Dermatologic conditions are routinely overlooked and misdiagnosed in people of color. The COVID-19 pandemic provides another notice of why dermatology training needs urgent updating.
During a recent “Ethics Talk” videocast from the AMA Journal of Ethics® (@JournalofEthics), Jenna Lester, MD, assistant professor of dermatology at the University of California, San Francisco, School of Medicine talked about why “COVID toes” should bring physicians’ attention to long-standing health inequities.
The most well-known dermatologic manifestation of COVID-19 is “COVID toes,” a purplish-red discoloration of the tops and tips of the toes. There are other cutaneous manifestations, such as papulosquamous eruptions, pityriasis rosea-like eruptions and more vasculitic-type lesions.
"A lot of these have a basis of inflammation, and inflammation appears differently in different tones of skin,” Dr. Lester said. “So what may look red or pink in someone with light skin may actually look purple to blue, or darker—dark brown even—in someone with darker skin. So … if your eye is not trained to recognize these things in different skin tones, it might be quite easy to miss it.”
If properly trained, however, physicians can help patients keep an eye out for skin signs of COVID-19 infection.
“One of the great things about the skin is that it's an external organ that patients can look at with us,” she said. “So if doctors, and then subsequently patients, are aware of the manifestations in all different skin tones … we might be able to say, ‘If you notice something like this on your skin, this could be an early sign of COVID-19. You should consider sheltering in place, self isolating, getting testing if you can.’”
The problem is that most physicians are not, in fact, trained to recognize dermatologic conditions in varying skin tones, Dr. Lester said. Most of the photos in medical education textbooks, for example, show white patients.
“We need to think about increasing representation in our photographs in dermatology specifically,” she said, adding that terminology is important too. “So we're not saying ‘the salmon pink patches of psoriasis … are classic presentations of psoriasis,’ because psoriasis in someone with dark skin does not look like that.”
But there are also systemic forces in play, Dr. Lester noted. Economics, for example, plays a role in patient access: Dermatology is a lucrative specialty, and many dermatologists do not accept Medicaid.
Dr. Lester started a skin-of-color clinic at UCS, that provides high-quality dermatologic care for Black, Latino, Asian, Native Indian and Pacific Islander communities.
“There’s research that suggests that patients of color, particularly Black patients, appreciate having a dermatology space that is built for them. They feel better getting care in a skin of color clinic than in a general dermatology clinic,” she said. “My ultimate goal would be that these clinics don't have to exist, that we're able to provide this same type of care where patients feel as comfortable in any dermatology setting. For now, I think it's important to create a place where these patients feel comfortable coming and returning to.”
For a model like this to work at a wider level, though, the system itself needs to change, Dr. Lester noted.
“We know that there are fewer Black men in medical school now than there were in the ’70s,” she said. “So how can we, as a profession, diversify the people who make up our profession—that we have a diversity of thoughts and ideas and approaches to problems and solutions, as well? I really think that that is central to solving a lot of these issues.”
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