Health care providers play an important role in adolescent sex education, including in discussions on contraceptive use.

Adolescents may start engaging in sexual activity while undergoing the numerous physical and emotional changes that occur during their transformative period.

 By the age of 20 years, approximately 80% of young women have had sexual intercourse; however, adolescents (aged 15 to 19 years) have limited understanding of the various contraceptive methods available to them, and the lowest rates of contraceptive use.

 Counseling individuals about the various methods of contraception and increasing access to care can help address unplanned pregnancies and sexually transmitted diseases.

 As most females prefer oral contraceptives over other forms, such as injections, transdermal patch, and vaginal rings, familiarizing themselves with the safest and most effective use of all these products is good practice

). This article delves into the contraceptives available for adolescents and discusses their efficacy and safety.

Various methods of contraception are available for adolescents

). Medical providers should counsel them on the efficacy, safety, and adverse effects of contraception,

 informing them about the most effective options. Contraceptive options from most effective to least effective are as follows: intrauterine devices/progestin implants, progestin injections, and combined oral contraception (pills, patch, vaginal ring).

 Regarding efficacy, discussing aspects of “typical” use and “perfect” use is also recommended. Perfect use is when a contraceptive is used correctly all the time, whereas typical use takes human error into account;

 this includes missing pills or forgetting to change a patch, as well as using a condom.

 Common adverse effects are listed in Table 2.

Intrauterine devices (IUDs) are small, T shaped, and flexible. Currently, 3 are approved in the United States: levonorgestrel (Mirena) 52 mg, levonorgestrel (Skyla) 13.5 mg, and a copper-containing device (Paragard). Levonorgestrel 52 mg is approved for use for 3 years, levonorgestrel 13.5 mg for 5 years, and the copper IUD for 10 years.

 These devices are highly effective with a failure rate of less than 1%.

 Multiple data articles support the safety of these devices in adolescents.

 The one-time insertion of an IUD into the uterus reduces the risk of nonadherence,6 and thus the responsibility of maintaining effectiveness. This can make IUDs an ideal choice for a young woman who has not yet reached adulthood. The success rate for insertion is reported at 96%, but there is a risk of pelvic infection for the initial period (~21 days) after implantation. Choosing between the 2 different types of IUD can be challenging, but counseling patients about the risks and benefits with each option can help facilitate their decision. Counseling points to consider include the misconception of infertility with IUDs and safety in nulliparous females.

A progestin implant is a thin, flexible, single rod containing etonogestrel, which is placed under the skin of the upper arm. Etonogestrel 68 mg (Nexplanon) is available and has 3 years of effectiveness. Implants are highly effective with a failure rate of less than 1%. These exert their action by thickening cervical mucous, thinning the endometrial lining, and inhibiting ovulation. Implants do not seem to have a high impact on bone mineral density as higher levels of estradiol are seen in females using implants versus a progestin injection. Implants are a great option for adolescents who prefer not to take scheduled medication daily or who prefer a longer length of protection.

Depot medroxyprogesterone acetate (DMPA; Depo-Provera) is an injection administered every 3 months with a 96% efficacy rate in pregnancy prevention. DMPA causes anovulation and thickening of the cervical mucous by inhibiting pituitary gonadotropins. Advantages of this product include infrequent dosing, discreteness, improvement in dysmenorrhea, and protection against iron-deficiency anemia and endometrial cancer. Disadvantages include having to access a health care provider for injections, menstrual cycle irregularities, delayed fertility return, weight gain, headache, and hair loss. Weight gain is a concern for adolescents who gain more than 5% of body weight after 6 months of use. A black box warning exists for the drug’s potential to cause bone mineral density loss in the first 2 years of use; however, the American College of Obstetricians and Gynecologists states no restriction on the length of time that DMPA can be used.1,2 During this time, adolescents should be counseled on adequate daily intake of calcium and vitamin D (1300 mg calcium; 600 IU vitamin D), weight-bearing exercises, and smoking cessation.

Three different methods exist which contain both an estrogen and progestin: pill, patch, and vaginal ring. The 4- to 7-day hormonal-free interval can be used monthly or extended to once every several months. Data have shown safety with the extended approach. Hormonal contraception needs to be taken for at least 21 consecutive days for efficacy against unplanned pregnancy. The timing of contraception use varies and should be taken into consideration when choosing between the pill form, injectable form, patch, or vaginal ring. Adolescents can start these products immediately or can wait until their next menstrual cycle. Preferring a Sunday start or starting on the first day of the next menstrual cycle is common. This will ensure the adolescent is not pregnant before starting contraceptives. Current data, however, do not support evidence of any adverse effects of contraceptive hormone exposure on fetal development.

Combined oral contraceptive pills are the most commonly prescribed hormonal contraception and contain various amounts of ethinyl estradiol. Providers should suggest strategies such as using cell phone alarms, maintaining a regular schedule, and getting family member support. Discussion of missed doses is very important, as taking 7 consecutive hormone pills is required to prevent pregnancy. Many different formulations exist (monophasic and in-phasic) and choosing an appropriate pill that is covered under the adolescent’s insurance is preferred. Experts recommend starting with a monophasic formulation and transitioning over to an in-phasic regimen to alleviate adverse effects and/or correspond with the adolescent’s preference.

Contraceptive patches (Xulane, Zafemy) contain 150 mcg norelgestromin and 35 mcg ethinyl estradiol. The patch is worn weekly for 3 weeks and removed for 1 week to induce a withdrawal bleed. The abdomen, upper torso, upper arm, and buttocks are safe places on which to place the patch.

The vaginal ring (NuvaRing) is a round, flexible device that is inserted into the vagina weekly for 3 weeks that contains 15 mcg ethinyl estradiol and 120 mcg etonogestrel. During the doctor visit, patients should be shown a pelvic model to help explain where the vaginal ring will be; they should be reassured the ring will not fall out and that it can remain in with sexual intercourse.

Ott MA, Sucato GS; Committee on Adolescence. Contraception for adolescents. 

. 2014;134(4):e1257-e1281. doi:10.1542/peds.2014-2300

Committee on Adolescence. Contraception for adolescents. 

. 2014;134(4):e1244-e1256. doi:10.1542/peds.2014-2299

Todd N, Black A. Contraception for adolescents. 

. 2020;12(suppl 1):28-40. doi:10.4274/jcrpe.galenos.2019.2019.S0003

Committee on Adolescent Health Care. Committee Opinion No 699: adolescent pregnancy, contraception, and sexual activity. 

. 2017;129(5):e142-e149. doi:10.1097/AOG.0000000000002045

Di Meglio G, Crowther C, Simms J. Contraceptive care for Canadian youth. 

. 2018;23(4):271-277. doi:10.1093/pch/pxx192

Kumar N, Brown JD. Access barriers to long-acting reversible contraceptives for adolescents. 

. 2016;59(3):248-253. doi:10.1016/j.jadohealth.2016.03.039

Contraception explained: options for teens and adolescents. American Academy of Pediatrics. Updated July 20, 2020. Accessed April 27, 2022. https://www.healthychildren.org/English/ages-stages/teen/dating-sex/Pages/Birth-Control-for-Sexually-Active-Teens.aspx

Articles

Counseling patients about methods of contraception and increasing access to care can help address unplanned pregnancies and sexually transmitted diseases.

Best practices on discussing birth control for adolescents

 sat down with Johanna Olson-Kennedy, MD, medical director of the Center for Transyouth Health and Development at Children’s Hospital Los Angeles about the best practices for providing gender-affirming care—treatments for supporting a transgender or nonbinary person in their gender transition—for pediatric patients; who should be a part of the team providing that care; and the small ways that practices can show they’re a safe space for all patients.

Q. What are the best practices for providing compassionate gender-affirming care to children and adolescents in the general pediatric office?

 That question gets broken down into a couple of things. Are we talking about somebody practicing gender care or just anyone practicing pediatrics? Because those are 2 different things. I would think that for general pediatricians, if they’re not comfortable doing gender-specific care, they should refer to someone that is. We have a dearth of training for this work in the general pediatric curriculum, though I think that will change over time. But right now, things such as puberty blockers feel complicated for general pediatricians. So the first thing is to make sure young people are where they’re going to get the most informed care. In the world of gender, it is really important that people understand that having protocols creates more problems than it solves. For a lot of reasons, there are just so many intersecting developmental trajectories that have to be considered when helping people move forward [with transitioning]. And that’s why if you’re not comfortable with the care, don’t do it. The most compassionate care is care that considers the individual, where they are developmentally and chronologically in their gender understanding and consolidation process, and then, where they and their families are in relationship to interventions. And it’s not just 1 overarching thing. It’s individualized.

Q. What are some small changes that pediatricians can enact in their practice to provide a caring and accepting environment for gender-diverse children and teenagers, even if they aren’t providing that care?

 Just even the small act of having a poster or something similar in your waiting room, that says “We welcome all genders here” or “Tell us about your gender” or handouts with basic information can be really helpful. We think about the impact of those changes on kids that are in the trans community, or in the LGBTQIA+ community, but they actually have an impact on everyone. Because that kind of change, that kind of openness, that kind of welcoming message models for everyone the way that it should be for people within the community, but they’re super important for everyone. Also, do you only ask questions about gender in response to some kind of gender expression that feels maybe a little bit outside the stereotype? Or is this something we ask everyone? With the HEEADSSS [home, education/employment, eating, activities, drugs, sex] exam [psychological screening tool for adolescents], we ask about sexuality. We said everyone 12 and older was getting HEEADSSS, outside the presence of their parents.

So with that in mind, for younger kids, we might ask are you having crushes? Do you have crushes on boys, girls, both, neither? So you can provide them information about health and safety. I think a similar thing about gender. You ask something like, “I’ve known you since you were born and we have assumed you were a girl. Does that does that feel right for you?” It may allow them to disclose something that they wouldn’t have otherwise disclosed. It’s also important to talk about the limits of confidentiality with all of those questions so they know that you’re not going to disclose that information to their parents unless they want you to. One of the tricky things about being trans is that if you want to do anything about it, you have to out yourself to providers so they can get you what you need.

I don’t think there’s great consensus about what age you would ask someone this. The most common thing I’ve heard from parents of my patients is “this wasn’t even on our radar.” Thinking about how we can get parents into a place where they are asking their kids these things more routinely, I think that would also take the medical emphasis off gender, refocusing the conversation about gender in the familial setting, or in the social setting, which is way more relevant for prepubertal kids.

Q. For pediatricians who want to create an affirming medical home for this group of patients, what other professionals would you consider bringing into that medical home?

The world of gender work is complicated, right? I always say it takes a village to raise a trans kid. Having networks with mental health providers is really important. Psychiatrists or psychologists or social workers, people who are going to have a little bit more time to spend with kids who need maybe extra support. But I also think if you are going to do gender work within the context of your own pediatric practice, you have to book out enough time. This is not the kind of work you can do in 15-minute visits. Some people create intake forms that give them a lot of information before they meet with the family and the patient.

I also think that either having a really good knowledge of endocrinology or having some endocrinology backup for you if you need it could be really important, depending on the age of patients that you’re taking care of. Another network that’s important is surgeons. Those are all probably good folks to have on your team.

Q. What are your recommendations for pediatricians who want to be advocates for gender-diverse children, outside the exam room?

 Learn, educate yourself, participate in conferences that talk about trans youth and the care of trans youth. If you hear anti-trans stuff, you can say, “I’m wondering if you have any experience with trans youth? Have you sat in rooms with people? Are you just talking and making assumptions about things?” I think that most providers attend some trainings and conferences and I think it’s worth it to ask, if you’re hearing someone present data, “Is there a consideration about trans kids in this data?” But I also think it’s really important to vote. Now, unfortunately, you have to be politically active if you really want to advocate for the community.

Q. What are the best practices for ensuring a smooth transition from pediatric to adult care when a gender-diverse patient reaches their 18th birthday?

 I don’t know if there is 1 way I can tell you in our clinic. People don’t leave our practice until they’re 25. We understand 2 things: Adolescence isn’t limited to ending at 18. Secondly, and more relevant for trans youth, many trans youth get bumped off of the developmental trajectory because they’re spending a lot of their brain space and energy managing and navigating gender dysphoria. And because of that, they may not tend to the tasks of development that other cisgender adolescents are tending to. And so a lot of our kids are not learning how to drive, for example; they’re just behind. And so it’s really important that they stay in pediatric services during this time, as they’re more comprehensive. Adult services are oftentimes very truncated. Like suddenly, on your 18th birthday, you’re supposed to be able to understand how to navigate the health care system.

So in our program, when people are about 21 or 22, I start talking about it, telling patients that they can stay with me until they are 25. But after that, they have to graduate out to adult services. And let’s be real, we have a terrible health insurance system in this country. It is not healthy or secure, or a system, right? It’s terrible. And so where you ended up being able to get adult trans-related services is largely dependent on your insurance. So we will think about where they are geographically, what kind of insurance they have, and what kind of insurance they’re likely to get after their they drop off their parent’s insurance, because that’s another thing. That’s weird as we see people to 25. But we also know in a year with the ACA [Affordable Care Act], they’re going to drop off their parent’s insurance, right? So they may have to do 2 transitions of care in the space of a year. Finally, I tell this to all my patients: If you’re struggling to land somewhere on your care, please call, let us help. So that can be really helpful, too.

Q. How can pediatricians support gender-diverse patients who have parents or caregivers who do not support them?

 It’s probably one of the hardest things for a young person not to have a supportive parent. But I also think that when we talk about support, we need to remember, support is a spectrum. And so there can be someone who is super supportive of their kid using different pronouns or dressing differently, or using a different name, but they absolutely will not support medical intervention for them. That’s a very different parent than a parent that’s saying, “This trans stuff is nonsense.”

It’s important to figure out where the parents are, and again, this does not lend itself to a 15-minute visit. You don’t just have to understand the developmental trajectories of the young person, but you also have to understand the developmental trajectory of the caregiver. This is also one of those reasons to have mental health people on your team because the downstream fallout of gender dysphoria is anxiety and depression. Mental health providers can help give patients the tools to navigate, how to talk to their parents about their gender, how to connect the parents to their gender, their kid’s gender dysphoria. The parents might also feel that they love their kid, but they’re scared. And so it’s really important to try to figure out what the fear is, so that you can dismantle that, and that’s a lot. That’s a lot for a pediatrician to do. Those are really important things.

Another thing, at least in my practice, is I always ask patients, “What name do you want me to use? What pronouns do you want me to use?” I ask that with everyone in the room. I feel really strongly that I need to honor somebody’s authentic sense of self. And so sometimes there’ll be a conversation and the parents are using 1 set of pronouns and I’m using another set of pronouns. But it’s modeling and shaping how people think about this. Parents are such a critical part of that young person’s health and well-being.

Q. Why is gender-affirming care important to ensuring the best possible outcomes for gender-diverse children and teenagers?

The science tells us that if people’s gender dysphoria is addressed and treated, their mental health outcomes improve. More and more data has come out over the last 10 years that backs this up with decades of clinical experience that many of us have. You’d be hard pressed to disagree with the idea that parents want the best mental health outcomes for their kids. And I also think there’s sort of a macro and a micro level. The macro level is the right to live authentically. It is a human right. And we also know that when people are able to live authentically, they function better. But then there’s also the micro level, the individual person, and there’s the struggle in gender work. We have a broken world, but we can’t fix the world all at once. And we have a human being who’s suffering, and so we can alleviate some of that suffering. And that’s really important. That’s why we do it.

A conversation on best practices for helping a child who is thinking of transitioning to another gender.

Providing gender-affirming care in pediatrics

The COVID-19 pandemic has upended the world of respiratory diseases. Every cough and sniffle raises red flags in a clinical area that already was a drain on health care resources. Roughly 12% of US adults have chronic sinusitis, and about 2.7 million physician and 234,000 emergency department visits are attributed to this diagnosis each year.

Drawing the line between acute sinusitis and every other respiratory bug can be difficult, though. As with many other conditions driven by viral infection, there is little clinicians can really offer patients for sinusitis other than supportive care and calls for patience.

As COVID-19 transmissions are lessening, patients and clinicians are equally concerned about respiratory symptoms, but experts say the pandemic isn’t really changing the game plan for sinusitis.

“I think the biggest thing I try to explain to patients is the disease process,” says Jane Carnazzo, MD, of Children’s Hospital and Medical Center in Omaha, Nebraska.

Observations of mucus changes can help patients determine where they are in a bout with sinusitis, she explains, adding that green mucus is common for about a week after infection and doesn’t really signal a severe infection.

“When it comes to sinusitis, your acute sinusitis is really going to be someone who is sick for 10 to 14 days. You have to give a cold a good week to get better,” she adds.

A high fever or copious amounts of mucus right away is a different story, she says, but this level of infection isn’t common. 

COVID-19 isn’t the only worry when it comes to respiratory symptoms, Carnazzo adds. Antibiotic resistance is a real problem and one she says she tries to educate her patients about. Prescribing antibiotics may give patients a peace of mind regarding their symptoms, but Carnazzo says 75% of her patients don’t return for a prescription after a bit of education about what to expect and what is normal in terms of symptoms and progression of sinusitis.

Besides education, she says offering patients an alternative for symptom management can help. People like to turn to over-the-counter (OTC) remedies that dry out mucus at the first sign of illness, but she says this is really the opposite of how you want to manage sinusitis.

“You want the nose to drain. When it comes to preventing a sinus infection, it’s the best you can do,” she says. 

Saline rinses have become a popular choice among her patient population, Carnazzo adds, but lavage can sometimes make symptoms worse. Instead, things like promoting crying, exposure to cold weather, and anything else that can help make the nose run works well, she says. 

The exception, she explains, is children who have issues such as anatomical problems that could increase mucus retention, immune deficiencies, and conditions including Down syndrome that may predispose a child to smaller sinus cavities. Even with these patients, though, Carnazzo says clinicians should use caution about jumping to antimicrobial treatments.

Time is an important tool in the clinician’s arsenal, and many patients will improve in about a week with little intervention. It’s also to be expected that some children will appear to have chronic sinus problems, but constant antibiotic therapy isn’t an option, she notes.

“Kids in day care have runny noses all the time but you can’t just keep them on antibiotics,” she says. “It’s just a matter of trying to sort it out. Give it some time and try to get them to clear their nasal passages. Don’t try to dry it up too much.”

Pushing OTC medications isn’t much help, she adds, and imaging studies like x-ray and computed tomography scans are not generally recommended for diagnosis.

The best thing pediatricians can do is to get a good history and description of how symptoms developed, what they feel like, and when they are worse.

“History, symptoms, and presentation are key,” Carnazzo says. “Chronic sinus issues may need imaging, but lab work and imaging are really not necessary. Just because the sinuses are plugged doesn’t mean they are infected.”

Purulent drainage is the key symptom in diagnosing an infection that needs more intervention, she says. Pediatricians especially also need to remember a less common differential diagnosis: foreign objects.

Foul or smelly drainage—especially on just 1 side of the nose—is a red flag for possibly finding things stuckin the nasal cavity, Carnazzo says.

Overall, the best practice for sinusitis, she adds, is to stress patience and exercising restraint when it comes to antibiotics and medications that dry mucus. Mucus is an annoying symptom, but drainage is what sinusitis needs, she says.

“We’re always looking for a quick and easy fix, even if there isn’t one,” she adds.

For symptom relief, Carnazzo says she tends to point parents to menthol products, hydration, and humidifiers rather than OTC medications. If antibiotics are needed, Carnazzo says amoxicillin is the first choice, while zithromax is not recommended because of resistance. The lowest-spectrum antibiotic is always best to use first, she adds.

“Just telling them it will take time and offering comfort is key,” she says.

Centers for Disease Control and Prevention. Chronic sinusitis. Updated January 27, 2022. Accessed May 2, 2022.


https://www.cdc.gov/nchs/fastats/sinuses.htm

Patience and antimicrobial stewardship are key to treating sinusitis.

Trends in sinusitis

Most children outgrow an adverse drug reaction to oral antibiotics, according to a retrospective observational study conducted in Iceland.

One to 2 years after an antibiotic provocation test was conducted in 1440 participants aged 5 months to 18 years, investigators conducted a second provocation test in 64 of the 92 participants who showed a possible mild allergic reaction after the first test. Participants received one-tenth of a full standard dose of the same antibiotic they originally received, most often amoxicillin with or without clavulanic acid (85.7%). Late mild reactions, mostly rashes, were seen in 11 participants, and 53 had no reaction at all. Investigators concluded that it is safe to perform an oral antibiotic provocation test after a mild possible allergic reaction and that patients who have a mild reaction to antibiotics at one time may possibly be prescribed the same antibiotic later.

Too many children and adolescents have received an erroneous diagnosis of antibiotic allergy, resulting in the use of less optimal or more expensive medicine. This study indicates that mild

Gu›nadóttir GK, Jónasson G, Clausen M, Sørensen TG, Kristjánsson S. Antibiotic oral provocation challenge in children. Acta Paediatr. 2022;111(5):1056-1060. doi:10.1111/apa.16211

Most children outgrow an adverse drug reaction to oral antibiotics, according to an Icelandic study.

Does that child really have an antibiotic allergy?

Fewer than half of adolescents who receive a diagnosis of a sexually transmitted infection (STI) in an emergency department (ED) filled the prescriptions they were given, according to a telephone survey of teenagers who sought care in the ED and were prescribed outpatient treatment. Mean age of participants was 17.2 years; most were non-Hispanic Black, female, and publicly insured.

Interviewers used a standardized script to administer the survey, which consisted of multiple choice questions. Whereas 12 of 24 participants receiving STI treatment filled their prescriptions at the pharmacy, 10 returned to the ED for treatment (some patients who did not receive treatment in the ED were called back when laboratory results were positive), 2 patients were treated elsewhere, and 2 had no treatment. Fewer than one-third of patients with chlamydia filled their prescription at a pharmacy, compared with more than 75% of those with pelvic inflammatory disease. Interestingly, whereas all teenagers who filled their prescription at the pharmacy told their caregivers about their diagnosis, only half of those who returned to the ED did so.

Survey participants indicated that adhering to the recommended treatment posed challenges, including cost, transportation issues, lack of an insurance card, and knowing how to pick up a prescription. Asked their opinion about alternative ways to overcome obstacles to adherence, nearly all respondents expressed interest in using a mobile device, whereas school-based clinics inspired little interest.

This is a problem in private practice as well as in the ED. Ask teenagers who need treatment if they anticipate having problems getting the prescription and have someone follow up with a phone call. Ensure you get their cell phone number so that you do not have to go through the family.

Sankar MG, Boyle MD, Badolato GM, Tran JQ, Lieberman A, Goyal MK. The adolescent experience of filling prescriptions for the treatment of sexually transmitted infections.

Published online December 24, 2021. doi:10.1016/j.jpag.2021.12.009

A survey saw that of teenagers who sought care in the ED and were prescribed outpatient treatment, fewer than half who received an STI diagnosis filled their prescriptions.

Teens find that adhering to STI treatment isn’t easy

Many different terms are used to describe skin color, from using actual colors to categorize individuals to identification based on one’s ethnicity. The most common terminology used in dermatology is the Fitzpatrick skin phototypes scale that classifies skin types from I (White) to VI (Black). This staging is graded by sensitivity or ability of the skin to tan with UV exposure.

 The term “skin of color” has been defined in many ways, but it typically includes individuals of Asian, Hispanic, Native American, Indian, and African descent.

Melanocytes in the basal layer of the epidermis produce cutaneous pigment known as melanin. Biological differences in different skin types underlie the overall color of the skin. For example, Black skin is naturally rich in melanin because melanosomes are distributed throughout the entire epidermis, whereas with fair White skin, few melanosomes are found at the stratum basale and melanosomes are absent in the upper layers of epidermis.

Understanding the difference in biology and clinical presentations of cutaneous conditions in different skin types is critical for health care professionals to treat a diverse population. The epidemiology, role of genetics, clinical presentation, and treatment considerations for atopic dermatitis, acne, and vitiligo in all skin types of the pediatric population are discussed here.

Atopic dermatitis (AD) is widely considered to be the most common chronic skin disease and typically starts in early infancy or childhood.

 Up to 25% of children and up to 8% of adults have a past or present diagnosis of AD.

 The pathology behind AD is thought to be multifactorial and likely includes a genetic predisposition combined with epidermal dysfunction, as well as environmental and socioeconomic factors.

 Additionally, AD is included in the “atopic diathesis,” along with food allergies, asthma, and allergic rhinitis (hay fever). Other comorbidities may include behavioral and psychosocial concerns.

Prevalence of AD in the United States is notably higher among Black children, who are 1.7 times more likely to be diagnosed with AD compared with White children.

 Furthermore, individuals of Asian descent are 7 times more likely to be diagnosed with AD than White individuals.

Filaggrin (FLG) loss-of-function mutations are currently the most-thoroughly studied genetic component of AD.

 Filaggrin is a major structural protein of the stratum corneum barrier, the outermost layer of the epidermis.

 Individuals with mutations of the FLG gene typically present with an earlier onset of atopic disease, more severe disease, and a higher risk of superinfection.

 Other polymorphisms in genes related to innate or adaptive immunity in Th2 signaling pathways are thought to play a role in the development of AD.

 Although psoriasis is thought to be related to issues in the Th1 signaling pathway including Th17 and interleukin 23 (IL-23), IL-17–positive T-cell expansion has been noted in Asian populations.

 Furthermore, it is postulated that the increased prevalence of AD seen in Asian populations may be due to a stronger Th17/22 polarization that may lead to a phenotype with AD-psoriasis overlap.

Presentation of AD across all racial spectrums generally includes intense pruritus and xerosis accompanied by eczematous papules or plaques.

 However, subtleties of AD may present differently among various races. For example, skin lesions often appear more well demarcated in those of East Asian descent or may have greater extensor involvement in Black individuals.

 Additionally, xerosis and hyperlinear palms and soles may be more prominent in those with darker skin.

Of note, the majority of studies concerning treatment of AD were conducted on White individuals, which may lead to difficulty in individualizing treatment regimens.

 Current guidelines support similar treatments for AD across all racial backgrounds, with first-line therapy including topical corticosteroids and calcineurin inhibitors.

Additionally, one phosphodiesterase- 4 inhibitor, crisaborole, may be used for the treatment of mild to moderate AD.

 Anecdotally, topical steroids appear to be effective in all skin types; however, those of high potency should be approached with caution because they may lead to hypopigmentation particularly in skin of color.

 Systemic treatment can be considered for moderate to severe AD.

Acne is consistently a top 3 reported skin condition in the general population in the United States, United Kingdom, and France

 and is in the top 3 most common dermatoses in Black, Hispanic, and Asian adolescents.

 The pathophysiology of acne is multifactorial, beginning with a microcomedone and progressing to comedones. Follicular hyperkeratinization, increased sebum production, and proliferation of Cutibacterium acnes lead to subsequent follicular plugging, release of inflammatory cytokines, and activation of toll-like receptor 2.

 This process creates inflammatory papules, pustules, and nodules.

 The resulting sequelae involve various types of scarring as well as postinflammatory hyperpigmentation (PIH).

Acne affects patients of many ages, but roughly 20% of young people suffer from moderate to severe acne.

Some degree of acne affects almost all individuals aged 15 to 17 years, with an estimated 85% prevalence rate among individuals aged 12 to 24 years.

 A higher percentage of Hispanic teens have reported acne compared to Black and Asian teens.

 Frequency of acne in different ethnic groups has been studied, but results are mixed, largely due to difficulty with selection bias of study populations. Overall, prevalence and incidence appears to be similar among ethnic groups.

Little research is available regarding pathophysiologic differences among ethnic groups.

 Of the available research, most involve White and Black skin types, with less information available regarding acne in Asian and Hispanic skin types.

There is no defined ethnic association or gene mutation in individuals with acne, although certain skin types are affected differently.

Heritability is almost 80% in firstdegree relatives. It tends to be more severe and occur earlier in patients with a positive family history of acne.

 Severity of acne also increases with maturity and dehydroepiandrosterone sulphate levels.

 It typically begins in early teen years with onset of facial sebum production.

 Of note, the follicular epithelium of the pilosebaceous unit is thicker in patients of skin type V and IV than skin types I and II. These follicles are more likely to keratinize and form comedones, rather than inflammatory and cystic lesions seen in patients with lighter skin types.

Papular lesions are the most common type of acne lesion described in patients across all skin types.

Postinflammatory hyperpigmentation and hyperpigmented macules most commonly affect darker skin types.

 Clinically, White and Asian patients tend to have more inflammatory acne than African American patients, who tend to have more comedonal acne.

 White, Hispanic, and Asian patients are more likely to present with nodulocystic acne compared with African American patients.

 In addition, Hispanic patients typically experience more pustular lesions and more scarring compared with Asian and African American patients, although African Americans experience more PIH.

Asian and Middle Eastern patients report mostly papular and comedonal lesions and less PIH.

 Keloidal scarring is not a common complication of acne, but the risk is much greater in darker skin types.

Several studies have shown significant differences in illness perception and quality of life in White vs non-White patients, specifically regarding White patients with acne experiencing less negative impact on social functioning compared to non-White patients with acne.

 A study by Barbieri et al showed that non-Hispanic Black patients were more likely to be seen by a dermatologist for acne compared with non-Hispanic White patients but were prescribed fewer acne medications.

These papers, however, most commonly study adult patients, so much less literature is available regarding these concerns in the pediatric population.

 Regardless, this should be kept in mind when treating pediatric acne in all skin types.

In general, a thorough history of a patient’s skin type and sensitivity is necessary to formulate an appropriate treatment regimen. Hyperpigmentation, more common in patients of darker skin types, has been shown to be more distressing to many patients than the acne itself.

 Keep in mind that although comedones in Black patients do not appear red or inflamed clinically, there is a marked amount of histologic inflammation.

This is especially seen in Black female patients.

 Postinflammatory hyperpigmentation can occur from the acne lesions themselves or from overly aggressive therapies that are irritating to the skin.

 Thus, care must be taken to avoid inducing irritation and retinoid dermatitis when starting acne therapy in patients with darker skin of color.

Irritant contact dermatitis seems to be more prevalent in clinical practice in patients with darker skin of color, although the American Contact Dermatitis Society has studied this and found no difference in incidence between African American and White patients.

 Regardless, keep this in mind when selecting topical treatment regimens for this patient population.

 Vehicles such as lotions and creams should be utilized in patients with dry, sensitive skin prone to irritation, with methods such as slowly increasing frequency of product use at initiation. Also consider starting at low strength and slowly increasing the strength as tolerated.

Other vehicles such as solutions and gels are more appropriate for patients with oily skin that is not prone to irritation.

Vitiligo is a disorder of depigmentation resulting from loss of melanocytes.

 Due to the potential disfiguring nature of the disease, psychosocial functioning can be impacted in both patients and their families.

 This is especially true in patients who develop vitiligo in childhood. The pathogenesis of vitiligo is not fully elucidated, but one of the most widely considered theories considers vitiligo to be autoimmune in nature, with the predominant cause of melanocyte loss due to attack by CD8-positive cytotoxic T cells.

The prevalence of vitiligo worldwide is approximately up to 2% of the population, including both children and adults.15 Up to 80% of patients develop vitiligo before aged 30 years, with up to 25% of patients developing their first depigmented lesion by the age of 10.

 The disease may impact all racial groups and skin types; however, there appears to be geographical differences regarding prevalence of disease.17 Women do appear to bemore commonly affected than men.

Genetic involvement in the development of vitiligo is thought to be very complex, and there is no specific genetic test for vitiligo.

 Involved genes are typically related to immune regulation, melanogenesis, and apoptosis.

 A familial association has been made with approximately 10% of patients having at least 1 first-degree relative also diagnosed with vitiligo.

Lesions consistent with a diagnosis of vitiligo are amelanotic macules, possibly coalescing into larger depigmented patches, with distinct margins.

 Vitiligo is classified into nonsegmental, segmental, and undetermined.

 Nonsegmental vitiligo can then be further classified based on distribution.

 Additionally, halo nevi, melanocytic nevi surrounded by depigmented rims, may be visualized in individuals with vitiligo.

Vitiligo is often associated with additional comorbid disorders.

 Comorbid autoimmune conditions are present in 10% to 15% of patients with vitiligo (thyroid disease is the most common.)

 Racial variation in autoimmune disease has been noted; hypothyroidism is most common in White patients; psoriasis is the most frequent in Asian patients. Systemic lupus erythematosus and rheumatoid arthritis are the most common comorbidities in Black patients.

Due to the chronic and often progressive nature of vitiligo, treatment expectations must be clearly explained and discussed.

 Furthermore, treatment often spans several months and possibly years on an intermittent basis.

 All patients with a diagnosis of vitiligo should be encouraged to wear a daily sunscreen (SPF 30 or greater) due to the likelihood of burning depigmented skin.

If desired, several brands of cosmetic camouflage and concealers exist and have demonstrated improvement in quality of life.

Main treatment modalities for vitiligo include topical therapies and phototherapy. The 3 main classes of topical treatments include steroids, calcineurin inhibitors, and vitamin D.

 Phototherapy, mainly narrowband UV-B, is typically favored for widespread disease or disease that is rapidly progressive.

 Phototherapy may also be combined with use of topical steroids, which may increase the efficacy of UV-B.

Dermatologic conditions have a wide variety of presentations across different skin types, with differing implications in prognosis and treatment. This variation is multifactorial, due to biological and environmental differences and cultural practices across individuals of different skin types. Clinical differences when treating a variety of skin of color involve pigmentary and inflammatory predilections and their sequelae. There are numerous etiological and treatment considerations for patients of differing skin types that providers should consider when evaluating this population. This is well described in darker skin types for certain dermatologic procedures such as cryotherapy and intralesional steroids.

The conditions discussed here are only a few of the many dermatologic conditions for which more research is needed in skin of color in the pediatric population. Little comprehensive research is available regarding many cutaneous diseases in the pediatric population—and even less regarding difference across skin types. More validated information is needed for better directed and individualized care for this vast patient population.

References
1. Taylor SC. Skin of color: biology, structure, function, and implications for dermatologic disease. 

. 2002;46(suppl 2):S41-S62. doi:10.1067/mjd.2002.120790
2. Brunner PM, Guttman-Yassky E. Racial differences in AD. 

 2019;122(5):449-455. doi:10.1016/j.anai.2018.11.015
3. Croce EA, Levy ML, Adamson AS, Matsui EC. Reframing racial and ethnic disparities in AD in Black and Latinx populations. 

 2021;148(5):1104-1111. doi:10.1016/j.jaci.2021.09.015
4. Kaufman BP, Guttman-Yassky E, Alexis AF. AD in diverse racial and ethnic groups-variations in epidemiology, genetics, clinical presentation and treatment. 

 2018;27(4):340-357. doi:10.1111/exd.13514
5. Noda S, Suárez-Fariñas M, Ungar B, et al. The Asian atopic dermatitis phenotype combines features of AD and psoriasis with increased TH17 polarization. 

. 2015;136(5):1254-1264. doi:10.1016/j.jaci.2015.08.015
6. Monir RL, Schoch JJ, Garvan CW, Neu J, Lemas DJ. Association between atopic dermatitis and race from infancy to early childhood: a retrospective cohort study

 Published online August 11, 2021. doi:10.1111/ijd.15805
7. Bhate K, Williams HC. Epidemiology of acne vulgaris

 2013;168(3):474-485. doi:10.1111/bjd.12149
8. Maymone MBC, Watchmaker JD, Dubiel M, Wirya SA, Shen LY, Vashi NA. Common skin disorders in pediatric skin of color. 

 2019;33(6):727-737. doi:10.1016/j.pedhc.2019.04.019
9. Halder RM, Brooks HL, Callender VD. Acne in ethnic skin

 2003;21(4):609-615, vii. doi:10.1016/s0733-8635(03)00082-2
10. Ashton R, Weinstein M. Acne vulgaris in the pediatric patient

 2019;40(11):577-589. doi:10.1542/pir.2018-0137
11. Taylor SC, Cook-Bolden F, Rahman Z, Strachan D. Acne vulgaris in skin of color. 

2002;46(suppl 2):S98-S106. doi:10.1067/mjd.2002.120791
12. Morrone A, Franco G, Valenzano M, et al. Clinical features of acne vulgaris in 444 patients with ethnic skin. 

 2011;38(4):405-408. doi:10.1111/j.1346-8138.2010.00976.x
13. Nagpal N, Gordon-Elliott J, Lipner S. Comparison of quality of life and illness perception among patients with acne, eczema, and psoriasis. 

 2019;25(5):13030/qt3fk3f989.
14. Barbieri JS, Shin DB, Wang S, Margolis DJ, Takeshita J. Association of race/ethnicity and sex with differences in health care use and treatment for acne. 

 2020;156(3):312-319. doi:10.1001/jamadermatol.2019.4818
15. Ezzedine K, Silverberg N. A practical approach to the diagnosis and treatment of vitiligo in children. 

Understanding the difference in biology and clinical presentations of cutaneous conditions in different skin types is critical for health care professionals to treat a diverse population.

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