Atopic Eczema in Darker Skin: Presentation and Management

00:01 So how does atopic eczema manifest? In children under the age of one year, the distribution tends to be on the extensor surfaces. In older patients and adults, it tends to be flexural.

00:16 The morphology of the lesions can vary from erythema, vesicles, erythematous papules, or patches.

00:25 This picture shows a child with erythema with edema as well as excoriations due to pruritus. This also shows the papular vascular lesions that one may appreciate in patients with atopic eczema. Oftentimes, we do see extensive atopic eczema, which involves more than 90% of the body surface area, and when it is more than 90% of the body surface area, we call it a retro dynamic atopic eczema.

01:02 So atopic eczema can present clinically as mild atopic eczema, moderate or severe forms of atopic dermatitis.

01:11 So let's first look at the characteristics of the mild form of atopic eczema.

01:16 It's usually localized areas of dry skin.

01:19 There may be infrequent pruritis.

01:21 And this has a minimal impact on activities for example sleep and psychosocial well-being.

01:28 What about moderate atopic eczema? Usually, localized areas of dry skin, pruritis frequent and erythema, as well as localized skin thickening with or without excoriation.

01:43 The moderate patients with moderate eczema, the effect on activities may be mild, and also the psychosocial well-being effect may be moderate.

01:55 Sleep may be disturbed frequently as well.

02:00 Severe atopic eczema, for example, like erythroderma eczema, as I have mentioned, where you have more than 90% body surface area involved, it's widespread. There's incessant pruritus or itch, extensive erythema, extensive skin thickening, bleeding, oozing, cracking and altered pigmentation, particularly in patients of skin of color.

02:25 And you may also have secondary infection from bacteria or secondary infection with herpes virus infection. This has severe impact on activities, psychosocial functioning and sleep, and very poor quality of life.

02:44 So what are some of the challenges and unique presentations in skin of color? There's varied clinical presentation.

02:51 One tends to find follicular accentuation of atopic eczema.

02:57 We also tend to see papular lichenoid lesions.

03:00 Lichenification and xerosis, it is quite prominent.

03:05 And of course the location is usually similar to other skin color, which is extensor involvement.

03:10 One m ay also encounter psoriasis form clinical presentation.

03:15 So these are lesions that may look like psoriasis but it's not psoriasis.

03:20 Erythema is obviously less evident because the skin is darker and the erythema is masked by the melanin pigment. So some of these may even look more purple or dark or lichenoid in nature.

03:36 Severe cases may not be treated adequately because erythema may be hard to identify in dark skins.

03:42 And if one looks at the scoring systems like SCORAD that use erythema, you may actually underestimate the severity of atopic eczema in black skin when using the standard scoring systems that are used in clinical research.

03:58 So the severity, as I mentioned, of the easy score and scores are difficult and may be underestimated. Moving on to the diagnosis of atopic eczema, it's usually clinical. However, biopsy may be required.

04:15 For example, if one wants to differentiate from other skin conditions like psoriasis, mycosis fungoides, and drug reactions.

04:26 Serum Ige may be elevated in about 80% of patients.

04:31 So how do we treat patients with atopic eczema? This is firstly general measures.

04:36 Avoid triggers as listed over here.

04:38 Low humidity heat and excessive bathing.

04:42 Treat associated skin infections like staph aureus and herpes.

04:46 Skin hydration is paramount and it is so crucial.

04:50 Frequent use of emollients, and particularly those that contain urea, ceramides, glycerin, etc. and some of the humectants.

05:02 Specific treatment involves using use of topical corticosteroids.

05:09 One has to be careful and not use strong steroids for a long time, as these may lead to skin atrophy and other adverse effects like skin infections.

05:20 Calcineurin inhibitors the second line treatment.

05:23 We also use that. And then of course phosphodiesterase or crisaborole, which is a new drug that has now been used in atopic eczema.

05:35 Oral antihistamines are beneficial when sleep is disturbed by itchy skin.

05:41 And these are the different antihistamines that we use for treating atopic eczema.

05:48 Oral immunosuppressants. We use this for severe disease, extensive disease or disease that may be moderate but actually affects the quality of life of the patient. And the following are like cyclosporine.

06:01 And of course recurrence is common upon discontinuation of treatment.

06:05 So one has to make sure that you maintain the patient's treatment after stopping cyclosporine.

06:12 Human monoclonal antibodies biologics have also been used.

06:16 And lastly, phototherapy is another mode of treatment for atopic eczema, particularly narrow band UVB.