Saba Saleem BS, Kristina Burger BS,

Introduction

Dermatologic treatment disparities lead to inequitable health outcomes in vulnerable populations (3). Race, age, sex, education level, and health insurance status are all known contributing factors that magnify these disparities (2). The U.S. Census Bureau projects that by 2050 about half of all dermatologic patients who require treatment will have a skin of color. Skin conditions can present differently in patients with a darker complexion, but primary care physicians and dermatologists are not adequately trained to recognize this (1). This is because the current dermatologic literature does not describe pathology presentations in people of color.

Furthermore, one study found that only 2% of teaching provided at meetings hosted by the American Academy of Dermatology addressed the issue (2). As a result, medical students have reduced accuracy in diagnosing skin conditions if shown an image of the disease on darker skin (6). In this discussion, we will focus on the life-threatening complications of Kawasaki Disease and congenital measles and highlight the potential for their associated skin findings to go unrecognized in pediatric patients of color. The implication of this suggests that minority patients may receive delayed or less aggressive therapy compared to their white counterparts (3). Late or misdiagnosis can lead to a higher morbidity and mortality rate that disproportionately affects this population, which largely comprises Hispanic and African American patients (2). Consequently, patients and their families may mistrust physicians and the healthcare system, worsening their care outcomes (4). 

Kawasaki Disease 

Kawasaki Disease is an acute, systemic vasculitis that predominantly affects infants and young children between the ages of 6 months to 2 years (7, 10). It is the most common cause of acquired heart disease in American children, with 76% of patients being younger than age five (8, 12). The median age of onset is about two years old. Thus, presentation in the neonatal period is considered extremely rare (8, 10). The highest disease incidence is in patients of Japanese descent, followed by black and non-Hispanic white individuals, respectively (8, 9). The diagnostic criteria for Kawasaki Disease include a high fever (greater than 102° F) for five or more days and the presence of at least 4 of the following: bilateral non-purulent conjunctivitis, oral mucosa abnormalities, polymorphous skin rash, peripheral extremity changes, and cervical lymphadenopathy (5).

During the acute phase (1-2 weeks of onset), the most characteristic symptoms are a “strawberry red” tongue, cracked lips, and a maculopapular rash. Watchful waiting may be necessary to confirm the diagnosis in patients who do not display all these clinical features at once (8). However, if treatment is considerably delayed or not provided, it can lead to Coronary Artery Aneurysm (CAA) formation (5). Lack of treatment can also cause sudden death in the subacute phase (2-8 weeks after onset) due to an increased risk of thrombosis. During this period, the patient may appear to be doing better because of the disappearance of fever and other physical symptoms. However, being left untreated results in an elevated platelet count, which creates a hypercoagulable state. Therefore, all children diagnosed with Kawasaki Disease require intravenous immunoglobulin (IVIG) in combination with high-dose aspirin within the first ten days of illness. The most efficacious period is within seven days from the onset of fever. Providing IVIG and aspirin decreases the risk of CAA development to less than 5% and inhibits platelet activation to prevent thrombus formation (8). 

Kawasaki Disease is an acute, systemic vasculitis that predominantly affects infants and young children between the ages of 6 months to 2 years (7, 10). It is the most common cause of acquired heart disease in American children, with 76% of patients being younger than age five (8, 12). However, it is important to note that even with prompt diagnosis and treatment initiation, the research suggests that there are also racial and ethnic discrepancies in treatment response.

One study found that despite no racial difference in time to diagnose and provide treatment, black children with Kawasaki Disease still had worse outcomes than white children. Black patients had more severe inflammation and worse response to IVIG, requiring adjuvant medications such as Etanercept and longer hospitalizations. Providing the standard treatment of IVIG and aspirin within the recommended window did not reduce the risk of coronary artery abnormalities in black children to the same extent as in other demographics (9). This highlights the fact that recognition of physical exam findings of Kawasaki Disease in darker skin tones is only one part of the solution to improving treatment outcomes. There must also be an emphasis on individualizing therapy to the racial and ethnic background of the patient once the diagnosis is made. 

Congenital Measles 

Measles (rubeola) is a highly contagious and potentially fatal disease caused by a viral respiratory infection. It is a vaccine-preventable disease and was almost completely eradicated in the United States (19). However, due to declining vaccination rates, there has been a worldwide resurgence between 2017-2019. Fortunately, between 2020-2021, the case numbers dropped again, which was attributed to social distancing with the COVID-19 pandemic (20). Despite this positive news, there is a growing concern that outbreaks will occur again as restrictions ease and the number of unvaccinated children increases (21). Measles symptoms begin 7-14 days after exposure and include high fever (above 101° F), maculopapular rash, and at least one of the three C’s: cough, coryza, conjunctivitis (19, 20). However, vaccinated individuals can have mild-to-no symptoms. Thus, diagnosis depends on detecting specific IgM antibodies in the serum, fluid, or viral RNA in bodily fluids (20). Acute management for measles includes vitamin A supplementation, a potent immune system enhancer that reduces the risk of blindness and death by 87% for children under two years (22, 23). It is also imperative to monitor and treat secondary bacterial infections with antibiotics. However, since there is no specific antiviral therapy, disease control largely depends on vaccine-driven prevention (21). Recognizing the measles rash and other characteristic symptoms is essential for early diagnosis and treatment (23). The rash begins on the face and spreads to the neck and upper trunk, followed by the lower trunk and extremities. The lesions on the face may become confluent, and the palms and soles are rarely involved. After 3-4 days, the rash changes to a purple-brown color and begins to fade with desquamation (24). 

Measles infection before one year of age can cause SSPE due to the immaturity of the brain (26). Thus, measles is often more deadly in infants and young children (28). Other complications include otitis media, laryngotracheobronchitis, and pneumonia, as the virus destroys epithelium, which favors bacterial superinfections (27). Pregnant women and infants under one year are among the highest-risk groups for these life-threatening complications because of their inability to receive the MMR vaccine (19). This is known as congenital measles, when an infected pregnant woman transmits the virus to her fetus. It is further defined as the presence of the measles rash at birth or within the first ten days of life. Mothers infected with measles late in pregnancy can also transmit the virus postpartum. Newborns with measles display a more severe and rapidly progressive form of SSPE (28). Regarding MMR vaccination before pregnancy, a study on maternal vaccine acceptance found that Black and Hispanic women are less confident in vaccine safety and efficacy and less likely to perceive the risk of acquiring vaccine-preventable diseases (29). These results suggest that congenital measles may be more prevalent in minority populations; however, further research is required. 

In summary, to correctly identify the measles rash when it presents in a patient of color, healthcare providers should have a high index of suspicion based on the patient history and vaccination status. Prevention is the most critical component of treatment, and it begins with communication. Providing families with evidence-based vaccine information will help them make informed decisions and clear misconceptions (19). Lastly, implementing a nationwide “catch-up vaccination campaign” would help alert parents to the urgency of resuming their child’s immunization schedule as the pandemic disrupted it. With these strategies in place, we can better address treatment disparities and improve health outcomes. 

Conclusion: 

Kawasaki Disease and congenital measles can be fatal in pediatric populations if left untreated. Both diseases share a characteristic maculopapular rash; however, this skin finding and other symptoms vary among racial and ethnic groups. Healthcare providers should be aware of potential treatment resistance to Kawasaki Disease in black children and the risk of congenital measles in black and Hispanic newborns with unvaccinated mothers. Physicians can use this information to help guide their diagnosis and management, which can be helpful in vague or unclear clinical presentations. The clinical course of these diseases, particularly in neonates, requires swift recognition and treatment within a certain timeframe; otherwise, there can be deadly consequences. 

One way to address this issue is by incorporating health education, open dialogue, and family engagement in discussions about preventing the spread of highly infectious diseases. Another solution is to update dermatologic literature to include more images of skin conditions in patients with a darker complexion. This is especially necessary for diseases with a higher incidence in patients with brown or black skin. For instance, African American children with atopic dermatitis are more likely to develop eczema herpeticum, a medical emergency, than white children. The research shows that due to decreased healthcare utilization in black communities, the disease presentation becomes more advanced than what may be shown in textbooks. Increased disease severity also occurs because darker skin masks the associated erythema, further delaying care (30). An organization that aims to promote awareness of this problem is The Skin of Color Society, which educates providers and the public on dermatologic diseases in the skin of color to help achieve health equity. Better health outcomes will then translate into a stronger trust between the patient and their physician. 

References: 

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31. Financial Disclosures: The authors have no financial disclosures to report.