Identifying the three highest skin priorities for Indigenous patients
AD, bacterial infections, diabetic skin disease have significant impact on remote and rural patient populations (Issue #246, 1,400 words, 7 minutes)
The highest priority skin conditions among Indigenous North American populations are atopic dermatitis, bacterial skin infections, and diabetic skin disease, Dr. Rachel Asiniwasis told delegates at the first Indigenous Skin Spectrum Global Summit on April 5 in Montreal.
Dr. Asiniwasis is a dermatologist and clinician researcher based in Regina, Saskatchewan. She is the founder of Origins Dermatology Centre, a combined multidisciplinary model that services the general population and provides in-person and virtual outreach clinics for underserved, remote and rural Indigenous communities. She is of Plains Cree, Saulteaux, and English background.
In Canada, AD shows prevalence rates of 10% to 25% and presents significant burdens on Indigenous children and youth, said Dr. Asiniwasis. It is the top chronic health condition observed regionally and nationally. The U.S. lacks pediatric data but has prevalence rates of 8% to 17% in Indigenous adults. Social and environmental factors in both countries, such as remote locations, lack of access to health care, language barriers, and overcrowding, often present barriers to care.
An ongoing review also shows high prevalence rates of bacterial skin and soft tissue infections, including MRSA, in remote and northern Indigenous Canadian communities, said Dr. Asiniwasis. The incidence of infection is much higher than in the general population. Studies show similar prevalence among Indigenous populations in remote parts of the U.S.
There are strikingly disproportionate rates of diabetic comorbidities in North American Indigenous peoples, said Dr. Asiniwasis. There are higher rates of lower extremity amputations, with several risk factors such as peripheral vascular disease, end-stage renal disease, and foot and ankle deformities. Acanthosis nigricans can be a sign of diabetes risk in these populations.
Bottom Line: The most common skin conditions among Indigenous North American populations are atopic dermatitis (AD), bacterial skin infections and diabetic skin disease. There is a lack of data on some skin conditions in Indigenous peoples, but the prevalence rates are often higher, and the health outcomes are often worse in those populations.
From the literature on AD in skin of colour
Development of novel patient-reported outcome instruments to assess atopic dermatitis-associated dyspigmentation and xerosis in patients with skin of colour
This paper describes the development and content validation of patient-reported outcome (PRO) questionnaires to assess atopic dermatitis (AD)-related xerosis and dyspigmentation in patients with skin of colour.
Researchers conducted a targeted literature review to understand and identify AD-related disease sequelae and quality-of-life impacts relevant to patients with skin of colour and any instruments used to assess AD in the target population. They developed two draft PRO questionnaires assessing xerosis (X-AD) and dyspigmentation (D-AD) and refined the drafts following advice meetings with three clinical experts. Investigators explored questionnaire content validity during hybrid concept elicitation and cognitive debriefing interviews with 15 adult and adolescent patients with skin of colour who have moderate-to-severe AD.
The review found 10 concept-focused articles, three websites, 17 labels, one U.S. Food and Drug Administration compendium and one clinical trial that confirmed that xerosis and dyspigmentation are important AD-related disease sequelae. Patients with skin of colour [47% girls/women; mean (SD) age 33.3 (21.2) years] reported that the questionnaires were relevant to their AD experience in an appropriate recall timeframe and were readily understood, and that meaningful responses were easy to select. The final X-AD questionnaire consisted of one 11-point numerical rating scale (NRS) assessing xerosis severity and two items assessing the level of bother associated with xerosis appearance and feeling over the past week, a 0 to 4 verbal rating scale. The final D-AD questionnaire consisted of two 11-point NRS items assessing dyspigmentation severity and two assessing the level of bother associated with how dyspigmentation looked over the past week.
The authors conclude that their study supports the initial development of the questionnaires by regulatory guidelines and best practices; however, psychometric validation is required to evaluate the properties of each questionnaire and develop score interpretation guidelines.
Racial and ethnic representation in atopic dermatitis clinical trials
Investigators analyzed racial and ethnic representation in recent atopic dermatitis (AD) clinical trials, identifying 73 completed AD trials on clinicaltrials.gov with results available from Jan. 1, 2019, to May 13, 2024. Of the identified trials, 68 trials involving 20,679 patients provided race and ethnicity data.
Out of all clinical trial participants, 65.4% identified as White, 17.3% identified as Asian, 13.4% identified as Black or African American, 0.5% identified as American Indian or Alaskan Native, 0.4% identified as Native Hawaiian or Pacific Islander, and 1.3% identified as more than one race. Hispanic or Latino participants comprised 10.8% of the clinical trial population.
The study authors say their findings highlight an increasing trend in the inclusion of African American/Black and Asian populations in AD clinical trials. However, Hispanic participants remain notably underrepresented despite increased ethnicity reporting.
“These disparities emphasize the necessity of diverse representation in AD clinical trials to ensure equitable treatment outcomes, especially given the higher disease prevalence in skin of colour groups,” the authors write. “Achieving equitable representation will improve the generalizability of trial results, enhance treatment access, and reduce health inequities. Greater inclusivity in AD clinical trials is crucial for understanding the safety, efficacy, and side effects of treatments across diverse populations and should be a cornerstone of dermatologic clinical research.”
Eczema severity scoring in skin of colour: A review of current best practice and need for future improvement
In this article, researchers review the common and novel atopic dermatitis (AD) outcome measures in patients with skin of colour, highlighting best practices and where further research to develop, adapt, and validate outcome measures will benefit patients with AD with skin of colour or from minoritized ethnic groups.
The authors note initial validation studies of the most commonly used outcome measures for AD underrepresent patients with skin of colour or fail to report race, ethnicity, and skin colour altogether.
They note that various adaptations have been proposed. For example, upgrading the erythema score by one when using the Eczema Area and Severity Index in patients with skin of colour has been suggested but has not yet been validated. However, using a “grey scale” instead of the erythema component has been reported to improve inter-rater reliability.
Because patients of different ethnicities or with skin of colour may be impacted in various ways by AD, pooling patient-reported outcome measures is not recommended.
Researchers mention the Patient-orientated SCORing for Atopic Dermatitis tool for Black skin as an example of a patient-reported outcome measure specifically adapted and validated for Black skin.
Some novel methods for assessing AD severity include biomarker assessment using tape strips, photonic testing, and measuring subepidermal low echogenic band thickness.
VIDEO: Spotting diabetes foot complications in dark skin tones: When the 'red flag’ might not be red
Consultant diabetologist Dr. Chris Manu (London, U.K.), Luxmi Dhoonmoon, Queen’s Nurse Consultant Tissue Viability (London, U.K.), and Debbie Sharman, Consultant Podiatrist (Dorset, U.K.), discuss why traditional foot assessments may not work for people with dark skin tones.
At the intersection of skin and society
Submissions are being accepted for the 2025 Canadian Skin of Colour & Diversity Research Scholarship Program for dermatology residents, supported by Pfizer Canada.
As part of our mutual commitment to empowering dermatologists to elevate Canadian healthcare and knowledge, an independent committee of dermatologists seeks applications from Canadian dermatology residents across the country to propose innovative projects to address care gaps in skin diseases in underrepresented populations, including Canadians with deeper skin tones, Indigenous people, and other racialized groups.
Selected recipients will receive the scholarship funds to support the development and implementation of their initiative.
Interested Canadian dermatology residents should submit their research proposals by September 2, 2025, to improve dermatologic care for skin of colour.
For details on the scholarship program and the application process, visit skinofcolourscholarship.com.
This week
May 26 to June 1 is Type 2 Diabetes Prevention Week in the U.K.
June 1 is National Cancer Survivors Day in the U.S.
June is National Indigenous History Month in Canada
Something to think about in the week ahead . . .
—Harriet Beecher Stowe (1811-1896), U.S. author
Next week
Dr. Carsten Sauer Mikkelsen, a dermatologist practicing in Denmark and Norway, discusses some of the challenges to managing the skin health of the Indigenous population in Greenland.
If you enjoy Skin Spectrum Weekly, why not check out the Chronicle’s other publications, podcasts, and portals?
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:
Dr. Jérôme Coulombe (Montreal) provides practical pearls for diagnosing bumps and masses in pediatric patients..
Drs. Mark Lupin (Victoria, BC), Ilya Shoimer (Calgary), and Michael Stevens (Halifax) review the treatments for actinic keratoses and basal cell carcinoma, including the importance of field treatments, new medications, and consideration in patients with skin of colour.
Dr. Ashfaq A. Marghoob (Long Island, NY) provides guided diagnoses of challenging melanomas.
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