Exploring Dx Issues in SOC Atopic Dermatitis at ACAAI

Ama Alexis, MD

“Over the past few years, we've become increasingly aware of significant health disparities in patients with atopic dermatitis and skin of color population,” shared Ama Alexis, MD, at the American College of Allergy, Asthma and Immunology (ACAAI) 2023 Annual Scientific Meeting in Anaheim, California. “In response, the college have published an article, and it really proposes solutions to address health disparities in atopic dermatitis [AD].”¹

In preparing the article and proposed solutions, investigators conducted a survey and found that almost 70% said racial disparities make it difficult for people with skin of color to receive adequate treatment for AD and food allergies and 40% of patients are concerned about finding a specialist near them that has expertise in recognizing and treating AD in people of color, added Alexis, clinical assistant professor of pediatrics at Weill Cornell Medical College, Cornell University, in New York, New York.

Key to the importance of improving awareness is understanding how AD is diagnosed—based on patient presentation and history, she explained. Understanding that presentation may be different in skin of color patients becomes essential. “If you're not familiar with it, you're not going to get to the right diagnosis. They're not going to get to the right diagnosis. You will not treat appropriately.”

Differences in morphologies and anatomical locations have been associated various races, she said. For instance, in Black patients, there may be more papular or perifollicular primary morphology, more xerosis, Dennie-Morgan lines, palmar hyperlinearity, periorbital hyperpigmentation, and prurigo nodularis, and there may be extensor and truncal involvement.²

Erythema in skin of color is different than what might be seen in white patients, with red plus violet, purple, brown, or gray. If a clinician is unaware of this difference, they may underestimate the degree of erythema and inflammation, which in turn can lead to undertreatment, Alexis explained.

Similarly, she noted melanocytes decrease melanin production resulting in get hyperpigmentation when inflammation and injury are added to highly pigmented skin. High potency topic steroids used for long enough period can also induce changes.

There are some specific considerations for pediatric patients, too, Alexis said. “Follicular prominence may be the only sign of atopic dermatitis in pediatric patients with SOC.” Pruritic follicular accentuation over the chest, back, abdomen, and flanks are common indicators in this patient population.

Other differences include lichenoid activity, which in African American and Hispanic patients tend to round as opposed to polygonal papules and are predominantly extensor lesions. Increased severity of xerosis is also common and may be more stigmatizing in darkly pigmented skin.

Once AD is recognized, it is important to remember treatment plans should be individualized, Alexis said.

“Always keeping in mind you want to address inflammation. If you undertreat, your will see dyspigmentation; if you treat too long or with too potent topical steroids, you'll see this dyspigmentation. You want to stress protections with tons of moisturizers and it's always helpful to give the patient a handout.”

Ultimately, it is important to be aware of the potential differences to make the correct diagnosis, Alexis concluded. “The presentation [of AD] is heterogeneous, and that's okay,” she said. “Just know what to look for. You'll see a multitude of morphologies and erythema in different hues. Be familiar with variations in location and the impact of primary hyperpigmentation. This will be much appreciated by your patients.”

References

1. Corbett M, Allen A, Bobo N, et al. Proposed solutions by the American College of Allergy, Asthma, and Immunology and advocacy experts to address racial disparities in atopic dermatitis and food allergy. Ann Allergy Asthma Immunol. 2023;130(3):392-396.e2. doi:10.1016/j.anai.2022.12.017

2. McKenzie S, Brown-Korsah JB, Syder NC, Omar D, Taylor SC, Elbuluk N. Variations in genetics, biology, and phenotype of cutaneous disorders in skin of color. Part II: Differences in clinical presentation and disparities in cutaneous disorders in skin of color. J Am Acad Dermatol. 2022;87(6):1261-1270. doi:10.1016/j.jaad.2022.03.067