Dermatological Assessment of Skin of Colour (SoC)

Question 1

Skin of colour traditionally refers to

Answer 1

that of persons of African, Asian,
Native American, Middle Eastern,
and Hispanic backgrounds.

2. Categorized as Fitzpatrick types III
   to VItypically.

Question 2

Skin Assessment

Answer 2

• 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!

Question 3

Palmar Pallor

Conjunctival Pallor

Answer 3

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

Question 4

Cyanosis

Answer 4

• “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

Question 5

Erythema

Answer 5

• 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

Question 6

Jaundice

Answer 6

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)

Question 7

Ichthyosis

Answer 7

Widespread scaling of skin • Identify: • In darker skin, hyperpigmentation and

thickening may be present
• Cracks between scales appear lighter

Question 8

Keloid Scarring

Answer 8

• 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

Question 9

Bruising

Answer 9

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)

Question 10

Melanonychia (Pigmented Nail Bands)

nail and scalp are part of derm assessment

Answer 10

• 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

Question 11

Tinea Capitis

Answer 11

• 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

Question 12

Common Conditions in Skin of Colour

Answer 12

1. Pseudofolliculitis Barbae
2. Dermatosis Papulosa Nigra
3. Acne Keloidalis Nuchae
4. Acral Lentiginous Melanoma
5. Actinic Prurigo
6. Melasma

Question 13

Pseudofolliculitis Barbae “razor bumps”

Answer 13

• “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

Question 14

Dermatosis Papulosa Nigra

Answer 14

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

Question 15

Acne Keloidalis Nuchae

Answer 15

• 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

Question 16

Acral Lentiginous Melanoma

Answer 16

• 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

Question 17

Actinic Prurigo

Answer 17

• 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

Question 18

Melasma

Answer 18

• 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

Question 19

Hair Care Practices

Answer 19

• 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

Question 20

Alopecia

Answer 20

Traction Alopecia

Central Centrifugal
Cicatricial alopecia - hair care can exacerbate

off label minoxidil 5%

Question 21

Sun Protection

Answer 21

• 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!)