Atopic dermatitis, the most common type of eczema, is a chronic inflammatory skin disease that can affect anyone. But research shows that it’s more prevalent in some communities of color, especially Black children.
In the United States, 19.3 percent of Black children have atopic dermatitis, compared with 16.1 percent of white children and 7.8 percent of Hispanic children. And compared with white individuals, Asians and Pacific Islanders are seven times more likely to be diagnosed with the condition during an office visit to a physician.
The reasons for the disparities are complex and include various genetic, immune, and environmental factors. “It’s truly multifactorial as to why people of color are disproportionately affected with atopic dermatitis,” says Shawn Kwatra, MD, the chief of service in dermatology and the chair of the department of dermatology at the University of Maryland School of Medicine in Baltimore. Here’s what you should know about the symptoms, causes, diagnosis, and treatment of atopic dermatitis in skin of color.
Signs and Symptoms of Atopic Dermatitis in Skin of Color
Many symptoms of atopic dermatitis are similar for everyone with the condition, but some can vary by skin tone.
In general, the condition causes dry, itchy skin and rashes on various areas on the body, which can include the face, hands, feet, elbows, behind the knees, or the scalp, says DiAnne Davis, MD, a cosmetic dermatologist at Hopkins Dermatology in Dallas. The affected areas can be swollen, warm, itchy, dry, or scaly, says Kemunto Mokaya, MD, a dermatologist at Complete Dermatology in Woodland, Texas.
It can be more challenging to diagnose
atopic dermatitis in skin of color than in light skin tones because the condition has a different appearance on darker skin and can be more severe, according to research published in 2023 by Dr. Kwatra and his team. “The disease has a unique presentation on skin of color,” he says.
In lighter skin tones, rashes can appear in various shades of red, ranging from a pale pink to salmon color, says Dr. Mokaya. But on darker skin, it can appear like a purplish bruise or a darker brown patch. Then the affected skin may become darker than the areas around it after the rash has healed (known as hyperpigmentation).
“The erythema (redness) is less visible on darker skin, making inflammation harder to assess,” says Mokaya. Over time, “the dry patches can appear ashy or gray on darker skin, while they look white and flaky on lighter skin.”
Black patients also are more prone to what’s known as papular lesions, or small bumps on the torso, arms, and legs, says Kwatra. These bumps can also show up around hair follicles, a condition known as follicular accentuation, he adds.
Causes of Atopic Dermatitis in Skin of Color
As mentioned, atopic dermatitis is not contagious. It’s caused by a combination of genetic, immune-related, and environmental factors, some of which can vary by race or ethnicity.
Genetic and Immune-Related Factors
Genetics often play a major role in atopic dermatitis. Many children with the condition have at least one family member with atopic dermatitis or related chronic health problems, such as asthma and allergies. “Studies found this to be true for 70 percent of the patients with atopic dermatitis,” says Dr. Davis.
Atopic dermatitis is often linked to a weakened skin barrier and underlying immune system issues within the body. “Patients may have a genetic mutation that leads to abnormality in proteins (filaggrin) that form the skin barrier,” says
Vivian Shi, MD, an associate professor in dermatology at the University of Arkansas for Medical Sciences in Little Rock. The lack of normal protein levels can compromise the skin barrier, leading to loss of moisture and increased susceptibility to inflammation. This mutation [filaggrin] is more common in white children than in Black children, research shows.
But people with darker skin tones are more likely to develop dry skin, a known trigger of atopic dermatitis, than people with lighter skin tones. That’s because darker skin has a higher rate of transepidermal water loss (TEWL) than lighter skin, which means that darker skin loses moisture faster, says Dr. Shi. TEWL is the amount of water vapor lost through the skin when sweat glands aren't active.
What’s more, darker skin tones have lower levels of ceramides (lipids that help protect the skin) than lighter skin tones, Kwatra adds. Lower levels of ceramides are also linked to increased skin dryness.
Environmental and Socioeconomic Factors
As for the environmental influence, children of color — particularly Black children — are more likely to grow up in cities where they’re exposed to harmful pollutants and allergens, like dust and mold, says Kwatra. Research shows that exposure to secondhand smoke and air pollution from traffic are contributing factors to developing atopic dermatitis, Kwatra adds.
Over time, this increased exposure can trigger or worsen atopic dermatitis, says Mokaya.
“Socioeconomic factors affecting some people of color like limited access to healthcare and effective treatments can delay diagnosis and management, exacerbating the condition,” adds Mokaya. One reason is that people in many communities of color are less likely to have health insurance than their white counterparts, data shows.
Children with darker skin tones also often have decreased access to pediatric dermatology, which can offer more specialized care for skin conditions like atopic dermatitis than primary care.
High levels of stress can also worsen the condition, Mokaya notes.
Diagnosis of Atopic Dermatitis in Skin of Color
Most diagnoses of atopic dermatitis are based on personal health history, family history, and a skin exam. To receive the correct diagnosis as a person of color, it can help to find a dermatology provider who specializes in treating skin of color. “Seek out a culturally competent healthcare provider who understands atopic dermatitis in skin of color and advocates for your specific needs,” says Shi.
Be sure to write down all the symptoms you’re experiencing and bring the list to your appointment. For a diagnosis of atopic dermatitis, the focus should be on how itchy the skin feels, says Kwatra. “I am focused on the itch with all of my patients, and I ask them to rank their worst itch level from 1 to 10,” he says. “Asking about the itch level is a way to eliminate the disparities.”
Treatment Options for Atopic Dermatitis in Skin of Color
Treatments for atopic dermatitis are the same for all skin tones, but the specific treatments someone receives will vary according to their symptoms and the severity of their condition. The most common treatment options include:
- Topical Treatments Prescription topical steroids and other topical treatments reduce inflammation and itching during a flare-up. They’re often used for mild cases, Davis says.
- Antihistamines Antihistamines can help reduce severe itch.
- Light Therapy Also known as phototherapy, light therapy involves exposing symptomatic areas of your skin to controlled amounts of natural sunlight. This treatment option is most often used among people whose symptoms don’t improve with topical treatment or quickly flare up again after treatment.
- Oral Steroids (Oral Immunosuppressants) To treat severe flare-ups, a doctor may prescribe oral steroids. “[These medications help] modulate the immune system to get the condition under control,” Davis says.
- Systemic Medications For people with moderate to severe eczema that doesn’t improve with topical treatments or light therapy, systemic medications such as injectable biologic medications or a new class of medications known as JAK inhibitors could help.
- Self-Care There are several gentle skin-care strategies you can do at home to care for your skin and lower your risk of flare-ups. This includes avoiding hot showers, bathing in lukewarm or cool water for no more than 10 minutes, using gentle non-soap cleansers rather than traditional soaps, gently patting your skin dry after a bath or shower, and applying an unscented moisturizing cream or ointment quickly after showering or bathing to lock in moisture.
Along with treatment, it’s also important to identify any allergens or irritants that trigger your symptoms and avoid them. “Those allergens may include, but are not limited to scented products like perfumes or colognes,” Davis says. Other common triggers include heat, abrasive fabrics like wool, chemicals like cleaners or detergents, and stress, she notes.
