Atopic Dermatitis Risk in People With Darker Skin

Atopic dermatitis (AD) is a chronic (long-term) skin condition that causes itchy, dry, and inflamed skin. It is the most common type of eczema, a group of inflammatory skin disorders that typically start during childhood. For many children, the condition typically resolves as they reach their teenage years, but for some, it may last a lifetime.

Although atopic dermatitis can affect anyone, certain ethnic groups, especially people with darker skin, are at a higher risk. Black children are nearly two times more likely to develop AD compared to white children.

Genetic, environmental, and socioeconomic factors can affect the chances of developing atopic dermatitis. A family history of AD or other allergies may increase the risk of developing the condition.

Atopic dermatitis is influenced by several genes that protect the skin barrier and immune system activity. Genes are traits passed down through families. Filaggrin, a protein made by the FLG gene, plays an important role in maintaining the skin barrier’s function. When filaggrin mutates, there is a higher risk of developing AD. This genetic mutation is found in 50% of European and 27% of Asian populations with AD.

People with darker skin tones are less likely to have the FLG gene mutation and are more likely to have mutations in the FLG2 gene, which plays a role in the skin barrier’s function and can lead to more persistent cases of atopic dermatitis. Other genetic mutations that can affect people with darker skin include claudin 1, cornulin, trichohyalin, and hornerin.

Additionally, the health of the immune system plays a crucial role in the development of atopic dermatitis. The Th2 and Th22 pathways, two immune responses in the body linked to allergic reactions and conditions like AD, are more common in people with darker skin.

The environment you live in can play a role in developing atopic dermatitis, especially for people with darker skin, who may face harsher consequences due to systemic racism and housing discrimination.

Environmental risk factors include:

• Air pollution: Pollutants from traffic, factories, and tobacco smoke can contribute to the development of AD. People with darker skin, especially those living in low-income neighborhoods, are more likely to live in areas with high levels of air pollution.
• Pests: Cockroaches, mice, house dust mites, and molds may be more common in low-income households.
• Certain personal care products: People with darker skin are more likely to be exposed to endocrine-disrupting chemicals (EDCs) from their personal care products. EDCs are chemicals that can affect the body’s hormones, leading to harmful skin changes.
• Bacteria: Research suggests children of African American descent have the highest rate of Staphylococcus aureus on their skin, a known risk factor for severe atopic dermatitis and skin barrier challenges.
• Stress: Stress may affect the immune system, resulting in the development of atopic dermatitis. People with darker skin may be more prone to stress than other populations. Common causes of stress include poverty, lack of access to good healthcare, exposure to violence, and lack of access to quality food.

Socioeconomic factors, including income, education, access to healthcare, and neighborhood, play a significant role in people’s overall health. People with a lower socioeconomic status (SES) often experience severe health conditions due to limited access to healthcare and living in environments that may make their condition, including atopic dermatitis, worse.

Centuries of racism and discrimination make people of darker skin more likely to have a lower SES, which may lead to several health conditions. People with a lower SES often have more severe and chronic atopic dermatitis. Lower SES can also impact access to quality healthcare, making it difficult for people to afford over-the-counter (OTC) treatments and prescription medications.

People with darker skin who have atopic dermatitis may also have a higher risk of hospitalization and emergency department visits, leading to higher out-of-pocket costs. Even for people with insurance, there are limited options for dermatologic care, which includes treatment for skin, hair, and nail conditions. Moreover, people with a lower SES are more likely to live with increased exposure to air pollution and allergens, further increasing the risk of developing severe AD.

Atopic dermatitis can look different based on its type. Acute (short-term) AD appears as red blisters that can ooze and dry, as well as red, scaly patches on the skin after healing from a flare. Chronic atopic dermatitis can lead to thick, leathery skin. AD can also look different depending on your skin tone and ethnicity.

People with darker skin are more likely to develop atopic dermatitis on the outer parts of their arms and legs, often as small bumps or rashes. Some people with darker skin may also develop AD that looks like lichen planus, a condition that causes an itchy rash and sores.

If you have darker skin, you may not have redness, which is a common indicator of atopic dermatitis. Other signs, such as warmth, swelling, or flaky skin, may be useful in detecting AD among people with dark skin.

Other signs of atopic dermatitis common in people with dark skin include:

• Very dry skin
• Folds or lines under the eyes
• Lines on palms
• Thick, leathery skin (lichenification)
• Excessive itching of the skin that may lead to bumps

People with darker skin are more likely to develop skin color changes after an AD flare, also known as post-inflammatory dyspigmentation. These skin changes can look like dark spots (hyperpigmentation) or light patches (hypopigmentation).

If you experience redness, itching, or a rash on one or more parts of your body, consider talking with a healthcare provider, such as a dermatologist. Dermatologists are medical doctors who specialize in diagnosing and treating conditions affecting the hair, skin, and nails. Reaching out to a dermatologist can help diagnose the condition early and prevent it from getting worse.

You may also want to visit your dermatologist following an atopic dermatitis diagnosis if:

• Symptoms don’t improve even after applying moisturizer or medication to the skin
• Itching becomes so severe that it affects your sleep or daily activities
• Your skin shows signs of infection, including crusting, pain, and small fluid-filled bumps
• You experience symptoms of anxiety or depression 

Your dermatologist will ask about your family history of allergies, previous skin-related problems, and examine your rashes. They may recommend a few tests, such as certain blood tests and a skin biopsy, to confirm your diagnosis. Skin biopsies involve a healthcare provider taking a small sample of skin for further examination.

Atopic dermatitis is a skin condition that typically develops during childhood but can also occur later in life. It can cause dry, itchy, inflamed skin that can turn leathery if left untreated. People with darker skin are at a higher risk of developing the condition due to the influence of genetic, environmental, and socioeconomic factors.

If you experience itchy rashes that do not go away easily, consider reaching out to a healthcare provider. They may recommend blood tests and a skin biopsy to accurately diagnose your condition. Early diagnosis and treatment can help prevent atopic dermatitis from worsening.