Dermatology in Skin of Color: From Unmet Needs to Culturally Competent Care

This article is the first of a 2-part feature on skin of color in medical education and dermatology practice. Check out part 2 of this feature series.

Projected demographic shifts in the US underscore the need for knowledgeable dermatologists who are competent in caring for patients with skin of color (SoC). Individuals with Fitzpatrick’s skin phototypes 4 through 6 may represent more than half of the US population by 2060, suggesting increased education and awareness of concerns in this population are needed to ensure optimal patient outcomes in the future.¹

SoC in Dermatology: Disparities and Unmet Needs

Disparities in education

Racial disparities in dermatology are related to several factors, including (but not limited to) a lack of robust training during the earliest stages of medical education on the recognition of skin manifestations across different skin tones.² Dermatology residents have also reported little exposure to patients of color during their residency, but the implementation of more curriculum on SoC improved their self-reported confidence to care for diverse patient populations.³

A recent analysis of American Academy of Dermatology (AAD) basic dermatology curriculum modules found a low prevalence of SoC representation in atopic dermatitis and alopecia modules, despite the high incidence of these disorders in patients with SoC.² in addition, there was a higher percentage of images that depicted mostly Fitzpatrick skin phototypes 1 and 2, further highlighting the gaps in dermatologic education on diverse patient populations.

Disparities in medical and aesthetic dermatology

Compared with White patients with skin cancer, patients with SoC and skin cancer tend to experience higher levels of morbidity and mortality, given diagnosis of disease is typically delayed in the latter population.⁴ Unfortunately, gaps exist across major dermatologic organizations in skin cancer prevention messaging for SoC, and many clinicians who care for patients with dermatologic conditions lack appropriate levels of confidence in caring for ethnically and racially diverse populations.⁵

Aside from medical conditions, certain knowledge gaps and myths persist among dermatologists as they relate to the aesthetic treatment of patients with SoC. That is, some clinicians reportedly believe darker-skinned patients of African descent do not seek injectable filler for the lips or that dermal fillers are not necessary or useful for these patients.⁶Also, some medical providers believe only clinicians with SoC can understand how to manage the aesthetic treatment of patients with SoC.⁶ As such, these dermatologists may place limits on their own practice and therefore leave some of their patients with their needs unmet.

Expert Considerations for US Skin Centers and Medical Education: Advancing Care for Patients With SoC

To discuss disparities in dermatology and the role of ethnic skin centers in addressing these issues, we interviewed Angela Lamb, MD, an Associate Professor of Dermatology at Icahn School of Medicine at Mount Sinai and Director of the Westside Mount Sinai Dermatology Faculty Practice in New York City.

Dr Lamb explained that the typical dermatologist who is not specialized or highly experienced in managing SoC does not often take cultural nuances into consideration when it comes to clinical decision making. And, some dermatologists are not vigilant in asking the “right questions” to address the needs of their racially/ethnically diverse patients.

“There are some blind spots unless you are very intentional,” said Dr Lamb. “These [blind spots] can be around issues of hair styling, hyperpigmentation, and cosmetic treatments.” Given these challenges, Dr Lamb suggests cultural competency training and education is crucial for ensuring comprehensive, tailored care that closes gaps in caring for SoC.

Furthermore, Dr Lamb noted that specialized medical education on SoC represents an important need, and this education could easily be incorporated into residency programs and implemented in US skin centers to improve care of darker skin. “Certainly, education is the start, [and] special lectures and series that take these aspects into account are needed,” she said.

Dr Lamb added: “Also, having [SoC] be part of the lexicon of the education is important. Sometimes, it is not always practical to have a separate SoC focus, but as a complement to this you could have more faculty of color or faculty who are sensitive to these needs – [and] they don’t need to be of color – so that the subject is an organic part of a residency training program.”

Unfortunately, the current SoC dermatology education landscape in North America remains suboptimal, suggesting greater awareness on this issue is needed to improve the level of culturally competent training medical students receive.⁷ Survey data show that dermatology residents from less diverse regions strongly value dedicated SoC clinics and rotations to improve their competency compared with residents from regions with more diversity.⁸ These data underscore the desire among dermatologists-in-training to increase their knowledge on how to diagnose and treat racially and ethnically diverse populations.

In terms of primary drivers of racial and ethnic disparities in US skin centers, Dr Lamb suggests that the sheer number of dermatologists of color may be exacerbating unmet needs in SoC. “There are not enough dermatologists of color or dermatologists to go around who might be sensitive to the needs of patients of color,” she said. Dermatologists of color or those who are sensitive to the needs of patients with SoC tend to be very focused on large urban areas, she explained.

Also, Dr Lamb noted there is a stigma around seeking medical treatment for dermatologic conditions in SoC and/or there is a tendency to minimize the value in seeking treatment for these disorders. “There has not been enough high-quality research into the root causes of some conditions that impact patients with SoC, like keloids and scarring hair loss, but we hope to change this,” she added.

Solutions and Resources

Several solutions have been proposed to reduce disparities in dermatology, including awareness campaigns and improved medical education curriculum that covers more diverse skin types in the context of dermatologic disorders. Dr Lamb listed what US-based ethnic skin centers are doing to provide an example for typical skin centers on how to improve care of SoC: “Some ethnic centers practice culturally sensitive patient care, educate the medical community, and perform collaborative research to advance knowledge and management of conditions prevalent in SoC.”

The typical dermatologist in clinic, however, may not always have the resources that are available at larger skin centers and will likewise require more support to improve their practice. Dr Lamb suggests the first start is for these dermatologists is to attend trainings on SoC while “being an avid reader of literature that comes out to address certain populations.”

References

1. Projections of the size and composition of the U.S. population: 2014 to 2060. United States Census Bureau website. https://www.census.gov/library/publications/2015/demo/p25-1143.html. Updated March 3, 2015. Accessed January 27, 2022.
2. Perlman KL, Williams NM, Egbeto IA, Gao DX, Siddiquee N, Park JH. Skin of color lacks representation in medical student resources: A cross-sectional study. Int J Womens Dermatol. 2021;7(2):195-196. doi:10.1016/j.ijwd.2020.12.018
3. Mhlaba JM, Pontes DS, Patterson SS, Kundu RV. Evaluation of a skin of color curriculum for dermatology residents. J Drugs Dermatol. 2021;20(7):786-789. doi:10.36849/JDD.6193
4. Grewal SK, Reddy V, Tomz A, Lester J, Linos E, Lee PK. Skin cancer in skin of color: A cross-sectional study investigating gaps in prevention campaigns on social media. J Am Acad Dermatol. 2021;85(5):1311-1313. doi:10.1016/j.jaad.2020.08.121
5. Kailas A, Solomon JA, Mostow EN, Rigel DS, Kittles R, Taylor SC. Gaps in the understanding and treatment of skin cancer in people of color. J Am Acad Dermatol. 2016;74(5):1020-1021. doi:10.1016/j.jaad.2015.11.028
6. Alexis AF, Few J, Callender VD, et al. Myths and knowledge gaps in the aesthetic treatment of patients with skin of color. J Drugs Dermatol. 2019;18(7):616-622.
7. Onasanya J, Liu C. Dermatology education in skin of colour: where we are and where do we go? Can Med Educ J. 2021;12(6):124-125. doi:10.36834/cmej.73112
8. Cline A, Winter RP, Kourosh S, et al. Multiethnic training in residency: a survey of dermatology residents. Cutis. 2020;105(6):310-313.