February is Black History month; celebrating the African diaspora as well as the achievement of spectacular individuals of African origin have made beyond and in spite of the collective experiences of oppression and resistance. As diverse ethnicities and cultures globalize from a common background of origin, our modern and evolving world has the privilege of witnessing a beautiful blending of cultures, practices, and perspectives. We also get to bear witness to the expansion of genetic diversity and physical expression of mixed backgrounds. This is where our medical perspective and purpose for writing this post comes in: When it comes to the skin, it’s never one size fits all. When it comes to skin of color and individuals with richer complexions (not limited to black skin), even more special considerations come into play. Let’s take a look at a few clinical and cosmetic conditions, where conscientious Board Certified Dermatologists typically guide their patients with caution.
Acne is a common condition for individuals of any age or ethnicity to experience at any point in life. Treatment plans differ for everyone, and often, multiple follow ups and feedback over the course of months to years are required to hone in on the exact balance of lifestyle modifications, supplements, and/or medications which work best for the individual. In general, treatments are aimed at controlling sebum production, exfoliating dead skin cells and debris, as well as regulating bacterial growth. As a result, therapies can occasionally be drying or cause irritation. We are particularly guarded against chronic irritation caused by topicals such as Benzoyl Peroxide or Retinoids in skin of color not because of the medication themselves, rather, because the side effect of irritation which may result in unwanted temporary pigment changes. The problem, here, is not the acne, or the treatment, but instead, the inflammation, itself. When skin of any pigment richness is irritated and inflamed, it is not uncommon to see pigment changes which can appear as red patches, or significantly darkened well defined patches of skin which stand out in contrast to the skin’s normal coloration. Hyperpigmentation can last longer than the inflamed acne lesion, itself, which is why we recommend sticking with over the counter strength Benzoyl Peroxide formulations, and weaker formulations of retinols and retinoids such as adapalene or differin. Even then, products should be started “low and slow”, as spot treatments, increased only as needed and as tolerated, to avoid lingering irritation and inflammation.
Maintenance of the skin’s protective barrier is important for all skin types concerned with eczema. Patients with richer skin coloration tend to visually notice dry skin, called ‘xerosis’, and eczema, or atopic dermatitis, much more as a common complaint is that the effected skin appears “ashy”. Over time, with chronic itching and inflammation, skin then becomes subject to hypopigmentation (light to white spots) or hyperpigmentation (a darkening of spots), as well as lichenification (thickening of chronically scratched spots). A Board Certified Dermatologist can counsel a patient on preventative lifestyle modifications to support the skin’s protective ceramides and immune ecology, as well as prescribe treatment when rescue therapy is needed, preferably before discoloration and textural skin changes occur.
African Americans are seven times more likely to develop keloids than Caucasians. Keloids appear as raised or thickened growths which occur at a site of injury, puncture, or breakage of the skin. They tend to be irregularly shaped, raised, and occasionally darker in pigment. A defining characteristic of keloids is that they extend beyond the boundary of the original injury or scar, itself. Keloids are believed to be caused by genetic predispositions with a higher incidence between twins which validates the genetic hypothesis. Multiple approaches are favorable for keloid treatment, ranging from intralesional steroid injections to immunotherapy with 5 flourouracil to superficial radiation treatment (SRT), to topical prescriptions and more. Of course these treatment recommendations vary on a case by case basis and coordination with an experienced skin expert, a board certified dermatologist, is imperative for improvement.
PRURIGO NODULARIS (PICKER’S NODULES)
A large and long term (5 year) study in The Journal of the American Academy of Dermatology demonstrated the correlation between cardiovascular and psychiatric comorbidities, prurigo nodularis, and African American descent. The study demonstrated the disproportionate effects of prurigo nodularis (PN) and the African American community. Prurigo nodules appear as thick, crusted, itchy bumps, which grow anywhere the skin is chronically scratched, picked or rubbed. The appearance of these lesions can cause significant distress to the patient and their loved ones. Once the cycle begins, it can be difficult to break without assistance. Dermatologists often use a combination of topical creams, light therapy, or intralesional steroid injections. They can also recommend helpful herbal and nutritional supplements, as well as other specialists for emotional support if warranted. For best outcomes, a multifaceted approach is the most successful for intervention and a cosmetically neutral recovery.
LASER TREATMENTS & MICRONEEDLING WITH RADIOFREQUENCY
It’s important to exercise caution when performing heat based elective therapies to address skin texture or dyspigmentation in richer complexions. This is because melanin, which is the pigment that we observe in skin, is produced from melanocytes which sit in the basal layer (bottom layer) of the epidermis. This might sound like they’re deep down in the skin; however, the epidermis, which is the very top layer of the skin, is only 0.05mm thick compared to the deeper dermis (1-4mm thick) or the subcutaneous layer of the skin (1.65-25.2mm depending on BMI). This is why special considerations are given to individuals with deeper complexions, from Fitzpatrick III-VI. The risk is thermal (heat induced) damage to melanocytes, as well as post-inflammatory hyperpigmentation. Resurfacing targeted procedures such as CO2 and Fraxel lasers pose the most risk, whereas restructuring treatments such as microneedling with radiofrequency, can be performed with less risk when treatment is targeted below the vulnerable epidermis. There are exceptions to this, such as the ND-Yag lasers, often used for laser hair removal; however, the common denominator determining a patient’s safety and outcome will always be the level of awareness, experience and caution of the technician.
Similarly, while chemical peels do not pose the risk of thermal injury, they can cause abrasive injury to the top layer of the skin. The main concern is hyperpigmentation from intense inflammation caused by an overly aggressive chemical peel; however, hypopigmentation has also been known to occur. We recommend approaching peels with caution and sticking with a series of salicylic acid peels. Many individuals think that deeper peels will get them toward their goal in less time; however, aggressive treatment is not always the best answer, regardless of skin type, and especially in darker skin types. Therefore, we have found that lowering intensity of the peel while increasing the frequency of treatments (much like going to the gym), is our favorite approach in regard to both patient safety as well as patient satisfaction.
In the field of Dermatology, it is rare for African Americans and patients with higher Fitzpatrick skin types to come in for their annual full body exams. These lookovers are just as important as they are in patients with lighter skin types, because while the incidence of sun induced tumors such as basal and squamous cell carcinomas are lower in these populations, there are still a plethora of other common conditions for which Dermatologists can provide surveillance and guidance. Of note, it is important to remember that melanomas can still occur in darker skinned patients. Studies have demonstrated that the 5 year survival rate after diagnosis of melanoma is only 67% compared to 92% in Caucasians. This is probably related to the findings in another study which showed that late stage (advanced) melanoma cases are much more common in Hispanic and Black patients than non-Hispanic white patients. After decades of working in Dermatology, our personal observation of this is because most patients with richer complexions believe that a higher concentration of melanin protects them from sunburns and therefore, melanoma; however, this is a dangerous and often fatal misconception. This is because melanoma has been shown to have more of a causal relationship with genetics than the sun, especially in darker Fitzpatrick populations. The fact that many melanomas are often diagnosed in areas typically not exposed to sunlight, such as the buttocks, genitals, and the palms or soles of the feet further validates. In fact, many people are not aware of the fact that the late Bob Marley, cherished not only by our Caribbean and South Florida community, but the one love of the world, transitioned on May 11, 1981. The cause of his death was cancer, specifically, a melanoma he accidentally found under the nail of his toe after sustaining an injury while playing football in 1977. This is why we encourage our African American patients to remember their annual full body exam and remind all of our patients to perform regular self-checks and monitor between visits.
At Aesthetix Skin & Surgery, our providers aim to provide effective, compassionate and customized care for every individual. We take pride in treating our community with our providers, Dr. Igor Chaplik, and Nicole Gentile (MMS, PA-C) who have cumulatively practiced Dermatology for over 30 years in South Florida. We look at the whole individual, background, past medical history, lifestyle, personal goals and preferences – when considering the best treatment plan, and take pride in helping our patients understand their condition so that they may be the most valuable part of their own healthcare team.