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Medical Dermatology

Apr 08
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Challenging Cases in Skin of Color Dermatology Patients

By Media Coverage, Medical Dermatology, Sessions
Skin of Color patient dermatology cases

Source: Next Steps in Derm

This year at the 17th Annual ODAC Dermatology, Aesthetic & Surgical Conference (ODAC), Dr Amy McMichael presented the audience with new pearls of advice on how to approach and diagnose complex medical dermatology cases in patients with skin of color. During her session, she addressed the important need for providers to be able to recognize disease in patients of all races. The majority of the global population consists of people with skin of color and the US population is changing to include a higher percentage of patients with diverse backgrounds. She covered a wide range of diagnoses from psoriasis to melasma and how these may present differently is darker skin types. As she walked the audience through each case it became apparent that being able to recognize and treat certain conditions in patients with skin of color is not only essential but also complex in nature.

First, Dr McMichael summarized the top conditions that African American patients were evaluated for during a dermatologist visit. The top 6 conditions included:

This helped to set the scene for the first case involving a 40-year-old African American female with hidradenitis suppurativa presenting with draining gluteal plaques. Even though the biopsy showed granulomatous dermatitis, the patient was not improving with multiple treatments and developed worsening pain and drainage from gluteal plaques. On a second biopsy the pathology showed psoriasis with granulomatous changes. The patient eventually improved with the systemic treatment Humira, a TNF-a inhibitor. Her major takeaways from this case included:

  • Do a second biopsy if the patient’s skin is not responding as expected to the treatment you have prescribed
  • Psoriasis can have a unique presentation similar to existing hidradenitis
  • Use systemic treatments early to help control symptoms

Second, she tackled the challenge of treating melasma with combination therapies. In melasma, there is too much melanin being created by melanocytes and it is then carried by keratinocytes. These cells then release melanin into the dermis, causing blotchy pigmentation often on the face. Topical therapies are usually directed towards preventing increased creation of melanin by melanocytes. People often use hydroquinone 2% or 4% along with encouragement of consistent daily sunscreen use. If used at too high of a concentration, then hydroquinone may cause ochronosis (skin becomes bluish – grey).

Dr McMichael suggested adding a novel treatment called cysteamine to the regimen for melasma treatment for more effective results. Cysteamine is an aminothiol that is made in our cells from the amino acid cysteine. Although more interest is arising now for its use in treating melasma, cysteamine was actually researched in 1966 when scientist Dr Chavin injected it into black goldfish skin and observed partial depigmentation. Cysteamine 5% cream may be a more effect treatment for melasma with less side effects.

Another novel treatment Dr McMichael discussed was the use of tranexamic acid for resistant melasma. This is another derivative of an amino acid, lysine, and it works as an anti-fibrinolytic. It has the ability to block UV-induced plasmin activity within keratinocytes. Patients would need to be screened out by their providers for a past medical history of DVT, pulmonary embolism, heart disease, and stroke before starting the oral medication. She emphasized the importance of getting a good medical history related to these conditions since tranexamic acid could increase the risk of these conditions. For patients who are able to take the medication they are expected to experience a few side effects such as mild GI upset and palpitations. This medication could provide improvement for many patients with chronic melasma who have had to struggle with this condition.

Third, in the next case we were reminded by Dr McMichael that keloids can be very disfiguring and distressful to patients. She talked about using intralesional Kenalog with contact cryotherapy as effective treatments of keloids. Other options for treatment included combining cryosurgery, intralesional Kenalog, and doxycycline. It was eye opening for the audience to hear her say we should be thinking about keloids not just as scars but tumors representing overgrowth of tissue. This paradigm shift of how we think about keloids can further shape how we think about treatment modalities for keloids as well.

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Dec 09
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Rosacea in Skin of Color

Rosacea in Skin of Color

By Medical Dermatology, Sessions

What is Rosacea? 

Rosacea is a common chronic inflammatory skin disease that primarily impacts the face, and includes papules, pustules, erythema, telangiectasias, perilesional redness, phymatous changes, and even eye involvement. Symptoms may vary among different patients and even vary over time in an individual patient. Central facial redness affects many adults and can be an indicator of the chronic inflammatory disease rosacea. Rosacea is a clinical diagnosis based on the patient’s history, physical examination, and exclusion of other disorders.

Rosacea is often under-diagnosed, particularly in individuals with skin of color. As a result, Skin of Color Update held a lecture on the topic at the most recent event.

Rosacea: Nuances in Clinical Presentation and Treatment 

At Skin of Color Update 2019, Dr. Fran Cook-Bolden aimed to catch us all up to speed in how to recognize rosacea in more richly pigmented skin. Her lecture on Rosacea: Nuances in Clinical Presentation and Treatment was brimming with practical tips on how to identify the often subtle and overlooked ways that rosacea can manifest in skin of color.  The following is an excerpt of an article by Kimberly Huerth, MD published on Next Steps in Derm.

Because rosacea can have a nuanced presentation in skin of color (SOC), with erythema and telangiectasias that may be difficult to discern in the setting of increased background pigmentation, it was incorrectly assumed for a long time to simply not be there. The reality is that the prevalence of rosacea in SOC is not well characterized but is likely underestimated.1Dermatologists who see a large number of SOC patients, however, will tell you that rosacea is by no means rare in this population. And I am one of these dermatologists—at my Howard University clinic, where I see predominantly black and Hispanic patients, I see several of cases of rosacea every week.

And because a diagnosis not considered is a diagnosis not made, there is often unnecessary progression of rosacea in SOC patients that results from delayed and/or inaccurate diagnosis, which in turn engenders inappropriate or inadequate treatment. As a consequence, this can lead to morbidity in the form of disfiguring, occasionally irreversible cutaneous findings, as well as intense and chronic emotional distress.

Pearls

  • Look for the nuanced clinical findings!!
  • Fixed centrofacial erythema may appear more reddish/violet
  • A patient complains of “acne,” but has no comedones. Additionally, papules and pustules are superimposed on an erythematous background. Inflammatory papules may also appear on the chest and back.
  • Telangiectasias can be difficult to appreciate with the naked eye in FST V – VI, so use your dermatoscope to help you find them
  • Check for scleral injection, which may be a sign of ocular rosacea. Be aware that the onset of ocular findings may proceed cutaneous ones.
  • Phymatous rosacea is a giveaway!
  • Facial edema of the upper 2/3 of the face in a patient who has complained of longstanding rosacea symptoms may represent progression to Morbihan disease. Case in point (quite literally)—a poster that I presented at the Skin of Color Update highlighted a case of Morbihan disease in a black man who had reported symptoms of rosacea to his non-dermatology providers for 16 YEARS before he came to see me and received a correct diagnosis. To learn more about this case, and Morbihan disease, check out Dr. Lola Adekunle’s interview on Next Steps in Derm.
  • Pertinent negatives are just as important as pertinent positives. Know that post-inflammatory hyperpigmentation (PIH) is ALMOST NEVER directly related to rosacea, unless the disease is very chronic and severe OR if the patient has been injured their skin in some way while trying to self-treat disease manifestations (picking at lesions, using harsh topical therapies)

For more rosacea pearls and AHA moments, visit the article on Next Steps in Derm.

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