Health Disparities That Are Skin Deep

By: Yeeun Lee

Ellen Buchanan Weiss is a mother to a young boy who woke up one morning with a rash with several bumps. Confused and concerned, she decided to look it up on Google — as one does. To her surprise, she found no images that looked like what her son was experiencing, not even on reputable websites like the CDC or Mayo Clinic. Ellen’s son also has brown skin. While there were several images of common skin conditions, they were all on white skin. She recalls having to “scroll down like 80 pictures to find a single one on brown skin.” However, this is not exclusive to the internet. 

According to Dr. McKinley-Grant, a dermatology professor at Howard University, the images of skin conditions in people of color is limited even in medical schools. She stated that there is a diversity gap in medical training as health professionals do not get the full picture. That is, the skin conditions they were taught in medical school are exclusively on white skin. This becomes a bigger issue since medical training — especially in dermatology — relies heavily on pattern recognition, and not all patients have identical skin patterns. Medical students look at thousands of similar images and learn to classify them as a certain condition. But when those images are unrepresentative of the entire population, some people can go undiagnosed. For example, eczema can look extremely different depending on a person’s skin color. 

In 2006, a study analyzing major textbooks and resources used in dermatology found that there were limited photos of those same conditions in darker skin tones. [1] Until recently, “examples in people of color were limited to diseases that were more common in people of color,” says Dr. Papier, a corresponding author on the study. To illustrate what this might look like in the classroom setting, LaShyra Nolen, a first-year medical student at Harvard University, recounts an incident in her microbiology class. Her class was shown the classic image of Lyme disease, a bull’s eye rash, “when someone asked how the disease presents on darker skin. The professor struggled to provide an answer, Nolen recalls.” But this outrageous reality is far from surprising. After all, the standard of medicine has historically been based on the white male anatomy. And as technology advances, these racial disparities in diagnosis will only be further exacerbated.

The clearest example of this is artificial intelligence, also known as AI. AI is increasingly being incorporated into medicine and like medical students, these machines learn through pattern recognition. If the algorithms used to create these machines come from databases that predominantly feature skin images from white racial groups, people of color could go misdiagnosed for serious conditions like cancer. Individuals and institutions have recognized the need to address this grave issue in order to provide the best care for all patients. At the educational level, there has been a discussion surrounding this topic. A study conducted in 2012 stated that according to the U.S. Census Bureau, more than half of the U.S. population will consist of non-Caucasians by 2050. The report highlights that “skin of color will no longer be a question of ‘minority health’ but will apply to the majority of the population.”[2] The U.S melting pot is constantly expanding and diversifying, which emphasizes the medical need for more accurate dermatologic categorization of skin conditions that commonly affect people of color

Furthermore, changes at the institutional level have been made as well.  The University of California San Francisco recently opened a dermatology clinic specifically for people of color in order to address disparities in care. Having physicians of color in fields like dermatology is also imperative. For instance, Dr. Desai is a dermatologist that created Skin of Color Society, “an international professional dermatologic organization dedicated to promoting awareness of, and excellence in, the area of skin of color.” The organization seeks to enhance the care for patients by equipping physicians with educational resources to help dispel myths surrounding people of color, which can lead to delayed or inaccurate diagnoses. 

But on a corporate level, changes have been smaller and less impactful. For instance, WebMD has a site designed for darker tone skin conditions that explains these different conditions such as eczema, vitiligo, keloids, and melanoma. However, the site has yet to add images. Nonetheless, for a popular health website consulted by the general public,  the addition of a dedicated site is an integral step forward. 

And with brave individuals like Ellen, progress has been made towards the individual level. The lack of resources provided to people of color influenced Ellen to create the Instagram account Brown Skin Matters. While the images in the Instagram account should not substitute a medical exam, the account is a welcomed additional resource. For mothers like Ellen, this means they can consult the account whenever their kids, who have non-white skin tones,  suddenly have a rash or skin blister. With over 10,000 followers, the account is bringing attention towards the issues people of color face.

Undeniably, our medical system is filled with racial and ethnic disparities that impact health outcomes. While the issue is complex, understanding why these gaps are created and addressing them is crucial. Raising awareness is key to addressing this problem because it emphasizes that there is a need to understand skin of color and how dermatologic conditions can look on different skin tones. In dermatology, the lack of images of skin conditions in people of color creates disparities in diagnosis and thus in treatment. In the future, our healthcare system can aim to be more inclusive and representative of all patients by recognizing these gaps, identifying their causes, and finding ways to minimize them. 

References 

[1]  Ebede, T., & Papier, A. (2006). Disparities in dermatology educational resources. Journal of the American Academy of Dermatology, 55(4), 687-690.

[2] Henderson, M., Abboud, J., Cogan, C., Poisson, L., Eide, M., Shwayder, T., & Lim, H. (2012). Skin‐of‐Color Epidemiology: A Report of the Most Common Skin Conditions by Race. Pediatric Dermatology, 29(5), 584-589.