The first doctor you see sends you home with a prescription for a steroid cream, which seems to do nothing. Weeks later, the discoloration finally fades but your muscles ache and you feel depleted, and another doctor guesses you have chronic fatigue syndrome. You feel sick for months before you consult yet another physician, who finally runs the right tests and informs you, correctly, that you have Lyme disease. With Lyme disease, early diagnosis and treatment are critical. But the first physician you saw didn’t consider that your rash might be due to Lyme, because they’d been trained to look for a red-and-pink bull’s-eye — and that’s not what Lyme typically looks like on Black skin. This scenario and others like it play out again and again in doctors’ offices when people of color try to get help for illnesses that affect their skin. Medical training that places white patients front and center is another problem — and when it comes to diseases that affect the skin, problems are often hiding in plain sight. For instance, an analysis of dermatology textbooks, published in the Journal of the American Academy of Dermatology in April 2020, found that the percentage of images of dark skin ranged from 4 to 18 percent. Many of the textbooks had zero images of skin of color with psoriasis, dermatitis, or acne. Valerie Harvey, MD, MPH, a dermatologist and the president-elect of the Skin of Color Society — an education and advocacy group founded in 2004 — points out that there haven’t been enough clinical studies focused on skin conditions as they affect BIPOC groups. “Certain conditions are more prevalent or present more uniquely across different populations,” says Dr. Harvey. “Some of these conditions haven’t been fully explored from a research basis.” She adds that there needs to be more training, “not only for dermatologists but for primary care physicians, too, to understand and be able to appreciate the nuances of how skin disease presents in different skin tones and hues and with different backgrounds.” The lack of dermatologists of color is a problem as well: One study, published in October 2017 in the Journal of Investigative Dermatology Symposium Proceedings, found that only 3 percent of dermatologists identify as Black, and 4 percent as Hispanic. “There is certainly an urgent need for more diversity within the field of dermatology,” says Harvey. “We’re the second-to-last most diverse specialty,” she says, the least diverse being orthopedics. RELATED: 7 Ways to Stay Empowered as a Black Woman With Psoriasis and Psoriatic Arthritis Diseases and conditions where this can come into play include:
Melanoma This dangerous skin cancer is often diagnosed at a later stage in Black and Hispanic patients, says Harvey. While white patients typically have melanoma on sun-exposed skin, people of color often get melanoma lesions on the undersides of feet, on fingernails or toenails, on the palms of the hand, or inside the mouth. According to the Skin of Color Society, symptoms of melanoma on a fingernail or toenail can include a brown or black pigmented band.Psoriasis Psoriasis on white skin typically looks red or pink with a silvery scale, while a Hispanic person is more likely to have salmon-colored plaques with silvery-white scale, according to the American Academy of Dermatology Association. In Black patients psoriasis often looks violet with a gray scale; or it can be dark brown, which makes it difficult to see.Cellulitis This skin infection looks red on white skin, says Harvey, “but [against] a background of brown skin it looks more purple or dusky.”Vitiligo This condition, in which the immune system attacks pigment cells, results in white or lightened patches on the skin. Vitiligo affects all races, but as it progresses it can be more distressing for patients of color because the discoloration is starker. Misdiagnosis can also be a problem for people of color, since vitiligo patches can look like other conditions, such as tinea versicolor, a common fungal infection.Eczema According to the National Eczema Association, eczema on Black or brown skin tends to look brown, violet, or ash gray — not reddish, as it typically does in patients with lighter skin. People with dark skin are also more likely to develop small bumps on the arms, legs, and torso and around the hair follicles, as well as drier skin and dark under-eye circles that can thicken and become bumpy when scratched. Individuals are also more likely to experience post-inflammatory dyspigmentation, a condition in which the skin appears lighter or darker in areas recently affected by eczema.
RELATED: Lower Risk, Greater Danger: What People of Color Need to Know About Skin Cancer In 2020, at age 21, a medical student in the UK named Malone Mukwende published the clinical handbook Mind the Gap, a photo-driven reference guide to signs and symptoms on skin of color. Available online for free, it has been downloaded more than 250,000 times in more than 100 countries; the actress Lupita Nyong’o has tweeted about it and Angelina Jolie interviewed Mukwende for Time. Mukwende is now working on a related social platform called Hutano, on which people with a specific disease or condition that affects their skin can create a profile, join a community of others facing the same challenges, and discuss their shared experiences. Another change-maker is a North Carolina mother named Ellen Buchanan Weiss, who discovered the lack of medical images of brown skin when her mixed-race son developed a rash at age 2. She started an Instagram feed called Brown Skin Matters where parents and the general public can upload images of what a skin condition — anything from shingles to cancer — looks like on a real patient of color (who remains incognito). An MD reviews the photos before Weiss posts them.
An Ambitious New Collaboration May Help the Cause
One larger-scale effort is Project Impact, launched in February 2021 by a company called VisualDx in collaboration with the Skin of Color Society and the New England Journal of Medicine Group. The goal of Project Impact is to raise awareness about misdiagnosis and share resources and strategies that help physicians more accurately diagnose disease in Black and brown skin. “We’re focused on all kinds of bias — racial and gender bias — and the reasons doctors make mistakes,” says Art Papier, MD, a dermatologist at the University of Rochester in New York and the founder of VisualDx. The company makes desktop and mobile apps for physicians that help them recognize skin-symptom patterns in patients across a range of skin colors with an assist from AI (artificial intelligence). The apps rely on VisualDx’s extensive library of images. A University of Connecticut study published in June 2020 in the Journal of the American Academy of Dermatology surveyed more than 15,000 images of skin conditions across six printed textbooks and two online resources, and found that VisualDx’s image library had the highest percentage of dark skin images (28.5 percent) compared with six printed textbooks (roughly 10 percent) and two web sources (about 22 percent). “The key to good AI is good data,” says Dr. Papier. “We’ve been very purposeful since the inception of our company to collect imagery from people of all skin tones.” Papier says he was inspired to create VisualDx after witnessing a misdiagnosis early in his career. When he was in training as a dermatology resident more than 20 years ago, he was in the ER when a patient with dark skin was brought into the intensive care unit with a serious rash caused by a rare condition called Stevens-Johnson syndrome. The patient said the rash had started two weeks earlier, but other doctors hadn’t recognized its severity because it looks subtler on brown skin, Papier recalls. “That made me get committed to the idea of getting as many images as we could find in patients of color,” he says.
To Move Forward, Some Institutions Are Looking Back
A growing awareness of the impact of racism on dermatology is causing some institutions to come to terms with a difficult history and work to forge a new path forward. A recent example involves Susan C. Taylor, MD, one of the founders of the Skin of Color Society and a coauthor of the 2009 book Dermatology for Skin of Color. In August 2021, Dr. Taylor became the first vice chair of diversity, equity, and inclusion at the University of Pennsylvania’s Perelman School of Medicine (Penn Medicine) in Philadelphia. Taylor was also named the university’s inaugural Bernett L. Johnson Jr., MD, Professor. Dr. Johnson was a Black dermatology professor who distinguished himself for his work on diversity and inclusion during his more than two decades at Penn Medicine. The Bernett Johnson Professorship was formerly named for the dermatologist Albert Kligman, MD, PhD, who passed away in 2010 at the age of 93. Known for his pioneering work on retinoid acid (Retin-A) as an acne and wrinkle treatment, Dr. Kligman has become notorious for conducting unethical research experiments on inmates, most of whom were Black, beginning in the 1950s and continuing for decades. Acknowledging the various ways racism affects dermatology will hopefully lead the way to a healthier future for BIPOC patients. “I think there’s been appropriate attention finally being called to these issues,” says Harvey. “I hope it’s sustained and people will want to generally understand and improve, so we can deliver better care — excellent care — to our patients.”
