Atopic Dermatitis in Skin of Color: Your Questions Answered

Here, Mohiba Tareen, MD, a Minnesota-based dermatologist, Castle Connolly Top Doctor, and Everyday Health medical reviewer, answers common questions about how eczema affects skin of color and what patients can do to get the right diagnosis and medical treatment and manage their symptoms. The interview has been edited for clarity and length.

Everyday Health: How prevalent is atopic dermatitis in people of color, compared with the general population? 

Dr. Mohiba Tareen: Atopic dermatitis is most common among African Americans. Approximately 20 percent of African Americans develop eczema at some point in their lifetime, compared with about 16 percent of Caucasian Americans and 8 percent of Hispanic Americans.

EH: What are the most common eczema symptoms in people of color? And do they vary much from patient to patient?

MT: The No. 1 symptom of eczema in anyone of any color is itching. That’s the hallmark symptom, where we say, “If it’s not itchy, then it’s probably something else.”

Particularly in people of color, because of our thicker collagen [a protein that gives skin its structure], eczema can form more bumpy skin. So unlike Caucasians, who can get scaly, people with darker skin can get bumpy. You run your hand over it and it feels almost like a little spine.

Rather than the redness you’d see in white skin, atopic dermatitis patients of color can have more of a dark gray, kind of purple “ashiness.”

Furthermore, because of our increased melanin load, we can also get hyperpigmentation [areas where skin is darker than normal] and hypopigmentation [lighter areas].

EH: Why does atopic dermatitis tend to be more severe in Black patients?

MT: There are two reasons. Number one, genetic factors. There’s a protein expressed [produced] in everybody’s skin called ceramide that helps retain moisture. The ceramide-protein ratio is lower in African Americans. So genetically, darker-skinned people are holding onto less moisture.

Number two, there’s a situational-environmental reason why African Americans have worse eczema. That’s because, in general, many African Americans tend to live in urban settings with many irritants, allergens, pollution, humidity, higher UV radiation load, hard water, dust — these are all things that can exacerbate eczema and compromise the immune system.

EH: What is the connection between atopic dermatitis and allergies?

MT: Not everybody with atopic dermatitis has allergies, but if you look at a Venn diagram, they will very much overlap.

Why? First, with atopic dermatitis, you get little cracks in the skin from itching and scratching, and allergens have an easier time getting in. Our skin should be a brick wall keeping things out, but with eczema, that brick wall is compromised. So an allergen can get in and cause more of an inflammatory response than it would in somebody who has totally intact skin.

Number two, people with atopic diathesis — people with asthma or seasonal allergies — genetically have a higher immunological response. It’s like if you have two kids, one is mellow and the other one is bouncing off the walls. The second kid is like the immune system of an atopic person. It’s an immunological reaction.

EH: Is atopic dermatitis difficult to diagnose in patients of color?

MT: Yes, doctors have more trouble diagnosing patients of color. Often, only Caucasian people are featured in many medical textbooks. They did a study where 98 percent of the photos in dermatology textbooks were white skin. If you’re not a darker-skin expert, sometimes you don’t get exposure to this in your training.

A lot of doctors don’t know that atopic dermatitis in darker skin may appear different in color than in Caucasian skin. They also might not know that while Caucasians can get scaly skin, African Americans can get bumps.

Also, interestingly, the location of atopic dermatitis can be different in dark skin versus white skin. Jon Hanifin, MD, a dermatologist who practiced out of Portland, Oregon, who literally wrote the diagnostic criteria of eczema, said that atopic dermatitis appears on the flexors, the joints that bend on the inside of the elbows and behind the knees.

But we know now from studies that with African Americans, atopic dermatitis affects the extensors, the front of the knees and the back of the elbows. It’s the opposite distribution. But because criteria are not inclusive for dark-skinned people, they’re exclusive, and this criteria has not even been updated.

EH: Does atopic dermatitis get misdiagnosed in people of color?

MT: It’s often not taken seriously. I’ve seen many patients with atopic dermatitis who are dark skinned and their eczema has either been brushed under a rug or not recognized because it’s not so red. That poor patient may be miserable, but they’re not getting diagnosed.

EH: Why does eczema lead to skin pigment changes in darker skin?

MT: Pigment change is a protective mechanism. It’s essentially just the melanocytes [skin cells that produce the pigment melanin] triggering because they’ve been “insulted” by inflammation.

The more pigment you have, the darker you get.

You can also get lightness, too. Lightness can be seen as resolving because those melanocytes are tired — they overshot themselves during the pigment phase and now they’re retreating.

EH: Eczema is one of the most common skin disorders in children, especially children of color. Can you tell us about this?

MT: In America, eczema is the most common skin condition diagnosed in the first 10 years of life. We know that rates are on the rise. That may be due to pollution, living in more urban areas, and exposure to more allergens.

EH: What can parents do to care for children with eczema?

MT: I always counsel parents, as puberty hits and the hormones come into effect, the kid will get a little greasier, just naturally, and that hydrates the skin. They may always have a little bit of eczema, but it’s not going to be as bad as when they were younger.

Moisturizing is also really key. They did a study in children in families who were prone to atopic dermatitis, comparing intense moisturization versus less intense. And the kids who were moisturized regularly after the bath, from zero to six months of age, had lower incidence of eczema as they grew up. So it’s really important to keep that skin barrier intact and healthy when the baby is little.

For children with eczema, I always suggest the most simple moisturizers. Vaseline is a great one. Parents can even use Crisco on their babies — it’s better than nothing. Sunflower oil is really inexpensive. So really basic things.

If your child has a problem with itchiness, keep the skin covered. With pajamas, wear the onesies or wear the full lengths. They can be light; they can be cotton.

You should seek dermatologic care with a provider who knows skin of color so that the child doesn’t scar or have extensive hyperpigmentation. We also know that itching can lead to less sleep and make these kids not perform well in school.

EH: Are there any foods or household products that are problematic for kids with eczema?

MT: Many parents will withhold a certain food because it might have flared a child’s eczema in the past, and then the child can actually get nutritionally deficient. If you’re concerned that your child’s eczema is getting flared by foods, you should see an allergist to have formal food testing. Do not withhold food.

Products to stay away from: Fragrance is the No. 1 thing for kids. You don’t want to use fragrance. You don’t want to use formaldehyde or clothes that are dry-cleaned.

EH: Are there any complications of eczema to look out for in kids?

MT: Secondary infections are a complication of dermatitis. You see it in kids all the time, where scratching leads to bacteria in the skin, especially Staphylococcus aureus. There have been some interesting studies where they actually give kids a different type of bacteria to help regulate the bacterial load on the skin.

There’s something called a bleach bath, where you take very dilute bleach and soak your kid in a bathtub with a little bit of bleach — about a half a cup of bleach in a full bathtub of water. Then you rinse them off and apply moisturizer, and it helps regulate the bacterial load of the skin. This is essentially equivalent to the concentration of chlorine in a pool.

EH: How do social and economic issues factor into treatment? 

MT: If you’ve got hard water, you live in an apartment with a lot of pollution, you don’t have enough money to buy moisturizer, how will your poor baby who is already genetically prone to eczema develop that skin barrier?

If you don’t have access to medical care, your pediatrician only knows white skin and doesn’t see the issues, that’s another thing.

EH: What other advice do you have for people of color trying to manage eczema?

MT: Number one, take a little extra vitamin D. You can talk to your doctor about it. We typically recommend anywhere between 1,000 to 4,000 international units a day. The reason is, vitamin D is an immune stabilizer. Evolutionarily, people with darker skin are supposed to live by the equator. We’re not supposed to live in these northern climates. Our skin doesn’t manufacture enough vitamin D from the sun, so you have to get it in a bottle. Once you take extra vitamin D, it helps with your skin not being as reactive.

Number two, get a humidifier. Sleeping in a bedroom with a humidifier helps keep up that skin barrier.

Number three, moisturize after the bath and don’t use soap all over all the time. As dermatologists, we say, “Use soap in your sweaty areas, like the armpits, under the breasts, and the groin, if you need to, and on the back of the scalp, but you don’t have to use soap all over all the time.”