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Eczema in Skin of Colour

John Montgomery6 min read

Eczema in Skin of Colour

Atopic Dermatitis is at least as common in Black and Asian children as in White children. A review by Kaufman, Guttman-Yassky and Alexis (Exp Dermatol 2018) found it occurs more often in Asian and Black people. Most textbook pictures and severity tools, however, were built on light skin. In a toddler with brown or black skin the main sign, redness, is often not visible. Inflammation shows instead as a violaceous (purple-brown), ashen-grey or darker-brown patch, or just as skin darker than the child’s usual tone (Sarkar et al., IJD 2026; BSPAD). NHS Scotland’s pathway describes eczema in pigmented skin as “pink, red and purple, or a subtle darkening of existing skin colour”. Its mild, moderate and severe bands say “redness or altered pigmentation in skin of colour”. Because redness is the cue most parents and clinicians look for, eczema on darker skin is more often missed, misdiagnosed or judged milder than it is (Gan et al., AJGP 2023).

Eczema in Skin of Colour [part-of] Atopic Dermatitis

Shape and distribution. Skin of colour also changes the pattern of eczema, not just its colour. Follicular (perifollicular) eczema is common: clusters of small 1–2 mm itchy bumps around hair follicles, mostly on the trunk and forearms, rather than flat red patches (NES; BSPAD; DermNet). Papular and discoid (nummular) forms are also more frequent, and the skin may look psoriasiform, lichenoid or very scaly (Gan 2023; Sarkar 2026). Dry white or grey scale stands out more on dark skin (NES). NICE CG57 tells clinicians that in Asian, Black Caribbean and Black African children eczema “can affect the extensor surfaces rather than the flexures”. This matters for diagnosis, because “visible flexural dermatitis” is a core item in the UK Working Party Criteria. In an Italian study of 128 children (mean age 6), flexural eczema was seen in 53% of children with skin of colour against 76% of others. Extensor eczema was seen in 45% against 11%, and nummular eczema, prurigo-type nodules and severe xerosis were mostly in the skin-of-colour group (Herzum et al., 2024). Children with darker skin are also more prone to thick Lichenification and Prurigo Nodularis with chronic scratching (DermNet; Sarkar 2026).

Eczema in Skin of Colour [relates] UK Working Party Criteria Eczema in Skin of Colour [relates] Lichenification NICE CG57 [defines] Eczema in Skin of Colour

Pigment changes. Eczema leaves marks that are far more visible on darker skin. Post-Inflammatory Hyperpigmentation (darker patches) and hypopigmentation (lighter patches) can persist for months, sometimes years, after a flare settles. Families can find this more upsetting than the eczema itself (NES). Pityriasis Alba, a low-itch, low-grade eczema giving pale scaly patches on the face, is more common (or at least more visible) in darker skin and shows most in summer, because the patches do not tan (NES). The National Eczema Society notes that parents often blame pale patches on Topical Corticosteroids. It says the hypopigmentation is caused by the eczema, not the treatment. Sarkar et al. add that steroid-related hypopigmentation is more noticeable on dark skin when it does occur. The main way to limit lasting colour change is to treat inflammation promptly, plus sun protection, which helps PIH fade (NES).

Atopic Dermatitis [causes] Post-Inflammatory Hyperpigmentation Pityriasis Alba [relates] Eczema in Skin of Colour Topical Corticosteroids [relates] Post-Inflammatory Hyperpigmentation

Pale or dark patches are not proof of steroid damage

On darker skin, pale and dark marks after a flare are usually the eczema’s own pigment changes. Stopping steroid treatment because of them can leave the eczema active and make the colour change last longer (NES). Ask a clinician to check before stopping.

Under-scoring severity. SCORAD and EASI both score redness as an intensity sign. A London cohort of 137 children, assessed with SCORAD by one observer up to four times, compared black and white children. On crude analysis black children had a slightly lower risk of severe eczema (OR 0.84, not significant). After adjusting for the erythema score their risk was about six times higher (OR 5.93, 95% CI 1.94–18.12) (Ben-Gashir & Hay, BJD 2002). The authors concluded that “erythema can be a misleading indicator of severity in black children” and that severe cases may go untreated. DermNet adds that culture and communication gaps between families and clinicians can also lead to under-estimation. Some experts now suggest scoring erythema one level higher in skin of colour, or leaning on signs that colour does not hide, such as papules, scale, Lichenification, scratch marks, itch and sleep loss (Sarkar 2026). For parents this means that “it doesn’t look very red” is not a reliable sign that a dark-skinned toddler’s eczema is mild. Itch, sleep and skin thickening are better guides, and they are what POEM asks about.

Eczema in Skin of Colour [contradicts] SCORAD Eczema in Skin of Colour [contradicts] EASI POEM [relates] Eczema in Skin of Colour

Not just eczema. Some rashes are easier to confuse with eczema on dark skin. Lichen planus and lichen nitidus can resemble lichenoid or papular eczema in darker skin tones; checking the mouth and looking for the Koebner phenomenon helps tell them apart (Sarkar 2026). See Differential Diagnosis of Toddler Eczema. Patient resources with skin-of-colour images include BSPAD, the National Eczema Society and DermNet; the British Association of Dermatologists also publishes skin diversity descriptors (NHS Scotland pathway).

Eczema in Skin of Colour [relates] Differential Diagnosis of Toddler Eczema

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