Dermatological Assessment of Skin of Colour (SoC) Flashcards
Skin of colour traditionally refers to
that of persons of African, Asian,
Native American, Middle Eastern,
and Hispanic backgrounds.
- Categorized as Fitzpatrick types III
to VItypically.
Skin Assessment
• Ensure adequate lighting • Have patient bring in previous pictures of their skin and lesions • Compare skin to family members (not the most reliable) • Be extra vigilant in inspecting, hands, nails and feet • Immediate biopsy of suspicious lesions is critical – refer!
Palmar Pallor
Conjunctival Pallor
Palmar Pallor • Pale appearance of skin due to reduced
oxyhemoglobin levels.
• Identify: • Reduced darkness in palmer creases • Possibly compare to family member if similar
in color (?)
• Conjunctival Pallor
• In all skin types, the conjunctiva, when the lower lid
is pulled down, will be a healthy pink.
• Identify: • Look for pale pink or white coloration
Cyanosis
- “Blue or grey” discoloration of skin due to deoxygenated hemoglobin.
- Harder to detect in darker skin if looking at hands and feet.
- Identify:
- May be described as ashen (pale grey/ blue)
- Look at areas where skin is thin, and has high vasculature (i.e. lips) or mucous membranes (buccal, SL)
- Look for pink tones
Erythema
• Redness to the skin due to inflammation, infection. Erythema may
not always be apparent in darker skin – this leads to under
treatment!
• Need discussion on “greyhemia”, validated screening tools lack this spectrum
• Identify:
• In SoC will have a burgundy/ purple undertone
• Skin may appear taught and shiny
Jaundice
Yellow discolouration of the skin and soft
tissues due to hyperbilirubinaemia.
• Identify: • In darker skin, yellow hue may be subtle • Eye signs are more obvious (whites of
the eyes appear yellow)
Ichthyosis
Widespread scaling of skin • Identify: • In darker skin, hyperpigmentation and
thickening may be present
• Cracks between scales appear lighter
Keloid Scarring
• Thick, enlarged scars which are bigger than the original wound
• More common in people with darker skin • Can occur from minor injury or
spontaneously
• Identify: • Raised, firm to touch, hairless
appearance and will be similar in
colour or darker than surrounding skin
• Location: earlobes, cheeks, upper
chest
Bruising
Patches where capillaries break or burst.
• Identify:
• In darker skin may present purple or dark brown
• Yellow discoloration of older bruises may not
be obvious
• Hypo or Hyper- Pigmentation
• Due to increased type of melanin from melanocytes
which are more reactive, signs of hypo
- or hyperpigmentation are the only indicators of an underlying dermatological condition
• Identify: • Look for discolouration of surrounding skin,
ask about symptoms experienced as part of
history (trauma to skin, itch)
Melanonychia (Pigmented Nail Bands)
nail and scalp are part of derm assessment
• Pigmented line that runs vertically along the nail • Caused by deposition of melanin from melanocytes in the proximal nail matrix (benign) • Normal variant in 90% of black people • Can be mistaken for melanoma and vice versa • Identify: • Thin, very light, even and uniform line • No lumps or bumps • Does not extend to proximal nail fold as seen on image to the left
Tinea Capitis
• Tinea capitis (TC) is an infection affecting patients of color disproportionately in the United States, especially Black and LatinXchildren • Confused with seborrhea dermatitis often • Hairs may become brittle • Skin will appear dry and flaky • Default to referring a child who presents with scaling
Common Conditions in Skin of Colour
- Pseudofolliculitis Barbae
- Dermatosis Papulosa Nigra
- Acne Keloidalis Nuchae
- Acral Lentiginous Melanoma
- Actinic Prurigo
- Melasma
Pseudofolliculitis Barbae “razor bumps”
• “Erythematous” and hyperpigmented
• Papules and pustules after shaving or plucking (tightly
curled hair)
• Can be painful and tender, secondary infection possibly
• Treatment:
• Topical steroids, benzoyl peroxide, topical antibiotics,
and topical retinoids
• Changing hair removal techniques such as suggesting
clippers, single blade razor, avoid plucking
compress can help calm it down
Dermatosis Papulosa Nigra
Benign lesions (dome shaped) on the skin • Usually, the bumps are not painful and do not itch
• Onset after puberty, genetic predisposition
• Treatment:
• Excision, laser, electrodessication,
cryotherapy
Acne Keloidalis Nuchae
• Tender papules, pustules and plaques on
posterior of scalp
• Unknown etiology
• Results in hair loss
• Treatment:
• Topical antibiotics, potent topical steroids,
oral antibiotics for s/ s of infection, laser,
surgical excision
Acral Lentiginous Melanoma
• Type of skin cancer • Found on hands, feet, nails and mouth • Blacks – 36% • Asian/ Pacific Islander – 18% • Hispanic – 9% • Non-Hispanic whites – 1% • Treatment: • Refer to a Dermatologist immediately! • Surgical excision, possibly lymph node removal and chemotherapy
Actinic Prurigo
• Prevalent in Indigenous population
• Likely due to genetic variation in HLADR4,
DRB1*0407 gene and UV exposure
• Commonly arises in childhood
• Worse in summer, but can be present year-round
• Sun-exposed sites develop eczematous eruptions,
crusting, hemorrhage and pitted scars
• Can also develop conjunctivitis and cheilitis
• Treatment:
• Sun protection, corticosteroids, anti-malarials,
pentoxifylline, thalidomide, azathioprine,
cyclosporine
often missed
Melasma
• People with SoCare at elevated risk of developing melasma
• Sun protection year-round is crucial to prevent the development of
pigment changes. Sunscreen must be a high SPF value, at least 30, and must be broad-spectrum, covering both UVA, UVB and visible light
• Zinc, titanium, and iron oxide will block visible light
• Treatment:
• Hydroquinone (concentration ~4%) remains a gold standard
of treatment (sometimes combined with a tretinoin)
• Oral or topical (?) tranexamic acid - ensure patients do not have a history of pulmonary embolisms, deep vein
thromboses or coagulation issues.
• Alpha arbutin (inhibits tyrosinase activity) is found in OTC products
Hair Care Practices
• Cultural practices such as hair braiding and use of
chemical relaxers, weaves, and hot combs could
explain the higher frequency of visits for alopecia
and folliculitis in the black patients
• Unique grooming practices can result in buildup of
hair products leading to further damage of hair
• Use of conditioner helps with fragility
• Do not apply hair care products directly to
scalp as it may accumulate there and
contribute to development of seborrheic
dermatitis
• Washing with shampoo 1 x week is a standard
routine for afro textured hair
Alopecia
Traction Alopecia
Central Centrifugal
Cicatricial alopecia - hair care can exacerbate
off label minoxidil 5%
Sun Protection
• Patients with skin of colour are less likely to use sun protection
• Conditions such as melasma and postinflammatory
hyperpigmentation may be exacerbated
• Encourage sun protection habits which include: • Sunscreen (SPF 30 or higher) • Iron oxide sunscreen to protect as visible light • Sunglasses with UV-absorbing lenses, and avoidance of tanning booths
- Recommendations in prevention of skin cancer in skin of colour
- Monitor closely changing pigmented lesions on the palms and soles and hyperkeratotic or poorly healing ulcers in immunosuppressed patients
- Patients may be hesitant to use sunscreen because of white cast left on the skin (suggest the right product!)
