Dermatology Has a Problem With Skin Color

Another example of systemic racism in medicine:

In the spring, teenagers started showing up at doctors’ offices in droves with angry red and purple blisters on their fingers and toes. The latest unexpected feature of the coronavirus infection fascinated the public, and suddenly photographs of so-called Covid toes were everywhere on social media.

But almost all of the images depicted glossy pink lesions on white skin. Though people of color have been affected disproportionately by the pandemic, pictures of Covid toes on dark skin were curiously hard to find.

The problem isn’t unique to Covid toes or to social media. Dermatology, the medical specialty devoted to treating diseases of the skin, has a problem with brown and black skin. Though progress has been made in recent years, most textbooks that serve as road maps for diagnosing skin disorders often don’t include images of skin conditions as they appear on people of color.

That’s a glaring omission that can lead to misdiagnoses and unnecessary suffering, because many key characteristics of skin disorders — like red patches and purple blotches — may appear differently on people with different complexions, experts say.

“Pattern recognition is central to dermatology, and a lot of the pattern recognition is training your eye to recognize certain colors that trigger you to think of certain diseases,” said Dr. Jenna Lester, director of the skin of color program at the University of California, San Francisco.

“But the color in question is impacted by the surrounding color,” she said. “It can look different in darker skin. If you’re only trained to look at something in one color, you won’t recognize it in another color.”

Dr. Lester recently reviewed 130 images of coronavirus skin disorders published in medical journals and found they were overwhelmingly of white people.

As the coronavirus spread, dermatologists started an international registry to catalog examples of skin manifestations of Covid-19. The registry compiled more than 700 cases, but only 34 of disorders in Hispanic patients and 13 in Black patients were submitted.

It wasn’t until July that Dr. Roxana Daneshjou and her colleagues at Stanford University published some of the first pictures of Covid toes in nonwhite patients in the Journal of the American Academy of Dermatology.

“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,” said Dr. Hao Feng, an assistant professor of dermatology at the University of Connecticut.

Dr. Feng reported recently that the omissions are still pervasive in textbooks, where only 10 percent of images illustrate dermatologic diseases in dark skin. When pictures of Black patients were available, they most often described syphilis. He found that one digital resource, VisualDx, had a more diverse display of images: 28.5 percent represented dark skin.

“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,” said Dr. Art Papier, a dermatologist who co-founded VisualDX.

All doctors observe the skin for clues to disease. Changes in the skin can be the first indication of life-threatening conditions like sepsis, cellulitis or severe drug reactions to medications.

About Andrew
Andrew blogs and tweets public policy issues, particularly the relationship between the political and bureaucratic levels, citizenship and multiculturalism. His latest book, Policy Arrogance or Innocent Bias, recounts his experience as a senior public servant in this area.

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