It was World Atopic Eczema Day 2025[1] on September 14th, and the focus this year is on raising awareness of the lived experience of people with the condition and advocating for better care. The image, and this article, have been created by people who suffer from atopic eczema.
With lived experiences in mind, let's learn a bit more about eczema, and in particular, how photos of the condition need to represent people of all ancestries to avoid misdiagnosis.
Introduction
Atopic dermatitis, sometimes known as atopic eczema, is a chronic skin condition that can cause lifelong irritation. It is a hereditary condition, passed on through genetic components and is not infectious or transmissible. People who have other atopic diseases, such as asthma, hay fever (atopic rhinitis) or food allergies, are more likely to have eczema.
What causes eczema?
Your skin is a complex ecosystem and that's before we consider the things we put on our skin, both intentionally and unintentionally. The skin is a barrier site, and is a place where we come into contact with things that are not part of us and are the focus of immune responses. In some cases, our immune systems tolerate things as they are part of us genetically, or are parts of our own ecosystem such as friendly bacteria in the gut and skin dwelling yeasts, such as different strains of Malassezia, a yeast which establishes itself shortly after birth, and whose major antigen can be seen in the artwork. For some people though, we mount a strong immune response and that in turn causes conditions such as eczema and asthma. To make it even more complex, some individuals can tolerate some external components of the ecosystem, whereas for others, a reaction occurs due to inherited variable factors in the immune system, or immune dysregulation because of environmental factors and diseases.
The causative agents for eczema vary, from fragrances in moisturisers, to allergens such as pollen, house dust or dander from animals, and even irritation from rough clothing. A variety of factors, such as dry air, extreme temperatures, and, like many conditions with an immune component, stress exacerbates it!
What does eczema look like, and why does it not always look the same as we've been led to believe?
It presents as itchy, red, or inflamed skin, with patches of dryness that sometimes include cracking and thickening. Well, that's what the picture that traditional and historical textbooks will tell you about the disease, but it's only part of the story. To be more precise, it's only the story for a small proportion of people who suffer from eczema, and it skews the rates of diagnosis and treatment, and is a very pertinent example of the ancestry bias which runs through healthcare.
Eczema is often underdiagnosed or, worse for the sufferers, misdiagnosed in individuals of non-White ancestry. The small blotches that are characteristic of the disease are more likely to be purple, grey or hyperpigmented, on darker skin tones, with areas of whiter dry skin surrounding. Many medical textbooks will only show illustrations of the effect of eczema on White skin, and as such, recently graduated medical students may not recognise the disease across a wide range of ancestries and skin tones. Eczema can be more severe in people with darker skin tones, and may be more common if diagnosed correctly.
Areas of the skin look grey, white and dry. The eczema covers most of the back of the knees
There are areas of skin that are pink and raised.
The NHS in the UK is leading the way on representative imagery about the disease, with images of the disease on a variety of skin tones displayed on its online resource[2], from which these images came.
How is it treated, and how may current research change this?
Eczema is treated with regular moisturising with fragrance-free and medicated creams, or ointments. Often these creams contain corticosteroids that reduce eczema's inflammation and itching by calming the body's inflammatory response. Even though the cream is applied topically to the affected area, it is still not as targeted as it could be, damping down many immune cells locally rather than just those that cause the condition.
A special immune system molecule, called CD1a[3], which has a highly homologous shape and sequence to molecules of the Major Histocompatibility Complex (MHC), is expressed in Langerhans cells in the skin and binds lipid molecules, presenting them to T-cells[6]. If the lipids are perceived to be “non-self”, the resulting immune cascade causes inflammation.
Human CD1a in complex with a lipid antigen and a T-cell receptor [4,5] - PDB ID 4X6C. The CD1a chain is in dark green and binds Beta-2 microglobulin (straw colour) and the lipid (represented as atom coloured sticks in the binding site). The T-cell receptor chains are in pink and bright green.
Unusually for the molecules that T-cells recognise, CD1a is monomorphic, meaning the protein has the same amino acid sequence and lipid binding specificity for everyone in the world. This is in stark contrast to classical MHC molecules whose polymorphisms define alleles which are associated with specific ancestries and is the most variable or polymorphic part of the genome. This means that any therapy which involves blocking adverse reactions mediated by CD1a will work for everyone, everywhere[7].
Atopic eczema is a prime example that for equitable healthcare to occur for all people worldwide, we need to ensure that all ancestries are represented in all health settings, especially in medical textbooks. However, there is hope for a medication that will be universally effective and hopefully universally available.
About the artwork
Due to their personal experiences, Tessa and Jinxuan's artwork focuses on themes of dermatitis. Using paint, canvas, air-dry clay, and glaze, they vividly portray a hand emerging from the canvas with visible dermatitis, symbolising the challenges of this skin condition. Their creative portrayal realistically captures the experience of living with dermatitis.
#AtopicEczemaJourney
Structure in artwork - https://www.ebi.ac.uk/pdbe/entry/pdb/2p9w
Structure of CD1a with a lipid and T-cell receptor -
References
