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

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

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

Fitzpatrick Skin Typing

Normal Variations in Individuals with Skin of Color

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

Pigmentary Demarcation Lines

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

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

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

Melanonychia Longitudinal …. Transverse …

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.

So … Benign

Acral Lentiginous Melanoma Wide band that extends length of nail

Another example …

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

Palmar Crease Hyperpigmentation

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.

Punctate Keratoses/Pits

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

Gingivae Hyperpigmentation

Oral Hyperpigmentation

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, 1981. 16.

Plantar Pigmentation

Common Skin Disorders Appearing Differently in Individuals with Skin of Color

What is this inflammatory skin disorder on the face?

Also Common on Ears and Neck

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.

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

Can be quite disfiguring d/t scarring and alopecia

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

Lesions can be Purple, Brown or Black in SOC

Lichen Planus

Lichen Planus

Genital LP

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

Oral Lichen Planus

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

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

Erythema may again be difficult to appreciate in SOC

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

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

Annular, hypopigmented Ulcerated

Ichthyosis

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.

Vitiligo Face Perioral and ocular

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, 2003. Oxford: Update Software.

Vitiligo

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.

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

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

TV on the Face

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.

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. 2014.

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.

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.

Psoriasis Guttate Plaque

Psoriasis Scalp Intertriginous Not all skin fold rashes are candidal

Psoriasis

Skin Disorders More Common in Skin of Color

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, 2003. Oxford: Update Software.

Melasma

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

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

Acne –induced PIH

Trauma-induced PIH

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

Keloid Scar

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

Earlobe Keloids Anterior Posterior

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)

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

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

Pathogenesis

Acne Keloidalis Nuchae

Acne Keloidalis Nuchae lesion requiring excision

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

“Razor Bumps”

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.

Sponging can add traction to help prevent ingrown hairs

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

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

Traction Alopecia

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

Pomade Acne

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

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

Dermatosis Papulosa Nigra

Famous Person …

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

Conditions Among Infants and Children

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

Common in Lumbosacral area Also legs/shoulders/tru

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 48-72 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

Transient Neonatal Pustular Melanosis

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

Infantile Acropustulosis

But Prominent Bumpiness – may actually be Lichen Nitidus

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

What is our Most Common Childhood Skin Disorder?

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, 2003. Oxford: Update Software.

Atopic Dermatitis Common Sites Flexural Areas Note the hyperpigmentation

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

Follicular Accentuation – common in eczema in SOC

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

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

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

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

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

Thank You! Questions???