Vivian Shi, MD, FAAD, offers her insights into the experiences of patients with skin of color (SOC) and what dermatologists need to know about atopic dermatitis and SOC.
Dr Shi is an associate professor of the department of dermatology at the University of Arkansas for Medical Sciences in Little Rock.
Dr Shi: I'm going to preface by saying we don't know enough about skin of color skin conditions, not just atopic dermatitis. A majority of the research done in skin and AD is in developed countries and mainly in Caucasian individuals. With the social awareness that's growing rapidly, it's important that we gain awareness in this matter.
The clinical presentation is different. Dr Guttman's work has recently shown us that, for example, atopic dermatitis in an Asian individual is clinically, and also these molecules referred to as the biomarkers, are more similar to that of a psoriasis in the Caucasian than an atopic dermatitis patient who is Caucasian.
That's quite interesting. In my experience of volunteering, doing missions in Southeast Asia and East Asia earlier in my career, I truly had trouble distinguishing psoriasis and atopic dermatitis in these patients. That's getting more attention.
Also, because of some of the socioeconomic barriers and access to health care resources in many of the skin of color individuals in our country, and likely globally, they often present much later to the doctor for their eczema, and when they do present, both because of social reasons and also intrinsically in their disease, they are more severe at presentation.
In addition to that, we also find that there are some differential responses in various treatments across skin of color, and of course, there is language barriers and cultural differences in skin care practices that we need to keep in mind too.
Skin of color individuals are more likely to have certain mutations in the skin that predisposes them to getting eczema, and for the longest time, we talked about filaggrin. African Americans, for example, have a special variant of filaggrin called filaggrin‑2 that has a much higher mutation rate than other individuals. That already sets them to be at a higher risk of getting eczema because they're more likely to get dry or ashy skin, and that allows entries of bad things and evaporation of water.
In addition to that, they also get other comorbidities on the skin associated with eczema, so they're more likely to get these Dennie‑Morgan lines I talked about underneath the eyes. They have a special variant of eczema that's called papular eczema where we get these little bumps around the hair follicles. A lot of my patients say, "Oh, my goodness, it's like chicken skin, or goose bump skin that are itchy." That can commonly be misdiagnosed and not caught and labeled as atopic dermatitis and treated appropriately.
I think gaining awareness on the different clinical presentations across skin of color is so important, but also in treatment. For example, some of the topical corticosteroids that we use to treat eczema can cause pigment loss temporarily in skin of color individuals, and that can be a barrier in compliance or adherence in treatment.
Often, as providers, we don't consciously think about these and counsel our patients and families. There's a lost opportunity in communication and having a good outcome.
Depending on which research you look at, the prevalence for AD is up to 20% in children and up to 10% in adults, but this number is a global number. In certain parts of the country, for example, especially in the South where I live, I see a lot of skin of color patients here. The prevalence of eczema that walks through my door, sometimes, it's every other patient, and many of them are very mild with dry skin or early eczema patches.
In the United States, our racial demographic makeup is changing rapidly and is becoming more diversified. We will see a rising demographic of skin of color, especially in the Hispanic population, multiracial, and Asian American population.
The skin phenotype will be changing rapidly in the next few decades, and as dermatologists, we're in the forefront of recognizing these changes and be able to counsel our patients and implement treatments accordingly.