Dermatological Conditions in Skin of Color—Approach to Treating Seborrheic Dermatitis in Skin of Color

by Archana M. Sangha, MMS, PA-C

Ms. Sangha is a senior medical science liaison for Incyte Corporation in Wilmington, Delaware. Prior to that, she spent over a decade as a dermatology PA specializing in general, surgical, and cosmetic dermatology. She is a fellow of the American Academy of Physician Assistants in Alexandria, Virginia. She is also a Past President of the Society of Dermatology Physician Assistants.

Funding: No funding was provided for this article.

Disclosures: Ms. Sangha is an employee of Incyte Corporation in Wilmington, Delaware.

J Clin Aesthet Dermatol. 2024;17(5–6 Suppl 1):S20–S23.

Seborrheic dermatitis (SD) is a common chronic inflammatory skin disorder that affects approximately five percent of the worldwide population.¹ The worldwide geographical distribution of SD prevalence is highest in Sub-Saharan Africa, North America, and Western Europe.² SD was found to affect 6.5 percent of African Americans.³ In Singapore, SD prevalence is 3.2 percent among children and seven percent among adults.⁴ In India, SD prevalence among children was found to be 13.4 percent.⁵

SD most commonly affects the face, scalp, and chest. Its cause is thought to be multifactorial, with Malassezia furfur, skin lipids, and individual predisposition all playing a role. SD is often characterized by erythematous patches with an overlying “greasy” scale.⁶ As mentioned in previous articles, erythema in skin of color (SOC) patients is difficult to visualize due to larger amounts of melanin in the skin. The clinical presentation of SD in SOC can vary significantly from that of White patients. This article will highlight some of the nuances in treating SOC patients with SD.

Outlined below are clinical pearls for diagnosing SD in SOC patients.

1. Look for hypo- or hyperpigmentation on the face, neck, or chest. The hypo/hyperpigmentation often resolves by treating SD.⁷
2. Look for petaloid lesions. These lesions appear pink or hypopigmented and have coalescing rings with little-to-no scale.⁸ These lesions can be mistaken for tinea or lupus erythematosus.
3. When evaluating scalp SD, look for signs of alopecia, especially in women. If signs of alopecia are visible, it is important to aggressively treat the underlying SD to minimize alopecia.⁹

Cultural Competency Pearls

Often, the treatment for SD affecting the scalp is to use antifungal shampoo several times per week. This recommendation does not take into account hair texture, hair styling, or hair washing frequency among different ethnicities.

For example, one study found that hairstyle choice determined hair washing frequency in Black women. Black women with natural, non-traction hairstyles washed their hair on average every 14 days, whereas the hair washing frequency of those with braid or weave styles was 18 to 32 days.¹⁰ Therefore, it is impractical to expect a patient to use a prescription shampoo several times per week if their hair washing frequency is typically once or twice per month.

It is also important to inquire about the use of hair products. For example, natural oils (e.g.,  coconut oil, olive oil, etc.) are commonly used by many SOC patients. Many cultures believe these oils promote scalp health. One study found that these oils can contribute to growth of Malassezia, especially when combined with infrequent shampooing and in those with tightly coiled hair.¹¹ Additionally, the use of these oils can make it difficult to diagnose SD, as they might mask the scale. When prescribing shampoos, educate patients to apply them directly to the scalp versus the hair to minimize dryness.¹² Consideration should be given to the use of prescription ointments, oils, or leave-in foams in for patients whose haircare does not involve daily washing.³

In regards to Asian populations, studies have shown they are more likely than White patients to be sensitive to irritants found in topical medications/cosmetics.^13–15 It is important to keep this in mind when prescribing topical treatments and to avoid those that are more likely to cause skin irritation.

There remains a paucity of data when it comes to treating SD in several other ethnicities; thus, more research is necessary.

I have found that it is often difficult for clinicians to have an open dialogue with patients who are of a discordant race when it comes to discussing haircare practices. Clinicians have shared with me that their greatest fear is to appear unaware and therefore lose patient confidence. My approach when treating all patients is one of openness and curiosity. I say to my patients, “I want to create a treatment plan that works for you. In order for me to select the best options, I need to know how you care for your hair on a monthly basis. Can you walk me through what your haircare looks like?” See Box 1 for specific questions to ask if the patient is vague.

While leading with curiosity is an important first step in caring for patients, it’s just that—a step. Caring for patients is a privilege and one that we honor by staying up to date on research and best practices. We must constantly seek to improve our knowledge on how diseases present in all skin types. In order to appropriately treat patients of all ethnicities, clinicians must take it upon themselves to learn about the skin and hair characteristics of all races. A great place to start is by reading peer-reviewed articles or attending conferences/trainings with a focus on ethnic skin and cultural competency.

References

1. Palamaras I, Kyriakis KP, Stavrianeas NG. Seborrheic dermatitis: lifetime detection rates. J Eur Acad Dermatol Venereol. 2012;26(4):524–526.
2. Buja A, Miatton A, Cozzolino C, et al. The global, regional, and national burden of seborrheic dermatitis: results and insights from the Global Burden of Disease 2019 Study. Arch Dermatol Res. 2023;315(5):1143–1149.
3. Elgash M, Dlova N, Ogunleye T, Taylor SC. Seborrheic dermatitis in skin of color: clinical considerations. J Drugs Dermatol. 2019;18(1):24–27.
4. Goh CL, Akarapanth R. Epidemiology of skin disease among children in a referral skin clinic in Singapore. Pediatr Dermatol. 1994;11(2):125–128.
5. Banerjee S, Gangopadhyay DN, Jana S, Chanda M. Seasonal variation in pediatric dermatoses. Indian J Dermatol. 2010;55(1):44–46.
6. Tucker D, Masood S. Seborrheic dermatitis. Updated 16 Feb 2023. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024.
7. Jackson JM, Alexis A, Zirwas M, Taylor S. Unmet needs for patients with seborrheic dermatitis. J Am Acad Dermatol. 2024;90(3):597–604.
8. Wu T, Frommeyer TC, Rohan CA, Travers JB. Uncommon petaloid form of seborrheic dermatitis seen in Fitzpatrick skin types V-VI. J Clin Investig Dermatol. 2023;11(1):10.13188/2373-1044.1000086.
9. Raffi J, Suresh R, Agbai O. Clinical recognition and management of alopecia in women of color. Int J Womens Dermatol. 2019;5(5):314–319.
10. Dadzie OE, Salam A. The hair grooming practices of women of African descent in London, United Kingdom: findings of a cross-sectional study. J Eur Acad Dermatol Venereol. 2016;30(6):1021–1024.
11. Mayo T, Dinkins J, Elewski B. Hair oils may worsen seborrheic dermatitis in Black patients. Skin Appendage Disord. 2023;9(2):151–152.
12. Taylor SC, Barbosa V, Burgess C, et al. Hair and scalp disorders in adult and pediatric patients with skin of color. Cutis. 2017;100(1):31–35.
13. Robinson MK. Population differences in acute skin irritation responses. Race, sex, age, sensitive skin and repeat subject comparisons. Contact Dermatitis. 2002;46(2):86–93.
14. Goh CL, Tang MB, Briantais P, et al. Adapalene gel 0.1% is better tolerated than tretinoin gel 0.025% among healthy volunteers of various ethnic origins. J Dermatolog Treat. 2009;20(5):282–288.
15. Modjtahedi SP, Maibach HI. Ethnicity as a possible endogenous factor in irritant contact dermatitis: comparing the irritant response among Caucasians, Blacks, and Asians. Contact Dermatitis. 2002;47(5):272–278.