The unique needs of patients with highly-pigmented skin was the topic of dermatological presentations during the Skin of Color Society’s annual Media Day in New York City. The event, held at the offices of Dr. Dhaval G. Bhanusali’s Hudson Dermatology & Laser Surgery, attracted more than 50 reporters from a variety of publications including The Wall Street Journal, Essence and Glamour.


Dr. Andrew Alexis, director, Skin of Color Center, and Bhanusali reviewed safety considerations in skin of color, including a higher risk of dyspigmentation, keloids/hypertrophic scars and, perhaps, a need for longer treatments. Both dermatologists reviewed botched treatments by unqualified users and offered solutions; however, in some cases, they noted, fully rectifying the problem is impossible. Alexis showed depigmentation caused by using the wrong laser hair removal treatment for a patient with Fitzpatrick IV skin type. In contrast, the appropriate device used incorrectly can lead to scarring. To illustrate his point, Alexis showed an Asian patient who was scarred during a skin tightening procedure using ultrasound. He hypothesized that the damage may have been caused by something as simple as poor handpiece placement. Bhanusali reviewed skin damage to skin type IV-VI caused by long-pulsed YAG laser. Similarly, skin may be damaged when lasers are incorrectly used to treat hyperpigmentation and even skin tone, he added.


“Cosmetic procedures in darker skin types are associated with higher risks of pigmentary alterations and scarring, but can be performed safely with special considerations,” said Bhanusali, who stressed to reporters that consumers must do their research when selecting a dermatologist.


“Make sure that your ‘doctor’ went to medical school,” he explained. “Select a board-certified dermatologist with expertise in treating diverse skin types.”


Once patients have selected a board-certified dermatologist, they should share their ancestry and history of hyperpigmentation and scarring with their treatment provider during consultation, they advised.


“Patients may need pre- and post-treatment skin care as well as less aggressive treatment settings for best outcomes,” concluded Alexis. “A ‘slow and steady’ approach is sometimes needed.”


It’s What’s on the Inside that Counts

Poets have suggested that the eyes are the window to the soul, but Dr. Lynn McKinley-Grant, associate professor, Howard University, and Dr. Donald Glass, assistant professor, University of Texas Southwestern, explained that skin issues can be external signs of internal disease. For example, skin color changes can reveal organ failure, said McKinley-Grant.

“Icterus and jaundice are due to liver disease and pallor is the result of anemia,” she said.

Glass pointed out that many types of inflammation signal more serious health issues. Lupus, he said, is characterized by purple- and red-toned skin, while sarcoidosis is reflected by “apple currant” brown skin. Even a heliotrope rash could be the result of dermatomyositis, a form of cancer, he warned.

Dire health issues can be reflected in the eyes. Icterus is the result of liver disease, proptosis is the result of hyperthyroidism and, in contrast, madarosis is the result of hypothyroidism. Even acne can reveal health issues. McKinley-Grant noted that polycystic ovary syndrome (PCOS) is a disorder involving irregular menstrual periods, acne, hirsutism and often, excess male hormone (androgen) levels.


Skin Cancer & UV Protection

In perhaps the presentation of most interest to Happi readers, Dr. Susan C. Taylor of the University of Pennsylvania and Dr. Maritza Perez of UConn Health provided an update on skin cancer and sun protection in melanin-rich skin. According to Taylor, dermatologists are determined to promote five facts regarding sun care for pigmented skin:

• Skin cancer does occur in melanin-rich skin;
• Sun protection is necessary for disorders common in melanin-rich skin;
• Chemical sunscreen aesthetics are preferred;
• Chemical sunscreen is minimally absorbed; and
• Physical sunscreens combined with iron oxides and other sun protection measures are the best way to protect against UV damage.

“Melanin-rich skin is susceptible to skin cancer,” asserted Taylor, noting that a 2016 Centers for Disease Control study found that melanoma incidence in the US per 100,000 people included 25.2 white, 5.2 American Indian/Alaska Native, 4.6 Hispanic, 1.2 Asian/Pacific Islander and 0.9 Black.


Taylor ticked off several diseases that require sun protection including pigmentation (melasma, PIH and vitiligo), Lupus erythematosus, Solar urticaria, polymorphous light, medication-induced sun sensitivity for hypertension, diabetes and acne to name a few; and photoaging.


Unfortunately, it is a fact that those with melanin-rich skin do not use sunscreen as often as they should. Some reasons include falsely assuming that melanin-rich skin is already photo-protected and forgetting to use it. However, formulators and manufacturers must share some of the blame, as many consumers find formulas too laborious to apply, do not like residual color left by zinc- and titanium dioxide-based formulas, nor do they like the feel or consistency of these physical sunscreens.
“Chemical sunscreen aesthetics are preferred in melanin-rich skin,” noted Taylor.


She noted that chemical sunscreens, including avobenzone, oxybenzone, octocrylene, homosalate, octisalate and octinoxate, are absorbed in skin, but noted that more studies are needed and that “patients should not refrain from using them.”


Finally, Taylor noted that sunscreen is just one part of complete sun protection.


“Physical sunscreens plus iron oxide found in tinted sunscreens block visible light that exacerbates melasma,” she concluded. “Protective clothing, hats, sunglasses and sun avoidance strategies are also important.”


Perez detailed findings of a multi-decade ethnicity study to develop a fundamental understanding of the molecular mechanisms which contribute to skin aging, both intrinsic and extrinsic, across different ages, body sites and ethnicities.


Researchers found that solar elastosis was most pronounced in the sun-exposed skin (face, arm) of Caucasian women in their  40s. However, elastosis was also apparent in the skin of women with darker skin tones, especially Hispanic and Chinese in their 60s, although less so in the skin of the African-American women. These results confirm there is an inverse relationship between the degree of solar elastosis and the degree of melanin pigmentation in the skin (Young et al. 2010. Clin Exp Dermatol 35: 392-6). However, the results also suggest that even women of darker skin tones must include sun protection in their skin care regimen.


Furthermore, epidermal thickness significantly decreased with age in the facial skin of Caucasian women in their 50s onward as compared to the 20s group.


According to Perez, the decrease in epidermal thickness was also apparent in the facial skin of Hispanic and Chinese women, with a significant decrease occurring as early as the 40s in the Hispanic group. However, there was not a significant change in epidermal thickness in the facial skin of the African-American women.


The dermatologist identified similar patterns of both epidermal and dermal gene expression across ethnicities with aging. Gene expression in facial epidermis and dermis for each age group was compared to the 20s group for each ethnicity; i.e., Caucasian, African-American, Hispanic and Asian (Chinese).


Heat map depiction of facial epidermal gene expression indicated the majority (approximately 75%) of genes increased in expression with age (red). In contrast, the majority (approximately 75%) of dermal genes decreased in expression with age (blue), with the lowest level of expression in the oldest group sampled.


“However, there are also clearly differences between the ethnicities that we plan to dig into further, which may help elucidate biological mechanisms underlying the ethno-specific skin structure changes highlighted in the previous slides,” said Perez.


A detailed heat map for Caucasian epidermal samples indicated numerous changes in gene expression profiles with each decade, even at the earliest age transition from the 20s to the 30s.


“So one could say that skin ‘aging’ starts to happen much earlier than many people may think, with implications for skin care needs,” said Perez. “For example, the decrease in gene activity related to natural antioxidant production in skin which we see occurring in the 20s, indicates that skin starts to lose some of its natural protection against environmental stressors such as UV exposure, which is very interesting as we looked at the effects of UV exposure on gene expression across the decades.”


Among the genes evaluated by transcriptomics profiling, CDKN2A increased with age, especially in photo-exposed skin site, with the exception of buttocks epidermis. According to Perez, it is more pronounced in the Caucasian group, compared to African-American volunteers. Caucasians show larger and earlier increases in cell senescence gene expression, especially in sun-exposed body sites, however the African-American data indicates that even darker skin tones are susceptible to UV damage and need to adopt suitable sun protection habits.


In the epidermis, CDKN2A expression was highest in the face in 40+ skin, with significant correlation with age. In the dermis, CDKN2A expression increased significantly in skin from all body sites. Perez explained that autophagy is a fundamental cellular process that involves degradation and recycling of damaged cells, proteins and organelles. She noted that autophagy has not been well studied in skin, but may play a fundamental role in skin processes such as barrier formation and pigmentation.


“Autophagy activities in sun-exposed facial skin were maintained or up-regulated until 40-50s, then down-regulated afterwards,” she said. “Autophagy activities in sun-protected site (buttocks) were maintained during aging in comparison to facial skin in Caucasian American women.


“These results suggest an impact of sun exposure on the essential ability of skin to degrade and recycle damaged cells and their components,” explained Perez. “In sun-exposed facial skin, autophagy activities decrease from an earlier age and more significantly under certain lifestyle conditions such as lack of usage of sun protection, moisture lotion, lack of exercise and smoking.”


The researchers observed similar trends, but also subtle differences in skin changes with age across the four studied ethnicities, warranting further investigations.
Transcriptomic analysis showed significant changes in epidermal and dermal gene expression across multiple pathways from the earliest age transition studied.


“UV exposure strongly affects skin biology and influences changes in gene expression, including genes related to senescence, autophagy and transcriptional regulation, making a clear case for good sun protection habits across all ages and ethnicities,” she concluded.


Pigment Disorders & Skin Care

Skin dyschromia is the No. 1 concern of skin of color patients, according to Dr. Seemal Desai, president and medical director, Innovative Dermatology and clinical assistant professor of dermatology, University of Texas Southwestern. More specifically, hyperpigmentation is the No. 1 aesthetic concern of Latin-type patients, accounting for 80% of Latin patient concerns.


Post-inflammatory hyperpigmentation is the No. 1 concern of West Asian- and African-type patients, accounting for 70% of African-type visits to the dermatologist’s office. Finally, facial aging dyschromia is the No. 1 concern of East Asian-type patients, according to Desai, noting that the most common disorders are hypopigmentation (vitiligo and post-inflammatory hypopigmentation) and hyperpigmentation (melasma and post-inflammatory hyperpigmentation).


In reviewing the latest research on melasma, Desai noted that while well-established components of melasma include UV light, hormonal influences and heat, newer components include vascular inflammation, blue light and environmental pollution. Vitiligo treatments include topical therapies, oral steroids, light treatments, JAK inhibitors, psychological therapy and combination therapies. But no matter what treatment regimen is prescribed, “always assess patient desires,” warned Desai.


The gold standard for melasma has been hydroquinone, but Desai said that topical and oral tranexamic acid, iron oxides in tinted formulas, and antioxidants such as cysteamine and glutathione are new advances. Procedures for melasma include microneed-ling, chemical peels and lasers.


He warned that addressing stubborn dyschromia concerns is a long and difficult process that needs time, patience and compliance with a daily program conducted over weeks.


“There are no quick fixes,” said Desai, who noted that cysteamine has applications as a skin pigmentation disorder treatment.


The use of antioxidants, such as alpha lipoic acid and vitamins C and E, in skin of color was the topic of a presentation by Dr. Laura Scott, associate director, skin of color division, University of Miami, Dr. Philip Frost department of dermatology and cutaneous surgery.

After reviewing reports of mercury poisoning from skin lightening creams, Scott noted that there is a shift toward “natural and non-toxic” ingredients such as licorice root, kojic acid, niacinamide, arbutin, bakuchiol, azelaic acid and soy.


Hair Happenings

Not to be neglected, Dr. Amy McMichael, professor and chair of dermatology, Wake Forest School of Medicine, and Dr. Crystal Aguh, professor and director, ethnic skin, Johns Hopkins School of Medicine, reviewed the unique hair care needs of skin of color consumers. McMichael discussed the relatively common Central Centrifugal Cicatricial Alopecia, a form of scarring that can cause permanent hair loss. According to McMichael, the malady is linked to PAD13, a new gene mutation that has been identified in 25% of women and has been associated with an increased rate of fibroids. In addition to standard medical treatments such as steroid injections and creams, new options include topical metformin cream and surgical treatments involving platelet-rich plasma.


Traction alopecia, explained Aguh, is a very common cause of hair loss which presents along the hairline and is due to stress caused by wigs, weaves and braids. Standard medical treatments include steroid injections and ointments, minoxidil applications, or, if necessary, surgical hair transplants.


“There are several popular hair styles to avoid,” explained Aguh.


McMichael detailed the causes and complications of alopecia areata, the autoimmune form of hair loss that typically appears as sudden patches of hair loss that can sometimes be associated with stress.”


“New medical treatments such as JAK inhibitors suppress the immune system, but they are the most effective option for widespread hair loss,” according to McMichael.


Adrogenetic alopecia, also known as hormonal or “pattern” hair loss, occurs in at least 50% of women by age 50. Medical treatments include minoxidil, red light lasers and low level light. Procedural treatments include hair transplants, or more recently, PRP.


Hair breakage, aka, acquired trichorrhexis nodosa, is a malady that can befall women with tightly curled hair styles, said Aguh, who tells patients to wash and deep condition their hair often, every one or two weeks.


“Use products containing glycerin or silicone derivatives for added moisture and softening of the hair,” she advised.


At the same time, Aguh urges patients to minimize the use of tight extensions such as braids, weaves and wigs.


“This can lead to or worsen hair loss,” she explained.


In conclusion, the dermatologists noted that the US Food and Drug Administration has issued a warning against the use of biotin due to its impact on bloodwork and a lack of data showing hair growth effectiveness.