Treating skin of color

First of a three-part series

Most skin diseases occur in people of all nationalities, regardless of their skin color. Particular problems encountered in the skin are more common in people with different hues of skin, and sometimes a disorder seems more prominent because it affects skin color. This column and the two that follow will consider these problems and their treatments.

Skin tones
Variations in human skin tone

Variations in skin color

Skin color is determined by cells called melanocytes. Melanocytes are specialized cells within the skin that produce a pigment known as melanin. Melanin is produced and stored within special structures known as melanosomes, contained in the melanocytes.

The melanocytes make up only a small percentage of overall skin cells. In fact, only two to three percent of all skin cells are melanocytes. The variation in skin color we see across all people is determined by the type and amount of melanin produced by the melanocytes.

All people inherently have the same number of melanocytes. A recent theory indicates that the differences in skin color are really a reflection of the skin’s ability to protect against ultraviolet radiation.

Persons living closer to the equator produce more melanin because the ultraviolet radiation is more intense and ultraviolet protection is required by the human body. Groups of people living further away from the equator produce less melanin, resulting in lighter skin color.

One reason treating pigmented skin can be somewhat tricky is that traditional textbooks have had only black and white photographs. Additionally, many lesions have been described as red, pink, salmon, or fawn-colored. This certainly is true in Caucasian skin; indeed, many of the textbooks that were written had this as the majority patient type.

However, in tan, brown, or dark-brown skin, inflammation can look grey, copper, or violaceous in color. Additionally, certain conditions will have a slightly different presentation in pigmented skin.

Post-inflammatory hyperpigmentation and hypopigmentation

Melanocytes can either stop producing color or produce excessive color in cases of inflammation. Generally, in children, the cells stop producing color, especially in irritation of the diaper area. (I explain to parents that the cells tend to go to sleep.)

It is very common for a child of color to have a very light area of post-inflammatory hypopigmentation. This is where the inflammation of diaper irritation causes the melanocytes to stop producing color, leaving light or white patches.

With the appropriate treatment, the color almost always returns to normal within a few weeks. In older patients, inflammation can lead to post-inflammatory hyperpigmentation. This is most commonly seen in areas where acne blemishes heal, leaving a dark spot behind. These, too, will fade with time; however, it can be quite persistent.

Vitiligo

Vitiligo is a skin condition that occurs in all people, but it is most noticeable in patients with tan, brown, or dark-brown skin. I believe that vitiligo is really the end stage of several different disorders.

In some disorders, the melanocytes are attacked by the immune system, and they die. In other conditions, the melanocytes are pre-programmed to die early. No matter what the cause, ultimately, patches of vitiligo are white spots devoid of melanin.

Because these areas lack natural protection, vitiliginous patients must wear sunscreens to prevent ultraviolet radiation exposure and subsequent cancer later in life. In the majority of cases, vitiligo is probably the result of an auto-immune or inflammatory attack on melanocytes.

In these cases, topical anti-inflammatories and phototherapy, most notably narrow-band ultraviolet B, tend to be most effective. We have a success rate of approximately 75 percent in our clinic. In the remaining cases, these are probably related to a genetic program in the melanocytes where they die prematurely. Usually, with the appropriate treatment, signs of vitiligo can be reversed in one to two months.

Pityriasis alba

Pityriasis alba is a condition where white patches occur on the arms, trunk and, most notably, on the face. This is a widespread condition seen primarily in adolescent patients of color. It is a result of very mild irritation and/or eczema leading to post-inflammatory hypopigmentation where the melanocytes temporarily stop producing color.

Gentle topical anti-inflammatory lotions, mild cleansing bars, and ultra- moisturizing lotions can be used to treat pityriasis alba. The loss of color in this condition is usually only temporary and is most notably seen on the cheeks of adolescents.

Dermatosis papulosa nigra

This most commonly occurs in African American patients. Some people call them “flesh moles,” “Bill Cosby spots,” “Morgan Freeman spots,” and, more recently, “Condoleezza Rice spots.”

It tends to occur slightly more frequently in women than in men. These are tan to brown to black, raised papules that can occur on the forehead, cheeks, and neck. Under the microscope, they resemble other benign growths known as seborrheic keratoses.

We use a unique surgical technique in our clinic that can achieve excellent results in treating dermatosis papulosa nigra. Indications for treatment can be pain, itching, irritation, and cosmetic reasons.

Treating skin of color: part three

Conclusion of a three-part series

Most skin diseases occur in people of all nationalities, regardless of their skin color. Particular problems encountered in the skin are more common in people with different hues of skin, and sometimes a disorder seems more prominent because it affects skin color. This column completes our consideration of these problems and their treatment in this series.

Pseudofolliculitis barbae

This condition is also known as “razor bumps.” Hair is made of a protein called keratin, and it can be extremely inflammatory to the skin. It is called “pseudo” folliculitis because the hair can actually come out of the follicular opening and penetrate nearby skin, causing it to look like inflammation, or folliculitis, of that pore.

However, because it is just nearby the actual follicle, it is “pseudo” folliculitis. This is most often seen in persons with curly hair or hair that grows at an oblique angle to the skin.

Sometimes, if curly hair is cut extremely close, it never even exits the skin surface, instead penetrating the sidewall of the follicle (known as transfollicular penetration), or it comes out of the follicle and pokes the skin (known as extrafollicular penetration). The results are the same: The keratin invades the skin, producing a brisk inflammatory reaction that causes itching and the formation of pustules.

When pseudofolliculitis is mild to moderate, many topical treatments can be implemented, including a very gentle oatmeal-based shaving cream, and a non-electric razor with a safety guard, so the hairs are not cut too short. Shaving after a shower is also recommended when the hair is hydrated, so the final tip is soft as opposed to sharp.

Also, using a soft-bristle toothbrush to make circular motions in the beard area before bedtime can prevent the hair from penetrating as it grows throughout the night. Topical anti-inflammatory aftershave lotions and oral anti-inflammatories can also be used if necessary. In the majority of cases, this can provide satisfactory relief.

However, in certain instances in which relief is not achieved through these means, the best treatment is to remove the offending agent. In this case, I recommend laser hair removal.

Pseudofolliculitis barbae has been a vexing problem throughout history and can even interfere with occupations that require a clean-shaven face, such as military officers, peace officers and firefighters. Thankfully, this condition can be addressed by implementing appropriate treatments and techniques.

Tinea capitis

Tinea capitis, also known as ringworm, is endemic in African American children. Any child with a scaling, itching scalp should be thoroughly investigated for tinea capitis.

One of the clues to this is enlarged lymph nodes in the nape of the neck. I recommend a topical anti-itch anti-inflammatory lotion in addition to an oral antifungal agent. No matter what agent is used, it is essential that treatment occurs for at least eight weeks at a somewhat high dose, as advised by a board-certified dermatologist.

It is also recommended that all objects that touch the hair, such as combs, barrettes, rubber bands and pillowcases, be replaced or treated to prevent re-infection. I also advise all members of the household to use an anti-fungal shampoo throughout the treatment period for two months.

This is a prevalent yet easily treatable condition in young children. I believe that as people get older, the milieu of their scalp sebum changes, preventing an active infection. However, many adults can be carriers and pass it to their children, who are prone to the infection.

Melanonychia striata

This is a condition where brown to black longitudinal bands occur in many, if not all, the fingernails and toenails. This is a common, benign condition that is often seen in multiple family members. However, if one band should occur spontaneously without a family history, this should be evaluated for an underlying mole or melanocytic malignancy.

Voigt or Futcher lines

These are lines seen most commonly on the upper arms and sometimes thighs and are normal variations. They were named after a physician and anatomist who first described these near the turn of the century. They are harmless.

Melasma

Melasma is a common and vexing problem that I see on a regular basis in our clinic. It presents as hyperpigmented patches occurring on the cheeks, upper lip, forehead, and sometimes dorsal forearms. It can be extremely challenging to treat, and I inform patients that 25 percent of the time there’s not much we can do about it.

I also tell patients that it is a lifelong battle and something that we’ll always have to treat and use preventive measures to keep from coming back. It’s usually a result of hormones, genetics, and sun exposure. Commonly the hormones can include the initiation of oral contraceptives and/or pregnancy and childbirth.

I often tell patients that it’s a very rapid, uneven suntan occurring in the areas described. It’s exacerbated by sun exposure and, we discovered recently, heat exposure. So, people who enjoy saunas, hot showers, steam baths, and warm climates should know these can exacerbate the condition.

I had one patient who we had difficulty treating, and I asked if heat might be a potential factor in his melisma. He looked at me with a frown and said, “I’m a chef. I’m over a hot stove and opening ovens all the time.”

So, patients with melisma must consider meticulous sun protection and heat avoidance. I tell patients that they need to apply sun protection before they leave the house. Any amount of sunlight that touches their skin while walking from a car across a parking lot into a building, even on a cloudy day, is enough to trigger its occurrence.

Treatments include topical lightening agents, deep skin peels, and newer laser treatments. In three-quarters of patients, we certainly can see satisfactory results, although it’s one of the most challenging conditions that I treat. I see it almost on a daily basis in my practice.

Treating skin of color part 2

Second of a three-part series

Most skin diseases occur in people of all nationalities, regardless of their skin color. Particular problems encountered in the skin are more common in people with different hues of skin, and sometimes a disorder seems more prominent because it affects skin color. This column continues from last week our consideration of these problems and their treatments.

Acne

When treating persons of color, post-inflammatory hyperpigmentation (brown spots after the acne blemishes have healed) and active acne need to be differentiated. It is important to note that when one is treating acne, the brown spots that occur afterward are only residual effects, not active acne.

SEE ALSO: Treating skin of color Part 1

I usually employ a combination therapy when I am treating acne to achieve optimal results. This usually involves topical treatments, oral treatments, laser treatments and, in persons of color, topical lightening agents. These can include retinol, anti-inflammatory agents, and the bleaching agents kogic acid and hydroquinone.

I also discuss with patients the difference between active inflammatory, bumps, and the flat, brown spots left behind.

Dry or “ashy” skin

This is a problem seen in all patients, but when one has tan, brown, or dark-brown skin, dry skin tends to turn silvery white. This phenomenon is often referred to as having “ashy” skin.

I believe the most important component of any skin care program is a gentle, non-detergent cleanser and an ultra-moisturizing lotion. I recommend the lotion be applied immediately after patting the skin dry after a bath or shower.

This seals in the moisture achieved from the shower, and the appropriate moisturizing lotion can provide continuous moisture and protection throughout the day. Often, two or three days of this program can completely reverse dry or “ashy” skin.

Keloids

keloids

Throughout evolution, our skin has become quite skillful at repairing any sites of injury or damage. Once the integrity of the skin barrier has been interrupted, invaders such as bacteria, fungus and virus can penetrate the skin and essential bodily fluids can leak out. As a result, the skin’s repair system is rapid and complete.

Cells known as fibroblasts migrate into the area and produce protein to fill in the hole. The primary component of the repair product is collagen, and that is what makes up a scar.

Unfortunately, in some cases, and commonly in African Americans, the fibroblasts receive the signal to come in and repair the defect, but they do not get the message to turn off. As a result, too much collagen is produced, and the scar can become thick and hard.

When the collagen presses on nearby sensory nerves, the keloidal scar can also produce tenderness, pain, and extreme itching. The difference between hypertrophic and keloidal scars is that hypertrophic scars usually stay right at the site of injury, whereas keloids can actually spread and invade normal surrounding skin.

In our clinic, we use an aggressive six-month program to treat keloids effectively. It is one thing to remove a keloid surgically, yet it is another thing to keep it from coming back. Remember, the development of a keloid is a response to injury. By surgically removing a keloid, the skin is being re-injured — and that area has already shown it can form a keloid.

We perform regular treatments every two to four weeks over six months, including anti-inflammatory injections, topical silicone-based preparations, pressure dressings, and laser treatments to prevent the return of keloids.

Acne keloidalis nuchae

neck treatment

This condition is also known as folliculitis keloidalis nuchae, where small, very itchy bumps can occur at the nape of the neck. This is most commonly seen in African American patients, but to a lesser degree it can affect all patients.

It is most commonly seen in men, but can also be seen in women. Many male patients believe this is a result of a barbershop treatment where the barber had unclean clippers. This is entirely untrue, and I have seen many cases that develop without any previous haircuts.

One theory is that this condition is a result of a deep fungal infection. However, in my experience, I have performed many biopsies and analyzed cultures for fungus and special histology stains, but I have not yet identified a fungus infection. I believe this condition is just an anatomic and genetic variant, with itchy bumps developing from very mild irritation in this particular anatomic location.

Smaller bumps can be treated very effectively with a combination of topical and oral anti-inflammatory medication. In many cases, a short course can provide long-term results. Often a surgical approach is required if the lesions are too large. Nevertheless, the condition can be managed quite well.

What you should know about acne – Part #1

The medical term for acne is “acne vulgaris.” Acne is the most common skin disorder in the United States and the number-one reason patients visit a dermatologist.

Approximately 50 million Americans suffer from acne. Over 80 percent of all teenagers battle acne. Continue reading What you should know about acne – Part #1

What skin care products do dermatologists recommend?

Original article

Skin care is not an easy topic to discuss. With so many possibilities to set up a skin care routine – and so many products to choose, chances are you might get lost in all of these choices. So let’s ask the experts, shall we? Dermatologists see people’s skin every day, and treat them every day. They know what affects the skin and how to take best care of is. So: what skincare products do dermatologists recommend? We sat down with two of them to find out.
Continue reading What skin care products do dermatologists recommend?

The Best Face Moisturizer for Very Dry Skin & Skin Toner for African-American Women

No matter how hot you look, dry skin can make you feel hopelessly uncomfortable. Celebrity physician Dr. Michael Roizen states that African-American women can experience higher rates of transepidermal (literally, “through the skin”) water loss than Caucasian women, which can make skin drier. While you’re on the hunt for the products to include in your skin care arsenal, keep your eyes peeled for those that contain natural ingredients, which your dry skin craves.

What to Look For

The best face moisturizer for über-dry African-American skin is one that contains naturally moisturizing ingredients. Read the label and look for jojoba oil, sunflower seed oil, beeswax, shea butter or coconut oil. Moisturizers containing plant extracts help nourish and tone your skin. Vitamins and supplements are other ingredients to seek. For example, vitamin E and omega-3 can enhance the overall health of your skin and promote healing. When shopping for a daytime moisturizer, sunscreen is a must, especially if you want to reverse hyperpigmentation (the higher the SPF the better). If you happen to have an uneven skin tone, look for a tinted moisturizer that contains vitamin C, which will help reduce the appearance of dark spots. Dr. Charles E. Crutchfield, associate professor of dermatology at the University of Minnesota Medical School, says that the moisturizing lotion that you choose should continually protect your face all day and keep it moisturized. If your face is really hurting because it’s so dry, look for a medicated skin moisturizer (a drugstore pharmacist can direct you to a good over-the-counter option) and make an appointment with a dermatologist.

The Skin Toner Debate

Some estheticians say that face toner is essential to rebalancing the pH of your skin after you cleanse it. Other professionals say toner is unnecessary because your skin’s pH will go back to normal after an hour or so. The choice to use skin toner is personal. If you feel like you need a skin toner to reduce the size of your pores after you wash your face, look for a toner that doesn’t contain alcohol or witch hazel because your skin will dry out even more and become ashy. Instead, spritz rosewater, lavender water, orange flower water or a mix of cooled chamomile and green teas onto your face. These natural ingredients are soothing and act like a natural astringent.

What to Avoid

While it may sound soothing, never let a moisturizer with mineral oil near your face if you want to keep it kissable. The higher levels of melanin in African-American skin can make it more sensitive to certain ingredients. Mineral oil, parabens, dioxanes, phthalates and oxybenzone can clog your pores and have the potential to irritate your skin and cause dark patches to form. If a bottle of moisturizer or toner just states that it contains “fragrances” in the list of ingredients, put it back on the shelf. An undisclosed fragrance has the potential to harm your already sensitive skin.

Your Skin Care Routine

Moisturizing your skin is only one small, yet important, step in a beauty regimen. Whenever you wash and rinse your face, do so with warm water because hot water actually causes your skin to become dry, according to Crutchfield. Even taking a hot shower can take a toll on your dry skin. Cleanse your face with a product that contains glycerin, petrolatum or hyaluronic acid but doesn’t create suds. Then gently pat your face dry with a soft towel. If you feel that you need it, spritz on some toner. Crutchfield says to finish up your skin care routine by immediately applying moisturizer to your face. To help your skin stay hydrated, drink eight cups of water a day and watch your salt intake.

Original article

It’s summertime — time to be skin smart and sun safe – Part 1 of 2

Let’s face it: With summer comes the opportunity for all kinds of skin problems. This includes attacks by mosquitoes and ticks; sporting activities where bumps, bruises, cuts and abrasions abound; and the notorious ultraviolet radiation from the sun.

It’s always a good idea to be sun smart and sun safe. When it comes to taking good care of your skin, there are three key principles:

1) Gentle cleansing. This is extremely important to do for your skin to reduce irritation and increase cleanliness and hygiene. I recommend using non-detergent or low-detergent cleansing products such as Dove, Vanicream cleansing bar, Neutrogena products, Cetaphil and Basis. All of these work well to cleanse the skin without irritation.

2) Skin hydration. This is one of the most important things you can do for your skin. A little-known trick and one of the biggest things you can do to keep your skin hydrated is to use a gentle cleanser that won’t take away the natural oils in your skin.

In addition to the cleansers listed above, it’s also important to use a good emollient, hydrating lotion or cream. I like to use CeraVe lotion or cream because it contains a technology called a microvesicular emulsion. This means there are little microspheres of moisturizing lipids in water that break down over several hours, constantly replenishing the skin’s moisture.

There are other over-the-counter lotions that contain ammonium lactate, which will actually penetrate the skin and assist in holding water in the skin. In summer the two most important things you can do for skin hydration is to use a gentle cleanser and to use moisturizers.

The most important time to use a moisturizer is immediately after bathing or showering. As soon as you finish the bath or shower, step out and gently pat your skin dry with a cotton towel and immediately apply the moisturizing lotion, cream or emollient.

This serves two important functions: Number one, it seals in all of the water your skin has absorbed during your bathing, and secondly, it adds another layer of moisturization to help replenish the water normally lost throughout the day. This is very important in the winter when humidity levels are low and the air extremely dry.

3) Protection from ultraviolet radiation. There are mainly three types of ultraviolet radiation. Ultraviolet C is almost totally blocked out by the ozone layer. Ultraviolet B and A penetrate the ozone and can have profound effects on our skin.

Ultraviolet B, “wavelength 290-320 nanometers,” is responsible for irritation and sunburns. Ultraviolet A, “wavelength 320-400 nanometers,” is a much longer wavelength and can penetrate much deeper into the skin. This ultraviolet A actually wreaks much more havoc on our skin than most of us realize.

When we use a sunscreen, the SPF number is really a sun protection factor indicating the blocking of ultraviolet B rays, the ones responsible for burning the skin. In the old days, if you could stay out for one hour without getting burned, an SPF of 15 theoretically means 15 hours. Although in actuality this doesn’t quite hold true, that’s where the SPF number calculation comes from.

Not so long ago, most sunscreens only had an SPF factor, but they didn’t block ultraviolet A. Ultraviolet A is responsible for sun freckles, the development of wrinkles, and most importantly the development of skin cancer. Ultraviolet A can actually penetrate and break DNA, causing all kinds of signs associated with aging skin.

Next week: skin color, vitamin D, and some basics of skin protection.

Charles E. Crutchfield III, MD is a board certified dermatologist and Clinical Professor of Dermatology at the University of Minnesota Medical School. He also has a private practice in Eagan, MN. He received his M.D. and Master’s Degree in Molecular Biology and Genomics from the Mayo Clinic. He has been selected as one of the top 10 dermatologists in the United States by Black Enterprise magazine. Dr. Crutchfield was recognized by Minnesota Medicine as one of the 100 Most Influential Healthcare Leaders in Minnesota. He is the team dermatologist for the Minnesota Twins, Vikings, Timberwolves, Wild and Lynx. Dr. Crutchfield is an active member of both the American and National Medical Associations.

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