Clinicians should be aware of the differing severity and presentation of atopic dermatitis (AD) in African Americans. The frequency of atopic dermatitis is increasing, and is more common among Blacks, Asians, and Pacific Islanders. [Desai 2009] In fact, eczema is the second most frequent skin disease in African Americans. [Silverberg 2013] In the US, African American children are more likely to have AD (20% as compared to 12% among Caucasians) [Shaw 2011] and are more likely to have more severe disease, with African American children being 6 times more likely to have severe AD than white children. [Brunner 2019, Poladian 2019]. Conversely, the disease is less common among African American adults, with just 7.7% of African American adults being diagnosed with eczema, as compared with 10.8% of Hispanic, 10.5% of white, 9.1% of Asian, and 7.8% of Native American adults.
AD is a disease of unknown etiology that results in a malfunction in the immune system and epithelial barrier disturbance. A genetic mutation leading to loss of function in filaggrin, a protein found in skin that is essential in epidermal homeostasis, has been found in up to 50% of European and 27% of Asian patients with AD, but was found to be 6 times less common in African American patients. [Silverberg 2019] These mutations in filaggrin have been associated with increased risk of early-onset, severe, persistent AD with asthma and allergies. Additionally, those who live in an urban setting or are exposed to environmental allergens (e.g. dust mites) are at greater risk for developing AD.
AD is typically characterized by pruritus, xerosis, lichenification and eczematous lesions, with distribution on face, neck and extensors in children, on flexural surfaces in both children and adults. AD presents more often in African Americans with papular eczema on the torso, arms and legs. In African American patients, eczema can result in lesions that are darker brown, ashen or gray in color, with changes in pigmentation and papular eczema on the torso, arms and legs. [Kaufman 2019] Affected areas may be inflamed, pruritic and xerotic. African Americans with eczema can experience extensive dryness and dark circles around the eyes, causing the skin to thicken due to rubbing. Prurigo nodules can also be found in this area due to the irritation of the skin during disease flares. Hypopigmentation can appear in areas where a flare has occurred, but this hypopigmentation typically returns to normal over time.
Given the chronic nature of AD, the health care burden that accompanies the disease has been well-documented. African American patients have a higher health care burden than other patients, with higher rate of office visits for AD than white patients. [Sanyal 2019] The chronic nature of AD has been found to put financial strain on patients, due to the high number of office visits and treatment medications needed over the course of the disease. [Koszuru 2019] AD has been found to affect patient’s quality of life (QOL), with negative impacts on mental health, sleep, physical activity, social functioning, as well as academic and occupational performance. The negative impacts on QOL have been found to be greater in patients of color. [Poladian 2019]
Brunner, Patrick M. et al. Racial differences in atopic dermatitis. Annals of Allergy, Asthma & Immunology. 2019. Volume 122, Issue 5, 449 – 455.
Desai, N., & Alexis, A.F. (2009). Atopic Dermatitis and Other Eczemas. In A.P. Kelly & S.C. Taylor (Eds.), Dermatology for Skin of Color. China: McGraw-Hill.
Kaufman B, Alexis A. Eczema in skin of color: What you need to know. https://nationaleczema.org/eczema-in-skin-of-color/.
Poladian K, De Souza B, McMichael AJ. Atopic Dermatitis in Adolescents With Skin of Color In Collaboration With the Skin of Color Society. Cutis. 2019 September;104(03):164-168.
Sanyal RD, et al. Atopic dermatitis in African American patients is TH2/TH22-skewed with TH1/TH17 attenuation. Annals of Allergy, Asthma & Immunology. 2019. Volume 122, Issue 1, 99 – 110.e6
Shaw TE, Currie GP, Koudelka CW, Simpson EL. Eczema prevalence in the United States: data from the 2003 National Survey of Children’s Health. J Invest Dermatol. 2011;131(1):67-73.
Silverberg JI. Revolutionizing Atopic Dermatitis. Cutis. 2019 September;104(03):142-143.
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;132(5):1132-1138.