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DERMATOLOGIC ISSUES IN PEOPLE OF COLOR

Jun

2009

Vol. 28. No. 2

Introduction

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.

Melanoma Arising in African-, Asian-, Latino- and Native-American Populations

Brenda A. Shoo, MD | Mohammed Kashani-Sabet, MD

This review highlights melanoma trends observed among African-, Asian-, Latino- and
Native-American populations. Melanoma is the most lethal form of skin cancer, accounting
for about 75% of all skin cancer deaths. Generally, incidence rates increase with age, peak
after age 40, and are greater in men than women. However, these trends do not reflect what
is typically seen in minority ethnic groups, where incidence rates are lower. In addition, for
some groups, relative disease-specific survival also is lower compared with European-
Americans. Melanomas in minority populations also tend to appear in atypical locations
and are of unclear etiology. To improve our understanding of the causes of melanoma
arising in ethnic minority populations future research efforts are needed. In addition, the
general lack of awareness of this disease entity among minority populations and the fact
that certain ethnic groups tend to present with advanced disease further highlight the need
for educational programs for both patients and health care professionals.
Semin Cutan Med Surg 28:96-102 © 2009 Elsevier Inc. All rights reserved.

Hair Care Practices in African-American Patients

Amy J. McMichael, MD | Ingrid E. Roseborough, MD

The unique properties of hair in those patients of African descent allow a limitless range of
hair-care options. For the clinician, a general understanding of hair-care practices is an
important aid in the diagnosis and treatment of hair shaft and scalp disorders. This review
highlights common hair-care practices in women, men, and children of color. Cleansing,
moisturizing, and styling techniques are discussed, as well as potential complications
associated with their use.
Semin Cutan Med Surg 28:103-108 © 2009 Elsevier Inc. All rights reserved.

Approach to Hair Loss in Women of Color

Jennifer M. Fu, MD | Vera H. Price, MD, FRCP(C)

Hair loss in women of color represents a unique diagnostic challenge that requires a
systematic approach. In women of color, clinical examination of the hair and scalp is most
helpful when performed first and used to guide subsequent history-taking to arrive at a
clinical assessment. The most common hair problems in women of color are hair breakage,
traction alopecia, and central centrifugal cicatricial alopecia. A careful detailed clinical
examination and history will guide the clinician to appropriate counseling and management.
It is important to recognize that a patient may have more than one of these 3 diagnoses and
each requires separate attention. Traction alopecia is completely preventable with appropriate
education of the public and medical establishment.
Semin Cutan Med Surg 28:109-114 © 2009 Elsevier Inc. All rights reserved.

Differences in Perceptions of Beauty and Cosmetic Procedures Performed in Ethnic Patients

Lily Talakoub, MD | Naissan O. Wesley, MD

The United States has become progressively more multicultural, with the ethnic population
growing at record rates. The US Census Bureau projects that, by the year 2056, greater
than 50% of the US population will be of non-Caucasian descent. Ethnic patients have
different cosmetic concerns and natural features that are unique. The cosmetic concerns of
ethnic patients also differ as the result of differences in skin pathophysiology, mechanisms
of aging, and unique anatomic structure. There is no longer a single standard of beauty. We
must now adapt to the more diverse population and understand how to accommodate the
diversity of beauty in the United States. Ethnic patients do not necessarily want a Westernized
look because what constitutes beauty is determined by racial, cultural, and environmental
influences. We as leaders in skin care must understand these differences and
adapt our practices accordingly. This article will focus on the differences in aging in
different ethnic populations and highlight procedures unique to skin of color.
Semin Cutan Med Surg 28:115-129 © 2009 Elsevier Inc. All rights reserved.

The Use of Lasers in Darker Skin Types

Cylburn E. Soden, Jr, MD, MA | Eliot F. Battle, Jr, MD

The demographics of the US population continue to change at an extremely rapid pace. As
of 2008, Asians, Hispanics, and African Americans accounted for 31% of the US population,
and it is estimated that by the year 2050 half of the population of America will be
represented by darker ethnic skin types. With the increase in the total number of individuals
of skin of color, the demand for safe and effective laser therapy in darker skin types
continues to increase. However, despite the increase in demand, the current literature
regarding the use of lasers in darker skin remains limited. Most of the treatment parameters
defined for laser platforms have been established primarily through extensive testing on
skin phototypes I to III, and those studies that have been conducted on darker skin
phototypes have been overwhelmingly conducted on Asian skin. Nevertheless, it has
become clear that effective cutaneous laser surgery in darker skin types can be accomplished
despite a relative overall greater risk for complications. Therefore, as the diversity
of America continues to grow, the laser surgeon needs to maintain a clear understanding
of the complexities associated with treating ethnic skin and remain mindful of the current,
and ever-changing, therapeutic modalities available. This will allow the conscientious
physician to maximize outcome and minimize risk when performing laser surgery on darker
skin types.
Semin Cutan Med Surg 28:130-140 © 2009 Elsevier Inc. All rights reserved.