Men with skin of color require subtle differences in care

Men with skin of color often have unique skincare needs. This month’s special report features insight and clinical pearls from three industry experts on some of the best practices for caring for this group of patients.

Dermatology Times: Talk in general about African-American male skin.

Andrew Alexis, M.D., M.P.H.: I’m going to … call it … men of African ancestry, so it’s not limited to African-Americans per se in the United States but Africans globally.

Men of African ancestry represent a geographically and culturally diverse group, but they share some basic hair structure and grooming characteristics. (They have the tendency) to … groom the hair and the beard in certain ways and have the structure of the hair in common. … The follicle tends to be curved; giving rise to a hair shaft that is curly or coiled shape. This has implications on skin and hair disorders.

So there are a number of hair and skin disorders that disproportionately affect men of African ancestry. These include pseudofolliculitis barbae, acne keloidalis nuchae and dissecting cellulitis of the scalp.

DT: How about on the cosmetic side? What are major cosmetic concerns in this population?

Dr. Alexis: Similar to other groups with darker pigmented skin: disorders of pigmentation, including postinflammatory hyperpigmentation, and to a lesser extent melasma, which is less common in men but still affects men of color.

DT: Are there nuances to how you treat these patients?

Dr. Alexis: Yes. Starting with pseudofolliculitis barbae, one of the treatment options for pseudofolliculitis barbae is laser hair removal. That has really been the greatest advantage in the management of this often difficult to treat disorder. The greatest advance that we’ve seen in the past 10 to 15 years is the development of lasers that can be safely used in this population. There are certainly nuances to which lasers to use and the types of settings that one uses in darker skin types. Specifically, the safest lasers are the long-pulse 1064 nm Nd:YAG lasers, and when using conservative settings, including lower fluences and longer pulse durations, we can perform this treatment safely. Now, for lighter skin types, different lasers would be frequently used.

“The safest lasers are the long-pulse 1064 nm Nd:YAG lasers, and when using conservative settings, including lower fluences and longer pulse durations.”

Andrew Alexis, M.D., M.P.H.

New York

Acne keloidalis nuchae presents with keloid-like or fibrotic papules on the posterior part of the scalp. Haircare practices - namely, the use of electric clippers to groom the hair short - might play a role. Mechanical factors, such as the friction from electric clippers, can at least exacerbate the condition, although they have not been shown to be causative. Since that haircare practice is so common in men of African ancestry, it’s very relevant to treating this condition in this group.

We're often advised to decrease the use of anything that would create friction on the back of the scalp. (This means) growing the hair a little bit longer and trying to minimize the degree of friction from clippers at the barber shop that might aggravate the papules on the back of the scalp.

There aren’t any specific nuances to treating (dissecting cellulitis of the scalp) in this group; it’s just that it’s seen more frequently and more prevalent in men of African ancestry. It … can cause a lot of psychological and quality-of-life impairment because, in severe cases, it can be quite disfiguring.

DT: What about treating the pigmentary issues in men of African descent?

Dr. Alexis: There aren’t that many major differences in treating men versus women with hyperpigmentation on the face. The treatments include superficial chemical peels, the use of topical bleaching agents and sun protection. There can be some additional barriers in terms of getting men to use sunscreen daily. It’s a bit more difficult for them to get into that routine than female patients … just generally speaking.

DT: What about cultural considerations or psychosocial concerns specific to this population?

Dr. Alexis: There is some literature that suggests that there are barriers to access to healthcare, in general … in the United States among African-American men.

When it comes to grooming practices and how they relate to the scalp and hair conditions, like acne keloidalis nuchae, just understanding the tendency to wear the hair very short and go to get haircuts at the barber shop on a weekly or every two week basis. (This) is quite a common practice among African-American men.

DT: Is there anything I haven’t asked you that dermatologists need to know?

Dr. Alexis: Talking about pseudofolliculitis barbae, that’s the most common of the three disorders that we mentioned and it’s estimated to affect between 45 and 83 percent of black men. In the past, it has been the source of racial tensions in the military and in other places where a clean, shaven face is required. It can be quite problematic when shaving is associated with a tremendous amount of irritation and exacerbation of razor bumps.

In some instances where men who have the condition are in workplaces where a clean shaven face is typically required, the option of growing a beard exists. The option of discontinuation of shaving results in improvement or resolution of the problem within four to six weeks, on average.

So, I do give patients the option of growing a beard, and those that wish to do so, I’m happy to give letters to their employers to allow them to grow a beard - usually a well-groomed beard. … A typical example in my office would be police officers who do have a code where their faces need to be shaved. I do write letters for them, and they are able to keep a well-groomed, short-cropped beard.

However, in many cases, with alterations in shaving technique (including pre- and post-shaving routine), men with pseudofolliculitis barbae can continue to shave safely. Patient education about proper shaving technique is a must. A helpful resource is on the American Academy of Dermatology website - http://www.aad.org/dermatology-a-to-z/health-and-beauty/general-skin-care/how-to-shave.

Andrew Alexis, M.D., M.P.H., associate pprofessor of clinical dermatology, Columbia University College of Physicians and Surgeons, practices in New York.

Disclosures: Dr. Alexis is a consultant for Galderma and Schick.

Dermatology Times: Speak about Asian-American skin in men.

Ronald Moy, M.D.: There are a couple of differences in Asians versus Caucasians. One of the differences in ethnic skin, overall, is people who are of darker color usually (have thicker, more pigmented skin). It wrinkles, but not as much. Because the skin is thicker, when we’re doing surgery, the healing is a little different. There can be more keloids … if not keloids, hypertropic scars.

Generally, the other way to look at it is the differences aren’t that great. There are light-skinned Chinese. My wife would say that I’m really dark-skinned compared to what she is. She is really fair - closer to Caucasian skin. You could argue that the differences are really small, depending on the pigment of the person. Because in America, everybody is so mixed, it’s hard to know what percentage (a person is).

But, if we talk about generalities, we’d say (the population) has thicker skin, more pigment, and often with aging people get the darker pigmented lesions. There can be sun damage, even with more pigment. You get blotchiness. You get the brown spots and things.

DT: What skin concerns are prevalent in this population?

Dr. Moy: In Asians, bags around the eyes is a little more common than in Caucasians. There is generally more fat around the eyes with aging. With Caucasians, there can be fat accumulation, but often it’s the loss of fat around the orbital rim.

And … when we’re doing surgery (on Asians), we end up being a little more careful about trying to prevent scars. If we’re doing a facelift in an Asian, for example, we have to be very careful about not getting any type of hypertrophic scars. So, we might … do things under less tension. And (we should realize) that getting a hypertrophic scar would require treatment with steroids, which is easier with someone who has thinner skin.

Those are the major differences. The majority of the time, we see the same skin diseases; the same skin problems.

“If we’re doing a facelift in an Asian … we have to be very careful about not getting any type of hypertrophic scars. So, we might … do things under less tension.”

Ronald Moy, M.D.

Beverly Hills, Calif.

DT: What about skin cancer among Asian-Americans?

Dr. Moy: It’s less common. In our practice, we maybe remove 2,000 skin cancers a year and maybe five or six among Asians. … We do see basal cell carcinomas and melanomas in Chinese and Asians and Japanese. I personally have an actinic keratosis on my left ear. So, it happens.

DT: What cultural considerations or psychosocial concerns should dermatologists be aware of when treating these patients?

Dr. Moy: Among darker skinned people, it’s actually more attractive to be lighter skinned. It’s sort of a Western influence. People like my mother would always say put sunscreen on (not to prevent skin cancer but because you’re getting dark). 

Ron Moy, M.D., Beverly Hills, Calif., is past-president of the American Academy of Dermatology and dermatology professor at UCLA’s David Geffen School of Medicine.

Disclosures: Dr. Moy reports no relevant financial interests.

Dermatology Times: Please talk about South Asian skin types among men. What do dermatologists need to know?

Vic Narurkar, M.D.: There are several issues that are very prominent on South Asian skin. The first one is the under-eye hyperpigmentation, which patients often refer to as dark circles. That is one of the things that a lot of the men come in for because of the appearance of eyes always being tired, the skin underneath the eyes looking darker.

The second issue that is quite significant is the presence of postinflammatory hyperpigmentation, especially occurring after inflammatory conditions, such as dermatitis as well as acne.

DT: Any nuances in the skin of South Asian men? Might it be different than Caucasian skin, for example?

Dr. Narurkar: The thing to remember is South Asian skin represents (many) different skin types and it ranges from being very fair to very dark. So, within South Asian skin, you have components of numerous ethnicities. An analogy I always use … is in the United States you might see a blonde, blue-eyed woman and you perform say a procedure on her and (discover) she has some pigment. Later you find out that she has Native American heritage also. When you look at South Asian skin, you (should not assume) that it’s supposed to behave in a particular way, as it is represents a diverse range of skin types.  

“When you look at South Asian skin, you (should not assume) that it’s supposed to behave in a particular way, as it is represents a diverse range of skin types.”

Vic Narurkar, M.D.

San Francisco

DT: How do you treat South Asian men for the concerns you mentioned?

Dr. Narurkar: The number one treatment for under-eye circles, which is usually due to volume loss, is the use of hyaluronic acid fillers, such as Juvéderm (Allergan) and Restylane (Medicis). … And we perform Fraxel re:Store (Solta Medical) 1550 nm nonablative laser resurfacing to improve the pigmentation. Sometimes, we also use a Q-switched 1064 nm laser. In addition, we also recommend an under-eye cream such as the TNS Illuminating Eye Cream (SkinMedica) to hydrate the intraorbital area. We also recommend a broad-spectrum sunscreen. It’s sort of a combination treatment, using fillers for loss of volume, Fraxel resurfacing and a skincare regimen.

For the second issue, postinflammatory hyperpigmentation, the main thing I always (recommend to patients is the) religious use of sunscreen, because the sun can make things darker.

Now we’re also using a lot of alternatives to hydroquinone. … We’re using products such as Lytera (SkinMedica) and Phloretin (SkinCeuticals), a topical vitamin C product that is particularly well-suited for dark complected skin. They are our go-to products in darker skin for issues of blotchiness and hyperpigmentation, particularly in men.

If they do have postinflammatory hyperpigmentation on the face (and) it has not responded to the sunscreen and the products, then we often do a series of light peels. Our peels of choice are Vitalize peels (SkinMedica), and they contain resorcinol and retinoic acid. Most recently we started using the Clear + Brilliant Permea laser (Solta Medical) in conjunction with C E Ferrulic (SkinCeuticals) and Lytera (SkinMedica) for enhanced permeation of topical products.

DT: What about psychosocial or cultural consideration when treating this population?

Dr. Narurkar: It’s not just unique to this population, but men, regardless of their ethnicity, rarely like to talk about (these things). It’s difficult to engage in discussions about appearance-related issues.

Make sure that any procedure done does not incur a lot of recovery. A lot of times, people don’t want others to know anything has been done. We want to be sensitive to discretion. 

Vic A. Narurkar, M.D., San Francisco, is associate clinical professor of dermatology at University of California, Davis, Medical School.

Disclosures: Dr. Narurkar reports no relevant financial interests.