Challenges in Diagnosing Skin of Color: Recognizing Knowledge Gaps

One of the key differences between diagnosing AD in patients with skin of color compared to White skin is erythema.

Recognizing knowledge gaps can help address disproportionate treatment that affects patients with skin of color (SOC), according to a speaker at the Winter Clinical Dermatology Conference, held this week in Kauai, Hawaii.1

Susan Taylor, MD, of the University of Pennsylvania’s Perelman School of Medicine, said it is important for dermatologists to understand the different presentations of conditions like atopic dermatitis (AD) and psoriasis in patients with SOC, because correct diagnosis is directly correlated with adequately treating these patients.

“Black children are nearly twice as likely to develop AD compared with White children after controlling for socioeconomic factors, and Asian and Pacific Islanders are 7 times more likely than White [patients] to be diagnosed with AD,” which makes accurate diagnosis all the more important, Taylor said.

She noted 1 of the key differences between diagnosing AD in patients with SOC is erythema.

“We think of inflammation as being red, but not so much in our patients with [SOC],” Taylor said. “That can be a problem because erythema is a significant portion of the EASI and other scoring systems for AD and as such they often underestimate AD prevalence in [SOC].”

Patients with SOC may get hypo-or hyperpigmentation, she said, and follicular morphology is more commonly seen in Black patients compared with White patients. This is key, she said, because follicular prominence in AD may be the only sign in this population.

One pearl she offered for diagnosing this condition in patients with SOC was to: “close your eyes and palpate the skin, using your fingertips may be helpful in identifying a flare.” She also said patients have variability in color in their flares, as the flares could be more brown or grey in appearance, with some scaling.

Keloidal prurigo is sometimes present in Black patients with AD, and Taylor said, Black and Asian patients may present more with lichenification when compared to White patients.

Describing other AD in SOC characteristics, Taylor noted Dennie-Morgan lines, periorbital hyperpigmentation, and palmar hyperlinerarity.

Disparities to access

Taylor noted that several studies have also shown that SOC patients are less likely to be correctly diagnosed than white patients with skin diseases. Additionally, some studies have indicated these patients may be less likely to be prescribed proper treatment.

One study by Bell et al, demonstrated that Black patients were less likely to receive topical corticosteroids, topical immunomodulators, crisaborole, or dupilumab despite other data showing good efficacy of these medications in these population for treatment of atopic dermatitis.2

This article was originally published on Dermatology Times.

References:

  1. Taylor S. Managing challenges in skin of color. Presented at: 2022 Winter Clinical Dermatology Conference; January 14 to 19, 2022; Kauai, Hawaii.
  2. Bell MA, Whang KA, Thomas J, Aguh C, Kwatra SG. Racial and ethnic disparities in access to emerging and frontline therapies in common dermatological conditions: A cross-sectional study. J Natl Med Asoc. 2020; 112(6)650-653.