Pigmentation Disorders

Ethnic hair can become dry, brittle, and fractured when exposed to harsh solvents, heat, and repeat chemical treatments. To combat these issues, consider discussing the use of dry shampoo with your patients.

Dry shampoo is a powdered substance used to absorb oil in hair when traditional shampoo is not available, or for use with hair that dries out after repeat washings.

The ingredients in dry shampoo are called "absorbing agents," which soak up excess oil and dirt on the scalp. The most common absorbing agents are Oryza sativa starch, aluminum starch octenylsuccinate, zea mays starch, and silica.

There are two types of dry shampoo: those that come in a loose powder form and those that come in an aerosol form.

Powder dry shampoo can be applied directly to the scalp from the bottle and either brushed through or massaged in. Dry shampoo aerosol can be sprayed directly onto the scalp from a few inches away.

Recent advances in dry shampoos have instituted different coloring agents to help match the hair, as well as fragrances to mask any odor.

Many of these products can be found on www.dryshampoo.com.

- Lily Talakoub, M.D.

Do you have questions about treating patients with darker skin? If so, send them to [email protected].

Ethnic hair can become dry, brittle, and fractured when exposed to harsh solvents, heat, and repeat chemical treatments. To combat these issues, consider discussing the use of dry shampoo with your patients.

Dry shampoo is a powdered substance used to absorb oil in hair when traditional shampoo is not available, or for use with hair that dries out after repeat washings.

The ingredients in dry shampoo are called "absorbing agents," which soak up excess oil and dirt on the scalp. The most common absorbing agents are Oryza sativa starch, aluminum starch octenylsuccinate, zea mays starch, and silica.

There are two types of dry shampoo: those that come in a loose powder form and those that come in an aerosol form.

Powder dry shampoo can be applied directly to the scalp from the bottle and either brushed through or massaged in. Dry shampoo aerosol can be sprayed directly onto the scalp from a few inches away.

Recent advances in dry shampoos have instituted different coloring agents to help match the hair, as well as fragrances to mask any odor.

Many of these products can be found on www.dryshampoo.com.

- Lily Talakoub, M.D.

Do you have questions about treating patients with darker skin? If so, send them to [email protected].

Ethnic hair can become dry, brittle, and fractured when exposed to harsh solvents, heat, and repeat chemical treatments. To combat these issues, consider discussing the use of dry shampoo with your patients.

Dry shampoo is a powdered substance used to absorb oil in hair when traditional shampoo is not available, or for use with hair that dries out after repeat washings.

The ingredients in dry shampoo are called "absorbing agents," which soak up excess oil and dirt on the scalp. The most common absorbing agents are Oryza sativa starch, aluminum starch octenylsuccinate, zea mays starch, and silica.

There are two types of dry shampoo: those that come in a loose powder form and those that come in an aerosol form.

Powder dry shampoo can be applied directly to the scalp from the bottle and either brushed through or massaged in. Dry shampoo aerosol can be sprayed directly onto the scalp from a few inches away.

Recent advances in dry shampoos have instituted different coloring agents to help match the hair, as well as fragrances to mask any odor.

Many of these products can be found on www.dryshampoo.com.

- Lily Talakoub, M.D.

Do you have questions about treating patients with darker skin? If so, send them to [email protected].

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.

Over the past 4 decades, cutaneous T-cell lymphoma diagnoses have been on the rise, especially among black and other skin of color patients. Unfortunately, this form of skin cancer can be a diagnostic challenge.

Regarding diagnosis, cutaneous T-cell lymphoma (CTCL) is the wild card of dermatology; it is a great mimicker of many skin disorders, and can look like almost anything. However, the most striking feature of the condition – and the key to diagnosis in ethnic skin – is its polymorphous pigmentation that is unique to skin of color.

Photo (c) Elsevier

CTCL lesions may be flat or raised, and may mimic other skin disorders associated with pigment change. These can include tinea versicolor, vitiligo, pityriasis rosea, and psoriasis. Lichen planus pigmentosus and progressive macular hypomelanosis are other important CTCL mimickers. Consider all of these conditions in the differential diagnosis.

An excellent resource for photos and descriptions of CTCL, as well as CTCL look-alikes, is an article by Dr. Ginette A. Hinds and Dr. Peter Heald (J. Am. Acad. Dermatol. 2009;60:359-75). The article also highlights the clinical variants within the mycosis fungoides subtype, the most common form of CTCL among blacks.

For example, look out for the "herald patch" of unilesional mycosis fungoides, which takes the form of a single large, dyspigmented patch. According to the authors, this variant has an excellent prognosis, possibly because of an active immune response that limits the initial spread of disease and contributes to preventing relapse.

Photo (c) Elsevier

Another variant is pigmented purpuric mycosis fungoides, which can often be confused with the benign pigmented purpura syndromes of Schamberg’s disease (progressive pigmented purpuric dermatitis), Gougerot-Blum syndrome (pigmented purpuric lichenoid dermatitis), Majocchi’s disease (purpura annularis telangiectodes), Doucas and Kapetanakis (lymphocytic capillaritis of unknown cause), and lichen aureus. The key to diagnosis in this case is recalling that "the lesions of the benign syndromes rarely assume the morphology and distribution found with mycosis fungoides," Dr. Hinds and Dr. Heald wrote.

Not only is mycosis fungoides difficult to diagnose, but it is especially prevalent among black patients. For instance, a 1988 study looking at Surveillance, Epidemiology, and End Results (SEER) data from 1973 through 1984 found that the incidence among black patients was twice that of white patients: 0.52/100,000 vs. 0.26 (JAMA 1988;260:42-46).

Similarly, in another study of 132 black patients with skin cancer, mycosis fungoides represented 12.1% of all skin neoplasms (Dermatol. Clin. 1988;6:397-405).

Mycosis fungoides is the fourth most common skin cancer among Japanese patients, representing approximately 5% of all skin malignancies in the population.

The incidence of CTCL and its subtypes is only increasing. A 2007 study that extended the SEER data mentioned above from 1973 to 2002 and included all CTCL cases found an incidence rate of 9.0 for black patients, per 1 million person-years, compared with 6.1 for white patients (Arch. Dermatol. 2007;143:854-9).

As in many skin cancers, early diagnosis can make the difference in successful outcomes. So add CTCL, and especially the mycosis fungoides subtype, to your differential when confronting pigmentation disorders in skin of color patients.

Dr. Roberts is past president of the Women’s Dermatologic Society (WDS) as well as past president of the California Society of Dermatology and Dermatologic Surgery (Calderm). She was a founding director of dermatopathology at the Loma Linda University Medical Center (Calif.). She currently runs a private practice in Rancho Mirage, Calif.

She disclosed financial relationships with Allergan, L’Oréal/La Roche Posay, Skin Medica, and Valeant Pharmaceuticals.

Over the past 4 decades, cutaneous T-cell lymphoma diagnoses have been on the rise, especially among black and other skin of color patients. Unfortunately, this form of skin cancer can be a diagnostic challenge.

Regarding diagnosis, cutaneous T-cell lymphoma (CTCL) is the wild card of dermatology; it is a great mimicker of many skin disorders, and can look like almost anything. However, the most striking feature of the condition – and the key to diagnosis in ethnic skin – is its polymorphous pigmentation that is unique to skin of color.

Photo (c) Elsevier

CTCL lesions may be flat or raised, and may mimic other skin disorders associated with pigment change. These can include tinea versicolor, vitiligo, pityriasis rosea, and psoriasis. Lichen planus pigmentosus and progressive macular hypomelanosis are other important CTCL mimickers. Consider all of these conditions in the differential diagnosis.

An excellent resource for photos and descriptions of CTCL, as well as CTCL look-alikes, is an article by Dr. Ginette A. Hinds and Dr. Peter Heald (J. Am. Acad. Dermatol. 2009;60:359-75). The article also highlights the clinical variants within the mycosis fungoides subtype, the most common form of CTCL among blacks.

For example, look out for the "herald patch" of unilesional mycosis fungoides, which takes the form of a single large, dyspigmented patch. According to the authors, this variant has an excellent prognosis, possibly because of an active immune response that limits the initial spread of disease and contributes to preventing relapse.

Photo (c) Elsevier

Another variant is pigmented purpuric mycosis fungoides, which can often be confused with the benign pigmented purpura syndromes of Schamberg’s disease (progressive pigmented purpuric dermatitis), Gougerot-Blum syndrome (pigmented purpuric lichenoid dermatitis), Majocchi’s disease (purpura annularis telangiectodes), Doucas and Kapetanakis (lymphocytic capillaritis of unknown cause), and lichen aureus. The key to diagnosis in this case is recalling that "the lesions of the benign syndromes rarely assume the morphology and distribution found with mycosis fungoides," Dr. Hinds and Dr. Heald wrote.

Not only is mycosis fungoides difficult to diagnose, but it is especially prevalent among black patients. For instance, a 1988 study looking at Surveillance, Epidemiology, and End Results (SEER) data from 1973 through 1984 found that the incidence among black patients was twice that of white patients: 0.52/100,000 vs. 0.26 (JAMA 1988;260:42-46).

Similarly, in another study of 132 black patients with skin cancer, mycosis fungoides represented 12.1% of all skin neoplasms (Dermatol. Clin. 1988;6:397-405).

Mycosis fungoides is the fourth most common skin cancer among Japanese patients, representing approximately 5% of all skin malignancies in the population.

The incidence of CTCL and its subtypes is only increasing. A 2007 study that extended the SEER data mentioned above from 1973 to 2002 and included all CTCL cases found an incidence rate of 9.0 for black patients, per 1 million person-years, compared with 6.1 for white patients (Arch. Dermatol. 2007;143:854-9).

As in many skin cancers, early diagnosis can make the difference in successful outcomes. So add CTCL, and especially the mycosis fungoides subtype, to your differential when confronting pigmentation disorders in skin of color patients.

Dr. Roberts is past president of the Women’s Dermatologic Society (WDS) as well as past president of the California Society of Dermatology and Dermatologic Surgery (Calderm). She was a founding director of dermatopathology at the Loma Linda University Medical Center (Calif.). She currently runs a private practice in Rancho Mirage, Calif.

She disclosed financial relationships with Allergan, L’Oréal/La Roche Posay, Skin Medica, and Valeant Pharmaceuticals.

Over the past 4 decades, cutaneous T-cell lymphoma diagnoses have been on the rise, especially among black and other skin of color patients. Unfortunately, this form of skin cancer can be a diagnostic challenge.

Regarding diagnosis, cutaneous T-cell lymphoma (CTCL) is the wild card of dermatology; it is a great mimicker of many skin disorders, and can look like almost anything. However, the most striking feature of the condition – and the key to diagnosis in ethnic skin – is its polymorphous pigmentation that is unique to skin of color.

Photo (c) Elsevier

CTCL lesions may be flat or raised, and may mimic other skin disorders associated with pigment change. These can include tinea versicolor, vitiligo, pityriasis rosea, and psoriasis. Lichen planus pigmentosus and progressive macular hypomelanosis are other important CTCL mimickers. Consider all of these conditions in the differential diagnosis.

An excellent resource for photos and descriptions of CTCL, as well as CTCL look-alikes, is an article by Dr. Ginette A. Hinds and Dr. Peter Heald (J. Am. Acad. Dermatol. 2009;60:359-75). The article also highlights the clinical variants within the mycosis fungoides subtype, the most common form of CTCL among blacks.

For example, look out for the "herald patch" of unilesional mycosis fungoides, which takes the form of a single large, dyspigmented patch. According to the authors, this variant has an excellent prognosis, possibly because of an active immune response that limits the initial spread of disease and contributes to preventing relapse.

Photo (c) Elsevier

Another variant is pigmented purpuric mycosis fungoides, which can often be confused with the benign pigmented purpura syndromes of Schamberg’s disease (progressive pigmented purpuric dermatitis), Gougerot-Blum syndrome (pigmented purpuric lichenoid dermatitis), Majocchi’s disease (purpura annularis telangiectodes), Doucas and Kapetanakis (lymphocytic capillaritis of unknown cause), and lichen aureus. The key to diagnosis in this case is recalling that "the lesions of the benign syndromes rarely assume the morphology and distribution found with mycosis fungoides," Dr. Hinds and Dr. Heald wrote.

Not only is mycosis fungoides difficult to diagnose, but it is especially prevalent among black patients. For instance, a 1988 study looking at Surveillance, Epidemiology, and End Results (SEER) data from 1973 through 1984 found that the incidence among black patients was twice that of white patients: 0.52/100,000 vs. 0.26 (JAMA 1988;260:42-46).

Similarly, in another study of 132 black patients with skin cancer, mycosis fungoides represented 12.1% of all skin neoplasms (Dermatol. Clin. 1988;6:397-405).

Mycosis fungoides is the fourth most common skin cancer among Japanese patients, representing approximately 5% of all skin malignancies in the population.

The incidence of CTCL and its subtypes is only increasing. A 2007 study that extended the SEER data mentioned above from 1973 to 2002 and included all CTCL cases found an incidence rate of 9.0 for black patients, per 1 million person-years, compared with 6.1 for white patients (Arch. Dermatol. 2007;143:854-9).

As in many skin cancers, early diagnosis can make the difference in successful outcomes. So add CTCL, and especially the mycosis fungoides subtype, to your differential when confronting pigmentation disorders in skin of color patients.

Dr. Roberts is past president of the Women’s Dermatologic Society (WDS) as well as past president of the California Society of Dermatology and Dermatologic Surgery (Calderm). She was a founding director of dermatopathology at the Loma Linda University Medical Center (Calif.). She currently runs a private practice in Rancho Mirage, Calif.

She disclosed financial relationships with Allergan, L’Oréal/La Roche Posay, Skin Medica, and Valeant Pharmaceuticals.

For many years, cocoa butter has played a major role in the ethnic skin care market. Derived from cocoa beans in tropical regions, it has been used in topicals for moisturization, stretch marks, scars, fade creams, and more. In recent years, shea butter has also become prominent in emollient creams and lotions. Cocoa butter, shea butter, mango seed butter, and cupuacu butter are all found as ingredients in many products.

So which butter is better for your patients? The answer is not a simple one, but here are some fun facts and the latest research about each option.

Cocoa butter

Cocoa butter – also called theobroma oil – is a pale yellow, pure, edible vegetable fat extracted from the cocoa bean. It is used to make chocolate and baked goods, and it is also used in topical preparations, including moisturizers and striae creams.

Cocoa butter is currently available in many skin care brands, but Palmer's is one of the most well-known brands of topical cocoa butter preparations on the market. The brand has been family-owned since the mid-19th century and under current ownership since 1971.

Ex vivo studies demonstrate that cocoa polyphenols improve skin elasticity and skin tone, namely, glycosaminoglycans and collagen I, III, and IV (Int. J. Cosmet. Sci. 2008;30:339-45).

However, one study that examined comedogenicity of ingredients and vehicles in cosmetics, found cocoa butter to be comedogenic in external rabbit ear canals (Cutan. Ocul. Toxicol. 2007;26:287-92).

A randomized, double-blind placebo controlled trial of 300 pregnant Afro-Caribbean women in Jamaica found that cocoa butter cream did not prevent striae gravidarum. This study found that development of striae was related to the young age of the mother and large neonates (Int. J. Gynaecol. Obstet. 2010;108:65-8).

And another randomized placebo controlled trial of 210 nulliparous women in Lebanon also found that topical application of cocoa butter cream did not decrease the likelihood of striae gravidarum, compared with placebo (BJOG 2008;115:1138-42).

Ingestion of cocoa butter in the forms of baked goods or chocolate has some antioxidant value because of the high levels of polyphenols. Oral consumption of cocoa also has anecdotal antimalarial effects through increased availability of antioxidants in plasma, membrane effects in general and erythrocyte membrane in particular, increased plasma levels of nitric oxide, antimalarial activity of cocoa flavanoids and their derivatives, and boosted immune system mediated by components of cocoa, including cocoa butter, polyphenols, magnesium, and zinc.

Shea butter

Shea butter is a slightly yellowish or ivory-colored fat extracted from the nut of the African shea tree (Vitellaria paradoxa). It has been used traditionally throughout Africa as a moisturizer; it has also been used in combination with coconut oil, palm oil, and gobi oil as a natural mosquito repellant (one that also protects against onchocerciasis).

In Africa, shea butter is used as cooking oil, as a waterproofing wax, for hairdressing, for candle-making, and as an ingredient in medicinal ointments. It is also used by makers of traditional African percussion instruments to increase the durability of wood.

Shea butter has been shown to have anti-inflammatory effects in studies through inhibition of iNOS, COX-2, and cytokines via the Nf-κB pathway in LPS-activated J774 macrophage cells (J. Complement. Integr. Med. 2012;9:Article 4).

Like cocoa butter, shea butter contains polyphenols. It also contains exceptionally high levels of triterpenes, indicating that shea nuts and shea fat constitute a significant source of anti-inflammatory and anti-tumor promoting compounds (J. Oleo. Sci. 2010;59:273-80).

Shea butter also contains no IgE-binding soluble proteins, making it of low allergenic potential (J. Allergy Clin. Immunol. 2011;127:680-2).

Mango seed butter

Mango seed butter's solid content profile is very similar to that of cocoa butterexcept it is softer (Bioresour. Technol. 2004;92:71-8). It is rich in beta carotene, essential fatty acids, and vitamins A and E. It is also used in skin creams, but not much has been published about mango seed butter in peer-reviewed journals.

Cupuacu butter

Cupuaçu (Theobroma grandiflorum) is a tropical rainforest tree related to cacao. Common throughout the Amazon basin, it is widely cultivated in the jungles of Colombia, Bolivia, Peru, and in northern Brazil. Some skin care brands, particularly in Brazil, use cupuaçu butter in topical emollient creams.

It has been shown to contain high concentrations of polyphenolic antioxidants, but less caffeine than its cocoa counterpart.

Activity-guided fractionation of cupuacu seeds in one study resulted in the identification of new sulfated flavonoid glycosides, theograndins I and II. In addition, nine flavonoid antioxidants were identified (J. Nat. Prod. 2003;66:1501-4). The theograndins had antioxidant effects and were weakly cytotoxic against human colon cancer cells.

No head-to-head comparative studies have been performed on these butters. Given the research to date, shea butter has a slight edge due to the sheer number of studies that show positive properties.

- Naissan Wesley, M.D.

Do you have questions about treating patients with darker skin? If so, send them to [email protected].

For many years, cocoa butter has played a major role in the ethnic skin care market. Derived from cocoa beans in tropical regions, it has been used in topicals for moisturization, stretch marks, scars, fade creams, and more. In recent years, shea butter has also become prominent in emollient creams and lotions. Cocoa butter, shea butter, mango seed butter, and cupuacu butter are all found as ingredients in many products.

So which butter is better for your patients? The answer is not a simple one, but here are some fun facts and the latest research about each option.

Cocoa butter

Cocoa butter – also called theobroma oil – is a pale yellow, pure, edible vegetable fat extracted from the cocoa bean. It is used to make chocolate and baked goods, and it is also used in topical preparations, including moisturizers and striae creams.

Cocoa butter is currently available in many skin care brands, but Palmer's is one of the most well-known brands of topical cocoa butter preparations on the market. The brand has been family-owned since the mid-19th century and under current ownership since 1971.

Ex vivo studies demonstrate that cocoa polyphenols improve skin elasticity and skin tone, namely, glycosaminoglycans and collagen I, III, and IV (Int. J. Cosmet. Sci. 2008;30:339-45).

However, one study that examined comedogenicity of ingredients and vehicles in cosmetics, found cocoa butter to be comedogenic in external rabbit ear canals (Cutan. Ocul. Toxicol. 2007;26:287-92).

A randomized, double-blind placebo controlled trial of 300 pregnant Afro-Caribbean women in Jamaica found that cocoa butter cream did not prevent striae gravidarum. This study found that development of striae was related to the young age of the mother and large neonates (Int. J. Gynaecol. Obstet. 2010;108:65-8).

And another randomized placebo controlled trial of 210 nulliparous women in Lebanon also found that topical application of cocoa butter cream did not decrease the likelihood of striae gravidarum, compared with placebo (BJOG 2008;115:1138-42).

Ingestion of cocoa butter in the forms of baked goods or chocolate has some antioxidant value because of the high levels of polyphenols. Oral consumption of cocoa also has anecdotal antimalarial effects through increased availability of antioxidants in plasma, membrane effects in general and erythrocyte membrane in particular, increased plasma levels of nitric oxide, antimalarial activity of cocoa flavanoids and their derivatives, and boosted immune system mediated by components of cocoa, including cocoa butter, polyphenols, magnesium, and zinc.

Shea butter

Shea butter is a slightly yellowish or ivory-colored fat extracted from the nut of the African shea tree (Vitellaria paradoxa). It has been used traditionally throughout Africa as a moisturizer; it has also been used in combination with coconut oil, palm oil, and gobi oil as a natural mosquito repellant (one that also protects against onchocerciasis).

In Africa, shea butter is used as cooking oil, as a waterproofing wax, for hairdressing, for candle-making, and as an ingredient in medicinal ointments. It is also used by makers of traditional African percussion instruments to increase the durability of wood.

Shea butter has been shown to have anti-inflammatory effects in studies through inhibition of iNOS, COX-2, and cytokines via the Nf-κB pathway in LPS-activated J774 macrophage cells (J. Complement. Integr. Med. 2012;9:Article 4).

Like cocoa butter, shea butter contains polyphenols. It also contains exceptionally high levels of triterpenes, indicating that shea nuts and shea fat constitute a significant source of anti-inflammatory and anti-tumor promoting compounds (J. Oleo. Sci. 2010;59:273-80).

Shea butter also contains no IgE-binding soluble proteins, making it of low allergenic potential (J. Allergy Clin. Immunol. 2011;127:680-2).

Mango seed butter

Mango seed butter's solid content profile is very similar to that of cocoa butterexcept it is softer (Bioresour. Technol. 2004;92:71-8). It is rich in beta carotene, essential fatty acids, and vitamins A and E. It is also used in skin creams, but not much has been published about mango seed butter in peer-reviewed journals.

Cupuacu butter

Cupuaçu (Theobroma grandiflorum) is a tropical rainforest tree related to cacao. Common throughout the Amazon basin, it is widely cultivated in the jungles of Colombia, Bolivia, Peru, and in northern Brazil. Some skin care brands, particularly in Brazil, use cupuaçu butter in topical emollient creams.

It has been shown to contain high concentrations of polyphenolic antioxidants, but less caffeine than its cocoa counterpart.

Activity-guided fractionation of cupuacu seeds in one study resulted in the identification of new sulfated flavonoid glycosides, theograndins I and II. In addition, nine flavonoid antioxidants were identified (J. Nat. Prod. 2003;66:1501-4). The theograndins had antioxidant effects and were weakly cytotoxic against human colon cancer cells.

No head-to-head comparative studies have been performed on these butters. Given the research to date, shea butter has a slight edge due to the sheer number of studies that show positive properties.

- Naissan Wesley, M.D.

Do you have questions about treating patients with darker skin? If so, send them to [email protected].

For many years, cocoa butter has played a major role in the ethnic skin care market. Derived from cocoa beans in tropical regions, it has been used in topicals for moisturization, stretch marks, scars, fade creams, and more. In recent years, shea butter has also become prominent in emollient creams and lotions. Cocoa butter, shea butter, mango seed butter, and cupuacu butter are all found as ingredients in many products.

So which butter is better for your patients? The answer is not a simple one, but here are some fun facts and the latest research about each option.

Cocoa butter

Cocoa butter – also called theobroma oil – is a pale yellow, pure, edible vegetable fat extracted from the cocoa bean. It is used to make chocolate and baked goods, and it is also used in topical preparations, including moisturizers and striae creams.

Cocoa butter is currently available in many skin care brands, but Palmer's is one of the most well-known brands of topical cocoa butter preparations on the market. The brand has been family-owned since the mid-19th century and under current ownership since 1971.

Ex vivo studies demonstrate that cocoa polyphenols improve skin elasticity and skin tone, namely, glycosaminoglycans and collagen I, III, and IV (Int. J. Cosmet. Sci. 2008;30:339-45).

However, one study that examined comedogenicity of ingredients and vehicles in cosmetics, found cocoa butter to be comedogenic in external rabbit ear canals (Cutan. Ocul. Toxicol. 2007;26:287-92).

A randomized, double-blind placebo controlled trial of 300 pregnant Afro-Caribbean women in Jamaica found that cocoa butter cream did not prevent striae gravidarum. This study found that development of striae was related to the young age of the mother and large neonates (Int. J. Gynaecol. Obstet. 2010;108:65-8).

And another randomized placebo controlled trial of 210 nulliparous women in Lebanon also found that topical application of cocoa butter cream did not decrease the likelihood of striae gravidarum, compared with placebo (BJOG 2008;115:1138-42).

Ingestion of cocoa butter in the forms of baked goods or chocolate has some antioxidant value because of the high levels of polyphenols. Oral consumption of cocoa also has anecdotal antimalarial effects through increased availability of antioxidants in plasma, membrane effects in general and erythrocyte membrane in particular, increased plasma levels of nitric oxide, antimalarial activity of cocoa flavanoids and their derivatives, and boosted immune system mediated by components of cocoa, including cocoa butter, polyphenols, magnesium, and zinc.

Shea butter

Shea butter is a slightly yellowish or ivory-colored fat extracted from the nut of the African shea tree (Vitellaria paradoxa). It has been used traditionally throughout Africa as a moisturizer; it has also been used in combination with coconut oil, palm oil, and gobi oil as a natural mosquito repellant (one that also protects against onchocerciasis).

In Africa, shea butter is used as cooking oil, as a waterproofing wax, for hairdressing, for candle-making, and as an ingredient in medicinal ointments. It is also used by makers of traditional African percussion instruments to increase the durability of wood.

Shea butter has been shown to have anti-inflammatory effects in studies through inhibition of iNOS, COX-2, and cytokines via the Nf-κB pathway in LPS-activated J774 macrophage cells (J. Complement. Integr. Med. 2012;9:Article 4).

Like cocoa butter, shea butter contains polyphenols. It also contains exceptionally high levels of triterpenes, indicating that shea nuts and shea fat constitute a significant source of anti-inflammatory and anti-tumor promoting compounds (J. Oleo. Sci. 2010;59:273-80).

Shea butter also contains no IgE-binding soluble proteins, making it of low allergenic potential (J. Allergy Clin. Immunol. 2011;127:680-2).

Mango seed butter

Mango seed butter's solid content profile is very similar to that of cocoa butterexcept it is softer (Bioresour. Technol. 2004;92:71-8). It is rich in beta carotene, essential fatty acids, and vitamins A and E. It is also used in skin creams, but not much has been published about mango seed butter in peer-reviewed journals.

Cupuacu butter

Cupuaçu (Theobroma grandiflorum) is a tropical rainforest tree related to cacao. Common throughout the Amazon basin, it is widely cultivated in the jungles of Colombia, Bolivia, Peru, and in northern Brazil. Some skin care brands, particularly in Brazil, use cupuaçu butter in topical emollient creams.

It has been shown to contain high concentrations of polyphenolic antioxidants, but less caffeine than its cocoa counterpart.

Activity-guided fractionation of cupuacu seeds in one study resulted in the identification of new sulfated flavonoid glycosides, theograndins I and II. In addition, nine flavonoid antioxidants were identified (J. Nat. Prod. 2003;66:1501-4). The theograndins had antioxidant effects and were weakly cytotoxic against human colon cancer cells.

No head-to-head comparative studies have been performed on these butters. Given the research to date, shea butter has a slight edge due to the sheer number of studies that show positive properties.

- Naissan Wesley, M.D.

Do you have questions about treating patients with darker skin? If so, send them to [email protected].

Sailesh Konda, MD, Aanand N. Geria, MD, and Rebat M. Halder, MD

Pigmentary abnormalities are among the most common reasons why patients with skin of color visit a dermatologist. Hydroquinone has been a cornerstone for the treatment of hyperpigmentation; however, concerns regarding adverse effects have prompted a search for alternative agents. Some promising topical treatments include soy, licorice, rucinol, mulberry, niacinamide, ellagic acid, resveratrol, and dioic acid. Oral agents, primarily used for the prevention of postprocedural hyperpigmentation, include procyanidins, tranexamic acid, and Polypodium leucotomos. Advances in Q-switched lasers, intense pulse light, fractional photothermolysis, and the advent of tretinoin peeling add to the clinician’s armamentarium for treating hyperpigmentation.

*For a PDF of the full article, click on the link to the left of this introduction.

Sailesh Konda, MD, Aanand N. Geria, MD, and Rebat M. Halder, MD

Pigmentary abnormalities are among the most common reasons why patients with skin of color visit a dermatologist. Hydroquinone has been a cornerstone for the treatment of hyperpigmentation; however, concerns regarding adverse effects have prompted a search for alternative agents. Some promising topical treatments include soy, licorice, rucinol, mulberry, niacinamide, ellagic acid, resveratrol, and dioic acid. Oral agents, primarily used for the prevention of postprocedural hyperpigmentation, include procyanidins, tranexamic acid, and Polypodium leucotomos. Advances in Q-switched lasers, intense pulse light, fractional photothermolysis, and the advent of tretinoin peeling add to the clinician’s armamentarium for treating hyperpigmentation.

*For a PDF of the full article, click on the link to the left of this introduction.

Sailesh Konda, MD, Aanand N. Geria, MD, and Rebat M. Halder, MD

Pigmentary abnormalities are among the most common reasons why patients with skin of color visit a dermatologist. Hydroquinone has been a cornerstone for the treatment of hyperpigmentation; however, concerns regarding adverse effects have prompted a search for alternative agents. Some promising topical treatments include soy, licorice, rucinol, mulberry, niacinamide, ellagic acid, resveratrol, and dioic acid. Oral agents, primarily used for the prevention of postprocedural hyperpigmentation, include procyanidins, tranexamic acid, and Polypodium leucotomos. Advances in Q-switched lasers, intense pulse light, fractional photothermolysis, and the advent of tretinoin peeling add to the clinician’s armamentarium for treating hyperpigmentation.

*For a PDF of the full article, click on the link to the left of this introduction.

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.

WAIKOLOA, HAWAII  – The use of eflornithine cream may increase the effectiveness of laser hair removal for treating pseudofolliculitis barbae, according to Dr. Andrew F. Alexis.

Laser hair removal has proved to be a game changer in the treatment of pseudofolliculitis barbae, a common chronic, inflammatory dermatosis that’s often been a difficult therapeutic challenge, Dr. Alexis said at the seminar sponsored by Skin Disease Education Foundation (SDEF). And the use of adjunctive eflornithine cream makes laser therapy even more effective, based on a recent study, which is one of the few rigorous studies conducted in pseudofolliculitis barbae (PFB) patients, noted Dr. Alexis, director of the skin of color center at St. Luke’s–Roosevelt Hospital and a dermatologist at Columbia University, New York.

Photo: Dermatologic Clinics 2003;21;629-44

The double-blind placebo controlled study was carried out by U.S. military physicians. PFB, which is predominantly a disorder of black men, has at times been a source of racial tension in the military because the simplest treatment for PFB is to stop shaving and grow a beard, a form of individual expression at odds with regulations.

The study included 27 men with PFB. They received laser therapy once every 4 weeks for 16 weeks. In addition, they applied eflornithine cream to one side of their bearded neck region and placebo to the other side twice daily.

At 16 weeks, the laser plus eflornithine cream side produced a median 99.5% reduction in hair count and inflammatory papules. This was a significantly better result than the median 85% reduction on the laser plus placebo–treated side (J. Am. Acad. Dermatol. 2012 Jan. 8; in press).

The PFB study follows an earlier study by other investigators who demonstrated that eflornithine cream as an adjunct to laser hair removal for facial hirsutism in women was more effective than laser therapy alone (J. Am. Acad. Dermatol. 2007;57:54-9).

Dr. Alexis said performing laser hair removal safely in darker-skinned patients with PFB requires attention to several key principles: longer wavelengths, lower fluences, longer pulse durations, and plenty of epidermal cooling.

"The No. 1 thing is to use longer wavelengths, because the goal is deeper penetration to maximize the ratio of the temperature in the bulb of the follicle to the temperature in the epidermis," he explained.

The long-pulsed 1,064-nm Nd:YAG laser has the lowest rate of associated epidermal burns, hypopigmentation, and other adverse events in darker-skinned patients, as has been shown in a review of a wide assortment of lasers (J. Drugs Dermatol. 2007;6:40-6). It is clearly the safest laser option in patients with skin types IV-VI. The 810-nm diode laser is a reasonable alternative in skin types IV-V, Dr. Alexis said.

In treating patients for PFB with the 1,064-nm Nd:YAG laser, he said that he typically starts with a fluence of 20 J/cm² and a pulse duration of 20-30 milliseconds. After several sessions, as he makes inroads into the initially dense follicular distribution, he said that he might increase the fluence to a maximum of 50 J/cm² in the setting of skin type VI, and as high as 100 J/cm² in skin types IV or V.

Longer pulse durations allow for more efficient epidermal cooling. This minimizes heat injury to melanin-containing epidermal cells. For the 810-nm diode laser, Dr. Alexis said he uses pulse durations of 100 or 400 milliseconds.

Epidermal cooling can be accomplished in several ways. His preferred method is to utilize contact cooling via a sapphire tip or chilled copper plate attached to the laser; the cooling is done before delivering the laser pulse. Alternatively, the epidermal cooling can be done using cold gels, forced air, or spray cooling, although dyschromia can occur in darker skin types if the spray technique isn’t optimal. Another option is to apply an ice pack for 5-10 minutes post treatment.

Laser therapy is expensive, so Dr. Alexis said he likes to give his patients a range of therapeutic options. These include growing a beard, chemical depilation with barium sulfide or calcium thioglycolate every 2-4 days, modification of shaving practices, and salicylic acid chemical peels.

"It’s kind of a long conversation," he said.

Whatever form of therapy the patient decides upon, it’s important that the patient stops tweezing to remove ingrown hairs. This is a common practice that induces trauma and worsens postinflammatory hyperpigmentation.

Dr. Alexis reported that he serves as a consultant to Schick and is on the advisory board for Allergan. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII  – The use of eflornithine cream may increase the effectiveness of laser hair removal for treating pseudofolliculitis barbae, according to Dr. Andrew F. Alexis.

Laser hair removal has proved to be a game changer in the treatment of pseudofolliculitis barbae, a common chronic, inflammatory dermatosis that’s often been a difficult therapeutic challenge, Dr. Alexis said at the seminar sponsored by Skin Disease Education Foundation (SDEF). And the use of adjunctive eflornithine cream makes laser therapy even more effective, based on a recent study, which is one of the few rigorous studies conducted in pseudofolliculitis barbae (PFB) patients, noted Dr. Alexis, director of the skin of color center at St. Luke’s–Roosevelt Hospital and a dermatologist at Columbia University, New York.

Photo: Dermatologic Clinics 2003;21;629-44

The double-blind placebo controlled study was carried out by U.S. military physicians. PFB, which is predominantly a disorder of black men, has at times been a source of racial tension in the military because the simplest treatment for PFB is to stop shaving and grow a beard, a form of individual expression at odds with regulations.

The study included 27 men with PFB. They received laser therapy once every 4 weeks for 16 weeks. In addition, they applied eflornithine cream to one side of their bearded neck region and placebo to the other side twice daily.

At 16 weeks, the laser plus eflornithine cream side produced a median 99.5% reduction in hair count and inflammatory papules. This was a significantly better result than the median 85% reduction on the laser plus placebo–treated side (J. Am. Acad. Dermatol. 2012 Jan. 8; in press).

The PFB study follows an earlier study by other investigators who demonstrated that eflornithine cream as an adjunct to laser hair removal for facial hirsutism in women was more effective than laser therapy alone (J. Am. Acad. Dermatol. 2007;57:54-9).

Dr. Alexis said performing laser hair removal safely in darker-skinned patients with PFB requires attention to several key principles: longer wavelengths, lower fluences, longer pulse durations, and plenty of epidermal cooling.

"The No. 1 thing is to use longer wavelengths, because the goal is deeper penetration to maximize the ratio of the temperature in the bulb of the follicle to the temperature in the epidermis," he explained.

The long-pulsed 1,064-nm Nd:YAG laser has the lowest rate of associated epidermal burns, hypopigmentation, and other adverse events in darker-skinned patients, as has been shown in a review of a wide assortment of lasers (J. Drugs Dermatol. 2007;6:40-6). It is clearly the safest laser option in patients with skin types IV-VI. The 810-nm diode laser is a reasonable alternative in skin types IV-V, Dr. Alexis said.

In treating patients for PFB with the 1,064-nm Nd:YAG laser, he said that he typically starts with a fluence of 20 J/cm² and a pulse duration of 20-30 milliseconds. After several sessions, as he makes inroads into the initially dense follicular distribution, he said that he might increase the fluence to a maximum of 50 J/cm² in the setting of skin type VI, and as high as 100 J/cm² in skin types IV or V.

Longer pulse durations allow for more efficient epidermal cooling. This minimizes heat injury to melanin-containing epidermal cells. For the 810-nm diode laser, Dr. Alexis said he uses pulse durations of 100 or 400 milliseconds.

Epidermal cooling can be accomplished in several ways. His preferred method is to utilize contact cooling via a sapphire tip or chilled copper plate attached to the laser; the cooling is done before delivering the laser pulse. Alternatively, the epidermal cooling can be done using cold gels, forced air, or spray cooling, although dyschromia can occur in darker skin types if the spray technique isn’t optimal. Another option is to apply an ice pack for 5-10 minutes post treatment.

Laser therapy is expensive, so Dr. Alexis said he likes to give his patients a range of therapeutic options. These include growing a beard, chemical depilation with barium sulfide or calcium thioglycolate every 2-4 days, modification of shaving practices, and salicylic acid chemical peels.

"It’s kind of a long conversation," he said.

Whatever form of therapy the patient decides upon, it’s important that the patient stops tweezing to remove ingrown hairs. This is a common practice that induces trauma and worsens postinflammatory hyperpigmentation.

Dr. Alexis reported that he serves as a consultant to Schick and is on the advisory board for Allergan. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII  – The use of eflornithine cream may increase the effectiveness of laser hair removal for treating pseudofolliculitis barbae, according to Dr. Andrew F. Alexis.

Laser hair removal has proved to be a game changer in the treatment of pseudofolliculitis barbae, a common chronic, inflammatory dermatosis that’s often been a difficult therapeutic challenge, Dr. Alexis said at the seminar sponsored by Skin Disease Education Foundation (SDEF). And the use of adjunctive eflornithine cream makes laser therapy even more effective, based on a recent study, which is one of the few rigorous studies conducted in pseudofolliculitis barbae (PFB) patients, noted Dr. Alexis, director of the skin of color center at St. Luke’s–Roosevelt Hospital and a dermatologist at Columbia University, New York.

Photo: Dermatologic Clinics 2003;21;629-44

The double-blind placebo controlled study was carried out by U.S. military physicians. PFB, which is predominantly a disorder of black men, has at times been a source of racial tension in the military because the simplest treatment for PFB is to stop shaving and grow a beard, a form of individual expression at odds with regulations.

The study included 27 men with PFB. They received laser therapy once every 4 weeks for 16 weeks. In addition, they applied eflornithine cream to one side of their bearded neck region and placebo to the other side twice daily.

At 16 weeks, the laser plus eflornithine cream side produced a median 99.5% reduction in hair count and inflammatory papules. This was a significantly better result than the median 85% reduction on the laser plus placebo–treated side (J. Am. Acad. Dermatol. 2012 Jan. 8; in press).

The PFB study follows an earlier study by other investigators who demonstrated that eflornithine cream as an adjunct to laser hair removal for facial hirsutism in women was more effective than laser therapy alone (J. Am. Acad. Dermatol. 2007;57:54-9).

Dr. Alexis said performing laser hair removal safely in darker-skinned patients with PFB requires attention to several key principles: longer wavelengths, lower fluences, longer pulse durations, and plenty of epidermal cooling.

"The No. 1 thing is to use longer wavelengths, because the goal is deeper penetration to maximize the ratio of the temperature in the bulb of the follicle to the temperature in the epidermis," he explained.

The long-pulsed 1,064-nm Nd:YAG laser has the lowest rate of associated epidermal burns, hypopigmentation, and other adverse events in darker-skinned patients, as has been shown in a review of a wide assortment of lasers (J. Drugs Dermatol. 2007;6:40-6). It is clearly the safest laser option in patients with skin types IV-VI. The 810-nm diode laser is a reasonable alternative in skin types IV-V, Dr. Alexis said.

In treating patients for PFB with the 1,064-nm Nd:YAG laser, he said that he typically starts with a fluence of 20 J/cm² and a pulse duration of 20-30 milliseconds. After several sessions, as he makes inroads into the initially dense follicular distribution, he said that he might increase the fluence to a maximum of 50 J/cm² in the setting of skin type VI, and as high as 100 J/cm² in skin types IV or V.

Longer pulse durations allow for more efficient epidermal cooling. This minimizes heat injury to melanin-containing epidermal cells. For the 810-nm diode laser, Dr. Alexis said he uses pulse durations of 100 or 400 milliseconds.

Epidermal cooling can be accomplished in several ways. His preferred method is to utilize contact cooling via a sapphire tip or chilled copper plate attached to the laser; the cooling is done before delivering the laser pulse. Alternatively, the epidermal cooling can be done using cold gels, forced air, or spray cooling, although dyschromia can occur in darker skin types if the spray technique isn’t optimal. Another option is to apply an ice pack for 5-10 minutes post treatment.

Laser therapy is expensive, so Dr. Alexis said he likes to give his patients a range of therapeutic options. These include growing a beard, chemical depilation with barium sulfide or calcium thioglycolate every 2-4 days, modification of shaving practices, and salicylic acid chemical peels.

"It’s kind of a long conversation," he said.

Whatever form of therapy the patient decides upon, it’s important that the patient stops tweezing to remove ingrown hairs. This is a common practice that induces trauma and worsens postinflammatory hyperpigmentation.

Dr. Alexis reported that he serves as a consultant to Schick and is on the advisory board for Allergan. SDEF and this news organization are owned by Elsevier.

How many times a week do you get asked by your patients how to get rid of the "dark circles" under their eyes? The term is a catch-all used by physicians and patients to refer to problems that have a vast range of genetic, environmental, and skin-related causes. It is a common and frustrating problem, with little structure in its definition and few full-proof treatments.

Below is my proposed classification system for the definition of dark circles and clinical pearls for their treatment. Most patients, however, have a combination of each type and multifactorial causes that need to be addressed.

©Elsevier Inc.

1. Infraorbital fat pad protrusion. Also known as "eye bags."

• Blepharoplasty is the best, and for now the only, solution for severe fat pad prominence. Referral to a board certified plastic surgeon or dermatologic surgeon is recommended.

• If the protrusion is mild and tear troughs are prominent, fillers may be injected into the tear trough area to help mask the protrusion. My favorites for this area are hyalauronic acid fillers like Juvéderm Ultra or Restlyane, sometimes double diluted with normal saline or injected with a 32-gauge needle.

• For loose skin with "bags," radiofrequency lasers can provide some benefit. The Thermage eyelid tip produces results over 3-6 months, with repeat treatment possible at 6 months. I always advise patients that this treatment is not a replacement for surgery but can provide some benefit in those who are not surgical candidates or who do not want surgery.

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying or water retention from high blood pressure or eating high sodium foods are some of the reasons the loose, thin epidermis becomes edematous.

• Treat seasonal allergies with over-the-counter allergy medications or prescription medications for resistant allergies or possible sinus infections.

• Advise patients to switch their sleep position. Sleep position can be contributing to undereye bags through gravity. Sleeping on the side or stomach can encourage fluids to collect under the eyes. If patients report being a side sleeper, you may notice a heavier bag on the side they report sleeping on. Patients who wake up with puffy eyes can sleep on their back and add an extra pillow under their head.

• Also advise patients to avoid rubbing their eyes, going to bed with makeup on, and using harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags could be a sign of an underlying medical condition, especially if bags appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause undereye fluid retention and patients will need to see their primary care doctors for further evaluation.

• Patients can place an ice pack, slices of cucumbers, chilled tea bags, refrigerated eye gels, or even a package of frozen peas on their eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin undereye skin.

• Again, advise patients to avoid rubbing the area. Chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened undereye skin.

• Retinoic acid creams can help slough the dark pigmented skin. It should, however, be used in very small amounts that increase over a few weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid can be found in varying strengths. Hydroquinone creams have been successful in lightening undereye hyperpigmentation. Strengths in over-the-counter preparations start at 1-2% and in prescription strength can be compounded to higher than 4%, but caution should be used to avoid further irritation and potential post-inflammatory pigment from these products.

• Light chemical peels can assist in lightening dark undereye pigmentation. Peels with hydroquinone or retinoic acid can be used for an added lightening benefit.

• Intense pulse light can help minimize undereye pigmentation, particularly UV-induced pigmentation. Q-switched lasers have also been reported to be effective.

Most often, dark circles aren't about changes in the color of the skin. Instead, they're created by a loss of volume in the area around the eye, exposing the orbital bone and creating a hollow trough that shows up as a dark circle. These changes are often genetic, but significant weigh loss can also expose undereye tear trough depressions.

• The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Use caution, however; this is a highly technical and injector-dependent procedure.

• There are crucial vascular structures around the eye that need to be avoided, and over-filled troughs will give patients a puffy appearance and may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not FDA approved to treat undereye depressions, so patients should be knowledgeable to the risks and benefits prior to undergoing these procedures.

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin, which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:YAG laser can be recommended. However, in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques.

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3-4 months apart will ensure long lasting benefits and because botulinum toxin wears off, repeat treatments are needed.

• Laser resurfacing with CO2 or fractionated CO2 lasers provide excellent benefit for periocular rhytides. A traditional CO2 laser may require repeat treatment in 6-12 months. Fractionated CO2 lasers typically require 4-6 treatments spaced about 4 weeks apart to provide benefit.

Overall tips:

• For most of the types of infraorbital issues, makeup can help conceal or mask some imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If they have mild discoloration, advise or help them pick a liquid formula for more prominent imperfections. A cream, full coverage concealer works best.

• Encourage patients to quit smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Always remind patients to apply sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation.

• Advise patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

- Lily Talakoub, M.D.

Do you have questions about treating patients with darker skin? If so, send them to [email protected].

How many times a week do you get asked by your patients how to get rid of the "dark circles" under their eyes? The term is a catch-all used by physicians and patients to refer to problems that have a vast range of genetic, environmental, and skin-related causes. It is a common and frustrating problem, with little structure in its definition and few full-proof treatments.

Below is my proposed classification system for the definition of dark circles and clinical pearls for their treatment. Most patients, however, have a combination of each type and multifactorial causes that need to be addressed.

©Elsevier Inc.

1. Infraorbital fat pad protrusion. Also known as "eye bags."

• Blepharoplasty is the best, and for now the only, solution for severe fat pad prominence. Referral to a board certified plastic surgeon or dermatologic surgeon is recommended.

• If the protrusion is mild and tear troughs are prominent, fillers may be injected into the tear trough area to help mask the protrusion. My favorites for this area are hyalauronic acid fillers like Juvéderm Ultra or Restlyane, sometimes double diluted with normal saline or injected with a 32-gauge needle.

• For loose skin with "bags," radiofrequency lasers can provide some benefit. The Thermage eyelid tip produces results over 3-6 months, with repeat treatment possible at 6 months. I always advise patients that this treatment is not a replacement for surgery but can provide some benefit in those who are not surgical candidates or who do not want surgery.

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying or water retention from high blood pressure or eating high sodium foods are some of the reasons the loose, thin epidermis becomes edematous.

• Treat seasonal allergies with over-the-counter allergy medications or prescription medications for resistant allergies or possible sinus infections.

• Advise patients to switch their sleep position. Sleep position can be contributing to undereye bags through gravity. Sleeping on the side or stomach can encourage fluids to collect under the eyes. If patients report being a side sleeper, you may notice a heavier bag on the side they report sleeping on. Patients who wake up with puffy eyes can sleep on their back and add an extra pillow under their head.

• Also advise patients to avoid rubbing their eyes, going to bed with makeup on, and using harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags could be a sign of an underlying medical condition, especially if bags appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause undereye fluid retention and patients will need to see their primary care doctors for further evaluation.

• Patients can place an ice pack, slices of cucumbers, chilled tea bags, refrigerated eye gels, or even a package of frozen peas on their eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin undereye skin.

• Again, advise patients to avoid rubbing the area. Chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened undereye skin.

• Retinoic acid creams can help slough the dark pigmented skin. It should, however, be used in very small amounts that increase over a few weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid can be found in varying strengths. Hydroquinone creams have been successful in lightening undereye hyperpigmentation. Strengths in over-the-counter preparations start at 1-2% and in prescription strength can be compounded to higher than 4%, but caution should be used to avoid further irritation and potential post-inflammatory pigment from these products.

• Light chemical peels can assist in lightening dark undereye pigmentation. Peels with hydroquinone or retinoic acid can be used for an added lightening benefit.

• Intense pulse light can help minimize undereye pigmentation, particularly UV-induced pigmentation. Q-switched lasers have also been reported to be effective.

Most often, dark circles aren't about changes in the color of the skin. Instead, they're created by a loss of volume in the area around the eye, exposing the orbital bone and creating a hollow trough that shows up as a dark circle. These changes are often genetic, but significant weigh loss can also expose undereye tear trough depressions.

• The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Use caution, however; this is a highly technical and injector-dependent procedure.

• There are crucial vascular structures around the eye that need to be avoided, and over-filled troughs will give patients a puffy appearance and may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not FDA approved to treat undereye depressions, so patients should be knowledgeable to the risks and benefits prior to undergoing these procedures.

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin, which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:YAG laser can be recommended. However, in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques.

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3-4 months apart will ensure long lasting benefits and because botulinum toxin wears off, repeat treatments are needed.

• Laser resurfacing with CO2 or fractionated CO2 lasers provide excellent benefit for periocular rhytides. A traditional CO2 laser may require repeat treatment in 6-12 months. Fractionated CO2 lasers typically require 4-6 treatments spaced about 4 weeks apart to provide benefit.

Overall tips:

• For most of the types of infraorbital issues, makeup can help conceal or mask some imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If they have mild discoloration, advise or help them pick a liquid formula for more prominent imperfections. A cream, full coverage concealer works best.

• Encourage patients to quit smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Always remind patients to apply sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation.

• Advise patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

- Lily Talakoub, M.D.

Do you have questions about treating patients with darker skin? If so, send them to [email protected].

How many times a week do you get asked by your patients how to get rid of the "dark circles" under their eyes? The term is a catch-all used by physicians and patients to refer to problems that have a vast range of genetic, environmental, and skin-related causes. It is a common and frustrating problem, with little structure in its definition and few full-proof treatments.

Below is my proposed classification system for the definition of dark circles and clinical pearls for their treatment. Most patients, however, have a combination of each type and multifactorial causes that need to be addressed.

©Elsevier Inc.

1. Infraorbital fat pad protrusion. Also known as "eye bags."

• Blepharoplasty is the best, and for now the only, solution for severe fat pad prominence. Referral to a board certified plastic surgeon or dermatologic surgeon is recommended.

• If the protrusion is mild and tear troughs are prominent, fillers may be injected into the tear trough area to help mask the protrusion. My favorites for this area are hyalauronic acid fillers like Juvéderm Ultra or Restlyane, sometimes double diluted with normal saline or injected with a 32-gauge needle.

• For loose skin with "bags," radiofrequency lasers can provide some benefit. The Thermage eyelid tip produces results over 3-6 months, with repeat treatment possible at 6 months. I always advise patients that this treatment is not a replacement for surgery but can provide some benefit in those who are not surgical candidates or who do not want surgery.

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying or water retention from high blood pressure or eating high sodium foods are some of the reasons the loose, thin epidermis becomes edematous.

• Treat seasonal allergies with over-the-counter allergy medications or prescription medications for resistant allergies or possible sinus infections.

• Advise patients to switch their sleep position. Sleep position can be contributing to undereye bags through gravity. Sleeping on the side or stomach can encourage fluids to collect under the eyes. If patients report being a side sleeper, you may notice a heavier bag on the side they report sleeping on. Patients who wake up with puffy eyes can sleep on their back and add an extra pillow under their head.

• Also advise patients to avoid rubbing their eyes, going to bed with makeup on, and using harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags could be a sign of an underlying medical condition, especially if bags appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause undereye fluid retention and patients will need to see their primary care doctors for further evaluation.

• Patients can place an ice pack, slices of cucumbers, chilled tea bags, refrigerated eye gels, or even a package of frozen peas on their eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin undereye skin.

• Again, advise patients to avoid rubbing the area. Chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened undereye skin.

• Retinoic acid creams can help slough the dark pigmented skin. It should, however, be used in very small amounts that increase over a few weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid can be found in varying strengths. Hydroquinone creams have been successful in lightening undereye hyperpigmentation. Strengths in over-the-counter preparations start at 1-2% and in prescription strength can be compounded to higher than 4%, but caution should be used to avoid further irritation and potential post-inflammatory pigment from these products.

• Light chemical peels can assist in lightening dark undereye pigmentation. Peels with hydroquinone or retinoic acid can be used for an added lightening benefit.

• Intense pulse light can help minimize undereye pigmentation, particularly UV-induced pigmentation. Q-switched lasers have also been reported to be effective.

Most often, dark circles aren't about changes in the color of the skin. Instead, they're created by a loss of volume in the area around the eye, exposing the orbital bone and creating a hollow trough that shows up as a dark circle. These changes are often genetic, but significant weigh loss can also expose undereye tear trough depressions.

• The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Use caution, however; this is a highly technical and injector-dependent procedure.

• There are crucial vascular structures around the eye that need to be avoided, and over-filled troughs will give patients a puffy appearance and may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not FDA approved to treat undereye depressions, so patients should be knowledgeable to the risks and benefits prior to undergoing these procedures.

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin, which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:YAG laser can be recommended. However, in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques.

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3-4 months apart will ensure long lasting benefits and because botulinum toxin wears off, repeat treatments are needed.

• Laser resurfacing with CO2 or fractionated CO2 lasers provide excellent benefit for periocular rhytides. A traditional CO2 laser may require repeat treatment in 6-12 months. Fractionated CO2 lasers typically require 4-6 treatments spaced about 4 weeks apart to provide benefit.

Overall tips:

• For most of the types of infraorbital issues, makeup can help conceal or mask some imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If they have mild discoloration, advise or help them pick a liquid formula for more prominent imperfections. A cream, full coverage concealer works best.

• Encourage patients to quit smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Always remind patients to apply sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation.

• Advise patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

- Lily Talakoub, M.D.

Do you have questions about treating patients with darker skin? If so, send them to [email protected].

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.