Diagnosis of Allergic Dermatoses in Skin of Color.

PURPOSE OF REVIEW: This review aims to deliver a comprehensive report of the most recent knowledge on diagnosing allergic dermatoses in skin of color (SOC) patients. RECENT FINDINGS: Allergic dermatoses can affect populations of all backgrounds. However, racial/ethnic variations in epidemiology, clinical features, and associated allergens have been reported. Nuances in the approach to diagnosis, including the assessment of erythema and interpretation of patch tests, are important considerations when treating patients with SOC. In this review, we outline various manifestations of allergic dermatoses in SOC with a focus on important clinical presentations and diagnostic tools, aiming to support clinicians in accurate recognition of diseases, thereby opening avenues to improve outcomes across diverse skin types.

Best practices in the treatment of melasma with a focus on patients with skin of color.

BACKGROUND: Melasma is a chronic hypermelanosis of the skin that affects approximately 1% of the global population, predominantly affects women, and is more prevalent in skin of color. Melasma is a common driver for patients with skin of color to seek out a dermatologist for treatment, and ensuring the right approach for these patients is important because some treatments may be associated with adverse side effects. Because of the chronicity of the disease and established psychosocial and emotional impacts, there is a large need to ensure care follows the best available evidence on the treatment of patients with melasma. OBJECTIVE: Here, we summarized current available topical treatments for melasma with considerations dermatologists should have for their patients with skin of color. METHODS: Steering committee consensus on clinical best practices. RESULTS: We describe a flexible and focused treatment algorithm that reflects both treatment and maintenance periods that is a consensus of our extensive clinical experience. LIMITATIONS: Use of real-world evidence and potential for individual practice bias. CONCLUSION: Melasma can be challenging to treat, particularly in patients with skin of color, and our recommendations for best practices for patients in the United States are an important step toward standardizing care.

Photobiomodulation CME part II: Clinical applications in dermatology.

Photobiomodulation (PBM) is an emerging treatment modality in dermatology with increasing office and home-based use. PBM is the use of various light sources in the red light (620-700 nm) and near-infrared (700-1440 nm) spectrum as a form of light therapy. PBM is often administered through low-level lasers or light-emitting diodes. Studies show that PBM can be used effectively to treat conditions secondary to cancer therapies, alopecia, ulcers, herpes simplex virus, acne, skin rejuvenation, wounds, and scars. PBM offers patients many benefits compared to other treatments. It is noninvasive, cost-effective, convenient for patients, and offers a favorable safety profile. PBM can be used as an alternative or adjuvant to other treatment modalities including pharmacotherapy. It is important for dermatologists to gain a better clinical understanding of PBM for in-office administration and to counsel patients on proper application for home-use devices to best manage safety and expectations as this technology develops. PBM wavelengths can induce varied biological effects in diverse skin types, races, and ethnicities; therefore, it is also important for dermatologists to properly counsel their skin of color patients who undergo PBM treatments. Future clinical trials are necessary to produce standardized recommendations across conditions and skin types.

Photoprotective measures among adolescents stratified by region: An analysis utilizing the National College Health Assessment.

BACKGROUND/PURPOSE: Exposure to sunlight has been shown to cause pigmentary alterations, photoaging and photocarcinogenesis. Understanding photoprotective patterns in adolescent populations is beneficial to public health initiatives. We utilized data provided by the American College Health Association's National College Health Assessment to evaluate photoprotective behaviors among adolescent populations. METHODS: Behavioral questions related to photoprotection were analyzed from the American College Health Association (ACHA) National College Health Assessment (NCHA) (Version III). RESULTS: When comparing races, Black/African American respondents had the lowest association of practicing photoprotective behaviors in comparison to white respondents (p < .05). When comparing US geographic regions, the south had the lowest association of photoprotective measures (p < .05). LIMITATIONS: The response rate of each institution varied, although there was still a large quantity of respondents. Finally, we cannot discern the specific reasoning for adolescent populations not using sunscreen. CONCLUSION: These data identify demographics where efforts to enhance education on photoprotective behaviors, specifically among skin of color and southern population, to support public health initiatives.

Predicting the evolution of clinical skin aging in a multi-ethnic population: Developing causal Bayesian networks using dermatological expertise.

INTRODUCTION: Software to predict the impact of aging on physical appearance is increasingly popular. But it does not consider the complex interplay of factors that contribute to skin aging. OBJECTIVES: To predict the +15-year progression of clinical signs of skin aging by developing Causal Bayesian Belief Networks (CBBNs) using expert knowledge from dermatologists. MATERIAL AND METHODS: Structures and conditional probability distributions were elicited worldwide from dermatologists with experience of at least 15 years in aesthetics. CBBN models were built for all phototypes and for ages ranging from 18 to 65 years, focusing on wrinkles, pigmentary heterogeneity and facial ptosis. Models were also evaluated by a group of independent dermatologists ensuring the quality of prediction of the cumulative effects of extrinsic and intrinsic skin aging factors, especially the distribution of scores for clinical signs 15 years after the initial assessment. RESULTS: For easiness, only models on African skins are presented in this paper. The forehead wrinkle evolution model has been detailed. Specific atlas and extrinsic factors of facial aging were used for this skin type. But the prediction method has been validated for all phototypes, and for all clinical signs of facial aging. CONCLUSION: This method proposes a skin aging model that predicts the aging process for each clinical sign, considering endogenous and exogenous factors. It simulates aging curves according to lifestyle. It can be used as a preventive tool and could be coupled with a generative AI algorithm to visualize aging and, potentially, other skin conditions, using appropriate images.

Special Considerations of Atopic Dermatitis in Skin of Color.

Atopic dermatitis (AD) is a chronic inflammatory skin condition with heterogeneous presentations and prevalence across different skin tones. In this chapter, AD is explored through the lens of racial and ethnic diversity, emphasizing the special considerations among patients with skin of color (SOC). Specific ethnic groups may exhibit unique AD phenotypes, and these differences pose unique diagnostic and management challenges, especially given the disproportionate impact of AD in African American and Asian populations due to environmental exposures and social factors (i.e., decreased access to healthcare resources). Addressing these social disparities, increasing representation in medical education and the clinical space, as well as ongoing research can help better serve this patient population.

An inventory of current interventions to improve dermatologic clinical assessment in skin of color and recommendations for continued advancement.

Despite documented disparities with regard to treatment of skin of color (SOC) among dermatology trainees, a consensus has not yet been established as to how to improve trainee experiences with regard to SOC pathology. Our study objective was to systematically review the literature and assess interventions that have been implemented thus far to increase trainee competence and/or confidence in assessing SOC pathology. A systematic review of PubMed, Scopus, and Science Direct in January 2022 was performed, yielding a total of 1097 records. Inclusion of primary literature only resulted in 669 records. After assessing records for relevance to the objective, a total of 3 were included. Two studies assessed interventions among medical students and 1 among dermatology resident physicians. In general, the interventions assessed the effect of a specific SOC curriculum, but varied in how they came up with the curriculum. One study engaged with medical students of color to develop their curriculum, and 1 study retrospectively identified and included images of patients with SOC into a new database that was used for educational purposes. Interventions that engage with SOC communities may be most relevant, whether this is done by using patient data or by allowing leadership with medical students of color. We present a system for future future interventions to engage with medical students of color at their institution to improve trainee experiences with skin of color and long-term recruitment and support of a diverse medical student body to the field of dermatology.

Racial and ethnic disparities in clinical research and the dermatology workforce: Part 2.

Although racial and ethnic demographics are shifting in this country, it is not reflected in the diversity of clinical trial research participants; science, technology, engineering, and mathematics pipeline programs; or the workforce in the field of dermatology. Barriers to recruitment of minority patients for research studies also exist for numerous reasons including lack of education of prospective subjects, lack of awareness of ongoing trials, and mistrust within the health care system. Gaps in the science, technology, engineering, and mathematics pipeline for racial and ethnic minorities, particularly Black, Hispanic/Latinx, and American Indian or Alaska Native, are due in large part to structural racism. Lack of exposure as well as lack of educational, mentorship, and research opportunities contribute to gaps in the dermatology workforce. Having a representative population in the dermatology workforce and in clinical research trial patients is essential for optimum patient care, excellence in the specialty, and knowledge of appropriate treatments for minority populations. This article will discuss knowledge gaps for increasing minority subjects who participate in clinical research trials and discuss mechanisms to engage this community in trial recruitment. Additionally, this article addresses lack of racial and ethnic diversity of the dermatology workforce and performance gaps in the recruitment of racial/ethnic minorities into dermatology.

Melanoma in skin of color: Part II. Racial disparities, role of UV, and interventions for earlier detection.

Despite a higher incidence of melanoma among White individuals, melanoma-specific survival is worse among individuals with skin of color. Racial disparities in survival are multifactorial. Decreased skin cancer education focused on people with skin of color, lower rates of screening, increased socioeconomic barriers, higher proportions of more aggressive subtypes, and underrepresentation in research and professional education contribute to delays in diagnosis and treatment. Although high, intermittent UV exposure during childhood has been established as a significant modifiable risk factor for melanoma in individuals with lighter skin phototypes, there are limited data on UV exposure and melanoma risk in people with darker skin phototypes. The second article of this continuing medical education series will examine factors contributing to racial disparities in melanoma-specific survival, discuss the role of UV radiation, and address the need for further research and targeted educational interventions for melanoma in individuals with skin of color.

Gaps in medical education curricula on skin of color in medical school, residency, and beyond: Part 1.

Various studies have revealed a disproportionately low representation of skin of color (SOC) dermatology in the medical education system of the United States. This disparity contributes to adverse experiences, missed and/or delayed diagnoses, and overall health inequities for individuals of color. The lack of sufficient SOC education begins at the medical school level and continues throughout residency, fellowship, and beyond formal training. This lack of education can be seen in the dearth of images of common and uncommon skin conditions in darker skin in widely used textbooks and educational resources as well as in the lack of formal training in SOC in many residency programs. Thus far, there have been valuable strides to make dermatologic education more inclusive of all skin colors, but there remains significant work to be done. With the population of the United States expected to continue to diversify and with the expectation that SOC will be a trait of over half of the population of the United States by 2050, it is important to strive for health equity by ensuring that comprehensive and inclusive medical training incorporates SOC. This paper will explore the issue of gaps in medical education in SOC dermatology at all levels and offer a strategic call to action to aid in rectifying this situation.

Melanoma in skin of color: Part I. Epidemiology and clinical presentation.

Although there is a higher incidence of melanoma among non-Hispanic White individuals, melanoma is diagnosed at more advanced stages and associated with worse survival rates among individuals with skin of color (SOC). The proportions of melanoma subtypes differ across racial groups, with acral lentiginous melanoma and mucosal melanoma representing higher proportions of melanoma diagnoses in individuals with SOC compared to White individuals. The recognition of distinct differences in anatomic locations and dermatoscopic patterns may facilitate the appropriate differentiation of physiologic from pathologic pigmentation. The first article of this continuing medical education series will focus on the epidemiology and clinical presentation of melanoma in individuals with SOC, with the aim of improving early diagnoses and clinical outcomes.

Racial and ethnic underrepresentation in dermatology clinical trials.

BACKGROUND: Including participants of diverse racial and ethnic populations in clinical trials is important to reduce disparities and promote health care equity. OBJECTIVE: To evaluate racial and ethnic representation in dermatology clinical trials. METHODS: Participant data from dermatology trials completed in the United States from 2017 to 2021 from ClinicalTrials.gov were compared to census data to determine if minority groups were represented at rates that reflect population demographics. Participation was compared with prevalence rates for the most underrepresented racial group. RESULTS: Of 246 trials that met inclusion criteria, 87.4% (215) reported racial data. Compared to census data, Black/African American, American Indian/Alaskan Native, and 2 or more races were underrepresented. Hispanic or Latinos were an underrepresented ethnic group. LIMITATIONS: The search was limited to ClinicalTrials.gov registered studies that fell within search parameters. Race reporting methods were not specified. Detailed analysis was only performed for the most underrepresented racial group. CONCLUSION: Certain minority groups were underrepresented in dermatology trials. Black/African Americans were most underrepresented and underrepresented even when accounting for prevalence rates. Trial representation that accurately reflects population demographics and subgroup prevalence rates can help reduce health inequity, improve clinical understanding, and enhance treatment access for the growing diverse population.

Treatment recommendations for acne-associated hyperpigmentation: Results of the Delphi consensus process and a literature review.

Acne vulgaris can be associated with hyperpigmentation, particularly in individuals with skin of color. This acne-induced macular hyperpigmentation (AMH), also called postinflammatory hyperpigmentation, is often long lasting and negatively impacts quality of life. Large-scale, randomized, controlled clinical trials with regard to the treatment of acne and AMH are lacking. For this reason, evidence-based treatment recommendations cannot be made. However, AMH is a common condition, and it is important for clinicians to have guidance on management strategies. The authors, a group of 10 board-certified dermatologists, conducted a modified Delphi consensus process to reach a consensus on first-line therapy for AMH and determine whether therapeutic choices change in different patient subgroups. We reached a consensus that most patients with acne and AMH should receive early and efficacious acne treatment with a topical retinoid and benzoyl peroxide. Therapies aimed at addressing AMH-including hydroquinone, azelaic acid, chemical peel, or antioxidants-may also be considered for enhancing the effect of the treatment regimen on acne and pigmentation. Chemical peels may be used as adjunctive or second-line therapy. This article details the results of the Delphi process, reviews relevant literature for providing recommendations for AMH, and discusses appropriate treatment options.

Artificial Intelligence for the Classification of Pigmented Skin Lesions in Populations with Skin of Color: A Systematic Review.

BACKGROUND: While skin cancers are less prevalent in people with skin of color, they are more often diagnosed at later stages and have a poorer prognosis. The use of artificial intelligence (AI) models can potentially improve early detection of skin cancers; however, the lack of skin color diversity in training datasets may only widen the pre-existing racial discrepancies in dermatology. OBJECTIVE: The aim of this study was to systematically review the technique, quality, accuracy, and implications of studies using AI models trained or tested in populations with skin of color for classification of pigmented skin lesions. METHODS: PubMed was used to identify any studies describing AI models for classification of pigmented skin lesions. Only studies that used training datasets with at least 10% of images from people with skin of color were eligible. Outcomes on study population, design of AI model, accuracy, and quality of the studies were reviewed. RESULTS: Twenty-two eligible articles were identified. The majority of studies were trained on datasets obtained from Chinese (7/22), Korean (5/22), and Japanese populations (3/22). Seven studies used diverse datasets containing Fitzpatrick skin type I-III in combination with at least 10% from black Americans, Native Americans, Pacific Islanders, or Fitzpatrick IV-VI. AI models producing binary outcomes (e.g., benign vs. malignant) reported an accuracy ranging from 70% to 99.7%. Accuracy of AI models reporting multiclass outcomes (e.g., specific lesion diagnosis) was lower, ranging from 43% to 93%. Reader studies, where dermatologists' classification is compared with AI model outcomes, reported similar accuracy in one study, higher AI accuracy in three studies, and higher clinician accuracy in two studies. A quality review revealed that dataset description and variety, benchmarking, public evaluation, and healthcare application were frequently not addressed. CONCLUSIONS: While this review provides promising evidence of accurate AI models in populations with skin of color, the majority of the studies reviewed were obtained from East Asian populations and therefore provide insufficient evidence to comment on the overall accuracy of AI models for darker skin types. Large discrepancies remain in the number of AI models developed in populations with skin of color (particularly Fitzpatrick type IV-VI) compared with those of largely European ancestry. A lack of publicly available datasets from diverse populations is likely a contributing factor, as is the inadequate reporting of patient-level metadata relating to skin color in training datasets.

Skin type specific photobiological response to visible light is mediated by constitutional melanin.

BACKGROUND: Visible light (VL) induces varying photobiological responses between skin types, likely influenced by inherent melanization. Individual typology angle (ITA) objectively measures skin types. We hypothesize that epidermal melanin content and distribution determine VL response. OBJECTIVES: This study describes clinical and histologic responses to VL and examines the potential role of melanin in the underlying mechanistic pathways. METHODS: We grouped enrolled participants by ITA (Light = 5, Intermediate = 4, Dark = 7) per colorimetry (CR-400, Konica Minolta). Photoprotected sites were exposed daily to 480 J/cm2 of VL (Fiber-Lite High Intensity Illuminator, Series 180, Dolan Jenner Industries Inc.) for 4 days (total = 1920 J/cm2 ), as tolerated. Treated and control sites were biopsied 96 h after first exposure. We used hematoxylin and eosin and Fontana-Mason to assess histological changes and melanin deposition, respectively. p53 and Ki67 immunohistochemical stains were done to assess DNA damage and proliferation. Matrix metalloproteinase (MMP)-1 expression was detected by immunohistochemical staining and immunofluorescence microscopy. RESULTS: Darker skin did not tolerate the full VL regimen with blistering occurring in most subjects at doses of 220-880 J/cm2 . Intermediate and Dark skin showed tanning. Light skin developed erythema. p53 counts were highest in Intermediate, followed by Light skin, although this was not statistically significant. VL treatment led to MMP-1 expression and nuclear localization in keratinocytes in Dark and Intermediate but not in Light skin, however differences between groups were not statistically significant. CONCLUSIONS: Skin types demonstrate unique biological responses to VL. The role of melanin in photoprotection is well-defined. However, given the pro-apoptotic function of nuclear MMPs, we suggest a potential mechanism by which melanin may mediate VL-induced phototoxicity.

Special considerations in adolescents of color with acne and textured hair.

Acne is a common dermatologic condition that affects most adolescents. In adolescents of color with textured hair, it is paramount to consider how hair care practices may affect acne distribution and treatment. Dermatologists should be familiar with hair care cultural norms when treating this population.

Lasers for the treatment of eyebrow microblading and cosmetic tattoo pigment: a review of the literature.

We aim to discuss the use of laser for the treatment of eyebrow microblading and cosmetic tattoo complications through a review of the literature. Our research question is whether quality-switched or picosecond laser is superior for the removal of eyebrow tattoos. This structured review was conducted using a PubMed search using the search terms "laser tattoo removal" AND "cosmetic tattoo" AND "eyebrow" with the article type filtered to "case reports," "clinical trial," and "randomized controlled trial" ranging from dates 1994-2023. All case reports or series evaluating the effect of laser on eyebrow cosmetic tattooing pigment were included. We summarize the results of 11 studies evaluating the use of laser for cosmetic tattoo removal, with 129 patients treated specifically for eyebrow pigment. Most studies (8/11) report Fitzpatrick skin type or race. Seven studies utilize quality-switched (QS) neodymium-doped yttrium aluminum garnet (Nd:YAG), alexandrite or ruby, three used picosecond (PS) Nd:YAG or alexandrite, and three used carbon dioxide (CO2) laser. We report laser energy, spot size, and pulse duration, as well as treatment outcomes and adverse events. Historically, methods of pigment removal included dermabrasion, cryosurgery, electrosurgery, radiofrequency, infrared light, intense pulsed light, and surgical excision; however, these methods often led to poor cosmetic outcomes including scarring and further dyspigmentation. QS laser treatments provided superior cosmetic outcomes and thus were considered the gold standard treatment option for pigment removal. However, the advent of PS lasers has challenged this given their increased selectivity, lower fluence requirements, and reduction in surrounding thermal damage. Our review demonstrates that PS Nd:YAG is quicker and more effective that QS Nd:YAG in the treatment of eyebrow tattoos. Additionally, the paradoxical darkening seen with QS lasers is less common with PS lasers. We also demonstrate that CO2 laser may be a helpful adjunct to QS or PS laser. This review focuses on Fitzpatrick skin type and race, providing a unique perspective on the use of laser treatment in skin of color, which often poses an additional treatment challenge.

Photography in dermatology - a scoping review: Practices, skin of color, patient preferences, and medical-legal considerations.

Clinical photography is essential in dermatology. However, a comprehensive literature review of photography in dermatology is lacking. This scoping review aims to summarize the literature regarding photography practices in dermatology, photography of skin of color, patient preferences, and medical-legal considerations. A search was conducted utilizing Embase, MEDLINE, PubMed, and Evidence Based Medicine databases in accordance with the PRISMA extension for Scoping Reviews. In total, 33 studies were summarized. Clinical photography is commonly used in biopsy site marking, assessment, diagnosis, disease monitoring, evaluation of treatment response, medical education, research, seeking advice from colleagues, and teledermatology. Although dermatologic photography remains devoid of skin of color representation, photographic considerations for darker skin are available. Most patients support medical photography, with a preference for clinical photographs to be taken by their own physicians, and for use of clinic/hospital-owned cameras over personal devices. Pertinent medical-legal issues include concerns around privacy, personal device use, and documentation of consent. Photography in dermatology is continuously evolving with broader applications. Improved practices and innovations will benefit individuals of various skin tones. Management of consent and privacy must be upheld to sustain the increasing ease of image capture and sharing.

Misconceptions of photoprotection in skin of color.

Terrestrial sunlight is the portion of electromagnetic radiation that is emitted by the sun and reaches Earth's surface. It encompasses 3 major components: UV radiation (290-400 nm), visible light (400-700 nm), and infrared radiation. The deleterious effects of UV radiation have been appreciated for decades, particularly among those with light skin tones (Fitzpatrick skin types I-II) who primarily manifest with burns of varying degrees of severity with sun exposure. In recent years, studies have increasingly shown the negative impact of visible light on skin health, particularly in individuals with skin of color (Fitzpatrick skin types IV-VI), including the exacerbation of hyperpigmentation disorders such as melasma and post-inflammatory hyperpigmentation, as well as induction of the former. Recommendations from medical societies and the US Food and Drug Administration for photoprotection have been evolving along with the knowledge base. Yet, misconceptions about skin damage related to sunlight and the benefits of photoprotection (particularly among those with Fitzpatrick skin types V-VI) are still prevalent among both clinicians and patients. Among patients with skin of color, disorders of hyperpigmentation and other consequences from sun exposure have been associated with impaired skin health and negative burden on quality of life. This review summarizes currently available evidence of the impact of both UV and visible wavelengths and the low utilization of photoprotection measures among people with skin of color, with the goal of providing recommendations to help educate patients.

Photoprotection for skin of all color: Consensus and clinical guidance from an expert panel.

The negative effects of sun exposure have become better accepted among health care professionals and the lay public over recent decades. Most attention has been focused on the effects of UV light, particularly UVB wavelengths (290-320 nm). Accordingly, products to protect skin from sunlight-associated harm (sunscreens) have been developed to minimize UVB exposure. The effects of longer wavelengths, including UVA (320-400 nm) and visible light (VL, 400-700 nm), are increasingly appreciated. VL accounts for approximately half of the solar radiation that reaches the earth's surface and understanding of its effects on the skin is improving. Studies have shown that VL can induce hyperpigmentation in individuals with dark skin types (Fitzpatrick skin types IV-VI). In addition, VL can contribute to the exacerbation of pigmentary disorders, including melasma. Because these findings are relatively new, there are gaps in understanding the needs for photoprotection and guidance for clinicians. A panel of dermatologists and photobiologists was convened to develop consensus recommendations and clinical guidance about sunscreen use relevant to the current understanding of risks associated with sun exposure using a modified Delphi method.