In this episode of Topical Conversations, Dr James Del Rosso and Dr Amy McMichael discuss the challenges of identifying candidates for systemic treatment of atopic dermatitis (AD), with a particular focus on patients with skin of color. They explore how AD presents differently in diverse populations, considerations for assessing disease severity, and the role of systemic therapies like lebrikizumab in improving patient outcomes. 

Challenges in diagnosing atopic dermatitis in skin of color 

Dr Del Rosso highlights a key challenge in evaluating AD severity in diverse populations—the reliance on erythema as a primary indicator of disease activity. Assessments often include the presence of redness; however, erythema can be subtle or difficult to detect in darker skin tones, making it essential for dermatologists to look beyond color-based cues. 

Dr McMichael reinforces this by emphasizing tactile and symptomatic assessments. She advises dermatologists to train patients and caregivers not just to treat when skin appears red but also when it feels rough or textured. In some cases, violaceous changes may be more apparent than classic erythema. Additionally, symptoms like itching, irritation, and sleep disturbances can be critical indicators of disease severity, even when visible skin changes seem minimal. 

Another diagnostic challenge is hidden or underreported disease involvement. Patients may initially present with localized symptoms, but a thorough full-body skin exam can reveal more extensive disease, particularly in skin folds, scalp, or diaper areas for pediatric patients. This is especially important when considering systemic therapy, as true body surface area involvement and diffuse itching patterns can help guide treatment decisions. 

The impact of hyperpigmentation, hypopigmentation, and lichenification 

They also discuss discuss postinflammatory pigmentary changes that frequently affect patients with skin of color: Hyperpigmentation, which often resolves over time but can be persistent and distressing for patients; hypopigmentation, which can be more challenging to treat, and if chronic, may not fully recover even after the underlying AD is controlled; and lichenification, which is a common long-term consequence of chronic AD in darker skin tones and can persist despite active treatment. 

Dr McMichael emphasizes that chronic hypopigmentation resulting from prolonged scratching can cause lasting skin damage. While systemic treatments can control AD, they do not always restore lost pigment, making early and aggressive treatment crucial. Dr Del Rosso adds that hyperpigmentation tends to improve over time, but the contrast in skin tone can make these changes more noticeable and distressing for patients with darker skin. 

Systemic therapy for atopic dermatitis: when to escalate treatment 

Dr McMichael follows a stepwise approach when treating AD, usually beginning with topical treatments as the first-line therapy for mild-to-moderate cases. She then moves on to systemic agents for moderate-to-severe cases that are not adequately controlled with topicals. 

She emphasizes escalating treatment quickly when necessary, particularly when AD affects daily life, including school performance, sports participation, and sleep quality. She highlights the importance of early treatment education, noting that patients and caregivers need to understand that AD is a chronic condition, not a disease with a simple cure. 

The role of positive reinforcement in patient compliance 

Dr McMichael stresses the importance of positive feedback in patient care. When patients or caregivers follow treatment plans diligently, acknowledging their efforts reinforces good habits. Encouraging words from a dermatologist can motivate patients to continue treatment, improving long-term outcomes. 

Key takeaways 

• Diagnosing AD in skin of color requires looking beyond redness, focusing on texture, itching, and pigmentary changes 
• Systemic therapy should be considered when AD significantly impacts daily life, especially when topical treatments are insufficient 
• Hyperpigmentation often improves over time, but hypopigmentation can be permanent, emphasizing the importance of early, aggressive treatment 
• Newer biologics, like lebrikizumab, show promising results in addressing AD 
• Cultural considerations and patient adherence play a major role in treatment success, requiring a simplified, consistent, and collaborative approach