December 04, 2018

Nearly 50% of dermatology residents and dermatologists indicate that they have received inadequate training on skin conditions in people of color.

According to the United States Census Bureau, people of color will comprise an estimated 50% of the US population by the year 2050.¹ This ever-increasing diversity underscores the need for healthcare providers to be educated about differences in clinical presentation and outcomes of conditions in people of color compared with white patients. In a US survey published in 2011, 47% of dermatologists and dermatology residents indicated that they had received inadequate training on skin conditions in people of color.²

“Skin of color, also known as ethnic skin, traditionally refers to that of persons of African, Asian, Native American, Middle Eastern, and Hispanic backgrounds. These skin types are usually categorized as Fitzpatrick types III to VI, and are more richly pigmented,” as stated in a 2013 paper published in American Family Physician.¹ “There are notable differences in skin disease incidence, presentation, and treatment based on skin type…. due to structural and functional differences in the skin and hair, as well as the influence of cultural practices.”

Andrew F. Alexis, MD, MPH, chair of the department of dermatology and director of the Skin of Color Center at Mount Sinai St Luke’s and Mount Sinai West in New York and associate professor at the Icahn School of Medicine at Mount Sinai, highlighted 5 conditions that affect people of color with greater frequency compared with other populations.

Central Centrifugal Cicatricial Alopecia (CCCA)

CCCA is a common cause of permanent, scarring hair loss that predominantly affects black women. It is diagnosed by in-office examination and biopsy of the scalp.³Clinically, there is a centrally located patch of diminished hair growth with a reduction of follicular ostia. Bogginess may be appreciated on palpation.

CCCA is treated with anti-inflammatory medications including oral doxycycline, intralesional triamcinolone, and topical corticosteroids; growth stimulating agents such as minoxidil 5% foam; and haircare modifications including avoidance of traction-associated styles and minimization of scalp exposure to heat and chemical relaxers. The goal of treatment is to reduce inflammation and further hair loss.

Dr Alexis and colleagues at Mount Sinai West are currently enrolling participants for an open-label pilot study investigating the efficacy of apremilast in the treatment of CCCA.

Melasma

Women comprise approximately 90% of those with melasma, which most commonly affects people of color.⁴ In a recent study, the most frequently reported triggers were pregnancy (40%), sun exposure (37%), and hormonal oral contraception use (22%).⁵Melasma is typically characterized by symmetric tan brown patches that may involve the cheeks, forehead, and upper lip. Wood’s light can be helpful in distinguishing predominantly epidermal vs dermal melasma.

The condition is treated with combination therapy, including a hydroquinone- and nonhydroquinone-based topical bleaching agent; in-office procedures such as chemical peels and low-density nonablative fractional lasers; and vigilant photoprotection.

Pseudofolliculitis Barbae

The highest prevalence of this disorder is found among men of African descent, with a reported prevalence of 45% to 85%, followed by Hispanic men.⁶ Characteristic clinical features include perifollicular inflamed papules or pustules in areas of shaving — for example, the male beard or the underside of the female chin, and evidence of coarse hair shafts reentering the skin may also be seen on close examination. Associated hyperpigmentation is common.

Treatment consists of the use of topical retinoids and clindamycin lotion. In-office procedures such as chemical peels and laser hair removal are also useful — the latter being associated with long-term remission.

Atopic Dermatitis

This condition is more common in African Americans and Asian Americans/Pacific Islanders (with 2-fold and 6-fold greater number of related doctor’s visits) compared with whites and is often more severe at the time of diagnosis in people of color.^2,7

Erythema may be more challenging to detect in darker skin types. Lesions are typically “hyperchromic” rather than red and may appear to be red-brown, dark brown, or grayish in color depending on the skin type and severity of the condition.

Early and efficacious treatment is important given the higher risk for long-term sequelae such as postinflammatory hyperpigmentation and hypopigmentation, as well as permanent depigmentation in areas of longstanding severe disease that have been excoriated for many years.

Multisystem Disorders

Certain multisystem disorders are more prevalent in skin of color, including sarcoidosis, discoid lupus erythematosus, and scleroderma.

According to conservative estimates, there is a 3-fold incidence of sarcoidosis in individuals of African vs European descent.⁸ The disease can present in myriad ways. One common presentation in African Americans is dermal flesh-colored papules on the face — especially periorificially. This variant usually responds to oral minocycline.

Studies suggest that the prevalence of systemic lupus erythematosus is 2-fold to 3-fold higher in people of color of various ethnicities compared with people of European origin.⁸ People with discoid lupus erythematosus frequently have oval-shaped patches or plaques on the scalp or face. Hyperpigmentation or hypopigmentation can be seen within lesions. Treatment consists of topical or intralesional corticosteroids with or without hydroxychloroquine, depending on the severity of disease.

The highest prevalence of scleroderma is observed in Choctaw Indians, and rates are 1.5 to 3.5 times greater among people of African vs European descent.⁸ The disease may present with “salt-and-pepper”-like dyspigmentation, especially on the upper trunk. These involved areas are indurated and, when found, warrant examination of the digits and screening for systemic signs and symptoms.

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References

1. Kundu RV, Patterson S. Dermatologic conditions in skin of color: part I. Special considerations for common skin disorders. Am Fam Physician. 2013;87(12):850-856.

2. Buster KJ, Stevens EI, Elmets CA. Dermatologic health disparities. Dermatol Clin. 2012;30(1):53-59.

3. Heath CR, Robinson CN, Kundu RV. Central centrifugal cicatricial alopecia (CCCA). http://skinofcolorsociety.org/dermatology-education/central-centrifugal-cicatricial-alopecia-ccca/. Accessed November 16, 2018.

4. Pandya AG. Melasma. http://skinofcolorsociety.org/dermatology-education/1406-2/. Accessed November 16, 2018.

5. D’Elia MPB, Brandão MC, de Andrade Ramos BR, et al. African ancestry is associated with facial melasma in women: a cross-sectional study. BMC Med Genet. 2017;18(1):17.

6. Kundu RV, Patterson S. Dermatologic conditions in skin of color: part II. Disorders occurring predominately in skin of color. Am Fam Physician. 2013;87(12):859-865.

7. Janumpally SR, Feldman SR, Gupta AK, Fleischer AB Jr. In the United States, blacks and Asian/Pacific Islanders are more likely than whites to seek medical care for atopic dermatitis. Arch Dermatol. 2002;138(5):634-637.

8. Petit A, Dadzie OE. Multisystemic diseases and ethnicity: a focus on lupus erythematosus, systemic sclerosis, sarcoidosis and Behçet disease. Br J Dermatol. 2013;169(Suppl 3):1-10.