Most photographs used to teach eczema are photographs of red skin, and redness is the sign that travels worst across skin tones. On deeply pigmented skin a flare more often reads as violaceous, ashen grey or dark brown (Sarkar and Verma, 2026). The NHS describes affected skin as "red, white, purple or grey, or lighter or darker than the skin around it", depending on skin tone (NHS, Atopic eczema).
This is not a small mismatch between the pictures and the patient. Eczema is more common, not less, in the groups whose skin is hardest to assess by colour: it occurs more frequently in Asian and Black individuals than in white individuals (Kaufman et al, 2018). The signs worth reading on brown and black skin are the ones that do not depend on redness. The shape of the lesions, the texture of the surface, where on the body they sit, and the pigment change left behind once the flare settles.
Redness is the least reliable sign
Erythema, the reddening that most severity scores are built around, "tends to be more difficult to discern in darker skin types" (Sarkar and Verma, 2026). The inflammation is present either way. It is being read through melanin, which absorbs much of the light the eye would otherwise use to judge it.
Three signs survive the loss of colour. Texture is the first: the surface roughens, scales or thickens, and thickened skin catches light differently from the skin beside it. Warmth and swelling are the second, and both can be checked by touch rather than by looking. Itch is the third, and it is reported rather than seen, so it does not depend on reading colour at all.
Where colour does register, the colour itself is informative. Patches "may appear less erythematous and more violaceous, ashen grey or a dark brown colour" (Sarkar and Verma, 2026). A grey or purple cast on a patch that also itches and feels rough is not a different disease from the red patch in the textbook.
The shapes a flare takes
Morphology shifts as well as colour. Eczema in people with skin of colour "may appear psoriasiform, lichenoid, scaly or papular, with a violaceous colour" (Gan et al, 2023). Sarkar and Verma report more hyperkeratosis and follicular prominence, meaning raised bumps around individual hair follicles rather than a continuous sheet of inflamed skin. They also note that lichenoid papules, which can be mistaken for lichen planus, are seen more often in patients of Indian and African descent.
The psoriasiform pattern comes with clearer demarcation (Sarkar and Verma, 2026), and that is worth knowing, because a sharp border is one of the standard cues for telling eczema and psoriasis apart. The border is a weaker cue on deeply pigmented skin than it is on white skin. Site, scale and the character of the itch carry more of the decision.
In Indian and other Asian populations, white dermographism is reported as a notable finding: a transient pale response where the skin has been rubbed or stroked (Sarkar and Verma, 2026).
Where it sits on the body
NICE tells clinicians that in Asian, Black Caribbean and Black African children, "atopic eczema can affect the extensor surfaces rather than the flexures, and discoid (circular) or follicular (around hair follicles) patterns may be more common" (NICE CG57, 1.1.1.2). That guideline covers children under 12, so it is a statement about children and not a claim about adults.
The British Association of Dermatologists describes the same two patterns without tying them to skin tone: coin-sized areas of inflammation in a discoid pattern, or many small bumps around the hair follicles in a follicular pattern (BAD, Atopic eczema).
The practical consequence is that eczema on the outside of the elbows and the front of the knees is not a reason to discard the diagnosis, and neither is a scattering of discrete circles. Distribution still does useful work when the question is eczema against contact dermatitis or seborrheic dermatitis, where the shape of the exposure and the sebum-rich sites are the distinguishing features.
What this does to diagnosis and severity scoring
Gan and colleagues, who write AD for atopic dermatitis, report that these differences "may limit the use of AD assessment tools in people with skin of colour, leading to the potential for misdiagnosis and underestimation of severity, particularly in relation to assessment of erythema" (Gan et al, 2023). Underestimation is not only a labelling problem. Severity scores decide what treatment is offered and funded, so a score that reads erythema off skin where erythema is hard to see can put moderate or severe disease in a milder bracket.
Two things help inside a short appointment. Photograph the skin in daylight at the worst point of a flare rather than on the day you are seen, because a settled patch photographs as pigment change rather than as inflammation. And describe what a visual score cannot capture: nights broken by itch, how long the flare has run, how much of the body is involved, what has already been tried. When to ask for a dermatology referral sets out the thresholds the NHS works to.
The pigment change that outlasts the flare
For many people this is the part that lasts longest and bothers them most. "On brown or black skin, the redness may be harder to see, but the area may also become darker or lighter than the surrounding unaffected skin. This is called post-inflammatory hyperpigmentation (darker) or hypopigmentation (lighter)" (BAD, Atopic eczema). Post-inflammatory dyspigmentation is more prevalent in people with skin of colour than in affected individuals of white ethnicity (Gan et al, 2023), and pigment change of either kind can persist longer than the active eczema itself, and tends to be more pronounced in chronic, relapsing cases (Sarkar and Verma, 2026).
The mechanism explains why it lingers. Post-inflammatory hyperpigmentation "follows damage to the epidermis and/or dermis with deposition of melanin within the keratinocytes (skin cells) and/or dermis" (DermNet). Where the basal layer is injured, melanin is released and then trapped by macrophages in the papillary dermis, which DermNet calls dermal melanosis or pigment incontinence. That distinction matters for what can be done about it, because the physical treatments used on epidermal pigment "are not effective in dermal hypermelanosis" (DermNet). Either way, the pigment is more common and more intense in darker skin, and it persists for longer there than in lighter skin (DermNet).
What DermNet describes there is a change in where melanin sits, not tissue that has been lost, which is why the patches follow the outline of the old flare and why they are most conspicuous on exposed skin, particularly on the face.
The pale patches are usually something specific
Hypopigmented patches on the cheeks and upper arms of a child with eczema often have a name of their own. Pityriasis alba is "a low-grade type of eczema/dermatitis mainly seen in children" that "often coexists with dry skin and atopic dermatitis", mainly affecting people aged 3 to 16, and its hypopigmentation is more prominent, and perhaps more common, in dark skin than in white skin (DermNet). Its course has been measured: it "clears after an average of one year, with a range of a few months up to two or three years", and "the colour gradually returns completely to normal" (DermNet). That timescale belongs to pityriasis alba specifically and is not a general figure for pigment change after eczema.
What helps the colour recover
Two things, and neither is a bleaching product. The first is fewer and shorter flares, because each episode of inflammation is what deposits the pigment in the first place. The second is sun protection on exposed sites: DermNet advises daily broad-spectrum SPF 50+ where pigmentation affects an exposed area, to limit further darkening from UV. Choosing a sunscreen that a compromised barrier tolerates is its own problem, covered in sunscreen with eczema.
Topical lightening treatments exist for epidermal pigment, usually in combination and with variable success (DermNet), and the deeper dermal pigment is the one those treatments do not reach. Which category a patch falls into is not something to judge from a mirror, so that is a conversation with a GP or dermatologist rather than a purchase.
References
- British Association of Dermatologists. Atopic eczema, patient information leaflet. https://www.bad.org.uk/pils/atopic-eczema/
- DermNet. Postinflammatory hyperpigmentation. https://dermnetnz.org/topics/postinflammatory-hyperpigmentation
- DermNet. Pityriasis alba. https://dermnetnz.org/topics/pityriasis-alba
- Gan C, Mahil S, Pink A, Rodrigues M. Atopic dermatitis in skin of colour. Part 2: considerations in clinical presentation and treatment options. Clinical and Experimental Dermatology, 2023. https://doi.org/10.1093/ced/llad162
- Kaufman BP, Guttman-Yassky E, Alexis AF. Atopic dermatitis in diverse racial and ethnic groups: variations in epidemiology, genetics, clinical presentation and treatment. Experimental Dermatology, 2018. https://doi.org/10.1111/exd.13514
- National Institute for Health and Care Excellence. Atopic eczema in under 12s: diagnosis and management (CG57), 2007, updated September 2025. https://www.ncbi.nlm.nih.gov/books/NBK571009/
- NHS. Atopic eczema. https://www.nhs.uk/conditions/atopic-eczema/
- Sarkar R, Verma D. Atopic dermatitis in skin of colour: a review. Indian Journal of Dermatology, 2026. https://pmc.ncbi.nlm.nih.gov/articles/PMC13336541/