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Dana Turner

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.

Read Full Article….

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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The Business of Dermatology

By | Aesthetic Dermatology, Medical Dermatology | No Comments
The Business of Dermatology

Business intellect, a vital aspect of managing a practice, is not taught in residency. From the infancy of their training, dermatologists are trained to think broadly and scrupulously, using each clue, each corporeal sense, and each available tool to accurately diagnose and manage a plethora of cutaneous conditions. After residency, dermatologists set out armed with the knowledge and drive to deliver expert care to their future patients. However, despite their education and best intentions, lack of business acumen can hinder even the brightest and most motivated of practitioners. In order to enlighten oneself in the complicated field of business management, clinicians are left to fend for themselves, often learning as they go, sometimes making unnecessary mistakes, and adjusting their business practices reactively. Retrospective “trial and error” learning is time-consuming, cumbersome, and costly. Why not short track and get the goods without the trial and error, making costly mistakes and taking years. The new book, The Business of Dermatology is a cornerstone achievement in the standardization of business education for dermatologists.

Edited by Drs. Jeffrey S. Dover and Kavita Mariwalla, and authored by impressive experts in the field, The Business of Dermatology offers a comprehensive guide to opening, maintaining, and sustaining a practice. To start, the power of this textbook fundamentally lies in the experience and scope of its authorship. The authors were hand-selected by the editors ensuring that each chapter was written by a tried and true expert in that subject. Unlike other textbooks in the field of business management and administration that are primarily written by individuals from the business world, some of whom have no insight into the inner machinations of the medical world, or hands-on experience, the authors of this book are well-known, respected dermatologists that hail from thriving practices of their own. The reader has an unprecedented opportunity to learn from the firsthand experiences of top authorities who live and breathe dermatology. Using conversational prose, the authors depict their experiences, trials, and errors, employing specific real-world examples and scenarios while tackling each subject.

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Skin of Color Update 2020 Goes Virtual

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On behalf of Skin of Color Update co-chairs, Andrew Alexis, MD, MPH and Eliot F. Battle, Jr. MD, and conference organizers, we know the past months have been a very challenging time for everyone in our country and around the world and we stand together with you.

Based on the results of our Skin of Color Update audience survey, and with the safety of everyone in mind, we have taken this opportunity to reimagine the meeting for today’s landscape. We have made the decision to change the conference to a virtual learning experience.

This is a difficult, but necessary decision and we appreciate in advance your understanding. The mission of Skin of Color Update Virtual (SOCVU), to provide trending evidence-based research and new practical pearls for treating skin types III-VI, is now more important than ever and we are committed to providing the same essential content in a virtual setting.

Skin of Color Update Virtual will continue to be held virtually on September 12 -13, 2020 with a revised agenda to accommodate the updated setting. Live sessions, Q&A, poster sessions and panel discussions will be included in the program. The full agenda can be found here.

All registrants will receive access to the content, on-demand, following the event through December 31, 2020.

Additional information can be found here. To register for only $49, click here.

Black Lives Matter | A Message From Our CEO

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Black Lives Matter

NEW YORK, (June 3, 2020) –  Shelley Tanner, SanovaWorks (the parent company of Skin of Color Update) CEO/President

The below was sent to the employees of SanovaWorks.

This is an issue we should all be aware of, we should all be engaged in, and we should all be actively fighting together against for a solution. Each company, as a collective of humans, has a responsibility to do everything we can to protect our fellow humans and ensure that we all have access to the things we hold dear. We cannot stand by knowing that our fellow Americans are being targeted unjustly from all angles.

On the heels of the global and national devastation of the coronavirus pandemic, we are witness to the glaring evidence of an epidemic that has existed for hundreds of years in the USA, and that is the systematic racism and injustice against black Americans. The devastation that results from this affects lives in literally every facet: education, careers, health, families, finances, safety, etc.

The pandemic unveiled in clear numbers the disparity between black and white communities in this country, where only 13% of the population are African American, yet represent 23% of the deaths. In some states, like Georgia, African Americans make up little more than 30% of the population, yet almost 50% of deaths are from within this group.

On May 25th this year George Floyd, a black man from Minneapolis who is also a brother, a cousin, a nephew, a friend, a boyfriend, a son, and a fellow human, was murdered in a horrific incident that has reinvigorated people to stand up and say that this is not acceptable, spurring the nationwide protests that are not only just, but also necessary to demand change for a reality that has been accepted through complacency and inaction.

What can we do?

For our employees who are impacted by this, we need to support you. As a team and your friends we are here to back you up.

If you don’t already know how you can personally help, I hope you will take the time to learn what we can all be doing at this time to be a part of the solution. You might feel helpless or overwhelmed by this matter, and feel like there is nothing you can do, but this is part of the problem. Doing nothing is a choice and an action. The support we show for one another matters. One of my friends sent me this article on the weekend, for which I was extremely grateful, as it outlines many things we can all be doing for racial justice.

READ What White People Can do for Racial Justice

President Barack Obama

On June 1, President Obama published an article on how he believes we can use what is happening now as a turning point for real change that is definitely worth the read. In this article there is a link to a very detailed report and toolkit developed while he was in office by the Leadership Conference on Civil and Human Rights, along with a dedicated site of resources and organizations to learn about and get involved with.

READ How to Make this Moment The Turning Point for Real Change

Grassroots Organizations

Below is a list of grassroots organizations supporting this cause. I have personally donated, and I encourage you all to consider doing the same. There are many more that I have read about and perhaps that speak to you more personally. I encourage you to look up some of these groups and read about what they are doing.

https://minnesotafreedomfund.org/

https://www.blackvisionsmn.org/

https://www.reclaimtheblock.org/home

https://www.northstarhealthcollective.org/

On Wednesday June 3rd

We as a company will take a moment of silence at 1:30pm ET to reflect on these injustices, and how we personally might help. I would like us all to pause together and show solidarity. For those who choose to sit on their own, know we are with you.

I am committed to ensuring that this is not the end of the conversation for SanovaWorks. Stay tuned for more information and please get in touch with me directly if you have thoughts on this. I welcome all ideas and feedback.

And finally. To ALL of our friends of color: know that we see you, we appreciate you, and we will do everything we can to support you.

Shelley N. Tanner
President/CEO

Recommendations for Managing Lichen Planopilaris With Hydroxychloroquine During the COVID-19 Pandemic

By | COVID-19 Resources | No Comments
Recommendations Chart

Source: Journal of Drugs in Dermatology

The recommendations are noted in the article, Considerations of Managing Lichen Planopilaris With Hydroxychloroquine During the COVID-19 Pandemic, will be available in the June print issue of the Journal of Drugs in Dermatology.

Chloroquine (CQ) and hydroxychloroquine (HCQ), two well-known drugs among dermatologists, have shown their efficacy in the inhibition of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) replication.1,2 HCQ is found to possess a better clinical safety profile, more potency, and fewer drug–drug interactions compared to chloroquine.3 HCQ has been reported to exert efficacy in the inhibition of SARS-CoV-2 in vitro replication through diverse mechanisms. First, it interferes with the glycosylation of angiotensin-converting enzyme 2 (ACE2), resulting in a subsequent reduction in the binding efficacy between ACE2 on host cells and the SARS-CoV-2 spike protein. Second, it blocks the fusion of the virus to the host cell. Finally, it suppresses the “cytokine storm” accountable for the disease progression to acute respiratory distress syndrome (ARDS). Although studies are underway to confirm the in vivo effectiveness of HCQ in the SARS-CoV-2 infection, promising primary results have led to a shortage of the drug for dermatologic purposes, which is a real concern in the current pandemic.1

While we are amid a pandemic with the possible shortage of HCQ, dermatologists should be reminded that:

  • The anti-inflammatory effect of HCQ may improve the clinical signs of LPP; however, administration of this drug is insufficient to prevent the subclinical disease progression.9 Dermatologists may discontinue the use of HCQ in responders after 1 year with monitoring the patients for recurrence or relapse.5
  • Topical and intralesional super potent corticosteroids are recommended as the first-line treatment in localized LPP.4
  • Oral cyclosporine followed by systemic corticosteroid may be the most effective medications in LPP; however, disease relapse may be detected.10 Mycophenolate mofetil has a more favorable safety profile compared to cyclosporine11 but the immunosuppressive nature of these medications necessitates extreme caution toward their administration during COVID-19 pandemic.12
  • Acitretin (25 mg/day) may be an appropriate alternative since it has shown improvement in 66% of patients.7
  • Pioglitazone (hypoglycemic drug, 15–30 mg/day) has shown some efficacy in the treatment of LPP and can be considered as an alternative to HCQ.4
  • Tetracyclines antibiotics can also be considered as an alternative due to favorable outcomes in previous studies.13

Read Full Article….

Ethnicity Matters: Medical Dermatology Concerns Across Ethnic Groups

By | Medical Dermatology, Sessions | No Comments
Wendy Roberts Presenting at SOCU

Source: Dermatology News

This is an excerpt from Dermatology News’ coverage of Skin of Color Update 2019.

For women with pseudofolliculitis barbae, an empirically-based strategy of microdermabrasion, laser treatment, emollients, and maintenance retinoids has been found highly effective, Wendy Roberts, MD, reported at the Skin of Color Update 2019.

“We didn’t have great treatments for this problem in the past, but the technology has evolved, and you can now get most women clear,” Dr. Roberts, a dermatologist who practices in Rancho Mirage, Calif., said at the meeting.

This approach is appropriate in all women, but Dr. Roberts focused on her experience with black patients, for whom an antioxidant cream is added to address the inflammatory-associated hyperpigmentation that often accompanies pseudofolliculitis barbae, a chronic inflammatory skin condition typically characterized by small, painful papules and pustules.

Start with microdermabrasion to treat the hypertrophic hair follicles and address keratin plugs, Dr. Roberts said. The microdermabrasion smooths the skin and increases penetration of subsequent creams and topics, she said.

“In the same session, I treat with Nd-YAG 1064 nm laser using short pulses,” she noted. For black women, she makes four passes with the laser at a level of moderate intensity. For those with lighter skin, she might perform as many as six passes with the laser set higher.

The microdermabrasion is repeated monthly for three or four treatments, but can be extended for those with persistent symptoms, Dr. Roberts pointed out. She presented a case of a patient who required seven treatments to achieve a satisfactory response.

Read More….

On-Demand Recording: COVID-19: Special Considerations for the Skin of Color Patient – A Conversation with the Experts

By | COVID-19 Resources | No Comments
SOC COVID 19 Webinar

This webinar was previously recorded on April 27th, 2020 and is now available on demand. Almirall has graciously supported the on-demand broadcast of this webinar.

Skin of Color Update (SOCU) and JDD invite you to attend “COVID-19: Special Considerations for the Skin of Color Patient – A Conversation with the Experts”. During this 90-minute webinar, Dr. Andrew Alexis will be joined by skin of color key opinion leaders to discuss special considerations and practical approaches to managing dermatologic disorders in skin of color during the COVID-19 pandemic.

 

Topics to be addressed include the following:

  • Hair Disorders
  • Pigmentary Disorders
  • Aesthetic Concerns
  • Inflammatory Disorders (including acne, atopic dermatitis, psoriasis, and others)
  • How to stay connected with your skin of color patients on social media
  • Vitamin D deficiency among people of color and its potential relevance to COVID-19 in patients of color
  • COVID-19 related shifts in common dermatologic concerns in skin of color
  • Impact on the practice of aesthetic dermatology for skin of color

MODERATOR:

Andrew Alexis, MD, MPH (Chair, Department of Dermatology, Mount Sinai West and Mount Sinai Morningside and Professor, Icahn School of Medicine at Mount Sinai)

 

PANELISTS:

Eliot F. Battle, Jr., MD (CEO and Co-Founder of Cultura Dermatology & Plastic Surgery)

Amy McMichael, MD (Professor and Chair of Dermatology, Wake Forest Baptist Medical Center)

Heather Woolery-Lloyd, MD (Director, Skin of Color Division, University of Miami School of Medicine)

Pearl Grimes, MD (Founder and Director, Vitiligo and Pigmentation Institute of Southern California)

Supported by:

Almirall Logo

COVID-19: Special Considerations for the Skin of Color Patient – A Conversation with the Experts

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SOC COVID 19 Webinar
Register Now
Skin of Color Update and JDD invite you to attend “COVID-19: Special Considerations for the Skin of Color Patient – A Conversation with the Experts”. During this 90-minute webinar, Dr. Andrew Alexis will be joined by skin of color key opinion leaders to discuss special considerations and practical approaches to managing dermatologic disorders in skin of color during the COVID-19 pandemic.

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