Dermatology: Practical and Conceptual Review | Dermatol Pract Concept. 2023;13(4):e2023259 1 Atopic Dermatitis in Individuals of Asian and African Ancestry: A Scoping Systematic Review Chiedu Enechukwu Ufodiama1, 2, 3, Blessing Fabowale-Makinde4, Christine Elise Kleyn1,2 1 Department of Dermatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK 2 Dermatology Centre, Salford Royal Hospital, Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester, UK 3 Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK 4 Medway Maritime Hospital, Medway NHS Foundation Trust, Gillingham, Kent, UK Key words: atopic dermatitis, eczema, skin of color, african skin types, asian skin types Citation: Ufodiama CE, Fabowale-Makinde B, Kleyn CE. Atopic Dermatitis in Individuals of Asian and African Ancestry: A Scoping Systematic Review. Dermatol Pract Concept. 2023;13(4):e2023259. DOI: https://doi.org/10.5826/dpc.1304a259 Accepted: May 12, 2023; Published: October 2023 Copyright: ©2023 Ufodiama et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Chiedu Ufodiama, Salford Royal Hospital, Email: Chiedu.ufodiama@doctors.org.uk Introduction: Atopic Dermatitis (AD) affects individuals from all ethnicities and backgrounds. It has the highest global disease burden of dermatoses. There is a widely held belief that the presentation of AD is not described well in individuals with non-European ancestry in peer-reviewed literature. How- ever, to our knowledge, this has not been investigated previously. Objective: To quantify the number of peer-reviewed literature describing the appearance of clinical features of AD in non-European ancestry, particularly those originating from the Asian and African continents. Methods: A systematic scoping review between December 2020 and January 2021 was performed to quantify the number of studies describing AD in individuals of African and Asian ancestry. Results: Sixteen studies were identified. None of the studies provided a clear description of AD in our population groups. Two studies described features of lichen planus like-AD in African American individuals. All studies reported on observed clinical features of AD. Conclusions: The review confirmed a lack of literature describing AD in populations of non-European heritage. It should encourage authors to make a deliberate effort to describe the appearance of clinical features of AD to enable understanding of how they may differentiate in individuals originating from different parts of the globe. ABSTRACT 2 Review | Dermatol Pract Concept. 2023;13(4):e2023259 Introduction Atopic dermatitis (AD) is a chronic, inflammatory, immune-mediated skin disease that has the highest disability adjusted life years globally, of all dermatoses [1,2]. Its ad- verse impact on quality of life is experienced by individuals irrespective of their ancestry. In the United Kingdom (UK), 11.8% of the population identified as being from Black, Asian, or other (non-White) ethnic groups and 2.2% identified as mixed ethnicity. An in- crease of ethnic diversity in the UK with more individuals reporting non-European ancestry is predicted, which further highlights the need to assess skin accurately regardless of ethnicity [3-5. Widely used criteria to diagnose AD are based on the Hanifin and Rajka criteria (HRC), or a derivative thereof, however, the limitations of HRC have been previously re- ported [6]. These include that the HRC is based predomi- nantly on a European population although the UK Working Party Criteria (UKC) endeavored to adjust for this [7]. Con- sequently, descriptions or definitions used historically may not accurately reflect the appearance of AD in all individuals. Objectives In view of the abovementioned disparities, we conducted a scoping systematic review to assess the extent of currently available peer-reviewed literature which describes AD le- sions in individuals of non-European ancestry. Methods The review included results from EMBASE (OVID), MED- LINE (OVID, PubMed) and a free text search (("Atopic Dermatitis" AND ("Africa* OR Asia*)) of the first 10 pages of Google© during December 2020 and January 2021 and follows the PRISMA extension for scoping systematic re- views (PRISMA-ScR) checklist [8]. The search protocol was registered on the Open Science Framework (Registration DOI: 10.17605/OSF.IO/UCK97). The search strategies included English language, peer-reviewed literature (Supplementary tables S1, S2). Search terms can be found in the supplementary tables. Ex- clusion criteria included non-English language, conference abstracts, communication letters and textbook chapters. The primary outcome was to quantify the number of studies describing the clinical features and presentation of AD in individuals of African and Asian ancestry. Secondary outcomes were to identify how frequently features of AD (as previously outlined in "Taylor and Kelly's Dermatology for Skin of Color" [9]), including pigmentation, erythema, lichenification, follicular prominence, site(s) of lesion(s), crusting, scales, lichenoid presentation were documented, and whether comparisons were made to European skin types (phototype I-III). Two independent researchers (CEU and BFM) inde- pendently searched the databases according to the inclusion and exclusion criteria. EK was the third reviewer and acted as arbitrator in disagreements. Results Study Selection The search strategy (Figure 1) identified 16 articles for full screening and appraisal (Table 1). Study Characteristics of Included Papers Twenty-five per cent of papers identified were either obser- vational studies or reviews, 19% were cross-sectional studies and 13% were case reports (Figure 2). A systematic review, an epidemiological survey and a case series each represented 6% of the remaining selection. Clinical features of AD in individuals from eight different geographical skin types were described (Figure 3). Description of Clinical Features Aspects of the clinical features of AD were described by 6 studies (Table 2). Saleh et al and Summey et al both de- scribed clinical features of lichen planus-like AD in African American individuals. Saleh described lesions as "licheni- fied hyperpigmented violaceous polygonal papules and plaques" that presented on the palms, whilst Summey de- scribed "brownish gray-purple plaques" [10,11]. Lopez Carrera et al reports that African Americans may present with less obvious erythema that may appear reddish blue or purple violaceous with a flexural predominance [12]. In addition, perifollicular accentuation, papulation, scaling, lichenification and pigmentary changes were described as being more prominent. Similarly, Vachiramon et al reported features of AD may be more subtle in African American children with scattered papular lesions occurring in an annular distribution on extensor surfaces and trunk [13]. A greater tendency for obvious post inflammatory hyper and hypopigmentary changes was also noted. Furthermore, AD, in a south-eastern Nigerian population, has been described as scattered, micropapular, annular lesions localized to hair follicles on the extensors, with associated hyperpigmen- tation and lichenification [14]. Moreover, Kaufman et al, in a review of AD in a global† population describe more Review | Dermatol Pract Concept. 2023;13(4):e2023259 3 Figure 1. Adapted PRISMA flow diagram of the retrieved studies. Three databases were screened, a review of the citations and a Google© free text search was conducted. Once completed, as illustrated above, 16 studies were included. well-demarcated lesions and increased scaling and licheni- fication in Asian individuals [15]. Reported Clinical Features Site of lesion, lichenification and erythema were the most reported. All studies reported at least one clinical feature of AD (Table 2). All papers reporting on African American or African individuals noted pigmentary changes, whilst ery- thema was often reported in studies of individuals from the Asian continent. Often clinical features were reported in tab- ular form, which outlined the frequency of presentation that they occurred. Comparison to Skin on Individuals With European Ancestry Five studies reported comparisons with skin of European an- cestry (Table 2). No study made comparisons with reference to the Fitzpatrick scale. Yew et al compared clinical features of AD from several regions to European studies. They re- ported higher prevalence of erythroderma, truncal, exten- sor, scalp, and auricular involvement in individuals from East Asian as compared to those from Europe. Truncal in- volvement and lichenification were also reported to be more prevalent in individuals from southeast Asia as compared to Africa where a higher prevalence of papular lichenoid lesions were reported. Vachiramon et al compared pathophysiology, clinical presentation, and treatment of AD between African American children and Caucasians (European American), they reported on the difficulty of initially diagnosing AD in African American children, citing lack of erythema as well as differences in distribution of lesions as contributing to diag- nostic challenges. Studies by Kaufman et al. and Silverberg et al utilize European skin as a reference to contrast features seen in other global skin types [15,16]. Conclusions The majority of included studies were observational or non-systematic literature reviews, thus the strength of ev- idence was relatively poor [17]. AD in individuals with African ancestry were the most reported population and these studies often referenced a paper by Nnoruka when re- porting the clinical features of AD [14]. It was important to include reviews, to give a true appreciation on the depth of peer reviewed description of AD in non-European ancestry that were available and accessible. The primary outcome was to quantify the number of peer-reviewed literature that described clinical features of AD in non-European individuals. Six studies described cer- tain features of AD in non-European individuals; these were 4 Review | Dermatol Pract Concept. 2023;13(4):e2023259 Ta b le 1 . S tu di es in cl ud ed in t he s co pi ng r ev ie w . S ix te en s tu di es w er e id en ti fie d; t ho se w it h A fr ic an d es ce nt ( A fr ic an , A fr ic an -A m er ic an , A fr ic an C ar ri bb ea n) w er e th e m os t th e re po rt ed d em og ra ph ic . S om e st ud ie s gr ou pe d by c on ti ne nt al r eg io ns , w hi ls t ot he rs id en ti fie d in di vi du al c ou nt ri es . M os t  st ud ie s w hi ch w er e in cl ud ed w er e ob se rv at io na l. Ti tl e A u th o r Ye ar D em o g ra p h ic /C o u n tr y St u d y Ty p e L ic he no id a nd o th er c lin ic al p re se nt at io ns o f at op ic d er m at it is in a n in ne r ci ty p ra ct ic e. A lle n et  a l.  [2 3] 20 08 A fr ic an A m er ic an C as e re po rt A to pi c de rm at it is in in fa nt s an d ch ild re n in I nd ia D ha r et a l [ 24 ] 20 10 In di an R ev ie w A to pi c de rm at it is in d iv er se r ac ia l a nd e th ni c gr ou ps -V ar ia ti on s in ep id em io lo gy , g en et ic s, c lin ic al p re se nt at io n an d tr ea tm en t. K au fm an e t al [ 15 ] 20 18 A si an , W hi te , A fr ic an d es ce nt R ev ie w A du lt -o ns et a to pi c de rm at it is : a c ro ss -s ec ti on al s tu dy o f na tu ra l hi st or y an d cl in ic al m an if es ta ti on K ul th an an e t al [ 18 ] 20 07 T ha ila nd C ro ss -s ec ti on al st ud y. T he c lin ic o- ep id em io lo gi ca l p ro fil e an d th e ri sk f ac to rs a ss oc ia te d w it h th e se ve ri ty o f at op ic d er m at it is ( A D ) in e as te rn I nd ia n ch ild re n. K um ar e t al [ 25 ] 20 00 In di a (E as t In di an ) E pi de m io lo gi ca l st ud y M in or c ut an eo us f ea tu re s of a to pi c de rm at it is in S ou th K or ea L ee e t al [ 26 ] 20 08 So ut h K or ea O bs er va ti on al s tu dy C lin ic al f ea tu re s of A du lt /A do le sc en t A to pi c D er m at it is a nd C hi ne se C ri te ri a fo r A to pi c D er m at it is L iu e t al [ 27 ] 20 16 C hi na O bs er va ti on al s tu dy E pi de m io lo gy , D ia gn os is , a nd T re at m en t of A to pi c D er m at it is in th e D ev el op in g C ou nt ri es o f A si a, A fr ic a, L at in A m er ic a, a nd t he M id dl e E as t: A R ev ie w . L op ez C ar re ra e t  al [1 2] 20 19 E as t A si a, S ou th ea st A si a, L at in A m er ic a, N or th A fr ic a, Su b- Sa ha ra n A fr ic a, m id dl e ea st R ev ie w C ur re nt e pi de m io lo gy o f at op ic d er m at it is in s ou th -e as te rn N ig er ia N no ru ka [ 14 ] 20 08 N ig er ia O bs er va ti on al s tu dy A R ar e C as e of L ic he n Pl an us -L ik e A to pi c D er m at it is I nv ol vi ng t he H an ds . Sa le h et a l [ 10 ] 20 20 A fr ic an A m er ic an C as e re po rt D is tr ib ut io n of a to pi c de rm at it is le si on s in U ni te d St at es a du lt s Si lv er be rg e t al [ 16 ] 20 04 C au ca si an /W hi te , A fr ic an -A m er ic an /B la ck , H is pa ni c, M ul ti ra ci al /o th er C ro ss -s ec ti on al st ud y. L ic he n pl an us -l ik e at op ic d er m at it is : e xp an di ng t he d if fe re nt ia l di ag no si s of s po ng io ti c de rm at it is Su m m ey e t al [ 11 ] 20 07 A fr ic an A m er ic an C as e se ri es C lin ic al a na ly se s of a to pi c de rm at it is in t he a ge d Ta ne i e t al [ 28 ] Ja pa n O bs er va ti on al s tu dy . A to pi c de rm at it is in A fr ic an A m er ic an c hi ld re n: a dd re ss in g un m et ne ed s of a c om m on d is ea se . V ac hi ra m on e t al [ 13 ] 20 12 A fr ic an D es ce nt ( A fr ic an A m er ic an , A fr ic an , a nd A fr ic an C ar ib be an ) R ev ie w Pr ev al en ce a nd c lin ic al f ea tu re s of a du lt a to pi c de rm at it is in t er ti ar y ho sp it al s in C hi na W an g et a l [ 29 ] 20 17 C hi na C ro ss -s ec ti on al st ud y. A s ys te m at ic r ev ie w a nd m et a- an al ys is o f th e re gi on al a nd a ge - re la te d di ff er en ce s in a to pi c de rm at it is c lin ic al c ha ra ct er is ti cs Y ew e t al [ 30 ] 20 19 A m er ic as ( U S, M ex ic o, C ol om bi a) , E as t A si a (C hi na , J ap an , K or ea ), So ut h E as t A si a (S in ga po re , T ha ila nd ), In di a, M id dl e E as t (I ra n) , E ur op e (B os ni a, D en m ar k, F in la nd , Fr an ce , G er m an y, I ta ly , T he N et he rl an ds , N or w ay , P ol an d, R om an ia , S w ed en , S w it ze rl an d, T ur ke y, U K , M ul ti pl e si te s) , A fr ic a (N ig er ia , S ou th A fr ic a, T un is ia ), A us tr al ia Sy st em at ic R ev ie w an d M et a- A na ly si s Review | Dermatol Pract Concept. 2023;13(4):e2023259 5 Figure 2. Proportion of the types of peer-reviewed studies included. Observational studies and review ar- ticles were the most identified studies with each representing 25% (N = 4) of identified works respectively. Figure 3. Frequency of geographical skin types reported in included studies. Studies were grouped to allow for the data to be meaningfully assessed; 9 out of 17 studies identified reported on individuals with African descent. primarily comments on the lack of erythema and the presence of hyperpigmentation. The case reports on lichen-planus like AD presented the most plausible example of comprehensive description on the morphological appearance of AD in non- European individuals. Across all included studies, site of lesion, erythema and lichenification were the most reported clinical feature. Follicular prominence and pigmentation were also de- scribed; their association with AD in individuals of sub-Saharan African descent has previously been reported by others [9]. Five studies used European criteria/skin type as a point of reference when comparing AD to skin types of different non-European ancestries. Kulthanan et al studied the clin- ical features of adult-onset AD in Thai patients. In their discussion, they concluded that most clinical features of adult-onset AD in their population were very similar to what had previously been reported in non-Asian populations [18]. Conducting the study presented challenges, including to the categorization of skin types. We adopted the approach of 6 Review | Dermatol Pract Concept. 2023;13(4):e2023259 Ta b le 2 . S um m ar y of in di vi du al s tu dy fi nd in gs . S ix o f 16 s tu di es in cl ud ed d es cr ib ed t he c ha ra ct er is ti cs o f on e or m or e cl in ic al f ea tu re s re po rt ed b y th e au th or . L ic he ni fic at io n, e ry th em a an d si te o f le si on w er e th e cl in ic al f ea tu re s th at w er e m os t co m m en te d up on . O nl y 5 st ud ie s in cl ud ed m ad e co m pa ra bl e re fe re nc e to E ur op ea n sk in t yp es Ye ar C lin ic al Fe at u re s D es cr ib ed C lin ic al F ea tu re s R ep o rt ed C o m p ar is o n t o Eu ro p ea n S ki n t yp es Pi g m en ta ti o n Er yt h em a Li ch en ifi ca ti o n Fo lli cu la r Pr o m in en ce Si te s o f le si o n C ru st in g Sc al es Li ch en o id Pr es en ta ti o n A lle n et a l 20 08    D ha r et a l 20 10     K au fm an e t al 20 18          K ul th an an e t al 20 07    K um ar e t al 20 00   L ee H J et a l 20 08   L iu e t al 20 16 L op ez C ar re ra e t al 20 19      N no ru ka 20 08       Sa le h et a l 20 20      Si lv er be rg e t al 20 04  Su m m ey e t al 20 07       Ta ne i e t al 20 08    V ac hi ra m on e t al 20 12         W an g et a l 20 17   Y ew e t al 20 19        Review | Dermatol Pract Concept. 2023;13(4):e2023259 7 Am J Dermatopathol. 2020;42(3):215-217. DOI: 10.1097/ DAD.0000000000001593. PMID: 31855583.. 11. Summey BT, Bowen SE, Allen HB. Lichen planus-like atopic dermatitis: expanding the differential diagnosis of spongi- otic dermatitis. J Cutan Pathol. 2008;35(3):311-314. DOI: 10.1111/j.1600-0560.2007.00806.x. PMID: 18251746. 12. Lopez Carrera YI, Al Hammadi A, Huang YH, Llamado LJ, Mahgoub E, Tallman AM. Epidemiology, Diagnosis, and Treat- ment of Atopic Dermatitis in the Developing Countries of Asia, Africa, Latin America, and the Middle East: A Review. Dermatol Ther (Heidelb). 2019;9(4):685-705. DOI: 10.1007/s13555-019 -00332-3. PMID: 31650504. PMCID: PMC6828917. 13. Vachiramon V, Tey HL, Thompson AE, Yosipovitch G. Atopic dermatitis in African American children: addressing unmet needs of a common disease. Pediatr Dermatol. 2012;29(4):395-402. DOI: 10.1111/j.1525-1470.2012.01740.x. PMID: 22471955. 14. Nnoruka EN. Current epidemiology of atopic dermatitis in south-eastern Nigeria. Int J Dermatol. 2004;43(10):739-744. DOI: 10.1111/j.1365-4632.2004.02360.x. PMID: 15485531. 15. Kaufman BP, Guttman-Yassky E, Alexis AF. Atopic derma- titis in diverse racial and ethnic groups-Variations in epide- miology, genetics, clinical presentation and treatment. Exp Dermatol. 2018;27(4):340-357. DOI: 10.1111/exd.13514. PMID: 29457272. 16. Silverberg JI, Margolis DJ, Boguniewicz M, et al. Distribution of atopic dermatitis lesions in United States adults. J Eur Acad Dermatol Venereol. 2019;33(7):1341-1348. DOI: 10.1111 /jdv.15574. PMID: 30883885. 17. Murad MH, Asi N, Alsawas M, Alahdab F. New evidence pyr- amid. Evid Based Med. 2016;21(4):125-127. DOI: 10.1136 /ebmed-2016-110401. PMID: 27339128. PMCID: PMC4975798. 18. Kulthanan K, Samutrapong P, Jiamton S, Tuchinda P. Adult-onset atopic dermatitis: a cross-sectional study of natural history and clinical manifestation. Asian Pac J Allergy Immunol. 2007;25(4):207-214. PMID: 18402293. 19. Ebede T, Papier A. Disparities in dermatology educational re- sources. 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