According to recent findings in The Journal of Dermatology, children who experience eczema flare-ups in the spring and summer months are more likely to have hay fever. Approximately one-third of children with hard-to-treat atopic eczema experience most of their flares during the pollen season. Children with eczema may benefit from avoiding exposure to pollen exposure and from treatment with antihistamines.
Dalhousie University in Halifax has added a new elective course to educate students on the Black Canadian experience in healthcare. The “Centering Black Canadian Health” course is open to Dalhousie Health and Faculty of Arts and Social Sciences students, and uses a social determinants lens to educate students on Black Canadians’ experiences in healthcare. It will offer insight into how Canadian education, justice, and social systems have impacted, and continue to impact, Black Canadians’ physical, emotional, and mental health. For more information, visit www.dal.ca/faculty/health/ news-events/news/2023/02/28/a_new_black_canadian_ health_course.html.
Here are some tips that will help your skin during the hottest months of the year.
Meet SPF minimums
The Canadian Dermatology Association recommends using a sunscreen with an SPF of 30 or higher. It is good practice to apply sunscreen during the summer every time you go outside with exposed skin.
Apply sunscreen before sun exposure & reapply
You should always apply your sunscreen before sun exposure to give it time to penetrate the skin. Also, SPF numbers are
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tested on how sunscreen protects for two hours, so there is no guarantee of it being as effective after that time.
Most sunscreens are water resistant, which means you can stay in the water playing or playing sports for about 40 or 80 minutes (depending on the sunscreen you use) without having to reapply. Once you get back to your towel and the skin has dried, it is best to reapply in case some of the sunscreen has washed off your skin.
If you are spending a long time on the beach, wear a hat, bring an umbrella with you or seek shelter in the beach bar or under a tree.
Sun exposure, sand, and salty water can really dehydrate your skin. To make up for the drying effects of these elements, apply a moisturizing body lotion and face moisturizer after showering.
One in a while, it is recommended to visit your dermatologist and get a full-body exam. Your doctor will examine your moles and marks and see how they evolve over time. Keeping moles in check can help to prevent problems such as melanoma in the future. Remember to always see your dermatologist if a mole changes or grows bigger.
Hot showers can dry your skin more, so it is better to use warm or cool water for your skin. Turning the water temperature down a little bit may also have great benefits for the body.
Staying in sweaty or wet clothes for a long time creates a bacteria-friendly environment. It can cause skin rashes or even lead to a skin condition called folliculitis, in which the skin follicles get infected and cause inflammation and red pimples around the follicle. Changing and washing your clothes after sweaty physical activity can help to prevent folliculitis.
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A Canadian healthcare professional answers your questions.
QWhat is the safest hair removal method?
(Is there a safe way to remove unwanted hair?)
AThere are many ways to remove unwanted hair. Each method has advantages, disadvantages, and risks. Shaving is the most common, convenient, and inexpensive method of hair removal for large areas. It is temporary and leaves a blunt tip but does not affect the density or rate of hair growth. Risks include skin irritation, ingrown hairs, and secondary skin infections. Chemical depilatories are chemicals that dissolve hair. They are inexpensive and effective for large areas, with effects typically lasting two weeks. Unfortunately, they commonly cause skin irritation. Results from waxing and sugaring last for two to eight weeks and are effective for large areas. Risks include skin irritation and burns. People on medications such as Accutane are advised to avoid waxing while on the medication and for a minimum six months afterwards because of an increased risk of skin peeling. Threading involves gliding a sharp thread over the skin. It is effective for shaping hairs such as the eyebrows and is usually done by estheticians. It is more expensive and can be painful. Laser hair removal is one of the most common cosmetic procedures. It is worth noting that while laser hair removal is highly effective and long-lasting, it is still considered a temporary method of hair removal. Various types of lasers are applied directly to the skin surface and target the hair follicle. It can be less effective for red and gray hair and in darker skin types. Risks include scarring, postprocedure pigment changes, and burns, and it should only be done by a licensed provider as the procedure varies person to person based on skin colour, hair colour, and hair density. Electrolysis is the only approved method of permanent hair removal. A needle or probe is directly inserted into the hair follicle and an electric current is applied which destroys the follicle. Multiple treatments are usually required. It is the most expensive hair removal method and can be quite painful. It is typically used in small areas, and results are dependent on the skill of the person providing the service.
QAs I’ve gotten older, I have started to get these white bumps like whiteheads on my face – what are they and what can I do?
APlease recognize that doctors need to examine your skin and consider your medical history first before accurately diagnosing you and recommending an effective treatment plan! Whitehead-like bumps on the face that occur as people get older could be due to many things, including but not limited to sebaceous hyperplasia, milia, papules and pustules in acne rosacea, and less commonly, skin cancers such as basal cell carcinoma. Sebaceous hyperplasia refers to overgrowth of the sebaceous glands and commonly occurs on the forehead. These are benign but can bother people for cosmetic reasons. Milia are benign, minuscule white cysts commonly seen around the eyes and on the cheeks. Certified dermatologists can treat sebaceous hyperplasia and milia using various techniques including electrodessication (using electric current to remove a lesion). Acne rosacea is traditionally thought to cause redness and flushing in the center of the face related to heat, alcohol, coffee, and spicy or acidic foods, but it can be accompanied by bumps that look like acne. These rosacea papules and pustules can be effectively treated with topical creams and oral medications including antibiotics by registered dermatologists. Basal cell carcinomas are the most common skin cancer and often occur on sun-exposed sites including the face and ears. They can have varied appearances including skin- or pearly-coloured bumps. As always, proper skin care year-round includes the use of a gentle cleanser, regular moisturizer, and daily sunscreen application. Trying to remove any lesion from the skin yourself with picking or burning is not recommended, as it carries a risk of bleeding, infection, and scarring. Assessment by your primary care provider and/or a dermatologist is necessary to make the diagnosis and discuss treatments.
REFERENCES
Dr. Raed Alhusayen is a consultant dermatologist at Sunnybrook Health Sciences Centre, in Toronto, ON.
Dr. Dimitra Bednar is a dermatology resident at the University of Toronto.
Got a question? Send it to info@canadianskin.ca.
1. Fernandez AA, Franca K, Chacon AH, Nouri K. From flint razors to lasers: a timeline of hair removal methods. J Cosmet Dermatol. 2013 Jun;12(2):153-62.
By
Increasing conversations surrounding equity, diversity, and inclusion in North American dermatology show the need for a better reflection of modern patient and practitioner demographics and healthcare needs. Calls to action have been made to close gaps in health disparities faced by some racialized minorities because individuals from these groups often do not receive the same standard of care despite their high prevalence of skin disease. Some of these calls include the need for improved academic and research representation, as well as improved diagnosis and treatment of skin conditions in people with darker skin types.
Canada prides itself on being multicultural, diverse, and eclectic, welcoming people from around the world of often vastly different
backgrounds. Although Indigenous peoples are regionally diverse in language, culture and values, their longstanding treatments in Canadian historical, social, and legal contexts have contributed to complex health inequalities. Examples include reserves historically representing legislated racial segregation, intergenerational trauma from residential schools (the last closing in 1996 in southern Saskatchewan), systemic racism, and exposure to assimilationist policies limiting personal and economic freedom such as the ‘Indian Act’ pass system (only repealed in 1951). In fact, it was not until 1960 that First Nations peoples received the right to vote without losing their Indigenous status.1,2,3,4
Despite such deeply rooted inequities and lack of opportunity, Indigenous peoples of Canada
(First Nations, Metis, and Inuit) continue to demonstrate strength in a modern era characterized by growing public recognition of rights and reconciliation, both nationally and internationally. According to the Government of Canada (2020)5, Indigenous peoples are the youngest and fastest-growing population in Canada.
One of the main reasons I went back to school for a Master of Health Sciences in clinical and translational research after completing my residency was to better understand and represent Indigenous and rural patients who frequently represent my catchment populations in my home region of southern Saskatchewan. Over the years, as a doctor, I have observed some severe and poorly documented cases of common chronic skin diseases such as childhood atopic dermatitis
Rachel Asiniwasis MD, MS(HS), FRCPC, FAAD Dermatologist, Regina, Saskatchewan
and secondary skin infections in rural and northern Canadian Indigenous communities.6 I was surprised to see my experience was similar to that reported in Canadian media articles out of Indigenous communities in northern Ontario and Quebec. 7-15 At the same time, I had difficulty finding published literature on both problems and solutions regarding this issue. After meeting with health region representatives to discuss my experience, it became increasingly clear to me that in order to truly raise awareness, these skin health disparities needed to be more formally documented. I started with a detailed assessment of the incidence and prevalence of skin disease among North American Indigenous peoples to provide an overview, which will be presented in multiple publications. Among the themes that will be included are common inflammatory skin diseases, skin infections, diabetic skin complications and wounds, pediatric skin conditions, autoimmune connective tissue disease, acne, and other dermatological conditions.
but all rural Canadians!). Canada represents the world’s second-largest country by landmass, and the majority (estimated 60%) of the Canadian Indigenous population lives in remote and northern communities.16 Working with Indigenous communities and medical leadership takes time to build trust, particularly since many northern and remote communities face barriers to care such as lack of healthcare access, inadequate community infrastructure, long waiting lists, transportation/ travel distances, high out-of-pocket costs when basic skin care or hygiene products may be cost-inflated, water safety, language, and crowded housing conditions, to name some.17,18,19
To date, major textbooks in dermatology have included evidence-based medicine developed ultimately from research in the field. Research advances our specialty by generating new knowledge. In the area of Indigenous skin health, a new form of knowledge in the form of multistakeholder translational research initiatives is needed to raise awareness of disparities, with the
and representation)21 of Indigenous research principles to engage and empower individuals, families and communities living with skin disease.
1. Allan, B. & Smylie, J. (2015). First Peoples, second class treatment: The role of racism in the health and well-being of Indigenous peoples in Canada. Toronto, ON: the Wellesley Institute.
2. Waldram, J., Herring, D., Ann, Y., Kue, T. (2006). Aboriginal Health in Canada: Historical, Cultural and Epidemiological Perspectives (2nd ed.) University of Toronto Press.
3. National Collaborating Centre for Aboriginal Health (NCCAH; 2013). Setting the Context: An Overview of Aboriginal Health in Canada.
4. CBC News (2010). First Nations right to vote granted 50 years ago. Retrieved from: www.cbc.ca/news/canada/north/firstnations-right-to-vote-granted-50-years-ago-1.899354.
5. Government of Canada (2020). Annual Report to Parliament 2020. Indigenous Services Canada. Retrieved from: www.sac-isc. gc.ca/eng/1602010609492/1602010631711.
6. Asiniwasis RN, Heck E, Amir Ali A, Ogunyemi B, Hardin J. Atopic dermatitis and skin infections are a poorly documented crisis in Canada’s Indigenous pediatric population: It’s time to start the conversation. Pediatr Dermatol. 2021;38 Suppl 2:188-189. doi:10.1111/pde.14759.
7. Dehaas, J. (2016, Mar 23.) ‘Social emergency’: Kashechewan skin problems blamed on poverty, overcrowding. CTV News. Retrieved from: www.ctvnews.ca/canada/socialemergency-kashechewan-skin-problems-blamed-on-povertyovercrowding-1.2830199.
8. Dehaas, J. (2016, March 24.) Kashechewan skin infections exacerbated by ‘social emergency’. CTV News. Retrieved from: www.ctvnews.ca/canada/kashechewan-skin- infectionsexacerbated-by-social-emergency-1.2831317.
9. Kirkup, K. (2016, March 29). Doctors treating Indigenous children’s rashes cite medical crisis. The Globe and Mail Retrieved from: www.theglobeandmail.com/news/national/ doctors-treating-indigenous-childrens-rashes-cite-medicalcrisis/article29414627/.
10. Martens, K. (2018). Retrieved from: www.aptnnews.ca/nationalnews/kashechewan-mother-says-she-was-told-to-givedaughter-a-bleach-bath-to-cure-her-daughters-skin-sores/.
11. Bell, S., and Stewart, D. (2021, Nov 18). Police called on Cree family for trying to access care for baby in distress in northern Quebec. CBC News. Retrieved from: www.cbc.ca/news/ canada/north/cree-health-board-whapmagoostui-eczemadiscrimination-1.6253641.
12. CBC News (2016, Mar 18). Kashechewan family wants answers after baby plagued by skin infections. Retrieved from: www.cbc. ca/news/canada/sudbury/kashechewan-water-health-skinrash-1.3498710.
It is my hope that this literature may assist as a foundational base to further inform regional and national priorities for Indigenous skin health. Although manuscripts are still in progress, outcoming reports will show that North American Indigenous peoples are consistently under-represented in research and academia, followed by calls to action to address skin health disparities in broader contexts.
Although many programs are increasingly showing interest in rural outreach, Canadian academic residency programs are vastly urbanbased. A more collaborative effort needs to be made in Canadian dermatology to be more proactive and inclusive of improving clinical care and research engagement of rural and remote Canadian populations in general (not just Indigenous peoples,
ultimate goal of eventually closing gaps and improving health outcomes –but there is still a long way to go.
Currently, studies on Canadian Indigenous skin disease being conducted out of Origins Dermatology Centre based in Regina, Saskatchewan include qualitative and quantitative research projects that engage our own Indigenous patients under community, leadership, and ethics approval. In particular, more information on the preferences and values of Indigenous patients living with skin disease and the role of virtual care is needed. Any researcher interested in primary research engagement with Indigenous peoples and communities should be familiar with OCAP (ownership, control, access, and possession)20 and the 6Rs (respect, relationship, relevance, reciprocity, responsibility,
13. CBC News (No Author listed). (2016, Mar 21.) Kashechewan children’s skin lesions not caused by water: health minister. CBC News. Retrieved from: www.cbc.ca/news/canada/sudbury/ kashechewan-water-health-skin-rash-update-1.3500631.
14. CBC Radio (2016, Mar 25). Kashechewan rash outbreak highlights woeful First Nations health care, says critics. Retrieved from: www.cbc.ca/radio/thecurrent/the-currentfor-march-25-2016-1.3507260/kashechewan-rash-outbreakhighlights-woeful-first-nations-health-care-say-critics-1.3507262.
15. Abedi, M. and Russell A. (Feb 7, 2019). ‘We’re not blu ng’: Ontario First Nation Urges Trudeau, O’Regan to Witness Housing Crisis. CBC News. Retrieved from: https://globalnews.ca/ news/4934630/cat-lake-first-nation-housing-health-crisis/.
16. OECED (2022). Profile of Indigenous Canada: Trends and Data Needs. Organisation for Economic Cooperation and Development. Retrieved from: www.oecd-ilibrary.org/sites/e6cc8722-en/index. html?itemId=/content/component/e6cc8722-en.
17. First Nations Information Governance Centre/FNIGC (2012). First Nations Regional Health Survey (RHS) Phase 2 (2008/10) Ontario Region Final Report.
18. First Nations Health Authority. (2012). British Columbia provincial results 2008-10 First Nations Regional Health Survey.
19. First Nations Information Governance Centre (2018). National Report of the First Nations Regional Health Survey Phase 3: Volume One.
20. FNIGC (2022). First Nations Principles of OCAP. Retrieved from: https://fnigc.ca/ocap-training/.
21. Indigenous Research Resources. O ce of Research Services, Dalhousie University. Retrieved from: www.dal.ca/dept/researchservices/resources/indigenous-research-resources.html.
“It is my hope that this literature may assist as a foundational base to further inform regional and national priorities for Indigenous skin health.”
BY SIDDHARTHA SOOD
What is melasma?
Melasma is a benign (not cancerous) skin condition that typically involves hyperpigmentation of small spots or larger patches of the skin. This means that affected areas – commonly on sun-exposed areas such as the face and forearms – may look tanned, brown, or darker than the rest of your skin. This is due to increased melanin (skin pigment) produced by skin cells known as melanocytes.
Who is at risk for melasma?
Adult women between the ages of 20 and 40 are at the highest risk of melasma, especially those with darker skin types.1,2 Melasma is also known as the “mask of pregnancy” as it is estimated that 15% to 50% of pregnant women develop the condition.1 Similarly, due to hormonal effects, women on oral contraceptive pills (“birth control pills”) may be at higher risk for melasma.1 Those with thyroid disease have also been shown to have increased rates of melasma.1 Finally, the condition may run in families due to the influence of genes.3 However, amongst all of these, the most important risk factor for developing melasma has been shown to be cumulative sun exposure.1
What are the signs of melasma?
Melasma usually appears on the face (forehead, cheeks, nose, upper lip, and chin) or on the forearms.1,3,4 Generally, sun-exposed areas are at the highest risk.1 Spots or patches typically consist of a singular brown or greyish-brown colour and are painless and flat. They are usually also evenly distributed across both sides of the face or body and may have irregular borders.1,4
This sounds like I might have melasma! What should I do?
Although melasma is physically benign, it can cause distress and low self-esteem. 2 If you are concerned about melasma, it is important to
schedule an appointment with your family doctor and/or dermatologist to discuss an individualized treatment plan. In order to reduce the appearance of the discolouration, your provider may prescribe medicated creams such as: hydroquinone, tretinoin, and corticosteroids. If these options do not work, chemical peels, laser-therapy, tranexamic acid, or microneedling can be considered. 3,5 As melasma can be a relapsing condition with emotional impacts, we encourage seeking support from your physician, mental health professional, and/or patient support groups if needed.
How can I prevent melasma?
Using sun-safe practices and limiting your UV exposure is the most important action you can take to prevent melasma in the first place or from it reoccurring after treatment.1 Recommendations include: using sunscreen with an SPF of greater than 30, avoiding peak sunlight
hours during the day, and wearing UV-protective clothing and accessories such as a wide-brim hat.6,7
1. Basit H, Godse KV, Al Aboud AM. Melasma. In: StatPearls StatPearls Publishing; 2022. Accessed March 5, 2023. http:// www.ncbi.nlm.nih.gov/books/NBK459271/
2. Handel AC, Miot LDB, Miot HA. Melasma: A clinical and epidemiological review. An Bras Dermatol. 2014;89(5):771-782. doi:10.1590/abd1806-4841.20143063
3. Rajanala S, Maymone MB de C, Vashi NA. Melasma pathogenesis: A review of the latest research, pathological fi ndings, and investigational therapies. Dermatol Online J 2019;25(10). doi:10.5070/D32510045810
4. Melasma. Australian Journal of General Practice. Accessed March 5, 2023. https://www1.racgp.org.au/ajgp/2021/ december/melasma
5. Neagu N, Conforti C, Agozzino M, et al. Melasma treatment: A systematic review. J Dermatol Treat 2022;33(4):1816-1837. do i:10.1080/09546634.2021.1914313
6. Sunscreen. Canadian Dermatology Association. Accessed March 5, 2023. https://dermatology.ca/recognized-products/ sunscreen/
7. Li H, Colantonio S, Dawson A, Lin X, Beecker J. Sunscreen Application, Safety, and Sun Protection: The Evidence. J Cutan Med Surg. 2019;23(4):357-369. doi:10.1177/1203475419856611
Siddhartha Sood is a second-year medical student at the University of Toronto.
By Rawaan Elsawi, BHSc, MD and Sadaf Ekhlas BSc, MPH
Pharmacists play a crucial role in the healthcare system, as they help manage patients’ medications and ensure that they take them safely and effectively. However, in recent years, pharmacists’ role has expanded to include prescribing certain medications, more recently in Ontario and British Columbia, with policy changes going into effect throughout 2023.1,2 This change looks to benefit patients by providing easier and quicker access to essential medications for common health conditions.
In addition, pharmacists’ prescribing practices have also expanded to include some dermatologic conditions (conditions that affect the skin, hair, and nails), such as acne, rosacea, and psoriasis. Although they may be referred to as “minor ailments,” these conditions can have a big impact on the lives of patients and their families. These conditions can be frustrating and debilitating, but with pharmacists’ new prescribing authority, patients may now receive the treatment they need without having to wait to see their primary care provider.
What kind of training does my pharmacist have to be able to prescribe these medications?
Pharmacists in Canada require additional training and certification to be able to prescribe medications for minor ailments. The training and certification requirements vary by province and territory, but in general, pharmacists must complete an accredited educational program and pass a certification exam to become authorized prescribers.
For example, in Ontario, pharmacists must complete a Prescribing and
Therapeutics course that covers diagnosing and managing minor conditions, pharmacology, and the legal and ethical aspects of prescribing. They must also pass an exam administered by the Ontario College of Pharmacists to become authorized prescribers. 3 In British Columbia, pharmacists must complete a Minor Ailments Prescribing course and pass an exam administered by the British Columbia College of Pharmacists.4
In addition to the initial training and certification, pharmacists must participate in ongoing continuing education to maintain their prescribing authority. This ensures that they stay up-to-date with the latest medications and are able to provide safe and effective care to their patients.
It’s important to note that while pharmacists can prescribe medications for minor ailments, they will refer patients to a physician or specialist if they determine that further evaluation or treatment is necessary. For instance, if a patient has shingles involving the head, the pharmacist must refer this patient to a physician for further assessment.
In Canada, pharmacists can prescribe medications for a variety of skin, hair, and nail conditions. Prescribing practices differ per province: most provinces have published guidelines on which conditions pharmacists can prescribe medications for (see table below), except Nunavut and Northwest Territories, 5 where pharmacists currently do not have any prescribing privileges. In the majority of provinces (Alberta, Ontario, BC, New Brunswick, Newfoundland & Labrador, PEI, Saskatchewan, NS, Quebec, and Yukon), there is no specific list of medications that are permitted to be prescribed by pharmacists.
Pharmacists should refer patients to primary care doctors and dermatologists if the skin, hair, or nail condition falls beyond their scope and standard of practice. Additionally, for patients whose minor dermatologic condition is worsening, referral to a primary care doctor and/ or dermatologist is needed to deal
with the condition. To streamline the care of patients with dermatologic conditions, an online portal can be introduced, consisting of pharmacists, primary care doctors, and consultant dermatologists who can answer questions asked by pharmacists and primary care physicians.
To learn more about what pharmacists can prescribe across Canada, visit the treatments section on the CSPA website: www.canadianskin.ca/skinconditions/treatments.
1. DeClerq, K. (2023, March 23). Ontario pharmacists to be given new prescribing powers. Toronto. Retrieved from https://toronto. ctvnews.ca/ontario-pharmacists-to-be-given-new-prescribingpowers-1.6326199
2. CBC/Radio Canada. (2022, September 29). B.C. pharmacists granted limited prescribing powers under new Health Plan | CBC news. CBC news. Retrieved from www.cbc.ca/news/canada/ british-columbia/b-c-pharmacists-granted-limited-prescribingpowers-1.6600667
3. Ontario College of Pharmacists. Initiating, adapting and renewing prescriptions. OCPInfo.com. (2023, March 23). Retrieved from www.ocpinfo.com/regulations-standards/practice-policiesguidelines/adaptations-renewing-prescriptions/
4. Ministry of Health British Columbia. (2023, March 24). Minor ailments and contraception service (MACS). Province of British Columbia. Retrieved from www2.gov.bc.ca/gov/content/health/ practitioner-professional-resources/pharmacare/initiatives/ppmac
5. Pharmacists’ Scope of Practice in Canada. Canadian Pharmacists Association. (n.d.). Retrieved from www.pharmacists.ca/cpha-ca/ function/utilities/pdf-server.cfm?thefile=%2Fcpha-on-theissues%2FScopeOfPractice_Dec22.pdf
Acne vulgaris
Calluses and corns
Dermatitis (atopic, contact, irritant)
Diaper dermatitis, Candidal
Eczema (mild to moderate)
Folliculitis Impetigo
Pediculosis (head lice)
Psoriasis
Onychomycosis (fungal nail infection)
Seborrheic dermatitis
Tinea skin infections (tinea corporis, tinea cruris, tinea pedis, tinea unguium)
Urticaria (mild) Warts (excl. facial and genital)
Dandru Shingles
Alberta
British Columbia*
Manitoba
New Brunswick
Newfoundland & Labrador
Nova Scotia
Ontario
PEI
Quebec
Saskatchewan
Yukon
*This article was written before British Columbia announced the launch date for their new pharmacy services.
The articles from which these summaries of the latest in skin research are taken are hot off the press!
How scalp biopsies influence the diagnosis of alopecia in Black women
Alopecia refers to a loss of hair, from discrete patches to a more general thinning of hair. It can be caused by many factors, including autoimmune conditions, nutritional deficiencies, and hormone imbalances. A biopsy, which involves taking a small piece of the scalp and analyzing the sample, can help clinicians make a diagnosis about what is causing the hair loss. Hair loss can have significant negative impacts on patient quality of life, and early diagnosis and treatment can prevent further hair loss, and in some cases, permanent hair loss. A new study published in 2023 in the Journal of the American Academy of Dermatology analyzed historic data from Black women diagnosed with alopecia to look at how scalp biopsies influenced diagnoses and outcomes.
The data of 420 patients with alopecia were analyzed in this study. The study
found that when a biopsy was taken, the results changed the first diagnosis 70% of the time. The frequency of the most common type of alopecia in these patients, called traction alopecia, was decreased from 38% to 5% post-biopsy. Unfortunately, less than 10% of patients actually had a biopsy, with the majority of patients receiving their diagnoses based on clinical examination alone.
What does this mean for people with alopecia?
Obtaining an accurate diagnosis is important for appropriate and timely treatment of hair loss. However, the diagnosis of the cause of alopecia is not always clear-cut. It is also important for clinicians to be aware of how hair and scalp disorders present in people of African descent. The study recommends that scalp biopsies be evaluated by a physician who specializes in hair, like a dermatologist.
Remote monitoring of mild to moderate psoriasis through photographs and patient self-report
Psoriasis is a chronic inflammatory skin disease where people experience red, scaly, and raised bumps on their skin that can be itchy; in darker skin types, it can appear dark brown or purplish-grey. Psoriasis can occur at any age and can have a very negative impact on patients’ well-being, as people with psoriasis often experience physical changes in their skin and a social stigma due to how their skin looks. Recently, remote monitoring or teledermatology has been more frequently used to track patient progress and has been shown in some studies to be just as effective as in-person visits in improving patients’ mild to moderate
psoriasis. A study published recently in the Journal of the American Academy of Dermatology compared how photographs of patients’ skin along with a self-reported score, corresponded with physician scores.
Using social media advertisements, 32 patients were recruited to the study. The study found that overall, self-reported scores were similar to the scores given by physicians. The photographs taken by patients were also given similar scores by physicians as when they saw the patients at the clinic.
For patients who live in more rural places, or in neighbourhoods where there are no physicians nearby to treat their psoriasis, the delivery of remote healthcare can greatly improve how these patients access care for their mild to moderate psoriasis. Additionally, patients with disabilities who may face additional challenges seeking care for their psoriasis may also benefit from remote monitoring. The findings from this study are reassuring that photographs and selfreport scores were similar to in-person visits for these patients.
1. Ali, Z., Zibert, J.R., Dahiya, P., Egeberg, A., Thomsen, S.F. (2023). Mild to moderate severity of psoriasis may be assessed remotely based on photographs and self-reported extent of skin involvement. JAAD int. https://doi.org/10.1016/j. jdin.2023.02.004.
2. Douglas, A., Romisher, A., Cohen, A., Zaya, R., Wang, J., Suriano, J., Zachian, R., Nikbakht, N. (2023). Scalp biopsy influences diagnostic accuracy and treatment in Black women with alopecia: A retrospective study. JAAD. https://doi. org/10.1016/j.jaad.2023.01.022.
When I was young, my friends and I would gather around the boxes on pizza day at school. Meticulously, we would select our slices by toppings and size. Of course, the goal of our search was to identify the best slices, which in my social circle were always those with the biggest pizza bubbles. So, one day when my best friend pointed at the unusually large congenital hemangioma across my right cheek, and affectionately called it my “pizza bubble,” I felt great pride. Sure, pizza bubbles are not the most attractive reference, but they were
highly impressive and cherished by me and my friends. My birthmark had always been impressive for the wrong reasons and naming it this was empowering.
By contrast, people with facial differences unfortunately often face unpleasant encounters with strangers, consisting of demanding questions and scrutinizing stares. While growing up I feared scenarios where complete strangers could approach me easily and frequently, such as at summer camps or amusement parks. It was the empowering moments with friends and family, like dubbing it my “pizza bubble,” which gave me the confidence to flip the narrative. I would defiantly answer their intrusive questions by choosing to instead introduce myself, thereby forcing them to see me not for my facial difference, but for the individual I am. Before my surgeon examined my hemangioma, he asked to first hear about the bullying experiences that brought me to his office. To me, this demonstrated that he had seen me for who I was –a girl tirelessly advocating for herself beneath a facial difference.
These experiences illustrated the diverse ways in which physicians can change lives. They inspired me to dedicate my life to helping others as an empathetic, practicing physician. Today my hemangioma persists after multiple debulking surgeries, and I
proudly represent the facial difference community as I graduate from Queen’s University this year as a Doctor of Medicine and enter my residency in Otolaryngology-Head & Neck Surgery. Moreover, I believe my hemangioma contributed to my strengths in tenacity throughout the rigorous training of medical school and in my dedication to recognizing patients first as people, not their diseases. The facial difference community deserves this same recognition as individuals and respect from our society, whether this is in a hospital or an amusement park. I may have a birthmark that looks like a pizza bubble, but I like to introduce myself as Olivia and I thank you for learning my story.
AboutFace is Canada’s facial difference charity. Our mission is to cultivate equity and opportunity for individuals with a facial difference through supportive programming, advocacy, and education. Our work focuses on three core values: acceptance, community, and empowerment. To learn more, visit www.aboutface.ca, and follow us on social media to stay connected.
Accidents happen, and our skin gets hurt. When an injury happens, our body has a special way to heal the wound and make our skin whole again.
In other words, our broken skin can fix itself, rebuilding the barrier between the outside world and our body. Just like a team of workers repairing a fence, different types of cells in our skin work together to patch up our broken skin.
If the wound is only a scrape and not too deep, it can heal with a little scar or no scar at all. For smaller wounds, like paper cuts, it usually just takes a few days to heal. For larger wounds, such as deep cuts, it can take a few weeks. However, just like we can see the area where a fence was repaired, most wounds on our skin heal leaving a scar
The size of the scar will depend on how deep or wide the original wound was.
The skin repair process is called wound healing. Many events take place during wound healing. These events happen in different steps, called phases. In fact, we can imagine ‘wound healing’ as a well-coordinated band. The musicians of this band are the different types of cells in the skin.
The first phase, hemostasis (stopping the bleeding), is done by a type of cells in the blood, called platelets. When wounded, these cells get activated and send out signals to promote clotting (thickening) of the blood. The blood clot plugs the hole and prevents further blood loss. It’s like a farmer quickly stopping a fence from falling down!
Following this, the inflammatory phase starts, where the body’s immune system (defense system) is activated, and white blood cells (soldiers of the defense system) are recruited from the blood to the wound site to remove any germs that got in. These white blood cells also make lots of special chemicals to kick-start the healing process. When a farmer needs to repair a fence, he calls workers to help out. A similar process happens when our body repairs a wound.
The third phase of wound healing is called the proliferative phase. During this stage, cells such as keratinocytes (cells in the skin’s upper layer) multiply and migrate to close the wound.
PHASE 1: Stop blood flow (Hemostasis)
PHASE 2: Activate the immune system (Inflammation)
PHASE 3: Cells in the skin multiply (Proliferation)
PHASE 4: New skin is strengthened/a scar is formed (Remodelling)
Also, fibroblasts (cells in the middle layer of the skin) multiply and produce proteins like collagen to fill in the gap created by the wound.
In addition, a lot of new blood vessels are produced at the wound site which brings in the oxygen and nutrients for the hardworking cells.
Just like workers fixing a fence, the different types of cells are working hard to make sure the wound heals properly. It’s incredible how our skin works to heal itself!
The fourth phase of wound healing is called remodelling or scar maturation In this phase, the scar tissue that got made with the help of proteins like collagen becomes more mature. This is to make the rebuilt skin stronger so that it will not easily get torn.
Even so, in the end, the rebuilt skin is only 80% as strong as the original unwounded skin.
The different skin layers are completely dependent on each other, working together to support one another. They are close friends, always in communication with each other.
So next time you get a cut or scrape, remember that your superhero skin is already hard at work making you whole again!
People with darker skin types face unique challenges when it comes to wound care, such as difficulty identifying the signs of inflammation and monitoring the healing process. We will explore wound care tips for different skin conditions, including bedsores, hidradenitis suppurativa (HS), eczema, psoriasis, and keloids.
In people with darker skin types, inflammation often appears as a purplish or brownish hue as opposed to the bright red colour (“erythema”) seen in lighter skin tones. Pressure injuries, also known as bedsores or pressure ulcers, can be more difficult to identify visually on darker skin tones. This can make it challenging to assess wounds and predict risk, leading to delayed treatment and an increased risk of complications.1,2 However, a recent study has found promising scanning technologies that may soon be available for use in local hospitals, enabling healthcare providers to better diagnose and treat pressure injuries in people with darker skin types.2
Hidradenitis suppurativa (HS) is a skin condition that causes painful lumps in areas where there are sweat glands, including the armpits, groin, and buttocks. It is more common in individuals with darker skin tones, such as African and Hispanic populations. 3,4 Currently, there is little research on targeted therapies for HS in darker skin; however, topical products such as benzoyl peroxide and clindamycin, intralesional triamcinolone injection, antibiotic therapy with clindamycin and rifampicin, and metformin as an adjuvant therapy (a ‘helper’ therapy that improves the effectiveness of
other treatments) have been commonly used and found to be effective. 5 When caring for HS-related wounds, it’s essential to keep the affected area clean and dry to prevent infection and promote healing.
For eczema or psoriasis, dry, itchy skin can crack and bleed, leading to wounds. While many skincare products work on all skin types, research shows that dark skin may hold moisture differently and should be kept hydrated throughout the day. Using fragrance-free moisturizers can help wounds heal, whereas harsh soaps and detergents should be avoided. In some cases, dressings or bandages may be necessary to protect the wound from infection.
Keloids are a type of raised scar that occur when the body produces too much collagen in response to skin damage. They are more common in individuals with darker skin types and may be more noticeable and difficult to treat.6 To prevent keloids, avoid unnecessary skin trauma like piercings, tattoos, scratching or picking at your skin (including popping pimples). Should you develop a keloid, do not pick at your skin, seek medical attention. Treatment options include injections, silicone sheets or gels, cryotherapy, and surgery, but recurrence rates are high.
To maintain healthy skin, it’s important to use dermatologist-recommended products that help keep your skin well hydrated. For example, instead of soap, consider using a moisturizing liquid body wash. For at-risk skin, you may want to consult a dermatologist who can work with you to develop a personalized skin care routine.7
You should also consider reducing your sun exposure, minimizing the frequency of bathing and ensuring that the water temperature is not too hot, and patting – rather than rubbing –your skin dry with a soft towel.
it is important to speak to your doctor to determine the best option for you.
Proper wound care is crucial for healthy skin, particularly in individuals with darker skin tones, where it can often be overlooked and undertreated.
As a person with darker skin tones, it’s very important to protect your skin from the harmful effects of the sun. You can do this in many ways, such as avoiding direct sunlight during peak hours, seeking shade, wearing sun-protective clothing like hats and long sleeves, and applying a broad spectrum sunscreen – a sunscreen that protects against UVA and UVB rays – with an SPF of at least 30. 8 You should also consider tinted sunscreens as they may provide better coverage.
Post-inflammatory hyperpigmentation refers to dark marks on the skin that can persist after the treatment of inflammatory skin conditions like psoriasis or acne. These spots can be more noticeable and last longer in people with darker skin types. Treatment options for skin hyperpigmentation include topical medications like hydroquinone or retinoids, and second-line topical treatments like azelaic acid, cosmeceuticals, topical tranexamic acid, kojic acid, cysteamine, and tranexamic acid.9 Each medication has benefits and possible side effects, so
Consult a dermatologist for personalized advice on wound prevention and care and remember to keep your skin well hydrated and protected from the sun. We hope that by practicing proper care, you can confidently showcase your healthy, radiant skin.
1. Oozageer Gunowa N, Hutchinson M, Brooke J, Jackson D. Pressure injuries in people with darker skin tones: A literature review. J Clin Nurs. 2018;27(17-18):3266-75.
2. Scafide KN, Narayan MC, Arundel L. Bedside Technologies to Enhance the Early Detection of Pressure Injuries: A Systematic Review. Journal of Wound Ostomy & Continence Nursing. 2020;47(2):128-36.
3. Wipperman J, Bragg DA, Litzner B. Hidradenitis Suppurativa: Rapid Evidence Review. Am Fam Physician. 2019;100(9):562-9.
4. Lee DE, Clark AK, Shi VY. Hidradenitis Suppurativa: Disease Burden and Etiology in Skin of Color. Dermatology. 2017;233(6):456-61.
5. Zouboulis CC, Goyal M, Byrd AS. Hidradenitis suppurativa in skin of colour. Exp Dermatol. 2021;30 Suppl 1:27-30.
6. Kelly AP, Taylor SC, Lim HW, Maria ASA. Dermatology for skin of color. 2 ed. United States of America: The McGraw Hill Companies; 2016.
7. Best Practice Recommendations For Holistic Strategies to Promote and Maintain Skin Integrity 2020.
8. Seck S, Hamad J, Schalka S, Lim HW. Photoprotection in skin of color. Photochem Photobiol Sci. 2023;22(2):441-56.
9. Moolla S, Miller-Monthrope Y. Dermatology: How to manage facial hyperpigmentation in skin of colour. Drugs Context. 2022;11.
Adrienn Bourkas, MSc, is a medical student at Queen’s University.
Cathryn Sibbald, MD, MSc, is an Assistant Professor at the University of Toronto and a staff dermatologist in the Division of Dermatology, Department of Pediatrics at The Hospital for Sick Children.
While many skincare products work on all skin types, research shows that dark skin may hold moisture diff erently and should be kept hydrated throughout the day.
CSPA in action: A spotlight on our latest activities, events and other information of importance to skin patients in Canada
As the weather gets warmer, most people look forward to t-shirt weather and long days at the beach (if possible!). However, nice weather can come with its own challenges for the skin, hair, and nail patient community. As we learned from our recent report on atopic dermatitis, many individuals feel the need to hide the physical symptoms of their condition due to shame or embarrassment. Sun exposure can also cause flare-ups for certain conditions, making the summer season difficult for so many in the community.
The Canadian Skin Patient Alliance (CSPA) considers the psychological and emotional impacts of skin, hair, and nail conditions as serious as their physical impacts, which is why it continues to expand its educational resources and advocacy efforts. Our Self-Empowerment Toolkit is growing to help you take charge of your diagnosis, receive the proper treatments, and better manage your condition. The newest resource, Guide for the Newly Diagnosed, was
developed by a clinical psychologist to help you cope with the different range of emotions that you may experience following a diagnosis. There is also another resource on what you can expect before, during, and after your dermatologist appointment, called You and Your Derm. These and upcoming resources can be found at: www.canadianskin.ca/education/selfempowerment-toolkit.
Feel free to share these resources with others and visit our website regularly for more helpful information on skin conditions.
Improving our skin, hair, or nail conditions can make a positive impact on our mental health. In the meantime, the CSPA is actively working on providing patient input to the groups that help decide whether new treatments should be included in public drug plans. We have most recently participated in these processes for new drugs for psoriasis, hidradenitis suppurativa, atopic dermatitis (eczema), and acne.
Decision-makers want to hear from patients. We encourage you to check out our Open Surveys (https://canadianskin.ca/research/ open-surveys) and follow our social channels for new opportunities to share your experiences with people who make these decisions – there are more to come!
This fall, we will welcome our Affiliate Member organizations for the first in-person meeting in many years. We are planning a meeting in Toronto to learn from one another and discuss important issues facing the skin patient community: more dermatological research in Canada, how to improve our advocacy work together, and how to measure our impacts when we work collectively.
If you are involved with an organization in Canada that supports skin patients and are interested in becoming an Affiliate Member of the CSPA (www.canadianskin.ca/get-involved/ affiliate-members), please reach out to learn more about our program.
AbbVie is the Founding Sponsor of the Canadian Skin Magazine and an ongoing supporter of CSPA’s 2023 publications.
We want to hear from you!
What do you like most about our magazine?
What would you like to see us talk about?
Your feedback is important to us and it helps us better understand the needs of our skin patient community. Let us know by completing this one-question survey –we’d love to hear from you!
https://forms.office.com/r/ GKAcazqpc6
Thank you to the Medical Advisors, Board Members, and Volunteers who support the work of the CSPA. For an updated list of names, visit canadianskin.ca/about-us.
AboutFace: aboutface.ca
Acne and Rosacea Society of Canada: acneaction.ca (acne) rosaceahelp.ca (rosacea)
Alberta Lymphedema Association: albertalymphedema.com
BC Lymphedema Association: bclymph.org
Camp Liberté Society: campliberte.ca
Canadian Alopecia Areata Foundation (CANAAF): canaaf.org
Canadian Arthritis Patient Alliance: arthritispatient.ca
Canadian Association for Porphyria: canadianassociationforporphyria.ca
Canadian Burn Survivors Community (CBSC): canadianburnsurvivors.ca
Canadian Chronic Urticaria Society –Société canadienne d’urticaire chronique: chronicurticaria.ca
Canadian Psoriasis Network: cpn-rcp.com
Canadian Skin Cancer Foundation: canadianskincancerfoundation.com
DEBRA Canada (epidermolysis bullosa): debracanada.org
Eczéma Québec: eczemaquebec.com
Eczema Society of Canada: eczemahelp.ca
Firefighters’ Burn Fund: burnfundmb.ca
Hidradenitis & Me Support Group: hidradenitisandme.ca
HS Heroes: hsheroes.ca
Lymphedema Association of Ontario: lymphontario.ca
Mamingwey Burn Society: mamingwey.ca
Melanoma Canada: melanomanetwork.ca
Myositis Canada: myositis.ca
Neurofibromatosis Society of Ontario: nfon.ca
Save Your Skin Foundation: saveyourskin.ca
Scleroderma Association of B.C.: sclerodermabc.ca
Scleroderma Atlantic: sclerodermaatlantic.ca
Scleroderma Canada: scleroderma.ca
Scleroderma Manitoba: sclerodermamanitoba.com
Scleroderma Society of Ontario: sclerodermaontario.ca
Stevens–Johnson Syndrome Canada: sjscanada.org
Tumour Foundation of BC: tumourfoundation.ca
AbbVie is not providing editorial support for the magazine. The CSPA is responsible for the final content featured in Canadian SkinCSPA AFFILIATE MEMBERS
Do you have a friend or family member who deserves special thanks for the care they provide to someone impacted by a skin, hair, or nail condition?
Nominate them for our annual Tanny Nadon Caregiver Award!
We choose a recipient based on their:
• Dedication to providing assistance that goes beyond tending to physical needs
• Compassion and strength
• Extraordinary effect on those for whom they care
• Problem-solving techniques
• Approach to staying educated about the condition
• Use of services available to patients or caregivers in the community, such as attending support groups, information sessions, or medical appointments to help manage the condition
The honoree receives a certificate, an embroidered blanket, and a Spotlight Profile on CSPA’s media channels. A new award winner is announced every fall!
Find out more about how to nominate someone at www.canadianskin.ca/get-involved/patientsand-caregivers/tanny-nadon-caregiver-award.
The CSPA is proud to honour the memory and legacy of Tanny Jean Nadon (1941–2016), a dedicated and selfless volunteer. The CSPA celebrates Tanny Nadon’s life by recognizing those who go above and beyond in their role of caregiver to an individual impacted by a skin, hair, or nail condition.
