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