Q&A: Representation of skin of color in dermatology texts necessary to reduce misdiagnosis
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Key takeaways:
- Lack of diversity in dermatology leads to misdiagnosis of skin conditions in patients with skin of color.
- Cultural competency training may improve patient satisfaction for patients with skin of color.
Skin conditions are often misdiagnosed among Black patients due to the lack of diversity in dermatology teaching materials, which tend to contain disproportionately fewer photographs of skin diseases in darker skin tones.
To provide inclusive care, it is crucial for dermatologists to know how different skin diseases and conditions vary across skin tones.
Healio spoke with Miranda Uzoma Ewelukwa, MD, FAAD, a board-certified dermatologist at U.S. Dermatology Partners Sugar Land in Sugar Land, Texas, to learn more about racial disparities in dermatology care and how the historic lack of representation affects outcomes for people of color.
Healio: Are there racial disparities in dermatology care? If so, what examples can you tell me about?
Ewelukwa: Yes, racial disparities exist in dermatological care for a variety of reasons. First is the lack of diverse dermatology teaching materials. With dermatology being a visual field, learning how different skin conditions present on different skin tones is critical to providing inclusive care. Most dermatology textbooks and online teaching materials contain disproportionately few photographs of skin diseases in darker skin. Most descriptions of various diseases and conditions in dermatology are based on presentation on lighter skin and don’t describe how the presentation can vary on darker skin.
Additionally, the lack of diversity in board-certified dermatologists has negatively impacted access, research and care as dermatology is one of the least-diverse specialties in medicine. Finally, according to studies, Black patients tend to be dissatisfied with the care and communication they get due to a lack of cultural competency. To improve this, there should be an industry-wide increase in cultural competency training, which involves educating dermatologists and other health care providers about the cultural, social and economic factors that may impact the health and well-being of patients from diverse backgrounds.
Fortunately, efforts are underway to create a more diverse specialty through scholarships, mentorship and leadership training by the American Academy of Dermatology with the goal to increase the number of dermatology residents from Black, Latino and Indigenous communities to 50% by the year 2027. The American Board of Dermatology is adding more skin of color questions to the board exam to ensure that graduating dermatologists are better equipped to treat patients from these communities.
Healio: Can you provide an example of how the lack of representation in dermatology texts can lead to misdiagnosis of skin conditions among people with skin of color?
Ewelukwa: Psoriasis, for example, is classically described as red or pink with silvery scaling. In darker skin tones, psoriasis commonly presents as thick, dark brown plaque-like lesions that can leave behind significant hyperpigmentation. Even to the most astute dermatologist, this condition can be challenging when present on a patient with skin of color.
With dermatology being an extremely visual field, it is critical that physicians are properly trained to diagnose conditions and provide proper treatment on all skin tones. Without representation in medical textbooks and clinical images, people of color are more likely to be misdiagnosed.
Healio: How does lack of representation affect outcomes for people of color in dermatology?
Ewelukwa: Due to the lack of early detection and diagnosis for certain conditions in skin of color, such as skin cancer and various dermatoses, these patients have a disproportionately high mortality rate and morbidity, respectively, as skin cancer in these groups is often detected at a late stage and dermatoses are incorrectly diagnosed and mismanaged for prolonged periods of time. Furthering representation of people with skin of color in dermatology could save lives by detecting skin cancer at much earlier stages.
Healio: What contributing factors, such as underrepresentation in the dermatologic workforce, should dermatologists consider when treating people with skin of color?
Ewelukwa: When treating patients with skin of color, dermatologists should take the factors that lead to racial disparities in dermatology into consideration. Given the historic lack of education on how skin conditions present in skin of color, dermatologists should refer to accurate reference photos on skin of color and be certain to do a very thorough examination that explores all possible diagnoses. Further, dermatologists should undergo cultural competency training to better understand and appreciate cultural differences while providing quality health care to all patients.
Healio: How can practitioners gain more knowledge about this topic and better address the lack of representation in dermatology?
Ewelukwa: It is important that we continue the discussion of health care 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.
Healio: What would you like future research to focus on in terms of racial disparities in dermatology?
Ewelukwa: In general, people with skin of color are rarely included in clinical trials and dermatological research. In the future, I hope to see more people with skin of color involved in these studies to create more accurate results that are reflective of the general population and analyze how the subject varies across skin tones.
In particular, psoriasis is a major area of research within the dermatology community with the FDA approval of many topical and biologic therapeutics for patients over the past few years. Psoriasis impacts approximately 3% of the adult population with no race predilection. However, most of the clinical trial subjects are white. This presents a problem of applicability of results to diverse populations.
In addition, certain scarring alopecia, which disproportionately affect women of color, specifically central centrifugal cicatricial alopecia, have very little research or literature to support the practicing dermatologist to treat appropriately. It is imperative that research articles and clinical trials are conducted and inclusive of not only patients with skin of color, but conditions that tend to impact patients with skin of color.
Healio: Is there anything else you would like to add?
Ewelukwa: I have been with U.S. Dermatology Partners for 4 years and am thankful that my company provided me the support and tools to build a practice that supports the skin of color community. Approximately 75% of my patients are people with skin of color. In addition, U.S. Dermatology Partners works to recruit a diverse staff that reflects the communities they work in and engages the conversations of diversity in dermatology and skin conditions that impact skin of color populations through various media and educational efforts.
For more information:
Miranda Uzoma Ewelukwa, MD, FAAD, can be reached via email at mewelukwa@usdermpartners.com or on her website, U.S. Dermatology Partners.