Q&A: Patients with skin of color experience disparities in dermatology treatment
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February is Black History Month, a time to celebrate and reflect upon the history of the African diaspora.
Although the U.S. healthcare system has come a long way in addressing equity in medicine, Black patients still face disparities in treatment and diagnosis of skin conditions.
Healio spoke with Kassahun Bilcha, FAAD, a board-certified dermatologist with U.S. Dermatology Partners practicing in Centreville, Virginia, about the importance of cultural competence and racial representation in dermatology.
Healio: Why is it important that providers be aware of the differences between darker and lighter skin?
Bilcha: Most skin diseases are equally prevalent regardless of skin color. Many such as eczema, psoriasis and rosacea may have different presentations in darker skin, and providers unfamiliar with darker skin tones may have difficulty differentiating such common conditions. Certain conditions such as melasma and keloid are more prevalent in darker skin, others such as vitiligo are equally prevalent but may have a devastating psychological impact in darker skin.
These conditions are often challenging to treat due to the historical lack of quality pharmaceutical research. In addition, there are also complex sociocultural and economic differences among skin colors of which providers should be aware. These differences often affect treatment outcomes. Hispanic and Black people are less likely to have insurance, therefore access to essential medications and procedures is limited and often lacking. Research has shown an implicit bias against Black people often leads to reduced rapport and poor communication.
Other factors to consider are religious and spiritual differences, which is why it is important for all providers to understand the complex dynamic of culture in healthcare by being inquisitive and open-minded.
Healio: Historically, how has access to dermatology care differed for people of color?
Bilcha: There are three important reasons why access to dermatology care has differed for people of color:
1. Lack of dermatology teaching materials that more inclusive With dermatology being a visual field, Kodachromes have historically been the main teaching source. Most dermatology textbooks and online teaching materials contain disproportionately few photographs of skin diseases in darker skin. Most descriptions in dermatology such as erythema, pityriasis rosea and violaceous have lighter skin origins.
2. Lack of diversity in the field of dermatology Dermatology is among the least diverse specialties in medicine, second only to orthopedics. This in turn has contributed negatively to access and research.
3. Inadequate cultural competence in the field of healthcare: According to studies, lack patients have a tendency to be dissatisfied with the care and communication they get. There is a tendency to leave out invasive procedures for darker-skinned people due to a lack of communication and a lack of rapport between patient and provider.
What is the biggest contributing factor to the misdiagnosis of skin conditions in people of color?
Bilcha: One of the biggest contributing factors to the misdiagnosis of skin conditions in people of color is a lack of adequate training. Only a few training institutions provide robust training and exposure to a variety of skin conditions in skin of color. At the start of their practice, many providers find themselves unfamiliar with diagnosing and managing common conditions that affect darker skin. In addition, there is often less awareness of unique complications of procedures that are implemented in dark skin including post-inflammatory hyperpigmentation.
Healio: Have you seen progress in this area throughout your career?
Bilcha: Definitely! The cause of healthcare disparity is deeply rooted, and there is no simple solution. In spite of this, significant progress has been made in the last few years. I have noticed that many healthcare institutions and organizations incorporate diversity and inclusiveness in their strategic plans. More teaching materials are finally now focusing on darker skin complexions and are being developed, and implicit bias training has been implemented to improve cultural competence among providers however, it is not enough.
As we humans become more connected to each other through social media and the internet, race, ethnicity and skin color lines are becoming more blurry contributing to the better socioeconomic well-being of Black communities. These, in turn, will improve healthcare, including skin care, in the future.
What do you believe would be effective solutions to the problem?
Bilcha: There is no simple solution. It is important that we continue the discussion of healthcare disparity, cultural competence and implicit bias. We should also continue developing more teaching materials focusing on darker skin complexions, and cultural competence training should be part of the residency curriculum. Lastly, focusing on recruiting providers from different cultural backgrounds, including those from disadvantaged groups can also help.
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Kassahun Bilcha, MD, FAAD, can be reached at adriana@projectmockingbird.com