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  • Visual observation can be more useful than sophisticated technology in distinguishing abnormalities from common nuances of skin of color.

  • Futcher lines, abrupt color demarcations on the flexor surface of the upper arm, are common among adults with skin of color, although rare in infants.

  • In children, hair lines, characterized by an abrupt linear demarcation between the darker, lateral, lanugo hair-containing area of the arm and the medial non-hairy area, occur in a similar pattern as Futcher lines.

  • Forearm and thigh lines, less common than Futcher lines and often hard to distinguish, are seldom mentioned in the literature.

  • Linea nigra and linea alba demarcations of the trunk are common among patients with darker skin of color.

  • Although not found in infants, palmar and plantar hyperpigmentation becomes more common in older patients.

  • Infants with darker skin of color frequently have localized areas of hyperpigmentation.

  • Hyperpigmentation of the oral mucosa and sclera, although common in adults, is not found in young children, but infants often have a lip discoloration that disappears quickly.

  • Melanonychia striata, common in older adults, is rare in young children, suggesting trauma as the usual cause, although melanoma must be considered.

  • Idiopathic guttate hypomelanosis, characterized by hypopigmented patches primarily on the anterior leg, is more common in older patients.

  • Mongolian spots that present in Native American, Asian, and African American infants may not appear in the classic lumbosacral region but rather on the hip.

Skin, our largest organ, is a window of human biology and pathology. Yet too often, clinical observation is undervalued on the assumption that it will add nothing to information obtained by light or electron microscopy, immunofluorescent techniques, and other more sophisticated investigative approaches. Additionally, until recently, dermatology has focused on Caucasian skin. Now, however, it is beginning to focus on skin of color as a definitive area of study. This chapter focuses on visual observations of several skin nuances in individuals with skin of color, particularly in people with darker pigmentation. Many such nuances have not been described previously or were called abnormal, even though they were common to a large percentage of people with more darkly pigmented skin [Figure 20-1, A and B].

FIGURE 20-1.

(A) and (B) A larger percentage of people with darker skin display hyperpigmentation as part of their normal skin color (Used with permission from Karen Heidelberg, MD, USA.)

Dramatic shifts in worldwide demographics are anticipated throughout the twenty-first century and beyond. For example, in 2013, Hispanics, Asians, and African Americans composed 37% of the American population. By 2060, they will represent more than half of the population in the United States.1

Although Niedelman’s article, Abnormalities of Pigmentation in the Negro, was published over 60 years ago,2 and Kelly3 and Johnson...

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