Representation of dark skin images of common dermatologic conditions in educational resources: A cross-sectional analysis

To the Editor: Cutaneous pathology appears significantly different on disparate skin tones. Access to educational materials illustrating across all tones plays a crucial role in developing pattern recognition skills and improving diagnostic confidence.1Rimoin L. Altieri Craft N. Krasne S. Kellman P.J. Training of lesion morphology, configuration, distribution.J Am Acad Dermatol. 2015; 72: 489-495Abstract Full Text PDF PubMed Scopus (23) Google Scholar,2Fourniquet E. Garvie K. Beiter Exposure dermatological color increases physician student confidence diagnosing patients color.FASEB J. 2019; 33: 606.18Google Scholar Given increasingly diverse patient population known dermatologic health disparities,3Buster K.J. Stevens E.I. Elmets C.A. Dermatologic disparities.Dermatol Clin. 2012; 30: 53-59Abstract (100) we aimed assess prevalence dark images widely used contemporary print web-based dermatology resources. Eight commonly resources (6 textbooks 2 resources) 65 conditions were selected for review. For each condition, categorized as light images, (DSIs) (Fitzpatrick phototypes V or VI), indeterminate (because extent disease involvement, image frame, lighting). Of 15,445 resources, 19.5% DSIs. Online had greater representation DSIs (22.1%) compared printed texts (10.3%) (Table I). online VisualDx (28.5%) DermNet NZ (2.8%). DSI varied based conditions. Disorders Langerhans cells macrophages greatest (36.8%), whereas neoplasms (10.6%) adnexal diseases (12.3%) lowest II). These discrepancies are not consistently reflective incidence population; overall, there is disproportionately lower when comparing proportion epidemiologic data. However, high such sarcoidosis syphilis may be disproportionate dark-skinned individuals.Table IExtent illustration learning common included this studyLearning resourcesTotal, nLight, nDark, nIndeterminate, %Printed texts346930673564610.3 Dermatology, 4th editionBolognia4Bolognia Schaffer Cerroni Dermatology (4th ed.). Elsevier, Amsterdam, The Netherlands2018Google Scholar748634991513.2 Andrews' Diseases Skin, 13th editionJames5James W. Elston D. Treat Rosenbach M. Neuhaus I. (13th Netherlands2019Google Scholar37229574319.9 Fitzpatrick's 9th editionKang6Kang (2019). Ninth Edition, 2-Volume Set (Fitzpatricks General Medicine) (9th New York: McGraw-Hill Education/Medical.Google Scholar516428781015.1 Rook's Textbook 8th editionBurns7Burns T, Breathnach S, Cox N, & Griffiths C. (2010). (8th Hoboken: Wiley-Blackwell.Google Scholar54449340117.4 Clinical Dermatology: A Color Guide Diagnosis Therapy, 6th editionHabif8Habif TP. (2015). E-Book: Therapy (6th Mosby.Google Scholar8638223924.5 Atlas Synopsis editionWolff9Wolff K, Johnson AR, Saavedra A, Roh (2017). Scholar4263952656.1Online resources11,976926926525522.1 VisualDx9007641725692128.5 NZ2969285283342.8Total15,44512,336300810119.5 Open table new tab Table IIExtent (printed available data these conditionsDermatologic diagnosesTotal nDark %Disease incidence/prevalence general populationDisease by race/ethnicityDisorders macrophages47317436.8 Sarcoidosis20111657.77.6-8.8 per 100,000 (general population)17.8-46 (African American) Xanthoma1955226.71%-4% population)No reliable figures Necrobiosis lipoidica7767.80.3%-1.2% with diabetes)No availableInfections, infestations, bites4095101024.7 Syphilis43625959.43-18.7 population)8.4-28.1 Pityriasis versicolor1665533.11.1% Sweden)No determined difference ethnicity Tinea52615329.121.3 population)17.8 Varicella1985628.34.1 population)7.8 Herpes zoster2617026.812.4% aged 60+ years)8% Molluscum2225323.9<5% pediatric population); 33% (patients HIV)2-4 odds ratio (not white white) Impetigo2425723.61080-2220 Warts4049523.537.3% male population)45.7% American patients) Scabies3106220221-281 Insect bite1672615.6No availableNo Measles1111614.40.02-0.04 population)0.04 (minority populations) Candidiasis2463514.2No simplex3625013.847.8% (HSV1); 11.9% (HSV2) population)58.5% 34.6% Cellulitis1131513.3200.3 population)200.6 Erysipelas7756.5249 Erythema infectiosum5511.890% seropositivity years)No migrans12221.627.0 population)4.8 Rubella4600<0.01 population)9% cases African Roseola310077% 24 months)No ethnicityRheumatologic systemic diseases199648824.4 Vitiligo28810937.80.2 Scleroderma/morphea31910131.724.2 population)31.5 Alopecia1765330.12.1% lifetime population)1.77 lupus erythematosus45011425.34.2 population)119 Systemic erythematosus2204721.42.9 population)7.2 Granuloma annulare2214319.50.1%-0.4% seeking consultations)No Lichen sclerosis et atrophicus232198.2100-330 US Armed Forces)1.4 (dermatology consultations nodosum9022.20.38%-0.5% availablePapulosquamous eczematous dermatoses284559620.9 simplex chronicus10048484.04%-12% rosea1898142.9172.2 population)2 individuals rest population) Erythroderma1414632.60.9-2 Ichthyosis2206027.30.5 Seborrheic dermatitis1393726.61%-11.6% population)0.36-0.39 (light brown black skin) planus3598523.71.27% Psoriasis5189919.13.2% adult population)1.9% Stasis dermatitis1312015.36%-7% 50+ Atopic dermatitis1512013.20.2%-24.6% population)1.7 European individuals) annulare centrifugum1111311.71 Contact dermatitis7568511.220% Cheilitis3725.40.7% population)17% (individuals tones)Urticarias, erythemas, purpuras, vascular disorders121819215.8 multiforme26263240.01%-1% Drug eruptions4226615.6180-700 hospitalized patients)No Vasculitis2113114.7200 Infantile hemangioma1671710.24.5% population)3.5% Urticaria156159.60.23% population)0.29% American)Vesicobullous diseases3695615.2 Bullous pemphigoid1533019.612 population)15.4 Americans) Dermatitis herpetiformis741216.210-11.2 Pemphigus vulgaris142149.90.42-0.68 availableAdnexal diseases118014512.3 Keratosis pilaris952425.340%-80% Miliaria1152622.630% Acne vulgaris5696411.214.3%-24% population)37% women) Folliculitis220219.5No Rosacea181105.55.496% patients)10% (skin color)Neoplasms skin326934710.6 Neurofibroma1194840.333.3 T-cell lymphoma300108361.07 population)1.15 Kaposi sarcoma2014723.40.6 population)2.96 keratosis203209.990% Squamous cell carcinoma/keratoacanthoma363328.8296-497 population)3 Benign melanocytic nevus791587.395% population)0.12 versus I II) Dermatofibroma1715.9No Melanoma620243.922 population)0.9 Basal carcinoma38192.4226-353 population)0.06 Actinic keratosis2740011%-26% availableTotal15,445300820.1HSV, virus. HSV, This analysis underscores variations among relate limited space, need show classic cases, reuse images. have more flexibility add their database, allowing comprehensive pathology. Accordingly, shows remarkably other Our an exceedingly low skin, which consistent prior studies.10Louie P. Wilkes R. Representations race tone medical textbook imagery.Soc Sci Med. 2018; 202: 38-42Crossref (67) Although most cancers often worse clinical outcomes, including higher morbidity mortality.3Buster Scholar,11Davis S.A. Narahari Feldman S.R. Huang Pichardo-Geisinger R.O. McMichael A.J. Top color: nationally representative data.J Drugs 11: 466-473PubMed Consequently, rather than reflecting population, must comprehensively illustrate spectrum includes presentations that trainees unlikely encounter through course training. Images should supplemented pearls harder diagnose darker tones, although replace high-quality photographs. study inherent subjective nature designating tone, omission racial/ethnic minorities lighter inability directly link outcomes. Increased effort guidance pertaining specifically photographing needed, given challenges skin. With gap availability materials, play providing exposure Skin matters: call actionJournal Academy DermatologyVol. 84Issue 6PreviewTo We read Alvarado al's recent study1 great interest. Cultural competency care delivery fundamental reducing disparities unbiased care. Ultimately, cultural will help us connect our foster better patient–provider relationship. becoming diverse, continue lag behind, evidenced studies shed Full-Text