Ethnic variations in presentation, pathogenesis of AD
Ethnic variations in presentation, pathogenesis of AD
More lesions on the trunk, different interleukin activity observed in patients with darker skin types (1,500 words, 7 minutes)
The pathogenesis and presentation of atopic dermatitis (AD) may vary among different ethnic groups, and the condition may cause more severe consequences in patients of colour.
This message was part of a presentation by Dr. Mohannad Abu-Hilal at the 9th annual Skin Spectrum Summit.
Dr. Abu-Hilal is an associate professor and the head of the dermatology division at McMaster University in Hamilton.
Research from the U.S. and U.K. suggests AD affects about 30% of children and 10% of adults, Dr. Abu-Hilal said. He added those studies also show AD affects Black children and Asian adults at a higher rate. Studies also indicate that AD causes more disability in those patients than in patients with fair skin. One of the reasons may be that these patients have less access to healthcare or specialists, he said.
The presentation of AD may also differ in different skin types, he said. In patients of colour, AD often presents more on the chest, back, and extensor surfaces rather than the flexural areas. In patients with darker skin types V or VI a physician may not be able to clinically observe the redness associated with AD—there may be a violaceous hue instead—which can also lead to misdiagnosis.
Data also suggests the pathogenesis of AD might also be different in patients of colour, said Dr. Abu-Hilal. With AD, there is a Th2 inflammation, but patients of colour also have Th2-elevated cytokines and higher levels of interleukin-22. These cytokines make the skin very thick and this can happen even at the level of the hair roots. This thickness and follicular accentuation can lead to misdiagnosis, he said.
Asian patients have more Th17 cytokines and more interleukin-17, said Dr. Abu-Hilal. They also have more significant head and neck AD involvement, which may affect the kinds of treatment physicians should recommend.
Bottom line: The presentation and pathogenesis of AD differs by skin type and ethnic group. Physicians should be aware of these differences to improve their ability to diagnose the condition and ensure all patients get prompt, effective care.
From the literature on atopic dermatitis in skin of colour
Atopic dermatitis in individuals of Asian and African ancestry: A scoping systematic review
This paper quantifies the number of peer-reviewed literature describing the appearance of clinical features of atopic dermatitis (AD) in non-European ancestry, particularly those originating from the Asian and African continents.
The researchers identified 16 studies. None of the studies provided a clear description of AD in the population groups of interest. Two studies described features of lichen planus-like AD in African American individuals. All studies reported on observed clinical features of AD.
Phenotypes, endotypes and genotypes of atopic dermatitis and allergy in populations of African ancestry on the continent and diaspora
The authors of this paper summarize the available data on ethnicity-specific variations in clinical presentation of atopic dermatitis (AD), immune endotypes and genetic susceptibility, with specific consideration of AD in populations of African ancestry.
Some highlights include the observation of AD lesions on extensor surfaces, lichen planus-like AD, prurigo-type AD and follicular AD in African populations. They also note a consistent absence of dominant filaggrin gene defects has been reported by researchers. The detection of normal filaggrin protein content in AD skin implicates the contribution of alternative mechanisms in the pathogenesis of AD in African patients, they write. Markedly high IgE has been described in pediatric and adult African AD. While Th2, Th22, and Th17 activation in African AD skin shares the same direction as with other populations, it has been noted that the magnitude of activation is dissimilar. Reduced Th17 cytokines have been observed in the circulation of moderate to severe pediatric AD.
Abrocitinib efficacy and safety in moderate-to-severe atopic dermatitis by race, ethnicity, and Fitzpatrick skin type
For this study, the investigators pooled data post-hoc from patients treated with abrocitinib 200 mg, 100 mg, or placebo in three monotherapy trials (NCT02780167, NCT03349060, and NCT03575871).
Participants self-reported race and ethnicity, and investigators determined Fitzpatrick skin type. The sample included 628 White, 204 Asian, and 83 Black patients; 37 were Hispanic or Latino; 624 had skin type I to III and 320 had IV to VI.
Researchers found treatment with either abrocitinib dose was associated with greater proportions of patients achieving Investigator’s Global Assessment of clear or almost-clear skin, ≥75% improvement in Eczema Area and Severity Index, ≥75% improvement in SCORing AD, and a ≥4-point improvement in Peak Pruritus Numerical Rating Scale, or greater score changes from baseline in Dermatology Life Quality Index and Patient-Oriented Eczema Measure vs placebo regardless of race, ethnicity, or skin type.
They observed that dose-response was most prominent in White patients. In Black patients, the effects of the two doses were similar. Treatment-emergent adverse events were more common in White and Black than in Asian patients.
Improved patient- and caregiver-reported outcomes distinguish tacrolimus 0.03% from crisaborole in children with atopic dermatitis
This open-label study randomized 47 child-caregiver dyads to either crisaborole or tacrolimus for 12 weeks. A total of 36 dyads completed the study. Children (mean age=8.0±3.9 years) had mild baseline atopic dermatitis and were diverse by race (39% White; 36% Black) and gender (53% males). The caregivers were mostly female (78%; mean age=37±7.6 years).
Children in both study arms had improvements in their disease severity (Eczema Area and Severity Index) from baseline to 12 weeks (crisaborole=-2.4 vs. tacrolimus = -1.9). Within-arm analyses comparing baseline to 12 weeks revealed tacrolimus, but not crisaborole, improved all child and caregiver patient-reported outcomes except sleep (all p<0.05).
VIDEO: Atopic dermatitis in skin of colour
Dr. Kelly Maples, Associate Professor of Pediatrics and Internal Medicine at Eastern Virginia Medical School in Norfolk, Va., discusses the clinical and physiologic differences of atopic dermatitis in skin of colour, how to approach treatment in these patients, and factors that can contribute to disparities in care.
At the intersection of skin and society
Kids Help Phone, a Canadian 24/7 e-mental health service for young people, has announced it is launching a new program to support Black youth.
According to a press release this new program, called RiseUp, will build on Kids Help Phone’s existing services and programs to support African, Caribbean, and Black youth across Canada by expanding e-mental health services to become more equitable, accessible, and culturally informed.
Understanding that e-mental health services for Black youth must be community-informed and community-led, RiseUp was informed by consultation with Black youth and community leaders, according to the release. Kids Help Phone engaged with more than 200 African, Caribbean, and Black youth to find out more about barriers they face when accessing support for mental health care.
Following the engagement sessions, Kids Help Phone developed the KHP Black Advisory Council—a group of community leaders—to provide strategic direction for the ongoing development of RiseUp. The action plan will be implemented by KHP’s Black Youth Initiatives team.
Through this action plan, Kids Help Phone will innovate new and responsive ways of supporting Black youth with their mental health and wellness. This includes:
Expanding awareness of KHP services for Black youth and building trust in communities by developing deeper connections with community centres, schools, pediatric hospitals, shelters, sports organizations, and Black content creators.
Adding 200 Black community resources into KHP's Resources Around Me database—an interactive tool that helps young people find and connect with trusted community supports.
Increasing the number of African, Caribbean, and Black employees at KHP to ensure its staff reflects the voices and experiences of young people from the Afro-diaspora.
Recruiting more than 100 African, Caribbean and Black volunteers as crisis responders each year
Developing volunteer and mentorship programs tailored for African, Caribbean, and Black youth.
“At Kids Help Phone, we're always striving to better understand barriers to mental health care that African, Caribbean, and Black youth experience,” said Katherine Hay, President and CEO of Kids Help Phone, in the release. “Our work to offer services that are more relevant, equitable and accessible will never be done. We are fully committed to taking definitive actions—in partnership with communities and the KHP Black Advisory Council—that ensure Black youth across Canada are met with the e-mental health care they deserve to thrive in their worlds.”
“Long histories of injustice and colonization, compounded by tragic events, can take a toll on the mental health of young people from the Afro-diaspora. Through the implementation of the 2023-2026 RiseUp action plan, Kids Help Phone's services can continue to bridge the gap to support Black youth with critical e-mental health services, particularly when other community-based services are not available,” said Barbara Ukwuegbu, Manager Black Youth Initiatives, a program supported by The Slaight Family Foundation at Kids Help Phone.
This week
March 21 is International Day for the Elimination of Racial Discrimination
March 22 is World Water Day
Something to think about in the week ahead. . .
—Mary Kay Ash, U.S. businesswoman and founder of Mary Kay Cosmetics (1918-2001)
Next week
As part of a roundtable discussion published in Podiatry Today, a panel of four physicians discuss dermatology in the lower extremities of patients with skin of colour. As part of their discussion, they cover important aspects of history-taking and physical examination in these patients.
If you like Skin Spectrum Weekly, why not check out Chronicle’s other publications, podcasts, and portal?
Established in 1995, The Chronicle of Skin & Allergy is a scientific newspaper providing news and information on practical therapeutics and clinical progress in dermatologic medicine. The latest issue features:
Drs. Brittany Waller (Regina, Sask.), Charles Lynde (Markham, Ont.), Gurbir Dhadwal (Surrey, B.C.), Ashley O’Toole (Peterborough, Ont.) and Monica Li (Vancouver) discuss new treatments for challenging diseases available or expected in 2024.
Dr. Afsanah Alavi (Rochester, Minn.) details recent research showing a link between lower limb lymphedema and skin cancer.
Drs. Reetesh Bose (Ottawa), Morvarid Hessami (Toronto), and Marissa Joseph (Toronto) describe the establishment of dermatology clinics specializing in skin of colour, and the outcomes they are achieving.
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The Women in Dermatology e-newsletter updates new findings concerning dermatologic issues that affect women and the female dermatologists who care for them. Read the current issue here.
Season three of the Vender on Psoriasis podcast with Dr. Ron Vender has begun. Listen to the new season here. In episode five, Dr. Vender discusses whether or not vitamin D has any impact on psoriasis severity, sex differences in psoriatic inflammation itch, and the risk of psychiatric disorders associated with acitretin.
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