AD is common in Indigenous patients. Here are effective treatment and support strategies
Language barriers, distrust of the medical system, and lack of access to resources must all be managed to ensure good outcomes, according to Dr. Carolyn Jack (1,600 words, 8 minutes)
Atopic dermatitis (AD) is one of the significant diseases burdening Canadian Indigenous populations, Dr. Carolyn Jack told the 2024 Summit on Atopic Dermatitis on May 11. To improve AD outcomes, it is critical to communicate with Indigenous patients and to respect their traditions and beliefs.
Dr. Jack is an assistant professor of dermatology at McGill University in Montreal and a junior scientist at the Infectious Diseases and Immunity in Global Health Program of the Research Institute of the McGill University Health Centre. In 2018, Dr. Jack founded the McGill University Hospital Network Centre of Excellence for Atopic Dermatitis, Canada's first tertiary care centre dedicated to adult atopic dermatitis.
AD is one of the top three diseases affecting Indigenous populations in Ontario, British Columbia, and Saskatchewan and is a significant problem across the entire country, said Dr. Jack. It is a “crazy burden” in these populations, and healthcare workers report difficulty managing it. The approach to managing care with Indigenous patients needs to be improved, she said.
Because McGill is an English-speaking institution in a majority French-speaking province, it is responsible for many northern Indigenous communities whose second language is often English rather than French, said Dr. Jack. She said she has worked for years with Darryl Napash, an Indigenous patient partner who is also an interpreter for Cree Patient Services for the McGill University Health Centre. She said Mr. Napash stresses the importance of Indigenous people keeping their traditions.
When discussing AD with an Indigenous patient, Dr. Jack said she begins by explaining what AD is. In the Cree language, there is no word for eczema, so she has to think about what eczema means to patients in Indigenous communities.
Indigenous patients also often have a negative impression of the healthcare system, Dr. Jack said, which can affect their willingness to try treatments or medications.
When considering patient care, Dr. Jack said she thinks about a therapeutic journey, how to examine the patient's skin from head to toe, mitigate risks, act as a guide to the patient, and discuss options such as immune therapy.
Dr. Jack said the usual stepwise approach to AD treatment used in most clinics might not be practical when managing patients from rural and remote communities, as Indigenous patients may not have access to moisturizing creams or clean water. It might be necessary to jump to systemic therapies, which a physician should discuss in more detail with the patient.
Bottom Line: AD is one of the top three diseases affecting Indigenous populations in Ontario, British Columbia, and Saskatchewan, and is a significant problem across the entire country. Language, patient trust, and access to clean water and medications are all potential barriers to good patient outcomes that physicians and the healthcare system must address to improve health equity in AD.
From the literature on dermatology in skin of colour
Analyzing racial disparities in pediatric atopic comorbidity emergency department visitation using electronic health records
Researchers conducted a retrospective study of patients younger than 21 years who visited the emergency department at a large US pediatric hospital for atopic dermatitis (AD), food allergy, asthma, allergic rhinitis, and eosinophilic esophagitis between 2015 and 2019.
They determined the probability of patients not having emergency department encounters for patients identified as Black/African American and White/European American. Investigators also assessed potentially underlying allergic, demographic, and place-based factors and potential interactions between factors.
A total of 30,894 patients (38% Black, 62% White) had 83,078 emergency department encounters (38,378 first encounters and 44,700 recurrent encounters) during the study period. Asthma and allergic rhinitis showed the highest rate of comorbidity in encounters in both Black and White children. Black children exhibited a higher hazard ratio for encounters following index AD and asthma encounters.
The researchers found an interaction between the type of insurance and race in emergency department encounters for AD, food allergy, allergic rhinitis, and eosinophilic esophagitis. In Black children, those insured by Medicaid demonstrated a higher hazard ratio for any encounter than those with commercial insurance. Conversely, in White children, those with Medicaid insurance showed a lower hazard ratio than their commercially insured peers. Regardless of race, allergic comorbidity increased the hazard ratio of emergency department encounters (1.12-1.62) for all allergic diseases. At 5-year follow-up, mean differences in time to recurrence were shorter in Black children compared to White children in AD, food allergy, and asthma.
Sociodemographic factors linked to food allergy diagnosis among high-risk children with atopic dermatitis
This retrospective cohort study was conducted to determine whether socioeconomic conditions, as measured by the area deprivation index and insurance status, or racial/ethnic self-identity, were associated with the risk of food allergy diagnosis (DFA), evaluation by an allergist, or objective food allergy testing among high-risk children with atopic dermatitis (AD).
The study included 3,365 pediatric subjects with physician-diagnosed AD who had received primary care at a single urban academic tertiary care centre between 2009 and 2022.
Among the subjects, 41.3% identified as non-Hispanic Black, 33.9% Hispanic, 6.9% Asian, and 14.9% non-Hispanic White.
Hispanic children with AD and DFA were significantly less likely to be evaluated by an allergist than White or Asian children (65.9% vs 82.8% and 80.3%, p=0.001 and p=0.02). Non-Hispanic Black children with AD and DFA were more likely to have no objective food allergy testing than White children (20.9% vs 12.1%, p=0.04). The White and Asian children were more likely to undergo the thorough combination of both blood and skin testing for DFA than Black or Hispanic children (15.5% and 22.4% vs 7.1% and 7.9%, respectively, p=0.007, p=0.00005, p=0.03, p=0.0008).
Clinical features of atopic dermatitis in pediatric patients with skin of colour and comparison with different phototypes
In this study, researchers aimed to improve the characterization of atopic dermatitis (AD) among different shades of skin by characterizing clinical signs of AD in skin of colour (SOC) patients and comparing these signs with those of non-SOC patients.
To do this, they conducted a retrospective study on all the consecutive AD patients attending the Dermatology Unit of the Pediatric Hospital IRCCS Giannina Gaslini in Genoa from Sept. to Dec. 2023.
Researchers collected and evaluated data on Fitzpatrick skin type, characteristic clinical signs of AD disease (site and type of the lesions, associated symptoms), chronic or remittent disease course, and personal or family history of atopy. The researchers included 128 patients between zero and 18 years of age (mean age 6.1 years). The patients did not present other chronic dermatological diseases and did not receive any systemic treatment.
Overall, the researchers found that the main clinical features of AD in SOC were intense xerosis and xerosis-related features such as nummular eczema, prurigo nodularis-type lesions, and extensor site eczema. The typical SOC-related eczema involves the extensor surfaces of the arms and legs, known for being dry and exposed to irritant external agents, with features of hyperkeratosis (e.g., prurigo nodules) and typical nummular shapes.
In their conclusion, the authors write, “As the evidence on the interracial genetic variability of AD is growing, it becomes clear that also the clinical features of AD are wider than previously described in only light-skinned focused dermatology. These features deserve to be adequately described and addressed, as they might indeed represent underestimated major issues in SOC patients and might help with a more complete digital assessment of atopic dermatitis with teledermatology.”
At the intersection of skin and society
Canada will fund an Indigenous-led study into how oil sands development affects the health of local communities following a tailings water leak from an Imperial Oil site that heightened pollution concerns, reports Reuters.
On Aug. 7, 2024, Environment Minister Steven Guilbeault announced that the Government of Canada will make nearly $12 million available over ten years for the Fort Chipewyan Health Study. The community-led health study, with the Athabasca Chipewyan First Nation, the Mikisew Cree First Nation, and the Fort Chipewyan Métis Nation, is intended to examine the impacts of the oil sands on community members’ health.
Fort Chipewyan is one of several Indigenous communities in remote Northern Alberta that last year learned that tailings water containing residual bitumen had been seeping for months from Imperial's nearby Kearl mining site.
According to the Reuters article, Chief Allan Adam of the Athabasca Chipewyan First Nation told reporters those communities have for years reported higher rates of cancer and other health issues. He added that his community first called for a health study in 1992.
Guilbeault told reporters on the call that if the study points to impacts on communities from the oil sands, it will force the federal and provincial governments and companies to implement more robust environmental and health measures.
“That would be the only reasonable course of action,” he said. “I have heard first-hand how the Kearl mine spill affected the communities but also how these concerns are not new.”
Last chance! Register today for this Saturday’s 2024 Colloquium on the Black Patient
In recognition of persistent gaps in dermatologic training concerning skin of colour, the Colloquium on the Black Patient will discuss topics in dermatology specific to Black patients and recent progress in advancing the inclusion of diverse skin tones in research and medical education.
Chaired by Dr. Andrew Alexis (New York), this live discussion will be held virtually this coming Saturday, Aug. 17, 2024, from 10 a.m. to 1:30 p.m. ET.
Speakers include:
Dr. Renée Beach (Toronto)
Dr. Ncoza Dlova (Umhlanga, South Africa)
Dr. Marissa Joseph (Toronto)
Dr. Jenna Lester (San Francisco)
Dr. Monica Li (Vancouver)
Dr. Yvette Miller-Monthrope (Toronto)
Dr. Patricia Oyetakin (Atlanta)
Dr. Susan C. Taylor (Philadelphia)
Dr. Heather Woolery-Lloyd (Miami)
The Colloquium will cover the state of therapies, research, and education in dermatology for skin of colour, focusing on progress in Canada.
This non-accredited program will be available to attend at no charge, thanks to the support of our sponsors.
More details are available at this link.
This week
August is Psoriasis Action Month
August is National Water Quality Month in the US.
Aug. 12 is International Youth Day
Something to think about in the week ahead . . .
—Wernher von Braun, German rocket scientist (1912-1977)
Next week
In a recent paper, Ian A. Myles, MD, MPH, discusses how assumptions of innate biologic disadvantage have clouded assessments of racial disparities in disease beyond the topics that are more stereotypical of race science.
Dr. Myles is the Principal Investigator in the Epithelial Therapeutics Unit and Chief Medical Research Officer in the US Public Health Service Commissioned Corps.
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