This webinar was recorded on February 20, 2024

Atopic dermatitis is more common and sometimes more severe in Black/African American people and Hispanic/Latino people, especially children. Because of its unique appearance in skin of color, it is often misdiagnosed. It is vital that physicians and patients recognize symptoms in skin of color and understand how social and economic factors can impact diagnosis, management and treatment in people of color.

Speaker:

  • Kelly Maples, MD

Dr. Maples is an Associate Professor of Pediatrics and Internal Medicine at Eastern Virginia Medical School. She teaches pediatric residents and cares for patients at Children’s Hospital of The King’s Daughter. Dr. Maples served a 3-year term on the Board of Regents of the American College of Allergy, Asthma, and Immunology (ACAAI) and a one-year term on the ACAAI Executive Board. She has been the Chair of the ACAAI Dermatology Committee for the last 6 years and serves as Chair of the ACAAI Dermatology Scientific Counsel and the ACAAI Expert Committee on Atopic Dermatitis.

Dr. Maples is committed to improving the care of atopic dermatitis in patients with skin of color and teaches residents and other allergists about this topic. She recently helped develop www.eczemainskinofcolor.org with a team at the ACAAI and AAN. Her team won a 2022 Ragan Diversity award for their work on this website.

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Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.

Lynda: Hi, everyone, welcome to the webinar. We will wait a few minutes as we have more people filling the zoom room, so hang in there, and we will get started shortly.

Hello, everyone, thank you for joining us. I’m Linda Mitchell, CEO of Allergy and Asthma Network. Welcome to this afternoon’s webinar. I’m delighted to have Dr. Kelly Maples as our presenter, she is a real expert on eczema and skin of color.

We have a few housekeeping items to go over with you before we start today’s program. First, all participants will be on mute for the entire webinar. We will be recording the webinar and it will be posted on her website within a few days after the webinar has been completed. You can always find our recorded webinars by going to allergyasthmanetwork.org. You will find the recorded webinars and any upcoming webinars as well. The webinar will be one hour in length and will include time for questions at the end. During the session you can put your questions in the Q&A box at any time. The Q&A box should be at the bottom of your screen. We have someone monitoring both the chat and the Q&A and we will get to as many questions as we can before we conclude the session at 4:00 p.m. The webinars presented in partnership with the American College of Allergy, Asthma, and Immunology. The College offers CME’s and credits for all others. You can attain CME or attendance credits. All attendees will be offered a certificate of attendance from Allergy & Asthma Network as well. No other continuing education credit is provided.

After the webinar, you will receive emailed supplemental information and a link to download the certificate of attendance as well. We will try to add a certificate of attendance in the chat. Sometimes it works with zoom and sometimes it doesn’t. Today’s topic is atopic dermatitis in skin of color.  Atopic dermatitis is more common and sometimes more severe in Black and Hispanic people. It is often misdiagnosed. It is vital that physicians and patients recognize symptoms in skin of color and understand how social and economic factors can impact diagnosis, management, and treatment in people of color.

It is my pleasure to introduce our speaker, Dr. Kelly Maples. Dr. Maples is a full professor — congratulations, Dr. Maples, of pediatrics and internal medicine at Eastern Virginia medical school. She teaches pediatric residents and cares for patients at Children’s Hospital of The King’s Daughter. Dr. Maples served a three-year term on the Board of Regents for the American College of Allergy Asthma and Immunology and a one-year term on the ACAII executive board. She’s been the chair of the ACAII dermatology committee for the last six years and serves as chair of the ACAII dermatology scientific Council and the expert committee on atopic dermatitis. Dr. Maples is committed to improving the care of atopic dermatitis to patient with skin of color and teaches residents and other allergist about this topic. She recently also worked with us to create the eczema in skin color.org website with the team both at the college and with allergy asthma network. This team of producers won an award for their work on this website. So, thank you for being here today, Dr. Maples. I will turn it over to you.

Dr. Maples: Thank you so much for having me and thank you everybody for taking time out of your busy day to learn more about this important topic. Once again, Kelly Maples and I work at Children’s Hospital of the Kings Daughters and I’m full-time faculty at Eastern Virginia medical school. I have served as a speaker and consultant for AbbVie. Here are our learning objectives for today. First and most important is to describe the clinical and physiologic differences of atopic dermatitis in patients with skin of color and use those to form a treatment approach for those patients and discuss factors that can lead to disparities in atopic dermatitis care, other than the different appearances in skin of color. Here’s an outline of what I will talk about today.

First, I will discuss the epidemiology of atopic dermatitis in patients with skin color and then we’ll focus on clinical differences and images to help them improve diagnostic skills and we will discuss treatment and then addressing other disparities in these patients as well. I want to take a brief moment to thank Dr. Andrew Alexis. I did a similar presentation for the Allergy and Asthma Network back in 2021 and when I was doing it, it was very hard to find clinical images of atopic dermatitis in skin of color and I was kind of scrambled to make a good meaningful presentation and Dr. Alexis very generously lent me a lot of clinical images that I used for 95% of the images for that presentation. Fortunately, today, it is a lot easier to get good quality images of eczema and skin of color but I’ve has still use many of his images throughout and I have indicated when they are from Dr. Alexis on my slides. There’s a bunch of images where I don’t have any citation, and they are from eczemainskinofcolor.org, which I will talk more about later.

First, I will talk about the epidemiology. Most of you listening know that atopic dermatitis is very common and is the most common skin disease and the general population. Eczema is more common in patients with skin of color than their white counterparts, and by 2050, more than half of the U.S. population will have skin of color. That means it is a really common problem that we really need to be able to manage and diagnose correctly. Eczema is more prevalent in patients with skin of color than in European Americans. This is true for both pediatric and adult patients. So in children in the U.S., the prevalence of atopic dermatitis is just above that you will see the data in adults, there is even a bigger difference in adults where the prevalence is about 19% in African-Americans and only 3%-4% in European American adults. In Asian countries, the prevalence is 7%-10%. Not only is eczema more common, Black and Asian patients are more likely to visit a doctor for atopic dermatitis than white patients are. Asian patients have about six times as many visits but that’s not because they are going to the doctor more in general, it’s only specific for atopic dermatitis. The 2002 study looked at what percentage of visits were for what condition and for what population. Out of 8 million visits for atopic dermatitis, 16% of those were for Asian and Pacific Islander patients, and about 20% of those were for African American patients. Compared to their white counterparts, Asian Americans had a ratio of 6.7, so 6.7 times or likely to visit than white counterparts and African Americans had a rate of 3.4. Indigenous people were not included in the study. So, I’m unfortunately unable to give you the data for that.

I mentioned that although patients with skin of color go to the doctor more for atopic dermatitis, it’s not because they go to the doctor more overall. It is also not true for other skin conditions. Here on the graph we see that for atopic dermatitis, Asian patients the gray bar and African-American patients on the black bar, do see physicians more often than their white counterparts, but if you look at other conditions such as warts and psoriasis, that is not the case. So, they are not over utilizing health care in general, it’s just that atopic dermatitis is impacting them more and they are ending up using more health care.

We know that two of the most bothersome symptoms are more pronounced in African-American and Asian patients with atopic dermatitis, likely leading to this increased health care utilizations for atopic dermatitis specifically. In addition to going to the doctor more, they are missing more school. U.S. study of about 8000 kids found that African-American kids had a 1.5 fold higher chance of missing six or more school days over a six-month period than white children with eczema. In addition to the loss of learning which can be harmful for the child, this can also lead to loss of income for families because when the child is unable to go to school, often, a parent has to stay home from work, so it can have a huge impact on quality of life of the entire family, not just the child. The authors of the study concluded that atopic dermatitis has more impact on quality of life. Another study found that 89%, a large portion found their social lives and leisure activities were impacted because of the eczema, including things like avoiding athletics and outdoor activities. So, in addition to affecting their quality of life, this is also starting to affect their exercise, which can have a huge impact on their health, their skin and their sleep.

A lot of what I want to focus on today is clinical presentation. The diagnosis of atopic dermatitis is a clinical one. If you don’t know what to look for, you might miss the diagnosis or underestimate the severity of a patient’s disease, and both of these mistakes can lead to the under treatment of atopic dermatitis in patients with skin of color. We just talked about how this affects the quality of life and they don’t exercise and they miss school and they go to doctors more and spend more on health care. So, under treatment can lead to suboptimal outcomes for patients.

Just this month, the whole JAQI issue was published dedicated to disparities in health care and they did address the under diagnosis of atopic dermatitis. They found the lack of ability and training of providers in diagnosing atopic dermatitis in underrepresented minorities when it presents differently from other populations is what leads to other diagnoses. So today I hope to increase your ability to diagnose atopic dermatitis. in patients with skin of color.

Before I show clinical images and talk specifically about diagnosis, I like to start with two clinical vignettes, they are very brief. I’m not going to give any solutions, I just want to get you thinking about it, and be honest with yourself about how you would diagnosis currently and then we will see if your opinions change and revisit these patients later on.

Jack is a 14-year-old young man and he comes to you really itchy, dry, itchy patches on his arms and legs. He did go to his primary doctor who told him he had dry skin and to use petroleum jelly. Jack has been really good about it, but he said it is still not working, he is still itchy and has these patches. In the photo on the bottom you can see what it looks like. So how would you describe this? Does Jack have erythema? Does he have post inflammatory hyperpigmentation? What treatment would you recommend for this young man?

The next patient is Tracy, a 27-year-old woman. She has been so itchy, she is itchy all the time but it bothers her the most at night time because she can’t sleep and it is starting to impact her job. She has been using sensitive skin so, free and clear detergent for her laundry, she applies a thick moisturizer prescribed by her primary care doctor few times a day. Recently she has resorted to taking sleeping pills so she can fall asleep. Take a look at that, think about what you think, how would you describe her physical exam? And then maybe what treatment options you would recommend based on what you’re feeling is, does she have atopic dermatitis and what is the severity of her atopic dermatitis?

This is a quote from the National Eczema Association. In the blue circle you see a prompt that they gave parents of Black children. Here is one example from their website. I won’t read the whole thing, but to give you an idea, “I wish more dermatologists knew that eczema in patients of color can present differently than it does in white patients. Instead of having red and visible areas of patchiness and dryness, it is usually more difficult to see symptoms of eczema due to our skin tones.” So, it is possible they might go to the doctor and still be misinformed about what their child has or how severe the child’s eczema is.

I’ll start the image portion of the presentation, but here are some main differences in the clinical presentation of atopic dermatitis. Black patients have post inflammatory hyperpigmentation and hypopigmentation are seen by patients with atopic dermatitis and can be more bothersome cosmetically. A papular morphology is common in atopic dermatitis in patients with Black skin. We talk about how not to miss that. Patients with skin of color tend to have more xerosis and Dennie-Morgan lines are more common. It is more common in patients with African-American skin. Periorbital hyperpigmentation is often seen with Black skin and sometimes they have increased pruritus. I will show you photos of all of these. The distribution is different, other involvement can be seen as well. The message is we might see more different colors, morphologies and distributions in patients with Black skin than their white counterparts. In Asian patients, the lesions can have an annular appearance, and biopsies on histology look a lot like psoriasis as well.

One important part of diagnosing atopic dermatitis is the presence of erythema and even our guidelines rely on erythema. So, the definition is abnormal redness of the skin or mucous membranes due to capillary congestion as inflammation. If we stop there, we will miss the diagnosis in a lot of patients, or patients who have severe disease will not get the great systemic therapies that are available now if you underestimate their severity.

One pearl to take away from this is that erythema does not equal redness. Erythema can be red, but it doesn’t mean only red.

Here on the left we see a picture of the classic erythema that so many of us so in medical school and textbooks and everywhere, where we see pink to red erythema from the increased blood flow. But on the right, we see Jack’s arm, the patient from the first vignette that I showed you. He has increased erythema and congestion from inflammation, but he has a more gray appearance to his erythema. He has some follicular lesions as well. The main thing I want you to focus on is just the inference in the way the erythema looks. You can also try to look for a patch of clear skin and then compare it with your eye to the area of involvement. That can help you appreciate the erythema as well. The pigments in his overlying skin make the erythema look like a different color than erythema does in his white counterpart. This is why it is so important to realize when you’re doing things like the validated assessment score that you are not underestimating the severity of your patient’s disease. The concern is that the lack of clinical images of skin of color is leading to a gap in medical education. Not just an issue for providers but when patients are seeking advice online, they might see this red thing and say don’t have that, and not realize they really do have erythema and eczema that needs to be treated.

As many of you know, in November of 2023, a joint task force guidelines came out and there are multiple areas of the guidelines addressing disparities and even the definition of erythema. This is directly from those guidelines. Atopic dermatitis can present with different morphologies, including popular, lichenoid, nummular and follicular clinical forms, and extensor surface,  eyelid and inverse flexural involvement. Erythema reflects increased blood flow to superficial capillaries and if it’s literal Greek meaning, red, is followed, the diversity of presentations can be importantly underappreciated. Consistent with calls to improve representation of diverse ethnic backgrounds and skin tones and society, we define erythema to include transient skin alterations characteristic of active atopic dermatitis inflammation including red, shades of brown, violaceous, or gray appearances. So now erythema is officially defined to include all the different spectrum of colors that we may see in patients with skin of color.

This is not a scientific study, but I mentioned earlier in 2021I did a presentation on the same topic. These are just screenshots of my Google images. The top one is erythema eczema and skin of color. Definitely not representative of the appearance of erythema in patients with skin of color.

Earlier this month when I was eating my slides together for this presentation, I’m happy to say that these are the results I got. This is a great example of all the different ways that erythema can look in patients with atopic dermatitis and skin of color. And here’s a shout out to my website which I will tell you more about.

I’m happy to say there is increased industry awareness of eczema in skin of color and that’s great, because representation is important for patients with skin of color. Even if they are not trying to actively search for our website, they can see that eczema in skin of color has a different presentation. This is from an Aveeno ad.

Now we will talk about how the morphology can be different. This patient, this little girl’s belly, a lot of patients would say it’s just follicular eczema and she does have dermatitis. This might be the only presentation of atopic dermatitis and this follicular eczema tends to be very itchy and often doesn’t respond well to corticosteroids. It is important to realize that this is atopic dermatitis and it might be the only thing you see. You don’t want to see that and just tell patients to use moisturizer especially if they are scratching their skin which can lead to the risk of infection. We don’t want to miss erythema but we don’t want to miss this follicular appearance. This patient also has a follicular appearance but it has more classic erythema and it’s in an area where people are really looking.

Some reminders for the guidelines of the diagnosis of atopic dermatitis. The classic guidelines have the three major criteria, with chronic relapsing dermatitis and a family history, along with pruritus. The minor criteria, this is not a new criteria for the diagnosis of atopic dermatitis. We see other findings that are more common in patients with skin of color. Xerosis can cause more stigma, patients don’t want to appear ashy. Orbital darkening is also more common in patients with skin of color.

Here’s a diagnostic criteria according to the American Academy of Dermatology. In addition to looking for erythema in the classic scaly patches, we want to keep in mind we may see truncular involvement as well.

African American patients can often have lichenoid appearance. It’s usually on the extensor surfaces as you see here. You see a silvery appearance and here we can see some brown to reddish brown erythema with these lesions on this child’s upper extremity.

Pigmentary changes can be bothersome in patients with atopic dermatitis, but they are more cosmetically noticeable in patients with skin of color. On the left you see a patient with some hyperpigmentation from topical corticosteroids. Most hyperpigmentation in patients with skin of color or eczema is not due to topical corticosteroids. Most of it is due to inflammation, rubbing, and excoriation. This can be prevented by treating eczema early so we don’t miss the diagnosis and severity and get them on the right treatment we can help prevent this. Once I do have pigmentary changes, using a good sunscreen is important because the areas of normal skin will continue to tan but the deep pigment areas won’t tan, so the summertime sign can make the area more pronounced and more cosmetically displeasing.

Many patients with African-American skin with atopic dermatitis develop this nodular appearance as well. Here we see a lot of papules on the extensor surface. It looks like some of them may have become excoriated as well. Sometimes these patients do develop a nodular appearance because controlling the itch of that can be quite difficult as well.

Shifting to Asian patients, they have what is been labeled a blended phenotype between white patients with atopic dermatitis and those with psoriasis. We see thick, scaly, circular plaques with raised edges and epidermal thickening as well. Asian patients with atopic dermatitis tend to have more TH 17 and TH 22 cells in their skin biopsies.

Here is a comparison of an Asian patient with atopic dermatitis and a European patient with atopic dermatitis on the right. We see trunk involvement which is common in Asian patients but can certainly occur in white patients as we see here. This patient has brown to violet plaques with raised edges, some of them are circular in appearance. You can see on the back how raised they are. In contrast to these larger areas of pink to red patches with excoriation on the extensor services and trunk of this white individual. Here if we look at their biopsy we see the Asian skin eczema biopsy looks a lot like psoriasis this thickened epidermis. Here’s a graph showing the epidermal thickness is greater as well.

Here’s another great example of truncal involvement in an Asian American adult. You see this classic scaly appearance and circular pink plaque with raised edges. We see another plaque down here with a fine scale overlying it and a raised border. This is classic of Asian skin atopic dermatitis.

Here we see pictures of an Asian, Caucasian, and African-American babies with atopic dermatitis. We see that more violet to brown erythema in the patient with African American skin and here we see plaques compared to more diffuse pink patches. All of these patients will have increased Th2 cells on biopsy, but the Asian patients tend to have increased TH 17 and TH 22 cells, much like you would see in a psoriasis biopsy. Patients with atopic dermatitis tend to have more elevated IgE levels but it is more pronounced in babies.

Here’s a few more comparisons. Here we see classic psoriasis, with a long, thickened epidermis. Compared with Asian skin, once again we see some on the torso of this patient. The erythema looks quite different and is a different morphology than a patient with African-American skin with this violet to brown patches and a little bit of follicular eczema. Th2 involvement is common with all the forms of atopic dermatitis but is absent in psoriasis. The Asian pattern of TH 22 and 17 cells is more similar to what we see over here in psoriasis. Skin barrier function is important in atopic dermatitis and patients with atopic dermatitis have skin barrier dysfunction. This leads to transepidural water loss and starts a cycle of atopic dermatitis. Loss of function mutations are very common in European-American patients with atopic dermatitis but they are not common in African-American patients. European-American patients have six times higher likelihood of having this mutation then patients with Black skin. There’s definitely more than one gene that is coming into play, we just haven’t identified a common one yet. Asian patients who have some decrease but you can see the mutations that have been identified in the Asian population are different and distinct from wheat Asians found in the European or American patients.

Our new guidelines from the 2023 joint task force do address North American Indigenous people. I don’t have any specific photos to show you from North American Indigenous people nor do I have photos of Latino patients but hopefully if I am invited back I will have more photos. The guidelines do want to address health care disparities in North American Indigenous people. The social determinants of health that affect eczema care in North American Indigenous people include the remote locations where they live, housing conditions on reservations and suboptimal access to health care. To address these disparities, the joint task force guidelines suggest actively and equitably engaging North American Indigenous people in research and policymaking. And also incorporating culturally sensitive decision-making during clinical encounters. If you do care for North American Indigenous people it is important to appreciate involving them in research practices.

So now here is our gallery, I want to have as many images as we can for everybody to see of atopic dermatitis in skin of color. Here on the left once again if we think about the location, it’s on the extensor surface and the morphology here, we see a lot of follicular and popular atopic dermatitis with the brown to violet erythema. On the right, once again we see the extensor surface involvement. We have a lot of different findings in this patient. If you find a spot of clear skin so we can compare the abnormal skin and that helps you see the erythema. On her upper thighs and area of clear skin. We see here she has a lot of brown plaque with overlying calcification and a lot of excoriated papules. On her upper thigh we see a follicular pattern and some papular eczema as well. And we see some deep pigmentation on her lower extremities from her atopic dermatitis.

This slide, just rainbows of erythema. The picture on the bottom right is one of my favorite ones for demonstrating how different erythema can look. Here it looks grey and then it starts to look violet to pink. We see the plaque with some overlying fine scale at the nape of their neck. This top right photo we have that lichenoid appearance, once again on the sensor surfaces, similar findings on the top left. At the bottom, we see brown erythematous patches and plaques with overlying xerosis, we see some excoriated nodules as well as fully cooler lesions.

On the next page, I mentioned earlier , a lot of xerosis with thick scale. Always try to look for the spot of clear skin, that can help you and when you compare this area to this, we see that she definitely has a lot of brown erythema with the scale as well as some follicular lesions.

Here we see a child with the classic flexural involvement. We see brown to reddish brown erythema with popular lesions as well as fine scale.

Here we see a similar finding but with a lot more excoriation and this child also has some follicular eczema on her upper thighs. We talked about the xerosis is more significant and cosmetically significant. This is one that I don’t think would get missed as much, but some might still call that post inflammatory hyperpigmentation. If we look at his clear skin it does have a violet red appearance to it.

Here we see a baby, once again a good example of how the xerosis is worse in African-American patients with skin of color. There’s not much clear skin to compare it to, we could maybe use the child’s thumb and see the child has brown skin with thick scale over a large body surface area.

Here we see erythematous to violet erythema in the picture on the top right, I would call brown erythematous plaque with overlying papules and this metal bracelet makes you think a little bit about contact dermatitis. Contact dermatitis does often occur in patients with atopic dermatitis, and I will address that later on.

Here we see a lot of the nodular appearance.

Here we can see some excoriated nodules surrounded by brown to violet erythema.

Here we see more than one finding of follicular eczema, depigmented areas and brown erythematous nodules.

Here we see some depigmentation and nodules that are brown to pink erythema. Here we see some excoriated nodules and papules scattered over the extensor surfaces of this lower extremity. Here is a brown erythematous patch with some thick excoriated nodules and on the rest of their back we see scattered lesions. We talked about depigmentation and hypopigmentation. This is right at the area of the abdomen that is overlying the belt buckle with this is how pigmentary changes are so much more bothersome and can stigmatize patients with darker skin. On this patients hand, we see a Latino patient with erythematous patches and areas of hypopigmentation on the dorsum of the hand. This is a erythematous plaque with excoriation and a few excoriated nodules there on the periphery.

Here’s an example of some red-brown erythematous patches on the extensor surface as well. This is going back to Tracy come of the patient from our second clinical vignette. She could not sleep and she was taking sleeping pills so she could go to work the next day. Can look for some little pockets of some clear skin and really appreciate that she has enlarged body surface involvement of this great erythematous plaques and patches. There are some excoriation on her back and here is nine months after starting therapy. She has improved and she is not itchy, but it helps you compare her normal skin so you do not miss that erythema. It would be very easy to miss the erythema, with such a big body surface area covered, it is hard to see those pockets of normal skin.

Here’s a teenager who has a — scaly patches around their neck and we have excoriated papules as well. This distribution around the neck is common in African American patients but sometimes can be suspicious for atopic dermatitis as well. He received violet and great shades of erythema and a nodular appearance on the neck, chest, and abdomen of this gentleman.

Next we will switch over to treatment. Now we know to look for unique shades of erythema and different distributions in patients with skin of color who have atopic dermatitis. Now we want to move on to treatment, so the new eczema guidelines say that although there may be different inflammatory responses and some genetic differences in different racial groups with atopic dermatitis, the treatment really isn’t that different. Principles of atopic dermatitis care remain similar for all skin types. Hence, although there is interest in understanding potential variation in the atopic dermatitis inflammatory response across race, ethnicity, or ancestry, the relevance of these findings to informing treatment selection is not clear, and so for multiple agents display no differential treatment response across these groups.

The important thing to take away is we don’t want to miss who needs more aggressive treatment. First, we don’t want to underestimate the severity or miss the diagnosis and we want to avoid under treatment, consider systemic therapy, and you want to address skin barrier issues and xerosis. You want to address bathing regimens with patients. A lot of patients have been informed that baths are bad for eczema, so we will see patients who get a bath once a week. A lot of things you put in the bathtub can be bad for atopic dermatitis, but if done the right way, they can be helpful. I recommend soap free, detergent free and fragrance-free cleansers in the bath. Soap free, recommended because the alkaline pH of soap activates proteases, so the skin cells are held together by special connectors that break these down for normal healthy skin balance. The alkaline pH of soap activates those proteases so they can accelerate the skin breakdown and in patients with eczema who already have inadequate skin barrier function, breaking down the skin barrier even more is not what we want to do. That’s why I recommend soap free cleansers than detergent free cleansers. So a lot of body care products make a lot of different bubbles. And, usually sodium lauryl sulfate is the detergent doing that and  they dissolve a portion of the skin barrier. The layer of fats in our skin barrier that helps hold in water keeps allergens and irritants out. Sodium lauryl sulfate will dissolve all that. The reason we recommend fragrance free is because many fragrances are strong contact allergens and they can cause contact dermatitis in patients with atopic dermatitis. So those things all make eczema seem worse, soap, detergent, and fragrance. Patients should get warm baths, not hot. It’s important to know they cannot scrub it away, that will make their eczema worse. After the bath, they should use a good moisturizer, usually a thick cream or ointment based moisturizer. If they don’t like the feel of them, they will never use them, so it’s important to find a moisturizer that the patient will tolerate. There’s a great hand out the guideline showing that the thicker, goopy or ones are more effective, but sometimes the thinner lotion ones are more tolerable. If they don’t tolerate the thick one, using a thinner lotion is better than nothing after the bath. We want to target inflammation while avoiding overuse of potent topical steroids. So many patients are worried about this pigmentation and hypopigmentation in the skin of all of their patients, but especially those with darker skin. If you overuse high potency steroids, this can occur. If you are under treat their eczema, the post inflammatory hyperpigmentation may be more exaggerated and you can prevent that by using adequate amounts of topical corticosteroids or other topical anti-inflammatories. If the patient has concerns about topical steroids, you can consider topical calcineurin inhibitors or others in moderate to severe atopic dermatitis. Letting them know that treating their eczema can help prevent hyperpigmentation and can prevent hypopigmentation from scratching and excoriation. And controlling each with good medications, or go to systemic therapy.

Despite differences in atopic dermatitis, I mentioned earlier how much better our patient Tracy got with dupilumab. Before I start systemic therapy, I consider patch testing. Some patients with atopic dermatitis have allergic contact dermatitis and them I have since to one of their topical corticosteroids and with patch testing if you can identify that and help avoid that allergen, they might have a significant improvement in their skin where they are not as interested in systemic therapies. So, I think that is important. But there are limitations, recall the limitation of classic erythema when interpreting patch testing. This area of erythema is easy to appreciate, but some patients have much darker skin and seeing erythema on patch testing can be hard. Always remember to palpate every single patch, and it is also helpful to look for different changes in skin color that may reflect erythema when interpreting patch testing and someone who has atopic dermatitis.

In addition to being aware of the diagnoses there other things like — that impact the care of our atopic dermatitis patients. Recently this month the impact of socioeconomic factors on allergic diseases was published and so there is scientific evidence that socioeconomic status of disadvantaged patients, especially those living in poverty and the authors concluded that the lack of specialty care leads to decreased quality of care and management in atopic diseases.

So there’s a lot of factors that come together that lead to less specialty care. A lot of patients don’t have good transportation and they miss doctor appointments or may have to reschedule them. Poverty can certainly affect access to health care and health insurance. Some low-income families may live in areas that don’t even have specialists and they might skimp on their medications to make them last longer or even avoid doctor’s appointment, so they don’t get a bill. Environmental triggers can be worse, so patients who live in substandard housing might be exposed to more potential eczema triggers including dust mites and tobacco smoke. There’s educational inequalities, a lack of knowledge and understanding about their skin condition that can lead to problems such as using medications incorrectly or not following through on their own treatment. That’s why sharing a lot of resources with them is important. And language and cultural differences, people who speak Spanish as their primary language might struggle to get appropriate health services or to fully understand their treatment plan. The Asthma and Allergy Network, on their website has Spanish language handouts, not only for atopic dermatitis but for asthma and other conditions as well. So, if you don’t have Spanish language handouts in your clinic, that’s a great resource for you so you can help your patients.

This is a little diagram showing how the patient, the provider, the community and policymakers affect five aspects of quality health care which are availability, accommodation, affordability, accessibility, and acceptability. Includes education, thinking about things like eczema skin care can be overwhelming and can affect their care as well. There is implicit bias and lack of training, we might not realize those patches are active eczema and not post inflammatory hyperpigmentation. So, we can continue to better ourselves but we need more diversity in clinical trials. The community can affect them, if they live in substandard housing, they have worse exposures to known triggers for the asthma and eczema. We should continue to vote and advocate for our patients to help with structural changes that can lead to improve care.

Here’s another set of recommendations, the College did a survey of members, I think 200 responded and there was a roundtable as well, repose solutions by the College to address racial disparities. They asked specialists what problems lead to inadequate care. It is a great study, these are already patients who had access to a member of the College so they already had access to specialist care and were already more fortunate than a lot of patients. 69 percent said access to a specialist who takes Medicaid. We need our policymakers to make it possible for doctors to continue to accept Medicaid so our patients can have access to care. Lack of awareness and education about their symptoms and conditions. So we can do our best to educate our patients and give them handouts they are able to read and in their language, inadequate insurance, costs associated with treatments. Access to a specialist near their home who has experience recognizing atopic dermatitis in black and brown skin. Hopefully all of you can do that and you can continue to spread this. A lot of you teach students. When you show them patients with eczema on skin of color. The bottom of these are all important but not related to atopic dermatitis.

The recommendations are to identify ways to recruit more people with skin of color into clinical trials and medical school, because representation does not just matter on a website, it matters seeing their health care providers look like them. Educate health care providers about the diagnosis and treating atopic dermatitis in skin of color, develop culturally appropriate materials and strive for longer appointment times for patients who need them.

The 2023 guidelines made the following recommendations as well. Given the complex factors driving disparities, improved research and educational initiatives alongside interdisciplinary and multi-stakeholder involvement are needed to help reduce gaps in care. At individual and population levels, clinicians hoping to achieve optimal atopic dermatitis outcomes will actively address unconscious implicit biases and account for patient contextual factors and shared decision-making. Clinicians should also promote structural and organizational change. So Eczema in Skin of Color is the website that we started after I did my presentation in 2021. There’s a gallery, and a lot of the images I shared come from that resource. If you have images you would like to add to the gallery, let us know, that would be awesome. In addition to being a resource for you and for medical students, it’s also great resource for patients. Patients have been appreciative when I showed them the website and helps them know what eczema would look like in their own skin. Or recordings of different experts talking about eczema in skin of color.

In summary, atopic dermatitis is more common in skin of color so we need to be able to take care of it in patients with skin of color. It presents with different colors and morphologies, it tends to cause more symptoms, and we want to make sure we don’t miss the diagnosis or undertreat. Make sure you are aware of all the different ways it could look. And we need to do more to address health care disparities. Thank you so much for having me, thank you to Asthma and Allergy Network for supporting the Eczema in Skin of Color website. And now I’m happy to take questions.

Lynda: Thank you, Dr. Maples. We got some really great comments in the chat about how informative this has been. It’s just a much-needed topic and we are so glad you take the lead on teaching so much about this topic. I have some questions, I’ll try to do it rapid fire since we are really close to 5:00. We have a lot of school nurses in the audience who have students who probably have undiagnosed eczema or are living with the pain and itch of eczema. Can you give some pointers to what school nurses can do to support the students?

Dr. Maples: It’s very hard, even if they know, talking to their parents, sharing handouts from the Asthma and Allergy Network website, sharing pictures from the website, talking about some basic skin care, even just emollients after the bath and maybe seeking additional care from their primary care doctor if skincare recommendations are not helpful.

Lynda: That’s wonderful, thank you so much. What is a good emollient to use, or can you recommend a detergent free cleanser that is commonly used?

Dr. Maples: Cera-Ve cream, it is cream based but is not super slimy. It has ceramides in it, and  hyaluronic acid. It helps hold in water and keep irritants out. It’s fragrance free and does not have a lot of the most common contact allergens. I do not recommend using Aquaphor with little kids, it has lanolin in it which is another strong contact sensitizer and that can cause allergic contact dermatitis. They are putting lanolin on the spots that bothered them and it they’re not getting better, and now they are allergic to their moisturizer. Aveeno eczema balm is another good one. I do prefer the cream if they tolerate it. Vaseline itself is not a moisturizer, believe it or not. It is occlusive. It will help hold some water in, but it is not adding any emollients to the skin. So, it is very affordable so it can be helpful, but I would prefer a cream or eczema balm.

Lynda: You answered another question that someone was asking about Vaseline.

Dr. Maples: Cera-Ve makes a lot of cleansers, Burt’s Bees and a lot of other brands make soap free cleansers.

Lynda: Somebody just put something in the chat. I don’t know if I understand the question. My question is about CARD11 mutation and the risk of developing psoriasis like pictures after dupilumab treatment.

Dr. Maples: I’m aware of different dermatitis rashes that have developed in patients, but I can’t speak to the mutation specifically for that.

Lynda: Why do we use eczema and atopic dermatitis interchangeably when some people with eczema have no allergy history?

Dr. Maples: Eczema is really not equivalent to atopic dermatitis. Someone can have an eczema rash and it doesn’t mean they have atopic dermatitis. In the diagnostic criteria, personal or family history is one of the major diagnostic criteria. Sometimes it might just be a dry, scaly rash that might be like an irritant contact dermatitis. When doctors say eczema, they might mean the finding on the skin but not the diagnosis or the cause of the rash.

Lynda: It’s a little past 5:00, I just want to thank you so much for this wonderful presentation. We really learned a lot today and it is really important topic that we need to make more people aware of so they can get the diagnosis and treatment that they need. So we will say thank you again and I will go ahead and move on to closing up for the day.

We have two webinars coming up later this month, spring allergies and asthma on March 14, 12:00 p.m., so if you want to join us at lunch time, we will be here, and we welcome Dr. David Golden on March 21st at 12:00 p.m. to talk about insect stings and allergies. Please join us for both those wonderful speakers. You’ll receive an email with the link to the recording. An evaluation will follow after a close out of Zoom. Thank you again from all of us here at allergy and asthma network. Join us as we work every day to improve the quality of life and health for people with asthma, allergies, and related conditions. Bye, everybody.