DR. BENJAMIN BARANKINDermatologist

Medical Director & Founder of Toronto Dermatology Centre

Dermatology of Darker Skin: Useful Pearls & Potential Pitfalls

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Demographics of Darker Skin

80% of the world has pigmented skin

Demographics of Darker Skin

Canadian 2006 census visible minority population over 5 million

16.2% total Canadian population

If current immigration trends continue, members of visible minority groups could account for roughly one-fifth of the total population by 2017.

Visible Minorities, Canada, 2006

Source: 2006 Census of Canada.

Chinese24%

South Asian24.9%

Black15.5%

Filipino8.1%

LatinAmerican

6%

Arab5.2%

SoutheastAsian4.7%

Korean2.8%

Japanese1.6%

WestAsian3.1%

VisibleMinority

n.i.e.1.4%

MultipleVisible

Minority2.6%

Classification

Skin Phototype system – Fitzpatrick Classification

Skin Type

Skin Color Characteristics

I White; very fair; red or blond hair; blue eyes; freckles

Always burns, never tans

II White; fair; red or blond hair; blue, hazel, or green eyes

Usually burns, tans with difficulty

III Cream white; fair with any eye or hair color; Sometimes mild burn, gradually tans

IV Beige/lightly tan; olive skin tone Rarely burns, tans with ease

V Brown very rarely burns, tans very easily

VI Black Never burns, tans very easily, deeply pigmented

3 Friends3 Fitzpatrick skin types

V

IV

VI

Natural Selection and Skin Colour

Geographic Migration and Skin

Type I, II III exposed to ++UV light = solar damage

Geographic Migration and Skin

http://pro.corbis.com/

Are you getting enough vitamin D?

The sunshine vitamin: Researchers sound alarm over shortage among non-whites

Vitamin D deficiency in:

• 100% African origin ; 93% South Asian ; 85% East Asian Chinese, Indochinese

Biology of Skin Pigmemt

there are no racial difference in the NUMBER of melanocytes

skin colour difference is due to variation in number, size and aggregation of melanosomes within the melanocyte

Practical Pearls

Acne in Pigmented Skin

No evidence of different pathogenesis vs. white skin

Difference in sequelae

On biopsy, comedones in white skin are non-inflammatory, while comedones in dark skin have marked inflammation with lots of neutrophils

Early and aggressive treatment needed to prevent scarring and “acne hyperpigmented macules” (AHM)

Halder et al. 1996

Acne in Pigmented Skin

Doctor, I have acne and now my skin is scarred!

Acne and Pigmented Skin

Patients construe the dyspigmentation as scarring.

Management: Topical retinoids and sunscreen are critical to treatment

Patients must keep hands off their pimples

Bleaching agents (hydroquinones) are very useful adjuncts

Chemical peels can be beneficial

Important to get acne under rapid control due to risk of pigmentary changes. Therefore, consider more aggressive treatments sooner than with Caucasian skin.

Doctor, I had a rash and now look!

Post-inflammatory hyperpigmentation

Doctor, I had a rash and now look!

Get rashes under quick control with aggressive treatment

More potent topical steroids and/or topical calcineurin inhibitors (e.g. tacrolimus) should be considered

Area should be protected from sunlight

Once rash and/or pruritus has subsided, can go about gently bleaching the area.

Doctor, seriously, my skin is scarred!

Keloids

Darker skin patients are readily prone to keloids (~15%), especially on the chest, shoulders and back.

Patients should be warned about surgical procedures to their skin, including piercings.

Management:

Intralesional kenalog is treatment of choice (+/- 5-FU).

Less commonly: excision, radiation, imiquimod, cryotherapy

If keloids due to underlying process such as acne, make sure to quickly & aggressively get the acne under control

Iatrogenic Hyperpigmentation

Doctor, you told me that laser hair removal would work well for me, and now look what happened:

Lasers and Pigmented Skin

Dark skin is risky for laser hair removal and should be performed at a medical/dermatology office using an Nd:Yag laser only.

Be careful referring or recommending things as you may be held liable.

Cost for treatment often comparable between dermatologist vs. esthetician/spa

Doctor, I recently had a baby, and look what developed on my face!

Melasma

Many individuals with darker skin do not wear sunscreen since they rarely burn and are not as concerned with skin cancer as fair Caucasian skin

Melasma is due to the combined effects of estrogen (pregnancy, birth control pill) and sun exposure

Management:

Educate – Chronic, relapsing

Critical to wear SPF 30 or greater & reapply

Bleaching agents should be slowly introduced e.g. hydroquinones (many now have sunscreen in them), Kligman’s formulation, Vitamin C based products.

Chemical peels can be beneficial

Many new options: Lytera, Dermamelan, Fractional lasers

Don’t be too aggressive with bleaching, or you’ll make more problems:

Cultural Practices and Skin

Darker pigmented skin in a variety of cultures wanting to be “more fair”

Watch for OTC illegally imported “skin lightening creams” “Fair and Lovely” , “New Youth”, “Gentle Magic

May contain very high concentrations of steroid and hydroquinones can lead to severe steroid dermatitis when used for prolonged periods

(Rathi 2006)Indian Journal of Dermatology

Iatrogenic Hypopigmentation

The walk-in clinic told me I had a wart on my face and then proceeded to do liquid nitrogen treatment. Now look!

Pigmented Skin and Iatrogenic Hypopigmentation

Dark skin is very sensitive to liquid nitrogen cryotherapy and melanocytes can very quickly be destroyed, and often permanently.

This is a very common cause of lawsuits, especially when the face or other visible areas are treated and depigmentation occurs.

Think twice before doing cryotherapy in dark skin. Either refer to a dermatologist, or consider other treatment options if possible.

Pigmented Skin and Skin Cancer

Doctor, this bump has been slowly growing on my face. Could it be a skin cancer?

Skin Cancer in Pigmented Skin

Dark skin patients can develop skin cancers.

Basal cell skin cancers are often pigmented in darker skin.

Level of suspicion should be high for growing lesions, especially ones that bleed & scab.

Skin cancers in darker skin, especially melanoma, have a worse prognosis since they are often diagnosed in advanced metastatic stages vs those in Caucasian skin.

Remember to assess acral sites (eg. Bob Marley)

(Byrd et al 2004)

Summary

Ethnic people are increasing in numbers as a proportion of the Canadian population.

6 skin types according to the Fitzpatrick Classification.

Caution with laser and cryotherapy in dark skin

Pigmentary disturbances in darker skin as noted with acne, melasma, and post-inflammatory hyperpigmentation require prompt recognition and treatment. At the same time, be careful not to over-treat.

Keloid scarring is more prevalent in darker skin, while skin cancers are less common (& odd locations – e.g. melanoma/palmoplantar) and thus are often detected in more advanced stages.

Thank you !

Dr. Benjamin Barankin, MD FRCPCDermatologist & Medical Director of

Toronto Dermatology Centre4256 Bathurst St. #400 (Bathurst & Sheppard)

Ph: 416-633-0001 Fax: 416-633-0002www.torontodermatologycentre.com

benbarankin@gmail.com