Treating skin of color

Most skin diseases occur in people of all nationalities, regardless of their skin color. Certain problems encountered in the skin are more common in people with different hues of skin, and sometimes a disorder seems more prominent because it affects skin color. This week continues our review of these disorders and their treatment.

Keloids

Throughout evolution, our skin has become quite skillful at repairing any sites of injury or damage. Once the integrity of the skin barrier has been interrupted, invaders such as bacteria, fungus, and virus can penetrate the skin and important

bodily fluids can leak out. As a result, the skin’s repair system is rapid and complete.

Cells known as fibroblasts migrate into the area and produce protein to fill in the hole. The major component of the repair product is collagen, and that is what makes up a scar. Unfortunately, in some cases, and commonly in African Americans, the fibroblasts receive the signal to come in and repair the defect; however, they do not get the signal to turn off.

As a result, too much collagen is produced and the scar can become thick and hard. When the collagen presses on nearby sensory nerves, the keloidal scar can also produce tenderness, pain, and extreme itching.

The difference between a hypertrophic and kelodial scar is that that hypertrophic scars usually stay right at the site of injury, whereas keloids can actually spread and invade normal surrounding skin. In our clinic, we use an aggressive six-month program to effectively treat keloids.

It is one thing to surgically remove a keloid, yet it is another thing to keep it from coming back. Remember, the development of a keloid is a response to injury. By surgically removing a keloid, the skin is being re-injured, and that area has already shown it can form a keloid.

We perform regular treatments every two to four weeks over a six-month period, including anti-inflammatory injections, topical silicone-based preparations, pressure dressings, and laser treatments to prevent the return of keloids.

Acne keloidalis nuchae

This condition is also known as folliculitis keloidalis nuchae, where small, very itchy bumps can occur at the nape of the neck. This is most commonly seen in African American patients, but to a lesser degree it can affect all patients. It is most commonly seen in men, but can also be seen in women.

Many male patients believe this is a result from a barber shop treatment where the barber had unclean clippers. This is quite untrue, and I have seen many cases that develop without any previous haircuts.

One theory is that this condition is a result of a deep fungal infection. However, in my experience, I have performed many biopsies and analyzed cultures for fungus and special histology stains, but I have not yet identified a fungus infection. I believe this condition is just an anatomic and genetic variant, with itchy bumps developing from very mild irritation in this particular anatomic location.

Smaller bumps can be treated very effectively when treated with a combination of topical and oral anti-inflammatory medications. In many cases, a short course can provide long-term results. Often a surgical approach is required if the lesions are too large. Nevertheless, the condition can be managed quite well.

Pseudofolliculitis barbae 

This condition is also known as “razor bumps.” Hair is made of protein called keratin and it can be extremely inflammatory to the skin. It is called “pseudo” folliculitis because the hair can actually come out of the follicular opening and penetrate nearby skin, causing it to look like an inflammation or folliculitis of that pore. However, because it is just nearby the actual follicle, it is “pseudo” folliculitis.

This is most often seen in persons with curly hair or hair that grows at an oblique angle to the skin. Sometimes, if curly hair is cut extremely close, it never even exits the skin but instead penetrates the sidewall of the follicle (known as transfollicular penetration), or it comes out of the follicle and pokes the skin (known as extrafollicular penetration). The results are the same: the keratin invades the skin, producing a brisk inflammatory reaction that causes itching and the formation of pustules.

When pseudofolliculitis is mild to moderate, many topical treatments can be implemented, including a very mild oatmeal-based shaving cream, and a non-electric razor with a safety guard so the hairs are not cut too short. Shaving after a shower is also recommended — the hair is hydrated, so the final tip is soft as opposed to sharp.

In addition, using a soft-bristle toothbrush to make circular motions in the beard area before bedtime can prevent the hair from penetrating as it grows throughout the night. Topical anti-inflammatory aftershave lotions and oral anti-inflammatories can also be used if necessary.

In the majority of cases, this can provide satisfactory relief. However, in certain cases where relief is not achieved through these means, the best treatment is to remove the offending agent. In this case, I recommend laser hair removal.

Pseudofolliculitis barbae has been a vexing problem throughout history and can even interfere with occupations that require a clean-shaven face, such as military officers, peace officers and firefighters. Thankfully, this condition can be addressed by implementing appropriate treatments and techniques.

Next week: more skin problems common to people of color

Charles E. Crutchfield III, MD is a board certified dermatologist and Clinical Professor of Dermatology at the University of Minnesota Medical School. He also has a private practice in Eagan, MN. He has been selected as one of the top 10 dermatologists in the U.S. by Black Enterprise magazine and one of the top 21 African American physicians in the U.S. by the Atlanta Post. Dr. Crutchfield is an active member of the Minnesota Association of Black Physicians, MABP.org.