By 2050, more than 50% of the US population will be people with skin of color, according to the Skin of Color Society.1 With a figure like this, diversity and training in the field of dermatology are more important than ever. There are myriad skin disorders that are more prevalent, or underdiagnosed in, patients with skin of color, but depending on their background and day-to-day exposure not every dermatologist is well acquainted with them.
Valerie Harvey, MD, the director of the Hampton University Skin of Color Research Institute, a board member of the Skin of Color Society, and a private practitioner, says it is imperative that the treatment of skin of color become normalized so that there can be a better understanding of certain dermatologic disorders often seen in patients with skin of color. She believes this is best accomplished through research.
Research is Required
Her hope is that the dermatology community will “grow the body of research and innovation so that we can really make progress in treating skin conditions that disproportionately affect” the skin of color populations, Dr Harvey said. “For so long there has been a set of ‘neglected conditions’ that really haven’t received the attention that they deserve, especially given the amount of people that they affect.”
Although people with skin of color experience conditions such as eczema, acne, and psoriasis at similar rates as White patients, Dr Harvey explained that there are sequelae unique to skin of color that other patients don’t often experience, such as the post-inflammatory hyperpigmentation that can occur several months after insult or injury of commonplace, pre-existing skin disorders.
Dr Harvey noted that certain types of hair loss are also more prevalent in those with skin of color, such as trishul alopecia, also known as central centrifugal sickle. Although some of these disorders, she explained, stem from biology, others are a direct result of the conditions that years of systemic racism has created for these populations. Moreover, some disorders worsen into regional and metastasis disease when not treated thoroughly.
“Systemic lupus is more common in African Americans and Hispanics and so, sometimes people have cutaneous manifestations of those diseases as well,” Dr Harvey explained. “Hidradenitis suppurativa is another condition that, at least in the United States, appears to be more common in African American women. It’s also associated with low socioeconomic status, and there are some associations with high BMI for obesity.”
Experience and Exposure
Lynn Mc-Kinley Grant, MD, an accomplished lecturer, author, and researcher at Howard and Duke Universities, as well as the president of the Skin of Color Society, said that systemic racism also affects the access people with skin of color have to specialists and medical therapies, which likely exacerbates minor conditions. She described a neighborhood in Dallas, TX to highlight the disparity some communities experience in seeking care.
“They have 2 dermatologists in a 40- or 50-mile radius, and the rest are all on the outskirts of this 1 area that is a very poor, low income area,” she said. “When patients do get to the doctor, there’ll be certain drugs that their insurance won’t pay for. There are a lot of [therapies] that you can’t get unless they’re special request, and then it takes months and months. It’s definitely a challenge to get people treated.”
Dr McKinley-Grant explained that there are certain telltale signs of disease that many dermatologists may not recognize if they aren’t experienced in treating patients with skin of color.
“There are a lot of textbooks on dark skin, but somehow, [the content] is not necessarily incorporated into the major textbooks,” said Dr. McKinley-Grant. “One of my goals in dermatology has been to get people to see redness in dark skin. People will say, ‘erythema means red, it’s not red in dark skin and I can’t see it.’ They’re absolutely right. The inflammation in White skin is erythematous. In darker skin, it’s more of a purple. It depends on what else is going on in the blood in terms of how red something is.”
She also mentioned warts as an example of how treatment should be carried out differently on skin of color. “You can freeze them with liquid nitrogen, but, in dark skin, you just can’t freeze it too hard, because you get a white spot,” she described, “and then people are not happy with their skin.”
Dr McKinley-Grant explained that, when she is involved with processes to select applicants for a dermatology specialty, it is important to her to give opportunities to those students who may otherwise be overlooked if they don’t have the same connections, resources, or grades as the typical applicant.
“We want to look at the whole person; we want to look at how far they have traveled before they’ve applied to dermatology,” she said. “A lot of African Americans and Latinos have come from very difficult neighborhoods. It’s important to see how much they’ve done rather than the test scores. Some students might be older, some didn’t go to Harvard. Some people apply and they’ve never seen a dermatologist and their school doesn’t have a department of dermatology, so the efforts made to get the experiences are enormous.”
Diversity, Equity, and Inclusion
Both Dr Harvey and Dr McKinley-Grant are embodying their hopes for the future in the form of work on their various projects and with the Skin of Color Society. In the end, they’d like for the dermatology specialty to have what every field should be pursuing: more diversity, equity, and inclusion, and more awareness of the needs of those with skin of color within and outside of the field.
“With everything that’s going on socially and with the pandemic, there’s certainly a heightened awareness for more diversity in dermatology,” said Dr. Harvey. “I’m hoping that we really make strides in our understanding of the basic physiology of these conditions, and of course, developing treatments that are more effective for our patients.”
Skin of Color Society. Accessed February 24, 2021. https://skinofcolorsociety.org/