Should Eczema treatments vary based on skin color? It’s a question that many physicians have asked and Dr. Nada Elbuluk of The Skin of Color Society is helping us get to the bottom of things.
Here’s what she had to say to MDNewsline about treating eczema in patients of color.
MDNewsline: As a dermatologist, can you tell us, what unique concerns do patients of color with eczema face?
Dr. Nada Elbuluk: Patients of color can have unique clinical presentations of eczema including a variant called papular eczema. This is where eczema can present more as fine bumps with prominent follicles. The degree of inflammation from eczema can also be less evident in darker skin, since melanin can mask the redness that eczema causes. This can lead to undertreatment or underdiagnosis of the severity of the condition. This is also why it is so important for physicians to be trained in treating conditions in all skin types.
Additionally, eczema can be a very itchy condition and the inflammation of the skin from the condition as well as the scratching of the skin which occurs can lead to hyperpigmentation in darker skin. So many times we see that when the eczema goes away, our darker skin patients are left with a lot more discoloration of their skin and that hyperpigmentation, which we call post-inflammatory hyperpigmentation can last for months. The hyperpigmentation can also be very distressing for patients because not only are they dealing with their eczema, but now they’re also dealing with their skin being discolored from eczema and it lasting a long time.
MDNewsline: Would you say that some of these same issues are for black and brown skin equally?
Dr. Nada Elbuluk: Well, the hyperpigmentation, which are the dark spots that can be left after having eczema can happen in anybody of color. So, that extends yes, beyond the African American community to people of Hispanic or Middle Eastern, Asian, and Native American descent. Typically in people of color, the body often wants to increase melanin production in response to the inflammation but in a smaller subset of people, the body can reacts by actually decreasing production. So, some people may end up with light spots in the areas where they had eczema. There’s actually a variant of eczema in young kids called Pityriasis Alba which tends to present with the light spots instead of dark spots.
MDNewlsine: Is there any groundbreaking research or treatments in the field of dermatology, with regards to eczema or atopic dermatitis, that you feel is important to be highlighted now?
Dr. Nada Elbuluk: Well, I think there’s a lot of great research going on with atopic dermatitis, which is the term we often use when we’re describing what patients will call eczema. Recent studies have shown us that African Americans may have more inflammation caused by there eczema and may require higher treatment doses for relief. There may also be some differences in the mutations that are causing eczema. So some of the mutations that are more common in non-African American patients they have found are not present in African American patients. So the underlying, even molecular basis, in some African Americans may be different, which is fascinating. Additionally the cytokine profile may differ in African American patients.
This research is shedding light on differences in the disease manifestation which may necessitate different approaches to evaluation and treatment of the disease.
MDNewsline: So, as it stands right now, generally, are dermatologists treating white and African American patients about the same when it comes to Eczema?
Dr. Nada Elbuluk: I would say, in general yes. In terms of our treatment armamentarium, both topically orally, and procedurally we choose from the same treatments for our patients of all skin types.
MDNewsline: When you have a patient come to you that’s been diagnosed what are your steps to figure out whether it’s better to treat them topically, orally, or procedurally? Are there a particular treatments that stand out that you experienced the most success with?
Dr. Nada Elbuluk: There are a couple of things you need to consider when deciding on appropriate eczema treatment in any patient. One is the percent of body distribution– how much of their body is affected with eczema? The second is what treatments they’ve already tried. Sometimes you’re seeing someone for the first time and they’ve never been professionally assessed. Sometimes they’ve been to multiple dermatologists, and it’s something they’ve had for years. From there you have to assess what they’ve been on, what they haven’t been on, how long they were on it, what worked, what didn’t work, you have to assess the severity of it. There are also different factors in the skin that we look at including redness or erythema, scaling, discoloration of the skin as well as degree of itching and quality of life.
All of those things in combination really help you decide on how to treat the patient. Sometimes if it’s a very localized disease and they haven’t really been on treatments, you might be able to just start with localized topical care and talking about good skincare. It’s important to talk to all eczema patients about gentle skincare products, bathing habits, exposure to water, detergents used, all these things can affect one’s daily life with eczema and their ability to maintain a healthy skin barrier. If the topicals are not sufficient, then we think about whether we need to add oral medications. Sometimes we also recommend light therapy or phototherapy as well.
Many times, we’re doing combination treatments where we might do phototherapy and a topical, or a topical, and an oral, or oral and phototherapy, it really just depends on the complete assessment of the patient.
MDNewsline: What has your experience been with regards to the amount of research and information that speaks particularly to cultural health? Do you feel like there’s an adequate opportunity for dermatologists and other physicians in general to learn more about cultural health and how these chronic conditions impact patients differently?
Dr. Nada Elbuluk: I think for sure we know from all the data that’s out there already, that there are significant health disparities that affect people of color and these exist across the field of medicine, including dermatology. The reality is that even though there is some data and research done, it’s not enough. So much more work still needs to be done to properly address these disparities to understand why certain diseases, including dermatologic ones, disproportionately affect people of color. We really need to understand on a scientific level is the disease different? If so, how does that affect our treatment approach? I think having that research and knowledge is step one. Step two is making sure that people, physicians, residents, fellows and medical students, in training receives that information and put it into practice.
That’s the other gap is that sometimes people aren’t being taught about healthcare disparities, how diseases may be different in different skin types and cultural competence. I think addressing these areas in medicine are essential to improving health care outcomes.
Dr. Nada Elbuluk, MD, MSc, FAAD is a board-certified dermatologist and associate professor at University of Southern California, Keck School of Medicine Department of Dermatology. She received her bachelor’s degree in Psychology from Princeton University where she also minored in Gender Studies and African American Studies. She went on to complete her medical degree from the University of Michigan where she graduated with a distinction in research. While there she received an NIH award that allowed her to also obtain a Master of Science in Clinical Research from the University of Michigan School of Public Health. She completed her dermatology residency at Johns Hopkins Hospital. Afterward, she served as a fellow and clinical instructor in the dermatology department at the University of Pennsylvania. She then spent four years on faculty at New York University where she oversaw the diversity program and pigmentary diseases clinic.
Dr. Elbuluk’s clinical and research interests include general and cosmetic dermatology, with a special interest in ethnic skin and pigmentary disorders including vitiligo, melasma, and post-inflammatory hyperpigmentation. Dr. Elbuluk is a Diplomate of the American Academy of Dermatology and holds professional memberships with the American Academy of Dermatology, the American Society for Dermatologic Surgery, the Women’s Dermatologic Society, and the Skin of Color Society.
Follow Dr. Nada on instagram at @SkinDrNada