The Racial Reckoning in Dermatology : Short Wave Many skin conditions, from rashes to Lyme disease to various cancers, present differently on dark skin. Yet medical literature and textbooks don't often include those images, pointing to a bigger problem in dermatology. Today on the show, we take a close look at how the science of skincare has evolved to better serve patients of color, but still has a long way to go.

Meet The Dermatologists Advancing Better Care For Skin Of Color

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You're listening to SHORT WAVE from NPR. Hey, everybody. Maddie Sofia here with SHORT WAVE reporter Emily Kwong. Hi, Emily.

EMILY KWONG, BYLINE: Hey, Maddie. So today, I want to talk about the field of dermatology.

SOFIA: That's the one treating hair, skin, nails.

KWONG: Yeah, it's an amazing field. So skin is the largest organ of the body. We shed more than a pound of dry skin throughout the year. And it's a really visual field, OK? So dermatologists like Dr. Ginette Okoye rely on pictures to get a sense of what a disease looks like so they can recognize it in the moment.

GINETTE OKOYE: We're really scanning the patient from the minute we walk in the room, and many of our diagnoses - we actually know them from the door because rote memorization of what things look like is such a big part of our training.

KWONG: Ginette is chair of the department of dermatology at Howard University College of Medicine. And like a lot of dermatologists, she was paying close attention last spring when COVID-19 was giving some patients skin rashes. Do you remember that?

SOFIA: Yeah, I do. There were reports of COVID toes - like, people's toes swelling up. It usually showed up with more mild cases.

KWONG: Yeah, it was considered kind of a COVID red flag. But Ginette was noticing the pictures in clinical papers about COVID toes and other skin manifestations were overwhelmingly of light skin.

OKOYE: Historically, Black skin, brown skin is not represented in our literature appropriately, so it wasn't a surprise. It's just that on the heels of all the things that were going on in the country last summer, we thought that it was worth calling it out in a way that we hadn't called out our colleagues in the past.

KWONG: And out on the West Coast, dermatologist Dr. Jenna Lester was really noticing this, too.

JENNA LESTER: Here we have this disease that at that point we knew was disproportionately impacting communities of color, and we didn't know at that point what these rashes could help us understand.

KWONG: Jenna is an assistant professor in the department of dermatology at the University of California, San Francisco.

LESTER: That frustration turned from what I would consider, like, potential energy to kinetic energy when I was speaking to one of my mentors, Eleni Linos, and we decided to do this systematic review of the literature.

SOFIA: Turning your kinetic energy into data gathering - I like this, Emily.

KWONG: Well, you're going to like what happened next, because Jenna, her mentor Eleni and Ginette at Howard, alongside two medical students at the time, looked at all of the papers that had been published up to that point, having to do with COVID-19-related skin lesions, which is just a fancy word to mean that a part of the skin looks different from the rest. And they evaluated 130 pictures, categorizing them using the Fitzpatrick skin type system.

LESTER: And it's a scale from 1 to 6 where 1 is very light and 6 is very dark skin.

KWONG: And the results confirm their suspicion. The overwhelming majority of photos, 92%, were for skin types 1 through 3, so on the lighter end of the spectrum. There were a handful of type 4 photos and zero clinical images representing types 5 and 6, which are on the darker end of the spectrum.

SOFIA: I wish I was surprised about that, but I'm not, you know?

KWONG: Yeah, Jenna and her co-authors weren't surprised, and they published these findings in The British Journal of Dermatology in May 2020.

SOFIA: I mean, understanding this - like, understanding how COVID toes showed up in Black and brown people could have been really helpful diagnosing patients early on, right?

KWONG: Yes, exactly. And COVID toes is just the latest example of what dermatologists have known about their field for a long time, which is that skin of color has not been represented in a field that purports to care for the skin of all.

SOFIA: So today on the show, we take a close look at dermatology - how the science of skin care has evolved to better serve patients of color, but it still has a long way to go. This is SHORT WAVE, the daily science podcast from NPR.


SOFIA: All right, Emily, so today, we're talking about dermatology and skin of color.

KWONG: Right, and skin of color, by the way, Ginette tells me, is a term that not everyone uses.

OKOYE: People say skin of color. People say ethnic skin. Some people say multicultural skin or pigmented skin. I don't think it really matters. I think it's all a euphemism for non-white skin.

KWONG: And dermatology, historically, like all medicine, has not provided equitable care for patients of color. It's a field that has quite literally centered white skin to the detriment of Black and brown patients, because there are many skin conditions that present differently on dark skin. And this racial disparity - it shows up. It shows up in medical journals.

SOFIA: Like, with the COVID toes?

KWONG: Exactly, yeah. And Jenna Lester at UCSF says it shows up in medical textbooks, which overall lack images of skin of color. And when patients go to see a dermatologist, it shows up there too. Like, just listen to this commercial for psoriasis.


UNIDENTIFIED COMMERCIAL NARRATOR: Those itchy, flaky red patches you see on the outside could be a sign of inflammation on the inside.

LESTER: And in textbooks, they're described as salmon pink patches with silvery scales. That's the, quote-unquote, "classic" description of psoriasis. And I hate the word classic because generally, classic describes a rash as it appears in light skin.

KWONG: But on dark skin, Jenna says, psoriasis can present very differently.

LESTER: Inflammation can look more purple in dark skin. It can look more magenta-colored. It can even just be dark brown, several shades darker than the background skin tone. So any condition that presents or manifests with inflammation can look significantly more subtle in dark skin and also just may be a completely different color than you're expecting.

SOFIA: So, Emily, how has this ultimately affected patients?

KWONG: Well, we have solid evidence of serious health disparities in dermatology. Lyme disease, all kinds of rashes and cancers can go misdiagnosed or underdiagnosed in patients with skin of color.

SOFIA: Yeah, and that plus all the systemic problems that create health disparity in the first place can lead to poorer outcomes too.

KWONG: Yeah. For example, Ginette says a certain type of lymphoma called mycosis fungoides is easily misdiagnosed as eczema or some other benign skin condition if you don't know what to look for.

OKOYE: Many of the photographs in our textbooks, in our journal articles and lectures just didn't even include skin of color, so our eyes were not trained to find it in Black patients. So, you know, that's one example of a disease that actually kills people when we don't find it in time.

SOFIA: I mean, this is a really serious problem. And I know with melanoma, for instance, the five-year survival rate is lower with Black patients.

KWONG: Yeah, yeah, I'm glad you brought that up. It's around 66% for Black patients, compared with about a 90% five-year survival rate for white patients.

SOFIA: And that's in part because it's not being caught early enough, right?

KWONG: Exactly. So there's disparity around skin conditions being diagnosed correctly, but also disparity in being treated correctly with the right injections or creams. That's actually one of the reasons Ginette got into dermatology in the first place.

OKOYE: During medical school, I saw a dermatologist for a scalp condition, and he prescribed a medicated shampoo, and he told me to use it every day. And I thought, well, he must not know that Black women don't wash their hair every day, and that really stuck with me.

KWONG: And when Ginette entered residency, which was 15 years ago, she went beyond her textbooks to source images of skin of color, taking whatever condition she was learning about in school and researching how it presents on dark skin.

OKOYE: As I was trying to build my expertise in skin of color, I actually found this long, comprehensive journal article about skin of color that was written by Susan Taylor. And it sort of became my Bible during residency. I read it so many times.

KWONG: OK, so Susan Taylor is a name I heard a lot in these interviews. She's a professor of dermatology at University of Pennsylvania and a trailblazer in her field, Maddie. I had to call her up for this story because we might not be talking about skin of color this way if it weren't for Dr. Susan Taylor's contributions.

SUSAN TAYLOR: When I began practicing and I opened a practice in Philadelphia, many patients of color would come to me and say, you know, Dr. Taylor, I've been looking for so long for a physician who looks like me, who understands my skin, who understands my hair, and I am just so grateful to finally find you. And then I noticed that over the years, I had increasing numbers of skin of color patients.

KWONG: And she went on to revolutionize the field. So in 1999, she founded the first skin of color clinic at St. Luke's Roosevelt Hospital Center to advance treatment and research and cosmetic procedures for patients of color.

SOFIA: Wow, that's pretty cool.

KWONG: Yeah. And in 2004, she created the Skin of Color Society, which now supports dermatologists at over a dozen clinics across the U.S., including one that Jenna runs. Susan basically built the foundation upon which today's dermatologists are standing.

TAYLOR: We're making great strides. Now, here's one area where the gap remains, and that is in the workforce - the skin of color workforce.

KWONG: So when we look at the workforce of dermatologists in the U.S., only 3% are Black and about 4% percent are Hispanic.

SOFIA: Yeah, wow. That's super low. I mean, I've heard that dermatology is one of the least diverse specialties in medicine.

KWONG: Yeah, only after orthopedic surgery. Now, those strides are real. The textbooks used to train dermatologists have diversified over the years, especially the two big ones, "Dermatology" and "Andrews' Diseases Of The Skin." The American Academy of Dermatology has been pushing to create an image bank and more training materials. But you can't fix an entire field of medicine with pictures alone.

SOFIA: Right, I mean, there's a lot to focus on - recruiting and training more dermatologists of color, funding more clinical trials focused on patients of color.

KWONG: Yes, all of those things are important together. There's a lot of work to do. But this next generation of dermatologists, people like Ginette Okoye at Howard, are determined to do it.

OKOYE: So one of the things I try to instill in my trainees is we have to treat all of our patients like VIPs. The horror stories I hear from my patients about how they were treated by physicians of different types - I just want to erase all of that. I want them to have a really great experience with us. I want to sit in the room, spend time with them, touch them when other people wouldn't have touched them and make sure they understand their plan of care. We write things down for people, and we spend a lot of time getting to understand their life.

SOFIA: Wow. I mean, she sounds like an awesome doctor, Emily. I'll say it.

KWONG: Yes, she is. And Jenna Lester in California is, too. She continues to write about systemic racism in medicine, calling out the institutional barriers to becoming a dermatologist. And Susan is so proud of the work that Ginette and Jenna are doing. She sees them as the next generation, taking skin of color dermatology where it needs to go.

TAYLOR: And they're going to bring the people behind them up.

KWONG: Yeah.

TAYLOR: And then I can go to the beach and retire.


KWONG: Which beach would you want to go to first?

TAYLOR: Wai'alae. I love Wai'alae, you know, in Maui.

KWONG: Oh, yeah, awesome.

TAYLOR: That would be my beach, Emily. That's my beach. It's waiting for me.

KWONG: (Laughter).

TAYLOR: It's waiting for me.

SOFIA: This is a person that deserves a beach, Emily Kwong. Absolutely.


SOFIA: You know what I mean?

KWONG: She does. She does. Dermatology has changed a lot, but it still has a really long way to go.

SOFIA: All right, Emily Kwong, as always, we appreciate you and your reporting.

KWONG: Thank you, Maddie.


KWONG: This episode was produced by Thomas Lu, edited by Viet Le and fact-checked by Rasha Aridi. Special thanks also to Marcia Davis. I'm Emily Kwong.

SOFIA: And I'm Maddie Sofia. You're listening to SHORT WAVE, the daily science podcast from NPR.

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