Historically, dermatology has focused on white skin. Dermatology was forged as an independent discipline in the late 18th and early 19th century, a time when anthropologists and philosophers were constructing a racial hierarchy. Unsurprisingly, this filtered into medicine, and dermatological conditions were described largely in Caucasian skin.
Unfortunately, mainstream dermatology practices in the West maintain a Eurocentric standard, despite a changing demographic. By 2044, the United States is predicted to have a ‘minority-majority’, with over 50% of the population representing an ethnic minority. Yet, studies highlight that clinicians and dermatologists lack confidence in treating skin conditions in BAME populations, and there is a shocking devoid in medical teaching. Increasing globalisation makes it ever-more paramount that active steps are taken to ensure dermatology is more representative.
This discussion is vital within eczema, as studies highlight a higher prevalence of eczema and greater severity in black patients (across US, UK,Canada and Nigeria). Yet, there is a vast under-representation of BAME patients in clinical trials. Further, BAME patients are more likely to be misdiagnosed, their eczema severity under-appreciated, and commonly used clinical scores fail to account for different skin tones.
Here, we will try to break-down firstly the key differences in skin architecture, how eczema presentation may vary between skin tones, and lastly how to spot skin colour changes.
Differences in skin
Skin colour — Skin colour at a basic level is due to melanin. Melanin is the pigment that gives human skin, hair and eyes their colour. Darker skin tones have a higher concentration of melanin producing cells. Skin colour is one of the key challenges in eczema, with erythema or redness described as a crucial factor in assessing eczema severity. Now, it does not take an expert to realise ‘redness’ is not the best marker in dark skin tones, underpinning the challenges patients and clinicians face. Moreover, those of BAME ethnicity are more likely to suffer from changes in skin colour (skin can become darker or lighter), after suffering from eczema.
Skin layers — Darker skin tones have more skin cell layers. Constant rubbing and scratching can cause skin thickening to be more pronounced in BAME skin tones.
Collagen — Black/brown skin has more tightly packed collagen fibres, whilst this is advantageous in keeping the skin taut and wrinkle-free, it also makes the skin more prone to scarring.
Ceramide — A waxy lipid found in skin. Darker skin has less ceramide therefore is more prone to dry skin.
Key differences in eczema presentation
Area — Eczema in BAME patients does not follow the pattern of Caucasian skin, it is more likely to appear on outer aspect of limbs (the front of the knee and back of elbows), and in a more irregular pattern.
Follicular eczema — Presents as small bumps around hair follicles (looks a little like goose bumps) and is exclusively seen in black patients.
Skin thickening — An issue often experienced by BAME patients, where itching leads to the skin becoming tougher and thicker.
Dyspigmentation — Darkening of skin colour may be a sign of active inflammation, or may be a change after a flare-up. Skin may also become lighter, which is more noticeable in BAME skin. Skin around the eyes can also appear dark and dry.
Keloid formation — Keloids are severe scarring in BAME patients which are very difficult to treat.
Spotting changes in BAME skin
Some common Eurocentric terms that are used in dermatology, are usually not applicable to BAME skin. We need to rethink common dermatology terminology, and consider what this looks like in BAME skin.
Pallor — pallor or paleness may be seen as ash grey/yellow brown/dark brown dull looking skin in BAME skin.
Inflammation — may be detected by darker brown discolouration or subtle darkening in skin tone.
Redness — look for a purplish tinge, the skin may feel warm to touch, or it may be taut and tender.
Whilst eczema was selected as a focus here, many of the points are relevant across dermatological conditions and healthcare in general. Many steps are required at different levels to make dermatology more representative and bridge the inequality gap. More BAME patients need to be recruited in research, ethnicity needs to be considered in reporting outcomes, medical education needs to be broadened and we need to redefine and rethink some commonly used terminology. Understanding variations in skin conditions is vital in bridging the health inequality gap.
But it's time for more than words on a blog post, here are the active steps we are taking as a company:
- We are an ethnically diverse team and are acutely aware of implicit biases.
- We are sourcing images of patients from all ethnicities to incorporate into our AI algorithm.
- We are seeking to utilise better terms to describe the symptoms of BAME patients with eczema.
- We pledge to create a social access scheme so our app is accessible to all.