Identifying the morphologic variants of AD in skin of colour

Dr. Marissa Joseph discusses the different morphologic variants of atopic dermatitis in patients with skin of colour

Atopic dermatitis (AD) has different morphologic variants in patients with skin of colour, in comparison with individuals with less richly pigmented skin. This was the key message from Dr. Marissa Joseph’s presentation on AD in skin of colour at Skin Spectrum Summit in Toronto in 2019.

According to Dr. Joseph, it is important to be aware of how AD presents itself in skin of colour patients. “Sixty per cent of Canadians are visible minorities, and we have the highest per-capita immigration rate in the world. You really have to think about disease processes in unique patient populations that are becoming, to be honest, not that unique,” stated Dr. Joseph. 

She described a case of a three-year-old girl who was referred to her with a rash. Dr. Joseph said the rash had very little to no red and was more of a “dusky grey.” She went on to say that her patient had follicular accentuation and a lichenoid presentation. In addition, the rash was present on her extensor surfaces. 

In darker skin types, “less erythema, violaceous-greyish hue [and] hypo- or hyperpigmentation may actually be the main indicators of severity. Follicular accentuation is quite common,” said Dr. Joseph.

“Classically, we are taught that [AD] will occur on flexor surfaces, but very commonly in darker skin types, it is prevalent on extensors, ... so that makes it a little bit difficult to differentiate it from psoriasis.” 

Another case Dr. Joseph described was of a young girl referred to her for acne. “When we look very carefully, those aren’t comedones; those are just little follicular bumps.” According to Dr. Joseph, eliciting specific information from the patient was extremely important, especially in this case.

“This was super itchy for her. Very, very itchy. She was scratching, making it difficult for her to concentrate. This would represent more of a follicular variant,” said Dr. Joseph. She prescribed a calcineurin inhibitor, which cleared the rash, something that would not likely happen if it was simple acne. 

In another case, Dr. Joseph saw a young man with no acutely visible rash but very itchy skin. Upon inspection, the patient had very fine flat-topped little bumps. “This would represent a lichenoid sort of presentation,” said Dr. Joseph. 

“It is not just the usual suspect of an ill-defined eruption on the flexor areas,” said Dr. Joseph. In patients with skin of colour, AD can have “perifollicular presentations, [and there can be] dyspigmentation in the presentation, a lack of erythema, lichenoid presentations and the presence [of AD] on extensor surfaces,” said Dr. Joseph. 

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FROM THE LITERATURE ON AD IN SKIN OF COLOUR

Medical students’ ability to diagnose common dermatologic conditions in skin of colour

  • In a study of 227 medical students, researchers found that among the skin conditions with the greatest disparity in visual diagnosis based on Fitzpatrick skin phototypes, atopic dermatitis was listed in the top three. Medical students visually diagnosed AD 74% of the time in patients with Fitzpatrick skin types IV-VI versus 86.2% in Fitzpatrick skin types I-III.

    From “JAAD”

Structural racism and its influence on the severity of atopic dermatitis in African American children

  • Structural racism may have a significant effect on the severity of atopic dermatitis in African American children, according to a recent survey of 201 patients up to the age of 18.

    From “Pediatric Dermatology”

A clinician's reference guide for the management of atopic dermatitis in Asians

  • Atopic dermatitis presents differently in Asian skin, with more demarcated lesions and more prominent scaling, according to the authors of this study. Researchers said that in treating atopic dermatitis in Asian patients, clinicians should take a more holistic approach which takes into account cultural nuances.

    From "Asia Pacific Allergy"

VIDEO: Patients with mild AD may not have systemic inflammation

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Thank you to our panelists and delegates for making Skin Spectrum Summit 2020 a great success. Conference highlights will soon be posted to the Skin Spectrum website. As always, we welcome your questions and comments on topics in Ethnodermatology.

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