Recognizing disease presentation in richly pigmented skin
A range of resources can assist physicians in developing their skills at diagnosing skin disease across the spectrum of skin types (1,400 words, 7 minutes)
In an interview with The American Journal of Managed Care, various dermatological conditions can present differently across the spectrum of diverse skin complexions, said New York dermatologist Dr. Andrew F. Alexis. During the interview, he gave some examples and recommendations for medical practitioners to improve their diagnostic skills.
Dr. Alexis is the vice chair for diversity and inclusion for the Department of Dermatology and a dermatologist at the Center for Diverse Skin Complexions at Weill Cornell Medicine in New York City. He is also a founding faculty member of the annual Skin Spectrum Summit medical conference.
Two examples of differences in disease presentation were:
In darker skin complexions, inflammatory lesions from conditions such as psoriasis or atopic dermatitis may appear reddish brown, purple to violet, or greyish. Much of the existing educational images show the pinkish or reddish lesions seen in lighter skin tones.
Eczema in Black skin is more likely to have a follicular appearance.
“Leveraging skin of colour–specific educational materials can help reduce disparities in clinical education for dermatologic conditions that have nuances or may disproportionately affect populations of colour,” Dr. Alexis said. “Broad efforts are being made across the [U.S.] to ensure broader inclusion of diverse patient populations within dermatology education materials.”
Resources Dr. Alexis mentioned for physicians to strengthen their skills at diagnosing skin conditions in all skin types include:
The American Academy of Dermatology Skin of Color Curriculum
The Skin of Color Society Dermatology E-Learning + Equity Platform
Continuing medical education meetings, such as the American Academy of Dermatology annual meeting, and skin of colour–specific meetings, such as the Annual Skin of Color Society Scientific Symposium, the Skin of Color Update in New York City, and others.
Bottom line: Improving diagnostic accuracy of skin conditions in darker skin types requires physicians to understand the differences in presentation between skin types. Many educational resources are available for physicians seeking training in this area.
From the literature on dermatology diagnosis in skin of colour
Artificial intelligence for the classification of pigmented skin lesions in populations with skin of colour: A systematic review
A new systematic review suggests that artificial intelligence (A.I.) models could potentially improve the early detection of skin cancers in people with skin of colour. The authors note the lack of skin colour diversity in A.I. training datasets may only widen the pre-existing racial discrepancies in dermatology.
The study identified 22 articles, and most of the studies were trained on datasets obtained from Chinese, Korean, and Japanese populations. Only seven studies used diverse datasets containing Fitzpatrick skin type I-III in combination with at least 10% from Black American, Native American, Pacific Islander, or Fitzpatrick IV-VI. A.I. models producing binary outcomes reported an accuracy ranging from 70% to 99.7%, while the accuracy of A.I. models reporting multiclass outcomes was lower, ranging from 43% to 93%.
The authors conclude that while this review provides promising evidence of accurate A.I. models in skin of colour populations, significant discrepancies remain in the number of A.I. models developed in people with skin of colour.
The relationship between the distribution of facial erythema and skin type in rosacea patients: A cross-sectional analysis
A new study conducted in China revealed that individuals with rosacea have different facial erythema distribution patterns, which may be related to their skin type.
Investigators divided skin types according to the Fitzpatrick scale, and oily-dry skin subtypes were determined according to the Baumann scale. They divided erythema distribution patterns into peace signs, wing shapes, and neither of the two patterns. The peace-sign pattern was more common in individuals with darker skin tones, and most individuals with the peace-sign design had oily combination skin. Individuals with a typical wing shape had dry combination skin.
The authors say their findings suggest that the differences in the immune microenvironment, Demodex habitation, and altered lipid content may explain the presence of the peace-sign pattern in the oily combination skin population. The wing-type patterns are associated with the lateral parts of the cheeks. They could be caused by abnormal vessel dilations of the anatomic branches of the zygomatic-facial and facial arteries, indicating that the primary pathogenesis for this type of rosacea may be neurovascular.
Allergic contact dermatitis and patch testing in skin of colour patients
This study was conducted to identify allergens that disproportionately cause contact dermatitis in skin of colour patients and to review the literature on interpreting patch testing results in this population.
After reviewing the literature, researchers found that African American patients commonly reacted positively to paraphenylenediamine (PPD), balsam of Peru, bacitracin, fragrance mix, and nickel. In contrast, Hispanic patients responded positively to Carba mix, nickel sulphate, and thiuram mix. Asian patients reacted positively to nickel sulphate, fragrance mix, and potassium dichromate.
The authors write that positive patch tests in patients with higher Fitzpatrick skin types presented with lichenification and hyperpigmentation rather than erythema and vesicles. The characteristic bright red or pink hues for positive results may appear violaceous or faint pink.
Classic ulcerative pyoderma gangrenosum in Fitzpatrick V skin type
This case report describes a 46-year-old man with Fitzpatrick V skin phototype and a history of obesity and hepatic steatosis that the authors write was likely secondary to non-alcoholic steatohepatitis. The patient presented with a rapidly-enlarging ulcer on his left upper abdomen. Minor abdominal trauma led to an extremely painful papule that progressed into an ulcer in less than ten days.
The medical team’s leading diagnosis became pyoderma gangrenosum (P.G.), as the patient met the histologic and four minor diagnostic criteria published for P.G.
After treatment was initiated, complete healing was noted in two to three weeks.
The authors write that in patients with darker skin, erythema surrounding an ulcer can be challenging to assess when evaluating for P.G. They also note that P.G. is more likely to cause excessive scarring or skin dyspigmentation in darker-skinned patients.
VIDEO: Diagnosis and management of psoriasis in skin of colour
At the intersection of skin and society
A new report from the advocacy group, People For Education, shows that publicly funded schools in Ontario have made significant progress in Indigenous education over the last decade. However, the report also identifies many steps to be taken before the province can say that it has fully implemented all the education-related Calls to Action from the Truth and Reconciliation Commission.
People For Education is an independent advocacy group that, since 1996, has conducted the Annual Ontario School Survey. This survey of each of Ontario’s 5,000 publicly funded schools tracks the impact of funding and policy changes on resources and programs.
The new report is based on responses from 1,044 principals from all of Ontario’s 72 publicly funded school boards. Findings from the report show that some schools have developed strong partnerships with local Indigenous communities. Still, many others say they need more support from their school board and the Ministry of Education to be successful. Generally, schools in Northern Ontario were more likely to offer Indigenous education opportunities, while schools in the GTA were least likely to provide them.
Among the findings:
The proportion of schools reporting professional development for school staff on Indigenous education has more than doubled over the last decade for elementary schools, to 76% in 2022-2023 from 34% in 2012-2013, and for secondary schools, to 82% in 2022-2023 from 34% in 2012-2013
72% of secondary schools reported offering an Indigenous studies course in 2022-2023, compared to 40% of secondary schools in 2013-2014
Between 2012 and 2022, the proportion of schools offering Indigenous languages programs has increased to 13% from 4% in elementary schools and to 20% from 11% in secondary schools
15 school boards are replacing the compulsory Grade 11 English course with an Indigenous-focused approach centred on First Nations, Métis, and Inuit voices
This week
May is National Asthma and Allergy Awareness Month in the U.S.
May 8 is World Red Cross Day
May 10 is World Lupus Day
Something to think about in the week ahead…
Harry S Truman, U.S. President, 1884-1972
Next Week
During a talk at the 8th annual Skin Spectrum Summit, Toronto’s Dr. Geeta Yadav discussed some special considerations when choosing treatments for atopic dermatitis for patients with darker skin types.
If you like Skin Spectrum Weekly, why not check out Chronicle’s other publications, podcasts, and portal?
Established in 1995, The Chronicle of Skin & Allergy is a scientific newspaper print providing news and information on practical therapeutics and clinical progress in dermatologic medicine. The latest issue features:
Dr. Michael Sidiropoulos (Toronto) discusses discoveries in the role histopathology plays in the diagnosis of skin conditions
A review of new and upcoming treatments for actinic keratoses and keratinocyte carcinomas featuring interviews with Dr. Ilya Shoimer (Calgary), Dr. Alia Bosworth (Halifax), Dr. Mark Lupin (Victoria, B.C.), and Dr. Michelle Pratt (St. John’s, N.L.)
An essay from Dr. Saima Ali (Burnaby, B.C) to the 2022 Dermatology Industry Taskforce on Inclusion, Diversity and Equity (DiTiDE) short essay contest. Dr. Ali wrote on the challenge of restoring the confidence of patients with skin of colour with the practice of dermatology.
Plus regular features, including the popular column “Vender on Psoriasis” by Hamilton dermatologist Dr. Ron Vender
Read a recent online edition here. To apply for a complimentary* subscription or to receive a sample copy, please email health@chronicle.org with your contact information.
The Women in Dermatology e-newsletter updates new findings concerning dermatologic issues that affect women and the female dermatologists who care for them. Read the current issue here.
Season two of the Shear Listening Pleasure podcast with Dr. Neil Shear has launched. Listen to the eighth episode here, where Dr. Shear speaks with dermatologist Dr. Sonja Molin (Kingston, Ont.) about allergology, patch testing, and the growth of Queen’s University’s dermatology division.
And if you’re looking for a web destination for all things derm, please visit derm.city, “Where Dermatology Lives.” Please like, rate, review, and share it with your colleagues.
The follicular presentation of eczema in Black skin being distinct from what most training images show is a straightforward example of how representation gaps in medical education translate into diagnostic errors. Great article!