Images of Darker Skin Are Absent from Medical Texts. Dermatologists Are Changing That.

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Dermatologist Dr. Jenna Lester remembers being a medical student and rarely seeing Black and brown skin tones in textbooks. Professors would describe how a medical condition would look different on dark skin.

“But they didn't have a photo of it," she said.

It felt unacceptable that she and her peers weren't given proper training to identify conditions on skin tones like hers, she said. That’s why she started the Skin of Color Program at the University of California, San Francisco in 2018. She wanted to bring focused care to people of color and train dermatology residents in treating skin of color.

Darker skin is underrepresented in medical training and textbooks, experts say, and research on treatments for skin of color often initially lag, all leading to missed diagnoses and inequities in care. More and more, dermatologists have been calling for action, raising awareness of the dearth and taking matters into their own hands to launch their own training programs.

“What's happening right now is, across the board, medical schools and training programs are all re-examining their curriculums and the resources they use and how they're teaching students, because there are gaps," said Dr. Nada Elbuluk, a dermatologist who founded the USC Skin of Color Center and the Pigmentary Disorders Clinic.

Doctors in training rely on images to develop familiarity with how skin conditions present. Eczema, psoriasis, inflammation, acne and other skin conditions show up differently in various skin tones.

For example, psoriasis patches in Black and Hispanic patients may be dark brown or purple-grey, and the scales that cover them can also be a grey or silver in color. In white people, these are pink or reddish in tone.

But studies have found medical textbooks lacking skin color diversity, mostly showing light skin as examples. Images of skin of color in dermatology textbooks have ranged from 4% to 19%. A study published earlier this year found a scant 11% of images in Review of Dermatology were skin of color, and only two of the images were of very dark skin.

Meanwhile, little progress has been made. Between 2006 to 2020, only 1 of 6 dermatology textbooks saw an increase in images of dark brown or Black skin, and half of textbooks lacked images of dark-skinned patients with common conditions like acne and psoriasis. Lester said Black skin has been more likely to appear in medical chapters on sexually transmitted infections, perpetuating harmful stereotypes.

To help educate doctors, Elbuluk created Project IMPACT at VisualDx, a database of clinical images that helps medical professionals form diagnoses where she serves as the director of clinical impact.

Working with the New England Journal of Medicine and the Skin of Color Society, Project IMPACT launched a skin of color webinar series on skin and hair disorders in people of color and structural racism and bias in medicine.

“We are working to improve health equity through medical education, and that medical education is disseminated through medical technology,” explained Elbuluk, who also is an assistant professor at the USC Keck School of Medicine.

Tools with more comprehensive skin of color images like VisualDX can help fill those, Elbuluk said. Increasingly, dermatologists are also calling attention to other resources such as the Skin of Color Society; tools like DFTB Skin Deep, a database with diverse images of skin disorders;and the recently published "Full Spectrum of Dermatology:A Diverse and Inclusive Atlas."

Meanwhile, faculty and trainees can help textbook publishers hasten change, wrote Trisha Kaundinya, a medical student at Northwestern University, and dermatologist Dr. Roopal Kundu in the Journal of Medical Education. They implored medical schools to begin implementing student-led curriculum review panels.

"Text publishers and editors are steadily beginning to address these disparities, but bottom-up change from trainees is necessary to comprehensively address this issue," they wrote.

One such medical student, Malone Mukwende at St. George's University of London medical school, collaborated with two professors to launch Mind the Gap, a handbook of clinical images of Black and brown skin. He also launched Hutano, a social platform that connects patients of color with data, research on skin conditions and other patients.

Gaps in research on skin of color treatments

The deficit has led to gaps in treatment research, said Dr. Neelam Vashi, founder of the Boston University Center for Ethnic Skin and author of the textbook "Dermatoanthropology of Ethnic Skin and Hair."

"When we look at all the research studies, they're mostly done on white skin,” she said, adding that the darkest tones are often excluded in research. “We base a lot of what we do on these historical research studies, but when you're not including this huge subset population, we don't know how they'll react.”

By the time certain conditions are diagnosed in darker-skinned patients, the disorders are often more advanced. Nail psoriasis, for example, more severely impacts patients of darker skin and is diagnosed later.

Similarly, although skin cancer is less common in darker-skinned patients, when it is diagnosed it's often at a later stage — and it's deadlier. One study found while about 90% of white patients were alive five years after a diagnosis of melanoma, only 66% of Black patients survived. Squamous cell carcinomas are also 10 times more likely to spread in Black patients compared to white.

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