Uncommon inflammatory conditions in dark skin
Prevalence and presentation of sarcoidosis, discoid lupus, and lichen planus in patients with skin of colour (1,200 words, 6 minutes)
Inflammatory skin diseases often present differently in darker skin types, including rarer conditions such as sarcoidosis, cutaneous lupus or ashy dermatosis. These conditions were discussed during Dr. Joël Claveau’s presentation at the 7th annual Skin Spectrum Summit on Nov. 4.
Dr. Claveau is an associate professor in the department of medicine at Laval University and director of the melanoma and skin cancer clinic at Le Centre Hospitalier Universitaire, Hôtel-Dieu de Québec.
While the morphology of these conditions is similar in different skin types, there can be subtle differences, said Dr. Claveau, and some of these conditions are more frequent in some populations.
Erythema in darker skin can be barely perceptible and can present with a blue, brown or grey tint, he said. A common difference in darker skin is the development of post-inflammatory hyperpigmentation or, occasionally, hypopigmentation.
There is an increased chance of post-inflammatory pigment changes, keloid, and hypertrophic scars with darker skin. Dr. Claveau noted that while pigment changes generally will improve over time, with more severe diseases such as lupus, or following trauma, those changes can affect skin more profoundly and last for years.
Dr. Claveau described several less common inflammatory skin conditions in skin of colour:
Discoid lupus: More common in the Black population and can include significant pigment changes. The condition is associated with increased photosensitivity which can also lead to hyperpigmentation.
Sarcoidosis: More common in the black population than in Caucasians. The prognosis is often poor, but it can be difficult to identify as it is a ‘great imitator.’ It can appear similar to lupus or psoriasis or scarring and have either hypo- or hyperpigmentation. A biopsy may be needed to distinguish it from lupus.
Lichen planus: Often appears with a violaceous colour in dark-skinned patients. Due to the Koebner phenomenon, linear lesions and pigment changes may arise from scratching behaviour. Hypertrophic lichen planus is more commonly seen on the legs in darker-skinned patients.
Erythema dyschromicum perstans: This appears as patches of brown to grey pigmentation deep in the dermis. The cause of this is not entirely known but it is likely an inflammatory disease similar to lichen planus.
Chronic actinic dermatitis: Often seen in older patients with a history of contact dermatitis—often due to pollen—or photodermatitis. In dark-skinned patients, there can be a lot of hyperpigmentation, sometimes looking like leprosy.
Bottom Line: Inflammatory diseases, including rarer ones, can present differently in skin of colour. The effects of post-inflammatory pigmentary changes common in dark-skinned patients can be more severe and longer-lasting.
From the literature on inflammatory skin conditions in skin of colour
Ichthyosiform sarcoidosis: Report of a case and comprehensive review of the literature
This paper includes a case report of a 42-year-old African American woman with ichthyosiform sarcoidosis on the bilateral lower extremities and a literature review on the condition. The authors note that ichthyosiform sarcoidosis is one of the rarest variants of sarcoidosis, and as a result, it is understudied and has primarily been documented in case reports and series. Their review identifies key clinicopathologic features of this form of sarcoidosis including the characterization of sites of cutaneous and systemic involvement, as well as typical histopathological findings.
Refractory palmoplantar discoid lupus erythematosus successfully treated with mycophenolate mofetil: Unusual localization and literature review
The authors of this paper discuss a 47-year-old African female patient with a six-month clinical history of palm and sole erosions. They describe histological analysis and direct immunofluorescence study confirmed that the patient had palmoplantar discoid lupus erythematosus (DLE). The authors note that these sorts of DLE lesions are rare and typically do not respond well to conventional treatments. This patient was treated with mycophenolate mofetil (MMF), which progressively cleared the palmoplantar lesions, drastically reduced pain and was well tolerated. The authors write that this case and literature review confirm that MMF may be a practical approach for managing this type of DLE with a safer profile than azathioprine regarding adverse effects and cutaneous malignancies risk.
Verrucous sarcoidosis: A rare clinical presentation of sarcoidosis
The authors of this paper note there is limited literature on verrucous sarcoidosis. They note that most lesions in this condition present on the lower extremities of African American males. In this paper, the authors present two cases detailing the unique manifestations of this form of sarcoidosis—one a middle-aged Hispanic woman with lesions on her arms and face, and the second a middle-aged African American woman with sole facial involvement. The authors write that a multi-disciplinary approach to diagnosis and treatment is required for verrucous sarcoidosis as it can present with clinical and histopathological features indistinguishable from infectious etiologies and has an association with pulmonary sarcoidosis.
Epidemiology, clinical features, and associated factors in 78 cases of lichen planus on black skin
This multicentric, prospective study was conducted over six months in sub-Saharan Africa. Of the 78 patients included, the majority (84.6%) were women, and a minority (41%) were overweight. Their average age was 38 years. Roughly one-quarter (24.4%) of the patients had a history of lichen planus, and most (96.2%) had reported pruritus. The most commonly reported clinical forms were typical (52.6%), erythematosquamous (17%), warty (14.5%), pigmented (14.5%), and blaschkolinear (one case). While almost all cases (97.4%) had skin involvement, involvement of the mucous membranes (15.4%), and hair and nails (5.1%) were also seen.
VIDEO: Black & rare: Sarcoidosis in black women
At the intersection of skin and society
A new searchable, sortable list of hundreds of Black Canadian creators has launched, hosting links to websites, podcasts, and social media sites. The Black Canadian Creator Directory was compiled by three Black bloggers and podcasters, according to a press release. The three are Casey Palmer of Casey Palmer, Canadian Dad, Kaya Marriott of Comfy Girl with Curls and Sherley Joseph of The Chonilla Network, who founded the Black Canadian Creators community.
Palmer says the directory “offers the opportunity for Black creators to collaborate with their peers, get connected with brands, and give others the chance to hear Black Canadian stories straight from the source.”
Part of the inspiration for the directory is that Palmer, Marriott, and Joseph had repeatedly heard that media decision-makers were often unable to find creators who are the right fit for the stories that others want to tell. Therefore, the Black Canadian Creator Directory was created to facilitate connecting Black creators and media companies easily and efficiently.
The directory can be found here: https://caseypalmer.com/black-canadian-creator-directory/ More information and the option for Black creators to add themselves to the directory are available at that site.
Vender on Psoriasis: Episode two
The Chronicle Podcast System has launched a new podcast to talk about everything psoriasis with Dr. Ronald Vender. The podcast is based on Dr. Vender’s popular column in The Chronicle of Skin & Allergy. In this second episode, Dr. Vender discusses talks about biologic treatment safety during Covid-19, the effect of intermittent fasting on psoriasis and five-year data on using tildrakizumab to treat psoriasis patients. Listen here.
This Week
Feb. 1-7 is African Heritage and Health Week in the US
Feb. 4 is the International Day of Human Fraternity
Feb. 4 is World Cancer Day
Something to think about in the week ahead…
Next Week
The differences in Asian patients’ facial anatomy and aesthetic goals and how they should guide the planning of aesthetic injection treatments were addressed by Dr. Monica Li at the 7th annual Skin Spectrum Summit. Our next edition covers Dr. Li’s talk and other news and research on aesthetic dermatology in dark skin.