Pigmentation Disorders

Melanoma accounts for 75% of all skin cancer deaths. Ultraviolet exposure is still targeted as the major etiologic factor, but for black patients, skin erythema has been estimated to occur at a UV radiation dose 6-to-33 times greater than that experienced by white patients. Many have concluded that this is why black patients experience lower rates of melanoma than white patients.

Black patients, however, present at a later stage and have a higher melanoma-specific mortality, both of which have been linked to time of diagnosis and the ability to seek care at the onset of localized disease. Thus, there still exists a barrier to the detection and treatment of melanoma in black patients.

Photos courtesy Dr. Gary Peck/Dr. Cherie Young

In the July issue of Archives of Dermatology (2012;148:797-801), an article highlighted the anatomic distribution of malignant melanoma in the non-Hispanic black patient in an effort to explore how distribution of melanoma relates to UV exposure.

Data from 46 population-based cancer registries were analyzed. The most frequent site of melanoma in non-Hispanic black patients – both male and female, between the years 1998 and 2007 – was found to be the lower limbs and hip (58.9%). Of those, 27% were of the acral lentiginous type, which is not associated with exposure to UV rays.

The second most common location was the trunk (16.5%), which affected patients at a younger age; 46% of females and 31% of males were less than 44 years of age. The median age was 56 years for males and 48 years for females at presentation.

This study reiterates the burden of melanoma in the black community. It also highlights gaps in the detection of melanoma, which may be because of site of diagnosis – such as those of the acral lentiginous types – and unclear risk factors, the general underestimation of risk, and access to care.

- Lily Talakoub, M.D.

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

Melanoma accounts for 75% of all skin cancer deaths. Ultraviolet exposure is still targeted as the major etiologic factor, but for black patients, skin erythema has been estimated to occur at a UV radiation dose 6-to-33 times greater than that experienced by white patients. Many have concluded that this is why black patients experience lower rates of melanoma than white patients.

Black patients, however, present at a later stage and have a higher melanoma-specific mortality, both of which have been linked to time of diagnosis and the ability to seek care at the onset of localized disease. Thus, there still exists a barrier to the detection and treatment of melanoma in black patients.

Photos courtesy Dr. Gary Peck/Dr. Cherie Young

In the July issue of Archives of Dermatology (2012;148:797-801), an article highlighted the anatomic distribution of malignant melanoma in the non-Hispanic black patient in an effort to explore how distribution of melanoma relates to UV exposure.

Data from 46 population-based cancer registries were analyzed. The most frequent site of melanoma in non-Hispanic black patients – both male and female, between the years 1998 and 2007 – was found to be the lower limbs and hip (58.9%). Of those, 27% were of the acral lentiginous type, which is not associated with exposure to UV rays.

The second most common location was the trunk (16.5%), which affected patients at a younger age; 46% of females and 31% of males were less than 44 years of age. The median age was 56 years for males and 48 years for females at presentation.

This study reiterates the burden of melanoma in the black community. It also highlights gaps in the detection of melanoma, which may be because of site of diagnosis – such as those of the acral lentiginous types – and unclear risk factors, the general underestimation of risk, and access to care.

- Lily Talakoub, M.D.

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

Melanoma accounts for 75% of all skin cancer deaths. Ultraviolet exposure is still targeted as the major etiologic factor, but for black patients, skin erythema has been estimated to occur at a UV radiation dose 6-to-33 times greater than that experienced by white patients. Many have concluded that this is why black patients experience lower rates of melanoma than white patients.

Black patients, however, present at a later stage and have a higher melanoma-specific mortality, both of which have been linked to time of diagnosis and the ability to seek care at the onset of localized disease. Thus, there still exists a barrier to the detection and treatment of melanoma in black patients.

Photos courtesy Dr. Gary Peck/Dr. Cherie Young

In the July issue of Archives of Dermatology (2012;148:797-801), an article highlighted the anatomic distribution of malignant melanoma in the non-Hispanic black patient in an effort to explore how distribution of melanoma relates to UV exposure.

Data from 46 population-based cancer registries were analyzed. The most frequent site of melanoma in non-Hispanic black patients – both male and female, between the years 1998 and 2007 – was found to be the lower limbs and hip (58.9%). Of those, 27% were of the acral lentiginous type, which is not associated with exposure to UV rays.

The second most common location was the trunk (16.5%), which affected patients at a younger age; 46% of females and 31% of males were less than 44 years of age. The median age was 56 years for males and 48 years for females at presentation.

This study reiterates the burden of melanoma in the black community. It also highlights gaps in the detection of melanoma, which may be because of site of diagnosis – such as those of the acral lentiginous types – and unclear risk factors, the general underestimation of risk, and access to care.

- Lily Talakoub, M.D.

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

Dr. Rossi discusses melanoma in the skin of color population including the incidence and presentation of melanoma as well as factors contributing to delayed diagnosis in these patients. He also gives recommendations to physicians to help educate their patients. For more information, read Dr. Rossi's article in the May 2012 issue, "Melanoma in Skin of Color." 

Dr. Rossi discusses melanoma in the skin of color population including the incidence and presentation of melanoma as well as factors contributing to delayed diagnosis in these patients. He also gives recommendations to physicians to help educate their patients. For more information, read Dr. Rossi's article in the May 2012 issue, "Melanoma in Skin of Color." 

Dr. Rossi discusses melanoma in the skin of color population including the incidence and presentation of melanoma as well as factors contributing to delayed diagnosis in these patients. He also gives recommendations to physicians to help educate their patients. For more information, read Dr. Rossi's article in the May 2012 issue, "Melanoma in Skin of Color." 

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.