An expert speaks with Dermatology Times about the nuances of diagnosing, treating and managing eczema in black patients.
Eczema, or atopic dermatitis, is more common in black than in white patients; yet, less is known about how do diagnose and treat eczema in skin of color patients, according to Andrew Alexis, M.D., M.P.H., chair of dermatology at Mount Sinai St. Luke’s and Mount Sinai West, and professor of dermatology at the Icahn School of Medicine at Mount Sinai.
“Prevalence of childhood atopic dermatitis in white children is about 11%, whereas for non-Hispanic black children it’s 17%,” says Dr. Alexis, a speaker for the National Eczema Association.
Beyond the epidemiologic differences there are clinical and morphological differences in how eczema behaves in patients of color.
Eczema in darker skin types presents in unique ways, according to Dr. Alexis.
“The follicular presentation of eczema is more common in individuals with African ancestry. Another pattern called the lichenoid presentation of atopic dermatitis is more commonly seen in patients with African ancestry,” he says.
Eczema-related erythema, which presents as redness in lighter skin patients, is more challenging to perceive in the background of darkly pigmented skin. Instead of shades of red and pink, dermatologists might see lesions that appear violaceous, grayish, red-brown or very dark brown and can be confused with other conditions.
“Clinicians typically use erythema as one of the various markers of eczema. If there are challenges in detecting erythema itself there’s the risk of underestimating the severity of the disease. That has implications in the real-world clinical setting and the research setting, or clinical trial setting, where erythema is used as one of the measures for severity,” Dr. Alexis says.
One solution is for providers to calibrate their eyes to better detect erythema in patients with skin of color.
“What I mean by that is I like to look at the normal skin first, finding an area of uninvolved, non-lesional skin, so I can determine what the patient’s normal skin color is. Then I go to the areas of active, symptomatic eczema and basically assess the difference in color and texture in the lesional versus non-lesional skin,” Dr. Alexis says “In doing that you get a much more accurate assessment of the erythema. It’s a better measure of severity.”
Another distinctive feature of atopic dermatitis in darker skin types is the tendency to develop pigmentary alterations of hyperpigmentation or hypopigmentation.
That contributes to the burden of the disease. Not only do the patients endure the itching and the scaling and the other disturbances, but once the lesions resolve they tend to leave behind weeks to months of pigmentation change, which could also be disfiguring, according to Dr. Alexis.
TREAT EARLY, AGGRESSIVELY
One solution is to treat the atopic dermatitis early and aggressively.
“In light of the tendency to develop long-lasting pigmentary alterations, it makes it especially important to avoid under-treatment or delays in treatment and delays in diagnosis of atopic dermatitis. It’s particularly important to have effective long-term management of this chronic disease as opposed to intermittent management of flares,” Dr. Alexis says.
Managing only intermittent flares increases the burden of disease, in general, and contributes to greater post-inflammatory pigment changes in skin of color patients because of those repeated flares, he says.
One of the challenges of early treatment in skin of color patients is that dermatologists might be less likely to see these patients. Researchers reported in a study published in 2017 in the Journal of the American Academy of Dermatology that healthcare utilization among non-Hispanic black children with atopic dermatitis is lower than it is for white children with atopic dermatitis.1 But when non-Hispanic black children did see providers about their atopic dermatitis, their healthcare utilization became higher than for white patients.
The study suggests two things, according to Dr. Alexis: One, there may be disparities in the utilization and access to a healthcare provider for the treatment of atopic dermatitis. Two, the pattern of high healthcare utilization among those who were actually diagnosed by a healthcare provider suggests greater severity of atopic dermatitis.
“It speaks to the importance of being able to better manage atopic dermatitis in patients of color since the suggestion from this and other studies is that the severity of atopic dermatitis and prevalence of atopic dermatitis among non-Hispanic blacks is greater than whites,” Dr. Alexis says. “The more we can improve access, the better we can contribute to earlier diagnosis and better long-term management of the disease through patient education, as well as in-office treatment, the better the overall outcomes and lower burden of disease.”
NUANCES OF TREATMENT IN SKIN OF COLOR
Dr. Alexis says he uses many of the same agents for treating atopic dermatitis in his black and white patients. Studies show that commonly used and newer therapies for atopic dermatitis, such as dupilumab and crisaborole, are generally safe across skin types.
However, there are some nuances including dermatologists’ management of the pigmentary alterations.
“If hyperpigmentation develops, we often need to use treatments such as hydroquinone to manage hyperpigmentation from the eczema. That can be a challenge because many of the treatments we use for hyperpigmentation can result in some degree of irritation, so we have to make sure we’re treating areas that are completely resolved of eczema,” he says.
Another nuance is that hypopigmentation from corticosteroids is more striking and more burdensome for patients with skin of color since the contrast between the lighter patch and the normal skin would be greater.
“It’s particularly important to be judicious with the use of topical corticosteroids, limiting the duration and making sure patients are educated about where to apply it and how long to apply,” Dr. Alexis says.
Dermatologists should also carefully consider the strength of the corticosteroids they’re prescribing in order to limit the development of steroid-induced hypopigmentation, he says.
GAPS IN UNDERSTANDING
There remain gaps in understanding with respect to genetic differences among races and ethnicities with atopic dermatitis.
“For example, one genetic factor that is very common is atopic dermatitis patients of European ancestry is the filaggrin loss of function mutation. This is far less prevalent in patients of African ancestry with atopic dermatitis, which suggests there are other genetic factors that are more relevant to patients of African ancestry with atopic dermatitis,” Dr. Alexis says.
While more research is needed looking at genetic and other factors that influence and contribute to atopic dermatitis in patients of all skin types, one thing that has emerged, according to Dr. Alexis, is that when it comes to diagnosing, treating and managing atopic dermatitis, there’s no one size fits all approach.
Dr. Alexis is a consultant and/or advisory board member for LEO,Valeant, Sanofi-Regeneron, Pfizer, Dermira, Unilever, L'Oreal and Beiersdorf. He has also served as an investigator for Galderma and LEO.
1. Fischer AH, Shin DB, Margolis DJ, Takeshita J. Racial and ethnic differences in health care utilization for childhood eczema: An analysis of the 2001-2013 Medical Expenditure Panel Surveys. J Am Acad Dermatol. 2017;77(6):1060-1067.
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