More than Skin Deep: Unmet Needs of Patients with Skin of Color

In health care, some instances of inequity and patient disparities are apparent to some—and others, obscure to all. But disparities in care for skin of color are becoming more visible to patients and dermatologists alike.

Dermatology is a medical field with a substantial visual element to it, after all. It should come as no surprise that differences in skin color often lead to misdiagnosis by clinicians in the predominantly White field.

“Skin of color patients are unique, and they sometimes have skin conditions that may affect them at a higher rate,” Omar Noor, MD, said in an interview with HCPLive.¹

A persistent issue exists in whether each and every patient is being given an equitable level of care based upon each individual’s unique needs, taking into account the diversity of different conditions and clinical manifestations.

Addressing the unmet needs of patients with skin of color may require an approach whereby clinicians and patients alike are better informed about where the issue lies, how it can be addressed, and what the future will look like if it is addressed to better serve and promote more equitable solutions for these neglected patient populations.

Simply put, some dermatology patients receive more attention than others, and this can lead to greater levels of unmet medical needs, misdiagnoses, and even higher rates of mortality for minority groups. An effective way to begin to address the needs of those with skin of color is to build a comprehensive and clear understanding of the issue.

Three major disparity concerns—including skin cancer, hair disorders such as alopecia, and poor representation in clinical trials—are highlighted here to serve as clear examples of the problem of unequal treatment in the dermatology field which strongly affect patients of color.

Unmet Needs with Skin Cancer Treatment

Skin cancer is known for being the most common form of cancer in the US, and melanoma is one of the most common and increasingly prevalent types seen in the US. Melanomas are likely caused by a mixture of ultraviolet radiation exposure and characteristics of sun-sensitive skin.²

Among those with darker skin types, including Black and Hispanic populations, there can be a perception of virtual immunity to melanoma due to melanin protection. This idea is prevalent given the widespread awareness that rates of skin cancer are higher among White individuals.

Yet this inaccurate perception of immunity among many different groups has had disastrous consequences over the years, especially as rates of melanoma continue to rise around the world. And it is perpetuated by lack of educational resources for the groups that need them most.

A 2019 study on US Cancer Statistics from 2001 - 2015, using data from the Public Use Research Database, starkly illustrated this point by demonstrating some of the most glaring examples of racial disparities in dermatology.

The findings indicated that while melanoma incidence is relatively rare among non-Hispanic Black individuals, survival rates were shown to be behind those of non-Hispanic White populations. Specifically, survival rates were 66% for Black patients compared to 90% for White patients.³

This likely indicates that while White patients are being diagnosed more commonly due to their skin’s susceptibility, Black patients are not being informed about the dangers that still pose a threat to their health in the form of skin cancers such as melanoma.

Another study reported that for Black individuals, melanoma often presents as acral lentiginous melanoma. This subtype is typically seen on the palms, foot soles, or beneath the nails, as opposed to areas of skin which are exposed more frequently to sunlight, as is more frequently observed in the lighter skin tones of White patients.⁴

"Our findings suggest diagnostic biases based on skin color exist in dermatology practice," Loren Krueger, MD, the study’s lead investigator, explained at the Annual Meeting of the Skin of Color Society Scientific Symposium in 2022. "A lower likelihood of biopsy of malignancy in darker skin types could contribute to disparities in cutaneous malignancies.”

These alarming statistics on skin cancer in the dermatology field should be cause for concern and demonstrate an urgent need to address racial disparities as soon as possible.

Disproportionate Burden of Hair and Scalp Disorders

The subject of hair and scalp disorders has also become more widely recognized, though it has been a longstanding concern for patients of color and especially patients identifying as Black. Much of this phenomenon relates to the reported lack of trust in clinician awareness of diverse hair characteristics, indicating a major concern which should be addressed.

Sotonye Imadojemu, MD, MBE, academic medical dermatologist for Brigham and Women’s Hospital, presented on this very topic at the Society of Dermatology Physician Assistants (SDPA) 2023 Annual Summer Dermatology Conference.⁵

“I want to start off with a statistic, that less than half of African American women believe that their physician understands African American hair,” Imadojemu began her presentation. “And you can substitute dermatologists in there. So, our first step is really gaining trust.”

Imadojemu’s point is an important one, given the potentially disastrous consequences of distrust between patients and physicians. For patients of color with alopecia areata, for example, this lack of awareness among clinicians could lead to fewer visits, less awareness among patient and physician, and generally more negative outcomes for those with conditions such as alopecia areata.

A recent study demonstrated that Black, Asian American, and Hispanic patients have a higher prevalence of alopecia areata and the condition’s subtypes.⁶ The data showed that self-reported prevalence of the hair disorder was 2.5, 2.0, and 2.2 times as high among Asian, Black, and Hispanic individuals, respectively, compared to White individuals.

This disproportionate burden of alopecia among those with skin of color, coupled with the lack of an obvious cause of higher prevalence, points to the notion that these populations require more specific attention by dermatologists, greater access to education, and more representation in the field.

Issues with Clinical Trial Representation

Perhaps the most vitally important racial disparity to be addressed in the dermatology field is the lack of representation in clinical trials of patients with skin of color.

A fairly recent example of this lack of representation is the absence of images of skin of color in publications of the cutaneous manifestations of COVID-19 such as the so-called ‘COVID toes.’

A systematic literature review demonstrated that there were not any published photos of the cutaneous manifestations in darker-skinned individuals (Fitzpatrick skin type V or VI), acknowledged by the study’s investigators as an issue given that skin disease often presents differently in skin of color.⁷

This particular case is alarming, given the state of emergency during the COVID-19 pandemic and the necessity of raising awareness during the height of the pandemic to prevent the loss of life of millions around the world.

The unequal distribution of burden which most are now aware affected Black and Hispanic populations most strongly during the pandemic is apparent in this example. This is only one of many obvious situations in the dermatology space where the needs of patients with skin of color were neglected and the field failed to promote the needs of these underserved populations.

Another example is a survey in the US which indicated that 47% of dermatologists and dermatology residents reported that their medical school and/or residency training inadequately informed them of the skin conditions in Black individuals.⁸

Furthermore, there have been studies which have shown imbalances in representation of darker Fitzpatrick skin categories in dermatology textbooks as well as dermatology journals, all of which can contribute to cognitive biases and lead to differential diagnoses for these populations.⁷

“We know for certain that if dark skin images are not well represented, skin doctors—but also other doctors who are not skin experts—are at a disadvantage for making a proper diagnosis,” Hao Feng, MD, assistant professor of dermatology at the University of Connecticut, said in a statement.

How is This Issue Being Addressed?

Overall, it is clear dermatologists must focus on developing tailored treatment approaches, promoting early detection of conditions, and fostering a more inclusive system to promote and protect the well-being of all patients.

This can be accomplished in a variety of ways, with an obvious one being to correct the aforementioned paucity in training materials and images teaching medical students. This change is essential as a means to address the existence of cognitive biases and the lack of knowledge in this area.

Another possible way to address the issue is the development of imaging and artificial intelligence tools to help patients with darker skin tones to enhance their diagnostic abilities and to improve diagnosis and management of conditions such as alopecia and melanoma.

In fact, there has even been a recent artificial intelligence algorithm developed with this exact purpose in mind, incorporating images from people of color to improve diagnostic sensitivity.⁹ Hopefully, improvements like these will continue to flourish in the coming years as technology advances.

Additionally, a general awareness of the importance of this topic could go a long way in improving health outcomes for people of color. More and more medical conferences are focusing on educating attendees on addressing unmet needs, diverse patient populations, and raising awareness of diversity in dermatology.

In general, it is essential for clinicians and the general public to realize that acknowledgement of the unmet needs of patients with skin of color is of paramount importance in the field of dermatology for promoting equitable access to quality care and ensuring optimal health outcomes for all.

Focusing on inclusivity, cultural competence, and personalized treatment approaches that cater to the specific needs and concerns of underserved patients is crucial to the future of health care in a country with an expanding population and greater diversity than ever before.

References

1. ^{Smith T. Omar Noor, MD: Challenging Cases in Skin of Color. HCPLive. June 26, 2023. https://www.hcplive.com/view/omar-noor-md-challenging-cases-skin-of-color. Accessed June 29, 2023.}
2. ^{Centers for Disease Control and Prevention. Skin cancer statistics. [Internet]. Available from: https://www.cdc.gov/cancer/skin/statistics/. Accessed June 28, 2023.}
3. ^{MB Culp, MPH, N Lunsford, PhD. Melanoma Among Non-Hispanic Black Americans. June 20, 2019. Accessed June 30, 2023. https://www.cdc.gov/pcd/issues/2019/18_0640.htm.}
4. ^{Melville NA. Study finds discrepancies in biopsy decisions, diagnoses based on skin type. Medscape. April 11, 2022. Accessed June 29, 2023. https://www.medscape.com/viewarticle/971910.}
5. ^{Smith T. Alopecia in Skin of Color: A Discussion of Procedural Treatments. HCPLive. Jun´24, 2023. Accessed June 28, 2023. https://www.hcplive.com/view/alopecia-in-skin-of-color-discussion-procedural-treatments}
6. ^{Sy N, Mastacouris N, Strunk A, Garg A. Overall and Racial and Ethnic Subgroup Prevalences of Alopecia Areata, Alopecia Totalis, and Alopecia Universalis. JAMA Dermatol. Published online March 01, 2023. doi:10.1001/jamadermatol.2023.0016.}
7. ^{Lester, J.C., Jia, J.L., Zhang, L., Okoye, G.A. and Linos, E. (2020), Absence of images of skin of colour in publications of COVID-19 skin manifestations. Br J Dermatol, 183: 593-595. https://doi.org/10.1111/bjd.19258.}
8. ^{Rabin RC. Dermatology Has a Problem With Skin Color. New York Times. Published August 30, 2020. Accessed June 27, 2023. Available from: https://www.nytimes.com/2020/08/30/health/skin-diseases-black-hispanic.html}
9. ^{Hurlbert M. Improving AI Performance for People of Color: Diagnosing Melanoma & Other Skin Cancers. Cure Melanoma. Available from: https://www.curemelanoma.org/blog/article/making-ai-work-for-people-of-color-diagnosing-melanoma-and-other-skin-cancers. Published August 12, 2022. Accessed June 28, 2023.}