Dermatosis Papulosa Nigra also known as DPN is characterized by small brown or black spots that are on the skin around the cheekbones and eyes. The dark spots may also be found on other areas of the face, neck, chest, and back. Some people with dermatosis papulosa nigra have a few, isolated spots while others have hundreds of spots. The spots may be flat or hang off the skin like a skin tag.
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This is Part II of a two-part article on dermatologic conditions in skin of color. Patient information: See related handout on common conditions in skin of color , written by the authors of this article.
See the CME Quiz. Several skin conditions are more common in persons with skin of color, including dermatosis papulosa nigra, pseudofolliculitis barbae, acne keloidalis nuchae, and keloids.
Dermatosis papulosa nigra is a common benign condition characterized by skin lesions that do not require treatment, although several options are available for removal to address cosmetic concerns. Pseudofolliculitis barbae occurs as a result of hair removal. Altering shaving techniques helps prevent lesions from recurring.
In acne keloidalis nuchae, keloidal lesions are found on the occipital scalp and posterior neck. Early treatment with steroids, antibiotics, and retinoids prevents progression.
A key part of the management of keloids is prevention. First-line medical therapy includes intralesional steroid injections. The distinct structure of the hair follicle in blacks results in hair care practices that can lead to common scalp disorders.
For example, chemical relaxers decrease the strength of hair and may cause breakage. Better patient education, with early diagnosis and treatment, often leads to better outcomes. Part I of this two-part article on dermatologic conditions in persons with skin of color discusses common conditions that require special consideration in this population. Medical management of pseudofolliculitis barbae includes a combination of topical steroids, benzoyl peroxide, topical retinoids, and topical antibiotics.
Topical retinoids, potent topical steroids, and topical antibiotics are initial therapies for acne keloidalis nuchae. Dermatosis papulosa nigra is a common benign skin condition that occurs predominantly in dark-skinned persons Table 1 2 — 8. It presents as 1- to 5-mm lesions appearing as multiple brown to dark-brown, dome-shaped papules on the face, neck, and trunk Figure 1.
Most patients incorrectly refer to the lesions as moles. The face is the most common location, with the malar and temple areas often involved. Usually there are no associated symptoms, although the lesions can occasionally be pruritic or become irritated. Strong genetic predisposition 2 — 4. Cosmetic therapeutic options for removal include scissor excision, laser therapy, electrodesiccation, curettage, cryotherapy, and microdermabrasion 4 — 8.
Information from references 2 through 8. Dermatosis papulosa nigra. Small, smooth brown papules in the malar area of a black woman. Onset is typically after puberty, and lesions increase in number over time.
The etiology is unknown. Most patients present seeking reassurance that these lesions are benign. Treatment is not required, although if removal is sought, treatment options include scissor excision, laser therapy, electrodesiccation, curettage, cryotherapy, and microdermabrasion.
Pseudofolliculitis barbae is an inflammatory condition typically involving the face and neck in persons with tightly curled hair Table 2 9 — It is commonly referred to as razor bumps and is recognized by follicularly-based erythematous and hyperpigmented papules and pustules.
Although the pustules are usually sterile, secondary infections may develop. Postinflammatory hyperpigmentation, hypertrophic scars, and keloids often result. Results from cut hairs penetrating the skin 9. Complete resolution is possible only with discontinuing hair removal Applying proper shaving techniques can help decrease the extent of disease Table 3. Medical management includes topical steroids, benzoyl peroxide, topical antibiotics, and topical retinoids 9 , 11 , Information from references 9 through Pseudofolliculitis barbae develops after shaving or other forms of epilation, when cut hairs with an acute angle curl in on themselves and penetrate the skin, producing a foreign-body inflammatory reaction 5 , 9 Figure 2.
Pseudofolliculitis barbae. Hyperpigmented and skin-colored papules and macules in a beard distribution on a black patient. Treatment options include discontinuation of hair removal, destruction of the hair follicle, proper hair removal techniques, and medical management. Use clippers, a single-blade razor, or depilatories; if depilatories cause skin irritation, discontinue use.
Loosen embedded hairs before shaving by brushing the neck, applying warm compresses, or gently rubbing with a towel. Information from references 5 , 9 , 10 , and Medical management includes use of a mild- to medium-potency topical steroid immediately after shaving, benzoyl peroxide or a topical antibiotic in the morning, and a mild retinoid e.
Permanent hair reduction e. Acne keloidalis nuchae is a progressive chronic folliculitis resulting in keloid-like papules and plaques on the occipital scalp Table 4 14 , 19 , Persons may present with 2- to 4-mm papules and pustules, typically at the occipital scalp and posterior neck, that may evolve to have a smooth, shiny appearance resembling keloids, often in a band-like distribution Figure 3.
Subcutaneous abscesses and draining sinuses may develop as well. Some patients experience pruritus and pain. Scarring alopecia in the involved area is common.
These lesions are benign, but are often of cosmetic concern. Presents as papules, pustules, and plaques at the posterior scalp that are commonly associated with hair loss. First-line therapy includes use of topical antibiotics and potent topical steroids Other therapies include intralesional steroids, topical and oral retinoids, imiquimod Aldara , laser therapy, and surgical excision 14 , 19 , Information from references 14 , 19 , and Acne keloidalis nuchae. Firm, pink papules coalescing into a keloidal plaque in a young Hispanic patient.
Significant hair loss is noted in the affected area. Acne keloidalis nuchae typically affects men, although women can be affected as well. Persons affected are primarily postpubertal, and onset is typically before 50 years of age. It is of unknown etiology. Theories include chronic irritation and a pseudofolliculitis barbae—like foreign body reaction, secondary to skin penetration of closely shaven hairs and subsequent inflammation.
Early treatment correlates with a good prognosis. Preventive measures include avoiding tight-fitting apparel that rubs the posterior hairline and not trimming the occipital hairline with a razor or clippers. Because treatment can be challenging, a combination of these therapies is usually indicated.
Topical steroids in combination with topical antibiotics or retinoids can be effective in flattening lesions and decreasing symptoms. For draining or purulent lesions, bacterial culture permitting appropriate oral antibiotic selection is helpful. Keloids are benign growths that represent an overgrowth of scar tissue at sites of trauma, such as acne, burns, surgery, ear piercing, tattoos, and infections.
Keloids are smooth, shiny, and firm papules, plaques, and nodules. They tend to be red or pink with progressive hyperpigmentation Figure 4. Common locations are ear lobes, jaw line, nape of the neck, scalp, chest, and back. Lesions are sometimes asymptomatic, but often are associated with pruritus, pain, and hypersensitivity.
There is a higher incidence in blacks, Hispanic persons, and Asians. The most common ages at presentation are 10 to 30 years. Although the exact etiology of keloids is unknown, they are related to aberrant collagen production and breakdown in wound healing.
Keloids are often confused with hypertrophic scars. Hypertrophic scars typically develop soon after the inciting trauma and are found on areas of the body with frequent motion, such as extensor surfaces. Conversely, keloids develop months to years after injury and are not usually located in areas of motion. Keloids extend beyond the borders of original injury, often progressing over time. Patient education with an emphasis on prevention is essential. Guidelines for the prevention of keloids and hypertrophic scars include avoiding excessive movements that stretch the wound after undergoing procedures, and keeping wounds clean Table 5.
Although treatment can be challenging, early treatment offers the best outcome and many options are available. Often, multiple therapies are used in combination. Triamcinolone acetonide at lower concentrations 10 mg per mL may be used initially and titrated up based on response. In general, higher concentrations can be used safely in firmer, more elevated lesions. The possible adverse effects of atrophy, hypopigmentation, striae, and telangiectasias should be discussed with the patient before therapy, and the patient should be evaluated for these signs before each treatment.
Lesions may be injected every four to eight weeks as indicated. In persons prone to keloids, avoid unnecessary trauma to the skin e. If surgery or other invasive procedures are required in a person prone to keloids, 24 avoid excessive movements that stretch the wound, friction, and scratching; keep wounds clean to avoid infection and foreign body reactions. Use low concentrations of intralesional steroids for initial injections and titrate up as indicated; assess for skin atrophy and striae before each treatment.
Intralesional steroid injections can be repeated every four to eight weeks Surgical excision alone has a high recurrence rate. Information from reference Other therapies exist, including silicone gel sheeting, pressure earrings, topical imiquimod, intralesional fluorouracil, intralesional bleomycin, surgical excision, laser therapy, and verapamil.
Although no biochemical differences of hair have been found among persons of different ethnicities, there are notable differences in the shape of the hair follicle, leading to differences in texture, fragility, and manageability of hair.
Persons of African descent have the greatest degree of curl and increased fragility.
Dermatosis Papulosa Nigra (DPN)
It is exceptionally common in puberty and adolescence. Acne usually affects the face, chest, back, and shoulders. In severe cases, cysts, nodules, and scarring occur. Acne begins at puberty when the increased secretion of androgen in both males and females increases the size and activity of the pilosebaceous glands. Specific inciting factors may include food allergies, endocrine disorders, therapy with adrenal corticosteroid hormones, and psychogenic factors. Vitamin deficiencies, ingestion of halogens, and contact with chemicals such as tar and chlorinated hydrocarbons may be specific causative factors. The fact that bacteria are important once the disease is present is indicated by the successful results following antibiotic therapy.