Treating black- or dark-skinned clients doesn't have to be an intimidating experience for either the client or the electrologist.
As with any electrolysis treatment, patience and practice, together with careful experimentation with different needles, modalities and intensities, will net excellent results for both parties.
TREATING DARK SKIN SUCCESSFULLY!
Stacey Elder began her electrolysis practice in 1990. Since 1994 she and her business partner, Barbara J. Williams, have operated The Epilation Clinic, a diverse urban practice located in Baltimore, Maryland. The clientele is 55% Black (black- or dark-skinned), 40% Caucasian, 5% other.
Ms. Elder turned to electrolysis for the same reason others have; i.e. a personal case of severe hirsutism and pseudofolliculitis barbae. Her first experience as a client was with a Caucasian electrologist who took one look at her face and referred her to the one and only black electrologist practicing in Maryland at the time. For Ms. Elder, this was truly a life- and career-changing experience. She hopes that this educational article will go toward assuring that future black- or dark-skinned persons are not refused our professional services.
Ms. Elder is a member of the Maryland State Board of Electrologists, the American Electrology Association, the International Guild of Professional Electrologists and the Maryland Association of Professional Electrologists.
THE PHRASE, "treating dark skin" is a myth. No electrologist ever treats skin alone. The skin, the body's largest organ, always comes wrapped around a person imbued with cultural habits and myths: a person confronting all the joy and pain of life, a person seeking relief from the seemingly intractable and constant problem of ghastly, unwanted hair. Thus, the dark-skinned person presents in the electrologist's office with all the anxiety of any other person seeking treatment, but his or her anxiety is exacerbated by the fear of scarring at the hands of an electrologist with little or no experience in treating someone who has black or dark skin.
Ironically, the heightened anxiety of the dark-skinned client is often matched by the anxiety of the fair-skinned electrologist. What is encouraging, however, is that in the last few years professional electrologists have developed a global perspective and are seeking information that will allow them to confidently expand their clientele. That's why this discussion is not centered on the person of African ancestry. Dark-skinned clients with similar concerns are of Indian, Mediterranean, Middle Eastern, Persian and Hispanic ancestry.
But ancestry is not the primary factor to consider, because there are light-skinned, straight-haired people in each of these groups. Factors to be taken into account are the degree of skin darkness (which can range from cafe au lait to very black), the hair type (from wavy to tightly coiled), previous methods of hair removal, and even what creams or ointments have been applied to the treatment area.
The ability to offer safe, effective hair removal to a wider population is especially important in this era of change and intense competition from laser hair removal clinics. At this time, the dark-skinned population still needs to seek out well- trained and knowledgeable electrologists, because laser hair removal may have an adverse effect on dark skin.
The absorbing target or chromophore for alexandrite and ruby lasers, as well as the filtered, intense pulsed light, is dark brown or black melanin. The melanin in the skin of the dark person (especially skin types IV, V, VI) absorbs the light energy and the targeted area is left severely hypopigmented or depigmented. Although less likely, there have been reports of hyperpigmented areas after laser hair removal.
Myths
Hyperpigmentation, keloid scars, pitting, ingrown hairs and pseudofolliculitis barbae, are conditions closely associated with dark skin in general and persons of African ancestry in particular. Lack of information, misinformation, and inexperience with these conditions have led to fear, misunderstanding and inappropriate electrolysis treatment procedures such as: using exceedingly high or low intensities; choosing a very small needle (that will "follow the curve of the follicle") and approaching the actual insertion with trepidation because the insertion itself is believed to be difficult; and, allowing infected and inflamed pustules to remain untouched while the source of the irritation -- the hair -- remains embedded in the skin. Although there may be something valid in each of these approaches, out of context and generally applied they will result in client dissatisfaction, and in some cases will exacerbate the very conditions the electrologist wishes to avoid. Accurate information concerning these conditions will enable the practitioner to treat dark-skinned clients confidently and successfully.
Keloids
Mention keloid to an electrologist and concern and anxiety will be the response. Common knowledge of a keloid scar seems to be limited to the image of an enlarged, fleshy scar that does not go away. No one wants to cause such a thing to form after treatment. But, what is a keloid? Why and how does it form?
Keloids are a type of hypertrophic scar. Hypertrophic scars exceed normal wound healing. They are normally confined to the site of injury and are common on the neck (near the crease of the neck and below it), the shoulders and chest wall. The scars will subside, i.e. get smaller, but it can take at least a year -- often much longer.
A keloid not only exceeds normal wound healing, it grows in an apparently unregulated way and tends to invade normal tissue surrounding the injury. It may not appear for months after the injury, but once present, it continues to grow. There are two types of keloid conditions: systemic keloidosis and inflammatory keloidosis. Both conditions can produce a true keloid but most people with keloidosis will form a keloid-type hypertrophic scar (a scar that does not resolve), or a hypertrophic scar (a scar that does resolve).
A person with systemic keloidosis will form a scar no matter how minor the injury: a scratch, a bug bite, whitehead or other acne lesion, or even electrolysis. These clients will be eager to inform the electrologist of their condition because they know that if a problem were to arise, they would have to visit the dermatologist for treatment ranging from a cortisone injection to Silastic gel sheeting. This client's face and chin can be treated successfully.
Inflammatory keloidosis is a condition in which a keloid-type scar will form in a wound associated with a prolonged inflammatory phase. If an electrologist is treating a person with ingrown hairs, and a large hard bump or nodule forms before the treatment time has elapsed, they should not treat the follicle again until the enlarged area has resolved. Any hair that grows in that area should be clipped.
Electrolysis will not cause a keloid or a hypertrophic scar to form unless the area is overtreated on a weekly basis and/or the follicle becomes infected. Keloids can be avoided with proper preparation: a comprehensive health history, a visual exam of all existing keloid scars -- treated or not -- and a test treatment on the edge of the area to be treated.
Treatment should involve careful insertions with a needle of the correct size, proper aftercare, and explicit home-care instructions, to prevent any chance of infection. The skin of the face, and the neck above the neck fold, should not form a keloid under these conditions. The neck fold and below, as well the chest should be treated with care -- slowly, and with low intensities.
A lower intensity reduces the trauma to the surrounding skin. This is important because the skin in these areas is usually taut and the mechanical tension from the skin movement can aggravate an injury and result in a hypertrophic scar or keloid.
Hyperpigmentation and Pseudofolliculitis Barbae
Hyperpigmentation is a skin condition characterized by the production of more melanin in a specific area or areas. This elevated melanin production is usually caused by trauma to the skin. However, the melasma (dark pigmentation of the skin) could be due to a hormonal disturbance, Addison's disease, or the side effects of certain medications.
Most dark-skinned clients seeking electrolysis already have hyperpigmented areas resulting from the hair. Deep, coarse, curly terminal hairs can irritate the epidermis by just their presence. If these hairs grow back into the skin, or if they grow sideways under the skin and cause an infection or a raised area, then the skin turns dark. This darkness is called post-inflammatory hyperpigmentation (PIH).
Infected pustules, bumps and ingrown hairs form the condition called pseudofolliculitis barbae (if the symptoms appear in a man's beard area it is called "barbae," but the same symptoms on the chest, sternum, abdomen or bikini line are simply referred to as pseudofolliculitis of the area). Many clients suffer extreme discomfort from these ingrown hairs and seek relief by tweezing them or digging them out with any sharp instrument that comes to hand. This action further traumatizes the infected skin surrounding the follicle, and the hyperpigmentation begins or deepens. If this procedure is followed regularly, not only will the entire area become dark but scar tissue will begin to form. The skin will appear lumpy and black. Sometimes this hyperpigmentation and scar tissue will be so dense it looks like black velvet. If this occurs, it is more difficult for the hairs to reach the surface of the skin. The area is tender, scarred, red, black, violet and bumpy. Although I have no clinical proof, it is my contention that this ongoing trauma causes hyperpigmentation below the epidermis and into the dermis. Consequently, it is going to take many months and consistent treatments for PIH of this nature to fade.
During the initial consultation, bleaching creams should be discussed. Many dark-skinned clients will already be using an over-the-counter or prescription bleaching agent (including many that complain the agents do not appear to be effective). As long as the hair is the irritant and the "root" of the hyperpigmentation, the skin will not lighten.
The client should be advised to discontinue the bleaching agent until the electrolysis treatment appointments are at least three weeks apart. Bleaching agents interfere with the normal healing process after electrolysis. The electrologist must be encouraging, and strongly suggest patience with the skin. If the client still insists that something more than time and electrolysis is necessary, skin care products with alpha hydroxy acids and enzyme exfoliants will help to return the skin to its normal pigmentation sooner.
Electrologists must also be sure to inquire whether or not clients are using cocoa butter or other rich, oily emollients on their skin to reduce blemishes and restore pigmentation. It actually works very well for the body because it both moisturizes and protects, but it is never to be used on the race and neck. The cocoa butter will clog the pores and the resulting hard oil plugs will be found wrapped around ingrown or embedded hairs.
Treating Ingrown Beard Hairs (PFB)
To treat PFB we need to have lots of cotton, alcohol (or other pre-cleanser) Tend Skin, hydrogen peroxide, triple antibiotic ointment with zinc, tea tree oil, a non-comedogenic moisturizer, and an aloe vera gel or an antioxidant serum or cream that contains vitamins A, C, D, and E. The antioxidant cream is an alternative for clients who are allergic to aloe vera, but it can also be used with the aloe if desired.
I use a flat lancet to open the pustules or to pierce the skin to retrieve the hairs. Others prefer to use the type of disposable needle that is used for injections. Whatever the instrument, it must have a fine point and a small diameter, in order to minimize the trauma to the area.
Step I. Examine the area to be treated. Note the diameter of the hair as it emerges from the skin, and the extent of the hair's curl. Choose the needle-size that corresponds to the hair's diameter. Many electrologists suggest a needle of smaller diameter size for extremely curly hair, but when I followed this advice at the beginning of my career, I found the amount of resulting regrowth to be unacceptable. If the hair diameter calls for a #5 needle, I believe that is the needle to be utilized. The exception is when the hair is a #5 but the skin is dry and thin, or combination skin, with very tight follicles. If the needle is too large for the follicle, bruising, discomfort and more hyperpigmentation will follow. The damage will be visible at the next appointment. If we move to a needle one size smaller and exercise patience, the hyperpigmentation will lighten in a matter of weeks because only the epidermis will have been impacted.
Step 2. The area is cleaned with alcohol or other skin cleanser, before Tend Skin (or other salicylic acid preparation) is applied to soften the hard tissue.
Step 3. If the skin is whitened from the Tend Skin, aloe vera gel is applied. The ingrown and embedded hairs are identified. The pustules and raised bumps are unroofed, and visible hairs are lifted up and out. As blood and pus ooze, the area is patted with a cotton ball dampened with hydrogen peroxide. If needed, the cotton ball can be held in place until the blood, pus and other lymphatic matter have stopped leaking. If the hair has not emerged, poking and searching should be discontinued to avoid any further traumatization of the skin. The client is informed that the hair is still there, and that it will be checked at the next visit.
The hair may attach itself to the scab that forms, and will fall out when the scab falls off. Or, another pustule may form. If another pustule forms, the client should apply hydrogen peroxide, sea breeze, and/or Tend Skin and moisturize. Clients should not attempt to free the hair themselves because very few clients use sterile or sanitized tools.
Step 4. Returning to the first hairs that were unroofed, the hair is lifted and given a slight tug to determine the angle of the insertion.
Step 5. The needle is inserted and the hair is treated. Progressive epilation may be necessary here for those practitioners who use the two-handed working method, or a modified progressive epilation technique for those who use the one-handed method. As always, the goal is to have the hair slide, slip, or even pop out, and not to tweeze or break it off.
Step 6. The skin must be watched carefully. Blanching and blistering are not acceptable and indicate that a reduction in the intensity is required. Virgin growth that has been tweezed will require fairly high intensities to release the hair in less than 10 seconds. However, intensity settings should start at a moderate level and be increased slowly. The timing is kept the same while the intensity is increased a little. If this does not release the hair, the timing is raised a notch before increasing the intensity once again. The exception is when flash thermolysis is the modality of choice: in this event the timing is kept the same or decreased while the intensity is increased. The hair should epilate easily with root sheath and bulb intact.
Step 7. Aftercare and home-care instructions are critical. After treatment the practitioner should apply hydrogen peroxide, Tend Skin, tea tree oil, aloe gel and triple-antibiotic ointment with zinc. If the client does not wish to appear shiny the moisturizer can be substituted. It must be stressed that there is to be no picking, scrubbing, makeup or sweating for 24 hours after treatment. Ice may be applied if swelling is excessive and uncomfortable. The next day the pustules will be flat and there will be no oozing. Some swelling and redness may be present, but by the second day that too should be gone and small scabs the size of the incision should have formed.
The Blend
Most deep, coarse, dark and curly terminal hairs in dark skin will respond very well to the blend technique. If the client does not have PFB in any form, and the hairs are straight or wavy, one can proceed as one would with a fair-skinned, straight-haired client. Overtreatment will be signaled by hyperpigmentation, excessive and large scabs and swelling that does not abate in 24 hours. At the next treatment, the appropriate adjustments are made, and there will be no permanent damage to the skin. However, if the area is continually overtreated, hyperpigmentation, pitting, scarring and infection, bruising and even the dreaded keloid can occur.
I usually lead with galvanic and end simultaneously. I will not attempt to recommend intensities because each epilator and control panel is different. If electrologists start low and increase slowly they will find a good working point. I only use thermolysis on dark-skinned patients in specific situations.
Thermolysis
If the client has an allergic reaction to the galvanic current as indicated by redness, hard nodules, hyperpigmentation and sensitivity, and the hairs do not epilate easily, then I switch to shortwave. I only use shortwave manually or slowly. This allows me to avoid damaging the epidermis. However, I have spoken to several experienced electrologists who have used flash successfully on dark skin.
Multiple-needle Galvanic
Multiple-needle galvanic works well on its own or in conjunction with the blend. If there is a lot of scar tissue around the follicle I wait until finer hair begins to grow, By that time the scar tissue is reduced, the needles are easier to insert -- and they stay where they are placed. If there is an allergic reaction, I discontinue and begin thermolysis treatments.
Treating black- or dark-skinned clients doesn't have to be an intimidating experience for either the client or the electrologist. As with any electrolysis treatment, patience and practice, together with careful experimentation with different needles, modalities and intensities, will net excellent results for everyone involved.
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