Skin of Color: Gaps in Knowledge + Common Diseases
We can do better in dermatology.
There are known disparities in the treatment of people with skin of color, both in dermatology, and in the wider medical field. This is not new. This post is focused on identifying these deficits and filling in some of those gaps in knowledge.
EDUCATION IS KEY.
Even though the incidence of skin cancer is relatively low in skin of color, if you have it, you have a higher chance of having metastatic (widespread) disease. Someone who is black and diagnosed with melanoma has a higher likelihood of having advanced disease (4x will present with stage IV) and dying from their melanoma than someone who is white.
Photo by Mohamed Lammah on Unsplash
WHY?
Lack of skin cancer education in both providers and patients of color. Skin cancers present differently in people of color (POC) and tend to be in places that are not exposed to the sun and can be overlooked during examination (palms, soles, inside the mouth, genitals, nails).
Most public health campaigns are aimed towards educating Caucasian patients with sun-related skin cancers. As physicians, we need to step up to educate our patients of color on what to look for, as well as to encourage annual skin examinations.
This will lead to earlier diagnosis of skin cancer, thus reducing mortality, particularly in melanoma.
OTHER KNOWLEDGE GAPS
Certain diseases are more prevalent in POC, such as:
hidradenitis suppurativa
keloids
pseudofolliculitis barbae
central centrifigual cicatricial alopecia
hyperpigmentation
Lack of experience and education of these conditions can lead to delays in treatment and progression of disease. I will briefly review these diseases below.
CULTURAL KNOWLEDGE
A survey study from JAMA Derm showed higher satisfaction in patients treated in a specialized skin of color clinic, especially because of increased cultural knowledge and sensitivity, particularly with regards to skin and hair care. We all owe it to our black patients to increase our knowledge of black skin and hair practices to be able to provide optimal care, starting from residency training and beyond.
As a physician, my first and primary job is to provide excellent, compassionate care for all of my patients. Addressing these deficits in knowledge and research is the first step in achieving equitable care.
Let’s do a deeper dive into specific issues and what we can do about them.
Photo by Bill Fairs on Unsplash
Skin Cancer
Did you know Bob Marley died from metastatic melanoma?
He had a dark spot underneath one of his toenails and thought that it was from a soccer injury. It was eventually diagnosed, but the melanoma had metastasized to other parts of his body and he died at 36.
Could he have lived longer if there was more awareness of how melanoma presents in people of color and his melanoma was diagnosed earlier?
Probably. A recent study (Dawes S, et al.) showed that melanoma in non-whites is associated with more advanced disease at diagnosis and worse survival outcomes. Blacks had significantly lower survival than white, Hispanic and Asian American patients and had a greater proportion of late stage (III, IV) melanomas.
There is a plethora of public health campaigns about how melanoma presents in lighter skin types, but little information specifically targeted to communities of color. Part of doing better is increasing melanoma education that is specific to people of color. Early recognition will improve outcomes and increase survival.
An advanced melanoma arising from the nail matrix, extending to proximal and distal nail folds.
Why is melanoma in people of color different?
The most common type of melanoma in POC is acral lentiginous melanoma, which occurs on the palms, soles, and in the nail unit. It can present as an irregular dark spot on the palms or soles, or a dark streak on a nail.
LOOK FOR — asymmetry, an irregular border, multiple colors within the lesion (black, brown, blue, etc.), or irregular width if it's a nail streak.
CAVEAT — it is very common to have benign moles on the palms, soles, or on the nail, especially in people of color. Not every dark spot in those areas is melanoma.
Trauma or fungus in the nail can also cause discoloration that can mimic melanoma. However, if something does not resolve or keeps progressing or changing after 6-8 weeks, please get it examined by a board-certified dermatologist.
If an acral melanoma is diagnosed early enough, local surgery may be the only treatment needed and it may not lead to a decreased mortality or shortened life. I recommend taking a look at your nails, palms, soles, and between your toes every month, in addition to a full-body skin examination by a dermatologist every year.
Sunscreen in Skin of Color
If you are a person of color, do you need to wear sunscreen?
This is a question that I get often and typically the misconception is that people with darker skin don’t need to wear sunscreen.
Yes, people with dark skin do have more “built-in” sunscreen due to the presence of more melanin. Melanin protects the DNA in the skin from UV damage through both scattering UV radiation and acting as a UV filter.
However, the presence of more melanin does not make the skin impervious to UV damage. This damage can still occur and lead to worsening of disorders of hyperpigmentation, like melasma and post-inflammatory hyperpigmentation, as well as the development of skin cancer. It is a myth that people of color don’t need sunscreen.
More on Hyperpigmentation
Hyperpigmentation is an issue that is much more prevalent in skin of color than lighter skin tones. Even just a small zit or bug bite can leave a dark mark that persists for months.
Why does this happen?
Any amount of inflammation in your skin can lead to damage to your epidermis, which causes the pigment in your skin (melanin) to drop down into the deeper layers of your skin, the dermis.
Darker skin inherently has more melanin, which leads to more pigment getting deposited in your dermis when your skin is damaged. This can happen in any type of inflammatory skin disease, like acne, eczema, psoriasis, as well as from elective procedures, like laser and chemical peels, and even irritating products.
How can you keep this from happening?
Prevention is key. Although you can’t completely stop this from happening, there are a few things you can do to make it less severe:
DON'T PICK, SCRATCH, OR RUB — This applies to acne, itchy rashes like eczema, or any irritated lesion you may have. Anytime you manipulate a lesion, you are causing damage to your skin, leading to more melanin dropping into the deeper levels of the skin.
Avoid using irritating products — If you are trying something new, use it for a few days on a small, discrete spot, like behind your ear.
If you are getting a procedure done, ask your provider how much experience they have with darker skin and what is the risk of hyperpigmentation — particularly with lasers and deeper peels, ask to test it first on a small area.
What do you do if you already have hyperpigmentation?
Time is the best treatment. Your own body has cells (called macrophages) that will chew up the pigment and cart it away, but it can take months, even years. Sun exposure can make it darker, so sun protection and sunscreen use are key. TBH, bleaching creams and other lightening agents don’t reach that far down into the epidermis, so don’t really help all that much. Peels (like higher percentage glycolic acid peels) and certain types of laser can help.
Hidradenitis suppurativa (HS)
Draining nodules and scarring characteristic of HS.
Photo: DermNet NZ
This is a chronic inflammatory disease of the sweat glands that leads to recurrent painful, draining boils in the armpits, groin, and under the breasts. It is much more prevalent in people of color and causes a significant impact on quality of life.
Many people suffer in solitude with this disease because of a lack of awareness of treatments for HS. Because this is a chronic disease, the best outcomes are seen with consistent, long-term follow-up with a dermatologist. Many people are inadequately treated with short courses of antibiotics from the emergency room and can go years without a correct diagnosis.
TREATMENT — Depending on the extent of the disease, it is treated with:
topical and oral antibiotics
steroid injections
biologic medications
in certain cases, surgery
Disease improvement is seen with weight loss, stopping smoking, laser hair removal.
If you think that you may have HS, you are not alone. Check out my video on HS for more information.
Keloids
Keloid after ear piercing.
Photo: DermNet NZ
A keloid is a scar that continues to grow beyond the normal time frame of healing, often becoming larger than the original injury and is firm, tender, and itchy. This is much more prevalent in people of color.
Keloids can form from even minor injury, such as a bug bite or pimple. They are very common in response to ear piercing, in which large keloids can form on the ear lobe.
TREATMENT — They are difficult to treat and often recur.
They are most commonly treated with a series of steroid injections.
However, surgical removal, radiation, freezing, chemotherapy injections, compression therapy and steroid tape have also been used.
Pseudofolliculitis barbae
Hyperpigmented, raised bumps and ingrown hairs in areas that are shaved characterize this disease. Pseudofolliculitis barbae is much more common in people of color due to the tightly coiled quality of hair.
When the hair is cut short, the curved hair penetrates the follicular wall rather than growing out of the skin, leading to inflamed bumps and scarring. This is often seen on the cheeks and neck.
TREATMENT — The best treatment is to leave the hair longer in affected areas and avoid shaving or plucking.
When shaving, do not stretch the skin and shave in the direction of hair growth — using a standard single razor blade can reduce the risk of embedding hairs underneath the skin.
Laser hair removal can help with removal of hair in chronically problematic areas.
Central centrifigual cicatricial alopecia
Photo: DermNetNZ
This type of hair loss, characterized by balding in the crown of the scalp, is seen almost exclusively in black women. There is destruction of hair follicles and permanent scarring can occur. This can present with pain or itching, however, it can also be asymptomatic.
The cause of this type of hair loss is unknown, but it is currently thought to be due to genetic factors.
TREATMENT — It is imperative to treat this condition early, before scarring develops.
It is treated with anti-inflammatory agents, such as steroids or oral antibiotics.
Minoxidil can help stimulate hair re-growth in non-scarred areas. Avoidance of harsh hair styling practices is recommended.
This is just a brief overview of a few diseases that tend to be more prevalent in people of skin of color.
Check out The Skin of Color Society for more information about these diseases and others.
Together, we can do better to address health disparities and increase equity for all.
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References
Brenner M and Hearing VJ. The Protective Role of Melanin Against UV Damage in Human Skin. Photochem Photobiol. 2008; 84(3): 539–549.
Dawes, S. Tsai S. Gittleman H. et al.Racial disparities in melanoma survival. J Am Acad Dermatol. 2016 Nov;75(5):983-991.
Gorbatenko-Roth K, Prose N, Kundu RV, et al. Assessment of Black Patients' Perception of Their Dermatology Care. JAMA Dermatol. 2019 Aug 21;155(10):1129-1134.