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Biomedical Research

The Lack of Racial Diversity in Dermatological Images

The hardships that many encounter when simply attempting to identify a skin condition is beyond a representation of today’s inequality for people of color.

Introduction

Ellen Weiss noticed uneven, desiccated patches on her toddler’s dark brown skin and wondered if the patches signified eczema, or rather a skin condition more serious. “I Googled it and noticed immediately the pictures were all of white skin. I Googled other conditions and it was the same. No matter what I searched, there were almost no images of dark skin,” she recounted (McFarling).

The availability of medical reference photos, particularly those depicting dermatological conditions on dark skin, is an issue that has not received the awareness it needs. Today, many Brown and Black individuals encounter problems identifying a condition on their skin. Even when approaching a doctor, people still do not receive the help that they need (Prescod). The inherent problem concerning medical images is the inequality of reference material from across the skin tone spectrum, necessary for care and treatment of their skin’s health.

Medical images are crucial in training future physicians as these images display the anatomical and etiological aspects of the body. With such material for reference, physicians are able to recognize certain diseases, disorders, and injuries a patient may have. For instance, an assessment of the intensity of burns is dependent upon a physician’s visual inspection (Schaefer). By looking at certain characteristics of a burn, doctors can identify the injury as one of three measures: first degree, second degree, and third degree. Burns are only an example of which its primary method of diagnosis is through visual inspection alone, and as this process enters the realm of dermatological conditions, it encounters complications that obstruct the way for an easy, and sometimes correct, diagnosis for individuals with dark skin (Singh).

Studies

Before investigating the hardships when it comes to diagnosing dermatological conditions on dark skin, it is imperative to first understand the inherent statistics of medical images concerning the measure of racial diversity that they encompass. 

Rhiannon Parker, a researcher at the University of Wollongong in Australia became aware of the lack of diversity in medical images. Parker and her colleagues sought to understand the extent to which the lack of diversity in dermatological reference photos exactly accounts to. Inspecting more than 6000 medical images derived from 17 different anatomy books published between the years 2008 and 2013, they firstly focused on gender disproportionality. They found that only 36 percent of images with an identifiable sex were female, and they furthermore analyzed these images’ racial make-up. Of these images that displayed females, 86 percent of them were White (Eveleth). 

A more recent study, conducted in April 2020 and led by Jules Lipoff, an assistant professor of clinical dermatology at the University of Pennsylvania, analyzed the skin type diversity in general medicine textbooks. Lipoff found that only 4.5 percent of images with an identifiable skin tone displayed dark skin (McFarling). The disproportionality within medical textbooks is evidently overwhelming.

Dermatological Conditions

Dermatology is a branch of medicine that focuses on the structure, etiology, and treatment of the skin. Dermatologists undergo years of training to especially develop an ability to diagnose a certain skin condition based on visual inspection. However, dermatologist Jenna Lester from the University of California, San Francisco describes the difficulties she encountered when preparing to treat her Black patients for a particular rash commonly associated with Covid-19. The popularly known “Covid-19 rash” is an emerging symptom of coronavirus that scientists are still researching. When Lester heard of this rash, she searched throughout various medical literature to analyze what the rash would particularly look like on dark skin. From her ongoing searches, Lester still did not find one picture displaying the rash on dark skin (Lester). 

She mentioned, “I was frustrated because we know Covid-19 is disproportionately impacting communities of color. I felt like I was seeing a disparity being built right before my eyes” (McFarling).

Considering the emerging idea that certain dermatological conditions can look very much different across the skin tone spectrum, the lack of racial diversity poses disadvantages for individuals with dark skin (Figure 1). As physicians continue to train upon a white foundation, those with darker skin face errors and complications made by doctors within inspection, and therefore face higher rates of misdiagnosis (Rabin). The hardships that many encounter when simply attempting to identify a skin condition is beyond a representation of today’s inequality for people of color.

The picture demonstrates how differently the same disease can present on dark versus light skin.

Figure 1: @brownskinmatters (2019, September 10). [Condition pictured: Kawasaki Disease]. Retrieved from https://www.instagram.com/p/B2PJtMyA2ub/

This issue is relatively new and merits a call for social awareness. For instance, Malone Mukwende, a second year medical student at St. George’s University of London, strives to combat the inadequate research in dermatological conditions on dark skin.. He and his colleagues are working together to write a book, “Mind the Gap,” which addresses the various clinical signs of skin disorders on black and brown skin (“A Medical Student”). At the time of this article, the book is not yet published, and still no official release date has been confirmed. Furthermore, a book by Cyron Mandia, “All About the Skin: A Microscopic Lens to the Integumentary System,” which will be published around this December, utilizes its incorporation of dark skin to combat the racial misrepresentation within dermatological images.

 As society continues its works to fight the lack of diversity in medical images, a modern and racially inclusive dermatological curriculum waits upon us. However, until then, it is our duty to continue to spread awareness for change.

Cyron Mandia, Youth Medical Journal 2020

References

A medical student couldn’t find how symptoms look on darker skin. He decided to publish a book about it. Washington Post. https://www.washingtonpost.com/gdpr-consent/?next_url=https%3a%2f%2fwww.washingtonpost.com%2flifestyle%2f2020%2f07%2f22%2fmalone-mukwende-medical-handbook%2f 

Eveleth, R. (2019, May 9). Medical Textbooks Overwhelmingly Use Pictures of Young White Men. VICE. https://www.vice.com/en/article/3k3kkn/medical-textbooks-overwhelmingly-use-pictures-of-young-white-men

McFarling, U. L. (2020, July 20). Dermatology faces a reckoning: Lack of darker skin in textbooks and journals harms care for patients of color. STAT. https://www.statnews.com/2020/07/21/dermatology-faces-reckoning-lack-of-darker-skin-in-textbooks-journals-harms-patients-of-color/ 

Prescod, J. (2020, March 4). Is the lack of dark skin in medical books harming us? Gal-Dem. https://gal-dem.com/is-the-lack-of-dark-skin-in-medical-books-harming-us/ 

Rabin, R. C. (2020, August 31). Dermatology Has a Problem With Skin Color. The New York Times. https://www.nytimes.com/2020/08/30/health/skin-diseases-black-hispanic.html 

Singh, N. (2020, August 17). Decolonising dermatology: why black and brown skin need better treatment. The Guardian. https://www.theguardian.com/society/2020/aug/13/decolonising-dermatology-why-black-and-brown-skin-need-better-treatment 

Schaefer, Timothy J. “Burn Evaluation And Management.” StatPearls [Internet]., U.S. National Library of Medicine, 10 Aug. 2020, www.ncbi.nlm.nih.gov/books/NBK430741/

Lester, J. C., Jia, J. L., Zhang, L., Okoye, G. A., & Linos, E. (2020). Absence of images of skin of colour in publications of COVID‐19 skin manifestations. British Journal of Dermatology, 183(3), 593–595. https://doi.org/10.1111/bjd.19258

By Cyron Mandia

Cyron Mandia is a student at Vladovic Harbor Teacher Preparation Academy in Wilmington, California. He is interested in the fields of microbiology and dermatology.

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