According to projections from the United States Census Bureau, people with skin of color will comprise approximately half of the U.S. population by 2050. This group, which includes African-Americans, Asians, Latinos and other ethnicities, are more prone to certain dermatologic problems than those with lighter skin tones due to their genetic make-up and in some cases cultural practices. For that reason, dermatologists - who understand the nuances of different skin tones - are poised to help patients of color by diagnosing and treating these conditions.
Speaking today at the 68th Annual Meeting of the American Academy of Dermatology (Academy), dermatologist Andrew F. Alexis, MD, MPH, FAAD, assistant clinical professor of dermatology at Columbia University College of Physicians and Surgeons and staff member at St. Luke's-Roosevelt Hospital Center, both in New York, discussed the leading medical and cosmetic dermatologic concerns in darker-skinned populations.
"Although people of color have more natural protection from ultraviolet (UV) radiation due to the increased amount of melanin in their skin, the cells that make melanin pigment tend to be more reactive to inflammation and injury, and therefore pigmentation problems are more common in skin of color," said Dr. Alexis. "These natural genetic factors, coupled with cultural differences in their skin and hair care practices, can result in differences in the appearance of common dermatologic conditions and the frequency in which they can occur."
Treating Pigmentation Disorders Takes Patience
The most common pigmentation problem (dyschromia) of the skin that can occur in people of color is post-inflammatory hyperpigmentation (PIH), which refers to increased pigmentation or dark spots at the sites of inflammation. Acne is one trigger for PIH, and the resulting dark spots often can be of equal or greater concern than the original pimples.
Dr. Alexis explained that although there are several effective treatments that can be used for PIH, none of these treatments are quick fixes and each requires time to take effect - from several weeks to several months in most cases. Common treatments include retinoid creams (vitamin A derivatives), bleaching creams (containing hydroquinone) and chemical peels.
"While in-office procedures, such as chemical peels or any skin resurfacing cosmetic treatment, can help correct pigmentation problems, they have to be administered with caution due to the higher risk of inducing other pigmentary abnormalities," stated Dr. Alexis. "That's why it is important to consult a dermatologist with an expertise not only in using these procedures, but in treating darker skin tones as well."
Melasma, often referred to as the "mask of pregnancy," is the second most common pigmentation problem occurring in skin of color patients. More women than men are affected by melasma, but the condition can occur independent of pregnancy and is commonly seen in people in their 40s, 50s and 60s. The cause of melasma is a combination of genetic and hormonal factors and UV exposure. Dr. Alexis added that melasma can be treated with the same topicals and in-office procedures used for PIH, and in some cases, lasers can be effective.
Since sun exposure can worsen dark spots, Dr. Alexis stressed that year-round sun protection is extremely important. "I recommend that my patients wear a moisturizer with sunscreen every day to protect their skin from further damage," said Dr. Alexis.
Solving Hair Problems Can Require Changing Habits
One common follicular problem that affects a disproportionate number of dark-skinned patients, particularly African-Americans, is pseudofolliculitis barbae (also known as razor bumps). Dr. Alexis noted that several studies have reported that pseudofolliculitis barbae affects an estimated 45 to 83 percent of African-American men. The cause of this condition stems from the structure of the hair follicle, which is curved in people with skin of color. Pseudofolliculitis barbae is aggravated by shaving, as it can cause the sharp tip of shaved hair to grow back into the skin and results in a bump.
Dr. Alexis advises patients affected by pseudofolliculitis barbae to discuss ways to modify their shaving habits with their dermatologist. He also noted that there are several effective treatment options available. For example, lasers have evolved over the years and can now be safely used to reduce and remove hair in skin of color patients. Two lasers Dr. Alexis recommends for use with darker skin are the 810 nanometer (nm) diode laser and the 1064nm Nd:YAG laser. Topical creams and gels also are effective in treating pseudofolliculitis barbae, including topical retinoids, topical antibiotics, topical steroids and the topical prescription medication eflornithine.
"Women of color also can be affected by pseudofolliculitis barbae, as they often wax or shave unwanted hair on their chin and neck that can cause these bumps and skin discoloration," said Dr. Alexis. "Many of these women are finding laser hair removal to be an effective treatment option for this problem."
Hair loss is another dermatologic concern in patients with skin of color. Traction alopecia is a form of hair loss caused by hairstyles (such as braids) that put tension on the hair and is most common in African-American women. "The majority of cases of traction alopecia are reversible, but patients must be willing to style their hair differently to stop and reverse hair loss," said Dr. Alexis. "Dermatologists also can administer injections of steroids into the affected areas, which we find can be quite effective if started early in the course of the condition."
Another form of hair loss common in dark-skin individuals that can be more difficult to treat is central centrifugal cicatricial alopecia (CCCA). Although the cause of CCCA is unknown, it also is thought to be related to common hair care practices in African-American women. Often referred to as "hot comb alopecia", this type of hair loss begins on the crown of the scalp and gradually spreads out to other areas of the scalp.
Dr. Alexis noted that once a hair follicle is scarred, it cannot produce hair any longer, but if caught early, hair loss can be treated with a variety of anti-inflammatory therapies, including injections into the affected areas of the scalp, topical steroids and oral antibiotics. Dr. Alexis added that minoxidil can be used in conjunction with anti-inflammatories to try to stimulate hair growth in healthy hair follicles.
Reversing Cosmetic Dermatologic Concerns Can Be Done Safely
Dr. Alexis explained that the water content of the skin decreases with age, especially when people enter their 60s. For people of color, this change in the water content of their skin can create an ashen look if they do not use moisturizers to help counteract the water loss. Other changes in the skin include textural irregularities, such as roughness, enlarged pores and dullness.
To help reverse some of these telltale signs of aging in darker-skinned individuals, a variety of topicals and non-invasive procedures can be used safely and effectively - including retinoids and other cosmeceuticals, chemical peels, and non-ablative laser resurfacing. Fillers can be used to correct nasolabial folds (lines around the mouth) and botulinum toxin is effective in softening wrinkles.
"It is important to note that injections of both fillers and botulinum toxin can be performed safely in darker-skinned patients, and these procedures are increasing in popularity with these patients to address aging skin," said Dr. Alexis.
Another skin condition that is common in African-American patients as they age is dermatoses papulosa nigra (DPNs), also referred to as flesh moles. These small, brown moles are especially common in the cheek area and can be removed by a dermatologist who carefully will remove these skin growths to minimize any injury to the skin.
"While people of color are prone to many unique medical and cosmetic skin conditions, dermatologists are well equipped to treat them using a variety of safe and effective treatment options," said Dr. Alexis. "The key is to seek treatment early."
American Academy of Dermatology