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Diagnosing hair loss in black patients starts with right questions
NEW YORK – To get to the root cause of hair loss in African American patients, ask them about their chemical styling and physical styling practices, advised Dr. Roopal V. Kundu.
"Ask them about the hair products they use; how they style their hair; what kind of relaxers they use; what kind of heat, how much of it, and how often they use it; and find out if they’re wearing extensions or weaves," she said to a packed room during the American Academy of Dermatology summer meeting.
"And get their hair stylist’s input," said Dr. Kundu, director of the Center for Ethnic Skin at Northwestern University, Chicago.
Central centrifugal cicatricial alopecia (CCCA) is one of the most common types of hair loss in African American women, Dr. Kundu said. The reason for the prevalence of CCCA in this population remains unclear, but data from several studies point not only to genetic and ethnic predispositions, but also to hair styling practices.
Data from one study showed that women with CCCA were significantly more likely to report recent traumatic hairstyling than were those who did not have the condition (J. Am. Acad. Dermatol. 2009;60:574-8).
"Educate your patients [about the effect of hairstyling practices on hair loss] as early as possible," and suspect CCCA in patients who present with a lot of breakage in their hair, even if they have no sign of alopecia or scalp inflammation, Dr. Kundu said.
Keep chemical and physical hairstyling practices in mind when examining and diagnosing hair loss in black women, she noted.
Chemical relaxers, also known as perms, are one of the most common treatments used by African American women. The relaxers are used to loosen tight curls and are applied every 6-8 weeks to new growth only. There are two types of relaxers: lye (professional product) or no lye (at-home use). The lye relaxers have more potential for irritation, Dr. Kundu said.
Physical styling, which usually pulls on hair, also can be a factor in hair loss, she explained. Some popular types of physical styling include:
• Braids, which often involve added synthetic hair and are left in place for weeks to months.
• Twisting, which involves interlocking two pieces of hair to create a loose or bound-down, three-dimensional hair style.
• Cornrows, which are braids that lie flat against the scalp, with or without added hair, that can cause excessive tension on the hair.
• Locks or dreads, which are matted coils of hair.
• Weaves, which can be clipped, glued, or sewn into place.
In addition, thermal styling (with tools such as flatirons) is a popular treatment that can damage the hair because of the high temperature of the iron, Dr. Kundu said.
When examining a skin of color patient who presents with hair loss, note their hairstyle first, Dr. Kundu emphasized. "Ask them to take their hairpiece off [if they are wearing one]. If the hairstyle doesn’t allow you to examine the scalp, the patient needs to come back between hairstyles," she said.
Grab a dermatoscope and examine the scalp, Dr. Kundu said. Look for hair loss, hair breakage, and traction. She cited a recent study suggesting that early CCCA should be considered in the differential diagnosis of these patients (Arch. Dermatol. 2012;148:1047-52).
"And don’t dismiss scalp dysesthesia* in a black woman," Dr. Kundu emphasized. "I really take this to heart," she said.
Biopsy the patient, "and always go for the periphery to see if there is active inflammation," since the central area of hair loss is usually scarred, she noted.
Dr. Kundu said that she usually prescribes potent to superpotent topical steroids, such as fluocinonide daily, and then reduces the steroid to 1-3 times a week for maintenance. She also performs intralesional injections every 6 weeks, and stops if she sees no efficacy after 3-4 serial injections.
When prescribing minoxidil, she advised taking the patient’s facial hair into consideration, and warns them about additional facial hair growth.
For patients with significant inflammation, Dr. Kundu said she first turns to doxycycline (starting at 100 mg twice a day and tapering to anti-inflammatory doses of 50 mg daily) for a total of 3-6 months.
Meanwhile, advise women with hair loss or hair loss concerns to modify their grooming practices to avoid hairstyles that pull on the scalp, she said. Also advise them to let their hair go natural completely for at least a year if possible. "It’s a hard job to do for some patients," she acknowledged, so at least encourage them to apply chemical relaxers less frequently, every 10-12 weeks instead, she said.
In addition, ask these patients to refrain from using heat on their hair more than once or twice per week, and suggest air-drying instead, she said.
Dr. Kundu had no relevant financial conflicts to disclose.
On Twitter @naseemsmiller
*CORRECTION, 10/21/13: An earlier version of this article misstated the effects of dysesthesia.
NEW YORK – To get to the root cause of hair loss in African American patients, ask them about their chemical styling and physical styling practices, advised Dr. Roopal V. Kundu.
"Ask them about the hair products they use; how they style their hair; what kind of relaxers they use; what kind of heat, how much of it, and how often they use it; and find out if they’re wearing extensions or weaves," she said to a packed room during the American Academy of Dermatology summer meeting.
"And get their hair stylist’s input," said Dr. Kundu, director of the Center for Ethnic Skin at Northwestern University, Chicago.
Central centrifugal cicatricial alopecia (CCCA) is one of the most common types of hair loss in African American women, Dr. Kundu said. The reason for the prevalence of CCCA in this population remains unclear, but data from several studies point not only to genetic and ethnic predispositions, but also to hair styling practices.
Data from one study showed that women with CCCA were significantly more likely to report recent traumatic hairstyling than were those who did not have the condition (J. Am. Acad. Dermatol. 2009;60:574-8).
"Educate your patients [about the effect of hairstyling practices on hair loss] as early as possible," and suspect CCCA in patients who present with a lot of breakage in their hair, even if they have no sign of alopecia or scalp inflammation, Dr. Kundu said.
Keep chemical and physical hairstyling practices in mind when examining and diagnosing hair loss in black women, she noted.
Chemical relaxers, also known as perms, are one of the most common treatments used by African American women. The relaxers are used to loosen tight curls and are applied every 6-8 weeks to new growth only. There are two types of relaxers: lye (professional product) or no lye (at-home use). The lye relaxers have more potential for irritation, Dr. Kundu said.
Physical styling, which usually pulls on hair, also can be a factor in hair loss, she explained. Some popular types of physical styling include:
• Braids, which often involve added synthetic hair and are left in place for weeks to months.
• Twisting, which involves interlocking two pieces of hair to create a loose or bound-down, three-dimensional hair style.
• Cornrows, which are braids that lie flat against the scalp, with or without added hair, that can cause excessive tension on the hair.
• Locks or dreads, which are matted coils of hair.
• Weaves, which can be clipped, glued, or sewn into place.
In addition, thermal styling (with tools such as flatirons) is a popular treatment that can damage the hair because of the high temperature of the iron, Dr. Kundu said.
When examining a skin of color patient who presents with hair loss, note their hairstyle first, Dr. Kundu emphasized. "Ask them to take their hairpiece off [if they are wearing one]. If the hairstyle doesn’t allow you to examine the scalp, the patient needs to come back between hairstyles," she said.
Grab a dermatoscope and examine the scalp, Dr. Kundu said. Look for hair loss, hair breakage, and traction. She cited a recent study suggesting that early CCCA should be considered in the differential diagnosis of these patients (Arch. Dermatol. 2012;148:1047-52).
"And don’t dismiss scalp dysesthesia* in a black woman," Dr. Kundu emphasized. "I really take this to heart," she said.
Biopsy the patient, "and always go for the periphery to see if there is active inflammation," since the central area of hair loss is usually scarred, she noted.
Dr. Kundu said that she usually prescribes potent to superpotent topical steroids, such as fluocinonide daily, and then reduces the steroid to 1-3 times a week for maintenance. She also performs intralesional injections every 6 weeks, and stops if she sees no efficacy after 3-4 serial injections.
When prescribing minoxidil, she advised taking the patient’s facial hair into consideration, and warns them about additional facial hair growth.
For patients with significant inflammation, Dr. Kundu said she first turns to doxycycline (starting at 100 mg twice a day and tapering to anti-inflammatory doses of 50 mg daily) for a total of 3-6 months.
Meanwhile, advise women with hair loss or hair loss concerns to modify their grooming practices to avoid hairstyles that pull on the scalp, she said. Also advise them to let their hair go natural completely for at least a year if possible. "It’s a hard job to do for some patients," she acknowledged, so at least encourage them to apply chemical relaxers less frequently, every 10-12 weeks instead, she said.
In addition, ask these patients to refrain from using heat on their hair more than once or twice per week, and suggest air-drying instead, she said.
Dr. Kundu had no relevant financial conflicts to disclose.
On Twitter @naseemsmiller
*CORRECTION, 10/21/13: An earlier version of this article misstated the effects of dysesthesia.
NEW YORK – To get to the root cause of hair loss in African American patients, ask them about their chemical styling and physical styling practices, advised Dr. Roopal V. Kundu.
"Ask them about the hair products they use; how they style their hair; what kind of relaxers they use; what kind of heat, how much of it, and how often they use it; and find out if they’re wearing extensions or weaves," she said to a packed room during the American Academy of Dermatology summer meeting.
"And get their hair stylist’s input," said Dr. Kundu, director of the Center for Ethnic Skin at Northwestern University, Chicago.
Central centrifugal cicatricial alopecia (CCCA) is one of the most common types of hair loss in African American women, Dr. Kundu said. The reason for the prevalence of CCCA in this population remains unclear, but data from several studies point not only to genetic and ethnic predispositions, but also to hair styling practices.
Data from one study showed that women with CCCA were significantly more likely to report recent traumatic hairstyling than were those who did not have the condition (J. Am. Acad. Dermatol. 2009;60:574-8).
"Educate your patients [about the effect of hairstyling practices on hair loss] as early as possible," and suspect CCCA in patients who present with a lot of breakage in their hair, even if they have no sign of alopecia or scalp inflammation, Dr. Kundu said.
Keep chemical and physical hairstyling practices in mind when examining and diagnosing hair loss in black women, she noted.
Chemical relaxers, also known as perms, are one of the most common treatments used by African American women. The relaxers are used to loosen tight curls and are applied every 6-8 weeks to new growth only. There are two types of relaxers: lye (professional product) or no lye (at-home use). The lye relaxers have more potential for irritation, Dr. Kundu said.
Physical styling, which usually pulls on hair, also can be a factor in hair loss, she explained. Some popular types of physical styling include:
• Braids, which often involve added synthetic hair and are left in place for weeks to months.
• Twisting, which involves interlocking two pieces of hair to create a loose or bound-down, three-dimensional hair style.
• Cornrows, which are braids that lie flat against the scalp, with or without added hair, that can cause excessive tension on the hair.
• Locks or dreads, which are matted coils of hair.
• Weaves, which can be clipped, glued, or sewn into place.
In addition, thermal styling (with tools such as flatirons) is a popular treatment that can damage the hair because of the high temperature of the iron, Dr. Kundu said.
When examining a skin of color patient who presents with hair loss, note their hairstyle first, Dr. Kundu emphasized. "Ask them to take their hairpiece off [if they are wearing one]. If the hairstyle doesn’t allow you to examine the scalp, the patient needs to come back between hairstyles," she said.
Grab a dermatoscope and examine the scalp, Dr. Kundu said. Look for hair loss, hair breakage, and traction. She cited a recent study suggesting that early CCCA should be considered in the differential diagnosis of these patients (Arch. Dermatol. 2012;148:1047-52).
"And don’t dismiss scalp dysesthesia* in a black woman," Dr. Kundu emphasized. "I really take this to heart," she said.
Biopsy the patient, "and always go for the periphery to see if there is active inflammation," since the central area of hair loss is usually scarred, she noted.
Dr. Kundu said that she usually prescribes potent to superpotent topical steroids, such as fluocinonide daily, and then reduces the steroid to 1-3 times a week for maintenance. She also performs intralesional injections every 6 weeks, and stops if she sees no efficacy after 3-4 serial injections.
When prescribing minoxidil, she advised taking the patient’s facial hair into consideration, and warns them about additional facial hair growth.
For patients with significant inflammation, Dr. Kundu said she first turns to doxycycline (starting at 100 mg twice a day and tapering to anti-inflammatory doses of 50 mg daily) for a total of 3-6 months.
Meanwhile, advise women with hair loss or hair loss concerns to modify their grooming practices to avoid hairstyles that pull on the scalp, she said. Also advise them to let their hair go natural completely for at least a year if possible. "It’s a hard job to do for some patients," she acknowledged, so at least encourage them to apply chemical relaxers less frequently, every 10-12 weeks instead, she said.
In addition, ask these patients to refrain from using heat on their hair more than once or twice per week, and suggest air-drying instead, she said.
Dr. Kundu had no relevant financial conflicts to disclose.
On Twitter @naseemsmiller
*CORRECTION, 10/21/13: An earlier version of this article misstated the effects of dysesthesia.
AT THE AAD SUMMER ACADEMY 2013
Product News: 10 2013
Botox Cosmetic
Allergan, Inc, obtains US Food and Drug Administration approval of Botox Cosmetic (onabotulinumtoxinA) for temporary improvement of moderate to severe lateral canthal lines (crow’s-feet) in adults. It blocks nerve impulses and reduces muscle movements around the eyes. This indication will allow physicians to treat both crow’s-feet and frown lines (approved in 2002 for this latter indication) with little downtime for patients. For more information, visit www.allergan.com.
Fabior Foam 0.1%
Stiefel, a GSK company, receives US Food and Drug Administration approval of Fabior (tazarotene) Foam 0.1% for the treatment of acne vulgaris in patients 12 years and older. Fabior Foam is applied once daily before bedtime. For more information, visit www.fabiorfoam.com.
NIA24 Intensive Retinol Repair
Niadyne, Inc, introduces NIA24 Intensive Retinol Repair for photodamage. It targets the major signs of UV damage including wrinkles, hyperpigmentation, lack of firmness, and uneven texture and tone. Formulated with ProNiacin and retinol, NIA24 Intensive Retinol Repair strengthens the skin barrier and increases collagen. It is an alternative for patients who cannot tolerate retinoic acid or traditional retinol treatments. A prescription is not required, and it can be applied daily. For more information, visit www.NIA24.com.
Stelara
Janssen Biotech Inc obtains US Food and Drug Administration approval of Stelara (ustekinumab) to treat patients with active psoriatic arthritis, alone or in combination with methotrexate. Stelara targets the cytokines IL-12 and IL-23 to control joint pain, swelling, and stiffness associated with psoriatic arthritis, in addition to psoriasis plaque thickness, scaling, and redness. Stelara is administered every 12 weeks after 2 starter doses for the treatment of psoriatic arthritis. For more information, visit www.stelarainfo.com.
XTRAC Velocity 7
PhotoMedex Inc introduces XTRAC Velocity 7 with an advanced user interface for psoriasis and vitiligo. Using UVB light, the XTRAC excimer laser treats areas of the skin affected by psoriasis or vitiligo without harming the surrounding tissue. XTRAC Velocity 7 offers increased efficiency, with the rate of output increasing the speed for delivery of treatment. Treatment guidelines and suggestions based on body area are provided using the touch screen. It can be used on hard-to-reach areas such as the elbows, knees, and scalp. Before and after photographs can be stored to show progression of resolution, enhancing patient compliance. The manufacturer also offers a patient advocacy program for patients to call and obtain answers to product and insurance questions from a live operator; patients also can book appointments with a participating physician faster using the XTRAC TeleCare Center. For more information, visit www.xtracnow.com
Botox Cosmetic
Allergan, Inc, obtains US Food and Drug Administration approval of Botox Cosmetic (onabotulinumtoxinA) for temporary improvement of moderate to severe lateral canthal lines (crow’s-feet) in adults. It blocks nerve impulses and reduces muscle movements around the eyes. This indication will allow physicians to treat both crow’s-feet and frown lines (approved in 2002 for this latter indication) with little downtime for patients. For more information, visit www.allergan.com.
Fabior Foam 0.1%
Stiefel, a GSK company, receives US Food and Drug Administration approval of Fabior (tazarotene) Foam 0.1% for the treatment of acne vulgaris in patients 12 years and older. Fabior Foam is applied once daily before bedtime. For more information, visit www.fabiorfoam.com.
NIA24 Intensive Retinol Repair
Niadyne, Inc, introduces NIA24 Intensive Retinol Repair for photodamage. It targets the major signs of UV damage including wrinkles, hyperpigmentation, lack of firmness, and uneven texture and tone. Formulated with ProNiacin and retinol, NIA24 Intensive Retinol Repair strengthens the skin barrier and increases collagen. It is an alternative for patients who cannot tolerate retinoic acid or traditional retinol treatments. A prescription is not required, and it can be applied daily. For more information, visit www.NIA24.com.
Stelara
Janssen Biotech Inc obtains US Food and Drug Administration approval of Stelara (ustekinumab) to treat patients with active psoriatic arthritis, alone or in combination with methotrexate. Stelara targets the cytokines IL-12 and IL-23 to control joint pain, swelling, and stiffness associated with psoriatic arthritis, in addition to psoriasis plaque thickness, scaling, and redness. Stelara is administered every 12 weeks after 2 starter doses for the treatment of psoriatic arthritis. For more information, visit www.stelarainfo.com.
XTRAC Velocity 7
PhotoMedex Inc introduces XTRAC Velocity 7 with an advanced user interface for psoriasis and vitiligo. Using UVB light, the XTRAC excimer laser treats areas of the skin affected by psoriasis or vitiligo without harming the surrounding tissue. XTRAC Velocity 7 offers increased efficiency, with the rate of output increasing the speed for delivery of treatment. Treatment guidelines and suggestions based on body area are provided using the touch screen. It can be used on hard-to-reach areas such as the elbows, knees, and scalp. Before and after photographs can be stored to show progression of resolution, enhancing patient compliance. The manufacturer also offers a patient advocacy program for patients to call and obtain answers to product and insurance questions from a live operator; patients also can book appointments with a participating physician faster using the XTRAC TeleCare Center. For more information, visit www.xtracnow.com
Botox Cosmetic
Allergan, Inc, obtains US Food and Drug Administration approval of Botox Cosmetic (onabotulinumtoxinA) for temporary improvement of moderate to severe lateral canthal lines (crow’s-feet) in adults. It blocks nerve impulses and reduces muscle movements around the eyes. This indication will allow physicians to treat both crow’s-feet and frown lines (approved in 2002 for this latter indication) with little downtime for patients. For more information, visit www.allergan.com.
Fabior Foam 0.1%
Stiefel, a GSK company, receives US Food and Drug Administration approval of Fabior (tazarotene) Foam 0.1% for the treatment of acne vulgaris in patients 12 years and older. Fabior Foam is applied once daily before bedtime. For more information, visit www.fabiorfoam.com.
NIA24 Intensive Retinol Repair
Niadyne, Inc, introduces NIA24 Intensive Retinol Repair for photodamage. It targets the major signs of UV damage including wrinkles, hyperpigmentation, lack of firmness, and uneven texture and tone. Formulated with ProNiacin and retinol, NIA24 Intensive Retinol Repair strengthens the skin barrier and increases collagen. It is an alternative for patients who cannot tolerate retinoic acid or traditional retinol treatments. A prescription is not required, and it can be applied daily. For more information, visit www.NIA24.com.
Stelara
Janssen Biotech Inc obtains US Food and Drug Administration approval of Stelara (ustekinumab) to treat patients with active psoriatic arthritis, alone or in combination with methotrexate. Stelara targets the cytokines IL-12 and IL-23 to control joint pain, swelling, and stiffness associated with psoriatic arthritis, in addition to psoriasis plaque thickness, scaling, and redness. Stelara is administered every 12 weeks after 2 starter doses for the treatment of psoriatic arthritis. For more information, visit www.stelarainfo.com.
XTRAC Velocity 7
PhotoMedex Inc introduces XTRAC Velocity 7 with an advanced user interface for psoriasis and vitiligo. Using UVB light, the XTRAC excimer laser treats areas of the skin affected by psoriasis or vitiligo without harming the surrounding tissue. XTRAC Velocity 7 offers increased efficiency, with the rate of output increasing the speed for delivery of treatment. Treatment guidelines and suggestions based on body area are provided using the touch screen. It can be used on hard-to-reach areas such as the elbows, knees, and scalp. Before and after photographs can be stored to show progression of resolution, enhancing patient compliance. The manufacturer also offers a patient advocacy program for patients to call and obtain answers to product and insurance questions from a live operator; patients also can book appointments with a participating physician faster using the XTRAC TeleCare Center. For more information, visit www.xtracnow.com
Treatment of Minocycline-Induced Cutaneous Hyperpigmentation With the Q-switched Alexandrite Laser
When a Tattoo Is No Longer Wanted: A Review of Tattoo Removal
Mulberry
Often in this column, several species within a family might be discussed in relation to a broad range of health benefits. Licorice and mushrooms are good examples. In this case, and in this column, the focus will be on several species within a family that are thought to confer the same type of dermatologic benefit. The Morus genus within the Moraceae family appears to include several species that display skin-lightening properties.
Tyrosinase is the enzyme that controls the production of melanin. Suppressing tyrosinase activity to achieve skin lightening is a well-established method in dermatologic practice. The desire for products with fewer side effects than the mainstay, hydroquinone, or natural products such as kojic acid or arbutin, has led to investigations of several species in the Moraceae family. Notably, several Moraceae trees have been found to exhibit antioxidant activity (Int. J. Mol. Sci. 2012;13:2472-80; Biol. Pharm. Bull. 2002;25:1045-8; Biosci. Biotechnol. Biochem. 2010;74:2385-95; J. Pharm. Pharmacol. 2004;56:1291-8). The focus here, though, will be on the skin-lightening activity of various parts of Morus (commonly known as mulberry) trees.
In 2013, Singh et al. assessed the effects of mulberry, kiwi, and Sophora extracts on melanogenesis and melanin transfer in human melanocytes and in cocultures with phototype-matched normal adult epidermal keratinocytes. The extracts were evaluated against isobutylmethylxanthine, hydroquinone, vitamin C, and niacinamide. The investigators found that compared with unstimulated control, mulberry, kiwi, and Sophora extracts significantly reduced melanogenesis in normal adult epidermal melanocytes and human melanoma cells. Melanin transfer also was lowered, as was filopodia expression on melanocytes. The authors concluded that the test compounds compared well with standard-bearing depigmenting agents and warrant consideration as topical agents for diminishing hyperpigmentation (Exp. Dermatol. 2013;22:67-9).
Encouraging results in melasma treatment
A randomized, single-blind, placebo-controlled trial of 50 Filipino patients (49 women, 1 man) to examine the safety and efficacy of 75% Morus alba (white mulberry) extract oil was conducted by Alvin et al. in 2011. Patients were evaluated at weeks 4 and 8. The Melasma Area and Severity Index (MASI) score, Mexameter score, and Melasma Quality of Life (MelasQOL) score were measured, with the mulberry extract group performing significantly better than the placebo group according to all metrics.
The 25 patients treated with mulberry extract showed improvement in the MASI score, from 4.076 at baseline to 2.884 at week 8 (mean difference, 1.19); the mean difference for the placebo group was 0.06. The mean Mexameter reading revealed a significant difference, with a slight increase for the mulberry group (indicating lighter pigmentation), and the placebo group scored a slightly higher value. In addition, the MelasQOL score for the mulberry group improved markedly from baseline to week 8 (58.84 to 44.16), whereas the placebo group score improved only slightly, from 57.44 at baseline to 54.28 at week 8.
Adverse events were rare, with mild itching in 4 patients reported from the mulberry group, and 12 cases of either itching or erythema reported by the placebo group.
The investigators concluded that 75% mulberry extract oil objectively diminishes the hyperpigmentation of melasma in skin types III-V, although they recommend additional research with a larger sample size and longer treatment duration and follow-up (J. Drugs Dermatol. 2011;10:1025-31).
Paper mulberry
The bark of paper mulberry (Broussonetia papyrifera, also known as Morus papyrifera) is composed of extremely strong fibers used to produce high-quality paper and cloth. In China, the leaves, stem, leaf juice, roots, fruits, and bark have all been found to impart various health benefits, with the stem and leaf juice used to treat skin disorders and insect bites (Phytother. Res. 2012;26:1-10).
In one study, a 0.4% concentration of paper mulberry extract was demonstrated to suppress tyrosinase activity by 50% compared with 5.5% hydroquinone and 10% kojic acid. Notably, paper mulberry is not considered a significant irritant even at 1% concentration (J. Drugs Dermatol. 2009;8:s5-9).
White mulberry
In 2002, Lee et al. investigated the in vitro effects of an 85% methanol extract of dried white mulberry leaves on melanin biosynthesis. They found that one of the primary bioactive constituents, mulberroside F (moracin M-6, 3’-di-O-beta-D-glucopyranoside), inhibited the tyrosinase activity that converts dopa to dopachrome in the melanin synthesis process and also suppressed the melanin formation of melan-a cells. In addition, the mulberry extract inhibited tyrosinase activity more potently than did kojic acid (Biol. Pharm. Bull. 2002;25:1045-8).
The following year, a different team found that the young twigs of white mulberry also suppressed tyrosinase activity as well as melanin production in B-16 melanoma cells. In vivo, the extracts decreased melanin synthesis in a guinea pig model without displaying toxicity (J. Cosmet. Sci. 2003;54:133-42).
In 2006, Wang et al. investigated 25 traditional Chinese herbal medicines potentially useful in dermatology, particularly for skin whitening, and found that white mulberry was one of four species to potently inhibit tyrosinase activity, and more strongly than arbutin did (J. Ethnopharmacol. 2006;106:353-9).
Chinese mulberry/shimaguwa
In 2012, Zheng et al. isolated constituents from the roots of Chinese mulberry and found that several ingredients, including oxyresveratrol, moracenin D, sanggenon T, and kuwanon O, displayed more potent tyrosinase inhibition than kojic acid did. They concluded that Chinese mulberry is a good natural source of tyrosinase inhibitors and is potentially useful in cosmetic skin-lightening products as well as in foods as antibrowning agents (Fitoterapia 2012;83:1008-13).
Conclusion
Mulberry is actively used within the dermatologic armamentarium as one of the many options for skin lightening. A significant body of evidence has emerged over the past 15 years to establish the antityrosinase activity of various mulberry species, particularly white mulberry and paper mulberry.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook "Cosmetic Dermatology: Principles and Practice" (McGraw-Hill, 2009), and a book for consumers, "The Skin Type Solution" (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001 and joined the editorial advisory board in 2004. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.
Often in this column, several species within a family might be discussed in relation to a broad range of health benefits. Licorice and mushrooms are good examples. In this case, and in this column, the focus will be on several species within a family that are thought to confer the same type of dermatologic benefit. The Morus genus within the Moraceae family appears to include several species that display skin-lightening properties.
Tyrosinase is the enzyme that controls the production of melanin. Suppressing tyrosinase activity to achieve skin lightening is a well-established method in dermatologic practice. The desire for products with fewer side effects than the mainstay, hydroquinone, or natural products such as kojic acid or arbutin, has led to investigations of several species in the Moraceae family. Notably, several Moraceae trees have been found to exhibit antioxidant activity (Int. J. Mol. Sci. 2012;13:2472-80; Biol. Pharm. Bull. 2002;25:1045-8; Biosci. Biotechnol. Biochem. 2010;74:2385-95; J. Pharm. Pharmacol. 2004;56:1291-8). The focus here, though, will be on the skin-lightening activity of various parts of Morus (commonly known as mulberry) trees.
In 2013, Singh et al. assessed the effects of mulberry, kiwi, and Sophora extracts on melanogenesis and melanin transfer in human melanocytes and in cocultures with phototype-matched normal adult epidermal keratinocytes. The extracts were evaluated against isobutylmethylxanthine, hydroquinone, vitamin C, and niacinamide. The investigators found that compared with unstimulated control, mulberry, kiwi, and Sophora extracts significantly reduced melanogenesis in normal adult epidermal melanocytes and human melanoma cells. Melanin transfer also was lowered, as was filopodia expression on melanocytes. The authors concluded that the test compounds compared well with standard-bearing depigmenting agents and warrant consideration as topical agents for diminishing hyperpigmentation (Exp. Dermatol. 2013;22:67-9).
Encouraging results in melasma treatment
A randomized, single-blind, placebo-controlled trial of 50 Filipino patients (49 women, 1 man) to examine the safety and efficacy of 75% Morus alba (white mulberry) extract oil was conducted by Alvin et al. in 2011. Patients were evaluated at weeks 4 and 8. The Melasma Area and Severity Index (MASI) score, Mexameter score, and Melasma Quality of Life (MelasQOL) score were measured, with the mulberry extract group performing significantly better than the placebo group according to all metrics.
The 25 patients treated with mulberry extract showed improvement in the MASI score, from 4.076 at baseline to 2.884 at week 8 (mean difference, 1.19); the mean difference for the placebo group was 0.06. The mean Mexameter reading revealed a significant difference, with a slight increase for the mulberry group (indicating lighter pigmentation), and the placebo group scored a slightly higher value. In addition, the MelasQOL score for the mulberry group improved markedly from baseline to week 8 (58.84 to 44.16), whereas the placebo group score improved only slightly, from 57.44 at baseline to 54.28 at week 8.
Adverse events were rare, with mild itching in 4 patients reported from the mulberry group, and 12 cases of either itching or erythema reported by the placebo group.
The investigators concluded that 75% mulberry extract oil objectively diminishes the hyperpigmentation of melasma in skin types III-V, although they recommend additional research with a larger sample size and longer treatment duration and follow-up (J. Drugs Dermatol. 2011;10:1025-31).
Paper mulberry
The bark of paper mulberry (Broussonetia papyrifera, also known as Morus papyrifera) is composed of extremely strong fibers used to produce high-quality paper and cloth. In China, the leaves, stem, leaf juice, roots, fruits, and bark have all been found to impart various health benefits, with the stem and leaf juice used to treat skin disorders and insect bites (Phytother. Res. 2012;26:1-10).
In one study, a 0.4% concentration of paper mulberry extract was demonstrated to suppress tyrosinase activity by 50% compared with 5.5% hydroquinone and 10% kojic acid. Notably, paper mulberry is not considered a significant irritant even at 1% concentration (J. Drugs Dermatol. 2009;8:s5-9).
White mulberry
In 2002, Lee et al. investigated the in vitro effects of an 85% methanol extract of dried white mulberry leaves on melanin biosynthesis. They found that one of the primary bioactive constituents, mulberroside F (moracin M-6, 3’-di-O-beta-D-glucopyranoside), inhibited the tyrosinase activity that converts dopa to dopachrome in the melanin synthesis process and also suppressed the melanin formation of melan-a cells. In addition, the mulberry extract inhibited tyrosinase activity more potently than did kojic acid (Biol. Pharm. Bull. 2002;25:1045-8).
The following year, a different team found that the young twigs of white mulberry also suppressed tyrosinase activity as well as melanin production in B-16 melanoma cells. In vivo, the extracts decreased melanin synthesis in a guinea pig model without displaying toxicity (J. Cosmet. Sci. 2003;54:133-42).
In 2006, Wang et al. investigated 25 traditional Chinese herbal medicines potentially useful in dermatology, particularly for skin whitening, and found that white mulberry was one of four species to potently inhibit tyrosinase activity, and more strongly than arbutin did (J. Ethnopharmacol. 2006;106:353-9).
Chinese mulberry/shimaguwa
In 2012, Zheng et al. isolated constituents from the roots of Chinese mulberry and found that several ingredients, including oxyresveratrol, moracenin D, sanggenon T, and kuwanon O, displayed more potent tyrosinase inhibition than kojic acid did. They concluded that Chinese mulberry is a good natural source of tyrosinase inhibitors and is potentially useful in cosmetic skin-lightening products as well as in foods as antibrowning agents (Fitoterapia 2012;83:1008-13).
Conclusion
Mulberry is actively used within the dermatologic armamentarium as one of the many options for skin lightening. A significant body of evidence has emerged over the past 15 years to establish the antityrosinase activity of various mulberry species, particularly white mulberry and paper mulberry.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook "Cosmetic Dermatology: Principles and Practice" (McGraw-Hill, 2009), and a book for consumers, "The Skin Type Solution" (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001 and joined the editorial advisory board in 2004. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.
Often in this column, several species within a family might be discussed in relation to a broad range of health benefits. Licorice and mushrooms are good examples. In this case, and in this column, the focus will be on several species within a family that are thought to confer the same type of dermatologic benefit. The Morus genus within the Moraceae family appears to include several species that display skin-lightening properties.
Tyrosinase is the enzyme that controls the production of melanin. Suppressing tyrosinase activity to achieve skin lightening is a well-established method in dermatologic practice. The desire for products with fewer side effects than the mainstay, hydroquinone, or natural products such as kojic acid or arbutin, has led to investigations of several species in the Moraceae family. Notably, several Moraceae trees have been found to exhibit antioxidant activity (Int. J. Mol. Sci. 2012;13:2472-80; Biol. Pharm. Bull. 2002;25:1045-8; Biosci. Biotechnol. Biochem. 2010;74:2385-95; J. Pharm. Pharmacol. 2004;56:1291-8). The focus here, though, will be on the skin-lightening activity of various parts of Morus (commonly known as mulberry) trees.
In 2013, Singh et al. assessed the effects of mulberry, kiwi, and Sophora extracts on melanogenesis and melanin transfer in human melanocytes and in cocultures with phototype-matched normal adult epidermal keratinocytes. The extracts were evaluated against isobutylmethylxanthine, hydroquinone, vitamin C, and niacinamide. The investigators found that compared with unstimulated control, mulberry, kiwi, and Sophora extracts significantly reduced melanogenesis in normal adult epidermal melanocytes and human melanoma cells. Melanin transfer also was lowered, as was filopodia expression on melanocytes. The authors concluded that the test compounds compared well with standard-bearing depigmenting agents and warrant consideration as topical agents for diminishing hyperpigmentation (Exp. Dermatol. 2013;22:67-9).
Encouraging results in melasma treatment
A randomized, single-blind, placebo-controlled trial of 50 Filipino patients (49 women, 1 man) to examine the safety and efficacy of 75% Morus alba (white mulberry) extract oil was conducted by Alvin et al. in 2011. Patients were evaluated at weeks 4 and 8. The Melasma Area and Severity Index (MASI) score, Mexameter score, and Melasma Quality of Life (MelasQOL) score were measured, with the mulberry extract group performing significantly better than the placebo group according to all metrics.
The 25 patients treated with mulberry extract showed improvement in the MASI score, from 4.076 at baseline to 2.884 at week 8 (mean difference, 1.19); the mean difference for the placebo group was 0.06. The mean Mexameter reading revealed a significant difference, with a slight increase for the mulberry group (indicating lighter pigmentation), and the placebo group scored a slightly higher value. In addition, the MelasQOL score for the mulberry group improved markedly from baseline to week 8 (58.84 to 44.16), whereas the placebo group score improved only slightly, from 57.44 at baseline to 54.28 at week 8.
Adverse events were rare, with mild itching in 4 patients reported from the mulberry group, and 12 cases of either itching or erythema reported by the placebo group.
The investigators concluded that 75% mulberry extract oil objectively diminishes the hyperpigmentation of melasma in skin types III-V, although they recommend additional research with a larger sample size and longer treatment duration and follow-up (J. Drugs Dermatol. 2011;10:1025-31).
Paper mulberry
The bark of paper mulberry (Broussonetia papyrifera, also known as Morus papyrifera) is composed of extremely strong fibers used to produce high-quality paper and cloth. In China, the leaves, stem, leaf juice, roots, fruits, and bark have all been found to impart various health benefits, with the stem and leaf juice used to treat skin disorders and insect bites (Phytother. Res. 2012;26:1-10).
In one study, a 0.4% concentration of paper mulberry extract was demonstrated to suppress tyrosinase activity by 50% compared with 5.5% hydroquinone and 10% kojic acid. Notably, paper mulberry is not considered a significant irritant even at 1% concentration (J. Drugs Dermatol. 2009;8:s5-9).
White mulberry
In 2002, Lee et al. investigated the in vitro effects of an 85% methanol extract of dried white mulberry leaves on melanin biosynthesis. They found that one of the primary bioactive constituents, mulberroside F (moracin M-6, 3’-di-O-beta-D-glucopyranoside), inhibited the tyrosinase activity that converts dopa to dopachrome in the melanin synthesis process and also suppressed the melanin formation of melan-a cells. In addition, the mulberry extract inhibited tyrosinase activity more potently than did kojic acid (Biol. Pharm. Bull. 2002;25:1045-8).
The following year, a different team found that the young twigs of white mulberry also suppressed tyrosinase activity as well as melanin production in B-16 melanoma cells. In vivo, the extracts decreased melanin synthesis in a guinea pig model without displaying toxicity (J. Cosmet. Sci. 2003;54:133-42).
In 2006, Wang et al. investigated 25 traditional Chinese herbal medicines potentially useful in dermatology, particularly for skin whitening, and found that white mulberry was one of four species to potently inhibit tyrosinase activity, and more strongly than arbutin did (J. Ethnopharmacol. 2006;106:353-9).
Chinese mulberry/shimaguwa
In 2012, Zheng et al. isolated constituents from the roots of Chinese mulberry and found that several ingredients, including oxyresveratrol, moracenin D, sanggenon T, and kuwanon O, displayed more potent tyrosinase inhibition than kojic acid did. They concluded that Chinese mulberry is a good natural source of tyrosinase inhibitors and is potentially useful in cosmetic skin-lightening products as well as in foods as antibrowning agents (Fitoterapia 2012;83:1008-13).
Conclusion
Mulberry is actively used within the dermatologic armamentarium as one of the many options for skin lightening. A significant body of evidence has emerged over the past 15 years to establish the antityrosinase activity of various mulberry species, particularly white mulberry and paper mulberry.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook "Cosmetic Dermatology: Principles and Practice" (McGraw-Hill, 2009), and a book for consumers, "The Skin Type Solution" (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001 and joined the editorial advisory board in 2004. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.
Perioral dermatitis and diet
Perioral dermatitis is a common and frustrating skin condition that is often treatment resistant and recurs when treatment stops. Perioral dermatitis is classified in the rosacea family of skin diseases, and it is often associated with fair skin, light eyes, and marked actinic damage.
Although it is common in white skin, perioral dermatitis is underdiagnosed and an increasing problem in skin of color as well. The condition often begins as a papular, erythematous rash around the mouth. In darker skin types, however, it is often misdiagnosed because the erythema is masked by the skin pigmentation, so it appears as reddish-brown or even hyperpigmented papules around the mouth or eyes.
Popular treatments for perioral dermatitis include oral doxycycline, topical metronidazole, and topical tacrolimus. Often patients self-treat with topical corticosteroids for quick relief, which can initially improve the condition. However, corticosteroid use can result in exacerbation of the disease once the steroid is stopped, and often leads to recalcitrant cases. In skin of color patients, topical steroids used around the mouth and eyes also cause hypopigmentation of the skin, which further masks the clinical presentation of the disease and contributes to underdiagnosis and improper management.
In my practice, I have seen a consistent link between perioral dermatitis in skin of color patients and diet. Often patients who develop the rash have gluten sensitivity or mild, undiagnosed gluten intolerance. When these patients are switched to a gluten-free diet, their skin condition improves. Similarly, patients with no clinically diagnosed gluten sensitivity but who adopt a carbohydrate-free/low-glycemic-index and high-protein diet have shown dramatic improvement with minimal oral or topical treatments and less recurrence.
Although there are no well-controlled studies – or even case reports – linking carbohydrate or gluten intake to perioral dermatitis, studies have shown a strong link between diet and rosacea. Erythematotelangiectatic and papulopustular rosacea are known to be exacerbated by alcohol, hot or spicy foods, and chocolate. However, the common ingredient in these foods has never been identified as a link to the exacerbation of the disease. As all of the aforementioned foods often contain carbohydrates, could the common link simply be carbs or processed sugar?
Carbohydrates are the most common nutrients in the American diet. Often, emigrants to the United States develop perioral dermatitis or other inflammatory skin conditions such as acne and rosacea that they did not have in their home countries. Perhaps the Paleo or Mediterranean diets that have become popular for weight loss help control both bowel and skin inflammation. More studies are needed to better define the complex relationship and causality between diet and perioral dermatitis. In the meantime, I have been recommending carb-free diets in addition to topical tacrolimus or metronidazole for my skin of color patients with perioral dermatitis to prevent recurrences, and I have seen excellent results.
Dr. Talakoub is in private practice in McLean, Va.
Do you have questions about treating patients with dark skin? If so, send them to [email protected].
Perioral dermatitis is a common and frustrating skin condition that is often treatment resistant and recurs when treatment stops. Perioral dermatitis is classified in the rosacea family of skin diseases, and it is often associated with fair skin, light eyes, and marked actinic damage.
Although it is common in white skin, perioral dermatitis is underdiagnosed and an increasing problem in skin of color as well. The condition often begins as a papular, erythematous rash around the mouth. In darker skin types, however, it is often misdiagnosed because the erythema is masked by the skin pigmentation, so it appears as reddish-brown or even hyperpigmented papules around the mouth or eyes.
Popular treatments for perioral dermatitis include oral doxycycline, topical metronidazole, and topical tacrolimus. Often patients self-treat with topical corticosteroids for quick relief, which can initially improve the condition. However, corticosteroid use can result in exacerbation of the disease once the steroid is stopped, and often leads to recalcitrant cases. In skin of color patients, topical steroids used around the mouth and eyes also cause hypopigmentation of the skin, which further masks the clinical presentation of the disease and contributes to underdiagnosis and improper management.
In my practice, I have seen a consistent link between perioral dermatitis in skin of color patients and diet. Often patients who develop the rash have gluten sensitivity or mild, undiagnosed gluten intolerance. When these patients are switched to a gluten-free diet, their skin condition improves. Similarly, patients with no clinically diagnosed gluten sensitivity but who adopt a carbohydrate-free/low-glycemic-index and high-protein diet have shown dramatic improvement with minimal oral or topical treatments and less recurrence.
Although there are no well-controlled studies – or even case reports – linking carbohydrate or gluten intake to perioral dermatitis, studies have shown a strong link between diet and rosacea. Erythematotelangiectatic and papulopustular rosacea are known to be exacerbated by alcohol, hot or spicy foods, and chocolate. However, the common ingredient in these foods has never been identified as a link to the exacerbation of the disease. As all of the aforementioned foods often contain carbohydrates, could the common link simply be carbs or processed sugar?
Carbohydrates are the most common nutrients in the American diet. Often, emigrants to the United States develop perioral dermatitis or other inflammatory skin conditions such as acne and rosacea that they did not have in their home countries. Perhaps the Paleo or Mediterranean diets that have become popular for weight loss help control both bowel and skin inflammation. More studies are needed to better define the complex relationship and causality between diet and perioral dermatitis. In the meantime, I have been recommending carb-free diets in addition to topical tacrolimus or metronidazole for my skin of color patients with perioral dermatitis to prevent recurrences, and I have seen excellent results.
Dr. Talakoub is in private practice in McLean, Va.
Do you have questions about treating patients with dark skin? If so, send them to [email protected].
Perioral dermatitis is a common and frustrating skin condition that is often treatment resistant and recurs when treatment stops. Perioral dermatitis is classified in the rosacea family of skin diseases, and it is often associated with fair skin, light eyes, and marked actinic damage.
Although it is common in white skin, perioral dermatitis is underdiagnosed and an increasing problem in skin of color as well. The condition often begins as a papular, erythematous rash around the mouth. In darker skin types, however, it is often misdiagnosed because the erythema is masked by the skin pigmentation, so it appears as reddish-brown or even hyperpigmented papules around the mouth or eyes.
Popular treatments for perioral dermatitis include oral doxycycline, topical metronidazole, and topical tacrolimus. Often patients self-treat with topical corticosteroids for quick relief, which can initially improve the condition. However, corticosteroid use can result in exacerbation of the disease once the steroid is stopped, and often leads to recalcitrant cases. In skin of color patients, topical steroids used around the mouth and eyes also cause hypopigmentation of the skin, which further masks the clinical presentation of the disease and contributes to underdiagnosis and improper management.
In my practice, I have seen a consistent link between perioral dermatitis in skin of color patients and diet. Often patients who develop the rash have gluten sensitivity or mild, undiagnosed gluten intolerance. When these patients are switched to a gluten-free diet, their skin condition improves. Similarly, patients with no clinically diagnosed gluten sensitivity but who adopt a carbohydrate-free/low-glycemic-index and high-protein diet have shown dramatic improvement with minimal oral or topical treatments and less recurrence.
Although there are no well-controlled studies – or even case reports – linking carbohydrate or gluten intake to perioral dermatitis, studies have shown a strong link between diet and rosacea. Erythematotelangiectatic and papulopustular rosacea are known to be exacerbated by alcohol, hot or spicy foods, and chocolate. However, the common ingredient in these foods has never been identified as a link to the exacerbation of the disease. As all of the aforementioned foods often contain carbohydrates, could the common link simply be carbs or processed sugar?
Carbohydrates are the most common nutrients in the American diet. Often, emigrants to the United States develop perioral dermatitis or other inflammatory skin conditions such as acne and rosacea that they did not have in their home countries. Perhaps the Paleo or Mediterranean diets that have become popular for weight loss help control both bowel and skin inflammation. More studies are needed to better define the complex relationship and causality between diet and perioral dermatitis. In the meantime, I have been recommending carb-free diets in addition to topical tacrolimus or metronidazole for my skin of color patients with perioral dermatitis to prevent recurrences, and I have seen excellent results.
Dr. Talakoub is in private practice in McLean, Va.
Do you have questions about treating patients with dark skin? If so, send them to [email protected].
Futcher Lines: A Case Report in Pregnancy and Literature Review
Addisonian Pigmentation and Vitamin B12 Deficiency: A Case Series and Review of the Literature
Test your knowledge on Addisonian pigmentation and vitamin B12 with MD-IQ: the medical intelligence quiz. Click here to answer 5 questions.
