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April 2005 BAL HARBOUR, Fla. – After Andrea Trowers, MD, became a dermatologist, she realized that some physicians have made assumptions about treating conditions that affect black patients, and the assumptions are incorrect. She attempted to dispel four myths about treating skin conditions in blacks during the Masters of Pediatrics meeting held here recently. Myth #1: Post inflammatory hyperpigmentation fades with time, therefore, the condition does not need to be treated. Post inflammatory hyperpigmentation is a condition characterized by dark spots that appear after an irritation to the skin. If they do fade with time – it’s a long time, she said, longer than many patients want to wait. “In one study that was done in a predominately black dermatology clinic it was found that pigment disorders were the third most common complaint among 2,000 black patients. This is a sign that a lot of patients or parents are going to be interested in information or treatment about this condition,” said Trowers, who is an assistant professor of dermatology and cutaneous surgery in the department of dermatology at the University of Miami School of Medicine. Several other conditions leave these dark marks on the skin. They include contact dermatitis, acne and bug bites, she said. Acne is a significant cause of this condition among blacks. Comedones in black patients have a significantly higher inflammatory response than white patients. “That’s probably why your white patients will say, ‘yes, I get a red spot after my pimple, and it goes away in a couple of days,’ but black patients who may have very mild acne are still complaining of these dark spots that are lasting for an extensive amount of time,” she said. Hyperpigmentation marks after acne can last four months or longer, according to one study. Many parents and patients mistake these marks for the acne itself. They complain that their acne is bad, but when Trowers examines the patient their acne is actually mild. “What they are complaining about when they complain about their acne is hyperpigmentation, because this is the thing that bothers them the most because it lasts a lot longer than the pimples do,” she explained. Another common cause of post inflammatory hyperpigmentation is bug bites. “Black parents are extremely concerned about this because they can last into the winter or even into the following summer,” she said, showing picture after picture of kids with dark spots on their legs from bug bites. Regardless of the cause for the marks, Trowers suggested treating with hydroquinone. There are over-the-counter treatments, but she said, their 2% concentration is not strong enough to do the job. Instead, compounded prescription strengths at 6% were superior. She also said in her experience, the gel formulations work better than the creams. Chemical peels are also a treatment for hyperpigmentation. Falicylic acid is the safest one in your patients with darker skin. Another study showed a marked improvement in patients who used sunscreen as well as hydroquinone. Hydroquinone rarely can have an idiosyncratic effect and can actually darken the involved skin. “This is extremely rare, while your patients complaints of hyperpigmentation are extremely common. So you should not let fear of this effect limit your use of the medication.” She said that sunscreen could hasten healing of these lesions when used with hydroquinone. “It is key that you also talk about the effects of the sun – they need to use sunscreen,” she said. Often, parents will argue that their kids don’t go to the beach, so they don’t need sunscreen. Trowers suggested that you compare an area of the kid’s body that does not get sun much, like their inner arm, with an area that does, like their outer arm. There will be a color difference, and that difference comes from the sun. Parents don’t realize that kids are exposed to sun in the car, through the windows of their house, etc., so sunscreen is important when treating hyperpigmentation. In addition, she recommends UV protective clothing to parents who have children who have dark spots on their skin. However, they can be expensive. A cheaper alternative is Sun Guard (Rit dye), a laundry additive that has a chemical that binds with the fibers of the clothing and increases the SPF of clothing. Myth #2: Vitiligo does not need to be treated. “Vitiligo has a huge psychosocial burden on children. Their self esteem comes from their outside environment, and I really do think this can have a psychological effect on darker skinned patients,” she said “because they are so apparent.” “I can’t tell you how many patients who come into my clinic who say they have already seen previous physicians who have told them that this condition really doesn’t respond to any type of medication and there really are no treatments options,” she said. Trowers uses topical steroids to treat vitiligo. If parents are concerned about using steroids, you can monitor their cortisol levels and schedule regular ophthalmology visits, she suggested. Choose a vehicle based on patient preference, especially in kids. “A lot of them don’t like greasy things that are going to go on their face. That will be another marker that there is something different about them. Luckily now, there are a lot of good vehicles that you can use such as creams and foams,” she said Other treatment options are topical retinoids, calcipotriene (Dovonex, Bristol-Myers Squibb), tacrolimus (Protopic, Fujisawa Healthcare) and pimecrolimus (Elidel, Novartis Pharmaceuticals). Camouflage creams or cosmetics are other great options. “Black patients are concerned that it will not match their skin tones, but make-ups have advanced,” Trowers said. However, parents should make sure that the make-up professional demonstrating the products was trained by the company that made the cosmetic. Phototherapy is another option, but not all children can use phototherapy. Compliance is important, she said, to avoid severe sunburn. Myth #3: The treatment of tinea capitis is the same for white and black patients. There are studies that show that t. capitis is more prominent in black patients, Trowers said. Standard therapy for t. capitis is griseofulvin 20-25 mg/kg for 6 to 8 weeks and Nizoral shampoo, which contains the antifungal ketoconazole three times a week. This regimen, however, is difficult for black patients, who tend to avoid washing their hair that often because it is more fragile and breaks easily. “Particularly, with your black patients, some of them don’t wash their hair every day, and it is just not necessary. It could be pretty traumatic if you were a black kid to be washing your hair every day. It can be tangled,” Trowers explained. “So, I think, you want to always ask [how often they wash their hair], don’t assume – some blacks have to wash their hair every day. But some black patients are only washing their hair every two weeks. And there is no way to know unless you ask.” Trowers suggested adapting therapy to your patients. “The main reason why you are using that Nizoral shampoo is to decrease the transmission of fungal spores as well. If you use Nizoral shampoo once a week, and you use Nizoral cream applied two times a week to the patient’s scalp, you can have that same decrease in fomites,” she said. “I think that is an option that will be less stressful to everyone involved.” She said to remember that household contacts might also need treatment. Myth #4: Pomade acne exists. There is disagreement among dermatologists about this one, but Trowers does not think that pomades are the reason for a child’s pimples, even if they are just on the forehead. “I see a lot of white patients with comodones on their forehead, and if you ask them, they are not using anything on their scalp. So, I think before jumping to this diagnosis, you want to think about the pathophysiology of acne and whether your patients are really using anything on their scalp that could be causing this condition,” Trowers suggested. “Before you say to your black patients, ‘you’re using these greasy products on your scalp, stop using pomades’ – remember that most kids don’t even know what your talking about because no one uses the word pomade anymore,” she said, so you date yourself with this diagnosis. In addition, many of the products that dermatologists thought caused this problem are no longer on the market. The most important thing to remember when treating black children is to “respect their preferences,” Trowers said. If they like greasy products, prescribe an ointment. If they like mousses, prescribe a foam, etc. Trowers said this simple rule would improve compliance and help the patient heal faster. For more information: |
