Vol. 28. No. 2


During the past several years, dermatologic issues pertaining to people of color have become more pervasive in the literature and in the media. Research has shown that differences in skin properties and pathophysiology do exist among people of different ethnicities. It is likely that these differences attribute to an increased prevalence of certain skin conditions in darker skinned people, as well as differences in disease presentation and response to treatment. Because there is a general lack of awareness of exactly what these differences are, clinicians are often less confident in the diagnosis and management of skin conditions seen in their darker skinned patients. This issue of Seminars in Cutaneous Medicine and Surgery, the first of its kind, is dedicated to providing the most up-to-date information about dermatologic conditions that affect people of color. Each article is written by authors who are leading authorities on pigmented skin, many of whom are also pioneers in the research and education of their respected topics. This special issue is divided into the most clinically relevant topics pertaining to skin of color, including management of common skin disorders, pigmentary disorders, skin cancer, diseases affecting hair, and cosmetic considerations. The issue begins with a comprehensive update on managing common disorders in darker skin types led by Dr Andrew Alexis, Director of the Skin of Color Center at St. Luke’s-Roosevelt Hospital Center. Dr A. Paul Kelly, pioneer in skin of color education and research and Chairman of Dermatology at King-Drew Medical Center, provides an update on the pathogenesis of another common condition, keloids, and a practical approach to their management. Disorders of pigmentation can be devastating for patients both socially and psychologically, and unfortunately preferentially affect people with darker skin. Dr Pearl Grimes, leader of dyschromia research, Clinical Professor of Dermatology at the University of California Los Angeles and Director of the Vitiligo and Pigmentation Institute of Southern California, provides a comprehensive review of the pathogenesis and most ground-breaking treatments for post-inflammatory hyperpigmentation and melasma. Dr Rebat Halder, dyschromia expert and Professor and Chairman of the department of dermatology at Howard University College of Medicine, reviews the latest advances in the etiology and pathogenesis of vitiligo and provides an evidence-based approach to the management of the vitiligo patient. Although skin cancer is a well-described subject within the field of dermatology, the etiopathogenesis in people of color is not as clear. The next two articles focus on skin cancer in people of color, as Dr Brooke Jackson, Mohs surgeon and Director of the Skin Wellness Center of Chicago, reviews nonmelanoma skin cancer, and Dr Mohammed Kashani- Sabet, Director of the Melanoma Center at the University of California San Francisco, leads a discussion of recent melanoma trends among African-, Asian-, Latin-, and Native- American people. Other than pigmentary disorders, diseases affecting hair are one of the most common complaints among those with skin of color and especially African-American patients. Hair care practices among African-American women are often poorly understood by non-African-American clinicians, yet important for dermatologists to understand given the propensity for some of these practices to lead to hair disorders. Dr Amy McMichael, Professor of Dermatology at Wake Forest University School of Medicine and editor of Hair and Scalp Diseases: Medical, Surgical, and Cosmetic Treatments, provides an in-depth review of common hair care practices in African-American patients and their consequences. Professor of Dermatology at the University of California San Francisco and hair authority, Dr Vera Price, addresses the diagnostic challenges that clinicians face when presented with hair loss and provides a practical approach to diagnosing and managing hair loss in women of color. Finally, with ethnic patients now accounting for approximately 24% of cosmetic patients, an 11% increase since 2007, cosmetic considerations in skin of color are addressed. Dr Lily Talakoub and I review differences in perception of beauty and cosmetic procedures performed in people of different ethnic backgrounds. Dr Eliot Battle, laser authority in darker skin types and director of Cultura Medical Spa, reviews the indications, benefits, potential risks, and treatment of complications associated with the use of lasers in darker skin. It has been an honor to work with this gifted and inspira- tional group of authors in creating this issue. I sincerely hope that the readers of this issue of Seminars in Cutaneous Medicine and Surgery find the information provided helpful and applicable to their daily practice. In addition, I hope that the issue is useful for the brilliant minds that will further research and delineate the differences and unique qualities of skin of color patients.

Update on the Management of Keloids

A. Paul Kelly, MD

Keloids are scars, unique to humans, that grow beyond the boundaries of a cutaneous
injury, inflammation, burn, or surgical incision. Although benign, keloids are often aesthetically
malignant. The etiology of keloids is uncertain. However, we do know that they occur
more often in African-American and Asian than Caucasian patients. There is no one
therapeutic modality that either prevents the formation of keloids or treats active or inactive
lesions. Consequently, there are many therapeutic options. In this review, an approach to
medical and surgical management of keloids is provided, as well as a review of experimental
therapeutic modalities.
Semin Cutan Med Surg 28:71-76 © 2009 Published by Elsevier Inc.


Managing Common Dermatoses in Skin of Color

Andrew F. Alexis, MD, MPH | Marcelyn K. Coley, MD

The demographics of the United States continue to evolve, with a growing proportion of the
population consisting of non-Caucasian racial and ethnic groups. As darker skin types
become more prevalent, so will the need to better understand their skin, the conditions that
affect it, and optimal approaches for treatment. This population poses a special challenge
for practitioners in part as a result of the sequelae often associated with the conditions in
their own right—postinflammatory hyperpigmentation and scarring—and potential iatrogenic
adverse effects that may occur during treatment. Through careful consideration of
cultural, clinical, and therapeutic nuances, safe and effective management of common
disorders in skin of color is achievable.
Semin Cutan Med Surg 28:63-70 © 2009 Elsevier Inc. All rights reserved.


Management of Hyperpigmentation in Darker Racial Ethnic Groups

Pearl E. Grimes, MD

Dyschromias, in particular hyperpigmentation, are major issues of concern for people of
color. Pigmentary disorders such as melasma and postinflammatory hyperpigmentation
(PIH) can cause psychological and emotional distress and can pose a negative impact on
a person’s health-related quality of life. The precise etiology of these conditions is unknown.
Therapies for melasma and PIH target various points during the cycle of melanin
production and degradation. Therapies for these conditions include topical agents and
resurfacing procedures. Hydroquinone remains the gold standard of topical agents. Other
efficacious agents include kojic acid, azelaic acid, mequinol, and retinoids. Cosmeceutical
agents include licorice, arbutin, soy, N-acetyl glucosamine, and niacinamide. Resurfacing
procedures that have been used to treat melasma and PIH include chemical peels, microdermabrasion,
lasers, and intense pulsed light. These procedures are best used in combination
with topical bleaching agents. Given the propensity of darker skin to hyperpigment,
resurfacing procedures should be used with care and caution. Maximal results are best
achieved with repetitive, superficial, resurfacing modalities. In addition, ultraviolet protective
measures such as broad-spectrum sunscreens are fundamental to the successful
management of these conditions.
Semin Cutan Med Surg 28:77-85 © 2009 Elsevier Inc. All rights reserved.


Vitiligo Update

Johnathan L. Chappell, MD | Rebat M. Halder, MD

Vitiligo is an acquired dyschromia of the skin in which there is a loss of epidermal
melanocytes. The prevalence of vitiligo is approximately 1% in the United States and
0.1-2% worldwide. The exact pathogenesis of vitiligo remains elusive and is likely multifactorial.
After completing this update, participants should be able to discuss the epidemiology
of vitiligo and summarize the proposed mechanisms for development of this
disease. In addition, they should be able to discuss physical findings, approach to the
patient, and some of the therapeutic modalities for this disorder.
Semin Cutan Med Surg 28:86-92 © 2009 Elsevier Inc. All rights reserved.


Nonmelanoma Skin Cancer in Persons of Color

Brooke A. Jackson, MD

Skin cancer is the most common form of cancer in the United States. Although skin cancer
is less common in persons of color than in Caucasians, the rates of morbidity and mortality
associated with skin cancer often are significantly greater in darker-skinned ethnic groups.
This article reviews special considerations in the approach and management of nonmelanoma
skin cancer in patients of color.
Semin Cutan Med Surg 28:93-95 © 2009 Elsevier Inc. All rights reserved.