Hair & Nails

Beth S. Ruben, MD

Probably the most common reason to perform biopsy of the nail unit is for the evaluation of irregular pigmentation, especially longitudinal melanonychia or pigmented bands. When narrow and solitary, these are usually the product of melanocytic activation/hypermelanosis, lentigines, or melanocytic nevi. Multiple pigmented bands are generally a benign finding, the result of melanocytic activation, as seen in racial pigmentation in darker-skinned patients, for example. In the context of an irregular, broad, heterogeneous or “streaky” band, the chief concern is the exclusion of subungual melanoma. Before assessing the histologic features of any such entities, it is important to understand the normal nail anatomy and melanocytic density of nail unit epithelium, as well as the type of specimen submitted, and whether it is adequate to undertake a proper histologic evaluation. The criteria for diagnosis and prognosis of melanoma of the nail unit are still evolving, and a variety of factors must be weighed in the balance to make a correct diagnosis. The importance of the clinical context cannot be overemphasized. There are also nonmelanocytic conditions to be considered that may produce worrisome nail discoloration, such as subungual hemorrhage, squamous cell carcinoma, and pigmented onychomycosis.

*For a PDF of the full article, click on the link to the left of this introduction.

Beth S. Ruben, MD

Probably the most common reason to perform biopsy of the nail unit is for the evaluation of irregular pigmentation, especially longitudinal melanonychia or pigmented bands. When narrow and solitary, these are usually the product of melanocytic activation/hypermelanosis, lentigines, or melanocytic nevi. Multiple pigmented bands are generally a benign finding, the result of melanocytic activation, as seen in racial pigmentation in darker-skinned patients, for example. In the context of an irregular, broad, heterogeneous or “streaky” band, the chief concern is the exclusion of subungual melanoma. Before assessing the histologic features of any such entities, it is important to understand the normal nail anatomy and melanocytic density of nail unit epithelium, as well as the type of specimen submitted, and whether it is adequate to undertake a proper histologic evaluation. The criteria for diagnosis and prognosis of melanoma of the nail unit are still evolving, and a variety of factors must be weighed in the balance to make a correct diagnosis. The importance of the clinical context cannot be overemphasized. There are also nonmelanocytic conditions to be considered that may produce worrisome nail discoloration, such as subungual hemorrhage, squamous cell carcinoma, and pigmented onychomycosis.

*For a PDF of the full article, click on the link to the left of this introduction.

Beth S. Ruben, MD

Probably the most common reason to perform biopsy of the nail unit is for the evaluation of irregular pigmentation, especially longitudinal melanonychia or pigmented bands. When narrow and solitary, these are usually the product of melanocytic activation/hypermelanosis, lentigines, or melanocytic nevi. Multiple pigmented bands are generally a benign finding, the result of melanocytic activation, as seen in racial pigmentation in darker-skinned patients, for example. In the context of an irregular, broad, heterogeneous or “streaky” band, the chief concern is the exclusion of subungual melanoma. Before assessing the histologic features of any such entities, it is important to understand the normal nail anatomy and melanocytic density of nail unit epithelium, as well as the type of specimen submitted, and whether it is adequate to undertake a proper histologic evaluation. The criteria for diagnosis and prognosis of melanoma of the nail unit are still evolving, and a variety of factors must be weighed in the balance to make a correct diagnosis. The importance of the clinical context cannot be overemphasized. There are also nonmelanocytic conditions to be considered that may produce worrisome nail discoloration, such as subungual hemorrhage, squamous cell carcinoma, and pigmented onychomycosis.

*For a PDF of the full article, click on the link to the left of this introduction.

NAPLES, Fla. — Many women with hirsutism have already removed their excess, unwanted hair before they present to dermatology. Look beyond the shaving, bleaching, plucking, and waxing, Dr. Elise A. Olsen said, because dermatologists play an important role in identification of important medical conditions associated with excess hair growth.

"Patients seen for the cosmetic treatment of hirsutism provide an opportunity to screen for [other] common findings." Accurate diagnosis also optimizes dermatology treatment. "Most of your patients with hirsutism will be coming in for laser hair removal. Evaluation for hirsutism will affect your [result]," Dr. Olsen said at the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons.

Polycystic ovarian syndrome, adrenal abnormalities, and drug reactions are important considerations in a differential diagnosis. Rule out these and other causes of hirsutism, as well as acromegaly and premature ovarian failure, Dr. Olsen said.

Hirsutism is a common problem that affects at least 5% of the female population, said Dr. Olsen, director of the Duke Dermatopharmacology Study Center and professor of dermatology at Duke University Medical Center in Durham, N.C.

Begin your evaluation with patient and family history. Ask about history of menses, acne, and how often the woman removes unwanted hair. Note affected anatomic sites during your physical examination, and use the Ferriman-Gallwey hirsutism index to score results, Dr. Olsen said. Also perform a pelvic examination and order ultrasound if you suspect a tumor or other abnormality.

Measurement of serum dehydroepiandrosterone sulfate (DHEAS), androstenedione, prolactin, and sex-hormone–binding globulin (SHBG) can facilitate diagnosis. Other helpful laboratory assays include luteinizing hormone/follicle stimulating hormone (LH/FSH) levels, a glucose tolerance test with insulin levels, and a fasting lipid panel.

Simple blood work includes a check of testosterone levels, Dr. Olsen said. "You will catch 40% [of hyperandrogenemia in hirsutism] with elevated testosterone alone and 60% with elevated free testosterone." In addition, she added, "I have started to do DHT or dihydrotestosterone because it can catch idiopathic cases."

Polycystic ovarian syndrome (PCOS) affects an estimated 3%-11% of women of reproductive age. Keep in mind that Rotterdam consensus criteria do not apply to adolescent girls, women on oral contraceptive pills, or postmenopausal women, Dr. Olsen said.

"One of the most important things I will talk about is that 50%-60% of these women with PCOS have insulin resistance. They have a three to seven times increased risk of type 2 diabetes, decreased fertility, and increased risk of cardiovascular disease," Dr. Olsen said. Risk of endometrial cancer is also elevated.

Part of ruling in PCOS is ruling out congenital adrenal hyperplasia, which can be challenging because many symptoms overlap, Dr. Olsen said. To diagnose congenital adrenal hyperplasia, look for premature pubarche with early pubic hair, cystic acne, and accelerated growth in girls. These girls also will have advanced bone age but premature closure of epiphyses, "so, ultimately, they have short adult stature." In adult women, include amenorrhea, anovulation, oligomenorrhea, and infertility in your differential diagnosis.

Tumors that cause hirsutism are rare, Dr. Olsen said. "If someone is suddenly developing hirsutism, that should be in the back of your mind."

Not surprisingly, androgen medications can cause excess hair growth in women. Danazol (Danocrine, Sanofi-Synthelabo Inc.; plus generics), valproate sodium (Depacon, Abbott; plus generics), and valproic acid (Depakene, Abbott; plus generics) are other common drug-related causes. Take a thorough medication history that includes these agents as well as progesterone.

There is no drug specifically indicated to treat hirsutism approved for marketing by the Food and Drug Administration. One agent, eflornithine (Vaniqa, SkinMedica Inc.) is approved only for reduction of unwanted facial hair. "It decreases the rate of hair growth and amount of shaving a woman has to do," Dr. Olsen said. "It's a decrease in the rate of hair growth only" and not the amount of hair, so patient education and realistic expectations are important.

Disclosures: Dr. Olsen said she is a consultant for Merck & Co., an investigator for Eisai Pharmaceuticals, and she receives research support from both companies.

NAPLES, Fla. — Many women with hirsutism have already removed their excess, unwanted hair before they present to dermatology. Look beyond the shaving, bleaching, plucking, and waxing, Dr. Elise A. Olsen said, because dermatologists play an important role in identification of important medical conditions associated with excess hair growth.

"Patients seen for the cosmetic treatment of hirsutism provide an opportunity to screen for [other] common findings." Accurate diagnosis also optimizes dermatology treatment. "Most of your patients with hirsutism will be coming in for laser hair removal. Evaluation for hirsutism will affect your [result]," Dr. Olsen said at the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons.

Polycystic ovarian syndrome, adrenal abnormalities, and drug reactions are important considerations in a differential diagnosis. Rule out these and other causes of hirsutism, as well as acromegaly and premature ovarian failure, Dr. Olsen said.

Hirsutism is a common problem that affects at least 5% of the female population, said Dr. Olsen, director of the Duke Dermatopharmacology Study Center and professor of dermatology at Duke University Medical Center in Durham, N.C.

Begin your evaluation with patient and family history. Ask about history of menses, acne, and how often the woman removes unwanted hair. Note affected anatomic sites during your physical examination, and use the Ferriman-Gallwey hirsutism index to score results, Dr. Olsen said. Also perform a pelvic examination and order ultrasound if you suspect a tumor or other abnormality.

Measurement of serum dehydroepiandrosterone sulfate (DHEAS), androstenedione, prolactin, and sex-hormone–binding globulin (SHBG) can facilitate diagnosis. Other helpful laboratory assays include luteinizing hormone/follicle stimulating hormone (LH/FSH) levels, a glucose tolerance test with insulin levels, and a fasting lipid panel.

Simple blood work includes a check of testosterone levels, Dr. Olsen said. "You will catch 40% [of hyperandrogenemia in hirsutism] with elevated testosterone alone and 60% with elevated free testosterone." In addition, she added, "I have started to do DHT or dihydrotestosterone because it can catch idiopathic cases."

Polycystic ovarian syndrome (PCOS) affects an estimated 3%-11% of women of reproductive age. Keep in mind that Rotterdam consensus criteria do not apply to adolescent girls, women on oral contraceptive pills, or postmenopausal women, Dr. Olsen said.

"One of the most important things I will talk about is that 50%-60% of these women with PCOS have insulin resistance. They have a three to seven times increased risk of type 2 diabetes, decreased fertility, and increased risk of cardiovascular disease," Dr. Olsen said. Risk of endometrial cancer is also elevated.

Part of ruling in PCOS is ruling out congenital adrenal hyperplasia, which can be challenging because many symptoms overlap, Dr. Olsen said. To diagnose congenital adrenal hyperplasia, look for premature pubarche with early pubic hair, cystic acne, and accelerated growth in girls. These girls also will have advanced bone age but premature closure of epiphyses, "so, ultimately, they have short adult stature." In adult women, include amenorrhea, anovulation, oligomenorrhea, and infertility in your differential diagnosis.

Tumors that cause hirsutism are rare, Dr. Olsen said. "If someone is suddenly developing hirsutism, that should be in the back of your mind."

Not surprisingly, androgen medications can cause excess hair growth in women. Danazol (Danocrine, Sanofi-Synthelabo Inc.; plus generics), valproate sodium (Depacon, Abbott; plus generics), and valproic acid (Depakene, Abbott; plus generics) are other common drug-related causes. Take a thorough medication history that includes these agents as well as progesterone.

There is no drug specifically indicated to treat hirsutism approved for marketing by the Food and Drug Administration. One agent, eflornithine (Vaniqa, SkinMedica Inc.) is approved only for reduction of unwanted facial hair. "It decreases the rate of hair growth and amount of shaving a woman has to do," Dr. Olsen said. "It's a decrease in the rate of hair growth only" and not the amount of hair, so patient education and realistic expectations are important.

Disclosures: Dr. Olsen said she is a consultant for Merck & Co., an investigator for Eisai Pharmaceuticals, and she receives research support from both companies.

NAPLES, Fla. — Many women with hirsutism have already removed their excess, unwanted hair before they present to dermatology. Look beyond the shaving, bleaching, plucking, and waxing, Dr. Elise A. Olsen said, because dermatologists play an important role in identification of important medical conditions associated with excess hair growth.

"Patients seen for the cosmetic treatment of hirsutism provide an opportunity to screen for [other] common findings." Accurate diagnosis also optimizes dermatology treatment. "Most of your patients with hirsutism will be coming in for laser hair removal. Evaluation for hirsutism will affect your [result]," Dr. Olsen said at the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons.

Polycystic ovarian syndrome, adrenal abnormalities, and drug reactions are important considerations in a differential diagnosis. Rule out these and other causes of hirsutism, as well as acromegaly and premature ovarian failure, Dr. Olsen said.

Hirsutism is a common problem that affects at least 5% of the female population, said Dr. Olsen, director of the Duke Dermatopharmacology Study Center and professor of dermatology at Duke University Medical Center in Durham, N.C.

Begin your evaluation with patient and family history. Ask about history of menses, acne, and how often the woman removes unwanted hair. Note affected anatomic sites during your physical examination, and use the Ferriman-Gallwey hirsutism index to score results, Dr. Olsen said. Also perform a pelvic examination and order ultrasound if you suspect a tumor or other abnormality.

Measurement of serum dehydroepiandrosterone sulfate (DHEAS), androstenedione, prolactin, and sex-hormone–binding globulin (SHBG) can facilitate diagnosis. Other helpful laboratory assays include luteinizing hormone/follicle stimulating hormone (LH/FSH) levels, a glucose tolerance test with insulin levels, and a fasting lipid panel.

Simple blood work includes a check of testosterone levels, Dr. Olsen said. "You will catch 40% [of hyperandrogenemia in hirsutism] with elevated testosterone alone and 60% with elevated free testosterone." In addition, she added, "I have started to do DHT or dihydrotestosterone because it can catch idiopathic cases."

Polycystic ovarian syndrome (PCOS) affects an estimated 3%-11% of women of reproductive age. Keep in mind that Rotterdam consensus criteria do not apply to adolescent girls, women on oral contraceptive pills, or postmenopausal women, Dr. Olsen said.

"One of the most important things I will talk about is that 50%-60% of these women with PCOS have insulin resistance. They have a three to seven times increased risk of type 2 diabetes, decreased fertility, and increased risk of cardiovascular disease," Dr. Olsen said. Risk of endometrial cancer is also elevated.

Part of ruling in PCOS is ruling out congenital adrenal hyperplasia, which can be challenging because many symptoms overlap, Dr. Olsen said. To diagnose congenital adrenal hyperplasia, look for premature pubarche with early pubic hair, cystic acne, and accelerated growth in girls. These girls also will have advanced bone age but premature closure of epiphyses, "so, ultimately, they have short adult stature." In adult women, include amenorrhea, anovulation, oligomenorrhea, and infertility in your differential diagnosis.

Tumors that cause hirsutism are rare, Dr. Olsen said. "If someone is suddenly developing hirsutism, that should be in the back of your mind."

Not surprisingly, androgen medications can cause excess hair growth in women. Danazol (Danocrine, Sanofi-Synthelabo Inc.; plus generics), valproate sodium (Depacon, Abbott; plus generics), and valproic acid (Depakene, Abbott; plus generics) are other common drug-related causes. Take a thorough medication history that includes these agents as well as progesterone.

There is no drug specifically indicated to treat hirsutism approved for marketing by the Food and Drug Administration. One agent, eflornithine (Vaniqa, SkinMedica Inc.) is approved only for reduction of unwanted facial hair. "It decreases the rate of hair growth and amount of shaving a woman has to do," Dr. Olsen said. "It's a decrease in the rate of hair growth only" and not the amount of hair, so patient education and realistic expectations are important.

Disclosures: Dr. Olsen said she is a consultant for Merck & Co., an investigator for Eisai Pharmaceuticals, and she receives research support from both companies.

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.

"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.

Photos courtesy Dr. George Cohen

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.

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.

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.

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.

"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.

Photos courtesy Dr. George Cohen

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.

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.

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.

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.

"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.

Photos courtesy Dr. George Cohen

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.

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.

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.