Providers Need to Be Educated About How Conditions May Vary in Skin of Color, Says Dr Andrew Alexis


Lack of knowledge about how skin conditions present on lightly pigmented skin has resulted in diagnostic delays, underassessment, and an impact on quality of life for patients with skin of color.

Medical textbooks and education of skin conditions tend to focus on how these diseases present in lightly pigmented skin types, resulting in diagnostic delays for patients with diverse skin types, explained Andrew Alexis, MD, MPH, FAAD, vice chair for diversity and inclusion for the Department of Dermatology and a dermatologist at the Center for Diverse Skin Complexions at Weill Cornell Medicine in New York City.

Patients with skin of color may have trouble recognizing their own conditions, experience diagnostic delays, and feel a greater impact on their quality of life, he added.

In an interview with The American Journal of Managed Care® (AJMC®), Alexis discussed how skin conditions can present differently for people of color and how a lack of knowledge about these differences result in variations in diagnostic acumen among health care providers.

AJMC: What should people know about how various skin conditions might present across diverse skin types? How do these conditions appear differently?

Alexis: Various dermatological conditions can present differently across the spectrum of diverse skin complexions. For example, whereas in lightly pigmented skin types, inflammatory conditions such as psoriasis and eczema may appear with lesions that are red or pink in color, in darker skin complexions these lesions may appear reddish brown, purple to violet, or grayish, making it difficult for patients to recognize their conditions using examples that may be found online or in other publicly available materials.

Beyond color, eczema, for example, is more likely to have what we call a follicular appearance (ie, small bumps) in Black skin. There are numerous other examples of differences in morphology of common skin conditions in skin of color.

AJMC: Research has shown that medical textbooks tend to lack images of darker skin. How does this affect patient care and what is being done to address it?

Alexis: A lack of photos depicting dermatologic disorders across diverse skin types (especially in richly pigmented skin) can contribute to variations in diagnostic acumen in the health care workforce. That said, there are many textbooks that focus entirely on skin of color that show numerous examples of conditions in populations with richly pigmented skin. There are examples at the Skin of Color Society site.

There are also numerous efforts underway to broaden the diversity of clinical images in learning materials, and some of these efforts—such as the Skin of Color Curriculum and the Skin of Color Society Dermatology E-Learning + Equity Platform—have been led by the American Academy of Dermatology and the Skin of Color Society.

AJMC: How are people of color impacted by misdiagnoses and delays in diagnosis?

Alexis: People of color may find it challenging to relate to patient-oriented educational materials that may be found online or other public domains. As images and descriptions may not quite reflect what they see in their own skin. In some cases, people of color may experience delays in their diagnosis or underassessment of disease severity due to variations in clinical experience/exposure to skin of color–specific educational materials among health care providers.

AJMC: What is the quality-of-life impact these patients deal with?

Alexis: There is evidence that there may be a higher quality-of-life impact on patients with skin of color for a number of dermatologic disorders. These would include pigmentary disorders, such as melasma and vitiligo; hair and scalp disorders, such as scarring alopecia; and inflammatory disorders, such as psoriasis in atopic dermatitis.

AJMC: How is their access to care and access to diverse providers compared with White patients?

Alexis: In the United States, there is generally lower access to specialty care and specialty treatments among populations of color. Also, the number of dermatologists who self-identify as Black/African American, Hispanic/Latino, or American Indian is much lower than the proportion found in the US population.

AJMC: What should providers do to be better able to diagnose and treat dermatologic conditions on diverse skin?

Alexis: Dermatology training covers the broad scope of skin, hair, and nail conditions across the diverse spectrum of patient populations. However, there may be geographic variations in exposure to populations with skin of color during residency training and clinical practice.

Leveraging skin of color–specific educational materials can help reduce disparities in clinical education for dermatologic conditions that have nuances or may disproportionately affect populations of color. Broad efforts are being made across the country to ensure broader inclusion of diverse patient populations within dermatology education materials. Examples include the ones above as well as robust content at continuing medical education (CME) meetings, such as the American Academy of Dermatology annual meeting, and skin of color–specific CME meetings, such as the Annual Skin of Color Society Scientific Symposium, the Skin of Color Update in New York City, and others.

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