COMMON SKIN AND SCALP CONDITIONS

Acanthosis Nigricans

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  • Acanthosis nigricans (AN) is a common skin manifestation of systemic abnormality.

  • It presents with dark-brown discoloration and velvety thickening of the neck, under the arms, forehead, inner side of elbows, behind the knees, groin, and umbilicus.

  • AN can be caused by and associated with a genetic predisposition, metabolic disorders (e.g. diabetes, PCOS, other endocrine diseases)/ obesity, autoimmune disease, cancer, medications.

  • Some associated factors include trauma, friction, heat, humidity, infections, and androgen hormones.  

  • Treatment includes the management of underlying medical issues and/ or the use of .oral medications (e.g. metformin, thiazolidinediones), retinoids, lasers, chemical peels or dermabrasion​.

References

Discoid Lupus

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  • Discoid lupus erythematosus (DLE) is an inflammatory scarring alopecia.  It is an autoimmune condition and a type of chronic skin lupus.

  • It presents as a sharply-demarcated red, scaly plaque with a central depressed scar, central skin lightening, follicle scale plug, and a surrounding dark patch. 

  • Although DLE can occur across all races and genders, DLE is most common in Black or African American women (4-5x more common in Black vs. White women).  Systemic lupus erythematosus (SLE) may develop in 5-25% of people with DLE.

  • It may be associated with other autoimmune conditions and increased risk for squamous cell carcinoma. 

  • Management includes the use of sun protection, anti-inflammatory medications (i.e. steroids (topical/ oral/ injection), tacrolimus, methotrexate, etc.).

References

Keloids

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  • Keloid scars appear slowly over months beyond the initial wound edges, while hypertrophic scars typically develop over a period of weeks and stay within the original margins of the wound.

  • Blacks or African Americans have a higher incidence of keloid formation.

  • They can present as firm, rubbery nodules or large plaques in an area of prior skin injury.

  • Keloids are caused by abnormal wound healing. 

  • Management includes occlusive dressing, compression therapy, intralesional steroids, intralesional and topical 5-fluorouracil, cryotherapy, excision, radiation, and laser.

References

Psoriasis

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  • Psoriasis is a chronic inflammatory disease that affects the skin and joints.

  • It occurs less frequently in Black or African Americans; however, when present, the condition is more severe as compared to Whites. 

  • It can present with itchy reddish-purple, well-demarcated plaques with a grey-white scale.  Darker-skinned patients tend to present with more with thickened plaques, nodules, and dark patches. There is typically less redness in darker skin types.

  • Psoriasis is thought to be caused by the interplay between autoimmunity, hyperproliferation of the skin, and environmental triggers.

  • Management includes avoiding triggers, gentle skin care, frequent moisturization, topical anti-inflammatory agents (e.g. corticosteroids, calcineurin), topical vitamin D analogs, oral anti-inflammatory medications (e.g. cyclosporine, methotrexate), topical and or oral retinoids, phototherapy, and biologics.

References 

Vitiligo

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  • Vitiligo is a chronic autoimmune pigmentary condition.

  • The highest incidence has been reported in India.  People of African descent do not seem to be preferentially affected, although, given the differences in pigment, it is more visible.

  • It presents as symmetric bilateral well-demarcated light or white nonscaly patches anywhere on the body (non-segmental) or limited to one side of the body (segmental). Darker skin types may present with a pale skin color compared with healthy skin (vitiligo minor).  The disease can have a negative psychosocial impact.

  • Vitiligo is as caused by an autoimmune attack of the pigment-producing cells (melanocytes) in the skin. New lesions may develop at the site of trauma of previously uninvolved skin (Koebner's phenomenon). 

  • It may be associated with other autoimmune conditions including thyroid disease and rheumatoid arthritis.    

  • Management includes topical and oral anti-inflammatory agents, narrow-band ultraviolet light therapy, surgical grafting, and seeking supportive care from a mental health professional.

References

Acne

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  • Acne is one of the most common skin conditions in the United States.  It is more common in Black or African American and Hispanic women compared to other races. 

  • Acne can present with blackheads, whiteheads, red and puss-filled bumps, and cysts. Hyperpigmentation and thickened scars are more common and distressing symptoms in darker skin patients.  

  • It is caused by a combination of genetic predisposition, excess growth (hyperproliferation) of the top layer of the skin (follicular epithelium), excess oil (sebum) production, and inflammation.

  • Acne has been associated with high carbohydrate diets, dairy products, and saturated fats.

  • Treatment is focused on reducing acne and minimizing dark marks while avoiding excess irritation that can occur with therapy. 

  • Topical agents: Adapalene, azelaic acid, benzoyl peroxide, clindamycin, dapsone, ​hydroquinone (spot treatment), retinoids (e.g. adapalene, tazarotene, tretinoin).

  • Procedures: Chemical peels, laser (more limited data)

References

Eczema

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  • Eczema/ Atopic dermatitis (AD) is a chronic inflammatory skin condition.

  • AD disproportionately affects Black or African Americans compared to other races.

  • It can present with itchy reddish-purple, brown, dark, scaly, sometimes thicked patches and plaques anywhere on the body.  Classic AD does occur on flexor surfaces (e.g behind knees and inner elbows).  Darker-skinned patients tend to present with more "follicular prominence", small bumps on the trunk and extensor surfaces, thickened plaques and nodules, and dark patches.

  • AD is thought to be caused by the interplay between defects in skin proteins reducing the ability to hold on to moisture, autoimmunity, and environmental triggers (e.g. diet, pollution, smoking).

  • Management includes avoiding triggers, gentle skin care, frequent moisturization, topical anti-inflammatory agents (e.g. corticosteroids, calcineurin inhibitors phosphodiesterase 4 inhibitors), oral anti-inflammatory medications (e.g. cyclosporine, methotrexate), phototherapy, intravenous immunoglobulin, interferon-gamma, and biologics (dupilumab).​

References

Post-Inflammatory Hyperpigmentation

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  • Post-inflammatory hyperpigmentation (PIH) is defined as an increased amount of pigment in the skin as the result of a prior inflammatory process (e.g acne).  It is seen in all skin types but is more common in darker skin types.

  • It presents with dark marks or patches.

  • It is caused by a variety of inflammatory skin conditions (i.e. acne, eczema, lupus).

  • Management includes reduction and treatment of skin inflammation, strict sun protection with broad-spectrum sunscreen with iron oxide, topical pigment reducing agents (i.e. hydroquinone), anti-oxidants, retinoids, microneedling, chemical peels, and laser.

Seborrheic Dermatitis

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  • Seborrheic dermatitis (SD) is a common scaly inflammatory skin condition (vs. dandruff- no inflammation).

  • It seems to occur more commonly in Blacks or African Americans, immunocompromised patients (e.g. human immunodeficiency virus (HIV), organ transplant recipients), men, and people with neurological and psychiatric diseases (e.g. Parkinsons disease).

  • It presents with greasy scaly light, dark, and/ or reddish-purple patches and plaques on sebaceous areas of the skin (e.g. scalp (most common area), eyebrows, nose, folds around the mouth, ears).

  • The exact cause of SD is unknown but it has been associated with a genetic predisposition, altered skin microbiome, increase sebum production, skin lipid composition, inflammation, abnormal immunity, stress, humidity, seasonal changes (winter), and western diet (e.g. meat, potato, and alcohol consumption).

  • Management includes topical / shampoo / oral anti-yeast agents, topical steroids, keratolytic (e.g. salicylic acid, coal tar-containing, natural (e.g. tea tree oil).

References

Acne Keloidalis Nuchae

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  • Acne (Folliculitis) Keloidalis (AKN) is a progressive scarring alopecia.  

  • AKN is more common in Black or African American men with curly hair however, it can occur across races and genders.

  • It presents with small, smooth, firm bumps with occasional puss on the posterior scalp and nape of the neck.  Over time lesions result in scarring hair loss and keloid scars.  

  • The exact cause is unknown.  

  • Some associated factors include the inherent properties of afro-textured hair, hair grooming techniques, trauma, friction, heat, humidity, infections, and androgen hormones.  

  • Treatment includes avoiding potential triggers (close shaving, frequent haircuts, shirts with high collars, helmets, chains, heavy greases, etc.), anti-inflammatories (topical, oral and/ or injection), antimicrobials, retinoids, destruction (liquid nitrogen, laser, etc), laser, surgery, and radiation (for severe cases).​

References

Hair Loss

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  • Hair loss is an extremely common and distressing complaint among African American women.  One study reported hair loss as the fourth most common diagnosis of Black or African Americans presenting to the dermatologist (1). Another study of 200 black women revealed 59% of respondents reported a history of excessive hair breakage or shedding (2)

  • There are various types of hair loss and they can be scarring (irreversible hair loss and permanent destruction of the hair follicle) or non-scarring (reversible hair loss, hair follicle still intact).

  • Hair loss can present with a constellation of symptoms ranging from itching, pain, soreness, redness, hair shedding, hair breakage, and bald patches.

  • It can be caused by and associated with, genetics, autoimmune disease, systemic disorders, stress, diet, and hair grooming practices.

  • Management includes optimizing hair grooming techniques, oral/ topical/ injection anti-inflammatory agents, platelet rich plasma, and hair transplant​.

MORE ON HAIR LOSS CONDITIONS

HAIR GROOMING

References

Pseudofolliculitis barbae

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  • Pseudofolliculitis barbae (PFB - "razor bumps") is a chronic recurrent inflammatory skin condition.

  • PFB is more common in patients with darker skin types and curly hair. 

  • It can present with itching, pain, bumps, puss-filled bumps, scarred bumps in an area previously shaved. Lesions can be reddish-purple and/ or dark.

  • PFB risk factors include genetic predisposition,  the curved shape of the hair follicle, the structure of the hair, and hair grooming practices (e.g. use of multiple blade razor).

  • Management includes improved shaving techniques (e.g removal of trapped hairs, cessation of shaving, electric clippers), topical keratolytics (e.g. retinoids, salicylic acid, and alpha-hydroxy acids), topical anti-inflammatory agents, topical antibiotics, oral antibiotics, topical steroids, topical skin lighteners (e.g. hydroquinone, azelaic acid), chemical peels, lasers.

References

Skin Cancer

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  • Basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma combined are the most common cancers in the United States (1).

  • Persons of African descent and darker skin types have a lowe incidence of skin cancer. When skin cancer is detected, it often presents at later stages and with poorer prognosis.  Additionally, in comparison to Whites, these patients experience treatment delays (2, 3).

  • Although cumulative sun exposure is a known risk factor for skin cancer in patients with fair skin tone, hair and eye color; the exact risk factors for patient of color are under investigation (4). 

  • Sunscreen use and sun-protective behavior are less common in patients of African descent, despite the potential for sunburns and other negative effects from sun exposure (5).

  • Risk factors for skin cancers in patients with darker skin types have NOT been well studied but include (5):

    • BCC: "UV radiation, albinism, scars, ulcers, exposure to ionizing radiation, arsenic ingestion, oral methoxsalen (psoralen), xeroderma pigmentosum, HIV, and iatrogenic immunosuppression​."

    • SCC: "Chronic scarring processes, inflammatory conditions, HPV, immunosuppression, burn scars, sites of radiation therapy, albinism, epidermodysplasia verruciformis, and chemical carcinogens"

    • Melanoma: "Role of UV exposure unclear

  • Clinical Presentation​ in patients with darker skin types include (3):

    • BCC​: Small pearly bump with rolled borders.  More common to have areas of pigment in the bump

    • SCC: Scaly bumps or patches, some with increased or decreased pigment.  More common on the legs

    • Melanoma: Dark asymmetric macule or patches with irregular borders, more common on the palms, soles, nailbeds

  • Management of skin cancer depends on the type and stage. It includes prevention​ (e.g. regular skin cancer screening, frequent and regular use of broad-spectrum sunscreen, sun-protective behavior), surgical removal, chemotherapy, and radiation.

References