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- Presentation
Atopic Dermatitis in Diverse Populations: Diagnosis, Epidemiology, Pathophysiology, and Treatment
Description
The talk reviewed atopic dermatitis (AD) in diverse populations, emphasizing that diagnosis can look very different across skin tones and ethnic groups. In darker skin, AD may appear more lichenified, papular, hyperpigmented, or poorly demarcated, while in Asian patients it can be more well-demarcated and may overlap clinically and histologically with psoriasis, making biopsies sometimes confusing. The speaker highlighted photo-exacerbated AD and other atypical presentations, especially in Asian populations, and noted marked post-inflammatory pigment changes and scratching-related depigmentation in skin of color. Epidemiologically, AD rates vary widely by region, with higher prevalence in urban areas than rural areas, likely reflecting environmental factors such as pollution and hygiene, and very low rates reported in some highly traditional settings like Tibet. In the U.S., children of immigrants and African-American patients are disproportionately affected, yet African-American patients are less likely to receive systemic biologic treatment. Pathophysiology remains primarily Th2-driven across populations, but there are differences in filaggrin mutations, ceramides, transepidermal water loss, and Th17/IL-22/TSLP pathways, particularly in Asian cohorts. These immune differences may help explain mixed AD/psoriasis features and may influence future therapies, including bispecific agents targeting multiple cytokine pathways. Treatment considerations included steroid phobia in some Asian countries, preference for topical calcineurin inhibitors and other nonsteroidals, possible benefit of antihistamines in some patients, and the need for more diverse clinical trials to better guide care across populations.
View moreConclusions
- Atopic dermatitis presents with substantial clinical variation across skin tones, so redness, morphology, and sequelae can be easily missed without population-aware diagnosis.
- Darker skin types often show more lichenification, papules, hyperpigmentation, and depigmentation, which can lead to underestimation of disease severity and delayed escalation of treatment.
- In Asian patients, atopic dermatitis may overlap clinically and histologically with psoriasis and may include a stronger Th17/Th22 component than classic textbook disease.
- Environmental factors such as urbanization, pollution, hygiene patterns, and migration appear to strongly influence atopic dermatitis prevalence, with higher rates often seen in urban and immigrant populations.
- Filaggrin and barrier defects contribute to atopic dermatitis across groups, but the specific mutations and their prevalence differ by ancestry, suggesting partially distinct genetic architectures.
- Despite these differences, atopic dermatitis remains largely a Th2-driven disease across populations, with cytokine differences refining rather than replacing that core framework.
- The evidence base is still limited by small, underpowered studies in many racial and ethnic groups, so larger and more diverse cohorts are needed to define true biologic differences.
- Treatment should be individualized by phenotype and access, with earlier consideration of systemic therapy in patients whose skin of color leads to more visible sequelae or greater burden.
- Cultural and practice differences, such as steroid phobia in some Asian populations and more common antihistamine use, meaningfully shape treatment patterns and adherence.
- Biologic therapies like dupilumab appear effective across diverse populations, but clinical trials and mechanistic studies need much broader representation to guide precision treatment.
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