or Hori's Macules
Acquired bilateral nevus of Ota-like macules or Hori's macules is a condition that affects 0.8% of the Asian population. Hori
[46]
et al.
described bluish-brown hyperpigmentation typically affecting the bilateral malar regions, forehead, and temples of
middle-aged women with no mucosal involvement. Histopathologic findings typically show a circumscribed melanocytosis in
[47]
the middle and upper dermis.
The disorder often coexists with other pigmentary disorders such as melasma and
lentigines. QS ruby, QS alexandrite, and QS 1064-nm Nd:YAG lasers have been shown to be effective in the treatment of
[48-50]
Hori's macules (figure 2).
However, shorter treatment intervals and more treatment sessions appear to be necessary
for a good result. Transient post-operative hyperpigmentation is a common adverse event, occurring in the majority of
[49,50]
[48]
treated subjects.
Permanent hypopigmentation has been reported after treatment with a QS ruby laser.
A recent
study has proposed use of a QS 532-nm Nd:YAG laser followed by a QS 1064-nm Nd:YAG laser to obtain a greater degree
[51]
of improvement.

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Figure 2.

Treatment of Hori's macules using a Q-switched ruby laser: (a) pre-treatment; (b) post-treatment.

3. Non-Ablative Skin Rejuvenation in Asians

Non-ablative skin rejuvenation with a laser/light source has gained much popularity in skin of color due to the lower risk of
[14]
complications and limited downtime.
Non-ablative skin rejuvenation involves the use of a laser or light source with a
cooling device to improve the signs of photoaging, which include lentigines, telangiectasia, increased pore size, uneven
texture, wrinkles, and skin laxity. Cooling is particularly important in skin of color as it protects the epidermis and reduces the
risk of erythema and edema, which may lead to subsequent PIH. Green and yellow lasers/light sources (532-nm Nd:YAG,
585- or 595-nm PDL) target the epidermal pigment and papillary dermal vessels. Injury to dermal vessels and microvascular
supply of sebaceous glands reduces telangiectasia and sebum production, in addition to promoting new collagen formation
[14,52]
during the healing process.
Near infra-red and infra-red lasers/light sources (1064-nm Nd:YAG, 1320-nm Nd:YAG,
1450-nm diode, 1540-nm erbium:glass) together with a cooling device target water in the dermis and, through
[4]
photothermolysis, cause a rise in dermal temperature, resulting in collagen tightening and increased collagen production.
Monthly treatments are required for a good effect (figure 3).

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Figure 3.

Photorejuvenation using non-ablative laser devices: (a) pre-treatment; (b) post-treatment.

More recently, a combination approach that uses different lasers and light sources in the same treatment session at monthly
[14,53]
intervals has been advocated.
This approach targets different skin chromophores and means optimal results can be
achieved. When a combination approach is used, a lower fluence should be used for each device to reduce adverse effects
due to cumulative heat generation.
Deep-tissue heating using unipolar radiofrequency and newer infra-red light sources affect the deep dermis and achieve
enhanced skin tightening. This approach is particularly effective for elevating the eyebrows, treating peri-orbital wrinkles, and
[14,54]
contouring the lower face and jawline.
With effective cooling, the epidermis is protected and PIH is rare even in darker
[55]
skin types.
Unipolar radiofrequency, using multiple passes at a low fluence, is an effective skin-tightening device and
[56]
results in little discomfort and few complications.
IPL sources that emit radiation in the infra-red spectrum have also been used to achieve deep-tissue heating with
subsequent skin tightening. Prolonged exposure with pulse width ranging from 6 to 9 seconds is required to heat up the
[14]
deep dermis. Contact cooling is again used to protect the epidermis and reduce the risk of PIH.
In patients with more severe degrees of photoaging, fractional resurfacing can be useful for wrinkle and pigment reduction
2
as well as acne scarring. By using a high fluence and low density (15 mJ, 1000 MTZ/cm ), dermal collagen remodeling is
induced with minimal epidermal injury. The newer generation of fractional resurfacing laser devices allows for changes in
spot size with higher energy and, thereby, permits a greater degree of penetration with a reduction in bulk tissue heating. In
skin of color, the principle of minimizing post-treatment erythema in order to reduce the risk of PIH is a useful one. Hence, a

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reduction in energy and density as well as lengthening of treatment intervals (2-4 weeks for epidermal lesions, 4-6 weeks for
[14]
dermal lesions) can also be helpful in reducing the risk of PIH.

4. Common Skin Diseases in Asians

[57]

listed the most common diagnoses as atopic dermatitis,

A survey of 74 589 Asians over a 2-year period in Singapore
acne, and viral infections. The survey identified more cases of urticaria in the Chinese, more psoriasis and alopecia in
Indians, and, unsurprisingly, more PIH in Malays and Indians, who tend to have darker skin compared with the Chinese.
4.1 Atopic Dermatitis
Atopic dermatitis (eczema) is a common presenting complaint in all dermatology clinics. There is some evidence suggesting
that eczema is more common in the Chinese population. A survey of the 12-month cumulative incidence of atopic dermatitis
in Chinese, Vietnamese, and White infants born in Melbourne, VIC, Australia showed that 44% of Chinese, 17% of
[58]
Vietnamese, and 21% of White infants were affected.
A higher incidence of atopic dermatitis was also seen in Chinese
[59]
infants compared with White infants living in San Francisco, CA, USA and Honolulu, HI, USA.
However, a study conducted in Leicester, UK, found that although there were more referrals of atopic dermatitis to the
dermatology department from the Asian community, the incidence was in fact the same in the Asian and non-Asian
[60]
groups.
These investigators suggested a poor knowledge of atopic dermatitis amongst the Asian community as the
reason for the higher rates of referral. Interestingly, there were frequent anecdotal reports from Asian patients of their
disease resolving when they visited India or Africa and flaring up on their return to the UK, suggesting an environmentrelated influence on disease expression.
Management of atopic dermatitis is similar in the different ethnic groups, and includes emollients, topical corticosteroids,
[61]
topical tacrolimus, phototherapy, oral antihistamines, and immunosuppressants in resistant cases.
4.2 Acne
[62]

A population-based prevalence study of acne in Hong Kong adolescents reported 91.3% of their subjects to be affected.
The majority (52.6%) of the subjects developed scarring and pigmentation as a result of acne but only 2.4% had consulted a
clinician. 26.6% were also disturbed psychologically by acne and 82.9% by its physical appearance. Topical medications
were the mainstay of treatment. The study highlighted the importance of public education of the management of this
exceedingly common condition, as well as early and aggressive intervention from clinicians, in order to prevent serious
sequelae such as pigmentary changes, scarring, and psychological disturbances.
[63]

The acne hyperpigmented macule is common in skin of color and persists for an average of 4 months or longer.
Ice-pick
scarring or keloidal scarring may also occur and can have a significant impact on the self-esteem of affected individuals.
Treatment modalities for acne include topical antibacterials, retinoids, adapalene, azelaic acid, oral antibacterials, hormonal
treatments, and oral isotretinoin. Tetracyclines are effective against acne but can be phototoxic. Strict sun avoidance and
protection are therefore essential when using tetracyclines, especially in skin of color. Macrolides such as erythromycin and
[62]
clarithromycin are non-phototoxic and should be considered as first-line antibacterial treatment in Asians.
Bleaching
agents such as hydroquinone may be used alone or in combination with other retinoids and corticosteroids for treatment of
[63]
the acne hyperpigmented macule.
Ablative laser resurfacing using carbon dioxide and erbi-um:YAG lasers has been shown to be effective in the treatment of
[64-66]
atrophic acne scars.
Clinical improvements of 30-75% can be achieved for patients with superficial atrophic acne
scars. However, this approach is associated with significant downtime and adverse effects, which include erythema,
hyperpigmentation, and hypopigmentation, that may be permanent.
Different wavelengths within visible radiation have been used to treat acne. Blue light causes activation of endogenous
[67]
porphyrins in Proprionibacterium acnes and kills the bacteria.
However, in Asian patients, an increase in pigmentation
[14]
can occur after prolonged blue light exposure and this is therefore not an ideal treatment modality in skin of color.
PDL
[68]
targeting hemoglobin has been suggested to be effective in the treatment of inflammatory acne with few adverse effects.
[69]
However, inconsistent findings have been reported and further confirmatory studies are required.
Photodynamic therapy,

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[70,71]

using a variety of visible wavelengths and a number of photosensitizing dyes, has been used to treat acne.
A previous
study showed a statistically significant clearance of inflammatory acne by topical aminolevulinic acid (3-hour occlusion) and
[72]
red light for at least 20 weeks after four treatments, and for 10 weeks after a single treatment.
Significant adverse effects
such as transient hyperpigmentation, exfoliation, and crusting were observed. In Asians, short-contact aminolevulinic acid
(10-hour occlusion) followed by activation using an IPL source can be effective against acne, with erythema being the main
[14]
complication.
Infra-red lasers are increasingly being used in the treatment of acne and acne scarring. Use of a non-ablative 1450-nm
diode laser with cryogen cooling spray for the treatment of atrophic acne scars in 57 Asian patients was evaluated by Chua
[73]
et al.
These investigators reported mild improvement of 16-20% after four to six treatments. Conventional single-pass,
2
high-energy (11-12 J/cm ) treatment was used in this study. Pain, erythema, and marked PIH in 39% of treated patients
[74]
2
were reported. Bernstein
recently published a pilot study demonstrating superiority of low-fluence (8-11 J/cm ),
double-pass 1450-nm diode laser treatment over conventional treatment. Low-fluence, double-pass therapy reduced acne
counts and pain to the extent that a topical anesthetic could be omitted. Recently, we evaluated use of a low-fluence,
multiple-pass approach in the treatment of acne vulgaris among Chinese patients and found that it was effective in those
with inflammatory acne, with a low prevalence of PIH (figure 4).

Figure 4.

Treatment of inflammatory acne with a 1450-nm diode laser: (a) pre-treatment; (b) post-treatment.
Fractional photothermolysis is particularly effective in the treatment of acne scarring in skin of color, and indeed this is one of
the main indications for its use. However, PIH is a potential complication of this approach. In a recent retrospective study of
[13]
37 Chinese patients who underwent fractional resurfacing for acne scarring and skin rejuvenation, Chan et al.
concluded

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that while both energy and density parameters are important considerations for reducing PIH in Asians, density is of
particular importance. These investigators concluded that in order to prevent PIH, a high-energy and low-density treatment is
[75]
preferable. A recent study in Asian patients by Kono et al.
reported similar findings and demonstrated that patient
satisfaction was also increased when higher fluence rather than higher density was used. The importance of adjunctive
cooling and lengthening of the treatment interval to 2-4 weeks for epidermal lesions and 4-6 weeks for dermal lesions to
[13]
reduce the risk of PIH has also been emphasized.
4.3 Hypertrophic and Keloid Scarring
It is well known that hypertrophic and keloid scars are more common in individuals of Asian descent than in their Caucasian
[76]
counterparts.
Both types of scars are characterized by deposition of collagen and glycoprotein. However, they differ
clinically; keloids extend beyond the original wound whilst hypertrophic scars remain within the borders of the original wound.
Silicone gels are commonly used with some success for the treatment of keloids and hypertrophic scars. However, a
[76]
The
successful outcome is highly dependent on patients adhering to the treatment regimen over a long period of time.
efficacy of corticosteroid injections in the treatment of keloids and hypertrophic scars is well established. Corticosteroids
[77]
have anti-inflammatory and vasoconstrictive effects, together with an anti-mitotic effect on fibroblasts and keratinocytes.
The most commonly used corticosteroid is triamcinolone. This agent is normally administered intralesionally into the scar, at
a concentration of 10-40 mg/mL, every 4-6 weeks for several months or until the scar is flattened. Multiple adverse effects,
[78,79]
including atrophy, telangiectasia, and pigmentary changes, can occur.
Recently, combined use of intralesional
triamcinolone and fluorouracil in the treatment of inflamed hypertrophic scars has been reported to be effective and can
[80]
avoid these potential complications.
The 585-nm PDL appears to be effective in the treatment of keloid and hypertrophic scars. Vascular proliferation plays a key
role in the early phase of scar formation. Through selective photothermolysis, the light energy emitted from a PDL is
[81,82]
absorbed by hemoglobin, generating heat and leading to coagulation necrosis.
Clinical studies of PDL treatment of
[83]
scars have noted no significant difference in treatment outcomes when minor variations in fluence were used.
However,
[84]
evaluated the
there was a trend for lower fluences to be associated with greater improvement. Manuskiatti and Fitzpatrick
clinical response of keloidal and hypertrophic scars after treatment with an intralesional corticosteroid alone or combined
with fluorouracil, fluorouracil alone, and the 585-nm flashlamp-pumped PDL. They found a significant clinical improvement in
all treated segments, but no significant difference between the different treatment modalities. Intralesional formulas resulted
in faster resolution of scar compared with PDL. Scar texture (erythema and pliability) responded better to PDL. Another
study that evaluated use of PDL in 29 Chinese patients with hypertrophic scars showed that apart from an improvement in
[85]
pruritus, there was no significant difference in scar thickness between the treatment and control groups.
However, a
supra-purpuric dose was used and excessive injury may have led to the poorer observed clinical outcome. Post-operative
[86]
purpura persisting for 7-10 days has also been reported following PDL use in other studies.
These findings suggest that
early treatment with a combination of intralesional triamcinolone and fluorouracil to flatten the scar, followed by sub-purpuric
PDL to improve color, texture, and pruritus, may be the most effective approach.
4.4 Psoriasis
[57]

Psoriasis was the seventh most common skin condition in a large Asian patient survey conducted in Singapore.
However,
psoriasis is more commonly seen in Caucasians than in Asians and Africans, and is very rare in Native Americans and
[87]
Hispanics.
Treatments for psoriasis include topical corticosteroids, tar, calcipotriene (calcipotriol), UVB, psoralen plus
UVA (PUVA), and other oral immunosuppressants such as methotrexate, acitretin, and cyclosporine (ciclosporin). An
interesting study examining 4294 long-term PUVA patients in Japan, Korea, Thailand, Egypt, and Tunisia found no apparent
[88]
increased risk of non-melanoma skin cancer with long-term PUVA therapy in Asian patients.
This is in contrast to the
Caucasian experience, for which strict PUVA therapy guidelines exist because of the increased risk of cutaneous
malignancies. Phototherapy is therefore a useful long-term treatment option for Asians with psoriasis and other skin
conditions such as vitiligo, cutaneous T-cell lymphoma, and atopic dermatitis.
4.5 Primary Cutaneous Amyloidosis
Primary cutaneous amyloidosis presents most commonly as either lichen or macular amyloidosis. It is a condition commonly
[89]
seen in southeast Asia and some South American countries.
Lichen amyloidosis is a persistent, pruritic, popular, and
plaque-like eruption with a predilection for the shins and extensor arms, and is most commonly seen amongst the Chinese.

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Macular amyloidosis presents as small brown macules coalescing into patches distributed typically in a rippled, symmetric
pattern on the upper back, limbs, chest, and buttocks. It most commonly presents together with lichen amyloidoisis as
biphasic amyloidosis. Histologically, deposits of amyloid are seen in the papillary dermis, and the diagnosis can easily be
[90,91]
confirmed by staining the amyloid red using congo red or metachromatically using crystal violet or toluidine blue.
Anosacral amyloidosis is a rare form of cutaneous amyloidosis reported previously in Chinese and Japanese patients
[92]
only.
It presents as pruritic, well demarcated, brownish patches or plaques fanning out in lines from the anus to the sacral
region. It is more common in men. This condition can be easily mistaken as lichen simplex chronicus, PIH, and tinea cruris
and a skin biopsy should be carried out if the diagnosis is in doubt.
Treatment of cutaneous amyloidosis can be difficult. Reducing friction to the skin is important. Topical high-potency
[93]
corticosteroids, oral retinoids, and cyclophosphamide have also been reported to be beneficial.
4.6 Kawasaki Disease
Kawasaki disease is an acute febrile vasculitis that may lead to coronary artery abnormalities. It has a much higher
[94,95]
incidence in Asian children.
The diagnostic criteria include fever (>38.3C) of 5 days duration plus at least four of the
following five criteria: (i) peripheral extremity changes; (ii) polymorphous exanthem; (iii) non-purulent bilateral conjunctival
injection; (iv) changes in the lips and oral cavity, such as erythema and strawberry tongue; and (v) acute, non-purulent
[96]
cervical adenopathy.
The polymorphic cutaneous eruption lasts 10-20 days and then subsides. One to two percent of
[91]
patients may die of a myocardial infarction soon after apparent recovery from the acute illness.
Diagnosis of Kawasaki disease is very important because steps to prevent coronary aneurysm and myocardial infarction can
then be taken. All patients should be hospitalized during the acute febrile stage, and a baseline echocardiogram
[91]
performed.
A single dose of intravenous -globulin at 2 g/kg should be given over a 10- to 12-hour infusion. Aspirin
(acetylsalicylic acid) should also be started at 100 mg/kg/day until the fever is controlled or until day 14 of the illness,
followed by 5-10 mg/kg/day until the sedimentation rate and platelet count are normal. The patient should have a repeat
echocardiogram 3-4 weeks after onset of fever. If both echocardiograms are normal, no further imaging needs to be done.
Patients should, however, be followed up periodically. The disease is self-limiting and the prognosis for most children is good
[91]
if an early diagnosis is made.
Studies have shown that a delay in diagnosis of >10 days or occurrence in infants aged <1
[94]
year carries a significantly higher risk of coronary artery abnormalities.

5. Cutaneous Malignancies in Skin of Color

The incidence of melanoma and non-melanoma skin cancers in the US is increasing yearly and may be partially attributable
[97]
to UV exposure.
However, the higher melanin content in skin of color confers some photoprotection from UV-induced
DNA damage. There also appears to be more efficient DNA repair mechanisms in skin of color, thereby reducing the
[7]
likelihood of carcinogenesis.
Public education campaigns to promote photoprotection and self-surveillance in individuals of all ethnicity can be beneficial
in reducing the rates of cutaneous malignancies.
5.1 Melanoma
The incidence of melanoma has been reported to range between 0.2 and 2.2 per 100 000 in Asians. In a Singapore study,
the incidence of melanoma was reported to be 0.2 per 100 000 in darker skinned Indians and 0.5 per 100 000 in fairer
[98]
skinned Chinese.
In Hong Kong, melanoma incidence was reported to be 1.1 per 100 000 women and 1.0 per 100 000
[99]
[100]
men.
The Japanese have roughly double the incidence of melanoma (2.2 per 100 000) than other Asian races.
In skin of color, the most common sites for the development of melanoma are non-sun-exposed areas, such as palmar,
plantar, subungual, and mucosal surfaces. In a study of 43 cases of melanoma in Chinese patients at the University of Hong
[101]
Kong from 1964 to 1982, 56% of tumors arose from the foot, with 83% occurring on the plantar surface (figure 5).
Forty-seven percent of these tumors developed within an existing pigmented lesion, and 100% of subungual tumors involved
the nail bed of the big toe or thumb. The most common histologic type was acral lentiginous melanoma with more than 80%
having a Breslow thickness >3 mm and 37% of these 9 mm. A study from Japan also reported the foot as the most

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[100]

commonly affected area with 50% being the acral lentiginous melanoma type.
advanced disease, with 30% demonstrating metastases and a poor prognosis.

A large percentage also presented with

Figure 5.

Melanoma on the plantar aspect of the foot.

Delays in diagnosis and treatment of melanoma are possibly due to lack of public and physician education and preventative
screening programs in Asian countries. There is often a misconception that darker skinned individuals do not develop skin
cancer. The sites of melanoma occurrence are also unexpected and difficult for patients to examine. In addition, acral tumors
[102]
tend to be intrinsically more aggressive and therefore present at a later stage, leading to poorer prognosis.
Both
physicians and patients therefore need to maintain a high index of suspicion for melanomas regardless of ethnicity and
particular attention needs to be paid to palms, soles, fingers, toes, subungual areas, and mucosal surfaces in Asian patients.
5.2 Non-Melanoma Skin Cancer
Basal cell carcinoma (BCC), followed by squamous cell carcinoma (SCC), are the most common skin cancers in Chinese
[98,100,103]
and Japanese individuals.
In Singapore, the incidence of BCC increased at a rate of 2.8% per year between 1968
[98]
and 1997, while the rates of SCC decreased by 0.9% yearly.
Chinese individuals, who are generally of lighter skin type,
were twice as likely to develop BCC and SCC as the darker skinned Malays and Indians. In a survey conducted between
1983 and 1987 of the Japanese population living in sunny Hawaii, USA, the incidence per 100 000 was 60 for BCC, 48 for
[104]
SCC, and 22 for Bowen disease.
The incidence of BCC in Japanese individuals living in native Japan was much lower,
[105]
at 16.5 per 100 000, demonstrating the harmful effects of UV radiation.
Known risk factors for BCC and SCC include UV exposure, Fitzpatrick skin types I-III, male sex, chemical and radiation
exposure, burn or scar injuries, genetic disorders such as xeroderma pigmentosum, Gorlin syndrome, immunosuppression,
[106]
and infection with human papillomavirus.
Photoprotection and early diagnosis can often lead to a better outcome.
5.3 Cutaneous T-Cell Lymphoma
[106]

Mycosis fungoides or cutaneous T-cell lymphoma is the fourth most common skin cancer amongst the Japanese.
Hypopigmented mycosis fungoides, with ill-defined, often pruritic, hypopigmented macules and patches, tends to present in
[107,108]
a younger patient population and only in skin of color (figure 6).
The disorder can often be mistaken for vitiligo,
pityriasis alba, tinea versicolor, or post-inflammatory hypopigmentation. Misdiagnosis can delay treatment. There is usually a
good response to PUVA, UVB phototherapy, or topical mechlorethamine (chlormethine), but recurrences are common. The
[109]
overall prognosis is good.

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Figure 6.

Hypopigmented mycosis fungoides.

6. Other Esthetic Procedures

Over the last few decades, there has been a surge of interest in, and performance of, esthetic enhancement procedures in
Asian countries. There has also been a greater cultural acceptance of esthetic modification and skin rejuvenation using
non-surgical techniques to reduce the stigmata of aging.
6.1 Botulinum Toxin Type A
Although wrinkling occurs later in Asians compared with Caucasians, rhytides appear in the same predictable manner as a

result of repetitive action of facial musculature. Botulinum toxin type A (Botox ; Allergan, Irvine, CA, USA) blocks the release
of the neurotransmitter acetylcholine at the neuromuscular junction, thereby causing paralysis of the affected muscle. It was
[110]
[111]
first reported to be an effective treatment of fine facial wrinkles in the 1990s.
Anh et al.
found no difference in the
longevity of treatment and the amount of toxin required for Asian skin despite the increased dermal thickness and collagen
content of the skin of Asian people. Common injection sites for elimination of facial hyperkinetic wrinkles include the lateral
[112]
canthal area, glabellar area, forehead, and nasal dorsum. Repeated injections are generally required every 4-6 months.
[113]
Flynn et al.
showed that botulinum toxin injected concomitantly into lateral and infra-orbital areas results in successful
improvement in infra and peri-orbital wrinkles and also widens the eye. The results were especially notable in Asians.
Botulinum toxin can also be used to reduce a prominent mandibular angle, the so-called 'square jaw,' in Asians. Kim et
[114]

al.
followed up 383 patients who received botulinum toxin injection (100-140 U) [Dysport ; Ipsen Ltd, Slough, UK] into
the inferior masseter borders and found an average 31% reduction in masseter hypertrophy on ultrasound 3 months after
treatment (figure 7). Ninety-three percent of patients were positive about the outcome. Re-injection was required after 4-7
months. Mild fatigue after vigorous chewing was the main complaint, followed by transient awkwardness when smiling. More
recently, botulinum toxin A has also been used for contouring of enlarged gastrocnemius muscles with no functional
[115,116]
disabilities. The improvement was well maintained for 6 months.

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Figure 7.

Use of botulinum toxin type A for masseter hypertrophy: (a) pre-treatment; (b) post-treatment.
6.2 Soft Tissue Fillers for Tissue Augmentation
Asian patients, like their Western counterparts, are increasingly seeking a more youthful face with fewer wrinkles and fuller
features. Fillers are therefore increasingly being used in the management of facial lines, lip augmentation, and treatment of
distensible atrophic facial scarring. Fillers can be divided into two groups; biodegradable materials that are used for
temporary augmentation, such as hyaluronic acid and bovine collagen, or non-biodegradable materials, such as silicon oil or
polymethylmethacrylate in combination with bovine collagen, which require some time to obtain a permanent result because
of encapsulation. The ideal filler is a non-allergenic, non-toxic, non-migratory replacement for lost collagen or subcutaneous
fat. It should be easy to use with a direct result and no adverse effects.
[117]

Skin reactions to bovine serum collagen have been well documented, and double skin testing is recommended.
There
may also be a risk of variant Creutzfeldt-Jakob disease or other pathogenic infections when materials derived from animal

origins are used. Hyaluronic acid fillers such as Restylane (Q-Med, Uppsala, Sweden) and Hylaform (Biomatrix, Inc,
Ridgefield, NJ, USA) are marketed as having minimal allergy risk and not requiring skin testing. Studies comparing the

efficacy and tolerability of Restylane with those of the bovine collagen Zyplast (McGhan Medical Inc., Santa Barbara, CA,

[118]
USA) have found Restylane to be superior in effectiveness and longevity.
However, 0.42% of a study population of 709
developed delayed skin reactions. Nevertheless, this is a much lower rate than that reported for bovine collagen, which is
[117,119]
[120]
between 3% and 4%.
Hyaluronidase can resolve any undesirable effects of Restylane .
Artecoll (Rofil Medical International, Breda, the Netherlands) is used as a long-lasting, deep dermal augmenting agent. It

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consists of microspheres of polymerized methylmethecrylate in a bovine collagen vehicle. A randomized controlled,

multicenter, clinical trial of 251 subjects reported Artecoll to be superior in terms of facial fold reduction and patient
[121]
satisfaction after 6 months compared with collagen.
Early lump formation, especially in the lips, may occur in patients
treated with Artecoll and is thought to be due to excess movement prior to full encapsulation by host fibrin and fibrinogen.
Talking should be minimized in the early days or concurrent use of botulinum toxin may be considered. Granuloma formation
is very rare and usually occurs 6-24 months after injection. The granulomas resolve spontaneously after 4-6 years.
[122,123]
Intralesional triamcinolone may speed up the process.
A good technique is important for reducing complications.
Poly-L-lactic acid (New-Fill; Ashford Aesthetics Inc., Brussels, Belgium or Sculptra; Aventis Pharmaceuticals,
Bridgewater, NJ, USA) has been used for the correction of HIV-related facial lipoatrophy and cosmetic rejuvenation of
[124]
[125]
Temporary edema and bruising are common adverse effects. However, a report by Beljaards et al.
non-HIV patients.
described three cases with serious giant cell granulomatous reactions after use of New-Fill or Sculptra. Intralesional
corticosteroid therapy and topical imiquimod were moderately effective for resolving these reactions.

7. Regulatory Issues
There is a lack of regulation of the use of lasers and esthetic procedures in most Asian countries. As a result, beauticians
working at beauty parlours and medical spas are offering esthetic enhancement procedures with no formal training and pose
a significant risk to their clients. Strict policies should be in place to restrict the use of lasers and the performance of esthetic
procedures to medical specialists such as dermatologists and plastic surgeons for the safety of patients.

8. Conclusion
With evolving demographics, there will be an increasing number of Asians presenting to dermatology outpatient clinics.
Increased epidermal melanin is photoprotective against UV damage. However, it is also responsible for causing several
pigmentary conditions that can be particularly troublesome to Asians in their quest for fair porcelain skin. Management of
Asian skin requires different considerations than when dealing with Caucasian skin, and development of laser technology
that protects epidermal melanin from damage makes laser surgery increasingly safe in skin of color. Awareness of
cutaneous disorders that are common or particular to skin of color is also important, especially for clinicians who work in
areas with a large Asian community.
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Acknowledgments
No sources of funding were used to assist in the preparation of this review. Dr Chan has acted as a consultant to Palomar,
Danish Dermatologic Development, and Thermage; has been an Advisory Board member for Laserscope, CureLight,
Johnson & Johnson, and Galderma; has received clinical trial grants from Palomar, Danish Dermatologic Development,
Candela, and Syneron Medical; and holds stock in Reliant Technologies and CureLight. Dr Ho has no conflicts of interest
that are directly relevant to the content of this review.

Reprint Address
Dr Henry H.L. Chan, 13/F Club Lusitano, 16 Ice House Street, Central, Hong Kong SAR, China. E-mail:
hhlchan@hkucc.hku.hk
Am J Clin Dermatol. 2009;10(3):153-168. 2009 Adis Data Information BV

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