Although current guidelines advocate for a multidimensional assessment of atopic dermatitis (AD) severity, disease burden may still be underrecognized when visible skin involvement appears limited.1 Clinical presentation can differ across skin tones, with inflammation often appearing violaceous, gray, or hyperpigmented changes rather than classic erythema.1 As a result, reliance on erythema-centered visual assessment may contribute to underestimation of disease severity and delays in treatment escalation.1
In individuals with skin of color, reduced visibility of erythema can further complicate clinical evaluation, increasing the risk of misclassification as milder disease and contributing to underrepresentation in clinical trial populations.1 These challenges highlight the limitations of assessment frameworks that depend heavily on visual inflammatory cues.
Importantly, limited cutaneous involvement does not necessarily reflect limited disease burden.2 Patients may experience pruritus, sleep disruption, impairment in daily activities, and psychosocial distress even in mild-to-moderate AD.2 Post-inflammatory pigmentary changes, which may persist after active inflammation has resolved, can further compound long term quality-of-life impact in patients with skin of color (Fitzpatrick skin types III-VI).3
Given these limitations, there is growing interest in approaches that reduce reliance on erythema-based assessment and improve diagnostic equity. Emerging non-visual and objective technologies, including high-frequency ultrasound, infrared thermography, and spectrophotometric analysis, may offer more standardized and pigment-independent measures of cutaneous inflammation.1 In parallel, incorporation of patient-reported outcomes such as itch intensity, sleep quality, and daily functioning can help provide a more complete assessment of disease activity across diverse populations.
Despite advances in topical therapies, many patients continue to cycle through repeated treatment courses without sustained disease control. While topical agents remain foundational, persistent or high-burden disease may warrant consideration of systemic therapy in appropriate patients.4 The expanding therapeutic landscape includes biologics targeting type 2 inflammatory pathways and oral Janus kinase (JAK) inhibitors.4,5 Agents such as lebrikizumab have demonstrated the potential to achieve sustained disease control and meaningful improvements in patient-reported outcomes in individuals with skin of color.4
As assessment strategies evolve, integrating objective diagnostic tools with multidimensional clinical evaluation may help reduce undertreatment, improve earlier recognition of high-burden disease, and support more equitable care across diverse patient populations.
Take our atopic dermatitis quiz to see how your knowledge compares to your peers.
