Scleroderma Foundation Greater Washington, DC Chapter

2015

Scleroderma and Skin of Color:

Unique Problems

Christine A. DeWitt MD

Georgetown University School of MedicineMedStarWashington Hospital Center

Department of Dermatology

Dr. DeWitt has no conflicts of interest to report.

Scleroderma in Skin of Color: Concerns

• Digital ulcerations

• Dryness & Itch

• Discoloration

• Vitamin D needs

Digital Ulcerations

• 40% patients with scleroderma

Digital Ulcerations

• Control Raynaud phenomenon

• Avoid trauma

• Infection control

– May need rx or antibiotics

– Topical antibiotics

• OTC triple and double antibiotic ointment (Neo/Polysporin)

• Rx bacitracin ointment (effective against MRSA)

• Wound care

Digital UlcerationsWound care

– Daily gentle cleansing

– Hydrogen Peroxide• Half strength if crust present (can cause tissue destruction

– Vinegar soaks• Acetic acid is antibacterial, astringent

• Symptomatic relief

• Soak with cotton, gauze or cloth x 10-15 min

Recipe: 1 part white vinegar to 10-40 parts water

– Cover with ointment• Avoid “scabbing over”

– Cover with bandage

Dryness & Itch

• Major cause of concern in scleroderma

• Very difficult to manage

• Chronic, due to inflammation and tightening

Gentle CleansingThe “Rules”

– AVOID physical exfoliation• Peach pits, sugars, salts, minerals, crystals

• Loofahs, puffs

– Use hands or soft cloth

– Gentle soaps or non-soaps• Dove

• Cetaphil

• CeraVe

– Avoid those with fragrance, added ingredients, colored, or “medicated” soaps

Dryness & Itch• Dryness (ashy skin)

– Emollient moisturization• Vasoline

• Cocoa/shea butters, Eucerin cream,

• Gloves in a Bottle, TheraSeal

– Humectants• Exfoliates via loosening skin cell bonds

– Opposed to scrubs, is more gentle

• Traps/locks moisture in skin– Best time is immediately after washing when skin is moist

• Lowers pH– Skin is naturally acidic, necessary for immune function

Dryness & Itch• Dryness (ashy skin)

– Emollient moisturization• Petroleum jelly/Vasoline• Butters, heavy creams, oils• Dimethicone, simethicone

– Humectants- consult with provider first!• Alpha hydroxy acids

– Glycolic acid, lactic acid, urea

• Separate needs for face versus body– Face: glycolic acid– Body:

» OTC: Eucerin Plus, Amlactin U-lactin» Rx: LacHydrin, Carmol (urea)

ItchAntihistamines

• OTC– Benadryl (diphenhydramine)

– Non-sedating antihistamines• Zyrtec

• Claritin

• Allegra (no sedation risk)

• Rx:– Atarax/hydroxyzine

– Doxepin

Itch

• Cooler, quicker showers

• Avoid harsh detergents

– Bar soaps, dish detergents

• Use gloves if doing work with chemical or irritatants

– Yellow gloves with cloth lining

• Moisturizers with camphor or menthol

– Aveeno, Eucerin, Sarna

Discoloration

• Greater tendency in skin of color

• Post-inflammatory hyperpigmentation

• Salt-and-pepper sign

– White skin with retention of skin

Discoloration

• Sun protection

• Retinoids

• Hydroquinone

Methods of Sun Protection

• A tan or naturally dark skin is NOT protective

• Avoid the sun-stay indoors during peak hours

• Sun protective clothing, hats, and sunglasses

• Sunscreens for UVA and UVB (“wide spectrum”)protection – High SPF>30

• Physical “barrier” sunscreens– Zinc oxide

– Titanium dioxide

Retinoids

• Vitamin A derived medication

• Available only by prescription

– Retinol formulation available OTC

• Evens skin pigment by improving cellular turnover

• Can cause irritation so

Hydroquinone

• “Bleaching” cream

• Turns off the enzyme (tyrosinase) that makes pigment

• Essential use of sun protection

• Available OTC and by prescription– 2% formulation- otc

– 4% forumation- rx

• Overuse can cause oochronosis, a paradoxical darking in the skin

Vitamin D needs

• Vitamin D is made in the skin

• Because of melanin in skin, higher doses of UV are needed to generate vitamin D in the skin– NOT recommended

• Necessary for:– Bone and muscle health

– Healthy heart

– Immune system function

– Cancer prevention

Vitamin D Deficiency

• What is considered deficiency?– >30 ng/ml for bone health

– >80 ng/ml for immune health

*Toxicity is not seen below serum levels of 100 ng/ml

• Why the “epidemic” of deficiency?– Low exposure to sunlight

– Melanin blocks production in skin of color

– Genetic polymorphisms (RA, MS, IBD, IDDM)

– Low nutritional intake

– Low bioavailability in obese due to sequestration in adipose tissue

– (We’re looking for it)

Vit D deficiency & Scleroderma

• 156 patients• Insufficient = 10-30 ng/ml

• Deficient = <10 ng/ml

– 131 insufficient, of those 44 were deficient

• 65 patients with SSc

– Insufficient: 43

– Deficient: 19• Longer disease duration (13.1 v. 9.4 yrs)

• Higher PAP (28.9 v. 22.8 mmHg)

• Lower DLCO (63.7 v 76.4)

• Higher ESR (40 v. 23)

• Higher CRP (7 v 2)

*Compared to insufficient group

Vacca A, J Rheumatol 2009Caramaschi P, Clin Rheumatol 2010

Vitamin D

• Serum test available to determine level

• Rx use: 50,000 IU taken once per week

• Daily supplemental use

– 1000-5000 IU/day D3

Conclusion

• Gentle skin care

• Avoiding irritation

• Good moisturization & sun protection habits

• Vitamin D needs are different in African-Americans

• Consult with provider familiar with skin of color for customized needs