Put your best face forward
Dermatology experts call for overhaul in how inflammatory skin diseases are diagnosed and treated in skin of color.
In a move to close longstanding diagnostic gaps, overlooked pathophysiology, and a shortfall of inclusive research, dermatologists are urging the medical community to fundamentally rethink how inflammatory skin diseases are recognized and treated in patients with skin of color.
These insights were the focus of the 2026 AAD Annual Meeting session, F035 – Inflammatory Skin Diseases in Skin of Color. Overcoming the inequities in skin care and rebuilding the traditional dermatologic framework is a passion and practice principle for George Han, MD, PhD, FAAD, an associate professor of dermatology at the Icahn School of Medicine at Mount Sinai in New York.
George Han, MD, PhD, FAAD
Diverse demographic challenges
According to Dr. Han, the appearance of many inflammatory skin conditions varies considerably in multiple domains, including distribution (flexural/extensor), morphology of individual lesions, and even histopathology.
“This makes it quite challenging for physicians, which explains data revealing that patients often have delays to diagnosis and are more likely to require a biopsy to establish a diagnosis,” he said. “Additionally, there is evidence that there are differences in cytokine profile, and thus the pathophysiologic basis for some of these inflammatory dermatoses among different populations.”
The demographics of new-onset atopic dermatitis (AD) are changing, Dr. Han said. Previously seen as a skin disease of childhood that could persist into adulthood, dermatologists now recognize that there may be more cases of AD presenting in adulthood, especially in Asian patients, he said. These patients may also have higher severity of skin disease due to cultural factors like less utilization of steroids.
Conversely, he added, after effective treatment of AD, post-inflammatory pigmentary alteration is more likely and suppression of Th2 inflammation can also release some of the counter-regulatory mechanisms that may have reduced Th17 inflammation. This results in “releasing the brakes” on psoriasiform dermatitis, he said.
“Given the relatively low historical rates of psoriasis in certain Asian populations, it’s quite possible that the clear split between AD and psoriasis, which we think of as discrete, is not so clear in certain populations,” Dr. Han said.
Session speaker Andrew Alexis, MD, MPH, FAAD, also underscored the important nuances in the clinical presentation and impact of inflammatory skin disorders in patients with skin of color. Dr. Alexis, a professor of clinical dermatology at Weill Cornell Medicine in New York City, said these include variations in the clinical appearance of erythema, specific morphologies that may predominate in specific populations, and associated pigmentary sequelae that may have an equal or greater impact on the patient than the inflammatory disorder.
Andrew Alexis, MD, MPH, FAAD
Look again
Overlooking differences in patients with skin of color can lead to missed diagnoses, said session presenter Pooja R. Shah, MD, FAAD, associate professor of dermatology at Hofstra University’s Zucker School of Medicine in Hempstead, New York. For example, she said, erythema, a marker of inflammation, often appears violaceous, grey, or hyperpigmented in skin of color, causing physicians to underestimate disease severity. In skin of color patients with inflammatory skin disease, there is a higher burden of lichenification, post-inflammatory hyperpigmentation, and scarring.
Pooja R. Shah, MD, FAAD
Sadly, the diagnostic paradigm in dermatology has long been anchored in erythema — a framework constructed from and calibrated to lighter skin phenotypes, she said. In skin of color patients, this erythema-centric model is actively misleading.
“Inflammation in darker skin tones frequently presents as textural change (lichenification, induration) and pigmentary shift (hyperpigmentation or violaceous discoloration, hypo- or de-pigmentation), rather than redness. Shifting from an erythema-centric to a ‘texture and pigment-centric’ diagnostic lens is not simply a cultural accommodation. It is a fundamental correction that improves diagnostic accuracy across all patients and reduces the inequities embedded in delayed diagnosis,” Dr. Shah said.
Common but distinct
Treating two other common inflammatory skin diseases — acne and rosacea — also requires a keen eye, said Heather Woolery-Lloyd, MD, FAAD, a professor of dermatology at the University of Miami Miller School of Medicine in Florida.
“Post-inflammatory hyperpigmentation (PIH) in patients with acne and skin of color is very common, with a prevalence ranging from 57-87%. It is often the primary concern and is associated with diminished social life, avoidance of public facilities, poor body image/self-esteem, and perception of more severe disease,” Dr. Woolery-Lloyd said. “Additionally, rosacea is likely underreported in patients with skin of color and is often misdiagnosed, prompting the need for more research.”
Up-and-coming treatments
Heather Woolery-Lloyd, MD, FAAD
For rosacea, Dr. Woolery-Lloyd discussed topical treatments, such as metronidazole, azelaic acid, ivermectin, and sodium sulfacetamide/sulfur as well as oral antibiotics for more severe cases.
According to Dr. Alexis, a key concept in the approach to treating inflammatory skin diseases in skin of color is recognizing that the desired treatment outcome is typically the resolution of both primary lesions of the inflammatory disorder and the pigment alterations caused by the inflammatory disorder. This requires a longer treatment timeline with longitudinal control of the underlying inflammatory/immunological pathways as well as potential adjunctive therapy for dyspigmentation, he said.
“We now have increasing evidence for the potential to improve pigmentary sequelae in inflammatory disorders when treating an immune-mediated skin disorder, such as psoriasis and atopic dermatitis with targeted therapies, or acne vulgaris with topical retinoids,” Dr. Alexis said.
He pointed to recent studies with lebrikizumab or dupilumab for AD and guselkumab for psoriasis, which have included pigmentary changes as exploratory endpoints and demonstrated improvement in PIH with treatment of the primary inflammatory disorder.
In addition, Dr. Alexis said trifarotene cream has been studied as a treatment of acne-induced hyperpigmentation.
“The practical takeaway for dermatologists is to convey to patients that effective long-term control of their chronic inflammatory skin disorder is expected to yield improvements in pigmentary changes. But these typically require months of therapy before resolution of hyper- or hypopigmentation occurs,” he said. “Secondly, adjunctive measures, including photoprotection and topical skin-lightening agents, may be used to hasten the resolution of PIH.”
Knowledge is power
Staying up to date with the most recent literature is perhaps the biggest advantage a dermatologist can have, Dr. Han said. It can help physicians make more confident diagnoses and establish appropriate therapeutic ladders that are appropriate for the patient, he said.
“The good news is that more targeted therapies and data on treatments for diverse patient populations with skin conditions such as atopic dermatitis and psoriasis have recently emerged, giving physicians the opportunity to be more nuanced in their approach to inflammatory skin diseases,” Dr. Han said.
All are included
Taking it a step further, all panelists agreed that more inclusion in research and clinical trials can make the biggest impact on treating patients with skin of color and inflammatory skin diseases.
Research has not kept pace with clinical need, Dr. Shah said. Key gaps include:
- Lack of racially diverse clinical trial enrollment
- Need for week-to‑week inflammatory biomarker data in different populations
- Limited validated PIH outcome measures
- Underreporting and misdiagnosis of conditions like rosacea in skin of color
Dermatology’s knowledge base still leans heavily on lighter-skinned patient data, she said, though new initiatives like AAD’s Skin of Color Curriculum and Clinical Image Collection are beginning to narrow the gap.
“Priority research areas should include diverse randomized controlled trial enrollment mandates, PIH as a validated treatment outcome, and skin of color-specific diagnostic and photographic curricula (especially in vulvar dermatoses),” Dr. Shah said. “Equitable dermatologic care is not treating all patients the same, but recognizing that our evidence base, diagnostic norms, and training have been built around lighter skin phenotypes. We need to close that gap at the bedside, mitigate diagnostic delays, address therapeutic undertreatment, and reduce the stigma borne disproportionately by patients with skin of color.”
The session also included speakers Raj J. Chovatiya, MD, PhD, FAAD; Michelle Min, MD, MSc, FAAD; Raja Sivamani, MD, FAAD; and Eingun James Song, MD, FAAD.
