Eczema in Skin of Color: Diagnosis and Treatment
Eczema in skin of color looks different than on white skin, so the diagnosis is often more challenging and is sometimes overlooked.
Familiarity with how eczema looks in skin of color is essential in making a correct diagnosis and prescribing the right treatment.
Allergists are trained to diagnose and treat skin conditions including eczema. Atopic dermatitis, a form of eczema, is often related to allergies.
Diagnosis and Testing
Many images of eczema you see online or in publications often show redness or red dots on light skin. Those symptoms appear quite differently in people with darker skin tones. What does eczema in skin of color look like? In black or brown skin, it may appear as dark brown, purple or ashen gray patches.
- intense itchy skin
- swelling
- dry, cracked, scaly skin
- affected skin feels warm when touched
- open, crusty or weepy sores
In people of color, eczema may also show as small bumps (called papules), especially on the chest, back, arms and legs. When bumps grow around hair follicles (called follicular accentuation), they can resemble goosebumps and result in thickened or firm skin with hair standing on its end.
Repeated scratching of affected areas can result in thickened or firm skin (called lichenification) with raised bumps called prurigo nodules.
Eczema-related inflammation can cause skin discoloration: 1) darkening of the skin – called hyperpigmentation, or 2) lightening of the skin – called hypopigmentation. These conditions often occur during post-inflammation, or when the skin is healing from a flare-up.
Since skin discoloration is often more noticeable in people of color, it can frequently cause distress. It can also cause anxiety and depression and impact quality of life, especially among adolescents and teenagers. Regular treatment usually helps resolve skin discoloration but it sometimes takes months or even years for it to go away completely.
Diagnosis of eczema is the same for all skin colors. First the doctor will ask about:
- types of soap, detergent and skin care products used
- any exposures that may cause or make eczema worse
Your doctor may look for allergens and irritants that can trigger a patient’s eczema. Flare-ups can be caused by:
- cosmetics
- soaps
- wool
- food
- pollen
- mold
- dust mites
- dog or cat dander
- dry climate
- stress
As part of the diagnosis, an allergist may perform tests to identify if there’s an allergen or irritant causing symptoms.
Skin prick test: the doctor will prick or puncture the patient’s skin. Then a diluted allergen is placed on the site of the prick. The test is usually done on the back or forearm in adults and on the back in children. Several allergens are often tested at the same time. The allergist will observe the tested area for about 15 minutes to see if a bump (wheal) or change in skin color (flare) develops.
Blood test: After a blood sample is drawn, it is analyzed to detect IgE antibodies directed at specific allergens. Tests may measure specific or overall levels of IgE. Some may also break down common allergens and measure IgE to specific components. The lab results may take several days to be returned.
Patch test: Chambers containing chemicals of potential triggers on adhesive strips are placed onto the patient’s back. After 2-3 days, the patches are removed by the doctor and the skin is evaluated for reactions. If symptoms appear, then it’s confirmation of an allergy. Patch testing is commonly used for contact allergies to fragrances, detergents, metals and other chemical sensitizers.
Oral food challenge: if it’s believed certain foods are causing eczema to flare, doctors may recommend a food test. The patient is asked to eat a tiny amount of a suspected food allergen, and then gradually larger amounts, to determine if there’s an allergic reaction. An oral food challenge should only be conducted by a doctor and at a medical facility that has access to emergency epinephrine in case of a severe allergic reaction.
Children under the age of 5 with moderate to severe eczema may need more testing. This is especially true if the child’s eczema does not get better after treatment. The child should be tested for food allergies including:
- milk
- egg
- peanut
- tree nuts
- wheat
- soy
Recent guidelines put infants with severe eczema and/or egg allergy in the highest risk category for peanut allergy. These high-risk infants should be seen by an allergist or pediatrician who can determine if they are candidates to be introduced to peanut-containing foods between 4-6 months in order to prevent peanut allergy.
Between 33 to 63 percent of young children with moderate to severe eczema also have food allergies.
Other tests:
Buccal swabs: used to detect mutations in the filaggrin gene, the protein that helps protect the body from allergens and bacteria. A lack of filaggrin weakens the skin barrier, leading to eczema.
Skin biopsy: a tiny piece of skin is removed and analyzed under a microscope. It can rule out other skin diseases such as skin cancer or psoriasis.
Treatment
Eczema treatment is the same for all patients, regardless of skin color. There is no cure for eczema but there are medications that can help relieve symptoms. An allergist’s specialized training can help patients to develop an eczema treatment plan. The goal is to enable patients to lead a life that is as normal and symptom-free as possible.
Eczema treatment starts with over-the-counter or prescription topical skin moisturizers and over-the-counter or prescription anti-inflammatory creams and ointments. These help protect the outer layer of the skin by sealing in moisture, combating dryness, keeping out allergens, irritants and bacteria and preventing flare-ups. They help soothe the skin for long-lasting hydration.
Doctors typically recommend applying a moisturizer at least twice a day, including once after a bath or shower. Patients are encouraged to develop a schedule so that moisturizing becomes part of a daily skincare routine.
For children with severe eczema, allergists may advise using the “soak and seal” treatment. Soak and seal can provide relief from the itching that comes with eczema. Here’s how it works:
- Bathe in lukewarm water at least once a day. (Doctors recommend short baths for eczema.)
- Use an unscented, dye- and fragrance-free cleaner for the skin. No soap.
- After bathing, gently pat the skin dry.
- Immediately apply moisturizer to “seal” in moisture.
Mild cases of eczema can also be treated with ointments such as petroleum jelly. These should be applied daily, even when the skin appears clear, to help prevent dryness.
In cases of moderate or severe eczema, an allergist may prescribe topical anti-inflammatory corticosteroids or calcineurin inhibitors. These medications are designed to reduce skin inflammation, relieve itch, combat dryness and prevent flares from reoccurring.
In 2016, the U.S. Food and Drug Administration (FDA) approved a new topical treatment for eczema: a PDE4 inhibitor called crisaborole. It’s approved for children 3 months of age and older and adults with mild to moderate eczema. Crisabarole targets the PDE4 enzymes deep within the skin to reduce swelling and inflammation. It’s well-tolerated with long-term use.
A special consideration for people of color is to avoid the overuse of high potency topical corticosteroids. These medications can cause hypopigmentation or lightening of the skin. Consider using topical calcineurin inhibitors instead.
If eczema is still difficult to control after topical treatments, then the next step may be an FDA-approved biologic medication called dupilumab. It’s indicated to treat serious, uncontrolled cases of eczema in patients 6 years of age and older.
Dupilumab (Dupixent®) is a biologic medication used to treat atopic dermatitis (eczema). It’s approved for adults and children 6 months of age and older with moderate to severe atopic dermatitis. The medication is for patients whose symptoms are not well controlled with other prescription topical therapies. It’s also for patients who cannot use other topical therapies. Dupixent can be used with or without topical corticosteroids.
Another biologic used to treat moderate-to-severe atopic dermatitis is tralokinumab (Adbry®). It’s approved for adults only.
Janus Kinase inhibitors, or JAK inhibitors for short, are also medications for moderate to severe eczema. These medications block off an overactive pathway of enzymes to limit the production of cytokines. These cytokines trigger the immune response that causes eczema symptoms.
JAK inhibitors are available as a topical and a pill. They can relieve itching and inflammation, reduce skin thickness and scaling, and help promote clear skin. Three are available: abrocitinib (Cibinqo®), ruxolitinib (Opzelura™) and upadactinib (Rinvoq®). They are approved for adults and children ages 12 and older whose eczema is not well controlled by other treatments.
Since JAK inhibitors alter the immune system’s ability to react to germs, this can put some patients at risk for bacterial, fungal and viral infections and other diseases. Talk with your doctor about the benefits vs. risks of taking JAK inhibitors.
Other Therapies
- Wet Wrap Therapy: Doctors recommend wet wrap therapy as an intervention for moderate-to-severe eczema. Here’s how it works: After the “soak-and-seal” bath and application of topical moisturizers or creams, wrap the patient’s eczema-damaged skin in wet cloth. Then top it with dry clothes such as pajamas, sweatshirt or tube socks. This therapy can help keep the skin hydrated, relieve inflammation and itching, protect the skin to allow healing and reduce the need for medication.
- Bleach Baths: Some doctors suggest putting a half-cup of household bleach or a cup of vinegar into the bath water. If properly diluted and used as directed, the bleach and vinegar can help kill bacteria and prevent infection. It’s most effective when combined with moisturizers and medications.
- Light Therapy: Also called phototherapy, light therapy is an in-office procedure that involves exposing eczema-damaged skin to ultraviolet (UV) light. It’s designed to reduce inflammation, lessen itch and boost the body’s bacteria-fighting ability in hard-to-control eczema. Light therapy may cause hyperpigmentation (darkening of the skin) in some people of color, so it’s important for doctors and patients to fully discuss benefits and side effects of this treatment.
Tried-and-True Eczema Management Tips
- Avoid wearing materials such as wool, which could irritate the skin.
- Moisturize skin at least twice a day.
- Take a warm bath daily. Some doctors suggest adding bath oil, salt, baking soda or uncooked oatmeal to help ease persistent itching.
- Use soap-free and detergent-free cleansers.
- Use a humidifier to add moisture to indoor air.
- Drink water often – hydration helps the skin.
- Wear gloves in cold weather to protect the skin.
- Cover itchy areas with bandages to avoid scratching them.
- If you must scratch, try pressing on the itchy area or stroking it using the top side of the hand instead of fingernails.
- Wear loose-fitting clothes that don’t rub against the skin.
How is eczema treated?
Controlling Your Eczema (Atopic Dermatitis) – ACAAI
Eczema Treatment Options – Allergy & Asthma Network
Coping with Eczema – Patient Information – Allergy & Asthma Network
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