10.5826/dpc.1303a259
Introduction: Atopic Dermatitis (AD) affects individuals from all ethnicities and backgrounds. It has the highest global disease burden of dermatoses. There is a widely held belief that the presentation of AD is not described well in individuals with non-European ancestry in peer-reviewed literature. However, to our knowledge, this has not been investigated previously
Objective: To quantify the number of peer-reviewed literature describing the appearance of clinical features of AD in non-European ancestry, particularly those originating from the Asian and African continents.
Methods: A systematic scoping review between December 2020 and January 2021 was performed to quantify the number of studies describing AD in individuals of African and Asian ancestry.
Reuslts: Sixteen studies were identified. None of the studies provided a clear description of AD in our population groups. Two studies described features of lichen planus like-AD in African American individuals. All studies reported on observed clinical features of AD.
Conclusions: The review confirmed a lack of literature describing AD in populations of non-European heritage. It should encourage authors to make a deliberate effort to describe the appearance of clinical features of AD to enable understanding of  how they may differentiate in individuals originating from different parts of the globe.
text/xml
2160-9381
3134
en
Christine  Kleyn
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
skin equity
Atopic Dermatitis in Individuals of Asian and African Ancestry: A Scoping Systematic Review
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Review
2023-10-31
2023-02-02
2023-10-31
2024-01-16
e2023259
Dermatol Pract Concept
Introduction: Atopic Dermatitis (AD) affects individuals from all ethnicities and backgrounds. It has the highest global disease burden of dermatoses. There is a widely held belief that the presentation of AD is not described well in individuals with non-European ancestry in peer-reviewed literature. However, to our knowledge, this has not been investigated previously
Objective: To quantify the number of peer-reviewed literature describing the appearance of clinical features of AD in non-European ancestry, particularly those originating from the Asian and African continents.
Methods: A systematic scoping review between December 2020 and January 2021 was performed to quantify the number of studies describing AD in individuals of African and Asian ancestry.
Reuslts: Sixteen studies were identified. None of the studies provided a clear description of AD in our population groups. Two studies described features of lichen planus like-AD in African American individuals. All studies reported on observed clinical features of AD.
Conclusions: The review confirmed a lack of literature describing AD in populations of non-European heritage. It should encourage authors to make a deliberate effort to describe the appearance of clinical features of AD to enable understanding of  how they may differentiate in individuals originating from different parts of the globe.
Christine  Kleyn
2023/10/31
10.5826/dpc.1303a259
e2023259
Department of Dermatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford; Dermatology Centre, Salford Royal Hospital, Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester, UK
2160-9381
skin equity
en
e2023259
Yew, Y. W., Thyssen, J. P. & Silverberg, J. I. A systematic review and meta-analysis of the regional and age-related differences in atopic dermatitis clinical characteristics. J Am Acad Dermatol 80, 390–401 (2019).
Atopic Dermatitis in Individuals of Asian and African Ancestry: A Scoping Systematic Review
https://dpcj.org/index.php/dpc/article/download/3134/2353
     Atopic Dermatitis in Individuals of Asian
and African Ancestry: A Scoping Systematic Review
   Chiedu Enechukwu Ufodiama1, 2, 3, Blessing Fabowale-Makinde4, Christine Elise Kleyn1,2


1 Department of Dermatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
2 Dermatology Centre, Salford Royal Hospital, Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester, UK
3 Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
4 Medway Maritime Hospital, Medway NHS Foundation Trust, Gillingham, Kent, UK



Key words: atopic dermatitis, eczema, skin of color, african skin types, asian skin types
Citation: Ufodiama CE, Fabowale-Makinde B, Kleyn CE. Atopic Dermatitis in Individuals of Asian and African Ancestry: A Scoping
Systematic Review. Dermatol Pract Concept. 2023;13(4):e2023259. DOI: https://doi.org/10.5826/dpc.1304a259
Accepted: May 12, 2023; Published: October 2023
Copyright: ©2023 Ufodiama et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Chiedu Ufodiama, Salford Royal Hospital, Email: Chiedu.ufodiama@doctors.org.uk




  ABSTRACT              Introduction: Atopic Dermatitis (AD) affects individuals from all ethnicities and backgrounds. It has
                        the highest global disease burden of dermatoses. There is a widely held belief that the presentation of
                        AD is not described well in individuals with non-European ancestry in peer-reviewed literature. How-
                        ever, to our knowledge, this has not been investigated previously.
                        Objective: To quantify the number of peer-reviewed literature describing the appearance of clinical
                        features of AD in non-European ancestry, particularly those originating from the Asian and African
                        continents.
                        Methods: A systematic scoping review between December 2020 and January 2021 was performed to
                        quantify the number of studies describing AD in individuals of African and Asian ancestry.
                        Results: Sixteen studies were identified. None of the studies provided a clear description of AD in
                        our population groups. Two studies described features of lichen planus like-AD in African American
                        individuals. All studies reported on observed clinical features of AD.
                        Conclusions: The review confirmed a lack of literature describing AD in populations of non-European
                        heritage. It should encourage authors to make a deliberate effort to describe the appearance of clinical
                        features of AD to enable understanding of how they may differentiate in individuals originating from
                        different parts of the globe.




Review | Dermatol Pract Concept. 2023;13(4):e2023259                                                                                 1
Introduction                                                       for Skin of Color" [9]), including pigmentation, erythema,
                                                                   lichenification, follicular prominence, site(s) of lesion(s),
Atopic dermatitis (AD) is a chronic, inflammatory,                 crusting, scales, lichenoid presentation were documented,
immune-mediated skin disease that has the highest disability       and whether comparisons were made to European skin types
adjusted life years globally, of all dermatoses [1,2]. Its ad-     (phototype I-III).
verse impact on quality of life is experienced by individuals         Two independent researchers (CEU and BFM) inde-
irrespective of their ancestry.                                    pendently searched the databases according to the inclusion
    In the United Kingdom (UK), 11.8% of the population            and exclusion criteria. EK was the third reviewer and acted
identified as being from Black, Asian, or other (non-White)        as arbitrator in disagreements.
ethnic groups and 2.2% identified as mixed ethnicity. An in-
crease of ethnic diversity in the UK with more individuals
reporting non-European ancestry is predicted, which further        Results
highlights the need to assess skin accurately regardless of
                                                                   Study Selection
ethnicity [3-5.
                                                                   The search strategy (Figure 1) identified 16 articles for full
    Widely used criteria to diagnose AD are based on the
                                                                   screening and appraisal (Table 1).
Hanifin and Rajka criteria (HRC), or a derivative thereof,
however, the limitations of HRC have been previously re-
ported [6]. These include that the HRC is based predomi-           Study Characteristics of Included Papers
nantly on a European population although the UK Working            Twenty-five per cent of papers identified were either obser-
Party Criteria (UKC) endeavored to adjust for this [7]. Con-       vational studies or reviews, 19% were cross-sectional studies
sequently, descriptions or definitions used historically may       and 13% were case reports (Figure 2). A systematic review,
not accurately reflect the appearance of AD in all individuals.    an epidemiological survey and a case series each represented
                                                                   6% of the remaining selection. Clinical features of AD in
                                                                   individuals from eight different geographical skin types were
Objectives                                                         described (Figure 3).
In view of the abovementioned disparities, we conducted a
scoping systematic review to assess the extent of currently        Description of Clinical Features
available peer-reviewed literature which describes AD le-          Aspects of the clinical features of AD were described by
sions in individuals of non-European ancestry.                     6 studies (Table 2). Saleh et al and Summey et al both de-
                                                                   scribed clinical features of lichen planus-like AD in African
                                                                   American individuals. Saleh described lesions as "licheni-
Methods
                                                                   fied hyperpigmented violaceous polygonal papules and
The review included results from EMBASE (OVID), MED-               plaques" that presented on the palms, whilst Summey de-
LINE (OVID, PubMed) and a free text search (("Atopic               scribed "brownish gray-purple plaques" [10,11]. Lopez
­Dermatitis" AND ("Africa* OR Asia*)) of the first 10 pages        Carrera et al reports that African Americans may present
of Google© during December 2020 and January 2021 and               with less obvious erythema that may appear reddish blue
follows the PRISMA extension for scoping systematic re-            or purple violaceous with a flexural predominance [12]. In
views (PRISMA-ScR) checklist [8]. The search protocol was          addition, perifollicular accentuation, papulation, scaling,
registered on the Open Science Framework (Registration             lichenification and pigmentary changes were described as
DOI: 10.17605/OSF.IO/UCK97).                                       being more prominent. Similarly, Vachiramon et al reported
    The   search   strategies     included   English   language,   features of AD may be more subtle in African American
peer-reviewed literature (Supplementary tables S1, S2).            children with scattered papular lesions occurring in an
Search terms can be found in the supplementary tables. Ex-         annular distribution on extensor surfaces and trunk [13].
clusion criteria included non-English language, conference         A greater tendency for obvious post inflammatory hyper and
abstracts, communication letters and textbook chapters.            hypopigmentary changes was also noted. Furthermore, AD,
    The primary outcome was to quantify the number of              in a south-eastern Nigerian population, has been described
studies describing the clinical features and presentation of       as scattered, micropapular, annular lesions localized to hair
AD in individuals of African and Asian ancestry. Secondary         follicles on the extensors, with associated hyperpigmen-
outcomes were to identify how frequently features of AD            tation and lichenification [14]. Moreover, Kaufman et al,
(as previously outlined in "Taylor and Kelly's Dermatology         in a review of AD in a global† population describe more




2                                                                             Review | Dermatol Pract Concept. 2023;13(4):e2023259
Figure 1. Adapted PRISMA flow diagram of the retrieved studies. Three databases were screened, a review of the citations and a
Google© free text search was conducted. Once completed, as illustrated above, 16 studies were included.




well-demarcated lesions and increased scaling and licheni-        were reported. Vachiramon et al compared pathophysiology,
fication in Asian individuals [15].                               clinical presentation, and treatment of AD between African
                                                                  American children and Caucasians (European American),
Reported Clinical Features                                        they reported on the difficulty of initially diagnosing AD in
Site of lesion, lichenification and erythema were the most        African American children, citing lack of erythema as well as
reported. All studies reported at least one clinical feature of   differences in distribution of lesions as contributing to diag-
AD (Table 2). All papers reporting on African American or         nostic challenges. Studies by Kaufman et al. and Silverberg
African individuals noted pigmentary changes, whilst ery-         et al utilize European skin as a reference to contrast features
thema was often reported in studies of individuals from the       seen in other global skin types [15,16].
Asian continent. Often clinical features were reported in tab-
ular form, which outlined the frequency of presentation that
                                                                  Conclusions
they occurred.
                                                                  The majority of included studies were observational or
Comparison to Skin on Individuals With European                   non-systematic literature reviews, thus the strength of ev-
Ancestry                                                          idence was relatively poor [17]. AD in individuals with
Five studies reported comparisons with skin of European an-       African ancestry were the most reported population and
cestry (Table 2). No study made comparisons with reference        these studies often referenced a paper by Nnoruka when re-
to the Fitzpatrick scale. Yew et al compared clinical features    porting the clinical features of AD [14]. It was important to
of AD from several regions to European studies. They re-          include reviews, to give a true appreciation on the depth of
ported higher prevalence of erythroderma, truncal, exten-         peer reviewed description of AD in non-European ancestry
sor, scalp, and auricular involvement in individuals from         that were available and accessible.
East Asian as compared to those from Europe. Truncal in-             The primary outcome was to quantify the number of
volvement and lichenification were also reported to be more       peer-reviewed literature that described clinical features of
prevalent in individuals from southeast Asia as compared to       AD in non-European individuals. Six studies described cer-
Africa where a higher prevalence of papular lichenoid lesions     tain features of AD in non-European individuals; these were




Review | Dermatol Pract Concept. 2023;13(4):e2023259                                                                           3
4
                                                            Table 1. Studies included in the scoping review. Sixteen studies were identified; those with African descent (African, African-American, African
                                                           Carribbean) were the most the reported demographic. Some studies grouped by continental regions, whilst others identified individual countries.
                                                                                                         Most studies which were included were observational.
                                                                                        Title                                            Author          Year                    Demographic/Country                          Study Type
                                                       Lichenoid and other clinical presentations of atopic dermatitis in an     Allen et al. [23]       2008   African American                                          Case report
                                                       inner city practice.
                                                       Atopic dermatitis in infants and ­children in India                       Dhar et al [24]         2010   Indian                                                    Review
                                                       Atopic dermatitis in diverse racial and ethnic groups-Variations in       Kaufman et al [15]      2018   Asian, White, African descent                             Review
                                                       epidemiology, genetics, clinical presentation and treatment.
                                                       Adult-onset atopic dermatitis: a cross-sectional study of natural         Kulthanan et al [18]    2007   Thailand                                                  Cross-sectional
                                                       history and clinical manifestation                                                                                                                                 study.
                                                       The clinico-epidemiological profile and the risk factors associated     Kumar et al [25]          2000   India (East Indian)                                       Epidemiological
                                                       with the severity of atopic dermatitis (AD) in eastern Indian children.                                                                                            study
                                                       Minor cutaneous features of atopic dermatitis in South Korea              Lee et al [26]          2008   South Korea                                               Observational study
                                                       Clinical features of Adult/Adolescent Atopic Dermatitis and Chinese Liu et al [27]                2016   China                                                     Observational study
                                                       Criteria for Atopic Dermatitis
                                                       Epidemiology, Diagnosis, and Treatment of Atopic Dermatitis in            Lopez Carrera et al     2019   East Asia, Southeast Asia, Latin America, North Africa,   Review
                                                       the Developing Countries of Asia, Africa, Latin America, and the          [12]                           Sub-Saharan Africa, middle east
                                                       Middle East: A Review.
                                                       Current epidemiology of atopic dermatitis in south-eastern Nigeria        Nnoruka [14]            2008   Nigeria                                                   Observational study
                                                       A Rare Case of Lichen Planus-Like Atopic Dermatitis Involving the         Saleh et al [10]        2020   African American                                          Case report
                                                       Hands.
                                                       Distribution of atopic dermatitis lesions in United States adults         Silverberg et al [16]   2004   Caucasian/White, African-American/Black, Hispanic,        Cross-sectional
                                                                                                                                                                Multiracial/other                                         study.
                                                       Lichen planus-like atopic dermatitis: expanding the differential          Summey et al [11]       2007   African American                                          Case series
                                                       diagnosis of spongiotic dermatitis
                                                       Clinical analyses of atopic dermatitis in the aged                        Tanei et al [28]               Japan                                                     Observational study.
                                                       Atopic dermatitis in African American children: addressing unmet          Vachiramon et al [13]   2012   African Descent (African American, African, and African   Review
                                                       needs of a common disease.                                                                               Caribbean)
                                                       Prevalence and clinical features of adult atopic dermatitis in tertiary   Wang et al [29]         2017   China                                                     Cross-sectional
                                                       hospitals in China                                                                                                                                                 study.
                                                       A systematic review and meta-analysis of the regional and age-            Yew et al [30]          2019   Americas (US, Mexico, Colombia), East Asia (China, Japan, Systematic Review
                                                       related differences in atopic dermatitis clinical characteristics                                        Korea), South East Asia (Singapore, Thailand), India,      and Meta-Analysis
                                                                                                                                                                Middle East (Iran), Europe (Bosnia, Denmark, Finland,
                                                                                                                                                                France, Germany, Italy, The Netherlands, Norway, Poland,
                                                                                                                                                                Romania, Sweden, Switzerland, Turkey, UK, Multiple sites),




Review | Dermatol Pract Concept. 2023;13(4):e2023259
                                                                                                                                                                Africa ­(Nigeria, South Africa, Tunisia), Australia
                 Figure 2. Proportion of the types of peer-reviewed studies included. Observational studies and review ar-
                 ticles were the most identified studies with each representing 25% (N = 4) of identified works respectively.




                Figure 3. Frequency of geographical skin types reported in included studies. Studies were grouped to allow
                for the data to be meaningfully assessed; 9 out of 17 studies identified reported on individuals with African
                descent.



primarily comments on the lack of erythema and the presence                  Five studies used European criteria/skin type as a point
of hyperpigmentation. The case reports on lichen-planus like             of reference when comparing AD to skin types of different
AD presented the most plausible example of comprehensive                 non-European ancestries. Kulthanan et al studied the clin-
description on the morphological appearance of AD in non-­               ical features of adult-onset AD in Thai patients. In their
European individuals. Across all included studies, site of lesion,       discussion, they concluded that most clinical features of
erythema and lichenification were the most reported clinical             adult-onset AD in their population were very similar to what
feature. Follicular prominence and pigmentation were also de-            had previously been reported in non-Asian populations [18].
scribed; their association with AD in individuals of sub-Saharan             Conducting the study presented challenges, including to
African descent has previously been reported by others [9].              the categorization of skin types. We adopted the approach of



Review | Dermatol Pract Concept. 2023;13(4):e2023259                                                                               5
6
                                                          Table 2. Summary of individual study findings. Six of 16 studies included described the characteristics of one or more clinical features reported by
                                                           the author. Lichenification, erythema and site of lesion were the clinical features that were most commented upon. Only 5 studies included made
                                                                                                              comparable reference to European skin types
                                                                                     Clinical                                       Clinical Features Reported
                                                                                    Features                                                 Follicular   Sites of                        Lichenoid        Comparison to
                                                                             Year   Described   Pigmentation   Erythema   Lichenification   Prominence     lesion    Crusting   Scales   Presentation   European Skin types
                                                       Allen et al           2008                                                                                                           
                                                       Dhar et al            2010                                                                                              
                                                       Kaufman et al         2018                                                                                                                       
                                                       Kulthanan et al       2007                                                                         
                                                       Kumar et al           2000                                                                          
                                                       Lee HJ et al          2008                                                              
                                                       Liu et al             2016
                                                       Lopez Carrera et al   2019                                                           
                                                       Nnoruka               2008                                                                      
                                                       Saleh et al           2020                                                                       
                                                       Silverberg et al      2004                                                                           
                                                       Summey et al          2007                                                                                                                          
                                                       Tanei et al           2008                                                                         
                                                       Vachiramon et al      2012                                                                                                                        
                                                       Wang et al            2017                                                                          
                                                       Yew et al             2019                                                                                                                         




Review | Dermatol Pract Concept. 2023;13(4):e2023259
categorizing skin based on geographical regional skin types –                   Am J Dermatopathol. 2020;42(3):215-217. DOI: 10.1097/
combining groups based on historic continental ancestry                         DAD.0000000000001593. PMID: 31855583..
                                                                          11.   Summey BT, Bowen SE, Allen HB. Lichen planus-like atopic
with the aim of objective categorization [19].
                                                                                dermatitis: expanding the differential diagnosis of spongi-
      To conclude, this scoping review confirms the paucity of
                                                                                otic dermatitis. J Cutan Pathol. 2008;35(3):311-314. DOI:
literature describing the appearance of AD in non-European                      10.1111/j.1600-0560.2007.00806.x. PMID: 18251746.
populations. It is recognized that there is limited research              12.   Lopez Carrera YI, Al Hammadi A, Huang YH, Llamado LJ,
and dermatology educational resources in non-European                           Mahgoub E, Tallman AM. Epidemiology, Diagnosis, and Treat-
populations and there is significant scope to achieve equity                    ment of Atopic Dermatitis in the Developing Countries of Asia,
                                                                                Africa, Latin America, and the Middle East: A Review. Dermatol
irrespective of ancestry or skin tone [19-21].
                                                                                Ther (Heidelb). 2019;9(4):685-705. DOI: 10.1007/s13555-019
                                                                                -00332-3. PMID: 31650504. PMCID: PMC6828917.
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                                                                                dermatitis in African American children: addressing unmet needs
The study was limited due to only including English-language                    of a common disease. Pediatr Dermatol. 2012;29(4):395-402.
                                                                                DOI: 10.1111/j.1525-1470.2012.01740.x. PMID: 22471955.
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