Managing AD and Treatment Adherence in Patients of Color



Andrew Alexis, MD, MPH, FAAD: Another area that we haven't touched on is the role of cultural factors. Of course, depending on one's community and one's own cultural norms, there may be differences in what are common home remedies for atopic dermatitis or eczema or the perceptions of skin health. And that can impact what types of treatments are widely accepted in different communities. Can you speak to some of the cultural differences you might see in your practice and how they might be helpful in better treating patients with skin of color?

Heather Woolery-Lloyd, MD: I practice in Miami, and we have a large Caribbean population here. Parents typically use washcloths for bathing children, and it's a part of the culture to kind of scrub the skin because your skin isn't clean if you haven't scrubbed it with a washcloth. A lot of times, I have to say throw that away and tell them soap is for the private areas and the underarms. But in kids with atopic dermatitis, we don't need to scrub their skin, their legs, and their arms with a washcloth because, of course, that destroys the barrier and can make it worse. That's something simple that I can address with patients.

Andrew Alexis, MD, MPH, FAAD: It can contribute lichenification. You sometimes see severe lichenification from chronic scrubbing.

Heather Woolery-Lloyd, MD: And patients look at me with raised eyebrows and say you don't want me to cleanse my child's skin? That's just blasphemy. But it's important because kids with eczema can't scrub their skin. We just need to just treat the important areas, the underarms and the private areas, cleanse, and make sure those areas are clean. But we don't need to scrub the forearms and the legs every single day, twice a day in hot water. That will not help.

Andrew Alexis, MD, MPH, FAAD: Jamie, any comments on cultural considerations in other populations? Asian populations? Latin populations?

Jamie Weisman, MD: Absolutely. It is important to ask what people are using. And sometimes people have preferences for things like olive oil or shea butter. And if it's not hurting them, then I don't have a problem with that at all. And I find sometimes if I endorse those practices and sort of say, that's good, this scrubbing or this cleaning is maybe not as good. Can we emphasize the things that are good?

And everyone has a different tolerance for how much they're going to wash their child or how much they want to bathe themselves. If their a person who feels like they need to bathe their child or they need to bathe every day, then trying to find a way that can be done with cold water—no one's going to do that—but cooler temperature water and applying the emollients afterward and just trying to be an ally and not oppose everything that they're doing—most people obviously don't want to have their child suffer and find a way to incorporate their practices in a way that's beneficial.

Andrew Alexis, MD, MPH, FAAD: That's key. Your last comment about being an ally and trying to incorporate our recommendations that are based on evidence and clinical experience and trying to integrate them into our patients' cultural norms and practices. It's important not to take the position that A, B, and C in your culture is wrong or right. It's more about taking that neutral standpoint from understanding the path of mechanisms of atopic dermatitis and explaining that in layman's terms and explaining how important moisturization is and how important it is to avoid over drying the skin from cleansing practices and avoidance of potential irritants.

If you can explain the basics of the disease itself and what the goals are, what the rationale behind our recommendations are—you can get most patients to buy in regardless of the culture they may come from. What are your thoughts?

Jamie Weisman, MD: I completely agree with that. Again, back to that original point; if they've come to you, they're seeking your help. They've already met you halfway. Our job is to meet them the other half and find out what their thoughts are, and not make assumptions. They want help. They came to your office. If we can listen to what their practices are and find some common ground, we're going to be much more likely to succeed.

Andrew Alexis, MD, MPH, FAAD: Yes. Asking and finding common ground. Those are good themes. Candrice, anything to add?

Candrice Heath, MD: I would just say that letting them know that there are different forms of the things that we use, and we're going to dive into that as well. Some people may prefer a cream over an ointment. They may prefer something a little lighter on the skin. I always ask about those preferences as well. Yes, culturally, there may be some cultures that are used to having heavier ointments on the skin and others not used to that. Like you said before, just ask the patient and the family their preference. Because the important thing is, if you don't ask, you may have a patient and family not adherent to your treatment plan because it just doesn't fit into their normal lifestyle.

Transcript Edited for Clarity

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