In this video, Dr Todd Schlesinger emphasizes the importance of understanding the nuances of treating atopic dermatitis patients with skin of color.

Transcript: 

Hello, and thank you for joining us. My name is Todd Schlesinger, and I'm a board-certified dermatologist and clinical investigator. Today, I'd like to discuss diversity in atopic dermatitis.

We will talk about how atopic dermatitis can differ across patients with skin of color and how providers can offer a personalized approach when treating this disease. It's important to understand that racial and ethnic differences among patients can impact both the presentation of dermatologic disease and the treatment response. The classic morphology of atopic dermatitis, or AD, includes erythematous, scaley papules, and plaques involving flexural sites.

It's actually important not to always use the word erythematous because it really doesn't describe the color as well as using the word pink, or red, or deep red, or violaceous. However, this is based on historical observations from predominantly White patients and does not necessarily apply to diverse populations. The distribution of morphology of AD can vary depending on geography and patient population.

This is important because morphology variants can contribute to delays in diagnosis and/or underdiagnosis. Now, certain morphologies that are present in patients with skin of color can be culturally stigmatizing, which is something healthcare providers should be aware of. Some morphologies are found to be more common in skin-of-color patients, and these can include perifollicular accentuation, lichenoid papules, nummular or psoriasiform plaques, prurigo nodules, and xerosis. Lesions can be found more commonly on extensor areas versus the classic flexural sites. The characterization of atopic dermatitis can be challenging in skin-of-color patients, particularly when looking at erythema. Erythema can look violaceous, purple, or brown in these patients instead of pink or red.

Healthcare providers should consider other factors when evaluating erythema, such as warmth of skin, edema or swelling, and overlaying scale. Overall, there is a need to redefine the typical features of AD and diagnostic criteria to reflect the diversity shown across patient populations. An additional consideration when treating skin-of-color patients is that across many dermatologic conditions, it is often found that skin of color can be associated with an increased severity of disease. For example, skin-of-color patients often experience an increased itch burden from AD. Studies have also shown that skin-of-color patients have an increased prevalence of lichenification or atopic prurigo.

Now that we've reviewed some differences in disease presentation among patients with skin of color, let's talk about treatment considerations. While diverse patient populations are included with clinical trials for AD, the numbers are usually not statistically powerful enough to perform meaningful subgroup analysis to determine whether there is a relationship between race and ethnicity and the treatment response. However, certain older therapies have been noted to be more or less effective in skin-of-color patients.

Firstly, topical steroids have been shown to have similar efficacy across patient populations regardless of color of skin. However, high-potency topical steroids can cause hypopigmentation in skin of color. When thinking about treatment with light therapy, narrowband ultraviolet B requires greater doses in highly pigmented skin types.

Newer therapies are increasingly being studied in skin-of-color patients. Data presented at the American Academy of Dermatology over the past years has delved into the safety and efficacy of these newer therapies in skin-of-color patients.

Also, an important consideration when initiating a treatment regimen is a patient’s skincare routine. Many countries have developed their own guidance for bathing practices and the use of soaps, moisturizers, and other creams for patients with AD. For patients using traditional oral and topical herbal remedies, certain prescription medications can be added, but healthcare providers need to be aware that patients may be using these remedies alongside their prescribed treatments.

How can healthcare providers cater to diverse populations to be more inclusive of patient preferences and needs when treating atopic dermatitis? Healthcare providers need to understand that presentation of AD can vary in skin of color. The classic description of AD is not sufficient for all skin types.

Its distribution and morphology are often different across populations. One of the primary examples of this is erythema and how it can look drastically different depending on skin type. And we touched on this earlier, for skin-of-color patients often have more severe disease, something to take into account when discussing patient needs and devising a treatment plan. When selecting a treatment for patients, we should be aware that some standard treatments of AD have been shown to be more or less effective in skin-of-color patients. It's important to be mindful that therapies can affect different skin types differently.

Please also consider cultural practices such as skincare routines and use of herbal or traditional remedies. Patients may be using products that cause flare-ups or have the potential to negatively interact with a prescribed therapy.

Thank you so much for joining us today. We hope you took away some clinical pearls for your practice while considering diversity in atopic dermatitis.