Expert Perspectives in the Management of Atopic Dermatitis in Skin of Color - Episode 7
Andrew Alexis, MD, MPH, FAAD: What do you think the level of awareness of atopic dermatitis in the physician community is with regards to racial-ethnic differences? And do you think that there are significant gaps, or what do you think the current state of affairs is as far as awareness?
Candrice Heath, MD: In the time that we're living in now, people are thinking more about skin of color. And it often brings us back to being comfortable with what we are used to seeing. If someone has trained and only cared for patients who have very fair skin tones, it may be more difficult to pick those subtleties up when it comes to atopic dermatitis on darker skin tones. But those things can be taught. And as we continue to get the message out, more people will become better at diagnosing skin disease in skin of color.
Andrew Alexis, MD, MPH, FAAD: It's important to note that there are a number of helpful resources out there that can help people at all levels, whether you're still in training or have a practice and even a seasoned practitioner. There are all sorts of helpful articles in the literature, public textbooks that are devoted to dermatology and skin of color. There are multiple textbooks with a great collection of clinical images to better understand the range of presentations in diverse patient populations. There are electronic educational resources. I won't mention any names just to be neutral. But there are a number of very helpful resources out there that people should leverage. And the Skin of Color Society, as a website, is a good resource for patients. We can direct patients there for information that's more specific in skin of color.
Heather Woolery-Lloyd, MD: We've covered a lot of ground, and you bring up a very good point. People who want to learn more can reach out to those resources. The Skin of Color Society has a great resource page for patients and for clinicians who are practicing who want to learn more.
Andrew Alexis, MD, MPH, FAAD: What would you say are some of the key challenges to atopic dermatitis in skin of color patient populations? What are some of the unique and key challenges, in your opinion?
Heather Woolery-Lloyd, MD: The biggest challenge and my patients' number one complaint is hyperpigmentation. Patients with eczema will have dry, itchy skin. But, unfortunately, in darkly pigmented skin, that inflammation leads to hyperpigmentation. And patients often come in with full-blown eczema to my practice and say, yes, I have eczema, but I want to get rid of these dark spots. And my answer to them is, I cannot treat the hyperpigmentation until we get the eczema under control. Once we have your atopic dermatitis under control, then we can start to carefully address the hyperpigmentation or dark spots.
Usually, they're on the legs. That's a very common complaint. Or on the forearms. And cosmetically, patients don't like it. That really bothers them. I'd say, in some cases, more than the itch. Addressing that is key. And once I do get the eczema under control, I use a combination of azelaic acid with triamcinolone, and that is sometimes helpful to reduce the hyperpigmentation that we see without irritating or aggravating the eczema.
Andrew Alexis, MD, MPH, FAAD: It's important to recognize that, in addition to all the usual burdens of atopic dermatitis that we all understand—itching, scaling, dry skin, red, oozing, crusting, depending upon the stage of atopic dermatitis, all of those clinical manifestations—on top of those features of atopic dermatitis itself, patients with skin of color also have to contend with long-lasting disfiguring pigmentary sequela of the disease.
In that context, it makes it especially important to manage the disorder effectively and continuously with longitudinally, and not doing the whole roller coaster ride of flare, putting out the flare, and then losing the patient to follow-up, and then they come back in for flare. It's particularly important to effectively manage these patients longitudinally and with good control. Of course, that's true for any patient with atopic dermatitis, but it's especially true in patients of color because you have this added sequela that is long-lasting and potentially disfiguring.
What are your thoughts about itch? There is some literature that suggests that with itch, there may be some differences in patient populations; some evidence that itch might be more severe or more prevalent in individuals of African ancestry. Is this something that you've seen in your practice? I'll just open that up to everybody.
Jamie Weisman, MD: I would say I've seen that in my practice. And, in addition, when the itch is severe enough, I've often seen people scratch to the point of actually losing pigmentation. And that's even more difficult to treat. It's important for us to address that. This probably goes along with your observation of more cases of and a deep lichenification that we see in skin of color and the need to not manage them episodically, but really have good control of the disease in the way that our patients understand that we have a setback when we lose control.
Transcript Edited for Clarity