Skin of Color
• Special Problems
• Unique Interventions
Nishit Patel, MD, FAAD
MINI-SYMPOSIUM
SKIN OF COLORWhy Does It Matter?
Changes in US Population
• Minority populations grew eight times faster than the majority white, non-Hispanic population.• White, non-Hispanic adults edged up 4.4% nationwide from 2000 to
2010. By contrast, all other adults including Hispanics, Asians, African-Americans and other races increased 32.2% and accounted for nearly three-quarters (74%) of all U.S. growth among the population ages 18 or older.
• The Asian population is the fastest-growing racial or ethnic group in the U.S., but it is even more highly concentrated than the Hispanic population.
• Among the 37.7 million African-Americans counted in the 2010 Census, many are moving to the suburbs and back to the South.
From: 2010 census data and http://adage.com/article/news/census-2010-surprising-facts-marketers/149692/
Most Common Problems
African Americans Hispanics Asians
• Acne
• Unspecified Dermatitis
• Eczema
• Seborrheic Dermatitis
• Dyschromia
• Psoriasis
• Alopecia
• Keloid scar
• Viral warts
• Sebaceous Cyst
• Acne
• Unspecified Dermatitis
• Psoriasis
• Benign skin neoplasm
• Viral Warts
• Actinic Keratosis
• Seborrheic Keratosis
• Rosacea
• Sebaceous Cyst
• Dyschromia
• Acne
• Unspecified Dermatitis
• Benign skin neoplasm
• Psoriasis
• Seborrheic Keratosis
• Eczema
• Viral wart
• Urticaria
• Sebaceous Cyst
• Seborrheic dermatitis
Davis et al. Top Dermatologic Conditions in Patients of Color: An Analysis of Nationally Representative Data. J Drugs
Dermatol. 2012 Apr;11(4):466-73.
Child Et al. A study of the spectrum of skin disease occurring in a black population in south-east London. British Journal of
Dermatology 1999; 141: 512±517.
BASIC SCIENCEA Brief Overview
Differences in Skin
• Darker skin has more melanosomes – NOT melanocytes
• 5 times as much UVB+UVA reach the upper dermis of Caucasian skin compared to black skin. SPF of black skin is between 8 - 13
• Photo aging is less common in black skin
• Black skin tends to lichenify
• Erythema on black skin looks darker; desquamation looks “ashy”
• Asian skin develops solar lentigines, SK’s and fine wrinkles
Image from http://www.element14.com/community/community/manufacturers/vishay/semiconductors/blog
Hair Facts
First follicles appear around 9 weeks of gestation, with
the bulk beginning development in 4-5 months.
There are approximately 100,000 follicles on the scalp.
While hairs initially served a physiological purpose, they
now define individuality, self esteem and often quality of
life.
Follicles are dynamic structures, permanently
regenerating.
Hair Differences
• Asian and Hispanic
• Round to elliptical
• Larger diameter
• Follicle usually straight
• Caucasian
• Round to elliptical
• Follicle usually straight
• African
• Elliptical
• Smallest diameter
• Follicle may be tortuous or even parallel to the skin, resulting in kinky, weak hair that is hard to comb Images from rehairducation.com
Image from http://www.rehairducation.com/wp-content/uploads/2014/06/hair-strand-shape.jpg
HAIR DISORDERSIn Skin of Color
Hair Loss
Non-Scarring
Alopecia Areata
Androgenetic Alopecia
Tinea capitis
Trichorrexis nodosa
Seborrheic dermatitis
Traction alopecia*
Scarring
Discoid lupus
erythematosus
Acne keloidalis nuchae
Dissecting cellulitis of the
scalp
Central centrifugal
scarring alopecia
Traction Alopecia
• Caused by anything that pulls on hair
• Tight braids
• Ponytails
• Curlers
• Added on braids or falls
• Pulling to straighten or twist hair
• Hot combs
• Initially non-scarring, but scarring in later stages
Traction Alopecia - Treatment
First Line:
Be sure you have made the correct diagnosis
Discontinue all hair care practices that place tension on the hair
Decrease manipulation of hair of affected area
Consider
Antibiotics – (anti-inflammatory)
Doxycycline 100mg BID for 2 wks then 100mg/day [Off-Label]
Intralesional steroid injection
Triamcinolone 2.5-5mg/cc q 4wks for 3 – 4 mo.
Low to mid-potency topical steroids
Central Centrifugal Ciciatricial Alopecia
• Formerly called “Hot comb alopecia”, “Follicular
degeneration syndrome”
• Incidence increased in females
• Progressive, spreads centrifugally and results in
permanent hair loss
• Cause is poorly understood
• Trauma?
• Chemical?
• Hereditary?
CCCA - Rx
• Dx and Tx early and aggressively to prevent permanent
hair loss
• IL triamcinolone 2.5-5mg/cc q 4wk for 3mo. [Off-Label]
• Doxycycline 100mg BID for 1mo., then decrease
• Topical steroid (as in seborrheic dermatitis) [Off-Label]
• 4 to 6 mo holiday from all chemicals and traumatic
practices
Acne Keloidalis Nuchae
• Presents in young black, Hispanic and Asian men as
persistent papules and pustules of posterior neck; areas
of involvement may develop into keloid scars, sinus tracts,
etc.
• Histologically, deep folliculitis with replacement of normal
connective tissue by hypertrophic and then sclerotic
connective tissue
• Progressive changes may be due to free hairs in the
dermis
AKN- Etiology
• Exact cause is not known
• More common in males
• Possibly hereditary predisposition
• Possibly associated with short hairstyle on neck (fades)
• Evidence for association with friction from collars, football
helmets, etc.
AKN- Tx
• Avoid buzz-cuts
• Intralesional triamcinolone
• 5-10mg/cc for inflammatory lesions
• 20-40mg/cc for hypertrophic scars
• Long term p.o. antibiotics (esp. tetracyclines)
• Doxycycline 100 BID for 4wks, then decrease as tolerated for maintenance [Off-Label]
• Topical corticosteroids/retinoids
• Fluocinonide sol. QAM / Tretinoin gel QHS
• Topical antibiotic/BPO combinations
• Surgical excision– go to the subcutaneous
• Laser
Pseudofolliculitis Barbae
• Inflammatory papules and pustules usually in the beard
area related to close shaving; may result in scarring
• More common among black men that shave than
Caucasian men who shave; prevalence greater than 50%
• Can occur among any individual that shaves wavy or curly
hair, including women
• Areas of predilection: chin, submandibular area, anterior
neck; other beard areas - upper lip spared
PFB – Prevention
• Gold standard – grow hair out 2-3mm
• Grow a beard
• Shave with clippers
• Special razor – several are on the market
• Topical eflornithine (Vaniqa®)
• Inhibits ornithine decarboxylase
• Takes 3mo to see effect – must maintain
• Hair Removal
• Dissolve disulfide bonds in keratin
• Topical depilatories
• Barium sulfate or sodium thioglycolate
• Laser hair removal
• Electrolysis NOT recommended
Bridgeman-Shah, S. The medical and surgical therapy of pseudofolliculitis barbae. Dermatologic Therapy, Vol. 17, 2004,
158–163
PFB - Rx
• Topical retinoids
• Start weak and advance
• Topical antiseptics
• Antibacterial soap
• Benzoyl peroxide
• Topical antibiotics
• Clindamycin 1% solution [Off-Label]
• Use with benzoyl peroxide
• Counteract irritation with topical steroids
• hydrocortisone, desonide lotion
Bridgeman-Shah, S. The medical and surgical therapy of pseudofolliculitis barbae. Dermatologic Therapy, Vol. 17, 2004,
158–163
COMMON SKIN LESIONSIn Skin of Color
Image from http://www.7borneo.com/other/dermatosis-papulosa-nigra
Image from: http://media.salon.com/2014/06/morgan_freeman.jpg
Dermatosis Papulosa Nigra (DPN)
• Presents as brown to black, 0.1 - 0.5 cm papules, usually on the face and neck
• Found in 35-70% of black adults; less common in other pigmented skin types
• Female to male ratio = 2:1
• Papules begin to develop around puberty and increase in number with age; peak incidence in 60’s
• Lesion morphology: discrete, smooth, dome-shaped to pedunculated, pigmented papules
• Most common location is malar cheeks, and 25% of these
patients will also have neck and upper trunk lesions
• Patients with more darkly pigmented skin tend to have more
lesions
DPN - Pathology
• Histopathologic changes similar to seborrheic keratoses
• DPN considered to be a type of nevus or variant of
seborrheic keratosis
• Differential diagnosis – skin tags, seborrheic keratoses,
nevi
• Treatment – cosmetic destruction (curettage, scissor-snip,
LN2, etc)
Lichen Nitidus
• Characterized by minute, shiny, flat-topped, pale,
asymptomatic, discrete papules
• Linear arrays (Koebner’s phenomenon) common
• Usually localized to penis and lower abdomen, inner
surfaces of thighs, flexor wrists, forearms
• Can become widespread & with lesions fusing into
erythematous, finely scaling plaques, affecting groin,
thighs, ankles, feet, hands, inframammary areas in
females, folds of neck, extensor surfaces of elbows
Lichen Nitidus (Continued)
• No racial (or age or sex) predilection
• Probably more associated with black skin due to its striking
presentation
• Cause unknown; rare familial cases
• Clinically & histologically distinct from lichen planus
• Slowly progressive course with exacerbations and remissions
• May spontaneously resolve
• Treatment not necessary
• Topical retinoids and topical steroids
COMMON SKIN
CONDITIONSIn Skin of Color
"Keloid, Post Surgical" by Htirgan - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons -
https://commons.wikimedia.org/wiki/File:Keloid,_Post_Surgical.JPG#/media/File:Keloid,_Post_Surgical.JPG
"Superficially Spreading Keloid" by Htirgan - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons -
https://commons.wikimedia.org/wiki/File:Superficially_Spreading_Keloid.jpg#/media/File:Superficially_Spreading_Keloid.jpg
"Earlobe Keloid, Bulky" by Htirgan - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons -
https://commons.wikimedia.org/wiki/File:Earlobe_Keloid,_Bulky.JPG#/media/File:Earlobe_Keloid,_Bulky.JPG
Keloids/Hypertrophic Scarring
• Hypertrophic Scar v. Keloid
• Within initial scar/trauma v. extends beyond
• Keloids differ from HT scarring in osmotic pressure and
metabolic activity
• More likely on anterior chest, ears, upper back and
shoulders
• 5-16x more common in African Americans
Keloids/Hypertrophic Scarring
• First Line:
• IL Kenalog 10mg/cc or higher
• Common Interventions [All Off-Label]:
• Cryotherapy
• Pulsed Dye Laser
• Other Interventions [All Off-Label]:
• XRT
• IL 5-FU
• IL Bleomycin
• Excision with second intention healing
• High recurrence rates
"Vitiligo2" by James Heilman, MD - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons -
https://commons.wikimedia.org/wiki/File:Vitiligo2.JPG#/media/File:Vitiligo2.JPG
Vitiligo
• No racial predilection
• Increased frequency of AI disorders
• Grave’s, Hashimoto’s, pernicious anemia
• Up to 1/3 with family history
• Acquired, idiopathic, genetic & non-genetic factors
• Often starts in 20’s; 0.5-2% population
• Pathogenesis
• Various pathogenic hypotheses (autoimmune, intrinsic defect,
oxidative stress etc)
• Multifactorial genetic + non-genetic factors Absence of
functional melanocytes 2/2 to melanocyte destruction
Vitiligo - Rx
• Topical Steroids
• Topical calcineurin inhibitors (Protopic®, Elidel®) [Off-
Label]
• Phototherapy
• Depigmentation therapy
• Surgical Interventions:
• Melanocyte transfer
• Autologous punch grafts
Vitiligo: repigmentation
• Usually perifollicular initially
• Face, mid-extremities, trunk respond best
• lips and distal most resistant
• After therapeutic repigmentation, the rate of recurrent depigmentation
of vitiligo lesions is ~40%
Sarcoidosis
• Presentation – similar to syphilis in its reputation for being
a great mimicker
• Lesion morphologies may vary widely: papules, nodules,
plaques, subcutaneous lesions, development within scars
(scars “grow”), erythroderma, ulcerations, alopecia,
annular, verrucous, icthyosiform, hypomelanotic,
psoriasiform, etc.
Sarcoidosis (Continued)
• World-wide distribution
• In U.S., three times more common in black patients than white patients and 2/3 of these are women
• Most prevalent in southeastern states and certain areas of New York City
• Most common among ages 20-40
• 19% of these patients have positive family history
Sarcoidosis - Evaluation
• Dx supported by biopsy showing characteristic findings of
“naked” (noncaseating) granulomas
• Systemic evaluation necessary since internal organ
involvement can be widespread and frequently
asymptomatic
• Skin lesions precede or accompany systemic disease
70% of the time
Sarcoidosis - Treatment
• Cutaneous
• Systemic steroids
• Intralesional triamcinolone 5gm/cc
• Antimalarials (second line) – e.g., hydroxychloroquine 200mg
BID [Off-Label]
• Systemic
• Systemic steroids
• Immunosuppresants (anecdotally reported)
Mycosis Fungoides
• Cutaneous T-cell lymphoma (CTCL)
• 1.6 times more common in African Americans than European Americans
• Patients present with asymptomatic, scaling macules and patches; often treated for years as eczema, contact dermatitis or psoriasis
• Can progress to fine atrophic wrinkling => tumors, erythroderma, other variants
• Predilection for sun protected areas, proximal extremities and body folds
Mycosis Fungoides (Continued)
• Incidence in U.S. = 0.36 / 100,000
• Most common form of CTCL
• Result of malignant CD4+ T cells that home to the skin;
recapitulate the trafficking pattern of the normal skin
associated lymphoid tissue (SALT)
• Dx usually made via routine histopathology but may be
difficult and elusive despite multiple biopsies
• Prognosis of patch stage disease is excellent, ~100%
survival at 15 years
UNIQUE FEATURES OF
COMMON SKIN CONDITIONSIn Skin of Color
Image from http://galleryhip.com/black-spots-on-skin-from-acne.html
Acne – Special challenges
• Postinflammatory hyperpigmentation
• Caused by minimal inflammation
• Persistent and recurrent
• Scarring
• Hypertrophic
• Atrophic
Image from www.dermpedia.org
Acne - Rx
• Treat early and aggressively
• Use doxycycline for anti-inflammatory properties
• Retinoids
• Comedolytic
• Anti-inflammatory
• Decrease hyperpigmentation
• Topical antibiotics with BPO
Postinflammatory Hyperpigmentation
(PIH)• Can be caused by subclinical inflammation
• Compounded by
• UV exposure
• Hormones
• Trauma
PIH - Rx
• Gold standard is
hydroquinone – apply BID
• 2% OTC
• 4% Rx
• Watch out for
exogenous ochronosis
• Rx: Consider Tri-Luma [Off
Label] (fluocinolone 0.01%/ HQ
4% / 0.05% Tretinoin)
PIH - Tx
• Photoprotection is essential
• Titanium looks white
• Zinc less obvious
• High SPF, then mineral based make-up (iron, etc.)
• Avoid trauma
• No picking or squeezing
• No facials
• Low strength peels may help
• Salicylic acid helps desquamate
• Others (glycolic, TCA, etc.) may irritate
Image from: http://www.aeskin.com/blog/post/how-to-treat-stubborn-melasma.html
Melasma in Pigmented Skin
• Women (90%)
• Secondary to hormone treatment, pregnancy or idiopathic
• Hyperfunctional melanocytes
• Treatment is same as for PIH
• Rx: hydroquinone alone or in combination
• OTC cosmeceuticals (kojic acid, AHA’s, salicylic acid)
• Physical modalities (dermabrasion, laser, etc. ) are difficult
and risky
• Photoprotection is essential
• Treatment can be negated in one day
Melasma: clinical
• Location: face > forearms >> other
• Patterns: centrofacial, malar, mandibular
• Symmetric patches of hyperpigmentation with irregular
borders
Image from Kelly & Taylor. Dermatology For Skin of Color. Chapter 22 Psoriasis.
Images from http://www.bellanaija.com/2010/09/24/skin-deep-series-2-the-rash-that-changed-my-life-living-with-psoriasis/
Psoriasis
• Psoriasis plaques tend to be more violaceous
• Scale can often have grey coloration
• Post-inflammatory hyperpigmentation is common
Atopic Dermatitis
• Often presents in a follicular pattern in African Americans
(follicular eczema)
• Often lichenifies
• Dx and Rx as for any atopic dermatitis patient
SUMMARY
Summary
• African hair is the most fragile
• Black skin lichenifies easily
• Post-inflammatory hyper- and hypo-pigmentation are a
problem (PIPA)
• Common skin conditions can look different in skin of color
• When in doubt – do a biopsy