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Special Considerations in Skin of Color

»	What is “skin of color”?
»	What accounts for differences in color between ethnic and racial groups?
»	Do any physiologic differences exist between black skin and that of other racial/ethnic groups?
»	Are the brown streaks on the nails of people with skin of color always a cause for concern?
»	Is pigmentation of the oral mucosa in people with skin of color invariably concerning?
»	Are there other areas of the body where hyperpigmentation represents a normal racial variant?
»	What are Futcher’s lines?
»	What causes postinflammatory hyperpigmentation?
»	What causes postinflammatory hypopigmentation?
»	Is pityriasis alba the same thing as postinflammatory hypopigmentation?
»	Is vitiligo more common in patients with darker skin?
»	Why does tinea versicolor cause hypopigmented spots on dark skin?
»	Why is it more difficult to appreciate erythema in darker skin?
»	Can any other generalizations be made about common cutaneous reaction patterns in skin of color?
»	What is the significance of multiple brown papules often seen on the periorbital area, cheeks, and nose?
»	What is cutaneous sarcoidosis?
»	What are keloids?
»	What are “razor bumps”?
»	How is pseudofolliculitis barbae treated?
»	Are there other racial differences that may affect the treatment of hair or scalp conditions in blacks?
»	Are patients with skin of color particularly susceptible to any life-threatening illnesses?
»	Do any special considerations exist when performing skin surgery on patients with skin of color?
»	Why is skin cancer less common in skin of color?
»	Are there any unique presentations of skin cancer when it does occur in patients with darker skin?
»	List skin diseases or conditions that are often considered more common in persons with skin of color.

What causes postinflammatory hyperpigmentation?

Fig. 62.2 Postinflammatory hyperpigmentation in a patient with lupus erythematosus. (Courtesy of James E. Fitzpatrick, MD.)

Fig. 62.3 Postinflammatory hyperpigmentation and hypopigmentation in a child with atopic dermatitis. (Courtesy of James E. Fitzpatrick, MD.)

Postinflammatory hyperpigmentation represents a residual darkening of the skin as a result of an inflammatory insult, such as lichen planus, lupus erythematosus (Fig. 62-2), or atopic dermatitis (Fig. 62-3). It is most severe in those diseases that result in significant disruption of the basal layer, which allows melanin to escape into the upper dermis where it is engulfed by macrophages. The resultant hyperpigmentation requires months to years for fading.
Treatment includes bleaching creams, such as hydroquinone, tretinoin, and azelaic acid; however, if the pigmentation is significantly deep, topical management does not often augment the body’s normal, albeit slow, corrective mechanisms. Bleaching agents containing >4% hydroquinone may cause exogenous ochronosis, with a resultant blue-gray discoloration of the skin. Patients from countries in Africa and Europe may have access to harsh bleaching agents without prescription, and should be warned against such use. Disorders such as inflammatory acne, occurring in dark skin types, should be treated early and aggressively, to prevent pigmentary alterations.

Olumide YM, Akinkugbe AO, Altraide D, et al: Complications of chronic use of skin lightening cosmetics, Int J Dermatol 47:344–353, 2008.