Recognizing atopic dermatitis flares in skin of color requires looking beyond traditional bright redness to identify purple, gray, deep brown, or violet tones. Dermatologists note that these variations, along with persistent pigment changes, often lead to delayed diagnoses and underestimated disease severity.
Why Traditional Signs Fall Short in Skin of Color
Chronic atopic dermatitis presents distinct diagnostic challenges across different patient populations, particularly when evaluating inflammation in darker skin tones. Dermatologists emphasize that bright redness, often seen in people with lighter skin, may be much less obvious in people with darker skin.
If you have atopic dermatitis (AD), it’s important to know that flare-ups don’t look the same for everyone. In people with lighter skin, inflammation often appears bright red,
says Tanya Evans, MD, a board-certified dermatologist and medical director of the skin cancer program at MemorialCare Saddleback Medical Center in Laguna Hills, California. In darker skin, however, redness may be much less obvious.
This difference can make atopic dermatitis more difficult to recognize — not just for you, but for healthcare providers, too. Research suggests the severity of atopic dermatitis may be underestimated in people with darker skin, which can delay proper diagnosis and treatment and lead to more skin discoloration after a flare. Knowing what an atopic dermatitis flare looks and feels like — both before and after — can help you recognize symptoms sooner, start treatment earlier, and reduce the risk of long-term skin changes.
Identifying Alternative Inflammatory Palettes and Discoloration
When classic redness is less obvious, active inflammation may present through different visual tones. Clinicians must scan for muted, deeper hues.
“In darker skin, inflammation often presents as purple, gray, deep brown, or violet tones, rather than bright red.”
Elizabeth Bahar Houshmand, MD, a board-certified dermatologist based in Dallas
Pigment changes can persist long after inflammation has resolved, so people with darker skin may underestimate how active their disease has been,
says Dr. Evans. Following your treatment regimen consistently and moisturizing daily, she adds, can help rebuild the skin barrier, which can help reduce the risk of future flares.
Even after a flare subsides, changes in skin color can linger for weeks or months, says Evans. In people with darker skin tones, these changes are often more noticeable than the eczema itself,
she says. Dark spots tend to develop after the inflammation fades, while lighter patches may occur because inflammation temporarily reduces pigment production, says Evans. The most important step is controlling the inflammation early and preventing recurrent flares, because every flare increases the risk of long-lasting pigment changes,
she says.
To help your skin recover, moisturize regularly and wear sunscreen every day. UV exposure can make dark spots persist longer and can make light spots appear more pronounced,
says Evans.
Your skin doesn’t have to look inflamed to be inflamed. A persistent itch can sometimes begin long before any visible changes appear on your skin, says Evans. As tempting as it may be, try to avoid scratching or rubbing the area as much as possible, since this can worsen the discoloration, she adds. If you can’t stop touching itchy skin, try gently patting the area instead. This may help you relieve the itch while avoiding further damage to the skin barrier.
Systemic Treatment Paradigms and Persistent Unmet Needs
Chronic atopic dermatitis (AD) is characterized by recurrent or persistent inflammation, with cycles of improvement followed by relapse. When the disease remains uncontrolled despite topical and systemic therapies, it is considered refractory, though patient behavioral factors such as poor adherence and sleep disturbance should be evaluated before making this diagnosis. The severity of AD is assessed through both physical signs of atopic dermatitis and its psychological impact, including effects on daily activities, sleep, and mood. Moderate to severe AD typically presents with dry skin, frequent itching and redness, noticeable impact on everyday life, and disturbed sleep.
According to the AAD guidelines, topical therapies are recommended across the severity spectrum, while systemic treatments are reserved for moderate to severe cases when topical regimens have failed. AD involves multiple inflammatory pathways and diverse T-cell subsets. While many current treatments have made great strides in improving patient outcomes in AD, there still exists an unmet need. Many treatments take an approach of selectively targeting type 2 inflammatory drivers, addressing only part of the immune activity involved in AD. This approach rarely leads to therapy-free remission, meaning disease control persists only with continuous dosing.
AD complexity stems from immune system dysregulation, with heterogeneous inflammation impacting cytokines like IL-4, IL-13, and IL-31. This heterogeneity varies across populations, ethnicities, and age groups, highlighting the need for individualized treatment strategies. Available systemic treatments include targeted biologic agents that address specific cytokine pathways, JAK inhibitors that interrupt the JAK/STAT signaling pathway, and conventional immunosuppressants requiring intense monitoring due to serious side effects. Guidelines advise against long-term corticosteroid use beyond 90 days due to increased adverse events risk.
Despite the significant progress made with these options, over 50% of adults identify flare recurrence as the most challenging disease aspect, while more than 55% report inadequate control while on treatment. Long-term adherence remains problematic due to treatment burden and complexity. Treatment goals should evolve toward achieving sustained disease stability without frequent or burdensome intervention, addressing the unmet need for lasting control while reducing patient burden.
