MINI-SYMPOSIUM

Skin of Color

• Special Problems • Unique Interventions

Nishit Patel, MD, FAAD SKIN OF COLOR Why 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 • Acne • Unspecified Dermatitis • Unspecified Dermatitis • Unspecified Dermatitis • Eczema • • Benign skin • Seborrheic Dermatitis • Benign skin neoplasm • Psoriasis • Dyschromia • Viral • • Psoriasis • • Eczema • Alopecia • Seborrheic Keratosis • Viral • • • Urticaria • Viral warts • Sebaceous • Sebaceous Cyst • Sebaceous Cyst • Dyschromia • 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 1999; 141: 512±517. BASIC SCIENCE A 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 • 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 . . While initially served a physiological purpose, they now define individuality, self esteem and often quality of life. . Follicles are dynamic structures, permanently regenerating. 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 DISORDERS In Skin of Color

Non-Scarring Scarring

. . Discoid erythematosus . Androgenetic Alopecia . . . . Trichorrexis nodosa Dissecting of the scalp . Seborrheic dermatitis . Central centrifugal . * scarring alopecia

Traction Alopecia

• Caused by anything that pulls on hair • Tight • • 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 . – (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 and pustules of posterior neck; areas of involvement may develop into keloid , sinus tracts, etc. • Histologically, deep 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 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 /BPO combinations • Surgical excision– go to the subcutaneous • Laser

Pseudofolliculitis Barbae

• Inflammatory papules and pustules usually in the area related to close ; 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 – several are on the market • Topical eflornithine (Vaniqa®) • Inhibits ornithine decarboxylase • Takes 3mo to see effect – must maintain • • Dissolve disulfide bonds in keratin • Topical depilatories • Barium sulfate or sodium thioglycolate • • 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 LESIONS In 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 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 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, , 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

• Slowly progressive course with exacerbations and remissions

• May spontaneously resolve

• Treatment not necessary

• Topical retinoids and topical steroids COMMON SKIN CONDITIONS In 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 /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, , 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 - 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 in its reputation for being a great mimicker • Lesion morphologies may vary widely: papules, nodules, plaques, subcutaneous lesions, development within scars (scars “grow”), , 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) • 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, or psoriasis • Can progress to fine atrophic wrinkling => tumors, erythroderma, other variants • Predilection for sun protected areas, proximal extremities and body folds (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 CONDITIONS In Skin of Color Image from http://galleryhip.com/black-spots-on-skin-from-acne.html Acne – Special challenges

• Postinflammatory • Caused by minimal • 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 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 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