Hana Elhassan is based in London.
As a trainee enthusiastic about medical dermatology, I was excited to start my first clinics and note the high dermatological caseload. I was working in South London with a large ethnic minority demographic, and a substantial African and Afro-Caribbean population. Given my affinity to the specialty, I was startled to notice an under-confidence in my formulation of dermatological diagnoses, calling my supervisor to review patients more frequently than usual. It soon dawned on me that there was a pattern to my reticence. With my White patients, I was decidedly more assured in my dermatologic assessment; my diagnostic challenge arose with patients with skin of colour. Being a person of colour myself, this realisation was disheartening.
To refresh my knowledge, I revisited my medical school notes and slides. I was perturbed to note the paucity of people of colour included. It was not something I had noticed then. Looking back, the dissonance between my clinical experience and the homogeneity of skin tones in my lecture notes was especially marked as I had also completed my undergraduate studies in London, with access to a diverse patient population. Perhaps I had not appreciated the disconnect then due to the pressures of trying to grapple with the breadth of content across the brief placement. I felt let down by my education, and in turn felt I was letting my patients down.
Discussing the matter with a paediatrician colleague, I was signposted to the website Skin Deep (https://dftbskindeep.com). Skin Deep is the brainchild of the Don’t Forget the Bubbles team, who produce open-access reference paediatric content that many GPs will already be familiar with. Skin Deep is a resource for dermatological conditions, with an emphasis on skin of colour, containing high-resolution images on a broad range of skin tones. It contains over 100 diagnoses, that can be browsed alphabetically or accessed via a user-friendly search function for conditions. Each page not only provides high-quality photographs reviewed by dermatologists, but also succinct topic summaries, making it a useful quality-controlled reference for a busy GP.
“Skin Deep [helps] to begin bridging one aspect of the racial health divide.”
We are all familiar with the challenges in making dermatologic diagnoses. Dermatoses are highly variable in patients, even of the same skin tone. There are added challenges in making these diagnoses on skin of colour that can feel overwhelming; an intrinsic challenge exists resulting from background melanocytic pigmentation but is further compounded by under-representation of skin of colour in medical education.
Poorer health outcomes in people of colour are well documented and have been further highlighted by the recent COVID-19 pandemic. Dermatological conditions are no exception, with UK doctors being subjectively under-confident1,2 and objectively inaccurate1 in making diagnoses in people of colour. As the first point of contact for patients, and with ever expanding secondary care waiting times, the importance of building GPs’ diagnostic confidence where possible has never been greater.
Underlying the issue is the under-representation of skin of colour in educational materials.3 When the initial teaching of a skin condition is on one skin tone, it constrains our cognitive representation of that condition, limiting our ability to recognise it in other skin tones. Skin Deep’s inclusion of a range of skin tones therefore begins to dismantle this.
Skin Deep thus has the added benefit of being a valuable educational tool in both the undergraduate and postgraduate settings for medical and non-medical professionals alike. Given the frequent under-representation of skin of colour in teaching resources, it can be useful in turning the tide on diagnostic under-confidence in skin of colour, and in a small way serve to begin bridging one aspect of the racial health divide.
References
1. Hutchinson E, Yoseph R, Wainman H. Skin of colour: essentials for the non-dermatologist. Clin Med (London) 2023; 23(1): 2–8.
2. Peterknecht E, Reid E, Cheung K, Rajasekaran A. Improving recognition among undergraduate and postgraduate trainees of dermatological conditions in skin of colour: a cross‐sectional quality improvement project. Clin Exp Dermatol 2022; 47(12): 2261–2264.
3. Kaundinya T, Kundu RV. Diversity of skin images in medical texts: recommendations for student advocacy in medical education. J Med Educ Curric Dev 2021; 8: 23821205211025855.
Featured photo by Nsey Benajah on Unsplash.
