Racial disparities create barriers for the treatment of atopic dermatitis (AD) and food allergies in people with skin of color. This was the majority opinion reported by 68% of American College of Allergy, Asthma, and Immunology (ACAAI) members who responded to a survey on racial/ethnic disparities in the treatment of AD and food allergies. Survey results were reported in a December 2022 article in the Annals of Allergy, Asthma and Immunology.1
The same journal article also cited extensive research revealing disparities in the prevalence, diagnosis, and treatment of atopic diseases and food allergy among Americans from various racial and ethnic groups. As the article reported, atopic dermatitis and food allergy more commonly affect Black children than White children, and greater illness severity has been observed in Black and Hispanic children with these diseases compared with White children.1
To address these racial disparities and treatment gaps, the ACAAI convened a roundtable and interviewed clinicians and advocates to explore the challenges and identify potential solutions. As a result of these discussions and survey results, roundtable panelists proposed the following recommendations:
- Identify strategies to increase clinical trial enrollment of people with skin of color.
- Increase recruitment of people with skin of color into medical school and the specialty of allergy, asthma, and immunology. Toward that end, the panel suggested increasing outreach to high school students in Science, Technology, Engineering, and Math (STEM) programs.
- Educate primary care providers and specialists about racial disparities in atopic disease via tools such as webinars, videos, and podcasts; develop culturally competent informational handouts for distribution to patients to increase awareness in the community.
- Advocate for revisions to Supplemental Nutrition Assistance Program (SNAP) policies to increase access to foods that are safe for children with food allergy.
- Develop a comprehensive library of images depicting AD in a wide range of skin types to improve provider recognition of the disease in people with skin of color and for use in educational activities.
- Create engaging, culturally appropriate, multi-language educational resources for patients with AD and food allergy; engage school nurses as key partners in this endeavor.
- Analyze the cost savings that may result from additional time spent with patients who have complex AD and food allergy issues; leverage this information to seek support from payers and health systems to allow longer physician visits for these patients.
- Leverage the findings and insights described by the ACAAI panel to improve care for patients with skin of color who are affected by AD or food allergy.
For more insight into racial disparities in the treatment of patients with AD and food allergy and how this problem can be mitigated, we interviewed Amy McMichael, MD, FAAD on the subject of atopic dermatitis and Ruchi Gupta, MD, MPH, on the topic of food allergy.
Dr McMichael, who has clinical and research expertise in dermatologic conditions in skin of color, is professor and chair in the department of dermatology at Wake Forest University School of Medicine in Winston-Salem, North Carolina.
Dr Gupta, an ACAAI member who participated as a panelist in the ACAAI roundtable on racial disparities in atopic dermatitis and food allergy1, is a professor of pediatrics and medicine at Northwestern University’s Feinberg School of Medicine in Chicago, clinical attending physician at the Ann & Robert H. Lurie Children’s Hospital of Chicago, and director of the Center for Food Allergy and Asthma Research at Northwestern University.
What are common racial disparities reported among patients with AD?
Dr McMichael: It is well known that patients of color, particularly Black patients, have an increased prevalence of AD and more severe disease as compared to other races and ethnicities. Black children are roughly 1.7-2.1 times more likely to receive a diagnosis of AD compared to White children.2
Recent studies have also shown that Black children with AD were more likely to have caregivers with low educational attainment, be exposed to tobacco smoke, live in rented homes, and live in multiple households.3
Also, AD outcome measures have poor reliability and validity in highly pigmented patients, with variations in erythema perception being a contributor.
The odds of seeing a dermatologist for AD are significantly lower in Black children, but when they do see a dermatologist, they are 3 times more likely to receive an AD diagnosis, which indicates missed diagnoses in primary care.2
What are some of the factors contributing to these disparities, and what are some ways for clinicians to help reduce these disparities?
Dr McMichael: The difficulty in perceiving erythema in those with pigmented skin can lead to undertreatment of disease that is still active and requiring treatment.4 There is a compendium of AD photos in all skin types in the VisualDx collection, but this can be made available to more primary care providers and specialist resident trainees.5
In addition, the social determinants of health must be understood for optimal treatment.6 As an example, if Black children with AD are more likely to live in multiple households, providers need to be aware of this and prescribe enough medication to have duplicates at all households where the child may be cared for.
What are your thoughts about the ACAAI recommendations1 on ways to address racial disparities in AD, and what should be the focus of future research in this area?
Dr McMichael: The recommendations of increasing research in patients of under-represented minorities (URMs) with skin disease, increasing URMs in medical school and the specialties of Dermatology and Allergy and Immunology, and working to make specialist visits more equitable are all great suggestions.
There is a need for all forms of research in AD — epidemiologic, genetic, immunologic, and clinical trials. We are lacking in all areas and will not serve our patients completely until these inroads are made.
What are examples of racial disparities affecting patients with food allergies?
Dr Gupta: Food allergy prevalence, associated health outcomes, access to timely diagnosis and care, and access to safe foods differ significantly by race and socioeconomic status, resulting in a disproportionate burden on non-White populations in the US.
Through interactions with patients, I often hear about challenges with timely access to specialists and issues with insurance, problems accessing safe foods that are affordable compared to the more expensive allergen-free options, confusion about food allergy symptoms and treatment, and more.
In our research, we found Non-Hispanic (NH) Black Americans had the highest rates of reported, convincingly immunoglobulin E (IgE)-mediated, and physician-confirmed food allergy compared with other groups. Hispanic Americans also reported significantly elevated rates compared to NH White Americans. Comorbid atopic conditions such as asthma, AD, and allergic rhinitis are also relatively higher in these populations.7,8
Black NH, Hispanic, and Asian NH children and adults have higher rates of lifetime food allergy-related emergency department visits relative to White Americans.8,9
Although proper diagnosis of food allergy is critical to receiving guideline-informed care, research indicates that Black children with food allergy and families earning less than $50,000 a year are significantly less likely to report receiving a physician diagnosis for food allergy.7,8 Diagnosis of AD is also critical to identifying those at high risk for peanut allergy development. There is a lack of representation of diverse skin tones in current assessment tools to categorize AD severity, and this is an area in which I’m glad to see progress.
Clinical trials have shown that more than 80% of peanut allergy cases can be prevented through regular feeding of peanut-containing foods during the first year of life.10 However, a cohort study of children with food allergy showed that nearly 89% of Black children were not introduced to peanuts by 1 year compared with 67% of White children.11
Food insecurity adversely impacts households with food allergy due to the high cost of allergen-free foods and less consistent availability at food pantries.12 In a cohort study of children with food allergy, we found that White caregivers were more likely to report access to allergen-free foods relative to Black caregivers — 88.1% vs 59%, respectively.13
There is a notable lack of awareness and screening among clinicians regarding the food insecurity status of their patients.12 There is great interest in implementing food insecurity assessments into practice to identify patients in need.
What are the key factors driving racial disparities among patients with food allergies, and how can these be addressed in clinical practice?
Dr Gupta: A variety of factors impact these disparities, including socioeconomic status, environmental exposures, food insecurity, reduced access to specialist care leading to less food allergy education, high costs of treatment, policies, and history of systemic racism and discrimination leading to inequitable health outcomes by race and ethnicity.14-16
In addition to the roundtable recommendations, these are other steps we can take in clinic:
- Incorporate food insecurity screening questions into clinic workflows, and provide resources and referrals to families, including Food Equality Initiative and Free From Market.
- Share tools and resources with fellow clinicians on the guidelines for the prevention of peanut allergies and eczema severity categorization to improve detection and treatment of high-risk patients.17,18
- Use the photo library of AD in diverse skin tones to create a severity score card to share with clinicians to improve accurate diagnosis.
- Counsel families on the importance of early introduction of allergens and share accessible resources on adding new foods to the diet.
- Share daily management tools with families and talk to them about treatment options.
What broader measures are needed to reduce these disparities?
Dr Gupta: Clinicians could consider creating or joining working groups to advocate for policies surrounding access to safe foods, specialist visits, and affordable treatments to help improve equitable care for the populations we serve.
We also need to continue improving racial representation in food allergy research. A group of food allergy clinicians, advocacy leaders, community-engaged researchers, and patients recently created 18 recommendations to combat inequitable research paradigms and increase participation of racially underrepresented populations in food allergy research.14
Physicians, allergists, patients, advocacy organizations, and policymakers must continue to work together to address these disparities through prioritizing comprehensive education, screening, management, and systemic policy change to achieve equitable care for all patients.
- Corbett M, Allen A, Bobo N, et al. Proposed solutions by the American College of Allergy, Asthma, and Immunology and advocacy experts to address racial disparities in atopic dermatitis and food allergy. Ann Allergy Asthma Immunol. 2022:S1081-1206(22)02001-4. doi:10.1016/j.anai.2022.12.017
- Croce EA, Levy ML, Adamson AS, Matsui EC. Reframing racial and ethnic disparities in atopic dermatitis in Black and Latinx populations. J Allergy Clin Immunol. 2021;148(5):1104-1111. doi:10.1016/j.jaci.2021.09.015
- Tackett KJ, Jenkins F, Morrell DS, McShane DB, Burkhart CN. Structural racism and its influence on the severity of atopic dermatitis in African American children. Pediatr Dermatol. 2020;37(1):142-146. doi:10.1111/pde.14058
- Sangha AM. Dermatological conditions in SKIN OF COLOR-: Managing atopic dermatitis. J Clin Aesthet Dermatol. 2021;14(3 Suppl 1):S20-S22.
- Dulmage B, Tegtmeyer K, Zhang MZ, Colavincenzo M, Xu S. A point-of-care, real-time artificial intelligence system to support clinician diagnosis of a wide range of skin diseases. J Invest Dermatol. 2021;141(5):1230-1235. doi:10.1016/j.jid.2020.08.027
- Eczema in Skin of Color. Social and economic factors. Accessed February 14, 2023.
- Gupta RS, Warren CM, Smith BM, et al. The public health impact of parent-reported childhood food allergies in the United States. Pediatrics. 2018;142(6):e20181235. doi:10.1542/peds.2018-1235
- Gupta RS, Warren CM, Smith BM, et al. Prevalence and severity of food allergies among US adults. JAMA Network Open. 2019;2(1):e185630. doi:10.1001/jamanetworkopen.2018.5630
- Mahdavinia M, Fox SR, Smith BM, et al. Racial differences in food allergy phenotype and health care utilization among US children. J Allergy Clin Immunol Pract. 2017;5(2):352-357.e1. doi:10.1016/j.jaip.2016.10.006
- Logan K, Bahnson HT, Ylescupidez A, et al. Early introduction of peanut reduces peanut allergy across risk groups in pooled and causal inference analyses. Published online November 27, 2022. Allergy. doi:10.1111/all.15597
- Brewer AG, Jiang J, Warren CM, et al; FORWARD Team. Racial differences in timing of food allergen introduction. J Allergy Clin Immunol Pract. 2022;10(1):329-332.e2. doi:10.1016/j.jaip.2021.10.024
- Shroba J, Das R, Bilaver L, et al. Food insecurity in the food allergic population: A work group report of the AAAAI Adverse Reactions to Foods Committee. J Allergy Clin Immunol Pract. 2022;10(1):81-90. doi:10.1016/j.jaip.2021.10.058
- Coleman AT, Sharma H, Robinson A, et al. Access to allergen-free food among Black and White children with food allergy in the FORWARD study. J Allergy Clin Immunol Pract. 2022;10(1):182-188. doi:10.1016/j.jaip.2021.08.005
- Bilaver LA, Galic I, Zaslavsky J, Anderson B, Catlin PA, Gupta RS. Achieving racial representation in food allergy research: A modified Delphi study. J Allergy Clin Immunol Pract. 2023;11(1):281-291. doi:10.1016/j.jaip.2022.09.041
- Leeds S, Nowak-Wegrzyn A. Defining socioeconomic and racial disparities in food allergy: The time is now. Ann Allergy Asthma Immunol. 2022;129(4):391-392. doi:10.1016/j.anai.2022.07.018
- Warren CM, Brewer AG, Grobman B, Jiang J, Gupta RS. Racial/ethnic differences in food allergy. Immunol Allergy Clin North Am. 2021;41(2):189-203. doi:10.1016/j.iac.2021.01.007
- Togias A, Cooper SF, Acebal ML, et al. Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases–sponsored expert panel. World Allergy Organ J. 2017;10(1):1. doi:10.1186/s40413-016-0137-9
- Hanifin JM, Baghoomian W, Grinich E, Leshem YA, Jacobson M, Simpson EL. The Eczema Area and Severity Index – A practical guide. Dermatitis. 2022;33(3):187-192. doi:10.1097/DER.0000000000000895