Challenges of diagnosis and management of eczema in patients with skin of colour

Primary care challenges of eczema in skin of colour

Eczema (atopic dermatitis, atopic eczema) is a common chronic, relapsing inflammatory skin condition that affects children and adults around the world, including about 2.8 million Australians.1

Most primary care health professionals are familiar with the classic presentation of eczema – recurrent, pruritic, poorly-demarcated erythematous patches with excoriation, predominantly affecting flexor surfaces.2 However, while this description defines eczema for people with lighter skin tones it is not adequate for diagnosis in people with skin of colour. 

Skin of colour refers to skin that is ‘non-white’, typically occurring in people from ethnic and racial groups such as Asian, African, Latino, Mediterranean, Middle Eastern, and First Nations Peoples.3,4

Apart from differences in presentation, eczema in people with skin of colour has also been reported to occur with increased frequency, severity, and persistence compared to people with lighter skin tones.4,5  Yet these populations remain under-reported and under-represented in dermatology trials. Such absences in knowledge can impact the capacity of health professionals to provide appropriate care for people with skin of colour who have eczema, leading to misdiagnosis, underestimation of severity and delay in treatment.5,6   

Dr Michelle Rodrigues MBBS (Hons), FACD, Consultant Dermatologist, The Royal Children’s Hospital, Melbourne, Vic; Honorary Senior Lecturer, The University of Melbourne, Melbourne, Vic; Founder, Chroma Dermatology.

How to improve care of eczema in skin of colour 

Do not rely on erythema to assess severity

In patients with skin of colour, erythema is not a useful determinant of eczema inflammation.4,5 Lesions can often appear violaceous or grey rather than textbook red. In highly pigmented skin, erythema may be difficult to see, potentially masking the severity of the disease.5 Skin warmth, oedema and overlying scale may help health professionals to detect erythema in these cases.5,6

Current scoring tools such as SCORing Atopic Dermatitis (SCORAD), Eczema Area and Severity Index (EASI) or validated Investigator Global Assessment scale for Atopic Dermatitis (vIGA-AD), reflect ‘classic’ erythema as it presents in lighter skin tones. The Australasian College of Dermatologists (ACD) notes that care should be taken when using these tools for people with skin of colour, including Aboriginal and Torres Strait Islander people, as they may delay diagnosis or underestimate eczema severity in pigmented skin.7 

The Eczema Management Algorithm developed in conjunction with and endorsed by the ACD recommends increasing the erythema score to avoid underestimation. This reflects similar recommendations made by the EASI authors and others, to increase the score by 1 grade or more in heavily pigmented skin.5,8,9 

Think outside the textbook

Apart from erythema, there is a small but growing body of research showing that eczema is a heterogeneous condition that presents differently across ethnic and racial groups.4–6,10  

For example, health professionals should be aware that:

• there is a predominance for eczema to present as psoriasiform variants, with lichenified, well-demarcated, scaly lesions in individuals of East Asian heritage (e.g. Chinese, Japanese and Korean);5 

• there is a tendency for eczema to have extensor involvement, perifollicular accentuation and distinct papules in people of African heritage. Lichenoid variants have also been reported to be more common in this population and also those with Indian ethnicity (Figure 1).5 

Figure 1. Scaly lichenoid patches of atopic dermatitis on the neck.

Secondary skin manifestations of eczema more likely to be seen in patients with skin of colour include:3–5  

• Dennie-Morgan lines – a linear fold beneath the lower eyelid often with surrounding dyspigmentation (Figure 2);
• Labial melanocytic macules – pigmented macular freckling usually of the lower lip is reportedly a unique feature among people of Asian ethnicity;
• Palmar hyperlinearity – exaggerated linear markings on the palm;
• Prurigo nodularis – firm, pruritic, abraded, thickened, often dyspigmented nodules, have been described in people with Black skin (Figure 3).

Figure 2. Facial atopic dermatitis with Dennie-Morgan lines.

Figure 3. Nodular prurigo.

Consider differential diagnosis

Eczema is a clinical diagnosis made on presentation and patient history, without definitive diagnostic tests. There are a number of inflammatory skin conditions, infections, infestations and other diseases that may mimic, overlap or manifest as complications of eczema.3,13,14  Differential diagnoses that have been specifically noted as relevant to patients with skin of colour are:3,5,13,15

• seborrehic dermatitis
• psoriasis
• lichen planus
• lichen nitidus 
• cutaneous T cell lymphoma

Proactively discuss potential pigmentation changes

In addition to the above-described presentations, people with darker skin tones who have eczema are also at higher risk for developing postinflammatory dyspigmentation (Figure 4).3,6 Dyspigmentation describes hyper- or hypopigmented skin around a present or previously inflamed eczematous lesion.3  

Health professionals should appreciate that for some patients these changes to skin colour can be as distressing as having eczema. Make patients aware early in treatment that these changes may occur as the eczema resolves and reassure them that most cases resolve spontaneously with time (typically weeks to months) and without specific treatment. 

Figure 4. Atopic dermatitis postinflammatory hypopigmentation.

Where a topical corticosteroid is involved for active flare management, emphasise the importance of treating to texture (smooth and itch-free) rather than appearance.

Chronic excoriation associated with severe eczema may result in permanent depigmentation in patients with darker skin.3,5

In cases where these changes are prolonged and becoming distressing to the patient or family, consider referral to a specialist dermatologist.

Dr Michelle Rodrigues 

Consider ethnicity and culture to inform management

For all patients with eczema, the goals of care are to manage active flares, prevent future ones and improve skin barrier function.4–6 Essential actions to achieve these goals include:

• regular use of moisturiser;
• avoidance of personal eczema triggers;
• timely application of appropriate flare control treatments;
• acknowledging and addressing psychosocial concerns to improve quality of life and daily functioning;
• prevention and treatment of skin infections.

Current recommendations for the management of eczema are similar across ethnic groups, with minor nuances due to differences in skin phototype, genetics and cultural practices.3,5,6,16

For example, evidence suggests that Asian skin may be more reactive or sensitive than skin of other races. Moisturisers containing humectants such as urea, glycerine and propylene glycol may be more irritating and should be used with care in this group.3,5 Other studies have reported that Black skin has lower levels of ceramides, which may contribute to greater pruritis and dryness and hence require specific considerations when choosing suitable moisturisers.17  

When discussing potential triggers, health professionals should remain aware that many cultures may have increased exposure to certain potential irritants due to practices and customs that involve food or plants as moisturisers (e.g. coconut oil), as medicines (e.g. Bush Medicine, Traditional Chinese Medicine, Ayurvedic medicine), or in the application of decorative dyes and tattoos (i.e. henna).4,6

Current Australian recommendations18,19 advise against:

• moisturisers with food-derived proteins, (i.e. nuts, coconut, milk), especially if a person has broken skin and does not readily eat the food or has an allergy to it. This is particularly important in infants, because sensitisation to food and environmental allergens may occur through a broken skin barrier.

• moisturisers with plant extracts or essential oils, i.e. lavender, rosemary and tea-tree.

While harm minimisation from these and other environmental triggers is important, discussions must be approached with sensitivity and respect for the person's culture, to build trust and optimise chances of treatment success. 

In Australia, some cultural and ethnic subpopulations may also experience socioeconomic challenges to effective eczema care. Contributing factors include rurality and remoteness, limited access to appropriate healthcare resources and limited disposable income for treatment-associated costs.4 The National Healthy Skin Guideline notes that sorbolene cream is the most widely available moisturiser that is inexpensive and comes in large volume tubs.12 For eczema that requires topical corticosteroids, PBS streamlined authority numbers exist for prescription of increased quantities, which can facilitate adherence by reducing barriers to access.

Dr Michelle Rodrigues 

Diagnosing and managing eczema in Australia’s ethnically and culturally diverse patients with skin of colour can be challenging. Health professionals need to look for clinical variations in presentation to reduce underdiagnosis or delayed care. Treatment should be proactive, to minimise inflammation and protect the skin barrier while also considering cultural practices. Clinicians should align skincare advice and prescriptions with each patient's cultural perspectives on skincare norms and treatment goals.

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In-consultation resources

• Eczema Management Algorithm

• Eczema Care Plan

Educational activities and CPD

• Podcast – Beyond Skin Deep: Unravelling the challenges of managing eczema

• Webinar –  The Eczema Equation: Burden of disease and challenges in management

• Virtual Educational Visiting