Treating pediatric skin of color

Miami - Common dermatoses may require different treatments in pediatric patients with skin of color.

Andrea Trowers, M.D., a voluntary faculty member at the University of Miami and a board-certified pediatric dermatologist, practices in Miami, and her patients come from a number of different backgrounds. She shared her experiences on diagnosing and treating ethnic children's dermatoses at the Masters of Pediatrics Conference here in January.

Taking the flare out

Treating hyperpigmentation can sometimes prove to be tricky. Dr. Trowers employs hydroquinone, which has a mechanism of action that inhibits tyrosinase. Formulations include Ambi 2 percent (OTC), Solaquin Forte 4 percent (ICN Pharmaceuticals;the gel being the more effective vehicle) and TriLuma (Galderma) 4 percent. An effective compounded hydroquinone formula is hydroquinone 6 percent to 10 percent, ascorbic acid, retinoic acid 0.025 percent to 0.1 percent, propylene glycol, with dexamethasone or hydrocortisone.

According to Dr. Trowers, there is an increased efficacy of hydroquinone in higher concentrations in skin of color, especially when it is combined with chemical peels and/or tretinoin.

In patients who applied hydroquinone and sunscreens, one study noted a 63 percent improvement in skin hyperpigmentation.

Treating vitiligo

Another common fallacy is that vitiligo does not have to be treated.

"Quite the contrary," Dr. Trowers says. "Vitiligo imparts a huge psychosocial burden for children, and it is even worse for patients with skin of color. As for treatment, the key is not to be afraid. Years of research have given us an arsenal of local therapies that if employed properly, have minimal risks for side effects," she says.

For the body, Dr. Trowers suggests a mid-potency topical steroid twice a day Monday through Friday, and a class 1 topical steroid twice a day on Saturday and Sunday. For the face, low-potency topical steroids can be used twice a day Monday through Friday, and in extremely compliant families a mid-potency topical steroid can be used twice a day on Saturday and Sunday.

A number of published studies have reported the safety and minimal risk of systemic absorption when using small amounts of high-potency topical steroids in young children. The vehicle chosen for these medications should be dependent on patient preference.

Dr. Trowers recommends limiting application of high-potency steroids to 5 percent of the body surface area at a time, due to pediatric patients' high ratio of body surface area (BSA) to body weight. She also stresses the importance of calming parents' fears, which are often stoked by the media, of using topical steroids on children. It's important at the same time to inform them of the possible side effects associated with improper use.

Other therapeutic options that have proven effective include topical retinoids, Dovonex (Leo Pharma), Protopic (Astellas) and Elidel (Novartis) as well as color creams for camouflage and phototherapy (narrow band UVB and PUVA systemic and topical).

Tactics for tinia

Dr. Trowers says that tinea capitis is a condition more commonly found in black patients compared to other ethnicities. This may be due to the fact that, as reported in one study, low socioeconomic status results in close proximity and the easier spread of fomites.

Standard therapy for tinea capitis is griseofulvin 20 mg/kg to 25 mg/kg for six to eight weeks and ketoconazole shampoo three times a week.