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Eight challenges of melanin-rich skin and how to rise up against them!

Melanin is the pigment that gives rise to dark brown or black hair, eyes, and skin. Darker skin contains more of a specific type of melanin called eumelanin, which acts like a natural ozone layer. It is the reason why black skin ages so beautifully. However, while eumelanin protects from the sun’s damaging ultraviolet (UV) rays, it doesn’t prevent the risk of premature aging, skin cancer, or hyperpigmentation. Beyond the painfully prevalent challenges of having black skin in this country, including systemic racism and healthcare disparities, there are several unique skincare challenges that people with black skin experience. At my practice, we emphasize the need to understand the varying skincare needs of each patient. We know that different skin types require differences in care. One size does not fit all, especially in medicine. Here’s what to look out for and some helpful tips when caring for melanin-rich skin.

 

Skin cancer 

The Challenge: Even though melanin is photo-protective against UV rays, it does not prevent skin cancer. This includes melanoma, the deadliest form of skin cancer. While melanoma is less common in people with melanin-rich skin, unfortunately when it does occur, it is significantly more fatal. African Americans are more likely to be diagnosed with melanoma at a later stage, which makes it harder to treat. 

Rise Up: Knowledge is power! Beloved music legend Bob Marley was only 36 years old when he died of melanoma. It started as a small sore under his toenail. But, by the time it was diagnosed, the cancer had already spread. Acral lentiginous melanoma (ALM) often appears as a small dark lesion on the palms of the hands, the soles of the feet, or under the nails. It is more likely to occur in African Americans. Monthly self-skin exams and regular visits to a dermatologist can save lives. One of the biggest risk factors for skin cancer is sun exposure. When you’re having fun in the California sun (before 10 a.m. or after 2 p.m. of course:)), don’t forget to apply (and re-apply!) sunscreen every 2 hours (more often if swimming or sweating). And remember to wear sun protective clothing and hats. 

Try Supergoop Unseen Sunscreen. It’s sheer, water-resistant, reef-safe, and has an oil-free formula.

Oily & dry skin!

The Challenge: African American skin has the highest oil content of any racial or ethnic group. At the same time, African American skin also has the lowest ceramide content. Ceramides are a crucial component of your skin’s barrier that lock in moisture. Low ceramide levels result in more water loss and dry, flaky, “ashy” skin. So having oily, acne prone skin in some areas and dry skin in other areas is a common scenario I see in practice, especially in my African American patients.  

Rise Up: You may find it necessary to modify your skincare regimen to meet the unique needs of different areas of skin. A bit annoying, yes, but totally worth it! Cleansing daily with a glycolic (AHA) or salicylic (BHA) cleanser can improve the appearance of fine lines, uneven pigmentation, and acne. I tend to avoid recommending products containing benzoyl peroxide in melanin-rich skin. I find them to be particularly drying and irritating in this skin type. For oily, acne-prone skin, look for an oil-free or “non-comedogenic” moisturizer that does not clog pores and worsen acne. For dry skin, try a moisturizer that contains ceramides and hyaluronic acid. Hyaluronic acid is a naturally occurring molecule that act as a sponge for dry skin cells, holding up to 1,000 times its weight in water! 

Try SkinstyleMD AHA Clear Cleanser (my favorite facial cleanser EVER!) and CeraVe PM moisturizing facial lotion and body cream.

Post-inflammatory hyperpigmentation

The Challenge: Post inflammatory hyperpigmentation (PIH) is darkening of the skin which occurs in response to inflammation (skin injury or irritation). Acne, eczema, burns, and insect bites, for example, can all cause inflammation leading to PIH. PIH occurs in all racial and ethnic groups. But, it has a much higher incidence in melanin-rich skin types, affecting over two-thirds of African Americans. 

Rise Up: Let’s start with the good news. Post-inflammatory hyperpigmentation almost always fades with time. Now for the bad news. PIH can take months to years to fully clear. But all hope is not lost! There are many ways to speed up this process. Some include topical hydroquinone (lightening cream), glycolic acid, corticosteroids, and retinoids, as well as in office treatments like chemical peels. It is also important to treat the underlying condition for the PIH to prevent new dark spots from occurring. Any injury to the skin can result in PIH. So it’s best to try not to pick at acne or scratch insect bites. Finally, the sun can make the dark spots appear darker and last longer. Sun protection, please! 

Melasma

The Challenge: Melasma is a common disorder of skin pigmentation which appears as symmetrical brown-gray patches on the face. Commonly affected sites include the cheeks, bridge of nose, and upper lip. The exact cause of melasma is unknown. But, risk factors for melasma include female sex, darker skin types, sun exposure, genetic predisposition, and changing hormones (ex. birth control pills, pregnancy). Melasma affects men just 10% of the time. 

Rise Up: Melasma is one of the most common and most frustrating skin conditions I see daily in my practice. Luckily, many effective treatments exist, though not all treatments are equally effective in every patient. A topical skin regimen with a few key ingredients is a great starting place. Hydroquinone is the most effective and commonly used skin-lightening agent. It works by decreasing the activity of melanocytes which are pigment-producing cells that live in the skin. Retinoids (ex. Retin-A) can be used to treat several causes of skin pigmentation, melasma included. Since hydroquinone and retinoids can be irritating to the skin (and skin irritation leads to hyperpigmentation), an anti-inflammatory corticosteroid cream like hydrocortisone can be added to soothe the skin.

Other skin-lightening agent include glycolic acid, salicylic acid, lactic acid, resorcinol, azaleic acid, tranexamic acid, and kojic acid. These agents can be added to your treatment regimen in a few ways. For example, in the form of skincare products, oral pills (tranexamic acid) and/or in-office procedures, like chemical peels and laser treatments. One of the safest and most effective laser treatments for melasma is LaseMDTM superficial laser resurfacing with laser-assisted delivery of transexamic acid. Be sure to seek care from an experienced board-certified dermatologist. Excellent sun protection is a must do, as even small doses of ultraviolet light can worsen melasma.

Try an in-office Melanage Peel for one of the best Melasma treatments available!

Dermatosis Papulosa Nigra

The Challenge: Dermatosis Papulosa Nigra (DPN) is characterized by small, raised, dark-brown or black spots on the skin around the cheekbones, eyes, and neck. The spots tend to appear in young adults, run in families, and increase in size and number with age. Africans Americans and Asians are the most frequently affected. Many people refer to them as “moles” or “warts” yet they are neither precancerous (like some moles) or contagious. But understandably, the spots are a nuisance to some people.  

Rise Up: Dermatologists can quickly and gently burn off tiny DPN spots using electrocautery (heat and electricity) with excellent cosmetic results and little to no discomfort. Please seek care from an experienced board-certified dermatologist. Many procedures carry a higher risk of pigment change or scarring in patients with melanin-rich skin. Although you can’t prevent DPN from occurring or recurring, sun protection may decrease spread and make spots look less noticeable. Sunscreen is clearly a must in dermatology!

Traction alopecia

The Challenge: Traction alopecia is a type of hair loss caused by constant pulling on the hair shaft. This results in permanent damage to the hair follicle. It is seen in people who wear tight hairstyles. A few examples include sleek ponytails, weaves, extensions, and tight braids – all of which put significant stress on hair follicles.  

Rise Up: The first signs of hair thinning due to traction alopecia are broken hairs at the front of your hairline, a receding hairline, or patchy hair loss where hair is tightly pulled. If you notice any of these signs, you should stop pulling on your hair immediately. This will prevent scarring of the hair follicle and irreversible hair loss! Looser, natural hairstyles are therapeutic and preventative. If you are planning on getting weaves or extensions, opt for the sewn-in kind. Braided styles should be kept in for no more than two to three months.

Pseudofolliculitis Barbae

The Challenge: Pseudofolliculitis barbae (PFB) is a chronic inflammatory skin condition. It typically occurs on the face and neck and mostly occurs in people with curly hair. It’s commonly referred to as “razor bumps” because the condition is made worse by shaving or plucking the hairs. Curly hairs are more likely once cut to curve back towards the skin and cause irritation of the hair follicle. The painful bumps often lead to dark spots and scarring. More than 50% of African American men are affected. Less often PFB occurs in the armpits or bikini area.  

Rise Up: The best treatment is not to shave or pluck hairs, but for many people, this isn’t an option. If you need to have a clean shaven appearance, try these suggestions. Apply a warm, wet washcloth before shaving to soften and loosen hairs and use lots of shaving cream. Avoid a close shave. Try clippers or depilatories (but only if they don’t cause skin irritation). Shave in the direction of hair growth. And avoid pulling skin taut while shaving.

Dermatologists can perform light chemical peels (glycolic or salicylic acid) and prescribe antibiotics, benzoyl peroxide, and retinoids to help. Vaniqa cream can also slow down hair growth so you have to trim hair less often. Laser hair removal is a great option for permanent hair reduction. Be sure to seek treatment at a practice familiar with treating melanin-rich skin as laser-induced irritation and redness can result in dark spots.

Keloid scarring

The Challenge: Keloids are reactive scars which continue to grow after wound healing should be complete. They are commonly seen at sites of surgical wounds and piercings. But, they can occur in response to an injury as minor as an insect bite. These hard, lumpy scars are significantly more common in African Americans and South Asians. Keloids can cause itching and discomfort in addition to the cosmetic impact. 

Rise up: Dermatologists can treat keloids with a variety of procedures. Most commonly this involves starting with monthly cortisone +/- chemotherapy injections directly into the scar. Surgical or laser excision is also possible but risky as keloids often recur. This risk can be reduced by maintaining close follow up with a dermatologist.

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It’s important to recognize differences in biology across different races and ethnicities so that we, as healthcare providers, can provide care that is best suited for each individual person. I’ve listed a few differences, but this is not a comprehensive list. There are dozens of differences that we must recognize and strive to treat on an individual basis. We cannot assume that one size fits all, or that one treatment will work for every race, ethnicity, or person. It’s our responsibility to make sure we know how to treat differences, both in medicine and in the greater scope of things. Change needs to happen at every level, especially medicine. As a doctor, a mother, and an ally —  I see you, I hear you, and I stand in solidarity with you.

Author
Shanthi Colaço, MD

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