Although pediatric atopic dermatitis (AD) and acne have some similarities among children with skin of color and lighter-skinned children, there are important differences when these common skin conditions affect darker skin types, according to Nanette Silverberg, MD, clinical professor of Dermatology and Pediatrics, Icahn School of Medicine at Mount Sinai, and chief, Pediatric Dermatology, Mount Sinai Health System, New York.
Starting with eczema
Atopic dermatitis is the most common skin condition of childhood and affects about 25% of children in the United States, according to Silverberg, who presented on the topic at the Skin of Color Seminar Series, held earlier this year in New York City.
“In particular, there have been studies that have shown AD is more common in children of African American descent or of Afro-Caribbean descent,” she says. “It certainly represents a very concerning issue in children of color.”
Differences in AD can occur in both the presentation and severity among children of color. “In somebody who is very light skinned, eczema is going to be red, but in children of color, we see much less erythema. Instead, we see much more in the way of lichenification, or thickening of the skin, and more follicular prominence," Silverberg explains. "These are particularly vexing types of eczema in that the lichenification or lichenoid type of dermatitis is often very thick and very itchy. And the follicular type can be quite deceptive. You don’t see redness. You don’t necessarily see thick or oozing skin, but it is incredibly itchy and it significantly affects children psychologically.”
One of the major challenges in treating AD in children of color is that there are biological differences in the basis of the condition itself, according to the dermatologist.
In African American children, it has been demonstrated that there are reductions in ceramide content, and that could be the reason the skin barrier is not working as effectively as it should be, Silverberg notes. As a result, physicians treating children of color with eczema often need to use thicker emollients, including those containing extra ceramide content or extra balanced fat content in order to enhance the skin barrier.
In children who are Caucasian of European descent, eczema is also more associated with a filaggrin defect—and these defects may not manifest in the same way across races. Filaggrin, (filament-aggregating protein) is a structural protein critical to maintaining the physical strength of the stratum corneum, and minimizing entry of foreign antigens and transepidermal water loss (TEWL).
“Filaggrin defects, particularly in Asian children, are somewhat different than those noted in Caucasian children,” Silverberg says. “We’re still moving forward to see whether the biologic basis of eczema affects how children respond to treatment. Many of the kids with AD will manifest in early childhood with a lot of hypopigmentation or lightness of the skin. These pigmentary alterations, which we see in kids of color, are temporary, but are sometimes very noticeable and can concern parents,” she continues. “But this generally resolves, and that’s something we can reassure parents about.”
Acne is common is the pediatric population and comes with different concerns in children with skin of color. “Whereas many of our Caucasian patients talk about the actual pimple lesions, most of our African American patients and many of our Hispanic and Asian patients will obsess over postinflammatory pigmentary alterations after their acne clears,” Silverberg notes.
Hispanic pediatric patients tend to have the most severe acne types among children of skin of color, Silverberg states. “We don’t see as much in the way of cystic acne in African American patients, historically and in the literature,” she says. “So, the population that we tend to focus on for more severe treatment or treatment, like isotretinoin, are usually Hispanic teenagers. It’s an important consideration because they have some tendency to have the cystic component. Although you can see it in everybody, it seems to be the most concerning among that population in the teenaged years.”
Physicians treating these children need to pay special attention to communicating the need for using good sun protection and to work with patients to develop a skincare regimen that’s effective both at clearing current lesions and preventing new lesions, so that pigmentation improves over time, according to Silverberg.
“There are some wonderful new acne guidelines that have come out recently from the American Academy of Dermatology . . . saying it’s clear that most patients of color will respond quite nicely to the products we have available, including topical retinoids . . . as well as azelaic acid, which has been demonstrated to be beneficial in improving both tone and skin lesions,” she says.