Pigmentation issues and dermatology issues in skin of colour have been shown in research conducted with Melbourne dermatologists and dermatology registrars to be poorly understood. We took the opportunity to interview our founder and director to get some background on these important sub-speciality areas of dermatology, Dr Michelle Rodrigues
Where does skin get its colour from?
Melanocytes are small cells that actually make melanin or pigment. The number of melanocytes is actually consistent amongst racial groups. Melanosomes store and transport pigment and it is the size, density, and the distribution of melanin within the melanosomes that give skin its colour. The melanosomes in those with lighter skin are smaller and clustered in groups and they quickly broken down and degraded. The melanosomes in those with darker skin are generally larger, dense, oval and are found throughout the epidermis (top layer of skin). They are degraded slowly.
What is ‘skin of colour?’
Skin of colour is a term that was coined in North America to describe patients with non- Caucasian skin types. It includes a wide variety of patients with Chinese skin, Indian skin, African skin and Pacific Islander skin. It even includes Middle Eastern, Hispanic, and Indigenous patients. It is a broad group, but it is important to differentiate these because patients with skin of colour do have biological, functional, and structural differences in their skin.
Research that I carried out here in Australia just a few years ago that was published in the Australasian Journal of Dermatology, revealed that the majority of dermatologists are not comfortable treating skin of colour and feel they need more training and education in this area. Likewise another research paper I led with our team showed that dermatology trainees are not confident treating those with skin of colour. While some positive changes have been made, we still have a way to go and I will continue to advocate and try to push things forward slowly but surely.
Do you feel pigment disorders are misdiagnosed and mismanaged?
Pigment disorders are an incredibly challenging part of dermatology. The topics are not taught well enough to leave dermatologists feeling really comfortable with pigment disorders in many cases. I really feel it requires expertise to make a correct diagnosis.
If we look at hyperpigmentation as an example, many people are diagnosed with melasma.
As a tertiary referral centre or sub specialist-centre for pigmentation issues, Chroma Dermatology sees thousands of patients who have struggled, despite seeking medical attention, with their hyperpigmentation. One of the issues is incorrect diagnosis and the other is having intimate knowledge of melasma biology which allows us to tweak settings on our device therapies and to prescribe unique combination therapies when needed.
Obtaining the correct diagnosis is absolutely critical to optimising outcomes and minimising the risks of treatment. By minimising the risk to patients, we are talking about everything from managing patient expectations and skin care regimens, through to using specialised settings on carefully selected devices and laser technologies.
There are literally over 40 causes of hyperpigmentation on the face other than melasma and as I said before, getting the right diagnosis is the first of a series of important steps.
What is the biggest misconception about pigmentation disorders?
I think the biggest misconception is that all pigmentary disorders are cosmetic. That is true for some pigment problems such as freckles and sun damage, but it is not true for those with vitiligo for example, which is an autoimmune pigmentary disorder in which pigment cells are destroyed and where white spots develop.
How do you get the right diagnosis for a patient with facial pigmentation?
I really feel it takes decades of experience and detailed scientific knowledge of the causes and effects of the particular problem you are dealing with. I actually had to travel to centres of excellence in the USA to spend nearly one year in total with pigment experts there and then even more time in other parts of the globe. I really needed to immerse myself in the world of pigmentary disorders before I was able to scratch the surface in terms of knowledge and skills. I then continued with research endeavours and continued those affiliations and visits and nearly a decade on from them, we still continue to collaborate and learn from each other which is fantastic for our patients and the community.
For dermatologists treating pigment issues, the first step is to take a detailed history of when the pigment started and then work out if there are associated symptoms, a family history and any other medical problems that may be relevant. A detailed examination of the skin is needed as well, which involves looking with the naked eye and sometimes using special equipment too. Very rarely a skin biopsy is needed. Sometimes blood tests might be necessary to organise as well. Again, it depends on the type of pigment problem that we are looking at.
Why is getting the right diagnosis important?
Let’s take sun-spots collecting on the cheeks as an example. These can be easily, effectively and safely treated with laser. The laser choice, the settings and so on would differ in a patient who has skin photo type 1 or 2 versus a patient with darker skin types.
A very similar looking type of pigmentation can be seen, but could be a result of melasma for example, which if a laser is used, could potentially make it darker. This illustrates the importance of getting the right diagnosis. The next step of course is picking the right equipment and correct settings for the individuals skin type, colour and exact problem.
What advice would you give to someone with skin of colour who is seeking skin treatments?
If you do have skin of colour or pigmented skin, it is important to make sure that the diagnosis that you have is the correct one. Because if you do, you are more likely to be able to obtain information on what the possible treatment options are. Then it is important to decide who you will trust to plan and execute your treatment and maintenance therapy when needed.
Dermatologists specialise in the prevention, diagnosis and management of skin, hair and nail issues. Dermatologists graduate from medical school and then go on to do another 6 rigorous years of training (minimum) before they have to sit and pass a series of national examinations before they can qualify as dermatologists.
It is ideal if you can find someone near you who specialises in pigment issues and pigmented skin problems. There are many in places like the USA, Africa, Asia and the UK where you can find someone to assist. It will give you an extra level of confidence in being given accurate information.
The information contained in this blog post is intended as a guide only and should not substitute seeking medical attention. Please see your healthcare provider for more information on suitability of products, treatments or procedures.