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    Some skin conditions more prevalent in East Indian patients

    San Diego - Lichen planus pigmentosus, melasma and cutaneous tuberculosis are among the diseases facing U.S. dermatologists in larger numbers as a result of immigration from the Indian subcontinent, according to Lalit K. Bhutani, M.D., a senior consultant in dermatology at the Sitaram Bhartia Institute of Science and Research in New Delhi.

    Some skin diseases are more prevalent in Asia than in the United States, and some manifest differently in people with skin of color than in light-skinned people. This can stump dermatologists more accustomed to treating patients of European descent.

    "I get several people referred from different parts of Europe and the United States," said Dr. Bhutani. "Sometimes I'm surprised that (their doctors) were not able to do the diagnosis."

    Second to Mexico, India is now the largest source of legal immigration to the United States; 66,864 East Indians immigrated in the year 2002 alone, according to the U.S. Bureau of Citizenship and Immigration Services.

    Skin of color At the 2004 American Academy of Dermatology annual meeting, Dr. Bhutani spoke on the subject of "Dermatology in Skin of Color." He presented an overview of some skin conditions that are particularly common among East Indians.

    "In general, you will find lichenoid reactions more frequent among Indians," he said. That includes lichen planus pigmentosus, which Dr. Bhutani helped identify in 1974. The syndrome presents as slate gray to brownish-black hyperpigmentation, mostly in a diffuse pattern, although sometimes reticular, perifollicular, or blotchy.

    "It's very common and it's getting more common," said Dr. Bhutani. "We don't know what causes it."

    Controversy remains about whether lichen planus pigmentosus is the same as ashy dermatosis and whether both should be classified as erythema dyschromicum perstans. All three syndromes are characterized by gray pigmentation of uncertain etiology. However, Dr. Bhutani is confident that lichen planus pigmentosus is a distinct clinical entity. Among the distinctions cited in literature on the diseases is that lichen planus pigmentosus involves mucosal surfaces, whereas erythema dyschromicum perstans and ashy dermatosis do not.

    No known cure There is no known cure for lichen planus, which usually resolves on its own after several months. Topical coricosteroids and oral antihistamines may relieve pruritis. Systemic steroids and ultraviolet light have also been used.

    There is no well-established therapy for erythema dyschromicum perstans/ashy dermatosis either, but clofazimine, an immunomodulator used to treat leprosy, has reportedly provided some relief.

    Another pigmentary condition most common in skin of color is melasma, also known as chloasma, or the "mask of pregnancy."

    An acquired hypermelanosis of sun-exposed areas, melasma presents as symmetric, hyperpigmented macules on the face, sometimes punctate and sometimes confluent.

    Because 90 percent of melasma cases are in women and because the syndrome often occurs with pregnancy, and sometimes with the use of oral contraceptives, female hormones appear to be involved. It may also be stimulated by thyroid or ovarian dysfunction, photosensitizing medications, and certain cosmetics.

    Melasma causes no physical discomfort and often resolves on its own, but in some cases it lasts indefinitely and many patients wish to treat it for cosmetic reasons.

    Avoiding sun exposure is the key to all therapies for melasma. Hydroquinone is often used as a depigmenting agent; however, Dr. Bhutani said that he has found azelaic acid in combination with a mild steroid to be the most effective treatment.

    Dr. Bhutani also cautioned U.S. dermatologists to be on the lookout for cutaneous tuberculosis. Although it is rare throughout the world, it is more common in India than in the West.

    The disease may present slightly differently in skin of color. For example, the term "apple jelly nodules" is often used to describe the gelatinous red-brown papules associated with lupus vulgaris. Seen in dark skin, the papules may not fit this description.