Rethinking Aging in Skin of Color: A Pigment-First Approach

At South Beach Symposium 2026, Cheri Frey, MD, delivered a clinically focused presentation on managing aging in patients with skin of color—an area that continues to demand nuance, technical precision, and individualized care. Her session emphasized both the biologic distinctions that influence aging patterns and the procedural considerations necessary to optimize outcomes while minimizing complications.

Distinct Patterns of Aging

One of the central themes of Frey’s talk was that aging manifests differently across racial and ethnic groups. In patients with skin of color, dyspigmentation, often described by patients as “dullness” or uneven tone, is typically the earliest and most prominent sign of aging. Mottled hyperpigmentation, periorbital darkening, and textural irregularities often precede the etched fine lines and coarse wrinkling that dominate in lighter phototypes.

Indeed, fine and coarse wrinkles tend to appear 10 to 15 years later in many patients with higher Fitzpatrick skin types. Melanin, while implicated in pigmentary disorders such as post-inflammatory hyperpigmentation (PIH), provides meaningful photoprotection against ultraviolet radiation—still the primary driver of extrinsic aging. Structural differences in the dermis, including denser collagen bundles and more active fibroblasts, may further delay visible wrinkling but do not eliminate age-related volume loss and laxity.

Frey underscored the heterogeneity within “skin of color.” Visual assessment alone is insufficient; clinicians must ask about ancestry, prior treatment responses, and patient priorities. Tailored treatment planning, guided by both the physician’s eye and the patient’s concerns, remains central to achieving satisfaction.

Procedural Risk: Avoiding Preventable Complications

A key caution involved the use of intense pulsed light (IPL) in Fitzpatrick IV–VI patients. Frey was unequivocal: IPL should not be used in these populations due to the high risk of pigmentary complications. Because IPL wavelengths overlap significantly with melanin absorption peaks, even well-intentioned vascular treatments can trigger PIH—or worse, hypopigmentation.

While PIH is common and generally manageable, post-inflammatory hypopigmentation or depigmentation is more difficult to correct and potentially permanent. Prevention is therefore paramount.

Pre-procedural optimization includes strict photoprotection, particularly against visible light. Tinted sunscreens containing iron oxides are recommended, especially in patients with melasma or dyschromia. Frey also advises discontinuing retinoids 5 to 7 days before procedures in skin of color, despite some industry claims that cessation is unnecessary. Her experience suggests that continuing retinoids increases the risk of exaggerated inflammatory responses following chemical peels or energy-based treatments.

Chemical Peels: Conservative and Effective

Superficial peels remain a cost-effective and versatile tool. Salicylic acid peels are particularly useful in acne-prone patients with concurrent dyschromia, given their lipophilicity and comedolytic action. Glycolic acid peels offer dual benefits: epidermal exfoliation and tyrosinase inhibition, with emerging evidence that alpha hydroxy acids may stimulate dermal fibroblasts.

Frey favors incremental improvement over aggressive single-session interventions. Superficial peels performed serially often yield excellent outcomes with lower risk than deeper or proprietary formulations applied without adequate pre-treatment protocols.

Energy-Based Devices: Precision Matters

Understanding chromophore absorption curves is essential when treating skin of color. Longer wavelengths, such as 1064 nm, are generally safer due to reduced melanin absorption. Non-ablative fractional lasers (1540–1550 nm) and 1927 nm thulium lasers can be used cautiously for fine lines, scarring, and pigmentation.

Picosecond lasers, especially when combined with topical agents such as cysteamine, may be effective for recalcitrant hyperpigmentation.

Frey also highlighted fractional radiofrequency microneedling as a versatile option for textural irregularities, acne scarring, rosacea, and even melasma. Depth control and pulse modulation are critical to minimizing thermal injury. Recent safety concerns, she noted, stem largely from improper training and excessive depth rather than inherent device limitations.

Contrary to historical hesitancy, ablative fractional lasers can be used in skin of color when performed with low density settings and minimized thermal load. Devices with very short pulse durations, such as 2940 nm erbium systems, reduce collateral heat injury and may safely address etched lines and scars.

Harnessing Dermal Biology: Biostimulatory Fillers

Given the tendency toward volume loss rather than early wrinkling, biostimulatory fillers—particularly poly-L-lactic acid—may be especially effective in skin of color. By leveraging robust fibroblast activity, clinicians can stimulate endogenous collagen production and address laxity more physiologically.

Post-Procedural Management

Inflammation drives results but also complications. Short courses of topical corticosteroids following peels or fractional lasers may reduce the risk of PIH without compromising outcomes when used judiciously. Barrier repair with thick emollients and strict photoprotection are essential. Some clinicians incorporate oral Polypodium leucotomos as adjunctive photoprotection.

Finally, proactive follow-up is critical. Early intervention at the first sign of complication improves outcomes and reassures patients.

Conclusion

Frey’s session reinforced a practical message: aging in skin of color requires a pigment-first mindset, conservative escalation, and meticulous technique. With thoughtful preparation and appropriate device selection, clinicians can safely address dyschromia, textural change, and volume loss, delivering meaningful rejuvenation while minimizing risk in this diverse and growing patient population.

Reference

1. Frey C. Managing pigment alterations in SOC. Presented at: South Beach Symposium 2026; February 5-7, 2026; Miami Beach, FL.