Experts urge competence treating diseases in all skin colors

Different skin colors react differently to the same treatment.

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S041 – Skin of Color
Saturday, March 26 | 1-4 p.m.
Room: 206B

Even though nearly half of the U.S. population, and most of the global population, has non-Caucasian skin, physicians still often encounter clinical images that feature only light-colored skin. Treating disease in a diverse range of skin colors requires knowledge and skill. Quite simply, different skin colors react differently to the same treatment. These issues will be discussed in depth during S041 – Skin of Color, happening today in Room 206B, from 1-4 p.m.

Diseases can present differently

“For example, if you do a chemical peel on someone with very light skin, they usually tolerate it well, recover, and have improvement in their appearance. But if you do the same peel on someone with darker skin, they may have profound hyperpigmentation or hypopigmentation and those changes can persist for weeks or months. If you don’t have knowledge or experience in the management of skin of color, you can make important errors in treatment,” said Amit G. Pandya, MD, FAAD, clinical professor of dermatology at The University of Texas Southwestern Medical Center and practicing dermatologist at the Palo Alto Foundation Medical Group in Sunnyvale, Callifornia. Dr. Pandya is among the speakers at today’s session.

Black patients are more likely to have central centrifugal cicatricial alopecia (CCCA), which manifests as scarring over the vertex scalp and expands outward circumferentially, than women with lighter skin. Black women are also more likely than women of other skin colors to develop traction alopecia, which begins as a nonscarring hair loss at the frontal scalp and progresses to scarring alopecia at the lateral sides of the scalp. Women of European descent more often have frontal fibrosing alopecia and typical lichen planopilaris.

Early detection

“The best practice in early diagnosis of cicatricial alopecia is to recognize mild disease early with trichoscopy and/or biopsy,” said Amy McMichael, MD, FAAD, professor and chair of dermatology at Atrium Wake Forest Baptist Medical Center. When early disease is found, it is important to treat with antiinflammatory topicals, injection,and systemic treatments long term. In the post-inflammatory stages, topical and oral minoxidil can be used for follicular rescue,” she said.

“There is a real need for dermatologists to be competent in recognizing how skin disease appears in all skin colors and how to approach the cultural skin and hair practices of all ethnicities,” Dr. McMichael added.

Hidradenitis suppurativa common in Black Americans

Just as skin cancer disproportionately affects lighter skin types, hidradenitis suppurativa (HS) is more common in individuals of African ancestry. Black Americans have three times the prevalence of HS compared to the general population, said Iltefat Hamzavi, MD, FAAD, lead at the Multicultural Dermatology Clinic, and director of the Hidradenitis Suppurativa Clinic at Henry Ford Hospital.

“It takes about seven years for the typical patient to get an HS diagnosis, so recognizing and treating it early can dramatically improve care,” he added. “A dermatologist can diagnose HS in 10 seconds with just two questions.”

Treatment has improved dramatically in recent years, including antibiotics, biologics, and surgery. Recent work suggests that Black patients with HS may be a subpopulation at lower risk of developing keloids following surgery, Dr. Hamzavi said.

HS patients do not take longer than the typical dermatology patient,” he said. “You just have to know what to do and to connect them with HS support groups. HS carries so much psychological trauma that support groups are critical for this community, online and in person.”

Stay cognizant of keloids

Keloids are not more common in skin of color but can occur in all races and ethnicities. On darker skin, the plaques and papules are skin-colored to hyperpigmented.

“You see keloids on individuals of European ancestry, but they don’t tend to be as protuberant as on darker skin,” said Donald Glass II, MD, PhD, FAAD, associate professor of dermatology at The University of Texas Southwestern Medical Center. “Dermatologists should be cognizant of keloids occurring across all skin tones. With the mix of ancestries in the United States, a Caucasian person may be able to develop keloids similar to a Black individual.”

Accurate diagnosis can be lifesaving. Keloids and dermatofibrosarcoma protuberans (DFSP) share common surface features, although DFSP tends to spread more than keloids.

“If you have what looks like an atypical keloid, if you palpate around the margin and find areas of induration, be concerned for DFSP,” Dr. Glass said. “Keloids don’t tend to send out roots underneath normal-appearing skin and DFSP can do that. Don’t be afraid to do a biopsy — you want to be sure you’re not missing something worse.”

Complications of vitiligo

Today’s session will also include in-depth discussion of vitiligo.

“About 1.5% of the population gets vitiligo regardless of skin type,” said John E. Harris, MD, PhD, FAAD, professor and chair of dermatology, founding director of the Vitiligo Clinic and Research Center and the Autoimmune Therapeutics Institute at University of Massachusetts Chan Medical School.

“Light skin has the complication of darkening in summer so you see the vitiligo that you can’t see in winter. A lot of people with light skin and vitiligo fear the sun because the vitiligo will ‘relapse’ in summer. I’m hoping that dermatologists will stop telling patients there’s no treatment; nothing to be done. That’s far from the truth.”

There is no cure for vitiligo, he said. But UVB treatment can dramatically reduce the severity of vitiligo in both light and dark skin and ease the psychosocial burden it can bring.

“Too many dermatologists are not familiar with the differences in skin of color compared to lighter skin,” Dr. Harris said. “And those differences can be critical to diagnosis and treatment. Even those dermatologists who practice in areas where they don’t see a lot of skin of color need to be prepared to take care of all their patients.”

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