By 2050, more than 50 percent of the US population will have skin of color, and clinical and cultural competency is needed to effectively treat skin diseases in these individuals. Lynn McKinley-Grant, MD, MA, FAAD, Associate Professor, Director of Curriculum Innovation and Development, Department of Dermatology, Howard University College of Medicine, Washington, DC and Skin of Color Society President, talked to Practical Dermatology® about diagnosing and treating rosacea, acne, and other skin diseases in skin of color patients.

What are the biggest concerns for your skin of color patients today?

Lynn McKinley-Grant MD: The biggest concerns are too much hair in the wrong places and too little hair on the scalp, and pigment in the skin—either too much or too little. For teens, it is acne and the post-inflammatory hyperpigmentation from acne, which is worse than having acne. Those in their 30s to 50s and up are now looking for cosmetic procedures (that many don’t need) in connection with aging concerns. Hair loss is also a major issue for this age group.

What is the greatest challenge when treating skin of color patients?

Dr. McKinley-Grant: First of all, there are many shades of brown. I have a strong passion about recognizing that erythema is a physiologic response to inflammation and infection. The clinical sign of erythema presents in shades of red in skin of color. Erythema can be a pomegranate red or Concord-grape purple in darker skin types. You must touch the skin to feel warmth of erythema, and you can use dermoscopy to detect blanching of the skin. The melanocyte is traumatized easily with inflammation or pressure. Pigmented skin is very sensitive to chemicals, cold, and trauma. The slightest bruise or pimple can cause a long-lasting mark.

With hair, there are so many cultural considerations physicians must be aware of. Hair loss in men and women is very traumatic and requires at least 30 to 45 minutes for a new patient visit. Every type of hair loss deserves a thorough history and physical exam to rule out systemic disease. To diagnose the etiology of hair loss, you must be aware of hair care practices and how they vary from Asians to Africans. You need to be able to describe the pattern of hair loss (scaring vs non-scarring). Use of a dermatoscope is becoming more common in diagnosing scarring alopecia.

How do you address hyperpigmentation disorders?

Dr. McKinley-Grant: You have to be aware and identify the cause, i.e. makeup, medications, hormones, trauma, sun, diabetes, kidney failure, etc. The causes need to be treated first, and patients need to wear non-comedogenic sunscreen, so the dark spots don’t get darker. Many with darker skin types may have photosensitivity because of medication or autoimmune conditions. Hydroquinones are compounded with retinoids in various concentrations and are effective. Adapalene, which is over the counter, is effective. There are chemical peels and lasers that are safe and effective if used cautiously in skin of color.

How do you treat rosacea in skin of color?

Dr. McKinley-Grant: You must be skilled and have experience in recognizing redness in all shades of skin of color. Rosacea vs. seborrhea can be difficult to differentiate, since they occur in the same location; often people have both. You can treat rosacea the same in all skin types as long as you are sensitive to chemicals that cause irritation, which will cause a pigmentary problem in skin of color.

How do you treat acne in skin of color?

Dr. McKinley-Grant: Acne in skin of color is more prone to PIH, so give fast-acting and not-too-drying medications. I am very cautious with benzoyl peroxide (BP) in my patients of color. Many develop an irritant or allergic dermatitis to BP and have severe hyperpigmentation after use. Always ask patients if they can tolerate BP or salicylic acid and stop using a medication if side effects occur. Make sure the patient is not treating seborrheic dermatitis with heavy oil, such as Vaseline. Oiling the scalp can worsen acne. Be sure the patient is not picking or manipulating the acniform papules. Use medications like adapalene, to help get rid of comedones and inflammatory papules and simultaneously use medications topically to treat infection. Patients have to review their cleansing regimen and the creams they are using. Too much oil will clog the pores. Many over-the-counter bleaching cream contain clobetasol and can cause serious problems.