With children of color, or individuals with Fitzpatrick skin types III to VI, representing a large portion of the pediatric population, it is critical for healthcare professionals to be aware of and recognize the unique clinical presentations and challenges affecting this growing demographic. Although the majority of dermatologic disorders can occur in patients of all ages and skin types, pediatric patients of color may experience differing patterns of symptoms, clinical presentation, as well as varying responsiveness to therapeutic methods. Effectively treating skin of color requires the specialized training of clinicians as well as their awareness of the facets of common dermatologic disorders that affect the Black pediatric patient population, including atopic dermatitis (AD), acne, pityriasis alba (PA), and pigmentation disorders.
Common Pediatric Disorders in Skin of Color
Although the following common pediatric disorders manifest in patients of all skin colors, there are several important distinctions in how these skin conditions present and progress in Black pediatric patients.
As the most common chronic inflammatory disease affecting patients of all ages and racial backgrounds, atopic dermatitis has an overall estimated prevalence between 9% and 25% within the United States. However, Black individuals are up to three times more likely to seek care for AD than White individuals.
Although the general clinical presentation of atopic dermatitis is similar among various ethnic groups, Black children are more likely to exhibit certain symptoms, such as a more papular variant of the disorders on their arms, legs, and periumbilical area. Additionally, pediatric patients of color present with less erythema, more thickening of the skin, as well as more follicular prominence. In this cohort, symptom onset mainly occurs in early childhood, while AD lesions are significantly more likely to resolve with hypo- or hyperpigmentation complications.
Furthermore, biological differences may impact treatment efficacy. Studies have observed reductions in ceramide content among Black children which could result in skin barrier vulnerability. Dermatologists treating pediatric patients of color for atopic dermatitis may need to prescribe thicker emollients with enhanced ceramide content to bolster the skin barrier during treatment and beyond.
Acne is one of the most common dermatologic disorders among children and adolescents regardless of racial background; nonetheless, the condition presents a variety of clinical challenges in patients with darker skin. Firstly, the presence of erythema may be difficult to distinguish in darker skin tones making it harder to diagnose this group of patients.
In addition, one of the primary concerns pertaining to acne in skin of color is the adverse complication of post-inflammatory pigmentary changes left behind after acne clears alongside both acne and keloid scars. This leads experts to recommend the aggressive treatment of acne in children of color to help diminish the probability of these repercussions.
Despite the similar general pathogenesis of the condition between racial groups, a notable difference has been observed in female patients of darker skin types who can histologically present higher levels of inflammation without corresponding clinical inflammation. Additionally, Black pediatric patients historically experience less cystic acne than Hispanic patients, who have the most severe acne manifestations among children of color.
A unique challenge in the treatment of this demographic is the high potential for retinoid dermatitis associated with the use of topical retinoids – the first-line therapy for acne. Experts recommend prescribing these medications with caution and beginning with minimal doses. Clinicians treating pediatric patients with darker skin types should emphasize the need for adequate sun protection and assist them in the development of appropriate skincare regimen for preventing future acne lesions and to allow the pigmentary changes to improve over time.
Pityriasis alba (PA) is a benign, hypopigmented dermatosis most commonly affecting children with darker skin types. Clinically characterized by poorly defined, hypopigmented macules and patches, early symptoms of PA can include subclinical dermatitis and erythema – which may be less noticeable in children with skin of color. Lesions typically develop on the face yet both the chest and back may also be affected. The primary age of disease onset ranges from 3 to 16 years.
In susceptible skin types, environmental factors such as sun exposure, long and frequent bathing, as well as mechanical exfoliation may be predisposing factors to the development of PA. Black children may be especially vulnerable to the condition as they are already genetically predisposed to xerosis.
As the development of pitryiasis alba can prove to be a significant burden on patients with darker skin, dermatologists are encouraged to provide patient counseling and caution patients against potential irritants. Additionally, clinicians should advise the implementation of safe sun habits, such as wearing sun-protective clothing and hats, as sunscreen may be difficult to tolerate in patients with darker skin types.
Pigmentation issues may arise in children in color that can persist into adulthood. The pigmentary disorder vitiligo provides such a challenge as the condition is most noticeable in dark-skinned patients and can be lifelong. Although the exact cause of the depigmentation characteristic of vitiligo is unknown, it is believed to be an autoimmune dysfunction that leads to the rapid loss of pigment in the skin with potential cycles of pigment loss in the future. As vitiligo has a genetic component, clinicians should inquire about family history of the disorder to predict the risk of vitiligo onset at a young age.
Approximately half of vitiligo cases occurring in patients of color begin in childhood with initial lesions appearing around the eyes, mouth, and lip area as well as on the chest, underarms, elbows, wrists, or around fingertips and toes. Early intervention is critical to improve the chances for proper repigmentation of the skin as well as to minimize the risk of psychological complications, including decreased self-esteem and quality of life. Out of the variety of available treatment methods, pediatric patients of color reportedly may respond better to treatments that include topical calcineurin inhibitors, such as tacrolimus, as well as narrowband UVB and excimer laser therapies.
Alongside differences in clinical presentation and therapeutic solutions to keep in mind when treating patients of color, it is important to remember the psychological burden dermatologic conditions carry with them and ensure pediatric patients receive adequate, comprehensive treatment as soon as possible after symptom onset. To assist clinicians in bridging the racial gaps in dermatologic care, LivDerm is offering a novel Deep Dive: Racial Disparities in Dermatology online learning program on March 6, 2021 that aims to equip dermatologists with the most effective and up-to-date strategies for combating inequities in the clinical practice.