Diagnostic Challenges in Patients With Skin of Color

There is an increasing amount of interest in the diagnosis and management of skin diseases in patients with skin of color, with clinical research focusing on the pathogenesis and outcomes data in psoriasis, atopic dermatitis, and many more. In this article, we look at the top dermatologic concerns for patients with darker skin types, how to overcome challenges with differential diagnoses, and what research is in the pipeline.

Common Dermatologic Concerns

Pigmentary disease is a top dermatologic concern for patients with skin of color. A classic example is vitiligo, which is extremely psychologically stigmatizing, with a strong psychological impact on both patients and their families.¹ Personally, I became a dermatologist because I have a family member with vitiligo and have seen firsthand the struggle that families face with this disease. Another dermatologic concern for patients with skin of color is melasma.² In my practice, I have had women come in postpartum who are devastated because they have horrible hyperpigmentation on their face that they never had before. Imagine struggling with what you are looking at in the mirror every day during such a happy time in your life as having your first child. We must keep in mind the needs of patients with skin of color by listening and thinking about the psychological impact that skin diseases have in patients with darker skin types. Especially because the psychological impact of skin diseases, and specifically pigmentary disorders, is very high.

One of the most common reasons patients with skin of color visit my practice is for pigmentary disorders, such hypo-, hyper-, or depigmentation. In fact, it is important to try and figure out the underlying cause of the pigmentary anomaly when you are diagnosing and examining these patients. For example, one of the classic scenarios I have experienced is patients with acne vulgaris who are more concerned about postinflammatory hyperpigmentation (PIH) and not necessarily the acne.

Another point to remember is that not all pigmentary disorders are created equal. Because PIH is the end result, we want to make sure to keep in mind what can cause it. In my practice, I have seen patients who were told they have "melasma" on their face when it is actually PIH from seborrheic dermatitis, or it is a connective tissue disease, or it is dermatomyositis that shows hyperpigmentation in the cheeks or the periocular area. Psoriasis is also a common condition in patients with skin of color that has a wide differential diagnosis, such as lichen planus, sarcoidosis, atopic dermatitis, and other eczematous processes. Often, the biopsy will reveal that it is psoriasis, but it does not look like psoriasis clinically. It does not look red, scaly, and thick; it looks more brown, purple, and smooth.³ The question is: How can dermatologists overcome these challenges?

Overcoming Diagnostic Challenges

While keeping an open mind to the differential diagnosis, physicians should not be afraid to perform a clinical biopsy when needed. Dermoscopy can be used to see if there is underlying erythema, increased vascularity, or any other clues to the patient’s condition. It is also important to take a detailed history of any over-the-counter skin care or skin lightening products that patients have tried, especially in patients with pigmentary disorders.

We must ask patients, “Are you using any medications?” The patients will say, “No.” “Have you tried any other products?” “No.” “Have you used any sort of new makeup?” “No.” And then we delve into the history, “What about herbal products? What about skin brighteners? What about things you might have bought online or overseas?” And then the plot starts to thicken. I have seen patients who buy skin lightening products online after seeing them on social media, and we do not know the ingredients in them. Unfortunately, many of them contain mercury and arsenic or high concentrations of topical steroids that can be harmful.^4,5

Empowering the public to seek out board-certified dermatologists is one of the most important things we can do. In particular, we need to be able to use social media influencers and societies and organizations to help encourage patients to seek out dermatologists. Personally, I direct people to the Skin of Color Society website because it has a "doctor finder" feature.⁶ The American Academy of Dermatology website also has a "find a dermatologist" feature that is accessible to the public, where dermatologists can list their areas of expertise.⁷

Another important aspect of overcoming diagnostic challenges is having dedicated trials on biologic therapy for patients with skin of color; for example, the new VISIBLE study for patients with moderate to severe psoriasis and skin of color.⁸ There is now research funding specifically looking at new vitiligo therapies, including those targeting IL-15.⁹ Additionally, there is new research being done on the biomarkers of vitiligo, which could potentially be a way to predict the severity of the disease.¹⁰ Research is also being done on new laser modalities, as well as chemical peel combination therapies, for hyperpigmentation and melasma. There are new cosmeceuticals and oral therapies for melasma also being studied. And the US Food and Drug Administration (FDA) recently approved ruxolitinib cream, a topical Janus kinase inhibitor, for patients aged 12 years and older to treat nonsegmental vitiligo.¹¹ This is the first FDA-approved pharmacologic treatment to repigment skin in patients with vitiligo, so it is an exciting time for new therapies and research.

Lastly, there is progress being made in textbooks to represent how skin diseases present in different skin tones for our next generation of physicians to learn to recognize, for example, what psoriasis may look like in a patient with skin of color.¹²

True Expertise

As board-certified dermatologists, we are the true experts in skin, hair, and nails. We must be the ones leading the charge, educating the public about skin diseases. We want to get the message out: Come seek us out. Do not wait until it is potentially too late.

Reference
1. Vitiligo: overview. American Academy of Dermatology. February 15, 2022. Accessed August 23, 2022. https://www.aad.org/public/diseases/a-z/vitiligo-overview

2. Melasma: overview. American Academy of Dermatology. June 29, 2022. Accessed August 23, 2022. https://www.aad.org/public/diseases/a-z/melasma-overview

3. Leavitt M. Diagnosing and treating psoriasis in skin of color. The Dermatologist. 2016;24(4):34, 36.

4. Mohammed T, Mohammed E, Bascome S. The evaluation of total mercury and arsenic in skin bleaching creams commonly used in Trinidad and Tobago and their potential risk to the people of the Caribbean. J Public Health Res. 2017;6(3):1097. doi:10.4081/jphr.2017.1097

5. Dey VK. Misuse of topical corticosteroids: a clinical study of adverse effects. Indian Dermatol Online J. 2014;5(4):436-440. doi:10.4103/2229-5178.142486

6. Find a doctor. Skin of Color Society. Accessed August 23, 2022. https://skinofcolorsociety.org/business-directory

7. Find a dermatologist. American Academy of Dermatology. Accessed August 23, 2022. https://fi nd-a-derm.aad.org

8. Janssen initiates first-of-its-kind clinical study to bridge critical gaps in care for people of color with moderate to severe plaque psoriasis. News release. PR Newswire. March 22, 2022. Accessed August 23, 2022. https://www.prnewswire.com/news-releases/janssen-initiates-fi rst-of-its-kind-clinical-study-to-bridgecritical-gaps-in-care-for-people-of-color-with-moderate-to-severe-plaque-psoriasis-301508367.html

9. Targeting IL-15 for the treatment of vitiligo (REVEAL). Immune Tolerance Network. Accessed August 23, 2022. https://www.immunetolerance.org/studies/targeting-il-15-treatment-vitiligo-reveal

10. El-Domyati M, El-Din WH, Rezk AF, et al. Systemic CXCL10 is a predictive biomarker of vitiligo lesional skin infi ltration, PUVA, NB-UVB and corticosteroid treatment response and outcome. Arch Dermatol Res. 2022;314(3):275-284. doi:10.1007/s00403-021-02228-9

11. FDA approves topical treatment addressing repigmentation in vitiligo in patients aged 12 and older. US Food and Drug Administration. July 19, 2022. Accessed August 23, 2022. https://www.fda.gov/drugs/news-events-humandrugs/fda-approves-topical-treatment-addressing-repigmentation-vitiligopatients-aged-12-and-older

12. Skin of color dermatology textbooks. Skin of Color Society. Accessed August 23, 2022. https://skinofcolorsociety.org/skin-of-color-dermatology-textbooks