Welcome to ReachMD. This medical industry feature titled, Closing the Gaps in Atopic Dermatitis: Screening & Diagnosis in Patients with Skin of Color, is sponsored by AbbVie US Medical Affairs.
The US Medical Affairs department of AbbVie Incorporated is the sole author and copyright owner of this presentation and has paid ReachMD to host this presentation. AbbVie is solely responsible for all written content within this presentation. Copyright 2021 AbbVie Incorporated. All rights reserved.
Personal opinions and thoughts are Dr. Shi’s own. Dr. Shi serves as a paid consultant for AbbVie.
Dr. Vivian Shi:
Atopic dermatitis, or AD for short, is one of the most common chronic inflammatory skin diseases in America.
It has a U.S. prevalence rate of 12 percent among children and 7.2 percent among adults.3,4
AD prevalence also varies according to ethnic and racial backgrounds, affecting a disproportionately larger percentage of African American and Asian American patients compared to European American patients.5,6
This disease is frequently associated with allergic and non-allergic comorbidities.
Inflamed skin causes itching, pain and discomfort, which can impact sleep quality and create emotional burdens of the disease that can lead to anxiety and depression.7 Patients with AD may also be at risk of skin-related infections1,2, lymphoproliferative malignancies2, cardiovascular and metabolic disorders2, autoimmune diseases3,8, gastrointestinal issues2,9, and bone and joint complications.9
Food allergy1, asthma1,2, allergic rhinitis1,2, and eosinophilic esophagitis are the most common comorbidities in the atopic family.
In addition to the occurrence of comorbidities, other psychosocial, economic, and lifestyle factors can also add to the overall burden of living with AD.
On the surface, the cycle between itching, consequent scratching, and exacerbations from this disease may cause bleeding, oozing, cracking, flaking, and drying, which can worsen an already defective skin barrier and lead to significant pain and discomfort.10
But diving a little deeper, patients with AD may also struggle with numerous psychological and socioeconomic impacts of the disease, such as mood and sleep disorders, increased risk of hospitalizations, and worsening sense of overall well-being. And this can be a cascade into broader-reaching burdens for patients such as magnified healthcare costs11, impaired productivity at work or school10,11, diminished relationships10, and several other quality of life impacts.10,11
AD-associated itch scratch cycle is not only burdensome in itself, but it can be a trigger for many other AD-related consequences. And that makes successful treating a priority in managing of AD.
But like many other diseases, effective treatment requires an appropriate diagnosis. And this can be challenging in AD because this skin disease has a heterogeneous presentation and distribution.3
As we know, AD lesions can affect many parts of the body, including the face, neck, arms, hands, legs, and feet. The classical presentation includes pruritus, eczematous lesions, and dry skin of the flexural surfaces, including creases of the elbow, knees, wrists, and ankles.12
But the diagnostic challenges go beyond AD lesion distribution. There are other significant barriers that we need to take into account, namely:
- access to care for AD patients,
- recognition gaps in the unique presentations of the disease, and
- underestimation of disease severity, all of which may contribute to inadequate treatment.
Likewise, for racial and ethnic minorities, there are additional factors contributing to misdiagnosis of AD, including:
- common under-representations of these patient populations in research studies, as well as
- nuances in AD presentation for non-white ethnic groups that are largely overlooked in the literature.
Taken together, these challenges may lead to underdiagnosed and misdiagnosed disease for people of color, which is enormously impactful when we recall the higher prevalence rates in AD in African American and Asian American patients.
So let’s examine some of the key differences in presentation that can be overlooked, starting with “erythema” which presents differently in more pigmented skin compared to fair skin.
In fair skin, this is usually identifiable by reddish or pinkish lesions.
However, erythema in darker patients can appear violaceous and may be missed completely. Additionally, darker skin has a higher risk of post-inflammatory dyspigmentation.5
In Asian skin, erythema may appear purple, brown and bruise-like rather than the salmonish colored erythema seen in white skin.
When looking for signs of Atopic Dermatitis in patients with skin of color, particularly in darker skin tones, look for potential lichenification or skin thickening, accentuation of skin lines, or excoriation.5 Patients may also present with perifollicular accentuation, scattered and distinct papules, known as papular eczema. Other common AD features in darker skin types include diffuse xerosis, Dennie-Morgan lines, hyperlinearity of the palms, prurigo nodularis, and post inflammatory dyspigmentation.5
In Asian patients, the main clinical characteristics of AD include well-demarcated lesions, scaling, lichenification, and histologic characteristics include epidermal hyperplasia, frequent hyperkeratosis, and greater acanthosis.5 These clinical and histologic features are similar to the presentation of psoriasis in white individuals.
Awareness of these key differences in clinical presentation across ethnic and racial groups is an important step in to helping to improve our diagnosis and treatment of this disease and reducing its many burdens on our patients.
This program was sponsored by AbbVie US Medical Affairs. If you missed any part of this discussion, visit ReachMD.com/IndustryFeature. This is ReachMD. Be part of the knowledge.
- Silverberg JI, Hanifin JM. Adult eczema prevalence and associations with asthma and other health and demographic factors: a US population-based study. J Allergy Clin Immunol. 2013 Nov;132(5):1132-8.
- Narala S, Hata TR. Adult Atopic Dermatitis with Comorbid Atopic Disease is Associated with Increased Risk of Infections: A Population-Based Cross-Sectional Study. Dermatol Ther (Heidelb). 2017 Mar;7(1):111-121.
- Silverberg JI. Public Health Burden and Epidemiology of Atopic Dermatitis. Dermatol Clin. 2017 Jul;35(3):283-289.
- Silverberg JI, Simpson EL. Associations of childhood eczema severity: a US population-based study. Dermatitis. 2014 May-Jun;25(3):107-14.
- Chiesa Fuxench ZC, Block JK, Boguniewicz M, Boyle J, Fonacier L, Gelfand JM, Grayson MH, Margolis DJ, Mitchell L, Silverberg JI, Schwartz L, Simpson EL, Ong PY. Atopic Dermatitis in America Study: A Cross-Sectional Study Examining the Prevalence and Disease Burden of Atopic Dermatitis in the US Adult Population. J Invest Dermatol. 2019 Mar;139(3):583-590.
- Narla S, Silverberg JI. Association between atopic dermatitis and autoimmune disorders in US adults and children: A cross-sectional study. J Am Acad Dermatol. 2019 Feb;80(2):382-389.
- Silverberg JI, Simpson EL. Association between severe eczema in children and multiple comorbid conditions and increased healthcare utilization. Pediatr Allergy Immunol. 2013 Aug;24(5):476-86.
- Schmitt J, Schwarz K, Baurecht H, Hotze M, Fölster-Holst R, Rodríguez E, Lee YAE, Franke A, Degenhardt F, Lieb W, Gieger C, Kabesch M, Nöthen MM, Irvine AD, McLean WHI, Deckert S, Stephan V, Schwarz P, Aringer M, Novak N, Weidinger S. Atopic dermatitis is associated with an increased risk for rheumatoid arthritis and inflammatory bowel disease, and a decreased risk for type 1 diabetes. J Allergy Clin Immunol. 2016 Jan;137(1):130-136.
- Simpson EL, Bieber T, Eckert L, Wu R, Ardeleanu M, Graham NM, Pirozzi G, Mastey V. Patient burden of moderate to severe atopic dermatitis (AD): Insights from a phase 2b clinical trial of dupilumab in adults. J Am Acad Dermatol. 2016 Mar;74(3):491-8.
- Whiteley J, Emir B, Seitzman R, Makinson G. The burden of atopic dermatitis in US adults: results from the 2013 National Health and Wellness Survey. Curr Med Res Opin. 2016 Oct;32(10):1645-1651.
- Drucker AM, Wang AR, Li WQ, Sevetson E, Block JK, Qureshi AA. The Burden of Atopic Dermatitis: Summary of a Report for the National Eczema Association. J Invest Dermatol. 2017 Jan;137(1):26-30.
- Silverberg JI, Gelfand JM, Margolis DJ, Boguniewicz M, Fonacier L, Grayson MH, Simpson EL, Ong PY, Chiesa Fuxench ZC. Patient burden and quality of life in atopic dermatitis in US adults: A population-based cross-sectional study. Ann Allergy Asthma Immunol. 2018 Sep;121(3):340-347.
- Boguniewicz M, Fonacier L, Guttman-Yassky E, Ong PY, Silverberg J, Farrar JR. Atopic dermatitis yardstick: Practical recommendations for an evolving therapeutic landscape. Ann Allergy Asthma Immunol. 2018 Jan;120(1):10-22.e2.
- Kaufman BP, Guttman-Yassky E, Alexis AF. Atopic dermatitis in diverse racial and ethnic groups-Variations in epidemiology, genetics, clinical presentation and treatment. Exp Dermatol. 2018 Apr;27(4):340-357.
- Brunner PM, Guttman-Yassky E. Racial differences in atopic dermatitis. Ann Allergy Asthma Immunol. 2019 May;122(5):449-455.