Expert Perspectives in the Management of Atopic Dermatitis in Skin of Color - Episode 4
Andrew Alexis, MD, MPH, FAAD: Let’s shift here into another area, this is one that I’m particularly passionate about, and that’s atopic dermatitis [AD] in patients with skin of color. We’re increasingly recognizing that there are variations by race and ethnicity and geographic populations, with respect to the prevalence, the clinical presentation and some nuances to the overall management of atopic dermatitis.
With that broad overview, Heather, I’m going to turn to you to dive deeper and let us know, what should we all know about differences in atopic dermatitis in patients with skin of color, that is darker skin types or nonwhite racial ethnic groups?
Heather Woolery-Lloyd, MD: This is another topic that’s near and dear to my heart. It’s something that we all need to recognize, that atopic dermatitis is more common in skin of color. Specifically, multiple studies have shown it’s more common in patients of African descent, and also in patients of Asian descent. We know that it’s much more common in skin of color. But not only is it more common, it’s much more severe.
When children present with atopic dermatitis, Black children are much more likely to have moderate to severe disease. This is a key point, because we want to make sure we recognize this so that those children are treated appropriately. I tend to be more aggressive because I know that this disease is not only more common, but more severe in my Black patients. That’s an important point that we all need to recognize. And it does influence my treatment algorithm.
Andrew Alexis, MD, MPH, FAAD: Heather, any ideas as to why it would be more severe in some groups like Black patients or African Americans? Any reasons why that would be?
Heather Woolery-Lloyd, MD: They’ve looked at that, and there are lots of genetic data out there. We know that in patients who are Caucasian, the more common defect is a filaggrin defect. But those defects are not as common in Black patients. The defects that we see in Caucasians, we don’t see in Black patients. But we do know that Black patients have a lower level of ceramides in their skins. Ceramides are barrier lipids, they maintain our barrier. They’re important to maintain the barrier in the skin. More than 1 study has shown that Black patients have lower levels of ceramides compared to white and Asian patients.
That could be contributing, a barrier issue. It’s probably multifactorial, but it’s something that we observe. We need more studies to find out exactly why. The barrier may be a big component of it, but it’s not definitive yet.
Andrew Alexis, MD, MPH, FAAD: Interestingly, when you look at the epidemiology studies that find a higher prevalence of atopic dermatitis in populations of African ancestry, even after they control for socioeconomic factors or geographic factors like urban residence versus rural, other factors that might confound the results, the higher prevalence still holds true.
Another thing that’s interesting is that you see this finding in completely different populations geographically. Multiple studies in the United States show that Black children have a higher prevalence of AD than white children. Then even outside the United States, such as a study from the United Kingdom that found that London-born children of Caribbean ancestry had a much higher prevalence of atopic dermatitis than their white counterparts residing in London as well. There seems to be a consistent phenomenon that might have some underlining genetic factors that explain it.
Heather Woolery-Lloyd, MD: That finding is so strong that one study showed that, in and of itself, being Black is a risk factor for developing atopic dermatitis in the first 6 months of life. Ethnicity alone is an independent risk factor for developing atopic dermatitis in the first 6 months of life. It’s something that’s very common, like you said, across the board, across different countries, geographies, across socioeconomic status.
Also, Black patients seek care for their atopic dermatitis more than white patients do even though they may have less access to care. It’s something that we as clinicians will see more of because these patients not only have more atopic dermatitis but are seeking care more frequently.
Andrew Alexis, MD, MPH, FAAD: Indeed. I’m glad you brought that up. There is that one study that you were referring to that found that Black individuals and Asians had a significantly higher number of visits per capita for atopic dermatitis than whites in the United States. It speaks to the higher burden of disease in these populations.
Transcript Edited for Clarity