After seeing a handful of providers who failed to accurately diagnose her, a young Black woman with severe psoriasis that would often interrupt her sleep came to Kindred Hair & Skin Center outside of Baltimore.
She had been struggling with intense itchiness for 2 years, but was never biopsied. Instead, she was diagnosed with eczema and repeatedly prescribed topicals that did not work. At one point, the woman was even prescribed psychiatric medication and told her condition was a symptom of anxiety, said Chesahna Kindred, MD, who operates the clinic in Columbia, Maryland.
“You can’t call yourself a dermatologist without knowing psoriasis,” said Kindred, the patient’s new provider. “The fact that she was diagnosed with anxiety and she had psoriasis was a disservice.”
It’s not uncommon for people of color to be misdiagnosed or overlooked in dermatology, and psoriasis in these patients may be more likely to go undiagnosed or untreated. Black patients have also been shown to receive lower rates of treatment for common conditions such as acne.
More recently, an analysis of COVID-19 skin manifestations depicted in medical literature suggested racial bias, with none of the 130 images portraying patients with Black or brown skin.
“Blacks carry the burden of COVID-19,” Kindred told MedPage Today. “How on Earth is there not a single photo of the rashes associated with COVID-19 [on Black skin]?”
While racial disparities permeate many aspects of medicine, dermatology — a visual field closely intertwined with culture and identity — has recently been cast into the spotlight for ranking next to last in terms of diversity. MedPage Today spoke with dermatologists about the disparities that exist and what efforts are underway to close the gaps.
Skin of Color Underrepresented
Cutaneous conditions were first portrayed on white skin in medical textbooks, establishing white skin as the “norm.” Black and white medical schools were also segregated in the U.S. until the mid 20th century, such that white dermatologists — who were and still are the majority — were not trained to treat conditions on Black skin.
Moreover, dermatology used to be considered a “luxury,” and Black patients did not have access to treatment, Kindred said.
Although the field has diversified some in recent decades, one 2018 study found that just 4.5% of images in medical textbooks showed conditions on dark skin.
Meanwhile, skin of color has been disproportionately represented for certain conditions like sexually transmitted infections, reinforcing damaging stereotypes, said Jules B. Lipoff, MD, of the University of Pennsylvania in Philadelphia.
“When there isn’t a good representation of skin of color, it implicitly suggests it is not very important,” Lipoff told MedPage Today. “Learning diseases in skin of color is taught in addition to the normal curriculum, and not inherently built in. That’s problematic.”
Without incorporating skin of color into medical training, dermatologists may not be adequately prepared to treat rashes or skin conditions like eczema that can present differently on dark versus white skin.
Some cutaneous manifestations can also be indicators of systemic disease like lupus or sarcoidosis, which may present more subtly in richly pigmented skin. This could lead to a later-stage diagnosis when the condition is already full-blown.
“What happens today is, people have to take extra time to learn about Black skin and hair, or attend special conferences on the weekend to learn about Black skin and hair, whereas you spend 3 years and 16,000 hours learning to treat white skin,” Kindred said.
Online, users have been submitting photos of skin conditions on Black and brown skin to Brown Skin Matters, a movement that has gained more than 65,000 followers.
In 1999, Susan Taylor, MD, founded the Skin of Color Center at Mount Sinai in New York City to specifically treat conditions that disproportionately affect people of color. The center, the first of about a dozen developed in the past 2 decades, also prioritizes research involving such patients for conditions like psoriasis, eczema, and keloids to supplant a dearth in the literature.
A disproportionately low number of patients of color have been included in medical research, and that extends to dermatology trials as well. As a result, therapeutic advances for conditions affecting these patients have lagged behind, said Andrew Alexis, MD, director of the Skin of Color Center.
“We would see this time and time again, yet not have good treatments for them,” Alexis told MedPage Today. “When you go to the literature, there was an absence of studies to help inform rather common treatment conditions for this patient population.”
In 2004, Taylor also founded the Skin of Color Society, which hosts an annual symposium and awards research grants to young dermatologists treating disorders that disproportionately affect patients of color. Taylor, now of the University of Pennsylvania, is also co-chair of the American Academy of Dermatology (AAD) Skin of Color Resident Curriculum Work Group, which will help establish a curriculum that will be available to all dermatology residents in the next year or so.
However, Kindred said there is still a long way to go before skin of color is equitably accounted for in the field.
“We need to get to the point where we don’t need a separate textbook for dermatology in Blacks,” Kindred said.
Workforce Diversity Lacking
Although racial and ethnic minority physicians are underrepresented in medicine overall, the gap is especially pronounced in dermatology, with Black and Hispanic doctors accounting for about 3.4% and 4.3% of the workforce, respectively.
An inequitable physician workforce has been directly tied to the quality of patient care. In one small study from 2019, Black patients who visited a center emphasizing skin of color reported greater satisfaction than patients who attended a conventional clinic.
Alexis said he experienced this firsthand the moment he started seeing patients in residency.
“On day one of my residency, patients of color would immediately express a sense of pride and satisfaction to see me walk in the room,” Alexis said. “They were not used to seeing a doctor in general, but specifically a dermatologist, who looked like them.”
Racial and ethnic minority physicians are more likely to practice in primary care and internal medicine than in specialty care.
In one 2019 study of racial and ethnic minority medical students, participants reported the current lack of diversity as well as a lack of mentorship opportunities and perceived exclusivity in the field as top factors steering them away from dermatology.
“A lot of us were told that we would not make it into the field of medicine and a lot of us in medical school were told we wouldn’t make it into dermatology,” Kindred said. “A lot of us believed the counselors and mentors that told us this.”
In 2018, the AAD President’s Conference on Diversity in Dermatology published a roadmap with a large focus on increasing diversity within the workforce, as well as including more topics related to skin of color, like keloids and melasma, in dermatology curriculum.
The Skin of Color Society is addressing the many ways that structural racism prevents minority students from entering the dermatology workforce, Taylor said. For example, many academic residency programs require research experience, but many medical students from underprivileged backgrounds do not have the resources available to take a year off from school to complete research, she said.
Moreover, many medical students are not exposed to dermatology until the fourth year of medical school, at which point it’s difficult to put together a competitive application, she added.
“Another effort by our different dermatology organizations is to expose the first and second year medical students to dermatology early, so they are aware and able to put together the components of a strong application,” Taylor told MedPage Today.
Breaks in the Pipeline
In the 2019 study of minority medical students, respondents also reported barriers related to medical education, including clinical grades, the U.S. Medical Licensing Examination (USMLE) Step 1, student debt, and the risk of not matching in the residency selection process.
Student debt has been shown to disproportionately burden students of color, with 59% of Black students, 43% of Latinx students, and 55% of Native Americans entering medical school with educational debt, compared to 32% of white students.
Racial bias has also surfaced when USMLE Step 1 cutoff scores are used to screen for residency interviews, with Black medical students three to six times less likely than white students to get an interview.
Increasing the number of mentorship programs available to students was also part of the AAD’s roadmap, and the organization has since launched several mentorship initiatives.
Kindred suggested journal editors stop accepting research performed in non-diverse populations, and that board examinations include questions about conditions affecting skin of color.
“If it is on the exam, then people will study it,” Kindred said. “And if it’s on an exam, residency [programs] will teach it.”
The AAD’s roadmap notes that addressing breaks in the pipeline “is a larger societal challenge that will also require active intervention and partnership with stakeholders outside the field of dermatology.”
Alexis said this is an “all hands on deck moment that has been in the making for two decades.”
“I consider this a watershed moment,” he said. “For the first time in my career, I’m seeing simultaneous engagement of the general public, the patient community, organized medicine, and industry, all overlapping to drive further advances in patient care, research, and education of skin of color.”
Source: MedicalNewsToday.com
