Eruptions and hyperpigmentation
Two unique presentations that are seen more commonly in darker skin types are micropapular and follicular eruptions, particularly in individuals of African ancestry. A lichenoid presentation that resembles lichen planus is rarer but has also been described in African Americans.
On the other hand, postinflammatory hyperpigmentation is a significant and common sequelae of atopic dermatitis in darker skin. “In fact, the hyperpigmentation can be almost as burdensome as the rash itself, whereby large areas of the body, including the arms, the legs and the torso, can be covered with hyperpigmented patches that are quite disfiguring,” Dr. Alexis says.
Pigmentary changes may also occur as a result of treatment with topical steroids, leading to hypopigmentation, “which is more pronounced visually in darker skin,” Dr. Alexis says.
For treatment overall of darker skin, “it is particularly important not to undertreat, but to aggressively target the underlying inflammation and to protect the skin barrier,” says Dr. Alexis, who advocates the liberal use of moisturizers, emollients and barrier repair products in conjunction with immunomodulatory therapies.
“With the advent of new therapies that target specific pathways within the pathogenesis of atopic dermatitis, it is likely we will be able to manage these patients more effectively,” Dr. Alexis says.
New treatment options
Two recent notable additions to treatment options for atopic dermatitis are topical crisaborole (Eucrisa, Pfizer), a phosphodiesterase type 4 inhibitor (PDE4), which blocks strategic parts of the pathway leading to the inflammation and barrier dysfunction in atopic dermatitis, and the injectable biologic agent dupilumab (Dupixent, Regeneron), which blocks two critical cytokines (IL-4 and IL-13) implicated in the skin disease.
“Both of these therapies have shown significant efficacy and safety,” says Dr. Alexis, director of the Skin of Color Center at Mount Sinai St. Luke’s and Mount Sinai West.
Studies enrolled a sizable proportion of non-white racial ethnic populations, with the Phase III crisaborole trials comprising approximately 40% non-white patients and the Phase III dupilumab studies involving about 32% non-white patients.
When comparing the safety and efficacy of dupilumab in white patients vs. black patients vs. Asian patients for the Phase III studies, “we found no racial ethnic differences in efficacy or safety for moderate to severe atopic dermatitis,” says Dr. Alexis, who was one of the investigators of the comparison study.