Welcome to the first episode of our new podcast series, “Atopic Dermatitis In Skin of Color.” The podcast series examines the importance of diagnosis, managing and treating atopic dermatitis, or eczema, in people of all skin colors. The first episode is “Understanding Atopic Dermatitis in Skin of Color.”
The podcast is a joint collaboration between Allergy & Asthma Network and The Itch Podcast led by co-hosts Kortney Kwong Hing and allergist and immunologist Payel Gupta, MD. In this episode, Kortney and Dr. Gupta welcome special guest and social media influencer Shiv Sewlal to the podcast.
You can also listen to or download the podcast on ItchPodcast.com for listening anytime, anywhere. The podcast can be downloaded at:
In this Episode…
- 2:18 – Why ‘Atopic Dermatitis in Skin of Color’ is an important to topic to cover
- 4:20 – What is atopic dermatitis or eczema?
- 6:02 – Child-onset vs. adult-onset atopic dermatitis
- 8:25 – Why is atopic dermatitis more persistent in Black and Hispanic Americans?
- 10:20 – How housing plays a role in atopic dermatitis
- 11:00 – Shiv Sewlal on air conditioning and its impact on her atopic dermatitis
- 12:55 – Why atopic dermatitis is under-diagnosed in people of color
- 14:05 – How eczema in skin of color might look different and why it’s important that doctors know the differences
- 16:20 – Shiv Sewlal on how her eczema presents and some of her experience of scarring and discoloration
- 17:25 – Shiv Sewlal on scarring and eczema
- 19:15 – A look at darkening and lightening of the skin due to eczema
- 20:58 – Symptoms to watch for eczema in skin of color
- 22:08 – Atopic dermatitis triggers
- 23:34 – Stress, anxiety and depression as triggers for atopic dermatitis
- 24:30 – Shiv Sewlal on how stress and anxiety of atopic dermatitis impacted her family
- 27:26 – A closer look at the itch-scratch cycle
The following is an edited transcript of the podcast “Understanding Atopic Dermatitis in Skin of Color.”
Kortney Kwong Hing: You’re listening to The Itch, a podcast exploring all things allergy, asthma and immunology. I’m your cohost Kortney, a real-life allergy, asthma and eczema girl.
Payel Gupta, MD: And I’m your second host, Dr. Payel Gupta, a board-certified allergy, asthma and immunology doctor. Kortney and I hope to balance each other out so that we get you all the information that you want and need about allergies, asthma and immunology.
Kortney: This is the first in our five-part series in collaboration with Allergy & Asthma Network about atopic dermatitis in skin of color. We’ll be covering the following topics over the next five months: understanding atopic dermatitis in all skin colors, diagnosing atopic dermatitis in people with skin of color, eczema medications, treating the whole person and managing atopic dermatitis in people of all colors, and finally, the role of the nurse in the care of eczema and Shared Decision-Making. It sounds like a lot, but it’s going to be really good because we’re going to be breaking it up into five really digestible podcast episodes.
And as always, we want to have a patient perspective. So we’ll be hearing from Shiv Sewlal about her experience with atopic dermatitis as someone with skin of color. You may know Shiv from TikTok or Instagram. Her handle is Shavika and she makes hilarious videos, so you probably want to check her out afterwards.
For more information about atopic dermatitis in skin of color, make sure to check out our show notes for helpful links or go to AllergyAsthmaNetwork.org for more resources. Today we’re talking about understanding atopic dermatitis in people with skin of color.
Just a quick note that we will most likely be shortening the term atopic dermatitis. As you’ve probably heard me say it about 100 times now, it’s AD because it’s just a little bit easier for us to say, and we want to keep this podcast relatively short. So we won’t be saying atopic dermatitis 100,000 times. So with that, let’s get right into it. Dr. G, can you tell us why this is an important topic to cover?
Dr. Gupta: Yes. So Kortney, I think this is such an important topic to cover, and I’m so glad that we’re getting the opportunity. Because unfortunately, we see that there is more severe disease and more persistent disease in people who are Black, African American and even Latinx populations in the United States. And urgent care or emergency department visits are significantly more common among Black or African American and Hispanic Americans for atopic dermatitis. And those patients who are admitted for their atopic dermatitis actually had a longer stay during hospitalization compared to patients who have White skin.
In addition, when they performed the National Survey of Children’s Health, they found that Black children in the United States were 1.7 times more likely to have atopic dermatitis compared to White children. And actually this persisted even after controlling for factors like insurance status, household income, metropolitan versus rural environment, or parental education level. So it wasn’t really external factors but maybe something more internal related to their race that accounted for them having more atopic dermatitis.
And then lastly, this is an important topic because we also see that there is a delay in the diagnosis of atopic dermatitis in these same populations. And so having more education for patients and doctors on this topic is very, very important.
Kortney: Thank you. I can really see why this is an important topic, especially with what you mentioned about delays in diagnosis. If we’re raising more awareness now, hopefully more people will be diagnosed sooner. Before we really get into more about AD and skin of color, can we start with some basic definitions? So what is atopic dermatitis? And is it also the same thing as eczema? Because I might interchange the two. I know it.
Dr. Gupta: Yes, of course. First, the terms atopic dermatitis and eczema, as you mentioned, are frequently used interchangeably. And when the term eczema is used alone, a lot of people usually use it to mean atopic dermatitis or atopic eczema. So we’ve talked about this before, Kortney, and our other eczema episodes on The Itch that people can find in our archives. But coming back to atopic dermatitis, atopic means allergic. So this is a specific type of dry skin condition where allergies are playing a role in some way.
So eczema and dermatitis in general refer to itchy scaly skin that can have crusting or some oozing at times. They are general terms, but now eczema from most people and even doctors specifically used for atopic eczema. This means that eczema has an underlying allergic component, and dermatitis is an even more general term and can refer to many conditions. So again, atopic dermatitis means that there’s an underlying allergic component to the rash. So technically, in the medical world, there are a lot of conditions that we can put under the category of eczema or dermatitis that has nothing to do with allergies, atopic dermatitis or atopic eczema, or for some people, they just abbreviate it to be eczema.
Kortney: Great. So I can call it eczema or AD, and we all know what we’re talking about in this episode. Can you talk to us about child-onset vs. adult-onset AD?
Dr. Gupta: So you’re not really born with eczema, but exposure to the outside world can start to trigger it quickly. A family history of allergic disease or atopic-like eczema, asthma or allergic rhinitis is the strongest risk factor for atopic dermatitis. Approximately 70% of people with atopic dermatitis have a positive family history of atopic diseases, and children with one atopic parent have 2-3 times increased risk of developing atopic dermatitis, and the risk increases to 3-5 times if both parents are atopic. And although atopic dermatitis often resolves during childhood, it can persist into adulthood in 20% to 50% of patients after the age of seven, close to 50% to 80% of children see their eczema disappear. However, dry and irritable skin will persist throughout their life, and on occasion during stressful events like during adolescence or adult life, eczema may reappear. So it’s kind of always in the background, lingering, but as far as it being a daily issue, it can go away or slow down. For most patients that have childhood eczema, being of Hispanic ethnicity, however, and either African-American or Black race, is associated with increased odds of it actually persisting into adulthood from childhood. And previously underrecognized is adult-onset atopic dermatitis. That is reported in about a quarter of adult patients with atopic dermatitis. So previously we thought you had it during childhood, then it kind of went into adulthood. But now we also see some patients that actually never had it during their childhood, that we can tell. And then they just started having symptoms as they were going into adulthood.
Kortney: Well, that’s really interesting. I’ve actually met a few people at eczema treatment who were adults who had known their lives without eczema. And then at 60, all of a sudden, they got eczema. So I can definitely say that’s an interesting population to talk to because they don’t know what they’re experiencing. You mentioned that AD is more persistent in Hispanic and Black populations. Do you know if there is a reason for this?
Dr. Gupta: So we still need a lot of research in this area, which is another big problem. And I want to mention that there’s actually a lot of factors that can play a role in why this might be. And we know particularly there’s something called social determinants of health. That means that there are conditions in our environment that can actually affect how our health plays out. So where you’re born, where you live, where you work, where you play for children, and so many other things in our environment can actually affect our health and our quality of life. And then that in turn can affect the outcomes and the risks that we might have for any particular health condition. So that’s always something that we need to remember. As I mentioned before, we did have some research that shows that maybe these social determinants of health aren’t an issue in certain circumstances, like in Black children. We did see that there are higher rates even when we accounted for all of those factors. And so that might mean that we need to do more research and the differences in the structure of the skin, which can account for potentially drier skin in different populations and that could lead to worse eczema and worse outcomes. So again, the take-home for this is that we really just need a lot more research to connect the dots and see why certain populations are affected more than others.
Kortney: It’s very multifactorial and we have to keep that in our minds. You said a lot and there are two things that I really want to unpack. The first is, can you explain a little bit about how housing might play a role in someone’s skin?
Dr. Gupta: Yes, absolutely. So where you live is very important. Poor housing conditions like exposure to mold, cockroaches, mice, the lack of ventilation, a lack of air conditioning can actually all play a role in making atopic dermatitis worse.
Kortney: Okay, that makes a lot of sense. And it sounds like these are all things that can trigger your skin and have eczema flares.
Dr. Gupta: So, as we mentioned, we had the opportunity to talk to Shiv Sewlal, and she actually mentioned her experience with lack of air conditioning when she was little. So let’s play that for everyone to hear.
Shiv Sewlal: My eczema really went very severe when [my parents] started introducing foods to me. We also didn’t have as much money then. The only air conditioning we had was in our car. So late at night, my parents would just be driving around with the AC on just to put me to bed. I was constantly in bandages. And so from then I started going to therapy, but then I stopped again, and I started again when I was in that teenage crucial phase.
Kortney: This is actually really interesting because my cousin, who lives in South Africa, also talked about how air conditioning was really important for her and her skin. So, Dr. G, can you just explain why air conditioning can impact people with atopic dermatitis?
Dr. Gupta: Yes, and I actually want to mention just really quickly that there are people in the U.S. that also don’t have the ability to have air conditioning in their home. So I’ve seen a lot of patients in New York City where they have an issue with high heat exposure at night and whenever they’re at home because they don’t have air conditioning in their home. And as we know, eczema is very much affected by temperature. And so a lot of the time we’ll tell patients to keep their skin cool, to maybe even put ice on their skin, to put their medications in the fridge to have a cooling effect, and all of that is just because of heat and humidity can really affect some people’s eczema and make it worse.
Kortney: So try and find the coolest little corner of your house in the summer and sleep there, which is what I do. Back to what you had said earlier – you mentioned that AD is often under-diagnosed in skin of color. Can we talk about why that is?
Dr. Gupta: Yes. So we are realizing more and more that there is a lack of training for doctors in recognizing and diagnosing different conditions in patients with skin of color. One study actually showed that less than 40% of medical resident physicians – so those are physicians in training – in primary care, felt that their medical school curriculum adequately prepared them to manage skin conditions and patients with skin of color. In addition, about 40% of dermatologists – these are specialists in skin care – stated that their training was inadequate in treating skin color. So there really needs to be more exposure for medical students, residents and fellows. Fellows are doctors who are going through more training on education and material, specifically on skin of color patients. And we’re really seeing more and more of that, which is super exciting.
Kortney: So I know that Shiv talked to us about what her eczema looks like. But before we jump into that clip, Dr. G, can you tell us a little bit about how eczema in skin of color might look different and why it’s important that doctors do know there are differences?
Dr. Gupta: Eczema in someone with skin of color will look different in eczema in somebody who has lighter skin. Generally, we find that certain areas of the body that are usually more affected by atopic dermatitis – like the inside of our arm, for example, and behind the knees – but what we find is that in Black patients they’re less likely to have these areas affected and actually present more with their elbows or knees affected. And this can be confusing for both patients and doctors. And I say Black patients, it’s a very large group of patients. So the genetics of different black populations are very different. But we were just talking in general about the Black American population and what we see here in the U.S. In addition, we have to be very careful to treat atopic dermatitis early in all populations to reduce the inflammation caused by the disease. But we find that this is even more important in patients with skin of color, because if we wait too long to treat their skin, then we see an increase in the way that the skin reacts to the inflammation. For patients with skin of color, they can have a darkening of the skin and also a lightening of the skin in response to the inflammation and the different medications that we use to treat atopic dermatitis. So these changes in the color of the skin can negatively impact a patient’s life because it’s very difficult to get the color of the skin to go back to normal. So it’s difficult to put pigment back into the skin, and it’s difficult to take pigment out of the skin. We can do it over time, but it doesn’t always normalize. So that can be very frustrating for patients.
Kortney: Great. And I think what will be really good for our audience is that we’re going to actually jump into our conversation with Shiv right now. She’s going to talk a little bit about her skin, how her eczema presents, and some of her experience of scarring and some of the discoloration that happens from it that Dr. G just mentioned.
Shiv Sewlal: I have a weeping, wet eczema that always gets stuck to my bandages, clothes and bed linen. The coloring of my eczema is a very dark, purplish black color. Many people assume it’s bruises and ask who punched me or if there’s any domestic violence at home.
Kortney: Do you also get dry skin?
Shiv Sewlal: Yes, all the time. I’m constantly reapplying my creams. I keep one on me. I moisturize with my full body cream multiple times a day, but I have this trusty cream that I moisturize the bad spots all the time.
Dr. Gupta: Yeah, and I think just going back to your comment about the differences in the color and the appearance of eczema for patients, it can really vary, and that’s something that we want to let patients know about, so that if they’re confused about what their condition is, that they do go see a specialist to confirm the diagnosis.
Kortney: Now, can you talk to us a little bit about scarring? Do you have any scarring from your eczema and what does that look like?
Shiv Sewlal: So I have a lot of scarring with my eczema on my whole body, but the worst one is the one on my upper lip as it looks like a mustache, especially because the scar is very dark in color. I’ve gotten many comments about it on social media, and it’s gotten to a point where I prefer to cover it up with makeup. I also have very dark eyelids because of eczema scarring. For my very first date, I decided to wear no makeup because I wanted to show that this is me. And one of the things he asked was, are you wearing any makeup? When I told him no and explained that it was scarring on my eyelids, he immediately responded with, ‘Oh, I thought you did your eyeshadow badly.’ And so I made sure to go into the date, explain about my eczema, explain about my allergies, and I didn’t think to explain about the scars because I thought the eczema is gone now, it’s just a scar. I didn’t think that it would be something someone constantly brings up. And on that same date, he even commented about maybe I should do my upper lip, like wax my upper lip. I had to explain to him, though, that’s also a scar. So I don’t know why it’s teenagers. I’ve noticed that as you grow up, the most comments I’ve gotten was when I was a teenager and a child. And as you get older, I think people realize that there’s some things you ask and some things you don’t.
Kortney: That was a very upfront person.
Dr. Gupta: I wanted to talk about lighter skin and darker skin because for people with skin of color, which is the focus of this podcast series, it is different as far as how the lightening and the darkening of the skin can affect people, and it is more prominent when you have skin of color. And what you were saying about your upper lip area is that it’s lighter or darker in general.
Shiv Sewlal: So all my scars are very dark. It’s a dark, purplish, blackish color. So it’s around my eyelids, my upper lip, and other parts of my body. And there’s only one spot that actually went lighter, and it’s on my ankles. And I’m unsure why that went lighter, but everything else is darker.
Dr. Gupta: Yes. And actually treating what we call hyperpigmentation – hyper means that there’s more pigment so it’s darker, and hypopigmentation means that there is less color and that it’s a lighter area. And so treating those areas can be a long-term process and sometimes it works and sometimes it doesn’t. And so I know how frustrating that can be because I personally also have some darker areas that I know over the years have not really lightened as I would want them to. That’s also important for people to remember that those things can happen. And the way that we know now to prevent that is from really treating the inflammation as quickly as possible. So treating the condition earlier with the right medications will help stop some of that hyper. And hyperpigmentation, sometimes you can’t help it when the disease is severe, it’s severe and people will have, unfortunately, that sequoia from it. But what we know is that the earlier you treat it, the better it is. So that’s also something important that we wanted to highlight.
Kortney: Just to recap, Dr. G, can you talk once more about the symptoms of AD and how it is different with different skin colors just so that we can revisit what you said before, shifts explanation of what her skin looks like and what other people could also be experiencing if it’s not similar to her.
Dr. Gupta: Yes. So as I mentioned, the places that eczema presents can be different in different populations. In addition, there can be more of a bumpy presentation to the skin that can be a sign of eczema and that’s more common in patients with skin of color. And eczema will also present for both populations with itchy red patches on the skin. For people with skin of color, it can actually present as dark brown, purple, as Shiv mentioned, or ashy patches on darker skin. And then again for all skin types, it is dry and cracked and may appear to be thicker or swollen. You can get the open oozing crafting stores that can lead to infection and that’s possible in mild, moderate or severe disease. And again in skin of color, the eczema tends to cause a darkening of the skin and sometimes a lightening of the skin.
Kortney: Can we talk about triggers for atopic dermatitis and what that means?
Dr. Gupta: Yes, we use the word trigger a lot in the atopic world and what a trigger is that they’re not things that are causing the eczema, but they’re contributing to its severity. So eczema is an internal condition, meaning it’s something genetic for some people and it’s a tendency for the skin to be drier, more irritable, and itchy, which leads to the disease. But the triggers are things that can make it worse for some people. And so those things are things like soap, shampoos, detergents, fragrances – these can all be triggers for some patients. Heavy or tight clothing can also be a trigger. Chemicals and skin products like cosmetics or antibacterial ointments, hot and humid temperatures. As I mentioned, for some people, the cold air can dry their skin out in the wintertime and that can contribute to the severity of their condition. Allergies can trigger eczema, including food allergies, environmental allergies like pollen, mold, pets and dust mates. And smoke exposure or exposure to secondhand smoke actually can also be a trigger for eczema symptoms.
Kortney: What about the mental aspects of life, like stress or anxiety? Can those also be a trigger for someone’s eczema?
Dr. Gupta: Yes. So that’s a really important topic to bring up and can actually affect all conditions. The stress, anxiety, depression – all of these things oftentimes can make any underlying disease state worse, and that’s especially true for eczema. We found that people with eczema tend to report more stress and anxiety because of their disorder. And sometimes it’s the chicken or the egg. Was it the stress that caused the eczema or was it the eczema that actually made you feel stressed out? And so sometimes it can be a vicious cycle that can keep repeating itself and that can make the itch-scratch cycle worse. And that’s why I think it’s really great that Shiv talked about the mental aspects of how she dealt with her condition and actually how her family dealt with it. And so I’d love to have everyone here that particular segment of our interview with Shiv right now.
Shiv Sewlal: I also want to mention about the therapy. A lot of people don’t realize that eczema affects the whole family and not only just the patient. And a lot of people are surprised that my mom had to go to therapy as well. My mom was affected a lot when I was going through that crucial – that first severe stage when I was around three years old. Seeing your child waking up bleeding and screaming and crying really impacted her. It got to a point where they advised her to step away from me, let my dad and my granny help dress me and clean my bandages out, because they said I could sense my mom’s stress and my mom’s being upset, that in turn makes me stressed and makes me flare. So she was very emotional and I could pick up on that. So she also had to go to therapy and had to get more stronger in how she dealt with me. And she taught me a lot about positivity and making lemonade out of lemon. So that’s the main thing of how I started my social media platform, really bringing that positivity and what she taught me and seeing the backstory about how she also dealt with it and had to learn coping mechanisms and really utilizing that, seeing it from the patient as well as the whole family. I also know that my sisters, even though they have very mild eczema, were still impacted by my eczema and my journey. And even my dad, who’s very quiet and silent. He was impacted in his own way, so it really impacts the whole family.
Dr. Gupta: And I think that’s an important message for doctors to hear, too. We have to see how everyone’s doing and not just the patient when someone is suffering from a condition.
Kortney: Thank you for sharing that. I think that we need to hear more often is that as much as it impacts us, everyone can feel it and everyone responds to it in a different way. And also looping in our family and letting them know how we’re feeling can also help us in the end. They might not realize we’re struggling and they might not realize why we are perhaps behaving in a certain way. So just keeping them looped in is always really good.
I know personally, I live with eczema and it’s flaring pretty much daily, and so everything that Shiv has said just spoke right to me. And I hope that if you’re living with atopic dermatitis right now, you feel like you’re not alone because of Shiv’s story. I certainly don’t feel alone anymore. One thing that I do relate to a lot is this idea of wanting to scratch and just kind of like that mental cycle that happens.
And Dr. G talked about it, and I’d love for us to revisit it. It’s the itch-scratch cycle. I know that I get into the vicious itch-scratch cycle, and it’s really hard to get out of it. So can you talk to us a little bit more about what is the Itch Scratch Cycle and why we should be aware of it as ad patients?
Dr. Gupta: Yes. So the itch-scratch cycle is really important for every eczema patient to understand. Here’s how it happens. When a patient scratches, it breaks down the outer layer of the skin, allowing allergens, irritants and bacteria to enter. The immune system responds by sending signals to the surface of the skin, causing more inflammation and more itching. This also increases the risk of a skin infection because our nails are dirty. And the more we scratch and the more we dig into the skin, the more likely we are to create an infection. And so when the skin is injured by this constant scratching, specifically for the darkening of the skin, there’s melanin, which is what attributes to the color of our skin. Melanin, we find, is released when we’re constantly scratching. And this actually could result in the darkening of the skin, especially in people with darker skin tones. So the scratch cycle can also affect our quality of life because scratching, having that sensation, can impact sleep. And we find this especially in children, but also adults. And so we find that people just aren’t sleeping as well. And then, of course, when we’re not sleeping as well, that can also affect our overall health and our overall functioning.
Kortney: It’s definitely like an all-encompassing cycle. It’s not just the actual itching and scratching, but it’s the whole mental aspect of it and getting out of it, which is really hard. And what you mentioned is really funny because, yes, it impacts children, but I am an adult who sleeps with gloves on still, so it impacts adults, too.
I feel like that was a really great introduction so far into AD in skin of color. I know that we have a lot more to cover on this topic and I know that we could go on and on and on, but that’s why it’s a five-part series and this is the first one. Before we close out, do you have any advice that you would give someone who suspects they or a family member or friend has eczema?
Dr. Gupta: I would say that it’s really important to make sure that you do voice your concerns to your doctor. And if you have already done that and you don’t feel like you’re getting the treatment that is helping, then I would ask for a referral to a specialist like an allergist or a dermatologist that really specializes in atopic dermatitis. And another message that I would give to patients is, as I mentioned earlier, unfortunately a lot of patients use the emergency room or urgent care to manage their chronic condition. And we really need to remember that the emergency room and urgent care is meant for emergencies and that these doctors are really well-trained in emergencies, but they won’t know how to manage a long-term condition like atopic dermatitis and the medications that we can use to prevent the flares that you’re having. And that’s really where a specialist like an allergist or dermatologist comes in to really help you understand how to treat your condition early and effectively. So the earlier we treat a condition, the better the outcome. We talked a lot about the inflammation and that cycle and if we’re able to catch the disease early on and manage the disease with preventative measures and preventative medications. That’s really our best bet at preventing those negative outcomes like hyperpigmentation, hypopigmentation, thickening of the skin and all of those things that really affect the quality of life for our patients.
Kortney: Super. Those are great tips. Well, my friends, that’s all we’ve got for you today. But again, this is only one of a five-part series and we’re excited to continue this conversation. Remember that spreading the word and raising awareness is how we can really help everyone get the best treatment they can for their atopic dermatitis. So if you have any questions, you can always hit us up on Instagram. And don’t forget to check out the show notes for more information about atopic dermatitis in skin of color. Thank you so much for listening. Have a wonderful rest of your day.
Dr. Gupta: Thank you for listening to today’s episode. Remember that all information you hear today is for informational purposes only and are not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified physician or healthcare provider. And also, don’t forget to subscribe to our podcast. And if you have a second, help spread the word by rating our podcast and sharing with your friends and family who might also be interested in learning more about allergies, asthma and immunology. You can always stay up to date by checking out our Instagram for The Itch podcast, where you can leave questions you are itching to know. Or check out our website, which is www.itchpodcast.com, which contains more information about the subjects we covered in today’s episode and every episode. Until next time, have a fabulous week.