For skin care professionals, passion drives growth. The meteoric rate in which devices, treatment options, and formulations continue to evolve within the skin health industry is staggering, and professionals are here for it! When it comes to melanin-rich skin, we have been seeing greater traction in our space for more inclusive and specific protocols to confidently treat higher Fitzpatrick classifications. There are more and more resources being made available to build professional confidence in caring for deeper skin tones. It is also encouraging to observe the number of improvements throughout industry devices to safely care for all cultures, skin tones, and classification scales. However, without a firm ability to identify skin conditions or skin abnormalities, the effective application for those formulas and devices are short circuited.
MISSING FOUNDATION
The not-so-great news is this: there are commonly misdiagnosed or nondiagnosed skin disorders within melanin-rich skin. This is, in large part, due to the under-representation of melanin-rich skin disorders and their respective images within dermatology textbooks and skin education curriculum. It simply has not been commonly seen.
The good news is we are in a momentum of slow but steady change in this area. There are organizations and dermatology associations focusing on shifting that narrative. Increased research access to images of skin concerns in all shades is necessary in order to adequately assist skin care professionals and experts in familiarizing themselves with what to look for.
Until we see a larger scale-up of academic literature being more available, it is our responsibility to grow in our own education. Still, this can sometimes be limited, and the change is often at a snail-like rate.
THE NOT SO USUAL SUSPECTS
Most professionals are likely quite familiar with the most common skin concerns for melanin-rich, such as hyperpigmentation and hypopigmentation. However, there are some more uniquely observed and in-depth skin concerns that may have not received as much awareness.
Here are the top misdiagnosed or nondiagnosed skin disorders in melanin-rich skin that often fly under the radar for skin care professionals.
Acral Lentiginous Melanoma (ALM)
Acral Lentiginous Melanoma is a form of melanoma classified as a pigmentary disorder. The word acral is Greek, meaning ”extremity,” referring to the furthest parts from the center of the body (hands and feet). Lentiginous refers to the darkened pigment that shows up. This type of melanoma typically appears on the palms of the hands, soles of the feet, or underneath the nails. It accounts for around 5% to 10% of all melanoma cases – so it is rare but tends to be pretty aggressive. Identifying acral lentiginous melanoma in melanin-rich skin can be tricky. It might look like a dark patch or spot that seems out of place, like a stubborn bruise or a funny-colored mole on the hands or feet. Sometimes, it can be tough to spot because it doesn’t follow the typical rules of pigmentary changes. Excluding dermatologists, it is outside of the skin professionals scope of practice to diagnose acral lentiginous melanoma or any form of malignant growth. Always defer the client to a dermatologist or other appropriate medical doctor.
Rosacea
Rosacea is classified as an inflammatory disease and disorder of the capillaries. The awareness of this disease within skin of deeper tones is gaining greater traction, although slowly. Traditional beliefs of rosacea were once emphasized around specific Northern and Celtic ethnicities and cultures. With continual education and clinical studies, the industry is recognizing that venous inflammatory disorders are not limited to an ethnicity, but they are genetically coded and can show up in a variety of patients.
Common indicators are flushing, blushing, stinging, telangiectasia, ocular inflammation, papules, and pustules. Within skin that is melanin-rich, these inflammatory indicators show up differently. Rosacea is sometimes mistaken for acne in dark skin, because the redness usually associated with rosacea on lighter skin isn’t always as visible. This can lead to incorrect treatment which can actually cause far more problems.
It is essential for professionals to understand that inflammatory disorders can only be managed not cured. Traditional treatments have incorporated the use of topical, oral, laser, and light-based treatments. This is where advanced grade levels should be referred onto dermatologists.
Epidermal Melanosis
This condition is characterized by increased melanin in the epidermis, leading to hyperpigmentation. It can appear as brown or grayish patches on skin. Inflammation in the epidermis stimulates melanocytes to increase melanin synthesis and subsequently transfer it to the surrounding cells.
Treatments may include topical depigmenting agents such as hydroxy acids, chemical peels, green peels, hydroquinone (PhD-guided), retinoids, and corticosteroids.
Dermal Melanosis (Pendulous Melanocytes)
Dermal melanosis involves the accumulation of melanin in the dermis. Pendulous melanocytes are melanin-producing cells that have migrated into the dermis. In other words, if the basal layer is injured, melanin pigment becomes trapped by macrophages within the papillary dermis. This makes it more difficult to treat with conventional treatment approaches that impact the cell turnover within the epidermal layer. Unconventional treatments may include laser therapy, chemical peels, or cryotherapy.
The rule of thumb with laser options for melanin-rich skin is to use nonablative lasers. These have longer wavelengths, like the Nd:YAG laser at 1064 nm, and have a longer coefficient. This means the laser penetrates skin at a depth of up to 4mm, bypassing the melanocyte cell and removing the risk of excessive trauma.
The best treatment approach may involve a combination of traditional and unconventional methods based on the predominant features of the condition.
Extensor Side Joint Hyperpigmentation
Hyperpigmentation at joints may be associated with chronic inflammation in conditions like inflammatory arthritis. Addressing the underlying inflammatory condition is crucial.
Topical treatments may include corticosteroids, while doctor prescribed systemic medications and lifestyle changes may also be considered.
Ashy Dermatosis
Ashy dermatosis presents as gray or ashy patches on skin. This is not effectively addressed by moisturizers and serums alone, as the source is more genetically coded rather than symptomatic.
Management may involve emollients, topical corticosteroids, and avoiding potential triggers. Consultation with a dermatologist is essential.
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Charmaine Cooper, known as The Skin Theologian, is an award-winning international speaker, author, and educator with 28 years in the skin profession. Renowned for her passion and ability to connect with diverse audiences, she has trained skin professionals and educators globally for 24+ years. Cooper’s work emphasizes skin health equity and cultural intelligence, particularly for melanin-rich skin. A recipient of the ACA 2024 favorite contributor award and author of the acclaimed “No Compromise Black Skin Care Guide” series & “Melanin-Rich,” she continues to inspire through her international webinars, media engagements, and transformative workshops. Connect with her on Instagram @theskintheologian.
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