Eczema in Skin of Color

What it is

Atopic dermatitis, the most common form of eczema, is a long-running condition in which the skin barrier does not hold moisture well and inflames easily. The most common symptom is itching, which can be severe [1].

Why this guide is written for Black patients

Research shows that atopic dermatitis is more common in non-Hispanic Black children, and that women and girls tend to develop the disease slightly more often than men and boys [1].

It also looks different. On darker skin tones the bumps tend to be gray to violet-brown in color, and the affected skin can appear dark brown, purple or grayish rather than red [2]. Small rough bumps are more common in darker skin tones [2]. The pattern differs too: in older children with darker skin, patches tend to form on the fronts of the knees, the elbows and the backs of the hands, and children with brown or black skin are more likely than white children to have atopic dermatitis on the trunk [2].

That matters because redness is how severity is usually judged. If a clinician is grading inflammation by how red the skin looks, skin that does not go red gets graded as milder than it is. The American Academy of Dermatology keeps a resource specifically on how skin diseases present in darker skin tones for exactly this reason [3].

After healing, the skin may be lighter or darker where the eczema was [2]. In darker skin tones, patients often see darkening or lightening in areas of inflammation [1], and those marks can last long after the itch has gone.

What to ask a clinician

• How are you judging how severe this is, given that my skin does not turn red?
• What is the plan for the itch, separately from the plan for the rash?
• Which moisturizer, how much, and how often, and when in relation to bathing?
• What do we do about the dark or light marks left behind once the eczema settles?
• If this treatment does not work in two weeks, what is next, and do I need to come back to get it?

What good care looks like

Good care treats the itch as the main event, because the itching is the most common symptom and can be severe [1], and scratching is what turns eczema into thickened skin, broken skin and infection.

It also treats the marks as part of the condition rather than as a cosmetic afterthought. If discoloration is what a patient is most upset about, saying so is not vanity, and a dermatologist who works with darker skin will have something to say about it.

Good care writes the plan down: which cream goes where, how thickly, how many times a day, and what to do on a bad week rather than a normal one. It also names the triggers to remove, which for many people include soaps and detergents, heat, sweat, and fabrics, and it gets specific about products rather than telling you to avoid irritants.

When it is urgent

Get seen the same day for skin that is weeping yellow fluid, crusting golden, spreading fast, or painful to touch, and for eczema with a fever, because infected eczema needs treatment quickly. Clusters of small punched-out sores, especially near a cold sore, need urgent care.

Book soon rather than waiting for a rash that has not settled in two weeks, sleep that is broken by scratching, or a child who is scratching until they bleed.

What to do next

Photograph the skin at its worst, in daylight, without a filter. Skin behaves on the day of the appointment.

Then book with a dermatologist who treats eczema in brown and black skin. Start with Black dermatologists, and bring the list of everything that touches the area, including soap, laundry detergent, body butter and anything used on a child's hair.