Eczema in skin of color looks different than on white skin, so the diagnosis is often more challenging and is sometimes overlooked. Familiarity with how eczema looks in skin of color is essential in making a correct diagnosis and prescribing the right treatment.
Allergists are trained to diagnose and treat skin conditions including eczema. Atopic dermatitis, a form of eczema, is often related to allergies.
Diagnosis and Testing
Many images of eczema you see online or in publications often show redness or red dots on light skin. Those symptoms appear quite differently in people with darker skin tones. What does eczema in skin of color look like? In black or brown skin, it may appear as dark brown, purple or ashen gray patches.
Common eczema symptoms to help confirm the diagnosis can include:
- intense itchy skin
- swelling
- dry, cracked, scaly skin
- affected skin feels warm when touched
- open, crusty or weepy sores
In people of color, eczema may also show as small bumps (called papules), especially on the chest, back, arms and legs. When bumps grow around hair follicles (called follicular accentuation), they can resemble goosebumps and result in thickened or firm skin with hair standing on its end.
Repeated scratching of affected areas can result in thickened or firm skin (called lichenification) with raised bumps called prurigo nodules.
Eczema-related inflammation can cause skin discoloration: 1) darkening of the skin – called hyperpigmentation, or 2) lightening of the skin – called hypopigmentation. These conditions often occur during post-inflammation, or when the skin is healing from a flare-up.
Since skin discoloration is often more noticeable in people of color, it can frequently cause distress. It can also cause anxiety and depression and impact quality of life, especially among adolescents and teenagers. Regular treatment usually helps resolve skin discoloration but it sometimes takes months or even years for it to go away completely.
It’s common for eczema symptoms in people of color to be misdiagnosed as another condition. A misdiagnosis or delayed diagnosis can lead to no treatment or the wrong treatment. It can also increase the risk of hyperpigmentation and hypopigmentation as the skin heals after a flare-up.
Diagnosis of eczema is the same for all skin colors. First the doctor will ask about:
- types of soap, detergent and skin care products used
- any exposures that may cause or make eczema worse
Your doctor may look for allergens and irritants that can trigger a patient’s eczema. Flare-ups can be caused by:
- cosmetics
- soaps
- wool
- food
- pollen
- mold
- dust mites
- dog or cat dander
- dry climate
- stress
As part of the diagnosis, an allergist may perform tests to identify if there’s an allergen or irritant causing symptoms.
Skin prick test: the doctor will prick or puncture the patient’s skin. Then a diluted allergen is placed on the site of the prick. The test is usually done on the back or forearm in adults and on the back in children. Several allergens are often tested at the same time. The allergist will observe the tested area for about 15 minutes to see if a bump (wheal) or change in skin color (flare) develops.
Blood test: After a blood sample is drawn, it is analyzed to detect IgE antibodies directed at specific allergens. Tests may measure specific or overall levels of IgE. Some may also break down common allergens and measure IgE to specific components. The lab results may take several days to be returned.
Patch test: Chambers containing chemicals of potential triggers on adhesive strips are placed onto the patient’s back. After 2-3 days, the patches are removed by the doctor and the skin is evaluated for reactions. If symptoms appear, then it’s confirmation of an allergy. Patch testing is commonly used for contact allergies to fragrances, detergents, metals and other chemical sensitizers.
Oral food challenge: if it’s believed certain foods are causing eczema to flare, doctors may recommend a food test. The patient is asked to eat a tiny amount of a suspected food allergen, and then gradually larger amounts, to determine if there’s an allergic reaction. An oral food challenge should only be conducted by a doctor and at a medical facility that has access to emergency epinephrine in case of a severe allergic reaction.
Children under the age of 5 with moderate to severe eczema may need more testing. This is especially true if the child’s eczema does not get better after treatment. The child should be tested for food allergies including:
- milk
- egg
- peanut
- tree nuts
- wheat
- soy
Recent guidelines put infants with severe eczema and/or egg allergy in the highest risk category for peanut allergy. These high-risk infants should be seen by an allergist or pediatrician who can determine if they are candidates to be introduced to peanut-containing foods between 4-6 months in order to prevent peanut allergy.
Between 33 to 63 percent of young children with moderate to severe eczema also have food allergies.
Other tests:
Buccal swabs: used to detect mutations in the filaggrin gene, the protein that helps protect the body from allergens and bacteria. A lack of filaggrin weakens the skin barrier, leading to eczema.
Skin biopsy: a tiny piece of skin is removed and analyzed under a microscope. It can rule out other skin diseases such as skin cancer or psoriasis.
© 2021 Allergy and Asthma Network
Last updated : 9/15/2021