As with many areas of medicine, within the practice of dermatology, ethnically minoritised groups suffer poorer health outcomes due to the existence of racial disparities. One study found that 47% of dermatologists in the US felt that their training was inadequate to diagnose skin diseases in skin of colour (Centers for Disease Control and Prevention, 2015). This can result in sub-optimal care. For example, a patient was forced to wait for several hours with a rash, which was later diagnosed as toxic epidermal necrolysis (a potentially life-threatening immune reaction with a mortality rate of up to 40% (Dhana and Lehloenya, 2019)). They were forced to wait because the ‘characteristic’ redness that dermatologists look for to make diagnosis can be subtle in skin of colour. This is just one of many examples of serious dermatological conditions missed because presentation does not match to that taught, which focused on fair skinned individuals (Lester et al, 2019).
Delays in diagnosis are common in people of medium and dark skin tones. This results in racial disparities in survival rates from dermatological conditions. When looking at melanoma, which is a type of skin cancer which grows quickly and has the ability to metastasise around the body, survival rates are worse in people with darker skin tones. Black men diagnosed with melanoma have about a 26% higher risk of dying than white men with the same cancer (Fernandez et al, 2023). People of light skin tones are more likely to present earlier, this may be because patients with darker skin are unable to find imagery on the internet showing melanoma on darker skin tones and delay seeking treatment.
There is a significant lack of imagery demonstrating dermatological conditions on darker skin tones. One study found that only 4.5% of images in general medical textbooks showed dark skin (Louie and Wilkes, 2018). However, within dermatological imagery there is one rather striking exception. Dark skin is more often used to depict the dermatological presentations of sexually transmitted diseases. Lester et al found in their 2019 study that up to 58% of imagery of STIs was of dark skin tones, showing large racial disparities and prejudice.
Looking into the future, artificial intelligence will be used to diagnose dermatological conditions. However, if AI is being trained with current datasets which consist disproportionately of light-skinned individuals, this will result in further disparity and health inequality among different racial groups.
A systematic review of 626 dermatological clinical trials found that only 52 reported the racial or ethnic demographics of study participants, just 11.3%. As different ethnic groups may respond differently to treatments, reporting of the ethnic makeup of trial participants and adequate representation is vital to ensure that everyone receives effective treatment. (Charrow et al, 2017)
References:
Charrow, A. et al. (2017) ‘Diversity in dermatology clinical trials’, JAMA Dermatology, 153(2), p. 193. doi:10.1001/jamadermatol.2016.4129
Dhana, A. and Lehloenya, R. (2019) ‘The ABCD-10 risk prediction model for in-hospital mortality among patients with Stevens-Johnson Syndrome/toxic epidermal necrolysis’, JAMA Dermatology, 155(9), p. 1087. doi:10.1001/jamadermatol.2019.1943.
Fernandez, J, Mata, E., Bubic, B, Kwan, K., Whitleym M., Wysong, A.(2023) ‘Racial and ethnic differences in males with melanoma: A retrospective cohort study of 205,125 cases from the National Cancer Database’, Journal of the American Academy of Dermatology [Preprint]. doi:10.1016/j.jaad.2023.05.080.
Lester, J.C., Taylor, S.C. and Chren, M. ‐M. (2019) ‘Under‐representation of skin of colour in dermatology images: Not just an educational issue’, British Journal of Dermatology, 180(6), pp. 1521–1522. doi:10.1111/bjd.17608
Louie, P. and Wilkes, R. (2018) ‘Representations of race and skin tone in medical textbook imagery’, Social Science & Medicine, 202, pp. 38–42. doi:10.1016/j.socscimed.2018.02.023.
Vital signs (2015), Centers for Disease Control and Prevention. Available at https://www.cdc.gov/vitalsigns/hispanic-health/index.html (last accessed 23 July 2023).
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