Atopic dermatitis (AD) remains one of dermatology’s most heterogeneous and nuanced conditions, especially in patients with skin of color. During their joint session at the most recent Skin of Color Update conference in New York City, Dr. Andrew Alexis and Dr. Raj Chovatiya highlighted the clinical diversity, immunologic complexity, and growing body of data that are reshaping how clinicians recognize and manage AD in diverse populations.
Clinical Heterogeneity: Learning From the Patient
Dr. Alexis opened the discussion by emphasizing that AD is a “great mimicker,” a chronic, relapsing disease with variable morphology depending on age, chronicity, and anatomic location. Interestingly, he noted that extensor surfaces may be more prominently involved in some patients of African ancestry, contrasting the classic flexural presentation often described in textbooks.
The Variable Landscape of Atopic Dermatitis
Studies continue to show that patients with skin of color often experience more severe disease, reflected in higher EASI and SCORAD scores among Black patients. Clinical manifestations also vary. For example, Dennie–Morgan folds are more common in Indian patients than in Black or White populations; Erythroderma tends to occur more in Asian patients; Xerosis is more pronounced in Black patients, while cheilitis is more frequent in White patients.
Recognizing erythema in darker skin can be especially challenging. In these patients, inflammation often appears gray-pink, red-brown, or deep red-violet rather than bright red. Dr. Alexis advised clinicians to calibrate their eye to non-lesional skin, use appropriate lighting, and palpate lesions to assess inflammation.
Patients with skin of color often display greater lichenification, which is a sign of severity and chronicity. Other morphologies more common in skin of color include perifollicular or micropapular lesions, and papulonodular lesions. Pigmentary alterations (hyperpigmentation, hypopigmentation, and even depigmentation) are frequent sequelae in skin of color patients, often prolonging disease burden long after inflammation subsides.
Dr. Alexis also highlighted research showing immunophenotypic variations in AD across different races. Th2 activation is universal across populations. However, Th17 upregulation is seen more in Asian patients, while attenuation of Th1 and Th17 has been reported in Black patients. These findings suggest endotypic variations across different racial or ethnic populations, but more research is needed to further elucidate distinct molecular features across specific subpopulations as well as their therapeutic relevance.
Addressing Disparities in Atopic Dermatitis
Dr. Alexis underscored striking disparities in access to care. Black and Hispanic infants are six and five times more likely than White patients, respectively, to be seen in the emergency department for AD rather than by a dermatologist. A management algorithm recently published by him and colleagues incorporates strategies for management of post-inflammatory pigment alteration, culturally competent counseling, and equitable access to advanced therapies.
Learnings from Recent Clinical Trials in Skin of Color
In part 2 of the presentation, Dr. Chovatiya highlighted the critical need for diverse representation in AD clinical trials. Currently, only about 10% of studies report racial or ethnic subgroup analyses, limiting interpretation and generalizability to these populations. Use of older therapies in skin of color patients is guided mainly by past clinical experience. However, these care gaps are slowly being addressed through clinical trials specifically designed to study the efficacy of newer medications in these populations.
ADmirable Trial: Lebrikizumab in Skin of Color
The ADmirable phase 3b open-label clinical trial evaluated lebrikizumab in moderate-to-severe AD specifically among patients with skin of color (Fitzpatrick type IV–VI). This diversity was captured during baseline assessment as well, and patients had variable morphologies including AD with prurigo nodules, follicular and perifollicular accentuation, pityriasis alba, and AD with nummular lesions. Investigators were specially trained to assess erythema and lichenification across a range of skin tones.
The efficacy of lebrikizumab was consistent with previous trials, with ~75% patients achieving EASI75 and 47% achieving EASI90. The trial was designed as a 24-week study to specifically account for lichenification and post-inflammatory pigment alteration. To evaluate this, the study introduced and validated the PDCA-Derm scale for post-inflammatory hyperpigmentation, showing a 33% improvement in hypopigmented lesions and up to 20% resolution to normal skin tone after 24 weeks.
DISCOVER Trial: Dupilumab in Skin of Color
The DISCOVER phase 4 trial examined dupilumab in patients with Fitzpatrick IV–VI skin types. Researchers implemented a novel Patient-Reported Outcome for xerosis, capturing both the appearance and feel of skin dryness. Results were similar to previous studies, with 76% of patients achieving EASI75, reaffirming dupilumab’s efficacy and safety across all skin tones.
Summary
Our understanding of clinical diversity and disparities in AD patients with skin of color is still growing. Our job as dermatologists is to accurately diagnose and treat AD, and to ask why these disparities exist. The answer lies not just in genetics or differences in the immunopathogenesis of AD, but also with social and cultural factors such as access to healthcare and environmental exposures.
Managing AD in patients with skin of color requires clinical and cultural competence, and also a commitment to bridging research gaps. With evolving data from inclusive trials and growing awareness of disparities, dermatologists are better equipped than before to move beyond the flare and deliver comprehensive, equitable care – but still with a long way to go.
References
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- Horeczko J, Alexis A, Silverberg JI. The Heterogeneous Clinical Manifestations of Atopic Dermatitis Across Diverse Patient Populations. Dermatitis. 2025;36(2):118-124. doi:10.1089/derm.2024.0197
- Guttman-Yassky E, Krueger JG. Atopic dermatitis and psoriasis: two different immune diseases or one spectrum?. Curr Opin Immunol. 2017;48:68-73. doi:10.1016/j.coi.2017.08.008
- Alexis AF, Woolery-Lloyd H, Andriessen A, Heath C, Han G. INDIVIDUAL ARTICLE: An Algorithm for the Management of Atopic Dermatitis in People With Skin of Color. J Drugs Dermatol. 2023;22(8):SF386361s3-SF386361s10.
This information was presented at the 2025 Skin of Color Update conference by Andrew F. Alexis, MD, MCR, FAAD and Raj J. Chovatiya, MD, PhD, MSCI, FAAD. The above highlights from this lecture were written and compiled by Riyad N.H. Seervai, MD, PhD.