Eczema, also known as atopic dermatitis, is a chronic skin condition that affects people of all skin types. However, it can present differently on skin of color, leading to challenges in diagnosis and treatment. Understanding these differences is essential for improving care and ensuring patients of all backgrounds receive accurate treatment.
What is Eczema?
Eczema is characterized by:
- Itchiness: This is the hallmark symptom of eczema, often leading to scratching, which can further damage the skin.
- Dryness and irritation: Eczema compromises the skin’s barrier, making it prone to dryness, inflammation, and irritation.
- Rashes: These can vary in appearance and location, depending on age and skin type.
Eczema can appear anywhere on the body, though it commonly affects the arms, legs, and face.
“The itching itself causes people to scratch the skin, and depending on your age, eczema can present a little differently in various body locations. As a dermatologist — I treat both adult and pediatric patients — I’m able to see eczema manifest in different stages. Often, in infancy, we see it on the cheeks and the extensor surfaces, like the arms and legs. As kids get older, it tends to affect the areas in the creases, like the folds of the arms and legs,” says Dr. Candrice Heath, M.D., Clinical Assistant Professor (Adjunct) in the Department of Urban Health and Population Science and the Center for Urban Bioethics at Temple University Lewis Katz School of Medicine in Philadelphia.
How Eczema Presents on Skin of Color
The presentation of eczema on darker skin tones differs significantly from how it manifests on lighter skin. Traditionally, medical textbooks and resources show eczema as red, scaly patches. However, this description doesn’t always apply to skin of color.
Common Symptoms on Skin of Color:
- Hyperpigmentation: Instead of red, inflamed patches, people with darker skin often experience brown or gray discoloration. This condition, known as post-inflammatory hyperpigmentation, can last long after the eczema flare-up has healed.
- Hypopigmentation: In some cases, eczema may cause lighter patches of skin, known as hypopigmentation, due to a loss of melanin in the affected areas.
- Thickened skin: Eczema on skin of color can result in thickened patches that appear darker than the surrounding skin.
- Bumps or goosebumps: On darker skin, eczema can sometimes resemble small, raised bumps, which may be mistaken for other conditions like keratosis pilaris.
“It can present in various ways, but one common thread is that patients with eczema often feel itchy — so much so that we sometimes call it ‘the itch that rashes’ because the scratching can lead to breaks in the skin, perpetuating a cycle of irritation,” Dr. Heath adds.
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Importance of Early Detection and Diagnosis
Because eczema can look different on skin of color, it is sometimes underdiagnosed or misdiagnosed. It’s crucial to recognize these variations early to prevent complications such as:
- Pigmentation changes: Prolonged scratching and inflammation can lead to lasting dark spots or scars.
- Sleep disruption: Severe itchiness can lead to chronic sleep issues, affecting overall health and well-being.
“It’s important to highlight that although itchy skin is common, eczema is a condition with many treatment options available, and even more treatments are emerging. So, there’s really no reason for people to suffer unnecessarily. Whether eczema is mild or severe, there are interventions that can help,” Dr. Heath notes. “I’d say if eczema is interfering with your life — for example, if itching keeps you up at night, or if your family members tell you to stop scratching and you don’t even realize you’re doing it — that’s a sign it has become part of your daily life in a way that may need more attention.”
If you’ve tried managing your eczema at home with gentle cleansing products and moisturizing, but you’re still uncomfortable or itching regularly, Dr. Heath notes that it’s a good time to bring it up with your healthcare team.
“Your primary care team can either help you directly or refer you to a dermatologist, especially if the eczema is significantly impacting your quality of life,” Dr. Heath notes.
Advocating for Proper Care
Patients, particularly in communities of color, may face barriers in receiving accurate diagnosis and treatment. Here are some strategies for advocating for your care:
- Request a dermatologist referral: If eczema is suspected and not improving with basic treatments, seeing a dermatologist, particularly one experienced with skin of color, can be key.
- Document your symptoms: Keep a log of when flare-ups occur, what might trigger them, and how your skin reacts. This information can help guide treatment.
- Explore support groups: Connecting with others who have eczema can provide support and lead to helpful resources and clinicians who understand skin of color.
“It’s also important to advocate for yourself because only you know what it feels like to have your skin in that condition. Sometimes the affected areas are covered, and people may not know that the condition is impacting your sleep or causing you to miss work. So, even if your skin looks fine on the day you see the doctor, if you’re experiencing symptoms that are really affecting your life, you deserve to have that conversation about treatment options,” Dr. Heath shares.
Treatment Options for Eczema in People of Color
Eczema treatments range from moisturizers to prescription medications. However, it’s important to choose treatments that address both the condition and any pigmentation changes that may occur.
- Moisturizers: Maintaining a strong skin barrier is essential for eczema patients, especially for those with darker skin prone to hyperpigmentation.
- Topical steroids: These are used to reduce inflammation but should be used cautiously to avoid side effects, such as further pigmentation changes.
- Non-steroidal topical treatments: These newer treatments help manage eczema without the risk of skin thinning or pigment alteration.
- Systemic treatments: For severe cases, oral or injectable medications targeting the immune system may be necessary.
“Keeping notes on how your skin reacts to treatments over time can be helpful. It’s good to track not only when your skin feels okay but also when it’s at its worst. Documenting these things can help your care team tailor treatments for you. It’s also important for patients with skin of color to understand that eczema can look different, and if you feel unheard, don’t give up. Seek out another clinician if necessary,” Dr. Heath advises.
Many eczema patients face challenges such as multiple treatments, misdiagnosis and the need for stronger medication. Dr. Heath shares that there can also be issues with insurance coverage, where a prescription may be approved but in a limited amount.
To address this, she says, “It’s helpful to bring your prescriptions and skincare products to your appointments so your care team has all the information they need. And, as new treatments emerge, sometimes we have to try older options first due to insurance requirements, but it’s part of a process to get you the most effective treatment.”
Recent Advancements in Treatment
The landscape for eczema treatment is rapidly evolving. New drugs that work by targeting specific immune pathways are making systemic treatment more effective and accessible to younger patients, including infants.
“There’s been a lot of progress. We’re familiar with topical medications like steroids, but now there are newer options that don’t contain steroids and work through different scientific pathways. Moisturizing the skin remains a critical part of managing eczema because the skin barrier is not as strong in those with the condition, and there are better moisturizers available now,” Dr. Heath shares.
“The most exciting developments are systemic treatments, like pills or injections, that target the immune system and help reduce eczema from within. These treatments can reduce itching, rashes, and even pigmentation issues. The good news is that many of these new drugs are being approved for use in younger patients, which allows us to treat eczema earlier and prevent long-term complications,” Dr. Heath adds.
Understanding the differences in how eczema presents on skin of color is essential for proper diagnosis and treatment. By recognizing symptoms early, advocating for yourself, and working with healthcare professionals familiar with diverse skin tones, you can achieve better outcomes and avoid long-term complications.
