Noninvasive Cosmetic Treatments for Fitzpatrick IV–VI: A Narrative Review of Safety and Efficacy Guidelines

Abstract

Background:

With the growing popularity and accessibility of noninvasive cosmetic procedures, the need for safe and proper protocols across a diverse patient population has become increasingly important. When treating patients with varying skin types and tones, it is essential to adopt patient-centered approaches that minimize risks and optimize outcomes.

Methods:

A narrative review was conducted using PubMed to identify studies highlighting key recommendations and guidelines from recent literature regarding microneedling, radiofrequency microneedling, chemical peels, skin-tightening devices, laser treatments, and nitrogen plasma resurfacing for patients with Fitzpatrick skin types IV–VI.

Results:

Microneedling and radiofrequency microneedling are generally very safe for Fitzpatrick skin types IV–VI. Superficial chemical peels are frequently used in this population and offer great patient satisfaction. Medium-depth chemical peels, however, require caution, and deep peels should be avoided altogether in patients with dark skin. Regarding laser treatments, the long-pulsed 1064-nm neodymium-doped yttrium aluminium garnet laser is the gold standard in darker-skinned patients for laser hair removal, whereas intense pulsed light lasers capable of skin resurfacing and hair removal should be avoided due to adverse effects such as hyper- and hypopigmentation.

Conclusions:

Patients with Fitzpatrick skin types IV–VI are at a higher risk for developing hypo- or hyperpigmentation following these procedures, emphasizing the need for tailored treatment strategies.

Takeaways

Question: What are the guidelines for noninvasive skin treatments for Fitzpatrick skin types IV–VI?

Findings: In optimizing noninvasive cosmetic treatments for Fitzpatrick types IV–VI, it is essential to prioritize safety and efficacy through evidence-based approaches tailored to these patients. Understanding the unique risks allows for careful selection of treatment modalities, including microneedling, lasers, and chemical peels, with appropriate parameters and protocols. By incorporating these practice guidelines, practitioners can enhance results while minimizing adverse effects.

Meaning: Depending on the procedure, these patients may require different approaches to noninvasive cosmetic treatments given the risks of possible adverse effects, such as hypo- or hyperpigmentation and scarring.

INTRODUCTION

Plastic surgeons serve a diverse patient population, requiring a comprehensive understanding of skin types and their unique characteristics. Patients with darker skin tones, particularly Fitzpatrick skin types IV–VI, have unique physiological traits influencing their response to certain cosmetic treatments. Due to increased melanocyte activity and higher melanin production, they are at an elevated risk for adverse effects, including postinflammatory hyperpigmentation (PIH), hypopigmentation, textural changes, and scarring.^1,2 As noninvasive procedures become increasingly popular and accessible, it is essential to implement tailored protocols prioritizing safety and efficacy by adhering to evidence-based guidelines that account for the unique needs of darker-skinned individuals. We explored current recommendations and best practices for noninvasive cosmetic treatments in patients with Fitzpatrick skin types IV–VI, focusing on microneedling and radiofrequency microneedling (RMF), chemical peels, lasers, and nitrogen plasma resurfacing.

MICRONEEDLING

Modern microneedling was developed in the early 1990s after the discovery that nonpigmented tattooing improved scarring. Microneedling involves rolling fine needles, typically 0.5–1.5 mm in length, onto the skin to puncture the dermis, creating controlled injuries stimulating collagen production and neovascularization via natural skin repair mechanisms.^3,4 These needles can be delivered on 2 types of devices—manual rollers or automated pen devices.⁵

Microneedling is used to treat skin texture irregularities, but can also address dyspigmentation, skin rejuvenation, and other skin concerns.³ An advantage of microneedling is the ability to deliver controlled injuries that do not disrupt the entirety of the epidermis, unlike chemical peels or lasers, thus reducing the risk for PIH.⁶ Reported adverse effects in darker-skinned patients include procedural pain, PIH, tram-track scarring, erythema, milia, edema, and crusting. Most of these effects are noted to be transient and self-resolve within 5–7 days posttreatment. Two studies reporting tram-track scarring in darker Fitzpatrick type patients cited that these injuries occurred secondary to excess pressure in the described cases, highlighting the significance of user error and care with pressure application.^7,8

Pretreatment topical anesthesia with lidocaine cream 30–60 minutes before microneedling treatment can help address procedural pain (Table 1). Immediately following treatment, patients should receive posttreatment cooling masks, cooling devices, and/or moisturizers. They should be advised regarding proper sun protection following treatment.

Table 1.

Microneedling Recommendations and Considerations

Pretreatment precautions	Topical anesthesia with lidocaine cream 30–60 min before treatment
During treatment	***
Posttreatment precautions	Posttreatment cooling masks, cooling devices, and/or moisturizers Proper sun protection and sun avoidance immediately following treatment
Adverse effects	Temporary effects: • Procedural pain • PIH • Erythema milia • Edema • Crusting Permanent effects: • Tram-track scars

RADIOFREQUENCY MICRONEEDLING

RFM delivers thermal energy converted from electrical currents via microneedles into the dermis. The delivered heat stimulates collagen production and promotes skin tightening.⁹ The depth of skin penetration can be adjusted by the radiofrequency energy, with lower frequency RFM targeting deeper skin depths. RFM can be further divided into delivery using monopolar, bipolar, or multipolar devices. Monopolar RFM allows for the greatest depth penetration, bipolar RFM allows for lower depth but increased control of energy delivery, and multipolar RFM allows for the most targeted treatment and prevention of skin damage.

RFM is used for skin rejuvenation, acne scars, acne, melasma, hair removal, hyperhidrosis, and rosacea.¹⁰ Unlike lasers, a major benefit of RFM for darker-skinned individuals is that specific chromophores, including melanin in the epidermis, are not targeted because RFM causes an electrothermal effect as opposed to a photothermal effect. This makes RFM safe for all skin types and a great option for individuals of color. Dayan et al¹¹ recommended starting at 15 kW or lower and adding 5 kW of energy gradually with each treatment course, to a maximum of 40 kW over soft tissue and 25 kW over bone, for skin of color. Chandrashekar et al¹² studied Fitzpatrick III–V patients with acne scarring who underwent RFM, citing that 58% of patients had moderate improvement, 9% good improvement, and 3% very good improvement. Reported adverse events included treatment-related pain, transient erythema, PIH, and track marks from the device. Kushikata et al¹³ studied monopolar RFM on Fitzpatrick III and IV patients for skin tightening, citing transient adverse effects including edema, burn, blister, and secondary hyperpigmentation. These were attributed to excess heat delivered by the probe and/or improper contact of the treatment tip with the patient’s skin. In a review by Tan et al,¹⁴ the authors strongly recommended using RFM to treat acne scars and acne vulgaris while weakly recommending its use for striae. Recommendations for RFM settings based on skin type are provided in Table 2.¹⁰

Table 2.

RMF Recommendations and Considerations

Treatment Areas	No. Passes	Depth of Penetration, mm	Radiofrequency Energy Level, kW	Device Tip
Bony areas, periorbital, forehead, chin	1–2	2	15–25	12 coated and 24 coated
Soft tissue, neck	3	1–3	15–30	24 coated
Body areas	2–3	2–4	20–30	24 coated

Data adapted from Magro et al.¹⁰

CHEMICAL PEELS

Chemical peels are a popular dermatologic treatment used to improve skin texture, tone, and overall appearance by exfoliating the outer layers of the skin through controlled destruction of the epidermis or dermis, followed by regeneration of new dermal and epidermal tissues. These peels are frequently used to improve types of skin dyschromia, ranging in texture and appearance, and to decrease the amount of acne-causing bacteria on the skin’s surface.¹⁵ The choice of chemical peel varies by treatment goals and depth of peel. The greatest risk associated with peels in Fitzpatrick skin types IV–VI is PIH, with remnant pigmentation often being a greater concern than the original inflammatory process.¹⁶ PIH typically presents 3–6 weeks after chemical peel treatments. It is important to follow patients weekly posttreatment for 6–8 weeks, as early treatment of PIH elicits better outcomes.¹⁷

Superficial peels, or those acting on the epidermis to papillary dermis, typically include salicylic acid (SA), glycolic acid, mandelic acid, lactic acid, and trichloroacetic acid (TCA) 10%–35% peels.^18,19 First-line superficial peel concentrations in Fitzpatrick IV–VI include 5%–30% SA, 30%–50% glycolic acid, and Jessner solution due to their strong safety profiles^15,18 (Table 3). SA is a self-limiting peel found to be safe in all Fitzpatrick skin types and indicated for numerous skin conditions, especially comedonal acne.^19,20

Table 3.

Superficial Chemical Peeling Agents Safe for Fitzpatrick IV–VI^15,18–20

	Mechanism of Action	Indications
SA	• 2-hydroxybenzoic acid with strong keratolytic and comedolytic properties • Promotes desquamation of the upper lipophilic layers of the stratum corneum	• Effective in treating all skin types • Reduces both inflammatory and noninflammatory lesions
Glycolic acid	• Exfoliative α-hydroxy acid that causes epidermolysis and desquamation • Reduces corneocyte adhesion and keratinocyte plugging at the stratum corneum • Requires neutralization	• Reduces both inflammatory and noninflammatory lesions
Jessner solution	• Combination of 14% salicylic acid, 14% resorcinol, and 14% lactic acid in 95% ethanol • Stacked mechanism of action due to the combination of agents in solution • Keratolysis, disruption of cell membranes, and bactericidal activity	• Effective in melasma and acne treatments
TCA, 10%–35%	• Crystalline inorganic compound that causes protein denaturation and acts as a bactericidal agent • Depth of penetration is directly related to concentration	• Effective treatment for superficial lesions (ie, melasma and acne) • Superficial wrinkles, but not deep wrinkles

Deeper peels penetrating the upper reticular dermis or into the mid-reticular dermis include phenol–croton oil and higher concentration TCA peels. For Fitzpatrick type IV–VI individuals, medium and deep peels are generally not recommended. With increased depth of peels, there is an increased risk for hypopigmentation in darker skin types due to penetration into the dermis where melanocytes reside. If too many melanocytes are destroyed, this can lead to permanent hypopigmentation.

Phenol is an aromatic alcohol used in conjunction with croton oil as a deep chemical peeling agent. These peels act as resurfacing agents to address rhytids and texture complaints via activation of dermal fibroblasts and new collagen synthesis.^17,18 In contrast to the Baker–Gordon peel, the Hetter peel technique reports that decreased concentrations of croton oil allow for better control of peel depth and mitigation of adverse effects. Previously reserved for Fitzpatrick I and II patients, new data support phenol–croton oil peels via the Hetter approach in Fitzpatrick skin types IV–VI.^21,22 Cortez et al¹⁷ endorsed 0.1%–0.2% Hetter peels or 89% United States Pharmacopeia phenol solution for all skin types for the resolution of refractory melasma. Acne scarring in Fitzpatrick types III-V has been effectively managed with a combination of microneedling and a 60% phenol and 0.2% croton oil peel.²³ Soon et al²⁴ described treating periorbital dark circles in Fitzpatrick skin types IV and V with phenol–croton oil peels but did not specify the formulation for each skin type. They reported similar rates of PIH between Fitzpatrick type II and III and type IV and V cases with dyschromia enduring up to 6 months before returning to baseline in Fitzpatrick IV and V patients. Additional research is warranted regarding the healing process, clinical outcomes, and ideal formulation in different skin types treated with phenol–croton oil peels.

Trichloroacetic acid (TCA) is a crystalline inorganic agent that can be used at varying depths depending on concentration. It causes denaturation of both epidermal and dermal proteins, destruction of dermal collagen, and coagulative necrosis of epidermal cells, resulting in dermal structure reorganization, increased collagen, glycosaminoglycans, and elastin in the dermis.¹⁸ TCA peels can be used in Fitzpatrick IV–VI skin but require much care. General recommendations are to use lower TCA concentrations (10%–35%) and elicit light frosting in this population.^15,20,25 Risks and complications post–TCA peel include persistent hyperpigmentation and, rarely, hypopigmentation.²⁵

Pretreatment preparation of the skin before application of chemical peels is key to allowing for optimal results while minimizing adverse reactions. Three goals of prepeel preparation include activation of the skin, controlling peel depth, and shortening recuperation.²⁵ Broad-spectrum sun protection is essential pre- and posttreatment. In darker skin types, pretreatment for at least 2 weeks with hydroquinone 2% is recommended to protect against PIH.¹⁹ Patients should be advised that pretreatment formulations consist of agents with skin-lightening properties but that these are used to counteract PIH. In addition, tretinoin cessation 1 week before application of the peel is recommended to prevent overpenetration resulting in PIH.¹⁹ Recommendations from an expert panel of facial plastic surgeons regarding pre- and posttreatment care for chemical peel patients are outlined in Table 4.¹⁷ These guidelines have resulted in satisfactory outcomes with no significant adverse effects postprocedure.¹⁷

Table 4.

Expert Panel Recommendations for Pre and Post Chemical Peel Treatment¹⁸

	Recommendations
Pretreatment	Pretreatment preparation consists of 8% hydroquinone, 1% hydrocortisone, and 0.05% retinoic acid in an emollient cream base. Apply the formulation twice per day and continue for 4–6 wk before the procedure. Advise patients that this pretreatment formulation consists of a reversible skin-lightening regimen intended to target hyperpigmentation.
Week 1	Posttreatment begins the day after the procedure. Advise patients not to use products if irritation occurs and to call their doctor with any questions and notify if rash, fever, or blisters appear. Spray the treated area 6 times daily with lukewarm water. Pat dry with unscented tissues and apply Vaseline. Apply Eucerin cream to treated areas via a gentle massaging motion. Avoid rubbing the skin between treatments and avoid the use of washcloths, cotton swabs, and Q-tips
Week 2	Continue cleaning using the above protocol if skin crusting still persists, and ensure the skin is moisturized at all times
Week 3	Water-based, hypoallergenic makeup may be introduced as long as the skin is smooth and free of crusts. Remove makeup in the shower with water only. Continue using Eucerin cream under base makeup as a moisturizer. Patients may resume the pretreatment preparation if skin reepithelialization has occurred
Week 4	Neutrogena (original formula) may be introduced to cleanse skin. Rinse thoroughly to remove soap film. Avoid the use of other cleansing products and moisturizers until further guidance from a physician
Week 5	Patients may resume use of oil-based makeup and sun protection factor 30 sunscreen. Recommend testing small portions of the treated area before full application. Patients may resume normal physical activity. Advise that the complete skin healing process can take up to 3–6 mo

LASERS

Laser therapy has been used for conditions such as acne scarring, melasma, benign pigmented lesions, hypertrichosis, hypertrophic scarring, hyperpigmentation, keloids, and skin rejuvenation.²⁶ Laser therapies can be broadly categorized into ablative, fractional, and nonablative therapies. Ablative lasers, such as CO₂ and erbium:YAG, resurface the skin through selective thermal destruction of the epidermis, with thermal damage extending to the level of the dermis.²⁷ They provide effective resurfacing but require extended postprocedure downtime. The general recommendation is to avoid ablative lasers for darker skin types due to significantly increased risk for postinflammatory hyper- and hypopigmentation.^1,28,29

Nonablative nonfractionated lasers, such as 1450-nm diode, 1320-nm neodymium-doped yttrium aluminium garnet (Nd:YAG), Q-switched ruby, and Q-switched alexandrite, work by targeting water in the dermis while leaving the epidermis intact. Because the epidermis is unaffected, nonablative lasers have shorter downtime and less adverse effects, including transient erythema, edema, and lower risks for PIH; however, multiple treatments are often necessary to see moderate skin improvement.^30,31

Fractional lasers create microthermal treatment zones, or thermally denatured columns of skin, in the dermis. These microthermal treatment zones are created at various widths and depths allowing for migration of keratinocytes for faster reepithelialization and healing compared with ablative lasers.¹ This leaves the skin intact between the columns, also contributing to faster recovery and lower adverse effects.¹⁵ They can be further divided into nonablative and ablative fractional lasers. Nonablative lasers are more commonly used in darker skin due to faster recovery and lower adverse effects compared with ablative lasers.³² The nonablative fractional 1540-nm Erbium laser is both efficacious and safe when used for skin resurfacing in Fitzpatrick IV–VI.^33,34 (See Supplemental Digital Content 1, which highlights studies reporting effective and safe use of lasers for various conditions in Fitzpatrick types IV–VI, https://links.lww.com/PRSGO/E724.)

Regardless of the laser type, darker-skinned individuals are more likely to develop complications such as prolonged erythema, wound infection, acne, milia, pigmentary changes, and scarring compared with lighter-skinned individuals.³⁵ General recommendations for laser use in darker-skinned individuals include longer wavelength, minimal threshold fluency to avoid burns, shorter pulse width, lower energy, lower density, fewer passes of the laser, increased time between treatments, and appropriate posttreatment cooling.^1,30,36 Pretreatment with topical retinoic acid is recommended to speed up reepithelialization and decrease severity and duration of hyperpigmentation.¹ The risk of PIH can be worsened by previous suntan and the degree of epidermal disruption. Sun avoidance and proper sunscreen application are important in preventing PIH.

INTENSE PULSED LIGHT

Intense pulsed light (IPL) is used to treat melasma, various pigmented lesions, vascular lesions, skin rejuvenation, and hair removal. It remains the gold standard for dark spots in Fitzpatrick I–IV, but there is limited research on the use of IPL in Fitzpatrick V and VI due to increased risk of transient purpura, hyperpigmentation, hypopigmentation, burns, erythema, blistering, and crusting.^15,37 Shin et al³⁸ performed 3 IPL sessions 4 weeks apart on Fitzpatrick III and IV patients and reported 84% improvement in pigmented lesions but recommended longer pulsed durations, lower energies, multiple passes, use of a cooling device, and limiting the use of IPL to Fitzpatrick IV and lower. Negishi et al^39,40 were the first to use IPL on types IV and V to treat pigmentation and telangiectasia, reporting transient erythema and blistering as adverse effects, but no scarring or dyspigmentation. A systematic review and meta-analysis by Hu et al²⁹ found that IPL for skin rejuvenation in Fitzpatrick types IV–VI had lower rates of PIH and prolonged erythema compared with diode and fractional erbium lasers and no adverse effects of acne, herpes simplex virus reactivation, erosions, blisters, or hypopigmentation with IPL. Amechi and Halpin¹⁵ recommended against using IPL in Fitzpatrick V and VI. If it is used at the discretion of the physician and Fitzpatrick V and VI patients, lower fluence should be used with longer/split pulses to allow skin cooling to prevent burning, and patients should be evaluated regarding pain with treatment.^15,37

Recommendations regarding IPL for hair removal are also varied. A within-patient, right–left comparison of long-pulsed Nd:YAG laser and IPL in women with Fitzpatrick IV–VI found that IPL did not cause lasting adverse effects, although the Nd:YAG laser was more effective and preferred by participants despite having higher pain scores.⁴¹ A review comparing IPL and lasers for hair removal in Fitzpatrick III and IV found IPL to have the same safety and efficacy profile as lasers.⁴² Contrastingly, Quiñonez et al²⁸ and Alexis⁴³ recommended against IPL use for hair reduction in darker-skinned individuals due to the high risk of burns and hyperpigmentation.

LASER HAIR REMOVAL

Laser hair removal devices include the long-pulsed 694-nm Ruby, long-pulsed 755-nm alexandrite, 800–810-nm diode laser, long-pulsed 1064-nm Nd:YAG laser, and IPL.¹ For Fitzpatrick IV–VI skin, long-pulsed 1064-nm Nd:YAG laser is the gold standard, given its long pulse duration and long wavelength, minimizing adverse effects in skin of color.²⁸ The longer pulse duration delivers energy over more time, allowing for thermal injury to the hair follicle and dissipation of the heat through epidermal cooling. This cooling effect leads to fewer adverse effects in colored skin, particularly PIH. The specific wavelength falls within the target absorptive spectrum of melanin in hair follicles while being long enough to avoid absorption by melanin in the epidermis.³² Multiple review papers have found that the risk of hyperpigmentation in darker skin after long-pulsed 1064-nm Nd:YAG laser was lower than with the long-pulsed 694-nm ruby, long-pulsed 755-nm alexandrite, and 800- to 810-nm diode laser.¹ Reported adverse effects from ruby lasers in darker skin include a higher incidence of hyperpigmentation and blistering compared with the Nd:YAG laser. Adverse effects from the long-pulsed alexandrite laser include PIH, and the diode laser has been reported to have a 10-fold increase in rates of PIH, skin sensitivity, and burns in darker-skinned patients compared with White and Asian patients.

Pretreatment recommendations for laser hair removal in darker skin include shaving 1 week before, avoiding plucking or waxing, and sun avoidance (Table 5).²⁸ Recommendations during treatment include keeping the skin dry, proper cooling of the epidermis, and avoidance of multiple passes with the lasers.¹ Posttreatment recommendations include proper cooling immediately following treatment, along with sun avoidance and strict photoprotection.²⁸

Table 5.

Laser Hair Removal Recommendations and Considerations^1,28

Pretreatment precautions	Shaving 1 wk before
	Discouraging plucking or waxing
	Avoidance of sun exposure
During treatment	Keeping the skin dry
	Proper cooling of the epidermis
	Avoidance of multiple passes with the lasers
	Long pulse duration and longer wavelengths
Posttreatment precautions	Proper cooling immediately after the treatment
	Avoidance of sun exposure
	Strict photoprotection after treatment
Adverse effects	Hyperpigmentation

NITROGEN PLASMA RESURFACING

Nitrogen plasma skin resurfacing emerged in the early 2000s and gained worldwide popularity due to its efficacy, versatility, and safety in Fitzpatrick types I–VI.⁴⁴ The device has US Food and Drug Administration clearance for the treatment of facial and nonfacial rhytids, acne scars, seborrheic and actinic keratoses, superficial skin lesions, and viral papillomas.^44–47 Treatments for Fitzpatrick V and VI are off label, but this author has safely and effectively treated these skin types (Fig. 1). Nitrogen plasma resurfacing is induced by using radiofrequency to activate nitrogen gas on the skin surface, converting it into plasma. This results in energy emitted in a millisecond pulse into the targeted skin in the form of heat without chromophore dependence, resulting in controlled thermal damage in the skin.⁴⁵ Given the versatility of its power intensities, the device can be used on the face, neck, and body to treat rhytids, acne scars, striae, surgical scars, and crepey skin.

Fig. 1.

Photograph of a 68-year-old African American woman, Fitzpatrick type V, 2 months postoperatively following 1 treatment with Neogen PSR (face, wet technique; 0.8 J × 2 passes; total, 900 pulses).

Patients are pretreated with 0.5% retinoic acid with 4% hydroquinone at least 2–4 weeks before treatment, and sun avoidance is advised. Treatment intensity is controlled by the distance between the plasma beam and the skin, use of a conductive gel, energy settings (joules), speed of pulse delivery (hertz), and the number of passes. For Fitzpatrick IV (dry technique), 0.5–1.9 J is recommended using 1–2 passes.⁴⁴

Dry technique treatment protocols for Fitzpatrick IV are as follows: (1) low-energy or “spa” treatments (0.5–0.9 J) with no downtime may require 4–6 treatments, 4 weeks apart; (2) medium-energy treatments (1.0–1.9 J) with 1- to 3-day downtime may require 2–4 treatments. High-energy treatments (2.0–4.0J) are not recommended.

The wet technique involves application of a conductive gel to the skin, driving the energy deeper into the dermal-epidermal junction and papillary dermis while sparing the epidermis. (See Video [online], which demonstrates the Neogen plasma skin resurfacing wet technique on a woman with Fitzpatrick type V skin.) The zone of thermal damage is blocked, whereas the zone of thermal modification reaches the papillary dermis, translating an ablative beam into a nonablative beam. Safety for Fitzpatrick IV–VI patients is ensured, sparing the melanocytes in the dermal-epidermal junction. For the wet technique, higher energy settings can be used, up to 2.5 J. For Fitzpatrick V and VI, only the wet technique is recommended, with energy settings of 0.5–2 J, 1 and 2 passes, repeated every 4 weeks for a total of 2–4 treatments.

Video 1. This video demonstrates the Neogen plasma skin resurfacing wet technique on a woman with Fitzpatrick type V skin.

Download video file ^{(1.9MB, mp4)}

Following treatment, an emollient petroleum-type balm is applied to the skin. Skin slough may occur in 48–72 hours, and reepithelialization is complete after 5–7 days, after which the patient’s typical skincare regimen can be resumed, and sunscreen applied. Mild erythema or edema can be experienced.⁴⁸ Complications are similar to those described for ablative laser treatments.⁴⁴

LIMITATIONS

Fitzpatrick skin types IV–VI have historically been underrepresented in dermatologic and cosmetic research, creating a significant gap in evidence-based treatment guidelines for darker skin tones. A study of plastic surgery residency curricula found that 83.2% of educational images featured Fitzpatrick types I–III, whereas only 13.1% represented types IV–VI.⁴⁹ Many of the studies cited in our article had small sample sizes, leading to limited data on the safety and efficacy of cosmetic procedures for darker skin tones and forcing practitioners to rely on anecdotal evidence and incomplete clinical guidelines. Addressing this disparity requires more inclusive research to ensure safe and effective treatments for all patients.

CONCLUSIONS

In optimizing noninvasive cosmetic treatments for Fitzpatrick types IV–VI, it is essential to prioritize safety and efficacy through evidence-based approaches tailored to darker skin tones. Understanding the unique risks—such as PIH and scarring—allows for careful selection of treatment modalities, including microneedling, lasers, and chemical peels, with appropriate parameters and protocols. By incorporating these guidelines, practitioners can enhance results while minimizing adverse effects. As research continues to address historical gaps in this underrepresented population, adopting inclusive guidelines ensures that all patients receive personalized, effective, and safe cosmetic care.

DISCLOSURES

Dr. Kimbrell serves as Key Opinion Leader and consultant for the following companies: APYX Medical (manufacturer and distributor of Renuvion), Energist (manufacturer of NeoGen PSR), Emergent MedTech (distributor of NeoGen PSR in the United States), Cytrellis (manufacturer and distributor of Ellacor), and Evolutionary Biologics (exosomes). The other authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

The patient provided written consent for the use of her image.

ACKNOWLEDGMENTS

The authors would like to give special thanks to our librarians Adam Roloff and Taylor Vazquez for their help throughout this process.