Viewpoint: Why dermatology for skin of colour matters

No patient should be disadvantaged because of their skin tone so we must take the opportunity to learn more about dermatology for skin of colour, writes Dr Sharon Belmo.

Dr Sharon Belmo
Dr Sharon Belmo

Dermatology for skin of colour focuses on skin and hair disorders in individuals with darker skin tones than those of white European ancestry. This includes people of African, Asian, Middle Eastern and Hispanic/Latinx descent, also taking inter-racial mixing into account.

Why is this important?

Dermatology for skin of colour is important because some conditions are unique, more prevalent or clinically variable in darker skin.

There are also cultural beliefs and habits among certain ethnic groups that may impact their skin and hair, such as hair grooming practices, skin lightening, hair coverings, traditional Chinese medicine, homeopathy and ayurvedic medicine. Historically, dermatology taught and practised in the Western world has focused on lighter skin types.

MIMS Learning webinar
Dr Belmo has presented a free on-demand MIMS Learning webinar discussing dermatology for skin of colour in more depth. You can watch this here.

There is a notable underrepresentation of skin of colour in our learning resources, and stereotypical images are not uncommon. For example, a review of images in two commonly used dermatology textbooks found that while 22-32% of images depicted skin of colour, darker skin was more likely to be used to illustrate sexually transmitted disease, accounting for 47-58% of these images.1

Such representation might condition clinicians to associate skin of colour with infectious disease rather than common dermatological conditions that are more relevant to most non-white people in the UK. This might lead to unnecessary or inappropriate investigations or questioning that can be detrimental to the patient-clinician relationship.

Inappropriate referrals or investigations might also occur as a result of unfamiliarity with nuances in skin of colour. For example, it is not uncommon for benign racial variants such as longitudinal melanonychia and dermal melanocytosis to be referred as melanoma or non-accidental injury, respectively.

The incidence of COVID-19 is disproportionately high among black, Asian and other minority ethnic groups in the UK and USA. Despite this, a 2020 review of 130 publications relating to cutaneous manifestations of COVID-19 found not a single image showing darker skin.2 All of the images used were of lighter skin types.

Furthermore, textbook descriptions of dermatological conditions are generally given in the context of white skin. For example, ‘erythema’ is widely used to denote inflammation in conditions such as eczema and psoriasis.

This description is most relevant to lightly-pigmented skin because redness may be masked in darker skin types, as a result of background pigmentation. Depending on the skin tone, inflammatory changes in skin of colour may be more subtle, or manifest as varying shades of brown, purple or grey, rather than red. Relying on erythema as a sign of inflammation in skin of colour may result in delayed or misdiagnoses.

It is important that the fundamentals of dermatology are taught with all skin types in mind. This may require some re-learning. There has been a significant lack of diversity in dermatology teaching and learning resources. It is time to change the narrative.

Is this relevant to the UK?

Demographics in the UK are rapidly diversifying. Between 2001 and 2011 there has been a 61% increase in the non-white population.3 By 2051, the non-white population in the UK is projected to increase to 21%, with the white population falling to 79%. The mixed-race population is predicted to rise by 148-249%, while the Asian population will also rise by 95-153%.4

Moreover, this diversity will spread to many more parts of the country, beyond the major cities where ethnic minorities are currently concentrated.4

Healthcare professionals nationwide will increasingly encounter a variety of skin and hair disorders in people of colour, and need to be trained to manage these effectively.

At present, there is no formal requirement in the dermatology curriculum for UK dermatology trainees to have any experience in skin of colour. In a 2013 survey of dermatology trainees, only 22% reported having ever had formal ethnic dermatology teaching and less than half felt that they would be competent in treating the UK’s ethnic minority population at the end of their training.5

To best serve our diverse population, it is important that our future dermatologists and other healthcare professionals are confident and competent in recognising and treating dermatological conditions in all skin types.

The ability to recognise subtle skin changes in darker skin is even more crucial now, with the increased use of teledermatology as a result of the COVID-19 pandemic.

It goes without saying that patients want clinicians who can treat disorders in their skin type. A survey of black patients attending a dermatology clinic found that they valued dermatologists who demonstrated experience and knowledge of ethnic dermatology, citing frustration with dermatologists who lacked this knowledge.6 Cultural competency has been cited as a major determinant of patient satisfaction.

No patient should be disadvantaged because of their skin tone.

Where do we go from here?

There has been a marked increase in awareness of diversity in medicine recently. Perhaps the Black Lives Matter movement and protests following the killing of George Floyd in 2020 have been a catalyst for a new era of diversity that UK dermatology needed. It is long overdue, but this is only the beginning.

I am honoured to have written the first dermatology for skin of colour syllabus, which will become an integral part of the UK dermatology specialist registrar training curriculum, as set by the British Association of Dermatologists (BAD). It is my hope that this will pave the way for future dermatology training and shape skin of colour education for other healthcare professionals.

To date there have only been a handful of training events fully dedicated to dermatology for skin of colour in the UK. It is imperative that more events follow and become integral to dermatology teaching and training.

You can watch my MIMS Learning webinar discussing dermatology for skin of colour on demand here.

I will also continue to run the Centre of Evidence Based Dermatology Skin of Colour Resource, a free learning tool dedicated to all things skin of colour.

The BAD is working on integrating skin of colour throughout their workstreams, learning resources and social media platforms, and have recently formed a Skin Diversity Sub-Committee.

I am pleased that dermatology for skin of colour has been given a platform, and it is important to maintain the momentum. We need to see more skin of colour clinical images, promote UK-based skin of colour clinical research and learning opportunities, encourage diversity within the workforce and mentor our trainees.

The demographics of the UK are changing, it’s time that dermatology caught up!

Dr Sharon Belmo is a consultant dermatologist at Croydon University Hospital and clinical lead for the Centre of Evidence Based Dermatology Skin of Colour Resource.

Dr Belmo is the guest editorial adviser for the latest issue of MIMS Learning Dermatology, which is dedicated to skin of colour. This viewpoint is taken from the issue, which is due to be published shortly.

References

  1. Lester JC, Taylor SC, Chren M‐M. Under‐representation of skin of colour in dermatology images: not just an educational issue. Br J Dermatol 2019; 180: 1521–2.
  2. Lester JC, Jia JL, Zhang L et al. Absence of images of skin of colour in publications of COVID-19 skin manifestations. Br J Dermatol 2020; 183(3): 593–5.
  3. Office for National Statistics. Ethnicity and National Identity in England and Wales 2011. 11 Dec 2012. [Accessed 1 March 2021].
  4. Wohland P, Rees P, Norman P, et al. Ethnic Population projections for the UK and local areas, 2001–2051. Working Paper 10/02. School of Geography, University of Leeds. July 2010.
  5. Salam A, Dadzie O. Dermatology training in the U.K.: does it reflect the changing demographics of our population? Br J Dermatol 2013; 169(6): 1360–2.
  6. Gorbatenko-Roth K, Prose N, Kundu RV, Patterson S. Assessment of Black Patients’ Perception of Their Dermatology Care. JAMA Dermatol 2019; 155(10): 1129–34.

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