The skin condition, which leads to dry, itchy, and inflamed skin, is the second most frequent skin disease seen in Black skin in the U.S., but experts believe it may be underdiagnosed since physicians are often trained to diagnose it on white skin.[i]
In Canada, the Canadian Dermatology Association estimates that up to 17% of Canadians live with eczema[ii] and that these numbers are likely higher in darker skin tones.
But with little to no data about Black, Indigenous, or People of Colour's (BIPOC) eczema issues in Canada, how can we be sure they're getting the proper treatment?
What’s wrong with this picture?
According to Dr. Sonya Abdulla, MD, a Toronto-based board-certified dermatologist in Canada and the U.S., "Physicians are typically taught that eczema is red, scaly, and itchy. In darker skin tones, this rarely applies. Eczema can present as ashen, brown, purple scaly areas that are often thickened from the chronicity. It is also more resistant to treatment.”
“The under-recognition or under-diagnosis of inflammatory skin disease in darker skin tones means that patients often present later, with more advanced disease, often having received treatments that may not adequately treat the underlying disease. Misdiagnosis or ambiguity of diagnosis can delay the start of treatment, further impacting a patient’s quality of life.”
In fact, many patients never make it to the specialist or even physician level. Black children with eczema are 30% less likely to see their doctor than white children, and those who see a doctor tend to have more visits and receive more prescriptions than white children, indicating a more severe disease.[iii]
Why is eczema so problematic for Black skin?
The risk for eczema is greater in ethnic groups because of how the skin is structured.
“Black skin has lower ceramide content and higher levels of transepidermal water loss,” says Dr. Abdulla. “Which increases the chance of skin barrier disruption and eczema flares. Recognizing the differences in skin structure and how they impact skin barrier function creates an excellent target for eczema prevention with skincare.”
However, with poor representation of Black and Brown skin in dermatology research journals and textbooks, how can clinicians provide optimal care for People of Colour?
A recent U.S. study found that less than 5% of the images in general medicine textbooks showed conditions on darker skin. In addition, the standard outcome measures used in patients with very dark skin have poor reliability and validity, making it even more difficult for doctors to recognize and diagnose medical conditions on skin with more pigment.[iv]
“Much of the research on drug development is done on Caucasian patients,” says Dr. Abdulla. “And this often carries over to limited teaching resources, including BIPOC patients used in teaching and publications.”
“However, I am proud to say that the University of Toronto has recognized this gap in the medical curriculum and is making concerted efforts to improve the representation of these clinical presentations in dermatology medical school teaching. While efforts are being made, it is a continuing area for improvement,” she adds.
Redressing the skin visibility balance
One institute that’s creating an open pathway to understanding the different skin tones and how they impact the clinical presentations of common skin diseases is the Canadian Dermatology Association (CDA).
The Skin Diversity Learning Series: Expanding Perspectives in Dermatology was launched last fall. This new program, made possible through sponsorship from Johnson & Johnson Consumer Health in Canada to the CDA’s Corporate Supporter Program, includes six accredited modules and is the CDA’s first program designed to expand and update dermatologists’ knowledge of diverse skin types, helping ensure all patients receive representative, optimal care.
“Movements like Black Lives Matter have brought many inequities to the forefront,” says Dr. Abdullah. “In dermatology, we recognize that it’s important to see colour and understand how it impacts our patients’ clinical presentation and their response to treatment. It’s important to highlight these differences to clinicians to heighten awareness and improve diagnostic accuracy, ultimately ensuring patients get the right treatment.”
Canadians can learn more about the program and the CDA’s diversity and inclusion commitments by visiting the CDA at dermatology.ca or CDA Statement on Diversity & Inclusion - Canadian Dermatology Association.
How to treat and manage eczema
Dr. Abdullah, who is a member of the CDA and earned the Dr. André Peloquin Award for excellence in patient care, says:
“Understand that eczema is chronic—it requires maintenance treatment to prevent flares and adequate treatment when flaring. While it can be frustrating to experience the ups and downs as a patient or the parent of a patient, skincare is one of the backbone strategies for prevention. Look for cleansers and moisturizers with soothing, ceramide-producing ingredients like oats. Limit exposure to fragrances and harsh soaps.
While many people around you may have opinions on the treatment of your skin, a board-certified dermatologist with experience in skin of colour is best positioned to establish your diagnosis and treatment plan. Ask questions about your diagnosis and look for guidance or suggestions on skin care options that are suitable for you.”
It’s imperative everyone, regardless of skin type, be proactive in their own skincare; becoming knowledgeable about your symptoms and being able to explain to your healthcare provider in detail what you’re experiencing will be helpful in your diagnosis.
Brands like Aveeno are facilitating conversations with dermatologists to drive awareness so that all Canadians can have healthy-looking skin. To learn more about the diagnosis and treatment of eczema on Black skin, visit aveeno.ca/skin-hair-solutions/eczema/skin-of-colour
[i] *Halder, R.M., Grimes, P.E., McLaurin, C.I., Kress, M.A., & Kenney, J.A. (1983). Incidence of common dermatoses in a predominantly black dermatologic practice. Cutis, 32, 388-390. Eczema Prevalence, Quality of Life and Economic Impact (nationaleczema.org) accessed 7.18.21
**Louie P, Wilkes R. Representations of race and skin tone in medical textbook imagery. Soc Sci Med. 2018 Apr;202:38-42. doi: 10.1016/j.socscimed.2018.02.023. Epub 2018 Feb 23. PMID: 29501717. Representations of race and skin tone in medical textbook imagery - ScienceDirect accessed 7.18.21
[iii] Fisher et al . Racial and ethnic differences in healthcare utilization for childhood eczema: an analysis of the 2001–2013 Medical Expenditure Panel Surveys. J Am Acad Dermatol. 2017 December ; 77(6): 1060–1067. doi:10.1016/j.jaad.2017.08.035.
[iv] . Louie P, Wilkes R. Representations of race and skin tone in medical textbook imagery. Soc Sci Med. 2018 Apr;202:38-42. doi: 10.1016/j.socscimed.2018.02.023. Epub 2018 Feb 23. PMID: 29501717. Representations of race and skin tone in medical textbook imagery - ScienceDirect accessed 7.18.21