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Learn from a Dermatology Leader: Dr Susan Taylor on Skin of Color · The Science of Skin

• 0:02
  SPEAKER_00: Hi, I'm Dr.
• 0:03
  SPEAKER_00: Patty Ferris.
• 0:04
  SPEAKER_00: I'm a board certified dermatologist, and I am your host for this episode of Skincare Confidential.
• 0:10
  SPEAKER_00: I couldn't be more excited about having anybody on this podcast than I am Dr.
• 0:15
  SPEAKER_00: Susan Taylor, who is a world-renowned dermatologist and a very close friend of mine.
• 0:21
  SPEAKER_00: Susan is the Bennett L.
• 0:23
  SPEAKER_00: Johnson Endowed Professor of Dermatology at Pearlman School of Medicine at Penn.
• 0:28
  SPEAKER_00: She received her medical degree from Harvard and is a diplomat of both the American Board of Internal Medicine and the American Board of Dermatology.
• 0:36
  SPEAKER_00: So Susan is double-boarded.
• 0:38
  SPEAKER_00: Dr.
• 0:38
  SPEAKER_00: Taylor's clinical and research focus is primarily on pigmentary disorders, acne, and alopecia.
• 0:46
  SPEAKER_00: She's authored over a hundred original publications as well as five textbooks, including Taylor and Kelly's Dermatology, textbook of dermatology for skin of color.
• 0:57
  SPEAKER_00: She's given more than 80 lectures both nationally and internationally.
• 1:02
  SPEAKER_00: In 1999, Susan founded the first Skin of Color Center at St.
• 1:06
  SPEAKER_00: Luke's Roosevelt Hospital.
• 1:09
  SPEAKER_00: She's also the founder and the first president of the Skin of Color Society, which she founded in 2004.
• 1:15
  SPEAKER_00: So, Susan, I want to start right there.
• 1:18
  SPEAKER_00: Let's talk about how you had the foresight to start the first Skin of Color Center in the United States and probably in the world.
• 1:26
  SPEAKER_00: And then also, how did you envision the way the Skin of Color Society would ultimately shape dermatology and dermatologists?
• 1:34
  SPEAKER_01: Well, Patty, thank you very much for having me and thank you for those questions.
• 1:39
  SPEAKER_01: So both the Skin of Color Center as well as the Skin of Color Society really came out of my interactions with my patients.
• 1:48
  SPEAKER_01: Also, Vince DeLeo, who was in New York at the time, had patients who came to him and said, you know, we're looking for dermatologists who more intimately understand our skin, hair, and nail problems.
• 2:02
  SPEAKER_01: And he gave me a call one day and said, You know, there's this big need in New York City, a very diverse population, for some type of center.
• 2:10
  SPEAKER_01: Would you come up here and create the center?
• 2:14
  SPEAKER_01: And I thought it was very important.
• 2:16
  SPEAKER_01: In Philadelphia, where I was practicing at the time, so many patients came and said, you know, the last dermatologist that I saw really didn't understand my hair, really didn't understand my skin.
• 2:29
  SPEAKER_01: So I created the center, and shortly thereafter, because those patients still had that same message, I thought, we need to create a society, a society that's going to educate our peers, a society that's going to help us conduct research, and a society that's going to help us mentor young people to be interested in dermatology and caring for this diverse patient population.
• 2:57
  SPEAKER_00: That's an unbelievable story.
• 2:59
  SPEAKER_00: And you have created something that really has had some legs in dermatology.
• 3:04
  SPEAKER_00: And, you know, congratulations.
• 3:06
  SPEAKER_00: You have many accomplishments, but this is certainly one of your greatest.
• 3:10
  SPEAKER_01: Thank you.
• 3:10
  SPEAKER_01: So, you know, Patty, I remember, like it was yesterday, a Sunday, I was sitting at my dining room table and I created a list of our colleagues who I thought might be interested in joining me in creating the society.
• 3:26
  SPEAKER_01: There were 14 names, and everyone that I called that Sunday morning said yes.
• 3:32
  SPEAKER_00: So, how many members now do we have in the Skincolor Society?
• 3:35
  SPEAKER_01: We have thousands of members from all over the world.
• 3:40
  SPEAKER_01: It's an international uh organization with thousands of members from the original 14.
• 3:46
  SPEAKER_00: Oh, that's that's just unbelievable.
• 3:48
  SPEAKER_00: I'm gonna turn to skincare because, of course, that's our area of interest here on skincare confidential.
• 3:54
  SPEAKER_00: And you're certainly one of the greatest authorities on skin of color and using topical skin care in that patient population.
• 4:01
  SPEAKER_00: Let's sort of start with basic science.
• 4:04
  SPEAKER_00: Let's talk about the differences between skin of color and uh lighter skin types, Caucasian skin, in terms of physiology and things like that.
• 4:14
  SPEAKER_01: So let me start off by saying when we group people as having skin of color, that's a very large, broad, and diverse group.
• 4:22
  SPEAKER_01: Correct.
• 4:22
  SPEAKER_01: And they have some similarities and they have many differences.
• 4:26
  SPEAKER_01: The other thing I want to start off with is acknowledging the fact that other factors like the social determinants of health, meaning socioeconomic status, exposure to pollutants, etc., may have a very important role.
• 4:43
  SPEAKER_01: With that being said, there are some genetic differences, there are physiologic variations, and the most prominent and the most well studied and known are the differences in melanin.
• 4:55
  SPEAKER_01: So, although all melanocytes are the same between fair and darker skinned individuals, what really differs is the amount and type of melanin.
• 5:04
  SPEAKER_01: And melanin is stored in these little packages called melanosomes.
• 5:08
  SPEAKER_01: Those in darker skinned individuals are very large, they're chock full of melanin.
• 5:13
  SPEAKER_01: Those in lighter skin, very small.
• 5:16
  SPEAKER_01: So this has implications for the types of disorders that we see and the reactions that we see to various skin care products.
• 5:25
  SPEAKER_01: Also, if we look at blacks in particular, the black population, there are differences in things like ceramides.
• 5:34
  SPEAKER_01: And ceramides are related to how dry the skin is.
• 5:38
  SPEAKER_01: So if black patients have lower ceramide levels and higher transepidermal water loss, they lose more water from their skin.
• 5:47
  SPEAKER_01: There's really a propensity for many in this population to have very dry skin, to have xrrosis.
• 5:53
  SPEAKER_01: So that's going to guide us to certain types of skincare products.
• 6:00
  SPEAKER_01: There are dermal changes, differences in fibroblasts, for example, that make collagen and mast cells that are probably responsible for the formation of keloidal scars.
• 6:12
  SPEAKER_01: So patients with darker skin tones, those of African descent, Latin descent, and some Asian populations are more prone to keloids, and we think that's because of the differences in the fibroblasts.
• 6:26
  SPEAKER_01: So those are just some of the differences I want to mention.
• 6:29
  SPEAKER_00: Yeah, that's so interesting.
• 6:31
  SPEAKER_00: What about um topical skin care products?
• 6:34
  SPEAKER_00: Sort of like maybe going through routine topical skin care products.
• 6:38
  SPEAKER_00: So you touched on the lower ceramides, so I'm assuming we need heavier moisturizers, more aggressive moisturization, but maybe in terms of a daily skincare regimen, what type of things do you recommend for skin of color patients?
• 6:52
  SPEAKER_01: So, first of all, I want to also acknowledge that there's variation, right, between the various skin of color populations.
• 6:59
  SPEAKER_01: But if we are going to continue upon that thread of xrosis and dry skin, of course we're going to select cleansers and moisturizers that are enriched with ceramides, for example, to help replace them.
• 7:12
  SPEAKER_01: The other thing we want to be mindful of, let's say someone has acne or hyperpigmentation, and we want to select products that are going to exfoliate.
• 7:21
  SPEAKER_01: It's critically important that we don't irritate that skin.
• 7:24
  SPEAKER_01: Because remember, sitting right there in that epidermis are those chock full melanosomes of melanin.
• 7:32
  SPEAKER_01: That's ready to make trouble.
• 7:33
  SPEAKER_01: Exactly.
• 7:34
  SPEAKER_01: So we really have to be cautious with products that contain alpha hydroxy acids, ethanols, for example.
• 7:43
  SPEAKER_01: That's not saying we can't use them, but we have to use them carefully and wisely.
• 7:50
  SPEAKER_00: Absolutely.
• 7:51
  SPEAKER_00: Talk about sun protection in darker skin types because I think that's often overlooked.
• 7:56
  SPEAKER_00: And so are there differences in the type of sunscreens that we might recommend?
• 8:00
  SPEAKER_00: We all are well aware of how difficult it is to use mineral sunscreens if you have darker skin.
• 8:05
  SPEAKER_01: Right.
• 8:06
  SPEAKER_01: Yes.
• 8:06
  SPEAKER_01: So, you know, there have been really huge gaps in knowledge in regard to sunscreen use in darker populations.
• 8:13
  SPEAKER_01: And that's on the side of physicians, but also with our patients.
• 8:17
  SPEAKER_01: Patients think that melanin is all protective and that they won't get sunburn, that they won't get skin cancer, that they won't get discolorations.
• 8:26
  SPEAKER_01: That's a fallacy.
• 8:27
  SPEAKER_01: So we have to educate our patients as well as our colleagues.
• 8:31
  SPEAKER_01: What we end everyone, everyone of color, really needs to use a broad spectrum SPF 30 or higher sunscreen on a daily basis, same recommendation, applied 20 to 30 minutes of going outside.
• 8:46
  SPEAKER_01: But what we have learned recently is the importance of visible light.
• 8:51
  SPEAKER_01: We have learned that in darker skin types, skin types 4, 5, and 6, and some 3s, that visible light is going to generate reactive oxygen species and reactive nitrogen species.
• 9:03
  SPEAKER_01: And that's really going to activate tyrosinase, that's going to make more melanin.
• 9:08
  SPEAKER_01: So visible light in the blue violet range is going to make dark marks darker and it's going to produce long-lasting up to 21 days pigmentation.
• 9:19
  SPEAKER_01: So it's critically important that patients use sunscreens that contain visible uh visible blockers of visible light.
• 9:27
  SPEAKER_01: Now, what are those sunscreens?
• 9:29
  SPEAKER_01: Those sunscreens have iron oxide.
• 9:32
  SPEAKER_01: We prefer 3% concentration, or those sunscreens can contain certain antioxidants that are going to squelch those free radicals.
• 9:42
  SPEAKER_00: Right.
• 9:43
  SPEAKER_00: So either antioxidants or your iron oxides.
• 9:47
  SPEAKER_00: Right.
• 9:48
  SPEAKER_00: Okay, that makes total sense.
• 9:50
  SPEAKER_00: Yeah.
• 9:50
  SPEAKER_00: Let's talk for a minute about treating acne patients because we know that acne causes post-inflammatory hyperpigmentation in darker skin types, and it's a huge problem.
• 10:00
  SPEAKER_00: So maybe go through how we would mitigate that and what special considerations for topical skin care, particularly our over-the-counters.
• 10:08
  SPEAKER_01: Right.
• 10:08
  SPEAKER_01: So there are many additional therapies over-the-counter in our armamentarium that we can use for our skin of color patients with acne.
• 10:17
  SPEAKER_01: So we're all familiar with benzyl peroxide and salicylic acid.
• 10:22
  SPEAKER_01: They've been on the market for many years.
• 10:24
  SPEAKER_01: They are still very effective, particularly in people who have mild acne.
• 10:29
  SPEAKER_01: I would tend for benzyl peroxide to avoid irritation of the skin, use 2.5% as opposed to 5 or 10%.
• 10:38
  SPEAKER_01: Um, salicylic acid comes in various concentrations.
• 10:42
  SPEAKER_01: 2%, but it can go down to 0.05%.
• 10:46
  SPEAKER_01: A little bit safer.
• 10:47
  SPEAKER_01: That's exactly right.
• 10:48
  SPEAKER_01: Now we have adaplene, which is OTC.
• 10:53
  SPEAKER_01: So as you know, uh Patty, a very effective retinoid, very gentle, very gentle, cost uh effective.
• 11:01
  SPEAKER_01: And even with that, I will ask my patients to just apply a pea size dot, let's say every other night or every third night to begin, and then apply their moisturizer over top.
• 11:14
  SPEAKER_01: So a regimen with a BPO in the morning and our adaplene initially every other or every third night, I think is a great, great start for therapy.
• 11:25
  SPEAKER_01: Now, there are other patients who want things that are more natural, quote unquote.
• 11:30
  SPEAKER_01: So there is data that things like tea tree oil, for example.
• 11:33
  SPEAKER_01: A good anti-inflammatory, yeah.
• 11:35
  SPEAKER_01: That's right.
• 11:35
  SPEAKER_01: So there's been some evidence of improvement with things like uh tea tree oil that patients like because they are um more natural.
• 11:45
  SPEAKER_01: Uh, there are some other exfoliants that can help acne as well.
• 11:49
  SPEAKER_01: But my word of caution is slow start slowly because it can lead to irritation and further post-inflammatory hyperpigmentation.
• 11:58
  SPEAKER_00: Good, good words of wisdom.
• 12:00
  SPEAKER_00: You you only make those mistakes once or twice, and then you realize that it's it's a real it's a real problem.
• 12:06
  SPEAKER_00: So, in the over-the-counter skincare market, I think one of the places we've seen some really exciting advances is in the treatment of hyperpigmentation.
• 12:14
  SPEAKER_00: So maybe you could go through some of the your favorites, some of the ingredients that you really like to use, and how you're using them in the darker skin types, treating PIH and melasma, which is also much more common in this uh population as well.
• 12:29
  SPEAKER_01: So there are over-the-counter products that you can get in the drugstore, and there are other over-the-counter cosmosceuticals that are quite commonly uh purchased in doctors' offices.
• 12:39
  SPEAKER_01: Now, I think there's a real important role for exfoliation uh for this patient population.
• 12:46
  SPEAKER_01: So using items that contain various hydroxy acids, it can be alpha hydroxy acids, it could be beta hydroxy acids.
• 12:54
  SPEAKER_01: There are a whole host of ingredients, be it niacinamide, arbutin, cogic acid.
• 13:00
  SPEAKER_01: Now we have topical tranhexamic acid, and many of the companies will combine combine several of these ingredients because their mechanism of action is a little bit different.
• 13:13
  SPEAKER_01: So you're uh you're attacking various different um spots in the production of melanin, for example.
• 13:23
  SPEAKER_01: Uh there are some new products on the or ingredients on the horizon.
• 13:29
  SPEAKER_01: Um, there's an ingredient called thiamidol that's been released in Europe and uh South America and um Africa.
• 13:38
  SPEAKER_01: And you know, my patients are coming in with it now because they're getting it from getting it elsewhere, exactly, even though it's not officially uh launched.
• 13:46
  SPEAKER_01: It too is a tyrosinase inhibitor, so it's gonna block the production of uh of melanin.
• 13:53
  SPEAKER_01: So we have many uh topicals in our uh armantarian, and we can mix and match and change depending upon the season, for example.
• 14:02
  SPEAKER_00: Yeah, do you use a lot of topical vitamin C?
• 14:06
  SPEAKER_00: Because that's another good skin lightener.
• 14:08
  SPEAKER_01: Um topical vitamin C has been around for a long, long time.
• 14:12
  SPEAKER_01: Um we I use it more often in patients with uh photodamage, you know, they'll have that kind of speckled hyper and hypopigmentation.
• 14:22
  SPEAKER_01: Uh it works pretty well in them.
• 14:25
  SPEAKER_01: But you know, there are some very nice uh vitamin C serums, you know, that are sort of soothing and can also help with patients with post-inflammatory hyperpigmentation.
• 14:36
  SPEAKER_00: Right.
• 14:36
  SPEAKER_00: Yeah, that that's one area I think we've got so many OTC options now.
• 14:41
  SPEAKER_00: And as we move away from hydroquinone, which we definitely are seeing that movement away from it, we both know that in patients with stubborn problems we have to turn to it.
• 14:51
  SPEAKER_00: But I think these great over-the-counters are such a nice alternative for us.
• 14:55
  SPEAKER_00: Another uh condition that I think maybe is a little underdiagnosed and perhaps often overlooked in darker skin types is rosacea.
• 15:06
  SPEAKER_00: And so talk a little bit about that.
• 15:09
  SPEAKER_00: How does it look?
• 15:10
  SPEAKER_00: What's the presentation, and then what sort of special considerations, because we know those are our stingers, our burners, our patients who have really sensitive skin.
• 15:19
  SPEAKER_00: Do you see that commonly in skin of color patients?
• 15:23
  SPEAKER_01: I absolutely do, and often it's misdiagnosed.
• 15:27
  SPEAKER_01: Yeah, sometimes it's very difficult to appreciate the erythema on the face in patients with darker skin tones.
• 15:35
  SPEAKER_01: The patient will know if his or her face is red, so you just have to ask the patient in many cases.
• 15:42
  SPEAKER_01: Um, there are other patients who have erythema, and their physicians think that it's uh a collagen vascular disease, like a form of lupus, for example, and they keep doing a workup and a workup, and you know it's negative for Ellie.
• 16:00
  SPEAKER_01: Uh, I find it uh one of the things that really help to uh elucidate the diagnosis is to ask the patient if you put on a moisturizer or use a cleanser, does your skin sting, right?
• 16:17
  SPEAKER_01: And many patients can make the diagnosis, many patients of color, you can make the diagnosis based upon those particular symptoms.
• 16:26
  SPEAKER_01: Patients will say, you know, my skin is very sensitive.
• 16:29
  SPEAKER_01: And guess what?
• 16:30
  SPEAKER_01: It is.
• 16:31
  SPEAKER_01: Yes, yes.
• 16:32
  SPEAKER_01: Um, so yeah, so to avoid missing that diagnosis in your skin of color patients, well, those particular with darker skin tones, query the patient about redness, particularly after certain triggers, hot spicy foods, red wine, etc., and ask about symptoms.
• 16:52
  SPEAKER_01: The other thing is uh that's very important is when you select their skincare regimen, they're cleansers, they're moisturizers.
• 17:00
  SPEAKER_01: Again, you don't want it to contain anything that's potentially irritating.
• 17:05
  SPEAKER_01: I particularly like products that have ceramides or have high alluronic acid, so they're very moisturizing for those patients.
• 17:14
  SPEAKER_00: Yeah, and it helps to build that barrier up, which we know is a problem in patients.
• 17:20
  SPEAKER_00: So avoiding the alpha hydroxies and all of those things.
• 17:23
  SPEAKER_00: And the retinol and the retinols and all of it.
• 17:26
  SPEAKER_01: Absolutely.
• 17:27
  SPEAKER_00: Talk for a minute about ashy skin.
• 17:29
  SPEAKER_00: I have a lot of patient complaints about ashy skin.
• 17:33
  SPEAKER_00: So give us it, give us your ashy skin.
• 17:36
  SPEAKER_00: How do we treat it?
• 17:37
  SPEAKER_00: What is it?
• 17:37
  SPEAKER_00: What's going on here?
• 17:39
  SPEAKER_01: Ashy skin is just simply another term for severe cirrhosis, so very dry skin.
• 17:45
  SPEAKER_01: And you know, when the skin is dry and you see those um scales on the skin, it contrasts quite significantly with the darker color of the skin.
• 17:55
  SPEAKER_01: So you it has almost an ashen appearance, and it's quite embarrassing for many patients.
• 18:02
  SPEAKER_01: So we have to start with, you know, at ground zero, instruct them how to cleanse their skin, short, lukewarm showers, a mild superfatted soap, pat dry, uh, apply your moisturizer to damp skin.
• 18:19
  SPEAKER_01: You might they might get better benefit from occlusive agents that maybe are petrolatin-based, or some of the butters like shea butter, coconut butter, or alternatively, some of the ammonium lactate-based products can be very, very helpful uh as well.
• 18:39
  SPEAKER_01: Many of them, urea, low concentrations, glycerin, etc.
• 18:44
  SPEAKER_01: Um, so it's important to explain that the patient needs more than simply a moisturizer.
• 18:52
  SPEAKER_01: You know, how they cleanse their skin is critically important and what they use to cleanse their skin.
• 19:00
  SPEAKER_00: Kind of moving away from the therapeutic side, talk a little bit about.
• 19:04
  SPEAKER_00: I know you've been gathering images so that dermatologists, especially our residents in training, can learn more about what different conditions look like in skin of color.
• 19:15
  SPEAKER_00: So, where are you with that project now?
• 19:17
  SPEAKER_00: In case you don't have enough to do, Susan, I know you've taken this on as your initiative, but this is so important.
• 19:24
  SPEAKER_01: Yeah, so you know, there are a couple of initiatives that are occurring.
• 19:29
  SPEAKER_01: First, I want to add, I helped to create a curriculum, a skin of color curriculum that's housed on the American Academy of Dermatology's website, uh training our um medical students, our residents, even our colleagues about skin of color.
• 19:47
  SPEAKER_01: Okay, with that being said, personally, I am uh in the last stages of completing an atlas for skin of color.
• 19:56
  SPEAKER_01: Um, that's going to be almost a companion to the textbook, uh, dermatology for skin of color.
• 20:03
  SPEAKER_01: So that should uh come out in the summer.
• 20:07
  SPEAKER_01: So that's one effort.
• 20:08
  SPEAKER_01: There's another textbook that was published about a year ago, strictly devoted to skin of color.
• 20:16
  SPEAKER_01: Uh, Adam Friedman is the lead author.
• 20:19
  SPEAKER_01: Now, with that being said, the Academy, the American Academy of Dermatology, is accumulating uh images for an image bank that that is going to be housed on their site.
• 20:31
  SPEAKER_01: The Journal of the Academy of Dermatology uh has available any images of color that's that have been published in their articles.
• 20:41
  SPEAKER_01: You know, so I'm and the Skin of Color Society is also working on this early stages.
• 20:47
  SPEAKER_01: So I need um people to understand this is a multi-pronged approach, and which uh is so rewarding to me.
• 20:54
  SPEAKER_01: It's so important uh to really get those those images so that Patty, when we're on the podium, we'll make sure we have adequate uh images for all of the diseases that we're talking about.
• 21:07
  SPEAKER_00: Yeah, and and that that is uh a noble, a noble uh goal, that's for sure, because we don't see a lot of darker skin type images usually.
• 21:18
  SPEAKER_00: Um, one of the things that I think is interesting we're seeing a lot in the cosmetic industry is a lot more of the trials are including patients with skin of color.
• 21:27
  SPEAKER_00: And every I think you and I have been on a number of advisory boards with a number of companies together over the year going, hey guys, you know, where are the patients with the darker skin types?
• 21:36
  SPEAKER_00: We're seeing them in studies, we're also seeing them in advertising now more.
• 21:40
  SPEAKER_00: And I know you work with lots of companies as well.
• 21:43
  SPEAKER_01: Yeah, so I'm very pleased, we're all very pleased, that many of our pharmaceutical companies are very interested in including skin of color patients in their pivotal trials, and that is very important.
• 21:56
  SPEAKER_01: We don't know if a medication or device is effective in this particular population unless they're in the clinical trials.
• 22:04
  SPEAKER_01: They're thinking more carefully about how to make the inclusion criteria broad enough to include patients of color.
• 22:14
  SPEAKER_01: So, for example, for psoriasis and eczema, if your evaluation tool is based upon or partially based upon erythema, and it's difficult to see erythema in dark skin, you know, they're not going to be included.
• 22:28
  SPEAKER_01: So they're rethinking that, for example.
• 22:30
  SPEAKER_01: Rethinking their protocols.
• 22:32
  SPEAKER_01: That makes sense.
• 22:32
  SPEAKER_01: That makes total sense.
• 22:34
  SPEAKER_01: To include more patients of color.
• 22:36
  SPEAKER_00: That's great.
• 22:37
  SPEAKER_00: Susan, we're out of time, but this was so informative, and I can't thank you enough for sharing your knowledge, your vast knowledge on skincare and treating patients with skin of color.
• 22:48
  SPEAKER_00: And I wish you all the best in all your ventures.
• 22:52
  SPEAKER_01: Well, thank you.
• 22:53
  SPEAKER_01: Thank you so much for having me on Skin Care Confidential.
• 22:57
  SPEAKER_01: You know, it's so important that everyone understand about uh diverse skin types.
• 23:01
  SPEAKER_01: So thank you for your interest and your time.
• 23:03
  SPEAKER_01: Great to see you.
• 23:04
  SPEAKER_00: Thank you, and that'll wrap this uh episode of Skin Care Confidential.