and associated postinflammatory pigment alteration in higher skin phototypes. In Black skin (populations of African descent), more frequent follicular accentuation, lichenoid morphologies, and papulonodular presentations may be seen.8
While data are limited, some studies have identified differences in skin barrier properties in racial/ethnic groups that may have implications for barrier function in the diverse spectrum of populations affected by AD.12 This project was conceived to summarize distinct features of AD in populations with SOC and provide recommendations on the role of skincare for treating AD in diverse populations.
While data are limited, some studies have identified differences in skin barrier properties in racial/ethnic groups that may have implications for barrier function in the diverse spectrum of populations affected by AD.12 This project was conceived to summarize distinct features of AD in populations with SOC and provide recommendations on the role of skincare for treating AD in diverse populations.
MATERIALS AND METHODS
The present study involved use of a modified Delphi communication technique for interactive decision-making for medical projects, adapted for a virtual platform from face-toface meetings.13,14 An expert panel of six dermatologists who commonly treat SOC patients with AD was virtually convened on May 15, 2021. In preparation for the meeting, a literature review was conducted on the management of AD in SOC patients with AD and the role skincare plays for AD treatment in different racial/ethnic populations.
Literature Review
Searches for English-language literature (2015– 2020) took place on April 12, 2021, on PubMed, with Google Scholar as a secondary source. The literature review gave priority to clinical studies published on SOC patients with AD; articles describing the current best practices in caring for AD in SOC patients; and recent clinical guidelines, consensus papers, and algorithms that specifically addressed these populations and skincare.
Excluded were duplications, articles of insufficient quality (small sample size, flawed methodology), and in the case of review articles, the most recent version was used. It is possible that small studies were included in the absence of studies involving larger patient populations.
Search terms used: Racial/ethnic differences in clinical presentation and sequela of AD; AD affected SOC barrier structure and function(s); Skin lipids and ceramides; Tolerance to treatment; Differences in expected treatment outcomes; Clinical and cultural significance of cleansers and moisturizers in the SOC individual and cleanser and moisturizer ingredients; OTC skincare, the efficacy; Safety; Tolerability; Skin irritation.
The searches yielded seventy-three papers deemed clinically relevant to inform current best practices in SOC patients with AD and skincare use. Unfortunately, robust comparative studies on skincare use for prevention, treatment, and maintenance of AD in SOC patients as monotherapies or adjuncts to prescription therapies are scarce and did not allow for a systematic review. However, the recommendations on skincare given in clinical guidelines, consensus papers, and algorithms available per region with different racial/ethnic populations provided valuable clinical information and were summarized.
However, the recommendations on skincare given in clinical guidelines, consensus papers, and algorithms available per region with different racial/ethnic populations provided valuable clinical information and were summarized.
Literature Review
Searches for English-language literature (2015– 2020) took place on April 12, 2021, on PubMed, with Google Scholar as a secondary source. The literature review gave priority to clinical studies published on SOC patients with AD; articles describing the current best practices in caring for AD in SOC patients; and recent clinical guidelines, consensus papers, and algorithms that specifically addressed these populations and skincare.
Excluded were duplications, articles of insufficient quality (small sample size, flawed methodology), and in the case of review articles, the most recent version was used. It is possible that small studies were included in the absence of studies involving larger patient populations.
Search terms used: Racial/ethnic differences in clinical presentation and sequela of AD; AD affected SOC barrier structure and function(s); Skin lipids and ceramides; Tolerance to treatment; Differences in expected treatment outcomes; Clinical and cultural significance of cleansers and moisturizers in the SOC individual and cleanser and moisturizer ingredients; OTC skincare, the efficacy; Safety; Tolerability; Skin irritation.
The searches yielded seventy-three papers deemed clinically relevant to inform current best practices in SOC patients with AD and skincare use. Unfortunately, robust comparative studies on skincare use for prevention, treatment, and maintenance of AD in SOC patients as monotherapies or adjuncts to prescription therapies are scarce and did not allow for a systematic review. However, the recommendations on skincare given in clinical guidelines, consensus papers, and algorithms available per region with different racial/ethnic populations provided valuable clinical information and were summarized.
However, the recommendations on skincare given in clinical guidelines, consensus papers, and algorithms available per region with different racial/ethnic populations provided valuable clinical information and were summarized.
RESULTS
The advisors agreed on five statements for insights and recommendations for treating AD in SOC patients.
Statement 1: AD is a common chronic inflammatory skin disease with a multifactorial pathogenesis that includes genetic (eg, filaggrin mutations), immunologic, and environmental factors. These factors may vary among diverse populations.
The pathogenesis of AD includes genetic and environmental factors that may vary among different racial/ethnic and geographic populations. A literature review on clinical and molecular features of AD in populations of diverse ethnic/racial backgrounds found differences in filaggrin (FLG) loss-of-function mutations across various ethnic groups with AD.7 The authors noted that studies in European American compared to Asian American AD populations have consistently shown a higher prevalence of FLG loss-of-function mutations of up to 50% of European and 27% of Asian American patients, respectively.7,8 They further suggested that the association between FLG lossof- function mutations and AD development in populations of African descent is unclear. Other genes may be involved in skin barrier dysfunction in Black populations with AD.8
Statement 2: Clinical and morphological differences of AD in patients with SOC have been described, including the presence of follicular/perifollicular papules and xerosis in Black AD patients, which can be culturally stigmatizing.
AD presents clinically as relapsing erythematous and pruritic patches of skin with varying severity; some features may be more or less prominent in patients with darker skin.8,15,16 Patients with more pigmented skin may present with variations in the appearance of erythema. In particular, AD lesions may appear reddish-brown, violaceous, gray, or deeply pigmented (hyperchromic) rather than bright red. (ie, in some SOC populations such as patients of African descent, lesions may present more frequently on extensor areas than the typical flexural lesions in the lighter skin types).8,16
Pruritus may be more frequent and severe in specific SOC populations; however, this data is from AD patients of Asian and African descent living in the US and Europe.17 Some authors suggest that this is important because the prevalence of AD in SOC populations living in the US and Europe seems to involve a complex interplay of, duration of residence in the immigrated nation, age at time of immigration, and diversity of heritage (with lower prevalence of atopic diseases in mixed-race individuals).18
Statement 1: AD is a common chronic inflammatory skin disease with a multifactorial pathogenesis that includes genetic (eg, filaggrin mutations), immunologic, and environmental factors. These factors may vary among diverse populations.
The pathogenesis of AD includes genetic and environmental factors that may vary among different racial/ethnic and geographic populations. A literature review on clinical and molecular features of AD in populations of diverse ethnic/racial backgrounds found differences in filaggrin (FLG) loss-of-function mutations across various ethnic groups with AD.7 The authors noted that studies in European American compared to Asian American AD populations have consistently shown a higher prevalence of FLG loss-of-function mutations of up to 50% of European and 27% of Asian American patients, respectively.7,8 They further suggested that the association between FLG lossof- function mutations and AD development in populations of African descent is unclear. Other genes may be involved in skin barrier dysfunction in Black populations with AD.8
Statement 2: Clinical and morphological differences of AD in patients with SOC have been described, including the presence of follicular/perifollicular papules and xerosis in Black AD patients, which can be culturally stigmatizing.
AD presents clinically as relapsing erythematous and pruritic patches of skin with varying severity; some features may be more or less prominent in patients with darker skin.8,15,16 Patients with more pigmented skin may present with variations in the appearance of erythema. In particular, AD lesions may appear reddish-brown, violaceous, gray, or deeply pigmented (hyperchromic) rather than bright red. (ie, in some SOC populations such as patients of African descent, lesions may present more frequently on extensor areas than the typical flexural lesions in the lighter skin types).8,16
Pruritus may be more frequent and severe in specific SOC populations; however, this data is from AD patients of Asian and African descent living in the US and Europe.17 Some authors suggest that this is important because the prevalence of AD in SOC populations living in the US and Europe seems to involve a complex interplay of, duration of residence in the immigrated nation, age at time of immigration, and diversity of heritage (with lower prevalence of atopic diseases in mixed-race individuals).18
