The common challenges in treating patients with skin of color have not changed over the years, but continuing research has borne new and innovative treatment approaches and techniques that can better and more safely address the conditions often seen in this patient population.
Miami Beach, Fla. - The common challenges in treating patients with skin of color have not changed over the years, but continuing research has borne new and innovative treatment approaches and techniques that can better and more safely address the conditions often seen in this patient population.
“Patients with skin of color have always been more challenging to diagnose and treat because many cutaneous diseases and conditions can often present differently compared to the same ‘textbook’ diagnosis in Caucasian skin,” says Wendy E. Roberts, M.D., a dermatologist in private practice in Rancho Mirage, Calif. “Being acutely aware of the varying presentations of a given condition across different skin types is crucial in not only exacting an accurate diagnosis but also in implementing an appropriate and safe therapy.”
Skin of color is a combination of a diverse group of skin types, says Dr. Roberts, who spoke at the annual meeting of the American Academy of Dermatology. This includes African, Asian, Caucasian and Hispanic skin tones, as well as a growing population of mixtures thereof, all of which may respond differently to standardized procedures and treatments. Skin of color may often go unrecognized because the patient is mistaken for Caucasian alone. It behooves physicians to ask about ancestry and familiarize themselves with these varying skin types and the newest treatments that work best for a certain subset in order to maximize treatment outcomes.
The variability seen among the different types of skin of color underscores the necessity of safer treatments in these patient populations, as different skin types will respond differently to a given treatment, Dr. Roberts says.
When performing therapeutic procedures such as surgery, chemical peels, cryotherapy and laser treatments, Dr. Roberts says it is paramount to keep skin of color in mind, as well as the type of skin color of the patient, as this vigilance will help guide the clinician’s choice of therapy, which hopefully may lead to fewer complications.
“Complications from laser and light treatments are not uncommon in multicultural, global mixed racial skin types. Patients may not appear to have skin of color and wrong settings may be used, which can result in hyperpigmentation, hypopigmentation and scarring,” she says.
Hypopigmentation and hyperpigmentation - such as vitiligo and melasma, respectively - are common conditions in patients with skin of color. Though truly effective therapies are few and far between, Dr. Roberts says, the first-line treatments for hypopigmentation and vitiligo are topical corticosteroids alone and in combination with vitamin D3 analogues and calcineurin inhibitors. Second-line treatments that could be used in recalcitrant vitiligo lesions include narrowband UVB with calcineurin inhibitors, systemic corticosteroids, topical L-phenylalanine, topical antioxidants, as well as the excimer laser.
An interesting new treatment with topically applied bimatoprost ophthalmic solution (a prostaglandin analogue - PGF2alpha) has also shown some promising results in repigmentation, Dr. Roberts says.
In a small, prospective pilot study including 10 patients, Dr. Tarun Narang of Gian Sagar Medical College, Banur, India, treated localized vitiligo lesions with bimatoprost 0.03 percent ophthalmic solution dosed at one drop per cm2 twice daily for four months.
Results showed that seven out of 10 patients demonstrated pronounced repigmentation beginning on average after two months of treatment. At the four-month follow-up, three patients had a 100 percent repigmentation,three had 75-99 percent repigmentation, and 1 patient showed 50-75 percent repigmentation of the treated lesions.
Patients with recalcitrant stable focal vitiligo lesions on the face responded particularly well to the topical F2-alpha analogue. Patients with disease duration of six months or less responded best to the treatment, with lesions on the face and scalp repigmenting the fastest, after only four to six weeks of treatment.
Although the mechanism of action remains unclear, Dr. Roberts says, it is thought to involve regulation of the melanocytes by prostaglandin. Dr. Narang recently presented the results of his study at the World Congress of Dermatology in Seoul, South Korea.
Hydroquinone remains the gold standard treatment for hyperpigmentation. Any emerging topical therapy in this field must show clinical efficacy equal or superior to hydroquinone in order to be considered a true alternative therapy, Dr. Roberts says.
“Besides ochronosis, we haven’t really seen any bad side effects with hydroquinone monotherapy. Nevertheless, there has been a worldwide trend to get away from this bleaching agent and in its place, try new and emerging agents. This trend results mostly from manufacturing practices which result in hydroquinone tainted with mercury and other contaminants,” she says.
Many different new proprietary products are showing to be very useful in the treatment of hyperpigmentation, Dr. Roberts says. Similar to hydroquinone, which targets one part of the melanin pathway by inhibiting tyrosinase, newer agents target multiple parts of the melanin pathway, including targeting the removal of stratum corneum pigment. Patients should also use sunblock with a SPF of 30 or higher, as UV radiation will contribute to a worsening of the condition. According to Dr. Roberts, the latest conventional wisdom is that the use of sunblock is extremely important in the treatment/prevention of melasma as well as for postinflammatory hyperpigmentation.
“This is a dynamic area with a lot of research yielding new and exciting products and techniques. Keeping up with the new literature and technologies are really the keys to success,” Dr. Roberts says.
Disclosures: Dr. Roberts reports no relevant financial interests.