Inflammatory Skin Diseases in Diverse Populations: Diagnosis, Burden, and Research Gaps

Conclusions

• Across atopic dermatitis, psoriasis, and hidradenitis suppurativa, many apparent skin-of-color differences are driven more by social, structural, environmental, and diagnostic factors than by simple intrinsic biological differences.
• Race and ethnicity are too inconsistently defined and too often conflated to serve as reliable biological categories, so research and clinical comparisons need more precise language and measurement of skin tone and ancestry-related context.
• Atopic dermatitis in darker skin tones is often underrecognized or mischaracterized because erythema may appear brown, purple, gray, or less obviously red, but the disease burden can still be severe and substantial.
• Psoriasis in skin of color can present with different visible features, such as purple-gray plaques, thicker scaling, pigment alteration, scalp and inverse involvement, and it is frequently misdiagnosed or diagnosed late.
• Hidradenitis suppurativa shows major disparities in severity and healthcare burden, with Black patients especially experiencing more severe disease and greater utilization, but no single race-specific phenotype explains the disease.
• Intrinsic genetic factors may contribute in some cases, but the evidence is limited and often population-specific, while extrinsic factors such as environment, obesity, smoking, friction, and access to care likely explain much of the observed disparity.
• The biggest gaps are in representative research, validated assessment tools, and diverse clinical trials, which are necessary to accurately measure disease severity and treatment response across skin tones.
• Recent studies demonstrate that well-designed trials in diverse populations are feasible and can yield useful new outcome measures, including tools for erythema, pigment alteration, and xerosis.
• Effective treatment responses appear broadly similar across populations, so the main challenge is improving recognition, equitable access, and appropriate outcome assessment rather than assuming fundamentally different therapeutic needs.
• Overall, better dermatologic care for skin of color depends on asking not only what the diagnosis is, but why the presentation, burden, and outcomes differ across populations.