AD morphology in darker skin
AD morphology in darker skin
Improving diagnosis and patient experience through awareness of variations in AD presentation (1,470 words, 7 minutes, 20 seconds)
Differences in how atopic dermatitis (AD) presents in darker skin types need to be taken into account to aid in accurate, timely diagnosis and ensure patients receive satisfactory treatment. Dr. Marissa Joseph emphasized these points during a talk at the 7th annual Skin Spectrum Summit on Nov. 4, 2021.
“There are unmet needs in the management of atopic dermatitis in skin of colour, which can lead to a delay in diagnosis, late referral to a dermatologist, more severe disease at the time of presentation,” she said. She noted that the initial referring physician might also not capture the actual severity of the disease.
Dr. Joseph is an academic dermatologist at the University of Toronto and medical director of the Schachter Dermatology Centre at Women's College Hospital.
There are several differences in atopic dermatitis (AD) morphology in Brown and Black skin, said Dr. Joseph. The acute lesions are often less erythematous, and more violaceous and greyish in hue, with hypopigmentation or hyperpigmentation being the leading indicator of severity.
Dr. Joseph also told the Summit that AD could be more prevalent on the extensors rather than the flexural areas in patients with darker skin, which can lead to a misdiagnosis of psoriasis.
Acute AD in dark skin can also present with thickened, diffuse plaques, papules, or hypopigmentation. Nummular or lichenoid variants, prurigo and perifollicular accentuation, are also uncommon in white skin. However, they can be important clues to AD diagnosis in patients of African, Southeast Asian or East Asian descent, said Dr. Joseph.
Dr. Joseph said the differing presentation could lead to delays in diagnosis. She said that she had seen two referrals with similarly severe cases of eczema in her practice, one in a child with light skin and one in a child with dark skin. The lighter-skinned patient’s referral presentation was ‘red, inflamed eczema,’ and they had been provided with a referral in two weeks. The patient with darker skin had waited three and one-half months and was described as just having ‘dry skin eczema’.
Dr. Joseph provided the following advice for improving experience and outcomes for patients with darker skin types and AD:
Consider the impact pruritus is having. Scratching is more likely to induce a nodular component to AD or cause dyspigmentation in dark skin.
Treating early and aggressively can help prevent inflammation-induced pigment changes. This can also improve treatment adherence as some patients may mistakenly attribute pigment changes to their topical medications.
Treatment guidance should also consider the way the patient’s AD manifests. Patients are often instructed to continue topical treatment until redness subsides, but this direction is not helpful to patients with AD that presents without erythema.
Bottom line:
Dyspigmentation may be a sign of acute AD in darker skin. Pruritis, lichenification and follicular involvement are more likely to be symptoms in patients of colour. Raising awareness of these differences in the presentation may help patients get diagnosed and treated earlier and achieve better outcomes.
From the literature on atopic dermatitis in skin of colour
Racial/ethnic variations in skin barrier: Implications for skincare recommendations in skin of colour
The authors of this paper undertook a literature review followed by panel discussions and an online review process to identify racial or ethnic differences in the structure of the stratum corneum (SC) barrier. They also sought to clarify whether there are differences in healthy skin barrier function and a need for specific cleansers and moisturizers in different racial or ethnic groups.
In their findings, the authors report that ethnic categories based on race and ethnicity in the literature they reviewed were often poorly defined and inconsistent across studies. Some studies have found differences in physical and biochemical skin barrier properties between ethnic groups, but those studies often had methodological flaws, had small populations, or had conflicting findings.
In the end, they conclude that robust comparative studies are needed to understand differences in skin barrier function between these groups to help tailor skincare and health education for skin of colour patients.
Dermatological conditions in skin of colour: Managing atopic dermatitis
This brief, open-access paper details many differences in US demographics and presentation of atopic dermatitis (AD) between different skin types. Some presentations more common in dark skin, such as lichenification and prurigo, are illustrated with photographic examples.
The paper also includes recommendations for treating and managing AD in these populations.
Reframing racial and ethnic disparities in atopic dermatitis in Black and Latinx populations
The authors of this paper discuss the greater prevalence, severity, and persistence of atopic dermatitis (AD) in Black Americans compared to White Americans and the possible reasons for that discrepancy. While the Latinx population is also considered, the authors note there is much less published literature describing AD in this population.
In particular, the authors note that genetic polymorphisms associated with increased risk or severity of AD are less common in the Black population, so they should be expected to confer lower AD risk rather than the elevated risk observed.
They conclude that socioeconomic, environmental, and healthcare factors are more likely to be the cause of the elevated AD severity and that reframing the prevailing view that innate differences among racial and ethnic groups are responsible for these disparities is necessary for the goal of shrinking these disparities.
Subtypes of atopic dermatitis: From phenotype to endotype
This review article examines the literature on atopic dermatitis (AD) subtypes, dividing them into immunoglobulin(Ig)E-high (extrinsic) and IgE-normal (intrinsic) subtypes. The authors then examine variations in AD between racial/ethnic groups and between sexes through this lens.
They describe a study that found filaggrin loss-of-function mutations are not prevalent in African American patients with AD, and Th1/Th17 attenuation and Th2/Th22 skewing were seen in these patients. Also, they write that Asian patients with AD are characterized by a unique blended immune dysregulation and barrier feature phenotype which has characteristics between those seen in European American patients with AD and those with psoriasis.
The authors conclude that the evidence supporting endotype classification of AD and other allergic disorders supports a need for personalized or precision medicine appropriate for each subtype of AD.
VIDEO: Caring for skin of colour - Eczema with Dr. Ginette Okoye
At the intersection of skin and society
One of Toronto-based Ghanian Canadian artist Ekow Nimako’s current ongoing projects, titled “Building Black Civilizations II: Journey of 2000 Ships,” will be premiering at the Regina Public Library on Oct. 15, 2022. The ongoing progress of the sculpture can be followed on Nimako’s website and Instagram pages.
Nimako, who works exclusively in black Lego pieces, told CNN in an interview that the toy plastic brick company would feature him and his body of work in a documentary this February. “The Lego Group has been really supportive of my work. After realizing what I do, there’s so much more that we’re going to be doing together,” he said in the CNN article.
According to Nimako’s site:
Rooted in his childhood hobby and intrinsic creativity, Nimako’s formal arts education and background as a lifelong multidisciplinary artist inform his process and signature aesthetic. His fluid building style, coupled with the Afrofuturistic themes of his work, beautifully transcend the geometric medium to embody organic and fantastical silhouettes.
His large-scale public installations include the monumental Cavalier Noir (Nuit Blanche, Scarborough Civic Centre/Toronto City Hall, 2018) which features a seven-foot Black rider atop a dauntless Black unicorn. Conceptualized in collaboration with Director X, the piece subverts the dominant imagination of public monuments and centres Black narratives.
Examples of Nimako’s work can be viewed on his site. Also on the site is information on Building Beyond, an educational activity in which participants get to imagine their distant futuristic descendants and build them from Lego. At the same time, Nimako shares insights on his art, the importance of Afrofuturism, and the role he feels Lego can have in making the world more inclusive.
A new podcast: Vender on Psoriasis
The Chronicle Podcast System has launched a new podcast to talk about everything psoriasis with Dr. Ronald Vender. The podcast is based on Dr. Vender’s popular column in The Chronicle of Skin & Allergy. In this premiere episode, Dr. Vender discusses the Psoriasis Area and Severity Index—PASI—and why dermatologists need to rethink this tool to score disease severity. Other topics covered in this episode include treating plaque psoriasis with botulinum toxin and the independent mortality risk associated with psoriasis. Listen here.
This week
January is National Slavery and Human Trafficking Prevention Month in the US
Jan. 17 is Martin Luther King Day in the US
Something to think about in the week ahead…
Next week
Next week’s edition of Skin Spectrum Weekly will cover a talk by Dr. Andrew F. Alexis, Vice-Chair for Diversity and Inclusion for the Department of Dermatology and dermatologist at the Center for Diverse Skin Complexions at Weill Cornell Medicine in New York. His talk at the 7th annual Skin Spectrum Summit detailed many differences in epidemiology and presentation of skin cancers in dark-skinned patients, including essential tips for effective screening in these populations.