Atopic dermatitis in colored skin

Atopic dermatitis (AD) presents differently in patients with skin of color (SOC) compared to lighter skin. This difference in presentation may be a cause of genetic factors, phenotypes and histological variations and may lead to misdiagnosis in SOC patients. The way to combat this is to recognize the clinical variation of AD in SOC and then develop strategies for this group of patients, according to a breakfast product theater at the Society of Dermatology Nurse’s 3rd Annual Symposium. Practitioners, sponsored by Sanofi and Regeneron Pharmaceuticals.1

There are few studies that have investigated the epidemiological differences between SOC and lighter skin. In phase 2 and phase 3 clinical trials for AD, between the years 2009 and July 2019, 54% of enrolled patients identified as white.2 Additionally, 8.9% identified as Black, 16% Asian, and 20.5% were other/unspecified. This demonstrates the lack of diversity in clinical trials for Alzheimer’s disease, according to the session.

Even in medical school and residency, depending on where healthcare professionals practice, there can be a lack of knowledge about COS. This can result in delayed treatment for patients of color (POC) and increased morbidity or mortality due to this delay. Compared to white patients, black patients were 3 times more likely to be diagnosed with AD, and Asians or Pacific Islanders were 7 times more likely.3

Alzheimer’s disease may also have a greater negative impact on quality of life (QOL) in SOC patients than their lighter-skinned counterparts and black patients had more doctor visits for Alzheimer’s disease. Alzheimer’s than white patients.4-6 Additionally, pediatric patients with OSC are more likely to have persistent AD and white patients are more likely to have controlled disease than black patients.7.8

Why could this be? It could be genetic variations such as filaggrin null (FLG) mutations that could contribute to skin barrier dysfunction. This mutation may be different depending on the race of the patient.9 Patients should be tested to determine if a mutation is present and that doesn’t always happen, according to the SDNP session. Additionally, black patients are 6 times less likely to be tested for mutations than white patients.ten

There might also be immunophenotypic variations between AD patients of different races.

The way Alzheimer’s disease presents is different in different skin tones and can be confusing for those who don’t have much experience with darker skin types. Black patients may be at higher risk for transepidermal water loss (TEWL) causing dry skin which has been studied in several small trials. This increased risk of dry skin would be consistent with a higher prevalence of AD.11

Beyond the examination and proper diagnosis of the disease, there is often an underestimation of the severity of AD in patients with COS.11 This difficulty could be due to the way erythema appears dark purple on darker skin types. Missing this key symptom can lead to more serious illness.11-13

Topical cortisone steroids (TCS) are a common way to treat AD, but this treatment can lead to other skin problems such as hypopigmentation in the SOC, especially in the black population. This may dissipate with discontinuation of treatment, but indicates a need for different treatment methods for COS.12,14,15

When treating AD in patients with darker skin, key pearls to keep in mind include8,11,12:

  • Long-term use of TCS may worsen hypopigmentation in darker skin tones
  • Higher doses of narrowband UVB are needed to treat skin with darker pigmentation
  • Delayed diagnosis and treatment may lead to greater severity of AD in SOC patients
  • Self-identified black patients may have poorer disease control than white patients
  • More data on the effectiveness of AD treatments in the SOC population are needed

References:

  1. Shades of atopic dermatitis in colored skin. Sponsored by Sanofi and Regeneron Therapeutics. Presented at: Society of Dermatology Nurse Practitioners Annual Symposium; April 22-23, 2022; Nashville, Tennessee.
  2. Price KN, Krase JM, Loh TY, Hsiao JL, Shi VY. Racial and ethnic disparities in global clinical trials for atopic dermatitis. Br J Dermatol. 2020;183(2):378-380. doi:10.1111/bjd.18938
  3. Shaw TE, Currie GP, Koudelka CW, Simpson EL. Prevalence of eczema in the United States: data from the 2003 National Survey of Children’s Health. J Invest Dermatol. 2011;131(1):67-73. doi:10.1038/jid.2010.251
  4. Wan J, Margolis DJ, Mitra N, Hoffstad OJ, Takeshita J. Racial and ethnic differences in school absences linked to atopic dermatitis in us children. JAMA Dermatol. 2019;155(8):973. doi:10.1001/jamadermatol.2019.0597
  5. Poladian K, De Souza B, McMichael AJ. Atopic dermatitis in adolescents with colored skin. Cutis. 2019; 104(03):164-168.
  6. McGregor SP, Farhangian ME, Huang KE, Feldman SR. Treatment of atopic dermatitis in the United States: analysis of data from the National Ambulatory Medical Care Survey. J Drugs Dermatol. 2017;16(3):250-255.
  7. Kim Y, Blomberg M, Rifas-Shiman SL, et al. Racial/ethnic differences in the incidence and persistence of childhood atopic dermatitis. J Invest Dermatol. 2019;139(4):827-834. doi:10.1016/j.jid.2018.10.029
  8. Abuabara K, You Y, Margolis DJ, Hoffmann TJ, Risch N, Jorgenson E. Genetic ancestry does not explain increased susceptibility to atopic dermatitis or worse disease control in African American subjects in 2 large cohorts Americans. J Allergy Clin Immunol. 2020;145(1):192-198.e11. doi:10.1016/j.jaci.2019.06.044
  9. Park J, Jekarl DW, Kim Y, Kim J, Kim M, Park YM. New FLG null mutations in Korean patients with atopic dermatitis and comparison of mutational spectra in Asian populations. J. Dermatol. 2015;42(9):867-873. doi:10.1111/1346-8138.12935
  10. Margolis DJ, Apter AJ, Gupta J, et al. The persistence of atopic dermatitis and filaggrin (Flg) mutations in a US longitudinal cohort. J Allergy Clin Immunol. 2012;130(4):912-917. doi:10.1016/j.jaci.2012.07.008
  11. Vachiramon V, Tey HL, Thompson AE, Yosipovitch G. Atopic dermatitis in African American children: addressing the unmet needs of a common disease. Pediatr Dermatol. 2012;29(4):395-402. doi:10.1111/j.1525-1470.2012.01740.x
  12. Kaufman BP, Guttman-Yassky E, Alexis AF. Atopic Dermatitis in Various Racial and Ethnic Groups – Variations in Epidemiology, Genetics, Clinical Presentation and Treatment. Exp Dermatol. 2018;27(4):340-357. doi:10.1111/exd.13514
  13. Ben-Gashir MA, Seed PT, Hay RJ. Quality of life and disease severity are correlated in children with atopic dermatitis. Br J Dermatol. 2004;150(2):284-290. doi:10.1111/j.1365-2133.2004.05776.x
  14. Eichenfield LF, Stein Gold LF. Addressing the immunopathogenesis of atopic dermatitis: advances in topical and systemic treatment. Semin Cutan Med Surg. 2017;36(2 Supplement 2):S45-S48. doi:10.12788/j.sder.2017.012
  15. Hengge UR, Ruzicka T, Schwartz RA, Cork MJ. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol. 2006;54(1):1-15; quiz 16-18. doi:10.1016/j.jaad.2005.01.010

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