Images of skin of colour in Covid-19 studies: Where are they?
California dermatologist Dr. Jenna Lester speaks about her study on the lack of images of skin of colour found in research articles on skin manifestations of Covid-19 (700 words, 4 minutes)
■ Dr. Lester will speak during the Skin Spectrum Summit 2020 virtual conference (Oct. 1-6.) This Group Learning program has been reviewed by the College of Family Physicians of Canada and is awaiting final certification by the College’s Ontario Chapter. Register now.
Only 6 per cent of images in research articles studying cutaneous manifestations of Covid-19 have portrayed patients with Fitzpatrick skin type IV, according to a research letter published online in the British Journal of Dermatology (May 29, 2020). The research also reports that no clinical images portraying Fitzpatrick types V or VI have been published.
Corresponding author Dr. Jenna Lester (pictured above) of the Department of Dermatology, University of California San Francisco said that she was not surprised by the findings of the study she conducted.
“All of the photos that I had seen circulated were of this disease manifestation in lighter skin,” she said in an interview with Skin Spectrum Weekly.
“I thought it was a pretty huge injustice that the very people worldwide who have been identified as having the worst outcomes in terms of hospitalization and death rates were not represented in these photos,” she said.
The authors of the study noted that in the United States and the United Kingdom, Black people represented 30 per cent of Covid-19 cases, but only comprised 13.4% of the population in those countries.
In the study, titled “Absence of images of skin of colour in publications of COVID‐19 skin manifestations,” Dr. Lester and the research team analyzed 36 articles on cutaneous manifestations of Covid-19, which included 130 clinical photos. Of the 130 photos, 120 depicted skin types I through III, seven images depicted skin type IV, and three could not be classified because the photos only portrayed acral skin, according to the study.
In the limited number of articles that did describe the race and ethnicity of the patients—six articles in total—91 per cent were described as white and 9% were described as Hispanic. Skin manifestations included chilblain-like urticaria and maculopapular and vesicular lesions, according to investigators.
“I felt motivated to share this with the rest of the medical community so that hopefully people would be aware of this and either begin the process of publishing more photos of types five and six, or take special care in examining these patients with COVID,” she said, encouraging physicians who observe patients of colour with these skin manifestations to document the cases.
What leads to this lack of representation? Dr. Lester said that in medical school, students are often taught about the “classic presentation” of a rash, which she says is always a rash or skin lesion as it appears on White skin.
“If that is how you are learning, you are maybe less able to pick up on that same disease in someone with darker skin, and if you do not see it, you do not photograph it either,” said Dr. Lester.
She believes that this contributes to a lack of representation in the literature at large, and believes is an aspect at play in her study.
“We don’t know exactly what these skin manifestations mean yet, but if a patient has a rash that is an early sign of Covid and they are able to self-isolate or go to their doctor sooner, this could prevent the spread of the virus,” she said.
The takeaway: Dermatologists and researchers should take special care to document skin manifestations related Covid-19 in patients with skin of colour for future studies.
FROM THE LITERATURE ON COVID-19 SKIN LESIONS
Association of COVID‐19 with skin diseases and relevant biologics: a cross‐sectional study using nationwide claim data in South Korea
In a new study, researchers from Seoul, South Korea have found that underlying skin disorders do not predispose patients to Covid-19. Skin conditions such as alopecia areata, atopic dermatitis, psoriasis, rosacea, and vitiligo, among others did not increase in the manner of likely mortality from Covid-19, either, according to investigators.
Enanthem in patients with Covid-19 and skin rash
Researchers have added enanthems to the growing list of possible Covid-19 symptoms. In a new research letter, researchers included petechial and puric changes to the list of cutaneous manifestations of the virus.
SARS‐CoV‐2 endothelial infection causes COVID‐19 chilblains: histopathological, immunohistochemical and ultrastructural study of seven pediatric cases
A recent study has strengthened the association between chilblains or “Covid toes” and Covid-19 infection. Researchers said that the virus was found in the skin biopsies of patients who did not test positive for the virus using throat swabs and antibody measurements.
VIDEO: Skin rash should be considered among key diagnostic Signs of COVID-19
Submit a question to a Skin Spectrum Summit presenter.
Skin Spectrum Summit 2020 will be held in three sessions: Thursday, October 1 at 7:30 pm, Saturday, October 3 at 10:30 am, and Tuesday, October 6 at 7:30 pm. Please register here.
On Day 1 of Skin Spectrum Summit, Dr. Jerry Tan from Windsor, Ont. will speak on the subject of rosacea in the skin of colour patient. If there are any questions you’d like to ask Dr. Tan, please submit them here:
AT THE INTERSECTION OF SKIN & SOCIETY
Mobile apps such as Instagram and Tik Tok may be perpetuating certain beauty stereotypes by offering camera filters that lighten the skin, according to a recent article in the lay magazine Popular Science. The article touches on the history of film and digital camera technology, which was originally designed to pick up the details of a Caucasian face, contextualizing the current trend of skin lightening app filters. “I’m trying to move social sciences from the issue of race to skin colour,” says cutaneo-chroma (skin colour) expert, Professor Ronald Hall in the article. “Let’s talk about different measures of skin colour. That’s where we’re headed.” Read the full article here.
THIS WEEK
Monday, Sept. 21 and Tuesday, Sept 22 10th International Conference on Human Genetics and Genetic Diseases webinar
September is Acne Awareness Month
Friday, Sept. 25 and Saturday, Sept. 26 4th International Conference on Natural Products and Medical Plants Research
Something to think about during the week ahead…
NEXT WEEK
A presentation by Dr. Jaggi Rao on hyperpigmentation consultations for patients with skin of colour. Subscribe to Skin Spectrum Weekly and have each issue sent directly to your phone or inbox.
Don’t forget to register now for the Skin Spectrum Summit 2020 Webinar Series, beginning October 1, 2020. Sign up here.
► Publisher’s Note: Dr. Mercy Alexis is currently recuperating from a health issue. Dr. Alexis has been an active delegate to each Toronto Skin Spectrum Summit and is a mentor and good friend to many readers of this newsletter. Please take a moment to sign her online get-well card here.