Dermatologic Disorders in Patients of Color: Clinical Pearls

Educational Objectives

The goal of this program is to improve management of dermatologic conditions in patients of color. After hearing and assimilating this program, the clinician will be better able to:

1. Counsel parents about treatment and prevention of common pediatric dermatologic conditions, such as diaper dermatitis and tinea capitis.

2. Describe mechanisms that cause vitiligo, keloids, and pseudofolliculitis barbae.

3. List treatment options for acne and atopic dermatitis.

Summary

Skin pigmentation: number of melanocytes same in all skin colors; difference in skin color due to amount of melanin produced by melanocytes; types of melanin include pheomelanin (imparts brown to orange color) and eumelanin (imparts brown and black color); melanocyte-keratinocyte unit consists of one melanocyte and ≈40 keratinocytes to which it supplies melanin; melanocytes 1% to 2% of cells in skin; melanocytes can move in skin, and feed keratinocytes with melanin via dendrite-like projections; UV exposure causes melanocyte to release premade melanin and triggers mechanism to produce additional melanin

Postinflammatory Pigmentation

Case presentation: patient presents with scarring and keloidal formation after spilling hot water on hand; results in postinflammatory hyper- and hypopigmentation (inform patient this may last 4-6 mo, and that topical agents may not be fully effective); management — keep skin hydrated with, eg, moisturizer or emollient twice daily to even skin tone; reassure patients that lighter areas of skin (especially from irritation) not due to vitiligo; hydroquinone may even skin tone (no reported problems); phototherapy may be useful for hypopigmentation; set patient’s expectations

Diaper dermatitis: melanocytes become dormant due to chronic irritation (eg, diaper rash); common in children of color; results in postinflammatory hypopigmentation; easily treated; management — discuss causes (ie, mild irritation from urine in diaper) with parents; reassure parents hypopigmentation not permanent and not due to vitiligo; treatment — apply cream containing acid mantle and antidermatophyte and topical lidocaine (eg, LidaMantle cream; restores natural pH of skin and decreases yeast growth) after diaper changes; color should return in 1 mo; change diapers frequently

Vitiligo: more severe on darker skin; challenging in adolescents; causes — 20% of cases due to premature cell death; 3 out of 4 cases due to immune attacks on certain melanocytes usually in background of halo nevus (trauma, insult, or injury [eg, scratch or insect bite] to mole causes immune system to attack melanocyte-filled mole, resulting in attack on other melanocytes); common in patients with multiple halo nevi; associated with anemia and thyroid disease; T cells usually attack melanocytes; treatment — class IV steroid (nonhalogenated; gentle); hydrocortisone cream (eg, Westcort 0.2% cream) effective; anecdotal reports suggest topical vitamin D helps return skin color, and protects melanocytes from additional destruction from immune system (same results not seen with oral vitamin D); calcipotriene (Dovonex) cream; once-daily anti-inflammatory steroid-sparing agent (eg, tacrolimus [Prograf, Protopic] or pimecrolimus [Elidel; black-box warning; no reported cases of lymphoma related to use); phototherapy — UV-B shuts down Langerhans cells that direct immune attack; effective for inflammatory conditions (eg, vitiligo, eczema, pruritus, psoriasis); results seen in 2 mo

Pityriasis alba: common (especially on cheeks of adolescents); skin becomes dry and irritated; melanocytes stop producing color; treatment — mild topical class V or VI steroid twice daily for 30 days plus emollient; phototherapy (2-3 times/wk for 1 mo); hydrate skin; reassure parents not due to vitiligo

Dermatosis papulosa nigra: histologically resembles seborrheic keratoses; genetic; easy to treat; treatment — hyfrecation or electrodesiccation on lowest setting under local anesthesia (consider lorazepam [Ativan, Lorazepam Intensol; 2 mg] or diazepam [Diastat AcuDial, Diazepam Intensol, Valium; 20 mg] for anxious patients; patient must have a driver); may cause mild hyperpigmentation (rare; use hydroquinone cream for 1-2 mo)

Acne: address active acne and postinflammatory hyperpigmentation; frame patient’s expectations (eg, “I’m going to treat your active acne, and treat residual dark spots afterwards”); treatment routes — 1) traditional suppressive route; topical retinoids (eg, tretinoin [eg, Altinac, Retin-A, Vesanoid]), adapalene (Differin), tazarotene (Avage, Tazorac); topical anti-inflammatory agents, eg, antibiotics (eg, clindamycin [eg, Cleocin, Clindagel, ClindaMax Lotion] or erythromycin [eg, Akne-Mycin, Emgel, Erygel]); oral anti-inflammatory agents, eg, antibiotics (eg, tetracycline, minocycline, amoxicillin); bacteriostatic agents, eg, benzoyl peroxide (eg, Acne 5, Clearasil Maximum Strength, Proactiv); 2) remittive treatment; eg, combination of laser therapy and α-hydroxy acid peels; 3) oral retinoids; can be curative; treat hyperpigmentation

Xerosis: dry skin; hyperkeratosis on skin surface makes skin appear gray or “ashy”; general skin care — gently cleanse, hydrate, and protect skin (with sunscreen)

Keloids: overrepairing of skin; normally after skin injury, fibroblasts produce collagen to repair skin damage, but in certain patients, activated fibroblasts fail to receive deactivation signal, leading to overrepair and heaping masses of collagen (keloids); can be caused by mild acne; common on back and chest; easy to treat; difficult to prevent recurrences; treatment — for keloids on earlobes, use pressure earrings overnight for 6 mo; when injecting keloids, use tuberculin syringe with fused end for easy injection (give twice-monthly injections for 3 mo, then once monthly for 3 mo to prevent recurrences); supplement with topical silicone scar gel (eg, Dermatix)

Acne keloidalis nuchae: common; can be mild or severe; may be associated with prurigo nodularis and lichen simplex chronicus; treat itchiness with minocycline (100 mg twice daily for 2 mo, then once daily for 2 mo; should be taken with food); topical class I or II steroid ointment (eg, betamethasone [Diprolene, Diprolene AF]) twice daily for 2 to 3 mo, then once daily for 3 mo; itching resolves within 1 mo

Pseudofolliculitis barbae: razor bumps; inflammatory reaction (eg, bumps, pustules, hyperpigmentation) to regrowth of curly hair or hair oriented at oblique angle to skin after being cut too short; occurs in beard area when hair grows sideways under skin; treatment — educate patient about cause; eliminate cause; laser hair removal targets melanin (can result in severe burns on brown skin; pulse duration of laser can be changed to selectively target melanosomes in hair rather than in skin; expensive); eflornithine (Ornidyl, Vaniqa; slows hair growth; feathers and softens tips of hairs) twice daily; cut hair after bathing or showering when hair is wet (cutting dry hair with razor results in sharp, pointy tip more likely to cause razor bumps); dislodge hairs with toothbrush; anti-inflammatory class VI steroid or over-the-counter hydrocortisone at bedtime; hydroquinone-containing cream for discoloration

Tinea capitis: occurs in children, but entire family must be treated (sebum in adult skin prevents full clinical infection); treatment — ketoconazole (Nizoral Cream Shampoo) for 2 mo; griseofulvin for 2 mo; terbinafine (Lamisil) tablets (5 mg/kg) once daily (maximum 250 mg/day) for 6 wk; treat fomites by, eg, sealing children’s caps, brushes, and barrettes with 5 mothballs in trash bag for 1 wk to prevent reinfection; warn patients that certain subset of patients may develop brisk inflammatory response (kerion with pus; resolves in 1 wk; occurs ≈10% of time; treatment should be continued); no liver testing required for use of griseofulvin in children being treated for ≤2 mo

Atopic dermatitis: affects entire family; can be controlled, but not cured; improves over time; important to recognize triggers; mild disability to repair skin barrier; treatment — reduce enzymatic irritation of skin from bacteria; rarely caused by food; bathe daily and use emollient; sleeping well important for school performance; can flare with common cold, earache, or dry skin during winter; can improve in 1 mo with treatment; ceramide-containing cream (eg, CeraVe Moisturizing Cream); bleach baths once weekly (add 2 capfuls of bleach to bath water); wash bedding and pajamas once weekly; mild class V steroids twice daily for 5 days; desonide (DesOwen, Tridesilon) for mild flares; Westcort for moderate flares

Melanonychia striata: may develop on all fingers and toes; reassure patients normal variation in skin of color

Readings

Alexis AF et al: Common dermatologic disorders in skin of color: a comparative practice survey. Cutis. 2007 Nov;80(5):387-94; Alster TS, Tanzi EL: Hypertrophic scars and keloids: etiology and management. Am J Clin Dermatol. 2003;4(4):235-43; Carten ML et al: Characteristics of Foreign-Born HIV Infected Individuals and Differences by Region of Origin and Gender. J Immigr Minor Health. 2012 May 5 [Epub ahead of print]; Davis SA et al: Top dermatologic conditions in patients of color: an analysis of nationally representative data. J Drugs Dermatol. 2012 Apr;11(4):466-73; Grover C et al: Comparative evaluation of griseofulvin, terbinafine and fluconazole in the treatment of tinea capitis. Int J Dermatol. 2012 Apr;51(4):455-8; Kleinert S et al: Screening for latent tuberculosis infection: performance of tuberculin skin test and interferon-γ release assays under real-life conditions. Ann Rheum Dis. 2012 May 14 [Epub ahead of print]; Liu Y et al: Estimating the impact of newly arrived foreign-born persons on tuberculosis in the United States. PLoS One. 2012;7(2):e32158; Lupo MP: Dermatosis papulosis nigra: treatment options. J Drugs Dermatol. 2007 Jan;6(1):29-30; Morrison TB et al: Disparities in Preventive Health Services Among Somali Immigrants and Refugees. J Immigr Minor Health. 2012 May 15 [Epub ahead of print]; Penrose K et al: Vitamin D Deficiency Among Newly Resettled Refugees in Massachusetts. J Immigr Minor Health. 2012 Mar 13 [Epub ahead of print]; Vesenbeckh SM et al: The use of interferon gamma release assays in the diagnosis of active tuberculosis. Tuberc Res Treat. 2012;2012:768723; Walker P. Immigrant Health. China: Elsevier Inc.; 2007; Walker PF, Jaranson J: Refugee and immigrant health care. Med Clin North Am. 1999 Jul;83(4):1103-20; Zhou L et al: Systemic analyses of immunophenotypes of peripheral T cells in non-segmental vitiligo: Implication of defective natural killer T cells. Pigment Cell Melanoma Res. 2012 May 16 [Epub ahead of print].

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Crutchfield spoke in Minneapolis, MN, at 26th Annual Family Medicine Today Primary Care Update: How to Know More About Everything, presented March 8-9, 2012, by the Department of Family Medicine, HealthPartners Medical Group & Clinics and Center for Continuing Professional Development, HealthPartners Institute for Medical Education. Visit www.imehealthpartners.com for information about upcoming meetings. The Audio-Digest Foundation thanks the speaker and the sponsor for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

FP602601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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