Enhancing the Care and Treatment of Skin of Color, Part 1: the Broad Scope of Pigmentary Disorders
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HIGHLIGHTING SKIN OF COLOR Enhancing the Care and Treatment of Skin of Color, Part 1: The Broad Scope of Pigmentary Disorders Susan C. Taylor, MD Scientific research and technologies related to reports that by 2050, approximately 50% of the skin pigmentation and dyschromias, which are US population will be composed of citizens with often key skin concerns for patients of color, skin of color.1 Skin of color is commonly defined have led to recent developments in skin care and as Fitzpatrick skin phototypes IV to VI.2 It should treatment. Differences and similarities between be noted that the Fitzpatrick scale describes the skin of color and white skin and current issues response of different skin types to UV light rather in the treatment of ethnic skin are reviewed. than the actual color of the skin. Recent research findings, such as the elucida- Despite the size and continuing growth of the tion of the protease-activated receptor 2 (PAR-2) skin of color population, most research related pathway and its role in pigmentation, and areas to the structure, function, and treatment of skin for further investigation, such as the pathogen- has been conducted in white subjects. Early data esis of pseudofolliculitis barbae (PFB), also are suggest that despite many similarities, there are discussed. Awareness of this information within differences between skin of color and white skin, the wider community of dermatologists, primary as well as different susceptibilities to skin condi- healthcare providers, and the media will help to tions. Although data from some of these seminal accomplish the objective of stimulating new pro- studies are conflicting or are based on small spective research. populations, they form an essential foundation for Cutis. 2005;76:249-255. continuing research.3-7 New technologies, such as diffuse reflectance spectroscopy (DRS), have permitted a greater understanding of the contribution of different New Horizons in Dermatology pigments to skin color.8 Recent research, such as People of color in the United States represent a the elucidation of the protease-activated receptor 2 wide range of ethnic groups, including African (PAR-2) pathway and its role in the regulation of Americans, Asians, Hispanics, Native Americans, pigmentation, has augmented our understanding and Pacific Islanders. The US Census Bureau of the interaction of the keratinocyte-melanocyte unit. This understanding may have an impact on the treatment of pigmentation disorders common Accepted for publication August 3, 2005. 9 From the Skin of Color Center, St Luke’s-Roosevelt Hospital in skin of color. Advanced research and emerg- Center, and the Department of Dermatology, Columbia University, ing technologies undoubtedly will provide increas- both in New York, New York; and Society Hill Dermatology, ing opportunities to deliver enhanced skin care, Philadelphia, Pennsylvania. therapies, and products to this growing segment This study was supported by Johnson & Johnson Consumer of the US population. Products Company, a Division of Johnson & Johnson Consumer Companies, Inc. Dr. Taylor is on the speakers bureau, and is an advisory board member and consultant for Johnson & Johnson. Ethnic Differences in Melanin Physiology Reprints: Susan C. Taylor, MD, Society Hill Dermatology, The most visible difference between skin of color 932 Pine St, Philadelphia, PA 19107 (e-mail: [email protected]). and white skin is the epidermal melanin content. VOLUME 76, OCTOBER 2005 249 Highlighting Skin of Color Melanosomes in the skin of individuals of African not correlate linearly with the calculated indices.10 descent are large and singly dispersed in kerati- DRS is a technology that uses reflected visible nocytes, whereas in white and Asian skin, the light to determine concentrations of melanin, oxy- melanosomes are aggregated within a surrounding hemoglobin, and deoxyhemoglobin, which are con- membrane.3,4 The epidermal melanin unit of skin tributors to skin color. Using DRS, it is possible of color contains more melanin and may undergo to distinguish between the vascular and the mela- slower degradation compared with other groups.5 nin components that contribute to erythema and Although increased melanin offers significant pho- pigmentation. It recently has been suggested that toprotection for deeply pigmented skin compared blood stasis, specifically the pooling of deoxyhe- with white skin, the potential for an exaggerated moglobin, can be confused with melanin pigmen- response by melanocytes to cutaneous trauma or tation.8 Hence, skin darkening does not depend inflammation can lead to a higher incidence of only on the concentration of melanin but is pigmentary disorders in skin of color.5,6 affected strongly by the concentration of deoxyhe- Skin pigmentation in response to UV irradiation moglobin in the superficial venous plexus. Future traditionally has been attributed to melanin; how- studies using DRS will be needed to separate the ever, advances in biomedical optics have permitted visual contributions of vascular and pigmentary a more detailed understanding of the contribution reactions in inflammatory conditions, especially in of other chromophores.8 Objective quantitative more deeply pigmented skin where erythema may evaluation of skin color reactions traditionally has be more difficult to visualize at the macro level used reflectance spectroscopy, either tristimulus in contrast with melanin pigmentation. reflectance colorimeters (Photovolt ColorWalk or the Minolta chromameter) or narrowband reflectance The Significance of Pigmentary Disorders spectrophotometers (DermaSpectrophotometer, the Pigmented skin frequently responds to trauma Erythema meter, or the Mexameter®). However, it or inflammation by becoming hyperpigmented or is reported that with both methods, what is clini- hypopigmented. Such pigmentary abnormalities cally perceived as erythema and pigmentation does can be distressing to individuals of color. In a Figure not available online Figure 1. The protease-activated receptor 2 (PAR-2) pathway. STI indicates soybean trypsin inhibitor; SLIGRL, serine-leucine-isoleucine-glycine-arginine-leucine. Reprinted with permission from Seiberg M. Keratinocyte–melanocyte interactions during melanosome transfer. Pigment Cell Res. 2001;14:236-242. ©2001, Blackwell Publishing.12 250 CUTIS® Highlighting Skin of Color cosmetic usage and needs survey of 100 women among skin types with regard to the pathogenesis of color, 86% of respondents stated that hyperpig- or the effectiveness and treatment of acne, there mentation or dark spots were a major concern.11 are important differences in clinical presentation, This concern is further supported by a study of histologic appearance, and sequelae.19 Physicians 2000 blacks by Halder et al,7 who found that 37% should be aware of these differences because they of patients were concerned about pigmentation. impact acne treatment protocols. In contrast with comedonal acne in white A Potential New Therapy for skin, which is defined as noninflammatory, Pigmentary Disorders comedone biopsy specimens from black subjects Potential new therapies for pigmentary disor- showed significant inflammation with infiltrates ders are being studied. One novel mechanism of polymorphonuclear leukocytes. Papular and for maintaining normal skin tone and possibly pustular lesions displayed inflammatory infiltrates preventing dyschromias may reside in the eluci- that extended beyond the actual acne lesion.20 dation of the PAR-2 pathway (Figure 1). PAR-2 Inflammation in these comedonal lesions, as well is a receptor expressed on keratinocytes but not as the marked inflammation present in inflam- on melanocytes and thus may regulate pigmen- matory lesions, may explain the propensity for tation via keratinocyte-melanocyte interactions. individuals of color to develop PIH as a sequela PAR-2 activation is involved in cell growth, of acne.21 The Skin of Color Center in New differentiation, and inflammatory processes.13 York City conducted a survey of 313 patients Two soy proteins, soybean trypsin inhibitor and of color with acne vulgaris. More than 50% of Bowman-Birk inhibitor, have been shown to respondents had PIH that lasted an average of regulate the PAR-2 pathway and partially inhibit 4 months, which often was longer than the pigmentation.13 In vitro studies have demon- actual acne lesions lasted; the PIH was noted strated that treatment with these soy proteins to be psychologically and cosmetically disturbing can reduce UV-induced pigment deposition by to the patients.21 PIH is frequently the present- reducing keratinocyte phagocytosis of melanin ing complaint of individuals of color with acne, from melanocytes.14 many of whom request a lightening agent to Pierard and colleagues15 studied the effect of treat the dark marks (Figure 2). These patients stabilized whole soy extracts in white women with find that the dark marks are more distressing a variety of hyperpigmentation disorders. A greater than the acne lesions. It is important to be than 25% improvement in hyperpigmentation was aware of the impact of PIH on patients of noted and was most evident in solar lentigines color and to treat both the acne lesions and and melasma. Additional studies involving indi- the PIH. viduals with skin of color will be needed. The recommendations of the Global Alliance to Improve Outcomes in Acne noted that acne Postinflammatory Hyperpigmentation treatment should target as many pathogenic fac- and Acne tors as possible.22 Hence, the mainstays of acne Postinflammatory