The 5-year-old girl in Peter Lio, MD’s office in Boston lay slumped on the examination table. It was the middle of the afternoon, but she looked asleep—as if she were taking a nap. At first glance, the child’s dark skin appeared to be dry, with some open sores from eczema, but when the dermatologist touched her, Dr. Lio found that her skin was warm and feverish. That’s also when he noticed that it was, in fact, red all over.
“Her skin was red, but it was hard to appreciate it because she had richly pigmented skin,” says Dr. Lio, who is now a clinical assistant professor at the Northwestern University Feinberg School of Medicine. “In someone with lighter skin, you would see that they were beet red, but the darker skin type masked some of that until I got very close.”
Dr. Lio realized the girl was experiencing erythroderma, a potentially dangerous complication of eczema that causes widespread redness of the skin, as well as scaling and peeling. So he picked her up and walked her down to the emergency department, where tests soon revealed she had sepsis: a blood infection.
“She had so much broken, open skin that bacteria took advantage of those open areas and went all the way to her blood,” says Dr. Lio. The girl was given antibiotics and made a full recovery, but her experience highlights the complexities people of color—particularly those with brown and Black skin—have in managing eczema, including atopic dermatitis, the most common form.
Why Eczema Is More Common in People of Color
Atopic dermatitis is an inflammatory skin condition that damages the skin barrier, causing itching, swelling, dryness, and open sores. It usually develops during childhood, with about 50 percent of people diagnosed with atopic dermatitis by the age of 1, and about 85 percent by the age of 5.
For some people, the symptoms disappear by the time they’re teenagers, but in 20 to 50 percent of people, the condition can flare up into adulthood. About 1 in 4 people also develop atopic dermatitis for the first time as an adult.
Although the condition affects people of all races and ethnicities—including more than 16.5 million adults and 9.6 million children in the U.S.—it’s most common among Black Americans. A review from 2022 concluded that Black children are about two times more likely to be diagnosed with atopic dermatitis than white children, and also twice as likely to experience severe symptoms.
Latinx children are also 1.5 times more likely to have severe symptoms of atopic dermatitis, although they also may have greater chances of developing the condition later in life. Some research shows that they’re about half as likely as white children to have atopic dermatitis by the age of 5, but nearly twice as likely to have it by the age of 15.
The reason for these discrepancies doesn’t appear to be genetic—in fact, some research shows that Black children are nearly six times less likely to have a mutation in a gene that causes a breakdown in skin-barrier function. Rather, the reason likely comes down to structural inequalities in the U.S., including environmental, socioeconomic, and healthcare disparities, says Brittany Oliver, MD, the director of medical student education at the School of Medicine at the University of Missouri-Kansas City and a member of the Skin of Color Society.
Research suggests that Black children who have atopic dermatitis are less likely to see a dermatologist than white children with the condition. Even getting an initial diagnosis can be harder for people with darker skin, in part because of what Dr. Lio encountered: The eczema may not appear red on first glance, but purple, brown, or gray, depending on the person’s skin tone.
“Identifying redness in Black and brown skin comes with experience and exposure, and photo atlases [used to teach trainees] were not always as diverse as they are now,” says Dr. Oliver, who also emphasizes that while education has improved in recent years for dermatologists, that’s not necessarily the case in other fields of healthcare. “Dermatology is a visual field, and we spend years learning to pick up on subtle clues present in the skin, but it’s not a large part of the typical medical-school curriculum. I’ve made the first diagnosis of eczema many times in adults and children who have a primary care provider, which suggests there are sometimes opportunities for an earlier diagnosis.”
Treating Atopic Dermatitis in Black Skin
Yet even though people of color are more likely to have atopic dermatitis and to experience more severe symptoms, they’re less likely to receive treatments for it. A study published in 2024 found that Black and Latinx patients were less likely to be prescribed medications such as topical calcineurin inhibitors, a topical ointment, and a biologic than white patients. It’s not clear what factors play the biggest role in this discrepancy, but the researchers suggested that doctor bias and a lack of access to specialty care may be to blame.
And when atopic dermatitis goes undertreated or undiagnosed, complications like erythroderma may be more likely to develop, much as for Dr. Lio’s 5-year-old patient. Indeed, research has found that Black and Latinx children are more likely to have higher rates of emergency-department visits for atopic dermatitis than white children. Untreated atopic dermatitis can also lead to a type of skin discoloration known as post-inflammatory hypo- and hyperpigmentation, in which the skin turns lighter or darker, respectively.
It is clear, though, that atopic-dermatitis treatments are effective for people of all skin colors. “It’s been shown in all populations that there are safe and simple treatment options available,” says Danilo Del Campo, MD, a dermatologist at the Chicago Skin Clinic—which makes the effort to resolve the inequalities in diagnosis and treatment of the condition all the more vital.
