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Featured Article

SKIN SPECTRUM™ QUARTERLY  FEATURED CASE REPORT 

Atopic Dermatitis in Skin of Color

Adhora Mir, MD1 Hailey Land, RN, BScN1 Reetesh Bose, MD, FRCPC1,2 Samira Jeimy3,4, MD, PhD, FRCP

1. Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

2. Division of Dermatology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada

3. Division of Clinical Immunology & Allergy, Department of Medicine, Western University, London, Ontario, Canada

4. Division of Clinical Immunology & Allergy, Department of Medicine, Lawson Health Research Institute, London, Ontario, Canada

Funding sources: None

Conflicts of Interest:

Samira Jeimy has been a member of advisory boards for Sanofi Genzyme, GSK, and ALK, received honoraria for speaking engagements from GSK and L’Oréal, and provided consultancy services for the Canadian Agency for Drugs and Technologies in Health. Dr. Jeimy has leadership roles with the Ontario Medical Association and the Canadian Society of Allergy and Clinical Immunology.

Patient consent: provided

KEY WORDS: atopic dermatitis, eczema, management, skin of color

A nine-year-old male with Fitzpatrick phototype V skin, presented with a violaceous rash of the extensor and flexor surfaces, as well as the shoulder.

Patients with skin of color (SOC) often present with different clinical features of atopic dermatitis (AD) than seen in Caucasian skin types, which may complicate accurate diagnosis and management. The dermatitis can be more violaceous, have a follicular phenotype, and be at higher risk for earlier and more severe post-inflammatory dyspigmentation.1 Black patients can present with greater extensor involvement and Asian patients may present with psoriasiform morphology. Current assessment tools, particularly those reliant on grading erythema, may not effectively diagnose or stratify AD severity in SOC patients due to under-appreciated clinical presentations and bias in AD scoring systems.2 This contributes to healthcare inequity. SOC patients have a disproportionate risk of negative impact on quality of life, increased risk of hospitalization with severe AD, and more missed work days related to atopic dermatitis.3 

There is persistent under-representation of SOC patients in atopic dermatitis trials. In a review of 27 Phase 2 and Phase 3 randomized control trials for atopic dermatitis (spanning 2009 to 2019), only 16.2% enrolled patients identified as Asian and 8.9% as Black.4

While darker skin types are predominant globally and ever-increasing in Canada, the lack of SOC representation in medical textbooks and curricula have been implicated in the propagation of bias contributing to worse treatment, patient satisfaction, and outcomes.5 Several resources can help clinicians in management of AD in SOC, including The Skin of Color Society, and content through the American Academy of Dermatology and Canadian Dermatology Association.

References

1.  Gan C, Mahil S, Pink A, Rodrigues M: Atopic dermatitis in skin of colour. Part 2: Considerations in clinical presentation and treatment options. Clinical and Experimental Dermatology Oct. 2023; 48(10):1091–1101. https://doi.org/10.1093/ced/llad162

2.  Ben-Gashir MA, Hay RJ: Reliance on erythema scores may mask severe atopic dermatitis in black children compared with their white counterparts. British Journal of Dermatology 2002; 147(5):920–925. https://doi.org/10.1046/j.1365-2133.2002.04965.x

3.  Narla S, Hsu DY, Thyssen JP, Silverberg JI: Predictors of hospitalization, length of stay, and costs of care among adult and pediatric in-patients with atopic dermatitis in the United States. Dermatitis 2018; 29(1):22–31. https://doi.org/10.1097/DER.0000000000000323

4.  Price KN, Krase JM, Loh TY, Hsiao JL, Shi VY: Racial and ethnic disparities in global atopic dermatitis clinical trials. British Journal of Dermatology 2020; 183(2):378–380. https://doi.org/10.1111/bjd.18938

5.  Perlman KL, Klein EJ, Park JH: Racial disparities in dermatology training: the impact on black patients. Cutis 2020; 106(6):300–301. https://doi.org/10.12788/cutis.0135

Challenges in Dermatologic Care for Diverse Populations

Research highlights several systemic challenges in providing equitable dermatologic care:

• Diagnostic Difficulties: Visual cues for inflammation, such as erythema (redness), are often subtle or absent in darker skin tones, leading to delayed or missed diagnoses.

• Treatment Disparities: Therapeutic approaches effective in Caucasian skin may not be equally efficacious or may carry different risks (e.g., dyspigmentation) in skin of colour.

• Underrepresentation in Research and Education: Historically, clinical trials and medical textbooks have lacked adequate representation of diverse skin types, perpetuating a knowledge gap among practitioners. This also extends to the lack of dermatologists from underrepresented racial and ethnic groups, which can impact access to care and patient comfort.

• Socioeconomic and Cultural Factors: Access to specialized care, cultural beliefs about health and illness, and socioeconomic determinants of health all play a significant role in dermatologic outcomes across different ethnicities.

What You Will Find on this Portal

The Skin Spectrum Quarterly™ online portal offers a rich array of content designed to meet the needs of busy practitioners and researchers:

• Original Research: Peer-reviewed articles presenting novel findings on dermatologic conditions in various ethnic groups.

• Review Articles: Comprehensive syntheses of existing literature, offering in-depth perspectives on specific topics in ethnodermatology.

• Clinical Observations and Case Studies: Practical insights derived from real-world clinical experience, highlighting diagnostic pearls and management strategies for challenging cases.

• Expert Commentaries: Perspectives from leading experts in the field, offering critical analysis and future directions.

• Educational Resources: Access to supplementary materials, webinars, and continuing medical education (CME) opportunities focused on ethnodermatology.

We invite all international dermatologists to explore skinspectrum.co and ethnodermatology.com. Join us in our mission to advance the science and practice of ethnodermatology, ensuring that every patient, regardless of their ethnic background or skin type, receives the highest standard of dermatologic care.

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