Activity Transcript

Andrew Alexis, MD, MPH: Hello, I'm Dr Andrew Alexis, professor at the Icahn School of Medicine at Mount Sinai in New York City. Welcome to this program today, titled Patient Questions and Expert Answers for Healthy Skin of Color. Joining me today for this discussion, it's my pleasure to introduce Dr Susan Taylor, Associate Professor of Dermatology at the Perelman School of Medicine at the University of Pennsylvania, in Philadelphia. And Dr Seemal Desai, who's immediate past president of the Skin of Color Society, and founder and medical director of Innovative Dermatology in Plano, Texas. Welcome, Susan and Seemal.

Susan C. Taylor, MD: Thank you.

Seemal R. Desai, MD: It's nice to be here.

Dr Alexis: In this program, we'll be discussing several common skin issues, dermatologic issues, that are very prevalent in patients with skin of color. Not only are they prevalent, but they have some unique considerations. And while we have many programs that cover prescription therapy for these common conditions, we're going to be taking an extra focus on over the counter products that could complement our overall treatment regimen for these common conditions. Let's start with the first condition, which is acne, which I think is a great place to start, given that acne is the most common dermatologic concern that patients with skin of color seek consultation by a dermatologist for. When acne presents in darker skin types or skin of color, there are a number of specific manifestations that are more common in this group, including postinflammatory hyperpigmentation, which is often the driving force for patients to come and see the dermatologist in the first place.

So, in other words, postinflammatory hyperpigmentation can be of equal or even greater concern as the acne itself that caused it. In fact, a study that I worked on with Dr Susan Taylor and Dr Valerie Callendar and others found that amongst women of color, eliminating the postinflammatory hyperpigmentation was the primary concern for a very sizable proportion of women with skin of color with postinflammatory hyperpigmentation caused by their acne.

So with that, I'm going to turn it over to my colleague, Dr Susan Taylor, and ask, what are some of the characteristics of skin of color as it pertains to acne and postinflammatory hyperpigmentation?

Dr Taylor: Well thank you, Andrew. We all know that inflammation in acne in our skin of color patients is quite brisk. And it's not only the non-comedonal lesions, but it's also the comedonal lesions. The brisk inflammation, as we all know, leads to stimulation of melanocytes and the overproduction of melanin. And that really explains postinflammatory hyperpigmentation in these patients. Additionally in many of our skin of color patients, the fibroblasts in the dermis are large, and they can produce large amounts of collagen. And that can explain some of the keloidal scarring we see as a result of acne lesions in our skin of color patients.

Dr Alexis: Thank you for that overview. Now, Seemal, one of the things that I'm sure we can all relate to, seeing patients that may have a component of their skin or their hair care that might be exacerbating their acne. So if you could speak to your experience and any advice for the audience about things to look out for with respect to skin and hair products that might exacerbate acne.

Dr Desai: I'd be happy to, Andrew. And I think the important message for all of our viewers here today, and I know that all of us, Dr Taylor, yourself, and myself, we have our skin of color population, which we're so passionate and enthusiastic about treating. Taking into account cultural practices as they pertain to their acne and skin care is so important. I think developing that rapport and letting the patient know that you understand some of the things they're using in their day to day life, for example, really will have a lot of credibility for that patient and you, between a patient physician relationship. For example, a lot of my patients with skin of color tend to use hair products that oftentimes may be thick and oil containing. These are important to recognize and discuss with the patient, especially, for example, if you have someone who has a lot of acne or occlusive lesions on the forehead, which we'll talk I'm sure a little bit later about. Also, I know that many of our patients tend to use a lot of cocoa butter, and thick products which they may have used in their families and since youth to help sort of lighten the skin, to help moisturize and hydrate. And those may feel good, but they're not necessarily good for our pores, for oil production, and for clogging. And ultimately leading to that follicular diskeratinization that we see with acne vulgaris. And I think that over the counter skin lightening and skin bleaching products are probably one of the biggest things that I see across so many different cultural paradigms. My patients from southeast Asia, the Indian subcontinent, from the Middle East, from Africa, from Latin America. In many of these cultures, we have to remember that skin lightening and skin whitening equates to higher socioeconomic and cultural status.

So in many of these cultures, having brighter, lighter skin and having a bleaching cream that can help to quote, do that, is something that becomes a mainstay of many practices. And we have to be careful, because many of these over the counter bleaching creams that patients use to lighten their dark spots actually may have over the counter topical steroids. And as you can see in this example, you can get these monomorphous, very closed papules that really necessarily don't have as much inflammation clinically but can leave behind postinflammatory hyperpigmentation and even scarring when we think about steroid induced acne.

Dr Alexis: I'm going to ask both of you another question about acne. When we're facing our patients with acne, they often have probably 5, 6 questions that we practically hear every day from our acne patients. So, I'm going to start with Dr Taylor. What are some of the top questions and concerns that your patients have when they present to you with acne?

Dr Taylor: All of our patients want to better understand why they have acne. They're searching for a whole host of answers. What I hear all day, every day, is, "Why am I still getting acne at my age?" There's a perception that acne is only for adolescents or teens, and then our adult women in their 20s, 30s, and 40s, they don't quite understand that acne is a disease that they can, indeed, get. Many patients are very interested in what foods could be triggering their acne. Many think chocolate, fried foods, greasy foods, are worsening their acne. They want to know what they should eat and what they should eliminate from their diet. They want to know what skincare products they should use. Many think that skincare products alone is going to solve their acne, and I'm happy to answer and tell them what products I think are best, but they have to understand it is in the setting of medications that we will prescribe. So those are really the top 3 questions that I get from my acne patients.

Dr Desai: And I completely agree with Susan. I echo that. Because we get these same sort of questions reproducibly amongst so many of our skin of color patients. For example, "How many times per day should I wash my face? Should I wash it only in the morning? What about after sporting activities? When I come from work? Before I go to bed? Should I wash 5 times, is that too much or too little? How can I make my dark marks go away?" In fact, Andrew, you alluded to this earlier. A lot of my acne patients with skin of color could care less at the first visit about their bumps or their papules or their pustules. They're more worried about the dark spots and the complexion. And that sort of segues into this overlying theme that I think we all hear from so many of our patients. "Do I really need to be on medications to make my acne go away? Can't I just use a good moisturizer, or skin care, or face wash?" And I think these themes are pervasive throughout so many of our different skin types.

Dr Alexis: I think that's a great segue to my next question, which I'm going to turn to Susan for this. Susan, what is your overall approach to designing a comprehensive skin care regimen for your acne patients? Because of course we use prescriptions, but non-prescriptions as well. So how do you go about the overall approach?

Dr Taylor: Sure, Andrew. So the first thing I'm going to do is assess the degree of severity of the patient. And my guiding principle is early and aggressive treatment. But trying to avoid irritation that can lead to further postinflammatory hyperpigmentation or scarring. And this is particularly important, as you know, in our skin of color patients. I think it's very important in our female patients to assess their hormonal status and their androgen state. I think it's important to understand if they're using oral contraceptive agents. If not, then perhaps I select one that might be most appropriate for them.

Now, looking at the patients holistically, I do have a discussion with them regarding diet. And there's some evidence that high carb diets can contribute to acne. Stress reduction, I find that increased stress is a huge component of flaring acne and have even seen it in my teledermatology patients recently since they've been home with COVID. I also want to assess the patient's willingness to include an oral medication in their regimen if necessary. It's very important that patients feel that they're in control of their body and in the selection. Now for me, a well-rounded regimen is going to begin with products, prescriptions that are well tolerated. I think for all of us, topical retinoids are really the mainstay of treatment in our skin of color acne patients. But it's going to be very important to understand, have they been on a retinoid before? If so, was it helpful? Was it not helpful? We want to know if their skin is dry or oily. And that's going to lead us to the selection of the proper retinoid, the dosing frequency, and I often will begin every other day or every third day. And their skin type is going to direct me to the strength or potency of the retinoid.

Topical antibiotics or antibacterials are also a mainstay of treatment, be it a benzoyl peroxide or clindamycin. Fixed combination products, I think, are really the cornerstone of many regimens because of ease of compliance. Patients can get a combination of, let's say a benzoyl peroxide and an adapalene in one product, so they only apply it once a day. And we all know there are a whole host of other medications. So that's the foundation, the fundamentals of a regimen. And then, it's important to talk about what over the counter products are going to be adjunctive treatments.

Dr Desai: I think that's so important. I know Susan nicely alluded to that. That treating acne in our skin of color patients, and really more broadly just as board-certified dermatologists, we want to take an approach that's comprehensive. Prescription therapy combined with over the counter products, but taking into account that in our skin of color patients we have to think about nuances in terms of their moisture content. If they're going to use a product and be compliant. If I tell my skin of color patient who's a dark Indian patient, or an African American patient, to use a pure white zinc oxide sunscreen, that patient is probably not going to be compliant. Because that's going to leave a very white, pasty residue on a darker skin type individual and be very noticeable, and maybe even uncomfortable for their skin type. So even selecting an over the counter product is not as easy as just saying, "Go buy X, Y, and Z." I really try to recommend a range of different ingredients, so that the patient still has some flexibility in knowing what they can get. But at the same time, I'm giving them some guidance in tailoring that to their skin type.

So for example, over the counter products, sunscreens, are a fundamental basic. Patients need to use a minimum SPF 30 or higher, because we have shown in studies that that impacts the development and slows down the progression of postinflammatory hyperpigmentation, which is such a huge concern in skin of color. So SPF 30 or higher, a broad spectrum sunscreen. Something that the patient is going to use. People ask me, "What brand should I buy?" I always tell them, "The best brand is the one that you feel comfortable using consistently." So it's really important to talk about SPF. Vitamin C, for example, is another ingredient. And a topical antioxidant that also has some brightening benefit. A variety of studies that have shown Vitamin C also helps mitigate PIH.

Using over the counter benzoyl peroxide washes, for example. Let's say you can't get a prescription product because of insurance coverage. An over the counter BPO cleanser, or one with salicylic acid, can be very helpful in our therapeutic armamentarium. Then thinking also about those non-comedogenic moisturizers that may be thick, but they're not oily and they're not going to clog the pore. Those are also really helpful. I will mention hydroquinone also, because we talk about the fact that hydroquinone is still our, quote, gold standard, I like to say, in my opinion, in topical skin lightening with limitations. But there are products that patients can get and use in a limited duration fashion that may even contain over the counter hydroquinone.

So those are the kind of things that I tell patients to get. But the flip side of this story is that it's also my job to make sure to tell my patients with skin of color what to really avoid. Sometimes that discussion is even more impactful, because I find that telling them what to avoid helps to narrow down that list. And if someone goes into a drugstore or into a health store and is overwhelmed by the shelves of products that are inundating them when they go in there, this may help to kind of guide them and not be as overwhelmed. So I tell my patients, avoid alcohol based toners. They're going to dry out your skin, make it irritated, and the body's response to that excess dryness may be to make more oil or sebum. Avoid harsh exfoliating products that have high concentrations of alpha hydroxy acids. Those may irritate. Irritation in skin of color may lead to more postinflammatory hyperpigmentation. Avoid over-washing your skin. Avoid those at home chemical peel kits. I always get nervous when my patients tell me, "Oh, I'm going to go do a peel at home." I don't know what ingredients they're using, and I need to make sure that I've sanctioned this and allowed it to make sure my patient has the best outcome.

Dr Alexis: So with that, why don't we shift gears and talk about another extremely common dermatologic disorder that our patients and color come to see us for and that's seborrheic dermatitis. I'm going to turn to Susan and, if you could share with us a little bit of background about your patients who come in with seborrheic dermatitis and have skin of color.

Dr Taylor: Sure. Seborrheic dermatitis in skin of color is very common. And in fact, it's the second most common diagnosis for black patients who visit a dermatologist. That's particularly prevalent, Andrew, in black women. Flaking is really the universal sign. It's been reported in 80% to 95% of black patients with seborrheic dermatitis. But here's the thing: it's often considered normal by these patients. We also see seborrheic dermatitis in skin of color patients in the setting of infrequent shampooing. Many of my patients of African descent perhaps will shampoo only once a month, or once every 6 months, or once every 6 weeks. And that is not preferred, as we will discuss. But those shampooing habits really are going to influence and impact the severity of seborrheic dermatitis. We also find that the disorder is associated with hair breakage and lichen simplex chronicus, because many of these patients are itchy. hey're going to scratch, they're going to rub, they're going to pat their scalp. So we see the associated breakage, as I said, or LSC, with seborrheic dermatitis.

Dr Alexis: Great. Thank you. Now, Seemal, if you could add to that. What are some of the other diagnoses that you would consider, that we all should consider, when faced with a patient who presents with seborrheic dermatitis? Especially those with skin of color.

Dr Desai: Well, I'll preface that by admitting that even as an expert in skin of color, something like seborrheic dermatitis has even fooled me, at times, in my patient consultations. Because it can be nuanced, as Susan alluded to. You may not see a lot of the classic features that you would in a lighter skin type patient because of those background pigment nuances. And the most common thing that this tends to be misdiagnosed or maybe even overlapped with, if you will, is psoriasis. And we know that even, when we think about psoriasis in skin of color, a lot of those cutaneous manifestations of scaling and erythema, we don't always see. And that sort of parlays as well into seborrheic dermatitis.

So, for example, on the scalp. Scalp psoriasis can happen as well. And sometimes you have to sort of think about this as a spectrum. Depending on how scaly and flaky the patient is, how itchy they are, check behind the ears, look under the axillary or breast or intertriginous areas. A lot of times I'll see what looks like seborrheic dermatitis on the scalp, but I get the patient in a gown and look in their groin folds or in the upper parts of the gluteal crease, and you'll notice very symmetric, almost a glossy violaceous to brown patch in those areas. And then you know, okay, this isn't just seborrheic dermatitis. This is maybe more sebopsoriasis, which is an overlap condition between the 2 that's not uncommon in both patients who have concomitant seborrheic dermatitis and in skin of color.

Tinea capitis, or the common ringworm of the scalp, very easy to not get those 2 to be distinguished very easily on clinical exam. You may need to do more diagnostic testing and workup. And also, lichen simplex chronicus, just in those chronic phases of scratching and itching that leads to that thickened lichenified appearance.

Dr Alexis: Now Susan, what advice do you give your patients who have seborrheic dermatitis and skin of color?

Dr Taylor: So the first thing that I think is very important, Andrew, that I do, is discuss the frequency of shampooing that will fit in or work into the patient's lifestyle. Now, personally I recommend once a week shampooing. But I will accept every 10 to 14 days once the seborrheic dermatitis is improved or controlled. And it's very important, patients will say, "What? You want me to shampoo how often? Once a week?" But if you talk through the fact that it's going to make a significant difference pretty quickly, I think patients come on board.

Now the selection of a shampoo is also very important. Medicated shampoos that contain ketoconazole, ciclopirox, zinc pyrithione, are recommended. But there are some caveats. All 3 of those ingredients, particularly in women of African descent, can lead to dryness and brittleness as well as hair breakage. So typically I advise that they apply the shampoo directly onto the scalp with a 4- to 5-minute contact time, and not apply the shampoo to the actual strands of hair. After 4 or 5 minutes, I'll instruct them to rinse the shampoo out and they can reapply it. But then, to shampoo their actual strands of hair with a conditioning shampoo followed by a separate conditioner for the hair. When they use a second shampoo for their strands of hair, as well as selecting a conditioner, there are certain ingredients that we want them to look for. So, for example, dimethicone, glycerin, various oils help to keep that hair from becoming dry and brittle and break. So many patients don't realize that they can indeed use a conditioner, so I think that's very important.

For the face, for facial seborrheic dermatitis. We talked about postinflammatory hyperpigmentation in our skin of color population. Well, postinflammatory hypopigmentation, we all see commonly in seborrheic dermatitis. And particularly on the face, in the eyebrow area, in the nasolabial folds. And in that case, low potent topical steroids combined with topical calcineurin inhibitors or topical antifungal agents work beautifully and, in addition to improving the flaking, they help with the hypopigmentation. And once you remove that inflammation, the skin is going to go back to the normal hue or color.

And there is a role for over the counter products in our seborrheic dermatitis patients. So this is a time to tell them, "You want to use a moisturizing cleanser. You want to avoid alcohol based toners. You want to use a moisturizer that's a little bit thicker and more potent." And sometimes with our seborrheic dermatitis patients, just over the counter products alone will make a significant difference, and then you can avoid the low or mid potency topical steroid.

Dr Alexis: Indeed. In fact some of the very well formulated over the counter prescription shampoos for seborrheic dermatitis of the scalp produce results that are comparable to prescription shampoos, in my experience.

Dr Taylor: I agree.

Dr Alexis: So let's spend the remaining time we have discussing another very important condition that, again, like the other 2 conditions, can affect anyone of any background but when it presents in skin of color has some unique challenges and nuances to approach. And that's atopic dermatitis. So Seemal, why don't you start by giving us a little bit of background on the key challenges and differences of atopic dermatitis in skin of color?

Dr Desai: Thanks Andrew, I'd be happy to. I'm really glad that we, as the experts here today, are spending some time talking about atopic dermatitis. Because if I look back, ever since my residency training up until now, this is probably one of those diagnoses that is still extremely challenging to treat along all spectrums of ages. And we think of atopic dermatitis, or oftentimes people refer to it as just eczema, but I really like to use the word atopic dermatitis, especially when we think about the fact that this really is the most common skin disease in childhood. And many of the children who have this chronic, pruritic inflammatory, eczematous, almost then papules and lesions that can develop on multiple parts of the body in childhood, many of those people can then persist to having this even into adolescence and longer.

And if we think about the fact that there's still multifactorial reasons to get atopic dermatitis, I still think we have a lot of work to do and shedding light on this today I think is one great way to educate other healthcare providers on how we can help these individuals.

We need to talk about the fact that the skin barrier is disrupted. We need to talk about the environmental triggers, hot and cold weather. Temperature extremes, playing outdoors, swimming. Lots of those activities all can affect the skin barrier and skin's inflammation.

So how can you really look at a patient, walk in an exam room, and in the first few minutes just get a good sense of what's going on if this is a darker skin type patient?

Well, don't rely on erythema. Erythema or redness alone is not going to necessarily be your clinching diagnostic clue that's going to make you get the diagnosis of atopic dermatitis right. Erythema in atopic dermatitis, and frankly as we've talked about in a lot of dermatoses in skin of color, is challenging to ascertain. And even for us, who are the leaders and experts in this, I know we struggle with this at times, too. It may not be red. Most of the time, it's not. It's probably going to be more of a darkish purple, or even a brownish color. But look at the distribution of the lesions. The extensor surfaces, the elbow creases, behind the knees. Look behind the neck. Look at areas on the face, the periocular area.

And then also, keep in mind that in skin of color, there have been reports that atopic dermatitis can present very patchy, can present in a lichen planus-like distribution, where you've got these sort of inflamed papular purple-ish sort of lesions. As you can see in this example, you've got a really scattered dermatosis where you're having these monomorphous papules coalescing into patches that almost have that violaceous purple or hyperpigmented hue.

Dr Alexis: Now, atopic dermatitis is another great example of a dermatologic condition where over the counter products are a critical component of our overall skin care regimen that we recommend to patients. So I'm going to turn to Susan. And I'd like to know a little bit more about over the counter products that can help address barrier dysfunction, dry skin, and other common issues that we see in atopic dermatitis in patients with skin of color. What moisturizers, cleansers, barrier repair strategies are you recommending for this population?

Dr Taylor: Well Andrew, the first thing I want to say is that since we all went to medical school, there have been some huge advances in the treatment of atopic dermatitis that have been transformative for our patients. But even with systemic treatment, the focus still remains on topical over the counter products. Because you want to really restore that epidermal barrier function. You want to protect that epidermis. And we do have a whole host of very good products that we can recommend to our patients. For example, colloidal oatmeal is a very common ingredient. It's very soothing, it's going to help with the barrier.

One of the main complaints of our atopic dermatitis patients is itching. They are exceedingly itching. It keeps them up at night. The scratching and the rubbing and the patting leads to thickening of the skin. So anything that's going to calm and soothe the skin like colloidal oatmeal is going to make a big difference. Now, we know that there's a derangement in ceramides in atopic dermatitis. And there are some very good products over the counter by a host of very good companies that contain ceramides, particularly in their moisturizers. So I recommend those.

There are occlusive agents that tend to be thicker, that are going to trap moisture into the skin, and prevent the evaporation of water. So something as simple as petrolatum, for example. Seemal mentioned cleansers, gentle cleansers. Those that have components of natural moisturizing factor that are going to be very mild, that are not going to strip and remove the sebum from the skin. So again, you can find over the counter products that on the label say, for eczema, eczema care. It makes it very easy for the patients. But I think it behooves us to give our patients specific recommendations. And we're very fortunate in that there are many cleansers and moisturizers that can repair the barrier, decrease itching, and protect from transepidermal water loss.

Dr Alexis: Now Seemal, how about your adolescent patients with atopic dermatitis? Including, children and adolescents. Any special considerations as far as giving care for them?

Dr Desai: So it's interesting that you bring that up. In fact I've noticed more and more trends of my younger and younger patients using things like cosmetics, for example, to cover their dyspigmentation on the skin, because they're so embarrassed about their atopic dermatitis. They don't want to go to school or a social event, or be around their friends, or take that selfie and post it to social media with the dyspigmentation. They want to cover it. But, the cosmetics that sometimes are used in adolescents with AD I have actually found can flare the condition.

Mainly because many of these cosmetic products, for example, and these trends in coverups, if you will, contain fragrance, which is known to irritate patients with atopic dermatitis. They already have an epidermal barrier that's disrupted, like we talked about. Fragrance is only going to exacerbate that. Allergens can contribute to atopic dermatitis as well. For example in harsh soaps, in sort of fade creams, quote unquote. Those can be challenging, and we need to be able to discuss that with the patient. And really what I like to do is encourage the patient to bring everything possible with them to a visit. I want to know everything from the soap they're using to the laundry detergent to the moisturizer to the eyeliner. I like to look at it all.

And it's really interesting when patients come in with that bag of stuff, what you will find that even during taking a good history the patient may forget to tell you.

Dr Alexis: And you know, I think a really important point as well to add is that when we're talking about atopic dermatitis and skin care, cleansing, the bathing practices, selection of cleansers, soaps, is very important. Because you can do harm, for example, using very harsh surfactants found in some traditional soaps that can dry the skin and exacerbate the atopic dermatitis. And then we have agents that are moisturizing cleansers and soaps that, in addition to gentle surfactants, have moisturizing ingredients like occlusives and humectants coupled with the surfactant to clean the skin. And those indeed are ideal for our patients with atopic dermatitis, especially those with skin of color where dry skin can be even more dramatic for that patient. Especially visually.

And I think that as we wrap up this robust and very informative discussion, I think one of the key takeaways that I'm hearing here is that over the counter products, be them cleansers, moisturizers, shampoos, conditioners, play a real integral role in the management of many of the common dermatologic disorders that we see in skin of color. In addition, patient education about what to avoid is just as important as what they should be looking for. As we heard many examples of ingredients and products that could worsen acne or that could dry the hair and lead to breakage, or that can dry the skin further in someone with atopic dermatitis. So careful selection of over the counter ingredients is so key in getting the optimal comprehensive treatment regimen going to get the outcomes that we're looking for for our patients. So with that, Susan, Seemal, I would like to thank you for joining me in this discussion. I think it was very informative and educational. And as always, it's great to partner with you on these educational programs. Thank you.

Dr Taylor: Thank you.

Dr Desai: It's a pleasure to be with you all again.

Dr Alexis: And thank you to our audience for participating in this educational activity. Please continue on to answer the questions that follow and complete the evaluation.

This is a verbatim transcript and has not been copyedited.