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Disparities of Ethnical Representation in Dermatology Textbooks

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Disparities of Ethnical Representation in Dermatology Textbooks

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A great experience presenting my poster on skin colour representation within dermatological literature today @warwickmed for the Midlands Racial Equality in Medicine conference. Met with @malone_mk, whose work formed the basis for the research question.

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A great experience presenting my poster on skin colour representation within dermatological literature today @warwickmed for the Midlands Racial Equality in Medicine conference. Met with @malone_mk, whose work formed the basis for the research question. https://t.co/d4x5mJOl7s

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Something went wrong, but don’t fret — let’s give it another shot.

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A great experience presenting my poster on skin colour representation within dermatological literature today @warwickmed for the Midlands Racial Equality in Medicine conference. Met with @malone_mk, whose work formed the basis for the research question. pic.twitter.com/d4x5mJOl7s
— George Gavoyannis (@gavoyannis) February 26, 2022

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A great experience presenting my poster on skin colour representation within dermatological literature today @warwickmed for the Midlands Racial Equality in Medicine conference. Met with @malone_mk, whose work formed the basis for the research question. https://t.co/d4x5mJOl7s

# data[].attributes.attachment_link.metadata.attachment_props.original_text
A great experience presenting my poster on skin colour representation within dermatological literature today @warwickmed for the Midlands Racial Equality in Medicine conference. Met with @malone_mk, whose work formed the basis for the research question. https://t.co/d4x5mJOl7s

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A great experience presenting my poster on skin colour representation within dermatological literature today @warwickmed for the Midlands Racial Equality in Medicine conference. Met with @malone_mk, whose work formed the basis for the research question.

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Why is it harder to diagnose disorders on non-white skin?

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Why is it harder to diagnose disorders on non-white skin?

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After finding unexplained dark marks on her skin which she couldn’t explain, BBC reporter Bree Johnson decided to investigate why it seems harder to diagnose skin conditions on non-white people.

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After finding unexplained dark marks on her skin which she couldn't explain, BBC reporter Bree Johnson decided to investigate why it seems harder to diagnose skin conditions on non-white people.

She speaks to Kanayo Dike-Oduah, who nearly died as a result of a rare skin disorder, and to Malone Mukwende, who wrote a guide to help medical professionals diagnose clinical signs on black and brown skin.

Professor Colin Melville, director of education and standards at the General Medical Council, says: "We want to be active in driving change that is real and effective in support of black and minority ethnic students, trainees, doctors and patients in the UK".
Video Journalist: Tobias Chapple Producer: Tammi Walker

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Why is it harder to diagnose disorders on non-white skin?

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After finding unexplained dark marks on her skin which she couldn't explain, BBC reporter Bree Johnson decided to investigate why it seems harder to diagnose skin conditions on non-white people. She speaks to Kanayo Dike-Oduah, who nearly died as a result of a rare skin disorder, and to Malone Mukwende, who wrote a guide to help medical professionals diagnose clinical signs on black and brown skin.

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Wakelet collection of resources to support anti-racist pedagogy

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A collection of resources to support anti-racist pedagogy #blacklivesmatter

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VisualDx is a diagnostic clinical decision support system. Includes:
- Curated medical image library
- Smart search for chief complaints, diagnoses & drug reactions
- Custom patient-specific differential diagnosis builder
Image library includes disease on all skin types and Dermatology Skin of Color section.  In differential diagnosis builder, can select to display images in darker skin tones.
Requires subscription but 30 day free trial available.

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Skin Deep aims to improve the diversity of paediatric skin images online. It is a project led by Don’t Forget The Bubbles and the Royal London Hospital.

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Dr. Jenna Lester, director of the skin of color program at University of California, San Francisco. "If you're only trained to look at something in one color, you won't recognize it in another color," she said. Credit... Sarahbeth Maney for The New York Times

Common conditions often manifest differently on dark skin. Yet physicians are trained mostly to diagnose them on white skin.

Dr. Jenna Lester, director of the skin of color program at University of California, San Francisco. "If you're only trained to look at something in one color, you won't recognize it in another color," she said. Credit... Sarahbeth Maney for The New York Times

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.

Images of skin cancer in dark skin were underrepresented in educational materials examined in Dr. Feng's study - yet skin cancer, though less common in people with darker skin, is more deadly in Black and Hispanic patients, and often diagnosed at a later stage.

The five-year survival rate is 66 percent for non-Hispanic Black patients, compared with 90 percent for non-Hispanic white patients.

Black patients are generally less likely than whites to see a dermatologist and less likely to undergo screening for skin cancer. Even when they do see a dermatologist, studies have shown, Black patients are less likely to get certain treatments than white people with the same conditions, like oral antibiotics for acne.

"I can tell you from my own clinical experience a lot of things get missed because people don't recognize the disease process in darker skin," Dr. Feng said.

Even relatively common skin conditions can stump physicians if they have never seen them in people of color.

When Dr. Lester was in medical school, she recalled, a Black patient came to the clinic with a mysterious rash that had a purplish hue. "No one knew what it was," Dr. Lester said.

A biopsy revealed it was a common skin condition that doctors usually diagnose on sight, without tests or procedures: psoriasis. Yet it often goes unidentified and untreated in people of color.

The medical literature describes psoriasis as "salmon pink patches with silvery white scales, but that's not what it looks like in dark skin," Dr. Lester said. "It has more of a purple hue, and a lot of my Black patients put tons of moisturizer on when the skin is dry, so the scales aren't as visible."

Many garden-variety rashes will vary in appearance in different complexions. Eczema, which is typically described as making skin red and itchy, tends to be more bumpy in Black people, Dr. Lester said. Pityriasis rosea is usually described as having a distinctive pattern composed of a large spot with smaller spots branching out from it - but it may not appear this way in people with dark skin.

Melanoma, the most serious form of skin cancer, often develops in Black people in spots where doctors may not think to look for it: on the palms of the hands or soles of the feet.

Doctors often miss rosacea in Black patients, too, because clinicians expect to see redness and visible blood vessels on the face, said Dr. Amy McMichael, chair of the dermatology department at Wake Forest Baptist Health in Winston-Salem, N.C.

"You don't see as much red if the background skin color is brown," she said.

Pallor, which can be an indication of anemia as well as reduced blood flow and oxygen, will also have a different appearance in Black patients, said Dr. Lynn McKinley-Grant, an associate professor at Howard University College of Medicine and president of the Skin of Color Society, which promotes awareness and education about these variations.

"It's a different color, kind of a grayish color," she said. "I have actually thought of George Floyd. When he's on the ground, his skin is a gray brown, showing lack of oxygen."

Kawasaki disease, a children's disease that bears similarities to a Covid-19 complication called multisystem inflammatory syndrome, causes inflammation in blood vessels and presents with redness, but "how it appears in darker skin tone is very different," said Dr. Susan Taylor, associate professor of dermatology at the University of Pennsylvania Perelman School of Medicine.

"You don't want to miss that in a kid because you don't know how to look for the rash and your eye isn't trained to see it," she said.

Dr. Taylor is a co-author of "Dermatology for Skin of Color," one of the first textbooks that focused on the treatment of skin conditions in moderately to heavily pigmented skin. But new textbooks are not the solution, she said.

"We shouldn't have to write separate textbooks - that information should be integrated into the quote-unquote standard textbooks," Dr. Taylor said.

Nearly half of dermatologists and dermatology residents say they were not adequately trained to treat skin conditions in people of color. For Black patients, that often translates into a prolonged, disheartening search for the right diagnosis.

When Tierra Styles, 31, of Auburn, Ga., asked her pediatrician about a rough patch of skin on the back of her toddler's neck, the doctor said it was nothing. On later visits, it was diagnosed as scabies, then eczema. But the prescribed ointments had no effect.

Finally, Ms. Styles took her son to a dermatologist who was Black. She said the sandpaper-like patch was a benign skin condition called keratosis pilaris.

"The doctor tried to pull up a picture on the internet, but she couldn't find one," Ms. Styles said. "There was not one picture of an African-American person that she could show me."

Ellen Buchanan Weiss, a white mother of a multiracial child in Raleigh, N.C., was so frustrated by her fruitless online searches for information on her child's skin rashes that she started her own repository of skin images in an Instagram feed called Brown Skin Matters.

Anyone can submit a photo; a physician reviews the images before they are posted.

"It started as a casual reference for other mothers," Ms. Weiss said. "What's been surprising to me is that it's been used mostly by clinicians - doctors, nurses, professionals teaching in medical schools."

Many Black patients prefer to see Black dermatologists, who may be more familiar with and have a greater understanding of not only skin issues - like acne, which can leave dark, hyperpigmented spots on dark skin - but hair predicaments, said Dr. Natalie Moulton-Levy, a dermatologist in Manhattan.

Image

Dr. Natalie Moulton-Levy, a dermatologist in Manhattan. Credit... Jeenah Moon for The New York Times

"We as Black people don't do hair the same way a non-Black person does," Dr. Moulton-Levy said. "When you're giving treatment options, some dermatologists are not familiar with that and say, 'OK, you have to wash your hair every day.' We don't wash our hair every day."

But getting in to see a dermatologist can be difficult, and waits are notoriously long. There is a shortage of dermatologists generally, and a shortage of dermatologists of color in particular: Only 4 percent of practicing dermatologists identify as Hispanic, and only 3 percent identify as Black or African-American, according to one study.

Black and Hispanic patients are far more likely than white patients to use the emergency room for dermatology problems, especially in rural areas and smaller cities where there are fewer dermatologists, studies have shown. People of color are half as likely as white patients to see a dermatologist for the same conditions.

Health insurance can also be a barrier to care. A 2014 study by the physician staffing firm Merritt Hawkins reported that dermatology was among the specialties least likely to accept Medicaid, with only 27 percent of dermatologists accepting payment from the government health plan compared with 63 percent of cardiologists.
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At some safety-net hospitals, waits as long as a year to see a dermatologist have been recorded. Delayed doctors' appointments, especially for pediatric dermatologists, can have serious consequences.

A Connecticut woman said that when her biracial daughter first developed patches of blanched, hypopigmented skin at age 10, it was misdiagnosed as a benign condition called pityriasis alba.

The woman, who asked not to be identified, to protect her daughter's privacy, tried to get her child an appointment with a dermatologist, but few in the area took Medicaid and those who did had an eight-month wait.

When the mother switched jobs and obtained commercial health insurance, she made an appointment with a specialist at Yale University, who diagnosed her daughter with a rare cancer, primary cutaneous T-cell lymphoma, also called mycosis fungoides.

The treatment, which consists of ultraviolet light therapy, has been successful, and the blanched spots are no longer visible on her daughter's "medium brown skin," the mother said. But it took two years to get the diagnosis. When she searched online, she said, "I couldn't find anything that looked like my daughter, and it was mostly images of white skin."

Physicians often say that they "do not see color," Dr. Moulton-Levy said. "They are trying in a nice, benevolent way to say skin color doesn't matter."

"But it absolutely matters, in dermatology and all of health care," she said. "'Colorblind' is a very difficult term for me to hear."

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Dermatology Has a Problem With Skin Color

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Common conditions often manifest differently on dark skin. Yet physicians are trained mostly to diagnose them on white skin. Dr. Jenna Lester, director of the skin of color program at University of California, San Francisco. "If you're only trained to look at something in one color, you won't recognize it in another color," she said.

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Decolonising dermatology: why black and brown skin need better treatment

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Decolonising dermatology: why black and brown skin need better treatment

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Article in The Guardian, written by Neil Singh.
Neil Singh is a primary care physician and senior teaching fellow in the department of primary care and public health at Brighton and Sussex Medical School.

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s I sat making small talk with my patient, I was trying not to think about the ants. It was "flying ant day": that moment every summer when the heat inspires thousands of ants to grow wings and swarm in their thousands, mating mid-air in a huge, frenzied orgy. My only source of cool air was a skylight, but having it open meant that every so often stray black garden ants were dropping between me and my patients, making me jumpy.

My patient was a rangy black man, early 40s, with hair just starting to grey at the temples. He looked younger than he was, wearing a black T-shirt and cut-off denim shorts. It was well into music festival season, and he wore several wristbands to prove it. I asked what kind of music he was into. It turned out he was not just a music fan; he was a roadie and gig manager. He had come in to ask me about his skin. He lifted up his T-shirt, showing me his chest, and I was shocked to see a splash of rough, silvery patches all over his torso.

I had no idea what to make of them. I was initially quite alarmed, thinking of a host of possible causes, some really serious. But he reassured me: "I get these quite a lot." He saw my blank look and explained, politely. "I have psoriasis." I went back to his medical record, and there it was, a listed diagnosis that I had failed to spot: chronic plaque psoriasis. He was having a flare-up and wondered if there was an alternative treatment he could try. In the end, it was a straightforward case, which simply required a trial of a different cream. But, after he'd gone, I was left feeling unsettled, because if this had been the first time he'd had this rash, I would probably have been way off the mark with my diagnosis.

I thought back to the dermatology training I had received in medical school. I could recall only three occasions when dark skin was used to demonstrate a skin problem: once, to illustrate how black skin can heal in thick bands called keloid scars; once, during a session about syphilis and other genital ulcers; and once, in a presentation on vitiligo, a disorder in which patches of skin lose their pigment. Dark skin had only ever been used to demonstrate these dermatological rarities, and never as part of core teaching on common disorders.

I am not the only one reflecting on this failure of medical education. In June, Michael Mackley, a third-year medical student in Canada, wrote a widely shared Twitter thread about feeling unprepared to spot skin changes in a black patient. "Patients are left seeking equal care in a system that is entirely built on white skin," he wrote. But what made my own ignorance all the more unsettling was that this had never occurred to me as a problem, even though I am a person of colour.

t a Black Lives Matter protest in Brighton this summer, I saw a black teenager proudly wearing a T-shirt bearing the word "MELANINAIRE". This brand name is eye-catching precisely because, in nearly every other circumstance, the amount of melanin in your skin is directly proportional to the amount of discrimination you encounter in everyday life. After all, melanin has been used, along with facial features and hair type, for more than four centuries to sort the world into a hierarchy, with white-skinned groups at the top.

Melanin - which comes from the Greek word, melas, meaning dark - is a group of pigments found throughout the natural world, responsible for the brown spots on bananas, the ink of cephalopods such as squid, and even the colour of ants. Three types of melanin are found in the human body, but the most common is eumelanin: a brown-black pigment responsible for most of the colouring of human skin, hair and eyes. It is made in specialised skin cells, melanocytes, where it is packaged into discs called melanosomes, which are passed on to other skin cells to help protect our DNA from sun damage. These discs surround the nucleus, guarding it like tiny parasols, blocking out ultraviolet rays.

The difference between light and dark skin is simply the amount and distribution of eumelanin in cells in the epidermis, the outermost layer of skin. That's it. Although we can temporarily raise the amount of eumelanin in our skin by tanning, the baseline amount is controlled by our genes. Which raises the question: why don't all humans have the same colour skin?

The best answer we have has been offered by Nina Jablonski, a professor of anthropology at Penn State University, and author of Living Color: The Biological and Social Meaning of Skin Color. Her research has shown that this baseline level of eumelanin has evolved differently in different populations, based on the need to optimise the amount of two essential vitamins: folate and vitamin D. Folate is used to regenerate fast-growing tissues, such as those in sperm and embryos. Without sufficient folate, men can become infertile and babies can develop spinal cord defects. Meanwhile, vitamin D is required to absorb calcium from our diet. Without sufficient vitamin D, we cannot form normal skeletons or immune systems.

The ultraviolet radiation in sunlight depletes the level of folate in your body, which is why eumelanin's ability to block such radiation is so useful. But there's a catch. Ultraviolet radiation is also vital: vitamin D cannot be made without it. To survive and reproduce, our skin needs to allow in just enough ultraviolet radiation so we can produce sufficient vitamin D, but not so much that our folate levels get dangerously low. Nearer the equator, there is more ultraviolet radiation to block, which is why humans whose ancestors evolved in this region have more eumelanin. As some human populations migrated nearer the poles, where there is less ultraviolet radiation reaching the skin, humans in these regions evolved to have less eumelanin (and thus paler skin), to prevent vitamin D deficiency.

Skin colour became just one of many genetic divergences that occurred between geographically separated populations over time; no more socially relevant than other genetic bifurcations that could have been used to divide populations - such as whether you can or can't digest milk, or whether you have wet or dry ear wax. For millennia, skin colour meant difference, but not systematically differential treatment. But in Europe, during the early modern period, skin colour began to take on a very different meaning. In an age of rising capitalism and colonialism, it became a convenient way for white people to divide up the world into those who would labour hardest, and those who would benefit most from the wealth this produced. Irene Silverblatt, a professor of cultural anthropology at Duke University, describes how the Spanish were the first to systematically divide the world by skin colour in the 17th century: "white, black, and brown [became] abridged, abstracted versions of coloniser, slave, and colonised."

The Fitzpatrick scale of skin phototypes

These days, skin colour is formally categorised into one of six gradations called the Fitzpatrick phototypes. These range from I (pale skin that never tans and burns easily) to VI (dark skin that never burns). This schema is named after Thomas B Fitzpatrick, an influential white dermatologist who worked at Massachusetts General hospital in the second half of the 20th century. A wise-cracking, pipe-smoking detective of dermatology who kept a magnifying glass in his watch pocket, Fitzpatrick formed a double-act with Wallace H Clark, his more introverted pathologist colleague. For several decades, they were the Holmes and Watson of skin cancer: Fitzpatrick researched how healthy tanning can go awry and cause cancer, while Clark developed a staging system of skin cancer depth that is still used today.

But Fitzpatrick's spectrum reflects his own biases as much as it does objective science. His phototypes are skewed towards white people, with three of the six types covering what we would commonly call white skin, two for brown skin, and only one type to encompass the many kinds of blackness.

n recent years, a generation of race-conscious medical students who are used to choosing the exact skin colour of their emojis have raised concerns that the images through which they study are almost exclusively white. From the anatomy posters they hang above their beds, to the plastic mannequins they practise chest compressions upon, the default patient is almost always the same: a white-skinned man (only a woman when showing a relevant organ) with a hairless body and a neat side-parting of trimmed, mousy hair. This persists, despite the fact that white people are a global minority.

A 2018 study analysed more than 4,000 images in four major US medical textbooks, and found that only 4.5% of images showed dark skin. This is a problem in every branch of medicine, as it reinforces whiteness as the norm, but it is most troubling in the teaching of dermatology, where every problem is set against the canvas of skin it arises from. Ademide Adelekun and Ginikanwa Onyekaba, from the Perelman School of Medicine at the University of Pennsylvania, recently published a similar study, but this time focusing on dermatology textbooks. Only 11.5% of images showed dark skin (of Fitzpatrick phototype V or VI). Earlier this year, I gave a lecture at the medical school I work at, about common skin problems. Even making a conscious effort to include pictures of various skin tones, I found it difficult to find relevant images in online medical libraries.

"Not all patients present with illness in the same way," said Subash Jayakumar, in a lecture he gave in 2018 at University College London Medical School, where he teaches. "Significant differences exist in patients from different ethnic backgrounds." Jayakumar works as a primary care physician in Brent, a London borough where 65% of residents are people of colour. He reminded the audience that skin changes are easy to miss if you don't know what you are looking for. Blue-tinged fingertips are a harbinger of dangerously low oxygen levels; the yellow stain of jaundice can be an early warning sign of irreversible liver damage; and a patient who is bleeding internally might be saved by a doctor who knows to look for pallor not in the cheeks, but under the eyes and inside the mouth. How can we expect doctors to correctly name a colour change in coloured skin if they've never seen it before?

This reminded me of a problem that the photography world has been grappling with for decades. Just like in medicine, modern photography was designed with white people in mind. In fact, a white person with a name: Shirley. From the 50s, Shirley was the name given to the woman on the test cards against which all photographic laboratory technicians would judge their colour balance and exposure when using Kodak film. The model chosen for the test card changed with each decade, but the formula was always the same: an ivory-skinned brunette who represented "normal", allowing every technician to develop all Kodak film in a way that made Shirley look ideal.

One of the 'Shirley cards' used by Kodak for calibrating the reproduction of skin tones on photographic film. Photograph: Kodak

The problem was that it made people of colour look terrible: erasing the subtleties of tone and contour, so their faces became black blobs with the bright whites of their eyes and teeth glaring out. In 1977, the French-Swiss film director Jean-Luc Godard refused to use Kodak film when filming in Mozambique, calling it "racist". It was only in the 80s, after manufacturers of chocolate and wooden furniture had complained that their products all looked the same using their film, that Kodak developed new film stocks. Kodak introduced Gold Max film, boasting that it would allow any photographer "to photograph the details of a dark horse in low light".

The problem still persists, to a lesser degree, in digital photography. Despite improvements in colour-balancing and colour-correction, Sarah Lewis, an assistant professor at Harvard university, writes that "if the light source is artificial, digital technology will still struggle with darker skin".

Medicine seems to have been built with the same solipsism as photography. For instance, pulse oximeters - those devices health workers peg to your finger, which read your oxygen levels by pinging a red light through your skin - were calibrated using white patients, and they have been shown to consistently overestimate oxygen levels in dark-skinned people by up to 7%. "If we don't fix the biases we have in healthcare before we jump to training a computer to do it, we're just going to actually perpetuate those biases," said Roxana Daneshjou, a dermatologist at Stanford University, in an interview with National Public Radio last year.

There are several artificial-intelligence smartphone apps that claim to be able to identify skin conditions. One of these apps, Skin Image Search, compares the image you upload to a database in which less than 10% of images show dark skin. Ugandan researchers have reported that the diagnostic accuracy of this app was just 17% for dark skin when they tested it on a set of 123 patients with black skin. Here we see how the failings in these disciplines interconnect: even if medical textbooks and apps do become based on a proportionate number of pictures of patients of colour, the images are less likely to be accurate if cameras aren't able to properly capture richly pigmented skin.

till reeling from my own inability to recognise psoriasis in the dark skin of my patient, I spoke to other patients of colour who had bad experiences seeking treatment for skin problems. Afia Ahmed Chaudhry, a history teacher and researcher based in London, told me how her mother felt her skin colour meant she got stuck in a cycle of mistreatment. "[Patients of colour] are often fobbed off," Chaudhry told me, "and then you keep going round and round until you give up, or have to pay to go private." She is furious that it took her mother 15 years to be offered the correct treatment for her severe acne. "She shouldn't have had to wait so long," she said. "They shouldn't have taken advantage of her and given her the same topical treatments that never worked."

For centuries, African societies have had expertise in dealing with richly pigmented skin, using infusions, poultices and ointments made from plants: from the prickly pear extracts used as emollients, to aloe vera used to heal wounds, to rooibos used to treat dermatitis. But much of this traditional knowledge has been lost. Mohamed Soumah - a professor of dermatology at Donka National hospital, in Conakry, Guinea - told me that "in Africa there is little work that deals with dermatology on dark skin". African doctors still study using textbooks mainly written in the west, he said, so doctors must pick up what their books fail to teach them through everyday exposure to dark-skinned patients.

To address western medicine's ignorance of patients of colour, clinics have been set up where people can see dermatologists who take a special interest in darker skin. Most major western cities now have such "skin of colour clinics", many operating under the banner of "ethnic dermatology" or "multicultural dermatology". The first dedicated skin of colour clinic was created by John A Kenney Jr, who was born in Alabama in 1914. His father was a pioneering black surgeon who became known for his social activism; he wrote a book called The Negro in Medicine, and tried to persuade local hospitals to employ more black doctors. One night in 1922, when Kenney Jr was only eight years old, he and his family woke to find the Klu Klux Klan had burned a cross on their front lawn. After repeated death threats, one delivered by a patient of Kenney's father while he was treating him, the family eventually fled to New Jersey.

Kenney went on to become one of the first black dermatologists in the US, setting up the first skin clinic specifically aimed at black people, at Howard University hospital, just outside Washington DC. Kenney died in 2003, but his legacy remains; by the time of his death, he had personally trained a third of the black dermatologists in the US.

The premise behind having such dedicated skin of colour clinics is that dark skin is, in a clinically relevant way, different to white skin. But exactly what and how medically important these differences are is still contested. In many cases, long-debunked ideas remain widespread. In 1851, Samuel Cartwright, a pro-slavery doctor, argued that black people had thicker, less sensitive skin, as part of a disorder he called "dysaesthesia aethiopica", which he thought made workers sluggish. He taught that the only cure was a good whipping. "The best means to stimulate the skin," he wrote, is "to anoint it all over in oil, and to slap the oil in with a broad leather strap; then to put the patient to some hard kind of work in the sunshine." A 2016 study showed that a third of American medics still believe myths about black patients, such as thinking they have thicker skin, with fewer nerve endings.

DermNet NZ is a popular and trusted online dermatology repository, edited by the New Zealand dermatologist Amanda Oakley and used by doctors the world over. Its entry on "ethnic dermatology" claims that "darker skin tends to have a thicker dermis", even though this notion has been debunked. (After I raised this with Oakley, she agreed to have this article revised. On request, she also pledged to include more pictures of darker skin tones with every DermNet NZ article.)

It is a positive step that we now have more specialists with experience of darker skin types, but these clinics come with their own potential pitfalls. Many seem to focus on minor, cosmetic skin concerns - often skin-lightening "treatments" - and nearly all the clinics in the UK are run privately, for profit. What started with Kenney offering a reparative service, helping people of colour to receive the same quality of care as white people, can easily become corrupted under the influence of the market. The danger is that such clinics become part of a lucrative industry that preys upon people who feel their skin is flawed because it is dark. If we are not careful, we could end up with a branch of medicine that medicalises blackness and then profits from the very patients the industry makes feel abnormal.

kin conditions are more than just a nuisance - they can kill. Bob Marley's early death from skin cancer is totemic, and not just because he was a musical giant. His story reminds us of the extra complications that black patients have to navigate when seeking healthcare, and how our health systems are set up in a way that has improved treatment for white patients while leaving people of colour behind.

Marley first told his friends that something was wrong in the summer of 1977. During a game of football in Paris, he injured his right big toe, and his toenail became painful. He admitted it was not the first time - he'd had a spot under his nail for a few years, and assumed it was a tiny bruise. He had to see two doctors before he was offered a biopsy, which confirmed the deadliest kind of skin cancer: acral lentiginous melanoma. Unlike the other three kinds of melanoma, which usually occur on soft, sun-exposed skin, acral lentiginous melanoma occurs in easy-to-miss places, such as the soles of your feet, or under your toenails.

Bob Marley, who died from skin cancer that developed under his toenail. Photograph: MAZ/LFI/London Features International

The kind of melanoma that Marley developed, and which is by far the most common subtype in dark-skinned people, was not on the radar of most doctors. In 1977, the year Marley first developed symptoms, the world's most popular medical textbook, the Merck Manual of Diagnosis and Therapy, published its 13th edition. It has entries on the three subtypes of melanoma that are most common in pale skin, but acral lentiginous melanoma isn't even mentioned. Even today, it is the subtype of melanoma with the fewest successful treatment options.

Sunlight damages skin DNA, and while this is normally corrected within seconds, sometimes these genetic errors cannot be fixed, causing cancer. That's why white people, who have less melanin to shield their DNA, are more than 20 times more likely to get skin cancer than black patients. But what's really striking is how, in the US, the five-year survival rate after a melanoma diagnosis has changed in these two sub-populations, from the 70s to the present day. In white patients, the survival rate has improved from 68% to 90%. In black patients, it has gone down from 67% to 66%.

Such health outcome disparities help explain why a 2007 study in the American Journal of Public Health found that black patients were less likely than white people to trust medical professionals. They have good reason to be sceptical, given medical science's long history of racism. It was only in 1975, for instance, that the family of Henrietta Lacks became aware that tissue removed from her body in 1951, without consent, was still being used in lucrative medical research. Then there is the case of the Tuskegee Study, a shocking medical experiment conducted in the US between 1932 and 1972, in which black men were denied treatment for syphilis so that investigators could study exactly how the disease killed people.

As a result of these betrayals, and an often condescending attitude from doctors - I have heard doctors bemoan the fact that black patients come too late to be cured, or refuse to engage with cancer screening programmes, or hold unscientific beliefs that hold them back - many black people have stopped entrusting their bodies to medicine altogether, a phenomenon sociologists have termed "the wisdom of distrust". This forces some to seek help from alternative practitioners, or avoid treatment entirely. Marley himself missed some follow-up appointments with his doctors, instead trying an unproven dietary regime recommended by Josef Issels, a German quack.

By the time Marley was eventually given a skin graft, his cancer had already grown down through the layers of his skin and started its spread. In September 1980, he played his final show, before trying some last-ditch conventional cancer treatment. It didn't work. Weighing just 37kg, he died on 11 May 1981 at the age of 36, at the Cedars of Lebanon Hospital in Miami.

A year after Marley died, the state of Florida started collecting cancer data in a state-wide registry. Shasa Hu, a melanoma expert and researcher at the University of Miami Hospital (the same hospital in which Marley died, now renamed), has studied the data on melanoma outcome disparities between white patients and patients of colour. Her research has shown how little has changed in the past four decades; just like in the 80s, black patients in Miami are still far less likely to be diagnosed in time to be cured.

am not a dermatologist, but as a primary care physician, I am the first person people bring their rashes to, and nearly all doctors examine skin several times every day. But our training is woefully lacking, leaving medics entirely unprepared to serve our patients of colour.

There is a growing movement online to change this. In September 2019, unable to find adequate information regarding a rash her mixed-race son had, Ellen Buchanan Weiss set up the website Brown Skin Matters. It provides concerned parents and doctors with a collection of images showing how skin conditions both common and rare can present differently in richly pigmented skin. And as I write, there is a petition urging the UK General Medical Council to require that medical schools include a diverse representation of skin tones in their teaching.

One of the youngest people campaigning for this is Malone Mukwende, a second-year medical student at St George's Medical School in London, who has co-authored a handbook, Mind the Gap, which aims to help fill this educational blind spot. But, while important, diversifying the skin tones we learn from is just the first, and easiest, step in a much broader struggle to reshape the medical profession to make it foreground the perspectives of people of colour, and eliminate the disparities that they have long suffered.

Despite having more than a decade of experience as a doctor, I have already learned a lot by going through the Brown Skin Matters website - which is good, not only for my future patients, but also for me. I soon realised that, despite experience in examining skin, I had never seen my own skin that way; I was always the reader, but never the page. I was shocked to see that several of the images showed skin changes that I have had myself, but which I had never thought to diagnose: the dry, crazy-paving skin on my lower legs looks like their picture of icthyosis; and I sometimes get rough patches that would do for nummular eczema, which can look subtle on brown skin.

Even right now, I have an unusual, itchy rash on my ankles. I've heard of similar rashes in people who have Covid-19, and it can be the only symptom. But again, I cannot find the information to know for certain. Jenna Lester, an assistant professor of dermatology at the University of California San Francisco, recently led a systematic review of papers describing Covid-19 skin changes. She found that, of the 130 images she reviewed, 92% showed white skin, 6% showed medium-brown skin, and none showed dark brown or black skin. So I have not even mentioned my rash to my own doctor. Because I know that they, like me, won't know what to do. For now, we are all operating in the dark.

* Follow the Long Read on Twitter at @gdnlongread, and sign up to the long read weekly email here

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Decolonising dermatology: why black and brown skin need better treatment

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The long read : During my medical training, it was almost always assumed that my patients would be white. That prejudice is harmful in its own right - and when it comes to dangerous skin conditions, it can be deadly

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Browse Hundreds of Diverse Images for Your Online Projects

Black illustrations is a series of digital designs of black people for your next online project. Use our designs anywhere.  There just isn’t a lot of diversity in design.  People of color are often underrepresented in illustrations, lacking in the design process and often go unseen in visuals across the internet.

We saw the lack of diversity as an opportunity to create a free resource for everyone.  As a way to add diversity to online content by showcasing black people and people of color in a myriad of tasks, we hope to be the spark that creates more change in the digital landscape.

www.blackillustrations.com

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Hundreds of Diverse Images
for Your Online Projects

People of color are often underrepresented in illustrations, lacking in the design process and often go unseen in visuals across the internet.

We saw the lack of diversity as an opportunity to create a free resource for everyone. As a way to add diversity to online content by showcasing Black people and people of color in a myriad of tasks, we hope to be the spark that creates more change in the digital landscape.

BROWSE ILLUSTRATIONS

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Illustrations of Black People for Your Next Digital Project | Black Illustrations

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People of color are often underrepresented in illustrations, lacking in the design process and often go unseen in visuals across the internet. We saw the lack of diversity as an opportunity to create a free resource for everyone.

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This atlas, containing more than 300 color photos, focuses on those dermatologic conditions that are most common in ethnic skin or skin of color. It includes succinct explanations of each disease process, describes clinical findings, and presents key information on diagnosis and treatment. Individual chapters are devoted to pigmentary disorders, follicular disorders, hair and scalp disorders, eczemas, papulosquamous disorders, granulomatous disorders, connective tissue diseases, infectious diseases, scarring disorders, cutaneous neoplasms, photodermatoses and drug eruptions. The fact that this atlas covers skin disorders that affect patients of all ethnic backgrounds ensures that it will be of worldwide relevance. It will serve as a valuable reference for dermatologists and a range of other health care providers.

Ethnic Medical dermatology Pigmentary disorders

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This atlas, containing more than 300 color photos, focuses on those dermatologic conditions that are most common in ethnic skin or skin of color. It includes succinct explanations of each disease process, describes clinical findings, and presents key information on diagnosis and treatment.

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It seems that you're in USA. We have a dedicated site for USA

Springer Book Archives: eBooks only 8.99 each! Save now >>

Includes high quality photographs and illustrations

Features comprehensive and concise bullet text for practical useWritten for residents and practicing dermatologists

Show all benefits

Buy this book

eBook 169,99 €

Hardcover 207,99 €

About this book

As both experience and evidence-based findings indicate, specific dermatological conditions can prove harder to diagnose in patients with darker skin tones. Lack of knowledge or experience can compromise effective treatment and management, leading to lasting consequences for the patient. This atlas strives to supplement a lack of real world experience by providing more than 800 hundred high quality photographs and illustrations help guide physicians in treating the nuances of darker skinned patient populations.
Dr. Moiin's own professional experience in treating patients of color on a daily basis and the sheer volume with which he is acquainted with these diseases on darker skin, enable him to provide broader insight and include a myriad of photos to better illustrate diagnoses and treatment plans. Photos range from common to rare diseases to aid in delineating nuances in diseases. Since dermatology is a highly visual field, the focus is more on the images, while the text is comprehensive but concise and often bulleted to allow for practical use.
Written for residents and practicing dermatologists and all other medical professionals, Atlas of Black Skin is an essential tool for practitioners looking to broaden the scope of their care.

About the authors

Ali Moiin, MD FAAD.Clinical professor of Dermatology Wayne State University, School of Medicine
Dr Moiin has been a practicing dermatologist for last twenty years at WSU and private practice in Detroit serving its diverse community. Dr. Moiin is board-certified in dermatology by the American Board of Dermatology and is a fellow of the American Laser Surgery and Medicine Society. Dr. Moiin is the chairman of medical education for the Michigan Dermatological Society.
Dr. Moiin is an associate professor of dermatology at Wayne State University School of Medicine. He also served as chief of dermatology at Harper Hospital. Recently, Dr. Moiin was chosen as the best professor of dermatology at Wayne State University. He maintains affiliations with major medical centers in the Detroit metro area, including Detroit Medical Center, St. John's Hospital, St. Mary's Hospital and William Beaumont Hospital. He is also a a member of the Board of Medicine of the state of Michigan.
Dr. Moiin received his bachelor's degree in pharmacology and master's degree in biology from the University of California, Santa Barbara. He received further training in pharmacy at the University of California, San Francisco. After a year of internal medicine training in San Francisco, he completed residency training in dermatology at Wayne State University School of Medicine. He has received additional training in cosmetic dermatology at Tulane University Medical Center.

Reviews

"The audience is medical students and clinical dermatologists who are interested in expanding their diagnostic skills by recognizing how dermatoses can appear in black skin. ... Being adept at diagnosing dermatologic diseases in lighter skin is a prerequisite for being able to fully benefit from the information in this book." (Patricia Wong, Doody's Book Reviews, May 29, 2020)

Buy this book

eBook 169,99 €

Hardcover 207,99 €

Recommended for you

Bibliographic Information

Bibliographic Information

Book Title

Atlas of Black Skin

Editors

Copyright

2020

Publisher

Springer International Publishing

Copyright Holder

The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG

eBook ISBN

978-3-030-31485-9

DOI

10.1007/978-3-030-31485-9

Hardcover ISBN

978-3-030-31484-2

Edition Number

1

Number of Pages

XIII, 236

Number of Illustrations

7 b/w illustrations, 831 illustrations in colour

Topics

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Atlas of Black Skin | Ali Moiin | Springer

# data[].attributes.attachment_link.description
It seems that you're in USA. We have a dedicated site for USA Springer Book Archives: eBooks only 8.99 each! Save now >> Includes high quality photographs and illustrations Features comprehensive and concise bullet text for practical useWritten for residents and practicing dermatologists Show all benefits eBook 169,99 € Hardcover 207,99 € About this book As both experience and evidence-based findings indicate, specific dermatological conditions can prove harder to diagnose in patients with darker skin tones.

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Taylor and Kelly's Dermatology for Skin of Color, 2e

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To promote awareness of and excellence within the area of special interest of dermatology – skin of color.
Education of health care providers and the general public on dermatologic health issues related to skin of color.
Supports research and other activities that impact individuals with skin of color.

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The Skin of Color Society was established in 2004 by Susan C. Taylor, M.D. The purpose of the society is to promote awareness of and excellence within the area of special interest of dermatology - skin of color. The Society is committed to the education of health care providers and the general public on dermatologic health issues related to skin of color.

The Society supports research and other activities that impact individuals with skin of color. Partnerships with dermatologists from the national and international communities, professional medical organizations, corporate and industry groups, and community ensures our success in serving all individuals with skin of color. We invite you to join us in this important endeavor.

The "Find a Doctor" database ("Doctor Database") is intended to provide the public with easy access to information on SOCS member physicians. To locate a physician in your area, read and accept the terms and conditions of this Access Agreement.

The differences between this website and other sites:

SOCS educates physicians.

We do not promote individual doctors.

We do not charge to be listed on the website.

We aim to educate patients on how to find a doctor who is right for them.

Read the SOCS Database Access Agreement
Accept & Continue Decline

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Dermatology | Skin of Color Society | International Dermatology Organization

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The Skin of Color Society was established in 2004 by Susan C. Taylor, M.D. The purpose of the society is to promote awareness of and excellence within the area of special interest of dermatology - skin of color. The Society is committed to the education of health care providers and the general public on dermatologic health issues related to skin of color.

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Primary Care Dermatology Society - Pigmented skin types - clinical variations

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Primary Care Dermatology Society - Pigmented skin types - clinical variations

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Differences in cutaneous structure and function of pigmented skin, as well as cultural practices, can result in conditions with distinct presentations and varying prevalence that require unique treatment. This chapter is set out as follows:

Aetiology

Clinical findings

Images

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Created: 21st September 2017 | Last Updated: 20th November 2017

General problems related to pigmented skin

An increased incidence of eczema, pityriasis alba, tinea capitis, pseudofolliculitis, acne keloidalis nuchae, scars, acanthosis nigricans, lichen planus and fixed drug eruptions. Although sarcoid is an uncommon condition it is more prevalent in black skin and has many presentations

Post-inflammatory hyperpigmentation, sometimes post-inflammatory hypopigmentation, and the misuse of skin lightening agents are all more common

Although skin cancer is less common the proportion of acral lentiginous melanoma amongst all melanoma is higher in pigmented skin

An increased awareness of tropical infection is required in immigrants arriving from certain parts of the world

Morphology

​Increases in pigment may make it difficult to recognise erythema

Surface scales takes on a grey appearance

Increased follicular involvement eg in eczema

More pronounced lichenification

Psoriatic lesions can have a dark purple hue

Eczema can affect the extensor surfaces of the limbs, particularly at the elbows and knees

Scabies may have more in the way of pustules

Skin conditions that are more pronounced / problematic in pigmented skin

Pigmentary demarcation lines

​In all races, the dorsal skin of the limbs is darker than the ventral surfaces. This is more pronounced in pigmented skin, especially the anterolateral portion of the upper arm. These pigmentary demarcation lines (also known as Futcher's or Voight's lines) are seen in 20-30% of the black population

For more information refer to the clinical chapter on pigmentary demarcation lines

Vitiligo

​​The contrast between normal skin and areas affected by vitiligo is more marked in persons with pigmented skin, and as such the psychological impacts are often greater

If treatment is to be beneficial it needs to be initiated early - for more information refer to the chapter on vitiligo

Acne vulgaris

Acne is no more common or severe in pigmented skin, but post-inflammatory hyperpigmentation can be significant and often persists for months to years. As such, early and more aggressive treatment is advocated, including early referral for consideration of isotretinoin

Secondary acne can be a result of cultural practices - hair oil can induce pomade acne on the forehead and skin lightening products containing topical steroids can cause a steroid-induced acne

Topical retinoids, benzoyl peroxide and azelaic acid play an important role in the treatment of the comedonal aspects of acne. If used daily they often cause dryness and irritation, which in pigmented skin can lead to further hyperpigmentation. Accordingly these treatments should initially be used for shorter periods of time (eg in an evening and washed off before bed) and perhaps less frequently (eg every 2nd or 3rd day), if tolerated the duration and/or frequency of treatment can be increased - if used in this way then as well as treating the comedones they may help treat hyperpigmentation rather than aggravate it

For more information refer to the chapter on acne vulgaris

Lichen planus pigmentosus

​This variant of lichen planus may or may not be associated with typical LP papules and itch is often absent

The macular hyperpigmentation involves chiefly the face, neck and upper limbs, although it can be more widespread, and varies from slate grey to brownish black. It is mostly diffuse, but reticular, blotchy and perifollicular forms are seen. Occasionally there is a striking predominance of lesions at intertriginous sites, especially the axillae

The duration ranges from 2 months to 2 years and there is no known effective treatment

For more information refer to the chapter on lichen planus

Post-inflammatory hyper- or hypopigmentation

​​Post-inflammatory hyperpigmentation (and less so hypopigmentation) is more common in pigmented skin

It is usually caused by an inflammatory dermatosis and sometimes trauma

The situation can be made worse if the patient attempts to self-treat and apply various chemical bleaching substances (eg hydroquinone) to the skin, this is referred to as exogenous ochronosis

The main aim of treatment is to treat any on-going inflammation

Epidermal post-inflammatory hyperpigmentation will take 6-12 months to fade. Deeper pigment may take years. An important part of therapy is sunscreen with a minimum sun protection factor (SPF) of 30 to prevent darkening of the post-inflammatory hyperpigmentation. For post-inflammatory skin conditions of the face please refer above to the notes on acne vulgaris

Post-inflammatory hypopigmentation may also improve over time. Phototherapy has been successfully used in some patients

Patients can also be referred for camouflage

​Pseudofolliculitis barbae

​This is an inflammatory follicular condition with an estimated prevalence of 45-85% in African-Americans. Hispanic men are the next most-affected group

It is most common in men, affecting the beard area or neck, but can also affect women on areas of the body where hair removal practices have been used

It is thought that the natural tendency for curly hair to recoil in this ethnic group predisposes cut hairs to re-enter the skin. As the hair re-enters the dermis, it causes an inflammatory foreign body response, which manifests as papules and pustules

Hyperpigmentation and keloid scarring are frequent complications

For more information refer to the chapter on pseudofolliculitis barbae

Acne keloidalis nuchae

Occurs in persons of all races but most commonly in men of African descent, followed by Hispanic, Asian, and white men. Persons affected are primarily post-pubertal, and onset is typically before 50 years of age

Close shaving and close-cropped hair are the main risk factors, but friction from shirt collars and helmets has also been implicated

The condition begins as a chronic folliculitis of the posterior neck and occipital scalp, which progresses to keloidal papules and plaques causing a scarring alopecia - early treatment correlates with a good prognosis

Scarring - keloid, hypertrophic and atrophic

​There is a higher incidence in black skin, Hispanic persons, and Asians

Keloids are benign growths that represent an overgrowth of scar tissue at sites of trauma, or sometimes arise spontaneously. Keloids are often confused with hypertrophic scars. Hypertrophic scars typically develop soon after the inciting trauma and are found on areas of the body with frequent motion, such as extensor surfaces. They are confined to the borders of initial injury and may regress. Conversely, keloids develop months to years after injury and most commonly arise on the ears, jaw line, nape of the neck, scalp, chest, and back. Keloids extend beyond the borders of original injury, often progressing over time

Refer to the chapter on keloid scars for more information

Alopecia

​Hair care practices - although no biochemical differences of hair have been found among persons of different ethnicities, there are notable differences in the shape of the hair follicle, leading to differences in texture, fragility, and manageability of hair. Persons of African descent have the greatest degree of curl and increased fragility. Educating patients about avoiding traumatic hair practices is key in prevention

Traction alopecia - is the loss of hair from excessive pulling, and may result from tension placed on the hair with braids and weaves. Hair loss often occurs at the frontal and temporal hair lines. For more information refer to the chapter on traction alopecia

Tinea capitis - is an infection of hair follicles and surrounding skin with dermatophyte fungi and presents with inflammation, scaling and sometimes patchy hair loss. The condition is most commonly seen in African-Caribbean prepubertal children in urban communities. This is thought to be a result of hairstyling practices, such as close-cropped styles and tight plaits, which make the follicles more vulnerable to infection - patients are advised against sharing hair clippers because this can spread the infection. It is clear that the pattern of tinea capitis in the UK has changed in the past ten years with a significant rise in the incidence and prevalence of cases of infection due to Trichophyton tonsurans. For more information refer to the chapter on tinea capitis

Central centrifugal cicatricial alopeciais a condition exclusively seen in Fitzpatrick type VI skin. It presents as a diffuse scarring alopecia that begins at the crown and spreads outwards, classically starting in the mid-30s. Women are more commonly affected than men. The aetiology is unknown, the initial hypotheses was that the condition was associated with heated styling instruments or chemical straighteners. Patients are encouraged to discontinue use of relaxers, limit traction, and decrease the amount of heat applied to the hair. No ideal treatment currently exists; however, options include topical and intralesional steroids with oral antibiotics. Early intervention is most effective

Dermatosis papulosa nigra

​Is a common benign skin condition that occurs predominantly in pigmented skin presenting with multiple 1-5 mm multiple brown to dark-brown, dome-shaped papules predominantly on the face and neck

The highest prevalence is in black skin, reportedly between 10% and 30%. However, the condition also affects Asians, Hispanic persons, and whites. Onset is typically after puberty

Treatment is not usually required, and should be avoided if possible as the risks of any physical treatments include post-inflammatory hyper- or hypopigmentation

For more information refer to the chapter on dermatosis papulosa nigra

Skin cancer

​Although skin cancer is relatively uncommon in pigmented skin, patients are likely to present with more advanced skin cancer and have lower survival rates when compared to Caucasians

Basal cell carcinoma is often more pigmented than compared to lesions in Caucasian skin

Squamous cell carcinoma is the most common skin cancer in black skin and Indians, and the second most common in Chinese, Japanese, and Hispanic persons. UV exposure is a known risk factor in Caucasians, with most lesions in sun-exposed areas. In comparison, the influence of UV light on the aetiology of squamous cell carcinoma in pigmented skin is unclear, and lesions commonly occur in non sun-exposed sites. The most important risk factors in pigmented skin is chronic inflammation and scarring

Acral lentiginous melanoma (melanoma involving the palms, soles, or nail beds) is the most common subtype of melanoma in black skin and Asians. Superficial spreading melanoma is the most common subtype in Hispanic persons and in whites. Evaluation of melanoma of the nail bed can be difficult because many persons with darkly pigmented skin have melanonychia (benign linear pigmentation of the nails) - this can be seen in childhood, but becomes more obvious with age. The width of pigmented bands varies from a few millimetres to the whole width of the nail and the colour varies from light brown to black. Pigmentation often affects multiple nails, which helps to distinguish it from subungual haemorrhage, melanocytic naevi and most importantly, melanoma - for more information refer to the chapter on nail disorders

Tropical infection

Please click on images to enlarge or download. The PCDS would like to thank Dermatoweb, DermQuest (Galderma), and others who have contributed images. All named individuals and organisations maintain copyright for the relevant images. This website is non-profit and holds the images for educational purposes only. Any image downloaded must only be used for teaching purposes and not for commercial use. Notice and credit must be given to the PCDS or other named contributor. Please follow this link if you have any high-quality images that you can contribute to the website.

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Pigmented skin types - clinical variations

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The term 'pigmented skin' refers to Fitzpatrick skin types IV to VI. This encompasses a wide range of ethnic and cultural groups, including Africans, African-Caribbeans, African-Americans, Hispanics, South East Asian, Chinese, Japanese and Native American Indians. Differences in cutaneous structure and function of pigmented skin, as well as cultural practices, can result in conditions with distinct presentations and varying prevalence that require unique treatment.

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Brown Skin Matters - @BrwnSkinMatters Twitter

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Brown Skin Matters - @BrwnSkinMatters Twitter

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Making up for the lack of reference photos of dermatological conditions on non-white skin. For personal reference only. Find us on Instagram for more.

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Mind the Gap: a handbook of clinical signs on black and brown skin,  St George's University of London

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Mind the Gap: a handbook of clinical signs on black and brown skin,  St George's University of London

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Published: 18 June 2020

Second year medic, Malone Mukwende, has been working with Senior Lecturer in Diversity and Medical Education, Margot Turner, and Clinical Lecturer in Clinical Skills, Peter Tamony, as part of a student-staff partnership project looking at clinical teaching on black and brown skins. Malone highlighted that, as a black student, he felt alienated with the way clinical skills is currently being taught due to the lack of discussion around clinical signs on darker skin.

It was agreed that this was a very important issue and an essential part of decolonizing the curriculum. The trio have designed a booklet, which will be available shortly, to raise awareness of how symptoms and signs can present differently on darker skin as well as highlighting the different language that needs to be used in descriptors.

Malone explains, "The aim of this booklet is to educate students and essential allied health care professionals on the importance of recognising that certain clinical signs do not present the same on darker skin. This is something which is not commonly practiced in medical textbooks as there is a 'white skin bias'. It is important that we as future healthcare professionals are aware of these differences so that we don't compromise our care for certain groups.

"The booklet addresses many issues that have been further exacerbated during the Covid-19 pandemic, such as families being asked if potential Covid patients are 'pale' or if their lips 'turned blue'. These are not useful descriptors for a black patient and, as a result, their care is compromised from the first point of contact. It is essential we begin to educate others so they are aware of such differences and the power of the clinical language we currently use. We will be hosting a training session for clinical skills peer tutors which will take place in July 2020.

"Multiple conversations are now taking place around what can be done to tackle health disparities in the UK and we would love for St George's to be a part of that growing conversation. Recently there was a petition calling for teaching clinical skills on black and brown skins that now has over 125,000 signatures. The petition, Covid-19 pandemic and the Black Lives Matter movement all illustrate there is an urgent need for change."

Mind the Gap is not currently published and so is not available to distribute however discussions with potential publishers are ongoing.

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Mind the Gap: a handbook of clinical signs on black and brown skin

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Published: 18 June 2020 Second year medic, Malone Mukwende, has been working with Senior Lecturer in Diversity and Medical Education, Margot Turner, and Clinical Lecturer in Clinical Skills, Peter Tamony, as part of a student-staff partnership project looking at clinical teaching on black and brown skins.

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University of Nottingham, Centre of Evidence Based Dermatology - Skin of Colour Resource

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University of Nottingham, Centre of Evidence Based Dermatology - Skin of Colour Resource

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Information sources, systematic reviews and review articles on topics of relevance to skin of colour.

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A resource bringing together systematic reviews, reviews and information sources on skin of colour, produced by the Centre for Evidence Based Dermatology (CEBD).

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Dermnet NZ - Dermatological Conditions in Skin of Colour

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Dermnet NZ - Dermatological Conditions in Skin of Colour

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Link to DermNet's pages about skin conditions with a tendency to affect skin of colour or with special characteristics in people with dark-coloured skin.

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Dermatological conditions in skin of colour

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Authoritative facts about the skin from DermNet New Zealand Trust.