Clinical and therapeutic differences in darker skin

Children with darker skin types have different presentations and concerns than Caucasians when it comes to pigmentation and hair issues, according to Nanette Silverberg, M.D., clinical professor of dermatology and pediatrics, Icahn School of Medicine at Mount Sinai and chief, pediatric dermatology, Mount Sinai Health System, New York.

Hair concerns start early

Children of color have a spectrum of hair issues, starting with seborrheic dermatitis, which generally doesn’t have a standard cradle top appearance in darker skin children, according to Dr. Silverberg, who presented on the topic at The Skin of Color Seminar Series, held earlier this year in New York City.

“[In infants with darker skin types] we’ll often see erythema, redness, flaking and hypopigmentation, including hypopigmentation of the folds of the skin, which will sometimes overlie atopic dermatitis. That makes the hypopigmentation look worse,” Dr. Silverberg says.

As skin of color children age, their hair styling can cause problems, according to Dr. Silverberg.

An African American teenage girl with traction alopecia from long-term braiding. Photo: Nanette Silverberg, M.D.“In African American kids we see braiding and pony tails, multiple pony tails or the addition of hair extensions, hair braiding or hair twisting. And many of these processes are used by African American girls and boys. You’ll also see a lot of tight pony tail usage among Latino girls,” Dr. Silverberg says. “Those contribute to traction alopecia, which is a thinning along the marginal parts, from chronic pulling on the curved or straight hair follicle.”

The traction alopecia that results from hair styling practices can be made worse by use of gel pomades or oils to slick hair back. These products ultimately block the hair follicles and may result in folliculitis around the follicle and, eventually, scarring and hair loss.

Dermatologists who notice acne along the forehead should suspect kids are using pomades to pull back their hair, according to Dr. Silverberg.

Other hair issues common in children and teens of color include hair breakage and bubble hair, which comes from over-styling, including hot air styling.

“I’ll also see hair infections on the scalp in kids of color-in particular, tinea capitis,” Dr. Silverberg says. “Tinea capitis is a dermatophyte infection of the scalp and hair structure. It goes down to a certain point in the hair where keratin starts to be produced and that’s called Adamson’s Fringe. When we see an infection, we’re not able to treat it with topical agents. It’s very contagious in the classroom setting and households, particularly when kids are sharing products, like combs or brushes.”

Dr. Silverberg says dermatologists will typically encounter pediatric tinea capitis between three to 11 years of age.

“When you see it clinically, it’ll appear initially almost like a little dandruff-fine flaking and redness. But as it progresses, we’ll see hair loss where the hairs break. Those are called black dot hairs. Or we’ll see something called kerion, which is an inflammatory form of tinea capitis,” Dr. Silverberg says.

Dermatologists should intervene right away to avoid scarring and hair loss. Often, the first step is to use antifungal shampoos to make the children less contagious. Dermatologists should counsel parents and children to avoid sharing hats, combs, brushes and pillow cases.

“Then, we put them on an oral antifungal, to address the fungus from inside out because the topical medications only reach the hair follicle,” Dr. Silverberg says. “It’s very important that when we see hair loss accompanied by flaking and glands in the neck, it is more than 80 percent likely that the child has tinea capitis. And we start treatment even before we get the cultures back, which can take five to six weeks.”

Long-term prevention means avoidance of certain hair care products. Dr. Silverberg recommends products that are silicone or water-based, rather than oil-based or mineral-oil based, which are more likely to damage hair and block pores.

The next step, according to Dr. Silverberg, is to consider initiating acne treatments to help keep the pores open. 

Pigmentation issues

Pigmentation issues that arise in children of color can also be seen in adults.

“The most vexing, of course, being vitiligo,” Dr. Silverberg says.

Vitiligo is an autoimmune condition in which the body forms an immune reaction to the pigment cells in the body and this can progress over time. It appears in standard areas, especially around the eyes, around the mouth, lips and chest, around the fingertips, around the toes and in joint spaces, around underarms, crooks of the elbows and wrists.

“And many times, in kids, we see other features, such as trauma or with an aggravating illness. Sometimes, we’ll see loss of pigmentation around moles, which are called halo nevi,” Dr. Silverberg says.

Although it is seen in all populations, there is some data to demonstrate that it affects patients of color in different ways because it’s so noticeably obvious when white spots are on the skin against a darker background, she says.

“In [skin of color] patients, about .5 to 2 percent of the population has vitiligo and about half of those cases begin in childhood,” Dr. Silverberg says.

Dermatologists should ask about family history of vitiligo, because children who have family members with the skin disease are more likely to develop it at a young age.

Although technically vitiligo isn’t dangerous, it is a progressive loss of pigmentation. And if dermatologists don’t treat it early on in skin of color, it can affect how children feel about themselves and their quality of life.

“Younger kids may not be as bothered, but teenagers often become very concerned with their appearance,” she says. “We have a variety of different treatments. We know that patients of color may respond a little bit better than other patients to treatments that include topical calcineurin inhibitors, such as tacrolimus. We also have good data on the use of narrow band UVB and the excimer laser, which is also a UVB narrow band wavelength, in children and adults of color with good results. We have an expectation that if we intervene early, we may be able to help patients achieve good repigmentation.”

Disclosure: Dr. Silverberg reports no relevant disclosures.