Common Dermatologic Conditions in Skin of Color

Home , Acne keloidalis nuchae, Granuloma annulare, Hydroquinone, Keloid, Kerion, Lichen simplex chronicus

Common Dermatologic Conditions in Skin of Color Sujitha Yadlapati MBBS Disclosure u I have no actual or potential conflict of interest in relation to this program/presentation. Review skin disorders Discuss normal variations that are more commonly in skin of color seen in darker skin types

Discuss skin disorders Review dermatologic that appear differently conditions in infants and in individuals with skin children with skin of of color color

Objectives Our Main focus today !!! uHypopigmentation uHyperpigmentation Defining Skin of Color u Skin of color, also known as ethnic skin refers to Fitzpatrick skin type III to VI u Includes a wide range of racial and ethnic groups including those of African, Asian, Latino or Hispanic, East Asian, Native American, Middle Eastern descent u There are notable differences in presentations and prevalence of skin conditions

Case Scenario 1

u A 50 Y African American female presents with a new dark band underneath the finger nail of her index finger, that she noticed one year ago . She is concerned regarding this because she has noticed these bands on multiple fingers and toes over the last year. Diagnosis? u A) Physiologic Longitudinal Melanonychia u B) Subungual Melanoma u C) Subungual hematoma Longitudinal Melanonychia u Dark band of nail pigment starting at the matrix of the nail, extending to the tip of the nail u Common in individuals with pigmented skin u 77% of AA over age 20, 100% over age 50 u Strong family history u Occurs only in 1% of Caucasians u Causes: u Benign nevi represent 12% of LM in adults, 50% in children. u Trauma, especially in great toes. u Drugs–chemotherapy agents, antimalarials. u Endocrine disorders. u ALWAYS consider the possibility of a subungual melanoma!!! Diagnostic clues that indicate Longitudinal melanonychia is Subungual Melanoma

u Hutchinson’s sign (melanoma until proven otherwise) u In a single digit u Sixth decade of life or later u Abrupt onset u Suddenly darkens or widens u Dark skinned patient, thumb or great toe u History of melanoma u Nail dystrophy Hutchinson’s sign u 29 Y female with primary acral lentiginous melanoma u She was referred to Dermatology for a nail biopsy u Biopsy results confirmed melanoma u Patient had MOHS surgery with graft placement. Biopsy

u Definitive diagnosis of nail discoloration is made with a nail biopsy. u Patients with darker skin, involvement of multiple nails often only need to be observed. u Melanonychia in Caucasian patients should always be biopsied. u A 3 mm punch biopsy can be performed at the origin of the darkest part of the band within the nail matrix. Differentials u Physiologic longitudinal melanonychia Treatment and does not require treatment. Follow up. u Nail changes suspicious for melanoma – follow up early referral to Dermatology for biopsy and management. u Histologic diagnosis of atypical Case scenario 2

u 30 Y Somali female with pruritic, dark rash on the flexor surface of elbows since 3 months. On close examination, there are concentric rings of scaling, erythema with central clearing. She was treated with topical antifungals two months ago, but stopped using the topical medication after two days because she did not notice improvement. Her lesions continued to progress. u Diagnosis? u A) Psoriasis u B) Tinea corporis u C) Granuloma Annulare u D) Cutaneous larva migrans Tinea corporis

u Common superficial fungal infection

u Well demarcated, annular lesions with central clearing and scaling in the periphery. Concentric rings are highly specific for tinea.

u Dermatophyte infection

u Diagnosis:

u Clinical

u Concentric rings are highly specific (80%)

u Pruritis is a hallmark

u KOH positive for branching hyphae Differentials Tinea vs. Granuloma Annulare Tinea vs. Nummular dermatitis Richard Usatine MD Tinea incognito

u KOH prep

u Skin scraping and culture: gold standard, but expensive, takes weeks. Not commonly used.

u Biopsy

u Treatment

u Small areas : topical terbinafine 1% cream or solution, applied once a day x 7 days (NNT=1.6)

u Large areas: oral antifungal medication

u Terbinafine 250 mg daily x 2 weeks

u Itraconazole 200 mg daily x 1 weeks

u Itraconazole 100 mg daily x 2 weeks Case scenario no 3

u A young African American male presents to the office with 4 year history of white spots on the trunk. He is worried that this is contagious. Spots get worse during the summer months and never go away completely. u Diagnosis? u A)Tinea corporis u B) Tinea versicolor u C) Vitiligo u D) Pityriasis alba Tinea Versicolor

Non communicable, recurring, cutaneous yeast infection caused by Malassezia species

Hypo- or hyperpigmented macules that coalesce into larger patches

Common on upper trunk, neck, upper extremities (areas with active sebaceous glands). This distribution is mostly in teens & adults . Face – children

Worse in heat/humidity

Without rx the disorder can be chronic Clinics in Dermatology Volume 28,Issue 2 Hypopigmented variants

What do you find on KOH prep? KOH prep : “spaghetti and meatball” pattern Differentials – when skin simply won’t tan Pityriasis rosea Rx of Tinea Versicolor

Topical Oral u Usually asymptomatic, treatment is mostly for u Itraconazole (Sporonox) 200mg/day X 7 d OR as a cosmetic reasons 400mg sgl dose

u Mainstay of treatment is using topical therapy with u Fluconazole (Diflucan) 300mg/week for about 3 antidandruff products doses or single dose of 400 mg oral fluconazole

u Selsun Blue Shampoo (selenium sulfide) u Ketoconazole in varying dosages and regimens ( u Comes in 1% (OTC) and 2.5% 400 mg/d x 3 days , 400 mg/week x 2 weeks); may cause hepatotoxicity u 2.5 % shampoo daily x 1 week

u Typically regimen involves a 10 min application, and then washing it off

u Ketoconazole 2%shampoo – for 3 days

u Ketoconazole (Nizoral) 2% cream – daily for two weeks

u Terbinafine 1 % solution, 1% cream, 1% gel BID x 1 week Case scenario 4

u 16 Y black male presents with a rash of the forearms, wrists, ankles and chest . He states that the rash is itchy and he does not like the way it looks. Rash has been present for 2 months or more . Diagnosis ?

u A) Guttate psoriasis

u B) Atopic dermatitis

u C) Lichen planus

u D) Pityriasis rosea Lichen Planus Lichen planus

u Papulosquamous rash that occurs forearms, wrists, ankle and back u Idiopathic, inflammatory reaction to an unknown antigen u Has been associated with medications (ACE ,thiazides, metals), Hep C, UC, alopecia, myasthenia u Classically presents with the 5 P’s u Purple u Polygonal u Papular u Pruritic u Planar u Well demarcated, flat topped lesions, overlying reticular pattern known as Wickham’s striae u An initial lesion is located on the flexor surfaces of the limbs such as the wrists , spreads over 2 to 16 weeks Lichen Planus

u Cutaneous Lichen planus

u Typical symptom at presentation is itching

u Patients can present with rash and no other associated symptoms as well

u Variants u Diagnosis u Management u Punch biopsy u Self limiting. u Most lesions resolve in 6 months – 1 year u Topical u Mid to high potency steroids BID u Topical calcineurin inhibitors u Systemic u Oral steroids – prednisone 15- 20 mg, 3-6 week taper u Steroid sparing therapies used by Dermatology – azathioprine, cyclosporine etc. u Follow up u Follow oral and vaginal lesions more closely – risk of malignant transformation although very low (0.2%) u Self limiting u Takes about 12-18 months to resolve u May reoccur Case Scenario 5

u 23 Y female delivers a healthy baby boy. Enquires about the rash on her face. Started with the first pregnancy but worse this time. She is hoping the pigment will fade with treatment. Diagnosis? Treatment of Melasma u Setting realistic expectations u Melasma u Topical agents u Sunscreen: SPF 30 or greater u Hydroquinone 2 or 4 % which is a bleaching agent u Tretinoin 0.1% u Tri-Luma (combination of Retin-A, fluocinonide, hydroquinone) – used daily u Azelaic acid 20 % u Kojic acid u Patch testing for bleaching agent. If inflammation that occurs as a result is anything more than mild, refrain from using bleaching agents. u Bleaching agents used on inflamed skin lead to PIH. u Combining tretinoin and hydroquinone (used at different times) can potentiate the effect. u Chemical peels u Laser and light therapies Post inflammatory Hyperpigmentation u Dark patches occur at sites of prior inflammation; darkly complected individuals experience this often u GENERAL RULE: It is easier to prevent hyperpigmentation than to treat it Inflammatory Diseases Causing Hyperpigmentation

u Drug eruptions u Acne vulgaris u Lichen planus u Folliculitis u Psoriasis u Eczema u Lichen simplex chronicus u Tinea u Trauma (scratches, abrasions …) u Impetigo Ø Management should focus on treating the underlying inflammatory condition Ø Encourage sun protection Ø Avoid irritants that may exacerbate the condition (e.g., alcohol, witch hazel, irritating makeups and cleansers)

Ø Combination topical therapies have been shown to be most effective. Regimens involve topical tretinoin 0.1% , hydroquinone 4 %, azelaic acid 20 %, glycolic acid , salicylic acid peels, sunscreen.

Ø First line – hydroquinone 4 % BID , sunscreen – 12 weeks. See patient back. Treat for another 12 weeks. Max efficacy is seen around 20 weeks. If no improvement is seen at all in the first 12 weeks, discontinue.

Ø Alternate day use of retinoids

Ø Triple agent, azelaic acid

Ø Chemical peels Ø Lasers Acne in skin of color

JDD Treatment pearls for acne in SOC

u Reduce inflammation u Initiate effective and appropriately aggressive treatment early on in the disease course u Include topical BPO and topical retinoids in treatment regimen u Low threshold to initiate oral antibiotics when indicated u Minimize irritation u Appropriate selection of vehicle concentration and dosing u Eliminate exacerbating factors u Use silicone based hair products, non comedogenic make up and moisturizer u Educate patients about PIH u Difference between active lesions and PIH u Importance of sun protection Topical therapies

u BPO – antimicrobial effect (gel, cream, lotion) (2.5,5,10%), 10% causes more irritation and is no more effective u Topical retinoids

u Tretinoin (Retin A)- gel, cream, liquid, micronized

u 0.025%, 0.05%,0.1% cream;0.05% gel, 0.04% microsphere formulation

u Adapalene gel – less irritating than tretinoin

u 0.1% used most commonly; Differin(OTC)

u Tazarotene – strongest topical retinoid, strongest risk of irritation

u 0.05% cream u Topical clindamycin 1% u Azelaic acid 20% u Dapsone 5% gel Oral therapies for acne u Oral antibiotics- doxy, minocycline. u Isotretinoin (Accutane) u Lower threshold to initiate treatment u Reduces inflammation at an earlier stage, thus reducing risk of PIH and scarring Procedural therapies u Comedone extraction u Intralesional corticosteroids for painful nodules and cysts. (triamcinolone 2.5- 5.0 mg/cc) can be used to treat inflammatory lesions. u Dilute 0.1 cc of 10 mg/cc Kenalog with 0.4 cc sterile saline for a 2 mg/cc suspension u Inject 0.1 cc into each lesion with googleimages a tuberculin syringe and 30 gauge needle Famiilydoctor.org American academy of Dermatology

Keloids u Injected directly into the middle of the keloid until the keloid Injecting a keloid blanches. u Advance the needle to the tip of the keloid, and then as you withdraw the needle inject into the canal that was created with the needle. u Do not try to achieve blanching to the edge of the keloid as this runs the risk of the steroid diffusing into the surrounding normal skin and inducing a rim or atrophy around the keloid. u Start with Kenalog, 10 mg/cc, and inject the keloid approximately every three to four weeks. If the keloid is shrinking, I continue to use the same strength. u If it is not responding, increase the concentration by 10 mg/cc

Library.med.Utah.edu with each injection until I use a maximum of 40 mg/cc. Case scenario 6 u 17 Y old, African American, male comes to your office with uncomfortable bumps on the back of his neck that have been present for 2 years. He notices that the bumps get irritated and larger when he shaves his hair on the back of his neck. He also has bumps on his face which get irritated with shaving his face.

u A) Folliculitis

u B) Acne vulgaris

u C) Pseuodofolliculitis barbae and acne keloidalis nuchae Acne Keloidalis Nuchae

u Despite the name, lesion is NOT acne or keloid

u Symptoms include burning, itching, purulent drainage, and slowly growing nodules

u Mostly affects men age 15 – 28.

u Early on, conservative treatment may hold it in check.

u Patient education. Avoid shaving close to the neck line.

u Tretinoin at night time, and 0.1% triamcinolone cream to neck area, 1% hydrocortisone to the face area for pseudo folliculitis

u With large, well-established lesions wide excision, injecting with intralesional steroids . Management of Pseudo folliculitis Barbae

u Refrain from shaving for 1 month u skin-cleansing sponges provide gentle hair traction to decrease “ingrown hairs” u Hydrocortisone 1% cream as needed to reduce inflammation u Topical Benzaclin (benzoyl peroxide plus clindamycin) used twice daily u Topical hydrocortisone u Oral antibiotics for more severe inflammation u Oral or topical antibiotics can be used if there is evidence of infection Dermatosis Papulose Nigra Case scenario 7

u A 1 year old Asian American girl is brought to her family physician for evaluation of new rash on the face and legs. The child is scratching both areas but is otherwise healthy .There is family Richard Usetine MD history of asthma, allergic rhinitis. Diagnosis? u Contact dermatitis u Scabies u Atopic dermatitis u Psoriasis u Seborrheic dermatitis Richard Usetine MD

Pityriasis alba Bathing modification

Atopic Moisturization and barrier repair dermatitis – Lifestyle alteration skin care for Topical medication children of color Pruritis care / relief of sleep disturbance

Severe or recalcitrant atopic dermatitis Topical calcineurin Topical corticosteroids inhibitors •Low potency (class 5-7) •Pimecrolimus (Elidel) 1% steroids for the face cream, for mild to mod and intertriginous areas dermatitis, age 2 years •Mid potency steroids for or more moderate to severe •Tacrolimus ( Protopic ) disease 0.03% ointment , mod to severe, ages 2-15 years •Tacrolimus 0.1% ointment for mod to severe atopic dermatitis, 16 and older, children who have incomplete response with 0.03%

• Oral antihistamines at bedtime • Wet pajamas covered by dry pajamas Severe or recalcitrant atopic dermatitis • Refer to Dermatology • Narrow band UVB • Immunosuppressants ( cyclosporine) Case scenario 7

u A 16 year old young woman is brought to the office by her mom because of a rash that appeared 3 weeks ago for no apparent reason. She is feeling well, rash is only occasionally pruritic. She is not sexually active. She has not come into contact with other individuals with a similar rash. Diagnosis? u A) Tinea corporis u B) Pityriasis rosea u C) Tinea versicolor u D) Secondary syphilis Pityriasis Rosea Secondary Syphilis Tinea versicolor Tine corporis Case scenario 8

u 11 year old boy with 2 month history of patchy hair loss. He has itching of the scalp but his mother is worried about his hair loss. Physical exam reveals alopecia with scaling of the scalp. Dx? Scientific Figure on ResearchGate. u A) Alopecia areata

u B) Tinea capitis

u C) Trichotillomania

u D) Traction alopecia Tinea capitis

u More common in young black males u Most common dermatophyte infection in children < 10 y. Rare after puberty and in adulthood. u Spread from person to person through direct contact or contact with contaminated object (combs, brushes)

u Most common clinical finding:

u Alopecia and scaling of the scalp

u Broken hairs look like black dots in areas of hair loss

u Kerion

u Cervical lymphadenopathy

Clinical

KOH prep- septate , branching hyphae

Woods lamp – low yield because only Microsporum species will fluoresce Treatment

Topical agents – not adequate, oral agents are needed

Oral agents –

• Griseofulvin • Less expensive • Available in liquid formulation for children • 6 to 8 weeks of treatment • Dose : 20 mg/kg/day for microsize formulation. 10 mg/kg/day for an ultramicrosize formulation which is more concerntrated, does not come in liquid form • Terbinafine • 2 to 4 weeks course = 6 to 8 weeks of griseofulvin • Effective • Short duration • Available as sprinkles • Kerion – a short course of steroids along with oral antifungals is helpful Thank You!

Questions??? u Visual Dx u UpToDate u Derm net NZ References u Taylor and Kelly’s dermatology skin of color u Color atlas of family medicine by Richard Usatine MD u Crutchfielddermatology.com