Summary
Certain dermatological conditions are more common among individuals with skin of color than among individuals with lighter skin tones. Recognition of these conditions is important to ensure that patients receive timely and appropriate management. This article covers three conditions that are more common in individuals with skin of color: pseudofolliculitis barbae, acne keloidalis nuchae, and dermatosis papulosa nigra. Keloid scarring and postinflammatory hyperpigmentation, both of which are more common in skin of color, are covered in separate articles.
For a more detailed overview of dermatological considerations, including presentations of common malignant and nonmalignant skin conditions, see “Skin of color.”
Pseudofolliculitis barbae
An inflammatory skin reaction in response to short hair that becomes entrapped within the skin
Epidemiology [1]
Most common in Black men
Etiology [2]
- Usually occurs due to shaving (also known as razor bumps)
- Common in individuals with tightly curled hair
Pathophysiology [2]
Foreign body reaction to hair as a result of:
- Extrafollicular penetration: Hair enters the interfollicular epidermis after it exits the follicular orifice.
- Transfollicular penetration: Hair penetrates the dermis before exiting the follicular orifice.
Clinical features [2][3]
- Firm, hyperpigmented or erythematous papules and pustules
- Most commonly occurs in the beard region (i.e., cheeks, jaw, and neck)
- Lesions may be tender and/or pruritic.
Diagnostics [2]
- Usually a clinical diagnosis
- The diagnosis can be confirmed with dermoscopy, which shows follicular penetration.
Treatment [2][3]
-
First line
- Advise patients to stop shaving for at least 8 weeks. [3]
- Educate patients on shaving techniques to minimize the risk of recurrence.
- Advise photoprotective measures to reduce the risk of postinflammatory hyperpigmentation.
-
Adjunctive or alternative treatments: Consider the following topical agents alone or in combination. [2][3]
- Retinoids
- Low-dose corticosteroids
- 5% Benzoyl peroxide gel
- 1% clindamycin gel
-
Persistent lesions or definitive treatment: Consider dermatology referral for procedural therapy, e.g.:
- Permanent hair-removal techniques (e.g., laser hair removal with or without eflornithine)
- Chemical peels
Use of depilatory products (e.g., calcium thioglycolate cream) may result in fewer lesions but can cause high levels of skin irritation. [2]
Complications [2]
- Postinflammatory hyperpigmentation
- Keloid scars
- Secondary bacterial infection (folliculitis barbae)
Acne keloidalis nuchae
A chronic inflammatory skin condition affecting the nuchal and occipital region of the scalp
Epidemiology [2]
Etiology [2]
- Unclear; male preponderance suggests an association with increased androgen levels.
- Lesions are caused by an abnormal immune response to trauma.
Clinical features [2]
The following features are circumscribed to the region surrounding the posterior hairline.
- Keloid-like papules, plaques, and/or pustules
- Cicatricial alopecia
- Can cause itching, pain, and bleeding [4]
Diagnosis [5]
- Usually a clinical diagnosis
- Can be confirmed with dermoscopy
Management [2]
- Avoid irritation of the area, e.g., from short haircuts, tight-fitting headwear, or high-necked shirts.
- Mild to moderate disease
- Papules < 3 mm: topical triamcinolone with or without topical retinoid for 2–4 weeks [2]
- Papules ≥ 3 mm or plaques: intralesional triamcinolone
- Pustules: adjunctive treatment with topical clindamycin or oral antibiotics (e.g., tetracyclines)
- Severe or refractory disease: Consider dermatology referral for additional treatment options, e.g.: [6]
- Laser therapy (most effective treatment)
- Phototherapy
- Cryotherapy
- Oral isotretinoin
- Surgical excision
Dermatosis papulosa nigra
A skin condition characterized by pigmented papules on sun-exposed areas (especially the face)
Epidemiology [7]
- High prevalence (up to 70%) in individuals with skin of color; especially in people of African descent
- Onset in adolescence
- ♀ > ♂ (2:1)
- Size and number of lesions often increase with age. [2]
Etiology [2]
- Genetic
- UV exposure
Clinical features [2][7]
-
Hyperpigmented filiform or sessile papules
- Typically 1–5 mm in diameter with 1–3 mm elevation
- Symmetrically distributed in sun-exposed areas (most commonly cheeks and neck)
- Lesions may be painful or itchy.
Diagnostics [7]
- Diagnosis is usually clinical.
- Consider biopsy in cases of diagnostic uncertainty.
Management [2][7]
- Treatment is not required; photoprotective measures may prevent further development. [8]
- Refer patients who desire cosmetic treatment to dermatology. Treatment options include:
- Laser therapy
- Cryotherapy
- Curettage
- Electrodesiccation
- Scissor excision (for pedunculated lesions)
Advise patients that treatment may cause pigment changes and/or scarring. [9][10]