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Download Presentation 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 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 Primary Lesions Primary Lesions are physical changes in the skin considered to be caused directly by the disease process. Primary Lesions ● Macule ● Bullae ● Papule ● Pustule ● Nodule ● Wheal ● Tumor ● Burrow ● Plaque ● Telangiectasia ● 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 ● Scar ● Erosion (Abrasion) ● Eschar ● Keloids ● 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 hair loss 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 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 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 melanin • More and larger singly distributed melanosomes • No difference in number of melanocytes 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 stratum corneum (or genetics) 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 dermis • 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 epidemiology 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. Acne 1. Acne 2. Dyschromia 2. Lesion of unspecified behavior 3. Contact dermatitis and other eczema 3. Benign Neoplasm of skin/trunk 4. Alopecia 4. Contact dermatitis and other eczema 5. Seborrheic Dermatitis 5. Psoriasis 6. Lesion of unspecified behavior 6. Seborrheic Dermatitis 7. Hirsutism 7. Rosacea 8. Folliculitis 8. Actinic Keratosis 9. Atopic dermatitis 9. Viral Warts 10. Keloid 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 salicylic acid facial wash with no improvement of symptoms. She continues her daily moisture regimen of Jergen’s lotion. 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, 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 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
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