Eczema. Psoriasis. Vitiligo. Ringworm. School nurses are accustomed to frequent visits from students with all sorts of rashes. Students in our schools represent a diverse population with a variety of shades of skin color. Addressing the unique expression of skin condition on various shades of skin is essential in both diagnosis and treatment.

• Some skin conditions are more prevalent in people with lighter skin and others in people with darker skin.
• Some skin conditions are more responsive to different types of treatment depending on the shade of skin of the person with the condition.
• Many skin conditions require different diagnostic information depending on the shade of skin of the person involved.

Prevalence

Some skin conditions, like atopic dermatitis, the most common kind of eczema, are “more prevalent in African American and Asian/ Pacific Islanders individuals than Caucasians” (Espinosa, M.,B.S. & Lio, 2019). Others, like psoriasis, are “found more frequently in white (3.6 percent) than in African American (1.9 percent) and Hispanic (1.6 percent) populations.” (National Psoriasis Foundation, 2021).

Treatment

Skin conditions can affect various skin types in unique ways, requiring different treatments. For example, Nanette Silverberg, MD, clinical professor of Dermatology and Pediatrics, Icahn School of Medicine at Mount Sinai, and chief, Pediatric Dermatology, Mount Sinai Health System, New York, explains that African American children with atopic dermatitis often respond better to a different treatment than children with other shades of skin. “In African American children … reductions in ceramide content … could be the reason the skin barrier is not working as effectively as it should be… As a result, physicians treating children of color with eczema often need to use thicker emollients, including those containing extra ceramide content or extra balanced fat content in order to enhance the skin barrier.” (Hilton, 2016).

Diagnosis

Skin and rash color is often used when diagnosing skin condition, and changes in skin color caused by rash appears different on different shades of skin. Other diagnostic traits of rashes, even beyond appearance, can differ among people with different shades of skin.

Silverberg explains that, “In somebody who is very light skinned, eczema is going to be red, but in children of color, we see much less erythema. Instead, we see much more in the way of lichenification, or thickening of the skin, and more follicular prominence … These are particularly vexing types of eczema in that the lichenification or lichenoid type of dermatitis is often very thick and very itchy. And the follicular type can be quite deceptive. You don’t see redness. You don’t necessarily see thick or oozing skin, but it is incredibly itchy and it significantly affects children psychologically.” (Hilton, 2016)

Diagnostic Imagery

Imagery, like the images in a Dermatology DDXDeck, help medical professionals diagnose skin conditions. Recently, awareness has been raised that much of the diagnostic imagery most frequently used for skin conditions includes images mostly of light-colored skin and does not adequately include various shades of skin colors, which can impact diagnosis and treatment for people with darker skin. Recent media pieces that brought awareness to this issue include:

• A 2020 New York Times article, “Dermatology Has a Problem with Skin Color,” references a lack of diversity of imagery in diagnostic materials as well as dermotological textbooks.
• An NPR morning edition piece, “Diagnostic Gaps: Skin Comes In Many Shades And So Do Rashes,” shares the perspective of a parent, Ellen Buchanan Weiss, who could not find images of a skin condition her son had on shades of skin similar to her son’s skin.
• The same NPR piece also references concerns from Dr. Lynn McKinley-Grant, a dermatology professor at Howard University and president of the Skin of Color Society, that medical schools have “limited pictures of diseases in skin of people of color."

Original reference decks like the Pediatric Dermatology DDXDeck and Dermatology DDXDeck include images of the most common dermatologic diagnoses. Newer tools that encompass the diversity of shades of skin color include:.

• VisualDx: Essential Dermatology in Pigmented Skin desk reference and online decision support system.
  • Contains over 700 full-color illustrations of skin diseases in adults and children with darkly pigmented skin.
  • Gives users point-of-care assistance in diagnosing and managing skin diseases in darkly pigmented skin.
  • Was written and edited by clinicians with extensive experience caring for patients with pigmented skin, including Hispanics, African-Americans, and diverse patients from many countries.
• Dermatology Atlas for Skin of Color.
  • Contains more than 300 color photos.
  • Focuses on dermatologic conditions that are most common in ethnic skin or skin of color.
  • Includes succinct explanations of each disease process, describes clinical findings, and presents key information on diagnosis and treatment

Whether a student comes to a school nurse with warts or a more serious skin condition, having diagnostic tools that properly reflect how various skin conditions impact people with all shades of skin is essential.

References

 “Diagnostic Gaps: Skin Comes In Many Shades And So Do Rashes.” Shots: HEALTH NEWS FROM NPR, NPR. 4 Nov. 2019, https://www.npr.org/sections/health-shots/2019/11/04/774910915/diagnostic-gaps-skin-comes-in-many-shades-and-so-do-rashes

 Espinosa, M.,B.S. & Lio, P., M.D. “Skin Issues That Affect Patients With Skin of Color.” Dermatology Times, Dermatology Times and Multimedia Medical, LLC. 5 Feb. 2019. https://www.dermatologytimes.com/view/skin-and-disparity-issues-affect-patients-color.

 Hilton, Lisette. “Common pediatric disorders in skin of color.” Contemporary Pediatrics, 1 Oct. 2016, https://www.contemporarypediatrics.com/view/common-pediatric-disorders-skin-color.

 “Psoriasis and Skin of Color.” Advance Online, National Psoriasis Foundation, 16 Feb. 2021,   https://www.psoriasis.org/advance/diagnosing-psoriasis-in-skin-of-color/.

 Rabin, Roni Caryn. “Dermatology Has a Problem With Skin Color.” New York Times, 30 Aug. 20