Review

Characteristics and management of Asian skin

~o Cohen, MD, Marisa G. da Cunha, MD, and Luciana C. Maluf, MD
I Lym Chan, MD, Sima

Faculdade de Medicina do ABC, Santo Abstract

 , Sa
Andre ~o Paulo, Brazil Color differences in skin are due to the amount and distribution of epidermal melanin. The
number of melanocytes is almost the same in all skin types, but higher phototypes exhibit
Correspondence
I Lym Chan, MD
more melanocytes, which produce more melanin and melanosomes that are individually
Faculdade de Medicina do ABC distributed throughout the keratinocyte layers. This characteristic ensures a natural,
Rua Carlos Weber, 1379/104 significant photoprotection in darker skins. Asians are a population with various skin
~o Paulo, SP
Vila Leopoldina, Sa phototypes, ranging from type III to IV Fitzpatrick0 s classification in Chinese and Japanese
Brazil
to type IV and V in Indian and Pakistani people. Asian skin tends to present
E-mail: ilymchan@yahoo.com.br
postinflammatory hyperpigmentation, melasma, lentigines and freckles, nevus of Ota, and
Hori nevus. The main skin diseases reported in Asians are acne, atopic dermatitis, and
Conflict of interest: none.
viral infections. Wrinkles and skin thickness, early signs of aging in Caucasians, are less
doi: 10.1111/ijd.14153 evident in Asian skin. However, pigmentary changes occur earlier. Additionally, this ethnic
population is increasing worldwide. The aim of this study is to show the importance of
studying the characteristics of Asian skin for the better management of skin diseases in
this population, which are being increasingly observed in doctor’s offices. Based on a
broad review of the medical literature, we report the characteristics of Asian skin, as well
as some dyschromias and common skin disorders in this ethnic group. The objective of the
article is to study the characteristics of Asian skin and differences in relation to other ethnic
groups to achieve improved clinical and cosmetic management of diseases and other skin
disorders. This article will discuss the concept of beauty in different ethnic groups,
treatments with lasers and other light sources, and cosmiatric treatments in Asian skin. An
extensive review of the literature was performed using the databases Scielo and Bireme,
from Medline and Lilacs sources, over the last 50 years. The keywords used were as
follows: Asian skin, ethnic skin, melanin. Due to the peculiarities of each ethnic group, this
article demonstrates the importance of studying the characteristics of Asian skin to
elucidate improved cosmiatric approaches for these patients.

population shows a greater tendency to have pigmentary disor-

Introduction
Asian people are becoming an important ethnic group due to their
differential skin characteristics, way of life, and peculiar habits.
The term “Asian” is used for people from Southeast Asia, the Far
East, or the Indian subcontinent. It embraces a group with several
cutaneous phototypes varying from – according to the Fitzpatrick
scale – type III (light brown) to IV (moderate brown) among Chi-
nese and Japanese people and types IV and V (dark brown)
among Indians and Pakistanis.1 In the 21st century, there was an
important demographic change, with half of the world’s population
being Asian. In the U.S.A., the Asian group will double by
2050.2,3 Based on this information, it is important to study the
characteristics of Asian skin to achieve better management of
cutaneous diseases in this population, which increasingly pre-
sents at dermatology outpatient clinics.1,4,5
The greater amount of melanin endows Asians with superior
natural photoprotection; however, as a consequence, this
ders. Lentigines, ephelides, and melasma are the most common
epidermal abnormalities, while nevus of Ota and Hori’s nevus
are also frequent dermal pigmentary disorders in this group.
Postinflammatory hyperpigmentation is peculiar to this skin type,
occurring after cutaneous damage including after the use of
lasers and other light sources. Thus, there is a need to study
the characteristics of Asian skin and the differences among
other skin types to identify better therapeutic strategies and
improved clinical and cosmiatric management of dyschromias
and other skin conditions.1
Discussion
The concept of beauty is subjective. Several studies have previ-
ously attempted to objectively define and measure it, especially
in relation to facial features. In the past, standardized mathe-
matical proportions were used to define these qualities.
1

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2 Review Characteristics and management of Asian skin
Examples are the neoclassical canons based on Greco-Roman
standards of beauty, or the “phi mask” of Marquadt, a model
based on the golden or “phi” ratio frequently found in nature
and considered attractive in faces. Beyond the Caucasian ver-
sion, there are African and Asian versions of this mask (Fig. 1).
However, these models are incapable of including the full range
of ethnicities. Although studies suggest that proportional faces
are considerably attractive, the most attractive faces tend to be
those with one or two characteristics that reflect ethnicity.2,6–11
The ethnic patient seeking aesthetic procedures is likely
seeking to improve his or her self-image within his or her stan-
dards of beauty while maintaining his or her ethnic, racial, and
cultural identity. There are many ethnicities within the Asian cul-
ture, each with its peculiar characteristics. We can cite the fol-
lowing as common characteristics of all of them: a round face,
full upper lip, high eyebrow, low nasal bridge,2,12–14 increased
2,12 2,12,13,15
intercanthal distance, short palpebral fissure,
increased malar fat.2,12,16 Approximately 50% of Asians show a
diminished or absent superior palpebral fold.2,12,13,15,17 Koreans
who live in the U.S.A. show, in general, a wider mandibular
angle and lower face.2,12,18
Studies suggest that Asians have a weaker facial skeletal
framework that results in greater malar fat pad ptosis, gravita-
tional soft tissue descent of the midface, and tear trough forma-
tion with aging.12–14 They also have a moderate premaxillary
deficiency, a larger malar fat pad in the midface, and a more
prominent soft tissue in the lips compared to Caucasians, who
12,16
have thinner lips and a more prominent chin.
Other characteristics of Asians are a wider intercanthal dis-
tance, short palpebral fissure, broad prominent forehead, and
the absence of a supratarsal crease.12,13,15 Koreans also have
International Journal of Dermatology 2018
Chan et al.
Figure 1 Ethnic variations of the phi mask.
In: Sturm-O’Brien AK, Brissett AEA, Brissett
AE. Ethnic trends in facial plastic surgery.
Facial Plast Surg 2010; 26: 69–74
a wider mandibular angle and a wider lower face with a
recessed chin.12,18
A careful evaluation of the proportions of the face is neces-
sary prior to performing any aesthetic procedure; it must con-
sider ethnic variations of facial structure during aging and the
different perceptions of beauty for each ethnicity. Leonardo da
Vinci suggested dividing the face in thirds: the distance
between the frontal hairline and the top of the brow, from the
brow to the base of the nose, and from the base of the nose
to the distal portion of the chin. Caucasian facial proportions
correspond to an oval face with prominent cheekbones, a nar-
row nasal base, thin lips, and a tapered jawline.12,19,20 In con-
trast, African-Americans have a decreased nasal projection,
broad nasal base, orbital proptosis, bimaxillary protrusion,
increased soft tissue of the midface, prominent lips, and
increased facial convexity.9,12 The term “Latinos” includes sev-
and eral ethnicities. However, in general, Hispanics show a bimaxil-
lary protrusion, an increased bizygomatic distance, a greater
convexity angle, a broad rounded face, a broader nose, and a
receded chin.9,12
As the ideals and standards of beauty of our society evolve,
cosmetic procedures resulting in racial transformation are being
replaced by a trend toward racial preservation, with the aim of
creating a harmonious, balanced appearance, considering the
race and ethnicity of each patient. It is necessary to take into
account the desires and concepts of beauty of each patient
while maintaining his or her racial characteristics.2
In relation to cosmiatric procedures, Asiatic countries are
showing an increasing interest. However, the desire for a west-
ernized appearance is not necessarily sought or appropriate for
all.21 In Asia and Southeast Asia, for example, many women
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Chan et al.
prefer extremely fair skin to tanned skin, and the cosmetic pro-
cedures reflect this attitude.12,22
Cosmiatric, laser, and other common light source treatments
will be mentioned for Asian ethnicity, as well as some postpro-
cedure complications:
Botulinum toxin type A (BTA)
Authors have found no differences in the durability of treatment
and quantity of toxin necessary for Asian skin, despite its
increased thickness and greater quantity of collagen.1,23 Tzou
et al.24 found that Europeans have wider facial movements than
Asians; Tsukahara et al.25 indicate that Caucasians show a
higher rate of wrinkle development than Japanese. These fac-
tors complicate the total quantity of BTA to be applied. Ahn
et al. suggest six to nine points of application of 1–1.5 IU in the
frontal muscle, resulting in a total dose between 6 and 13.5 IU,
and intradermal and oblique injections. For the glabella, authors
suggest a more conservative treatment in Asians, with a total
dose of 8 IU divided into three points, as compared to 20–30 IU
in Caucasians.26 Studies in cadavers have shown that the cor-
rugator muscle in Asians is more square, while in Caucasians it
is a more extended muscle.26–29 Kim et al.30 also reference a
small number of units in glabellar muscles in Asians compared
to Caucasians (8–12 units, 10–30 in women, and 20–40 in
men). An explanation would be the higher frequency of the “11”
pattern (perpendicular glabellar lines only) and reduced “U” pat-
tern (perpendicular and transverse glabellar lines) among
Asians, in addition to the observed differences cited in corruga-
tor muscles.30 In relation to eyebrows, Asian women are not
favored by an abruptly arched brow with a lateral peak because
it gives an aggressive look. Authors recommend suppression of
the corrugators to obtain a favorable Asian brow shape.26
Injection of BTA in the lateral region of the orbicular muscle
(in the “crow’s feet”) is a very popular procedure among Asians,
with a total dose of 7 IU per side by intradermal injection, while
in Caucasians the total dose is 10–15 IU per side delivered
intramuscularly. Caucasians exhibit greater periorbital wrinkling
than Asians.24,31 The size of the muscle fibers of the orbicular
muscle is smaller in Asians, who also present thicker skin, an
important factor for determining the level of periorbital wrin-
kling.26,32 A groove caused by contraction and hypertrophy of
the pretarsal orbicularis oculi (the “jelly roll”) is desired by Asian
women, whereas Caucasians typically want to remove this
groove.26 Carruthers et al.33 suggest injection of BTA at intra-
dermal points 1 cm below the ciliary line in Asians and 1–2 mm
below the ciliary line in Caucasians.
In Asians, BTA can be injected in the lower eyelid to create a
wider ocular aperture. This procedure is usually performed with
1–2 IU delivered subdermally at the midpupillary line, 3 mm
below the ciliary margin.12,34 For the treatment of bunny lines
(wrinkles on the side part of the nasal dorsum), a slightly higher
total dose is recommended in Asians (approximately 6 IU along
three points).26 Other complaints in Asians are nasal flare and a
ª 2018 The International Society of Dermatology
Characteristics and management of Asian skin Review 3
depressed nasal tip, for which correction by BTA or by rhino-
plasty is common.26 However, correction of perioral wrinkles is
less frequently performed in Asians than in Caucasians
because many Asians have protruding lips, which is thought to
make them more sensitive to complications.26 For the treatment
of “gummy smile,” dimpled chin, marionette lines, and platysmal
bands, the recommended doses are similar to those for Cau-
casians.26 A common procedure in Asians consists of the appli-
cation of BTA for benign masseter hypertrophy because of their
more developed mandibles; this benign hypertrophy of the mas-
seter muscle contributes to an undesirable quadrangular and
wide lower face. Good results can be achieved with repeated
injections, with a total recommended dose of 50–60 IU by appli-
cation.26,35 Other studies suggest approximately 25 IU at the
inferior masseter border.12,35,36 Another popular procedure is
the treatment of calf hypertrophy. In general, Asian women
have shorter legs and thicker calves compared to Caucasians.
The procedure makes the legs look long and slim, and the total
dose recommended is 100–120 IU in the calf muscles.12,26,37,38
Park et al. analyzed lateral canthal rhytids in Asian patients,
dividing it into three types: upper, lower, and bidirectional. The
bidirectional type was the most common, and the authors
observed a tendency toward the upper and the lower types
becoming bidirectional over the years. For the treatment of
these rhytids with BTA, the authors suggest taking into account
this classification; for instance, in the upper type, the inferior
point of the three commonly used types can be suppressed,
and in the lower type, the superior point can be suppressed.39
Injectable filler agents
In relation to soft tissue augmentation with hyaluronic acid (HA),
no reports were found concerning differences in durability in
comparison to other ethnicities. It is necessary to consider the
properties of ethnic skins when selecting the kind of filler and
the technique to be used, including the thickness of the skin
and the quantity of pigment.12
Fillers that stimulate the production of elastin, of collagen, or
skin tightening are more effective for this ethnicity. Patients
experience greater stimulation of collagen by these procedures
and histologically show less thinning of collagen bands and
elastic tissue at baseline and after treatment. Therefore, they
should require less treatment than Caucasian patients.21,40–42
Odunze et al. monitored 60 patients for at least 6 months
after HA injection (Restylane) for the treatment of several
regions of the face: 40 of phototypes I to III (by Fitzpatrick) and
20 of phototypes IV to VI. Among the first ones, permanent side
effects were not observed in relation to HA applications. One
patient had idiopathic angioedema of the lips for 36 hours that
resolved spontaneously, and another patient had an inclusion
cyst: incision and drainage with a 30-gauge needle and antibi-
otic therapy for 7 days were necessary. Permanent or transitory
adverse effects were not observed in patients of phototypes IV
to VI, such as hypersensitivity, hyperpigmentation, formation of
International Journal of Dermatology 2018
4 Review Characteristics and management of Asian skin
keloids, or hypertrophic scars. HA had the same efficacy in
patients with higher phototypes, provided that it was applied
using an appropriate and meticulous technique.43
Some studies have suggested that serial threading, cross
hatching, and fanning techniques decrease the potential for
additional trauma by minimizing multiple injections.12 It is rec-
ommended to abstain from or minimize the use of multiple
puncture techniques when injecting soft tissue fillers in patients
with ethnic skins to prevent postinflammatory hyperpigmentation
(PIH). When HA is used, slower injection rates decrease the
incidence of PIH and clinical bruising with occasional subse-
quent hemosiderin deposition in patients with higher photo-
types.21,44 Although keloid formation has not been generally
reported with the use of injectables, it is a necessary caution in
patients with a history of hypertrophic scars and keloids.21
Melasma 3 intense pulsed light (IPL)
For the treatment of melasma with IPL, some authors have
observed improvement after some sessions, but rebound repig-
mentation has been observed after a few months. Thus, there
is a necessity for repeated treatments to maintain the improve-
ment. Several authors have suggested the use of a lower
energy to achieve minimal erythema, prevent excessive thermal
damage to labile melanocytes, and reduce the risk of PIH.1,45,46
Bae et al. showed good results with IPL at a low energy and
short-pulse  10 or 13 J/cm2 in all regions of the face, using
weekly sessions (six in total), a wavelength of 550–800 nm, and
two passes, with the purpose of protecting the superficial epi-
dermis from excess heat and reducing side effects.47 Yun et al.
also described good results for the treatment of melasma in
Koreans who underwent six sessions of fractionated IPL or six
sessions of a combination between fractionated IPL and QS-Nd
YAG 1,064 nm at a low energy, with intervals of 2 weeks. Frac-
tionated IPL generates a light spectrum between 560 and
800 nm and supplies fractionated pulses of 40 ls (conventional
IPL supplies pulses of 1–3 ms), with more than 100 pulses
emitted in 10 ms.48 Gradually, it increases the skin temperature
and supplies continuous contact cooling, and it is considered
safer than conventional IPL.48–51 Patients who underwent the
combined treatment experienced a greater reduction in MASI
compared with patients who underwent fractionated IPL.48
Resurfacing with fractional lasers has been used to treat mel-
asma. This procedure consists of the use of a laser that creates
microzones of thermal injury surrounded by normal skin, from
where keratinocytes migrate to these injured microzones, initiat-
ing cutaneous reepithelialization in 24 hours. Moreover, the
temporary injury to epidermal barrier should cause better
absorption of the topical whitening agents.1,52,53
Melasma 3 lasers
Ablative fractional lasers are used with the objective of prevent-
ing the clonal expansion of hyperactive melanocytes in the
basal epidermal layer. They can also increase the absorption of
International Journal of Dermatology 2018
Chan et al.
topical whitening agents in patients with an affected epidermal
barrier.1
There are reports of the use of carbon dioxide lasers for the
treatment of melasma.54,55 However, the long recovery time
and adverse effects of these lasers have made its use unpopu-
lar.1 Despite being considered the best therapeutic option for
wrinkles and acne scars, due to the risks, they are less attrac-
tive for patients with higher phototypes. There are reports of the
use of several types of equipment in Asians and Hispanics,
such as carbon dioxide lasers: Sharplan CO2 with Ultrapulse or
SilkTouch flashscanner,56,57 UltraPulse 500v (CO2 laser),58,59
Unipulse CO2 laser resurfacing system,60 Er:YAG lasers,61,62 or
a combination of CO2 and Er:YAG.63 None of the authors
observed inaesthetic scars with these treatments. PIH occurred
in some patients, with a duration of approximately 3–4 months.
Postinflammatory hypochromia was described in rare cases:
two patients with a CO2 laser (one beginning 6 months after
treatment, regression at 12 months; the other beginning
12 months after treatment);60 and one patient with a Er:YAG
laser, with a duration of 2 months.56,62
Scars 3 lasers
Jung et al. suggested that fractional CO2 laser should be the
treatment of choice in patients with scars and those who opt to
achieve a better result.64 Hwang et al. observed an improve-
ment of acne scars and wrinkles by resurfacing with a
10,600 nm CO2 laser, using energy pulses of 5–7 mJ, covering
10–70% of the treated area with increases of 5%.65 Alexis rec-
ommended the following parameters for the 1,550 nonablative
fractional erbium laser (Fraxel 1,500; Solta Medical Inc., Hay-
ward, CA, USA) for acne scars in phototypes IV–VI: energy
from 40 to 70 mJ and a density of 200–392 MTZ/cm2 (Fig. 2).66
Photoaging 3 lasers
Jung et al. suggested – when comparing the effects of CO2
10,600 nm fractional ablative lasers and Er:YAG 2,940 nm in a
study of hemifaces of Asian patients – that Er:YAG is more indi-
cated for the treatment of superficial and moderate lesions,
such as those observed in photoaging, and for people who
desire a minimal recovery time.64
Nonablative lasers and other light sources can improve wrin-
kles, poikiloderma, and other signs of chronological aging and
photoaging, with fewer associated pigmentary complications and
significantly less downtime.56,67 A low energy and long duration
pulse should be applied to limit the extent of tissue damage
because more pigmented skin (with more melanin) absorbs the
laser energy more efficiently. Authors refer to an improvement of
lentigines, ephelides, wrinkles, and skin flaccidity of the face and
neck in Asians with the use of nonablative lasers: 595-nm dye
laser with a long pulse,68 Ruby Q-switched laser,69 Nd-YAG
1,320 nm (Cooltouch II),70 QS-Alexandrite laser,71 nonablative
infrared,72 and light-emitting diode (830 nm, 633 nm, and com-
bined),73 as well as a full spectrum of infrared light (700–
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Chan et al.
Figure 2 Improvement on acne scars after
three sessions of nonablative laser with 8%
retinoic acid peeling +1 session of
microneedling + filler in each scar
2,000 nm) and bipolar radiofrequency (electro-optical synergy
[ELOS]) combined74 and IPL.75–77 Few patients had PIH.56
Nonablative skin rejuvenation involves the use of lasers or
other light sources with a cooling device. These devices gener-
ate heat in the superficial layer of the skin up to 1 mm of depth.
Due to the reduced risk of complications and shorter recovery
time, these procedures are becoming popular for the treatment
of ethnic skins. The objective is to improve the signs of pho-
toaging, such as dilated pores, a nonhomogeneous texture,
telangiectasia, lentigines, wrinkles, and skin flaccidity. Cooling is
important because it protects the epidermis, reducing the
chance of erythema and edema, which lead to PIH.1,52
During the use of fractional nonablative lasers, the deep der-
mal heating produces dermal remodeling without significant skin
changes. As a result, proinflammatory marker upregulation and
new collagen formation, including collagen type III, are
observed. The most significant side effect of the 1,550 nm laser
diode is pain. After treatment, erythema, transient swelling,
desquamation, and PIH or “bronzing” of the skin are observed.
Treatment of a small area with multiple passes without allowing
sufficient time for cooling can produce bulk heating and, conse-
quently, scarring.56,78,79 Authors have referred to an improve-
ment in photoaging of Asian patients after treatment with the
1,550-nm laser diode. They have also reported a reduced
prevalence of PIH with a high energy and low density.56,80,81
Lasers and other light sources that use yellow and green lights
(Nd:YAG 532 nm, pulsed-dye laser 585 and 595 nm) target the
skin pigment and the vessels in the papillary dermis. A lesion in
the vessels of the dermis and the microvasculature of sebaceous
glands leads to a consequent reduction of telangiectasias and of
the production of sebum, in addition to promoting neocollagenesis
during the healing process.1,52,82 Other lasers or light sources
that use infrared light or a similar light (Nd:YAG 1,064 nm, Nd:
YAG 1,320 nm, diode 1,450 nm, erbium: glass 1,540 nm),
together with a cooling device, target the water in the dermis. By
photothermolysis, they increase the dermal temperature, leading
to increased neocollagenesis and collagen tightening. Several
monthly sessions are necessary to achieve a good result.1,83
However, laser diode 1,450 nm is associated with a significant
risk of PIH (7–39%) due to excessive cooling.52
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Characteristics and management of Asian skin Review 5
Aging and wrinkles 3 lasers
A study has shown that fractional laser resurfacing is also well
indicated for photorejuvenation, with an improvement in wrin-
kles, hyperchromias, and acne scars, including atrophic condi-
tions.84 Several wavelengths are used – 1,320, 1,440, 1,540
and 2,940 nm – with a penetration depth between 25 lm and
1.2 mm.84 To reduce the risk of PIH in higher phototypes, it is
necessary to minimize postprocedure erythema, to reduce the
energy and density, and to expand the intervals between ses-
sions (2–4 weeks for epidermal lesions, 4–6 weeks for dermal
lesions).1,52 Chan et al. observed a reduced prevalence of PIH
in patients treated with a high energy and low density than in
those treated with a low energy and high density.80 Alexis rec-
ommended the use of the 1,550 nm nonablative fractional
erbium laser (Fraxel 1,500; Solta Medical Inc., Hayward, CA,
USA) for melasma with the following parameters: 15 mJ and
125 MTZ per turn, eight times in total, with time for cooling the
skin between turns.66,85,86 There are reports concerning the use
of the laser Nd:YAG 1,064 nm with a low pulse for nonablative
resurfacing in patients of phototypes V and VI, with a low risk of
side effects.66,87,88
Ethnic skin has increased levels of epidermal melanin, and
melanin has a wide absorption spectrum, between 250 and
1,200 nm. Therefore, it is a target of most currently used lasers.
Epidermal melanin competes for laser absorption, and thus,
less energy reaches the targeted chromophore. This phe-
nomenon decreases the efficacy of the treatment, resulting in a
worse clinical result. Concurrently, when the energy absorbed
by epidermal melanin is converted into heat, it can cause non-
specific thermal damage, such as bubbles, scars, atrophy, tex-
ture change, and permanent dyschromia.12,56,89,90
Kim and Cho reported the effective use of the QS-Nd:YAG
laser at a low fluency for the treatment of PIH caused by acne
in 20 Korean patients with phototypes IV and V. They used the
device RevLite (HOYA Conbio, Freemont, CA), Q-switched Nd:
YAG 1,064 nm laser, with five weekly sessions for the full face
(5–10 with a spot of 6 mm, 10 Hz and fluency of 3.3 J/cm2 in
the first session and 5.8 J/cm2 in the last session). The authors
observed an improvement of PIH with the laser compared to
the control group. They did not observe adverse effects
International Journal of Dermatology 2018
6 Review Characteristics and management of Asian skin
(erythema, edema, purpura, or scars) at 3 months after the
treatments.66,91
Diascopy during laser therapy, a technique in which pres-
sure with the spot device is applied to the skin to compress
and empty the dermal vessels to reduce the risk of dermal
vascular damage and hemosiderin deposition, is a way to
reduce the risk of PIH. The use of laser or light sources with
a shorter wavelength (350–500 nm) restricts thermal damage
to the epidermis and represents another way to reduce the
risk of PIH.1,83
Studies using QS-Nd:YAG, QS-alexandrite, and QS-ruby
for the treatment of pigmented lesions in Asians have demon-
strated a risk of PIH of approximately 25%.1,71,92,93 There is
a report comparing the use of several Nd:YAG 532-nm lasers
for the treatment of facial lentigines in Chinese, indicating a
similar effectiveness with QS-Nd:YAG and Nd:YAG with a
long pulse. However, there was a higher risk of PIH in QS-
Nd:YAG, probably because QS-Nd:YAG, which delivers high-
energy radiation in nanoseconds, causes higher photothermal
and photomechanical effects, while Nd:YAG with a long pulse
causes tissue damage only by photothermolysis. The undesir-
able photomechanical effect targets melanin, but it also
induces damage to the surrounding oxyhemoglobin, causing
inflammation of the superficial vessels, altered activity of mel-
anocytes, and subsequent PIH.1,52,71,76,93,94
Laser hair removal
In relation to laser hair removal, the safest wavelengths for
phototypes IV–VI are those near the infrared spectrum, cor-
responding to diode lasers 800–810 nm and Nd:YAG
1,064 nm (Fig. 3). The Nd:YAG 1,064 nm laser with a long
pulse is preferred for phototype VI because it shows the
smallest incidence of side effects.66,95 When diode lasers
800–810 nm are applied in phototypes V and VI, prior test-
ing is necessary because there is risk of hypopigmentation
caused by thermal injury.66 Ross et al. observed that the
most tolerated fluency in higher phototypes was 100 J/cm2
for phototypes IV and V and 50 J/cm2 for phototype VI,
using the laser Nd:YAG 1,064 nm (Lyra-Laserscope, San
Jose, CA).96 The use of lower fluencies is recommended for
treatment of the highest phototypes to minimize thermal
injury to the epidermis with a reduced risk of disfiguring pig-
ment changes. Long-pulse durations facilitate efficient epider-
mal cooling, with less adverse effects.97 Examples of pulse
durations considered safe for phototypes IV–VI are as fol-
lows: 30 ms for Nd:YAG 1,064 nm with contact cooling, and
400 ms for laser diode 810 nm. IPL is not indicated for hair
removal in phototypes V and VI due to the high risk of PIH.
Finally, it is important to remember to cool the skin before
and after laser application.66
Nd:YAG 1,064 nm with a long pulse is the treatment of
choice for hirsutism and pseudofolliculitis barbae in African-
American patients with phototypes V and VI.12,96
International Journal of Dermatology 2018
Chan et al.
Figure 3 Hair removal of the face on an Asian patient with a
810 nm laser
Tattoo removal
For tattoo removal, the best laser for blue/black pigments in
patients with high phototypes is the Q-switched Nd:YAG
because it has the longest wavelength, resulting in the least risk
of scarring and dyschromias. For green/purple pigments, the Q-
switched alexandrite laser is often used, and for red pigment,
the Q-switched Nd:YAG 532 nm laser is the best option.12,98
Vascular lasers
For the treatment of vascular lesions (telangiectasias, heman-
giomas, portwine stains, and veins) in darker-skinned patients,
lasers with the longest wavelengths are recommended, such as
the Nd:YAG, to minimize scarring and epidermal damage. This
is a controversial treatment because the absorption spectrum of
hemoglobin is within the spectrum of absorption for mela-
nin.12,99,100 Lasers with shorter wavelengths, such as 595 nm
pulsed dye, can be used to achieve more effective results,
although they may also absorb melanin in addition to hemoglo-
bin. A test spot with the shorter wavelength lasers is recom-
mended before treating the entire affected area, if the longer
wavelength lasers are ineffective (Fig. 4).12
Melanin absorption decreases exponentially with increasing
wavelength, so lasers with longer and more deeply penetrating
wavelengths are in general safer and produce more reliable
clinical results in higher phototypes.56,90
In the preprocedural evaluation, it is important to identify the
patient’s ethnicity and to obtain any history of isotretinoin or
gold salts, previous cosmetic procedures and outcomes, and
tendency toward dyspigmentation, hypertrophic scarring, and
keloid formation. It is also important to consider the personal
and family history of glucose-6-phosphate dehydrogenase defi-
ciency, sickle cell anemia, and thalassemia, common condi-
tions in black-skinned and Asian patients, which may affect
postoperative healing. Cutaneous leishmaniasis must also be
considered because it is a frequent cause of scars in develop-
ing countries.56,101 It is necessary to educate the patient in
relation to the most common side effect, transient PIH, which
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Chan et al.
Figure 4 Port-wine stain: test with IPL
affects 68–100% of patients with Fitzpatrick skin types greater
than III. Pretreatment with retinoic acid, hydroquinone, and gly-
colic acid (GA) reduces the severity and duration of PIH, with-
out decreasing its incidence. It is important to avoid sunlight
and regularly use a broad-spectrum sunblock with SPF greater
than 30 for as long as possible preprocedure and postproce-
dure.56,90
Photoaging and pigmented lesions 3 IPL
Intense pulsed light consists of a broadband, pulsed light source
that emits noncoherent light over a spectrum from 515 to
1,200 nm and produces photothermal effects only.1,102 Using
diverse cutoff filters, it can selectively target chromophores,
such as melanin, hemoglobin, or tissue water, providing benefi-
cial effects on pigmented and vascular skin lesions and on skin
texture through dermal remodeling.102–105 Several studies have
described good results with IPL for the management of epider-
mal pigmentation in Asians.1 Ephelides showed better
responses in comparison to lentigines.1 The advantage of using
IPL is that several authors did not observe PIH postprocedure,
making it a good option for photorejuvenation in Asians.1,76,106–
108
Its use is suggested in patients with a risk of PIH and with
availability for several sessions of treatment. Contact cooling of
the epidermis is necessary to prevent PIH.1,52 Shin et al. inves-
tigated the effects of photorejuvenation in Asians treated with
IPL. In subjective assessments and objective noninvasive mea-
surements, a more remarkable improvement of pigmentation,
elasticity, and skin tone was observed in relation to facial wrin-
kles and hydration.102
Li et al. conducted a study in which IPL (515–1,200 nm) was
applied to one side of the face in 24 Chinese female patients
with photoaging and compared the results to the other
untreated side. After four sessions at 3- to 4-week intervals,
they observed a reduction of photoaging signs and an improve-
ment of skin texture. Side effects were minimal and acceptable.
Histopathologically, treatment with IPL caused a decrease in
epidermal melanin and promoted the remodeling of collagen
ª 2018 The International Society of Dermatology
Characteristics and management of Asian skin Review 7
and elastic fibers, in addition to neocollagenesis. These effects
can explain the improvement of photoaging. IPL is referred to
as a safe modality for the treatment of photoaging skin in the
Chinese population.109
Wrinkles and flaccidity 3 radiofrequency (RF) or infrared
light (IR)
Unipolar RF and newer IR light sources heat the deep dermis,
reaching a depth of 2–4 mm, and achieve enhanced skin tight-
ening. PIH is rare, even in darker skin types, with effective cool-
ing to protect the epidermis. These treatments are very
effective for the periorbital wrinkles, the lower face, and the jaw-
line contour, and for elevating the eyebrows.1,52,66,110,111
Combination of procedures
There are reports of combined approaches using several types
of lasers and light sources at the same session, with monthly
intervals. Several skin chromophores are targeted in this kind of
approach, with good results. However, a lower fluency must be
used with each device to reduce the adverse effects associated
with cumulative heat generation.1,52,112
Kim et al. described a combined treatment of IPL, IR light,
and laser diode, all of which are associated with RF, in the
same session (four sessions in total with 3-week intervals). The
authors indicated that all patients showed reductions in the glo-
bal index of photoaging, improvements of melanin rates and
elasticity, and increases in procollagen types I and III and elas-
tin levels. The combination of three different energy sources
with bipolar RF in the same session was effective for improving
several parameters, such as texture, tone, and laxity observed
in photoaged Asian skin, with a short recovery time.113
Chemical peels
In a review of acne and acne scar management, superficial
chemical peels in Asians were considered an adjuvant therapy
for all forms of acne, leading to a faster clinical response and
patient satisfaction.114 Treatments with 30% salicylic acid (SA)
International Journal of Dermatology 2018
8 Review Characteristics and management of Asian skin
and 35–70% GA were considered efficient for reducing inflam-
matory and noninflammatory acne lesions in Asians. SA has a
lightening effect, which is favorable for Asians with high photo-
types and patients with associated PIH. GA is a safe agent for
the treatment of acne, even in darker skin types, as well as a
complementary treatment of acne scars. Jessner solution has
been shown to be as effective as 70% GA, but the exfoliation
caused by the first one has dissatisfied some patients. The
combination of SA and mandelic acid peels has demonstrated
better results than 35% GA.114
For the treatment of acne scars, the most commonly used
peel is 35–100% trichloroacetic acid (TCA), which is isolated or
combined with another peeling agent such as Jessner’s solu-
tion. Lower concentrations are useful for rolling scars and
atrophic boxcar scars, while the CROSS (chemical reconstruc-
tion of skin scars) technique uses 100% TCA for ice pick scars,
the treatment of which is difficult. Another peeling agent used
for more superficial scars is full strength lactic acid, but it is not
recommended for deep rolling, boxcar, or ice pick scars since it
is not aggressive. GA also has a complementary effect to resur-
facing procedures. Phenol has been associated with several
side effects, and it is less effective when compared to laser skin
resurfacing. Most peeling agents are considered effective, safe,
and easy to administer. They are more affordable compared to
the newer machine-based technologies available for the treat-
ment of acne and acne scars, and they can be performed in
any dermatology office with minimal downtime.114
SA is an excellent keratolytic agent; it solubilizes the intercel-
lular cement, reducing corneocyte adhesion,115,116 and its anti-
inflammatory action results from its effects on the arachidonic
acid cascade.114,117 Lee and Kim treated 35 Korean patients
with phototypes III or IV and mild to moderate acne with 30%
SA peels at 2-week intervals (five sessions in total). This treat-
ment was effective for reducing both inflammatory and nonin-
flammatory acne lesions. Permanent PIH or scarring was not
observed. SA peels were considered safe and effective in Asian
patients, and they can be combined with traditional acne ther-
apy to facilitate the resolution of inflamed papules and come-
dones.115 Another study observed an improvement of the
appearance and whitening effect in 24 Korean patients with
acne who were treated with serial chemical peels of 30% SA
every 2 weeks for 3 months; colorimetric changes of the face
were registered with a reflectance spectrophotometer device.118
SA is a b-hydroxy acid and acts mainly on superficial layers of
the epidermis and sebaceous glands due to its peculiar charac-
teristic of lipophilicity. At a high concentration, SA exfoliates
only the cornified cells of the epidermis and hair follicles, with-
out inflammatory or degenerative changes, leading to regenera-
tion of the epidermis and papillary dermis.118–120 The
antiinflammatory and comedolytic effects are suitable for both
inflammatory and noninflammatory acne lesions. Patients with
acne have shown improvements of cosmetically problematic
conditions such as dryness, greasiness, and scaliness.118
International Journal of Dermatology 2018
Chan et al.
GA is a fruit acid that is found in sugar cane juice and is
synthetically produced for use in dermatologic products. At
low concentrations, it diminishes epidermal cohesion,121–124
while at high concentrations, it causes epidermolysis. This
wounding and reepithelization process removes epidermal
lesions as well as pigmentation.121 At concentrations ranging
from 50 to 70%, there is also a moderate improvement in
fine wrinkling and skin texture.121,125,126 Lim et al. evaluated
10 Asian patients with phototypes IV and V with moderate to
severe melasma receiving twice daily applications of a cream
containing 10% GA and 2% hydroquinone (Neostrata AHA
Age Spot and Skin Lightening Gel) to both sides of the face
and 20–70% GA peels every 3 weeks to one half of the face,
using the Neostrata Skin Rejuvenation System, with a total of
26 weeks of treatment. Daily application of the cream
improved melasma and fine wrinkling, but the improvement
was greater in combination with GA peels. However, this
improvement was not statistically significant (P > 0.059 for
improvement of melasma and P > 0.240 for improvement in
fine wrinkling), and it was apparent after three successive
peels, probably due to the epidermolytic effect of GA at
higher concentrations. GA peels are generally safe and easy
to administer. Without downtime and evidence of post peel
persistent erythema or hyperpigmentation and typically without
scarring, it is a useful adjuvant for the treatment of mel-
asma.121 GA peels are also effective for treating inflammatory
eruptions and noninflammatory lesions. In addition to the
antibactericidal effects on Propionibacterium acnes and antiox-
idant action, they can also correct the abnormal keratinization
associated with acne, promoting epidermolysis, dispersing epi-
dermal and dermal HA and basal layer melanin, and enhanc-
ing collagen gene expression through an increase in
secretion of interleukin-6.122,127–129 When used to treat mild
to moderate facial acne, GA peels reduce acne lesions, an
effect that becomes more apparent with an increasing number
of sessions. Noninflammatory lesions (comedones) exhibit a
more rapid improvement than inflammatory lesions. In con-
trast, cystic or nodular acne lesions are less or not respon-
sive to GA peels.122,125,130–132
Hong et al. compared the effect of one session of 15% TCA
peeling (Obagi Blue Peel; Obagi Medical Products, Long
Beach, CA) to one session of 1,550-nm erbium-doped fractional
photothermolysis laser treatment (Fraxel SR 1,500 Laser;
Solta Medical, Inc., Hayward, CA) in a split-face study of the
malar region of 18 Korean female patients, phototype III or IV,
with moderate to severe bilateral melasma. There was an
improvement of lesions 4 weeks after the sessions but recur-
rence at 12 weeks. PIH occurred in 28% of the patients in
4 weeks, with resolution; however, it persisted for 12 weeks in
one patient. There was no difference between the two treat-
ments, which were equally effective and safe when used to
treat moderate to severe melasma, but neither treatment was
long-lasting.133
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Chan et al.
Co^te
 et al. showed a new genetico-racial skin classification,
which was first suggested by Fanous et al., based on the skin
color and features of the patient and country of origin of the
patient’s parents.134–140 Genetic programming of the different
races determines the patient’s response to skin treatments and
susceptibility to complications. Patients who belong to the most
Northern (Nordics) and the most Southern (Indo-Pakistanis and
Africans) categories are potentially dangerous candidates
because they are susceptible to permanent complications, such
as scarring (in the first group due to thinner skin) and hypopig-
mentation (in the latter group due to more pigmentation and
thicker skin). The main reaction of Northern and Central Asians
is moderate to severe hyperpigmentation and erythema. South-
ern Asians also tend to hypopigmentation due to their more pig-
mented skin. In general, Asians are very good candidates for
medium or medium-to-deep peels as well as for conservative
laser resurfacing, excluding Southern Asians, who are good
candidates for treatments but require greater attention and gen-
134
tler treatments.
Conclusion
Considering demographic changes, the possibility of treating dif-
ferent ethnic groups in our dermatologic offices has increased.
It is necessary and important to study differences among tones,
physiology, and characteristics of ethnic skin, to guide safer
choices for an improved therapeutic strategy. Asians are show-
ing a progressive increase in the global population. The greater
amount of epidermal melanin allows more effective photoprotec-
tion against UV radiation, but it can lead to several pigment dis-
orders. Asian skin shows different characteristics in relation to
other ethnicities, which must be considered in the clinical and
cosmiatric management of pathologies and skin afflictions in
this ethnic population.
Questions (answers found after references)
1 What are the skin phototypes, according to the Fitzpatrick
scale, of the Asian population?
a Type I to III.
b Type II to IV.
c Type III to V.
d Type III to VI.
2 What are the most common pigmentary disorders of Asian
skin?
a Albinism, vitiligo, tinea versicolor, and pityriasis alba.
b Lentigines, ephelides, melasma, and postinflammatory
hyperpigmentation.
 au lait macules, and phytophoto-
c Ephelides, lentigines, cafe
dermatitis.
d Pityriasis alba, vitiligo, melasma, and postinflammatory
hyperpigmentation.
ª 2018 The International Society of Dermatology
Characteristics and management of Asian skin Review 9
3 What are the main skin diseases reported in Asians?
a Acne, atopic dermatitis, and viral infections.
b Numular eczema, dermatophytosis, and impetigo.
c Acne, urticaria, and vitiligo.
d Atopic dermatitis, viral warts, and impetigo.
4 There are many ethnicities within the Asian culture. We can
cite the following as common characteristics of all of them:
a A square face, low eyebrow, decreased malar fat, and high
nasal bridge.
b An oval face with prominent cheekbones, a narrow nasal
base, thin lips, and a tapered jaw line.
c A decreased nasal projection, broad nasal base, orbital
proptosis, bimaxillary protrusion, increased soft tissue of
the midface, prominent lips, and increased facial convexity.
d A round face, full upper lip, high eyebrow, low nasal bridge,
increased intercanthal distance, short palpebral fissure,
diminished or absent superior palpebral fold, and increased
malar fat.
5 What are the recommendations to reduce the risk of postin-
flammatory hyperpigmentation when we treat melasma in
Asian skin with Intense Pulsed Light?
a Use a higher energy and long pulse, to achieve maximum
erythema and damage the melanocytes.
b Use a lower energy and short pulse to achieve minimal
erythema and prevent excessive thermal damage to labile
melanocytes.
c Use a lower energy and long pulse to achieve minimal ery-
thema and prevent excessive thermal damage to labile
melanocytes.
d Use a higher energy and short pulse to achieve maximum
erythema and damage the melanocytes.
6 Diascopy during laser therapy:
a Reduces the risk of dermal vascular damage and hemosi-
derin deposition. It is a way to reduce the risk of postin-
flammatory hyperpigmentation.
b Increases the exposure of dermal vessels, increasing the
risk of postinflammatory hyperpigmentation.
c Reduces the risk of dermal vascular damage and hemosi-
derin deposition, but it does not reduce the risk of postin-
flammatory hyperpigmentation.
d Increases the risk of dermal vascular damage and hemosi-
derin deposition.
7 In relation to laser hair removal, the safest wavelengths for
phototypes IV–VI are:
a Intense Pulsed Light and Q-switched Nd:YAG 532 nm.
b Nd:YAG 1,064 nm and Intense Pulsed Light.
c Diode lasers 800–810 nm and Nd:YAG 1,064 nm.
d CO2 laser 10,600 nm and diode lasers 800–810 nm.
International Journal of Dermatology 2018
10 Review Characteristics and management of Asian skin
8 For tattoo removal, the best laser for blue/black pigments in
patients with high phototypes is:
a CO2 laser.
b Intense Pulsed Light.
c Er:YAG.
d Q-switched Nd:YAG.
9 For tattoo removal of green/purple and red pigments, which
lasers are the best options:
a Q-switched alexandrite laser and Q-switched Nd:YAG
532 nm laser.
b CO2 laser and Er:YAG laser.
c Intense Pulsed Light and 1,550 nm nonablative fractional
erbium laser.
d Q-switched ruby laser and diode lasers.
10 Which chemical peels are recommended to treat acne
lesions on Asian skin?
a 30% salicylic acid.
b 35–70% glycolic acid.
c Jessner solution.
d All of them.
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Answers
1. c, Type III (light brown) to IV (moderate brown) among Chi-
nese and Japanese people and types IV and V (dark brown)
among Indians and Pakistanis.
2. b
3. a
4. d
5. b
6. a
7. c
8. d
9. a
10. d
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