Dermatologist Dr. Jenna Lester remembers being a medical student and seeing black and brown skin tones rarely appear in textbooks. Teachers describe how the disease appears on black skin.
But they didn't have a photo.
She said it was unacceptable that she and her peers were not adequately trained to recognize skin tone conditions like hers. So, in 2018, he started a skin color program at the University of California, San Francisco. She wanted to provide targeted care to people of color and train dermatology residents to treat skin pigmentation.
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Darker skin has disappeared from medical training and textbooks, and research into treating skin pigmentation is often slow to get off the ground, leading to missed diagnoses and disparities in care, experts say. Dermatologists have taken matters into their own hands to raise awareness of the shortage and start their own training programs.
"What's happening right now is that medical schools and training programs in general have gaps in their curriculum and the resources they use and how they teach their students," said Dr. Nada Elbuk, a dermatologist. Founder of the USC Skin Color Center and Color Disorders Clinic.
Physicians in training rely on imaging to determine how skin diseases occur. Eczema, psoriasis, inflammation, acne and other skin conditions appear differently on different skin tones.
For example, in black and Hispanic patients, the pessary patches may be dark brown or purplish-gray, and the overlying scales may be gray or silver. In whites, it is pink or red in color.
But research shows that medical textbooks that don't discriminate against skin tones mainly feature fair skin. Pictures of colored skin in dermatology textbooks range from 4% to 19%. According to a study published earlier this year, only 11% of the images in the Dermatology review were of color and two of the images were of black skin.
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So far, however, there has been little progress. From 2006 to 2020, only 1 in 6 dermatology textbooks included images of dark brown or dark skin, and half of the textbooks did not include images of dark-skinned patients with common diseases such as acne and psoriasis. Lester notes that black skin is more prominent in medical chapters on sexually transmitted infections, perpetuating harmful stereotypes.
To help educate physicians, Elbook founded Project IMPACT, a clinical imaging database that helps clinicians make diagnoses on VisualDx, where he is director of clinical impact.
© America Today Dr. Nada ElbulkThe IMPACT Project, in partnership with the New England Journal of Medicine and the Society of Colorism, has launched a series of colorist webinars on skin and hair disorders in medicine and prejudice, colorism, and structural racism.
"We work to improve health equity in medical education and advance medical education through medical technology," said Elbulu, an assistant professor at the USC Keck School of Medicine.
According to Elbulu, tools like VisualDX that cover a wide range of color images can help bridge that gap. Dermatologists are increasingly turning to other sources such as pigmented skin; Tools like DFTB Skin Deep, a database of various skin disease images; and the latest "The Full Spectrum of Dermatology: A Diverse and Inclusive Atlas".
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In the meantime, educators and practitioners can help textbook publishers accelerate change, Northwestern University medical student Trisha Kaundinia and dermatologist Rupal Kundu wrote in the Journal of Medical Education. He urged medical schools to begin creating student-led curriculum review committees.
"Text editors and editors are constantly starting to address these inconsistencies, but bottom-up change is needed to solve this problem," he said.
One such medical student, St George's University School of Medicine in London, collaborated with two professors to launch Mind the Gap, a clinical imaging guide for black and brown skin. She also launched Hutano, a community platform that connects patients of color with information, dermatology research and other patients.
Dr. Neelam Vashi, founder of Boston University's Ethnic Skin Center and author of "Ethnic Skin and Hair Dermatology," said the shortages have left gaps in medical research.
© America Today Dr. Neelam Vashi"If we look at all the research studies, it's mostly done on white skin," he said, adding that studies ignore black skin. "What we're doing is based on these historical studies, but if you don't include this large subgroup, we don't know how they're going to respond."
When certain conditions are known, black patients are more likely to be exposed to the disease. For example, nail psoriasis affects patients with dark skin more and is diagnosed later.
Similarly, although skin cancer is less common in patients with dark skin, it often occurs later and is more lethal when diagnosed. One study showed that nearly 90% of white patients were alive five years after being diagnosed with melanoma, while 66% of black patients were alive. Squamous cell carcinoma is 10 times more common in white patients.
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Many socioeconomic factors that disproportionately affect people of color, such as insurance rates or pollution, exacerbate disparities in skin health, experts say.
Lester points to pollution, heat and allergies as triggers for eczema flare-ups. Climate change and historical redundancies disproportionately affect communities of color. According to him, doctors should think about the whole life of their patients.
Dermatologist Candice Heath, a professor at Temple University's Louis Katz School of Medicine, says that even though insurance coverage affects quality of life for conditions that are more common in people of color, it can be considered cosmetic.
© USA TODAY Dr. Candice HeathFor example, laser treatment for vitiligo, a loss of skin color, is not covered by insurance. But the same phototherapy used to treat psoriasis on lighter skin may be covered by insurance, Heath explained.
"There are many times in dermatology where there are conditions that are very common or unique to people of color," Heath said, in terms of research and funding. After growing up, her sister had a large birthmark on her face. And laser treatment for the skin condition was initially only tested on white patients.
"Patients of color ... have been excluded from dermatology," Lester said. "Fortunately, we have programs to change, but you never know what you don't know."
Contact Nada Hassanein at nhassanein@usatoday.com or on Twitter @nhassanein_.
This article originally appeared in USA Today: Images of Dark Skin Missing from Medical Texts. Dermatologists are changing that.