SOC. This nuance may indicate that the increased AD prevalence in African Americans is not fully explained by ancestry-related genetic effects.11,12 Multiple genes involved in epithelial barrier function and immune regulation are implicated in AD pathogenesis, which results from the synergistic effect of numerous genes.7
Racial/Ethnic Variations in Atopic Dermatitis Presentation
Although AD presents similarly across racial/ethnic groups as chronic and relapsing pruritic eczematous lesions, it can differ in clinical presentation and morphology in certain populations with SOC. AD may present as gray, hyperchromic, reddish-brown, or violaceous rather than bright red in patients of color.8 Furthermore, AD patients of color may show more frequent and prominent xerosis, pruritus, pigmentary sequelae (erythema and post-inflammatory dyspigmentation), follicular accentuation, lichenoid morphologies, and papulonodular presentations.7-9
Populations with SOC remain underreported and under-represented in dermatology and clinical trials.13-15 When reporting occurs, the racial/ethnic categorization and incorporation of the racial/ethnic data into the results are often lacking. The lack of diversity in AD clinical trials contributes to the lack of knowledge and documentation surrounding the various possible AD clinical manifestations on multiple skin tones, which may impact clinicians' ability to diagnose AD in patients of color. Recognizing differing AD clinical presentations, and disease course, including morphological variations in ethnically diverse patients is important for an accurate and early diagnosis, plus appropriate short- and long-term treatment.16
Atopic Dermatitis Impact on Quality of Life for Patients With Skin of Color
More pronounced AD clinical and morphological variations in patients of color may critically impact QoL.7-9 In populations with SOC, AD prevalence was shown to be higher, while disease control was poorer.12 Due to greater visibility in the context of darker skin, AD-associated xerosis and post-inflammatory dyspigmentation are more pronounced and stigmatizing in patients of color.7,9 The increased xerosis prevalence and severity in patients of color is likely due to racial/ethnic differences in skin barrier properties. One study in 311 American women from four ethnic groups (African-American, Caucasian, Chinese and Mexican) showed that the skin dryness index markedly increases in African-American and Caucasian groups, but not in Chinese and Mexican counterparts.17 Moreover, AD-related pruritus is more burdensome in patients of color due to potential scarring and lasting post-inflammatory dyspigmentation.7,9,18 For example, one study reported higher levels of pruritus-related burning and scarring, as well as greater emotional impact in patients of color.18 Another study reported children with SOC were more likely to be absent from school due to AD, which was not explained by sociodemographic factors, healthcare visits, and atopic comorbidities.19
Disturbing racial/ethnic disparities in health care utilization and access to standard-of-care therapies for AD have been identified in populations with SOC, impacting QoL.4-6,9,20,21 Additionally, structural racism likely has a significant impact on AD progression for patients of color.22 AD patients with SOC have reduced specialty care utilization and more frequent primary care, urgent care, emergency department, and hospital utilization.20-24 Among patients with AD, African-Americans are less likely than white to receive specialty care, such as a dermatologist.20,21,23,24 Thus, efforts to improve access to specialty dermatologic AD care are needed to potentially decrease healthcare costs and improve outcomes for populations with SOC.
Overall, AD impact on QoL in patients of color is significant compared to white counterparts due to the disease burden, potential long-lasting sequelae, and disparities in healthcare, which impose many barriers to proper treatment.
Skincare Management of Atopic Dermatitis in Patients With Skin of Color
Epidermal skin barrier dysfunction plays a key role in AD development, and various types of emollients are shown to prevent AD in both pediatric and adult patients.25-27 Maintaining an intact skin barrier by using gentle cleansers and moisturizers can attenuate AD by delaying or reducing flares.9,26 AD-associated hyperpigmentation is more frequent and pronounced in patients with SOC; however many hyperpigmentation treatments, such as hydroquinone, can be irritating in AD affected skin.9 Moreover, though effective, long-term continuous AD treatment with standard-of-care topical corticosteroids and calcineurin
