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 • Acne • Unspecified Dermatitis • Unspecified Dermatitis • Unspecified Dermatitis • Eczema • Psoriasis • Benign skin neoplasm • Seborrheic Dermatitis • Benign skin neoplasm • Psoriasis • Dyschromia • Viral Warts • Seborrheic Keratosis • Psoriasis • Actinic Keratosis • Eczema • Alopecia • Seborrheic Keratosis • Viral wart • Keloid scar • Rosacea • Urticaria • Viral warts • Sebaceous Cyst • 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 Dermatology 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 • 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 DISORDERS In Skin of Color Hair Loss Non-Scarring Scarring . Alopecia Areata . Discoid lupus erythematosus . Androgenetic Alopecia . Tinea capitis . Acne keloidalis nuchae . Trichorrexis nodosa Dissecting cellulitis of the scalp . Seborrheic dermatitis . Central centrifugal . Traction alopecia* 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 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 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 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