1. Dermatology in Individuals with SKIN OF COLOR
Kathleen O’Hanlon, M.D.
Professor, Family & Comm. Health
JCESOM/Marshall University
Huntington, WV

2. Goals of this Presentation
Discuss normal variations in skin of color
Review skin disorders that are more common among individuals with skin of color
Discuss skin disorders that appear differently in individuals with skin of color
Review dermatologic conditions in infants and children with skin of color

3. Defining Skin of Color
2000 NIH Conference struggled with the definition as it encompasses individuals of various races and ethnicity
Includes Blacks, Asians, Hispanics, Latinos (all increasing segments of U.S. population)
Fitzpatrick skin classification system or objective color measurement devices are useful, but have limitations
Taylor SC. Cutis 2002; 69:435

4. Fitzpatrick Skin Typing

5. Normal Variations in Individuals with Skin of Color

6. Pigmentary Demarcation Lines
PDLs are also known as Futcher’s Lines or Voight’s Lines
Type A PDLs are the abrupt transition between light and dark skin on the anterior portion of both arms
Type B PDLs are on the posterior legs
Type C, most common in AA and Latino children, is vertical hypopig. over sternum
Lesions require no clinical intervention

7. Pigmentary Demarcation Lines

8. PDL Type C Inherited as autosomal dominant
Incidence 70% in prepubertal AA children
Incidence is 30-40% in AA adults
Less noticeable w age

9. PDLs continued …
About 75% of African Americans have at least 1 demarcation line; believed to be due to arrest of migration planes of melanocytes
Lines are more common in AA women, Hispanic women and PG women. 4% Japanese. Rarely in Caucasians.
Lines typically occur in 5 recognized areas:
Anterolateral upper arms
Posteromedial lower legs
Hypopigmentation in the presternal area
Posteromedial trunk to spine
From the clavicle to the nipple

10. Longitudinal Melanonychia
Longitudinal pigmented nail bands commonly found in individuals with skin of color
The number of nails affected, and the degree of pigmentation tends to increase with age
More common in darkly pigmented individuals
The degree of pigment is uniform longitudinally, but may vary transversely

11. Melanonychia
Longitudinal ….
Transverse …

12. Longitudinal Melanonychia cont’d.
Main goal for primary care physicians is to exclude acral-lentiginous melanoma (ALM), the most common melanoma type in African Americans & Hispanics
Biopsy: those >6 mm wide, solitary (symmetrical involvement favors benign), dark or with signif. color variation, and those assoc’d with nail deformity or extension to the surrounding skin
Ethnic Skin. Mosby. , 1998.

13. So … Benign

14. Acral Lentiginous Melanoma
Wide band that
extends length
of nail

15. Another example …

16. Palmar Crease Hyperpigmentation
Palmar crease pigmentation commonly encountered on the lighter skin of the palms in individuals with skin of color
Degree of pigmentation in the creases parallels the overall darkness of the skin

17. Palmar Crease Hyperpigmentation

18. Palmar Crease Punctate Keratoses & Pits
Conical, hyperkeratotic papules or plugs in creases that evolve into pits once removed
Keratoses and pits common in African American adults, but not in children
Prior reports of a link with internal malignancy or manual labor appear unfounded
Treatment aimed at hyperkeratoses can be helpful (salicylic a., tretinoin, …), but no rx is required.
Hsu S. Am Fam Physician 2001; 64: 475.

19. Punctate Keratoses/Pits

20. Oral Hyperpigmentation
Common in both infants and adults; incidence probably >75% of AA; also common in Asians
Hyperpigmentation is found most often on the gingivae, but also occurs on the buccal mucosa, hard palate and tongue
Pigment usually symmetric but may be patchy, often parallels degree of skin color

21. Gingivae Hyperpigmentation

22. Oral Hyperpigmentation

23. Plantar Pigmentation
Asymptomatic, hyperpigmented macules commonly encountered on the plantar surface of AA individuals
Darker-skinned individuals more commonly affected
Pigmented areas usually multiple, patchy, with irregular borders
Other Dx’ic considerations: post-inflamm. hyperpig., tinea, 2ndary syphilis, and arsenic keratoses
Rosen T. Atlas of Black Dermatology,

24. Plantar Pigmentation

25. Common Skin Disorders Appearing Differently in Individuals with Skin of Color

26. What is this inflammatory skin disorder on the face?

27. Also Common on Ears and Neck

28. Discoid Lupus Erythematosus
Chronic inflammatory disorder which occurs twice as often in females
Peak age 35 – 45 yrs old
Begins as localized, edematous erythematous plaques which spread outward on sun-exposed skin
DLE only occurs in about 15% of patients with SLE (may precede, appear simultaneously or follow development of SLE)
Rodnan GT. Primer on Rheumatic Diseases. 8th ed.

29. Most lesions develop central hypopig. and atrophy
Most lesions develop central hypopig. and atrophy. Well estab’d lesions are rimmed with peripheral hyperpig.

30. Can be quite disfiguring d/t scarring and alopecia

31. Lichen Planus Papulosquamous dis. of unknown etiology
Typical lesion is polygonal, shiny, flat-topped, and “violaceous”
PIH may be present and persistent
Sites of predilection include wrists, ankles, penis and lumbar area
Has been associated with Hepatitis B and C

32. Lesions can be Purple, Brown or Black in SOC

33. Lichen Planus

34. Lichen Planus

35. Genital LP

36. Oral Lichen Planus Wickham’s striae – white, lacey network on the
buccal mucosa; more common in Caucasions

37. Oral Lichen Planus

38. Sarcoidosis
Systemic disorder wh produces granulomas in mult. tissues, skin involvement in 25%
Often presents w bilat. hilar adenopathy, pulmo. infiltrates, and skin or eyelid lesions
10X higher incidence in African Americans
2 female:1 male ratio
Skin changes include papules, plaques, scar-like changes – appearing over several months

39. E. Nodosum – Most Common Skin Manifestation of Sarcoidosis
Red tender nodules on
Extensor surfaces

40. Erythema may again be difficult to appreciate in SOC

41. Sarcoidosis – Facial & Eyelid Lesions
Dx estab’d by histologic evidence of non-caseating granulomas – Biopsy!

42. Cutaneous Manifestations Highly Variable in African Americans
Lesions can be annular
Lesions can be ichthyotic
Lesions can be ulcerative
Lesions can be hypopigmented macules
Scarring and alopecia can occur
Intralesional steroids are mainstay of rx
Johnson BL. Ethnic Skin. Mosb y. 1998

43. Annular, hypopigmented
Ulcerated

44. Ichthyosis

45. Lupus Pernio can be another skin manifestation of Sarcoidosis
Clusters of firm, raised, glistening violaceous papules on alar border of nose, lips and cheeks
Can give nose a bulbous appearance
Can appear on ears, fingers, and knees
Saboor SA. Br J Hosp Med 1992; 48: 293.

46. Vitiligo
Face
Perioral and ocular

47. Vitiligo
Probably autoimmune disorder (autoantibodies directed against melanocysts) affecting 1-2% of the world’s population
Most common sites of involvement include the hands, feet, genitalia and face – can be very striking in SOC
Can affect a dermatome or an entire extremity
Sudden pigment loss can follow a sunburn
Typically starts in 1st-3rd decades; 25% by age 10; often in pp with +FH
Barrett C, Whitton M. Interventions for Vitiligo. Cochrane Skin Group. Cochrane Protocol. Issue 2, Oxford: Update Software.

48. Vitiligo

49. Cosmetic camouflage, if <10% skin involvement high dose topical steroids may halt the spread & encourage repigmentation; PUVA (oral or topical psoralens & UVA radiation), and cognitive behavioral rx for psycho-social effects. Sunblock mandatory.
Nordlund JJ. Dermatol Clinics 1993; 11:27.

50. Tinea Versicolor
Chronic, superficial fungal infx (Pityrosporum obiculare ) (aka Malassezia furfur)
Depigmentation caused by tyrosinase inhibitory activity & toxic melanocyte effect of the acids produced
Hypo- or hyperpigmented macules that coalesce into larger patches
Common on upper trunk, neck, upper exts. (areas w active sebaceous glands – so mostly in teens & adults )
Worse in heat/humidity
Without rx the disorder can be chronic

51. TV – macules that coalesce into larger patches
Hyperpigmented …
… or Hypopigmented

52. TV on the Face

53. What do you find on KOH prep?
For active infection, look for presence of
scale & a + KOH. Hyper- or hypo-pigmentation
can persist for months after rx so not, alone,
indicative of an active process.

54. Rx of T. Versicolor Topical Oral
Selsun Blue Shampoo is often advised but has not been studied (1%)
Ketaconazole (Nizoral) 2% Shampoo –
Apply for 5min qd X 3
Px: Apply for 10min./mo.
Itraconazole (Sporanox) 200mg/d X 7 d OR as a 400mg sgl dose
Fluconazole (Diflucan) 300mg/once wk for about 3 doses OR as a 400mg sgl dose
Oral “azole’s” require good liver function
Ketaconazole NO longer recomm’d d/t rare liver tox
UpToDate.com

55. Psoriasis
Papulosquamous dis. less common in AAs (0.1% - 1.4% compared to 2% in caucasions)
Typical location (flexor surfaces ), silver scale, and raised plaques allow for the dx
Erythema often obscured in dark skin
PIH common & persistent
Predilection for elbows, knees, lumbosacral, scalp, genitalia and nails.

56. Psoriasis
Papulosquamous dis. less common in AAs (0.1% - 1.4% compared to 2% in Caucasians)
Typical location (flexor surfaces ), silver scale, and raised plaques allow for the dx
Erythema often obscured in dark skin
PIH common & persistent
Predilection for elbows, knees, lumbosacral, scalp, skin folds, genitalia and nails.

57. Psoriasis
Guttate
Plaque

58. Psoriasis
Scalp
Intertriginous
Not all skin fold rashes
are candidal

59. Psoriasis

60. Skin Disorders More Common in Skin of Color

61. Melasma
Common, benign symmetric facial hyperpigmentation primarily in women
Often due to sun or hormonal exposure in pregnancy or with OCP use
Usually lasts for several years
Combination tx advocated: 2% (OTC) or 4% hydroquinone, tretinoin (0.1%), azelaic acid 20% (rx often unsatisfactory)
Strict sun avoidance also helpful
Salim A, Rengifo M, Cuervo LG, Weeed J, Vincent S. Interventions for melasma. Cochrane
Skin Group. Cochrane Protocol. Issue 2, Oxford: Update Software.

62. Melasma

63. Postinflammatory Hyperpigmentation
Dark patches occur at sites of prior inflammation; darkly complected individuals experience more
Both epidermal and dermal pigmentary reactions are noted
GENERAL RULE: It is easier to prevent hyperpigmentation than to treat it

64. Inflammatory Diseases Causing Hyperpigmentation
Drug eruptions
Lichen planus
Psoriasis
Lichen simplex chronicus
Trauma (scratches, abrasions …)
Acne vulgaris
Folliculitis
Eczema
Tinea
Impetigo

65. Acne –induced PIH

66. Trauma-induced PIH

67. Keloids
Shiny, hyperpigmented, raised, hard, nodular tumors; by definition they extend beyond the borders of a wound
Benign, excessive reaction to trauma
Occur with greatest frequency in the second and third decade
Most common sites are the earlobes (esp. posterior), upper back, midchest and shoulders

68. Keloid Scar

69. Keloids cont’d
Most widely recognized skin disorder in individuals with skin of color (15-20 X’s higher
Incidence than in light toned skin)
Can be differentiated from hypertrophic scars by their extension from the wound and reaction to steroid injection
Rx modalities include: surgery , cryo, and steroid injxs

70. Earlobe Keloids
Anterior
Posterior

71. Prevent When You Can Avoid nonessential surgery High recurrence rates
Meticulous sterile technique
Minimize skin tension
Ab rx if secondary infection
Perioperative steroid injx (add triamcinolone
to Lidocaine 1% diluted to 2.5-5mg/ml)

72. Acne Keloidalis Nuchae
Deep, follicular inflammatory process most commonly located in the nuchal region (nape)
Condition practically unique to African Amers.
Tightly coiled hairs are involved in the pathogenesis: razor-shaved hair ends may curve back toward the skin & re-enter the epidermis, causing a foreign body rx
Ingrown hairs, papules & pustules, alopecia & even large nodules may result

73. Acne Keloidalis Nuchae cont’d
Despite the name, lesion is NOT acne or keloid
Sxs include burning, itching, purulent drainage, and slowly growing nodules
Mostly affects men age 15 – 28
Early on, conservative derm tx may hold it in check (avoid dble-edged razors, systemic abs)
With lg, well-estab’d lesions wide excision with primary closure advocated

74. Pathogenesis

75. Acne Keloidalis Nuchae

76. Acne Keloidalis Nuchae lesion requiring excision

77. Pseudofolliculitis Barbae
Irritant dermatitis found in 45% of AA men
Same Pathogenesis – closely shaved coiled facial hairs have reentered the skin of the face & neck
The combination of aberrantly growing hairs and shaved fragments left in the skin causes a foreign body reaction
Areas can become secondarily infected

78. “Razor Bumps”

79. Management of Pseudofolliculitis Barbae
Refrain from shaving for 1 month; skin-cleansing sponges provide gentle hair traction to decrease “ingrown hairs”
Resume shaving with electric razor
A magnifying mirror can be helpful in identifying looped hairs; use a needle to pull out the ingrown tip
Oral or topical antibiotics can be used if there is evidence of infection
Williams DF. Consultant 1998; 38: 189.

80. Sponging can add traction to help prevent ingrown hairs

81. Of Possible Benefit … Chemical depilatories – Eflornithine (Vaniqa)
Electrolysis – to lessen density and decrease ingrown hairs; may result in inflammatory papules and hyperpigmentation

82. Traction Alopecia
Gradual, patchy hair loss produced by chronic traction on the hair roots
Common on the vertex or temporal-parietal areas
Discourage tight braiding in kids & adolescents
Resolves within 3-4 months after cessation of casual traction
Heavy traction can result in follicular atrophy and permanent alopecia

83. Traction Alopecia

84. Pomade Acne (Acne Venata)
Acne-iform eruptions due to the application of oily substances (vaseline, mineral oil) to hair
Develops in 70% of persons using pomades for long periods
Typically closed comedones, but may progress to papulopustules/hyperpigmentation
Discontinued application of oils and pomades usually results in resolution

85. Pomade Acne

86. Management of Pomade Acne
Show consideration for patient’s hair needs
Avoid unreasonable requests such as “eliminate all hair care products”; better to suggest use qod etc.
Retinoids (tretinoin) or adapalene (Differin) can help decrease comedone formation
Wash face bid with a-hydroxy acid or salicylic acid containing cleansers

87. Dermatosis Papulosa Nigra
Multiple smooth, dome-shaped, pigmented papules 1-5 mm in size on cheeks, neck and upper chest
35 – 75% AA women affected
Probable genetic component
Histologically identical to seborrheic keratoses
Lesions may develop during adolescence; but peak incidence is in the 6th decade

88. Dermatosis Papulosa Nigra

89. Famous Person …

90. Management of DPN Similar to rx of seborrheic keratoses
Observation is best
Simple excision (Iris scissor curettage ) if unsightly

91. Conditions Among Infants and Children

92. Mongolian Spots (or Blue-Grey Macules of Infancy)
Single or multiple flat, blue-gray or black areas of hyperpigmentation with hazy borders
D/t the arrest of melanocytic migration in embryonic dermis
Prevalence:
African Amer 96%
Native Amer 90%
Asian 81 – 90%
Hispanic 46 – 70%
Require no rx; usually disappear by age 5
NO risk of transformation to melanoma

93. Common in Lumbosacral area
Also legs/shoulders/tru

94. Transient Neonatal Pustular Melanosis
Vesicopustular eruption which affects about 5% of African American newborns
Unknown etiology
Affects face, trunk, palms & soles
The pustules are usually gone w/i hrs
If lesions rupture in utero newborn may have hyperpigmented macules (vs. erythema toxicum neonatorum wh has erythema surrounding lesions)
Usually asymptomatic
No rx is required
Typically resolves spontaneously

95. Transient Neonatal Pustular Melanosis

96. Infantile Acropustulosis
Pruritic pustular condition most common at 6-10 mos of age, but may occur in newborn period
Discrete crops of 1-3mm papules/pustules on palms, soles & digits
CBC may show eosinophilia
Recurrent periods of eruption lasting 7 – 10 d; then remitting for 2 – 3 wks; then recurring
Rx – benadryl
Spontaneous resolution by 2-3 yrs of age

97. Infantile Acropustulosis

98. But Prominent Bumpiness – may actually be Lichen Nitidus

99. Lichen Nitidus
This is a papulosquamous dis. of unknown cause – innumerable pinhead-sized uniform flat-topped papules
Common in African Amer kids – on forearms, chest, abdomen and penis
Koebner’s phenomenon – lesions at sites of skin trauma
Rx: emollients, antihistamines, ammonium lactate cream 12% (Lac-Hydrin); steroid creams can be used
Self-limited; resolves over months to yrs

100. What is our Most Common Childhood Skin Disorder?

101. Atopic Dermatitis
Chronic dermatitis related to atopy (eczema) with exacerbations/remissions
Common on face and flexural areas of extremities
Transient erythema may be difficult to see in skin of color, but scratching can produce follicular papules, lichenification and hyperpigmentation or hypopigmentation
Xerosis (dry skin) is a hallmark; rx with oil based emollients; antihistamines can be used but are only helpful short-term, as tolerance to their effects develop
Often +FH of asthma, allergies, eczema
Eysenback G, Williams H, Diepgen TL. Antihistamines for atopic eczema. Cochrane
Skin Group. Cochrane Protocol. Issue 2, Oxford: Update Software.

102. Atopic Dermatitis Common Sites Flexural Areas
Note the hyperpigmentation

103. Hand dermatitis before age
15 is common in adults with
hand eczema

104. Follicular Accentuation – common in eczema in SOC

105. Scaling Rash of Scalp …
… Think Fungal! Trichophyton tonsurans most common cause of Tinea Capitus
Can produce inflammatory or non-inflamm alopecia (hard breakage of hairs at the roots produces “black dot alopecia”). +/- cervical lymphadenopathy.
The scale, pustules and black dots not seen in alopecia areata
Not seen with Wood’s lamp (but Microsporum can be seen )
Elewski B. Dermatol Clin 1996; 14: 23

106. Tinea capitus
Up Close …
The black dots favor Dx
over alopecia areata

107. Pustular boggy areas? … may have associated Kerion
Resist the temptation to I&D – oral rx is
the standard of care

108. Treatment Oral antifungals BEST: Fluconazole 6mg/kg/d for 20d
Add Ketoconazole 2% shampoo to decrease shedding & transmission to family members until cured
Griseofulvin & Itraconazole are alternatives but have more side effects

109. Credits
Much of the text in this talk was made available to me through the AAFP’s Skin Problems & Diseases course which I attended in South Carolina/2004.
All photos were made available through Google Images

110. Thank You!
Questions???