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Puzzling "Pimples" in Teens with Skin of Color

Puzzling "Pimples" in Teens with Skin of Color

  • Recognizing dermatoses in our patients with darker skin may require unique information and skills. Dermatologic conditions in these patients may vary from those that we are used to seeing in those with lighter skin.

  • You are going to see 2 young patients with pimples that are not improving after months of up-to date acne therapy prescribed by well-respected colleagues. One was told, “That’s not acne; I don’t know what it is, but you don’t need to worry about it.”

  • A 16-year-old male has been treated for 6 months with a topical retinoic acid formulation along with oral doxycycline, but the firm dark papules on his cheek have not resolved.

  • The boy’s pediatrician suggests that maybe he has been noncompliant with his treatment and now suggests that he see a dermatologist. But, there is a 4-month wait for an appointment.

  • On inspection, the findings are on his face (cheeks, templar area) where there are multiple, small, 1- to 5-mm diameter, smooth, firm, black and dark brown papules.

  • This dermatologic condition is common in African Americans. Patient and parent are shown similar images on the Internet.

  • An older woman with skin of color accompanies a granddaughter to an appointment; the grandmother's face is shown here and she has the same condition.

  • Visualized are firm 1- to 3-mm dark brown and black papules on her cheeks. The bumps have increased in number with age; enlarged ones on her neck catch her necklaces.

  • You explain that the condition is possibly inherited and is fairly common among African Americans; in fact, actor Morgan Freeman has it.

  • Visualized are firm 1- to 3-mm dark brown papules on the cheeks and neck of the 18-year-old female patient. She has “failed” several trials of oral and topical acne medications.

  • What is the correct diagnosis: A. Melanocytic nevi B. Folliculitis C. Acne cosmetica D. Keloids E. Seborrheic keratoses/dermatosis papulosa nigra

  • The correct answer is Seborrheic keratoses/dermatosis papulosa nigra.

  • Treatment is generally only recommended for DPN if lesions are cosmetically undesirable. Provide dermatology referral. Aggressive modalities can be complicated by postoperative hyper- or hypopigmentation, keloids. Options include: curettage, cryotherapy utilizing liquid nitrogen, electrodessication.

  • Nd:YAG laser has recently been reported to be effective.

  • DPN is a benign cutaneous; common among African Americans, dark-skinned Asians; characterized by multiple small, hyperpigmented, asymptomatic papules on the face of adult patients with darker skin. Histology resembles seborrheic keratosis

  • DPN most likely is genetically determined (autosomal dominant) with 40-50% of patients having a family history.

  • Affects ~30-35% of dark-skinned African Americans; less common in those with fairer complexion; also seen in dark-skinned Asians, Polynesians; women more frequently affected than males.

  • DPN lesions seen mainly on cheeks, forehead; also found on neck, upper back, chest. Papules are asymptomatic but may be considered unsightly. Usually begins in adolescence. Incidence, number, and size of lesions increase with age.

  • When discussing DPN, emphasize that the condition does NOT progress to skin cancer. It often helps to show patients images of cases of their condition, either in text books or on the Internet.

“Skin of color” traditionally refers to that of persons of African, Asian, Native American, Middle Eastern, and Hispanic backgrounds. Cutaneous structural and functional differences in skin of color can lead to skin conditions with distinct presentations that may differ from conditions seen in lighter-skinned individuals. Unique treatments may be required.

The ability to recognize these distinct dermatoses is important in primary care. It may help patients and families avoid costly consultations on one hand and expedite a referral for more serious conditions on the other hand.

Click through the 2 cases above to see if you can correctly identify the puzzling “pimples” on 2 African-American teens.


Love PB, Kundu RV. Clinical Cases in Skin of Color: Adnexal, Inflammation, Infections, and Pigmentary Disorders. Switzerland: Springer International Publishing; 2015.

Johnson BL, Moy RL, White GM. Ethnic Skin – Medical and Surgical. St Louis, Missouri: Mosby; 1998. 

Kundu RP, Patterson S. Dermatologic conditions in skin of color: part 1. Special considerations for common skin disorders. Am Fam Physician. 2013;87:850-856.

Kundu RP, Patterson S. Dermatologic conditions in skin of color: part II. Disorders occurring predominantly in skin of color. Am Fam Physician. 2013;87:859-865.

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