Presentation on theme: "Dermatology in Individuals with SKIN OF COLOR"— Presentation transcript:
1Dermatology in Individuals with SKIN OF COLOR Kathleen O’Hanlon, M.D.Professor, Family & Comm. HealthJCESOM/Marshall UniversityHuntington, WV
2Goals of this Presentation Discuss normal variations in skin of colorReview skin disorders that are more common among individuals with skin of colorDiscuss skin disorders that appear differently in individuals with skin of colorReview dermatologic conditions in infants and children with skin of color
3Defining Skin of Color2000 NIH Conference struggled with the definition as it encompasses individuals of various races and ethnicityIncludes Blacks, Asians, Hispanics, Latinos (all increasing segments of U.S. population)Fitzpatrick skin classification system or objective color measurement devices are useful, but have limitationsTaylor SC. Cutis 2002; 69:435
5Normal Variations in Individuals with Skin of Color
6Pigmentary Demarcation Lines PDLs are also known as Futcher’s Lines or Voight’s LinesType A PDLs are the abrupt transition between light and dark skin on the anterior portion of both armsType B PDLs are on the posterior legsType C, most common in AA and Latino children, is vertical hypopig. over sternumLesions require no clinical intervention
8PDL Type C Inherited as autosomal dominant Incidence 70% in prepubertal AA childrenIncidence is 30-40% in AA adultsLess noticeable w age
9PDLs continued …About 75% of African Americans have at least 1 demarcation line; believed to be due to arrest of migration planes of melanocytesLines 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 armsPosteromedial lower legsHypopigmentation in the presternal areaPosteromedial trunk to spineFrom the clavicle to the nipple
10Longitudinal Melanonychia Longitudinal pigmented nail bands commonly found in individuals with skin of colorThe number of nails affected, and the degree of pigmentation tends to increase with ageMore common in darkly pigmented individualsThe degree of pigment is uniform longitudinally, but may vary transversely
12Longitudinal Melanonychia cont’d. Main goal for primary care physicians is to exclude acral-lentiginous melanoma (ALM), the most common melanoma type in African Americans & HispanicsBiopsy: 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 skinEthnic Skin. Mosby. , 1998.
16Palmar Crease Hyperpigmentation Palmar crease pigmentation commonly encountered on the lighter skin of the palms in individuals with skin of colorDegree of pigmentation in the creases parallels the overall darkness of the skin
18Palmar Crease Punctate Keratoses & Pits Conical, hyperkeratotic papules or plugs in creases that evolve into pits once removedKeratoses and pits common in African American adults, but not in childrenPrior reports of a link with internal malignancy or manual labor appear unfoundedTreatment aimed at hyperkeratoses can be helpful (salicylic a., tretinoin, …), but no rx is required.Hsu S. Am Fam Physician 2001; 64: 475.
20Oral Hyperpigmentation Common in both infants and adults; incidence probably >75% of AA; also common in AsiansHyperpigmentation is found most often on the gingivae, but also occurs on the buccal mucosa, hard palate and tonguePigment usually symmetric but may be patchy, often parallels degree of skin color
23Plantar PigmentationAsymptomatic, hyperpigmented macules commonly encountered on the plantar surface of AA individualsDarker-skinned individuals more commonly affectedPigmented areas usually multiple, patchy, with irregular bordersOther Dx’ic considerations: post-inflamm. hyperpig., tinea, 2ndary syphilis, and arsenic keratosesRosen T. Atlas of Black Dermatology,
28Discoid Lupus Erythematosus Chronic inflammatory disorder which occurs twice as often in femalesPeak age 35 – 45 yrs oldBegins as localized, edematous erythematous plaques which spread outward on sun-exposed skinDLE 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.
29Most lesions develop central hypopig. and atrophy Most lesions develop central hypopig. and atrophy. Well estab’d lesions are rimmed with peripheral hyperpig.
30Can be quite disfiguring d/t scarring and alopecia
31Lichen Planus Papulosquamous dis. of unknown etiology Typical lesion is polygonal, shiny, flat-topped, and “violaceous”PIH may be present and persistentSites of predilection include wrists, ankles, penis and lumbar areaHas been associated with Hepatitis B and C
38SarcoidosisSystemic disorder wh produces granulomas in mult. tissues, skin involvement in 25%Often presents w bilat. hilar adenopathy, pulmo. infiltrates, and skin or eyelid lesions10X higher incidence in African Americans2 female:1 male ratioSkin changes include papules, plaques, scar-like changes – appearing over several months
39E. Nodosum – Most Common Skin Manifestation of Sarcoidosis Red tender nodules onExtensor surfaces
40Erythema may again be difficult to appreciate in SOC
41Sarcoidosis – Facial & Eyelid Lesions Dx estab’d by histologic evidence of non-caseating granulomas – Biopsy!
42Cutaneous Manifestations Highly Variable in African Americans Lesions can be annularLesions can be ichthyoticLesions can be ulcerativeLesions can be hypopigmented maculesScarring and alopecia can occurIntralesional steroids are mainstay of rxJohnson BL. Ethnic Skin. Mosb y. 1998
45Lupus Pernio can be another skin manifestation of Sarcoidosis Clusters of firm, raised, glistening violaceous papules on alar border of nose, lips and cheeksCan give nose a bulbous appearanceCan appear on ears, fingers, and kneesSaboor SA. Br J Hosp Med 1992; 48: 293.
47VitiligoProbably autoimmune disorder (autoantibodies directed against melanocysts) affecting 1-2% of the world’s populationMost common sites of involvement include the hands, feet, genitalia and face – can be very striking in SOCCan affect a dermatome or an entire extremitySudden pigment loss can follow a sunburnTypically starts in 1st-3rd decades; 25% by age 10; often in pp with +FHBarrett C, Whitton M. Interventions for Vitiligo. Cochrane Skin Group. Cochrane Protocol. Issue 2, Oxford: Update Software.
49Cosmetic 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.
50Tinea VersicolorChronic, superficial fungal infx (Pityrosporum obiculare ) (aka Malassezia furfur)Depigmentation caused by tyrosinase inhibitory activity & toxic melanocyte effect of the acids producedHypo- or hyperpigmented macules that coalesce into larger patchesCommon on upper trunk, neck, upper exts. (areas w active sebaceous glands – so mostly in teens & adults )Worse in heat/humidityWithout rx the disorder can be chronic
51TV – macules that coalesce into larger patches Hyperpigmented …… or Hypopigmented
53What do you find on KOH prep? For active infection, look for presence ofscale & a + KOH. Hyper- or hypo-pigmentationcan persist for months after rx so not, alone,indicative of an active process.
54Rx 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 3Px: Apply for 10min./mo.Itraconazole (Sporanox) 200mg/d X 7 d OR as a 400mg sgl doseFluconazole (Diflucan) 300mg/once wk for about 3 doses OR as a 400mg sgl doseOral “azole’s” require good liver functionKetaconazole NO longer recomm’d d/t rare liver toxUpToDate.com
55PsoriasisPapulosquamous 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 dxErythema often obscured in dark skinPIH common & persistentPredilection for elbows, knees, lumbosacral, scalp, genitalia and nails.
56PsoriasisPapulosquamous 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 dxErythema often obscured in dark skinPIH common & persistentPredilection for elbows, knees, lumbosacral, scalp, skin folds, genitalia and nails.
61MelasmaCommon, benign symmetric facial hyperpigmentation primarily in womenOften due to sun or hormonal exposure in pregnancy or with OCP useUsually lasts for several yearsCombination tx advocated: 2% (OTC) or 4% hydroquinone, tretinoin (0.1%), azelaic acid 20% (rx often unsatisfactory)Strict sun avoidance also helpfulSalim A, Rengifo M, Cuervo LG, Weeed J, Vincent S. Interventions for melasma. CochraneSkin Group. Cochrane Protocol. Issue 2, Oxford: Update Software.
63Postinflammatory Hyperpigmentation Dark patches occur at sites of prior inflammation; darkly complected individuals experience moreBoth epidermal and dermal pigmentary reactions are notedGENERAL RULE: It is easier to prevent hyperpigmentation than to treat it
67KeloidsShiny, hyperpigmented, raised, hard, nodular tumors; by definition they extend beyond the borders of a woundBenign, excessive reaction to traumaOccur with greatest frequency in the second and third decadeMost common sites are the earlobes (esp. posterior), upper back, midchest and shoulders
69Keloids cont’dMost widely recognized skin disorder in individuals with skin of color (15-20 X’s higherIncidence than in light toned skin)Can be differentiated from hypertrophic scars by their extension from the wound and reaction to steroid injectionRx modalities include: surgery , cryo, and steroid injxs
71Prevent When You Can Avoid nonessential surgery High recurrence rates Meticulous sterile techniqueMinimize skin tensionAb rx if secondary infectionPerioperative steroid injx (add triamcinoloneto Lidocaine 1% diluted to 2.5-5mg/ml)
72Acne 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 rxIngrown hairs, papules & pustules, alopecia & even large nodules may result
73Acne Keloidalis Nuchae cont’d Despite the name, lesion is NOT acne or keloidSxs include burning, itching, purulent drainage, and slowly growing nodulesMostly affects men age 15 – 28Early 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
77Pseudofolliculitis Barbae Irritant dermatitis found in 45% of AA menSame Pathogenesis – closely shaved coiled facial hairs have reentered the skin of the face & neckThe combination of aberrantly growing hairs and shaved fragments left in the skin causes a foreign body reactionAreas can become secondarily infected
79Management of Pseudofolliculitis Barbae Refrain from shaving for 1 month; skin-cleansing sponges provide gentle hair traction to decrease “ingrown hairs”Resume shaving with electric razorA magnifying mirror can be helpful in identifying looped hairs; use a needle to pull out the ingrown tipOral or topical antibiotics can be used if there is evidence of infectionWilliams DF. Consultant 1998; 38: 189.
80Sponging can add traction to help prevent ingrown hairs
81Of Possible Benefit … Chemical depilatories – Eflornithine (Vaniqa) Electrolysis – to lessen density and decrease ingrown hairs; may result in inflammatory papules and hyperpigmentation
82Traction AlopeciaGradual, patchy hair loss produced by chronic traction on the hair rootsCommon on the vertex or temporal-parietal areasDiscourage tight braiding in kids & adolescentsResolves within 3-4 months after cessation of casual tractionHeavy traction can result in follicular atrophy and permanent alopecia
84Pomade Acne (Acne Venata) Acne-iform eruptions due to the application of oily substances (vaseline, mineral oil) to hairDevelops in 70% of persons using pomades for long periodsTypically closed comedones, but may progress to papulopustules/hyperpigmentationDiscontinued application of oils and pomades usually results in resolution
86Management of Pomade Acne Show consideration for patient’s hair needsAvoid unreasonable requests such as “eliminate all hair care products”; better to suggest use qod etc.Retinoids (tretinoin) or adapalene (Differin) can help decrease comedone formationWash face bid with a-hydroxy acid or salicylic acid containing cleansers
87Dermatosis Papulosa Nigra Multiple smooth, dome-shaped, pigmented papules 1-5 mm in size on cheeks, neck and upper chest35 – 75% AA women affectedProbable genetic componentHistologically identical to seborrheic keratosesLesions may develop during adolescence; but peak incidence is in the 6th decade
92Mongolian Spots (or Blue-Grey Macules of Infancy) Single or multiple flat, blue-gray or black areas of hyperpigmentation with hazy bordersD/t the arrest of melanocytic migration in embryonic dermisPrevalence:African Amer 96%Native Amer 90%Asian 81 – 90%Hispanic 46 – 70%Require no rx; usually disappear by age 5NO risk of transformation to melanoma
93Common in Lumbosacral area Also legs/shoulders/tru
94Transient Neonatal Pustular Melanosis Vesicopustular eruption which affects about 5% of African American newbornsUnknown etiologyAffects face, trunk, palms & solesThe pustules are usually gone w/i hrsIf lesions rupture in utero newborn may have hyperpigmented macules (vs. erythema toxicum neonatorum wh has erythema surrounding lesions)Usually asymptomaticNo rx is requiredTypically resolves spontaneously
96Infantile Acropustulosis Pruritic pustular condition most common at 6-10 mos of age, but may occur in newborn periodDiscrete crops of 1-3mm papules/pustules on palms, soles & digitsCBC may show eosinophiliaRecurrent periods of eruption lasting 7 – 10 d; then remitting for 2 – 3 wks; then recurringRx – benadrylSpontaneous resolution by 2-3 yrs of age
98But Prominent Bumpiness – may actually be Lichen Nitidus
99Lichen NitidusThis is a papulosquamous dis. of unknown cause – innumerable pinhead-sized uniform flat-topped papulesCommon in African Amer kids – on forearms, chest, abdomen and penisKoebner’s phenomenon – lesions at sites of skin traumaRx: emollients, antihistamines, ammonium lactate cream 12% (Lac-Hydrin); steroid creams can be usedSelf-limited; resolves over months to yrs
100What is our Most Common Childhood Skin Disorder?
101Atopic DermatitisChronic dermatitis related to atopy (eczema) with exacerbations/remissionsCommon on face and flexural areas of extremitiesTransient erythema may be difficult to see in skin of color, but scratching can produce follicular papules, lichenification and hyperpigmentation or hypopigmentationXerosis (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 developOften +FH of asthma, allergies, eczemaEysenback G, Williams H, Diepgen TL. Antihistamines for atopic eczema. CochraneSkin Group. Cochrane Protocol. Issue 2, Oxford: Update Software.
102Atopic Dermatitis Common Sites Flexural Areas Note the hyperpigmentation
103Hand dermatitis before age 15 is common in adults withhand eczema
104Follicular Accentuation – common in eczema in SOC
105Scaling Rash of Scalp …… Think Fungal! Trichophyton tonsurans most common cause of Tinea CapitusCan 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 areataNot seen with Wood’s lamp (but Microsporum can be seen )Elewski B. Dermatol Clin 1996; 14: 23
106Tinea capitusUp Close …The black dots favor Dxover alopecia areata
107Pustular boggy areas? … may have associated Kerion Resist the temptation to I&D – oral rx isthe standard of care
108Treatment Oral antifungals BEST: Fluconazole 6mg/kg/d for 20d Add Ketoconazole 2% shampoo to decrease shedding & transmission to family members until curedGriseofulvin & Itraconazole are alternatives but have more side effects
109CreditsMuch 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