Wound Healing in Skin of Color

Written by: Mary Nielsen, Robert Bard, MD & Paul Dreschnack, MD / A report from DermalScanNYC.com

People with skin of color share some dermal characteristics, including a greater potential to develop post inflammatory hyperpigmentation, and keloid and/or hypertrophic scarring. Additionally erythema can be masked in darker skin tones because of the background pigmentation. Inflammatory changes in the skin can manifest as purple, grey or various shades of brown, rather than red. Relying on erythema as a sign of inflammation in skin of color may result in delayed diagnoses or misdiagnoses because most descriptions and photos of dermatological skin conditions are taught in the context of white skin.

Post-inflammatory hyperpigmentation (PIH) happens when there is injury, friction, irritation or heat applied to the skin, wounding the skin. The active melanocytes in skin of color react in an effort to protect the skin from further damage. The skin may turn tan, brown, or even a purple color. Over 65% of Americans of African descent experience symptoms of PIH.

PIH can be epidermal, involving the top layer of skin or dermal, in the deeper layers of the dermis or mixed. The type of PIH can be determined through special lighting using a digital system. Post inflammatory hyperpigmentation can take months and even years to clear. Often aggressive therapy to treat the PIH can risk the worsening of pigmentation as the melanocytes work to protect the skin.

Keloids are a type of raised scar that occurs on the skin after wounding. The healing process appears to be complete because the epidermis is intact. The reticular dermis is still in a state of inflammation, with fibroblast activity producing an over abundance of collagen. Keloids can develop due to wounding from piercings, cuts, tattoos, insect bites, puncture wounds, post- surgical scars, shaving cuts and even micro-injuries from tightly braided hair.

Keloids are more common in people of color, especially Asian, Latinx and African descent.

Keloids can appear three to twelve months after the wounding of the skin. The scar will eventually turn darker than the person’s skin, although initially it will be pink, red or purple. The borders are often darker than the center. Most keloids grow slowly over a period of weeks or months although some grow more rapidly. While they are growing keloids may feel tender and itchy. The sensations stop once the keloid stops growing. Most are solid and stable.

Wearing a pressure garment over a wounded area, including a pressure earring after a piercing may help prevent keloid growth.

Surgeons can take some proactive measures to help prevent keloid formation due to a surgical wounding of the skin. To close an incision, stitches should be placed in the subcutaneous and deep dermis. Dissolvable stitches that create tension-free closures are preferred. The use of special scar creams or silicone adhesives have been proven to improve the quality of the scar.

DERMAL TRANSILLUMNATION

Since 1906 light transmission in breast tissue has been useful in detecting deoxyhemoglobin which is produced by cancerous tissue and trauma. Light absorption quantification is particularly useful in evaluation of dermal and subdermal hemorrhage since it is more sensitive than the spatially limited human eye. Illumination has the advantage of a “no contact” technology and is being emulated by remote ultrasound analysis of reflected and refracted optical sources for future diagnostic uses.

DERMAL ELASTOGRAPHY

Advances in the physical elasticity properties of tissue were first investigated by the Japanese in malignant melanoma and soft tissue sarcomas in 1990 since cancers are firm and benign lesions are soft and pliable. Strain elastogram verifiable results led to more accurate and quantifiable shear wave data that is replacing tissue biopsies in tumors of the Achilles tendon, breast, thyroid, liver, pancreas, testicle and prostate in many countries.    As tissue hardens in a hyperimmune fashion, steps to diminish hyper inflammatory such as electromagnetic fields and other mesotherapies may prove useful.                                                   

FUNCTIONAL TREATMENT BIOLOGY

Radiation produces free radicals that damage DNA as the electromagnetic energy disrupts mitosis in rapidly dividing cells.  While normal cells repair damage, treated cancer cells cannot divide and are considered inactive or sterilized. This means that cancer cells that grow slowly may die slowly and the surgical specimen looks microscopically like active cancer but is, in fact, physiologically inactive while appearing functional to the pathologist. Therefore a biopsy may be “positive” while the cancer is biologically dormant. Similarly, the size of a treated tumor poorly correlates with treatment success since edema from dying cells or infiltration with T cells and other immunologic tissues transiently enlarge the tumor mass while it has lost its metastatic potential. (12, 13, 14)

TREATMENT VERIFICATION

The overall recurrence rate of disease is measurable by Doppler blood flow imaging and by quantitative shear wave elastographic changes and is being used as a bloodless biopsy in inflammatory disease therapeutic algorithms.

MICROVASCULAR PHYSIOLOGY

The smooth muscle content of vascular structures responds to the hormonal and autonomic nervous system control and is sensitive to electromagnetic fields (EMF) Blood flow measurable in the microvessels by Doppler ultrasound, speckle laser photometry, optical coherence tomography, intravital microscopy, dual photon-spectroscopy and reflective confocal microscopy may be studied non invasively in real time providing assessment of treatment effect and correlated with metabolic testing and functional genomics.

Blood distribution control mechanisms in the pre and post capillary microcirculation depends on the vessel caliber have 3-5 vasomotions/minute whereas larger vessels upstream and downstream have 1 vasomotion/minute. The faster vasomotion of the smallest vessels takes place autorhythmically while the larger vessels are controlled by the hormonal and/or autonomic nervous system. Aging effect and disease status reduces the frequency on vasomotion while certain signal configurations carried on the electromagnetic wave increase the vasomotion thereby increasing blood flow, tissue oxygenation, venous return and glymphatic clearance of waste products supporting tissue regeneration and immunologic activity.  Worldwide this non invasive technology is successfully used for diabetic disease of the eye and foot, inflammatory skin disease and has been FDA approved for fracture healing over 30 years ago.

INFLAMMATORY DERMATITIS / INTESTINAL INFLAMMATION

Generally considered autoimmune diseases, electromagnetic therapy increases venous flow out of the microvascular networks, extends the plasma distribution in the capillary network and increases spontaneous arteriolar vasomotion resulting in better regional oxygenation. Parallel changes of the subcutaneous tissue and intestine occur with functional electromagnetic treatment [1] The use for psoriasis began about 40 years ago in Italy [2] The immune system response to tissue injury involves homeostasis and cell signaling that affects the rate of healing and scarring as stem cells are important in tissue regeneration [3].  Low frequency EMF induces changes in cell proliferation, membrane structure and function, protein phosphorylation and adenosine triphosphate [ATP] synthesis [4] Successful regeneration requires an immune response that accurately polarizes immune cells so they balance between proinflammatory and pro-regenerative cell types. When inflammation becomes chronic multipotent mesenchymal stem cells [MSCs] modulate the recovery process [5] Healing involves cellular debris removal, activation of progenitor cells, immune modulation, angiogenesis and innervation  of the regenerating tissue [6] Electromagnetic induction dosimetry incudes frequency, intensity and duration/time of exposure to balance the pro and anti-inflammatory signaling processes of IL-1 beta secretion important in type 2 diabetes and other inflammatory states [7] EMF acts on Calcium concentrations and Na/K pathways in humans [8] and modulates endogenous electrical potential in plants, animals and humans [9]  Continuous anecdotal reporting of the salutary effects of EMF are likely due to the cellular effect on homeostatic mechanisms [10] and improvement in gut health seems due to decreased sticking of red blood cells and increased flow of white blood cells to penetrate into smaller capillaries

 

 Potential clinical studies from this stacking of diagnostic with therapeutic systems include:

1-skin thickness; epidermis and dermis with elastographic data on specific sites  a-glabrous skin vs non glabrous area; b-facial regions from eyelid, ear, nose, glabella including muscle thickness with 7 Tesla MRI correlation

2-nail thickness and elastogram hands/feet

3-treatment verification using laser speckle Doppler/OCT/RCM of elastographic changes during therapy in real time

4-analysis of skin of color: epidermis, intradermal layers with elastographic correlation

5-analysis of diabetic skin changes with elastography and blood flow

6-analysis of dense breast tissue with elastographic correlation

7-demonstrating abnormal systolic resistive indices as a surrogate marker to initiate reduced inflammatory response with PIH and keloid formation

 

REFERENCES

1-Mikrozirculation im Focus der Forschung  ISBN 978-3-033-01464-0; 421-424, 2008

2-Castelpietra R etal [Initial experiences in the treatment of psoriasis with pulsating magnetic fields] Minerva Med 75: 2381-2387, 1984

3-Ross CL etal  The use of Pulsed Electromagnetic Field to Modulate Inflammation and Improve Tissue Regeneration Bioelectricity 1:247-259, 201R9

4-Bassett C  Fundamental aspects of therapeutic uses of pulsed electromagnetic fields [PEMF] Crit Rev Biomed Eng 17:451-529, 1989

 

 

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