NAPLES, Fla. — Vitiligo, keloids, acne keloidalis nuchae, and hair and scalp concerns are among the challenges dermatologists face when treating darker skin, Dr. George Cohen said.

Black skin is prone to adverse pigmentary or hyperproliferative responses to cryotherapy, lasers, and chemical skin treatments. Because of these and other concerns in a growing population of patients with skin types IV through VI, Dr. Cohen suggested dermatologists learn more about recognition and treatment of these important differences.

To view an interview with Dr. George Cohen, click here.

"We are a more diverse society. Become culturally competent and learn as much as you can," Dr. Cohen said at the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons. Respect, inquire, and do not make assumptions—those are the three pillars of cultural competence, he said.

Cultural competence is not only good for patients; it can be good for your practice as well. "Access and acceptance are good for us—this creates more demand for services," said Dr. Cohen, of the department of dermatology and cutaneous surgery at the University of South Florida in Tampa.

Vitiligo

Vitiligo is the prototypic pigmentary challenge for patients with skin of color, Dr. Cohen said. Although the etiology is not completely understood, it may be related to the immune system. The challenge for dermatologists is that "some people respond to some things some of the time, so we don't always know who is going to respond," Dr. Cohen said.

The myriad of treatments available for vitiligo include:
- Narrow-band UVB therapy.
- Targeted laser treatment with the XeCL Excimer (308 nm).
- Topical steroids.
- Calcineurin inhibitors.
- Surgery.
- Depigmentation (using medications or 694-nm Q-switched Ruby laser).
- Makeup.

Unfortunately, "none of these work perfectly," he said.

A patient with acne keloidalis nuchae before excision. This clinical presentation is more common among patients with skin of color.

He cited the case of a patient with vitiligo who tried steroids, psoralen and UVA (PUVA), and other treatments to no avail. "He was desperate. He came to me with his family and asked: 'Doctor, can you make me one color?' I told him we can only make him one color—white—that is all we are able to do.

"Sometimes you cannot repigment the patient, and you have to know how to judiciously offer depigmentation. Some might say I robbed him of his culture. I say, no, I didn't, I robbed him of a disfiguring condition," said Dr. Cohen.

More research is clearly warranted to improve treatment options for vitiligo, such as studies to assess the biology of melanocytes, he said.

Keloids

Keloids are another challenge in skin of color patients. The therapeutic approach depends in part on the extent of the patient's condition. For example, a single keloid on the earlobe would be treated differently than more widespread presentation.

Again, more research is warranted on optimal treatments, Dr. Cohen said, because studies in the literature are contradictory and provide no consensus.
Acne keloidalis nuchae, "the keloids' cousin," most often occur in black men, he said. These nuchae can advance to plaque and form tumors, "and at the very least will need intralesional therapy." One clinical tip is to make an incision only within the keloid, he said.

The patient is shown during excision treatment.

If a patient presents with an acne keloidalis tumor, simply excise it. Once you get hemostasis, dress the wound with petroleum jelly only, and let it close by the magic of second intention

"I monitor these people. If I see any evidence of regrowth, I treat with triamcinolone early and often," he said.

Hair and Scalp Challenges

Hair and scalp concerns are common in patients with skin of color, Dr. Cohen said. A scalp biopsy is recommended to determine or confirm a diagnosis and to guide the course of clinical treatment.

These presentations can have a great psychosocial impact. "Do not underestimate the effect on patients," he said. Know your limitations and the limitations of therapy, and make sure you communicate those effectively to the patient. Otherwise, both the patient and provider can become frustrated.

Be honest with genetically-susceptible patients who present with scarring on the scalp from physical insult. In this population, scarring results when fibrous tissue replaces hair follicles. "Let them know up front that creams and other nonsense are not going to work," he said.

The patient is shown again after treatment.

Contrary to popular belief, Dr. Cohen said, hair transplants are an option in patients with skin of color. "Hair transplants in black patients are not scary— I've been doing them for years and never had keloids," he said.

Black hair is heterogenous, so not everyone has curved follicles. If a skin of color patient has straight follicles, standard hair transplant procedures—for example, with 4-mm donor grafts—would be an option.

Dr. Cohen said that he did not have any relevant financial disclosures.

Cultural Competence Key to Treating Skin of Color