EMMA WEDGWOOD

AESTHETIC MEDICINE IS NOT ONE SIZE FOR ALL

Emma Wedgwood discusses why true inclusivity means understanding the skin in front of you.

When we talk about diversity in aesthetic medicine, the conversation centres around representation. Who we see in advertising, on social media and in before-and-after imagery matters. But there is another side to this conversation; are we actually equipped to treat everyone safely?

True inclusivity means understanding that skin does not always respond to treatment in the same way, that certain concerns can present differently across skin tones, and that practitioners need the education and experience to recognise those differences.

SEEING IS NOT UNDERSTANDING

Aesthetic medicine is an incredibly visual speciality. We assess colour, texture, vascularity, pigmentation, inflammation and changes in the skin every day. Yet historically, much of the clinical imagery has focused on lighter skin.

A 2023 review of leading dermatology surgery textbooks analysed 1,501 clinical images and found that only 5.6% represented Fitzpatrick skin types IV–VI. That is a striking gap, particularly when we consider how important visual recognition is to clinical assessment.

This isn’t about suggesting that one skin tone is more difficult to treat than another. It is about education.

Different skin requires different knowledge and that knowledge needs to start during training and continue. It isn’t enough to learn the theory of skin of colour; practitioners need to see a wide range of presentations in real clinical settings and understand how skin may respond before, during and after treatment.

SKIN DOESN’T RESPOND THE SAME

Pigmentation is where this becomes particularly important.

Post-inflammatory hyperpigmentation can be a significant concern in skin of colour. Inflammation or injury to the skin can trigger increased pigment production, meaning that a treatment intended to improve one concern can potentially create another if the skin isn’t assessed and treated appropriately.

This is particularly relevant when we talk about energy-based treatments. Lasers and light-based devices can be incredibly effective, but they are not universally interchangeable across skin types. Melanin absorbs laser energy, and the risk of pigmentary complications is higher in Fitzpatrick IV–VI skin. Wavelength, fluence, pulse duration, treatment density and cooling all need to be considered carefully.

A systematic review and meta-analysis of 43 studies involving 1,654 patients with Fitzpatrick skin types IV–VI found that post-inflammatory hyperpigmentation was the most common adverse event following non-ablative laser and energy-based treatments, occurring in 8.1% of patients.

That doesn’t mean that some lasers cannot be used safely in darker skin. They absolutely can. It means that the practitioner needs to understand the skin they are treating and the technology they are using.

The same principle applies to pigmentation concerns such as melasma. It can be tempting to look at pigmentation as something that simply needs to be removed, but melasma is complex, chronic and often recurrent. Inflammation can exacerbate pigmentation, so an aggressive approach isn’t necessarily the best approach.

This is also where the Fitzpatrick scale is useful, but it should never become a tick-box exercise. Two patients can have the same Fitzpatrick classification and still have very different skin histories, sensitivities, pigmentation patterns and responses to treatment.

The consultation has to go beyond a number. The aim should not always be to do more. Sometimes the most appropriate treatment is the one that creates the least inflammation.

STARTING IN THE TRAINING ROOM

This is why I think representation in aesthetics needs to extend beyond marketing.

It is positive to see greater diversity in campaigns and on clinic websites, but representation needs to exist in education too. If practitioners are going to treat an increasingly diverse patient population, we need to see that diversity during our training.

A practitioner should be able to look at a patient’s skin, understand what they are seeing, recognise the potential risks and make an informed treatment decision, regardless of that patient’s skin tone.

THE INDIVIDUAL, NOT THE PROTOCOL

The more I work in aesthetics, the more I believe that good treatment is about moving away from protocols that assume everyone will respond in the same way.

We talk a lot about personalised aesthetics, but personalisation cannot simply mean choosing between different treatments. It means understanding the individual in front of you, their anatomy, their skin, their history, their concerns and their risk factors and adapting the treatment accordingly.

That includes knowing when to treat, how to treat and, sometimes, when not to treat. That is what true inclusivity looks like: not treating every skin tone identically, but making sure every skin tone is understood, respected and treated with the same level of clinical care.

EMMA WEDGWOOD

Emma Wedgwood is an advanced nurse practitioner and independent prescriber with over 20 years of medical expertise. Following an extensive career in NHS intensive care, she transitioned to facial rejuvenation in 2018, bringing clinical precision to skin health. Emma holds an MSc in Cosmetic Medicine and serves on the board of BAMAN.