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Lisette Hilton is president of Words Come Alive, based in Boca Raton, Florida.
Although pediatric atopic dermatitis and acne have some similarities among children with skin of color and lighter-skinned children, there are important differences when these common skin conditions affect darker skin types.
Reviewed by Nanette Silverberg, MD
Although pediatric atopic dermatitis (AD) and acne have some similarities among children with skin of color and lighter-skinned children, there are important differences when these common skin conditions affect darker skin types, according to Nanette Silverberg, MD, clinical professor of Dermatology and Pediatrics, Icahn School of Medicine at Mount Sinai, and chief, Pediatric Dermatology, Mount Sinai Health System, New York.
Atopic dermatitis is the most common skin condition of childhood and affects about 25% of children in the United States, according to Silverberg, who presented on the topic at the Skin of Color Seminar Series, held earlier this year in New York City.
“In particular, there have been studies that have shown AD is more common in children of African American descent or of Afro-Caribbean descent,” she says. “It certainly represents a very concerning issue in children of color.”
Differences in AD can occur in both the presentation and severity among children of color. “In somebody who is very light skinned, eczema is going to be red, but in children of color, we see much less erythema. Instead, we see much more in the way of lichenification, or thickening of the skin, and more follicular prominence," Silverberg explains. "These are particularly vexing types of eczema in that the lichenification or lichenoid type of dermatitis is often very thick and very itchy. And the follicular type can be quite deceptive. You don’t see redness. You don’t necessarily see thick or oozing skin, but it is incredibly itchy and it significantly affects children psychologically.”
One of the major challenges in treating AD in children of color is that there are biological differences in the basis of the condition itself, according to the dermatologist.
In African American children, it has been demonstrated that there are reductions in ceramide content, and that could be the reason the skin barrier is not working as effectively as it should be, Silverberg notes. As a result, physicians treating children of color with eczema often need to use thicker emollients, including those containing extra ceramide content or extra balanced fat content in order to enhance the skin barrier.
In children who are Caucasian of European descent, eczema is also more associated with a filaggrin defect-and these defects may not manifest in the same way across races. Filaggrin, (filament-aggregating protein) is a structural protein critical to maintaining the physical strength of the stratum corneum, and minimizing entry of foreign antigens and transepidermal water loss (TEWL).
“Filaggrin defects, particularly in Asian children, are somewhat different than those noted in Caucasian children,” Silverberg says. “We’re still moving forward to see whether the biologic basis of eczema affects how children respond to treatment. Many of the kids with AD will manifest in early childhood with a lot of hypopigmentation or lightness of the skin. These pigmentary alterations, which we see in kids of color, are temporary, but are sometimes very noticeable and can concern parents,” she continues. “But this generally resolves, and that’s something we can reassure parents about.”
Acne is common is the pediatric population and comes with different concerns in children with skin of color. “Whereas many of our Caucasian patients talk about the actual pimple lesions, most of our African American patients and many of our Hispanic and Asian patients will obsess over postinflammatory pigmentary alterations after their acne clears,” Silverberg notes.
Hispanic pediatric patients tend to have the most severe acne types among children of skin of color, Silverberg states. “We don’t see as much in the way of cystic acne in African American patients, historically and in the literature,” she says. “So, the population that we tend to focus on for more severe treatment or treatment, like isotretinoin, are usually Hispanic teenagers. It’s an important consideration because they have some tendency to have the cystic component. Although you can see it in everybody, it seems to be the most concerning among that population in the teenaged years.”
Physicians treating these children need to pay special attention to communicating the need for using good sun protection and to work with patients to develop a skincare regimen that’s effective both at clearing current lesions and preventing new lesions, so that pigmentation improves over time, according to Silverberg.
“There are some wonderful new acne guidelines that have come out recently from the American Academy of Dermatology . . . saying it’s clear that most patients of color will respond quite nicely to the products we have available, including topical retinoids . . . as well as azelaic acid, which has been demonstrated to be beneficial in improving both tone and skin lesions,” she says.
Some pigmentation issues that arise in children of color can persist into adulthood. “The most vexing, of course, being vitiligo,” says Silverberg.
Vitiligo is an acquired pigmentary disorder of the skin and mucous membranes characterized by circumscribed, depigmented macules and patches, and, microscopically, by the total absence of melanocytes. The exact cause of the destruction of these cells is not known but one possible explanation might be that the body's immune system destroys the cells, as in other autoimmune conditions. Although vitiligo affects all races equally, it is more noticeable in dark-skinned patients.
“In [skin of color] patients, about .5% to 2% of the population has vitiligo and about half of those cases begin in childhood,” Silverberg states.
Initial lesions occur most frequently around the eyes, the mouth, and the lips; on the chest and around underarms; in the crooks of the elbows and wrists and around the fingertips; and around the toes and in joint spaces. "Sometimes, we’ll see loss of pigmentation around moles, which are called halo nevi,” Silverberg says.
Physicians should inquire about family history of vitiligo, because children who have family members with the skin disease are more likely to develop it at a young age.
Vitiligo symptoms include an often rapid pigment loss in several areas of the skin. The initial appearance of the white patches can be followed by a stable period without any progression of the condition. Later on, further cycles of pigment loss and stability may be observed. If not treated treated early in skin of color, it can affect children's self-esteem and quality of life. “Younger kids may not be as bothered, but teenagers often become very concerned with their appearance,” Silverberg says.
“We have a variety of different treatments," notes Silverberg. "We know that patients of color may respond a little bit better than other patients to treatments that include topical calcineurin inhibitors, such as tacrolimus. We also have good data on the use of narrow band [ultraviolet B] and the excimer laser in both children and adults of color with good results. We have an expectation that if we intervene early, we may be able to help patients achieve good repigmentation.”
Children of color have a spectrum of hair and scalp issues including seborrheic dermatitis, which generally doesn’t have a standard cradle top appearance in children with darker skin, according to Silverberg.
“[In infants with darker skin types] we’ll often see erythema, redness, flaking, and hypopigmentation, including hypopigmentation of the folds of the skin, which will sometimes overlie AD. That makes the hypopigmentation look worse,” she says.
As these children age, their hair styling choices also can cause hair thinning problems, Silverberg continues. “In African American kids, we see braiding and pony tails, multiple pony tails or the addition of hair extensions, and hair braiding or hair twisting. And many of these processes are used by both African American girls and boys. You’ll also see a lot of tight pony tail usage among Latino girls,” she says. “Those contribute to traction alopecia, which is a thinning along the marginal parts, from chronic pulling on the curved or straight hair follicle.”
The traction alopecia that results from hair styling practices can be exacerbated by use of gel pomades or oils to slick the hair back. These products can ultimately block the hair follicles and may result in folliculitis around the follicle and, eventually, scarring and hair loss. Physicians who observe acne along the forehead should suspect kids are using pomades to slick back their hair, according to Silverberg.
Other hair issues common in children and teenagers of color include hair breakage and bubble hair, an acquired hair shaft abnormality characterized by multiple air-filled spaces within the hair shaft that result from over-styling and thermal injury.
“I’ll also see hair infections on the scalp of kids of color-in particular, tinea capitis,” Silverberg says. “Tinea capitis, also called ringworm of the scalp, is a dermatophyte infection of the scalp and hair structure. It goes down inside to a certain point in the hair where keratin starts to be produced called Adamson’s Fringe. In tinea capitis, dermatophytic infection of the hair shaft is restricted to this zone and the fungi do not penetrate further down the infected hair in the bulb of the follicle.
“When we see an infection, we’re not able to treat it with topical agents. It’s very contagious in the classroom setting and households, particularly when kids are sharing products, like combs or brushes,” Silverberg notes. Parents and children should be counseled to avoid sharing hats, combs, brushes and pillow cases.
Silverberg says physicians will typically encounter pediatric tinea capitis between ages 3 to 11 years. “When you see it clinically, it appears initially almost like a little dandruff-fine flaking and redness. But as it progresses, we’ll see hair loss where the hairs break. Those are called black dot hairs. Or we’ll see something called kerion, which is an inflammatory form of tinea capitis,” she says.
Physicians should intervene right away to avoid scarring and hair loss. Often, the first step is to use antifungal shampoos.
“Then, we put them on an oral antifungal, to address the fungus from inside out because topical medications only reach the hair follicle,” Silverberg says. “It’s very important that when we see hair loss accompanied by flaking and glands in the neck, it is more than 80% likely that the child has tinea capitis. We start treatment even before we get the cultures back, which can take 5 to 6 weeks.”
Long-term prevention also means avoidance of certain hair care products. Silverberg recommends products that are silicone or water based, rather than oil based or mineral-oil based, which are more likely to damage hair and block pores.
The next step, according to Silverberg, is to consider initiating acne treatments to help keep the pores open.
Ms Hilton is a medical writer who has covered health and medicine for 25 years. She resides in Boca Raton, Florida. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.