Clinical Presentation of AD in Skin of Color



Andrew Alexis, MD, MPH, FAAD: When atopic dermatitis does present in skin of color, we often talk about how it might present differently. What are some of the differences in morphology in clinical presentation? Candrice, why don't you take that?

Candrice Heath, MD: In skin of color, of course, pigmentation is a huge thing in lots of conditions. And we know that atopic dermatitis is an inflammatory condition. It can leave behind post inflammatory hyperpigmentation or dark spots. But even sometimes, it may begin with a subtle darkening in certain areas of the body. To the untrained eye, you may think, okay, these are just dark spots or these are just, dark patches on the skin. But really, that could be that person's very mild atopic dermatitis presentation. You may not see pink or redness of the skin at all.

Another presentation is follicular presentation. It just looks like really fine little bumps, follicular papules on the skin that can be very subtle. And often, you must touch the skin to feel those bumps. In a patient of color, that may be the only clue that the patient has atopic dermatitis. And along the lines of these raised bumps, you can have something called papular eczema. You may even have an exaggeration of these papules on the skin or these bumps on the skin are larger. They may even be in a distribution that the normal atopic dermatitis affects. They can be outside of that distribution, for sure. And you would see that could be a presentation for atopic dermatitis.

Also, the skin's reaction to atopic dermatitis is a big clue as well. Thickening of the skin, where you can see more lines in the skin, and accentuation of the lines, we call that lichenification. In patients with skin of color, they can have lichenification, but that lichenification can be very, very dark in color, very dark brown in color, and often very thick.

And then the thing that I'll talk about is how sometimes atopic dermatitis can even look lichenoid. This is another type of lesion. And when you think about lichenoid lesions, you think that okay, they may be flat-topped. Sometimes they may be brown and have these little red undertones to it. But they can be flat papules, almost as if someone just kind of chopped the top of the papule. And that can be a presentation for atopic dermatitis. It is well beyond just involving the antecubital fossa and the posterior fossa, behind the knees and the neck. But you also must think about all these other findings when you have a patient with skin of color.

Andrew Alexis, MD, MPH, FAAD: I completely agree with that, Candrice. And I would just add one other finding that I've observed in my practice. There's a greater tendency to have prurigo nodularis-like lesions or prurigo nodularis expression of the phenotype of this disease.

Candrice Heath, MD: Absolutely.You're definitely correct.

Transcript Edited for Clarity

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