Candrice R. Heath, MD

THE COMPARISON

A Elbow and forearm with erythematous, well-demarcated, pink plaques with mild micaceous scale in a 42-year-old White woman.

B Elbow and forearm with violaceous, well-demarcated plaques with micaceous scale and hyperpigmented patches around the active plaques in a 58-year-old Black man.

Epidemiology

Psoriasis prevalence in the United States has been estimated at 3.7%.^1-3 If broken down by race or ethnicity, the prevalence of psoriasis varies: 2.5% to 3.7% in White adults^1-4; 1.3% to 2% in Black adults^1-4; 1.6% in Hispanics/other adults^1-3; 1% in children overall; 0.29% in White children^1,5; and 0.06% in Black children.^1,5

Key clinical features in people with darker skin tones include:

• plaques that may appear more violaceous in color instead of pink or erythematous
• higher body surface area of involvement⁴ and thicker, more scaly plaques⁶
• increased likelihood of postinflammatory hyperpigmentation (PIH).

Worth noting

Although individuals of all skin tones may experience the psychosocial impact of psoriasis, quality-of-life measures have been found to be worse in those with skin of color (SOC) compared to White patients. ^1,4 This may be due to the lingering PIH and hypopigmentation that occurs even after inflammatory plaques are treated. Of course, lack of access to care contributes to greater disease burden and more devastating psychological impact.

Health disparity highlight

Psoriasis may be underreported and underdiagnosed in individuals with SOC, as factors contributing to health care disparities may play a role, such as access to health care in general,^1,7 and access to clinicians proficient in diagnosing cutaneous diseases in SOC may be delayed.⁸

Biologic medications are used less often in Black patients than in White patients, despite biologic medications being very efficacious for treatment of psoriasis.^1,9,10

THE COMPARISON

A Elbow and forearm with erythematous, well-demarcated, pink plaques with mild micaceous scale in a 42-year-old White woman.

B Elbow and forearm with violaceous, well-demarcated plaques with micaceous scale and hyperpigmented patches around the active plaques in a 58-year-old Black man.

Epidemiology

Psoriasis prevalence in the United States has been estimated at 3.7%.^1-3 If broken down by race or ethnicity, the prevalence of psoriasis varies: 2.5% to 3.7% in White adults^1-4; 1.3% to 2% in Black adults^1-4; 1.6% in Hispanics/other adults^1-3; 1% in children overall; 0.29% in White children^1,5; and 0.06% in Black children.^1,5

Key clinical features in people with darker skin tones include:

• plaques that may appear more violaceous in color instead of pink or erythematous
• higher body surface area of involvement⁴ and thicker, more scaly plaques⁶
• increased likelihood of postinflammatory hyperpigmentation (PIH).

Worth noting

Although individuals of all skin tones may experience the psychosocial impact of psoriasis, quality-of-life measures have been found to be worse in those with skin of color (SOC) compared to White patients. ^1,4 This may be due to the lingering PIH and hypopigmentation that occurs even after inflammatory plaques are treated. Of course, lack of access to care contributes to greater disease burden and more devastating psychological impact.

Health disparity highlight

Psoriasis may be underreported and underdiagnosed in individuals with SOC, as factors contributing to health care disparities may play a role, such as access to health care in general,^1,7 and access to clinicians proficient in diagnosing cutaneous diseases in SOC may be delayed.⁸

Biologic medications are used less often in Black patients than in White patients, despite biologic medications being very efficacious for treatment of psoriasis.^1,9,10

THE COMPARISON

A Elbow and forearm with erythematous, well-demarcated, pink plaques with mild micaceous scale in a 42-year-old White woman.

B Elbow and forearm with violaceous, well-demarcated plaques with micaceous scale and hyperpigmented patches around the active plaques in a 58-year-old Black man.

Epidemiology

Psoriasis prevalence in the United States has been estimated at 3.7%.^1-3 If broken down by race or ethnicity, the prevalence of psoriasis varies: 2.5% to 3.7% in White adults^1-4; 1.3% to 2% in Black adults^1-4; 1.6% in Hispanics/other adults^1-3; 1% in children overall; 0.29% in White children^1,5; and 0.06% in Black children.^1,5

Key clinical features in people with darker skin tones include:

• plaques that may appear more violaceous in color instead of pink or erythematous
• higher body surface area of involvement⁴ and thicker, more scaly plaques⁶
• increased likelihood of postinflammatory hyperpigmentation (PIH).

Worth noting

Although individuals of all skin tones may experience the psychosocial impact of psoriasis, quality-of-life measures have been found to be worse in those with skin of color (SOC) compared to White patients. ^1,4 This may be due to the lingering PIH and hypopigmentation that occurs even after inflammatory plaques are treated. Of course, lack of access to care contributes to greater disease burden and more devastating psychological impact.

Health disparity highlight

Psoriasis may be underreported and underdiagnosed in individuals with SOC, as factors contributing to health care disparities may play a role, such as access to health care in general,^1,7 and access to clinicians proficient in diagnosing cutaneous diseases in SOC may be delayed.⁸

Biologic medications are used less often in Black patients than in White patients, despite biologic medications being very efficacious for treatment of psoriasis.^1,9,10

Traction alopecia (TA)--one of the most common types of hair loss in Black women (although not exclusive to Black women)--is reversible when early corrective measures are taken; if chronic tension continues, however, permanent scarring alopecia ensues. Dermatologists can prevent worsening of this distressing hair loss. Due to a dearth of training among dermatologists in conditions occurring in patients with tightly coiled hair, it is imperative to add practical methods to the body of dermatology literature, with the goal of enhancing cultural humility.  

Hairstyling among Black women often is a lengthy process and often results in relationship bonding with the hair care giver, in turn imparting hair care traditions to the next generation. Therefore, a well-received discussion about TA prevention not only has an impact on the patient but potentially on a multigenerational family of women and friends. We present a memory aid for discussing TA, with a focus on cultural humility and patient-centered communication. 

Factors contributing to the risk of TA are hairstyles and hair care practices commonly used in Black individuals, including braids, locs, weaves, wigs, and chemical straightening.¹ These styles often are worn to increase hair manageability or as a creative expression of beauty. 

Discussing TA can be distressing for physicians and patients, especially in the setting of hair texture discordance. In a study that surveyed Black patients' perception of their dermatologic care both in and outside of a skin of color clinic, 71% of respondents (12/17) said that they prefer a race-concordant dermatologist. Some respondents reported that non-skin of color clinic dermatologists examined their hair with the end of a pencil or not at all; patients interpreted these interactions as disrespectful and racially insensitive.² Another study found that only 30.2% (19/63) of dermatology chief residents and 12.2% (5/41) of program directors reported a specific rotation during which residents gained experience treating skin of color patients.³ 

Due to a paucity of training in diagnosing and treating patients with tightly coiled hair who experience hair loss, some physicians might feel uncomfortable caring for patients who have tightly coiled hair. Although many Black patients prefer to see a race-concordant dermatologist because of their perceived cultural competence and shared experience, there is a paucity of Black dermatologists to see all patients who have tightly coiled hair.⁴ Therefore, all dermatologists should become skilled and comfortable discussing and treating TA in patients with all hair types. 

METHOD FOR COUNSELING 

The following scenarios are a guide to begin closing the competency gap in counseling about TA, using a "compliment, discuss, and suggest" method.  

Scenario 1 
A Black woman presents with a concern of "thinning edges" (a popular term on social media for TA). A hair-discordant dermatologist tells her, first, that she has TA caused by wearing tight hairstyles and, second, that the treatment is to stop wearing tight braids and weaves and to discontinue chemical relaxers. The dermatologist then leaves the room.  

The Patient's Perspective
It is not uncommon for the patient to have feelings of frustration about how they will style their hair, especially if they are unfamiliar with caring for their hair in its natural state.⁵ Also, they might have feelings of dismay that the loving childhood hair care giver, often their mother or grandmother, unintentionally harmed them with a tight style. They also might feel betrayed by their hairstylist, who might not have encouraged them to see a dermatologist, or who continued to oblige their request for a high-risk hairstyle. The patient might feel uncomfortable communicating the dermatologist's new recommendations to their hair care team, who also are part of her emotional support system. The patient also might think that the hair-discordant dermatologist has no idea what they "go through" with their hair.  

"Compliment, Discuss, and Suggest" Counseling
Traction alopecia is caused by tight hairstyles that often hurt when they are put in as tight braids, weaves, and ponytails.⁶ Risk increases if tight styles are applied to chemically straightened hair.¹ Braids, sew-in weaves, and wigs with adhesive sometimes are referred to as protective styles. However, these styles can still lead to TA due to excessive tension.  

• Compliment: "Your hair looks great. I know that you get many compliments."  
• Discuss: "However, some of the styles might be increasing your risk for hair loss. Our goal is to preserve as many of your follicles as possible."  
• Suggest: "Let's start by loosening the hairstyle if it is painful when being applied. Pain means inflammation, which can lead to scarring of hair follicles and worsening of hair loss." 

Using pronouns such as we, us, and our is intentional. Doing so signals that the dermatologist is a partner with the patient in the treatment of TA. Starting with a simple initial recommendation gives the patient time to process the common thoughts highlighted in The Patient's Perspective section.⁶  

Scenario 2 
A Black child (we'll call her "Janet") is accompanied by her mother for follow-up of mild atopic dermatitis on the body and scalp. When the dermatologist examines the patient's scalp, they note that she has the fringe sign--retained short hairs along the frontal hairline--that is consistent with TA. Janet's hair is adorned with 2 tight ponytails in the front with colorful decorative balls on ponytail ties, barrettes, and 6 cornrow braids in the back with plastic beads on the ends. The dermatologist counsels about the atopic dermatitis and leaves the room.  

"Compliment, Discuss, and Suggest" Counseling
The use of tight decorative balls on ponytail ties and numerous plastic beads increases the amount of tension and weight on the hair, which may lead to a higher risk for developing traction alopecia.⁶ It is quite common for children of African descent to wear hair adornments. Proper counseling regarding their use and possible implications is essential. 

1. Compliment: "You're doing a great job controlling the atopic dermatitis, which can cause Janet's scalp to be dry. Also, her hair is beautiful--it looks like you spent a lot of time on her hair. And Janet, I like the color of your barrettes." 
2. Discuss: "Mom, I just noticed that a few areas look tight. Let's look together." (The dermatologist points out areas where the scalp is tented upward due to traction, follicular pustules or papules, or the frontal fringe sign.) "I'm on a mission to #savetheedges because we want Janet to grow up with full edges." (Again, loss of "edges" refers to TA.) 
3. Suggest: "When you do Janet's hair, it's OK if every hair is not in place. In fact, making styles look and feel 1 or 2 weeks old will lessen tension on the scalp. Remove Janet's hair ties to release tension when she is at home and while she's sleeping, if possible. Every minute that the hair is loose really does help."⁶  

The Parent's Perspective

All parents take pride in their children. In some Black communities, mothers are judged by how well they manage and style their children's hair. Some people might even suggest that parents of children with nonstyled, tightly coiled hair are not fit parents. Anthropologist Sylvia Boone, PhD, found that among the Mende tribe in Sierra Leone, "unkempt, 'neglected,' or 'messy' hair implied that a woman either had loose morals or was insane."⁷ 

Braids are commonly worn by people of African heritage for a variety of reasons, including ease of manageability, to decrease daily hairstyling time, and as an expression of creativity. Intricate neat hairstyles, despite the risk of pain and TA, are perceived as a sign that the child is cared for and loved.⁶  

FINAL THOUGHTS 

Patient-centered communication is associated with the patient trusting the physician, which is especially important in race-discordant physician-patient relationships. A study found that patient-physician race discordance led to shorter visits, a lower rating of patient affect, and less shared decision-making.⁸ Moreover, in a study of primary care clinicians, implicit bias was found to affect communication patterns and social interactions, impacting patient outcomes. Downstream effects of racial bias resulted in less speaking, smiling, and social comments when interacting with Black patients.⁹  

These findings highlight the need to address interpersonal barriers to effective communication in race-discordant patient-physician dyads. A history of segregated neighborhoods and schools might contribute to structural barriers, resulting in lack of familiarity with cultural norms outside one's culture, which might globally perpetuate poor communication and patient outcomes.  

The "compliment, discuss, and suggest" method might lead to more positive physician-patient encounters by having the dermatologist focus on empathetically understanding the patient's perspective.¹⁰ Effective communication, understanding cultural hair care practices, and a thorough scalp examination are paramount for patients with tightly coiled hair.¹¹ Early intervention in TA is crucial and involves partnering with patients and parents to amend high-risk hairstyling routines with cultural humility. 

Traction alopecia (TA)--one of the most common types of hair loss in Black women (although not exclusive to Black women)--is reversible when early corrective measures are taken; if chronic tension continues, however, permanent scarring alopecia ensues. Dermatologists can prevent worsening of this distressing hair loss. Due to a dearth of training among dermatologists in conditions occurring in patients with tightly coiled hair, it is imperative to add practical methods to the body of dermatology literature, with the goal of enhancing cultural humility.  

Hairstyling among Black women often is a lengthy process and often results in relationship bonding with the hair care giver, in turn imparting hair care traditions to the next generation. Therefore, a well-received discussion about TA prevention not only has an impact on the patient but potentially on a multigenerational family of women and friends. We present a memory aid for discussing TA, with a focus on cultural humility and patient-centered communication. 

Factors contributing to the risk of TA are hairstyles and hair care practices commonly used in Black individuals, including braids, locs, weaves, wigs, and chemical straightening.¹ These styles often are worn to increase hair manageability or as a creative expression of beauty. 

Discussing TA can be distressing for physicians and patients, especially in the setting of hair texture discordance. In a study that surveyed Black patients' perception of their dermatologic care both in and outside of a skin of color clinic, 71% of respondents (12/17) said that they prefer a race-concordant dermatologist. Some respondents reported that non-skin of color clinic dermatologists examined their hair with the end of a pencil or not at all; patients interpreted these interactions as disrespectful and racially insensitive.² Another study found that only 30.2% (19/63) of dermatology chief residents and 12.2% (5/41) of program directors reported a specific rotation during which residents gained experience treating skin of color patients.³ 

Due to a paucity of training in diagnosing and treating patients with tightly coiled hair who experience hair loss, some physicians might feel uncomfortable caring for patients who have tightly coiled hair. Although many Black patients prefer to see a race-concordant dermatologist because of their perceived cultural competence and shared experience, there is a paucity of Black dermatologists to see all patients who have tightly coiled hair.⁴ Therefore, all dermatologists should become skilled and comfortable discussing and treating TA in patients with all hair types. 

METHOD FOR COUNSELING 

The following scenarios are a guide to begin closing the competency gap in counseling about TA, using a "compliment, discuss, and suggest" method.  

Scenario 1 
A Black woman presents with a concern of "thinning edges" (a popular term on social media for TA). A hair-discordant dermatologist tells her, first, that she has TA caused by wearing tight hairstyles and, second, that the treatment is to stop wearing tight braids and weaves and to discontinue chemical relaxers. The dermatologist then leaves the room.  

The Patient's Perspective
It is not uncommon for the patient to have feelings of frustration about how they will style their hair, especially if they are unfamiliar with caring for their hair in its natural state.⁵ Also, they might have feelings of dismay that the loving childhood hair care giver, often their mother or grandmother, unintentionally harmed them with a tight style. They also might feel betrayed by their hairstylist, who might not have encouraged them to see a dermatologist, or who continued to oblige their request for a high-risk hairstyle. The patient might feel uncomfortable communicating the dermatologist's new recommendations to their hair care team, who also are part of her emotional support system. The patient also might think that the hair-discordant dermatologist has no idea what they "go through" with their hair.  

"Compliment, Discuss, and Suggest" Counseling
Traction alopecia is caused by tight hairstyles that often hurt when they are put in as tight braids, weaves, and ponytails.⁶ Risk increases if tight styles are applied to chemically straightened hair.¹ Braids, sew-in weaves, and wigs with adhesive sometimes are referred to as protective styles. However, these styles can still lead to TA due to excessive tension.  

• Compliment: "Your hair looks great. I know that you get many compliments."  
• Discuss: "However, some of the styles might be increasing your risk for hair loss. Our goal is to preserve as many of your follicles as possible."  
• Suggest: "Let's start by loosening the hairstyle if it is painful when being applied. Pain means inflammation, which can lead to scarring of hair follicles and worsening of hair loss." 

Using pronouns such as we, us, and our is intentional. Doing so signals that the dermatologist is a partner with the patient in the treatment of TA. Starting with a simple initial recommendation gives the patient time to process the common thoughts highlighted in The Patient's Perspective section.⁶  

Scenario 2 
A Black child (we'll call her "Janet") is accompanied by her mother for follow-up of mild atopic dermatitis on the body and scalp. When the dermatologist examines the patient's scalp, they note that she has the fringe sign--retained short hairs along the frontal hairline--that is consistent with TA. Janet's hair is adorned with 2 tight ponytails in the front with colorful decorative balls on ponytail ties, barrettes, and 6 cornrow braids in the back with plastic beads on the ends. The dermatologist counsels about the atopic dermatitis and leaves the room.  

"Compliment, Discuss, and Suggest" Counseling
The use of tight decorative balls on ponytail ties and numerous plastic beads increases the amount of tension and weight on the hair, which may lead to a higher risk for developing traction alopecia.⁶ It is quite common for children of African descent to wear hair adornments. Proper counseling regarding their use and possible implications is essential. 

1. Compliment: "You're doing a great job controlling the atopic dermatitis, which can cause Janet's scalp to be dry. Also, her hair is beautiful--it looks like you spent a lot of time on her hair. And Janet, I like the color of your barrettes." 
2. Discuss: "Mom, I just noticed that a few areas look tight. Let's look together." (The dermatologist points out areas where the scalp is tented upward due to traction, follicular pustules or papules, or the frontal fringe sign.) "I'm on a mission to #savetheedges because we want Janet to grow up with full edges." (Again, loss of "edges" refers to TA.) 
3. Suggest: "When you do Janet's hair, it's OK if every hair is not in place. In fact, making styles look and feel 1 or 2 weeks old will lessen tension on the scalp. Remove Janet's hair ties to release tension when she is at home and while she's sleeping, if possible. Every minute that the hair is loose really does help."⁶  

The Parent's Perspective

All parents take pride in their children. In some Black communities, mothers are judged by how well they manage and style their children's hair. Some people might even suggest that parents of children with nonstyled, tightly coiled hair are not fit parents. Anthropologist Sylvia Boone, PhD, found that among the Mende tribe in Sierra Leone, "unkempt, 'neglected,' or 'messy' hair implied that a woman either had loose morals or was insane."⁷ 

Braids are commonly worn by people of African heritage for a variety of reasons, including ease of manageability, to decrease daily hairstyling time, and as an expression of creativity. Intricate neat hairstyles, despite the risk of pain and TA, are perceived as a sign that the child is cared for and loved.⁶  

FINAL THOUGHTS 

Patient-centered communication is associated with the patient trusting the physician, which is especially important in race-discordant physician-patient relationships. A study found that patient-physician race discordance led to shorter visits, a lower rating of patient affect, and less shared decision-making.⁸ Moreover, in a study of primary care clinicians, implicit bias was found to affect communication patterns and social interactions, impacting patient outcomes. Downstream effects of racial bias resulted in less speaking, smiling, and social comments when interacting with Black patients.⁹  

These findings highlight the need to address interpersonal barriers to effective communication in race-discordant patient-physician dyads. A history of segregated neighborhoods and schools might contribute to structural barriers, resulting in lack of familiarity with cultural norms outside one's culture, which might globally perpetuate poor communication and patient outcomes.  

The "compliment, discuss, and suggest" method might lead to more positive physician-patient encounters by having the dermatologist focus on empathetically understanding the patient's perspective.¹⁰ Effective communication, understanding cultural hair care practices, and a thorough scalp examination are paramount for patients with tightly coiled hair.¹¹ Early intervention in TA is crucial and involves partnering with patients and parents to amend high-risk hairstyling routines with cultural humility. 

Traction alopecia (TA)--one of the most common types of hair loss in Black women (although not exclusive to Black women)--is reversible when early corrective measures are taken; if chronic tension continues, however, permanent scarring alopecia ensues. Dermatologists can prevent worsening of this distressing hair loss. Due to a dearth of training among dermatologists in conditions occurring in patients with tightly coiled hair, it is imperative to add practical methods to the body of dermatology literature, with the goal of enhancing cultural humility.  

Hairstyling among Black women often is a lengthy process and often results in relationship bonding with the hair care giver, in turn imparting hair care traditions to the next generation. Therefore, a well-received discussion about TA prevention not only has an impact on the patient but potentially on a multigenerational family of women and friends. We present a memory aid for discussing TA, with a focus on cultural humility and patient-centered communication. 

Factors contributing to the risk of TA are hairstyles and hair care practices commonly used in Black individuals, including braids, locs, weaves, wigs, and chemical straightening.¹ These styles often are worn to increase hair manageability or as a creative expression of beauty. 

Discussing TA can be distressing for physicians and patients, especially in the setting of hair texture discordance. In a study that surveyed Black patients' perception of their dermatologic care both in and outside of a skin of color clinic, 71% of respondents (12/17) said that they prefer a race-concordant dermatologist. Some respondents reported that non-skin of color clinic dermatologists examined their hair with the end of a pencil or not at all; patients interpreted these interactions as disrespectful and racially insensitive.² Another study found that only 30.2% (19/63) of dermatology chief residents and 12.2% (5/41) of program directors reported a specific rotation during which residents gained experience treating skin of color patients.³ 

Due to a paucity of training in diagnosing and treating patients with tightly coiled hair who experience hair loss, some physicians might feel uncomfortable caring for patients who have tightly coiled hair. Although many Black patients prefer to see a race-concordant dermatologist because of their perceived cultural competence and shared experience, there is a paucity of Black dermatologists to see all patients who have tightly coiled hair.⁴ Therefore, all dermatologists should become skilled and comfortable discussing and treating TA in patients with all hair types. 

METHOD FOR COUNSELING 

The following scenarios are a guide to begin closing the competency gap in counseling about TA, using a "compliment, discuss, and suggest" method.  

Scenario 1 
A Black woman presents with a concern of "thinning edges" (a popular term on social media for TA). A hair-discordant dermatologist tells her, first, that she has TA caused by wearing tight hairstyles and, second, that the treatment is to stop wearing tight braids and weaves and to discontinue chemical relaxers. The dermatologist then leaves the room.  

The Patient's Perspective
It is not uncommon for the patient to have feelings of frustration about how they will style their hair, especially if they are unfamiliar with caring for their hair in its natural state.⁵ Also, they might have feelings of dismay that the loving childhood hair care giver, often their mother or grandmother, unintentionally harmed them with a tight style. They also might feel betrayed by their hairstylist, who might not have encouraged them to see a dermatologist, or who continued to oblige their request for a high-risk hairstyle. The patient might feel uncomfortable communicating the dermatologist's new recommendations to their hair care team, who also are part of her emotional support system. The patient also might think that the hair-discordant dermatologist has no idea what they "go through" with their hair.  

"Compliment, Discuss, and Suggest" Counseling
Traction alopecia is caused by tight hairstyles that often hurt when they are put in as tight braids, weaves, and ponytails.⁶ Risk increases if tight styles are applied to chemically straightened hair.¹ Braids, sew-in weaves, and wigs with adhesive sometimes are referred to as protective styles. However, these styles can still lead to TA due to excessive tension.  

• Compliment: "Your hair looks great. I know that you get many compliments."  
• Discuss: "However, some of the styles might be increasing your risk for hair loss. Our goal is to preserve as many of your follicles as possible."  
• Suggest: "Let's start by loosening the hairstyle if it is painful when being applied. Pain means inflammation, which can lead to scarring of hair follicles and worsening of hair loss." 

Using pronouns such as we, us, and our is intentional. Doing so signals that the dermatologist is a partner with the patient in the treatment of TA. Starting with a simple initial recommendation gives the patient time to process the common thoughts highlighted in The Patient's Perspective section.⁶  

Scenario 2 
A Black child (we'll call her "Janet") is accompanied by her mother for follow-up of mild atopic dermatitis on the body and scalp. When the dermatologist examines the patient's scalp, they note that she has the fringe sign--retained short hairs along the frontal hairline--that is consistent with TA. Janet's hair is adorned with 2 tight ponytails in the front with colorful decorative balls on ponytail ties, barrettes, and 6 cornrow braids in the back with plastic beads on the ends. The dermatologist counsels about the atopic dermatitis and leaves the room.  

"Compliment, Discuss, and Suggest" Counseling
The use of tight decorative balls on ponytail ties and numerous plastic beads increases the amount of tension and weight on the hair, which may lead to a higher risk for developing traction alopecia.⁶ It is quite common for children of African descent to wear hair adornments. Proper counseling regarding their use and possible implications is essential. 

1. Compliment: "You're doing a great job controlling the atopic dermatitis, which can cause Janet's scalp to be dry. Also, her hair is beautiful--it looks like you spent a lot of time on her hair. And Janet, I like the color of your barrettes." 
2. Discuss: "Mom, I just noticed that a few areas look tight. Let's look together." (The dermatologist points out areas where the scalp is tented upward due to traction, follicular pustules or papules, or the frontal fringe sign.) "I'm on a mission to #savetheedges because we want Janet to grow up with full edges." (Again, loss of "edges" refers to TA.) 
3. Suggest: "When you do Janet's hair, it's OK if every hair is not in place. In fact, making styles look and feel 1 or 2 weeks old will lessen tension on the scalp. Remove Janet's hair ties to release tension when she is at home and while she's sleeping, if possible. Every minute that the hair is loose really does help."⁶  

The Parent's Perspective

All parents take pride in their children. In some Black communities, mothers are judged by how well they manage and style their children's hair. Some people might even suggest that parents of children with nonstyled, tightly coiled hair are not fit parents. Anthropologist Sylvia Boone, PhD, found that among the Mende tribe in Sierra Leone, "unkempt, 'neglected,' or 'messy' hair implied that a woman either had loose morals or was insane."⁷ 

Braids are commonly worn by people of African heritage for a variety of reasons, including ease of manageability, to decrease daily hairstyling time, and as an expression of creativity. Intricate neat hairstyles, despite the risk of pain and TA, are perceived as a sign that the child is cared for and loved.⁶  

FINAL THOUGHTS 

Patient-centered communication is associated with the patient trusting the physician, which is especially important in race-discordant physician-patient relationships. A study found that patient-physician race discordance led to shorter visits, a lower rating of patient affect, and less shared decision-making.⁸ Moreover, in a study of primary care clinicians, implicit bias was found to affect communication patterns and social interactions, impacting patient outcomes. Downstream effects of racial bias resulted in less speaking, smiling, and social comments when interacting with Black patients.⁹  

These findings highlight the need to address interpersonal barriers to effective communication in race-discordant patient-physician dyads. A history of segregated neighborhoods and schools might contribute to structural barriers, resulting in lack of familiarity with cultural norms outside one's culture, which might globally perpetuate poor communication and patient outcomes.  

The "compliment, discuss, and suggest" method might lead to more positive physician-patient encounters by having the dermatologist focus on empathetically understanding the patient's perspective.¹⁰ Effective communication, understanding cultural hair care practices, and a thorough scalp examination are paramount for patients with tightly coiled hair.¹¹ Early intervention in TA is crucial and involves partnering with patients and parents to amend high-risk hairstyling routines with cultural humility. 

The Comparison

A Elbow and forearm with erythematous, well-demarcated, pink plaques with mild micaceous scale in a 42-year-old White woman.

B Elbow and forearm with violaceous, well-demarcated plaques with micaceous scale and hyperpigmented patches around the active plaques in a 58-year-old Black man.

Epidemiology
Psoriasis prevalence in the United States has been estimated at 3.7%.^1-3 If broken down by race or ethnicity, the prevalence of psoriasis varies: 2.5% to 3.7% in White adults^1-4; 1.3% to 2% in Black adults^1-4; 1.6% in Hispanics/ other adults^1-3; 1% in children overall; 0.29% in White children_^1,5; and 0.06% in Black children.^1,5

Key clinical features in people with darker skin tones include:

• plaques that may appear more violaceous in color instead of pink or erythematous
• higher body surface area of involvement4 and thicker, more scaly plaques⁶
• increased likelihood of postinflammatory hyperpigmentation (PIH).

Worth noting
Although individuals of all skin tones may experience the psychosocial impact of psoriasis, quality-of-life measures have been found to be worse in those with skin of color (SOC) compared to White patients.^1,4 This may be due to the lingering PIH and hypopigmentation that occurs even after inflammatory plaques are treated. Of course, lack of access to care contributes to greater disease burden and more devastating psychological impact.

Health disparity highlight
Psoriasis may be underreported and underdiagnosed in individuals with SOC, as factors contributing to health care disparities may play a role, such as access to health care in general,^1,7 and access to clinicians proficient in diagnosing cutaneous diseases in SOC may be delayed.⁸

Biologic medications are used less often in Black patients than in White patients, despite biologic medications being very efficacious for treatment of psoriasis.^1,9,10

The Comparison

A Elbow and forearm with erythematous, well-demarcated, pink plaques with mild micaceous scale in a 42-year-old White woman.

B Elbow and forearm with violaceous, well-demarcated plaques with micaceous scale and hyperpigmented patches around the active plaques in a 58-year-old Black man.

Epidemiology
Psoriasis prevalence in the United States has been estimated at 3.7%.^1-3 If broken down by race or ethnicity, the prevalence of psoriasis varies: 2.5% to 3.7% in White adults^1-4; 1.3% to 2% in Black adults^1-4; 1.6% in Hispanics/ other adults^1-3; 1% in children overall; 0.29% in White children_^1,5; and 0.06% in Black children.^1,5

Key clinical features in people with darker skin tones include:

• plaques that may appear more violaceous in color instead of pink or erythematous
• higher body surface area of involvement4 and thicker, more scaly plaques⁶
• increased likelihood of postinflammatory hyperpigmentation (PIH).

Worth noting
Although individuals of all skin tones may experience the psychosocial impact of psoriasis, quality-of-life measures have been found to be worse in those with skin of color (SOC) compared to White patients.^1,4 This may be due to the lingering PIH and hypopigmentation that occurs even after inflammatory plaques are treated. Of course, lack of access to care contributes to greater disease burden and more devastating psychological impact.

Health disparity highlight
Psoriasis may be underreported and underdiagnosed in individuals with SOC, as factors contributing to health care disparities may play a role, such as access to health care in general,^1,7 and access to clinicians proficient in diagnosing cutaneous diseases in SOC may be delayed.⁸

Biologic medications are used less often in Black patients than in White patients, despite biologic medications being very efficacious for treatment of psoriasis.^1,9,10

The Comparison

A Elbow and forearm with erythematous, well-demarcated, pink plaques with mild micaceous scale in a 42-year-old White woman.

B Elbow and forearm with violaceous, well-demarcated plaques with micaceous scale and hyperpigmented patches around the active plaques in a 58-year-old Black man.

Epidemiology
Psoriasis prevalence in the United States has been estimated at 3.7%.^1-3 If broken down by race or ethnicity, the prevalence of psoriasis varies: 2.5% to 3.7% in White adults^1-4; 1.3% to 2% in Black adults^1-4; 1.6% in Hispanics/ other adults^1-3; 1% in children overall; 0.29% in White children_^1,5; and 0.06% in Black children.^1,5

Key clinical features in people with darker skin tones include:

• plaques that may appear more violaceous in color instead of pink or erythematous
• higher body surface area of involvement4 and thicker, more scaly plaques⁶
• increased likelihood of postinflammatory hyperpigmentation (PIH).

Worth noting
Although individuals of all skin tones may experience the psychosocial impact of psoriasis, quality-of-life measures have been found to be worse in those with skin of color (SOC) compared to White patients.^1,4 This may be due to the lingering PIH and hypopigmentation that occurs even after inflammatory plaques are treated. Of course, lack of access to care contributes to greater disease burden and more devastating psychological impact.

Health disparity highlight
Psoriasis may be underreported and underdiagnosed in individuals with SOC, as factors contributing to health care disparities may play a role, such as access to health care in general,^1,7 and access to clinicians proficient in diagnosing cutaneous diseases in SOC may be delayed.⁸

Biologic medications are used less often in Black patients than in White patients, despite biologic medications being very efficacious for treatment of psoriasis.^1,9,10

THE COMPARISON

A Pink scaling plaques and erythematous erosions in the antecubital fossae of a 6-year-old White boy.

B Violaceous, hyperpigmented, nummular plaques on the back and extensor surface of the right arm of a 16-month-old Black girl.

C Atopic dermatitis and follicular prominence/accentuation on the neck of a young Black girl.

Epidemiology

People of African descent have the highest atopic dermatitis prevalence and severity.

Key clinical features in people with darker skin tones include:

• follicular prominence
• papular morphology
• prurigo nodules
• hyperpigmented, violaceous-brown or gray plaques instead of erythematous plaques
• lichenification
• treatment resistant.^1,2

Worth noting

Postinflammatory hyperpigmentation and postinflammatory hypopigmentation may be more distressing to the patient/family than the atopic dermatitis itself.

Health disparity highlight

In the United States, patients with skin of color are more likely to be hospitalized with severe atopic dermatitis, have more substantial out-of-pocket costs, be underinsured, and have an increased number of missed days of work. Limited access to outpatient health care plays a role in exacerbating this health disparity.^3,4

THE COMPARISON

A Pink scaling plaques and erythematous erosions in the antecubital fossae of a 6-year-old White boy.

B Violaceous, hyperpigmented, nummular plaques on the back and extensor surface of the right arm of a 16-month-old Black girl.

C Atopic dermatitis and follicular prominence/accentuation on the neck of a young Black girl.

Epidemiology

People of African descent have the highest atopic dermatitis prevalence and severity.

Key clinical features in people with darker skin tones include:

• follicular prominence
• papular morphology
• prurigo nodules
• hyperpigmented, violaceous-brown or gray plaques instead of erythematous plaques
• lichenification
• treatment resistant.^1,2

Worth noting

Postinflammatory hyperpigmentation and postinflammatory hypopigmentation may be more distressing to the patient/family than the atopic dermatitis itself.

Health disparity highlight

In the United States, patients with skin of color are more likely to be hospitalized with severe atopic dermatitis, have more substantial out-of-pocket costs, be underinsured, and have an increased number of missed days of work. Limited access to outpatient health care plays a role in exacerbating this health disparity.^3,4

THE COMPARISON

A Pink scaling plaques and erythematous erosions in the antecubital fossae of a 6-year-old White boy.

B Violaceous, hyperpigmented, nummular plaques on the back and extensor surface of the right arm of a 16-month-old Black girl.

C Atopic dermatitis and follicular prominence/accentuation on the neck of a young Black girl.

Epidemiology

People of African descent have the highest atopic dermatitis prevalence and severity.

Key clinical features in people with darker skin tones include:

• follicular prominence
• papular morphology
• prurigo nodules
• hyperpigmented, violaceous-brown or gray plaques instead of erythematous plaques
• lichenification
• treatment resistant.^1,2

Worth noting

Postinflammatory hyperpigmentation and postinflammatory hypopigmentation may be more distressing to the patient/family than the atopic dermatitis itself.

Health disparity highlight

In the United States, patients with skin of color are more likely to be hospitalized with severe atopic dermatitis, have more substantial out-of-pocket costs, be underinsured, and have an increased number of missed days of work. Limited access to outpatient health care plays a role in exacerbating this health disparity.^3,4

The Comparison

A Pink scaling plaques and erythematous erosions in the antecubital fossae of a 6-year-old White boy.

B Violaceous, hyperpigmented, nummular plaques on the back and extensor surface of the right arm of a 16-month-old Black girl.

C Atopic dermatitis and follicular prominence/accentuation on the neck of a young Black girl.

Epidemiology

People of African descent have the highest atopic dermatitis prevalence and severity.

Key clinical features in people with darker skin tones include:

• follicular prominence
• papular morphology
• prurigo nodules
• hyperpigmented, violaceous-brown or gray plaques instead of erythematous plaques
• lichenification
• treatment resistant.^1,2

Worth noting
Postinflammatory hyperpigmentation and postinflammatory hypopigmentation may be more distressing to the patient/family than the atopic dermatitis itself.

Health disparity highlight
In the United States, patients with skin of color are more likely to be hospitalized with severe atopic dermatitis, have more substantial out-ofpocket costs, be underinsured, and have an increased number of missed days of work. Limited access to outpatient health care plays a role in exacerbating this health disparity.^3,4

The Comparison

A Pink scaling plaques and erythematous erosions in the antecubital fossae of a 6-year-old White boy.

B Violaceous, hyperpigmented, nummular plaques on the back and extensor surface of the right arm of a 16-month-old Black girl.

C Atopic dermatitis and follicular prominence/accentuation on the neck of a young Black girl.

Epidemiology

People of African descent have the highest atopic dermatitis prevalence and severity.

Key clinical features in people with darker skin tones include:

• follicular prominence
• papular morphology
• prurigo nodules
• hyperpigmented, violaceous-brown or gray plaques instead of erythematous plaques
• lichenification
• treatment resistant.^1,2

Worth noting
Postinflammatory hyperpigmentation and postinflammatory hypopigmentation may be more distressing to the patient/family than the atopic dermatitis itself.

Health disparity highlight
In the United States, patients with skin of color are more likely to be hospitalized with severe atopic dermatitis, have more substantial out-ofpocket costs, be underinsured, and have an increased number of missed days of work. Limited access to outpatient health care plays a role in exacerbating this health disparity.^3,4

The Comparison

A Pink scaling plaques and erythematous erosions in the antecubital fossae of a 6-year-old White boy.

B Violaceous, hyperpigmented, nummular plaques on the back and extensor surface of the right arm of a 16-month-old Black girl.

C Atopic dermatitis and follicular prominence/accentuation on the neck of a young Black girl.

Epidemiology

People of African descent have the highest atopic dermatitis prevalence and severity.

Key clinical features in people with darker skin tones include:

• follicular prominence
• papular morphology
• prurigo nodules
• hyperpigmented, violaceous-brown or gray plaques instead of erythematous plaques
• lichenification
• treatment resistant.^1,2

Worth noting
Postinflammatory hyperpigmentation and postinflammatory hypopigmentation may be more distressing to the patient/family than the atopic dermatitis itself.

Health disparity highlight
In the United States, patients with skin of color are more likely to be hospitalized with severe atopic dermatitis, have more substantial out-ofpocket costs, be underinsured, and have an increased number of missed days of work. Limited access to outpatient health care plays a role in exacerbating this health disparity.^3,4

To the Editor:

Lichen planus (LP) is an inflammatory mucocutaneous disorder that primarily affects adults aged 30 to 60 years.¹ It can present across various regions such as the skin, scalp, oral cavity, genitalia, nails, and hair. It classically presents with pruritic, purple, polygonal papules or plaques. The proposed pathogenesis of this condition involves autoimmune destruction of epidermal basal keratinocytes.² Management involves a stepwise approach, beginning with topical therapies such as corticosteroids and phototherapy and proceeding to systemic therapy including oral corticosteroids and retinoids. Additional medications with reported positive results include immunomodulators such as cyclosporine, tacrolimus, and mycophenolate mofetil.^2-4 Dupilumab is a biologic immunomodulator and antagonist to the IL-4Rα on helper T cells (T_H1). Although indicated for the treatment of moderate to severe atopic dermatitis, this medication’s immunomodulatory properties have been shown to aid various inflammatory cutaneous conditions, including prurigo nodularis.^5-9 We present a case of dupilumab therapy for treatment-refractory LP.

A 52-year-old man presented with a new-onset progressive rash over the prior 6 months. He reported no history of atopic dermatitis. The patient described the rash as “severely pruritic” with a numeric rating scale itch intensity of 9/10 (0 being no itch; 10 being the worst itch imaginable). Physical examination revealed purple polygonal scaly papules on the arms, hands, legs, feet, chest, and back (Figure 1).

Treatment-refractory LP remains difficult to manage for both the patient and provider. Treatment regimens remain limited to small uncontrolled studies and case reports. Although primarily considered a T_H1-mediated disease, the interplay of various alternative signaling pathways has been suggested. Our case of dupilumab-responsive LP suggests an underlying pathologic role of T_H2-mediated activity. Dupilumab shows promise as an effective therapy for refractory LP, as evidenced by our patient’s remarkable response. Larger studies are warranted regarding the role of T_H2-mediated inflammation and the use of dupilumab in LP.

To the Editor:

Lichen planus (LP) is an inflammatory mucocutaneous disorder that primarily affects adults aged 30 to 60 years.¹ It can present across various regions such as the skin, scalp, oral cavity, genitalia, nails, and hair. It classically presents with pruritic, purple, polygonal papules or plaques. The proposed pathogenesis of this condition involves autoimmune destruction of epidermal basal keratinocytes.² Management involves a stepwise approach, beginning with topical therapies such as corticosteroids and phototherapy and proceeding to systemic therapy including oral corticosteroids and retinoids. Additional medications with reported positive results include immunomodulators such as cyclosporine, tacrolimus, and mycophenolate mofetil.^2-4 Dupilumab is a biologic immunomodulator and antagonist to the IL-4Rα on helper T cells (T_H1). Although indicated for the treatment of moderate to severe atopic dermatitis, this medication’s immunomodulatory properties have been shown to aid various inflammatory cutaneous conditions, including prurigo nodularis.^5-9 We present a case of dupilumab therapy for treatment-refractory LP.

A 52-year-old man presented with a new-onset progressive rash over the prior 6 months. He reported no history of atopic dermatitis. The patient described the rash as “severely pruritic” with a numeric rating scale itch intensity of 9/10 (0 being no itch; 10 being the worst itch imaginable). Physical examination revealed purple polygonal scaly papules on the arms, hands, legs, feet, chest, and back (Figure 1).

Treatment-refractory LP remains difficult to manage for both the patient and provider. Treatment regimens remain limited to small uncontrolled studies and case reports. Although primarily considered a T_H1-mediated disease, the interplay of various alternative signaling pathways has been suggested. Our case of dupilumab-responsive LP suggests an underlying pathologic role of T_H2-mediated activity. Dupilumab shows promise as an effective therapy for refractory LP, as evidenced by our patient’s remarkable response. Larger studies are warranted regarding the role of T_H2-mediated inflammation and the use of dupilumab in LP.

To the Editor:

Lichen planus (LP) is an inflammatory mucocutaneous disorder that primarily affects adults aged 30 to 60 years.¹ It can present across various regions such as the skin, scalp, oral cavity, genitalia, nails, and hair. It classically presents with pruritic, purple, polygonal papules or plaques. The proposed pathogenesis of this condition involves autoimmune destruction of epidermal basal keratinocytes.² Management involves a stepwise approach, beginning with topical therapies such as corticosteroids and phototherapy and proceeding to systemic therapy including oral corticosteroids and retinoids. Additional medications with reported positive results include immunomodulators such as cyclosporine, tacrolimus, and mycophenolate mofetil.^2-4 Dupilumab is a biologic immunomodulator and antagonist to the IL-4Rα on helper T cells (T_H1). Although indicated for the treatment of moderate to severe atopic dermatitis, this medication’s immunomodulatory properties have been shown to aid various inflammatory cutaneous conditions, including prurigo nodularis.^5-9 We present a case of dupilumab therapy for treatment-refractory LP.

A 52-year-old man presented with a new-onset progressive rash over the prior 6 months. He reported no history of atopic dermatitis. The patient described the rash as “severely pruritic” with a numeric rating scale itch intensity of 9/10 (0 being no itch; 10 being the worst itch imaginable). Physical examination revealed purple polygonal scaly papules on the arms, hands, legs, feet, chest, and back (Figure 1).

Treatment-refractory LP remains difficult to manage for both the patient and provider. Treatment regimens remain limited to small uncontrolled studies and case reports. Although primarily considered a T_H1-mediated disease, the interplay of various alternative signaling pathways has been suggested. Our case of dupilumab-responsive LP suggests an underlying pathologic role of T_H2-mediated activity. Dupilumab shows promise as an effective therapy for refractory LP, as evidenced by our patient’s remarkable response. Larger studies are warranted regarding the role of T_H2-mediated inflammation and the use of dupilumab in LP.

What does your patient need to know at the first visit?  

All patients, regardless of race, gender, or age, are afraid of an alopecia diagnosis. Often, the first thing a patient may say when I enter the examination room is, "Please don't tell me I have alopecia."  

The first step to a successful initial visit for hair loss is addressing the angst around the word alopecia, which helps to manage the patient's hair-induced anxiety. The next priority is setting expectations for the journey including what to expect during the diagnosis process, treatment, and beyond.  

Next is data collection. An extensive hair care practice investigation can begin with a survey that the patient fills out before the visit. Dive into and expand on hair loss history questions, including medical history as well as hair care practices (eg, history of use, frequency, number of years, maintenance for that particular hairstyle) such as braids (eg, individual braids, cornrow braids, with or without added synthetic or human hair), locs (eg, length of locs), chemical relaxers (eg, number of years, frequency, professionally applied or applied at home), hair color, weaves (eg, glued in, sewn in, combination), and more.¹ Include a family history of hair loss, both maternal and paternal.  

The hair loss investigation almost always includes a scalp biopsy, hair-pull test, dermoscopy, photographs, and even blood work, if applicable. Scalp biopsies may reveal more than one type of alopecia diagnosis, which may impact the treatment plan.² Sending the scalp biopsy specimen to a dermatopathologist specializing in alopecia along with clinical information about the patient is preferred. 

What are your go-to treatments?  

My go-to treatments for patients with skin of color (SOC) and hair loss really depend on the specific diagnosis. Randomized, placebo-controlled clinical trials focusing on treatment are lacking in central centrifugal cicatricial alopecia and traction alopecia, which holds true for many other types of alopecia.  

For black patients with central centrifugal cicatricial alopecia, I often address the inflammatory component of the disease with oral doxycycline and either a topical corticosteroid, such as clobetasol, or intralesional triamcinolone. Adding minoxidil-containing products later in the treatment process can be helpful. Various treatment protocols exist but are mainly based on anecdotal evidence.¹ 

For those with traction alopecia, modification of offending hairstyle practices is a must.³ Also, treatment of inflammation is key. Typically, I gravitate to topical or intralesional corticosteroids, followed by minoxidil-containing products. However, a challenge of treating traction alopecia is changing the hair care practices that cause tight pulling, friction, or pressure on the scalp, such as from the band of a tightly fitted wig.  

It is important to discuss potential side effects of any treatment with the patient. For the most common side effects, discuss how to best prevent them. For example, because of the photosensitivity potential of doxycycline, I ask patients to wear sunscreen daily. To prevent nausea, I recommend that they avoid taking doxycycline on an empty stomach, drink plenty of fluids, and avoid laying down within a few hours after taking the medication.  

How do you keep patients compliant with treatment? 

Dermatologists should try to understand their patients' hair. A study of 200 black women demonstrated that 68% of the patients did not think their physician understood their hair,⁴ which likely impacts patients' perceptions of their physician, confidence in the treatment plan, and even compliance with the plan. Attempting to understand the nuances of tightly coiled hair in those of African descent is the first step in the journey of diagnosing and treating hair loss in partnership with the patient.  

Setting the goal is a crucial step toward patient compliance. It may be going out in public without a wig or weave and feeling confident, providing more coverage so affected areas do not show as much, improving scalp tenderness, and/or preventing further progression of the condition. These are all reasonable outcomes and each goal is uniquely tailored to each patient.  

Familiarize yourself with various hair types, hairstyles, and preferred medication vehicles by attending continuing medical education lectures on alopecia in patients with SOC and on nuances to diagnosis and treatment, reading textbooks focusing on SOC, or seeking out mentorship from a dermatologist who is a hair expert in the types of alopecia most commonly affecting patients with SOC.  

What resources do you recommend to patients for more information 

For patients with scarring alopecia, the Cicatricial Alopecia Research Foundation (http://www.carfintl.org/) is a great resource for medical information and support groups. Also, the Skin of Color Society has dermatology patient education information (http://skinofcolorsociety.org/).  

For patients who are extremely distressed by hair loss, I encourage them to see a mental health professional. The mental health impact of alopecia, despite the extent of disease, is likely underestimated. Patients sometimes need our permission to seek help, especially in many SOC communities where even seeking mental health care often is frowned upon.  

What does your patient need to know at the first visit?  

All patients, regardless of race, gender, or age, are afraid of an alopecia diagnosis. Often, the first thing a patient may say when I enter the examination room is, "Please don't tell me I have alopecia."  

The first step to a successful initial visit for hair loss is addressing the angst around the word alopecia, which helps to manage the patient's hair-induced anxiety. The next priority is setting expectations for the journey including what to expect during the diagnosis process, treatment, and beyond.  

Next is data collection. An extensive hair care practice investigation can begin with a survey that the patient fills out before the visit. Dive into and expand on hair loss history questions, including medical history as well as hair care practices (eg, history of use, frequency, number of years, maintenance for that particular hairstyle) such as braids (eg, individual braids, cornrow braids, with or without added synthetic or human hair), locs (eg, length of locs), chemical relaxers (eg, number of years, frequency, professionally applied or applied at home), hair color, weaves (eg, glued in, sewn in, combination), and more.¹ Include a family history of hair loss, both maternal and paternal.  

The hair loss investigation almost always includes a scalp biopsy, hair-pull test, dermoscopy, photographs, and even blood work, if applicable. Scalp biopsies may reveal more than one type of alopecia diagnosis, which may impact the treatment plan.² Sending the scalp biopsy specimen to a dermatopathologist specializing in alopecia along with clinical information about the patient is preferred. 

What are your go-to treatments?  

My go-to treatments for patients with skin of color (SOC) and hair loss really depend on the specific diagnosis. Randomized, placebo-controlled clinical trials focusing on treatment are lacking in central centrifugal cicatricial alopecia and traction alopecia, which holds true for many other types of alopecia.  

For black patients with central centrifugal cicatricial alopecia, I often address the inflammatory component of the disease with oral doxycycline and either a topical corticosteroid, such as clobetasol, or intralesional triamcinolone. Adding minoxidil-containing products later in the treatment process can be helpful. Various treatment protocols exist but are mainly based on anecdotal evidence.¹ 

For those with traction alopecia, modification of offending hairstyle practices is a must.³ Also, treatment of inflammation is key. Typically, I gravitate to topical or intralesional corticosteroids, followed by minoxidil-containing products. However, a challenge of treating traction alopecia is changing the hair care practices that cause tight pulling, friction, or pressure on the scalp, such as from the band of a tightly fitted wig.  

It is important to discuss potential side effects of any treatment with the patient. For the most common side effects, discuss how to best prevent them. For example, because of the photosensitivity potential of doxycycline, I ask patients to wear sunscreen daily. To prevent nausea, I recommend that they avoid taking doxycycline on an empty stomach, drink plenty of fluids, and avoid laying down within a few hours after taking the medication.  

How do you keep patients compliant with treatment? 

Dermatologists should try to understand their patients' hair. A study of 200 black women demonstrated that 68% of the patients did not think their physician understood their hair,⁴ which likely impacts patients' perceptions of their physician, confidence in the treatment plan, and even compliance with the plan. Attempting to understand the nuances of tightly coiled hair in those of African descent is the first step in the journey of diagnosing and treating hair loss in partnership with the patient.  

Setting the goal is a crucial step toward patient compliance. It may be going out in public without a wig or weave and feeling confident, providing more coverage so affected areas do not show as much, improving scalp tenderness, and/or preventing further progression of the condition. These are all reasonable outcomes and each goal is uniquely tailored to each patient.  

Familiarize yourself with various hair types, hairstyles, and preferred medication vehicles by attending continuing medical education lectures on alopecia in patients with SOC and on nuances to diagnosis and treatment, reading textbooks focusing on SOC, or seeking out mentorship from a dermatologist who is a hair expert in the types of alopecia most commonly affecting patients with SOC.  

What resources do you recommend to patients for more information 

For patients with scarring alopecia, the Cicatricial Alopecia Research Foundation (http://www.carfintl.org/) is a great resource for medical information and support groups. Also, the Skin of Color Society has dermatology patient education information (http://skinofcolorsociety.org/).  

For patients who are extremely distressed by hair loss, I encourage them to see a mental health professional. The mental health impact of alopecia, despite the extent of disease, is likely underestimated. Patients sometimes need our permission to seek help, especially in many SOC communities where even seeking mental health care often is frowned upon.  

What does your patient need to know at the first visit?  

All patients, regardless of race, gender, or age, are afraid of an alopecia diagnosis. Often, the first thing a patient may say when I enter the examination room is, "Please don't tell me I have alopecia."  

The first step to a successful initial visit for hair loss is addressing the angst around the word alopecia, which helps to manage the patient's hair-induced anxiety. The next priority is setting expectations for the journey including what to expect during the diagnosis process, treatment, and beyond.  

Next is data collection. An extensive hair care practice investigation can begin with a survey that the patient fills out before the visit. Dive into and expand on hair loss history questions, including medical history as well as hair care practices (eg, history of use, frequency, number of years, maintenance for that particular hairstyle) such as braids (eg, individual braids, cornrow braids, with or without added synthetic or human hair), locs (eg, length of locs), chemical relaxers (eg, number of years, frequency, professionally applied or applied at home), hair color, weaves (eg, glued in, sewn in, combination), and more.¹ Include a family history of hair loss, both maternal and paternal.  

The hair loss investigation almost always includes a scalp biopsy, hair-pull test, dermoscopy, photographs, and even blood work, if applicable. Scalp biopsies may reveal more than one type of alopecia diagnosis, which may impact the treatment plan.² Sending the scalp biopsy specimen to a dermatopathologist specializing in alopecia along with clinical information about the patient is preferred. 

What are your go-to treatments?  

My go-to treatments for patients with skin of color (SOC) and hair loss really depend on the specific diagnosis. Randomized, placebo-controlled clinical trials focusing on treatment are lacking in central centrifugal cicatricial alopecia and traction alopecia, which holds true for many other types of alopecia.  

For black patients with central centrifugal cicatricial alopecia, I often address the inflammatory component of the disease with oral doxycycline and either a topical corticosteroid, such as clobetasol, or intralesional triamcinolone. Adding minoxidil-containing products later in the treatment process can be helpful. Various treatment protocols exist but are mainly based on anecdotal evidence.¹ 

For those with traction alopecia, modification of offending hairstyle practices is a must.³ Also, treatment of inflammation is key. Typically, I gravitate to topical or intralesional corticosteroids, followed by minoxidil-containing products. However, a challenge of treating traction alopecia is changing the hair care practices that cause tight pulling, friction, or pressure on the scalp, such as from the band of a tightly fitted wig.  

It is important to discuss potential side effects of any treatment with the patient. For the most common side effects, discuss how to best prevent them. For example, because of the photosensitivity potential of doxycycline, I ask patients to wear sunscreen daily. To prevent nausea, I recommend that they avoid taking doxycycline on an empty stomach, drink plenty of fluids, and avoid laying down within a few hours after taking the medication.  

How do you keep patients compliant with treatment? 

Dermatologists should try to understand their patients' hair. A study of 200 black women demonstrated that 68% of the patients did not think their physician understood their hair,⁴ which likely impacts patients' perceptions of their physician, confidence in the treatment plan, and even compliance with the plan. Attempting to understand the nuances of tightly coiled hair in those of African descent is the first step in the journey of diagnosing and treating hair loss in partnership with the patient.  

Setting the goal is a crucial step toward patient compliance. It may be going out in public without a wig or weave and feeling confident, providing more coverage so affected areas do not show as much, improving scalp tenderness, and/or preventing further progression of the condition. These are all reasonable outcomes and each goal is uniquely tailored to each patient.  

Familiarize yourself with various hair types, hairstyles, and preferred medication vehicles by attending continuing medical education lectures on alopecia in patients with SOC and on nuances to diagnosis and treatment, reading textbooks focusing on SOC, or seeking out mentorship from a dermatologist who is a hair expert in the types of alopecia most commonly affecting patients with SOC.  

What resources do you recommend to patients for more information 

For patients with scarring alopecia, the Cicatricial Alopecia Research Foundation (http://www.carfintl.org/) is a great resource for medical information and support groups. Also, the Skin of Color Society has dermatology patient education information (http://skinofcolorsociety.org/).  

For patients who are extremely distressed by hair loss, I encourage them to see a mental health professional. The mental health impact of alopecia, despite the extent of disease, is likely underestimated. Patients sometimes need our permission to seek help, especially in many SOC communities where even seeking mental health care often is frowned upon.  

Postnflammatory hyperpigmentation (PIH) is an acquired hypermelanosis that can occur in children and adults following an inflammatory cutaneous disease or trauma. Postinflammatory hyperpigmentation may last for months to even years. Although PIH may occur in all skin types, it is more common and presents with greater severity and intensity in individuals with skin of color. By the year 2050, 1 in 3 US residents is projected to be Hispanic.¹ It is projected that by 2044, non-Hispanic white individuals (all ages) will make up less than 50% of the US population.² Currently, the majority of the US residents younger than 18 years are minorities. The majority minority population in the United States already exists in those younger than 18 years and is predicted to occur in the adult population by 2044.²

Effective treatment options and management strategies for PIH in adults with skin of color have been described in the literature.³ Due to a paucity of research, the approach to management of PIH in children with skin of color has been based on clinical experience and lessons learned from adult patients. This article focuses on management of PIH in pediatric patients with skin of color, which includes black/African American, African-Caribbean, Hispanic, Asian, Pacific Islander, and American Indian individuals.

Underlying Inflammatory Dermatoses Resulting in PIH

There are numerous conditions that may result in PIH, including but not limited to atopic dermatitis (AD), acne, arthropod bites, and injuries to the skin. Postinflammatory hyperpigmentation may have more of a psychological impact than the inciting disease or injury itself. The most important step in the approach to managing PIH is treating the underlying inflammatory condition that caused the pigmentation.

Parents/guardians may report a chief concern of dark spots, manchas (stains), blemishes, or stains on the skin, often with no mention of a coexisting inflammatory dermatosis. Parents/guardians of children with skin of color often have personally experienced PIH and may be determined to shield their children from similar angst associated with the condition. Although physicians may see just another pediatric patient with PIH, the child’s parents/guardians may see a condition that will be readily perceptible during major life events, such as the child’s prom or even his/her wedding day. Promptly diagnosing and instituting early treatment of inflammatory conditions associated with PIH may accelerate resolution and prevent worsening of the pigmentation.³

Select inflammatory dermatoses that are common in children with skin of color and may lead to PIH are highlighted below. Although this list is not comprehensive, the approach and management strategies should prompt creation of plans that keep PIH in mind when treating primary inflammatory skin diseases.

Atopic Dermatitis
Atopic dermatitis may induce PIH or hypopigmentation of the skin in children with skin of color. Developing a plan for AD flare prevention, as well as management of mild, moderate, and severe AD flares, is imperative in pediatric patients. Prevention plans should include gentle skin care, twice-daily application of emollients to the full body, and reduction of Staphylococcus aureus loads on the skin. The treatment action plan for mild to moderate flares may include topical corticosteroids, immunomodulators, and nonsteroidal agents. Treatment options for severe AD or patients who were unsuccessfully treated with other therapies may include phototherapy, biologics, and methotrexate, among others.⁴ Creating action plans for AD flares is a vital step in the prevention of PIH in patients with skin of color. Additionally, PIH should not be considered a sign of AD treatment failure.

Acne
Acne is a common skin disorder seen in patients with skin of color.⁵ A prospective observational study found that 34.3% of 683 children aged 9 to 14 years in a pediatric ambulatory clinic had acne.⁶ The number of preadolescents with acne is growing. Most cases are not associated with underlying endocrinopathy.⁷ With the growing population of children with skin of color in the United States along with the increasing childhood acne rate and subsequent inherent risk for hyperpigmentation, early acne interventions should be considered in pediatric acne patients with skin of color to reduce the impact of PIH in those at risk.

In a survey study of 313 adult acne patients with skin of color, 37.2% reported the presence of dark marks lasting 4 months or longer.⁵ Regardless of the severity of the acne, treatment should be initiated as tolerated in those with PIH. Adolescent acne patients with skin of color may develop PIH that is more severe and longer lasting than the acne itself.

The foundation for treatment of acne in adolescent skin of color patients is the same as those without skin of color, including topical retinoids, topical antibiotics, oral antibiotics, and isotretinoin when needed. Topical tretinoin, adapalene, azelaic acid, and tazarotene not only treat acne but also are a valuable part of the treatment armamentarium for PIH. Several studies in adults with skin of color have demonstrated improvement of PIH from the use of topical retinoids alone.^8-10 Despite wanting to treat the acne aggressively, special guidance should be given to prevent retinoid dermatitis, which may lead to PIH.¹⁰ Demonstrating the application of the topical acne medications, discussing how to avoid potential side effects, and giving permission to skip applications, if needed, may empower families to make adjustments between visits to limit irritation that might prompt further PIH. Incorporating α-hydroxy acid–based cleansers, α-hydroxy acid–based chemical peels, or salicylic acid chemical peels may be warranted in the setting of intense PIH. Selecting treatments that not only help the inflammatory disease leading to the PIH but also can help improve the pigmentation are preferred; however, the risks and benefits have to be weighed because many treatments that work well for PIH also may cause irritation, leading to new or worsening PIH.

Arthropod Bites
Arthropod bites cause inflamed pruritic papules and nodules, and the resulting PIH in those with darker skin types may be quite dramatic. Parents/guardians should be instructed to have a low-potency topical corticosteroid on hand to use on bites for a few days when they appear, which will not only help with the inflammation associated with the bite but also will help decrease pruritus and subsequently skin injury from scratching. In homes with pets, checking animals routinely for fleas and other infestations is helpful. In the setting of repeated arthropod bites in the spring and summer, applying bug repellant with 10% to 30% DEET (N,N-diethyl-meta-toluamide) on the child’s clothing and exposed body areas before playing outside or in the morning before school or camp may prevent some bites. There are DEET alternatives, such as picaridin, that may be used. Product instructions should be followed when using insect repellants in the pediatric population.¹¹

PIH Management Strategies

Gentle Skin Care Routine
There are misconceptions that areas of hyperpigmentation on the skin are caused by dirt and that scrubbing the skin harder may help to lighten the affected areas. Parents/guardians may report that the child’s skin looks dirty or, in the setting of acne, view dirt as the cause of the skin condition, which may prompt the patient to scrub the skin and the friction further worsens the PIH. Use of daily gentle cleansers and moisturizers is advised to keep the skin moisturized and free of further potential irritation and dryness that may prompt scratching or flares of the underlying condition.

Photoprotection
During the treatment course for PIH, using sun protection is helpful to prevent further darkening of the PIH areas. Sun protection may be in the form of broad-spectrum sunscreen, hats, or sun-protective clothing. Patients should be encouraged to apply sunscreen daily and to reapply every 2 hours and after water-based activities.¹² For pediatric and adolescent populations, practicing sun-protective behaviors before school or outdoor activities also should be advised, as many families only think about sun protection in the setting of sunny vacation activities. Research has demonstrated that individuals with skin of color may not realize that they can be affected by skin cancer,¹³ thus they may not have any experience selecting, applying, or regularly using sunscreens. Products that do not leave a white hue on the skin are suggested for adolescents who may be sensitive about their appearance following sunscreen application.

Skin Lightening Treatments

Although the most important therapy for PIH is to treat the underlying inflammatory conditions, some parents/guardians may desire additional options due to the extent of involvement of the PIH, its psychological impact on the child, or adverse effect on the child’s quality of life.¹⁴ In adolescents, incorporating an α-hydroxy acid–based cleanser, glycolic acid chemical peels, salicylic acid chemical peels, and topical cosmeceuticals may be warranted in the setting of intense PIH and acne. However, irritation may lead to further dyspigmentation.

Topical ammonium lactate 12% is lactic acid neutralized with ammonium hydroxide that is formulated as a lotion or a cream. It is used to hydrate dry skin and may decrease corneocyte cohesion.¹⁵ Topical ammonium lactate also has been used anecdotally for PIH on the body during periods of watchful waiting.

Topical hydroquinone, the gold standard for treating hyperpigmentation,^3,16 is not approved in children, but some parents/guardians elect to utilize hydroquinone off label to accelerate the clearing of distressing PIH in adolescents. Careful consideration including a discussion of potential risks and alternatives (eg, watchful waiting) should be highlighted.

In the setting of chronic inflammatory conditions that recur and remit, potentially irritating topical treatments should be used only during periods when symptoms of inflammation such as itching or erythema are absent.

Conclusion

Despite the best management efforts, PIH in some patients with skin of color may be present for months to years. In the pediatric skin of color population, treatment of the underlying inflammatory condition, gentle skin care, use of photoprotection, and time may be all that is needed for PIH resolution. With their parent/guardians’ consent, adolescents distressed by PIH may decide to pursue more aggressive, potentially irritating treatments. Above all, the most important management in the setting of PIH is to treat the underlying inflammatory condition causing the PIH and set reasonable expectations. For challenging cases, pediatric dermatologists with special expertise in treating pediatric and adolescent patients with skin of color may be consulted.

Postnflammatory hyperpigmentation (PIH) is an acquired hypermelanosis that can occur in children and adults following an inflammatory cutaneous disease or trauma. Postinflammatory hyperpigmentation may last for months to even years. Although PIH may occur in all skin types, it is more common and presents with greater severity and intensity in individuals with skin of color. By the year 2050, 1 in 3 US residents is projected to be Hispanic.¹ It is projected that by 2044, non-Hispanic white individuals (all ages) will make up less than 50% of the US population.² Currently, the majority of the US residents younger than 18 years are minorities. The majority minority population in the United States already exists in those younger than 18 years and is predicted to occur in the adult population by 2044.²

Effective treatment options and management strategies for PIH in adults with skin of color have been described in the literature.³ Due to a paucity of research, the approach to management of PIH in children with skin of color has been based on clinical experience and lessons learned from adult patients. This article focuses on management of PIH in pediatric patients with skin of color, which includes black/African American, African-Caribbean, Hispanic, Asian, Pacific Islander, and American Indian individuals.

Underlying Inflammatory Dermatoses Resulting in PIH

There are numerous conditions that may result in PIH, including but not limited to atopic dermatitis (AD), acne, arthropod bites, and injuries to the skin. Postinflammatory hyperpigmentation may have more of a psychological impact than the inciting disease or injury itself. The most important step in the approach to managing PIH is treating the underlying inflammatory condition that caused the pigmentation.

Parents/guardians may report a chief concern of dark spots, manchas (stains), blemishes, or stains on the skin, often with no mention of a coexisting inflammatory dermatosis. Parents/guardians of children with skin of color often have personally experienced PIH and may be determined to shield their children from similar angst associated with the condition. Although physicians may see just another pediatric patient with PIH, the child’s parents/guardians may see a condition that will be readily perceptible during major life events, such as the child’s prom or even his/her wedding day. Promptly diagnosing and instituting early treatment of inflammatory conditions associated with PIH may accelerate resolution and prevent worsening of the pigmentation.³

Select inflammatory dermatoses that are common in children with skin of color and may lead to PIH are highlighted below. Although this list is not comprehensive, the approach and management strategies should prompt creation of plans that keep PIH in mind when treating primary inflammatory skin diseases.

Atopic Dermatitis
Atopic dermatitis may induce PIH or hypopigmentation of the skin in children with skin of color. Developing a plan for AD flare prevention, as well as management of mild, moderate, and severe AD flares, is imperative in pediatric patients. Prevention plans should include gentle skin care, twice-daily application of emollients to the full body, and reduction of Staphylococcus aureus loads on the skin. The treatment action plan for mild to moderate flares may include topical corticosteroids, immunomodulators, and nonsteroidal agents. Treatment options for severe AD or patients who were unsuccessfully treated with other therapies may include phototherapy, biologics, and methotrexate, among others.⁴ Creating action plans for AD flares is a vital step in the prevention of PIH in patients with skin of color. Additionally, PIH should not be considered a sign of AD treatment failure.

Acne
Acne is a common skin disorder seen in patients with skin of color.⁵ A prospective observational study found that 34.3% of 683 children aged 9 to 14 years in a pediatric ambulatory clinic had acne.⁶ The number of preadolescents with acne is growing. Most cases are not associated with underlying endocrinopathy.⁷ With the growing population of children with skin of color in the United States along with the increasing childhood acne rate and subsequent inherent risk for hyperpigmentation, early acne interventions should be considered in pediatric acne patients with skin of color to reduce the impact of PIH in those at risk.

In a survey study of 313 adult acne patients with skin of color, 37.2% reported the presence of dark marks lasting 4 months or longer.⁵ Regardless of the severity of the acne, treatment should be initiated as tolerated in those with PIH. Adolescent acne patients with skin of color may develop PIH that is more severe and longer lasting than the acne itself.

The foundation for treatment of acne in adolescent skin of color patients is the same as those without skin of color, including topical retinoids, topical antibiotics, oral antibiotics, and isotretinoin when needed. Topical tretinoin, adapalene, azelaic acid, and tazarotene not only treat acne but also are a valuable part of the treatment armamentarium for PIH. Several studies in adults with skin of color have demonstrated improvement of PIH from the use of topical retinoids alone.^8-10 Despite wanting to treat the acne aggressively, special guidance should be given to prevent retinoid dermatitis, which may lead to PIH.¹⁰ Demonstrating the application of the topical acne medications, discussing how to avoid potential side effects, and giving permission to skip applications, if needed, may empower families to make adjustments between visits to limit irritation that might prompt further PIH. Incorporating α-hydroxy acid–based cleansers, α-hydroxy acid–based chemical peels, or salicylic acid chemical peels may be warranted in the setting of intense PIH. Selecting treatments that not only help the inflammatory disease leading to the PIH but also can help improve the pigmentation are preferred; however, the risks and benefits have to be weighed because many treatments that work well for PIH also may cause irritation, leading to new or worsening PIH.

Arthropod Bites
Arthropod bites cause inflamed pruritic papules and nodules, and the resulting PIH in those with darker skin types may be quite dramatic. Parents/guardians should be instructed to have a low-potency topical corticosteroid on hand to use on bites for a few days when they appear, which will not only help with the inflammation associated with the bite but also will help decrease pruritus and subsequently skin injury from scratching. In homes with pets, checking animals routinely for fleas and other infestations is helpful. In the setting of repeated arthropod bites in the spring and summer, applying bug repellant with 10% to 30% DEET (N,N-diethyl-meta-toluamide) on the child’s clothing and exposed body areas before playing outside or in the morning before school or camp may prevent some bites. There are DEET alternatives, such as picaridin, that may be used. Product instructions should be followed when using insect repellants in the pediatric population.¹¹

PIH Management Strategies

Gentle Skin Care Routine
There are misconceptions that areas of hyperpigmentation on the skin are caused by dirt and that scrubbing the skin harder may help to lighten the affected areas. Parents/guardians may report that the child’s skin looks dirty or, in the setting of acne, view dirt as the cause of the skin condition, which may prompt the patient to scrub the skin and the friction further worsens the PIH. Use of daily gentle cleansers and moisturizers is advised to keep the skin moisturized and free of further potential irritation and dryness that may prompt scratching or flares of the underlying condition.

Photoprotection
During the treatment course for PIH, using sun protection is helpful to prevent further darkening of the PIH areas. Sun protection may be in the form of broad-spectrum sunscreen, hats, or sun-protective clothing. Patients should be encouraged to apply sunscreen daily and to reapply every 2 hours and after water-based activities.¹² For pediatric and adolescent populations, practicing sun-protective behaviors before school or outdoor activities also should be advised, as many families only think about sun protection in the setting of sunny vacation activities. Research has demonstrated that individuals with skin of color may not realize that they can be affected by skin cancer,¹³ thus they may not have any experience selecting, applying, or regularly using sunscreens. Products that do not leave a white hue on the skin are suggested for adolescents who may be sensitive about their appearance following sunscreen application.

Skin Lightening Treatments

Although the most important therapy for PIH is to treat the underlying inflammatory conditions, some parents/guardians may desire additional options due to the extent of involvement of the PIH, its psychological impact on the child, or adverse effect on the child’s quality of life.¹⁴ In adolescents, incorporating an α-hydroxy acid–based cleanser, glycolic acid chemical peels, salicylic acid chemical peels, and topical cosmeceuticals may be warranted in the setting of intense PIH and acne. However, irritation may lead to further dyspigmentation.

Topical ammonium lactate 12% is lactic acid neutralized with ammonium hydroxide that is formulated as a lotion or a cream. It is used to hydrate dry skin and may decrease corneocyte cohesion.¹⁵ Topical ammonium lactate also has been used anecdotally for PIH on the body during periods of watchful waiting.

Topical hydroquinone, the gold standard for treating hyperpigmentation,^3,16 is not approved in children, but some parents/guardians elect to utilize hydroquinone off label to accelerate the clearing of distressing PIH in adolescents. Careful consideration including a discussion of potential risks and alternatives (eg, watchful waiting) should be highlighted.

In the setting of chronic inflammatory conditions that recur and remit, potentially irritating topical treatments should be used only during periods when symptoms of inflammation such as itching or erythema are absent.

Conclusion

Despite the best management efforts, PIH in some patients with skin of color may be present for months to years. In the pediatric skin of color population, treatment of the underlying inflammatory condition, gentle skin care, use of photoprotection, and time may be all that is needed for PIH resolution. With their parent/guardians’ consent, adolescents distressed by PIH may decide to pursue more aggressive, potentially irritating treatments. Above all, the most important management in the setting of PIH is to treat the underlying inflammatory condition causing the PIH and set reasonable expectations. For challenging cases, pediatric dermatologists with special expertise in treating pediatric and adolescent patients with skin of color may be consulted.

Postnflammatory hyperpigmentation (PIH) is an acquired hypermelanosis that can occur in children and adults following an inflammatory cutaneous disease or trauma. Postinflammatory hyperpigmentation may last for months to even years. Although PIH may occur in all skin types, it is more common and presents with greater severity and intensity in individuals with skin of color. By the year 2050, 1 in 3 US residents is projected to be Hispanic.¹ It is projected that by 2044, non-Hispanic white individuals (all ages) will make up less than 50% of the US population.² Currently, the majority of the US residents younger than 18 years are minorities. The majority minority population in the United States already exists in those younger than 18 years and is predicted to occur in the adult population by 2044.²

Effective treatment options and management strategies for PIH in adults with skin of color have been described in the literature.³ Due to a paucity of research, the approach to management of PIH in children with skin of color has been based on clinical experience and lessons learned from adult patients. This article focuses on management of PIH in pediatric patients with skin of color, which includes black/African American, African-Caribbean, Hispanic, Asian, Pacific Islander, and American Indian individuals.

Underlying Inflammatory Dermatoses Resulting in PIH

There are numerous conditions that may result in PIH, including but not limited to atopic dermatitis (AD), acne, arthropod bites, and injuries to the skin. Postinflammatory hyperpigmentation may have more of a psychological impact than the inciting disease or injury itself. The most important step in the approach to managing PIH is treating the underlying inflammatory condition that caused the pigmentation.

Parents/guardians may report a chief concern of dark spots, manchas (stains), blemishes, or stains on the skin, often with no mention of a coexisting inflammatory dermatosis. Parents/guardians of children with skin of color often have personally experienced PIH and may be determined to shield their children from similar angst associated with the condition. Although physicians may see just another pediatric patient with PIH, the child’s parents/guardians may see a condition that will be readily perceptible during major life events, such as the child’s prom or even his/her wedding day. Promptly diagnosing and instituting early treatment of inflammatory conditions associated with PIH may accelerate resolution and prevent worsening of the pigmentation.³

Select inflammatory dermatoses that are common in children with skin of color and may lead to PIH are highlighted below. Although this list is not comprehensive, the approach and management strategies should prompt creation of plans that keep PIH in mind when treating primary inflammatory skin diseases.

Atopic Dermatitis
Atopic dermatitis may induce PIH or hypopigmentation of the skin in children with skin of color. Developing a plan for AD flare prevention, as well as management of mild, moderate, and severe AD flares, is imperative in pediatric patients. Prevention plans should include gentle skin care, twice-daily application of emollients to the full body, and reduction of Staphylococcus aureus loads on the skin. The treatment action plan for mild to moderate flares may include topical corticosteroids, immunomodulators, and nonsteroidal agents. Treatment options for severe AD or patients who were unsuccessfully treated with other therapies may include phototherapy, biologics, and methotrexate, among others.⁴ Creating action plans for AD flares is a vital step in the prevention of PIH in patients with skin of color. Additionally, PIH should not be considered a sign of AD treatment failure.

Acne
Acne is a common skin disorder seen in patients with skin of color.⁵ A prospective observational study found that 34.3% of 683 children aged 9 to 14 years in a pediatric ambulatory clinic had acne.⁶ The number of preadolescents with acne is growing. Most cases are not associated with underlying endocrinopathy.⁷ With the growing population of children with skin of color in the United States along with the increasing childhood acne rate and subsequent inherent risk for hyperpigmentation, early acne interventions should be considered in pediatric acne patients with skin of color to reduce the impact of PIH in those at risk.

In a survey study of 313 adult acne patients with skin of color, 37.2% reported the presence of dark marks lasting 4 months or longer.⁵ Regardless of the severity of the acne, treatment should be initiated as tolerated in those with PIH. Adolescent acne patients with skin of color may develop PIH that is more severe and longer lasting than the acne itself.

The foundation for treatment of acne in adolescent skin of color patients is the same as those without skin of color, including topical retinoids, topical antibiotics, oral antibiotics, and isotretinoin when needed. Topical tretinoin, adapalene, azelaic acid, and tazarotene not only treat acne but also are a valuable part of the treatment armamentarium for PIH. Several studies in adults with skin of color have demonstrated improvement of PIH from the use of topical retinoids alone.^8-10 Despite wanting to treat the acne aggressively, special guidance should be given to prevent retinoid dermatitis, which may lead to PIH.¹⁰ Demonstrating the application of the topical acne medications, discussing how to avoid potential side effects, and giving permission to skip applications, if needed, may empower families to make adjustments between visits to limit irritation that might prompt further PIH. Incorporating α-hydroxy acid–based cleansers, α-hydroxy acid–based chemical peels, or salicylic acid chemical peels may be warranted in the setting of intense PIH. Selecting treatments that not only help the inflammatory disease leading to the PIH but also can help improve the pigmentation are preferred; however, the risks and benefits have to be weighed because many treatments that work well for PIH also may cause irritation, leading to new or worsening PIH.

Arthropod Bites
Arthropod bites cause inflamed pruritic papules and nodules, and the resulting PIH in those with darker skin types may be quite dramatic. Parents/guardians should be instructed to have a low-potency topical corticosteroid on hand to use on bites for a few days when they appear, which will not only help with the inflammation associated with the bite but also will help decrease pruritus and subsequently skin injury from scratching. In homes with pets, checking animals routinely for fleas and other infestations is helpful. In the setting of repeated arthropod bites in the spring and summer, applying bug repellant with 10% to 30% DEET (N,N-diethyl-meta-toluamide) on the child’s clothing and exposed body areas before playing outside or in the morning before school or camp may prevent some bites. There are DEET alternatives, such as picaridin, that may be used. Product instructions should be followed when using insect repellants in the pediatric population.¹¹

PIH Management Strategies

Gentle Skin Care Routine
There are misconceptions that areas of hyperpigmentation on the skin are caused by dirt and that scrubbing the skin harder may help to lighten the affected areas. Parents/guardians may report that the child’s skin looks dirty or, in the setting of acne, view dirt as the cause of the skin condition, which may prompt the patient to scrub the skin and the friction further worsens the PIH. Use of daily gentle cleansers and moisturizers is advised to keep the skin moisturized and free of further potential irritation and dryness that may prompt scratching or flares of the underlying condition.

Photoprotection
During the treatment course for PIH, using sun protection is helpful to prevent further darkening of the PIH areas. Sun protection may be in the form of broad-spectrum sunscreen, hats, or sun-protective clothing. Patients should be encouraged to apply sunscreen daily and to reapply every 2 hours and after water-based activities.¹² For pediatric and adolescent populations, practicing sun-protective behaviors before school or outdoor activities also should be advised, as many families only think about sun protection in the setting of sunny vacation activities. Research has demonstrated that individuals with skin of color may not realize that they can be affected by skin cancer,¹³ thus they may not have any experience selecting, applying, or regularly using sunscreens. Products that do not leave a white hue on the skin are suggested for adolescents who may be sensitive about their appearance following sunscreen application.

Skin Lightening Treatments

Although the most important therapy for PIH is to treat the underlying inflammatory conditions, some parents/guardians may desire additional options due to the extent of involvement of the PIH, its psychological impact on the child, or adverse effect on the child’s quality of life.¹⁴ In adolescents, incorporating an α-hydroxy acid–based cleanser, glycolic acid chemical peels, salicylic acid chemical peels, and topical cosmeceuticals may be warranted in the setting of intense PIH and acne. However, irritation may lead to further dyspigmentation.

Topical ammonium lactate 12% is lactic acid neutralized with ammonium hydroxide that is formulated as a lotion or a cream. It is used to hydrate dry skin and may decrease corneocyte cohesion.¹⁵ Topical ammonium lactate also has been used anecdotally for PIH on the body during periods of watchful waiting.

Topical hydroquinone, the gold standard for treating hyperpigmentation,^3,16 is not approved in children, but some parents/guardians elect to utilize hydroquinone off label to accelerate the clearing of distressing PIH in adolescents. Careful consideration including a discussion of potential risks and alternatives (eg, watchful waiting) should be highlighted.

In the setting of chronic inflammatory conditions that recur and remit, potentially irritating topical treatments should be used only during periods when symptoms of inflammation such as itching or erythema are absent.

Conclusion

Despite the best management efforts, PIH in some patients with skin of color may be present for months to years. In the pediatric skin of color population, treatment of the underlying inflammatory condition, gentle skin care, use of photoprotection, and time may be all that is needed for PIH resolution. With their parent/guardians’ consent, adolescents distressed by PIH may decide to pursue more aggressive, potentially irritating treatments. Above all, the most important management in the setting of PIH is to treat the underlying inflammatory condition causing the PIH and set reasonable expectations. For challenging cases, pediatric dermatologists with special expertise in treating pediatric and adolescent patients with skin of color may be consulted.