INTRODUCTION
Atopic dermatitis (AD) is a chronic inflammatory condition affecting an estimated 129 million patients worldwide.1 The chronic relapsing disease is characterized by recurrent, spongiotic patches with ill-defined borders and persistent, intense pruritus. AD often presents in early childhood and frequently persists into adulthood, significantly impacting quality of life. Chronic complications may resemble other dermatologic conditions, including seborrheic dermatitis, ichthyoses, plaque psoriasis, and pityriasis rosea.2 Accurate diagnosis requires thorough history taking and differential diagnoses consideration, supported when necessary by skin biopsy.3 AD-induced hyperpigmentation, especially in higher Fitzpatrick skin types, is an underrecognized complication where patients routinely mistake pigmentary changes for persistent active disease, with significant clinical and psychosocial impact.
Post-inflammatory hyperpigmentation (PIH) in AD is a sequela that results from the chronic inflammation underlying AD. Few publications describe in detail the characteristic findings, duration, psychosocial impact, and the response to chronic pigmentary changes, even when new medications are administered. Recently, a case report focused on the reduction of PIH in one adult skin of color (SoC) patient with AD treated with dupilumab.4 Beyond AD, the VISIBLE study in psoriasis demonstrates the feasibility of intentional trial designs that capture historically underrepresented patients and SoC-relevant outcomes, including pigmentary changes.5,6
Patients with AD across all age groups, ethnicities, and Fitzpatrick skin types can experience PIH. Compared to Caucasian patients, African American and Hispanic patients are disproportionately affected by AD, and the clinical presentation may be more severe.7 SoC patients with AD are more likely to develop lichenification, prurigo nodularis, and "follicular lichenification" with firm papules or diffuse thickening with prominent skin markings.8,9 SoC patients may be delayed in referral to dermatology due to masking of the erythema associated with AD, resulting in delayed diagnosis and disease progression.10 Persistence of AD into adulthood is more common in children with SoC compared with non-Hispanic white children.11 While genetic predisposition may play a role, a variety of socioeconomic, environmental, and health care factors consistently influence AD severity, persistence, and prevalence among SoC patients.12
The literature discussing AD patients of diverse sex, gender, race, and ethnicity has been historically lacking. Less than 5% of publications in multiple high-impact dermatology journals focus on SoC populations.13 Underrepresentation leaves clinicians unprepared to manage AD in patients most affected by its severe manifestations. Additionally, current therapeutic guidelines for AD do not consider ethnicity despite important clinical differences.14
This discussion highlights the duration and distribution of AD-induced hyperpigmentation in higher Fitzpatrick skin types. PIH has been underappreciated in the medical literature, and these cases serve to emphasize its clinical significance, particularly in populations historically underrepresented in dermatologic research.
Post-inflammatory hyperpigmentation (PIH) in AD is a sequela that results from the chronic inflammation underlying AD. Few publications describe in detail the characteristic findings, duration, psychosocial impact, and the response to chronic pigmentary changes, even when new medications are administered. Recently, a case report focused on the reduction of PIH in one adult skin of color (SoC) patient with AD treated with dupilumab.4 Beyond AD, the VISIBLE study in psoriasis demonstrates the feasibility of intentional trial designs that capture historically underrepresented patients and SoC-relevant outcomes, including pigmentary changes.5,6
Patients with AD across all age groups, ethnicities, and Fitzpatrick skin types can experience PIH. Compared to Caucasian patients, African American and Hispanic patients are disproportionately affected by AD, and the clinical presentation may be more severe.7 SoC patients with AD are more likely to develop lichenification, prurigo nodularis, and "follicular lichenification" with firm papules or diffuse thickening with prominent skin markings.8,9 SoC patients may be delayed in referral to dermatology due to masking of the erythema associated with AD, resulting in delayed diagnosis and disease progression.10 Persistence of AD into adulthood is more common in children with SoC compared with non-Hispanic white children.11 While genetic predisposition may play a role, a variety of socioeconomic, environmental, and health care factors consistently influence AD severity, persistence, and prevalence among SoC patients.12
The literature discussing AD patients of diverse sex, gender, race, and ethnicity has been historically lacking. Less than 5% of publications in multiple high-impact dermatology journals focus on SoC populations.13 Underrepresentation leaves clinicians unprepared to manage AD in patients most affected by its severe manifestations. Additionally, current therapeutic guidelines for AD do not consider ethnicity despite important clinical differences.14
This discussion highlights the duration and distribution of AD-induced hyperpigmentation in higher Fitzpatrick skin types. PIH has been underappreciated in the medical literature, and these cases serve to emphasize its clinical significance, particularly in populations historically underrepresented in dermatologic research.
CASE PRESENTATION
This collection of cases illustrates PIH in a cohort of patients with AD aged 1 to 17 years, focusing on individuals with SoC. The pigmentary changes observed in this group varied both in morphology and in severity, with many of the hyperpigmented areas also manifesting lichen simplex chronicus.
Younger children (Figures 1-3) presented with scattered hyperpigmented macules and patches on the anterior, lateral, and posterior lower extremities. Hyperpigmentation persisting longer than the original spongiotic dermatitis was observed in each of these cases. Other areas with pigmentary changes included the dorsal hands and upper extremities. Adolescents (Figures 4-6) exhibiting PIH on the upper and lower extremities.
The hyperpigmented areas tend to be larger and more confluent than those in the younger cohort, often corresponding to regions of chronic AD involvement. A greater number of plaques related to the duration of chronic inflammatory changes in adolescents are seen compared to those plaques illustrated in the younger age groups.
Younger children (Figures 1-3) presented with scattered hyperpigmented macules and patches on the anterior, lateral, and posterior lower extremities. Hyperpigmentation persisting longer than the original spongiotic dermatitis was observed in each of these cases. Other areas with pigmentary changes included the dorsal hands and upper extremities. Adolescents (Figures 4-6) exhibiting PIH on the upper and lower extremities.
The hyperpigmented areas tend to be larger and more confluent than those in the younger cohort, often corresponding to regions of chronic AD involvement. A greater number of plaques related to the duration of chronic inflammatory changes in adolescents are seen compared to those plaques illustrated in the younger age groups.
