MDNewsline recently interviewed international skin of color expert and dermatologist Dr. Andrew F. Alexis about treating eczema in patients of color. Dr. Alexis is a member of the Skin of Color Society (SOCS) and we thank the SOCS for providing this interview opportunity.
MDNewsline: According to the National Eczema Association, 20.2% of African American children in the United States have some form of eczema. That is compared with 13% of Asian, 13% of Native American, 12.1% of white, and 10.7% of Hispanic children. Would you agree that there is a higher prevalence of eczema in African American children?
Dr. Alexis: Yes, there are multiple studies that show a higher prevalence of eczema in black children vs. other racial/ethnic groups. A study using the National Survey of Children’s Health (NSCH), a large population-based survey of >100,000 (102,353) families representing all 50 states, found that African American children are 1.7 times more likely to have AD than their white counterparts, even when adjusting for household income, parental education level, metropolitan versus rural environment, and health insurance coverage status.
The 2005-2006 National Health and Nutrition Examination Survey (NHANES), which estimated prevalence of AD of 15.6%, reported that eczema disproportionately affects AA children (19.3%) compared to EA (16.1%) and Hispanics (7.8%) [Fu 2014].
MDNewsline: The same article reports that just 7.7% of African American adults have eczema, compared with 10.8% of Hispanic, 10.5% of white, 9.1% of Asian, and 7.8% of Native American adults. Why is there a stark difference in the babies and children as it relates to the prevalence in the African American community? There seems to be contradicting research about the prevalence of eczema in African Americans so if you can comment about what you’re seeing it would be amazing.
Dr. Alexis: It is not clear why there are such differences reported between childhood atopic dermatitis (AD) and adult AD with respect to prevalence in racial/ethnic groups. Some potential explanations include differences in methodology and less data on adults with AD. Also, there is potential for under-detection of AD/eczema in patients of color due to barriers to specialty care as well as challenges in diagnosis. It is possible that the impact of these phenomena is greater among adults.
MDNewsline: How is atopic dermatitis’ onset different in patients of color?
Dr. Alexis: The onset is similar between racial/ethnic groups. What differs are the clinical features, severity, and sequelae. Clinically, eczema in skin of color (especially among blacks/African Americans) has a follicular prominence and may have varying shades of erythema due to the optical effects of higher epidermal melanin – e.g. it may present with red-brown, dark brown, grayish, or violaceous (purple) hues.
MDNewsline: What misconceptions do you feel need to be addressed by physicians treating patients of color in relation to atopic dermatitis? Are there any special conversations that need to be had?
Dr. Alexis: Understanding that skincare regimens can vary from culture to culture. It is important to discuss adjustments to skincare regimens in a culturally sensitive way that does not alienate the patient by dismissing long-held cultural practices. For example, a patient of African ancestry who prefers to use shea butter as a moisturizer can continue to do so but maybe encouraged to combine it with a ceramide containing moisturizing cream for better efficacy.
MDNewsline: A study published in Annals of Allergy, Asthma, and Immunology, the scientific journal of the American College of Allergy, Asthma, and Immunology, suggests that African Americans have greater treatment challenges with AD than European Americans and require higher doses of some medications to get relief. Is this something you’ve witnessed among patient populations? Are you seeing the same with Latinos, Native Americans, and other patients of color?
Dr. Alexis: Anecdotally, I tend to see more severe AD in black and Asian patients in my practice. Among my black patients, I also see the development of prurigo nodularis more commonly – as an associated feature of AD as well as more severe lichenification. In all patients of color, the development of pigmentary sequelae (hyper- and hypo-pigmentation) adds to the morbidity of the condition.
MDNewsline: Should physicians treating patients of color recommend different treatments to their patients based on skin color? If so can you please elaborate on how treatment should be different and if there are any cultural factors that play a role in eczema treatment?
Dr. Alexis: There is a need to address the pigmentary sequelae – first by not under-treating and ensuring long-term control of the inflammation associated with AD, and second by treating hyperpigmentation after the active lesions have resolved completely. Controlling the pruritus is also a key way to reduce the development of pigmentary sequelae as chronic scratching contributes to the risk of postinflammatory hyperpigmentation (as well prurigo nodularis) and in severe, longstanding cases can result in depigmentation.
MDNewsline: How does one convince a patient or caregiver not to use holistic treatments that may further irritate the skin?
Dr. Alexis: Explaining in a culturally sensitive manner the characteristics of preferred soaps, moisturizers for AD, and describing the potentially adverse consequences of overly drying or potentially sensitizing skincare routines/ingredients.
MDNewsline: Are topical corticosteroids your preferred first choice or injectables? Why or why not?
Dr. Alexis: Topical corticosteroids are my first choice for rapid, short-term improvement. However, non-corticosteroids are essential for long-term management – including topical calcineurin inhibitors or PDE4 inhibitors for mild-moderate cases and injectable dupilumab for moderate to severe cases. Among other well-known side effects, longer-term corticosteroids can cause hypopigmentation that is more disfiguring in skin of color.
MDNewsline: Anything else relevant for physicians treating minority patients with atopic dermatitis that you would like to share?
Dr. Alexis: Early detection and longitudinal control (as opposed to episodic flare management) are key strategies to produce the best outcomes in AD patients with SOC. Failure to do so results in greater long-term pigmentary sequelae, among other consequences of inadequately controlled AD.
Dr. Andrew F. Alexis, MD, MPH is Professor and Chair of the Department of Dermatology at Mount Sinai Mount Sinai West and Mount Sinai Morningside Director, Skin of Color Center, New York, NY.