Addressing Inflammatory Skin Conditions in Diverse Populations

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In this interview, Dr Nada Elbuluk discusses unique challenges in diagnosing and treating inflammatory skin conditions in patients with skin of color. She emphasizes the importance of recognizing different presentations, addressing cultural factors, and tailoring treatment approaches to manage both the primary disease and postinflammatory pigmentation.

The Dermatologist: What are some of the most common inflammatory skin conditions that affect individuals with skin of color, and how do their presentations differ from those in patients with lighter skin tones?

Dr Elbuluk: Many inflammatory disorders that we talk about in populations of color can happen to anyone, such as acne, atopic dermatitis, psoriasis, and seborrheic dermatitis. They are not necessarily unique to patients of color, but what is unique about them can be how they present. When you are evaluating these patients, you must make sure that you are reaching the right diagnosis because the conditions can look different across different skin colors. And the other important thing is the management approach, which can differ depending on the patient’s skin color or their hair type. For example, although acne is common to everybody, there are some unique considerations that happen with acne and darker skin, especially with the pigmentary sequela, so you may need to consider that in your management approach.

The Dermatologist: Can you provide an overview of the unique challenges and considerations when diagnosing and treating inflammatory skin conditions in skin of color compared to lighter skin tones?

Dr Elbuluk: One of the biggest challenges is that conditions can get underdiagnosed in terms of severity. For example, in patients with darker skin, conditions like atopic dermatitis or psoriasis can leave them with postinflammatory pigment change, usually hyperpigmentation. When a physician is first meeting a patient with these conditions and they see large, dark-brown patches and lichenified plaques, it can sometimes be hard to distinguish what is active disease vs what is chronic postinflammatory change. If you do not make that distinction correctly, you can think the patient has less active disease than they do, overestimating how much is postinflammatory hyperpigmentation and underestimating how much is active disease. And that leads to undertreatment of the condition. We see that sometimes there can be less systemic medications offered for some of these inflammatory conditions because it may be thought they are more localized than they are, but in many cases, patients do need more widespread therapy or systemic management to appropriately control all the disease they have. I think it is important to be able to make that distinction and ask about symptoms, as well as quality of life, because there is very high disease burden for a lot of these conditions in our populations of color.

Dispigmentation can be extremely distressing for patients because they have physical manifestations of their prior disease. You must think about both how to manage the active disease and then how to manage postinflammatory pigment alteration when you are treating populations with darker skin. Let patients know that it is a journey, but you are going to help them address both. This is important because sometimes patients are more bothered by the pigmentary change than the primary disease. Acne is a great example of using treatment approaches that can treat both. We have anti-inflammatory modalities to treat active acne that can also help with increasing skin cell turnover and melanin dispersion to address the hyperpigmentation from the acne as well.

The Dermatologist: In your experience, what cultural or societal factors influence the perception and management of inflammatory skin conditions among patients with skin of color and how do you address these factors in your practice?

Dr Elbuluk: When you are caring for diverse patient populations, many of them are coming from different racial and ethnic backgrounds. And with that can come different beliefs about Western medicine and different approaches to how to treat their conditions. Many people, depending on their background, may have home remedies, or Eastern medicine approaches, or holistic integrative-type approaches that they more traditionally use for treating their conditions. For many people in these populations, they have not seen a dermatologist, or they have underutilized dermatology as a specialty. By the time they do reach us, it is important that we first understand what their belief system is and what things they have tried, and then as we develop a treatment plan and go through a shared decision-making process, make sure we are recommending things they are comfortable with. Gauging someone’s health literacy and their comfort with treatments is imperative.

I find with some populations there can be higher mistrust of the medical system. With a systemic agent that may carry a higher side effect profile, it may be important to go into greater depth with the patient about why it is being recommended, what the benefits are for them, and why it is thought to be appropriate for their disease state. We can also think about how to integrate, if possible, some of the home remedies that are more comfortable for the patient if they are safe in conjunction with the treatment plan. Trying to find that balance is key.

The Dermatologist: What strategies or educational initiatives are essential for improving dermatologic care and outcomes for patients with skin of color who present with inflammatory skin conditions?

Dr Elbuluk: There is important education that can be done on both sides, physicians and patients. For physicians, it is about increasing awareness of some of the unique differences diagnostically and in the management approach, so they feel comfortable and culturally competent in treating diverse patient populations. For patients with skin of color, we need to educate them about these dermatologic conditions and when to see a dermatologist. As I mentioned earlier, there is underutilization of dermatology as a specialty, and many people just either do not realize they need to see a dermatologist, or they have difficulty accessing one. We want to ensure patients understand there are always ways to access dermatologic care and make it comfortable for them, so they feel when they are in the medical environment that they are being seen and heard and what is important to them is being considered in the treatment and management process.

The Dermatologist: Are there any tips or insights you would like to share with your dermatology colleagues regarding inflammatory skin conditions in patients with skin of color?

Dr Elbuluk: As physicians, we are all lifelong learners. I think it is helpful for all of us as we continue our practice to utilize journals, conferences, and other modalities to continue to stay up to date on the detailed information and nuances that are important to consider in the management of these patient populations.