Cultural and Aesthetic Considerations in Patients with Skin of Color

Culture is influenced by the prevalent art, customs, religions, and social institutions of one’s environment. As the human population continues to evolve, the world population is becoming more multicultural and multiethnic. By the year 2050, approximately 50% of the US population will include people with skin of color, demonstrating the importance of cultural sensitivity and awareness on the lives of our patients.1

HAIR AND HAIRSTYLE

Religion is a significant component of cultural practices. For example, Muslim women who wear headscarves require an establishment with private rooms for their haircuts. Since these establishments are few and far between in Western countries, most Muslim women become adept at cutting and styling their hair at home. As hair stylists are often the first to notice abnormal hair loss and complications of daily styling (eg, traction alopecia),2 women who cut their own hair may miss early-stage hair loss, resulting in late presentation to a dermatologist and subsequent irreversible scarring. The same applies to men who wear turbans.

In patients of African descent, certain hairstyles that exert traction on hair, such as braiding (eg, cornrows), are practiced since childhood.3 Caregivers experience unnecessary judgment if their child’s hair is deemed “messy,” which often results in braids that are too tight. With these repeated insults, patients are predisposed to traction alopecia and possibly central centrifugal cicatricial alopecia (CCCA).4 In addition, the Black Women’s Health Study found chemical relaxer use among postmenopausal Black women is associated with increased risk of developing uterine cancer.5

SUN PROTECTION

East Asians have a more prevalent culture of wearing sun-protective clothing compared to Asian Americans.6 This difference has implications in research as studies examining skin cancer in East Asia may not reflect the lifestyles and risk of Asian Americans, thus underestimating the frequency in the latter. Regarding sunscreen and many cosmetic therapies, Hispanics/Latinxs represent the “heaviest buyers” in skincare, yet many feel underrepresented in the media.7 Additionally, there is a need to develop more sunscreens for patients of color, specifically low-to-no white residue, low-priced, and suitable broad-spectrum SPF products, all of which are important factors to patients.8

SKIN CONCERNS

It is always an important reminder to keep an open mind and ask a patient to identify their most important concern. A woman wearing a niqab may have multiple cosmetic concerns, but her most important may be the lifting of the brows, the presence of tear troughs, or the health of the hands and nails, as these are the areas seen by most of the people with whom she interacts. The psychosocial impact and stigmatization of skin conditions in different communities is also important to remember. While scientific research and cultural awareness of vitiligo is increasing, in South Asian communities, this condition is still unfortunately associated with significant stigmatization.⁹ The role of psychodermatology should therefore be addressed in these consultations with a low threshold for psychiatric referrals.

The structural competencies that influence the social determinants of health also need to be heeded. Factors contributing to disparities in patient care include lack of transportation, housing instability, and differences in skin disease presentation by skin type.¹⁰ For example, patients living in highly segregated communities were significantly associated with a higher odd of developing atopic dermatitis.¹¹ Different measures to address these inequities include redistribution of resources to increase the accessibility of care to underserved populations. Direct measures include establishing clinics in underserved communities, and indirect measures include standardized skin-of-color residency training programs.

In conclusion, cultural competence is increasingly mandated in the context of dermatology consultations and should be compounded by cultural humility to address the lifelong dynamism of identities and eliminate our own implicit biases.

Dr. Palmer reports no financial interests.

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2. Ali S, Collins M, Pupo Wiss I, Burns L, Hagigeorges D, Pickford J, Senna M. Improving hairdressers’ knowledge and identification of scarring alopecia using an educational video. Int J Womens Dermatol. 2023 Apr 14;9(2):e079. doi: 10.1097/JW9.0000000000000079.

3. Billero V, Miteva M. Traction alopecia: the root of the problem. Clin Cosmet Investig Dermatol. 2018;11:149-159. doi: 10.2147/CCID.S137296.

4. Palmer V, Valdebran M. Central Centrifugal cicatricial alopecia in the adolescent population: an overview of available literature. Life (Basel). 2023;13(4):1022. doi:10.3390/life13041022

5. Bertrand KA, Delp L, Coogan PF, et al. Hair relaxer use and risk of uterine cancer in the Black Women’s Health Study. Environ Res. 2023;239(Pt 1):117228. doi:10.1016/j.envres.2023.117228

6. Bowers JM, Hamilton JG, Wu YP, Moyer A, Hay JL. Acculturation, sun tanning behavior, and tanning attitudes among Asian college students in the northeastern USA. Int J Behav Med. 2022;29(1):25-35. doi:10.1007/s12529-021-09993-x

7. Dow AA, Murphy MJ. Hispanic/Latinos and skincare: disparities in product development, marketing, and toxicity. J Drugs Dermatol. 2020;19(12):1258-1260. doi:10.36849/JDD.2020.5567

8. Song H, Beckles A, Salian P, Porter ML. Sunscreen recommendations for patients with skin of color in the popular press and in the dermatology clinic. Int J Womens Dermatol. 2020;7(2):165-170. doi:10.1016/j.ijwd.2020.10.008

9. Thompson AR, Clarke SA, Newell RJ, Gawkrodger DJ; Appearance Research Collaboration (ARC). Vitiligo linked to stigmatization in British South Asian women: a qualitative study of the experiences of living with vitiligo. Br J Dermatol. 2010;163(3):481-486. doi:10.1111/j.1365-2133.2010.09828.x

10. Narla S, Heath CR, Alexis A, Silverberg JI. Racial disparities in dermatology. Arch Dermatol Res. 2023;315(5):1215-1223. doi: 10.1007/s00403-022-02507-z.

11. Williams J, Amerson EH, Chang AY. How dermatologists can address the structural and social determinants of health—from awareness to action. JAMA Dermatology. 2022;158(4):351-352.