39 - Derm Disease in Skin of Colour

what factors play a role in creating dermatology related health inequity in racialized populations

Lack of high-quality evidence on treatment in racialized groups

Lack of healthcare provider education on diagnosis and management

Dermatology scoring tools (e.g. SCORAD, EASI) underestimating disease severity in skin of colour

Inequity in the environmental and social determinants disproportionately equity deserving groups

Reluctance to seek help or mistrust of healthcare providers • Limited access to dermatological care

how can you keep language respectful, neural, professional

Avoid terms (e.g., “darker”) that imply white is the normal or baseline skin colour

what should you not equate skin colour with

race ethnicity

E.g., Not all Black people have darkly pigmented skin

what are general principles for providing inclusive care

Ask for the patient’s perspective including their thoughts and feelings about their skin condition

Respect the patient’s individual cultural beliefs

Some cultures may mistrust established healthcare systems, especially if they have had negative experiences in the past

Ask about hair and skin care routines

Some patients may not feel comfortable disclosing cultural or personal belief-based health practices

Ask about alternative, complementary, traditional medications and health practices

what are skin conditions of higher prevalence in skin of colour

1. Pseudofolliculitis Barbae

2. Dermatosis Papulosa Nigra

3. Acne Keloidalis Nuchae

4. Actinic Prurigo

5. Vitiligo

6. Hidradenitis Suppurativa

7. Alopecia

what isPseudofolliculitis Barbae

“razor bumps”

“Erythematous” and hyperpigmented

Papules and pustules after shaving or plucking (tightly curled hair)

Can be painful and tender, secondary infection possibly

what is the treatment for Pseudofolliculitis Barbae

Topical steroids, benzoyl peroxide, topical retinoids, and topical antibiotics (infection)

Changing hair removal techniques such as suggesting clippers, single blade razor, avoid plucking

what is Dermatosis Papulosa Nigra

Benign lesions (dome shaped) on the skin

Usually, the bumps are not painful and do not itch

Onset after puberty, genetic predisposition

what is the treatment for Dermatosis Papulosa Nigra

No treatment necessary

Excision, laser, electrodessication, cryotherapy

what is Acne Keloidalis Nuchae

Tender papules, pustules and plaques on posterior of scalp

Unknown etiology

Results in hair loss

what is the treatment for Acne Keloidalis Nuchae

Avoid friction in area

Potent topical steroids, topical antibiotics, oral antibiotics for s/s of infection, laser, surgical excision

what is Actinic Prurigo

Prevalent in Indigenous population

Likely due to genetic variation in HLADR4, DRB1*0407 gene and UV exposure

Commonly arises in childhood

Worse in summer, but can be present year-round

Sun-exposed sites develop eczematous eruptions, crusting, hemorrhage and pitted scars

Can also develop conjunctivitis and cheilitis

what is the treatment for Actinic Prurigo

Sun protection, emollients, topical corticosteroids, oral immunosuppressants (antimalarials, azathioprine, cyclosporine)

what is Vitiligo

White, depigmented patches on the skin

Can be solitary, segmental or widespread

Associated with autoimmune comorbidities

Mental and emotional burden is worse in patients with skin of colour

what is the treatment for Vitiligo

There is no cure for vitiligo and treatment is often unsatisfactory, goal to stop progression

Sun protection measures

Camouflage makeup

Topical steroids, calcineurin inhibitors

Newer agents such as ruxolitinib (JAK Inhibitor) cream - also used in atopic dermatitis (exam question)

what is Hidradenitis Suppurativa

A chronic auto-inflammatory skin disorder that affects apocrine gland-bearing skin

• Axillae, groin, perianal, region, buttocks, and inframammary folds

Deep, painful nodules and abscesses that can fuse together to form sinus tracts

There can be discharge and scarring present

HS presents following puberty by the second to third decades of life

what are risk factors for Hidradenitis Suppurativa

Female sex, family history, obesity, cigarette smoking, mechanical trauma

what is the treatment for Hidradenitis Suppurativa

Education (skin care (antiseptic wash), manage pain, manage itch, manage weight, smoking cessation)

Topical antibiotic formulations (+BPO? +Fucidin?)

Intralesional steroid injection ( Triamcinolone acetonide) or oral steroid for short term

Systemic antibiotics for superimposed bacterial infections or tetracyclines for immunomodulatory effects

Anti-androgen (oral contraceptives, spironolactone)

Systemic Biologic:

Anti-TNF (Adalimumab), IL-17A inhib (Secukinumab), IL17A/F Inhib (Bimekizumab)

Surgery

what is Traction Alopecia

Form of acquired hair loss that results from prolonged or repetitive tension on the scalp hair

Chronic wearing of hair extensions, weaves, braids

Chemical Relaxers

Tightly worn head coverings

Mostly affects the front (frontal) and sides of the scalp, tension dependent

what is the treatment of alopecia

Loosen hair style or head covering

Avoid scalp exposure to chemicals and heat

Minoxidil

Topical or intralesional steroids

Hair replacement surgery

what can treating skin conditions early prevent

inflammation-induced pigment changes

In addition to treating inflammatory disease, patients or care providers may be more concerned about pigmentary changes - address!

how can post inflammatory hyperpigmentation be minimized

Titrate usage to overnight use, start low and go slow!

Applying a ceramide moisturizer to prep skin prior to applying medicated topical agents may mitigate irritation

what is the issue with instructing patients to continue treatment until redness subsides

this direction is not helpful to patients with deeply pigmented skin that presents without redness

what are sunscreen recommendations

Sunscreen is encouraged for all skin types

Patients may be hesitant to use sunscreen because of white cast left on the skin (suggest the right product!)

Sunscreens with zinc oxide, iron oxide, titanium oxide protect from visible light (“tinted sunscreens”)

what are issues with medicated shampoo for textured hair

may cause breakage due to drying agents

Modify treatment wash regimen

Suggest a lotion or foam base

Supplement with oral medication

Those with tightly coiled hair may prefer oil or foam-based products vs. creams or liquids