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Atopic Dermatitis in SOC

CE / CME

Addressing the Disproportionate Burden of Moderate to Severe Atopic Dermatitis in Patients With Skin of Color: Expert Perspectives for NPs and PAs

Physician Assistants/Physician Associates: 1.00 AAPA Category 1 CME credit

Nurse Practitioners: 1.00 Nursing contact hours, includes 1.00 hour of pharmacotherapy credit

Released: January 15, 2025

Expiration: January 14, 2026

Victoria Garcia-Albea
Victoria Garcia-Albea, PNP, DCNP
CME/CE Information

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Patient Perspective: Defining a “Successful” Treatment

Let’s revisit our patient to hear more about what matters most to her when discussing treatment options.

Clinical Presentation Variability

Clinical presentation of AD varies by age. In infants, the condition predominantly affects the cheeks, forehead, and scalp. This distribution is likely because infants have limited mobility and may scratch their faces against car seats or bedding. As they begin to crawl, the presentation expands to extensor extremities and flexural creases.16,17 

As patients progress through childhood, focal scratching becomes more pronounced, and the condition is frequently seen on the face, neck, palms, and soles. Adult patients typically present with classical involvement of flexural regions, including the antecubital and popliteal fossa, and the backs of the hands and feet.16-18

Patients with more richly pigmented skin exhibit unique diagnostic considerations. They may have more papular or follicular eruption, which may lack discrete lesions. On close examination or with side lighting, small skin-colored or slightly hypopigmented bumps that may resemble dry skin or follicular prominence and serve as a helpful diagnostic clue when AD is suspected but not immediately obvious.19,20

Patients with richly pigmented skin are also more prone to postinflammatory hyperpigmentation—a transient “footprint” after inflammation has resolved, either through treatment or spontaneously. Although this hyperpigmentation is not a permanent scar, it can take several months to resolve and often frustrates patients. Patient education and counseling can help during this process.19,20

Erythema in patients with richly pigmented skin can appear less obvious and may manifest as violaceous, or purplish, discoloration. This differs from patients with lighter skin, in whom erythema typically appears more distinctly as pink or red. For example in the top left picture of the infant with AD, the erythema may be strikingly red and easily visible in lighter skin tones, while in darker skin tones like the other pictures, the violaceous hue can be more subtle and challenging to detect.19,20

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Presentation on Varying Skin Tones

Here are some pictures showing the variation in presentation based on skin type. In the top left picture, which shows the anterior neck, erythema and scaling are visible. The second image on the top row, which shows the back of the knees, is a clear example of lichenification, characterized by increased skin markings, violaceous to hypopigmented discoloration, and scaling.21

In the bottom left image, the hand demonstrates a classic example of hand eczema, with very dry skin, some fissures, and white scaling, showing lichenification, hyperpigmentation, hyperlinearity, and violaceous discoloration.21

The top right image compares presentations in an Asian patient vs a patient with lighter skin. In the Asian patient, the erythema appears duskier, with violaceous discoloration rather than the red or pink tones seen in lighter skin. The adjacent image on the right demonstrates what is traditionally seen in textbooks as a “classic” case of erythema. However, we must broaden our understanding of the term, “classic”. For example, in the far-right image, the arms are crossed over the front of the abdomen, revealing significant redness, pink discoloration, and excoriations. This presentation is typical in patients with lighter skin and extensive involvement.22,23

The bottom 2 images on the right show two backs positioned side by side. The left image appears to show postinflammatory hyperpigmentation. However, it is essential to palate the area to assess whether the disease is still active. This is a critical step because it is important not to assume the condition has resolved and is merely presenting as postinflammatory hyperpigmentation. Evaluating for itch is also important, as pruritus can provide insight if the disease is still active.22,23

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Comorbidities of AD

Like what we observe in patients with psoriasis, there is growing recognition of the wide range of comorbidities associated with AD. These extend beyond the traditional atopic tetrad, which includes asthma, food allergies, allergic rhinitis, and eosinophilic esophagitis.24

Patients with AD are known to have a higher incidence of ocular complications, particularly conjunctivitis. Increasing evidence also highlights associations with immune-mediated conditions such as alopecia areata and urticaria.24

Furthermore, mental health conditions and substance use disorders are notably more common in these patients. These include higher rates of depression, anxiety, self-harm, substance use, attention deficit/hyperactivity disorder, and autism spectrum disorders.24

Cardiovascular diseases are a newer addition to the comorbidity profile of AD. Patients with AD are at a higher risk for hypertension, coronary and peripheral artery disease, heart failure, and thromboembolic events.24

Metabolic disorders are also more prevalent, including an increased risk of obesity and dyslipidemia. Bone health can also be affected with an increased likelihood of osteoporosis and fractures.24

Lastly, skin infections remain a significant concern, historically attributed to excessive scratching. However, skin infections are now recognized as an important comorbidity of the disease as well.24

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Clinical Assessment Tools

Several clinical assessment tools are available, although many of them are primarily used in research settings. For example, most clinicians do not routinely document an EASI score or a SCORAD index in daily practice.25,26

However, I want to highlight a few of these tools, including one that may be practical to incorporate into your routine clinical practice. These tools can provide valuable insights into the patient's experience, helping you better understand their condition.

Historically, these assessment tools have predominantly focused on objective clinical measurements, overlooking the patient’s subjective experience such as severity of itching, the degree to which AD disrupts their daily life, or how much sleep they are losing. Increasingly, there is a movement toward integrating these patient-centered factors into the assessment of disease severity, ensuring a more comprehensive evaluation of each patient’s AD.27

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Atopic Dermatitis Control Tool: ADCT

The Atopic Dermatitis Control Tool (ADCT) is a validated, brief, and user-friendly scoring system that allows patients with AD to self-assess their disease control. This tool can be used consistently at each visit to evaluate how well their disease is being managed.28,29

The ADCT consists of 6 questions that address key different dimensions of disease control, which are both relevant and meaningful to patients and clinicians. These dimensions include28,29:

  1. Overall symptom severity
  2. Frequency of intense itching episodes
  3. Extent of disease-related distress
  4. Frequency of sleep disruption
  5. Impact on daily activities
  6. Impact on mood and emotions

This tool represents a significant shift away from investigator-focused assessments, such as the Investigator Global Assessment (IGA) tool, which primarily evaluates the patient’s appearance from the HCP’s perspective. Instead, the ADCT emphasizes the patient’s perception of their disease, offering a more patient-centered approach.28,29

The ADCT can be self-administered or completed during routine consultations. Patients may fill it out at home before their appointment, or while waiting in the office. Its design is meant to facilitate meaningful discussions between patients and HCPs, promoting shared decision-making and strengthening the patient–provider relationship. 

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ADCT Measurements

Here is a closer look at the ADCT 6 questions. Question 4, asks: “Over the last week, how many nights did you have trouble falling asleep or staying asleep because of your eczema?” This question is weighted slightly higher than the others, reflecting the significant impact of sleep disturbances on disease control.28,29

An ADCT score of 7 or higher indicates that the patient’s AD is likely not well controlled. Answering at least 1 question in the highlighted box will place a patient in the “out of control” category. An increase of 5 or more points since the previous assessment signifies inadequate disease management.28,29

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When assessing AD severity in patients with skin of color, what surrogate measure can be used as an adjunctive assessment?

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