Cutaneous presentations of COVID-19 were a nasty surprise to many practitioners as the pandemic hit different shores, and clinicians scrambled to locate any helpful information to treat patients suffering from a whole host of disease-related manifestations. Given the particular nature of the vascular involvement in the disease, it’s not a surprise that there would be skin issues that might occur as a result of the infection. As more symptoms were documented in the literature, on question boards, and even on Twitter, it was clear that it wasn’t a few isolated cases. This was a complicated issue as there were not a lot of resources that showed a clear example, and the vast majority of them were in lighter skin tones. This is just one example of how skin color could affect accuracy and/or timing of a diagnosis in a range of patients. The presentation of a patient with “Covid Toes” could vary wildly, and patients with a range of skin colors might look very different in terms of evaluation.
Even devices designed to monitor symptoms of disease that are widely recommended for consumers, such as simple commercial pulse oximeters, could create an issue as they may not accurately measure rates in darker skin tones. Skin cancers are diagnosed at later stages on average in people with darker skin tones as well. That there were few examples of manifestations of Covid-19 in skins of color to assist with diagnosis is part of a much larger discussion about the representations of skins of color in clinical medical practice, publication, and pedagogy.
It is also an issue as we move into more Sim/Virtual learning environments. We are at a point where the “we don’t know what we don’t know” conversations need to include more diverse viewpoints in curriculum development and judgement of mastery. If the people developing the AI upon which modern medical education is leaning don’t make certain that a large and diverse stratum of examples are used, the learning environments aren’t adequate. And we are doing a disservice to our graduates and the communities upon whom their expertise is reliant.
Agbai ON, Buster K, Sanchez M, Hernandez C, Kundu RV, Chiu M, Roberts WE, Draelos ZD, Bhushan R, Taylor SC, Lim HW. Skin cancer and photoprotection in people of color: a review and recommendations for physicians and the public. J Am Acad Dermatol. 2014 Apr;70(4):748-762. Epub 2014 Jan 28. PMID: 24485530. Full Text
Bellicoso E, Quick SO, Ayoo KO, Beach RA, Joseph M, Dahlke E. Diversity in Dermatology? An Assessment of Undergraduate Medical Education. J Cutan Med Surg. 2021 Apr 13:12034754211007430. PMID: 33849302. Full Text
Buster KJ, Stevens EI, Elmets CA. Dermatologic health disparities. Dermatol Clin 2012; 30:535–9. PMID: 22117867. Full Text
Chan S, Reddy V, Myers B et al. Underrepresentation of skin of color images in dermatology and medical journals from 2008 to 2018. Presented at the 16th Annual Skin of Color Society 2020 Symposium. Denver, CO, 19 March 2020.
Kundu RV, Patterson S. Dermatologic conditions in skin of color: part I. Special considerations for common skin disorders. Am Fam Physician 2013; 87:8508–56. PMID: 23939567. Full Text
Kundu RV, Patterson S. Dermatologic conditions in skin of color: part II. Disorders occurring predominately in skin of color. Am Fam Physician. 2013 Jun 15;87(12):859-65. PMID: 23939568. Full Text
Lashbrook. A. "AI-Driven Dermatology Could Leave Dark-Skinned Patients Behind." The Atlantic. Link
Lester JC, Jia JL, Zhang L, Okoye GA, Linos E. Absence of images of skin of colour in publications of COVID-19 skin manifestations. Br J Dermatol. 2020 Sep;183(3):593-595. PMID: 32471009. Full Text
Lester JC, Taylor SC, Chren M-M. Under-representation of skin of colour in dermatology images: not just an educational issue. Br J Dermatol 2019; 180:1521–2. PMID: 31157429. Full Text
McFarling, UL. "Dermatology faces a reckoning: Lack of darker skin in textbooks and journals harms care for patients of color." Stat. www.statnews.com/2020/07/21/dermatology-faces-reckoning-lack-of-darker-skin-in-textbooks-journals-harms-patients-of-color/
Mukwende M, Tamony P, Turner M. Mind the Gap: A Handbook of Clinical Signs in Black and Brown Skin, Black and Brown Skin, www.blackandbrownskin.co.uk/.
Taylor and Kelly's Dermatology for Skin of Color, 2e (may prompt for HFHS remote login to use)