More pruritus in AD in dark skin
Itch, and pigmentation changes are more common and severe in skin-of-colour patients (Issue #218; 1,500 words; 8 minutes)
Dr. Monica Li told the 2024 Colloquium on the Black Patient in Dermatology on Aug. 17, 2024, that variations across racial and ethnic groups in skin barrier structure and function can influence how atopic dermatitis (AD) affects different populations.
Dr. Li [pictured below] is a double board-certified, fellowship-trained dermatologist in Canada and the United States and a clinical assistant professor in the Department of Dermatology & Skin Science at the University of British Columbia in Vancouver.
Dr. Li said there are differences in the skin barrier in different ethnic groups. Those with Black skin have lower levels of ceramides than people of Asian or European descent.
In skin-of-color patients, AD may not present with pinkish papules or plaques, said Dr. Li. Instead, it may present with dyspigmentation and signs of excoriation. Instead of pink or red erythema, physicians may see reddish-brown, violaceous, grey, or even deeply pigmented lesions. There may be follicular accentuation or lichenification. Sequelae such as post-inflammatory dyspigmentation may be more prominent. AD may present on extensor areas in darker-skinned patients rather than on flexor areas as in White patients.
Dr. Li said pruritus is often more severe in darker-skinned patients. Because of this, Black patients are more likely to scratch and develop prurigo nodularis. Chronic scratching in darker-skinned patients can lead to extensive and severe hyperpigmentation and even hypopigmentation, which can last for months or even years. Chronic excoriation can even lead to permanent dyspigmentation.
Pruritus may be more prominent and accentuated in these populations because mast cells in Black skin are larger, the pH of the stratum corneum tends to be lower, and there can be more significant transepidermal water loss, said Dr. Li. These skin differences mean Black patients are more likely to develop chronic pruritic disorders such as AD, prurigo nodularis, or cutaneous T cell lymphoma.
Bottom line: Because of structural and other differences in darker skin types, atopic dermatitis can present visibly differently and with more frequent and severe pruritus. This pruritus can lead to excoriation and lichenification, or even permanent dyspigmentation. Black patients are at elevated risk of developing chronic pruritic disorders.
From the literature on atopic dermatitis in skin of colour
Response to biologic therapy in skin-of-colour participants with moderate-to-severe psoriasis and atopic dermatitis: A systematic review
This systematic review summarized and identified if biologic treatment outcomes in moderate-to-severe atopic dermatitis and psoriasis varied in skin-of-colour (SOC) participants in phase III trials.
Investigators screened 3,209 articles from the MEDLINE, COCHRANE, and EMBASE databases and selected studies comprising 1,781 SOC participants. The mean participant age was 40.99±6.3 years 30.6-51.6 years). Male participants accounted for 76.9% (n=1370/1781) of the sample, and Chinese, Japanese, Taiwanese, and Korean participants accounted for 64.3%, 24.2%, 4.5%, and 3.4% of participants, respectively.
Participants with atopic dermatitis were treated with dupilumab (n=216/388), and participants with psoriasis were treated with adalimumab (n=313/1393), bimekizumab (n=62/1393), ixekizumab (n=13/1393), secukinumab (n=117/1393), and ustekinumab (n=289/1393).
The authors found no significant SOC population-based outcomes across treatment groups. However, they did observe differences in baseline characteristics or comorbidities, which suggests race or ethnic background should be considered when treatment is prescribed for psoriasis or atopic dermatitis.
Although investigators found no significant differential response to treatment among SOC participants, they conclude large-scale randomized controlled trials investigating comparable treatment outcomes and stratifying results by SOC population in atopic dermatitis and psoriasis are warranted to confirm their findings.
Safety and tolerance evaluation of a suncare product in ethnically diverse children with atopic dermatitis-prone skin
The authors of this paper note that while sun protection is important for children with eczema and AD-prone skin, some sunscreens can cause skin irritation due to their formulations.
In this study, researchers evaluated the safety and tolerance of an SPF 50 sunscreen in ethnically diverse children with a history of atopic dermatitis (AD) over four weeks.
A total of 45 children were included in the study. The participants had diverse racial or ethnic backgrounds (skin phototypes I-VI), were aged three to 12, and had a history of eczema and perceived sensitive skin.
All participants applied sunscreen daily on the face and body, at least 15 minutes before sun exposure and as needed. After four weeks, the participants and a dermatologist evaluated tolerability. Parents and guardians of pediatric participants also completed product performance questionnaires.
After four weeks of sunscreen application, tolerability assessments reported no skin dryness, peeling, erythema, or edema. Parent/guardian evaluations of sunscreen tolerability for their child revealed no perceived skin issues.
The parents and guardians reported that sunscreen application on children was smooth and even, with the absence of a white cast appearance on children with skin of colour.
Moving beyond biology: The critical role of social and structural determinants in atopic dermatitis
The authors of this review article note that while genetics and pathophysiology are crucial to understanding atopic dermatitis (AD), there is emerging evidence that social and structural determinants of health strongly influence the condition's onset, severity, and outcomes. Factors such as economic stability, education quality and access, healthcare quality and access, neighbourhood environment, and social and community context shape individual risk and disease experience. Structural determinants, including government processes, economic policies, social and public policies, and cultural and societal values, also directly and indirectly influence AD outcomes.
This review synthesizes current knowledge on the impacts of social and structural determinants of health on AD incidence, severity, and disparities.
In their conclusions, the authors say that embracing a biopsychosocial model is crucial to explaining the causes, epidemiology, and optimal management of AD. They suggest that future research adopt a holistic approach, moving beyond a purely biological perspective to consider the intricate interplay of social and structural determinants in understanding and managing AD.
VIDEO: Eczema symptoms and itch are worse in dark skin | Dr. Shawn Kwatra
Dermatologist Dr. Shawn Kwatra, Chair of the University of Maryland’s Department of Dermatology, discusses research on the differences in atopic dermatitis symptoms in darker-skinned patients.
At the intersection of skin and society
On Sept. 25, 2024, the Calgary Police Service released new race-based data as part of new processes to track various forms of contact between officers and members of the public explicitly measured by race, reports CBC News.
The data includes race-based information, including missing persons, officer contacts, victims of violent crime, offenders of violent and property crime, and use of force.
According to the news outlet, the report highlights trends by applying the concepts of disproportionality and disparity to interactions with police compared to the percentage of the same racial group in Calgary's population from the 2021 Statistics Canada census.
The news report quotes Heather Campbell, chair of the Calgary Police Commission’s finance and audit committee: “These are data that I've been asking for since I was appointed to commission in 2020.”
Race data was obtained from the Calgary Police Service's (CPS) records management system, where police officers input interactions that require documentation. Importantly, the race information is based on the officer's perception and not self-identification, and officers are not mandated to include race information when submitting reports, CBC reports.
Additionally, race data that had what CPS describes as "conflicting race descriptions"—such as race collected as White on one record and Indigenous in another—was reported under the "racially ambiguous" category.
A spokesperson for CPS emailed the news agency, noting that, on average, 63% of officers across all categories provided race data.
Some key findings from the report include:
Indigenous and Black individuals are disproportionately affected when compared to the population of Calgary's Black and Indigenous communities in categories such as officer contacts, police use of force, as well as both victims and offenders of crime
Indigenous persons are 2.5 times overrepresented as victims of violent crime
Young people aged between 12 and 17 are heavily overrepresented in missing persons reports
Female Indigenous youth, particularly those with a repeated history of going missing, are the most overrepresented group in the missing person d.ata.
The CPS acknowledged that the data has limitations that require its findings to be understood in the context of how it was collected. The organization says it recognizes that this data alone is not representative of the whole picture or personal lived experiences.
Register now for GLIDE 6.0
The Great Lakes Immunodermatology Exchange (GLIDE) 6.0 meeting will be held on Nov. 1 and 2, 202,4, at the Queen’s Landing Hotel in Niagara-on-the-Lake, Ont.
GLIDE is a forum featuring renowned experts in immunodermatology. The meeting provides an opportunity for community and academic dermatologists from Ontario and Canada to benefit from expert insight and opinion and discuss best practices and clinical issues with their peers and international opinion leaders in immunodermatology.
The theme of GLIDE 6.0 is “Immunodermatology: It’s Complicated.”
Drs. Neil Shear (Toronto) and Perla Lansang (Toronto) will co-chair the event, which will include presentations covering topics such as JAK inhibitors, Severe Cutaneous Adverse Reactions (SCARs), itch, artificial intelligence, skin of colour, interpreting data, and other highly relevant topics in immunodermatology.
Registration and more details for the meeting are available at this link.
This week
October is Canadian Islamic History Month
October is National Disability Employment Awareness Month in the U.S.
Oct. 7 is Child Health Day in the U.S.
Something to think about in the week ahead . . .
—T. S. Eliot, U.S. poet (1888 to 1965)
Next week
Skin Spectrum Weekly covers recent research into the safety and efficacy of picosecond Q-switched Nd-YAG lasers for the removal of black tattoos in Middle Eastern patients with Fitzpatrick skin type IV.
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Dr. Geeta Yadav (Toronto) advises on managing melasma using fractionated lasers.
Drs. Andrei Metelitsa (Calgary), Lisa Kellett (Toronto), and Vince Bertucci (Woodbridge, Ont.) review new and upcoming soft tissue filler products that may benefit Canadian practitioners.
Dr. Zaki Taher (Edmonton) shares his thoughts on the importance of lasers, radiofrequency microneedling, and platelet-rich plasma treatments in a cosmetic dermatology practice.
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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 vitamin D influences psoriasis severity, sex differences in psoriatic inflammation itch, and the risk of psychiatric disorders associated with acitretin.
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