Shifting the Perspective: Addressing Social Determinants and Pigmentary Impact in Atopic Dermatitis

In her presentation “Viewing Atopic Dermatitis Through a Different Lens,” Candrice Heath, MD, FAAD, an associate professor of dermatology at Howard University, used atopic dermatitis (AD) as a case study to examine how social determinants of health (SDOH), skin tone diversity, and structural inequities influence overall disease burden, treatment access, and outcomes. Speaking from her experience as both an adult and pediatric dermatologist, Dr. Heath, challenged attendees of the Society of Dermatology Physician Associates (SDPA) 2025 summer conference to recognize and act on the broader context of recognizing individual patient lives and the experiences in which patients live and manage chronic skin conditions.

AD Burden in Children of Color

AD remains one of the most common dermatologic conditions, with 25% of U.S. children affected. It is particularly prevalent in children with skin of color, who also experience more persistent and treatment-resistant disease. Citing data from the National Health Interview Survey, Dr. Heath emphasized that hospitalized pediatric AD patients are disproportionately non-white and Medicaid recipients. She also highlighted epidemiologic research indicating that non-Hispanic Black and Hispanic children are more likely to have persistent forms of AD that extend beyond early childhood.

"As a pediatric dermatologist, having a patient land in the hospital for severe atopic dermatitis feels like a failure," she said in her presentation. "We have effective treatments—so we have to ask why this is still happening."

Dr. Heath noted that African genetic ancestry was not found to independently correlate with AD risk or disease control, suggesting other factors contribute to these disparities. Among them: stressors such as living in under-resourced or perceived unsafe neighborhoods, exposure to pollutants, and crowding.

"What we're really seeing is the impact of the environment and the systems patients live in,” she explained.

The Legacy of Race

Dr. Heath encouraged attendees to rethink “race” in dermatology not as a biological determinant but a social construct with real consequences.

"Race is made up. It’s not science-based," she said. "But because of how society perceives it, it creates real, devastating effects—on income, education, housing, and yes, health outcomes."

Dr. Heath focused specifically on how the legacy of structural racism, including redlining and educational disparities, continues to restrict access to quality healthcare, healthy living environments, and generational wealth—all of which indirectly exacerbate AD. She also noted that being perceived as part of a racial group can itself predispose patients to systemic inequities, which accumulate over time and manifest in dermatologic disparities.

Pigmentary Changes and Clinical Silence

Hyperpigmentation associated with AD is a frequent but often unacknowledged concern among patients with darker skin tones, according to Dr. Heath. In one survey she helped design, she pointed out that pigmentation changes were common across all racial groups, with half of Black participants saying the discoloration bothered them "a lot."

"Many of those patients said their doctor never brought it up," she said of the findings. "One in three Black patients who did raise the issue said their concerns weren’t resolved or were brushed aside."

Dr. Heath recommended to attendees to prioritize clear and direct communication.

"We have to say, 'I see the dark spots. This medication will help your eczema and the spots.,'” she said. “If we don’t, patients assume we don’t care."

Bridging the Gaps

Dr. Heath also spent time during her talk outlining clinician-level interventions to mitigate disparities during her presentation. Some of these included:

• Community-based clinics and telehealth: Reducing geographic and transportation barriers.
• Flexible scheduling (“bring one, bring all”): Working to accommodate families with multiple affected children.
• Tailored dispensing: Providing duplicate prescriptions for children living across two households.
• Health literacy and navigation support: Teaching families how to advocate for prior authorizations and understand medication delivery logistics.

Cultural competence, Dr. Heath said, is crucial for practitioners. She pointed to an example of the need for understanding the use of baby perfumes in some Hispanic households (which are potential irritants in AD) can guide anticipatory guidance. She also pointed out that an awareness that patch testing is underutilized in populations of color opens opportunities for earlier identification of contact allergens.

Dr. Heath was also animate that clinicians routinely ask “why” and dig deeper into treatment nonadherence or disease persistence.

"Did the specialty pharmacy reach them? Was the medication too expensive? Did the parent understand the instructions? We can't fix what we never ask about," Dr. Heath said.

Source: Heath C. Presented at: SDPA 2025 Summer Conference; June 25-28, 2025; Washington, DC.