Disparities in AD Treatment: What Can Be Done?

What can be done for patients of color with atopic dermatitis (AD) to reduce disparities in their care? This is the question that was posed to the panelists of the final symposium held at Revolutionizing Atopic Dermatitis 2023. Panelists illustrated the gaps in care for patients of color and steps that can be taken to improve theiraccess to care.

Patients of color were more likely to have diagnosed AD, according to Andrew Alexis, MD, MPH, FAAD, vice chair for diversity and inclusion for the Department of Dermatology and a dermatologist at the Center for Diverse Skin Complexions at Weill Cornell Medicine in New York City. Data from several studies were presented, with one study finding that Black race was significantly associated with a higher prevalence of eczema (odds ratio [OR], 1.7; 95% CI, 1.22-2.37) compared with White race. A separate study also found that patients of Black race (OR, 3.4; 95% CI, 2.5-4.7) and Asian/Pacific Islander (OR, 6.7; 95% CI, 4.8-9.5) race were more likely to seek medical treatment for AD compared with patients of White race.

Alexis also noted that quality of life had a heavy impact on children of color following their diagnosis of eczema, with Black and Hispanic children more likely to have missed school because of eczema compared with White children; for Black children, their risk was 1.5-fold higher and for Hispanic children, their risk was 3.4-fold higher. Black children also had an increased risk of severe AD compared with White children (OR, 5.93; 95% CI, 1.94-18.12).

“When we look at access to therapies for atopic dermatitis, we see racial and ethnic disparities,” said Alexis. “A nice study from the Johns Hopkins group found that Black patients with atopic dermatitis were less likely to receive numerous frontline therapies for dermatitis, including dupilumab, crisaborole, primecrolimus, tacrolimus, and desonide.”

Alexis pointed to a lack of resources that addressed how AD appears among patients of color both generally and for medical students. “When we look at our educational resources…and how other health care providers have treated skin disease, where do they get their information? How do they trade? And how does that inform their level of competence in terms of diagnosing accurately atopic dermatitis and assessing the severity effectively, especially with variation erythema?" he asked.

Limited representation for darker skin types is prevalent throughout the medical world, with traditional educational resources either not representing darker skin colors at all in their textbooks or having very low proportions comparatively, according to data presented during the panel. Alexis also pointed to reduced representation of darker skin tones in clinical trials.

“Thankfully, we are seeing a great deal of progress, and there’s still a lot more progress to be made,” said Alexis. According to him, textbooks and atlases have been written to specifically address AD in darker skin colors. The American Academy of Dermatology has developed a curriculum for skin of color. Large clinical trials are beginning to specifically address skin of color, Alexis noted.

“What we’re seeing is this convergence of advocacy and patient community, leadership and organized medicine, and industry coming together to move the field forward,” said Alexis. “And while we have the stark disparities like never before, we see multiple stakeholders working together to reduce these disparities.”

One of the stakeholders working on closing the gaps in access to care is Adam Friedman, MD, FAAD, interim chair, Department of Dermatology, and professor of dermatology, The George Washington University School of Medicine & Health Sciences. Friedman has been testing the efficacy of teledermatology to help populations who are less likely to visit the office of a doctor who treats AD.

Freidman’s findings were local to the conference, with his reach out and teledermatology sites centralized to Washington, DC. Friedman acknowledged that although telehealth was a huge advantage in accessibility coming out of the COVID-19 pandemic, only 1.2% of patients who used teledermatology prior to his reach out were from at-risk areas, a findings that demonstrates the wide disparities gap.

“It’s not just about providing the care, it’s about making it sustainable so patients can continue that approach—in this case, telemedicine—that you continue to sustain that care over time. Because we all know, atopic dermatitis is not one and done,” said Friedman.

He presented the results of monthly church-based AD education and telemedicine clinics in Ward 8 of Washington, DC, run by medical students and dermatology residents. Friedman and his team started a partnership with community and religious leaders, recruited and trained volunteers, posted advertisements, informed potential patients, and recruited telehealth facilitators to develop the clinics. Pfizer and Lilly gave grants to fund this project, and the Rodham Institute was also a partner.

The clinics were advertised during church services, via flyers placed on cars and in mailboxes, and through social media posts. Friedman acknowledged that the social media posts were the most effective in advertising, in his experience.

There were 5 clinics conducted between February and June of 2022, with 46 patients treated overall. An average of 5 medical students and 3 dermatologists were present per clinic. All patients took a patient satisfaction survey after their visit.

“The overall satisfaction across the board in terms of did this impact their overall ability to take care of their condition, did it improve their impression of the dermatology field, should we keep this going across the board? The answers were, yes,” said Friedman.

Friedman said that these clinics are just one way that disparities in care can be addressed in areas where disparities are at their highest due to socioeconomic status and lack of accessibility to care.

Addressing care disparities based on skin color and accessibility are the primary ways that gaps in care can be reduced.