Assistant Professor of Dermatology University of Alabama at Birmingham Birmingham, AL
| Published August 15, 2023
Welcome to derm busters, where we discuss common misperceptions in the field of dermatology. I'm Dr. Nick Brownstone, here with Dr. Carly Elston, assistant professor of dermatology at UAB. Carly, nice to have you here. Wonderful to be here. I need some help because I see a lot of skin of color patients, and they swear they don't need sunscreen. So what should I tell them? That's a common myth and misperception amongst our patients. And I think we, as dermatologists, really play an important role in the patient education there. So there have been several recent studies in JAD that have shown that in skin of color patients, not only do they get skin cancer, they tend to be diagnosed later and they have higher mortality and morbidity. So, yes, I agree with you, absolutely. Sunscreen is important, and sun protection is important in patients with skin of color. One of those studies showed that in terms of melanoma survival for women, in particular, they stratified by white women, hispanic women, asian women, and black women. And what they found was that the survival rates for white women were the highest, and across the board, all of the other groups had lower survival rates and black women were the worst. There's a study that looked at location of melanoma and melanoma survival rates in hispanic patients specifically, and what they showed was that the most common histologic subtype was superficial spreading. Melanoma most commonly occurs on the leg, and that has the highest mortality rate. So this is obviously of significant importance. So I do recommend sunscreen for my skin of color patients. I tend to recommend things that I think will be cosmetically more favorable on pigmented skin. So some of the physical blockers can be a little bit challenging, unless they're nanoparticle, something that's going to be a sheer titanium or zinc. I'll often recommend sunscreens that are in a clear or a gel base that'll rub in. So a myth? Yes. Absolutely. A myth, yes. Most important thing. Most important thing. Should have led with that. No, that's great. Love what you said about making sure it's the right type of sunscreen for the patient. If they don't want to use it, they're not going to use it. Okay, one more question for you. Another issue that I have. My patients come in, I treat a lot of acne, obviously, as we all do, and we give them tretino, and they say it's not burning, so it's not working. Should I put more on, should I put it on twice a day? So I want to ask about a common misperception about top up on medications. If it's not burning, it's not working. So absolutely. Also a myth and very common misperception amongst my patients, too. I feel like all of my patients are burning from their tretinoin. So in your practice, that's great that your patients are not burning. So there are a lot of medications that burn or sting and have that perception because of what's in the vehicle. So things that are in an alcohol base, like solutions, for example, can burn. Lactic acid can induce burning in patients who are really sensitive to cosmetic products, what we call stingers. And then propylene glycol also can cause irritant effect. And that's the most common reason that it's stinging. Has absolutely nothing to do with the efficacy and whether or not it's working, just the irritancy of the drug. And then we have some drugs that cause irritation because of the drug effect. So the topical calcinarin inhibitors cause a capsaicin like burning reaction, which often gets better the longer patients use them. Works just as well when the burning stops. So common myth and misconception amongst patients. Amazing answers, Carly. I feel so much better now going into work counseling my patients on these two topics. So thanks for your time. Absolutely.
Do patients with skin of color need sunscreen?
First, Dr. Brownstone asks Dr. Elston how to advise patients with skin of color who believe they don’t need sunscreen. Dr. Elston references studies that show not only do patients with skin of color get skin cancer, they also tend to get diagnosed later and have higher mortality.
She details a study that examined melanoma survival among White, Hispanic, Asian, and Black women, which demonstrated that those with skin of color had lower survival rates, with Black women having the lowest.
To encourage sunscreen use among her patients with skin of color, Dr. Elston recommends products that will be more cosmetically favorable on pigmented skin; some of the physical blockers can be challenging, so she often recommends sunscreens that are in a clear- or a gel-base that will rub in.
If a topical medication isn’t burning, does that mean it’s not working?
Next, Dr. Brownstone chats with Dr. Elston on a common misperception heard from patients—if a topical medication isn’t burning, it isn’t working.
Dr. Elston explains that many medications burn or sting because of what’s in the vehicle, like lactic acid affecting patients who are sensitive to cosmetic products or propylene glycol causing an irritant effect. She explains to patients that the resulting stinging is not a result of the products’ efficacy. She also explains that other drugs cause burning because of the drug effect, for example, topical calcineurin inhibitors causing a capsaicin-like burning reaction that often gets better the longer patients use them. She helps dispel this common misconception by advising patients that these medications work just as well when the burning stops.