Skin of Color Seminar Series: Annual Seminar

NEW YORK – Much of the complementary and alternative medicine that is practiced by Asian and Hispanic cultures can actually do more harm than good, according to Dr. Roopal V. Kundu.

In these cultures, patients often view illness as having strong spiritual origins and consequences, she said at the seminar. Illness "can have a dramatic effect on psyche."

In the traditional Hispanic community, many individuals have seen or are concurrently seeing a local healer, said Dr. Kundu, director of the Northwestern Center for Ethnic Skin at Northwestern University, Chicago. These healers might be practitioners of curanderismo, in which they believe they are healing as a "gift from a higher power," while employing prayers, baths, and botanicals to combat illness. Another practice is espiritismo, which is a belief that good and evil spirits affect health.

Courtesy Dr. Roopal V. Kundu

Asian patients, meanwhile, have their own set of healers and practices. For example, patients may practice "cupping" for chronic pain and respiratory disease, whereby a glass or plastic cup is placed over the back to create a local vacuum, in the hopes of relieving congestion and increasing circulation.

"Wet cupping" is similar, except that a small scratch or incision is made prior to the cupping procedure.

Both cupping practices leave behind circular patterns of erythema, edema, and ecchymosis, and could be mistaken for child abuse or another skin disorder, said Dr. Kundu, who recently published a paper on this and other Asian dermatoses (Int. J. Dermatol. 2012;51:372-82).

Similarly, "coining," "spooning," or "cao gio" is a Vietnamese dermabrasion therapy, whereby skin is lubricated with oils and then rubbed firmly using the edge of a spoon or coin.

The result will be parallel lines of ecchymoses on the chest and back in a "pine tree" pattern, said Dr. Kundu.

Another Asian practice, moxibustion, or moxa, involves burning materials on the skin to combat atopic dermatitis, postherpetic neuralgia, and tinea pedis. The small, circular scars left behind approximate cigarette burns.

She also advised questioning the use of hair oils in Southeast Asian and black patients. Mustard, coconut, and amla oil are supposed to be toxic to certain dermatophytes, said Dr. Kundu. However, she warned, the theory might backfire in practice. "Are the different oils perpetuating different organisms and allowing [tinea capitas]?"

Finally, Dr. Kundu noted that among Asian and Hispanic populations, decision making by family consensus is the norm. "With almost all of my ethnic patients, I almost always have someone else in the room – a sister, brother, parent, child, uncle," she said. "You’re kind of engaging both of them in the dialogue and [the patient is] often looking toward that person for help in navigating the health care system."

Dr. Kundu stated that she had no relevant relationships with industry to disclose.

NEW YORK – Much of the complementary and alternative medicine that is practiced by Asian and Hispanic cultures can actually do more harm than good, according to Dr. Roopal V. Kundu.

In these cultures, patients often view illness as having strong spiritual origins and consequences, she said at the seminar. Illness "can have a dramatic effect on psyche."

In the traditional Hispanic community, many individuals have seen or are concurrently seeing a local healer, said Dr. Kundu, director of the Northwestern Center for Ethnic Skin at Northwestern University, Chicago. These healers might be practitioners of curanderismo, in which they believe they are healing as a "gift from a higher power," while employing prayers, baths, and botanicals to combat illness. Another practice is espiritismo, which is a belief that good and evil spirits affect health.

Courtesy Dr. Roopal V. Kundu

Asian patients, meanwhile, have their own set of healers and practices. For example, patients may practice "cupping" for chronic pain and respiratory disease, whereby a glass or plastic cup is placed over the back to create a local vacuum, in the hopes of relieving congestion and increasing circulation.

"Wet cupping" is similar, except that a small scratch or incision is made prior to the cupping procedure.

Both cupping practices leave behind circular patterns of erythema, edema, and ecchymosis, and could be mistaken for child abuse or another skin disorder, said Dr. Kundu, who recently published a paper on this and other Asian dermatoses (Int. J. Dermatol. 2012;51:372-82).

Similarly, "coining," "spooning," or "cao gio" is a Vietnamese dermabrasion therapy, whereby skin is lubricated with oils and then rubbed firmly using the edge of a spoon or coin.

The result will be parallel lines of ecchymoses on the chest and back in a "pine tree" pattern, said Dr. Kundu.

Another Asian practice, moxibustion, or moxa, involves burning materials on the skin to combat atopic dermatitis, postherpetic neuralgia, and tinea pedis. The small, circular scars left behind approximate cigarette burns.

She also advised questioning the use of hair oils in Southeast Asian and black patients. Mustard, coconut, and amla oil are supposed to be toxic to certain dermatophytes, said Dr. Kundu. However, she warned, the theory might backfire in practice. "Are the different oils perpetuating different organisms and allowing [tinea capitas]?"

Finally, Dr. Kundu noted that among Asian and Hispanic populations, decision making by family consensus is the norm. "With almost all of my ethnic patients, I almost always have someone else in the room – a sister, brother, parent, child, uncle," she said. "You’re kind of engaging both of them in the dialogue and [the patient is] often looking toward that person for help in navigating the health care system."

Dr. Kundu stated that she had no relevant relationships with industry to disclose.

NEW YORK – Much of the complementary and alternative medicine that is practiced by Asian and Hispanic cultures can actually do more harm than good, according to Dr. Roopal V. Kundu.

In these cultures, patients often view illness as having strong spiritual origins and consequences, she said at the seminar. Illness "can have a dramatic effect on psyche."

In the traditional Hispanic community, many individuals have seen or are concurrently seeing a local healer, said Dr. Kundu, director of the Northwestern Center for Ethnic Skin at Northwestern University, Chicago. These healers might be practitioners of curanderismo, in which they believe they are healing as a "gift from a higher power," while employing prayers, baths, and botanicals to combat illness. Another practice is espiritismo, which is a belief that good and evil spirits affect health.

Courtesy Dr. Roopal V. Kundu

Asian patients, meanwhile, have their own set of healers and practices. For example, patients may practice "cupping" for chronic pain and respiratory disease, whereby a glass or plastic cup is placed over the back to create a local vacuum, in the hopes of relieving congestion and increasing circulation.

"Wet cupping" is similar, except that a small scratch or incision is made prior to the cupping procedure.

Both cupping practices leave behind circular patterns of erythema, edema, and ecchymosis, and could be mistaken for child abuse or another skin disorder, said Dr. Kundu, who recently published a paper on this and other Asian dermatoses (Int. J. Dermatol. 2012;51:372-82).

Similarly, "coining," "spooning," or "cao gio" is a Vietnamese dermabrasion therapy, whereby skin is lubricated with oils and then rubbed firmly using the edge of a spoon or coin.

The result will be parallel lines of ecchymoses on the chest and back in a "pine tree" pattern, said Dr. Kundu.

Another Asian practice, moxibustion, or moxa, involves burning materials on the skin to combat atopic dermatitis, postherpetic neuralgia, and tinea pedis. The small, circular scars left behind approximate cigarette burns.

She also advised questioning the use of hair oils in Southeast Asian and black patients. Mustard, coconut, and amla oil are supposed to be toxic to certain dermatophytes, said Dr. Kundu. However, she warned, the theory might backfire in practice. "Are the different oils perpetuating different organisms and allowing [tinea capitas]?"

Finally, Dr. Kundu noted that among Asian and Hispanic populations, decision making by family consensus is the norm. "With almost all of my ethnic patients, I almost always have someone else in the room – a sister, brother, parent, child, uncle," she said. "You’re kind of engaging both of them in the dialogue and [the patient is] often looking toward that person for help in navigating the health care system."

Dr. Kundu stated that she had no relevant relationships with industry to disclose.

NEW YORK – All patients, regardless of skin color, need to be screened for skin cancer and receive sun protection education, according to Dr. Brooke A. Jackson.

"We have done a pretty good job of relaying the skin cancer awareness/risk message to fair skin types, but we still need to work on the message to darker skin types," noted Dr. Jackson. "This includes offering skin cancer screenings to all of our patients regardless of skin color, having a [high] level of suspicion for nonhealing lesions or changing lesions in darker skin types, and discussing skin cancer risks and sun protection with our patients who have darker skin."

Dr. Jackson and her colleagues surveyed 105 dark-skinned adult patients who presented to her private practice in Chicago for a variety of reasons.

Overall, 91 patients identified themselves as black, 9 as Hispanic, 4 as Asian, and 1 as Middle Eastern, noted Dr. Jackson, clinical assistant professor of dermatology at Northwestern University in Chicago.

Of the 105 patients, 9 had a Fitzpatrick skin type of III, 29 had type IV, 64 had type V, and 3 patients had type VI.

Patients read the descriptions for several types of lesions and were asked to identify whether a particular lesion was a risk factor for skin cancer, including "dark spot with irregular border," "new mole," "nonhealing wound," "bleeding lesion," and "shiny pink bump."

Dr. Jackson found that "regardless of ethnic origin or skin type, ‘dark spot with irregular borders’ followed by ‘new mole’ were the most frequent top two choices" selected as being high risk for skin cancer.

"Shiny pink bump" was the least selected choice for recognition of skin cancer and was not selected by any respondents with skin types III and VI, she reported.

Indeed, "15 respondents, most of whom were of African ethnicity and/or had skin type V, were unaware that skin of color was at risk for developing skin cancer," noted Dr. Jackson and her colleagues.

As for skin protective behaviors, 70 of the 91 black patients reported use of sunblock or sunscreen, and 47 used protective clothing. Twenty-nine black patients practiced sun avoidance. Ten of the black patients reported that they took no precaution at all with regard to sun exposure. Similarly, among the 64 Fitzpatrick skin type V patients, 13 reported practicing no sun protection.

Dr. Jackson stated that neither she nor her colleagues had any disclosures relevant to this presentation.

NEW YORK – All patients, regardless of skin color, need to be screened for skin cancer and receive sun protection education, according to Dr. Brooke A. Jackson.

"We have done a pretty good job of relaying the skin cancer awareness/risk message to fair skin types, but we still need to work on the message to darker skin types," noted Dr. Jackson. "This includes offering skin cancer screenings to all of our patients regardless of skin color, having a [high] level of suspicion for nonhealing lesions or changing lesions in darker skin types, and discussing skin cancer risks and sun protection with our patients who have darker skin."

Dr. Jackson and her colleagues surveyed 105 dark-skinned adult patients who presented to her private practice in Chicago for a variety of reasons.

Overall, 91 patients identified themselves as black, 9 as Hispanic, 4 as Asian, and 1 as Middle Eastern, noted Dr. Jackson, clinical assistant professor of dermatology at Northwestern University in Chicago.

Of the 105 patients, 9 had a Fitzpatrick skin type of III, 29 had type IV, 64 had type V, and 3 patients had type VI.

Patients read the descriptions for several types of lesions and were asked to identify whether a particular lesion was a risk factor for skin cancer, including "dark spot with irregular border," "new mole," "nonhealing wound," "bleeding lesion," and "shiny pink bump."

Dr. Jackson found that "regardless of ethnic origin or skin type, ‘dark spot with irregular borders’ followed by ‘new mole’ were the most frequent top two choices" selected as being high risk for skin cancer.

"Shiny pink bump" was the least selected choice for recognition of skin cancer and was not selected by any respondents with skin types III and VI, she reported.

Indeed, "15 respondents, most of whom were of African ethnicity and/or had skin type V, were unaware that skin of color was at risk for developing skin cancer," noted Dr. Jackson and her colleagues.

As for skin protective behaviors, 70 of the 91 black patients reported use of sunblock or sunscreen, and 47 used protective clothing. Twenty-nine black patients practiced sun avoidance. Ten of the black patients reported that they took no precaution at all with regard to sun exposure. Similarly, among the 64 Fitzpatrick skin type V patients, 13 reported practicing no sun protection.

Dr. Jackson stated that neither she nor her colleagues had any disclosures relevant to this presentation.

NEW YORK – All patients, regardless of skin color, need to be screened for skin cancer and receive sun protection education, according to Dr. Brooke A. Jackson.

"We have done a pretty good job of relaying the skin cancer awareness/risk message to fair skin types, but we still need to work on the message to darker skin types," noted Dr. Jackson. "This includes offering skin cancer screenings to all of our patients regardless of skin color, having a [high] level of suspicion for nonhealing lesions or changing lesions in darker skin types, and discussing skin cancer risks and sun protection with our patients who have darker skin."

Dr. Jackson and her colleagues surveyed 105 dark-skinned adult patients who presented to her private practice in Chicago for a variety of reasons.

Overall, 91 patients identified themselves as black, 9 as Hispanic, 4 as Asian, and 1 as Middle Eastern, noted Dr. Jackson, clinical assistant professor of dermatology at Northwestern University in Chicago.

Of the 105 patients, 9 had a Fitzpatrick skin type of III, 29 had type IV, 64 had type V, and 3 patients had type VI.

Patients read the descriptions for several types of lesions and were asked to identify whether a particular lesion was a risk factor for skin cancer, including "dark spot with irregular border," "new mole," "nonhealing wound," "bleeding lesion," and "shiny pink bump."

Dr. Jackson found that "regardless of ethnic origin or skin type, ‘dark spot with irregular borders’ followed by ‘new mole’ were the most frequent top two choices" selected as being high risk for skin cancer.

"Shiny pink bump" was the least selected choice for recognition of skin cancer and was not selected by any respondents with skin types III and VI, she reported.

Indeed, "15 respondents, most of whom were of African ethnicity and/or had skin type V, were unaware that skin of color was at risk for developing skin cancer," noted Dr. Jackson and her colleagues.

As for skin protective behaviors, 70 of the 91 black patients reported use of sunblock or sunscreen, and 47 used protective clothing. Twenty-nine black patients practiced sun avoidance. Ten of the black patients reported that they took no precaution at all with regard to sun exposure. Similarly, among the 64 Fitzpatrick skin type V patients, 13 reported practicing no sun protection.

Dr. Jackson stated that neither she nor her colleagues had any disclosures relevant to this presentation.

NEW YORK – To successfully treat alopecia in darker-skinned patients, it is important to first get to the root of a patient’s hair care regimen, according to Dr. Amy McMichael.

For the past 18 years, Dr. McMichael of Wake Forest University in Winston-Salem, N.C., has run a hair disorders clinic. She said she often finds herself at odds with patients who can’t understand why their hair won’t grow.

"Of course, we know it’s growing; it’s just breaking off. They’re having issues with damaged hair," she said at the Skin of Color Seminar Series. Patients "want me to find some underlying vitamin disorder or disease, or something [in their diet] that they can ‘cut out,’ " she said.

Photos courtesy Valerie Callender M.D.

Instead, the key is to specifically ask patients about their hair care regimen. She also uses a "60-second comb test" to assess fragility, whereby she instructs patients to brush their hair over a white pillow for 60 seconds and then count the broken and full-bulb hairs that are seen on the pillow.

More often than not, she said she finds that the number of full telogen hairs do not differ between white and darker-skinned people, but that broken hairs (versus bulb hairs) are found significantly more often in women of African descent.

This standardized approach may help convince women that, indeed, breakage – and not some underlying condition – is at the root of their problem, and that changes in behavior could have big effects.

Traction alopecia is a major issue in this population – even among patients who say they don’t pull their hair – and is likely because of the African American custom of getting tight braids starting at a young age. "They tell me their hair braids were so tight, they couldn’t chew the next day," she said. "That is not normal."

Additionally, many skin of color patients use powerful, lye-based chemical relaxers. The damage inflicted by these products, combined with braids, increases the risk for alopecia.

She pointed to a 2008 study of 574 African school girls and 604 African women that showed that females who both relaxed and braided their hair had a 3.5 times greater risk for traction alopecia, compared with patients who did neither (J. Am. Acad. Dermatol. 2008;59:432-8).

Central centrifugal scarring alopecia is also associated with particular cultural practices. For example, Dr. McMichael cited a 2009 study that looked at 101 black women with the condition and found that there was a strong association between scarring alopecia and patients who reported using sewn-in hair weaves and braided styles with hair extensions (J. Am. Acad. Dermatol. 2009;60:574-8).

A second 2011 study by Dr. McMichael and her colleagues confirmed this, but also found associations with chemical relaxers in 44 surveyed patients (Cosmet. Dermatol. 2011;24:331-7).

She recommends that patients discontinue tight braids, sewn-in weaves, relaxers, and heat treatments. "A lot of women still go under hooded hair dryers," she said. She also advocates serial trimming of the hair every 6-8 weeks, as well as gentle hair conditioning with positively charged silicones and dimethicone coating agents.

"These work very nicely in this population," she said. She also recommends using foams as a vehicle for treatments when available. For patients with more severe issues, however, she has administered intralesional corticosteroids, and followed with an off-label use of topical minoxidil.

Additionally, "a lot of women do well with surgical hair restoration," she said, despite initial patient concerns about it being prohibitively expensive. "It might be much less expensive [than patients think] because they have a small area to treat."

Finally, Dr. McMichael said she refers patients with cicatricial alopecia to the Cicatricial Alopecia Research Foundation.

Dr. McMichael stated that she has been an investigator for Abbott, Allergan, Intendis (now Bayer HealthCare), and Procter and Gamble. She also disclosed serving as a consultant for Allergan, Galderma, Guthy-Ranker, Johnson and Johnson, Procter and Gamble, and Stiefel.

NEW YORK – To successfully treat alopecia in darker-skinned patients, it is important to first get to the root of a patient’s hair care regimen, according to Dr. Amy McMichael.

For the past 18 years, Dr. McMichael of Wake Forest University in Winston-Salem, N.C., has run a hair disorders clinic. She said she often finds herself at odds with patients who can’t understand why their hair won’t grow.

"Of course, we know it’s growing; it’s just breaking off. They’re having issues with damaged hair," she said at the Skin of Color Seminar Series. Patients "want me to find some underlying vitamin disorder or disease, or something [in their diet] that they can ‘cut out,’ " she said.

Photos courtesy Valerie Callender M.D.

Instead, the key is to specifically ask patients about their hair care regimen. She also uses a "60-second comb test" to assess fragility, whereby she instructs patients to brush their hair over a white pillow for 60 seconds and then count the broken and full-bulb hairs that are seen on the pillow.

More often than not, she said she finds that the number of full telogen hairs do not differ between white and darker-skinned people, but that broken hairs (versus bulb hairs) are found significantly more often in women of African descent.

This standardized approach may help convince women that, indeed, breakage – and not some underlying condition – is at the root of their problem, and that changes in behavior could have big effects.

Traction alopecia is a major issue in this population – even among patients who say they don’t pull their hair – and is likely because of the African American custom of getting tight braids starting at a young age. "They tell me their hair braids were so tight, they couldn’t chew the next day," she said. "That is not normal."

Additionally, many skin of color patients use powerful, lye-based chemical relaxers. The damage inflicted by these products, combined with braids, increases the risk for alopecia.

She pointed to a 2008 study of 574 African school girls and 604 African women that showed that females who both relaxed and braided their hair had a 3.5 times greater risk for traction alopecia, compared with patients who did neither (J. Am. Acad. Dermatol. 2008;59:432-8).

Central centrifugal scarring alopecia is also associated with particular cultural practices. For example, Dr. McMichael cited a 2009 study that looked at 101 black women with the condition and found that there was a strong association between scarring alopecia and patients who reported using sewn-in hair weaves and braided styles with hair extensions (J. Am. Acad. Dermatol. 2009;60:574-8).

A second 2011 study by Dr. McMichael and her colleagues confirmed this, but also found associations with chemical relaxers in 44 surveyed patients (Cosmet. Dermatol. 2011;24:331-7).

She recommends that patients discontinue tight braids, sewn-in weaves, relaxers, and heat treatments. "A lot of women still go under hooded hair dryers," she said. She also advocates serial trimming of the hair every 6-8 weeks, as well as gentle hair conditioning with positively charged silicones and dimethicone coating agents.

"These work very nicely in this population," she said. She also recommends using foams as a vehicle for treatments when available. For patients with more severe issues, however, she has administered intralesional corticosteroids, and followed with an off-label use of topical minoxidil.

Additionally, "a lot of women do well with surgical hair restoration," she said, despite initial patient concerns about it being prohibitively expensive. "It might be much less expensive [than patients think] because they have a small area to treat."

Finally, Dr. McMichael said she refers patients with cicatricial alopecia to the Cicatricial Alopecia Research Foundation.

Dr. McMichael stated that she has been an investigator for Abbott, Allergan, Intendis (now Bayer HealthCare), and Procter and Gamble. She also disclosed serving as a consultant for Allergan, Galderma, Guthy-Ranker, Johnson and Johnson, Procter and Gamble, and Stiefel.

NEW YORK – To successfully treat alopecia in darker-skinned patients, it is important to first get to the root of a patient’s hair care regimen, according to Dr. Amy McMichael.

For the past 18 years, Dr. McMichael of Wake Forest University in Winston-Salem, N.C., has run a hair disorders clinic. She said she often finds herself at odds with patients who can’t understand why their hair won’t grow.

"Of course, we know it’s growing; it’s just breaking off. They’re having issues with damaged hair," she said at the Skin of Color Seminar Series. Patients "want me to find some underlying vitamin disorder or disease, or something [in their diet] that they can ‘cut out,’ " she said.

Photos courtesy Valerie Callender M.D.

Instead, the key is to specifically ask patients about their hair care regimen. She also uses a "60-second comb test" to assess fragility, whereby she instructs patients to brush their hair over a white pillow for 60 seconds and then count the broken and full-bulb hairs that are seen on the pillow.

More often than not, she said she finds that the number of full telogen hairs do not differ between white and darker-skinned people, but that broken hairs (versus bulb hairs) are found significantly more often in women of African descent.

This standardized approach may help convince women that, indeed, breakage – and not some underlying condition – is at the root of their problem, and that changes in behavior could have big effects.

Traction alopecia is a major issue in this population – even among patients who say they don’t pull their hair – and is likely because of the African American custom of getting tight braids starting at a young age. "They tell me their hair braids were so tight, they couldn’t chew the next day," she said. "That is not normal."

Additionally, many skin of color patients use powerful, lye-based chemical relaxers. The damage inflicted by these products, combined with braids, increases the risk for alopecia.

She pointed to a 2008 study of 574 African school girls and 604 African women that showed that females who both relaxed and braided their hair had a 3.5 times greater risk for traction alopecia, compared with patients who did neither (J. Am. Acad. Dermatol. 2008;59:432-8).

Central centrifugal scarring alopecia is also associated with particular cultural practices. For example, Dr. McMichael cited a 2009 study that looked at 101 black women with the condition and found that there was a strong association between scarring alopecia and patients who reported using sewn-in hair weaves and braided styles with hair extensions (J. Am. Acad. Dermatol. 2009;60:574-8).

A second 2011 study by Dr. McMichael and her colleagues confirmed this, but also found associations with chemical relaxers in 44 surveyed patients (Cosmet. Dermatol. 2011;24:331-7).

She recommends that patients discontinue tight braids, sewn-in weaves, relaxers, and heat treatments. "A lot of women still go under hooded hair dryers," she said. She also advocates serial trimming of the hair every 6-8 weeks, as well as gentle hair conditioning with positively charged silicones and dimethicone coating agents.

"These work very nicely in this population," she said. She also recommends using foams as a vehicle for treatments when available. For patients with more severe issues, however, she has administered intralesional corticosteroids, and followed with an off-label use of topical minoxidil.

Additionally, "a lot of women do well with surgical hair restoration," she said, despite initial patient concerns about it being prohibitively expensive. "It might be much less expensive [than patients think] because they have a small area to treat."

Finally, Dr. McMichael said she refers patients with cicatricial alopecia to the Cicatricial Alopecia Research Foundation.

Dr. McMichael stated that she has been an investigator for Abbott, Allergan, Intendis (now Bayer HealthCare), and Procter and Gamble. She also disclosed serving as a consultant for Allergan, Galderma, Guthy-Ranker, Johnson and Johnson, Procter and Gamble, and Stiefel.