Cultural barriers to pediatric skin health
More awareness needed on disease presentation and cultural treatment practices to improve dermatology outcomes in children with skin of colour (1,700 words, 8 minutes)
Skin Spectrum Weekly is published with unrestricted support from Bausch Health Canada
Systemic biases and cultural factors contribute to poorer dermatology outcomes in children with skin of colour, said Dr. Danielle Marcoux during a presentation at the 8th annual Skin Spectrum Summit on Sept. 17, 2022. She noted that improvements to diagnostic protocols and training in cultural competence could help overcome these challenges.
Dr. Marcoux is an associate professor in the Department of Pediatrics at the University of Montreal and a dermatologist at CHU Sainte-Justine.
In her talk, Dr. Marcoux noted that atopic dermatitis (AD) is widespread in older Black, Asian and Pacific Islander children, with a prevalence of up to 30%. However, diagnosis can be complicated by several factors. These patients might not have a family history of AD if their parents were born in Africa or the West Indies, where eczema is less common. As well, the Asian AD phenotype resembles psoriasis not only clinically but also on cellular and molecular levels.
Other differences in AD phenotype in dark skin can include more nummular eczema, follicular accentuation that is very itchy, and involvement of the extensor surfaces on the outside of the joints. Many of these patients may have lichenification from rubbing or scratching their skin in an attempt to relieve the itching, Dr. Marcoux said.
Dr. Marcoux noted that existing scoring systems for AD rely heavily on erythema, and so often underestimate the severity of AD in darker skin types. She said that after adjusting the erythema score compared to lighter-skinned children, Black children have a six times higher risk of being diagnosed with severe AD. New severity measurement tools are required, she added.
Dr. Marcoux said that adherence to topical treatment for AD is less than 30%, and some of that low percentage may be due to cultural competency—language or cultural barriers to patients understanding instructions—or cultural treatment phobias. She suggested that physicians provide patients with a treatment action plan to address these potential cultural barriers. If possible, she said that group or one-on-one workshops with patients and more frequent follow-ups with patients who need it can also help.
Dr. Marcoux had additional advice regarding pediatric dermatology in skin of colour:
Asian or African American children who are patch-tested are two times more likely to have concurrent AD than White children who are patch-tested
Stressing the importance of sun protection and understanding cultural attitudes to sun safety is vital. Non-White patients are more likely to present with melanoma at a younger age, with a mean age of 10 years
Camouflage products can help patients with visible conditions such as AD or vitiligo with their self-esteem and quality of life and improve care compliance and therapeutic outcomes. Physicians should recommend camouflage products that are durable, waterproof, opaque, and adherent to textured skin
Pomade acne can be a concern in dark-skinned children with curly hair, who may use pomades for hairstyling
Bottom Line: AD is common among African-American, Asian, and Pacific Islander children. AD may present differently in dark-skinned children. Physicians should address cultural barriers to therapy adherence through treatment plans or workshops. Sun protection is crucial. Camouflage of visible conditions can improve quality of life. Be mindful of pomades or oils in hairstyling, as they can lead to acne on the forehead.
From the literature on pediatric dermatology
The burden of atopic dermatitis and bacterial skin infections among urban-living Indigenous children and young people in high-income countries: A systematic review
The authors of this paper reviewed primary observational studies on atopic dermatitis (AD) and bacterial skin infections (BSI) written in English and containing epidemiologic data. They searched the MEDLINE, EMBASE, EMCARE, Web of Science and PubMed databases for articles published between Jan. 1990 and Dec. 2021.
From 2,278 original manuscripts, the authors included 16 in their assessment. Seven of the manuscripts documented eight studies on AD. Another nine manuscripts documented nine studies on BSI.
The researchers found that current and severe AD symptoms were more common in urban-living Indigenous children and young people (CYP) in high-income countries (HIC) compared with their non-Indigenous peers, with children having a higher prevalence than adolescents.
Urban-living Indigenous CYP in HIC had a higher incidence of all measures of BSI compared with their non-Indigenous peers and were over-represented for all measures of BSI compared with their proportion of the background population.
Follicular keratosis of the face in pediatric patients of colour
This paper describes the clinical presentation, histopathology, management, and outcomes of 20 pediatric cases of facial follicular keratosis (FK) in patients with skin of colour.
The authors write that FK is a poorly understood disorder presenting multiple, grouped hyperkeratotic follicular papules typically affecting the chin or jawline. It is thought to be related to rubbing or friction on the skin.
Patients in this study presented to a single pediatric dermatology practice between April 2019 and Oct. 2021. Their average age was 12.1 years, and all self-identified as Black or African American.
Each patient had an initially asymptomatic, hyperpigmented patch of skin containing multiple hyperkeratotic follicular papules located on the cheek, chin, upper lip, or jawline. Five of the patients said they had a history of rubbing the site. Nine patients had their lesions first appear during the Covid-19 pandemic.
Treatments included topical vitamin D analogs, corticosteroids, or retinoids. Topical vitamin D analogs and retinoids improved the texture and hyperpigmentation of the follicular lesions in only four patients, while topical corticosteroids did not improve the lesions. Histopathological examination of two patients showed signs of inflammation and follicles blocked with keratin.
Predictors of Vitamin D Insufficiency in children and adolescents with alopecia areata
To identify predictors of vitamin D insufficiency among children with alopecia areata (AA) in the US, researchers reviewed records on 439 pediatric patients diagnosed with AA between Jan. 2015 and Dec. 2017.
They included records with 25-hydroxyvitamin D levels and no documented vitamin supplementation, chronic illness, or other autoimmune comorbidities other than AA. Demographic data, Fitzpatrick skin type, and the month of blood collection were also recorded, as was monthly UV index information from Philadelphia corresponding to the month of blood collection.
In the study cohort, 60.4% of patients had insufficient vitamin D levels, of which 38.2% were deficient. The mean patient age was nine years.
When the data was analyzed, the investigators found that higher Fitzpatrick skin type, non-summer season, and non-White race were associated with vitamin D insufficiency. In contrast, the monthly UV index was inversely associated.
Safety assessment of propranolol for infantile hemangioma: A study in an Asian population
Researchers retrospectively analyzed 336 consecutive cases of infants with infantile hemangioma (IH) treated between Jan. 2016 and Oct. 2017 at Beijing Children’s Hospital. The patients were assessed in the hospital at the start of their treatment and later in an outpatient setting during therapy. Physicians monitored blood pressure (BP), heart rate (HR), blood glucose, liver and kidney function, myocardial enzymes, and serum lipids. Cardiac examinations in the outpatient follow-up included electrocardiography, ultrasound echocardiography, height, weight, and head circumference.
The authors found that propranolol decreased BP and HR at the start of treatment. Sinus bradycardia and hypoglycemia became more familiar with longer treatment lengths.
Treatment did not seem to impact the children's average height, weight, and head circumference. The incidence of PR prolongation was 0%-5.7%. Investigators found that the dose of propranolol did not impact its effect on the cardiovascular system, metabolism, and physical development.
VIDEO: Doctor V—Kids anti-scarring cream | Skin of colour | Brown or Black skin
At the intersection of skin and society
Heaven Solomon, a language teacher at the Mah-Sos kindergarten to Grade 5 school in Neqotkuk, or Tobique First Nation in New Brunswick and the current Miss New Brunswick, is using her renown from her pageant win to promote efforts to revive the threatened Wolastogey language, reports CBC News.
“To be Miss New Brunswick means that I have the opportunity to share my language,” Solomon said in an interview with the news outlet.
“It means that I also have the responsibility to hopefully inspire other Indigenous youth to … maybe try things they are not used to, to do things that might make them nervous because I was so nervous for the pageant.”
While Solomon did not grow up speaking the Wolastogey language, she is part of a growing number of individuals who have taken the effort to learn an Indigenous language.
The article notes that data from Statistics Canada show that the country's overall number of Indigenous language speakers dropped by about 4% between 2016 and 2021. However, in New Brunswick, the number increased by 3.5%.
Chris Penney, director of the Centre for Indigenous Statistics and Partnerships with Statistics Canada, told the CBC that while the number of people who speak an Indigenous language as their first language has declined, the effect is being counteracted by more people learning Indigenous languages as an additional language.
“There is growth in the number of Indigenous second-language speakers,” he said, referencing the latest census data.
“The numbers of people who could speak an Indigenous language, but did not have an Indigenous mother tongue, grew by seven per cent.”
Penney said there has been “broader interest in ensuring that languages are preserved,” which is critical given that many who speak Indigenous languages as their mother tongue are older.
Solomon said sharing her culture and language with a broader audience through her teaching and participation in pageants is vital because the population of first-language speakers of Indigenous languages is aging.
“We’re losing our speakers rapidly,” she said. “Without our language, we then, in turn, will lose our culture, and in turn will lose our connection to the land.”
November is Indigenous Disability Awareness Month in Canada /
Nov. 14 is World Diabetes Day
Nov. 18-24 is World Antimicrobial Awareness Week
Something to think about in the week ahead…
Abraham Joshua Heschel, Polish philosopher, 1907-1972
Middle eastern and south Asian patients represent “invisible visible minorities” in dermatology research, Toronto’s Dr. Raed Alhusayen reported during a presentation at the 8th annual Skin Spectrum Summit on Sept. 17, 2022. He discussed the lack of data on these populations in the context of hidradenitis suppurativa.
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