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Despite ever-increasing racial and ethnic diversity in the United States, dermatologic treatment options for people of color remain limited compared with White patients.1,4 Researchers have found, for example, that people of various racial and ethnic groups – including Black, Asian, and Hispanic/Latino patients – were less likely to receive acne care from a dermatologist vs a nondermatologist, and Black patients were less likely than White patients to visit a dermatologist or to receive any treatment for acne.2,3
Two recent studies further confirm these ongoing disparities. In a cross-sectional study published in July 2020 in the Journal of the National Medical Association, results showed significantly lower odds of receiving isotretinoin 0.26 (95% CI, 0.22-0.30), adapalene 0.72 (95% CI, 0.67-0.78), tazarotene 0.74 (95% CI, 0.64-0.86), and dapsone 0.39 (95% CI, 0.34-0.45) inBlack patients with acne compared with White patients (P <.001).4
In addition, Black patients with atopic dermatitis had lower odds of receiving desonide 0.90 (95% CI, 0.78-0.93), tacrolimus 0.75 (95% CI, 0.68-0.83), pimecrolimus 0.71 (95% CI, 0.60-0.84), crisaborole 0.39 (95% CI, 0.26-0.57), and dupilumab 0.42 (95% CI, 0.27-0.65) compared with White patients. For psoriasis, Black patients were less likely to receive cyclosporine 0.54 (95% CI, 0.35-0.83) and etanercept 0.65 (95% CI, 0.49-0.87).4
In a retrospective cohort study (n = 29,028) published in March 2020 in JAMA Dermatology, non-Hispanic Black patients were more likely to receive topical retinoids (OR, 1.25; 95% CI, 1.14-1.38) and topical antibiotics (OR, 1.35; 95% CI, 1.21-1.52) compared with non-Hispanic White patients, and less likely to receive oral antibiotics (OR, 0.80; 95% CI, 0.72-0.87), spironolactone (OR, 0.68; 95% CI, 0.49-0.94), and isotretinoin (OR, 0.39; 95% CI, 0.23-0.65).2
In a 2019 cross-sectional study published in JAMA Dermatology, researchers conducted surveys and focus groups with 19 Black patients treated at a skin of color clinic.5 Their findings suggest that patient “satisfaction would increase if dermatologists underwent enhanced residency training in skin of color, cultural competency, cost-conscious care, and empathic communication skills, and if there were greater dermatology workforce diversity.”
To further explore these issues, we interviewed the following experts: Andrew F. Alexis, MD, MPH, chair of the department of dermatology and director of the Skin of Color Center at Mount Sinai Morningside and Mount Sinai West in New York and professor of dermatology at the Icahn School of Medicine at Mount Sinai; Shawn Kwatra, assistant professor of dermatology at the Johns Hopkins University School of Medicine in Baltimore, Maryland, and co-author of the July 2020 study4 mentioned above; and John Barbieri, MD, MBA, dermatology research fellow at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia and co-author of the aforementioned March 2020 study.2
What does the literature suggest thus far about racial disparities in dermatology care – and if you’ve studied this topic, what do your recent findings add to our understanding of these issues?
Dr Alexis: There are several important racial/ethnic disparities in dermatology care. The proportion of dermatologists and dermatology trainees belonging to a racial/ethnic group that is considered underrepresented in medicine (UIM) is lower than most other specialties and well below the proportions of these groups – for example, Black/African American, Hispanic/Latinx, Native American/American Indian – in the US population. In a 2016 article published in the Journal of the American Academy of Dermatology, my co-authors and I wrote:
“Black dermatologists comprise only 3% of all dermatologists, despite the fact that 12.8% of Americans are black. For Hispanics, the statistics are just as sobering, with only 4.2% of dermatologists of Hispanic origin compared with 16.3% in the general population. These differences are worse for dermatology than physicians overall, and we are one of the least ethnically/racially diverse specialties, only slightly better than orthopedics.”6
In addition, many of the disorders that disproportionately affect populations with skin of color – such as pigmentary disorders, hair and scalp disorders including scarring alopecia, and keloids – have limited treatment options and are relatively understudied from a research or drug development standpoint.
Fortunately, these issues are changing, but we still have a ways to go. There are also disparities in access to specialty care including dermatology – Black and Latinx populations are less likely to see a dermatologist, and disparities in access may be one contributor to this.
Dr Kwatra: There are racial differences in the prevalence of many dermatologic conditions. While nonmelanoma and melanoma skin cancers are more common in White patients, many inflammatory skin conditions like atopic dermatitis, prurigo nodularis, and hidradenitis suppurativa are more common in Black and Asian patients. In addition, keloids, pigmentary disorders, and scarring forms of alopecia are more common in minority groups. There is a need for more research funding for these understudied conditions.
Dr Barbieri: Previous studies have found that Black patients with acne are less likely to receive isotretinoin than White patients. In addition, female patients are less likely to receive isotretinoin than male patients. There is also evidence that non-White patients and those with Medicaid insurance are less likely to see a dermatologist for acne than White patients and those with commercial insurance, respectively.
Our study adds to the prior literature by more comprehensively evaluating all acne treatments including topical medications, oral antibiotics, spironolactone, and isotretinoin.2 In addition, our dataset enables us to evaluate for associations between a broad set of sociodemographic characteristics and acne treatment use. Our results highlight that non-Hispanic Black patients are less likely to receive prescriptions for acne medications – in particular, they were more likely to be treated with topical medications and less likely to receive systemic medications such as oral antibiotics, spironolactone, and isotretinoin.
In addition, similar to prior studies, we found that women were less likely to receiveprescriptions for isotretinoin. Finally, those with Medicaid insurance were less likely to see a dermatologist, or to be prescribed acne treatments such as topical retinoids, oral antibiotics, spironolactone, or isotretinoin.
What are believed to be some of the reasons for these disparities, and what are some potential solutions to these issues?
Dr Alexis: Reasons include reduced exposure to the dermatology specialty among students who are UIM; a historical relative lack of funding and centers of excellence for research into scarring alopecias, hyperpigmentation, keloids, and other disorders that may be less common in the general population but highly prevalent in specific populations with skin of color; and socioeconomic factors.
Dr Kwatra: The fact that different skin conditions affect different racial and ethnic groups to varying degrees isn’t surprising. It is likely due to a combination of genetic, environmental, and structural differences in skin.
On a practical level, more research funding would spur more innovation and discovery. While psoriasis now has multiple biologics available, a condition like prurigo nodularis that disproportionately affects Black patients has no approved therapies.
Dr Barbieri: Since there are no data to suggest differences in acne severity by race/ethnicity, it is unlikely that underlying patient disease characteristics are responsible for these differences in treatment patterns. However, risk aversion, medical distrust, and physician bias are potential factors that may be responsible for the differences observed in our study. Poor coverage for acne medications by Medicaid may partially explain why those with Medicaid insurance were less likely to receive topical retinoids, oral antibiotics, spironolactone, and isotretinoin after controlling for other sociodemographic factors.
With respect to female patients being less likely to receive isotretinoin than male patients, these differences are likely related to the burdensome nature of the iPLEDGE pregnancy prevention program, which unfortunately several studies have demonstrated has not been effective at reducing fetal exposure to isotretinoin either. There is a need for iPLEDGE reforms to reduce administrative burdens and to improve patient safety.7
What are some recommendations for practitioners about how to address these issues in practice?
Dr Alexis: I suggest participating in mentorship programs such as those provided by the AAD, the Skin of Color Society, the Women’s Dermatological Society, and other organizations.
Dr Kwatra: Skin diseases can present differently in patients of varying race and ethnicity. For example, redness or erythema can be harder to discern in patients with darker skin tones. Also, a common condition like atopic dermatitis is classically taught to affect flexural areas, but oftentimes affects extensor areas and presents with more papular involvement in Black skin. In addition, in prurigo nodularis, the nodules tend to be harder and larger in Black patients.
Dr Barbieri: I think it is important for clinicians to always be self-reflective of their practice patterns and to try to identify potential sources of bias. We know that throughout medicine there are disparities in outcomes across a range of sociodemographic factors, and it is important for clinicians to reflect on what they can do to ensure they are providing empathetic, patient-centered care for all of their patients.
What are other remaining needs in this area in terms of research or education?
Dr Alexis: There is a need for research and new drug development for central centrifugal cicatricial alopecia, dissecting cellulitis of the scalp, acne keloidalis nuchae, melisma, postinflammatory hyperpigmentation, and lichen planus pigmentosus – to name a few conditions that disproportionately affect populations with skin of color and have limited treatment options
Dr Kwatra: There has been a great effort by dermatologists to increase medical photographs from diverse patient populations in our medical literature and textbooks. This should continue to improve in the future.
Dr Barbieri: There is a need for further study to understand the reasons for these potential disparities and to develop strategies and interventions to ensure equitable care for all patients with acne.
References
1. Lee BA, Martin MJR, Matthews SA, Farrell CR. State-level changes in US racial and ethnic diversity, 1980 to 2015: A universal trend? Demogr Res. 2017;37:1031-1048. doi:10.4054/DemRes.2017.37.33
2. Barbieri, JS, Shin DB, Wang S, Margolis DJ, Takeshita J. Association of race/ethnicity and sex with differences in health care use and treatment for acne. JAMA Dermatol. 2020;156(3):312-319. doi:10.1001/jamadermatol.2019.4818
3. Rogers AT, Semenov YR, Kwatra SG, Okoye GA. Racial disparities in the management of acne: evidence from the National Ambulatory Medical Care Survey, 2005-2014. J Dermatolog Treat. 2018;29(3):287-289. doi:10.1080/09546634.2017.1371836
4. Bell MA, Whang KA, Thomas J, Aguh C, Kwatra SG. Racial and ethnic disparities in access to emerging and frontline therapies in common dermatological conditions: a cross-sectional study. J Natl Med Assoc. Published online July 5, 2020. doi: 10.1016/j.jnma.2020.06.009
5. Gorbatenko-Roth K, Prose N, Kundu RV, Patterson S. Assessment of black patients’ perception of their dermatology care. JAMA Dermatol. 2019;155(10):1129-1134. doi:10.1001/jamadermatol.2019.2063
6. Pandya AG, Alexis AF, Berger TG, Wintroub BU. Increasing racial and ethnic diversity in dermatology: A call to action. J Am Acad Dermatol. 2016;74(3):584-587. doi:10.1016/j.jaad.2015.10.044
7. Barbieri JS, Frieden IJ, Nagler AR. Isotretinoin, Patient safety, and patient-centered care-time to reform iPLEDGE. JAMA Dermatol. 2020;156(1):21-22. doi:10.1001/jamadermatol.2019.3270
