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September 9, 2020

Most dermatologists are trained primarily on white skin. That's a big problem.

Daily Briefing

    Many skin conditions present themselves differently on dark skin than light skin, yet most dermatologists are trained almost exclusively on white skin—meaning skin conditions among people of color often go undiagnosed or are diagnosed late, Roni Caryn Rabin reports for the New York Times.

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    Dermatology's skin color problem

    One of the key skills taught in dermatology is being able to recognize patterns of different skin conditions, which often include color variations, according to Jenna Lester, director of the skin of color program at the University of California-San Francisco.

    But there's one issue, Lester told Rabin: "[T]he color [of a given condition] is impacted by the surrounding color." Therefore, Lester explained, a condition "can look different in darker skin"—so "[i]f you're only trained to look at something in one color, you won't recognize it in another color."

    For example, medical literature describes the common skin condition psoriasis as "salmon pink patches with silvery white scales, but that's not what it looks like in dark skin," Lester said. "It has more of a purple hue, and a lot of my Black patients put tons of moisturizer on when the skin is dry, so the scales aren't as visible," she added.

    But darker skin often isn't represented in training materials for providers, Lester noted. For instance, for a research letter published earlier this year in the British Journal of Dermatology, Lester reviewed 130 images of skin disorders related to the novel coronavirus, and she found that the vast majority of those images showed the conditions in white people.

    According to Rabin, dermatologists established an international registry cataloging skin conditions related to the coronavirus as the virus spread throughout the world, and of the more than 700 cases documented in the registry, just 34 involve Hispanic patients and 13 involve Black patients.

    Further, Hao Feng, an assistant professor of dermatology at the University of Connecticut, has found that people of color are largely excluded from dermatology textbooks, with just 10% of illustrations showing skin disease on dark skin, Rabin reports. Feng also found that, among the pictures that depicted conditions on Black patients' skin, they depicted how syphilis can affect the skin more than any other condition.

    According to Rabin, almost half of dermatologists and dermatology residents say they're not trained well enough to adequately treat skin conditions in people of color—and those disparities ultimately can lead to people of color having skin conditions that go undiagnosed or that are diagnosed in late stages. For example, Rabin reports that while skin cancer is less common in patients with comparatively darker skin, the condition also is deadlier among those patients. The five-year survival rate among non-Hispanic Black patients with skin cancer is 66%, compared with 90% among non-Hispanic white patients.

    "We know for certain that if dark skin images are not well represented, skin doctors—but also other doctors who are not skin experts—are at a disadvantage for making a proper diagnosis," Feng said.

    Art Papier—a dermatologist and co-founder of the digital resource VisualDx, which represents conditions on dark skin in 28.5% of its images, according to Feng—said showing skin conditions on dark skin is important to ensuring providers can properly diagnose patients. "If you have no experience with this in people of color, it's like saying you don't know how to examine the lungs or the heart," Papier said.

    What's being done to address the problem?

    To help address this issue, Susan Taylor, an associate professor of dermatology at the University of Pennsylvania Perelman School of Medicine, co-authored "Dermatology for Skin of Color," which is one of the first textbooks specifically focused on treating skin conditions in patients with moderately to heavily pigmented skin.

    However, Taylor said her and others' new textbooks focused on skin conditions in patients with darker skin are an imperfect solution. "We shouldn't have to write separate textbooks—that information should be integrated into the quote-unquote standard textbooks," she said.

    Meanwhile, Ellen Buchanan Weiss, a white mother of a multiracial child, has taken her own approach to solving the issue by starting an Instagram feed called Brown Skin Matters, which features images of skin conditions on dark skin. According to Rabin, Weiss started the initiative after she became frustrated with the lack of information online about her child's skin rashes. Anyone can submit a picture to the profile, and a physician reviews each photo before it's posted on the feed, Rabin reports.

    "It started as a casual reference for other mothers," Weiss said, but "[w]hat's been surprising to me is that it's been [mostly] used … by clinicians—doctors, nurses, professionals teaching in medical schools."

    According to Natalie Moulton-Levy, a dermatologist in Manhattan, physicians often say they "do not see color" because they're "trying in a nice, benevolent way to say skin color doesn't matter."

    "But it absolutely matters, in dermatology and all of health care," Moulton-Levy said (Rabin, New York Times, 8/30).

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