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By 2042, more than 50 percent of the US population will have skin of color, according to the Skin of Color Society. What’s more, the prevalence of atopic dermatitis appears to be increasing among Blacks, Asians, and Pacific Islanders. Here, Candrice R. Heath, MD, an assistant professor of dermatology at Lewis Katz School of Medicine at Temple University in Philadelphia, discusses the nuances in diagnosing and treating atopic dermatitis in patients with dark skin tones. Dr. Heath recently served as moderator at the Skin of Color Society’s “Meeting the Challenge Summit: Diversity in Dermatology Clinical Trials,” which was held in Washington, D.C.

How does atopic dermatitis present in patients with dark skin tones?

Candrice R. Heath, MD: People of African descent have the highest atopic dermatitis prevalence and severity. In these patients, atopic dermatitis often presents with follicular papules, a violaceous hue instead of the commonly described erythematous color, nummular plaques, and hypopigmentation or hyperpigmentation. The presenting complaint in those with darker skin tones may be “dark marks.” The goal is to diagnose the underlying cause of the dyschromia.

It is worth noting that postinflammatory hyperpigmentation and postinflammatory hypopigmentation may be more distressing to the patient/family than the atopic dermatitis itself.

Why is atopic dermatitis more severe in Black and LatinX populations?

Dr. Heath: Patients with skin of color are more likely to be hospitalized with severe atopic dermatitis, have more substantial out-of-pocket costs, be underinsured, and have an increased number of missed days of work. Limited access to outpatient health care plays a role in exacerbating this health disparity. New research has highlighted perspectives that implicate access to quality health care, socioeconomic status (income, education), environment (pollution, housing), psychosocial stress, and more as upstream factors influencing AD severity and persistence among Black and LatinX populations.

Do these differences affect treatment decisions?

Dr. Heath: Treating atopic dermatitis aggressively in these patients is important because it limits post-inflammatory hyperpigmentation. Undertreatment or delayed treatment can lead to pigmentary changes or scarring. Skin discoloration may be more bothersome to people of color than the itch and inflammation. It can cause severe anxiety and distress.

Are we getting better at making sure all skin tones are well represented in textbooks, medical education, clinical trials, and AI tools?

Dr. Heath: The gaps are still tremendous, but awareness has increased. Darker-skinned individuals with atopic dermatitis, despite being affected more commonly, are among the lowest enrolled research participants.

What gaps remain? How can we help fill them?

Dr. Heath: We need to increase diversity in clinical trials, increase training for diagnosing and treating dermatological conditions in those with darker skin tones, improve early access to dermatology, and establish best practices for approaching patients with cultural humility.

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