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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 3040% 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 sunexposed 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. 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, scarlike 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 noncaseating 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 –
• 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
– Apply for 5min qd X 3
– Px: Apply for 10min./mo.
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
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Acne vulgaris
Folliculitis
Eczema
Tinea
Impetigo
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•
•
•
Drug eruptions
Lichen planus
Psoriasis
Lichen simplex
chronicus
• Trauma (scratches,
abrasions …)
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
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•
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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; skincleansing 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
Native Amer
Asian
Hispanic
96%
90%
81 – 90%
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???