Pigmentation Disorders

Scarring alopecia is a common and devastating disease in skin of color patients. Although many controversial studies have looked at the effects of styling techniques and chemical treatments on hair loss, no direct relationships have been found.

A recent study published in the Journal of Cosmetic Dermatology found that there was an increased baseline level of the profibrotic cytokine IL-1 alpha and the IL-1 receptor antagonist in the scalp sebum of afro-textured hair. The study also highlighted the increased susceptibility to scarring alopecia in black patients.

Courtesy of CDC/Susan Lindsley

Interestingly, the levels of the profibrotic cytokines increased with chemical treatments and decreased with shampooing, which is also a feature unique to black patients.

When evaluating patients with scarring alopecia, I often inquire about shampooing frequency and chemical treatments. The frequency, type of treatment, chemical used, color used, and relaxing techniques are factors I document in order to evaluate hair loss for every patient.

This study sheds light on the increased risk of scarring alopecia in black patients; and it should alert dermatologists to elucidate hair practices in all patients with hair loss.

- Lily Talakoub, M.D.

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

Scarring alopecia is a common and devastating disease in skin of color patients. Although many controversial studies have looked at the effects of styling techniques and chemical treatments on hair loss, no direct relationships have been found.

A recent study published in the Journal of Cosmetic Dermatology found that there was an increased baseline level of the profibrotic cytokine IL-1 alpha and the IL-1 receptor antagonist in the scalp sebum of afro-textured hair. The study also highlighted the increased susceptibility to scarring alopecia in black patients.

Courtesy of CDC/Susan Lindsley

Interestingly, the levels of the profibrotic cytokines increased with chemical treatments and decreased with shampooing, which is also a feature unique to black patients.

When evaluating patients with scarring alopecia, I often inquire about shampooing frequency and chemical treatments. The frequency, type of treatment, chemical used, color used, and relaxing techniques are factors I document in order to evaluate hair loss for every patient.

This study sheds light on the increased risk of scarring alopecia in black patients; and it should alert dermatologists to elucidate hair practices in all patients with hair loss.

- Lily Talakoub, M.D.

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

Scarring alopecia is a common and devastating disease in skin of color patients. Although many controversial studies have looked at the effects of styling techniques and chemical treatments on hair loss, no direct relationships have been found.

A recent study published in the Journal of Cosmetic Dermatology found that there was an increased baseline level of the profibrotic cytokine IL-1 alpha and the IL-1 receptor antagonist in the scalp sebum of afro-textured hair. The study also highlighted the increased susceptibility to scarring alopecia in black patients.

Courtesy of CDC/Susan Lindsley

Interestingly, the levels of the profibrotic cytokines increased with chemical treatments and decreased with shampooing, which is also a feature unique to black patients.

When evaluating patients with scarring alopecia, I often inquire about shampooing frequency and chemical treatments. The frequency, type of treatment, chemical used, color used, and relaxing techniques are factors I document in order to evaluate hair loss for every patient.

This study sheds light on the increased risk of scarring alopecia in black patients; and it should alert dermatologists to elucidate hair practices in all patients with hair loss.

- Lily Talakoub, M.D.

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

MIAMI – Some hallmark signs of dermatologic problems in children – especially erythema and hyperpigmentation – often are less obvious in children with skin of color and can require more clinical detective work to diagnose.

Dr. Patricia A. Treadwell narrowed down the most likely dermatoses a pediatrician will encounter in this patient population at a pediatric update sponsored by Miami Children’s Hospital. Atopic and contact dermatitis, phytophotodermatitis, transient neonatal pustular melanosis, and neonatal lupus erythematosus are among the noteworthy clinical challenges, she said at the meeting.

"Children with increased pigmentation in their skin may end up testing your knowledge in terms of looking at their dermatitis and being able to diagnose that. Keep in mind it may be a little bit different in terms of the clinical presentation, but it’s important to identify it and start the proper treatment," said Dr. Treadwell, a pediatric dermatologist at Indiana University Health and Riley Hospital for Children in Indianapolis.

Overcoming this "masking" of a condition by skin pigmentation can be important, Dr. Treadwell said. She cited a patient born with a port-wine stain that went undiagnosed. The infant had subtle erythema and some asymmetry related to the overgrowth of the lesion. "This was not diagnosed based on the fact that the erythema was not apparent. The patient later developed a pyogenic granuloma, which is a complication that can be seen in patients with port-wine stains as they get older."

Photos courtesy Dr. Patricia A. Treadwell

Erythema can be missed in children of color with atopic dermatitis as well. For this reason, atopic dermatitis may be underdiagnosed in this population overall, she said. Another challenge is the common practice of grading the severity of atopic dermatitis in lighter-skinned patients based on the degree of erythema. "In children with a fair amount of pigmentation in their skin, the erythema may not be noted and the severity will not be recognized."

Similarly, you might need a higher index of clinical suspicion to diagnose a child of color with contact dermatitis. Again, the erythema can be subtle. In contrast, "contact dermatitis can be very clear in a Caucasian patient. But the lesions are the same – linear, asymmetrical, and occurring on exposed areas," Dr. Treadwell said. Pruritus is common, and edema and swelling also occur. Watch for development of vesiculobullous lesions.

Phytophotodermatitis is another dermatologic condition that may require some additional detective work in children of color. Dr. Treadwell described a girl with a unique hyperpigmentation pattern on her legs and arms. She was referred following a vacation in Cancun, Mexico, with her family, and there was a concern about an autoimmune process. "They asked if she needed blood work. I said no, she was eating a mango and went out in the sun." Some of the mango juice splashed on her legs and arms.

Phytophotodermatitis occurs when furocoumarins from tropical fruit, citrus, celery, fennel, or parsnip come into contact with skin subsequently exposed to the sun.

"This condition can have a fairly bizarre pattern of presentation," Dr. Treadwell said. "Again, if there is more pigment in the skin, hyperpigmentation can present in a less common way than might be expected."

Some dermatoses are noted more commonly in children of color, she said. For example, the hyperpigmented macules or pustules that characterize transient neonatal pustular melanosis are reported in 4.4% of African American infants and 0.2% of Caucasian infants. "The percentages here may be related to the pigmentation in the skin. This does occur in Caucasian infants, but it may not be as noticeable."

The condition can be present at birth. The macules and pustules can appear anywhere on the body, but most often on the chin, neck, upper chest, and/or lower back. The good news is they fade over time and are benign, so no treatment is necessary. The differential diagnosis from such conditions as herpes simplex and erythema toxicum is important, however, said Dr. Treadwell. One tip is to check for lesions on the palms and soles, which can be diagnostic in transient neonatal pustular melanosis, but not for erythema toxicum. A biopsy can confirm your clinical suspicions.

The cutaneous manifestations of neonatal lupus erythematosus can tip you off to this condition, she said. Skin lesions can be annular, discoid, or atrophic. Some children present with "raccoon eyes." Because this condition is related to maternal antibodies passed through the placenta during gestation, lesions generally clear by 6 months to 1 year of age.

The mother may have a diagnosis of an autoimmune disease, or she may be completely asymptomatic. In one instance, a mother brought her newborn to Dr. Treadwell’s clinic. He had annular lesions on his forehead with some erythema. The lesions were more edematous around the edges. He actually got some sun exposure between his first and second visits, and developed more-discoid lesions in his sun-exposed areas. He also presented with lesions in non–sun exposed areas.

"The mother had a positive ANA [antinuclear antibody] test. I told her she should go to her doctor for urine and blood pressure monitoring," Dr. Treadwell said. "She had no symptoms and thought I didn’t know what I was talking about." Two years later, the woman returned with a newborn daughter who also had neonatal lupus with lesions on her face and some patchy alopecia on her scalp.

"The brother came back in, ... and he had telangiectasias already present at age 2 years."

Your evaluation can be more family centered. Consider testing the parent and affected children for anti-Rho, anti-La, and anti-RNP.

"I usually treat them with sun avoidance, sun protection, and possibly hydrocortisone," Dr. Treadwell said. She also recommends one electrocardiogram to rule out any cardiac consequences.

Dr. Treadwell reported that she had no relevant financial disclosures.

MIAMI – Some hallmark signs of dermatologic problems in children – especially erythema and hyperpigmentation – often are less obvious in children with skin of color and can require more clinical detective work to diagnose.

Dr. Patricia A. Treadwell narrowed down the most likely dermatoses a pediatrician will encounter in this patient population at a pediatric update sponsored by Miami Children’s Hospital. Atopic and contact dermatitis, phytophotodermatitis, transient neonatal pustular melanosis, and neonatal lupus erythematosus are among the noteworthy clinical challenges, she said at the meeting.

"Children with increased pigmentation in their skin may end up testing your knowledge in terms of looking at their dermatitis and being able to diagnose that. Keep in mind it may be a little bit different in terms of the clinical presentation, but it’s important to identify it and start the proper treatment," said Dr. Treadwell, a pediatric dermatologist at Indiana University Health and Riley Hospital for Children in Indianapolis.

Overcoming this "masking" of a condition by skin pigmentation can be important, Dr. Treadwell said. She cited a patient born with a port-wine stain that went undiagnosed. The infant had subtle erythema and some asymmetry related to the overgrowth of the lesion. "This was not diagnosed based on the fact that the erythema was not apparent. The patient later developed a pyogenic granuloma, which is a complication that can be seen in patients with port-wine stains as they get older."

Photos courtesy Dr. Patricia A. Treadwell

Erythema can be missed in children of color with atopic dermatitis as well. For this reason, atopic dermatitis may be underdiagnosed in this population overall, she said. Another challenge is the common practice of grading the severity of atopic dermatitis in lighter-skinned patients based on the degree of erythema. "In children with a fair amount of pigmentation in their skin, the erythema may not be noted and the severity will not be recognized."

Similarly, you might need a higher index of clinical suspicion to diagnose a child of color with contact dermatitis. Again, the erythema can be subtle. In contrast, "contact dermatitis can be very clear in a Caucasian patient. But the lesions are the same – linear, asymmetrical, and occurring on exposed areas," Dr. Treadwell said. Pruritus is common, and edema and swelling also occur. Watch for development of vesiculobullous lesions.

Phytophotodermatitis is another dermatologic condition that may require some additional detective work in children of color. Dr. Treadwell described a girl with a unique hyperpigmentation pattern on her legs and arms. She was referred following a vacation in Cancun, Mexico, with her family, and there was a concern about an autoimmune process. "They asked if she needed blood work. I said no, she was eating a mango and went out in the sun." Some of the mango juice splashed on her legs and arms.

Phytophotodermatitis occurs when furocoumarins from tropical fruit, citrus, celery, fennel, or parsnip come into contact with skin subsequently exposed to the sun.

"This condition can have a fairly bizarre pattern of presentation," Dr. Treadwell said. "Again, if there is more pigment in the skin, hyperpigmentation can present in a less common way than might be expected."

Some dermatoses are noted more commonly in children of color, she said. For example, the hyperpigmented macules or pustules that characterize transient neonatal pustular melanosis are reported in 4.4% of African American infants and 0.2% of Caucasian infants. "The percentages here may be related to the pigmentation in the skin. This does occur in Caucasian infants, but it may not be as noticeable."

The condition can be present at birth. The macules and pustules can appear anywhere on the body, but most often on the chin, neck, upper chest, and/or lower back. The good news is they fade over time and are benign, so no treatment is necessary. The differential diagnosis from such conditions as herpes simplex and erythema toxicum is important, however, said Dr. Treadwell. One tip is to check for lesions on the palms and soles, which can be diagnostic in transient neonatal pustular melanosis, but not for erythema toxicum. A biopsy can confirm your clinical suspicions.

The cutaneous manifestations of neonatal lupus erythematosus can tip you off to this condition, she said. Skin lesions can be annular, discoid, or atrophic. Some children present with "raccoon eyes." Because this condition is related to maternal antibodies passed through the placenta during gestation, lesions generally clear by 6 months to 1 year of age.

The mother may have a diagnosis of an autoimmune disease, or she may be completely asymptomatic. In one instance, a mother brought her newborn to Dr. Treadwell’s clinic. He had annular lesions on his forehead with some erythema. The lesions were more edematous around the edges. He actually got some sun exposure between his first and second visits, and developed more-discoid lesions in his sun-exposed areas. He also presented with lesions in non–sun exposed areas.

"The mother had a positive ANA [antinuclear antibody] test. I told her she should go to her doctor for urine and blood pressure monitoring," Dr. Treadwell said. "She had no symptoms and thought I didn’t know what I was talking about." Two years later, the woman returned with a newborn daughter who also had neonatal lupus with lesions on her face and some patchy alopecia on her scalp.

"The brother came back in, ... and he had telangiectasias already present at age 2 years."

Your evaluation can be more family centered. Consider testing the parent and affected children for anti-Rho, anti-La, and anti-RNP.

"I usually treat them with sun avoidance, sun protection, and possibly hydrocortisone," Dr. Treadwell said. She also recommends one electrocardiogram to rule out any cardiac consequences.

Dr. Treadwell reported that she had no relevant financial disclosures.

MIAMI – Some hallmark signs of dermatologic problems in children – especially erythema and hyperpigmentation – often are less obvious in children with skin of color and can require more clinical detective work to diagnose.

Dr. Patricia A. Treadwell narrowed down the most likely dermatoses a pediatrician will encounter in this patient population at a pediatric update sponsored by Miami Children’s Hospital. Atopic and contact dermatitis, phytophotodermatitis, transient neonatal pustular melanosis, and neonatal lupus erythematosus are among the noteworthy clinical challenges, she said at the meeting.

"Children with increased pigmentation in their skin may end up testing your knowledge in terms of looking at their dermatitis and being able to diagnose that. Keep in mind it may be a little bit different in terms of the clinical presentation, but it’s important to identify it and start the proper treatment," said Dr. Treadwell, a pediatric dermatologist at Indiana University Health and Riley Hospital for Children in Indianapolis.

Overcoming this "masking" of a condition by skin pigmentation can be important, Dr. Treadwell said. She cited a patient born with a port-wine stain that went undiagnosed. The infant had subtle erythema and some asymmetry related to the overgrowth of the lesion. "This was not diagnosed based on the fact that the erythema was not apparent. The patient later developed a pyogenic granuloma, which is a complication that can be seen in patients with port-wine stains as they get older."

Photos courtesy Dr. Patricia A. Treadwell

Erythema can be missed in children of color with atopic dermatitis as well. For this reason, atopic dermatitis may be underdiagnosed in this population overall, she said. Another challenge is the common practice of grading the severity of atopic dermatitis in lighter-skinned patients based on the degree of erythema. "In children with a fair amount of pigmentation in their skin, the erythema may not be noted and the severity will not be recognized."

Similarly, you might need a higher index of clinical suspicion to diagnose a child of color with contact dermatitis. Again, the erythema can be subtle. In contrast, "contact dermatitis can be very clear in a Caucasian patient. But the lesions are the same – linear, asymmetrical, and occurring on exposed areas," Dr. Treadwell said. Pruritus is common, and edema and swelling also occur. Watch for development of vesiculobullous lesions.

Phytophotodermatitis is another dermatologic condition that may require some additional detective work in children of color. Dr. Treadwell described a girl with a unique hyperpigmentation pattern on her legs and arms. She was referred following a vacation in Cancun, Mexico, with her family, and there was a concern about an autoimmune process. "They asked if she needed blood work. I said no, she was eating a mango and went out in the sun." Some of the mango juice splashed on her legs and arms.

Phytophotodermatitis occurs when furocoumarins from tropical fruit, citrus, celery, fennel, or parsnip come into contact with skin subsequently exposed to the sun.

"This condition can have a fairly bizarre pattern of presentation," Dr. Treadwell said. "Again, if there is more pigment in the skin, hyperpigmentation can present in a less common way than might be expected."

Some dermatoses are noted more commonly in children of color, she said. For example, the hyperpigmented macules or pustules that characterize transient neonatal pustular melanosis are reported in 4.4% of African American infants and 0.2% of Caucasian infants. "The percentages here may be related to the pigmentation in the skin. This does occur in Caucasian infants, but it may not be as noticeable."

The condition can be present at birth. The macules and pustules can appear anywhere on the body, but most often on the chin, neck, upper chest, and/or lower back. The good news is they fade over time and are benign, so no treatment is necessary. The differential diagnosis from such conditions as herpes simplex and erythema toxicum is important, however, said Dr. Treadwell. One tip is to check for lesions on the palms and soles, which can be diagnostic in transient neonatal pustular melanosis, but not for erythema toxicum. A biopsy can confirm your clinical suspicions.

The cutaneous manifestations of neonatal lupus erythematosus can tip you off to this condition, she said. Skin lesions can be annular, discoid, or atrophic. Some children present with "raccoon eyes." Because this condition is related to maternal antibodies passed through the placenta during gestation, lesions generally clear by 6 months to 1 year of age.

The mother may have a diagnosis of an autoimmune disease, or she may be completely asymptomatic. In one instance, a mother brought her newborn to Dr. Treadwell’s clinic. He had annular lesions on his forehead with some erythema. The lesions were more edematous around the edges. He actually got some sun exposure between his first and second visits, and developed more-discoid lesions in his sun-exposed areas. He also presented with lesions in non–sun exposed areas.

"The mother had a positive ANA [antinuclear antibody] test. I told her she should go to her doctor for urine and blood pressure monitoring," Dr. Treadwell said. "She had no symptoms and thought I didn’t know what I was talking about." Two years later, the woman returned with a newborn daughter who also had neonatal lupus with lesions on her face and some patchy alopecia on her scalp.

"The brother came back in, ... and he had telangiectasias already present at age 2 years."

Your evaluation can be more family centered. Consider testing the parent and affected children for anti-Rho, anti-La, and anti-RNP.

"I usually treat them with sun avoidance, sun protection, and possibly hydrocortisone," Dr. Treadwell said. She also recommends one electrocardiogram to rule out any cardiac consequences.

Dr. Treadwell reported that she had no relevant financial disclosures.

Melasma can be a distressing condition for our darker skinned patients. When educating them about sun protection, remind them that:

1. SPF only refers to protection against UVB radiation; it has no implication on the amount of protection against UVA. UVA is highly implicated in the progression of melasma. UVA even penetrates window glass so, if your patients drive, sit near a window, and/or are "never in the sun," remind them that they still need UVA and UVB protection every day.

2. Sunscreen needs to be applied 365 days a year. Ultraviolet light is present on cloudy, snowy, and rainy days.

Photo credit: @2007 Elsevier Inc.

3. "Broad spectrum" does not mean complete coverage. The two sunscreens that offer complete coverage against both UVA and UVB are Anthelios with Mexoryl and Neutrogena with Helioplex technology.

4. Heat can worsen melasma. If your patients work around heat, such as cooking by a hot stove or being around hot air, the heat can contribute to their melasma.

5. Computer monitors emit a small amount of UV. Suggest that melasma patients purchase a UV shield for their screens.

6. UV bracelets or beads help monitor the amount of UV in a given area. With the help of the devices, patients can monitor the amount of UV at home, at work, and in their car. Consider demonstrating the technology to your patients in the office to teach them about UV exposures in their daily environments.

7. Purchasing sunscreens with high SPF and broad spectrum coverage can be difficult. Most sunscreens leave a white or ashy residue on darker skin. Sunscreens with micronized titanium dioxide or zinc oxide can minimize the white residue and are more cosmetically appealing. Similarly, newer foundations and makeup products on the market have been developed that contain high SPF sunscreens in a tinted base. Some of my favorites include Laura Mercier tinted moisturizer and Revision Intellishade. Both have a small amount of tint to counteract the white appearance on darker skin.

8. Practice aggressive sun avoidance and protection before medical management. I don’t treat any patient with melasma unless they are vigilant about sun protection.  The lasers, bleaching creams, medications (such as retinoids), and peels we use to treat melasma can make the skin more susceptible to UV radiation which can make melasma worse.

- Lily Talakoub, M.D.

Melasma can be a distressing condition for our darker skinned patients. When educating them about sun protection, remind them that:

1. SPF only refers to protection against UVB radiation; it has no implication on the amount of protection against UVA. UVA is highly implicated in the progression of melasma. UVA even penetrates window glass so, if your patients drive, sit near a window, and/or are "never in the sun," remind them that they still need UVA and UVB protection every day.

2. Sunscreen needs to be applied 365 days a year. Ultraviolet light is present on cloudy, snowy, and rainy days.

Photo credit: @2007 Elsevier Inc.

3. "Broad spectrum" does not mean complete coverage. The two sunscreens that offer complete coverage against both UVA and UVB are Anthelios with Mexoryl and Neutrogena with Helioplex technology.

4. Heat can worsen melasma. If your patients work around heat, such as cooking by a hot stove or being around hot air, the heat can contribute to their melasma.

5. Computer monitors emit a small amount of UV. Suggest that melasma patients purchase a UV shield for their screens.

6. UV bracelets or beads help monitor the amount of UV in a given area. With the help of the devices, patients can monitor the amount of UV at home, at work, and in their car. Consider demonstrating the technology to your patients in the office to teach them about UV exposures in their daily environments.

7. Purchasing sunscreens with high SPF and broad spectrum coverage can be difficult. Most sunscreens leave a white or ashy residue on darker skin. Sunscreens with micronized titanium dioxide or zinc oxide can minimize the white residue and are more cosmetically appealing. Similarly, newer foundations and makeup products on the market have been developed that contain high SPF sunscreens in a tinted base. Some of my favorites include Laura Mercier tinted moisturizer and Revision Intellishade. Both have a small amount of tint to counteract the white appearance on darker skin.

8. Practice aggressive sun avoidance and protection before medical management. I don’t treat any patient with melasma unless they are vigilant about sun protection.  The lasers, bleaching creams, medications (such as retinoids), and peels we use to treat melasma can make the skin more susceptible to UV radiation which can make melasma worse.

- Lily Talakoub, M.D.

Melasma can be a distressing condition for our darker skinned patients. When educating them about sun protection, remind them that:

1. SPF only refers to protection against UVB radiation; it has no implication on the amount of protection against UVA. UVA is highly implicated in the progression of melasma. UVA even penetrates window glass so, if your patients drive, sit near a window, and/or are "never in the sun," remind them that they still need UVA and UVB protection every day.

2. Sunscreen needs to be applied 365 days a year. Ultraviolet light is present on cloudy, snowy, and rainy days.

Photo credit: @2007 Elsevier Inc.

3. "Broad spectrum" does not mean complete coverage. The two sunscreens that offer complete coverage against both UVA and UVB are Anthelios with Mexoryl and Neutrogena with Helioplex technology.

4. Heat can worsen melasma. If your patients work around heat, such as cooking by a hot stove or being around hot air, the heat can contribute to their melasma.

5. Computer monitors emit a small amount of UV. Suggest that melasma patients purchase a UV shield for their screens.

6. UV bracelets or beads help monitor the amount of UV in a given area. With the help of the devices, patients can monitor the amount of UV at home, at work, and in their car. Consider demonstrating the technology to your patients in the office to teach them about UV exposures in their daily environments.

7. Purchasing sunscreens with high SPF and broad spectrum coverage can be difficult. Most sunscreens leave a white or ashy residue on darker skin. Sunscreens with micronized titanium dioxide or zinc oxide can minimize the white residue and are more cosmetically appealing. Similarly, newer foundations and makeup products on the market have been developed that contain high SPF sunscreens in a tinted base. Some of my favorites include Laura Mercier tinted moisturizer and Revision Intellishade. Both have a small amount of tint to counteract the white appearance on darker skin.

8. Practice aggressive sun avoidance and protection before medical management. I don’t treat any patient with melasma unless they are vigilant about sun protection.  The lasers, bleaching creams, medications (such as retinoids), and peels we use to treat melasma can make the skin more susceptible to UV radiation which can make melasma worse.

- Lily Talakoub, M.D.

Dermatosis papulosa nigra, also known as DPN, are small, soft brown papules that may occur on the face and neck of patients of African, Latin, Indian, or Asian descent. While they may not reach the size of their histologically similar seborrheic keratosis counterparts, the lesions do represent a sign of aging in darker skinned patients. However, the lesions can be safely, easily, and effectively removed.

Electrodesiccation with a hyfrecator or destruction with the KTP (532 nm) laser are my favorite methods for DPN removal. I prefer not to use curettage or cryotherapy because of the risk for dyspigmentation in darker skinned patients. Case reports of success with fractional photothermolyis (1,550 nm) and Nd:YAG lasers (1,064 nm) have been published.

2009/Elsevier

If electrodesiccation is performed, the application of topical anesthetic prior to the procedure helps make the patient more comfortable. For larger lesions, injection of 1% lidocaine with 1:100,000 epinephrine may be used.

Also, with electrodesiccation, conservative settings (0.6-2.0 W on the low setting) should be used; the lesions are desiccated using a blunt tip for a few seconds until they turn grayish.

Care is taken not to touch the surrounding skin. A sharp tip may be used with very small (less than 1 mm) lesions for more accurate precision. I wipe the tip from time to time with gauze to avoid char accumulation.

Larger or pedunculated lesions may be treated with electrodesiccation or snipped off with gradle scissors.

With the KTP laser, topical anesthesia is usually not required. I use a smaller spot size than the lesion itself to avoid targeting and potentially causing dyspigmentation of the surrounding skin.

A spot size of 1 mm is typically used, with 6-10 ms and 10-15 j/cm2. The laser tip is held approximately 1 cm away from the skin at a 90 degree angle. I start off with the lowest fluence and adjust it higher until the lesions turn grayish and a light popping sound is heard with the laser pulse.

A split-face study published in the American Journal of Dermatologic Surgery in 2009 showed that both electrodesiccation and KTP have comparable efficacy in removal of DPN. Without use of anesthetics, the KTP laser was preferred for patient comfort.

Immediately after treatment, patients can expect the treated lesions to become red and swollen - similar to insect bite reactions - for about an hour. Antibiotic ointment or aquaphor is applied to soothe the skin.

Patients are then told to leave the lesions alone, to avoid picking, and to avoid sun exposure. Patients are also advised to avoid alpha-hydroxy acids and other "anti-aging" products until healed. If the cheeks were treated, make-up (foundation, blush) may be applied in 3 to 4 days. Lesions typically fall off within a week.

If needed, repeat treatment may be performed in 2 to 4 weeks.

If you have any DPN removal tips, please feel free to share!

-Naissan Wesley, M.D.

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

Dermatosis papulosa nigra, also known as DPN, are small, soft brown papules that may occur on the face and neck of patients of African, Latin, Indian, or Asian descent. While they may not reach the size of their histologically similar seborrheic keratosis counterparts, the lesions do represent a sign of aging in darker skinned patients. However, the lesions can be safely, easily, and effectively removed.

Electrodesiccation with a hyfrecator or destruction with the KTP (532 nm) laser are my favorite methods for DPN removal. I prefer not to use curettage or cryotherapy because of the risk for dyspigmentation in darker skinned patients. Case reports of success with fractional photothermolyis (1,550 nm) and Nd:YAG lasers (1,064 nm) have been published.

2009/Elsevier

If electrodesiccation is performed, the application of topical anesthetic prior to the procedure helps make the patient more comfortable. For larger lesions, injection of 1% lidocaine with 1:100,000 epinephrine may be used.

Also, with electrodesiccation, conservative settings (0.6-2.0 W on the low setting) should be used; the lesions are desiccated using a blunt tip for a few seconds until they turn grayish.

Care is taken not to touch the surrounding skin. A sharp tip may be used with very small (less than 1 mm) lesions for more accurate precision. I wipe the tip from time to time with gauze to avoid char accumulation.

Larger or pedunculated lesions may be treated with electrodesiccation or snipped off with gradle scissors.

With the KTP laser, topical anesthesia is usually not required. I use a smaller spot size than the lesion itself to avoid targeting and potentially causing dyspigmentation of the surrounding skin.

A spot size of 1 mm is typically used, with 6-10 ms and 10-15 j/cm2. The laser tip is held approximately 1 cm away from the skin at a 90 degree angle. I start off with the lowest fluence and adjust it higher until the lesions turn grayish and a light popping sound is heard with the laser pulse.

A split-face study published in the American Journal of Dermatologic Surgery in 2009 showed that both electrodesiccation and KTP have comparable efficacy in removal of DPN. Without use of anesthetics, the KTP laser was preferred for patient comfort.

Immediately after treatment, patients can expect the treated lesions to become red and swollen - similar to insect bite reactions - for about an hour. Antibiotic ointment or aquaphor is applied to soothe the skin.

Patients are then told to leave the lesions alone, to avoid picking, and to avoid sun exposure. Patients are also advised to avoid alpha-hydroxy acids and other "anti-aging" products until healed. If the cheeks were treated, make-up (foundation, blush) may be applied in 3 to 4 days. Lesions typically fall off within a week.

If needed, repeat treatment may be performed in 2 to 4 weeks.

If you have any DPN removal tips, please feel free to share!

-Naissan Wesley, M.D.

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

Dermatosis papulosa nigra, also known as DPN, are small, soft brown papules that may occur on the face and neck of patients of African, Latin, Indian, or Asian descent. While they may not reach the size of their histologically similar seborrheic keratosis counterparts, the lesions do represent a sign of aging in darker skinned patients. However, the lesions can be safely, easily, and effectively removed.

Electrodesiccation with a hyfrecator or destruction with the KTP (532 nm) laser are my favorite methods for DPN removal. I prefer not to use curettage or cryotherapy because of the risk for dyspigmentation in darker skinned patients. Case reports of success with fractional photothermolyis (1,550 nm) and Nd:YAG lasers (1,064 nm) have been published.

2009/Elsevier

If electrodesiccation is performed, the application of topical anesthetic prior to the procedure helps make the patient more comfortable. For larger lesions, injection of 1% lidocaine with 1:100,000 epinephrine may be used.

Also, with electrodesiccation, conservative settings (0.6-2.0 W on the low setting) should be used; the lesions are desiccated using a blunt tip for a few seconds until they turn grayish.

Care is taken not to touch the surrounding skin. A sharp tip may be used with very small (less than 1 mm) lesions for more accurate precision. I wipe the tip from time to time with gauze to avoid char accumulation.

Larger or pedunculated lesions may be treated with electrodesiccation or snipped off with gradle scissors.

With the KTP laser, topical anesthesia is usually not required. I use a smaller spot size than the lesion itself to avoid targeting and potentially causing dyspigmentation of the surrounding skin.

A spot size of 1 mm is typically used, with 6-10 ms and 10-15 j/cm2. The laser tip is held approximately 1 cm away from the skin at a 90 degree angle. I start off with the lowest fluence and adjust it higher until the lesions turn grayish and a light popping sound is heard with the laser pulse.

A split-face study published in the American Journal of Dermatologic Surgery in 2009 showed that both electrodesiccation and KTP have comparable efficacy in removal of DPN. Without use of anesthetics, the KTP laser was preferred for patient comfort.

Immediately after treatment, patients can expect the treated lesions to become red and swollen - similar to insect bite reactions - for about an hour. Antibiotic ointment or aquaphor is applied to soothe the skin.

Patients are then told to leave the lesions alone, to avoid picking, and to avoid sun exposure. Patients are also advised to avoid alpha-hydroxy acids and other "anti-aging" products until healed. If the cheeks were treated, make-up (foundation, blush) may be applied in 3 to 4 days. Lesions typically fall off within a week.

If needed, repeat treatment may be performed in 2 to 4 weeks.

If you have any DPN removal tips, please feel free to share!

-Naissan Wesley, M.D.

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

Psychological distress from dyspigmentation in skin of color is highly prevalent. Disorders of pigmentation such as vitiligo have a significant impact on a patient’s quality of life. Similarly, in skin of color patients, melasma, acne scars, and post-inflammatory hypo- and hyperpigmentation are often hard to treat.

Skin camouflage is a great way to help patients overcome the distress of their pigmentary disorders. However, I have found in my practice that patients under use these masking products.

Once they are on board, remind patients that there is a big difference between over-the-counter corrective makeup and skin camouflage products. For instance, skin camouflage products are designed to last 8-16 hours and are significantly water resistant. They are also more durable, blend better with natural skin tone, and last longer than OTC corrective makeup.

The products are applied by blending a fine layer of camouflage cream followed by a setting powder.Standard makeup and sunscreen can then be applied over the camouflage products.

Choosing the right brand can be confusing to patients. Several lines of products can be bought at department stores and through mail order. And each brand varies in texture, durability, coverage, sun protection, and color.

In the U.S. many department stores carry skin camouflage brands. Although these products reside in the "cosmetic" section, they are not referred to as makeup, so as not to create distress for patients who do not normally wear cosmetics.

In my experience Dermablend, Covermark, and Dermacolor work well. However, there are several other brands available to experiment with.

I encourage my patients with dyspigmentation to look into these well-developed camouflage products. Often times I encourage testing of the product on their skin by an experienced company representative.

Understanding the art of skin camouflage can help many of our patients cover their skin imperfections and regain their self-confidence.

-Lily Talakoub, M.D.

Psychological distress from dyspigmentation in skin of color is highly prevalent. Disorders of pigmentation such as vitiligo have a significant impact on a patient’s quality of life. Similarly, in skin of color patients, melasma, acne scars, and post-inflammatory hypo- and hyperpigmentation are often hard to treat.

Skin camouflage is a great way to help patients overcome the distress of their pigmentary disorders. However, I have found in my practice that patients under use these masking products.

Once they are on board, remind patients that there is a big difference between over-the-counter corrective makeup and skin camouflage products. For instance, skin camouflage products are designed to last 8-16 hours and are significantly water resistant. They are also more durable, blend better with natural skin tone, and last longer than OTC corrective makeup.

The products are applied by blending a fine layer of camouflage cream followed by a setting powder.Standard makeup and sunscreen can then be applied over the camouflage products.

Choosing the right brand can be confusing to patients. Several lines of products can be bought at department stores and through mail order. And each brand varies in texture, durability, coverage, sun protection, and color.

In the U.S. many department stores carry skin camouflage brands. Although these products reside in the "cosmetic" section, they are not referred to as makeup, so as not to create distress for patients who do not normally wear cosmetics.

In my experience Dermablend, Covermark, and Dermacolor work well. However, there are several other brands available to experiment with.

I encourage my patients with dyspigmentation to look into these well-developed camouflage products. Often times I encourage testing of the product on their skin by an experienced company representative.

Understanding the art of skin camouflage can help many of our patients cover their skin imperfections and regain their self-confidence.

-Lily Talakoub, M.D.

Psychological distress from dyspigmentation in skin of color is highly prevalent. Disorders of pigmentation such as vitiligo have a significant impact on a patient’s quality of life. Similarly, in skin of color patients, melasma, acne scars, and post-inflammatory hypo- and hyperpigmentation are often hard to treat.

Skin camouflage is a great way to help patients overcome the distress of their pigmentary disorders. However, I have found in my practice that patients under use these masking products.

Once they are on board, remind patients that there is a big difference between over-the-counter corrective makeup and skin camouflage products. For instance, skin camouflage products are designed to last 8-16 hours and are significantly water resistant. They are also more durable, blend better with natural skin tone, and last longer than OTC corrective makeup.

The products are applied by blending a fine layer of camouflage cream followed by a setting powder.Standard makeup and sunscreen can then be applied over the camouflage products.

Choosing the right brand can be confusing to patients. Several lines of products can be bought at department stores and through mail order. And each brand varies in texture, durability, coverage, sun protection, and color.

In the U.S. many department stores carry skin camouflage brands. Although these products reside in the "cosmetic" section, they are not referred to as makeup, so as not to create distress for patients who do not normally wear cosmetics.

In my experience Dermablend, Covermark, and Dermacolor work well. However, there are several other brands available to experiment with.

I encourage my patients with dyspigmentation to look into these well-developed camouflage products. Often times I encourage testing of the product on their skin by an experienced company representative.

Understanding the art of skin camouflage can help many of our patients cover their skin imperfections and regain their self-confidence.

-Lily Talakoub, M.D.

For those of you who have had a busy year and haven't had the chance to regularly read the latest dermatology news on Skin and Allergy News Digital Network, we have you covered. As we ring in the new year, here's a rundown of last year's most-viewed stories:

10. Experts: Medical Dermatology Is Losing Ground, By Bruce Jancin: Experts in medical dermatology predicted the specialty will become narrower and less medically oriented by 2020. As we enter 2012, some experts said they were concerned about the emphasis on aesthetic dermatology and dermatologic surgery. 

Courtesy flickr user woodleywonderworks (Creative Commons)

9. Mohs Surgery in Medicare Patients Skyrocketing, By Sherry Boschert: Several Mohs surgery experts found that the rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009. Dr. Matthew Donaldson and his associates presented the data at the annual meeting of the American College of Mohs Surgery. 

8. Blog: New Isotretinoin Drug May Address Safety Concerns, By Amy Pfeiffer: This much-viewed blog post highlighted an investigational isotretinoin drug that may eliminate safety concerns associated with the drug, like IBD and depression. The gelatin capsules of CIP-iisotretinoin help reduce GI irritation and the drug is less food dependent.

7. Dosing Isotretinoin: Go Big to Avoid Second Course, By Jeffrey Eisenberg: In another isotretinoin study, investigators found that patients receiving a higher cumulative dose of the drug were no less likely to experience an acne relapse than those who received a lower cumulative dose. However, the investigators found that patients treated with a higher dose were less likely to need a second course of treatment. 

6. Knifelike Vulvar Ulcers May Signal Crohn's Disease, By Kate Johnson: Knifelike vulvar ulcers could be a sign of Crohn's disease in women, according to experts at a conference on vulvovaginal diseases. For some patients, ulcers may be the only manifestation of the disorder. 

5. Biologics Up Cardiovascular Risk, New Analysis Finds, By Sherry Boschert: Biologic therapies used to treat psoriasis have been linked to an increase in major cardiovascular events, according to researchers. One patient on placebo developed a major cardiovascular event in a study of etanercept. Five patients on ustekinumab, five on briakinumab, and one on adalimumab also developed major cardiovascular events.

4. Future Technologies Hold Promise for Hair Restoration, By Damian McNamara: At an annual meeting of dermatologic surgeons, Dr. Ricardo Mejia discussed technological advancements in hair restoration. He said the future for hair restoration could include technologies like robotic hair transfer, hair cloning, and technologies to optimize new growth. 

3. AAD: Potential Doxycycline, IBD Link Considered Worrisome, By Bruce Jancin: In more acne news, a retrospective cohort study linked tetracycline-class antibiotics with an increase in inflammatory bowel disease. The highly controversial findings were one of the hottest topics at the annual meeting of the American Academy of Dermatology and on this website.

2. Bimatoprost Repigments Vitiligo Patient Skin, By Bruce Jancin: A topical bimatoprost ophthalmic solution could serve as treatment for focal vitiligo, according to a pilot study presented at the World Congress of Dermatology. Researchers said 7 out of 10 patients exhibited pronounced repigmentation after 2 months of treatment. 

1. Marijuana Allergies "Fairly Common," Expert Says, By M. Alexander Otto: A heads up to physicians: allergy experts said marijuana allergies are more common than most people think. Patients with with a marijuana allergy exhibit symptoms including wheezing, sinusitis, throat swelling, and inhalation issues. 

Best wishes for 2012!

-- Frances Correa (FMCReporting)

For those of you who have had a busy year and haven't had the chance to regularly read the latest dermatology news on Skin and Allergy News Digital Network, we have you covered. As we ring in the new year, here's a rundown of last year's most-viewed stories:

10. Experts: Medical Dermatology Is Losing Ground, By Bruce Jancin: Experts in medical dermatology predicted the specialty will become narrower and less medically oriented by 2020. As we enter 2012, some experts said they were concerned about the emphasis on aesthetic dermatology and dermatologic surgery. 

Courtesy flickr user woodleywonderworks (Creative Commons)

9. Mohs Surgery in Medicare Patients Skyrocketing, By Sherry Boschert: Several Mohs surgery experts found that the rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009. Dr. Matthew Donaldson and his associates presented the data at the annual meeting of the American College of Mohs Surgery. 

8. Blog: New Isotretinoin Drug May Address Safety Concerns, By Amy Pfeiffer: This much-viewed blog post highlighted an investigational isotretinoin drug that may eliminate safety concerns associated with the drug, like IBD and depression. The gelatin capsules of CIP-iisotretinoin help reduce GI irritation and the drug is less food dependent.

7. Dosing Isotretinoin: Go Big to Avoid Second Course, By Jeffrey Eisenberg: In another isotretinoin study, investigators found that patients receiving a higher cumulative dose of the drug were no less likely to experience an acne relapse than those who received a lower cumulative dose. However, the investigators found that patients treated with a higher dose were less likely to need a second course of treatment. 

6. Knifelike Vulvar Ulcers May Signal Crohn's Disease, By Kate Johnson: Knifelike vulvar ulcers could be a sign of Crohn's disease in women, according to experts at a conference on vulvovaginal diseases. For some patients, ulcers may be the only manifestation of the disorder. 

5. Biologics Up Cardiovascular Risk, New Analysis Finds, By Sherry Boschert: Biologic therapies used to treat psoriasis have been linked to an increase in major cardiovascular events, according to researchers. One patient on placebo developed a major cardiovascular event in a study of etanercept. Five patients on ustekinumab, five on briakinumab, and one on adalimumab also developed major cardiovascular events.

4. Future Technologies Hold Promise for Hair Restoration, By Damian McNamara: At an annual meeting of dermatologic surgeons, Dr. Ricardo Mejia discussed technological advancements in hair restoration. He said the future for hair restoration could include technologies like robotic hair transfer, hair cloning, and technologies to optimize new growth. 

3. AAD: Potential Doxycycline, IBD Link Considered Worrisome, By Bruce Jancin: In more acne news, a retrospective cohort study linked tetracycline-class antibiotics with an increase in inflammatory bowel disease. The highly controversial findings were one of the hottest topics at the annual meeting of the American Academy of Dermatology and on this website.

2. Bimatoprost Repigments Vitiligo Patient Skin, By Bruce Jancin: A topical bimatoprost ophthalmic solution could serve as treatment for focal vitiligo, according to a pilot study presented at the World Congress of Dermatology. Researchers said 7 out of 10 patients exhibited pronounced repigmentation after 2 months of treatment. 

1. Marijuana Allergies "Fairly Common," Expert Says, By M. Alexander Otto: A heads up to physicians: allergy experts said marijuana allergies are more common than most people think. Patients with with a marijuana allergy exhibit symptoms including wheezing, sinusitis, throat swelling, and inhalation issues. 

Best wishes for 2012!

-- Frances Correa (FMCReporting)

For those of you who have had a busy year and haven't had the chance to regularly read the latest dermatology news on Skin and Allergy News Digital Network, we have you covered. As we ring in the new year, here's a rundown of last year's most-viewed stories:

10. Experts: Medical Dermatology Is Losing Ground, By Bruce Jancin: Experts in medical dermatology predicted the specialty will become narrower and less medically oriented by 2020. As we enter 2012, some experts said they were concerned about the emphasis on aesthetic dermatology and dermatologic surgery. 

Courtesy flickr user woodleywonderworks (Creative Commons)

9. Mohs Surgery in Medicare Patients Skyrocketing, By Sherry Boschert: Several Mohs surgery experts found that the rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009. Dr. Matthew Donaldson and his associates presented the data at the annual meeting of the American College of Mohs Surgery. 

8. Blog: New Isotretinoin Drug May Address Safety Concerns, By Amy Pfeiffer: This much-viewed blog post highlighted an investigational isotretinoin drug that may eliminate safety concerns associated with the drug, like IBD and depression. The gelatin capsules of CIP-iisotretinoin help reduce GI irritation and the drug is less food dependent.

7. Dosing Isotretinoin: Go Big to Avoid Second Course, By Jeffrey Eisenberg: In another isotretinoin study, investigators found that patients receiving a higher cumulative dose of the drug were no less likely to experience an acne relapse than those who received a lower cumulative dose. However, the investigators found that patients treated with a higher dose were less likely to need a second course of treatment. 

6. Knifelike Vulvar Ulcers May Signal Crohn's Disease, By Kate Johnson: Knifelike vulvar ulcers could be a sign of Crohn's disease in women, according to experts at a conference on vulvovaginal diseases. For some patients, ulcers may be the only manifestation of the disorder. 

5. Biologics Up Cardiovascular Risk, New Analysis Finds, By Sherry Boschert: Biologic therapies used to treat psoriasis have been linked to an increase in major cardiovascular events, according to researchers. One patient on placebo developed a major cardiovascular event in a study of etanercept. Five patients on ustekinumab, five on briakinumab, and one on adalimumab also developed major cardiovascular events.

4. Future Technologies Hold Promise for Hair Restoration, By Damian McNamara: At an annual meeting of dermatologic surgeons, Dr. Ricardo Mejia discussed technological advancements in hair restoration. He said the future for hair restoration could include technologies like robotic hair transfer, hair cloning, and technologies to optimize new growth. 

3. AAD: Potential Doxycycline, IBD Link Considered Worrisome, By Bruce Jancin: In more acne news, a retrospective cohort study linked tetracycline-class antibiotics with an increase in inflammatory bowel disease. The highly controversial findings were one of the hottest topics at the annual meeting of the American Academy of Dermatology and on this website.

2. Bimatoprost Repigments Vitiligo Patient Skin, By Bruce Jancin: A topical bimatoprost ophthalmic solution could serve as treatment for focal vitiligo, according to a pilot study presented at the World Congress of Dermatology. Researchers said 7 out of 10 patients exhibited pronounced repigmentation after 2 months of treatment. 

1. Marijuana Allergies "Fairly Common," Expert Says, By M. Alexander Otto: A heads up to physicians: allergy experts said marijuana allergies are more common than most people think. Patients with with a marijuana allergy exhibit symptoms including wheezing, sinusitis, throat swelling, and inhalation issues. 

Best wishes for 2012!

-- Frances Correa (FMCReporting)

Zain U. Syed, MD, and Iltefat H. Hamzavi, MD

Phototherapy has proven to be one of the most versatile and effective treatment options for a variety of inflammatory and pigmentary skin diseases. However, the use of these treatment modalities in patients of color requires some special considerations. The modality chosen, the dosing of the treatment and duration of treatment are all issues to be considered for patients of color treated with ultraviolet phototherapy. In addition, there are some diseases which are more commonly seen in patients of color. These diseases may have better treatment outcomes using newer phototherapeutic options such as the long pulsed Nd:YAG laser or UVA1. As our population in the United States becomes more diverse it would behoove all dermatologists to acquaint themselves with the special circumstances of treating ethnic patients with phototherapy.

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

Zain U. Syed, MD, and Iltefat H. Hamzavi, MD

Phototherapy has proven to be one of the most versatile and effective treatment options for a variety of inflammatory and pigmentary skin diseases. However, the use of these treatment modalities in patients of color requires some special considerations. The modality chosen, the dosing of the treatment and duration of treatment are all issues to be considered for patients of color treated with ultraviolet phototherapy. In addition, there are some diseases which are more commonly seen in patients of color. These diseases may have better treatment outcomes using newer phototherapeutic options such as the long pulsed Nd:YAG laser or UVA1. As our population in the United States becomes more diverse it would behoove all dermatologists to acquaint themselves with the special circumstances of treating ethnic patients with phototherapy.

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

Zain U. Syed, MD, and Iltefat H. Hamzavi, MD

Phototherapy has proven to be one of the most versatile and effective treatment options for a variety of inflammatory and pigmentary skin diseases. However, the use of these treatment modalities in patients of color requires some special considerations. The modality chosen, the dosing of the treatment and duration of treatment are all issues to be considered for patients of color treated with ultraviolet phototherapy. In addition, there are some diseases which are more commonly seen in patients of color. These diseases may have better treatment outcomes using newer phototherapeutic options such as the long pulsed Nd:YAG laser or UVA1. As our population in the United States becomes more diverse it would behoove all dermatologists to acquaint themselves with the special circumstances of treating ethnic patients with phototherapy.

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