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Home , Acne, Rosacea

Dermatologic Findings in a Diverse Patient Population

Kelly A. Lopez, M.D. Department of Family Medicine Faculty Disclosure

It is the policy of the Intensive Osteopathic Update (IOU) organizers that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All faculty in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of this material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Objectives

• Briefly review types and relevant terminology • Understand the history and significance of culturally competent research in • Explore the histologic characteristics of Fitzpatrick Skin Types 4-6 • Utilize patient cases and board style review questions to explore the most common diagnoses in patients with skin of color • Understand Research Limitations • Summary and Conclusion Primary

Primary Lesions are physical changes in the skin considered to be caused directly by the disease process. Primary Lesions

● Macule ● Bullae ● ● Pustule ● ● Wheal ● Tumor ● Burrow ● Plaque ● ● Vesicle ● Patch Secondary Lesions

Secondary lesions may evolve from primary lesions, or may be caused by external forces such as scratching, trauma, infection, or the healing process. The distinction between a primary and secondary lesion is not always clear. Secondary Lesions

● Scale ● Excoriation ● Crust ● Fissure ● Atrophy ● Ulceration ● Lichenification ● ● Erosion (Abrasion) ● Eschar ● ● Petechiae, purpura, and ecchymoses Patterns and Distribution Patterns and Distribution

● Annular ● Dermatomal, ● Discrete Zosteriform ● Clustered ● Eczematoid ● Confluent ● Follicular ● Guttate ● Iris or target lesions ● Koebner ● Multiform Phenomenon ● Reticular ● Linear ● Serpiginous ● Universalis ● Scarlatiniform ● Morbilliform ● Satellite Lesions Patient Scenario

• A 35 year old woman presents to your office with a CC of pruritis, pain, and on her scalp progressing over the past several months. Two of her children were diagnosed with ringworm last year and adequately treated. She is concerned that she may have acquired the same infection. Physical Exam Findings Which of the following is an appropriate treatment regimen for this patient?

a. Intralesional and oral b. Selenium Sulfide Shampoo c. Oral griseofulvin x 4-6 weeks d. Benza-clin gel applied topically e. Patient counselling and education Objectives

• Briefly review lesion types and relevant terminology • Understand the history and significance of culturally competent research in dermatology • Explore the histologic characteristics of Fitzpatrick Skin Types 4-6 • Utilize patient cases and board style review questions to explore the most common diagnoses in patients with skin of color • Understand Research Limitations • Summary and Conclusion Background

• In 2050, more than half of the U.S. population will have skin of color… • Rapidly changing demographics – Regional – National – International What Defines “Skin of Color”? • “…includes African American black persons (including Caribbean American black persons), Asian and Pacific Islanders, Native Americans, Alaskans, and those who report Latino or Hispanic ethnicity. Also includes certain peoples traditionally classified as Caucasian such as the majority of Indians, Pakistanis, and those of Middle Eastern origin” What Defines “Skin of Color”?

• Skin’s reaction to sunlight determines classification • Genetic traits may have allowed adaptation in the past • Still, racial classifications more or less arbitrary However…

• Differences within a group may be more significant than differences between groups • Individual Skin Phenotype (SPT) is key Objectives

• Briefly review lesion types and relevant terminology • Understand the history and significance of culturally competent research in dermatology • Explore the histologic characteristics of Fitzpatrick Skin Types 4-6 • Utilize patient cases and board style review questions to explore the most common diagnoses in patients with skin of color • Understand Research Limitations • Summary and Conclusion Fitzpatrick Skin Types

Fitzpatrick Skin Type Description

I Always burns, never tan

II Always burns, but sometimes tans

III Sometimes burns, but sometimes tans

IV Never burns, always tans

V Moderately pigmented skin

VI Darkly Pigmented skin Biology of Pigmentation

• Increased • More and larger singly distributed melanosomes • No difference in number of between races • Variations in size, number, aggregation of melanosomes • Aggregation of melanosomes is key Biology of Pigmentation

• Szabo et al studied melanosome distribution and effect on skin color • Individually dispersed-darker skin • Predominantly aggregated-fair skin • Both-medium skinned • Toda et al and Olson et al showed that sun exposure led to predominance of individually dispersed melanosomes Biology of Pigmentation

• Content of melanin and distribution of melanosomes impact photoprotection • Melanin confers UV protection • Study by Thompson et al in 1950s of Nigerian Africans (one albino) showed that skin color vs thickness of (or ) accounted for this Epidermal Structure • Racial differences in epidermal structure noted • Montagna and Carlisle found a compact and unaltered stratum lucidum in sun exposed black skin but a swollen, cellular one in sun exposed white skin • Marked differences between atrophy and cell cytology Hair Follicles

• Four hair types – Straight – Wavy – Helical – Spiral • Follicles of scalp and hair are curved • Hair has flattened, elliptical shape Hair Follicles

• Fewer elastic fibers anchoring hair follicles to the • Highly coiled hair forms more knots and fissures, ie “split ends” • Number of terminal hair follicles is less in black vs white subjects (p <.001) Common Dermatologic Disorders in Skin of Color: A Comparative Practice Survey

• Few studies have investigated racial/ethnic differences in the of skin disease • Most data available was from surveys and individual clinical experience Common Dermatologic Disorders in Skin of Color: A Comparative Practice Survey

Performed by Alexis et al, Cutis. 2007:80:387-394

Objective: Compare the most common diagnoses for which patients of various racial and ethnic groups were treated at a hospital based dermatology family practice.

Study Design: Retrospective chart review (n=1412) Common Dermatologic Disorders in Skin of Color: A Comparative Practice Survey

Diagnoses, Skin of Color Diagnoses, White skin 1. 1. Acne 2. Dyschromia 2. Lesion of unspecified behavior

3. Contact and other eczema 3. Benign of skin/trunk 4. Alopecia 4. and other eczema

5. Seborrheic Dermatitis 5. 6. Lesion of unspecified behavior 6. Seborrheic Dermatitis 7. 7. 8. 8. 9. 9. Viral 10. 10. Folliculitis Objectives

• Briefly review lesion types and relevant terminology • Understand the history and significance of culturally competent research in dermatology • Explore the histologic characteristics of Fitzpatrick Skin Types 4-6 • Utilize patient cases and board style review questions to explore the most common diagnoses in patients with skin of color • Understand Research Limitations • Summary and Conclusion 25 yo AA female presents to your office with CC of “heat bumps” on her forehead. Symptoms began one month ago, with the arrival of the summer. The patient has tried OTC wash with no improvement of symptoms. She continues her daily moisture regimen of Jergen’s . She does not report itching, but is annoyed at the cosmetic effect the bumps are having.

Patient Case, Continued

On further questioning, the patient reports having “gone natural” recently, abandoning the flat ironing/relaxers and wearing her hair in it’s natural, curly state. She is pleased with this life change and reports how much easier it is to maintain. She applies a coconut oil based pomade daily to keep her natural hair moisturized. Which of the following statements regarding this patient’s diagnosis are true?

a) It is a disease of the pilosebaceous unit that causes noninflammatory lesions, inflammatory lesions, and varying degrees of scarring b) It is an extremely common condition with a lifetime prevalence of approximately 85% c) It is associated with psychological disturbances such as poor self-image, , and , which leads to a negative impact on quality of life d) Topical therapies such as and are recommended as first line treatment (Grade A Recommendation) e) All of the above Which of the following statements regarding this patient’s diagnosis are true?

a) It is a disease of the pilosebaceous unit that causes noninflammatory lesions, inflammatory lesions, and varying degrees of scarring b) It is an extremely common condition with a lifetime prevalence of approximately 85% c) It is associated with psychological disturbances such as poor self-image, depression, and anxiety, which leads to a negative impact on quality of life d) Topical therapies such as benzoyl peroxide and clindamycin are recommended as first line treatment (Grade A Recommendation) e) All of the above Acne

• Most common presenting dermatologic diagnosis in all patients • Lesions include open and closed comedones, , pustules, nodules, and • Determine predominant lesion type and evaluate for postinflammatory and scarring Hair and history is important!

• Hair pomades and conditioners include – petrolatum – lanolin – vegetable, mineral, and animal oils • Can cause papular and comedonal acne Acne Key Points

• Increased potential for hyperpigmentation, scarring, and keloids • Skin and hair products may be comedogenic • Start at low concentrations with infrequent dosing, cream better tolerated than gels • Use lower concentration of benzoyl peroxide to avoid hyperpigmentation The patient is concerned with skin darkening in areas of previous comedones Which of the following statements regarding this postinflammatory hyperpigmentation is false?

a. It is rarely caused by disease processes such as eczema and acne b. Sun protection should be encouraged, even in patients who never burn c. It is associated with psychological disturbances such as poor self-image, depression, and anxiety, which leads to a negative impact on quality of life d. It is more common in African American patients e. All of the above are true Which of the following statements regarding this postinflammatory hyperpigmentation is false?

a. It is rarely caused by disease processes such as eczema and acne b. Sun protection should be encouraged, even in patients who never burn c. It is associated with psychological disturbances such as poor self-image, depression, and anxiety, which leads to a negative impact on quality of life d. It is more common in African American patients e. All of the above are true Postinflammatory Hyperpigmentation

• Ill defined, hyperpigmented macules and patches in the shape of prior lesions • from skin conditions such as acne, eczema, or therapeutic intervention • Can occur in anyone, more common in dark skin • Can cause more distress than causative disorder Postinflammatory Hyperpigmentation Key Points

• Does not require treatment, will improve with time! • Focus on underlying condition • Encourage sun protection • Avoid irritants • t/c daily 4% cream or combination of , , and hydroquinone • Be patient Cultural Practices and Dyschromia

• Skin lightening agents readily available • Often contain potent chemicals – • Most commonly used is hydroquinone 2-4 % • Can cause atrophy, , , and telangiectasia 4 year old male with history of presents with a pruritic, hyperpigmented, nonerythematous abdominal for several weeks. https://ethnomed.org/clini cal/dermatology/dermatol ogy- images/pigment1.html/im age_preview Which of the following is the most likely diagnosis?

a. Scarlatinoform Eruption secondary to Streptococcal species b. c. Contact Dermatitis b. Which of the following is the most likely diagnosis?

a. Scarlatinoform Eruption secondary to Streptococcal species b. Tinea Corporis c. Contact Dermatitis b. Tinea Versicolor Contact dermatitis secondary to nickel - belt buckle or button Contact Dermatitis Key Points

• Research equivocal on incidence in skin of color • Challenge in identifying erythema, patch testing • Hands and face most common areas • Presents as erythematous (hyper/hypo pigmented) and pruritic skin lesions that occur after contact with a foreign substance • Treat with mid- or high-potency steroid 15 year old male presenting with dark, dry area on back of neck as well as pale area on right shoulder, very itchy, has tried baby lotion with no improvement. Also with history of asthma, well controlled and seasonal .

Which of the following is the most likely diagnosis? a. Seborrheic Dermatitis b. Acanthosis Nigricans c. Contact Dermatitis b. Eczema Which of the following is the most likely diagnosis? a. Seborrheic Dermatitis b. Acanthosis Nigricans c. Contact Dermatitis b. Eczema Eczema Key Points

• Triggered by an overactive • Erythema, , papules and crusting followed by lichenification • May present with hyper- or hypo- pigmentation • Can resemble other diagnoses • Treatment is topical steroids/moisturization Patient Scenario, revisited Which of the following is an appropriate treatment regimen for this patient? a. Intralesional steroids and oral antibiotics b. Selenium Sulfide Shampoo c. Oral griseofulvin x 4-6 weeks d. Benza-clin gel applied topically e. Patient counselling and education Which of the following is an appropriate treatment regimen for this patient? a. Intralesional steroids and oral antibiotics b. Selenium Sulfide Shampoo c. Oral griseofulvin x 4-6 weeks d. Benza-clin gel applied topically e. Patient counselling and education Alopecia

• Loss of hair from excessive pulling • Occurs at frontal and temporal hair lines • May result from tension from braids/weaves • Caution about tightness and pull advised • May be worse in patients who relax their hair Traction Alopecia Central Centrifugal Cicatricial Alopecia

• Most common cause of hair loss in African Americans • Hair loss at the crown and spreads outward • Women>men • May have pruritis, tenderness, and pain • Etiology unknown, early intervention most effective Central Centrifugal Cicatricial Alopecia CCCA Suggested Causes

• Use of relaxers, heat, and traction • Weaves/braids pulling the hair from follicle • Not proven by studies, but intervention key to prevent further hair loss • No ideal treatment, may attempt intralesional steroids with oral antibiotics (not evidence based) CCCA vs Traction Alopecia Hair Disorders Key Points

• Persons of African descent have different degrees of curl • Excessive hair washing can lead to breakage, so less frequent shampooing is common • Hair should be washed at least every 1-2 weeks • Conditioning helps with hair fragility Hair Disorders Key Points

• Emollients: Good for manageability but comedonal • Chemically relax no greater than q8weeks • Heat increases manageability, increases breakage • Braids/weaves can cause traction alopecia • CCCA is very aggressive and requires early intervention 16 year old African American male presenting with scalp irritation and “dark spots” extending from the scalp to the forehead. He is also complaining of itching and irritation behind his ear

Which of the following statements is false regarding this patient’s disease process?

a. It is a chronic, relapsing, and usually mild form of dermatitis that occurs in infants and in adults b. Sebaceous glands may play a permissive role in the pathogenesis, possibly by creating a favorable milieu for the growth of fungi of the genus Malassezia c. It is usually characterized by well-demarcated, erythematous plaques with greasy-looking, yellowish scales distributed on areas rich in sebaceous glands, such as the scalp, the external ear, the center of the face, the upper part of the trunk, and the intertriginous areas d. Facial lesions almost never involve the forehead below the hairline, the eyebrows or glabella Which of the following statements is false regarding this patient’s disease process?

a. It is a chronic, relapsing, and usually mild form of dermatitis that occurs in infants and in adults b. Sebaceous glands may play a permissive role in the pathogenesis, possibly by creating a favorable milieu for the growth of fungi of the genus Malassezia c. It is usually characterized by well-demarcated, erythematous plaques with greasy-looking, yellowish scales distributed on areas rich in sebaceous glands, such as the scalp, the external ear, the center of the face, the upper part of the trunk, and the intertriginous areas d. Facial lesions almost never involve the forehead below the hairline, the eyebrows or glabella Seborrheic Dermatitis Key Points

• Scaly, flaky, itchy, and “erythematous” skin in rich areas • Often presents on scalp (cradle cap) and nasolabial folds • Can present as hyper/hypopigmentation in skin of color • Often misdiagnosed as eczema, tinea versicolor, and • First line treatment is selenium sulfide shampoo Seborrheic Dermatitis Key Points

A 36 year old African American male presents with several month history of “razor bumps” on his chin and neck. He reports the lesions are often pus filled and inflamed. You diagnose him with pseudofolliculitis barbae and counsel him on prevention and treatment. Which of the following represents an appropriate treatment regimen?

a. 100 mg BID x 10 days, then once daily for 12 weeks b. Low potency topical steroids in conjunction with close shaving daily c. Topical antibiotics in conjunction with lifestyle modifications such as avoiding close shaves d. Topical hydroquinone Seborrheic Dermatitis Key Points

A 36 year old African American male presents with several month history of “razor bumps” on his chin and neck. He reports the lesions are often pus filled and inflamed. You diagnose him with pseudofolliculitis barbae and counsel him on prevention and treatment. Which of the following represents an appropriate treatment regimen?

a. Doxycycline 100 mg BID x 10 days, then once daily for 12 weeks b. Low potency topical steroids in conjunction with close shaving daily c. Topical antibiotics in conjunction with lifestyle modifications such as avoiding close shaves d. Topical hydroquinone Pseudofolliculitis Barbae Pseudofolliculitis Barbae

• Inflammatory condition of face/neck • Tightly curled hair the culprit • Commonly referred to as “razor bumps” • Follicularly based erythematous and hyperpigmented papules and pustules • Pustules usually sterile, but can become secondarily infected Pseudofolliculitis Barbae

• In women presents on face, axilla, and suprapubic regions • Occurs when hair curls into itself and penetrates the skin, leading to a foreign body inflammatory reaction • Discontinue hair removal to prevent reoccurrence (not practical) Pseudofolliculitis Barbae Key Points

• Result of cut hair penetrating skin • Complete resolution if discontinue hair removal • Proper shaving technique can decrease extent • Medically manage with topical steroids, benzoyl peroxide, topical antibiotics, topical retinoids Recommended Shaving Technique

• Avoid a close shave, leave hair .5-3mm • Use clippers, a single blade razor, or depilatories • Shave in direction of hair growth • Do not pull skin taut while shaving • Loosen embedded hairs, apply warm compresses, gently rub with towel • Avoid plucking Keloids Keloids

• Benign growths at the site of trauma • Smooth, shiny, and firm papules, plaques, and nodules • Red or pink with progressive hyperpigmentation • Commonly on ear lobes, jaw line, nape of neck, scalp, chest, and back • Often associated with pain, pruritis, hypersensitivity Keloids

• Often confused with hypertrophic (which usually develop soon after trauma and are found usually on extensor surfaces and confined to border of injury) • Keloids develop months to years after injury and not at areas of motion, extend beyond injury borders • Intralesional steroids first line treatment Keloids Key Points

• Early treatment offers best outcome • Avoid unnecessary trauma if prone to keloid formation • If surgery required, avoid excessive movement and stretching of wound • Use low concentration intralesional steroids every 4-8 weeks • Surgical excision has high recurrence rate A 47 year old male presents to your office complaining of “” and scarring on the back of his head for several years. The patient reports being treated for ringworm of his scalp in the past with no improvement in his symptoms. Physical exam reveals the following-

Acne Keloidalis Nuchae

• Progressive, chronic folliculitis • Keloid like papules and plaques on occipital scalp • May develop subcutaneous and sinuses • Scarring alopecia common • Unknown etiology: theories include chronic irritation

• Early treatment=good prognosis • Avoid tight fitting apparel that hugs hairline and trimming occipital hairline • Treatment includes topical steroids (class 1 and 2), topical and oral antibiotics, topical and oral retinoids, imiquimod, therapy, and surgical excision Research Limitations

• Major studies available are not multi-center and are retrospective in nature • Many confounding cultural, environmental, and socioeconomic factors • Individual’s skin phenotype is self reported and unreliable • There are differences between individuals who belong to a single group (not generalizable) Summary and Conclusion

• The prevalence, presentation, and psychological impact of skin disease can vary between racial and ethnic groups • Genetic, environmental, socioeconomic, and cultural factors contribute • As the U.S. population becomes increasingly diverse, understanding these differences will be of growing importance Summary and Conclusion

• Patient’s with skin of color are prone to different dermatologic diseases than the white population • Presentations may vary in this patient subset • Early intervention, treatment, and education is key to provide optimum patient care References

• Taylor, SC. Epidemiology of skin diseases in ethnic populations. Dermatol Clin. 2003;21:601-607 • Taylor, SC. Skin of color: Biology, structure, function, and implications for dermatologic disease. J Am Acad Derm. 2002:46:S41- %62 • Richards, GM, Oresajo CO, Halder RM. Structure and Function of ethnic skin and hair. Dermatol Clin.2003:21:595-600 • Gries, PE, Stockton T. Pigmentary disorders in blacks. Dermatol Clin. 1988;6:271-281 • Wesley NO, Maibach HI. Racial differences in skin properties: the objective data. Am J Clin Dermatol. 2003:4:843-860 • Reed JT. Ghadially R, Elias PM. Effect of race, gender, and skin type on permeability function. J Invest Dermatol. 1994;102:537 • DeLeo VA, Taylor SC, et al. The effect of race on patch test results. J Am Acad Dermatol 2002;46:107-112 • US Census Bureau. US interim projections by age, , race, and origin. Available at www.census.gov/ipc/www/usinterimproj • Fitzpatrick TB/ The validity and practicality off sun reactive skin type 1-VI. Rch Derm 1988