In medicine, we are trained to be colorblind and treat all patients equally, to the best of our ability. The irony is that in dermatology we have to take skin color into account, because the color of the skin affects the presentation of skin conditions. This is important to consider in order to make an accurate diagnosis and weigh the best treatment options.
Appearance of skin conditions may vary based on skin color
Skin conditions may look different on darker skin than on lighter skin. For example, many rashes, including allergic reactions to medication, appear pink or red on lighter skin. On a person with darker skin, an allergic rash might look purple. This difference can be very important for correctly identifying certain rare rashes that may be life-threatening.
Skin disorders that alter pigment, or color, have a more pronounced effect on patients with darker skin. Vitiligo, for instance, is the loss of pigment-forming cells that results in white patches on the skin. Though people with lighter skin can have vitiligo, the contrast between unaffected and affected skin is more noticeable on people with darker skin. Not all light-colored spots are a sign of vitiligo. For example, other skin conditions, such as eczema, also present as light-colored patches on darker skin.
People with darker skin are more likely to experience darkening of the skin in areas of inflammation. Psoriasis and acne are common inflammatory disorders of the skin that can end up “spilling” pigment into the skin. This condition is known as post-inflammatory hyperpigmentation (PIH). PIH often takes a long time to clear, so prevention, via treating the underlying inflammatory process and protecting inflamed areas from sun exposure, is key.
Finally, although uncommon, people with darker skin can develop skin cancers such as melanoma. In those with darker skin, melanoma typically appears on the hands and feet. Those with darker skin should look for any unexplained growth, a lesion that does not heal, or enlarging area of brown/black pigment on the hands and feet, and bring them to their doctor’s attention.
Patients prefer dermatologists who understand their specific needs
A recent article in JAMA Dermatology reported black patients’ perceptions about their dermatology care. Perhaps not surprisingly, black patients were more satisfied with their care when they were in a specialized skin-of-color clinic, and when they perceived that their dermatologist understood their specific needs with regard to their skin and hair.
The JAMA Dermatology article also demonstrated that although skin color is not equivalent to race (individuals of the same race can have very different skin colors), patients preferred a dermatologist of similar race or ethnicity. The explanation was that patients felt that the dermatologist better understood their experience and just “got it.”
Tightly curled hair, for example, has its own unique properties. Curly hair is more likely to grow back into itself if the hair is cut very short, as when shaving a beard or scalp. This results in inflammation and sometimes the formation of a boil. Persistent inflammation can lead to scarring. A knowledgeable dermatologist, or one familiar with the experience, may be more likely to advise prevention (using a trimmer instead of getting a closer shave), or to prescribe topical steroids and antibiotics to decrease inflammation.
Cosmetic issues associated with aging can also vary by skin color. For example, treatment of dark spots and removal of benign growths may be more common in older individuals with darker skin, whereas wrinkles may be less of an issue.
Specialized dermatology clinics focus on needs of patients with darker skin
These days, most dermatology residency training programs include training in skin of color. And there are an increasing number of skin-of-color dermatology clinics, which are typically focused on addressing the specific needs of people with darker skin. Finally, don’t hesitate to help educate your physician if you think that he or she does not fully understand your experience. A patient-doctor relationship should always be a two-way street.
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