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Women have worse outcomes in cardiogenic shock
“These data identify the need for us to continue working to identify barriers in terms of diagnosis, management, and technological innovations for women in cardiogenic shock to resolve these issues and improve outcomes,” the senior author of the study, Navin Kapur, MD, Tufts Medical Center, Boston, said in an interview.
The study is said to be the one of the largest contemporary analyses of real-world registry data on the characteristics and outcomes of women in comparison with men with cardiogenic shock.
It showed sex-specific differences in outcomes that were primarily driven by differences in heart failure–related cardiogenic shock. Women with heart failure–related cardiogenic shock had more severe cardiogenic shock, worse survival at discharge, and more vascular complications than men. Outcomes in cardiogenic shock related to MI were similar for men and women.
The study, which will be presented at the upcoming annual meeting of the American Heart Association, was published online in JACC: Heart Failure.
Dr. Kapur founded the Cardiogenic Shock Working Group in 2017 to collect quality data on the condition.
“We realized our patients were dying, and we didn’t have enough data on how best to manage them. So, we started this registry, and now have detailed data on close to 9,000 patients with cardiogenic shock from 45 hospitals in the U.S., Mexico, Australia, and Japan,” he explained.
“The primary goal is to try to investigate the questions related to cardiogenic shock that can inform management, and one of the key questions that came up was differences in how men and women present with cardiogenic shock and what their outcomes may be. This is what we are reporting in this paper,” he added.
Cardiogenic shock is defined as having a low cardiac output most commonly because of MI or an episode of acute heart failure, Dr. Kapur said. Patients with cardiogenic shock are identified by their low blood pressure or hypoperfusion evidenced by clinical exam or biomarkers, such as elevated lactate levels.
“In this analysis, we’re looking at patients presenting with cardiogenic shock, so were not looking at the incidence of the condition in men versus women,” Dr. Kapur noted. “However, we believe that cardiogenic shock is probably more underrepresented in women, who may present with an MI or acute heart failure and may or may not be identified as having low cardiac output states until quite late. The likelihood is that the incidence is similar in men and women, but women are more often undiagnosed.”
For the current study, the authors analyzed data on 5,083 patients with cardiogenic shock in the registry, of whom 1,522 (30%) were women. Compared with men, women had slightly higher body mass index (BMI) and smaller body surface area.
Results showed that women with heart failure–related cardiogenic shock had worse survival at discharge than men (69.9% vs. 74.4%) and a higher rate of refractory shock (SCAI stage E; 26% vs. 21%). Women were also less likely to undergo pulmonary artery catheterization (52.9% vs. 54.6%), heart transplantation (6.5% vs. 10.3%), or left ventricular assist device implantation (7.8% vs. 10%).
Regardless of cardiogenic shock etiology, women had more vascular complications (8.8% vs. 5.7%), bleeding (7.1% vs. 5.2%), and limb ischemia (6.8% vs. 4.5%).
“This analysis is quite revealing. We identified some important distinctions between men and women,” Dr. Kapur commented.
For many patients who present with MI-related cardiogenic shock, many of the baseline characteristics in men and women were quite similar, he said. “But in heart failure–related cardiogenic shock, we saw more differences, with typical comorbidities associated with cardiogenic shock [e.g., diabetes, chronic kidney disease, hypertension] being less common in women than in men. This suggests there may be phenotypic differences as to why women present with heart failure shock versus men.”
Dr. Kapur pointed out that differences in BMI or body surface area between men and women may play into some of the management decision-making.
“Women having a smaller stature may lead to a selection bias where we don’t want to use large-bore pumps or devices because we’re worried about causing complications. We found in the analysis that vascular complications such as bleeding or ischemia of the lower extremity where these devices typically go were more frequent in women,” he noted.
“We also found that women were less likely to receive invasive therapies in general, including pulmonary artery catheters, temporary mechanical support, and heart replacements, such as LVAD or transplants,” he added.
Further results showed that, after propensity score matching, some of the gender differences disappeared, but women continued to have a higher rate of vascular complications (10.4% women vs. 7.4% men).
But Dr. Kapur warned that the propensity-matched analysis had some caveats.
“Essentially what we are doing with propensity matching is creating two populations that are as similar as possible, and this reduced the number of patients in the analysis down to 25% of the original population,” he said. “One of the things we had to match was body surface area, and in doing this, we are taking out one of the most important differences between men and women, and as a result, a lot of the differences in outcomes go away.
“In this respect, propensity matching can be a bit of a double-edge sword,” he added. “I think the non–propensity-matched results are more interesting, as they are more of a reflection of the real world.”
Dr. Kapur concluded that these findings are compelling enough to suggest that there are important differences between women and men with cardiogenic shock in terms of outcomes as well as complication rates.
“Our decision-making around women seems to be different to that around men. I think this paper should start to trigger more awareness of that.”
Dr. Kapur also emphasized the importance of paying attention to vascular complications in women.
“The higher rates of bleeding and limb ischemia issues in women may explain the rationale for being less aggressive with invasive therapies in women,” he said. “But we need to come up with better solutions or technologies so they can be used more effectively in women. This could include adapting technology for smaller vascular sizes, which should lead to better outcome and fewer complications in women.”
He added that further granular data on this issue are needed. “We have very limited datasets in cardiogenic shock. There are few randomized controlled trials, and women are not well represented in such trials. We need to make sure we enroll women in randomized trials.”
Dr. Kapur said more women physicians who treat cardiogenic shock are also required, which would include cardiologists, critical care specialists, cardiac surgeons, and anesthesia personnel.
He pointed out that the two first authors of the current study are women – Van-Khue Ton, MD, Massachusetts General Hospital, Boston, and Manreet Kanwar, MD, Allegheny Health Network, Pittsburgh.
“We worked hard to involve women as principal investigators. They led the effort. These are investigations led by women, on women, to advance the care of women,” he commented.
Gender-related inequality
In an editorial accompanying publication of the study, Sara Kalantari, MD, and Jonathan Grinstein, MD, University of Chicago, and Robert O. Roswell, MD, Hofstra University, Hempstead, N.Y., said these results “provide valuable information about gender-related inequality in care and outcomes in the management of cardiogenic shock, although the exact mechanisms driving these observed differences still need to be elucidated.
“Broadly speaking, barriers in the care of women with heart failure and cardiogenic shock include a reduced awareness among both patients and providers, a deficiency of sex-specific objective criteria for guiding therapy, and unfavorable temporary mechanical circulatory support devices with higher rates of hemocompatibility-related complications in women,” they added.
“In the era of the multidisciplinary shock team and shock pathways with protocolized management algorithms, it is imperative that we still allow for personalization of care to match the physiologic needs of the patient in order for us to continue to close the gender gap in the care of patients presenting with cardiogenic shock,” the editorialists concluded.
A version of this article appeared on Medscape.com.
“These data identify the need for us to continue working to identify barriers in terms of diagnosis, management, and technological innovations for women in cardiogenic shock to resolve these issues and improve outcomes,” the senior author of the study, Navin Kapur, MD, Tufts Medical Center, Boston, said in an interview.
The study is said to be the one of the largest contemporary analyses of real-world registry data on the characteristics and outcomes of women in comparison with men with cardiogenic shock.
It showed sex-specific differences in outcomes that were primarily driven by differences in heart failure–related cardiogenic shock. Women with heart failure–related cardiogenic shock had more severe cardiogenic shock, worse survival at discharge, and more vascular complications than men. Outcomes in cardiogenic shock related to MI were similar for men and women.
The study, which will be presented at the upcoming annual meeting of the American Heart Association, was published online in JACC: Heart Failure.
Dr. Kapur founded the Cardiogenic Shock Working Group in 2017 to collect quality data on the condition.
“We realized our patients were dying, and we didn’t have enough data on how best to manage them. So, we started this registry, and now have detailed data on close to 9,000 patients with cardiogenic shock from 45 hospitals in the U.S., Mexico, Australia, and Japan,” he explained.
“The primary goal is to try to investigate the questions related to cardiogenic shock that can inform management, and one of the key questions that came up was differences in how men and women present with cardiogenic shock and what their outcomes may be. This is what we are reporting in this paper,” he added.
Cardiogenic shock is defined as having a low cardiac output most commonly because of MI or an episode of acute heart failure, Dr. Kapur said. Patients with cardiogenic shock are identified by their low blood pressure or hypoperfusion evidenced by clinical exam or biomarkers, such as elevated lactate levels.
“In this analysis, we’re looking at patients presenting with cardiogenic shock, so were not looking at the incidence of the condition in men versus women,” Dr. Kapur noted. “However, we believe that cardiogenic shock is probably more underrepresented in women, who may present with an MI or acute heart failure and may or may not be identified as having low cardiac output states until quite late. The likelihood is that the incidence is similar in men and women, but women are more often undiagnosed.”
For the current study, the authors analyzed data on 5,083 patients with cardiogenic shock in the registry, of whom 1,522 (30%) were women. Compared with men, women had slightly higher body mass index (BMI) and smaller body surface area.
Results showed that women with heart failure–related cardiogenic shock had worse survival at discharge than men (69.9% vs. 74.4%) and a higher rate of refractory shock (SCAI stage E; 26% vs. 21%). Women were also less likely to undergo pulmonary artery catheterization (52.9% vs. 54.6%), heart transplantation (6.5% vs. 10.3%), or left ventricular assist device implantation (7.8% vs. 10%).
Regardless of cardiogenic shock etiology, women had more vascular complications (8.8% vs. 5.7%), bleeding (7.1% vs. 5.2%), and limb ischemia (6.8% vs. 4.5%).
“This analysis is quite revealing. We identified some important distinctions between men and women,” Dr. Kapur commented.
For many patients who present with MI-related cardiogenic shock, many of the baseline characteristics in men and women were quite similar, he said. “But in heart failure–related cardiogenic shock, we saw more differences, with typical comorbidities associated with cardiogenic shock [e.g., diabetes, chronic kidney disease, hypertension] being less common in women than in men. This suggests there may be phenotypic differences as to why women present with heart failure shock versus men.”
Dr. Kapur pointed out that differences in BMI or body surface area between men and women may play into some of the management decision-making.
“Women having a smaller stature may lead to a selection bias where we don’t want to use large-bore pumps or devices because we’re worried about causing complications. We found in the analysis that vascular complications such as bleeding or ischemia of the lower extremity where these devices typically go were more frequent in women,” he noted.
“We also found that women were less likely to receive invasive therapies in general, including pulmonary artery catheters, temporary mechanical support, and heart replacements, such as LVAD or transplants,” he added.
Further results showed that, after propensity score matching, some of the gender differences disappeared, but women continued to have a higher rate of vascular complications (10.4% women vs. 7.4% men).
But Dr. Kapur warned that the propensity-matched analysis had some caveats.
“Essentially what we are doing with propensity matching is creating two populations that are as similar as possible, and this reduced the number of patients in the analysis down to 25% of the original population,” he said. “One of the things we had to match was body surface area, and in doing this, we are taking out one of the most important differences between men and women, and as a result, a lot of the differences in outcomes go away.
“In this respect, propensity matching can be a bit of a double-edge sword,” he added. “I think the non–propensity-matched results are more interesting, as they are more of a reflection of the real world.”
Dr. Kapur concluded that these findings are compelling enough to suggest that there are important differences between women and men with cardiogenic shock in terms of outcomes as well as complication rates.
“Our decision-making around women seems to be different to that around men. I think this paper should start to trigger more awareness of that.”
Dr. Kapur also emphasized the importance of paying attention to vascular complications in women.
“The higher rates of bleeding and limb ischemia issues in women may explain the rationale for being less aggressive with invasive therapies in women,” he said. “But we need to come up with better solutions or technologies so they can be used more effectively in women. This could include adapting technology for smaller vascular sizes, which should lead to better outcome and fewer complications in women.”
He added that further granular data on this issue are needed. “We have very limited datasets in cardiogenic shock. There are few randomized controlled trials, and women are not well represented in such trials. We need to make sure we enroll women in randomized trials.”
Dr. Kapur said more women physicians who treat cardiogenic shock are also required, which would include cardiologists, critical care specialists, cardiac surgeons, and anesthesia personnel.
He pointed out that the two first authors of the current study are women – Van-Khue Ton, MD, Massachusetts General Hospital, Boston, and Manreet Kanwar, MD, Allegheny Health Network, Pittsburgh.
“We worked hard to involve women as principal investigators. They led the effort. These are investigations led by women, on women, to advance the care of women,” he commented.
Gender-related inequality
In an editorial accompanying publication of the study, Sara Kalantari, MD, and Jonathan Grinstein, MD, University of Chicago, and Robert O. Roswell, MD, Hofstra University, Hempstead, N.Y., said these results “provide valuable information about gender-related inequality in care and outcomes in the management of cardiogenic shock, although the exact mechanisms driving these observed differences still need to be elucidated.
“Broadly speaking, barriers in the care of women with heart failure and cardiogenic shock include a reduced awareness among both patients and providers, a deficiency of sex-specific objective criteria for guiding therapy, and unfavorable temporary mechanical circulatory support devices with higher rates of hemocompatibility-related complications in women,” they added.
“In the era of the multidisciplinary shock team and shock pathways with protocolized management algorithms, it is imperative that we still allow for personalization of care to match the physiologic needs of the patient in order for us to continue to close the gender gap in the care of patients presenting with cardiogenic shock,” the editorialists concluded.
A version of this article appeared on Medscape.com.
“These data identify the need for us to continue working to identify barriers in terms of diagnosis, management, and technological innovations for women in cardiogenic shock to resolve these issues and improve outcomes,” the senior author of the study, Navin Kapur, MD, Tufts Medical Center, Boston, said in an interview.
The study is said to be the one of the largest contemporary analyses of real-world registry data on the characteristics and outcomes of women in comparison with men with cardiogenic shock.
It showed sex-specific differences in outcomes that were primarily driven by differences in heart failure–related cardiogenic shock. Women with heart failure–related cardiogenic shock had more severe cardiogenic shock, worse survival at discharge, and more vascular complications than men. Outcomes in cardiogenic shock related to MI were similar for men and women.
The study, which will be presented at the upcoming annual meeting of the American Heart Association, was published online in JACC: Heart Failure.
Dr. Kapur founded the Cardiogenic Shock Working Group in 2017 to collect quality data on the condition.
“We realized our patients were dying, and we didn’t have enough data on how best to manage them. So, we started this registry, and now have detailed data on close to 9,000 patients with cardiogenic shock from 45 hospitals in the U.S., Mexico, Australia, and Japan,” he explained.
“The primary goal is to try to investigate the questions related to cardiogenic shock that can inform management, and one of the key questions that came up was differences in how men and women present with cardiogenic shock and what their outcomes may be. This is what we are reporting in this paper,” he added.
Cardiogenic shock is defined as having a low cardiac output most commonly because of MI or an episode of acute heart failure, Dr. Kapur said. Patients with cardiogenic shock are identified by their low blood pressure or hypoperfusion evidenced by clinical exam or biomarkers, such as elevated lactate levels.
“In this analysis, we’re looking at patients presenting with cardiogenic shock, so were not looking at the incidence of the condition in men versus women,” Dr. Kapur noted. “However, we believe that cardiogenic shock is probably more underrepresented in women, who may present with an MI or acute heart failure and may or may not be identified as having low cardiac output states until quite late. The likelihood is that the incidence is similar in men and women, but women are more often undiagnosed.”
For the current study, the authors analyzed data on 5,083 patients with cardiogenic shock in the registry, of whom 1,522 (30%) were women. Compared with men, women had slightly higher body mass index (BMI) and smaller body surface area.
Results showed that women with heart failure–related cardiogenic shock had worse survival at discharge than men (69.9% vs. 74.4%) and a higher rate of refractory shock (SCAI stage E; 26% vs. 21%). Women were also less likely to undergo pulmonary artery catheterization (52.9% vs. 54.6%), heart transplantation (6.5% vs. 10.3%), or left ventricular assist device implantation (7.8% vs. 10%).
Regardless of cardiogenic shock etiology, women had more vascular complications (8.8% vs. 5.7%), bleeding (7.1% vs. 5.2%), and limb ischemia (6.8% vs. 4.5%).
“This analysis is quite revealing. We identified some important distinctions between men and women,” Dr. Kapur commented.
For many patients who present with MI-related cardiogenic shock, many of the baseline characteristics in men and women were quite similar, he said. “But in heart failure–related cardiogenic shock, we saw more differences, with typical comorbidities associated with cardiogenic shock [e.g., diabetes, chronic kidney disease, hypertension] being less common in women than in men. This suggests there may be phenotypic differences as to why women present with heart failure shock versus men.”
Dr. Kapur pointed out that differences in BMI or body surface area between men and women may play into some of the management decision-making.
“Women having a smaller stature may lead to a selection bias where we don’t want to use large-bore pumps or devices because we’re worried about causing complications. We found in the analysis that vascular complications such as bleeding or ischemia of the lower extremity where these devices typically go were more frequent in women,” he noted.
“We also found that women were less likely to receive invasive therapies in general, including pulmonary artery catheters, temporary mechanical support, and heart replacements, such as LVAD or transplants,” he added.
Further results showed that, after propensity score matching, some of the gender differences disappeared, but women continued to have a higher rate of vascular complications (10.4% women vs. 7.4% men).
But Dr. Kapur warned that the propensity-matched analysis had some caveats.
“Essentially what we are doing with propensity matching is creating two populations that are as similar as possible, and this reduced the number of patients in the analysis down to 25% of the original population,” he said. “One of the things we had to match was body surface area, and in doing this, we are taking out one of the most important differences between men and women, and as a result, a lot of the differences in outcomes go away.
“In this respect, propensity matching can be a bit of a double-edge sword,” he added. “I think the non–propensity-matched results are more interesting, as they are more of a reflection of the real world.”
Dr. Kapur concluded that these findings are compelling enough to suggest that there are important differences between women and men with cardiogenic shock in terms of outcomes as well as complication rates.
“Our decision-making around women seems to be different to that around men. I think this paper should start to trigger more awareness of that.”
Dr. Kapur also emphasized the importance of paying attention to vascular complications in women.
“The higher rates of bleeding and limb ischemia issues in women may explain the rationale for being less aggressive with invasive therapies in women,” he said. “But we need to come up with better solutions or technologies so they can be used more effectively in women. This could include adapting technology for smaller vascular sizes, which should lead to better outcome and fewer complications in women.”
He added that further granular data on this issue are needed. “We have very limited datasets in cardiogenic shock. There are few randomized controlled trials, and women are not well represented in such trials. We need to make sure we enroll women in randomized trials.”
Dr. Kapur said more women physicians who treat cardiogenic shock are also required, which would include cardiologists, critical care specialists, cardiac surgeons, and anesthesia personnel.
He pointed out that the two first authors of the current study are women – Van-Khue Ton, MD, Massachusetts General Hospital, Boston, and Manreet Kanwar, MD, Allegheny Health Network, Pittsburgh.
“We worked hard to involve women as principal investigators. They led the effort. These are investigations led by women, on women, to advance the care of women,” he commented.
Gender-related inequality
In an editorial accompanying publication of the study, Sara Kalantari, MD, and Jonathan Grinstein, MD, University of Chicago, and Robert O. Roswell, MD, Hofstra University, Hempstead, N.Y., said these results “provide valuable information about gender-related inequality in care and outcomes in the management of cardiogenic shock, although the exact mechanisms driving these observed differences still need to be elucidated.
“Broadly speaking, barriers in the care of women with heart failure and cardiogenic shock include a reduced awareness among both patients and providers, a deficiency of sex-specific objective criteria for guiding therapy, and unfavorable temporary mechanical circulatory support devices with higher rates of hemocompatibility-related complications in women,” they added.
“In the era of the multidisciplinary shock team and shock pathways with protocolized management algorithms, it is imperative that we still allow for personalization of care to match the physiologic needs of the patient in order for us to continue to close the gender gap in the care of patients presenting with cardiogenic shock,” the editorialists concluded.
A version of this article appeared on Medscape.com.
FROM AHA 2023
Breaking barriers to colorectal cancer care for Black patients
Black Americans are about 40% more likely to die from the disease than most other groups of patients. A recent study also found that 26% of Black Americans are diagnosed with CRC that has already metastasized, meaning the cancer has spread to other places in the body.
“The impact of social determinants of health on CRC diagnosis and treatment is clear to me as a practicing [cancer doctor] and person of color,” said Jason Willis, MD, PhD, a clinical investigator in the departments of Gastrointestinal Medical Oncology and Genomic Medicine at the University of Texas MD Anderson Cancer Center, Houston. “At a systemic level, we know that inequalities in health care access disproportionately impact many racial and ethnic minority groups. This is especially important when it comes to accessing preventative care and routine screening for common cancers, like CRC.”
The problem often exists throughout entire neighborhoods or cities.
“It may reflect a lack of access to primary care, inadequate referrals for screening, cultural barriers, and/or community-level factors,” Dr. Willis said. “Evidence has also suggested that some of the differences in CRC risk observed among various racial/ethnic communities may also be driven by differences in the prevalence of its underlying risk factors, such as tobacco use and type 2 diabetes.”
Black patients can also face information roadblocks when it comes to early CRC evaluation, said Christina M. Annunziata, MD, PhD, senior vice president of extramural discovery science at the American Cancer Society.
Other barriers may include a fear of the invasiveness of a colonoscopy, a lack of understanding of the benefits of screening, and lack of understanding of how family history with the disease plays a role, Dr. Annunziata said. “These apply across the U.S. population and are amplified with Black patients.”
Then there are disparities in treatment, which may come from a lack of health care access, including insurance coverage, transportation challenges, and the time required for treatment such as surgery, radiation, and chemotherapy, she said. “In addition, Black patients diagnosed with advanced-stage cancers require more intensive, expensive, and time-consuming treatment regimens that can be unattainable due to social and economic barriers,” she said.
Are there biological reasons Black people are more at risk for colorectal cancer?
Most likely, no. When Black patients received high-quality colonoscopies, there was no difference in the number of precancerous CRC polyps, or CRC tumors, when compared to White patients tested with the same equipment, according to data from Memorial Sloan Kettering Cancer Center. This further shows the importance of Black patients receiving early and effective screening for the disease.
But genetics may be one reason why CRC in Black patients can be difficult to treat. Additional research from Memorial Sloan Kettering found that colon cancer patients of African ancestry may have tumors that don’t respond well to immunotherapy and targeted cancer therapy.
The researchers found that these patients’ tumors were less likely to have the molecular profiles needed for these treatments to work.
But more research is needed. For now, researchers have very few clues as to why, when, and how these molecular and biological differences of CRC exist among various racial/ethnic and ancestral backgrounds, he said.
Black patients are also more likely to be diagnosed under the age of 50 as well. Researchers don’t know why this is exactly yet, but they think that poor diet, unhealthy bacteria in the gut, and inflammation may contribute to the cause. (Healthy eating and more exercise may lower a person’s risk.)
What are the symptoms of colorectal cancer?
Colorectal polyps, which are growths that can turn into colon cancer, and colon cancer itself can come without symptoms. If a person does have symptoms, they can include:
- Changes in bowel habits
- Blood in bowel movements
- Diarrhea
- Constipation
- The sensation that bowel movements aren’t complete
- Persistent stomachache, stomach pain, or cramps
- Weight loss without any explanation
Any or all of these symptoms warrant a trip to the doctor. These symptoms are the same for all racial and ethnic groups. Because CRC symptoms aren’t always obvious, this makes screening all the more important.
Where colon cancer spreads
Once cancerous cells break off from a tumor, what areas of the body does it spread to first?
What can Black patients do to lower their risk of getting colorectal cancer?
There are a number of solutions patients can pursue themselves.
Learn about CRC online
The untimely death of Oscar-nominated actor Chadwick Boseman from colon cancer at age 43 significantly boosted awareness of the disease, particularly for Black Americans. A study from the University of British Columbia and Simon Fraser University’s Beedie School of Business found there was an increase in internet searches about colon cancer in the months after Mr. Boseman’s August 2020 passing, particularly in areas where many Black Americans live. The study authors emphasized the importance of public health leaders discussing Mr. Mr. Boseman’s diagnosis with their Black patient population, so they will not only be inspired by his brave battle against the disease but will be proactive about getting tested for colon cancer themselves.
Reading about Mr. Boseman’s journey is an important start to patient education. It’s also key to learn about the disease itself, plus how colon cancer screening works specifically. Then, writing down questions to bring to the doctor before screening is an excellent way to feel empowered, and to understand what specific test results will mean.
Be proactive
Find out about family history.
“It’s challenging to determine the best age for screening if the patient doesn’t know their family history,” said Dr. Annunziata. Asking older members of the family whether CRC has affected previous generations is a helpful step.
If there is a strong family history, a patient will likely need earlier screening.
“[Doctors] should explain the benefits of colon cancer screening with colonoscopy starting at age 45 in the general population or earlier if the person has a family history of colon cancer,” Dr. Annunziata said. If a patient’s doctor doesn’t offer this information upfront, it’s definitely the right move to ask for the testing directly.
If a Black patient gets diagnosed with CRC, they should educate themselves about critical follow-up care after a diagnosis. Doctors should also be more proactive about enrolling patients in key clinical trials. According to additional data from the American Cancer Society, only 7% of patients enrolled in the FDA’s clinical cancer drug trials are Black. Doctors should also be more proactive about enrolling patients in these and other key clinical trials; it’s completely appropriate for a patient to search out trials on their own and bring them to their doctor’s attention too.
And attending all appointments and completing chemo or radiation treatment is vital.
“For patients undergoing treatment, physicians can ensure that the patients understand the importance of receiving the full recommended course of treatment and receive the support to tolerate the anticipated side effects,” Dr. Annunziata said.
Reach out for reassurance
Patients who are diagnosed with colorectal cancer have many resources for emotional support. The American Cancer Society offers support for all physical and emotional aspects of cancer 24 hours a day. The Colorectal Cancer Alliance offers comprehensive resource guides as well.
Support groups, through local hospitals or communities, can also be extremely helpful.
Reading the stories of Black patients who are surviving and thriving despite a colorectal cancer diagnosis can be incredibly inspiring as well.
It’s also very important for Black patients to let their doctors know if they don’t have the support they need. A doctor can help by navigating extra help within a patient’s community – an approach that is truly breaking down barriers to CRC care.
“What’s very encouraging is that meaningful improvements in CRC screening rates and early detection among Black communities have been seen through purposeful interventions and outreach,” Dr. Willis said. “In this way, all doctors can play a significant role at a broad and systemic level by advocating for and implementing interventions in their communities.”
A version of this article appeared on WebMD.com.
Black Americans are about 40% more likely to die from the disease than most other groups of patients. A recent study also found that 26% of Black Americans are diagnosed with CRC that has already metastasized, meaning the cancer has spread to other places in the body.
“The impact of social determinants of health on CRC diagnosis and treatment is clear to me as a practicing [cancer doctor] and person of color,” said Jason Willis, MD, PhD, a clinical investigator in the departments of Gastrointestinal Medical Oncology and Genomic Medicine at the University of Texas MD Anderson Cancer Center, Houston. “At a systemic level, we know that inequalities in health care access disproportionately impact many racial and ethnic minority groups. This is especially important when it comes to accessing preventative care and routine screening for common cancers, like CRC.”
The problem often exists throughout entire neighborhoods or cities.
“It may reflect a lack of access to primary care, inadequate referrals for screening, cultural barriers, and/or community-level factors,” Dr. Willis said. “Evidence has also suggested that some of the differences in CRC risk observed among various racial/ethnic communities may also be driven by differences in the prevalence of its underlying risk factors, such as tobacco use and type 2 diabetes.”
Black patients can also face information roadblocks when it comes to early CRC evaluation, said Christina M. Annunziata, MD, PhD, senior vice president of extramural discovery science at the American Cancer Society.
Other barriers may include a fear of the invasiveness of a colonoscopy, a lack of understanding of the benefits of screening, and lack of understanding of how family history with the disease plays a role, Dr. Annunziata said. “These apply across the U.S. population and are amplified with Black patients.”
Then there are disparities in treatment, which may come from a lack of health care access, including insurance coverage, transportation challenges, and the time required for treatment such as surgery, radiation, and chemotherapy, she said. “In addition, Black patients diagnosed with advanced-stage cancers require more intensive, expensive, and time-consuming treatment regimens that can be unattainable due to social and economic barriers,” she said.
Are there biological reasons Black people are more at risk for colorectal cancer?
Most likely, no. When Black patients received high-quality colonoscopies, there was no difference in the number of precancerous CRC polyps, or CRC tumors, when compared to White patients tested with the same equipment, according to data from Memorial Sloan Kettering Cancer Center. This further shows the importance of Black patients receiving early and effective screening for the disease.
But genetics may be one reason why CRC in Black patients can be difficult to treat. Additional research from Memorial Sloan Kettering found that colon cancer patients of African ancestry may have tumors that don’t respond well to immunotherapy and targeted cancer therapy.
The researchers found that these patients’ tumors were less likely to have the molecular profiles needed for these treatments to work.
But more research is needed. For now, researchers have very few clues as to why, when, and how these molecular and biological differences of CRC exist among various racial/ethnic and ancestral backgrounds, he said.
Black patients are also more likely to be diagnosed under the age of 50 as well. Researchers don’t know why this is exactly yet, but they think that poor diet, unhealthy bacteria in the gut, and inflammation may contribute to the cause. (Healthy eating and more exercise may lower a person’s risk.)
What are the symptoms of colorectal cancer?
Colorectal polyps, which are growths that can turn into colon cancer, and colon cancer itself can come without symptoms. If a person does have symptoms, they can include:
- Changes in bowel habits
- Blood in bowel movements
- Diarrhea
- Constipation
- The sensation that bowel movements aren’t complete
- Persistent stomachache, stomach pain, or cramps
- Weight loss without any explanation
Any or all of these symptoms warrant a trip to the doctor. These symptoms are the same for all racial and ethnic groups. Because CRC symptoms aren’t always obvious, this makes screening all the more important.
Where colon cancer spreads
Once cancerous cells break off from a tumor, what areas of the body does it spread to first?
What can Black patients do to lower their risk of getting colorectal cancer?
There are a number of solutions patients can pursue themselves.
Learn about CRC online
The untimely death of Oscar-nominated actor Chadwick Boseman from colon cancer at age 43 significantly boosted awareness of the disease, particularly for Black Americans. A study from the University of British Columbia and Simon Fraser University’s Beedie School of Business found there was an increase in internet searches about colon cancer in the months after Mr. Boseman’s August 2020 passing, particularly in areas where many Black Americans live. The study authors emphasized the importance of public health leaders discussing Mr. Mr. Boseman’s diagnosis with their Black patient population, so they will not only be inspired by his brave battle against the disease but will be proactive about getting tested for colon cancer themselves.
Reading about Mr. Boseman’s journey is an important start to patient education. It’s also key to learn about the disease itself, plus how colon cancer screening works specifically. Then, writing down questions to bring to the doctor before screening is an excellent way to feel empowered, and to understand what specific test results will mean.
Be proactive
Find out about family history.
“It’s challenging to determine the best age for screening if the patient doesn’t know their family history,” said Dr. Annunziata. Asking older members of the family whether CRC has affected previous generations is a helpful step.
If there is a strong family history, a patient will likely need earlier screening.
“[Doctors] should explain the benefits of colon cancer screening with colonoscopy starting at age 45 in the general population or earlier if the person has a family history of colon cancer,” Dr. Annunziata said. If a patient’s doctor doesn’t offer this information upfront, it’s definitely the right move to ask for the testing directly.
If a Black patient gets diagnosed with CRC, they should educate themselves about critical follow-up care after a diagnosis. Doctors should also be more proactive about enrolling patients in key clinical trials. According to additional data from the American Cancer Society, only 7% of patients enrolled in the FDA’s clinical cancer drug trials are Black. Doctors should also be more proactive about enrolling patients in these and other key clinical trials; it’s completely appropriate for a patient to search out trials on their own and bring them to their doctor’s attention too.
And attending all appointments and completing chemo or radiation treatment is vital.
“For patients undergoing treatment, physicians can ensure that the patients understand the importance of receiving the full recommended course of treatment and receive the support to tolerate the anticipated side effects,” Dr. Annunziata said.
Reach out for reassurance
Patients who are diagnosed with colorectal cancer have many resources for emotional support. The American Cancer Society offers support for all physical and emotional aspects of cancer 24 hours a day. The Colorectal Cancer Alliance offers comprehensive resource guides as well.
Support groups, through local hospitals or communities, can also be extremely helpful.
Reading the stories of Black patients who are surviving and thriving despite a colorectal cancer diagnosis can be incredibly inspiring as well.
It’s also very important for Black patients to let their doctors know if they don’t have the support they need. A doctor can help by navigating extra help within a patient’s community – an approach that is truly breaking down barriers to CRC care.
“What’s very encouraging is that meaningful improvements in CRC screening rates and early detection among Black communities have been seen through purposeful interventions and outreach,” Dr. Willis said. “In this way, all doctors can play a significant role at a broad and systemic level by advocating for and implementing interventions in their communities.”
A version of this article appeared on WebMD.com.
Black Americans are about 40% more likely to die from the disease than most other groups of patients. A recent study also found that 26% of Black Americans are diagnosed with CRC that has already metastasized, meaning the cancer has spread to other places in the body.
“The impact of social determinants of health on CRC diagnosis and treatment is clear to me as a practicing [cancer doctor] and person of color,” said Jason Willis, MD, PhD, a clinical investigator in the departments of Gastrointestinal Medical Oncology and Genomic Medicine at the University of Texas MD Anderson Cancer Center, Houston. “At a systemic level, we know that inequalities in health care access disproportionately impact many racial and ethnic minority groups. This is especially important when it comes to accessing preventative care and routine screening for common cancers, like CRC.”
The problem often exists throughout entire neighborhoods or cities.
“It may reflect a lack of access to primary care, inadequate referrals for screening, cultural barriers, and/or community-level factors,” Dr. Willis said. “Evidence has also suggested that some of the differences in CRC risk observed among various racial/ethnic communities may also be driven by differences in the prevalence of its underlying risk factors, such as tobacco use and type 2 diabetes.”
Black patients can also face information roadblocks when it comes to early CRC evaluation, said Christina M. Annunziata, MD, PhD, senior vice president of extramural discovery science at the American Cancer Society.
Other barriers may include a fear of the invasiveness of a colonoscopy, a lack of understanding of the benefits of screening, and lack of understanding of how family history with the disease plays a role, Dr. Annunziata said. “These apply across the U.S. population and are amplified with Black patients.”
Then there are disparities in treatment, which may come from a lack of health care access, including insurance coverage, transportation challenges, and the time required for treatment such as surgery, radiation, and chemotherapy, she said. “In addition, Black patients diagnosed with advanced-stage cancers require more intensive, expensive, and time-consuming treatment regimens that can be unattainable due to social and economic barriers,” she said.
Are there biological reasons Black people are more at risk for colorectal cancer?
Most likely, no. When Black patients received high-quality colonoscopies, there was no difference in the number of precancerous CRC polyps, or CRC tumors, when compared to White patients tested with the same equipment, according to data from Memorial Sloan Kettering Cancer Center. This further shows the importance of Black patients receiving early and effective screening for the disease.
But genetics may be one reason why CRC in Black patients can be difficult to treat. Additional research from Memorial Sloan Kettering found that colon cancer patients of African ancestry may have tumors that don’t respond well to immunotherapy and targeted cancer therapy.
The researchers found that these patients’ tumors were less likely to have the molecular profiles needed for these treatments to work.
But more research is needed. For now, researchers have very few clues as to why, when, and how these molecular and biological differences of CRC exist among various racial/ethnic and ancestral backgrounds, he said.
Black patients are also more likely to be diagnosed under the age of 50 as well. Researchers don’t know why this is exactly yet, but they think that poor diet, unhealthy bacteria in the gut, and inflammation may contribute to the cause. (Healthy eating and more exercise may lower a person’s risk.)
What are the symptoms of colorectal cancer?
Colorectal polyps, which are growths that can turn into colon cancer, and colon cancer itself can come without symptoms. If a person does have symptoms, they can include:
- Changes in bowel habits
- Blood in bowel movements
- Diarrhea
- Constipation
- The sensation that bowel movements aren’t complete
- Persistent stomachache, stomach pain, or cramps
- Weight loss without any explanation
Any or all of these symptoms warrant a trip to the doctor. These symptoms are the same for all racial and ethnic groups. Because CRC symptoms aren’t always obvious, this makes screening all the more important.
Where colon cancer spreads
Once cancerous cells break off from a tumor, what areas of the body does it spread to first?
What can Black patients do to lower their risk of getting colorectal cancer?
There are a number of solutions patients can pursue themselves.
Learn about CRC online
The untimely death of Oscar-nominated actor Chadwick Boseman from colon cancer at age 43 significantly boosted awareness of the disease, particularly for Black Americans. A study from the University of British Columbia and Simon Fraser University’s Beedie School of Business found there was an increase in internet searches about colon cancer in the months after Mr. Boseman’s August 2020 passing, particularly in areas where many Black Americans live. The study authors emphasized the importance of public health leaders discussing Mr. Mr. Boseman’s diagnosis with their Black patient population, so they will not only be inspired by his brave battle against the disease but will be proactive about getting tested for colon cancer themselves.
Reading about Mr. Boseman’s journey is an important start to patient education. It’s also key to learn about the disease itself, plus how colon cancer screening works specifically. Then, writing down questions to bring to the doctor before screening is an excellent way to feel empowered, and to understand what specific test results will mean.
Be proactive
Find out about family history.
“It’s challenging to determine the best age for screening if the patient doesn’t know their family history,” said Dr. Annunziata. Asking older members of the family whether CRC has affected previous generations is a helpful step.
If there is a strong family history, a patient will likely need earlier screening.
“[Doctors] should explain the benefits of colon cancer screening with colonoscopy starting at age 45 in the general population or earlier if the person has a family history of colon cancer,” Dr. Annunziata said. If a patient’s doctor doesn’t offer this information upfront, it’s definitely the right move to ask for the testing directly.
If a Black patient gets diagnosed with CRC, they should educate themselves about critical follow-up care after a diagnosis. Doctors should also be more proactive about enrolling patients in key clinical trials. According to additional data from the American Cancer Society, only 7% of patients enrolled in the FDA’s clinical cancer drug trials are Black. Doctors should also be more proactive about enrolling patients in these and other key clinical trials; it’s completely appropriate for a patient to search out trials on their own and bring them to their doctor’s attention too.
And attending all appointments and completing chemo or radiation treatment is vital.
“For patients undergoing treatment, physicians can ensure that the patients understand the importance of receiving the full recommended course of treatment and receive the support to tolerate the anticipated side effects,” Dr. Annunziata said.
Reach out for reassurance
Patients who are diagnosed with colorectal cancer have many resources for emotional support. The American Cancer Society offers support for all physical and emotional aspects of cancer 24 hours a day. The Colorectal Cancer Alliance offers comprehensive resource guides as well.
Support groups, through local hospitals or communities, can also be extremely helpful.
Reading the stories of Black patients who are surviving and thriving despite a colorectal cancer diagnosis can be incredibly inspiring as well.
It’s also very important for Black patients to let their doctors know if they don’t have the support they need. A doctor can help by navigating extra help within a patient’s community – an approach that is truly breaking down barriers to CRC care.
“What’s very encouraging is that meaningful improvements in CRC screening rates and early detection among Black communities have been seen through purposeful interventions and outreach,” Dr. Willis said. “In this way, all doctors can play a significant role at a broad and systemic level by advocating for and implementing interventions in their communities.”
A version of this article appeared on WebMD.com.
Hypertensive disorders of pregnancy and high stroke risk in Black women
I’d like to talk with you about a recent report from the large-scale Black Women’s Health Study, published in the new journal NEJM Evidence.
This study looked at the association between hypertensive disorders of pregnancy, including preeclampsia and gestational hypertension, and the risk for stroke over the next 20 (median, 22) years. Previous studies have linked hypertensive disorders of pregnancy with an increased risk for stroke. However, most of these studies have been done in White women of European ancestry, and evidence in Black women has been very limited, despite a disproportionately high risk of having a hypertensive disorder of pregnancy and also of stroke.
– overall, a 66% increased risk, an 80% increased risk with gestational hypertension, and about a 50% increased risk with preeclampsia.
We know that pregnancy itself can lead to some remodeling of the vascular system, but we don’t know whether a direct causal relationship exists between preeclampsia or gestational hypertension and subsequent stroke. Another potential explanation is that these complications of pregnancy serve as a window into a woman’s future cardiometabolic health and a marker of her cardiovascular risk.
Regardless, the clinical implications are the same. First, we would want to prevent these complications of pregnancy whenever possible. Some women will be candidates for the use of aspirin if they are at high risk for preeclampsia, and certainly for monitoring blood pressure very closely during pregnancy. It will also be important to maintain blood pressure control in the postpartum period and during the subsequent years of adulthood to minimize risk for stroke, because hypertension is such a powerful risk factor for stroke.
It will also be tremendously important to intensify lifestyle modifications such as increasing physical activity and having a heart-healthy diet. These complications of pregnancy have also been linked in other studies to an increased risk for subsequent coronary heart disease events and heart failure.
This transcript has been edited for clarity.
Dr. Manson is professor of medicine and the Michael and Lee Bell Professor of Women’s Health, Harvard Medical School, and chief of the division of preventive medicine, Brigham and Women’s Hospital, both in Boston, and past president, North American Menopause Society, 2011-2012. She disclosed receiving study pill donation and infrastructure support from Mars Symbioscience (for the COSMOS trial).
A version of this article appeared on Medscape.com.
I’d like to talk with you about a recent report from the large-scale Black Women’s Health Study, published in the new journal NEJM Evidence.
This study looked at the association between hypertensive disorders of pregnancy, including preeclampsia and gestational hypertension, and the risk for stroke over the next 20 (median, 22) years. Previous studies have linked hypertensive disorders of pregnancy with an increased risk for stroke. However, most of these studies have been done in White women of European ancestry, and evidence in Black women has been very limited, despite a disproportionately high risk of having a hypertensive disorder of pregnancy and also of stroke.
– overall, a 66% increased risk, an 80% increased risk with gestational hypertension, and about a 50% increased risk with preeclampsia.
We know that pregnancy itself can lead to some remodeling of the vascular system, but we don’t know whether a direct causal relationship exists between preeclampsia or gestational hypertension and subsequent stroke. Another potential explanation is that these complications of pregnancy serve as a window into a woman’s future cardiometabolic health and a marker of her cardiovascular risk.
Regardless, the clinical implications are the same. First, we would want to prevent these complications of pregnancy whenever possible. Some women will be candidates for the use of aspirin if they are at high risk for preeclampsia, and certainly for monitoring blood pressure very closely during pregnancy. It will also be important to maintain blood pressure control in the postpartum period and during the subsequent years of adulthood to minimize risk for stroke, because hypertension is such a powerful risk factor for stroke.
It will also be tremendously important to intensify lifestyle modifications such as increasing physical activity and having a heart-healthy diet. These complications of pregnancy have also been linked in other studies to an increased risk for subsequent coronary heart disease events and heart failure.
This transcript has been edited for clarity.
Dr. Manson is professor of medicine and the Michael and Lee Bell Professor of Women’s Health, Harvard Medical School, and chief of the division of preventive medicine, Brigham and Women’s Hospital, both in Boston, and past president, North American Menopause Society, 2011-2012. She disclosed receiving study pill donation and infrastructure support from Mars Symbioscience (for the COSMOS trial).
A version of this article appeared on Medscape.com.
I’d like to talk with you about a recent report from the large-scale Black Women’s Health Study, published in the new journal NEJM Evidence.
This study looked at the association between hypertensive disorders of pregnancy, including preeclampsia and gestational hypertension, and the risk for stroke over the next 20 (median, 22) years. Previous studies have linked hypertensive disorders of pregnancy with an increased risk for stroke. However, most of these studies have been done in White women of European ancestry, and evidence in Black women has been very limited, despite a disproportionately high risk of having a hypertensive disorder of pregnancy and also of stroke.
– overall, a 66% increased risk, an 80% increased risk with gestational hypertension, and about a 50% increased risk with preeclampsia.
We know that pregnancy itself can lead to some remodeling of the vascular system, but we don’t know whether a direct causal relationship exists between preeclampsia or gestational hypertension and subsequent stroke. Another potential explanation is that these complications of pregnancy serve as a window into a woman’s future cardiometabolic health and a marker of her cardiovascular risk.
Regardless, the clinical implications are the same. First, we would want to prevent these complications of pregnancy whenever possible. Some women will be candidates for the use of aspirin if they are at high risk for preeclampsia, and certainly for monitoring blood pressure very closely during pregnancy. It will also be important to maintain blood pressure control in the postpartum period and during the subsequent years of adulthood to minimize risk for stroke, because hypertension is such a powerful risk factor for stroke.
It will also be tremendously important to intensify lifestyle modifications such as increasing physical activity and having a heart-healthy diet. These complications of pregnancy have also been linked in other studies to an increased risk for subsequent coronary heart disease events and heart failure.
This transcript has been edited for clarity.
Dr. Manson is professor of medicine and the Michael and Lee Bell Professor of Women’s Health, Harvard Medical School, and chief of the division of preventive medicine, Brigham and Women’s Hospital, both in Boston, and past president, North American Menopause Society, 2011-2012. She disclosed receiving study pill donation and infrastructure support from Mars Symbioscience (for the COSMOS trial).
A version of this article appeared on Medscape.com.
Black psychiatric inpatients more likely to be restrained and for longer
TOPLINE:
, new research suggests.
METHODOLOGY:
- The study, part of a larger retrospective chart review of inpatient psychiatric electronic medical records (EMRs), included 29,739 adolescents (aged 12-17 years) and adults admitted because of severe and disruptive psychiatric illness or concerns about self-harm.
- A restraint event was defined as a physician-ordered physical or mechanical hold in which patients are unable to move their limbs, body, or head or are given medication to restrict their movement.
- Researchers used scores on the Dynamic Appraisal of Situational Aggression (DASA) at admission to assess risk for aggression among high-risk psychiatric inpatients (scores ranged from a low of 0 to a high of 7).
- From restraint event data extracted from the EMR, researchers investigated whether restraint frequency or duration was affected by “adultification,” a form of racial bias in which adolescents are perceived as being older than their actual age and are treated accordingly.
TAKEAWAY:
- Of the entire cohort, 1867 (6.3%) experienced a restraint event, and 27,872 (93.7%) did not.
- Compared with White patients, restraint was 85% more likely among Black patients (adjusted odds ratio, 1.85; P < .001) and 36% more likely among multiracial patients (aOR, 1.36; P = .006), which researchers suggest may reflect systemic racism within psychiatry and medicine, as well as an implicit or learned perception that people of color are more aggressive and dangerous.
- Lower DASA score at admission (P = .001), shorter length of stay (P < .001), adult age (P = .001), female sex (P = .042), and Black race, compared with White race (P = .001), were significantly associated with longer restraint duration, which may serve as a proxy for psychiatric symptom severity.
- Neither age group alone (adolescent or adult) nor the interaction of race and age group was significantly associated with experiencing a restraint event, suggesting no evidence of “adultification.”
IN PRACTICE:
It’s important to raise awareness about racial differences in restraint events in inpatient psychiatric settings, the authors write, adding that addressing overcrowding and investing in bias assessment and restraint education may reduce bias in the care of agitated patients and the use of restraints.
SOURCE:
The study was carried out by Sonali Singal, BS, Institute of Behavioral Science, Feinstein Institutes for Medical Research, Manhasset, N.Y., and colleagues. It was published online in Psychiatric Services.
LIMITATIONS:
The variables analyzed in the study were limited by the retrospective chart review and by the available EMR data, which may have contained entry errors. Although the investigators used DASA scores to control for differences in aggression, they could not control for symptom severity. The study could not examine the impact of race on seclusion (involuntary confinement), a variable often examined in tandem with restraint, because there were too few such events. The analysis also did not control for substance use disorder, which can influence a patient’s behavior and be related to restraint use.
DISCLOSURES:
Ms. Singal reported no relevant financial relationships. The original article has disclosures of other authors.
A version of this article first appeared on Medscape.com.
TOPLINE:
, new research suggests.
METHODOLOGY:
- The study, part of a larger retrospective chart review of inpatient psychiatric electronic medical records (EMRs), included 29,739 adolescents (aged 12-17 years) and adults admitted because of severe and disruptive psychiatric illness or concerns about self-harm.
- A restraint event was defined as a physician-ordered physical or mechanical hold in which patients are unable to move their limbs, body, or head or are given medication to restrict their movement.
- Researchers used scores on the Dynamic Appraisal of Situational Aggression (DASA) at admission to assess risk for aggression among high-risk psychiatric inpatients (scores ranged from a low of 0 to a high of 7).
- From restraint event data extracted from the EMR, researchers investigated whether restraint frequency or duration was affected by “adultification,” a form of racial bias in which adolescents are perceived as being older than their actual age and are treated accordingly.
TAKEAWAY:
- Of the entire cohort, 1867 (6.3%) experienced a restraint event, and 27,872 (93.7%) did not.
- Compared with White patients, restraint was 85% more likely among Black patients (adjusted odds ratio, 1.85; P < .001) and 36% more likely among multiracial patients (aOR, 1.36; P = .006), which researchers suggest may reflect systemic racism within psychiatry and medicine, as well as an implicit or learned perception that people of color are more aggressive and dangerous.
- Lower DASA score at admission (P = .001), shorter length of stay (P < .001), adult age (P = .001), female sex (P = .042), and Black race, compared with White race (P = .001), were significantly associated with longer restraint duration, which may serve as a proxy for psychiatric symptom severity.
- Neither age group alone (adolescent or adult) nor the interaction of race and age group was significantly associated with experiencing a restraint event, suggesting no evidence of “adultification.”
IN PRACTICE:
It’s important to raise awareness about racial differences in restraint events in inpatient psychiatric settings, the authors write, adding that addressing overcrowding and investing in bias assessment and restraint education may reduce bias in the care of agitated patients and the use of restraints.
SOURCE:
The study was carried out by Sonali Singal, BS, Institute of Behavioral Science, Feinstein Institutes for Medical Research, Manhasset, N.Y., and colleagues. It was published online in Psychiatric Services.
LIMITATIONS:
The variables analyzed in the study were limited by the retrospective chart review and by the available EMR data, which may have contained entry errors. Although the investigators used DASA scores to control for differences in aggression, they could not control for symptom severity. The study could not examine the impact of race on seclusion (involuntary confinement), a variable often examined in tandem with restraint, because there were too few such events. The analysis also did not control for substance use disorder, which can influence a patient’s behavior and be related to restraint use.
DISCLOSURES:
Ms. Singal reported no relevant financial relationships. The original article has disclosures of other authors.
A version of this article first appeared on Medscape.com.
TOPLINE:
, new research suggests.
METHODOLOGY:
- The study, part of a larger retrospective chart review of inpatient psychiatric electronic medical records (EMRs), included 29,739 adolescents (aged 12-17 years) and adults admitted because of severe and disruptive psychiatric illness or concerns about self-harm.
- A restraint event was defined as a physician-ordered physical or mechanical hold in which patients are unable to move their limbs, body, or head or are given medication to restrict their movement.
- Researchers used scores on the Dynamic Appraisal of Situational Aggression (DASA) at admission to assess risk for aggression among high-risk psychiatric inpatients (scores ranged from a low of 0 to a high of 7).
- From restraint event data extracted from the EMR, researchers investigated whether restraint frequency or duration was affected by “adultification,” a form of racial bias in which adolescents are perceived as being older than their actual age and are treated accordingly.
TAKEAWAY:
- Of the entire cohort, 1867 (6.3%) experienced a restraint event, and 27,872 (93.7%) did not.
- Compared with White patients, restraint was 85% more likely among Black patients (adjusted odds ratio, 1.85; P < .001) and 36% more likely among multiracial patients (aOR, 1.36; P = .006), which researchers suggest may reflect systemic racism within psychiatry and medicine, as well as an implicit or learned perception that people of color are more aggressive and dangerous.
- Lower DASA score at admission (P = .001), shorter length of stay (P < .001), adult age (P = .001), female sex (P = .042), and Black race, compared with White race (P = .001), were significantly associated with longer restraint duration, which may serve as a proxy for psychiatric symptom severity.
- Neither age group alone (adolescent or adult) nor the interaction of race and age group was significantly associated with experiencing a restraint event, suggesting no evidence of “adultification.”
IN PRACTICE:
It’s important to raise awareness about racial differences in restraint events in inpatient psychiatric settings, the authors write, adding that addressing overcrowding and investing in bias assessment and restraint education may reduce bias in the care of agitated patients and the use of restraints.
SOURCE:
The study was carried out by Sonali Singal, BS, Institute of Behavioral Science, Feinstein Institutes for Medical Research, Manhasset, N.Y., and colleagues. It was published online in Psychiatric Services.
LIMITATIONS:
The variables analyzed in the study were limited by the retrospective chart review and by the available EMR data, which may have contained entry errors. Although the investigators used DASA scores to control for differences in aggression, they could not control for symptom severity. The study could not examine the impact of race on seclusion (involuntary confinement), a variable often examined in tandem with restraint, because there were too few such events. The analysis also did not control for substance use disorder, which can influence a patient’s behavior and be related to restraint use.
DISCLOSURES:
Ms. Singal reported no relevant financial relationships. The original article has disclosures of other authors.
A version of this article first appeared on Medscape.com.
FROM PSYCHIATRIC SERVICES
Black men are at higher risk of prostate cancer at younger ages, lower PSA levels
Black men are at higher risk of prostate cancer than their White counterparts at younger ages and lower prostate-specific antigen (PSA) levels, a large new study conducted in a Veterans Affairs health care system suggests.
The findings suggest the need for PSA biopsy thresholds that are set with better understanding of patients’ risk factors, said the authors, led by Kyung Min Lee, PhD, with VA Informatics and Computing Infrastructure, at Salt Lake City Health Care System.
The study, which included more than 280,000 veterans, was published online in Cancer.
Risk higher, regardless of PSA level before biopsy
The researchers found that self-identified Black men are more likely than White men to be diagnosed with prostate cancer on their first prostate biopsy after controlling for age, prebiopsy PSA count, statin use, smoking status, and several socioeconomic variables.
Among the highlighted results are that a Black man who had a PSA level of 4.0 ng/mL before biopsy “had the same risk of prostate cancer as a White man with a PSA level 3.4 times higher [13.4 ng/mL].”
The gap was even more evident at younger ages. “Among men aged 60 years or younger, a Black man with a prebiopsy PSA level of 4.0 ng/mL had the same risk of prostate cancer as a White man with PSA level 3.7 times higher,” they wrote.
Researchers also found that Black veterans sought PSA screening and underwent their first diagnostic prostate biopsy at a younger age than did their White counterparts. Logistic regression models were used to predict the likelihood of a prostate cancer diagnosis on the first biopsy for 75,295 Black and 207,658 White male veterans.
U.S. Black men have an 80% higher risk of prostate cancer that White men
Previous research has shown that, in the United States, Black men have an 80% higher risk than White men of developing prostate cancer and are 220% more likely to die from it. Rigorous early screening has been suggested to decrease deaths from prostate cancer in Black men, but because that population group is underrepresented in randomized controlled trials, evidence for this has been lacking, the authors wrote.
Different national screening guidelines reflect the lack of clarity about best protocols. The U.S. Preventive Services Task Force acknowledges the higher risk but doesn’t make specific screening recommendations for Black men or those at higher risk. Conversely, the National Comprehensive Cancer Network “explicitly recommends earlier PSA screening and a shorter retest interval at lower PSA levels for populations at greater than average risk (including Black men). However, it does not otherwise recommend a different screening protocol.”
Social determinants of health may play a role
The reasons for the higher risk in Black men is unclear, the authors said, pointing out that recent studies suggest that “Black men may have higher genetic risk as assessed by polygenic scores.”
The authors wrote that nongenetic causes, such as access to care, mistrust of the health system, and environmental exposures may also be driving the association of Black race or ethnicity with higher risk of prostate cancer.
“Identifying and addressing these risk factors could further reduce racial disparities in prostate cancer outcomes,” they wrote.
The authors acknowledged that they are limited in their ability to account for socioeconomic status individually and used ZIP codes as proxies. Also, veterans generally have more comorbidities and mortality risks, compared with the general population.
The authors declared no relevant conflicts of interest.
Black men are at higher risk of prostate cancer than their White counterparts at younger ages and lower prostate-specific antigen (PSA) levels, a large new study conducted in a Veterans Affairs health care system suggests.
The findings suggest the need for PSA biopsy thresholds that are set with better understanding of patients’ risk factors, said the authors, led by Kyung Min Lee, PhD, with VA Informatics and Computing Infrastructure, at Salt Lake City Health Care System.
The study, which included more than 280,000 veterans, was published online in Cancer.
Risk higher, regardless of PSA level before biopsy
The researchers found that self-identified Black men are more likely than White men to be diagnosed with prostate cancer on their first prostate biopsy after controlling for age, prebiopsy PSA count, statin use, smoking status, and several socioeconomic variables.
Among the highlighted results are that a Black man who had a PSA level of 4.0 ng/mL before biopsy “had the same risk of prostate cancer as a White man with a PSA level 3.4 times higher [13.4 ng/mL].”
The gap was even more evident at younger ages. “Among men aged 60 years or younger, a Black man with a prebiopsy PSA level of 4.0 ng/mL had the same risk of prostate cancer as a White man with PSA level 3.7 times higher,” they wrote.
Researchers also found that Black veterans sought PSA screening and underwent their first diagnostic prostate biopsy at a younger age than did their White counterparts. Logistic regression models were used to predict the likelihood of a prostate cancer diagnosis on the first biopsy for 75,295 Black and 207,658 White male veterans.
U.S. Black men have an 80% higher risk of prostate cancer that White men
Previous research has shown that, in the United States, Black men have an 80% higher risk than White men of developing prostate cancer and are 220% more likely to die from it. Rigorous early screening has been suggested to decrease deaths from prostate cancer in Black men, but because that population group is underrepresented in randomized controlled trials, evidence for this has been lacking, the authors wrote.
Different national screening guidelines reflect the lack of clarity about best protocols. The U.S. Preventive Services Task Force acknowledges the higher risk but doesn’t make specific screening recommendations for Black men or those at higher risk. Conversely, the National Comprehensive Cancer Network “explicitly recommends earlier PSA screening and a shorter retest interval at lower PSA levels for populations at greater than average risk (including Black men). However, it does not otherwise recommend a different screening protocol.”
Social determinants of health may play a role
The reasons for the higher risk in Black men is unclear, the authors said, pointing out that recent studies suggest that “Black men may have higher genetic risk as assessed by polygenic scores.”
The authors wrote that nongenetic causes, such as access to care, mistrust of the health system, and environmental exposures may also be driving the association of Black race or ethnicity with higher risk of prostate cancer.
“Identifying and addressing these risk factors could further reduce racial disparities in prostate cancer outcomes,” they wrote.
The authors acknowledged that they are limited in their ability to account for socioeconomic status individually and used ZIP codes as proxies. Also, veterans generally have more comorbidities and mortality risks, compared with the general population.
The authors declared no relevant conflicts of interest.
Black men are at higher risk of prostate cancer than their White counterparts at younger ages and lower prostate-specific antigen (PSA) levels, a large new study conducted in a Veterans Affairs health care system suggests.
The findings suggest the need for PSA biopsy thresholds that are set with better understanding of patients’ risk factors, said the authors, led by Kyung Min Lee, PhD, with VA Informatics and Computing Infrastructure, at Salt Lake City Health Care System.
The study, which included more than 280,000 veterans, was published online in Cancer.
Risk higher, regardless of PSA level before biopsy
The researchers found that self-identified Black men are more likely than White men to be diagnosed with prostate cancer on their first prostate biopsy after controlling for age, prebiopsy PSA count, statin use, smoking status, and several socioeconomic variables.
Among the highlighted results are that a Black man who had a PSA level of 4.0 ng/mL before biopsy “had the same risk of prostate cancer as a White man with a PSA level 3.4 times higher [13.4 ng/mL].”
The gap was even more evident at younger ages. “Among men aged 60 years or younger, a Black man with a prebiopsy PSA level of 4.0 ng/mL had the same risk of prostate cancer as a White man with PSA level 3.7 times higher,” they wrote.
Researchers also found that Black veterans sought PSA screening and underwent their first diagnostic prostate biopsy at a younger age than did their White counterparts. Logistic regression models were used to predict the likelihood of a prostate cancer diagnosis on the first biopsy for 75,295 Black and 207,658 White male veterans.
U.S. Black men have an 80% higher risk of prostate cancer that White men
Previous research has shown that, in the United States, Black men have an 80% higher risk than White men of developing prostate cancer and are 220% more likely to die from it. Rigorous early screening has been suggested to decrease deaths from prostate cancer in Black men, but because that population group is underrepresented in randomized controlled trials, evidence for this has been lacking, the authors wrote.
Different national screening guidelines reflect the lack of clarity about best protocols. The U.S. Preventive Services Task Force acknowledges the higher risk but doesn’t make specific screening recommendations for Black men or those at higher risk. Conversely, the National Comprehensive Cancer Network “explicitly recommends earlier PSA screening and a shorter retest interval at lower PSA levels for populations at greater than average risk (including Black men). However, it does not otherwise recommend a different screening protocol.”
Social determinants of health may play a role
The reasons for the higher risk in Black men is unclear, the authors said, pointing out that recent studies suggest that “Black men may have higher genetic risk as assessed by polygenic scores.”
The authors wrote that nongenetic causes, such as access to care, mistrust of the health system, and environmental exposures may also be driving the association of Black race or ethnicity with higher risk of prostate cancer.
“Identifying and addressing these risk factors could further reduce racial disparities in prostate cancer outcomes,” they wrote.
The authors acknowledged that they are limited in their ability to account for socioeconomic status individually and used ZIP codes as proxies. Also, veterans generally have more comorbidities and mortality risks, compared with the general population.
The authors declared no relevant conflicts of interest.
FROM CANCER
Race-specific lung-function values may skew IPF testing
HONOLULU – Old habits die hard, especially when it comes to pulmonary function testing in a diverse population of patients with interstitial lung disease (ILD).
Specifically, pulmonary care clinicians may be habitually relying on outdated and inaccurate race-specific reference values when evaluating respiratory impairment in persons of African and Hispanic/Latino ancestry, which can result in underrecognition, underdiagnosis, and undertreatment, reported Ayodeji Adegunsoye, MD, from the University of Chicago, and colleagues.
“Our results make a compelling case for re-evaluating the use of race as a physiological variable, and highlight the need to offer equitable and optimal care for all patients, regardless of their race or ethnicity,” Dr. Adegunsoye said in an oral abstract session at the annual meeting of the American College of Chest Physicians (CHEST).
Flawed assumptions
In an interview, Dr. Adegunsoye noted that race-specific notions, such as the automatic assumption that Black people have less lung capacity than White people, are baked into clinical practice and passed on as clinical wisdom from one generation of clinicians to the next.
Pulmonary function reference values that are used to make a diagnosis of idiopathic pulmonary fibrosis in Black or Hispanic/Latino patients “appear flawed when we use race-specific values. And beyond the diagnosis, it also appears to impact eligibility for key interventional strategies for managing the disease itself,” he said.
The use of race-specific equations can falsely inflate percent-predicted pulmonary function values in non-White patients, and make it seem as if a patient has normal lung function when in fact he may be have impaired function.
For example, using race-based reference values a Black patient and a White patient may appear to have the same absolute forced vital capacity readings, but different FVC percent predicted (FVCpp), which can mean a missed diagnosis.
Investigators who studied the association between self-identified race and visually identified emphysema among 2,674 participants in the Coronary Artery Risk Development in Young Adults study found that using standard equations to adjust for racial differences in lung-function measures appeared to miss emphysema in a significant proportion of Black patients.
PF registry study
In the current study, to see whether the use of race-neutral equations for evaluating FVCpp could change access to health care in patients with ILD, Dr. Adegunsoye and colleagues used both race-specific and race-neutral equations to calculate FVCpp values among separate cohorts of Black, Hispanic/Latino, and White patients enrolled in the Pulmonary Fibrosis Foundation Patient Registry who had pulmonary functions test within about 90 days of enrollment.
The race-specific equations used to calculate FVCpp was that published in 1999 by Hankinson and colleagues in American Journal of Respiratory and Critical Care Medicine. The race-neutral Global Lung Function Initiative (GLI) equations by Bowerman and colleagues were developed in 2022 and published in March 2023 in the same journal.
The investigators defined access to care as enrollment in ILD clinical trials for patients with FVCpp greater than 45% but less than 90%, and US payer access to antifibrotic therapy for patients with FVCpp of greater than 55% but less than 82%.
They found that 22% of Black patients were misclassified in their eligibility for clinical trials in each of two scenarios – those who would be excluded from trials using the 1999 criteria but included using the 2022 criteria, and vice versa, that is included with 1999 criteria but excluded by the 2022 GLI criteria. In contrast, 14% of Hispanic Latino patients and 12% of White patients were misclassified.
Using the 1999 criteria to exclude patients because their values were ostensibly higher than the upper cutoff meant that 10.3% of Black patients who might benefit would be ineligible for clinical trial, compared with 0% of Hispanic/Latinos and 0.1% of Whites.
Similarly, 11.5% of Black patients but no Hispanic/Latino or White patients would be considered eligible for clinical trials using the old criteria but ineligible under the new criteria.
Regarding antifibrotic therapy eligibility, the respective misclassification rates were 21%, 17%, and 19%.
“Our study showed that use of race-specific equations may confound lung function tests, potentially leading to misclassification, delayed diagnosis, and inadequate treatment provision. While our study suggests potential disparities in access to health care for patients with interstitial lung disease facilitated by race-specific equations, further research is required to fully comprehend the implications,” the investigators wrote.
ATS statement
In an interview, Juan Wisnievsky, MD, DrPh, from Mount Sinai Medical Center, New York, who also chairs the Health Equity and Diversity Committee for the American Thoracic Society, pointed to a recent ATS statement he coauthored citing evidence for replacing race and ethnicity-specific equations with race-neutral average reference equations.
“This use of race and ethnicity may contribute to health disparities by norming differences in pulmonary function. In the United States and globally, race serves as a social construct that is based on appearance and reflects social values, structures, and practices. Classification of people into racial and ethnic groups differs geographically and temporally. These considerations challenge the notion that racial and ethnic categories have biological meaning and question the use of race in PFT interpretation,” the statement authors wrote.
“There is some agreement that race-based equations shouldn’t be used, but all the potential consequences of doing that and which equations would be the best ones to use to replace them is a bit unclear,” Dr. Wisnievsky said.
He was not involved in the study by Dr. Adegunsoye and colleagues.
Data used in the study were derived from research sponsored by F. Hoffman–La Roche and Genentech. Dr. Adegunsoye disclosed consultancy fees from AbbVie, Inogen, F. Hoffman–La Roche, Medscape, and PatientMpower; speaking/advisory fees from Boehringer Ingelheim; and grants/award from the CHEST Foundation, Pulmonary Fibrosis Foundation, and National Institutes of Health. Dr. Wisnievsky had no relevant disclosures.
HONOLULU – Old habits die hard, especially when it comes to pulmonary function testing in a diverse population of patients with interstitial lung disease (ILD).
Specifically, pulmonary care clinicians may be habitually relying on outdated and inaccurate race-specific reference values when evaluating respiratory impairment in persons of African and Hispanic/Latino ancestry, which can result in underrecognition, underdiagnosis, and undertreatment, reported Ayodeji Adegunsoye, MD, from the University of Chicago, and colleagues.
“Our results make a compelling case for re-evaluating the use of race as a physiological variable, and highlight the need to offer equitable and optimal care for all patients, regardless of their race or ethnicity,” Dr. Adegunsoye said in an oral abstract session at the annual meeting of the American College of Chest Physicians (CHEST).
Flawed assumptions
In an interview, Dr. Adegunsoye noted that race-specific notions, such as the automatic assumption that Black people have less lung capacity than White people, are baked into clinical practice and passed on as clinical wisdom from one generation of clinicians to the next.
Pulmonary function reference values that are used to make a diagnosis of idiopathic pulmonary fibrosis in Black or Hispanic/Latino patients “appear flawed when we use race-specific values. And beyond the diagnosis, it also appears to impact eligibility for key interventional strategies for managing the disease itself,” he said.
The use of race-specific equations can falsely inflate percent-predicted pulmonary function values in non-White patients, and make it seem as if a patient has normal lung function when in fact he may be have impaired function.
For example, using race-based reference values a Black patient and a White patient may appear to have the same absolute forced vital capacity readings, but different FVC percent predicted (FVCpp), which can mean a missed diagnosis.
Investigators who studied the association between self-identified race and visually identified emphysema among 2,674 participants in the Coronary Artery Risk Development in Young Adults study found that using standard equations to adjust for racial differences in lung-function measures appeared to miss emphysema in a significant proportion of Black patients.
PF registry study
In the current study, to see whether the use of race-neutral equations for evaluating FVCpp could change access to health care in patients with ILD, Dr. Adegunsoye and colleagues used both race-specific and race-neutral equations to calculate FVCpp values among separate cohorts of Black, Hispanic/Latino, and White patients enrolled in the Pulmonary Fibrosis Foundation Patient Registry who had pulmonary functions test within about 90 days of enrollment.
The race-specific equations used to calculate FVCpp was that published in 1999 by Hankinson and colleagues in American Journal of Respiratory and Critical Care Medicine. The race-neutral Global Lung Function Initiative (GLI) equations by Bowerman and colleagues were developed in 2022 and published in March 2023 in the same journal.
The investigators defined access to care as enrollment in ILD clinical trials for patients with FVCpp greater than 45% but less than 90%, and US payer access to antifibrotic therapy for patients with FVCpp of greater than 55% but less than 82%.
They found that 22% of Black patients were misclassified in their eligibility for clinical trials in each of two scenarios – those who would be excluded from trials using the 1999 criteria but included using the 2022 criteria, and vice versa, that is included with 1999 criteria but excluded by the 2022 GLI criteria. In contrast, 14% of Hispanic Latino patients and 12% of White patients were misclassified.
Using the 1999 criteria to exclude patients because their values were ostensibly higher than the upper cutoff meant that 10.3% of Black patients who might benefit would be ineligible for clinical trial, compared with 0% of Hispanic/Latinos and 0.1% of Whites.
Similarly, 11.5% of Black patients but no Hispanic/Latino or White patients would be considered eligible for clinical trials using the old criteria but ineligible under the new criteria.
Regarding antifibrotic therapy eligibility, the respective misclassification rates were 21%, 17%, and 19%.
“Our study showed that use of race-specific equations may confound lung function tests, potentially leading to misclassification, delayed diagnosis, and inadequate treatment provision. While our study suggests potential disparities in access to health care for patients with interstitial lung disease facilitated by race-specific equations, further research is required to fully comprehend the implications,” the investigators wrote.
ATS statement
In an interview, Juan Wisnievsky, MD, DrPh, from Mount Sinai Medical Center, New York, who also chairs the Health Equity and Diversity Committee for the American Thoracic Society, pointed to a recent ATS statement he coauthored citing evidence for replacing race and ethnicity-specific equations with race-neutral average reference equations.
“This use of race and ethnicity may contribute to health disparities by norming differences in pulmonary function. In the United States and globally, race serves as a social construct that is based on appearance and reflects social values, structures, and practices. Classification of people into racial and ethnic groups differs geographically and temporally. These considerations challenge the notion that racial and ethnic categories have biological meaning and question the use of race in PFT interpretation,” the statement authors wrote.
“There is some agreement that race-based equations shouldn’t be used, but all the potential consequences of doing that and which equations would be the best ones to use to replace them is a bit unclear,” Dr. Wisnievsky said.
He was not involved in the study by Dr. Adegunsoye and colleagues.
Data used in the study were derived from research sponsored by F. Hoffman–La Roche and Genentech. Dr. Adegunsoye disclosed consultancy fees from AbbVie, Inogen, F. Hoffman–La Roche, Medscape, and PatientMpower; speaking/advisory fees from Boehringer Ingelheim; and grants/award from the CHEST Foundation, Pulmonary Fibrosis Foundation, and National Institutes of Health. Dr. Wisnievsky had no relevant disclosures.
HONOLULU – Old habits die hard, especially when it comes to pulmonary function testing in a diverse population of patients with interstitial lung disease (ILD).
Specifically, pulmonary care clinicians may be habitually relying on outdated and inaccurate race-specific reference values when evaluating respiratory impairment in persons of African and Hispanic/Latino ancestry, which can result in underrecognition, underdiagnosis, and undertreatment, reported Ayodeji Adegunsoye, MD, from the University of Chicago, and colleagues.
“Our results make a compelling case for re-evaluating the use of race as a physiological variable, and highlight the need to offer equitable and optimal care for all patients, regardless of their race or ethnicity,” Dr. Adegunsoye said in an oral abstract session at the annual meeting of the American College of Chest Physicians (CHEST).
Flawed assumptions
In an interview, Dr. Adegunsoye noted that race-specific notions, such as the automatic assumption that Black people have less lung capacity than White people, are baked into clinical practice and passed on as clinical wisdom from one generation of clinicians to the next.
Pulmonary function reference values that are used to make a diagnosis of idiopathic pulmonary fibrosis in Black or Hispanic/Latino patients “appear flawed when we use race-specific values. And beyond the diagnosis, it also appears to impact eligibility for key interventional strategies for managing the disease itself,” he said.
The use of race-specific equations can falsely inflate percent-predicted pulmonary function values in non-White patients, and make it seem as if a patient has normal lung function when in fact he may be have impaired function.
For example, using race-based reference values a Black patient and a White patient may appear to have the same absolute forced vital capacity readings, but different FVC percent predicted (FVCpp), which can mean a missed diagnosis.
Investigators who studied the association between self-identified race and visually identified emphysema among 2,674 participants in the Coronary Artery Risk Development in Young Adults study found that using standard equations to adjust for racial differences in lung-function measures appeared to miss emphysema in a significant proportion of Black patients.
PF registry study
In the current study, to see whether the use of race-neutral equations for evaluating FVCpp could change access to health care in patients with ILD, Dr. Adegunsoye and colleagues used both race-specific and race-neutral equations to calculate FVCpp values among separate cohorts of Black, Hispanic/Latino, and White patients enrolled in the Pulmonary Fibrosis Foundation Patient Registry who had pulmonary functions test within about 90 days of enrollment.
The race-specific equations used to calculate FVCpp was that published in 1999 by Hankinson and colleagues in American Journal of Respiratory and Critical Care Medicine. The race-neutral Global Lung Function Initiative (GLI) equations by Bowerman and colleagues were developed in 2022 and published in March 2023 in the same journal.
The investigators defined access to care as enrollment in ILD clinical trials for patients with FVCpp greater than 45% but less than 90%, and US payer access to antifibrotic therapy for patients with FVCpp of greater than 55% but less than 82%.
They found that 22% of Black patients were misclassified in their eligibility for clinical trials in each of two scenarios – those who would be excluded from trials using the 1999 criteria but included using the 2022 criteria, and vice versa, that is included with 1999 criteria but excluded by the 2022 GLI criteria. In contrast, 14% of Hispanic Latino patients and 12% of White patients were misclassified.
Using the 1999 criteria to exclude patients because their values were ostensibly higher than the upper cutoff meant that 10.3% of Black patients who might benefit would be ineligible for clinical trial, compared with 0% of Hispanic/Latinos and 0.1% of Whites.
Similarly, 11.5% of Black patients but no Hispanic/Latino or White patients would be considered eligible for clinical trials using the old criteria but ineligible under the new criteria.
Regarding antifibrotic therapy eligibility, the respective misclassification rates were 21%, 17%, and 19%.
“Our study showed that use of race-specific equations may confound lung function tests, potentially leading to misclassification, delayed diagnosis, and inadequate treatment provision. While our study suggests potential disparities in access to health care for patients with interstitial lung disease facilitated by race-specific equations, further research is required to fully comprehend the implications,” the investigators wrote.
ATS statement
In an interview, Juan Wisnievsky, MD, DrPh, from Mount Sinai Medical Center, New York, who also chairs the Health Equity and Diversity Committee for the American Thoracic Society, pointed to a recent ATS statement he coauthored citing evidence for replacing race and ethnicity-specific equations with race-neutral average reference equations.
“This use of race and ethnicity may contribute to health disparities by norming differences in pulmonary function. In the United States and globally, race serves as a social construct that is based on appearance and reflects social values, structures, and practices. Classification of people into racial and ethnic groups differs geographically and temporally. These considerations challenge the notion that racial and ethnic categories have biological meaning and question the use of race in PFT interpretation,” the statement authors wrote.
“There is some agreement that race-based equations shouldn’t be used, but all the potential consequences of doing that and which equations would be the best ones to use to replace them is a bit unclear,” Dr. Wisnievsky said.
He was not involved in the study by Dr. Adegunsoye and colleagues.
Data used in the study were derived from research sponsored by F. Hoffman–La Roche and Genentech. Dr. Adegunsoye disclosed consultancy fees from AbbVie, Inogen, F. Hoffman–La Roche, Medscape, and PatientMpower; speaking/advisory fees from Boehringer Ingelheim; and grants/award from the CHEST Foundation, Pulmonary Fibrosis Foundation, and National Institutes of Health. Dr. Wisnievsky had no relevant disclosures.
AT CHEST 2023
Attitudes Toward Utilization of Minimally Invasive Cosmetic Procedures in Black Women: Results of a Cross-sectional Survey
Beauty has been a topic of interest for centuries. Treatments and technologies have advanced, and more women are utilizing cosmetic procedures than ever before, especially neuromodulators, minimally invasive procedures, and topical treatments.1 Over the last decade, there was a 99% increase in minimally invasive cosmetic procedures in the United States.2 There also has been an observable increase in the utilization of cosmetic procedures by Black patients in recent years; the American Society of Plastic Surgeons reported that the number of cosmetic plastic surgery procedures performed on “ethnic patients” (referring to Asian, Black, or Hispanic patients) increased 243% from 2000 to 2013,3 possibly attributed to increased accessibility, awareness of procedures due to social media, cultural acceptance, and affordability. Minimally invasive procedures are considerably less expensive than major surgical procedures and are becoming progressively more affordable, with numerous financing options available.2 Additionally, neuromodulators and fillers are now commonly administered by nonaesthetic health professionals including dentists and nurses, which has increased accessibility of these procedures among patients who typically may not seek out a consultation with a plastic surgeon or dermatologist.4
When examining the most common cosmetic procedures collectively sought out by patients with skin of color (SOC), it has been found that an even skin tone is a highly desirable feature that impacts the selection of products and procedures in this particular patient population.5 Black, Hispanic, and Asian women report fewer signs of facial aging compared to White women in the glabellar lines, crow’s-feet, oral commissures, perioral lines, and lips.6 Increased melanocytes in darker skin types help prevent photoaging but also increase susceptibility to dyschromia. Prior studies have reported the most common concerns by patients with SOC are dyschromic disorders such as postinflammatory hyperpigmentation, postinflammatory hypopigmentation, and melasma.7 Common minimally invasive cosmetic procedures utilized by the SOC population include chemical peels, laser treatments, and injectables. Fillers are utilized more for volume loss in SOC patients rather than for the deep furrows and rhytides commonly seen in the lower face of White patients.8
We conducted a survey among Black women currently residing in the United States to better understand attitudes toward beauty and aging as well as the utilization of minimally invasive cosmetic procedures in this patient population.
Methods
An in-depth questionnaire comprised of 17 questions was created for this cross-sectional observational study. The study was submitted to and deemed exempt by the institutional review board at the University of Miami (Miami, Florida)(IRB #20211184). Survey participants primarily were recruited via social media posts on personal profiles of Black dermatologists, medical residents, and medicalstudents, including the authors, targeting Black women in the United States. Utilizing a method called snowball sampling, whereby study participants are used to recruit future participants, individuals were instructed to share the survey with their social network to assist with survey distribution. After participants provided informed consent, data were captured using the REDCap secure online data collection software. The questionnaire was structured to include a sociodemographic profile of respondents, attitudes toward beauty and aging, current usage of beauty products, prior utilization of cosmetic procedures, and intentions to use cosmetic procedures in the future. Surveys with incomplete consent forms, incomplete responses, and duplicate responses, as well as surveys from participants who were not residing in the United States at the time of survey completion, were excluded.
Data characteristics were summarized by frequency and percentage. A χ2 test was performed to compare participants’ age demographics with their attitudes toward beauty and aging, utilization of cosmetic procedures, and intention to try cosmetic procedures in the future. The Fisher exact test was used instead of the χ2 test when the expected cell count was less than 5. For all tests, P<.05 was considered statistically significant. All statistical analyses were performed using SPSS software version 28.
Results
General Characteristics of Participants—A sample of 475 self-identified Black women aged 21 to 70 years participated in the study, and 352 eligible participants were included in the final analysis. Of the 352 eligible participants, 48.3% were aged 21 to 30 years, 47.2% were aged 31 to 40 years, and 4.5% were aged 41 to 50 years. All survey participants identified their race as Black; among them, 4% specified Hispanic or Latino ethnicity, and 9% indicated that they held multiracial identities including White/Caucasian, Asian, and Native American backgrounds. Regarding the participants’ citizenship status, 54.3% reported that both they and their parents were born in the United States; 2.3% were not US citizens or permanent residents, 13.1% identified as first-generation Americans (born outside of the United States), and 30.4% identified as second-generation Americans (one or both parents born outside of the United States). Participant education levels (based on highest level) varied greatly: 4.5% were high school graduates, 1.1% attended trade or technical schools, 3.4% had associate’s degrees, 39.8% had bachelor’s degrees, 35.2% had master’s degrees, and 15.9% had doctorate degrees. Regarding household income, 6.3% earned less than $25,000 per year, 16.8% earned from $25,000 to $99,999, 75.6% earned from $100,000 to $499,999, and 1.4% earned $500,000 or more. Patient demographics are provided in Table 1.
Cosmetic Skin Concerns—The top 3 aging skin concerns among participants were fine lines and wrinkles (51.9%), dark circles (33.8%), and uneven skin tone (31.8%) (Table 2). Approximately 5.4% of participants reported no desire to avoid the natural aging process. Among age groups, fine lines and wrinkles were a major concern for 51.7% of 21- to 30-year-olds, 47.6% of 31- to 40-year-olds, and 43.5% of 41- to 50-year-olds. Dark circles were a major concern for 61.3% of 21- to 30-year-olds, 44.4% of 31- to 40-year-olds, and 46.8% of 41- to 50-year-olds. Uneven skin tone was a major concern for 56.2% of 21- to 30-year-olds, 46.5% of 31- to 40-year-olds, and 31.2% of 41- to 50-year-olds. There was no statistically significant association between participants’ age and their concern with aging skin concerns.
Differences in Experience and Acceptance of Cosmetic Procedures—Regarding participants’ prior experience with cosmetic procedures, 22.3% had tried 1 or more procedures. Additionally, 67.0% reported having intentions of trying cosmetic procedures in the future, while 10.8% reported no intentions. Of those who were uninterested in trying cosmetic procedures, 78.9% (30/38) believed it unnecessary while 47.3% (18/38) reported a fear of looking unnatural. Other perceived deterrents to cosmetic procedures among this subset of participants were the need to repeat treatment for lasting results (28.9% [11/38]), too expensive (31.6% [12/38]), and fear of side effects (39.5% [15/38]). A significant difference was found between participants’ age and their experience with cosmetic procedures (P=.020). Participants aged 21 to 30 years reported they were more likely to want to try cosmetic procedures in the future. Participants aged 31 to 40 years were more likely to have already tried a cosmetic procedure. Participants aged 41 to 50 years were more likely to report no desire to try cosmetic procedures in the future. There was no significant difference in cosmetic procedure acceptance according to citizenship status, education level, or household income.
Differences in Cosmetic Procedure Experience—Study participants indicated awareness of typically practiced cosmetic procedures. Of the 78 participants who have tried cosmetic procedures (Figure 1), the most common were laser hair removal (46.2% [36/78]), chemical peels (37.2% [29/78]), and microdermabrasion (24.4% [19/78])(Table 2). Age significantly influenced the type of cosmetic procedures utilized by participants (P<.001). Laser hair removal was the most common cosmetic procedure utilized by participants aged 21 to 30 years (64.7%) and chemical peels in participants aged 31 to 40 years (47.8%); participants aged 41 to 50 years reported equal use of chemical peels (50.0%) and microdermabrasion (50.0%).
Two hundred thirty-six participants reported interest in trying cosmetic procedures, specifically laser hair removal (57.6%), chemical peels (51.7%), and neuromodulators (41.9%)(Table 2). Although not statistically significant, age appeared to influence interest levels in cosmetic procedures. Participants aged 21 to 30 years and 31 to 40 years were most interested in trying laser hair removal (60.7% and 58.3%, respectively). Participants aged 41 to 50 years were most interested in trying neuromodulators (36.4%). There was no significant association between age and intention to try neuromodulators, chemical peels, or laser hair removal.
Attitudes Toward Beauty—Approximately 40.6% of participants believed that peak beauty occurs when women reach their 20s, and 38.6% believed that peak beauty occurs when women reach their 30s. Participants’ strategies for maintaining beauty were assessed through their regular use of certain skin care products. The most frequently used skin care products were face wash or cleanser (92.6%), moisturizer (90.1%), lip balm (76.1%), and facial sunscreen (62.2%). Other commonly used items were serum (34.7%), toner (34.9%), topical vitamin C (33.2%), and retinol/retinoid products (33.0%). Only 2.3% of participants reported not using any skin care products regularly.
Perceptions of Aging—Concerning perceived external age, most respondents believed they looked younger than their true age (69.9%); 24.4% believed they looked their true age, and 5.7% believed they looked older. Perception of age also varied considerably by age group, though most believed they looked younger than their true age.
Comment
This survey helped to identify trends in cosmetic procedure acceptance and utilization in Black women. As expected, younger Black women were more receptive to cosmetic procedures, which was consistent with a recent finding that cosmetic procedures tend to be more widely accepted among younger generations overall.8 Participants aged 21 to 30 years had greater intentions to try a cosmetic procedure, while those aged 31 to 40 years were more likely to have tried 1 or more cosmetic procedures already, which may be because they are just beginning to see the signs of aging and are motivated to address these concerns. Additionally, women in this age group may be more likely to have a stable source of income and be able to afford these procedures. It is important to note that the population surveyed had a much higher reported household income than the average Black household income, with most respondents reporting an average annual income of $100,000 to $499,000. Our data also showed a trend toward greater acceptance and utilization of cosmetic procedures in those with higher levels of income, though the results were not statistically significant.
Respondents were most concerned about fine lines and wrinkles, followed by dark circles and uneven skin tone. One report in the literature (N=2000) indicated that the most common cosmetic concerns in women with SOC were hyperpigmentation/dark spots (86%) and blotchy or uneven skin (80%).9 Interestingly, sunscreen was one of the more commonly used products in our survey, which historically has not been the case among individuals with SOC10 and suggests that the attitudes and perceptions of SOC patients are changing to favor more frequent sunscreen use, at least among the younger generations. Because we did not specify moisturizer vs moisturizer with sun protection factor, the use of facial sunscreen may even be underestimated in our survey.
Compared to cosmetic surgery or dermal fillers, the procedures found to be most frequently utilized in our study population—microdermabrasion, chemical peels, and laser hair removal—are less invasive and fairly accessible with minimal downtime. An interesting topic for further research would be to investigate how the willingness of women to openly share their cosmetic procedure usage has changed over time. The rise of social media and influencer culture has undoubtedly had an impact on the sharing of such information. It also would have been interesting to ask participants where they receive the majority of their health/beauty information.
All skin types are susceptible to photoaging; however, melanin is known to have a natural photoprotective effect, resulting in a lesser degree and later onset of photoaging in patients with darker vs lighter skin.11 It has been reported that individuals with SOC show signs of facial aging on average a decade later than those with lighter skin tones,12 which may be why the majority of participants believed they look younger than they truly are. As expected, dyspigmentation was among the top skin concerns in our study population. Although melanin does offer some degree of protection against UVA and UVB, melanocyte lability with inflammation may make darker skin types more susceptible to pigmentary issues.13
Study Limitations—The income levels of our study population were not representative of typical Black American households, which is a limitation. Seventy-seven percent of our study population earned more than $100,000 annually, while only 18% of Black American households earned more than $100,000 in 2019.14 Another major limitation of our study was the lack of representation from older generations, as most participants were aged 21 to 40 years, which was expected, as it is the younger generation who typically is targeted by a snowball sampling method primarily shared through social media. Additionally, because participants were recruited from the social media profiles of medical professionals, followers of these accounts may be more interested in cosmetic procedures, skewing the study results. Finally, because geographic location was not captured in our initial data collection, we were unable to determine if results from a particular location within the United States were overrepresented in the data set.
Conclusion
Although the discourse around beauty and antiaging is constantly evolving, data about Black women frequently are underrepresented in the literature. The results of this study highlight the changing attitudes and perceptions of Black women regarding beauty, aging, and minimally invasive cosmetic procedures. Dermatologists should stay abreast of current trends in this population to be able to make appropriate, culturally sensitive recommendations to their Black patients—for example, pointing them to sunscreen brands that are best suited for darker skin.
- Ahn CS, Suchonwanit P, Foy CG, et al. Hair and scalp care in African American women who exercise. JAMA Dermatol. 2016;152:579-580.
- Prendergast TI, Ong’uti SK, Ortega G, et al. Differential trends in racial preferences for cosmetic surgery procedures. Am Surg. 2011;77:1081-1085.
- American Society of Plastic Surgeons. Briefing paper: plastic surgeryfor ethnic patients. Accessed October 20, 2023. https://www.plasticsurgery.org/news/briefing-papers/briefing-paper-plastic-surgery-for-ethnic-patients
- Small K, Kelly KM, Spinelli HM. Are nurse injectors the new norm? Aesthetic Plast Surg. 2014;38:946-955.
- Quiñonez RL, Agbai ON, Burgess CM, et al. An update on cosmetic procedures in people of color. part 1: scientific background, assessment, preprocedure preparation. J Am Acad Dermatol. 2022;86:715-725.
- Alexis AF, Grimes P, Boyd C, et al. Racial and ethnic differences in self-assessed facial aging in women: results from a multinational study. Dermatol Surg. 2019;45:1635-1648.
- Talakoub L, Wesley NO. Differences in perceptions of beauty and cosmetic procedures performed in ethnic patients. Semin Cutan Med Surg. 2009;28:115-129.
- Alotaibi AS. Demographic and cultural differences in the acceptance and pursuit of cosmetic surgery: a systematic literature review. Plast Reconstr Surg Glob Open. 2021;9:E3501.
- Grimes PE. Skin and hair cosmetic issues in women of color. Dermatol Clin. 2000;18:659-665.
- Buchanan Lunsford N, Berktold J, Holman DM, et al. Skin cancer knowledge, awareness, beliefs and preventive behaviors among black and Hispanic men and women. Prev Med Rep. 2018;12:203-209.
- Alexis AF, Rossi, A. Photoaging in skin of color. Cosmet Dermatol. 2011;24:367-370.
- Vashi NA, de Castro Maymone MB, Kundu RV. Aging differences in ethnic skin. J Clin Aesthet Dermatol. 2016;9:31-38.
- Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis. 2007;80:387-394.
- Tamir C, Budiman A, Noe-Bustamante L, et al. Facts about the U.S. Black population. Pew Research Center website. Published March 2, 2023. Accessed October 20, 2023. https://www.pewresearch.org/social-trends/fact-sheet/facts-about-the-us-black-population/
Beauty has been a topic of interest for centuries. Treatments and technologies have advanced, and more women are utilizing cosmetic procedures than ever before, especially neuromodulators, minimally invasive procedures, and topical treatments.1 Over the last decade, there was a 99% increase in minimally invasive cosmetic procedures in the United States.2 There also has been an observable increase in the utilization of cosmetic procedures by Black patients in recent years; the American Society of Plastic Surgeons reported that the number of cosmetic plastic surgery procedures performed on “ethnic patients” (referring to Asian, Black, or Hispanic patients) increased 243% from 2000 to 2013,3 possibly attributed to increased accessibility, awareness of procedures due to social media, cultural acceptance, and affordability. Minimally invasive procedures are considerably less expensive than major surgical procedures and are becoming progressively more affordable, with numerous financing options available.2 Additionally, neuromodulators and fillers are now commonly administered by nonaesthetic health professionals including dentists and nurses, which has increased accessibility of these procedures among patients who typically may not seek out a consultation with a plastic surgeon or dermatologist.4
When examining the most common cosmetic procedures collectively sought out by patients with skin of color (SOC), it has been found that an even skin tone is a highly desirable feature that impacts the selection of products and procedures in this particular patient population.5 Black, Hispanic, and Asian women report fewer signs of facial aging compared to White women in the glabellar lines, crow’s-feet, oral commissures, perioral lines, and lips.6 Increased melanocytes in darker skin types help prevent photoaging but also increase susceptibility to dyschromia. Prior studies have reported the most common concerns by patients with SOC are dyschromic disorders such as postinflammatory hyperpigmentation, postinflammatory hypopigmentation, and melasma.7 Common minimally invasive cosmetic procedures utilized by the SOC population include chemical peels, laser treatments, and injectables. Fillers are utilized more for volume loss in SOC patients rather than for the deep furrows and rhytides commonly seen in the lower face of White patients.8
We conducted a survey among Black women currently residing in the United States to better understand attitudes toward beauty and aging as well as the utilization of minimally invasive cosmetic procedures in this patient population.
Methods
An in-depth questionnaire comprised of 17 questions was created for this cross-sectional observational study. The study was submitted to and deemed exempt by the institutional review board at the University of Miami (Miami, Florida)(IRB #20211184). Survey participants primarily were recruited via social media posts on personal profiles of Black dermatologists, medical residents, and medicalstudents, including the authors, targeting Black women in the United States. Utilizing a method called snowball sampling, whereby study participants are used to recruit future participants, individuals were instructed to share the survey with their social network to assist with survey distribution. After participants provided informed consent, data were captured using the REDCap secure online data collection software. The questionnaire was structured to include a sociodemographic profile of respondents, attitudes toward beauty and aging, current usage of beauty products, prior utilization of cosmetic procedures, and intentions to use cosmetic procedures in the future. Surveys with incomplete consent forms, incomplete responses, and duplicate responses, as well as surveys from participants who were not residing in the United States at the time of survey completion, were excluded.
Data characteristics were summarized by frequency and percentage. A χ2 test was performed to compare participants’ age demographics with their attitudes toward beauty and aging, utilization of cosmetic procedures, and intention to try cosmetic procedures in the future. The Fisher exact test was used instead of the χ2 test when the expected cell count was less than 5. For all tests, P<.05 was considered statistically significant. All statistical analyses were performed using SPSS software version 28.
Results
General Characteristics of Participants—A sample of 475 self-identified Black women aged 21 to 70 years participated in the study, and 352 eligible participants were included in the final analysis. Of the 352 eligible participants, 48.3% were aged 21 to 30 years, 47.2% were aged 31 to 40 years, and 4.5% were aged 41 to 50 years. All survey participants identified their race as Black; among them, 4% specified Hispanic or Latino ethnicity, and 9% indicated that they held multiracial identities including White/Caucasian, Asian, and Native American backgrounds. Regarding the participants’ citizenship status, 54.3% reported that both they and their parents were born in the United States; 2.3% were not US citizens or permanent residents, 13.1% identified as first-generation Americans (born outside of the United States), and 30.4% identified as second-generation Americans (one or both parents born outside of the United States). Participant education levels (based on highest level) varied greatly: 4.5% were high school graduates, 1.1% attended trade or technical schools, 3.4% had associate’s degrees, 39.8% had bachelor’s degrees, 35.2% had master’s degrees, and 15.9% had doctorate degrees. Regarding household income, 6.3% earned less than $25,000 per year, 16.8% earned from $25,000 to $99,999, 75.6% earned from $100,000 to $499,999, and 1.4% earned $500,000 or more. Patient demographics are provided in Table 1.
Cosmetic Skin Concerns—The top 3 aging skin concerns among participants were fine lines and wrinkles (51.9%), dark circles (33.8%), and uneven skin tone (31.8%) (Table 2). Approximately 5.4% of participants reported no desire to avoid the natural aging process. Among age groups, fine lines and wrinkles were a major concern for 51.7% of 21- to 30-year-olds, 47.6% of 31- to 40-year-olds, and 43.5% of 41- to 50-year-olds. Dark circles were a major concern for 61.3% of 21- to 30-year-olds, 44.4% of 31- to 40-year-olds, and 46.8% of 41- to 50-year-olds. Uneven skin tone was a major concern for 56.2% of 21- to 30-year-olds, 46.5% of 31- to 40-year-olds, and 31.2% of 41- to 50-year-olds. There was no statistically significant association between participants’ age and their concern with aging skin concerns.
Differences in Experience and Acceptance of Cosmetic Procedures—Regarding participants’ prior experience with cosmetic procedures, 22.3% had tried 1 or more procedures. Additionally, 67.0% reported having intentions of trying cosmetic procedures in the future, while 10.8% reported no intentions. Of those who were uninterested in trying cosmetic procedures, 78.9% (30/38) believed it unnecessary while 47.3% (18/38) reported a fear of looking unnatural. Other perceived deterrents to cosmetic procedures among this subset of participants were the need to repeat treatment for lasting results (28.9% [11/38]), too expensive (31.6% [12/38]), and fear of side effects (39.5% [15/38]). A significant difference was found between participants’ age and their experience with cosmetic procedures (P=.020). Participants aged 21 to 30 years reported they were more likely to want to try cosmetic procedures in the future. Participants aged 31 to 40 years were more likely to have already tried a cosmetic procedure. Participants aged 41 to 50 years were more likely to report no desire to try cosmetic procedures in the future. There was no significant difference in cosmetic procedure acceptance according to citizenship status, education level, or household income.
Differences in Cosmetic Procedure Experience—Study participants indicated awareness of typically practiced cosmetic procedures. Of the 78 participants who have tried cosmetic procedures (Figure 1), the most common were laser hair removal (46.2% [36/78]), chemical peels (37.2% [29/78]), and microdermabrasion (24.4% [19/78])(Table 2). Age significantly influenced the type of cosmetic procedures utilized by participants (P<.001). Laser hair removal was the most common cosmetic procedure utilized by participants aged 21 to 30 years (64.7%) and chemical peels in participants aged 31 to 40 years (47.8%); participants aged 41 to 50 years reported equal use of chemical peels (50.0%) and microdermabrasion (50.0%).
Two hundred thirty-six participants reported interest in trying cosmetic procedures, specifically laser hair removal (57.6%), chemical peels (51.7%), and neuromodulators (41.9%)(Table 2). Although not statistically significant, age appeared to influence interest levels in cosmetic procedures. Participants aged 21 to 30 years and 31 to 40 years were most interested in trying laser hair removal (60.7% and 58.3%, respectively). Participants aged 41 to 50 years were most interested in trying neuromodulators (36.4%). There was no significant association between age and intention to try neuromodulators, chemical peels, or laser hair removal.
Attitudes Toward Beauty—Approximately 40.6% of participants believed that peak beauty occurs when women reach their 20s, and 38.6% believed that peak beauty occurs when women reach their 30s. Participants’ strategies for maintaining beauty were assessed through their regular use of certain skin care products. The most frequently used skin care products were face wash or cleanser (92.6%), moisturizer (90.1%), lip balm (76.1%), and facial sunscreen (62.2%). Other commonly used items were serum (34.7%), toner (34.9%), topical vitamin C (33.2%), and retinol/retinoid products (33.0%). Only 2.3% of participants reported not using any skin care products regularly.
Perceptions of Aging—Concerning perceived external age, most respondents believed they looked younger than their true age (69.9%); 24.4% believed they looked their true age, and 5.7% believed they looked older. Perception of age also varied considerably by age group, though most believed they looked younger than their true age.
Comment
This survey helped to identify trends in cosmetic procedure acceptance and utilization in Black women. As expected, younger Black women were more receptive to cosmetic procedures, which was consistent with a recent finding that cosmetic procedures tend to be more widely accepted among younger generations overall.8 Participants aged 21 to 30 years had greater intentions to try a cosmetic procedure, while those aged 31 to 40 years were more likely to have tried 1 or more cosmetic procedures already, which may be because they are just beginning to see the signs of aging and are motivated to address these concerns. Additionally, women in this age group may be more likely to have a stable source of income and be able to afford these procedures. It is important to note that the population surveyed had a much higher reported household income than the average Black household income, with most respondents reporting an average annual income of $100,000 to $499,000. Our data also showed a trend toward greater acceptance and utilization of cosmetic procedures in those with higher levels of income, though the results were not statistically significant.
Respondents were most concerned about fine lines and wrinkles, followed by dark circles and uneven skin tone. One report in the literature (N=2000) indicated that the most common cosmetic concerns in women with SOC were hyperpigmentation/dark spots (86%) and blotchy or uneven skin (80%).9 Interestingly, sunscreen was one of the more commonly used products in our survey, which historically has not been the case among individuals with SOC10 and suggests that the attitudes and perceptions of SOC patients are changing to favor more frequent sunscreen use, at least among the younger generations. Because we did not specify moisturizer vs moisturizer with sun protection factor, the use of facial sunscreen may even be underestimated in our survey.
Compared to cosmetic surgery or dermal fillers, the procedures found to be most frequently utilized in our study population—microdermabrasion, chemical peels, and laser hair removal—are less invasive and fairly accessible with minimal downtime. An interesting topic for further research would be to investigate how the willingness of women to openly share their cosmetic procedure usage has changed over time. The rise of social media and influencer culture has undoubtedly had an impact on the sharing of such information. It also would have been interesting to ask participants where they receive the majority of their health/beauty information.
All skin types are susceptible to photoaging; however, melanin is known to have a natural photoprotective effect, resulting in a lesser degree and later onset of photoaging in patients with darker vs lighter skin.11 It has been reported that individuals with SOC show signs of facial aging on average a decade later than those with lighter skin tones,12 which may be why the majority of participants believed they look younger than they truly are. As expected, dyspigmentation was among the top skin concerns in our study population. Although melanin does offer some degree of protection against UVA and UVB, melanocyte lability with inflammation may make darker skin types more susceptible to pigmentary issues.13
Study Limitations—The income levels of our study population were not representative of typical Black American households, which is a limitation. Seventy-seven percent of our study population earned more than $100,000 annually, while only 18% of Black American households earned more than $100,000 in 2019.14 Another major limitation of our study was the lack of representation from older generations, as most participants were aged 21 to 40 years, which was expected, as it is the younger generation who typically is targeted by a snowball sampling method primarily shared through social media. Additionally, because participants were recruited from the social media profiles of medical professionals, followers of these accounts may be more interested in cosmetic procedures, skewing the study results. Finally, because geographic location was not captured in our initial data collection, we were unable to determine if results from a particular location within the United States were overrepresented in the data set.
Conclusion
Although the discourse around beauty and antiaging is constantly evolving, data about Black women frequently are underrepresented in the literature. The results of this study highlight the changing attitudes and perceptions of Black women regarding beauty, aging, and minimally invasive cosmetic procedures. Dermatologists should stay abreast of current trends in this population to be able to make appropriate, culturally sensitive recommendations to their Black patients—for example, pointing them to sunscreen brands that are best suited for darker skin.
Beauty has been a topic of interest for centuries. Treatments and technologies have advanced, and more women are utilizing cosmetic procedures than ever before, especially neuromodulators, minimally invasive procedures, and topical treatments.1 Over the last decade, there was a 99% increase in minimally invasive cosmetic procedures in the United States.2 There also has been an observable increase in the utilization of cosmetic procedures by Black patients in recent years; the American Society of Plastic Surgeons reported that the number of cosmetic plastic surgery procedures performed on “ethnic patients” (referring to Asian, Black, or Hispanic patients) increased 243% from 2000 to 2013,3 possibly attributed to increased accessibility, awareness of procedures due to social media, cultural acceptance, and affordability. Minimally invasive procedures are considerably less expensive than major surgical procedures and are becoming progressively more affordable, with numerous financing options available.2 Additionally, neuromodulators and fillers are now commonly administered by nonaesthetic health professionals including dentists and nurses, which has increased accessibility of these procedures among patients who typically may not seek out a consultation with a plastic surgeon or dermatologist.4
When examining the most common cosmetic procedures collectively sought out by patients with skin of color (SOC), it has been found that an even skin tone is a highly desirable feature that impacts the selection of products and procedures in this particular patient population.5 Black, Hispanic, and Asian women report fewer signs of facial aging compared to White women in the glabellar lines, crow’s-feet, oral commissures, perioral lines, and lips.6 Increased melanocytes in darker skin types help prevent photoaging but also increase susceptibility to dyschromia. Prior studies have reported the most common concerns by patients with SOC are dyschromic disorders such as postinflammatory hyperpigmentation, postinflammatory hypopigmentation, and melasma.7 Common minimally invasive cosmetic procedures utilized by the SOC population include chemical peels, laser treatments, and injectables. Fillers are utilized more for volume loss in SOC patients rather than for the deep furrows and rhytides commonly seen in the lower face of White patients.8
We conducted a survey among Black women currently residing in the United States to better understand attitudes toward beauty and aging as well as the utilization of minimally invasive cosmetic procedures in this patient population.
Methods
An in-depth questionnaire comprised of 17 questions was created for this cross-sectional observational study. The study was submitted to and deemed exempt by the institutional review board at the University of Miami (Miami, Florida)(IRB #20211184). Survey participants primarily were recruited via social media posts on personal profiles of Black dermatologists, medical residents, and medicalstudents, including the authors, targeting Black women in the United States. Utilizing a method called snowball sampling, whereby study participants are used to recruit future participants, individuals were instructed to share the survey with their social network to assist with survey distribution. After participants provided informed consent, data were captured using the REDCap secure online data collection software. The questionnaire was structured to include a sociodemographic profile of respondents, attitudes toward beauty and aging, current usage of beauty products, prior utilization of cosmetic procedures, and intentions to use cosmetic procedures in the future. Surveys with incomplete consent forms, incomplete responses, and duplicate responses, as well as surveys from participants who were not residing in the United States at the time of survey completion, were excluded.
Data characteristics were summarized by frequency and percentage. A χ2 test was performed to compare participants’ age demographics with their attitudes toward beauty and aging, utilization of cosmetic procedures, and intention to try cosmetic procedures in the future. The Fisher exact test was used instead of the χ2 test when the expected cell count was less than 5. For all tests, P<.05 was considered statistically significant. All statistical analyses were performed using SPSS software version 28.
Results
General Characteristics of Participants—A sample of 475 self-identified Black women aged 21 to 70 years participated in the study, and 352 eligible participants were included in the final analysis. Of the 352 eligible participants, 48.3% were aged 21 to 30 years, 47.2% were aged 31 to 40 years, and 4.5% were aged 41 to 50 years. All survey participants identified their race as Black; among them, 4% specified Hispanic or Latino ethnicity, and 9% indicated that they held multiracial identities including White/Caucasian, Asian, and Native American backgrounds. Regarding the participants’ citizenship status, 54.3% reported that both they and their parents were born in the United States; 2.3% were not US citizens or permanent residents, 13.1% identified as first-generation Americans (born outside of the United States), and 30.4% identified as second-generation Americans (one or both parents born outside of the United States). Participant education levels (based on highest level) varied greatly: 4.5% were high school graduates, 1.1% attended trade or technical schools, 3.4% had associate’s degrees, 39.8% had bachelor’s degrees, 35.2% had master’s degrees, and 15.9% had doctorate degrees. Regarding household income, 6.3% earned less than $25,000 per year, 16.8% earned from $25,000 to $99,999, 75.6% earned from $100,000 to $499,999, and 1.4% earned $500,000 or more. Patient demographics are provided in Table 1.
Cosmetic Skin Concerns—The top 3 aging skin concerns among participants were fine lines and wrinkles (51.9%), dark circles (33.8%), and uneven skin tone (31.8%) (Table 2). Approximately 5.4% of participants reported no desire to avoid the natural aging process. Among age groups, fine lines and wrinkles were a major concern for 51.7% of 21- to 30-year-olds, 47.6% of 31- to 40-year-olds, and 43.5% of 41- to 50-year-olds. Dark circles were a major concern for 61.3% of 21- to 30-year-olds, 44.4% of 31- to 40-year-olds, and 46.8% of 41- to 50-year-olds. Uneven skin tone was a major concern for 56.2% of 21- to 30-year-olds, 46.5% of 31- to 40-year-olds, and 31.2% of 41- to 50-year-olds. There was no statistically significant association between participants’ age and their concern with aging skin concerns.
Differences in Experience and Acceptance of Cosmetic Procedures—Regarding participants’ prior experience with cosmetic procedures, 22.3% had tried 1 or more procedures. Additionally, 67.0% reported having intentions of trying cosmetic procedures in the future, while 10.8% reported no intentions. Of those who were uninterested in trying cosmetic procedures, 78.9% (30/38) believed it unnecessary while 47.3% (18/38) reported a fear of looking unnatural. Other perceived deterrents to cosmetic procedures among this subset of participants were the need to repeat treatment for lasting results (28.9% [11/38]), too expensive (31.6% [12/38]), and fear of side effects (39.5% [15/38]). A significant difference was found between participants’ age and their experience with cosmetic procedures (P=.020). Participants aged 21 to 30 years reported they were more likely to want to try cosmetic procedures in the future. Participants aged 31 to 40 years were more likely to have already tried a cosmetic procedure. Participants aged 41 to 50 years were more likely to report no desire to try cosmetic procedures in the future. There was no significant difference in cosmetic procedure acceptance according to citizenship status, education level, or household income.
Differences in Cosmetic Procedure Experience—Study participants indicated awareness of typically practiced cosmetic procedures. Of the 78 participants who have tried cosmetic procedures (Figure 1), the most common were laser hair removal (46.2% [36/78]), chemical peels (37.2% [29/78]), and microdermabrasion (24.4% [19/78])(Table 2). Age significantly influenced the type of cosmetic procedures utilized by participants (P<.001). Laser hair removal was the most common cosmetic procedure utilized by participants aged 21 to 30 years (64.7%) and chemical peels in participants aged 31 to 40 years (47.8%); participants aged 41 to 50 years reported equal use of chemical peels (50.0%) and microdermabrasion (50.0%).
Two hundred thirty-six participants reported interest in trying cosmetic procedures, specifically laser hair removal (57.6%), chemical peels (51.7%), and neuromodulators (41.9%)(Table 2). Although not statistically significant, age appeared to influence interest levels in cosmetic procedures. Participants aged 21 to 30 years and 31 to 40 years were most interested in trying laser hair removal (60.7% and 58.3%, respectively). Participants aged 41 to 50 years were most interested in trying neuromodulators (36.4%). There was no significant association between age and intention to try neuromodulators, chemical peels, or laser hair removal.
Attitudes Toward Beauty—Approximately 40.6% of participants believed that peak beauty occurs when women reach their 20s, and 38.6% believed that peak beauty occurs when women reach their 30s. Participants’ strategies for maintaining beauty were assessed through their regular use of certain skin care products. The most frequently used skin care products were face wash or cleanser (92.6%), moisturizer (90.1%), lip balm (76.1%), and facial sunscreen (62.2%). Other commonly used items were serum (34.7%), toner (34.9%), topical vitamin C (33.2%), and retinol/retinoid products (33.0%). Only 2.3% of participants reported not using any skin care products regularly.
Perceptions of Aging—Concerning perceived external age, most respondents believed they looked younger than their true age (69.9%); 24.4% believed they looked their true age, and 5.7% believed they looked older. Perception of age also varied considerably by age group, though most believed they looked younger than their true age.
Comment
This survey helped to identify trends in cosmetic procedure acceptance and utilization in Black women. As expected, younger Black women were more receptive to cosmetic procedures, which was consistent with a recent finding that cosmetic procedures tend to be more widely accepted among younger generations overall.8 Participants aged 21 to 30 years had greater intentions to try a cosmetic procedure, while those aged 31 to 40 years were more likely to have tried 1 or more cosmetic procedures already, which may be because they are just beginning to see the signs of aging and are motivated to address these concerns. Additionally, women in this age group may be more likely to have a stable source of income and be able to afford these procedures. It is important to note that the population surveyed had a much higher reported household income than the average Black household income, with most respondents reporting an average annual income of $100,000 to $499,000. Our data also showed a trend toward greater acceptance and utilization of cosmetic procedures in those with higher levels of income, though the results were not statistically significant.
Respondents were most concerned about fine lines and wrinkles, followed by dark circles and uneven skin tone. One report in the literature (N=2000) indicated that the most common cosmetic concerns in women with SOC were hyperpigmentation/dark spots (86%) and blotchy or uneven skin (80%).9 Interestingly, sunscreen was one of the more commonly used products in our survey, which historically has not been the case among individuals with SOC10 and suggests that the attitudes and perceptions of SOC patients are changing to favor more frequent sunscreen use, at least among the younger generations. Because we did not specify moisturizer vs moisturizer with sun protection factor, the use of facial sunscreen may even be underestimated in our survey.
Compared to cosmetic surgery or dermal fillers, the procedures found to be most frequently utilized in our study population—microdermabrasion, chemical peels, and laser hair removal—are less invasive and fairly accessible with minimal downtime. An interesting topic for further research would be to investigate how the willingness of women to openly share their cosmetic procedure usage has changed over time. The rise of social media and influencer culture has undoubtedly had an impact on the sharing of such information. It also would have been interesting to ask participants where they receive the majority of their health/beauty information.
All skin types are susceptible to photoaging; however, melanin is known to have a natural photoprotective effect, resulting in a lesser degree and later onset of photoaging in patients with darker vs lighter skin.11 It has been reported that individuals with SOC show signs of facial aging on average a decade later than those with lighter skin tones,12 which may be why the majority of participants believed they look younger than they truly are. As expected, dyspigmentation was among the top skin concerns in our study population. Although melanin does offer some degree of protection against UVA and UVB, melanocyte lability with inflammation may make darker skin types more susceptible to pigmentary issues.13
Study Limitations—The income levels of our study population were not representative of typical Black American households, which is a limitation. Seventy-seven percent of our study population earned more than $100,000 annually, while only 18% of Black American households earned more than $100,000 in 2019.14 Another major limitation of our study was the lack of representation from older generations, as most participants were aged 21 to 40 years, which was expected, as it is the younger generation who typically is targeted by a snowball sampling method primarily shared through social media. Additionally, because participants were recruited from the social media profiles of medical professionals, followers of these accounts may be more interested in cosmetic procedures, skewing the study results. Finally, because geographic location was not captured in our initial data collection, we were unable to determine if results from a particular location within the United States were overrepresented in the data set.
Conclusion
Although the discourse around beauty and antiaging is constantly evolving, data about Black women frequently are underrepresented in the literature. The results of this study highlight the changing attitudes and perceptions of Black women regarding beauty, aging, and minimally invasive cosmetic procedures. Dermatologists should stay abreast of current trends in this population to be able to make appropriate, culturally sensitive recommendations to their Black patients—for example, pointing them to sunscreen brands that are best suited for darker skin.
- Ahn CS, Suchonwanit P, Foy CG, et al. Hair and scalp care in African American women who exercise. JAMA Dermatol. 2016;152:579-580.
- Prendergast TI, Ong’uti SK, Ortega G, et al. Differential trends in racial preferences for cosmetic surgery procedures. Am Surg. 2011;77:1081-1085.
- American Society of Plastic Surgeons. Briefing paper: plastic surgeryfor ethnic patients. Accessed October 20, 2023. https://www.plasticsurgery.org/news/briefing-papers/briefing-paper-plastic-surgery-for-ethnic-patients
- Small K, Kelly KM, Spinelli HM. Are nurse injectors the new norm? Aesthetic Plast Surg. 2014;38:946-955.
- Quiñonez RL, Agbai ON, Burgess CM, et al. An update on cosmetic procedures in people of color. part 1: scientific background, assessment, preprocedure preparation. J Am Acad Dermatol. 2022;86:715-725.
- Alexis AF, Grimes P, Boyd C, et al. Racial and ethnic differences in self-assessed facial aging in women: results from a multinational study. Dermatol Surg. 2019;45:1635-1648.
- Talakoub L, Wesley NO. Differences in perceptions of beauty and cosmetic procedures performed in ethnic patients. Semin Cutan Med Surg. 2009;28:115-129.
- Alotaibi AS. Demographic and cultural differences in the acceptance and pursuit of cosmetic surgery: a systematic literature review. Plast Reconstr Surg Glob Open. 2021;9:E3501.
- Grimes PE. Skin and hair cosmetic issues in women of color. Dermatol Clin. 2000;18:659-665.
- Buchanan Lunsford N, Berktold J, Holman DM, et al. Skin cancer knowledge, awareness, beliefs and preventive behaviors among black and Hispanic men and women. Prev Med Rep. 2018;12:203-209.
- Alexis AF, Rossi, A. Photoaging in skin of color. Cosmet Dermatol. 2011;24:367-370.
- Vashi NA, de Castro Maymone MB, Kundu RV. Aging differences in ethnic skin. J Clin Aesthet Dermatol. 2016;9:31-38.
- Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis. 2007;80:387-394.
- Tamir C, Budiman A, Noe-Bustamante L, et al. Facts about the U.S. Black population. Pew Research Center website. Published March 2, 2023. Accessed October 20, 2023. https://www.pewresearch.org/social-trends/fact-sheet/facts-about-the-us-black-population/
- Ahn CS, Suchonwanit P, Foy CG, et al. Hair and scalp care in African American women who exercise. JAMA Dermatol. 2016;152:579-580.
- Prendergast TI, Ong’uti SK, Ortega G, et al. Differential trends in racial preferences for cosmetic surgery procedures. Am Surg. 2011;77:1081-1085.
- American Society of Plastic Surgeons. Briefing paper: plastic surgeryfor ethnic patients. Accessed October 20, 2023. https://www.plasticsurgery.org/news/briefing-papers/briefing-paper-plastic-surgery-for-ethnic-patients
- Small K, Kelly KM, Spinelli HM. Are nurse injectors the new norm? Aesthetic Plast Surg. 2014;38:946-955.
- Quiñonez RL, Agbai ON, Burgess CM, et al. An update on cosmetic procedures in people of color. part 1: scientific background, assessment, preprocedure preparation. J Am Acad Dermatol. 2022;86:715-725.
- Alexis AF, Grimes P, Boyd C, et al. Racial and ethnic differences in self-assessed facial aging in women: results from a multinational study. Dermatol Surg. 2019;45:1635-1648.
- Talakoub L, Wesley NO. Differences in perceptions of beauty and cosmetic procedures performed in ethnic patients. Semin Cutan Med Surg. 2009;28:115-129.
- Alotaibi AS. Demographic and cultural differences in the acceptance and pursuit of cosmetic surgery: a systematic literature review. Plast Reconstr Surg Glob Open. 2021;9:E3501.
- Grimes PE. Skin and hair cosmetic issues in women of color. Dermatol Clin. 2000;18:659-665.
- Buchanan Lunsford N, Berktold J, Holman DM, et al. Skin cancer knowledge, awareness, beliefs and preventive behaviors among black and Hispanic men and women. Prev Med Rep. 2018;12:203-209.
- Alexis AF, Rossi, A. Photoaging in skin of color. Cosmet Dermatol. 2011;24:367-370.
- Vashi NA, de Castro Maymone MB, Kundu RV. Aging differences in ethnic skin. J Clin Aesthet Dermatol. 2016;9:31-38.
- Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis. 2007;80:387-394.
- Tamir C, Budiman A, Noe-Bustamante L, et al. Facts about the U.S. Black population. Pew Research Center website. Published March 2, 2023. Accessed October 20, 2023. https://www.pewresearch.org/social-trends/fact-sheet/facts-about-the-us-black-population/
Practice Points
- Cosmetic procedures may be more widely accepted among younger Black women than older Black women.
- Age has a considerable influence on the types of cosmetic procedures that Black women are interested in trying.
- Microdermabrasion, chemical peels, and laser hair removal were the most frequently utilized procedures in this study population.
- As attitudes and perceptions of young Black women are changing and favoring more frequent sunscreen use, dermatologists should remain on top of current trends to provide culturally sensitive and relevant recommendations to patients with darker skin tones.
Suture Selection to Minimize Postoperative Postinflammatory Hyperpigmentation in Patients With Skin of Color During Mohs Micrographic Surgery
Practice Gap
Proper suture selection is imperative for appropriate wound healing to minimize the risk for infection and inflammation and to reduce scarring. In Mohs micrographic surgery (MMS), suture selection should be given high consideration in patients with skin of color.1 Using the right type of suture and wound closure technique can lead to favorable aesthetic outcomes by preventing postoperative postinflammatory hyperpigmentation (PIH) and keloids. Data on the choice of suture material in patients with skin of color are limited.
Suture selection depends on a variety of factors including but not limited to the location of the wound on the body, risk for infection, cost, availability, and the personal preference and experience of the MMS surgeon. During the COVID-19 pandemic, suturepreference among dermatologic surgeons shifted to fast-absorbing gut sutures,2 offering alternatives to synthetic monofilament polypropylene and nylon sutures. Absorbable sutures reduced the need for in-person follow-up visits without increasing the incidence of postoperative complications.
Despite these benefits, research suggests that natural absorbable gut sutures induce cutaneous inflammation and should be avoided in patients with skin of color.1,3,4 Nonabsorbable sutures are less reactive, reducing PIH after MMS in patients with skin of color.
Tools and Technique
Use of nonabsorbable stitches is a practical solution to reduce the risk for inflammation in patients with skin of color. Increased inflammation can lead to PIH and increase the risk for keloids in this patient population. Some patients will experience PIH after a surgical procedure regardless of the sutures used to repair the closure; however, one of our goals with patients with skin of color undergoing MMS is to reduce the inflammatory risk that could lead to PIH to ensure optimal aesthetic outcomes.
A middle-aged African woman with darker skin and a history of developing PIH after trauma to the skin presented to our clinic for MMS of a dermatofibrosarcoma protuberans on the upper abdomen. We used a simple running suture with 4-0 nylon to close the surgical wound. We avoided fast-absorbing gut sutures because they have high tissue reactivity1,4; use of sutures with low tissue reactivity, such as nylon and polypropylene, decreases the risk for inflammation without compromising alignment of wound edges and overall cosmesis of the repair. Prolene also is cost-effective and presents a decreased risk for wound dehiscence.5 After cauterizing the wound, we placed multiple synthetic absorbable sutures first to close the wound. We then did a double-running suture of nonabsorbable monofilament suture to reapproximate the epidermal edges with minimal tension. We placed 2 sets of running stitches to minimize the risk for dehiscence along the scar.
The patient was required to return for removal of the nonabsorbable sutures; this postoperative visit was covered by health insurance at no additional cost to the patient. In comparison, long-term repeat visits to treat PIH with a laser or chemical peel would have been more costly. Given that treatment of PIH is considered cosmetic, laser treatment would have been priced at several hundred dollars per session at our institution, and the patient would likely have had a copay for a pretreatment lightening cream such as hydroquinone. Our patient had a favorable cosmetic outcome and reported no or minimal evidence of PIH months after the procedure.
Patients should be instructed to apply petrolatum twice daily, use sun-protective clothing, and cover sutures to minimize exposure to the sun and prevent crusting of the wound. Postinflammatory hyperpigmentation can be proactively treated postoperatively with topical hydroquinone, which was not needed in our patient.
Practice Implications
Although some studies suggest that there are no cosmetic differences between absorbable and nonabsorbable sutures, the effect of suture type in patients with skin of color undergoing MMS often is unreported or is not studied.6,7 The high reactivity and cutaneous inflammation associated with absorbable gut sutures are important considerations in this patient population.
In patients with skin of color undergoing MMS, we use nonabsorbable epidermal sutures such as nylon and Prolene because of their low reactivity and association with favorable aesthetic outcomes. Nonabsorbable sutures can be safely used in patients of all ages who are undergoing MMS under local anesthesia.
An exception would be the use of the absorbable suture Monocryl (J&J MedTech) in patients with skin of color who need a running subcuticular wound closure because it has low tissue reactivity and maintains high tensile strength. Monocryl has been shown to create less-reactive scars, which decreases the risk for keloids.8,9
More clinical studies are needed to assess the increased susceptibility to PIH in patients with skin of color when using absorbable gut sutures.
- Williams R, Ciocon D. Mohs micrographic surgery in skin of color. J Drugs Dermatol. 2022;21:536-541. doi:10.36849/JDD.6469
- Gallop J, Andrasik W, Lucas J. Successful use of percutaneous dissolvable sutures during COVID-19 pandemic: a retrospective review. J Cutan Med Surg. 2023;27:34-38. doi:10.1177/12034754221143083
- Byrne M, Aly A. The surgical suture. Aesthet Surg J. 2019;39(suppl 2):S67-S72. doi:10.1093/asj/sjz036
- Koppa M, House R, Tobin V, et al. Suture material choice can increase risk of hypersensitivity in hand trauma patients. Eur J Plast Surg. 2023;46:239-243. doi:10.1007/s00238-022-01986-7
- Pandey S, Singh M, Singh K, et al. A prospective randomized study comparing non-absorbable polypropylene (Prolene®) and delayed absorbable polyglactin 910 (Vicryl®) suture material in mass closure of vertical laparotomy wounds. Indian J Surg. 2013;75:306-310. doi:10.1007/s12262-012-0492-x
- Parell GJ, Becker GD. Comparison of absorbable with nonabsorbable sutures in closure of facial skin wounds. Arch Facial Plast Surg. 2003;5:488-490. doi:10.1001/archfaci.5.6.488
- Kim J, Singh Maan H, Cool AJ, et al. Fast absorbing gut suture versus cyanoacrylate tissue adhesive in the epidermal closure of linear repairs following Mohs micrographic surgery. J Clin Aesthet Dermatol. 2015;8:24-29.
- Niessen FB, Spauwen PH, Kon M. The role of suture material in hypertrophic scar formation: Monocryl vs. Vicryl-Rapide. Ann Plast Surg. 1997;39:254-260. doi:10.1097/00000637-199709000-00006
- Fosko SW, Heap D. Surgical pearl: an economical means of skin closure with absorbable suture. J Am Acad Dermatol. 1998;39(2 pt 1):248-250. doi:10.1016/s0190-9622(98)70084-2
Practice Gap
Proper suture selection is imperative for appropriate wound healing to minimize the risk for infection and inflammation and to reduce scarring. In Mohs micrographic surgery (MMS), suture selection should be given high consideration in patients with skin of color.1 Using the right type of suture and wound closure technique can lead to favorable aesthetic outcomes by preventing postoperative postinflammatory hyperpigmentation (PIH) and keloids. Data on the choice of suture material in patients with skin of color are limited.
Suture selection depends on a variety of factors including but not limited to the location of the wound on the body, risk for infection, cost, availability, and the personal preference and experience of the MMS surgeon. During the COVID-19 pandemic, suturepreference among dermatologic surgeons shifted to fast-absorbing gut sutures,2 offering alternatives to synthetic monofilament polypropylene and nylon sutures. Absorbable sutures reduced the need for in-person follow-up visits without increasing the incidence of postoperative complications.
Despite these benefits, research suggests that natural absorbable gut sutures induce cutaneous inflammation and should be avoided in patients with skin of color.1,3,4 Nonabsorbable sutures are less reactive, reducing PIH after MMS in patients with skin of color.
Tools and Technique
Use of nonabsorbable stitches is a practical solution to reduce the risk for inflammation in patients with skin of color. Increased inflammation can lead to PIH and increase the risk for keloids in this patient population. Some patients will experience PIH after a surgical procedure regardless of the sutures used to repair the closure; however, one of our goals with patients with skin of color undergoing MMS is to reduce the inflammatory risk that could lead to PIH to ensure optimal aesthetic outcomes.
A middle-aged African woman with darker skin and a history of developing PIH after trauma to the skin presented to our clinic for MMS of a dermatofibrosarcoma protuberans on the upper abdomen. We used a simple running suture with 4-0 nylon to close the surgical wound. We avoided fast-absorbing gut sutures because they have high tissue reactivity1,4; use of sutures with low tissue reactivity, such as nylon and polypropylene, decreases the risk for inflammation without compromising alignment of wound edges and overall cosmesis of the repair. Prolene also is cost-effective and presents a decreased risk for wound dehiscence.5 After cauterizing the wound, we placed multiple synthetic absorbable sutures first to close the wound. We then did a double-running suture of nonabsorbable monofilament suture to reapproximate the epidermal edges with minimal tension. We placed 2 sets of running stitches to minimize the risk for dehiscence along the scar.
The patient was required to return for removal of the nonabsorbable sutures; this postoperative visit was covered by health insurance at no additional cost to the patient. In comparison, long-term repeat visits to treat PIH with a laser or chemical peel would have been more costly. Given that treatment of PIH is considered cosmetic, laser treatment would have been priced at several hundred dollars per session at our institution, and the patient would likely have had a copay for a pretreatment lightening cream such as hydroquinone. Our patient had a favorable cosmetic outcome and reported no or minimal evidence of PIH months after the procedure.
Patients should be instructed to apply petrolatum twice daily, use sun-protective clothing, and cover sutures to minimize exposure to the sun and prevent crusting of the wound. Postinflammatory hyperpigmentation can be proactively treated postoperatively with topical hydroquinone, which was not needed in our patient.
Practice Implications
Although some studies suggest that there are no cosmetic differences between absorbable and nonabsorbable sutures, the effect of suture type in patients with skin of color undergoing MMS often is unreported or is not studied.6,7 The high reactivity and cutaneous inflammation associated with absorbable gut sutures are important considerations in this patient population.
In patients with skin of color undergoing MMS, we use nonabsorbable epidermal sutures such as nylon and Prolene because of their low reactivity and association with favorable aesthetic outcomes. Nonabsorbable sutures can be safely used in patients of all ages who are undergoing MMS under local anesthesia.
An exception would be the use of the absorbable suture Monocryl (J&J MedTech) in patients with skin of color who need a running subcuticular wound closure because it has low tissue reactivity and maintains high tensile strength. Monocryl has been shown to create less-reactive scars, which decreases the risk for keloids.8,9
More clinical studies are needed to assess the increased susceptibility to PIH in patients with skin of color when using absorbable gut sutures.
Practice Gap
Proper suture selection is imperative for appropriate wound healing to minimize the risk for infection and inflammation and to reduce scarring. In Mohs micrographic surgery (MMS), suture selection should be given high consideration in patients with skin of color.1 Using the right type of suture and wound closure technique can lead to favorable aesthetic outcomes by preventing postoperative postinflammatory hyperpigmentation (PIH) and keloids. Data on the choice of suture material in patients with skin of color are limited.
Suture selection depends on a variety of factors including but not limited to the location of the wound on the body, risk for infection, cost, availability, and the personal preference and experience of the MMS surgeon. During the COVID-19 pandemic, suturepreference among dermatologic surgeons shifted to fast-absorbing gut sutures,2 offering alternatives to synthetic monofilament polypropylene and nylon sutures. Absorbable sutures reduced the need for in-person follow-up visits without increasing the incidence of postoperative complications.
Despite these benefits, research suggests that natural absorbable gut sutures induce cutaneous inflammation and should be avoided in patients with skin of color.1,3,4 Nonabsorbable sutures are less reactive, reducing PIH after MMS in patients with skin of color.
Tools and Technique
Use of nonabsorbable stitches is a practical solution to reduce the risk for inflammation in patients with skin of color. Increased inflammation can lead to PIH and increase the risk for keloids in this patient population. Some patients will experience PIH after a surgical procedure regardless of the sutures used to repair the closure; however, one of our goals with patients with skin of color undergoing MMS is to reduce the inflammatory risk that could lead to PIH to ensure optimal aesthetic outcomes.
A middle-aged African woman with darker skin and a history of developing PIH after trauma to the skin presented to our clinic for MMS of a dermatofibrosarcoma protuberans on the upper abdomen. We used a simple running suture with 4-0 nylon to close the surgical wound. We avoided fast-absorbing gut sutures because they have high tissue reactivity1,4; use of sutures with low tissue reactivity, such as nylon and polypropylene, decreases the risk for inflammation without compromising alignment of wound edges and overall cosmesis of the repair. Prolene also is cost-effective and presents a decreased risk for wound dehiscence.5 After cauterizing the wound, we placed multiple synthetic absorbable sutures first to close the wound. We then did a double-running suture of nonabsorbable monofilament suture to reapproximate the epidermal edges with minimal tension. We placed 2 sets of running stitches to minimize the risk for dehiscence along the scar.
The patient was required to return for removal of the nonabsorbable sutures; this postoperative visit was covered by health insurance at no additional cost to the patient. In comparison, long-term repeat visits to treat PIH with a laser or chemical peel would have been more costly. Given that treatment of PIH is considered cosmetic, laser treatment would have been priced at several hundred dollars per session at our institution, and the patient would likely have had a copay for a pretreatment lightening cream such as hydroquinone. Our patient had a favorable cosmetic outcome and reported no or minimal evidence of PIH months after the procedure.
Patients should be instructed to apply petrolatum twice daily, use sun-protective clothing, and cover sutures to minimize exposure to the sun and prevent crusting of the wound. Postinflammatory hyperpigmentation can be proactively treated postoperatively with topical hydroquinone, which was not needed in our patient.
Practice Implications
Although some studies suggest that there are no cosmetic differences between absorbable and nonabsorbable sutures, the effect of suture type in patients with skin of color undergoing MMS often is unreported or is not studied.6,7 The high reactivity and cutaneous inflammation associated with absorbable gut sutures are important considerations in this patient population.
In patients with skin of color undergoing MMS, we use nonabsorbable epidermal sutures such as nylon and Prolene because of their low reactivity and association with favorable aesthetic outcomes. Nonabsorbable sutures can be safely used in patients of all ages who are undergoing MMS under local anesthesia.
An exception would be the use of the absorbable suture Monocryl (J&J MedTech) in patients with skin of color who need a running subcuticular wound closure because it has low tissue reactivity and maintains high tensile strength. Monocryl has been shown to create less-reactive scars, which decreases the risk for keloids.8,9
More clinical studies are needed to assess the increased susceptibility to PIH in patients with skin of color when using absorbable gut sutures.
- Williams R, Ciocon D. Mohs micrographic surgery in skin of color. J Drugs Dermatol. 2022;21:536-541. doi:10.36849/JDD.6469
- Gallop J, Andrasik W, Lucas J. Successful use of percutaneous dissolvable sutures during COVID-19 pandemic: a retrospective review. J Cutan Med Surg. 2023;27:34-38. doi:10.1177/12034754221143083
- Byrne M, Aly A. The surgical suture. Aesthet Surg J. 2019;39(suppl 2):S67-S72. doi:10.1093/asj/sjz036
- Koppa M, House R, Tobin V, et al. Suture material choice can increase risk of hypersensitivity in hand trauma patients. Eur J Plast Surg. 2023;46:239-243. doi:10.1007/s00238-022-01986-7
- Pandey S, Singh M, Singh K, et al. A prospective randomized study comparing non-absorbable polypropylene (Prolene®) and delayed absorbable polyglactin 910 (Vicryl®) suture material in mass closure of vertical laparotomy wounds. Indian J Surg. 2013;75:306-310. doi:10.1007/s12262-012-0492-x
- Parell GJ, Becker GD. Comparison of absorbable with nonabsorbable sutures in closure of facial skin wounds. Arch Facial Plast Surg. 2003;5:488-490. doi:10.1001/archfaci.5.6.488
- Kim J, Singh Maan H, Cool AJ, et al. Fast absorbing gut suture versus cyanoacrylate tissue adhesive in the epidermal closure of linear repairs following Mohs micrographic surgery. J Clin Aesthet Dermatol. 2015;8:24-29.
- Niessen FB, Spauwen PH, Kon M. The role of suture material in hypertrophic scar formation: Monocryl vs. Vicryl-Rapide. Ann Plast Surg. 1997;39:254-260. doi:10.1097/00000637-199709000-00006
- Fosko SW, Heap D. Surgical pearl: an economical means of skin closure with absorbable suture. J Am Acad Dermatol. 1998;39(2 pt 1):248-250. doi:10.1016/s0190-9622(98)70084-2
- Williams R, Ciocon D. Mohs micrographic surgery in skin of color. J Drugs Dermatol. 2022;21:536-541. doi:10.36849/JDD.6469
- Gallop J, Andrasik W, Lucas J. Successful use of percutaneous dissolvable sutures during COVID-19 pandemic: a retrospective review. J Cutan Med Surg. 2023;27:34-38. doi:10.1177/12034754221143083
- Byrne M, Aly A. The surgical suture. Aesthet Surg J. 2019;39(suppl 2):S67-S72. doi:10.1093/asj/sjz036
- Koppa M, House R, Tobin V, et al. Suture material choice can increase risk of hypersensitivity in hand trauma patients. Eur J Plast Surg. 2023;46:239-243. doi:10.1007/s00238-022-01986-7
- Pandey S, Singh M, Singh K, et al. A prospective randomized study comparing non-absorbable polypropylene (Prolene®) and delayed absorbable polyglactin 910 (Vicryl®) suture material in mass closure of vertical laparotomy wounds. Indian J Surg. 2013;75:306-310. doi:10.1007/s12262-012-0492-x
- Parell GJ, Becker GD. Comparison of absorbable with nonabsorbable sutures in closure of facial skin wounds. Arch Facial Plast Surg. 2003;5:488-490. doi:10.1001/archfaci.5.6.488
- Kim J, Singh Maan H, Cool AJ, et al. Fast absorbing gut suture versus cyanoacrylate tissue adhesive in the epidermal closure of linear repairs following Mohs micrographic surgery. J Clin Aesthet Dermatol. 2015;8:24-29.
- Niessen FB, Spauwen PH, Kon M. The role of suture material in hypertrophic scar formation: Monocryl vs. Vicryl-Rapide. Ann Plast Surg. 1997;39:254-260. doi:10.1097/00000637-199709000-00006
- Fosko SW, Heap D. Surgical pearl: an economical means of skin closure with absorbable suture. J Am Acad Dermatol. 1998;39(2 pt 1):248-250. doi:10.1016/s0190-9622(98)70084-2
Lack of racial, ethnic diversity in cryopreserved donor sperm in the U.S.
, according to a study presented at the American Society for Reproductive Medicine’s 2023 meeting.
“This really highlights the need to identify barriers to increase recruitment of these donors so that we can support family-building for all populations,” said Lauren Gibbs, MD, a resident in the department of obstetrics and gynecology at the Morehouse School of Medicine in Atlanta.
Dr. Gibbs and her colleagues compared the racial and ethnic makeup of sperm donors from online and self-reported profiles at 14 of the largest donor banks in the United States for March and April of 2023. Historical data were pulled from two large, national banks. The investigators compared these data to census estimates from 2021 for men between the ages of 18 and 44 years.
Donors who identified as Hispanic (10.9%) or Black (3.3%) were significantly underrepresented as compared to the U.S. population, of which Hispanic men compose 22% and Black men make up 13.3%.
Asian donors were overrepresented, making up 21.9% of the donors but only 6.5% of the U.S. population. White donors were proportionately represented in relation to national demographics, making up 56.6% of the donors and representing 55% of the U.S. population, according to the researchers. None of the donors identified as Native/Hawaiian/Pacific Islander or American Indian/Alaskan Natives; these groups represent 0.22% and 0.79% of the U.S. population, respectively.
“Next steps will be figuring out why this is happening and how to address it,” said Valerie L Baker, MD, director in the division of reproductive endocrinology and infertility at Johns Hopkins Medicine in Lutherville, Md., who was not involved in the study.
The study sheds light on the need to identify and address the barriers that discourage potential donors from underrepresented groups from participating in sperm donation, according to Kimball Pomeroy, PhD, scientific director at the World Egg and Sperm Bank in Scottsdale, Ariz.
“Sometimes there are inhibitors of different ethnic groups to want to act as sperm or egg donors, so trying to understand if that’s the case is important; but I’m sure a lot of it is also related to access,” Dr. Pomeroy, who was not part of the study team, said in an interview.
Longitudinal data from the two national donor banks did not indicate any significant increase or decrease in donation trends across the 5-year period from 2018 to 2022, highlighting the persisting issue of representation disparities. Dr. Gibbs said strategies need to be developed to increase recruitment of donors from underrepresented groups. Increasing the diversity of the donor pool will ultimately support family-building options for all patients, according to Dr. Gibbs.
Funding for the study was provided by the EMD Serono REI Diversity Fellowship Grant. Dr. Gibbs reports no relevant financial relationships.
, according to a study presented at the American Society for Reproductive Medicine’s 2023 meeting.
“This really highlights the need to identify barriers to increase recruitment of these donors so that we can support family-building for all populations,” said Lauren Gibbs, MD, a resident in the department of obstetrics and gynecology at the Morehouse School of Medicine in Atlanta.
Dr. Gibbs and her colleagues compared the racial and ethnic makeup of sperm donors from online and self-reported profiles at 14 of the largest donor banks in the United States for March and April of 2023. Historical data were pulled from two large, national banks. The investigators compared these data to census estimates from 2021 for men between the ages of 18 and 44 years.
Donors who identified as Hispanic (10.9%) or Black (3.3%) were significantly underrepresented as compared to the U.S. population, of which Hispanic men compose 22% and Black men make up 13.3%.
Asian donors were overrepresented, making up 21.9% of the donors but only 6.5% of the U.S. population. White donors were proportionately represented in relation to national demographics, making up 56.6% of the donors and representing 55% of the U.S. population, according to the researchers. None of the donors identified as Native/Hawaiian/Pacific Islander or American Indian/Alaskan Natives; these groups represent 0.22% and 0.79% of the U.S. population, respectively.
“Next steps will be figuring out why this is happening and how to address it,” said Valerie L Baker, MD, director in the division of reproductive endocrinology and infertility at Johns Hopkins Medicine in Lutherville, Md., who was not involved in the study.
The study sheds light on the need to identify and address the barriers that discourage potential donors from underrepresented groups from participating in sperm donation, according to Kimball Pomeroy, PhD, scientific director at the World Egg and Sperm Bank in Scottsdale, Ariz.
“Sometimes there are inhibitors of different ethnic groups to want to act as sperm or egg donors, so trying to understand if that’s the case is important; but I’m sure a lot of it is also related to access,” Dr. Pomeroy, who was not part of the study team, said in an interview.
Longitudinal data from the two national donor banks did not indicate any significant increase or decrease in donation trends across the 5-year period from 2018 to 2022, highlighting the persisting issue of representation disparities. Dr. Gibbs said strategies need to be developed to increase recruitment of donors from underrepresented groups. Increasing the diversity of the donor pool will ultimately support family-building options for all patients, according to Dr. Gibbs.
Funding for the study was provided by the EMD Serono REI Diversity Fellowship Grant. Dr. Gibbs reports no relevant financial relationships.
, according to a study presented at the American Society for Reproductive Medicine’s 2023 meeting.
“This really highlights the need to identify barriers to increase recruitment of these donors so that we can support family-building for all populations,” said Lauren Gibbs, MD, a resident in the department of obstetrics and gynecology at the Morehouse School of Medicine in Atlanta.
Dr. Gibbs and her colleagues compared the racial and ethnic makeup of sperm donors from online and self-reported profiles at 14 of the largest donor banks in the United States for March and April of 2023. Historical data were pulled from two large, national banks. The investigators compared these data to census estimates from 2021 for men between the ages of 18 and 44 years.
Donors who identified as Hispanic (10.9%) or Black (3.3%) were significantly underrepresented as compared to the U.S. population, of which Hispanic men compose 22% and Black men make up 13.3%.
Asian donors were overrepresented, making up 21.9% of the donors but only 6.5% of the U.S. population. White donors were proportionately represented in relation to national demographics, making up 56.6% of the donors and representing 55% of the U.S. population, according to the researchers. None of the donors identified as Native/Hawaiian/Pacific Islander or American Indian/Alaskan Natives; these groups represent 0.22% and 0.79% of the U.S. population, respectively.
“Next steps will be figuring out why this is happening and how to address it,” said Valerie L Baker, MD, director in the division of reproductive endocrinology and infertility at Johns Hopkins Medicine in Lutherville, Md., who was not involved in the study.
The study sheds light on the need to identify and address the barriers that discourage potential donors from underrepresented groups from participating in sperm donation, according to Kimball Pomeroy, PhD, scientific director at the World Egg and Sperm Bank in Scottsdale, Ariz.
“Sometimes there are inhibitors of different ethnic groups to want to act as sperm or egg donors, so trying to understand if that’s the case is important; but I’m sure a lot of it is also related to access,” Dr. Pomeroy, who was not part of the study team, said in an interview.
Longitudinal data from the two national donor banks did not indicate any significant increase or decrease in donation trends across the 5-year period from 2018 to 2022, highlighting the persisting issue of representation disparities. Dr. Gibbs said strategies need to be developed to increase recruitment of donors from underrepresented groups. Increasing the diversity of the donor pool will ultimately support family-building options for all patients, according to Dr. Gibbs.
Funding for the study was provided by the EMD Serono REI Diversity Fellowship Grant. Dr. Gibbs reports no relevant financial relationships.
FROM ASRM 2023
The Clinical Diversity of Atopic Dermatitis
Atopic dermatitis (AD) is a chronic inflammatory disorder that affects individuals worldwide.1 Although AD previously was commonly described as a skin-limited disease of childhood characterized by eczema in the flexural folds and pruritus, our current understanding supports a more heterogeneous condition.2 We review the wide range of cutaneous presentations of AD with a focus on clinical and morphological presentations across diverse skin types—commonly referred to as skin of color (SOC).
Defining SOC in Relation to AD
The terms SOC, race, and ethnicity are used interchangeably, but their true meanings are distinct. Traditionally, race has been defined as a biological concept, grouping cohorts of individuals with a large degree of shared ancestry and genetic similarities,3 and ethnicity as a social construct, grouping individuals with common racial, national, tribal, religious, linguistic, or cultural backgrounds.4 In practice, both concepts can broadly be envisioned as mixed social, political, and economic constructs, as no one gene or biologic characteristic distinguishes one racial or ethnic group from another.5
The US Census Bureau recognizes 5 racial groupings: White, Black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or other Pacific Islander.6 Hispanic or Latinx origin is considered an ethnicity. It is important to note the limitations of these labels, as they do not completely encapsulate the heterogeneity of the US population. Overgeneralization of racial and ethnic categories may dull or obscure true differences among populations.7
From an evolutionary perspective, skin pigmentation represents the product of 2 opposing clines produced by natural selection in response to both need for and protection from UV radiation across lattitudes.8 Defining SOC is not quite as simple. Skin of color often is equated with certain racial/ethnic groups, or even binary categories of Black vs non-Black or White vs non-White. Others may use the Fitzpatrick scale to discuss SOC, though this scale was originally created to measure the response of skin to UVA radiation exposure.9 The reality is that SOC is a complex term that cannot simply be defined by a certain group of skin tones, races, ethnicities, and/or Fitzpatrick skin types. With this in mind, SOC in the context of this article will often refer to non-White individuals based on the investigators’ terminology, but this definition is not all-encompassing.
Historically in medicine, racial/ethnic differences in outcomes have been equated to differences in biology/genetics without consideration of many external factors.10 The effects of racism, economic stability, health care access, environment, and education quality rarely are discussed, though they have a major impact on health and may better define associations with race or an SOC population. A discussion of the structural and social determinants of health contributing to disease outcomes should accompany any race-based guidelines to prevent inaccurately pathologizing race or SOC.10
Within the scope of AD, social determinants of health play an important role in contributing to disease morbidity. Environmental factors, including tobacco smoke, climate, pollutants, water hardness, und urban living, are related to AD prevalence and severity.11 Higher socioeconomic status is associated with increased AD rates,12 yet lower socioeconomic status is associated with more severe disease.13 Barriers to health care access and suboptimal care drive worse AD outcomes.14 Underrepresentation in clinical trials prevents the generalizability and safety of AD treatments.15 Disparities in these health determinants associated with AD likely are among the most important drivers of observed differences in disease presentation, severity, burden, and even prevalence—more so than genetics or ancestry alone16—yet this relationship is poorly understood and often presented as a consequence of race. It is critical to redefine the narrative when considering the heterogeneous presentations of AD in patients with SOC and acknowledge the limitations of current terminology when attempting to capture clinical diversity in AD, including in this review, where published findings often are limited by race-based analysis.
Epidemiology
The prevalence of AD has been increasing over the last few decades, and rates vary by region. In the United States, the prevalence of childhood and adult AD is 13% and 7%, respectively.17,18 Globally, higher rates of pediatric AD are seen in Africa, Oceania, Southeast Asia (SEA), and Latin America compared to South Asia, Northern Europe, and Eastern Europe.19 The prevalence of AD varies widely within the same continent and country; for example, throughout Africa, prevalence was found to be anywhere between 4.7% and 23.3%.20
Lesion Morphology
Although AD lesions often are described as pruritic erythematous papules and plaques, other common morphologies in SOC populations include prurigo nodules, lichenoid papules, perifollicular papules, nummular lesions, and psoriasiform lesions (Table). Instead of applying normative terms such as classic vs atypical to AD morphology, we urge clinicians to be familiar with the full spectrum of AD skin signs.
Prurigo Nodules—Prurigo nodules are hyperkeratotic or erosive nodules with severe pruritus, often grouped symmetrically on the extensor surfaces of the arms, legs, and trunk (Figure 1).14,21 The skin between lesions usually is unaffected but can be dry or lichenified or display postinflammatory pigmentary changes.14 Prurigo nodules are common. In a study of a cohort of patients with prurigo nodularis (N=108), nearly half (46.3%) were determined to have either an atopic predisposition or underlying AD as a contributing cause of the lesions.21
Prurigo nodules as a phenotype of AD may be more common in certain SOC populations. Studies from SEA have reported a higher prevalence of prurigo nodules among patients with AD.28 Although there are limited formal studies assessing the true prevalence of this lesion type in African American AD patients in the United States, clinical evidence supports more frequent appearance of prurigo nodules in non-White patients.29 Contributing factors include suboptimal care for AD in SOC populations and/or barriers to health care access, resulting in more severe disease that increases the risk for this lesion type.14
Lichenoid Papules—Papular lichenoid lesions often present on the extensor surfaces of the arms and legs in AD (Figure 2).22 In a study of Nigerian patients with AD (N=1019), 54.1% had lichenoid papules.24 A systematic review of AD characteristics by region similarly reported an increased prevalence of this lesion type in African studies.28 Lichenoid variants of AD have been well described in SOC patients in the United States.23 In contrast to the lesions of lichen planus, the lichenoid papules of AD usually are round, rarely display koebnerization, do not have Wickham striae, and predominantly are located on extensor surfaces.
Perifollicular Papules—Perifollicular accentuation—dermatitis enhanced around hair follicles—is a well-described lesional morphology of AD that is noted in all racial/ethnic groups (Figure 3).22 In fact, perifollicular accentuation is included as one of the Hanifin and Rajka minor criteria for AD.30 Studies performed in Nigeria and India showed perifollicular accentuation in up to 70% of AD patients.24,31 In a study of adult Thai patients (N=56), follicular lesions were found more frequently in intrinsic AD (29%) compared with extrinsic AD (12%).32
Nummular and Psoriasiform Lesions—Nummular lesions may be red, oozing, excoriated, studded with pustules and/or present on the extensor extremities (Figure 4). In SOC patients, these lesions often occur in areas where hyperpigmentation is noted.22 Studies in the United States and Mexico demonstrated that 15% to 17% of AD patients displayed nummular lesions.23,33 Similar to follicular papules, nummular lesions were linked to intrinsic AD in a study of adult Thai patients.32
Psoriasiform lesions show prominent scaling, lichenification, and clear demarcation.25 It has been reported that the psoriasiform phenotype of AD is more common in Asian patients,25 though this is likely an oversimplification. The participants in these studies were of Japanese and Korean ancestry, which covers a broad geographic region, and the grouping of individuals under a heterogeneous Asian category is unlikely to convey generalizable biologic or clinical information. Unsurprisingly, a systematic review of AD characteristics by region noted considerable phenotypical differences among patients in SEA, East Asia, Iran, and India.28
Disease Severity
Several factors contribute to AD disease severity,34 including objective assessments of inflammation, such as erythema and lichenification (Table), as well as subjective measures of symptoms, such as itch. The severity of AD is exacerbated by the social determinants of health, and a lower socioeconomic status, lower household income, lower parental education level and health, dilapidated housing, and presence of garbage on the street are among factors linked to worse AD disease severity.13,17 Although non-White individuals with AD often are reported to have more severe disease than their White counterparts,35 these types of health determinants may be the most relevant causes of observed differences.
Erythema—Erythema is a feature of inflammation used in the AD severity assessment. Erythema may appear in shades beyond red, including maroon, violaceous, or brown, in patients with darker pigmented skin, which may contribute to diagnosis of AD at a later disease stage.26 Multiple AD severity scoring tools, such as the SCORing Atopic Dermatitis and Eczema Area and Severity Index, include erythema as a measure, which can lead to underestimation of AD severity in SOC populations. After adjusting for erythema score, one study found that Black children with AD had a risk for severe disease that was 6-times higher than White children.36 Dermatological training must adequately teach physicians to recognize erythema across all skin tones.37
Erythroderma (also known as exfoliative dermatitis) is rapidly spreading erythema on at least 90% of the total body surface area, often sparing the palms and soles.32 Erythroderma is a potentially life-threatening manifestation of severe AD. Although erythroderma may have many underlying causes, AD has been reported to be the cause in 5% to 24% of cases,38 and compared to studies in Europe, the prevalence of erythroderma was higher in East Asian studies of AD.28
Excoriation and Pruritus—Pruritus is a defining characteristic of AD, and the resulting excoriations often are predominant on physical examination, which is a key part of severity scores. Itch is the most prevalent symptom among patients with AD, and a greater itch severity has been linked to decreased health-related quality of life, increased mental health symptoms, impaired sleep, and decreased daily function.39,40 The burden of itch may be greater in SOC populations. The impact of itch on quality of life among US military veterans was significantly higher in those who identified as non-White (P=.05).41 In another study of US military veterans, African American individuals reported a significantly higher emotional impact from itch (P<.05).42
Lichenification—Lichenification is thickening of the skin due to chronic rubbing and scratching that causes a leathery elevated appearance with exaggerated skin lines.27 Lichenification is included as a factor in common clinical scoring tools, with greater lichenification indicating greater disease severity. Studies from SEA and Africa suggested a higher prevalence of lichenification in AD patients.28 A greater itch burden and thus increased rubbing/scratching in these populations may contribute to some of these findings.42,43
Xerosis—Xerosis (or dry skin) is a common finding in AD that results from increased transepidermal water loss due to a dysfunctional epidermal barrier.44 In a systematic review of AD characteristics by region, xerosis was among the top 5 most reported AD features globally in all regions except SEA.28 Xerosis may be more stigmatizing in SOC populations because of the greater visibility of scaling and dryness on darker skin tones.1
Postinflammatory Dyspigmentation—Postinflammatory pigment alteration may be a consequence of AD lesions, resulting in hyperpigmented and hypopigmented macules and patches. Patients with AD with darker skin tones are more likely to develop postinflammatory dyspigmentation.26 A study of AD patients in Nigeria found that 63% displayed postinflammatory dyspigmentation.45 Dyschromia, including postinflammatory hyperpigmentation, is one of the most common reasons for SOC patients to seek dermatologic care.46 Postinflammatory pigment alteration can cause severe distress in patients, even more so than the cutaneous findings of AD. Although altered skin pigmentation usually returns to normal over weeks to months, skin depigmentation from chronic excoriation may be permanent.26 Appropriately treating hyperpigmentation and hypopigmentation in SOC populations can greatly improve quality of life.47
Conclusion
Atopic dermatitis is a cutaneous inflammatory disease that presents with many clinical phenotypes. Dermatologists should be trained to recognize the heterogeneous signs of AD present across the diverse skin types in SOC patients. Future research should move away from race-based analyses and focus on the complex interplay of environmental factors, social determinants of health, and skin pigmentation, as well as how these factors drive variations in AD lesional morphology and inflammation.
- Alexis A, Woolery-Lloyd H, Andriessen A, et al. Insights in skin of color patients with atopic dermatitis and the role of skincare in improving outcomes. J Drugs Dermatol. 2022;21:462-470. doi:10.36849/jdd.6609
- Chovatiya R, Silverberg JI. The heterogeneity of atopic dermatitis. J Drugs Dermatol. 2022;21:172-176. doi:10.36849/JDD.6408
- Taylor SC, Cook-Bolden F. Defining skin of color. Cutis. 2002;69:435-437.
- Georgetown University Center for Child and Human Development. Bridging the cultural divide in health care settings: the essential role of cultural broker programs. Accessed October 6, 2023. https://nccc.georgetown.edu/culturalbroker/8_Definitions/2_Definitions.html#:~:text=ethnic%3A%20Of%20or%20relating%20to,or%20cultural%20origin%20or%20background
- Shoo BA, Kashani-Sabet M. Melanoma arising in African-, Asian-, Latino- and Native-American populations. Semin Cutan Med Surg. 2009;28:96-102. doi:10.1016/j.sder.2009.04.005
- US Census Bureau. About the topic of race. Revised March 1, 2022. Accessed October 5, 2023. https://www.census.gov/topics/population/race/about.html
- Williams HC. Have you ever seen an Asian/Pacific Islander? Arch Dermatol. 2002;138:673-674. doi:10.1001/archderm.138.5.673
- Jablonski NG, Chaplin G. Colloquium paper: human skin pigmentation as an adaptation to UV radiation. Proc Natl Acad Sci U S A. 2010;107(Suppl 2):8962-8968. doi:10.1073/pnas.0914628107
- Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988;124:869-871. doi:10.1001/archderm.124.6.869
- Amutah C, Greenidge K, Mante A, et al. Misrepresenting race—the role of medical schools in propagating physician bias. N Engl J Med. 2021;384:872-878. doi:10.1056/NEJMms2025768
- Kantor R, Silverberg JI. Environmental risk factors and their role in the management of atopic dermatitis. Expert Rev Clin Immunol. 2017;13:15-26. doi:10.1080/1744666x.2016.1212660
- Fu T, Keiser E, Linos E, et al. Eczema and sensitization to common allergens in the United States: a multiethnic, population-based study. Pediatr Dermatol. 2014;31:21-26. doi:10.1111/pde.12237
- Tackett KJ, Jenkins F, Morrell DS, et al. Structural racism and its influence on the severity of atopic dermatitis in African American children. Pediatr Dermatol. 2020;37:142-146. doi:10.1111/pde.14058
- Huang AH, Williams KA, Kwatra SG. Prurigo nodularis: epidemiology and clinical features. J Am Acad Dermatol. 2020;83:1559-1565. doi:10.1016/j.jaad.2020.04.183
- Hirano SA, Murray SB, Harvey VM. Reporting, representation, and subgroup analysis of race and ethnicity in published clinical trials of atopic dermatitis in the United States between 2000 and 2009. Pediatr Dermatol. 2012;29:749-755. doi:10.1111/j.1525-1470.2012.01797.x
- Polcari I, Becker L, Stein SL, et al. Filaggrin gene mutations in African Americans with both ichthyosis vulgaris and atopic dermatitis. Pediatr Dermatol. 2014;31:489-492. doi:10.1111/pde.12355
- Silverberg JI, Simpson EL. Associations of childhood eczema severity: a US population-based study. Dermatitis. 2014;25:107-114. doi:10.1097/DER.0000000000000034
- Hua T, Silverberg JI. Atopic dermatitis in US adults: epidemiology, association with marital status, and atopy. Ann Allergy Asthma Immunol. 2018;121:622-624. doi:10.1016/j.anai.2018.07.019
- Odhiambo JA, Williams HC, Clayton TO, et al. Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three. J Allergy Clin Immunol. 2009;124:1251-8.e23. doi:10.1016/j.jaci.2009.10.009
- Ait-Khaled N, Odhiambo J, Pearce N, et al. Prevalence of symptoms of asthma, rhinitis and eczema in 13- to 14-year-old children in Africa: the International Study of Asthma and Allergies in Childhood Phase III. Allergy. 2007;62:247-258. doi:10.1111/j.1398-9995.2007.01325.x
- Iking A, Grundmann S, Chatzigeorgakidis E, et al. Prurigo as a symptom of atopic and non-atopic diseases: aetiological survey in a consecutive cohort of 108 patients. J Eur Acad Dermatol Venereol. 2013;27:550-557. doi:10.1111/j.1468-3083.2012.04481.x
- Silverberg NB. Typical and atypical clinical appearance of atopic dermatitis. Clin Dermatol. 2017;35:354-359. doi:10.1016/j.clindermatol.2017.03.007
- Allen HB, Jones NP, Bowen SE. Lichenoid and other clinical presentations of atopic dermatitis in an inner city practice. J Am Acad Dermatol. 2008;58:503-504. doi:10.1016/j.jaad.2007.03.033
- Nnoruka EN. Current epidemiology of atopic dermatitis in south-eastern Nigeria. Int J Dermatol. 2004;43:739-744. doi:10.1111/j.1365-4632.2004.02360.x
- Noda S, Suárez-Fariñas M, Ungar B, et al. The Asian atopic dermatitis phenotype combines features of atopic dermatitis and psoriasis with increased TH17 polarization. J Allergy Clin Immunol. 2015;136:1254-1264. doi:10.1016/j.jaci.2015.08.015
- Kaufman BP, Guttman-Yassky E, Alexis AF. Atopic dermatitis in diverse racial and ethnic groups-variations in epidemiology, genetics, clinical presentation and treatment. Exp Dermatol. 2018;27:340-357. doi:10.1111/exd.13514
- Girolomoni G, de Bruin-Weller M, Aoki V, et al. Nomenclature and clinical phenotypes of atopic dermatitis. Ther Adv Chronic Dis. 2021;12:20406223211002979. doi:10.1177/20406223211002979
- Yew YW, Thyssen JP, Silverberg JI. A systematic review and meta-analysis of the regional and age-related differences in atopic dermatitis clinical characteristics. J Am Acad Dermatol. 2019;80:390-401. doi:10.1016/j.jaad.2018.09.035
- Vachiramon V, Tey HL, Thompson AE, et al. Atopic dermatitis in African American children: addressing unmet needs of a common disease. Pediatr Dermatol. 2012;29:395-402. doi:10.1111/j.1525-1470.2012.01740.x
- Hanifin JM. Diagnostic features of atopic dermatitis. Acta Derm Venereol. 1980;92:44-47.
- Dutta A, De A, Das S, et al. A cross-sectional evaluation of the usefulness of the minor features of Hanifin and Rajka diagnostic criteria for the diagnosis of atopic dermatitis in the pediatric population. Indian J Dermatol. 2021;66:583-590. doi:10.4103/ijd.ijd_1046_20
- Kulthanan K, Boochangkool K, Tuchinda P, et al. Clinical features of the extrinsic and intrinsic types of adult-onset atopic dermatitis. Asia Pac Allergy. 2011;1:80-86. doi:10.5415/apallergy.2011.1.2.80
- Julián-Gónzalez RE, Orozco-Covarrubias L, Durán-McKinster C, et al. Less common clinical manifestations of atopic dermatitis: prevalence by age. Pediatr Dermatol. 2012;29:580-583. doi:10.1111/j.1525-1470.2012.01739.x
- Chovatiya R, Silverberg JI. Evaluating the longitudinal course of atopic dermatitis: a review of the literature. J Am Acad Dermatol. 2022;87:688-689. doi:10.1016/j.jaad.2022.02.005
- Kim Y, Blomberg M, Rifas-Shiman SL, et al. Racial/ethnic differences in incidence and persistence of childhood atopic dermatitis. J Invest Dermatol. 2019;139:827-834. doi:10.1016/j.jid.2018.10.029
- Ben-Gashir MA, Hay RJ. Reliance on erythema scores may mask severe atopic dermatitis in black children compared with their white counterparts. Br J Dermatol. 2002;147:920-925. doi:10.1046/j.1365-2133.2002.04965.x
- McKenzie S, Brown-Korsah JB, Syder NC, et al. Variations in genetics, biology, and phenotype of cutaneous disorders in skin of color. part II: differences in clinical presentation and disparities in cutaneous disorders in skin of color. J Am Acad Dermatol. 2022;87:1261-1270. doi:10.1016/j.jaad.2022.03.067
- Cuellar-Barboza A, Ocampo-Candiani J, Herz-Ruelas ME. A practical approach to the diagnosis and treatment of adult erythroderma [in English, Spanish]. Actas Dermosifiliogr (Engl Ed). 2018;109:777-790. doi:10.1016/j.ad.2018.05.011
- Lei DK, Yousaf M, Janmohamed SR, et al. Validation of patient-reported outcomes information system sleep disturbance and sleep-related impairment in adults with atopic dermatitis. Br J Dermatol. 2020;183:875-882. doi:10.1111/bjd.18920
- Silverberg JI, Gelfand JM, Margolis DJ, et al. Patient burden and quality of life in atopic dermatitis in US adults: a population-based cross-sectional study. Ann Allergy Asthma Immunol. 2018;121:340-347. doi:10.1016/j.anai.2018.07.006
- Carr CW, Veledar E, Chen SC. Factors mediating the impact of chronic pruritus on quality of life. JAMA Dermatol. 2014;150:613-620. doi:10.1001/jamadermatol.2013.7696
- Shaw FM, Luk KMH, Chen KH, et al. Racial disparities in the impact of chronic pruritus: a cross-sectional study on quality of life and resource utilization in United States veterans. J Am Acad Dermatol. 2017;77:63-69. doi:10.1016/j.jaad.2017.01.016
- Oh CC, Li H, Lee W, et al. Biopsychosocial factors associated with prurigo nodularis in endogenous eczema. Indian J Dermatol. 2015;60:525. doi:10.4103/0019-5154.164451
- Vyumvuhore R, Michael-Jubeli R, Verzeaux L, et al. Lipid organization in xerosis: the key of the problem? Int J Cosmet Sci. 2018;40:549-554. doi:10.1111/ics.12496
- George AO. Atopic dermatitis in Nigeria. Int J Dermatol. 1989;28:237-239. doi:10.1111/j.1365-4362.1989.tb04811.x
- Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis. 2007;80:387-394.
- Grayson C, Heath CR. Dupilumab improves atopic dermatitis and post-inflammatory hyperpigmentation in patient with skin of color. J Drugs Dermatol. 2020;19:776-778. doi:10.36849/jdd.2020.4937
Atopic dermatitis (AD) is a chronic inflammatory disorder that affects individuals worldwide.1 Although AD previously was commonly described as a skin-limited disease of childhood characterized by eczema in the flexural folds and pruritus, our current understanding supports a more heterogeneous condition.2 We review the wide range of cutaneous presentations of AD with a focus on clinical and morphological presentations across diverse skin types—commonly referred to as skin of color (SOC).
Defining SOC in Relation to AD
The terms SOC, race, and ethnicity are used interchangeably, but their true meanings are distinct. Traditionally, race has been defined as a biological concept, grouping cohorts of individuals with a large degree of shared ancestry and genetic similarities,3 and ethnicity as a social construct, grouping individuals with common racial, national, tribal, religious, linguistic, or cultural backgrounds.4 In practice, both concepts can broadly be envisioned as mixed social, political, and economic constructs, as no one gene or biologic characteristic distinguishes one racial or ethnic group from another.5
The US Census Bureau recognizes 5 racial groupings: White, Black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or other Pacific Islander.6 Hispanic or Latinx origin is considered an ethnicity. It is important to note the limitations of these labels, as they do not completely encapsulate the heterogeneity of the US population. Overgeneralization of racial and ethnic categories may dull or obscure true differences among populations.7
From an evolutionary perspective, skin pigmentation represents the product of 2 opposing clines produced by natural selection in response to both need for and protection from UV radiation across lattitudes.8 Defining SOC is not quite as simple. Skin of color often is equated with certain racial/ethnic groups, or even binary categories of Black vs non-Black or White vs non-White. Others may use the Fitzpatrick scale to discuss SOC, though this scale was originally created to measure the response of skin to UVA radiation exposure.9 The reality is that SOC is a complex term that cannot simply be defined by a certain group of skin tones, races, ethnicities, and/or Fitzpatrick skin types. With this in mind, SOC in the context of this article will often refer to non-White individuals based on the investigators’ terminology, but this definition is not all-encompassing.
Historically in medicine, racial/ethnic differences in outcomes have been equated to differences in biology/genetics without consideration of many external factors.10 The effects of racism, economic stability, health care access, environment, and education quality rarely are discussed, though they have a major impact on health and may better define associations with race or an SOC population. A discussion of the structural and social determinants of health contributing to disease outcomes should accompany any race-based guidelines to prevent inaccurately pathologizing race or SOC.10
Within the scope of AD, social determinants of health play an important role in contributing to disease morbidity. Environmental factors, including tobacco smoke, climate, pollutants, water hardness, und urban living, are related to AD prevalence and severity.11 Higher socioeconomic status is associated with increased AD rates,12 yet lower socioeconomic status is associated with more severe disease.13 Barriers to health care access and suboptimal care drive worse AD outcomes.14 Underrepresentation in clinical trials prevents the generalizability and safety of AD treatments.15 Disparities in these health determinants associated with AD likely are among the most important drivers of observed differences in disease presentation, severity, burden, and even prevalence—more so than genetics or ancestry alone16—yet this relationship is poorly understood and often presented as a consequence of race. It is critical to redefine the narrative when considering the heterogeneous presentations of AD in patients with SOC and acknowledge the limitations of current terminology when attempting to capture clinical diversity in AD, including in this review, where published findings often are limited by race-based analysis.
Epidemiology
The prevalence of AD has been increasing over the last few decades, and rates vary by region. In the United States, the prevalence of childhood and adult AD is 13% and 7%, respectively.17,18 Globally, higher rates of pediatric AD are seen in Africa, Oceania, Southeast Asia (SEA), and Latin America compared to South Asia, Northern Europe, and Eastern Europe.19 The prevalence of AD varies widely within the same continent and country; for example, throughout Africa, prevalence was found to be anywhere between 4.7% and 23.3%.20
Lesion Morphology
Although AD lesions often are described as pruritic erythematous papules and plaques, other common morphologies in SOC populations include prurigo nodules, lichenoid papules, perifollicular papules, nummular lesions, and psoriasiform lesions (Table). Instead of applying normative terms such as classic vs atypical to AD morphology, we urge clinicians to be familiar with the full spectrum of AD skin signs.
Prurigo Nodules—Prurigo nodules are hyperkeratotic or erosive nodules with severe pruritus, often grouped symmetrically on the extensor surfaces of the arms, legs, and trunk (Figure 1).14,21 The skin between lesions usually is unaffected but can be dry or lichenified or display postinflammatory pigmentary changes.14 Prurigo nodules are common. In a study of a cohort of patients with prurigo nodularis (N=108), nearly half (46.3%) were determined to have either an atopic predisposition or underlying AD as a contributing cause of the lesions.21
Prurigo nodules as a phenotype of AD may be more common in certain SOC populations. Studies from SEA have reported a higher prevalence of prurigo nodules among patients with AD.28 Although there are limited formal studies assessing the true prevalence of this lesion type in African American AD patients in the United States, clinical evidence supports more frequent appearance of prurigo nodules in non-White patients.29 Contributing factors include suboptimal care for AD in SOC populations and/or barriers to health care access, resulting in more severe disease that increases the risk for this lesion type.14
Lichenoid Papules—Papular lichenoid lesions often present on the extensor surfaces of the arms and legs in AD (Figure 2).22 In a study of Nigerian patients with AD (N=1019), 54.1% had lichenoid papules.24 A systematic review of AD characteristics by region similarly reported an increased prevalence of this lesion type in African studies.28 Lichenoid variants of AD have been well described in SOC patients in the United States.23 In contrast to the lesions of lichen planus, the lichenoid papules of AD usually are round, rarely display koebnerization, do not have Wickham striae, and predominantly are located on extensor surfaces.
Perifollicular Papules—Perifollicular accentuation—dermatitis enhanced around hair follicles—is a well-described lesional morphology of AD that is noted in all racial/ethnic groups (Figure 3).22 In fact, perifollicular accentuation is included as one of the Hanifin and Rajka minor criteria for AD.30 Studies performed in Nigeria and India showed perifollicular accentuation in up to 70% of AD patients.24,31 In a study of adult Thai patients (N=56), follicular lesions were found more frequently in intrinsic AD (29%) compared with extrinsic AD (12%).32
Nummular and Psoriasiform Lesions—Nummular lesions may be red, oozing, excoriated, studded with pustules and/or present on the extensor extremities (Figure 4). In SOC patients, these lesions often occur in areas where hyperpigmentation is noted.22 Studies in the United States and Mexico demonstrated that 15% to 17% of AD patients displayed nummular lesions.23,33 Similar to follicular papules, nummular lesions were linked to intrinsic AD in a study of adult Thai patients.32
Psoriasiform lesions show prominent scaling, lichenification, and clear demarcation.25 It has been reported that the psoriasiform phenotype of AD is more common in Asian patients,25 though this is likely an oversimplification. The participants in these studies were of Japanese and Korean ancestry, which covers a broad geographic region, and the grouping of individuals under a heterogeneous Asian category is unlikely to convey generalizable biologic or clinical information. Unsurprisingly, a systematic review of AD characteristics by region noted considerable phenotypical differences among patients in SEA, East Asia, Iran, and India.28
Disease Severity
Several factors contribute to AD disease severity,34 including objective assessments of inflammation, such as erythema and lichenification (Table), as well as subjective measures of symptoms, such as itch. The severity of AD is exacerbated by the social determinants of health, and a lower socioeconomic status, lower household income, lower parental education level and health, dilapidated housing, and presence of garbage on the street are among factors linked to worse AD disease severity.13,17 Although non-White individuals with AD often are reported to have more severe disease than their White counterparts,35 these types of health determinants may be the most relevant causes of observed differences.
Erythema—Erythema is a feature of inflammation used in the AD severity assessment. Erythema may appear in shades beyond red, including maroon, violaceous, or brown, in patients with darker pigmented skin, which may contribute to diagnosis of AD at a later disease stage.26 Multiple AD severity scoring tools, such as the SCORing Atopic Dermatitis and Eczema Area and Severity Index, include erythema as a measure, which can lead to underestimation of AD severity in SOC populations. After adjusting for erythema score, one study found that Black children with AD had a risk for severe disease that was 6-times higher than White children.36 Dermatological training must adequately teach physicians to recognize erythema across all skin tones.37
Erythroderma (also known as exfoliative dermatitis) is rapidly spreading erythema on at least 90% of the total body surface area, often sparing the palms and soles.32 Erythroderma is a potentially life-threatening manifestation of severe AD. Although erythroderma may have many underlying causes, AD has been reported to be the cause in 5% to 24% of cases,38 and compared to studies in Europe, the prevalence of erythroderma was higher in East Asian studies of AD.28
Excoriation and Pruritus—Pruritus is a defining characteristic of AD, and the resulting excoriations often are predominant on physical examination, which is a key part of severity scores. Itch is the most prevalent symptom among patients with AD, and a greater itch severity has been linked to decreased health-related quality of life, increased mental health symptoms, impaired sleep, and decreased daily function.39,40 The burden of itch may be greater in SOC populations. The impact of itch on quality of life among US military veterans was significantly higher in those who identified as non-White (P=.05).41 In another study of US military veterans, African American individuals reported a significantly higher emotional impact from itch (P<.05).42
Lichenification—Lichenification is thickening of the skin due to chronic rubbing and scratching that causes a leathery elevated appearance with exaggerated skin lines.27 Lichenification is included as a factor in common clinical scoring tools, with greater lichenification indicating greater disease severity. Studies from SEA and Africa suggested a higher prevalence of lichenification in AD patients.28 A greater itch burden and thus increased rubbing/scratching in these populations may contribute to some of these findings.42,43
Xerosis—Xerosis (or dry skin) is a common finding in AD that results from increased transepidermal water loss due to a dysfunctional epidermal barrier.44 In a systematic review of AD characteristics by region, xerosis was among the top 5 most reported AD features globally in all regions except SEA.28 Xerosis may be more stigmatizing in SOC populations because of the greater visibility of scaling and dryness on darker skin tones.1
Postinflammatory Dyspigmentation—Postinflammatory pigment alteration may be a consequence of AD lesions, resulting in hyperpigmented and hypopigmented macules and patches. Patients with AD with darker skin tones are more likely to develop postinflammatory dyspigmentation.26 A study of AD patients in Nigeria found that 63% displayed postinflammatory dyspigmentation.45 Dyschromia, including postinflammatory hyperpigmentation, is one of the most common reasons for SOC patients to seek dermatologic care.46 Postinflammatory pigment alteration can cause severe distress in patients, even more so than the cutaneous findings of AD. Although altered skin pigmentation usually returns to normal over weeks to months, skin depigmentation from chronic excoriation may be permanent.26 Appropriately treating hyperpigmentation and hypopigmentation in SOC populations can greatly improve quality of life.47
Conclusion
Atopic dermatitis is a cutaneous inflammatory disease that presents with many clinical phenotypes. Dermatologists should be trained to recognize the heterogeneous signs of AD present across the diverse skin types in SOC patients. Future research should move away from race-based analyses and focus on the complex interplay of environmental factors, social determinants of health, and skin pigmentation, as well as how these factors drive variations in AD lesional morphology and inflammation.
Atopic dermatitis (AD) is a chronic inflammatory disorder that affects individuals worldwide.1 Although AD previously was commonly described as a skin-limited disease of childhood characterized by eczema in the flexural folds and pruritus, our current understanding supports a more heterogeneous condition.2 We review the wide range of cutaneous presentations of AD with a focus on clinical and morphological presentations across diverse skin types—commonly referred to as skin of color (SOC).
Defining SOC in Relation to AD
The terms SOC, race, and ethnicity are used interchangeably, but their true meanings are distinct. Traditionally, race has been defined as a biological concept, grouping cohorts of individuals with a large degree of shared ancestry and genetic similarities,3 and ethnicity as a social construct, grouping individuals with common racial, national, tribal, religious, linguistic, or cultural backgrounds.4 In practice, both concepts can broadly be envisioned as mixed social, political, and economic constructs, as no one gene or biologic characteristic distinguishes one racial or ethnic group from another.5
The US Census Bureau recognizes 5 racial groupings: White, Black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or other Pacific Islander.6 Hispanic or Latinx origin is considered an ethnicity. It is important to note the limitations of these labels, as they do not completely encapsulate the heterogeneity of the US population. Overgeneralization of racial and ethnic categories may dull or obscure true differences among populations.7
From an evolutionary perspective, skin pigmentation represents the product of 2 opposing clines produced by natural selection in response to both need for and protection from UV radiation across lattitudes.8 Defining SOC is not quite as simple. Skin of color often is equated with certain racial/ethnic groups, or even binary categories of Black vs non-Black or White vs non-White. Others may use the Fitzpatrick scale to discuss SOC, though this scale was originally created to measure the response of skin to UVA radiation exposure.9 The reality is that SOC is a complex term that cannot simply be defined by a certain group of skin tones, races, ethnicities, and/or Fitzpatrick skin types. With this in mind, SOC in the context of this article will often refer to non-White individuals based on the investigators’ terminology, but this definition is not all-encompassing.
Historically in medicine, racial/ethnic differences in outcomes have been equated to differences in biology/genetics without consideration of many external factors.10 The effects of racism, economic stability, health care access, environment, and education quality rarely are discussed, though they have a major impact on health and may better define associations with race or an SOC population. A discussion of the structural and social determinants of health contributing to disease outcomes should accompany any race-based guidelines to prevent inaccurately pathologizing race or SOC.10
Within the scope of AD, social determinants of health play an important role in contributing to disease morbidity. Environmental factors, including tobacco smoke, climate, pollutants, water hardness, und urban living, are related to AD prevalence and severity.11 Higher socioeconomic status is associated with increased AD rates,12 yet lower socioeconomic status is associated with more severe disease.13 Barriers to health care access and suboptimal care drive worse AD outcomes.14 Underrepresentation in clinical trials prevents the generalizability and safety of AD treatments.15 Disparities in these health determinants associated with AD likely are among the most important drivers of observed differences in disease presentation, severity, burden, and even prevalence—more so than genetics or ancestry alone16—yet this relationship is poorly understood and often presented as a consequence of race. It is critical to redefine the narrative when considering the heterogeneous presentations of AD in patients with SOC and acknowledge the limitations of current terminology when attempting to capture clinical diversity in AD, including in this review, where published findings often are limited by race-based analysis.
Epidemiology
The prevalence of AD has been increasing over the last few decades, and rates vary by region. In the United States, the prevalence of childhood and adult AD is 13% and 7%, respectively.17,18 Globally, higher rates of pediatric AD are seen in Africa, Oceania, Southeast Asia (SEA), and Latin America compared to South Asia, Northern Europe, and Eastern Europe.19 The prevalence of AD varies widely within the same continent and country; for example, throughout Africa, prevalence was found to be anywhere between 4.7% and 23.3%.20
Lesion Morphology
Although AD lesions often are described as pruritic erythematous papules and plaques, other common morphologies in SOC populations include prurigo nodules, lichenoid papules, perifollicular papules, nummular lesions, and psoriasiform lesions (Table). Instead of applying normative terms such as classic vs atypical to AD morphology, we urge clinicians to be familiar with the full spectrum of AD skin signs.
Prurigo Nodules—Prurigo nodules are hyperkeratotic or erosive nodules with severe pruritus, often grouped symmetrically on the extensor surfaces of the arms, legs, and trunk (Figure 1).14,21 The skin between lesions usually is unaffected but can be dry or lichenified or display postinflammatory pigmentary changes.14 Prurigo nodules are common. In a study of a cohort of patients with prurigo nodularis (N=108), nearly half (46.3%) were determined to have either an atopic predisposition or underlying AD as a contributing cause of the lesions.21
Prurigo nodules as a phenotype of AD may be more common in certain SOC populations. Studies from SEA have reported a higher prevalence of prurigo nodules among patients with AD.28 Although there are limited formal studies assessing the true prevalence of this lesion type in African American AD patients in the United States, clinical evidence supports more frequent appearance of prurigo nodules in non-White patients.29 Contributing factors include suboptimal care for AD in SOC populations and/or barriers to health care access, resulting in more severe disease that increases the risk for this lesion type.14
Lichenoid Papules—Papular lichenoid lesions often present on the extensor surfaces of the arms and legs in AD (Figure 2).22 In a study of Nigerian patients with AD (N=1019), 54.1% had lichenoid papules.24 A systematic review of AD characteristics by region similarly reported an increased prevalence of this lesion type in African studies.28 Lichenoid variants of AD have been well described in SOC patients in the United States.23 In contrast to the lesions of lichen planus, the lichenoid papules of AD usually are round, rarely display koebnerization, do not have Wickham striae, and predominantly are located on extensor surfaces.
Perifollicular Papules—Perifollicular accentuation—dermatitis enhanced around hair follicles—is a well-described lesional morphology of AD that is noted in all racial/ethnic groups (Figure 3).22 In fact, perifollicular accentuation is included as one of the Hanifin and Rajka minor criteria for AD.30 Studies performed in Nigeria and India showed perifollicular accentuation in up to 70% of AD patients.24,31 In a study of adult Thai patients (N=56), follicular lesions were found more frequently in intrinsic AD (29%) compared with extrinsic AD (12%).32
Nummular and Psoriasiform Lesions—Nummular lesions may be red, oozing, excoriated, studded with pustules and/or present on the extensor extremities (Figure 4). In SOC patients, these lesions often occur in areas where hyperpigmentation is noted.22 Studies in the United States and Mexico demonstrated that 15% to 17% of AD patients displayed nummular lesions.23,33 Similar to follicular papules, nummular lesions were linked to intrinsic AD in a study of adult Thai patients.32
Psoriasiform lesions show prominent scaling, lichenification, and clear demarcation.25 It has been reported that the psoriasiform phenotype of AD is more common in Asian patients,25 though this is likely an oversimplification. The participants in these studies were of Japanese and Korean ancestry, which covers a broad geographic region, and the grouping of individuals under a heterogeneous Asian category is unlikely to convey generalizable biologic or clinical information. Unsurprisingly, a systematic review of AD characteristics by region noted considerable phenotypical differences among patients in SEA, East Asia, Iran, and India.28
Disease Severity
Several factors contribute to AD disease severity,34 including objective assessments of inflammation, such as erythema and lichenification (Table), as well as subjective measures of symptoms, such as itch. The severity of AD is exacerbated by the social determinants of health, and a lower socioeconomic status, lower household income, lower parental education level and health, dilapidated housing, and presence of garbage on the street are among factors linked to worse AD disease severity.13,17 Although non-White individuals with AD often are reported to have more severe disease than their White counterparts,35 these types of health determinants may be the most relevant causes of observed differences.
Erythema—Erythema is a feature of inflammation used in the AD severity assessment. Erythema may appear in shades beyond red, including maroon, violaceous, or brown, in patients with darker pigmented skin, which may contribute to diagnosis of AD at a later disease stage.26 Multiple AD severity scoring tools, such as the SCORing Atopic Dermatitis and Eczema Area and Severity Index, include erythema as a measure, which can lead to underestimation of AD severity in SOC populations. After adjusting for erythema score, one study found that Black children with AD had a risk for severe disease that was 6-times higher than White children.36 Dermatological training must adequately teach physicians to recognize erythema across all skin tones.37
Erythroderma (also known as exfoliative dermatitis) is rapidly spreading erythema on at least 90% of the total body surface area, often sparing the palms and soles.32 Erythroderma is a potentially life-threatening manifestation of severe AD. Although erythroderma may have many underlying causes, AD has been reported to be the cause in 5% to 24% of cases,38 and compared to studies in Europe, the prevalence of erythroderma was higher in East Asian studies of AD.28
Excoriation and Pruritus—Pruritus is a defining characteristic of AD, and the resulting excoriations often are predominant on physical examination, which is a key part of severity scores. Itch is the most prevalent symptom among patients with AD, and a greater itch severity has been linked to decreased health-related quality of life, increased mental health symptoms, impaired sleep, and decreased daily function.39,40 The burden of itch may be greater in SOC populations. The impact of itch on quality of life among US military veterans was significantly higher in those who identified as non-White (P=.05).41 In another study of US military veterans, African American individuals reported a significantly higher emotional impact from itch (P<.05).42
Lichenification—Lichenification is thickening of the skin due to chronic rubbing and scratching that causes a leathery elevated appearance with exaggerated skin lines.27 Lichenification is included as a factor in common clinical scoring tools, with greater lichenification indicating greater disease severity. Studies from SEA and Africa suggested a higher prevalence of lichenification in AD patients.28 A greater itch burden and thus increased rubbing/scratching in these populations may contribute to some of these findings.42,43
Xerosis—Xerosis (or dry skin) is a common finding in AD that results from increased transepidermal water loss due to a dysfunctional epidermal barrier.44 In a systematic review of AD characteristics by region, xerosis was among the top 5 most reported AD features globally in all regions except SEA.28 Xerosis may be more stigmatizing in SOC populations because of the greater visibility of scaling and dryness on darker skin tones.1
Postinflammatory Dyspigmentation—Postinflammatory pigment alteration may be a consequence of AD lesions, resulting in hyperpigmented and hypopigmented macules and patches. Patients with AD with darker skin tones are more likely to develop postinflammatory dyspigmentation.26 A study of AD patients in Nigeria found that 63% displayed postinflammatory dyspigmentation.45 Dyschromia, including postinflammatory hyperpigmentation, is one of the most common reasons for SOC patients to seek dermatologic care.46 Postinflammatory pigment alteration can cause severe distress in patients, even more so than the cutaneous findings of AD. Although altered skin pigmentation usually returns to normal over weeks to months, skin depigmentation from chronic excoriation may be permanent.26 Appropriately treating hyperpigmentation and hypopigmentation in SOC populations can greatly improve quality of life.47
Conclusion
Atopic dermatitis is a cutaneous inflammatory disease that presents with many clinical phenotypes. Dermatologists should be trained to recognize the heterogeneous signs of AD present across the diverse skin types in SOC patients. Future research should move away from race-based analyses and focus on the complex interplay of environmental factors, social determinants of health, and skin pigmentation, as well as how these factors drive variations in AD lesional morphology and inflammation.
- Alexis A, Woolery-Lloyd H, Andriessen A, et al. Insights in skin of color patients with atopic dermatitis and the role of skincare in improving outcomes. J Drugs Dermatol. 2022;21:462-470. doi:10.36849/jdd.6609
- Chovatiya R, Silverberg JI. The heterogeneity of atopic dermatitis. J Drugs Dermatol. 2022;21:172-176. doi:10.36849/JDD.6408
- Taylor SC, Cook-Bolden F. Defining skin of color. Cutis. 2002;69:435-437.
- Georgetown University Center for Child and Human Development. Bridging the cultural divide in health care settings: the essential role of cultural broker programs. Accessed October 6, 2023. https://nccc.georgetown.edu/culturalbroker/8_Definitions/2_Definitions.html#:~:text=ethnic%3A%20Of%20or%20relating%20to,or%20cultural%20origin%20or%20background
- Shoo BA, Kashani-Sabet M. Melanoma arising in African-, Asian-, Latino- and Native-American populations. Semin Cutan Med Surg. 2009;28:96-102. doi:10.1016/j.sder.2009.04.005
- US Census Bureau. About the topic of race. Revised March 1, 2022. Accessed October 5, 2023. https://www.census.gov/topics/population/race/about.html
- Williams HC. Have you ever seen an Asian/Pacific Islander? Arch Dermatol. 2002;138:673-674. doi:10.1001/archderm.138.5.673
- Jablonski NG, Chaplin G. Colloquium paper: human skin pigmentation as an adaptation to UV radiation. Proc Natl Acad Sci U S A. 2010;107(Suppl 2):8962-8968. doi:10.1073/pnas.0914628107
- Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988;124:869-871. doi:10.1001/archderm.124.6.869
- Amutah C, Greenidge K, Mante A, et al. Misrepresenting race—the role of medical schools in propagating physician bias. N Engl J Med. 2021;384:872-878. doi:10.1056/NEJMms2025768
- Kantor R, Silverberg JI. Environmental risk factors and their role in the management of atopic dermatitis. Expert Rev Clin Immunol. 2017;13:15-26. doi:10.1080/1744666x.2016.1212660
- Fu T, Keiser E, Linos E, et al. Eczema and sensitization to common allergens in the United States: a multiethnic, population-based study. Pediatr Dermatol. 2014;31:21-26. doi:10.1111/pde.12237
- Tackett KJ, Jenkins F, Morrell DS, et al. Structural racism and its influence on the severity of atopic dermatitis in African American children. Pediatr Dermatol. 2020;37:142-146. doi:10.1111/pde.14058
- Huang AH, Williams KA, Kwatra SG. Prurigo nodularis: epidemiology and clinical features. J Am Acad Dermatol. 2020;83:1559-1565. doi:10.1016/j.jaad.2020.04.183
- Hirano SA, Murray SB, Harvey VM. Reporting, representation, and subgroup analysis of race and ethnicity in published clinical trials of atopic dermatitis in the United States between 2000 and 2009. Pediatr Dermatol. 2012;29:749-755. doi:10.1111/j.1525-1470.2012.01797.x
- Polcari I, Becker L, Stein SL, et al. Filaggrin gene mutations in African Americans with both ichthyosis vulgaris and atopic dermatitis. Pediatr Dermatol. 2014;31:489-492. doi:10.1111/pde.12355
- Silverberg JI, Simpson EL. Associations of childhood eczema severity: a US population-based study. Dermatitis. 2014;25:107-114. doi:10.1097/DER.0000000000000034
- Hua T, Silverberg JI. Atopic dermatitis in US adults: epidemiology, association with marital status, and atopy. Ann Allergy Asthma Immunol. 2018;121:622-624. doi:10.1016/j.anai.2018.07.019
- Odhiambo JA, Williams HC, Clayton TO, et al. Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three. J Allergy Clin Immunol. 2009;124:1251-8.e23. doi:10.1016/j.jaci.2009.10.009
- Ait-Khaled N, Odhiambo J, Pearce N, et al. Prevalence of symptoms of asthma, rhinitis and eczema in 13- to 14-year-old children in Africa: the International Study of Asthma and Allergies in Childhood Phase III. Allergy. 2007;62:247-258. doi:10.1111/j.1398-9995.2007.01325.x
- Iking A, Grundmann S, Chatzigeorgakidis E, et al. Prurigo as a symptom of atopic and non-atopic diseases: aetiological survey in a consecutive cohort of 108 patients. J Eur Acad Dermatol Venereol. 2013;27:550-557. doi:10.1111/j.1468-3083.2012.04481.x
- Silverberg NB. Typical and atypical clinical appearance of atopic dermatitis. Clin Dermatol. 2017;35:354-359. doi:10.1016/j.clindermatol.2017.03.007
- Allen HB, Jones NP, Bowen SE. Lichenoid and other clinical presentations of atopic dermatitis in an inner city practice. J Am Acad Dermatol. 2008;58:503-504. doi:10.1016/j.jaad.2007.03.033
- Nnoruka EN. Current epidemiology of atopic dermatitis in south-eastern Nigeria. Int J Dermatol. 2004;43:739-744. doi:10.1111/j.1365-4632.2004.02360.x
- Noda S, Suárez-Fariñas M, Ungar B, et al. The Asian atopic dermatitis phenotype combines features of atopic dermatitis and psoriasis with increased TH17 polarization. J Allergy Clin Immunol. 2015;136:1254-1264. doi:10.1016/j.jaci.2015.08.015
- Kaufman BP, Guttman-Yassky E, Alexis AF. Atopic dermatitis in diverse racial and ethnic groups-variations in epidemiology, genetics, clinical presentation and treatment. Exp Dermatol. 2018;27:340-357. doi:10.1111/exd.13514
- Girolomoni G, de Bruin-Weller M, Aoki V, et al. Nomenclature and clinical phenotypes of atopic dermatitis. Ther Adv Chronic Dis. 2021;12:20406223211002979. doi:10.1177/20406223211002979
- Yew YW, Thyssen JP, Silverberg JI. A systematic review and meta-analysis of the regional and age-related differences in atopic dermatitis clinical characteristics. J Am Acad Dermatol. 2019;80:390-401. doi:10.1016/j.jaad.2018.09.035
- Vachiramon V, Tey HL, Thompson AE, et al. Atopic dermatitis in African American children: addressing unmet needs of a common disease. Pediatr Dermatol. 2012;29:395-402. doi:10.1111/j.1525-1470.2012.01740.x
- Hanifin JM. Diagnostic features of atopic dermatitis. Acta Derm Venereol. 1980;92:44-47.
- Dutta A, De A, Das S, et al. A cross-sectional evaluation of the usefulness of the minor features of Hanifin and Rajka diagnostic criteria for the diagnosis of atopic dermatitis in the pediatric population. Indian J Dermatol. 2021;66:583-590. doi:10.4103/ijd.ijd_1046_20
- Kulthanan K, Boochangkool K, Tuchinda P, et al. Clinical features of the extrinsic and intrinsic types of adult-onset atopic dermatitis. Asia Pac Allergy. 2011;1:80-86. doi:10.5415/apallergy.2011.1.2.80
- Julián-Gónzalez RE, Orozco-Covarrubias L, Durán-McKinster C, et al. Less common clinical manifestations of atopic dermatitis: prevalence by age. Pediatr Dermatol. 2012;29:580-583. doi:10.1111/j.1525-1470.2012.01739.x
- Chovatiya R, Silverberg JI. Evaluating the longitudinal course of atopic dermatitis: a review of the literature. J Am Acad Dermatol. 2022;87:688-689. doi:10.1016/j.jaad.2022.02.005
- Kim Y, Blomberg M, Rifas-Shiman SL, et al. Racial/ethnic differences in incidence and persistence of childhood atopic dermatitis. J Invest Dermatol. 2019;139:827-834. doi:10.1016/j.jid.2018.10.029
- Ben-Gashir MA, Hay RJ. Reliance on erythema scores may mask severe atopic dermatitis in black children compared with their white counterparts. Br J Dermatol. 2002;147:920-925. doi:10.1046/j.1365-2133.2002.04965.x
- McKenzie S, Brown-Korsah JB, Syder NC, et al. Variations in genetics, biology, and phenotype of cutaneous disorders in skin of color. part II: differences in clinical presentation and disparities in cutaneous disorders in skin of color. J Am Acad Dermatol. 2022;87:1261-1270. doi:10.1016/j.jaad.2022.03.067
- Cuellar-Barboza A, Ocampo-Candiani J, Herz-Ruelas ME. A practical approach to the diagnosis and treatment of adult erythroderma [in English, Spanish]. Actas Dermosifiliogr (Engl Ed). 2018;109:777-790. doi:10.1016/j.ad.2018.05.011
- Lei DK, Yousaf M, Janmohamed SR, et al. Validation of patient-reported outcomes information system sleep disturbance and sleep-related impairment in adults with atopic dermatitis. Br J Dermatol. 2020;183:875-882. doi:10.1111/bjd.18920
- Silverberg JI, Gelfand JM, Margolis DJ, et al. Patient burden and quality of life in atopic dermatitis in US adults: a population-based cross-sectional study. Ann Allergy Asthma Immunol. 2018;121:340-347. doi:10.1016/j.anai.2018.07.006
- Carr CW, Veledar E, Chen SC. Factors mediating the impact of chronic pruritus on quality of life. JAMA Dermatol. 2014;150:613-620. doi:10.1001/jamadermatol.2013.7696
- Shaw FM, Luk KMH, Chen KH, et al. Racial disparities in the impact of chronic pruritus: a cross-sectional study on quality of life and resource utilization in United States veterans. J Am Acad Dermatol. 2017;77:63-69. doi:10.1016/j.jaad.2017.01.016
- Oh CC, Li H, Lee W, et al. Biopsychosocial factors associated with prurigo nodularis in endogenous eczema. Indian J Dermatol. 2015;60:525. doi:10.4103/0019-5154.164451
- Vyumvuhore R, Michael-Jubeli R, Verzeaux L, et al. Lipid organization in xerosis: the key of the problem? Int J Cosmet Sci. 2018;40:549-554. doi:10.1111/ics.12496
- George AO. Atopic dermatitis in Nigeria. Int J Dermatol. 1989;28:237-239. doi:10.1111/j.1365-4362.1989.tb04811.x
- Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis. 2007;80:387-394.
- Grayson C, Heath CR. Dupilumab improves atopic dermatitis and post-inflammatory hyperpigmentation in patient with skin of color. J Drugs Dermatol. 2020;19:776-778. doi:10.36849/jdd.2020.4937
- Alexis A, Woolery-Lloyd H, Andriessen A, et al. Insights in skin of color patients with atopic dermatitis and the role of skincare in improving outcomes. J Drugs Dermatol. 2022;21:462-470. doi:10.36849/jdd.6609
- Chovatiya R, Silverberg JI. The heterogeneity of atopic dermatitis. J Drugs Dermatol. 2022;21:172-176. doi:10.36849/JDD.6408
- Taylor SC, Cook-Bolden F. Defining skin of color. Cutis. 2002;69:435-437.
- Georgetown University Center for Child and Human Development. Bridging the cultural divide in health care settings: the essential role of cultural broker programs. Accessed October 6, 2023. https://nccc.georgetown.edu/culturalbroker/8_Definitions/2_Definitions.html#:~:text=ethnic%3A%20Of%20or%20relating%20to,or%20cultural%20origin%20or%20background
- Shoo BA, Kashani-Sabet M. Melanoma arising in African-, Asian-, Latino- and Native-American populations. Semin Cutan Med Surg. 2009;28:96-102. doi:10.1016/j.sder.2009.04.005
- US Census Bureau. About the topic of race. Revised March 1, 2022. Accessed October 5, 2023. https://www.census.gov/topics/population/race/about.html
- Williams HC. Have you ever seen an Asian/Pacific Islander? Arch Dermatol. 2002;138:673-674. doi:10.1001/archderm.138.5.673
- Jablonski NG, Chaplin G. Colloquium paper: human skin pigmentation as an adaptation to UV radiation. Proc Natl Acad Sci U S A. 2010;107(Suppl 2):8962-8968. doi:10.1073/pnas.0914628107
- Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988;124:869-871. doi:10.1001/archderm.124.6.869
- Amutah C, Greenidge K, Mante A, et al. Misrepresenting race—the role of medical schools in propagating physician bias. N Engl J Med. 2021;384:872-878. doi:10.1056/NEJMms2025768
- Kantor R, Silverberg JI. Environmental risk factors and their role in the management of atopic dermatitis. Expert Rev Clin Immunol. 2017;13:15-26. doi:10.1080/1744666x.2016.1212660
- Fu T, Keiser E, Linos E, et al. Eczema and sensitization to common allergens in the United States: a multiethnic, population-based study. Pediatr Dermatol. 2014;31:21-26. doi:10.1111/pde.12237
- Tackett KJ, Jenkins F, Morrell DS, et al. Structural racism and its influence on the severity of atopic dermatitis in African American children. Pediatr Dermatol. 2020;37:142-146. doi:10.1111/pde.14058
- Huang AH, Williams KA, Kwatra SG. Prurigo nodularis: epidemiology and clinical features. J Am Acad Dermatol. 2020;83:1559-1565. doi:10.1016/j.jaad.2020.04.183
- Hirano SA, Murray SB, Harvey VM. Reporting, representation, and subgroup analysis of race and ethnicity in published clinical trials of atopic dermatitis in the United States between 2000 and 2009. Pediatr Dermatol. 2012;29:749-755. doi:10.1111/j.1525-1470.2012.01797.x
- Polcari I, Becker L, Stein SL, et al. Filaggrin gene mutations in African Americans with both ichthyosis vulgaris and atopic dermatitis. Pediatr Dermatol. 2014;31:489-492. doi:10.1111/pde.12355
- Silverberg JI, Simpson EL. Associations of childhood eczema severity: a US population-based study. Dermatitis. 2014;25:107-114. doi:10.1097/DER.0000000000000034
- Hua T, Silverberg JI. Atopic dermatitis in US adults: epidemiology, association with marital status, and atopy. Ann Allergy Asthma Immunol. 2018;121:622-624. doi:10.1016/j.anai.2018.07.019
- Odhiambo JA, Williams HC, Clayton TO, et al. Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three. J Allergy Clin Immunol. 2009;124:1251-8.e23. doi:10.1016/j.jaci.2009.10.009
- Ait-Khaled N, Odhiambo J, Pearce N, et al. Prevalence of symptoms of asthma, rhinitis and eczema in 13- to 14-year-old children in Africa: the International Study of Asthma and Allergies in Childhood Phase III. Allergy. 2007;62:247-258. doi:10.1111/j.1398-9995.2007.01325.x
- Iking A, Grundmann S, Chatzigeorgakidis E, et al. Prurigo as a symptom of atopic and non-atopic diseases: aetiological survey in a consecutive cohort of 108 patients. J Eur Acad Dermatol Venereol. 2013;27:550-557. doi:10.1111/j.1468-3083.2012.04481.x
- Silverberg NB. Typical and atypical clinical appearance of atopic dermatitis. Clin Dermatol. 2017;35:354-359. doi:10.1016/j.clindermatol.2017.03.007
- Allen HB, Jones NP, Bowen SE. Lichenoid and other clinical presentations of atopic dermatitis in an inner city practice. J Am Acad Dermatol. 2008;58:503-504. doi:10.1016/j.jaad.2007.03.033
- Nnoruka EN. Current epidemiology of atopic dermatitis in south-eastern Nigeria. Int J Dermatol. 2004;43:739-744. doi:10.1111/j.1365-4632.2004.02360.x
- Noda S, Suárez-Fariñas M, Ungar B, et al. The Asian atopic dermatitis phenotype combines features of atopic dermatitis and psoriasis with increased TH17 polarization. J Allergy Clin Immunol. 2015;136:1254-1264. doi:10.1016/j.jaci.2015.08.015
- Kaufman BP, Guttman-Yassky E, Alexis AF. Atopic dermatitis in diverse racial and ethnic groups-variations in epidemiology, genetics, clinical presentation and treatment. Exp Dermatol. 2018;27:340-357. doi:10.1111/exd.13514
- Girolomoni G, de Bruin-Weller M, Aoki V, et al. Nomenclature and clinical phenotypes of atopic dermatitis. Ther Adv Chronic Dis. 2021;12:20406223211002979. doi:10.1177/20406223211002979
- Yew YW, Thyssen JP, Silverberg JI. A systematic review and meta-analysis of the regional and age-related differences in atopic dermatitis clinical characteristics. J Am Acad Dermatol. 2019;80:390-401. doi:10.1016/j.jaad.2018.09.035
- Vachiramon V, Tey HL, Thompson AE, et al. Atopic dermatitis in African American children: addressing unmet needs of a common disease. Pediatr Dermatol. 2012;29:395-402. doi:10.1111/j.1525-1470.2012.01740.x
- Hanifin JM. Diagnostic features of atopic dermatitis. Acta Derm Venereol. 1980;92:44-47.
- Dutta A, De A, Das S, et al. A cross-sectional evaluation of the usefulness of the minor features of Hanifin and Rajka diagnostic criteria for the diagnosis of atopic dermatitis in the pediatric population. Indian J Dermatol. 2021;66:583-590. doi:10.4103/ijd.ijd_1046_20
- Kulthanan K, Boochangkool K, Tuchinda P, et al. Clinical features of the extrinsic and intrinsic types of adult-onset atopic dermatitis. Asia Pac Allergy. 2011;1:80-86. doi:10.5415/apallergy.2011.1.2.80
- Julián-Gónzalez RE, Orozco-Covarrubias L, Durán-McKinster C, et al. Less common clinical manifestations of atopic dermatitis: prevalence by age. Pediatr Dermatol. 2012;29:580-583. doi:10.1111/j.1525-1470.2012.01739.x
- Chovatiya R, Silverberg JI. Evaluating the longitudinal course of atopic dermatitis: a review of the literature. J Am Acad Dermatol. 2022;87:688-689. doi:10.1016/j.jaad.2022.02.005
- Kim Y, Blomberg M, Rifas-Shiman SL, et al. Racial/ethnic differences in incidence and persistence of childhood atopic dermatitis. J Invest Dermatol. 2019;139:827-834. doi:10.1016/j.jid.2018.10.029
- Ben-Gashir MA, Hay RJ. Reliance on erythema scores may mask severe atopic dermatitis in black children compared with their white counterparts. Br J Dermatol. 2002;147:920-925. doi:10.1046/j.1365-2133.2002.04965.x
- McKenzie S, Brown-Korsah JB, Syder NC, et al. Variations in genetics, biology, and phenotype of cutaneous disorders in skin of color. part II: differences in clinical presentation and disparities in cutaneous disorders in skin of color. J Am Acad Dermatol. 2022;87:1261-1270. doi:10.1016/j.jaad.2022.03.067
- Cuellar-Barboza A, Ocampo-Candiani J, Herz-Ruelas ME. A practical approach to the diagnosis and treatment of adult erythroderma [in English, Spanish]. Actas Dermosifiliogr (Engl Ed). 2018;109:777-790. doi:10.1016/j.ad.2018.05.011
- Lei DK, Yousaf M, Janmohamed SR, et al. Validation of patient-reported outcomes information system sleep disturbance and sleep-related impairment in adults with atopic dermatitis. Br J Dermatol. 2020;183:875-882. doi:10.1111/bjd.18920
- Silverberg JI, Gelfand JM, Margolis DJ, et al. Patient burden and quality of life in atopic dermatitis in US adults: a population-based cross-sectional study. Ann Allergy Asthma Immunol. 2018;121:340-347. doi:10.1016/j.anai.2018.07.006
- Carr CW, Veledar E, Chen SC. Factors mediating the impact of chronic pruritus on quality of life. JAMA Dermatol. 2014;150:613-620. doi:10.1001/jamadermatol.2013.7696
- Shaw FM, Luk KMH, Chen KH, et al. Racial disparities in the impact of chronic pruritus: a cross-sectional study on quality of life and resource utilization in United States veterans. J Am Acad Dermatol. 2017;77:63-69. doi:10.1016/j.jaad.2017.01.016
- Oh CC, Li H, Lee W, et al. Biopsychosocial factors associated with prurigo nodularis in endogenous eczema. Indian J Dermatol. 2015;60:525. doi:10.4103/0019-5154.164451
- Vyumvuhore R, Michael-Jubeli R, Verzeaux L, et al. Lipid organization in xerosis: the key of the problem? Int J Cosmet Sci. 2018;40:549-554. doi:10.1111/ics.12496
- George AO. Atopic dermatitis in Nigeria. Int J Dermatol. 1989;28:237-239. doi:10.1111/j.1365-4362.1989.tb04811.x
- Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis. 2007;80:387-394.
- Grayson C, Heath CR. Dupilumab improves atopic dermatitis and post-inflammatory hyperpigmentation in patient with skin of color. J Drugs Dermatol. 2020;19:776-778. doi:10.36849/jdd.2020.4937
Practice Points
- Social determinants of health play a central role in observed racial and ethnic differences in studies of atopic dermatitis (AD) in patients with skin of color.
- Prurigo nodules, lichenoid papules, perifollicular papules, nummular lesions, and psoriasiform lesions are among the diverse lesion morphologies seen with AD.
- Key signs of cutaneous inflammation and lesional severity, including erythema, may present differently in darker skin tones and contribute to underestimation of severity.
- Postinflammatory dyspigmentation is common among patients with skin of color, and treatment can substantially improve quality of life.
