People of color (POC) is a phrase commonly used in North America to describe those who do not identify as white, usually ethnic and racial minorities. It’s important for dermatologists to identify and understand disparities that might affect patient management, presentation and outcomes in people of color, especially while there are projections of non-whites being the majority among the US population by 2060.
Jenna Lester, assistant professor of dermatology at the University of California, San Francisco, like other doctors, was tasked with learning the latest information on COVID-19 in order to treat patients. She combed through medical resources to find what rashes on skin and toes (a symptom of COVID-19) looked like on black skin, to no avail. “I was frustrated because we know COVID-19 is disproportionately impacting communities of color,” said Lester... “I felt like I was seeing a disparity being built right before my eyes” (McFarling, 2020).
This is not a new incident. This is only one of the many cases in history where black and brown skin was unrepresented in the medical field, causing disparities in diagnosing skin disorders. With the recent surge in racism activism, many healthcare professionals are forced to acknowledge the systemic racism that strongly manipulates the medical field, and dermatology isn’t an exception.
Most skin cancer research has been done by studying white skin. Conducting research in people of color has been a long lasting problem within dermatology, and without such research and knowledge, the current racial disparities in the mortality of skin cancer will likely remain.
Skin Conditions in POC
In the United States, nonmelanoma skin cancer is the most common malignancy, and it’s becoming an increasing issue. In whites, Hispanics and certain populations of Asia (Chinese and Japanese), basal cell carcinoma is the most common type of nonmelanoma skin cancer, while squamous cell carcinoma is most common in Asian Indians and blacks.
By observing figure 1, one can see the incidence of skin cancer is low amongst people of color. However, despite these statistics, there are disproportionately higher rates of morbidity and mortality in these groups. For instance, squamous cell carcinoma, most commonly developed within blacks in chronic scars, has a metastasis rate of 20-40% as well as greater mortality compared to the cancer observed in whites, which has a typical rate of 1-4% of solar induced squamous cell carcinoma.
All minorities tend towards having a worse prognosis of melanoma, but in blacks the greatest discrepancy of melanoma has been observed, this group is 1.5 times more likely to die from melanoma than whites and 4 times more likely to present stage IV disease. Even after accounting for age, gender, stage, decade of diagnosis and treatment, these frightening rates stay the same.
It’s strange that a field focusing on the skin hasn’t even batted its eye at skin color. In dermatology, diagnosis is made with the help of referencing images of skin disorders, which play a huge role in the field both in education and treatment. Unfortunately, the lack of images of darker skin causes a barrier to proper diagnosis and treatment for people of color. When skin problems involve redness or pinkness, these symptoms can be masked with darker skin, and that means dermatologists who aren’t educated enough will misdiagnose skin conditions (McFarling, 2020).
Lipoff stated that the occurrence of images of dark skin in medical textbooks ranged from 4% to 18%. As the field shifts toward using artificial intelligence to improve diagnosis of skin conditions, many fear that it will increase disparities since currently, machine learning algorithms are trained to diagnose with predominantly light skin images.
Misconceptions
There are multiple contributing factors to dermatologic disparities in people of color, including physician perceptions and the education, perceptions and access of care for patients. It is a double edged sword, bringing better health and worse conflict, that there is a lower occurrence of skin cancer in people of color.
Those who have a lower risk at contracting skin cancer are also likely to believe they aren’t at high risk for it, and unfortunately as a result, are less likely to initiate measures of prevention for their wellbeing. In a study recently done on young adults from black and Hispanic groups, it’s revealed that they’re less likely than whites to practice methods of prevention to ensure sun safety, due to the lack of skin cancer occurrences in family history, non existent discussions surrounding safe skincare and their rare history of sunburns.
There are commonly misperceptions about skin cancer in groups with worse skin cancer results, such as people of color. According to an analysis of the Health Information National Trends Survey, blacks are less likely to believe lifestyle can cause skin cancer. This is despite the common knowledge that ultraviolet exposure is the largest risk factor in all skin types. Additionally, according to studies, blacks and Hispanics think skin cancer involves pain and other symptoms greater than other groups, and that not much action can be taken to lower skin cancer risk. This is directly related to the inadequate knowledge of how significantly lifestyle affects skin cancer likelihood.
Identifying Disorders
Another issue causing disparities in diagnosing nonmelanoma skin cancer in people of color are the locations on the body where diagnosis can be made. Whites and lighter skinned individuals tend to develop squamous cell carcinoma in areas of their body that are heavily exposed to the sun. Meanwhile, squamous cell carcinoma is more often seen in skin areas that aren’t exposed in people of color, like the lower extremities, anogenital regions and the plantar foot. This is at a rate 8.5 times greater than whites. The issue is, people often do not notice these non-exposed areas themselves, and as people of color are less likely to perform self skin exams, these factors lead to delayed presentation and much poorer outcomes for the whole group.
Patient perceptions and the medical field strongly affect disparities in diagnosing skin cancer. They tend to expect the same presentation of symptoms, however, the variety in the appearance of skin cancer in people of color is common, and not recognizing that may increase the morbidity and mortality rates of the group. For instance, basal cell carcinoma is common as a single translucent nodule with central ulceration, but, more than 50% of cases in people of color present themselves with additional pigmentation, making it more difficult to diagnose, hiding translucency and telangiectasias.
In people of color, squamous cell carcinoma has a varied appearance, including but not limited to “non-healing ulcer(s), scaly plaques, nodules, granulomatous lesions, verrucous papules and plaque” (Ezenwa and Buster, 2019). Also, acral lentiginous melanoma might look like a fungal infection or traumatic injury instead. Essentially, different appearances make it more likely that skin cancers are diagnosed as “benign lesions, such as seborrheic keratoses, leading to delayed treatment” (Ezenwa and Buster, 2019).
Even though most medical school textbooks use light skin images to portray skin conditions, there is an exception, that many find appalling. Black skin images are only seen as a majority in textbooks when images of sexually transmitted diseases are observed, the terrible result of stereotyping across North America. Lipoff found that many dermatology textbooks didn’t include darker skin when showing images of acne, psoriasis, or dermatitis. However, many books employed dark skin to show what syphilis looks like. 28% of infectious disease images were those of dark skin, but the darker skinned images showing sexually transmitted diseases were twice as high.
The lack of images representing darker skin is the cause for misdiagnosis of many skin conditions in people of color, causing health disparities. This is including but not limited to Lyme disease, spider bites and cancers. This has caused critical outcomes that could have been avoided. To illustrate, black patients have a 70% five year melanoma survival rate compared to white patients, who have a 94% survival rate.
About Resolving Disparities
Difficulty in accessing healthcare plays a role in skin cancer disparities in people of color, and not enough research on the topic is another barrier. Moreover, when there’s trouble accessing dermatologist services due to shortages in dermatologists (both as a whole group and those of color), differences in geographical density for dermatologists and limitations to insurance covering these services, disparities in diagnosing skin cancer are bound to happen. Additionally, according to the Medical Expenditure Panel Survey, it’s significantly less likely for blacks and Asians to see a dermatologist compared to whites. A 2018 study showed that within those who were dealing with dermatologic conditions, whites had double the likelihood of visiting a dermatologist compared to black and Hispanic peoples.
Education about people of color is the largest medicine for this problem, and has been shown to work effectively at combating disparities in skin disorders. There is a positive correlation between education and skin cancer screening. This is beneficial because skin cancer screenings significantly increase diagnosis, and self-skin exams in people of color.
Since people of color are hard to come by with dermatologists, increasing awareness about skin disorders in the community is very important, by taking advantage of local resources to reach people of color directly and through other means of community engagement. For instance, in Miami community health workers were trained by dermatology researchers to teach Hispanic communities about preventing skin cancer.
Involving people of color in research, both clinical and scientific, can help decrease disparities. In dermatology, mistreatment of minorities has caused people of color to be less involved in research. “A recent five-year retrospective analysis showed that 74.4 percent of dermatology research subjects were reported as white” (McFarling, 2020).
More people of color must be introduced into dermatology, to increase access to relevant services for people of color and to tackle disparities. It will encourage patients to feel an increased sense of security and support with their dermatologist. All dermatologists, regardless of their race, can raise awareness in their community by being mentors, and collaborating with organizations that combat disparities in diagnosing skin disorders in people of color.
Written by: Kobiga Seralathan
Edited by: Joyce Qian
References
Berg, S. (2017, July 19). In Dermatology, Health Disparities Can Be Skin Deep. Retrieved from https://www.ama-assn.org/delivering-care/patient-support-advocacy/dermatology-health-disparities-can-be-skin-deep
Ezenwa, E., & Buster, K. (2019, April). Health Disparities and Skin Cancer In People of Color. Practical Dermatology, 16(4).
McFarling, U. L. (2020, July 21). Dermatology faces a reckoning: Lack of darker skin in textbooks and journals harms care for patients of color. Retrieved April 3, 2021, from https://www.statnews.com/2020/07/21/dermatology-faces-reckoning-lack-of-darker-skin-in-textbooks-journals-harms-patients-of-color/
Prichep, D. (2019, November 04). Diagnostic Gaps: Skin Comes In Many Shades And So Do Rashes. Retrieved April 3, 2021, from https://www.npr.org/sections/health-shots/2019/11/04/774910915/diagnostic-gaps-skin-comes-in-many-shades-and-so-do-rashes
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