The Black Lives Matter movement asks us to reconsider for whom America’s institutions are built. Are they built with all Americans in mind or just some?
This question extends into many different facets of American life—from criminal justice, to education, and especially medicine.
By 2050, nearly half of Americans will belong to a minority group. Yet, diagnosis and treatment for skin conditions has been primarily based on knowledge of presenting symptoms on white skin. This problem impacts all non-white patients but especially those with darker skin, as signs of skin disease and internal infection may be harder to distinguish.
Dr. Hani Hassan, a newly-practicing physician in the United Kingdom, gained traction on Twitter for using her platform to address institutional bias in medicine, focusing specifically on dermatology. “Our knowledge/practice is steeped in scientific racism, but it presents itself as a discipline based on empirical truths about human nature/wellbeing. If disease (physical/mental) is a divergence from proscribed norms, whose norms are they?”
Using light skin as a standard for skin medicine can lead to deadly consequences for people of color.
One of the most pressing concerns for dermatologists is recognizing the manifestation of erythema, or skin redness caused by increased blood flow, in skin of color. In diagnosing early stages of Lyme disease, dermatologists look for erythema migrans—or a “bulls-eye” rash that expands from the tick bite over time. The rash is scarlet red and easy to spot in light-skinned individuals, but can often go unnoticed in people of color. If left untreated, Lyme Disease can lead to chronic joint inflammation and neurological problems such as facial palsy and impaired memory.
The fact that this critical stage of diagnosis can be easily missed in people of color signifies the need for more inclusive research and better understanding of darker skin.
Alisha Bridges has experienced the frustration of getting skin conditions diagnosed first-hand. At age 7, Bridges experienced her first flare-up of psoriasis and had difficulty getting diagnosed because her presenting symptoms were different from the “textbook definition” of psoriasis.
Bridges has spent over two decades trying out various treatments to find what works for her and, in doing so, has become a prominent advocate and blogger within the psoriasis community.
Throughout the years, she’s noticed several instances where she didn’t feel that her treatment was tailored towards her experience as a Black woman. For example, she was prescribed a shampoo for her scalp psoriasis that would require her to wash her hair every day. She found the treatment unhelpful because as an African-American woman, washing her hair everyday might cause breakage.
Tone-deaf recommendations such as these are numerous for people of color and much of the burden is placed on patients to advocate for themselves.
“I am the expert of my life, I am the expert of what to use, I am the expert of what works for me,” says Bridges—referring to how she has gained the confidence to advocate for herself as a patient after many years of psoriasis treatment. However, her experience signals larger issues within medical science.
She believes that the problem is twofold: “African Americans are hesitant to be a part of research. Doctors don’t know how to get involved and recruit African Americans in research.”
To counteract this, Bridges makes an effort to participate in clinical trials but has noticed a lack of minority representation.
“They never have people of color represented. My psoriasis looks a lot different than someone with fair skin,” she says.
While some of the textbook symptoms of psoriasis are raised red plaques, her skin can sometimes be purple or dark red. After psoriasis heals, it may appear darker than before, causing hyperpigmentation in melanated skin.
“The narrative within textbooks needs to change,” Bridges continued.
To improve treatment options for people of color, clinical research that incorporates the experiences of people of all skin types must be conducted.
However, this is not as easy as it sounds. African Americans specifically are less likely to participate in clinical trials, according to several studies. Historical distrust of clinical trials and lack of engagement by researchers are just some of the reasons they don’t participate in these trials.
Events such as the Tuskegee Syphilis Study in 1932, a clinical trial which severely violated ethical standards by infecting Black men with syphilis with no treatment offered, still causes distrust of the medical community today.
In fact, a 2013 study in the Journal of Public Health Management and Practice found that Black men with knowledge of the Tuskegee Syphilis Study were 50 percent less likely to participate in clinical research versus others that did not have knowledge of the study.
The Skin of Color Society addresses systemic issues in clinical research by focusing specifically on improving research on skin of color and increasing physician diversity within the field of dermatology. The organization has grants available for researchers to better understand skin of color and mentor POC medical students to help them to become practicing dermatologists.
Each year, they host an annual scientific symposium celebrating advancements of skin science funded by donations from the pharmaceutical industry and skincare companies. The symposium aims to “fill knowledge gaps and illuminate new principles” within the field.
“You need to know all the patterns. Color, shape, size; you need all of them to make a diagnosis,” says Dr. Lynn McKinley-Grant, dermatologist and president of the Skin of Color Society.
However, not all doctors are trained to diagnose skin conditions in people of color. Looking back to her time in medical school, Dr. McKinley-Grant said diseases weren’t presented on all skin types. Only dermatologists with a trained eye from working with diverse skin colors are able to notice erythema or other signs of skin conditions and internal disease. This is why, she believes, we need to increase the number of people of color practicing dermatology.
Improving Diversity in the Dermatology Workforce
The first step in improving diversity in the dermatology workforce is getting people of color into medical school. That’s why the Skin of Color Society’s mentorship program extends into high schools, providing young students the ability to plan for their education through medical school and residency programs.
Not only would an increase in physician diversity improve research and treatment of skin conditions, but it would also improve patient care.
“Many patients would like to go to people who are of similar backgrounds,” explains Dr. McKinley-Grant—referring to the fact that people of color may prefer to be treated by a physician of similar ethnicity. This trend is supported by research from the National Bureau of Economic Research which found that patient-doctor communication improved when Black doctors cared for Black patients and patients were more likely to receive all preventative services.
America’s future is diverse, and the field of medicine needs to evolve to meet the needs of tomorrow’s population. The medical field as a whole is still learning to grapple with its history of systemic racism and expand diversity in research.
Nevertheless, the field of dermatology is making strides to improve diagnosis and treatment of conditions in all skin types with the help of advocates such as Alisha Bridges and organizations like the Skin of Color Society.