Hidden impact of AD in skin of colour
Cultural factors, biased measuring tools may lead to underestimated impact of AD on quality of life in non-White patients (1,850 words, 9 minutes)
Atopic dermatitis (AD) has a more significant impact on the quality of life in patients with skin of colour. The limitations of relevant cultural knowledge among physicians and the tools for evaluating treatment outcomes contribute to this disparity.
These were some of the points raised in a presentation by Dr. Geeta Yadav at the 8th annual Skin Spectrum Summit on Sept. 17, 2022.
Dr. Yadav is the Medical Director and Founder of FACET Dermatology in Toronto.
AD has “a higher prevalence in Black, Hispanic, Latinx, Asian Pacific Islander and multiracial populations compared to White individuals,” Dr. Yadav said. “That has been shown in a variety of epidemiological studies.” She noted that children in non-White racial subgroups who have AD are also more likely to have their skin condition persist into adulthood.
During her talk, Dr. Yadav cited a survey of 377 adult Canadians with AD, that was conducted by the Eczema Society of Canada. That survey found that 87% of respondents said their daily life is negatively impacted by their AD.
“This is not specific by race or ethnicity, but it shows you the impact of the disease as a baseline,” she said.
Then, looking specifically at patients with skin of colour, she noted that 79% of patients described a lack of sleep or disturbed sleep and 64% reported anxiety.
It is also important to recognize that the impact of AD on patients of colour may be underestimated, Dr. Yadav explained. Clinical tools used to evaluate erythema may under-value AD that appears with greying or other darker pigment changes. The tools are “insufficient, they are inadequate and there is poor interrater reliability,” Dr. Yadav said. “We need better metrics to be able to measure the impact of disease and the efficacy of our therapeutics.”
Dr. Yadav also said that it is important for physicians to remember that a patient’s perception of their AD severity may not match what textbooks consider severe disease. Physicians should consider specific patient concerns when managing the patient’s AD, she said.
“It is not my disease to define as severe, it is theirs,” she said. “If they have bothered to come to me, and they waited to see their family doctor, and then they waited to see me, they probably care. So I am going to do my best to put them on sophisticated therapy, appropriate therapy.”
An example of a difference in disease experience in patients with dark skin is how the inflammation associated with AD can lead to post-inflammatory pigment changes which can persist for a long time.
“That is part of the anxiety of the disease, the disproportionate impact of the disease. It is not just about the disease state itself; it is about the sequela that comes after and the length of time that it takes to resolve.”
Parents, in particular, may be concerned that areas of lost pigment on their children’s skin might be vitiligo, she said. They need to be reassured that with treatment the child’s pigment will recover.
Bottom line: Patients with skin of colour and AD may have symptoms or cultural concerns that are not adequately addressed by common dermatology tools and messaging, leading to worse outcomes.
From the literature on AD in skin of colour
Prevalence of eczema among adults in the United States: a cross-sectional study in the All of Us research program
The authors of this study identified eczema cases using electronic health record (EHR) data that had been compiled as part of the U.S. National Institutes of Health All of Us research program. From this data, they calculated the prevalence of eczema and 95% confidence intervals (CI) among participants across age and self-identified racial and ethnic groups.
There was available EHR data for 203,813 All of Us participants (average age 55 years, standard deviation [SD] 17; 63% female). Among those records, the researchers identified 11,244 eczema cases with an average age of 59 years (SD 16) and a 2:1 female predominance (68% female).
The investigators found the prevalence of eczema increased with age, ranging from 3.6% (95% CI 3.4-3.8) in those aged 18 to 34 years to 8.3% (95% CI 8.0-8.7) in those aged 75 years and older.
Breaking the data down by race and ethnicity, the authors found that eczema prevalence was significantly higher in Asian and White participants (6.5% [95% CI 5.9-7.2] and 6.2% [95% CI 6.1-6.4], respectively) compared to Black and Hispanic participants (5.1% [95% CI 4.9-5.3] and 4.1% [3.9-4.3], respectively) (all pairwise comparisons p<0.001).
Impact of social determinants on the burden of asthma and eczema: Results from a US patient survey
Researchers conducted a survey to evaluate the perceptions among the general U.S. patient population with asthma or eczema of their disease and treatment burden and any barriers to adequate care.
The survey was completed by market research panellists between March 24, 2020, and April 6, 2020. Each participant was at least 18 years of age and said they had a diagnosis of asthma or eczema.
A total of 841 participants completed the survey. Of those, 554 had asthma, 398 had eczema, and 111 had both. Broken down by racial or ethnic group, 421 of the participants were White, 252 were Black and 95 were Hispanic.
The investigators found that more Black and Hispanic participants than White participants, and more participants with low income than higher income, said they felt health literacy was a barrier, impacting their ability to fill out official documents or understand written materials.
Participants with low income were less likely than participants with higher income to have an asthma action plan (42% vs 53%, respectively) and to discuss asthma control with their healthcare provider (54% vs 69%).
Black and Hispanic participants were more likely than White participants to have an emergency department visit (52% and 49% vs 31%, respectively) or hospitalization (31% and 39% vs 16%) for asthma within the last 12 months.
Participants reporting low income indicated that they experienced eczema symptoms more frequently than participants with higher income. As well, 35% of low-income participants reported that they had not tried any eczema treatments, compared to 15% of higher-income participants.
Participants in all racial/ethnic and income-level groups reported that their asthma or eczema impacted their lifestyle and daily activities.
Dermatology: How to manage atopic dermatitis in patients with skin of colour
This open-access, narrative review covers differences in the epidemiology, pathophysiology, clinical presentation and treatment of atopic dermatitis (AD) in skin of colour.
The authors highlight a need for greater inclusivity of non-White ethnic groups in clinical trials to develop targeted treatments for diverse populations.
They also write that greater awareness of differences in AD presentation amongst non-White individuals may encourage patients to seek medical care earlier, leading to timely management and improved outcomes.
Validation of remote atopic dermatitis severity assessment with the Eczema Area and Severity Index in children using caregiver-provided photos and videos
This study aimed to quantify the reliability and validity of remotely assessing the severity of pediatric atopic dermatitis (AD) by applying the Eczema Area and Severity Index (EASI) to caregiver-provided photos (p-EASI) and videos (v-EASI).
The researchers recruited 50 racially- and ethnically- diverse children (age [mean ± SD]: 4.3 ± 4.4 years; 42% female) with a range of AD severity (EASI: 6.3 ± 6.4) and Fitzpatrick skin types (1-2: 9%; 3-4: 60%; 5-6: 31%).
The children’s caregivers provided photos and a video of their child's skin. A clinician scored in-person EASI on the same day, then p-EASI and v-EASI for each participant 10 days or more between ratings. Two additional clinicians scored p-EASI and v-EASI.
The authors found that in this diverse population with a range of skin tones, p-EASI showed good criterion validity and good interrater reliability. They also write that v-EASI showed moderate to good criterion validity and moderate interrater reliability. Both may be reliable and valid options for remote AD severity assessment, the researchers conclude.
VIDEO: Key considerations in managing atopic dermatitis in Black patients
At the intersection of skin and society
Canadian Indigenous leaders are working to gain approval for clam harvesting at a sea garden site on the coast of Salt Spring Island, and another at nearby Russell Island in Gulf Islands National Park, British Columbia, reports CBC News.
The two sites were created and used by Indigenous peoples to collect food from the sea for thousands of years and are currently under restoration.
Indigenous peoples used the tides at the sites, along with rock walls, to trap clams, mussels, kelp and fish in the shallows.
Ken Thomas, the fisheries, wildlife and natural resources director for the Penelakut Tribe on southern Vancouver Island, is quoted saying that all stakeholders want to ensure the clams and other food from the gardens are safe to harvest. Safety testing is conducted by three agencies: the Department of Fisheries and Oceans, the Canadian Food Inspection Agency and Environment and Climate Change Canada.
Thomas told the news outlet that harvesting approval could come within one year, although others suggest it could be three or four years.
According to the news outlet, Indigenous nations, Parks Canada, scientists and academics are jointly participating in the restoration of the sea gardens, located along ancestral territories of Coast Salish First Nations.
Adam Olsen, Green Party MLA for Saanich North and the Islands, is quoted saying the sea gardens were managed for thousands of years until colonial settlers banned Indigenous peoples from the beaches.
“This is an example of environmental racism,” said Olsen, a member of the Victoria-area Tsartlip First Nation. “These policies are used to deliberately disconnect Indigenous people from their lands.”
Sept. 26 is World Contraception Day
Sept. 30 is National Day for Truth and Reconciliation in Canada
Something to think about in the week ahead…
John Cale—Welsh Musician
Skin Spectrum Weekly will feature a presentation by Dr. Joël Claveau on the epidemiology of skin cancer in skin of colour. Dr. Claveau, Associate Professor with the Department of Medicine at Laval University in Quebec and Director of the Melanoma and Skin Cancer Clinic at Le Centre Hospitalier Universitaire, Hôtel-Dieu de Québec, gave the talk at the 8th annual Skin Spectrum Summit.
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