Monthly Archives

July 2020

The Relevance of Vitamin D Supplementation for People of Color in the Era of COVID-19

By | COVID-19 Resources, Skin of Color Update Agenda | No Comments
Vitamin D

Source: JDD Online

The Journal of Drugs in Dermatology recently featured the article, The Relevance of Vitamin D Supplementation for People of Color in the Era of COVID-19, authored by Skin of Color Virtual Update faculty, Pearl E. Grimes MD, and Andrew F. Alexis MD MPH along with Nada Elbuluk MD MSU.

Introduction

African Americans (AA) and other people of color are dying at highly disproportionate rates from COVID-19. The statistics are staggering: in New York City alone, per 100,000 population, death rates in AA were 92.3, and in Hispanics 74.3, compared to 45.2 in Whites and 34.5 in Asians.1 Similar numbers have been reported in other cities and are presumed underestimations, given limited racial/ethnic reporting. In the states currently releasing the number of COVID-19 deaths by race and ethnicity, Blacks make up roughly 13 percent of the population, but 27 percent of the deaths. According to the American Public Media Research Lab, the rate of COVID-19 deaths nationally for Blacks has been reported as twice the rate of deaths of Asians and Latinos in the US and more than 2.5 times the rate for White residents.

Socio-economic reasons, pre-existing comorbidities, work circumstances, inconsistent healthcare access, stress, and decreased immunity, amongst other factors, have been posited as reasons for this shocking disparity. People of color, in particular AA and Hispanics, are more likely to be uninsured and to be frontline workers during the COVID-19 pandemic. This is compounded by the fact that comorbidities such as hypertension, diabetes, asthma, obesity, and cardiovascular disease are more common in AA and are also associated with higher COVID-19 mortality rates. Emerging evidence suggests that Vitamin D deficiency may represent another risk factor for poor outcomes from COVID-19.

Relevance of Vitamin D
Vitamin D is a secosteroid hormone synthesized in the skin following exposure to UVB ultraviolet radiation where it mediates the conversion of 7-dehydrocholesterol to pre-Vitamin D3. Following transport to the liver, it is hydroxylated to 25(OH)D, the primary circulating form typically used to measure serum Vitamin D levels. 25(OH)D is subsequently converted to the biologically active form 1,25, dihydroxy vitamin D in the kidneys by 1-alpha hydrolase. This active form binds to its nuclear Vitamin D receptor to induce the transcription of over 200 genes, affecting a wide range of physiologic functions.

Multiple studies have documented significant Vitamin D deficiency in people of color, especially in AA. Heavily melanized skin retards the synthesis of Vitamin D and necessitates longer periods of sun exposure for adequate synthesis of Vitamin D. Ginde et al. assessed demographic differences and trends of Vitamin D insufficiency in a US population.2Serum 25(OH)D levels were compared over two time periods (1988–1994 and 2001–2004) from the Third National Health and Nutrition Examination Survey (NHANES III) data base including two large populations (n=18,883 and n=13,369, respectively). Non-Hispanic Blacks had a significantly higher prevalence of Vitamin D deficiency, increasing in severity in the later data base. Recent NHANES data from 2011–2014 further documented the high risk of deficiency in non-Hispanic Blacks. In a recent prospective cohort study of 14,319 subjects, an estimated 65.4% of non-Hispanic Blacks were deficient in Vitamin D, compared to 29% of Hispanics and 14% of non-Hispanic Whites.3

Vitamin D deficiency has been shown to be a risk factor for many of the comorbidities that disproportionately plague AA including diabetes, hypertension, cardiovascular disease, autoimmune diseases such as lupus erythematosus, as well as aggressive forms of breast and prostate cancer.4 While the classic role of Vitamin D involves calcium and phosphorus homeostasis for healthy bone metabolism, it exerts a spectrum of pleotropic effects impacting cell growth, differentiation, inflammation, and immune regulation. Healthy levels of Vitamin D have been linked to significantly reduced mortality and improved health outcomes. Numerous investigations document the prolific role of Vitamin D in antimicrobial defense and modulation of the innate and adaptive immune responses. It mediates the induction of key antimicrobial peptides in the respiratory epithelium including cathelicidin (LL37) and beta defensins, which destroy invading organisms. In addition, Vitamin D inhibits the production of pro-inflammatory cytokines including IL-2, IFN-γ, TNF-α, and IL-6, while promoting Th2 responses by increasing IL-4, IL-5, and IL-10 production, hence skewing T cell responses to a down regulated, anti-inflammatory state.4

For the general population, the US Institutes of Medicine (IOM) recommends Vitamin D supplementation at doses that vary according to age and are based primarily on bone health. Current IOM supplementation recommendations are 400 IU (10ug) for infants, 600 IU/d (15ug) for children, adolescents, and adults, and 800 IU/d (20ug) for adults aged over 70 years to maintain a 25(OH)D concentration of 20ng/mL or higher. However, in individuals who are deficient in Vitamin D (25(OH)D level <20 ng/ mL), of which patients with skin of color are at a higher risk, supplementation is considerably higher. These recommendations are summarized summarized in Table 1.5

Conclusions

Vitamin D deficiency has been well documented in people of color, in particular AA. The aforementioned data suggest a relationship between low Vitamin D status and COVID-19 mortality rates. While myriad socioeconomic and health care disparities may be contributing factors, we must indeed consider key biological variables, including Vitamin D status, that may impact these observations. Future prospective studies are necessary to confirm these findings. As there is currently no readily available treatment or vaccine for COVID-19, treating physicians should be cognizant of the higher prevalence of Vitamin D deficiency in skin of color populations and its emerging potential role in COVID-19 outcomes. Given the devastating statistics of COVID-19 among minority communities and the multifaceted role of Vitamin D in skin and systemic health, dermatologists are essential partners in decreasing health care disparities by initiating the vitamin D dialogue. As such, we can play an invaluable role in improving the health outcomes of our patients, particularly people of color, during and beyond the COVID-19 pandemic.

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Frontal Fibrosing Alopecia Presenting as Androgenetic Alopecia in an African American Woman

By | Aesthetic Dermatology, Medical Dermatology, Sessions, Skin of Color Update Agenda | No Comments
Alopecia patient picture

Source: Next Steps in Derm

Frontal fibrosing alopecia (FFA) is a primary lymphocytic cicatricial alopecia that is currently regarded as a variant of lichen planopilaris. FFA has historically been considered rare in black patients, in whom traction alopecia, central centrifugal cicatricial alopecia, and androgenetic alopecia are frequently assumed to be more common. JDD author Kimberly Huerth, MD, ME describes a case of FFA in a black woman that both clinically resembled androgenetic alopecia and lacked many of the physical exam and dermoscopic findings associated with FFA. In doing so, she highlights the need for physicians to have a high index of suspicion for FFA in any black patient who presents with frontotemporal alopecia.

REPORT OF A CASE

A 53-year-old African American woman presented with a 6-month history of asymptomatic, moderately severe hair loss along the frontal hairline, which had not stabilized or improved with minoxidil 2% solution BID. Physical exam revealed decreased hair density affecting the frontal scalp, suggestive of androgenetic alopecia (Figure1). Dermoscopic examination showed decreased follicular ostia without perifollicular scaling or erythema. Eyebrow alopecia, facial papules, and glabellar red dots were absent, and there was no associated loss of body hair. A 4-mm punch biopsy sent for histopathologic examination revealed dense, chronic, perifollicular inflammation affecting the mid and upper portions of the follicles, with loss of associated sebaceous glands. Involved hairs demonstrated vacuolar interface disruption of the basilar and epibasilar layers at the level of the isthmus and infundibulum, with prominent exocytosis of lymphocytes into the outer root sheath. There was no miniaturization, dermal mucin, or inflammation affecting the epidermis, arrector pili muscles, and eccrine glands (Figure 2).

A diagnosis of FFA was confirmed by these findings. Our patient was managed with intralesional triamcinolone acetonide (10mg/cc) injections, clobetasol 0.05% ointment BID, hydroxychloroquine 200 mg PO BID, and minoxidil 5 mg PO daily. Unfortunately, her alopecia did not stabilize with these measures.

DISCUSSION

FFA is a primary lymphocytic cicatricial alopecia that is currently regarded as a variant of lichen planopilaris. It is characterized by band-like frontotemporal hairline recession, often with associated eyebrow alopecia, perifollicular erythema, and scaling. Clinical findings are frequently accompanied by pruritus and burning of the affected scalp. Since it was first described in 1994,1 FFA has largely been viewed as an alopecia of post-menopausal Caucasian women. This archetype has been maintained by patient demographics of subsequent published case series.2,3 FFA may thus be underdiagnosed in black women, in whom traction alopecia, central centrifugal cicatricial alopecia, and androgenetic alopecia are assumed to be more common. Furthermore, FFA can manifest uniquely in black women, who may be premenopausal4,5 and asymptomatic4 at the time of presentation. Classic signs of FFA may be subtle or absent among black patients, as increased pigmentation may render erythema difficult to appreciate, while oils and hair care products may diminish the appearance of scale.

It is important for dermatologists to both recognize that FFA is not uncommon in the black population,4,5 and to acknowledge how it initially came to be regarded as a disease of post-menopausal white women. Several of the larger published series come from geographic areas that lack a substantial skin of color population.2,3 There are also socioeconomic factors to consider. One series comprised exclusively of Caucasian women found their patients to be more affluent, which was speculated to be a surrogate marker for an unknown risk factor associated with the development of FFA.3 What these authors did not discuss, however, is that affluence enables access to specialty medical care. Affluence affects insurance status, which has been shown to vary widely among racial groups.6 Insurance status in turn bears upon who has access to dermatologic care, and who is ultimately included in a case series.

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Skin of Color Update 2020 Moves to Virtual Experience

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SKIN OF COLOR UPDATE 2020 MOVES TO VIRTUAL EXPERIENCE

Live sessions to be held September 12-13

New York (June 30, 2020) – Skin of Color Update, the largest medical education event focused on the dermatologic treatment of skin of color, is moving its 2020 event from an in-person to a virtual experience. The event will still be held September 12-13.

“We’ve made this difficult decision as a result of our goal to keep everyone safe, which was backed up by the wishes of the audience as demonstrated in a survey answered by more than 300 dermatologists,” said Shelley Tanner, CEO and president of SanovaWorks, which produces Skin of Color Update. “We know our mission of providing evidence-based research and practical pearls for treating skin of color is more important than ever. We are committed to providing the same essential content in a virtual setting.”

The Skin of Color Update agenda has been modified to reflect virtual learning. Live sessions, Q&A, poster sessions and panel discussions are included in the program.

Due to the change to virtual learning, the registration costs have been reduced. Registration is available to most medical professionals for $49. Registration includes unlimited access to on-demand content for the remainder of 2020.

“We hope the reduced costs and ease of attending will allow more dermatologists to learn how to care for the skin, hair and nails of our diversifying population,” said Skin of Color Update co-chair and founding dermatologist Eliot Battle, MD. “Everyone deserves safe and effective care no matter their skin color.”

Co-founding dermatologist Andrew Alexis, MD, also serves as an event co-chair. Common skin, hair and nail conditions in diverse populations will be covered. Sessions will address medical, surgical and cosmetic dermatology.

Skin of Color Update is a product of SanovaWorks, the publisher of the Journal of Drugs in Dermatology (JDD) and the producer of the ODAC Dermatology, Aesthetics & Surgical Conference.

CE credits (AMA PRA Category 1™) can be earned. Registration is available at skinofcolorupdate.com.

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