Naissan Wesley, MD

Persons with Fitzpatrick skin types III-VI and those of certain ethnic groups tend to have a higher risk of darker pigmentation on certain parts of the body. Melasma, postinflammatory hyperpigmentation, and lentigines often respond to treatment with topical antipigment agents, chemical peels, and lasers. Darker pigment on the elbows and knees, if bothersome also can be treated with topical antipigment creams, plus or minus topicals that promote exfoliation (such as urea-based topicals). If the skin is acanthotic on elbows or knees, a topical steroid can be used first to thin the area before applying a lightening agent.

But what about pigmentation of the eyelids, axillae, and neck? At these thinner, more sensitive areas of skin, the cause of darker pigment could be multifactorial. Treatment can be difficult because the same methods we use to treat pigmentation in other areas can be too aggressive for these locations. A recent study by Saedi and Ganesan (J. Drugs Dermatol. 2013;12:563-7) surveyed practicing dermatologists’ methods of treating hyperpigmentation of the eyelids, axillae, and neck. Fifty dermatologists completed the survey, and 46 (92%) reported treating patients with darker skin. The ethnic groups treated included Hispanic (97.8%), black (97.8%), Middle Eastern (77.6%), and Asian (88.9%). Thirty-six survey respondents reported treating patients with hyperpigmentation under the eyes, and 22 (61.1%) thought the hyperpigmentation was a result of idiopathic increase in melanin deposition. Forty-two responded to treating hyperpigmentation in the axilla, most of whom thought it was related to acanthosis nigricans (69.0%) or contact dermatitis (59.5%). Forty responded to treating hyperpigmentation on the neck, most of whom treated the condition with hydroquinone (66%). Treatments for these three areas were not found to be effective.

Pigment in these areas could be normal and purely genetic, such as variations in skin pigment because of embryonic pigment demarcation areas, versus an underlying pathology.

For the eyelids, that pathology could include increased pigment from inflammatory conditions (eczema, allergies, allergic or irritant contact dermatitis, photodermatitis), autoimmune conditions (dermatomyositis, lupus), medications (bimatoprost, among others), heavy metal poisoning (colloidal silver, lead, mercury), or increased vascularity. Treating these underlying conditions may help improve the appearance of darker eyelids. Hyperpigmentation treatment options include a series of light chemical peels, topical lightening agents such as kojic acid, and resurfacing lasers, but caution must be taken to avoid additional postinflammatory pigmentation from these procedures. Long-term sun protection and sunscreen use is imperative in any area after treatment.

Tear trough deformity because of volume loss under the eyes also can cause the appearance of darker lower eyelids. However, hyperpigmentation of the skin is not the primary issue in these cases, and the appearance can often improve with placement of dermal fillers.

For the axillae and neck, conditions that could promote hyperpigmentation include postinflammatory pigmentation (caused by irritant or allergic contact dermatitis, infection, waxing, or friction), UV exposure, acanthosis nigricans, and photodermatitis, especially from photosensitizing medications. All of these conditions may also respond to topical antipigment ingredients and attention to the underlying condition, but unfortunately, not always to the patient’s greatest satisfaction.

What are your strategies for hyperpigmentation on the tough-to-treat areas of the eyelids, neck, or axillae?

Dr. Wesley practices dermatology in Beverly Hills, Calif.

Do you have questions about treating patients with dark skin? If so, send them to sknews@frontlinemedcom.com.

Persons with Fitzpatrick skin types III-VI and those of certain ethnic groups tend to have a higher risk of darker pigmentation on certain parts of the body. Melasma, postinflammatory hyperpigmentation, and lentigines often respond to treatment with topical antipigment agents, chemical peels, and lasers. Darker pigment on the elbows and knees, if bothersome also can be treated with topical antipigment creams, plus or minus topicals that promote exfoliation (such as urea-based topicals). If the skin is acanthotic on elbows or knees, a topical steroid can be used first to thin the area before applying a lightening agent.

But what about pigmentation of the eyelids, axillae, and neck? At these thinner, more sensitive areas of skin, the cause of darker pigment could be multifactorial. Treatment can be difficult because the same methods we use to treat pigmentation in other areas can be too aggressive for these locations. A recent study by Saedi and Ganesan (J. Drugs Dermatol. 2013;12:563-7) surveyed practicing dermatologists’ methods of treating hyperpigmentation of the eyelids, axillae, and neck. Fifty dermatologists completed the survey, and 46 (92%) reported treating patients with darker skin. The ethnic groups treated included Hispanic (97.8%), black (97.8%), Middle Eastern (77.6%), and Asian (88.9%). Thirty-six survey respondents reported treating patients with hyperpigmentation under the eyes, and 22 (61.1%) thought the hyperpigmentation was a result of idiopathic increase in melanin deposition. Forty-two responded to treating hyperpigmentation in the axilla, most of whom thought it was related to acanthosis nigricans (69.0%) or contact dermatitis (59.5%). Forty responded to treating hyperpigmentation on the neck, most of whom treated the condition with hydroquinone (66%). Treatments for these three areas were not found to be effective.

Pigment in these areas could be normal and purely genetic, such as variations in skin pigment because of embryonic pigment demarcation areas, versus an underlying pathology.

For the eyelids, that pathology could include increased pigment from inflammatory conditions (eczema, allergies, allergic or irritant contact dermatitis, photodermatitis), autoimmune conditions (dermatomyositis, lupus), medications (bimatoprost, among others), heavy metal poisoning (colloidal silver, lead, mercury), or increased vascularity. Treating these underlying conditions may help improve the appearance of darker eyelids. Hyperpigmentation treatment options include a series of light chemical peels, topical lightening agents such as kojic acid, and resurfacing lasers, but caution must be taken to avoid additional postinflammatory pigmentation from these procedures. Long-term sun protection and sunscreen use is imperative in any area after treatment.

Tear trough deformity because of volume loss under the eyes also can cause the appearance of darker lower eyelids. However, hyperpigmentation of the skin is not the primary issue in these cases, and the appearance can often improve with placement of dermal fillers.

For the axillae and neck, conditions that could promote hyperpigmentation include postinflammatory pigmentation (caused by irritant or allergic contact dermatitis, infection, waxing, or friction), UV exposure, acanthosis nigricans, and photodermatitis, especially from photosensitizing medications. All of these conditions may also respond to topical antipigment ingredients and attention to the underlying condition, but unfortunately, not always to the patient’s greatest satisfaction.

What are your strategies for hyperpigmentation on the tough-to-treat areas of the eyelids, neck, or axillae?

Dr. Wesley practices dermatology in Beverly Hills, Calif.

Do you have questions about treating patients with dark skin? If so, send them to sknews@frontlinemedcom.com.

Persons with Fitzpatrick skin types III-VI and those of certain ethnic groups tend to have a higher risk of darker pigmentation on certain parts of the body. Melasma, postinflammatory hyperpigmentation, and lentigines often respond to treatment with topical antipigment agents, chemical peels, and lasers. Darker pigment on the elbows and knees, if bothersome also can be treated with topical antipigment creams, plus or minus topicals that promote exfoliation (such as urea-based topicals). If the skin is acanthotic on elbows or knees, a topical steroid can be used first to thin the area before applying a lightening agent.

But what about pigmentation of the eyelids, axillae, and neck? At these thinner, more sensitive areas of skin, the cause of darker pigment could be multifactorial. Treatment can be difficult because the same methods we use to treat pigmentation in other areas can be too aggressive for these locations. A recent study by Saedi and Ganesan (J. Drugs Dermatol. 2013;12:563-7) surveyed practicing dermatologists’ methods of treating hyperpigmentation of the eyelids, axillae, and neck. Fifty dermatologists completed the survey, and 46 (92%) reported treating patients with darker skin. The ethnic groups treated included Hispanic (97.8%), black (97.8%), Middle Eastern (77.6%), and Asian (88.9%). Thirty-six survey respondents reported treating patients with hyperpigmentation under the eyes, and 22 (61.1%) thought the hyperpigmentation was a result of idiopathic increase in melanin deposition. Forty-two responded to treating hyperpigmentation in the axilla, most of whom thought it was related to acanthosis nigricans (69.0%) or contact dermatitis (59.5%). Forty responded to treating hyperpigmentation on the neck, most of whom treated the condition with hydroquinone (66%). Treatments for these three areas were not found to be effective.

Pigment in these areas could be normal and purely genetic, such as variations in skin pigment because of embryonic pigment demarcation areas, versus an underlying pathology.

For the eyelids, that pathology could include increased pigment from inflammatory conditions (eczema, allergies, allergic or irritant contact dermatitis, photodermatitis), autoimmune conditions (dermatomyositis, lupus), medications (bimatoprost, among others), heavy metal poisoning (colloidal silver, lead, mercury), or increased vascularity. Treating these underlying conditions may help improve the appearance of darker eyelids. Hyperpigmentation treatment options include a series of light chemical peels, topical lightening agents such as kojic acid, and resurfacing lasers, but caution must be taken to avoid additional postinflammatory pigmentation from these procedures. Long-term sun protection and sunscreen use is imperative in any area after treatment.

Tear trough deformity because of volume loss under the eyes also can cause the appearance of darker lower eyelids. However, hyperpigmentation of the skin is not the primary issue in these cases, and the appearance can often improve with placement of dermal fillers.

For the axillae and neck, conditions that could promote hyperpigmentation include postinflammatory pigmentation (caused by irritant or allergic contact dermatitis, infection, waxing, or friction), UV exposure, acanthosis nigricans, and photodermatitis, especially from photosensitizing medications. All of these conditions may also respond to topical antipigment ingredients and attention to the underlying condition, but unfortunately, not always to the patient’s greatest satisfaction.

What are your strategies for hyperpigmentation on the tough-to-treat areas of the eyelids, neck, or axillae?

Dr. Wesley practices dermatology in Beverly Hills, Calif.

Do you have questions about treating patients with dark skin? If so, send them to sknews@frontlinemedcom.com.

In an effort to improve sun protection and curb skin cancer, dermatologists are doing a better job of educating patients of all skin types about the consequences of UV damage. Sunscreen manufacturers also continue to develop more elegant formulations of both chemical and physical blockers that do not leave a whitish hue on darker skin.

But what about some other, lesser-known innovative ways we can protect ourselves without looking chalky?

Just in time for summer, here’s some food for thought.

Strawberries, as well as other darker-colored berries, are known to contain polyphenols that are antioxidants. Researchers in Italy and Spain tested a strawberry extract on cultured human fibroblasts to see whether there was a photoprotective effect. They added strawberry extract in different concentrations (0.05, 0.25, and 0.5 mg/mL) to all but the control group. They then exposed the samples to a dose of UV light "equivalent to 90 minutes of midday summer sun in the French Riviera," said lead investigator Maurizio Battino. Strawberry extract, especially at a concentration of 0.5 mg/mL, provided UVA protection, and not only boosted cell survival and viability, but also minimized DNA damage, compared with the effects on control cells (J. Agric. Food Chem. 2012;60:2322-70). Perhaps there will be topical sunscreens that contain strawberry extract in the future.

Other foods high in antioxidants that have been considered to have potential sun-protective benefits include bell peppers (red, yellow, green) and yellow squash (high in carotenoids); tomatoes and watermelon (high in lycopene); dark berries such as blueberries, acai, blackberries, and cranberries (rich in anthocyanin); turmeric root (curcumin); pomegranate (ellagic acid); green and black tea (catechins); dark cocoa (flavenols); green leafy vegetables such as spinach and kale (xanthophylls, oxygenated carotenoids); and fish such as mackerel, salmon, trout, herring, and sardines (omega-3 fatty acids).

Of course, just because certain foods have protective benefits does not mean we can advise patients to eat some fruits and veggies and then go lie in the sun sans sunscreen. These foods are not a replacement for the more common methods of sun protection, but they certainly contribute to overall health and, by extension, to healthy skin of all types.

This column, "Skin of Color," appears regularly in Skin & Allergy News, a publication of Frontline Medical Communications. Dr. Wesley practices dermatology in Beverly Hills, Calif. Scan the QR code to read this column online at edermatologynews.com.

Do you have questions about treating patients with dark skin? If so, send them to sknews@frontlinemedcom.com.

In an effort to improve sun protection and curb skin cancer, dermatologists are doing a better job of educating patients of all skin types about the consequences of UV damage. Sunscreen manufacturers also continue to develop more elegant formulations of both chemical and physical blockers that do not leave a whitish hue on darker skin.

But what about some other, lesser-known innovative ways we can protect ourselves without looking chalky?

Just in time for summer, here’s some food for thought.

Strawberries, as well as other darker-colored berries, are known to contain polyphenols that are antioxidants. Researchers in Italy and Spain tested a strawberry extract on cultured human fibroblasts to see whether there was a photoprotective effect. They added strawberry extract in different concentrations (0.05, 0.25, and 0.5 mg/mL) to all but the control group. They then exposed the samples to a dose of UV light "equivalent to 90 minutes of midday summer sun in the French Riviera," said lead investigator Maurizio Battino. Strawberry extract, especially at a concentration of 0.5 mg/mL, provided UVA protection, and not only boosted cell survival and viability, but also minimized DNA damage, compared with the effects on control cells (J. Agric. Food Chem. 2012;60:2322-70). Perhaps there will be topical sunscreens that contain strawberry extract in the future.

Other foods high in antioxidants that have been considered to have potential sun-protective benefits include bell peppers (red, yellow, green) and yellow squash (high in carotenoids); tomatoes and watermelon (high in lycopene); dark berries such as blueberries, acai, blackberries, and cranberries (rich in anthocyanin); turmeric root (curcumin); pomegranate (ellagic acid); green and black tea (catechins); dark cocoa (flavenols); green leafy vegetables such as spinach and kale (xanthophylls, oxygenated carotenoids); and fish such as mackerel, salmon, trout, herring, and sardines (omega-3 fatty acids).

Of course, just because certain foods have protective benefits does not mean we can advise patients to eat some fruits and veggies and then go lie in the sun sans sunscreen. These foods are not a replacement for the more common methods of sun protection, but they certainly contribute to overall health and, by extension, to healthy skin of all types.

This column, "Skin of Color," appears regularly in Skin & Allergy News, a publication of Frontline Medical Communications. Dr. Wesley practices dermatology in Beverly Hills, Calif. Scan the QR code to read this column online at edermatologynews.com.

Do you have questions about treating patients with dark skin? If so, send them to sknews@frontlinemedcom.com.

In an effort to improve sun protection and curb skin cancer, dermatologists are doing a better job of educating patients of all skin types about the consequences of UV damage. Sunscreen manufacturers also continue to develop more elegant formulations of both chemical and physical blockers that do not leave a whitish hue on darker skin.

But what about some other, lesser-known innovative ways we can protect ourselves without looking chalky?

Just in time for summer, here’s some food for thought.

Strawberries, as well as other darker-colored berries, are known to contain polyphenols that are antioxidants. Researchers in Italy and Spain tested a strawberry extract on cultured human fibroblasts to see whether there was a photoprotective effect. They added strawberry extract in different concentrations (0.05, 0.25, and 0.5 mg/mL) to all but the control group. They then exposed the samples to a dose of UV light "equivalent to 90 minutes of midday summer sun in the French Riviera," said lead investigator Maurizio Battino. Strawberry extract, especially at a concentration of 0.5 mg/mL, provided UVA protection, and not only boosted cell survival and viability, but also minimized DNA damage, compared with the effects on control cells (J. Agric. Food Chem. 2012;60:2322-70). Perhaps there will be topical sunscreens that contain strawberry extract in the future.

Other foods high in antioxidants that have been considered to have potential sun-protective benefits include bell peppers (red, yellow, green) and yellow squash (high in carotenoids); tomatoes and watermelon (high in lycopene); dark berries such as blueberries, acai, blackberries, and cranberries (rich in anthocyanin); turmeric root (curcumin); pomegranate (ellagic acid); green and black tea (catechins); dark cocoa (flavenols); green leafy vegetables such as spinach and kale (xanthophylls, oxygenated carotenoids); and fish such as mackerel, salmon, trout, herring, and sardines (omega-3 fatty acids).

Of course, just because certain foods have protective benefits does not mean we can advise patients to eat some fruits and veggies and then go lie in the sun sans sunscreen. These foods are not a replacement for the more common methods of sun protection, but they certainly contribute to overall health and, by extension, to healthy skin of all types.

This column, "Skin of Color," appears regularly in Skin & Allergy News, a publication of Frontline Medical Communications. Dr. Wesley practices dermatology in Beverly Hills, Calif. Scan the QR code to read this column online at edermatologynews.com.

Do you have questions about treating patients with dark skin? If so, send them to sknews@frontlinemedcom.com.

Cosmetic tattooing, also known as micropigmentation or permanent makeup, is a technique in which tattooing is performed to address cosmetic skin imperfections. It is often used to create eyeliner or lip liner, but it can also be used to camouflage stable patches of vitiligo, to create eyebrows on those who have lost them due to alopecia areata or chemotherapy, to create areolas for women who have had mastectomies, or to correct the shape of a reconstructed cleft lip. Cosmetic tattooing is also useful in women who want to wear makeup, but who have trouble applying it due to visual deficits, tremor, stroke, multiple sclerosis, or Parkinson’s disease.

In Asian cultures, cosmetic tattooing is not uncommon. Many women have cosmetic tattooing procedures to create permanent eyeliner and eyebrows, since many Asian women have sparse brows at baseline that often become thinner with aging. Cosmetic tattooing of eyeliner also enhances the natural almond shape of the eyes.

In darker ethnic skin types, where vitiligo is more visible, stable patches can be effectively camouflaged by cosmetic tattooing. However, cosmetic tattooing is not recommended unless these patches have been stable for several years and the patient has failed other therapies. The best candidate would be the darker-skinned patient with long-standing segmental vitiligo, for whom pigment grafting would also be highly considered.

Individuals who wish to perform cosmetic tattooing can receive training and certification in micropigmentology. Many also undergo apprenticeships to receive more hands-on training. I have firsthand knowledge of this process because my mother received this training and performed cosmetic tattooing on her clients when I was growing up. Good training is key, as not every tattoo ink will have the same result in every skin tone. For example, brown eyeliner might eventually turn pink on skin that has a red undertone. On someone with yellow undertones or olive skin, black pigment liner might turn greenish. So the experienced practitioner will often use different color hues depending on the person’s underlying skin color and tone to prevent this discoloration. The best results of cosmetic tattooing are achieved when others can’t tell that the work has been done.

Pitfalls with cosmetic tattooing, as with tattooing in general, include infection, allergic reaction to the tattoo ink, scarring, photocytotoxicity, and cosmetic disfigurement if the tattoo is placed improperly. Delayed granulomatous response has also been reported in cases of permanent eyebrow tattooing. In addition to typical skin infections caused by staphylococcus or streptococcus, cases of mycobacterium infection with tattooing have been reported (although such infections have been reported more often with traditional tattooing than with permanent makeup).

Red ink is the more commonly reported allergen. Titanium dioxide (TiO₂) is widely used in tattoo inks to achieve certain colors. When TiO₂ is exposed to certain wavelengths of light, including UV light and certain lasers, hydroxyl radicals can form, leading to photocytotoxicity (also called paradoxical darkening), which often results in a change or darkening of the pigment color. This condition is more common with pink, peach, or white tattoo colors where TiO₂ is used in the color. Q-switched lasers are the most effective at removing tattoos.

If performed correctly by a properly trained person, cosmetic tattooing can be a useful aesthetic solution to various cosmetic and medical skin concerns.

This column, "Skin of Color," regularly appears in Dermatology News, a publication of Frontline Medical Communications. Dr. Wesley practices dermatology in Beverly Hills, Calif.

Do you have questions about treating patients with dark skin? If so, send them to sknews@elsevier.com.

Cosmetic tattooing, also known as micropigmentation or permanent makeup, is a technique in which tattooing is performed to address cosmetic skin imperfections. It is often used to create eyeliner or lip liner, but it can also be used to camouflage stable patches of vitiligo, to create eyebrows on those who have lost them due to alopecia areata or chemotherapy, to create areolas for women who have had mastectomies, or to correct the shape of a reconstructed cleft lip. Cosmetic tattooing is also useful in women who want to wear makeup, but who have trouble applying it due to visual deficits, tremor, stroke, multiple sclerosis, or Parkinson’s disease.

In Asian cultures, cosmetic tattooing is not uncommon. Many women have cosmetic tattooing procedures to create permanent eyeliner and eyebrows, since many Asian women have sparse brows at baseline that often become thinner with aging. Cosmetic tattooing of eyeliner also enhances the natural almond shape of the eyes.

In darker ethnic skin types, where vitiligo is more visible, stable patches can be effectively camouflaged by cosmetic tattooing. However, cosmetic tattooing is not recommended unless these patches have been stable for several years and the patient has failed other therapies. The best candidate would be the darker-skinned patient with long-standing segmental vitiligo, for whom pigment grafting would also be highly considered.

Individuals who wish to perform cosmetic tattooing can receive training and certification in micropigmentology. Many also undergo apprenticeships to receive more hands-on training. I have firsthand knowledge of this process because my mother received this training and performed cosmetic tattooing on her clients when I was growing up. Good training is key, as not every tattoo ink will have the same result in every skin tone. For example, brown eyeliner might eventually turn pink on skin that has a red undertone. On someone with yellow undertones or olive skin, black pigment liner might turn greenish. So the experienced practitioner will often use different color hues depending on the person’s underlying skin color and tone to prevent this discoloration. The best results of cosmetic tattooing are achieved when others can’t tell that the work has been done.

Pitfalls with cosmetic tattooing, as with tattooing in general, include infection, allergic reaction to the tattoo ink, scarring, photocytotoxicity, and cosmetic disfigurement if the tattoo is placed improperly. Delayed granulomatous response has also been reported in cases of permanent eyebrow tattooing. In addition to typical skin infections caused by staphylococcus or streptococcus, cases of mycobacterium infection with tattooing have been reported (although such infections have been reported more often with traditional tattooing than with permanent makeup).

Red ink is the more commonly reported allergen. Titanium dioxide (TiO₂) is widely used in tattoo inks to achieve certain colors. When TiO₂ is exposed to certain wavelengths of light, including UV light and certain lasers, hydroxyl radicals can form, leading to photocytotoxicity (also called paradoxical darkening), which often results in a change or darkening of the pigment color. This condition is more common with pink, peach, or white tattoo colors where TiO₂ is used in the color. Q-switched lasers are the most effective at removing tattoos.

If performed correctly by a properly trained person, cosmetic tattooing can be a useful aesthetic solution to various cosmetic and medical skin concerns.

This column, "Skin of Color," regularly appears in Dermatology News, a publication of Frontline Medical Communications. Dr. Wesley practices dermatology in Beverly Hills, Calif.

Do you have questions about treating patients with dark skin? If so, send them to sknews@elsevier.com.

Cosmetic tattooing, also known as micropigmentation or permanent makeup, is a technique in which tattooing is performed to address cosmetic skin imperfections. It is often used to create eyeliner or lip liner, but it can also be used to camouflage stable patches of vitiligo, to create eyebrows on those who have lost them due to alopecia areata or chemotherapy, to create areolas for women who have had mastectomies, or to correct the shape of a reconstructed cleft lip. Cosmetic tattooing is also useful in women who want to wear makeup, but who have trouble applying it due to visual deficits, tremor, stroke, multiple sclerosis, or Parkinson’s disease.

In Asian cultures, cosmetic tattooing is not uncommon. Many women have cosmetic tattooing procedures to create permanent eyeliner and eyebrows, since many Asian women have sparse brows at baseline that often become thinner with aging. Cosmetic tattooing of eyeliner also enhances the natural almond shape of the eyes.

In darker ethnic skin types, where vitiligo is more visible, stable patches can be effectively camouflaged by cosmetic tattooing. However, cosmetic tattooing is not recommended unless these patches have been stable for several years and the patient has failed other therapies. The best candidate would be the darker-skinned patient with long-standing segmental vitiligo, for whom pigment grafting would also be highly considered.

Individuals who wish to perform cosmetic tattooing can receive training and certification in micropigmentology. Many also undergo apprenticeships to receive more hands-on training. I have firsthand knowledge of this process because my mother received this training and performed cosmetic tattooing on her clients when I was growing up. Good training is key, as not every tattoo ink will have the same result in every skin tone. For example, brown eyeliner might eventually turn pink on skin that has a red undertone. On someone with yellow undertones or olive skin, black pigment liner might turn greenish. So the experienced practitioner will often use different color hues depending on the person’s underlying skin color and tone to prevent this discoloration. The best results of cosmetic tattooing are achieved when others can’t tell that the work has been done.

Pitfalls with cosmetic tattooing, as with tattooing in general, include infection, allergic reaction to the tattoo ink, scarring, photocytotoxicity, and cosmetic disfigurement if the tattoo is placed improperly. Delayed granulomatous response has also been reported in cases of permanent eyebrow tattooing. In addition to typical skin infections caused by staphylococcus or streptococcus, cases of mycobacterium infection with tattooing have been reported (although such infections have been reported more often with traditional tattooing than with permanent makeup).

Red ink is the more commonly reported allergen. Titanium dioxide (TiO₂) is widely used in tattoo inks to achieve certain colors. When TiO₂ is exposed to certain wavelengths of light, including UV light and certain lasers, hydroxyl radicals can form, leading to photocytotoxicity (also called paradoxical darkening), which often results in a change or darkening of the pigment color. This condition is more common with pink, peach, or white tattoo colors where TiO₂ is used in the color. Q-switched lasers are the most effective at removing tattoos.

If performed correctly by a properly trained person, cosmetic tattooing can be a useful aesthetic solution to various cosmetic and medical skin concerns.

This column, "Skin of Color," regularly appears in Dermatology News, a publication of Frontline Medical Communications. Dr. Wesley practices dermatology in Beverly Hills, Calif.

Do you have questions about treating patients with dark skin? If so, send them to sknews@elsevier.com.