By Nicollette Samuels
Skin plays an important role of the way we look. Its appearance can affect one’s confidence and self-esteem. Although flawless skin can be an asset to someone’s beauty; it is also the human body’s largest organ and can affect its health. On February 11th, the Skin of Color Society held its fourth annual Media Day, where dermatology experts discussed the many health and aesthetic skin issues that people of color tend to have and how to prevent them.
This year’s Media Day was held at the Offices of Dr. Dhaval Bhanusali, Hudson Dermatology and Laser Surgery in Hudson Yards in NYC. Sponsors included Almirall, Ceylon by Anim Labs, Dermablend Professional, Dermavant, Procter & Gamble—Gillette, Medscape, Procter & Gamble—Opte, Pfizer, Scientis, and SENTÉ.
The event consisted of multiple information sessions regarding various skin concerns with well-respected dermatologists. The first session touched on the topic of “Skin Cancer and Sun Protection in Melanin-Rich Skin” with Dr. Susan C. Taylor and Dr. Maritza I. Perez. Dr. Taylor began by sharing five facts.
1. People with melanin-rich skin are susceptible to skin cancer.
There is a common misconception about black people or people with large amounts of melanin in their skin not being able to get skin cancer. Well, this is entirely false. According to statistics of melanoma incidences from the CDC in 2016, while whites had the largest recorded accounts of cancer with 25.2 per 100,000 people, American Indians/Alaska Natives came in second place with 5.2, in third were Hispanics with 4.6, Asian/Pacific Islander in fourth with 1.2, and in last place, blacks with 0.9. “If you look at the numbers for the populations for the people of color, it is not zero! Melanoma does occur in these populations, the same with basal cell carcinoma. It’s more prevalent in the white population, but we do see it in Hispanics, Asians, and Blacks; it is not zero,” said Dr. Taylor. It is very important to know that skin cancer does occur in people of color and it can grow in the palms of the hands, fingernails, soles of the feet, toenails, and mucus membranes. Skin cancer should not go undiagnosed.
2. People of color need sun protection.
Sun protection is critical for people of color because they can develop skin diseases that make them more susceptible to the sun. Pigmentation conditions such as melasma, post inflammatory hyperpigmentation, and vitiligo all require sun protection. Diseases such as Lupus Erythematosus, Solar Urticaria, Polymorphous Light Eruption, and medication generated sun sensitivity for hypertension, diabetes, acne, and more.
3. Reasons given for not wearing sunscreen.
There are many excuses used for not using sunscreen. Some reasons are that melanin-rich skin is already protected from the sun (which is false by the way), it’s too hard to apply, forgetting to use it, and not liking the white cast and consistency or texture that physical sunscreens (zinc and titanium dioxide) have. This leads to people trying out chemical sunscreens or not wearing it at all.
4. Chemical sunscreen can be absorbed through the skin.
Chemical sunscreens are popular among people of color because of its ability to blend into the skin without leaving a white cast, which sometimes can make melanin-rich skin look purple or ashy. There has been research on chemical sunscreens and their absorption into the body. Commonly used chemical filters like Avobenzone, Oxybenzone, Octocrylene, Homosalate, Octisalate, and Octinoxate have shown up in the blood stream in a study. Although this revelation has been discovered, doctors and scientists don’t know how it effects the body. “I still advise my patients to wear sunscreens, wear protective clothing, hats, sunglasses, walk on shady sides of the street, and get under an umbrella,” Dr. Taylor said. So, don’t be afraid to try chemical sunscreens.
5. Physical sunscreens are beneficial.
Physical sunscreens may have a reputation of being unpleasant to apply to the skin, but they do have a purpose. Sunscreens in general were made to protect skin from UVA and UVB rays. UVA rays are what goes deep into the skin and cause aging, while UVB rays are what cause the skin to burn. Doctors have discovered that visible light can worsen skin issues like melasma and hyperpigmentation, but physical sunscreens containing iron oxide can help block visible light. Dr. Taylor recommends using tinted sunscreens that contain iron oxide in a two percent form and micronized formulations of physical sunscreens so that they may be more aesthetically pleasing to apply.
The second session was presented by Dr. Lynn McKinley-Grant and Dr. Donald Glass, who explained the “External Signs of Internal Diseases.” First, they discussed the different skin types based on the Fitzpatrick scale. Type I skin being the lightest (think of actress Emma Stone), which tends to freckle, burn and peel, but never tans, to type VI being the darkest (think of actress Lupita Nyong’o), tends to never freckle or burn, but tans darkly. Despite what the scale says, there are always exceptions, and according to Dr. McKinley-Grant, type V and VI skin do burn. “The textbook says that they don’t, but they do burn, so we are working on the Fitzpatrick skin type scale because the burning does not always apply as it used to, so we are working to change that,” Dr. McKinley-Grant said.
When diagnosing internal diseases or problems, one of the first places to examine is the skin. There are color changes in the skin that can reveal organ failure. Jaundice, the yellowing of the skin and eyes, can be a sign of liver disease. When the skin looks pale or gray in color, usually in the palms of hands, it can also be a sign of kidney disease and anemia.
Inflammation and erythema (the redness of the skin) are another set of external skin problems that may be symptomatic of internal health issues. Erythema may appear different on the skin depending on the skin tone or disease; on darker skin tones, it may appear as a purplish or pinkish red hue. Diseases and conditions such as psoriasis, which has a distinct red and scaly pattern on the skin, lupus, which can cause purple and red scarring on the skin, and sarcoidosis, that can cause inflammation and make darker skin an “apple currant” brown or deep red color.
Some skin signs to look out for are:
- Erythema- which can be a symptom of medication/drug reactions, eczema, cancer, and infection.
- Obesity, Impetigo (bacterial infection), Acanthosis Nigricans, and Necrobiosis Lipoidica Diabeticorum- signs of diabetes.
- Eye changes- symptom of jaundice liver disease, and thyroid disease.
- Bumps and Blisters- signs of autoimmune blistering diseases (Bullous Pemphigoid), cancer (Lymphoma) and Sarcoidosis.
- Unwanted facial hair and acne (Hirsutism)- signs of Polycystic Ovary Disease.
- Hair loss- diabetes, thyroid disease, and anemia.
- Hives- symptom of an allergy to medication.
- Widespread scaly rash (Pruritis)- symptom of diabetes and cancer (Lymphoma)
The third information session was with Immediate Past President, Dr. Seemal R. Desai and Associate Director of Skin of Color Miami, Dr. Laura Scott, who explained “State-of-the-Art in Treating Pigmentation Disorders and Skincare Products.”
“Pigmentation concerns and skin discoloration, no matter what we do in skin of color dermatology, is the number one complaint from patients who come into our practice,” said Dr. Desai. The two most common types of pigmentation disorders are Hypopigmentation (light spots), which includes vitiligo, and post-inflammatory hypopigmentation; and hyperpigmentation (dark spots), which include melasma and post-inflammatory hyperpigmentation.
Melasma is an acquired condition of hyperpigmentation that can appear after pregnancy, the use of birth control, using certain medications, from thyroid disease, or family history. Today there is more information regarding the advancement in understanding the condition. Newer data suggests that melasma is an inflammatory condition that can be exacerbated through visible/blue light, such as florescent light and the light from electronic devices. Melasma can also be worsened by environmental stress and pollution. “We are now making new advances in how to treat these patients from a chronic, long-term perspective. So, let’s get the pigmentation better initially, but also try to maintain the results,” Dr. Desai revealed.
The gold standard in treating melasma has always been hydroquinone, usually formulated in a triple combination treatment with hydroquinone, a retinoid, and a steroid to calm down possible inflammation. There are now new treatment alternatives for those who can’t be on hydroquinone or for maintaining the results after coming off hydroquinone since it is not recommended to stay on the gold standard forever, due to its toxicity. Tranexamic acid, in both topical and oral formulations, Iron oxides, which are great for protecting the skin from visible light and are easily found in some tinted makeup, and Cysteamine and glutathione, which are antioxidants that can protect you from environmental stressors and pollution.
“We try not to be procedure heavy when treating melasma, and when we do, we always make sure that we have pretreated the patient with hydroquinone or some other topical regimen and then we continue treating them throughout afterwards,” said Dr. Scott. Microneedling is a procedure that has shown some benefits and it doesn’t cause as much inflammation, but it is not a procedure where one will see immediate results; this will require multiple sessions to get the desired results of your dreams. This also goes for most procedures in general, so always set realistic expectations. Other procedures include chemical peels, which can be helpful if done correctly and at the right concentration, because it can also cause more inflammation and worsen the melasma that you started with. Laser treatments are another type of procedure that can be used to treat melasma but is not recommended to use in the summer or sunnier/warmer environments, as the sun can negatively affect the treatment. Also, if the laser is not used on the right settings, patients can be exposed to skin burning and worsened melasma.
The treatment of vitiligo is also making advancements in dermatology. There are many ointments, oral steroid pills and UV light treatments that have been used to help bring back the pigment in the skin for vitiligo patients, but now there are new developments like JAK inhibitor drugs. JAK inhibitors are immunomodulating drugs that help the immune system. “The important thing to know in treating any pigmentation disease, especially vitiligo, is that some of these patients have a large psychological burden. They are depressed, don’t want to go outdoors, don’t have relationships… they are truly ostracized. It is important to let our patients know that we are here to help them in their journey to get them better,” Dr. Desai said.
Antioxidants are great over the counter treatments to help with pigmentation issues such as Alpha Lipoic Acid, Vitamin C, Vitamin E, and Polypodium Leucotomos. A healthy and balanced diet, and keeping the body hydrated can also aid in helping pigmentation.
The current skincare trend is to use naturally occurring active ingredients to help target skin problems. Ingredients such as Licorice root, Kojic acid, Niacinamide, Vitamin C, Arbutin, Bakuchiol, Azelaic acid, and Soy are all ingredients used in the shift to “natural” and “non-toxic” from products filled with chemicals. Products with these ingredients can all be found easily over the counter.
The fourth session with Dr. Andrew Alexis and Dr. Dhaval Bhanusali educated the room on “Patient Safety in Cosmetic Procedures.”
“When it comes to patients of color, which include any of the non-white ethic groups, there are nuances to performing cosmetic procedures. Bottom line is, there are different risk profiles, different settings, and pre and post treatment parameters to deliver the best results. There isn’t a one size fits all,” says Dr. Alexis. Some safety considerations people of color should take into account before having a cosmetic procedure is the tendency to have a higher risk of dyspigmentation, whether it be hyperpigmentation or hypopigmentation. There is also a risk of enlarged and raised scars, such as keloids and hypertrophic scars. Due to these complications, device settings and treatments need to be tailor fit for your skin. There tends to be complications when the right device is not used for the patient’s skin type, or even when the right device is used, the wrong technique can be harmful. “The way we think of cosmetic procedures is that they can do tremendous good, but at the same time if not done with caution, they can also produce harm in patients of color,” Dr. Alexis explains.
Both Dr. Alexis’ and Dr. Bhanusali’s take home messages for being as safe as possible when considering doing a cosmetic skin procedure are:
- “Select a board-certified dermatologist with expertise in treating diverse skin types – Do your research!”
- “Make sure your ‘doctor’ went to medical school.”
- “Share your ancestry and your history of hyperpigmentation/scarring with your treatment provider (during consultation).”
- “You may need pre- and post-treatment skin care as well as less aggressive treatment settings for best outcomes.”
- “Slow and steady is sometimes needed.”
The fifth and final information session, “Hair Happenings,” was presented by Dr. Amy McMichael and Dr. Crystal Aguh.
Hair loss is a common condition for women of color, being one of the main reasons why women see a dermatologist. One reason why some women are experiencing hair loss or hair breakage, is because of the type of hairstyles they wear. Lace front wigs have become a huge hair trend today. While they may be beautiful and are sometimes used as a protective style, if not installed correctly and safely, they may cause more damage than protection. Applying various glues to the frontal hair line overtime can cause hair thinning, breakage, and permanent damage. Styles like lace front wigs, tight braids, and microlink extensions have been associated with hair loss, specifically Traction Alopecia.
Traction Alopecia is a very interesting form of hair loss because when it first starts it’s reversible, but most people who come in with this form of hair loss think natural oils can aid in that process, but unfortunately, by the time patients go to a dermatologist’s office, it has become a medical condition. Medical treatments for Traction Alopecia include steroid injections/ointments, and minoxidil (Rogaine); sometimes patients even require hair transplants.
Some alternative hairstyles to prevent hair tension and alopecia are crochet braids, and using hair pieces like ponytails, puffs, and buns to create more fullness to the hair. These are also great for covering hair loss as well.
Frontal Fibrosing Alopecia is a form of hair loss that is being seen more commonly today than it used to 30 years ago. This is an inflammatory scarring hair loss, which means that the hole where hair grows through on the scalp is scarred shut, making it very hard for hair to grow back out ever again. While this form of alopecia is generally seen in more white women, it is being under diagnosed in women of color.
Alopecia Areata is an autoimmune form of hair loss commonly just called “alopecia.” White blood cells attack the hair follicles, but don’t kill or scar them, they are just sleeping. New medical treatments such as JAK inhibitors that suppress the immune system are an option to help reverse this kind of hair loss and have been successfull on other patients. “In my experience, when I do a JAK inhibitor and someone who is going to respond, I get about 90% regrowth in about 6 months,” claimed Dr. Aguh.
Central Centrifugal Cicatricial Alopecia (CCCA), is a form of hair loss that is near the hearts of Dr. Aguh and Dr. McMichael. This type of alopecia was once called “Hot Comb Alopecia” in the 1950s, and then “Chemical Relaxer Induced Alopecia” in the 1990s, mostly because these were hair processes that were done to black hair, and this form of hair loss was mostly seen in Black women. However, now that a lot more black women have gone natural during recent years, the name has changed to Central Centrifugal Cicatricial Alopecia. According to research this form of hair loss seems to have a relation to fibroids. There are a few treatments for this, for example, steroid injections/creams; and newer options, such as, topical metformin cream and surgical treatments called platelet rich plasma (PRP). This surgical treatment may be familiar because it is the “vampire facial” that was very popular, where they take your blood, spin in down with a centrifuge, and apply it back on the scalp.
Hair supplements are one of the first things people think of taking when they are experiencing hair loss, breakage, or just want their hair to grow faster. The most popular hair supplement, biotin, has never been shown to lead to hair growth. Biotin has been proven to increase the strength of the nails, but not the hair; so those “Hair, Skin, and Nails” vitamins are just plain marketing. The use of biotin has also been warned against by the FDA due to its impact on blood work and data.
Overall, the Skin of Color Society Media Day was an educational and informative event. Being able to see doctors of color in their respective fields of dermatology is very inspiring and beneficial to communities that need help and care for their skin. It is also comforting to know that there are specialists that have taken the time to study the differences in skin of color and know exactly what they are doing when it comes to treating it.
Photography by: Swapnil Junjare (https://www.swapniljunjare.com/)