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Researchers reported key differences in atopic dermatitis presentation across racial groups and steps clinicians can take to better serve all patients.

Atopic dermatitis (AD) presents differently based on comorbidities, ethnicity and race, and subtype.

To help clinicians better understand these differences and improve dermatology care, Jonathan Silverberg, MD, PhD, and colleagues conducted a scoping review of AD research from 1960 to 2022, specifically looking at how the condition manifests in patients of East Asian, Asian, Black, Caucasian, and Middle Eastern descent. Their clinical findings and recommendations were reported in Dermatitis.

AD’s Presentation

AD presents differently depending on skin pigmentation. In those with lighter skin, it presents as red or pink plaques, papules, and ill-demarcated patches, symptoms the authors refer to as “classic presentation.” In darker skin, patches, plaques, and papules are often violet and may be overlooked by some practitioners since they don’t fit the “traditional” mold.

The authors pointed out other key differences in the presentation of AD:

• Erythema can be masked in patients with richly pigmented skin, making eczema detection more challenging.
• Pruritus is a universal symptom but may be more severe in Black patients. The authors noted this may be due to healthcare disparities.
• Lichenification may be more prominent in patients of East Asian descent or with darker skin. If present in Black patients, lichenification indicates a more severe case of AD, since skin pigmentation can mask erythema.
• Cheilitis (inflammation of the lips) occurs in up to 57% of patients of European or East Asian descent. Only 11% of Indian, 4% of Black, and 3% of Middle Eastern patients report cheilitis.
• Auricular fissures at the earlobe are often present in more severe cases, and 32% of patients of East Asian descent report this symptom.
• Nail changes occur in approximately 1 in 10 patients because of AD. This symptom is more common in African (20%) and European (16-23%) patients but less common in East Asian and Middle Eastern patients.
• Acquired atopic hyperpigmentation can be present regardless of skin tone or ethnicity.
• Xerosis (skin that’s rough and non-inflamed) carries an increased risk in Black patients due to lower ceramide content in the skin.
• Hyperlinear palms are highly prevalent (51.8%) in Black Nigerian children with AD. Overall, however, this symptom is more common in White children than Black children, suggesting palmar hyperlinearity is multifactorial.
• White dermatographism has been reported by 23% of Asian, 43% of Indian, and 50% of European patients with AD. It is less commonly reported in African or Middle Eastern patients.
• Orbital darkening occurs in 54% of Black patients with AD but is least common in Middle Eastern populations (9%).
• Hertoghe’s sign is most common in European patients with AD, but eyebrows typically regrow once AD is managed.

Presentation of Morphological Variants

Morphological variants also differ in diverse patient populations. Dr. Silverberg and coauthors pointed out a few key differences:

• Prurigo nodules, firm papules that accompany a severe itch, are reported in 27% of Black patients, compared with 4-8% of patients of other races.
• Lichenoid-appearing lesions are more common in richly pigmented skin.
• Nummular lesions occur in 11% of European patients and 16% of Asian patients. They are less common in other patient populations.
• Follicular eczema is present in all ethnic groups but is more common in patients with African, Hispanic, or Asian ancestry.
• Psoriasiform lesions may be more prevalent in Asian patients, though the authors note that little research has been conducted on this variant.
• Erythroderma is rare but presents most commonly in adults and East Asian patients. This variant can be life-threatening.
• Eyelid dermatitis is more common in children and East Asian patients. Approximately 50% to 75% of cases with this variant are associated with allergic contact dermatitis.
• Scalp dermatitis is reported in 34% of patients with AD. It’s most common in North American patients and less common in Middle Eastern and European populations.

Recognizing Diversity in AD Symptoms

Dr. Silverberg and colleagues wrote that it’s important for clinicians to be aware of how AD presents in diverse communities and for medical students to receive training accordingly.

“Residency training programs should ensure adequate didactic training and patient interactions with diverse populations,” the researchers said, adding that there are tools and resources that can help clinicians evaluate diverse patient populations, such as the abridged United Kingdom Working Party criteria.

Additionally, the researchers identified areas lacking a deeper breadth of research, such as how AD presents in Latinx/Hispanic populations and symptom variances between adults and children.

“Promoting awareness of the heterogeneous clinical manifestations of AD may benefit the diagnosis, treatment, and characterization of eczema,” Dr. Silverberg and colleagues said.