Presentation of Eczema in Skin of Color

Each month The Dermatologist features news, research, and key players in the area of eczema research.

In this article, which originally appeared on the National Eczema Association online magazine EczemaMatters.org, Bridget Kaufman, MD, and Andrew Alexis, MD, MPH, discuss how atopic dermatitis can look different on a range of skin tones, and how research is showing that certain ethnic groups are more at risk. They share some frequently asked questions and provide answers dermatologists and their staff can share with patients. 

While atopic dermatitis (AD) can affect anyone, research suggests that certain ethnic groups are at greater risk. The National Health and Nutrition Examination Survey, which evaluates the health and nutritional status of adults and children in the United States, found that 19.3% of African American children have AD compared to 16.1% of white and 7.8% of Asian children. Another study found that African-American children are 1.7 times more likely to develop AD than white children. 

AD typically begins during infancy and early childhood (before age 5), but adults may also develop this condition. Adult-onset disease appears to be more common in Asian than Western countries. 

Often patients have questions regarding eczema in skin of color. Here are some common questions from patients and the answers. Dermatologists can share the following information with their patients. 

Why are certain ethnic groups at greater risk for eczema?

Genetic and environmental factors influence one’s risk of developing AD. Typically, those with a family history of AD or other atopic diseases (asthma, hay fever) are more likely to have the condition.

This is because certain genetic mutations that affect the skin barrier cells and skin immune cells are passed from generation to generation. These mutations also tend to occur more often in some ethnic groups compared to others, which may help explain differences in the frequency and severity of eczema between whites, African Americans, Asians, Hispanics, and others.

In addition, people who live in an urban setting or are exposed to certain environmental allergens (ie, dust, mold) are at greater risk of developing AD.

What does eczema look like in darker skin?

Most people think of eczema as a red, dry, and itchy rash—how it appears in light skin. However, in brown or black skin, this redness may be difficult to see. Eczema tends to look darker brown, purple, or ashen grey in color. In the absence of characteristic redness, skin swelling, warmth, dryness/scaling, or itching may help patients and physicians confirm the diagnosis. The itching due to eczema has been shown to have a greater impact in African American patients. African Americans are also more likely to have severe disease (Figure).

Beyond differences in severity, color, and symptoms, unique forms of AD may be seen in darker skin. African Americans more commonly develop papular eczema or small bumps on the torso, arms, and legs. Sometimes, follicular accentuation or bumps develop around hair follicles and resemble goosebumps. 

African Americans also tend to have more extensive skin dryness and dark circles around the eyes. Those who repeatedly rub and scratch the eczema-prone areas may develop skin thickening and firm, raised bumps on the skin called prurigo nodules.

Following resolution of eczema, darker-skinned patients experience a greater rate of pigmentary changes. The healed skin may look darker or lighter than the surrounding normal skin. In some patients, this color change is more bothersome than the original eczema itself. Fortunately, once the eczema is controlled, the skin color typically returns to normal. This may take several months.

How is eczema treated in darker skin?

The treatment of eczema is similar in people of all races and ethnicities. Gentle skin care and liberal use of moisturizers is the mainstay of treatment. For some patients, topical or systemic medications may be needed.

Atopic skin tends to be dry and sensitive, so harsh and fragranced skin care products should be avoided to prevent worsening of AD. Increasing the moisture content of the skin is also essential. Fragrance-free emollients should be used at least once per day, ideally immediately after bathing. Thicker moisturizers, such as creams and ointments (rather than lotions), tend to work better. Shea butter is a useful natural alternative to commercially available moisturizers.

Further, eczema patients should bathe and shower in warm (not hot) water and limit the time to less than 10 minutes. Hot water can dry out the skin and trigger itching, making eczema worse. This tends to be particularly problematic in darker- skinned patients who may be more prone to dry, itchy skin.

Prescription medications may also be needed to adequately control eczema. Topical corticosteroids are typically the first-line treatment but are generally used for limited periods of time. Nonsteroid creams and ointments such as pimecrolimus (Elidel), tacrolimus (Protopic), and crisaborole (Eucrisa) may also be prescribed. These medications are highly effective and safe for use in all skin types.

In severe cases, eczema may be treated with phototherapy (light-based treatments) or systemic medications that target the immune system. These treatments may be pills or injections. Like topical treatments, these more aggressive therapies are safe and effective in diverse ethnic groups.

In general, some herbal and traditional remedies for eczema have the potential to make eczema worse through skin irritation or allergy. Additionally, many herbal products have not been studied, and their side effects are largely unknown. 

Points to Remember

• Eczema affects people of all races and ethnicities but appears to be more common in African Americans.
• Redness may be obscured in darker skin types, making areas of eczema look more brown, purple, or grey in color.
• Genetic and environmental factors influence one’s risk of developing AD and may explain differences in the frequency of this condition between ethnic groups.
• Liberal use of moisturizers and short, warm (rather than hot) baths and showers are essential for managing eczema.
• Topical, oral, and injectable medications for AD are effective and safe for use in all skin types. 

Dr Kaufman is a dermatopharmacology fellow at Mount Sinai Health System in New York, NY.

Dr Alexis is chair of the department of dermatology at Mount Sinai St. Luke’s and Mount Sinai West in New York, NY. He is also associate professor of dermatology at the Icahn School of Medicine at Mount Sinai. As Director of the Skin of Color Center, he is actively involved in advancing patient care, research, and education pertaining to dermatologic disorders that are prevalent in ethnic skin.