Lack of training leads to delayed dermatology diagnoses in patients with darker skin tones
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Poor representation of darker skin tones in dermatology training materials has led to delayed diagnoses and worse treatment outcomes in Black, Asian and non-white Latin American patients, according to a presenter.
“There is a huge focus on diversity and equity within medicine,” Saakshi Khattri, MD, director of the Rheumatology-Dermatology Clinic at Mount Sinai Hospital’s Icahn School of Medicine, in New York, told attendees at the 2024 American Women in Rheumatology annual conference. “The issue within dermatology is representation. It is not a field that is very heterogeneous.”
Nearly half of dermatologists in a recent survey reported that they had inadequate training in managing patients with darker skin colors, according to Khattri. She noted that many dermatology textbooks and training materials predominantly feature images of white patients and that the Fitzpatrick scale that is often used to assess dermatologic conditions is based on the likelihood of sunburn.
“The concept of sunburn does not apply to many darker-skinned individuals,” Khattri said. “These materials are not culturally sensitive. If you have a clinician who has never seen skin of color how would they know how to treat skin of color?”
According to Khattri, the dearth of images of patients of color in dermatology textbooks has led to delayed diagnosis for psoriasis in these patients.
“Given the delays in diagnosis, when they do present to a physician who knows what they are doing, it is no surprise that there is a higher disease burden,” she said, adding that these patients often demonstrate a lower quality of life as well.
Psoriasis
While psoriasis lesions tend to look pink or red in white individuals, they can appear much different in patients with darker skin tones, according to Khattri.
“It can look brown — you really cannot see it sometimes,” she said. “It can be violaceous.”
In addition, healing in darker-skinned patients leads to hyperpigmentation.
“It can even look gray on darker skin,” Khattri said.
She added that patients with darker skin tend to have more PsO on their face, scalp and flexural areas.
“Pustular psoriasis is more common in Asian and Hispanic patients,” Khattri said.
For Black patients with scalp psoriasis, clinicians should be mindful of cultural hair practices, as this can impact the choice of topical therapies or shampoo.
“Ask the patient, ‘How often do you wash your hair?’” Khattri said.
Atopic dermatitis
Regarding atopic dermatitis (AD), Khattri noted that Black and non-white Latin American individuals demonstrate a greater disease burden than white patients. Moreover, they experience delays in both visiting a practitioner and having their conditions diagnosed.
As with psoriasis, AD in lighter-skin individuals tends to be pink or red.
“In darker-skinned individuals, there is lichenification,” Khattri said. “Thickening is commonly seen in skin of color.”
Hyperpigmentation is also common in darker skin tones with AD. In addition, darker-skinned patients are more likely to have AD on the flexural areas. The edges of the rash can be blurry, Khattri added.
“Sometimes you need to do a biopsy,” she said.
As a final clinical pearl, Khattri noted that AD lesions can get infected, while psoriasis lesions cannot.
Hidradenitis suppurativa
Although there are few population-based studies in hidradenitis suppurativa (HS), some data show that the time to diagnosis is 1.6 years longer among Black patients, and 1.5 years longer among Hispanic patients, compared with white patients, according to Khattri.
Moreover, Black patients generally went 5 years before seeing a dermatologist, which was 2 years longer than white patients with HS.
This condition is marked by keloidal scarring, abscesses and double-headed comedones, Khattri said.
“Black and Hispanic patients had greater health care utilization because they presented at a later stage,” she added. “They were not diagnosed on time.”
Alopecia areata
According to Khattri, current data on alopecia areata is sparce. However, recent drug approvals have focused more attention on these patients.
“Relative to white patients, the prevalence of alopecia areata was 2.7 times higher for Asian patients,” Khattri said. “For Black patients, it was 1.3 times higher. For Hispanic/Latinx patients, it was 1.26. Again, this seems to be a condition that disproportionally affects diverse skin types.”
This condition involves a clinical diagnosis — a scalp diagnosis is not required, according to Khattri. However, she encouraged attendees to be mindful of delayed diagnoses in these patients.
“The longer the alopecia areata you have, the more recalcitrant to response you are,” she said.
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Khattri S. Cutaneous Manifestations Across Skin Colors: PsO, HS, AA and AD. Presented at: Association of Women in Rheumatology annual conference; July 25-27, 2024; Orlando, Florida (hybrid meeting).
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