Should a health care provider consider the color of a patient's skin in making a medical decision?
If they're a dermatologist, yes – as long as there's a scientific reason to do so.
"Ethnicity and skin tone can make a big difference in terms of diagnosis and treatment options with a number of different skin conditions," said Amy McMichael, M.D., professor and chair of dermatology at Wake Forest Baptist Medical Center.
The majority of skin problems – including the one most commonly seen by dermatologists, acne – occur in people of every ethnicity and skin color. However, the amount of melanin, which is the pigment that gives skin its color, an individual has can greatly influence their risk of and reaction to many different conditions. For an obvious example, a fair-skinned person with a low level of melanin is far more likely to get sunburn than someone with a melanin-rich dark complexion
But that doesn't mean darker-skinned people are immune to sun damage: Their higher levels of melanin offer greater, but not total, protection from the sun's ultraviolet rays. However, those same melanin levels also make darker skin more reactive to inflammation and injury, resulting in problems such as the development of long-lasting or permanent dark spots at the sites of even relatively minor irritations, such as insect bites.
Those dark spots, called hyperpigmentation, are among the dermatologic conditions that occur more frequently, are more severe or appear differently in people with skin of color – which broadly includes those of African, Asian, Hispanic, Middle Eastern, Native American and Pacific Island heritage – than in individuals of Caucasian descent.
"There are a lot of myths out there about which groups are or are not affected by certain conditions," said McMichael, who is currently the only African-American woman to chair a dermatology department in this country.
"That African-Americans don't get psoriasis is a big one. We've found that a number of people of African descent not only have it but that it can be a lot worse and a lot more extensive. And psoriasis is one of the conditions that can look so different in people with darker skin that it's confusing and often not recognized by family physicians or even people trained in dermatology."
Misconceptions about whether members of a particular ethnic group are or are not at elevated risk for certain skin diseases are not limited to people outside that group. The Skin of Color Society (SOCS), an international organization of physicians dedicated to advancing dermatology in people with pigmented skin, says that members of these populations "often have an inadequate understanding of the root causes of skin diseases that commonly affect them."
"There's probably more than one factor playing a role there, but I think a lot of it is cultural," said McMichael, immediate past president of SOCS. "I think if you're told 'This is what we get' you think 'This is what we get' and that's it. There's no understanding there that the condition can be treated, or maybe even prevented.
"There's also the problem of 'We don't get that.' For example, many people in the Hispanic community feel they're not at risk for skin cancer. That's not true. Hispanics come in all shades of the spectrum, but people of Hispanic descent who work outdoors and never put on sunscreen or a hat can definitely end up with skin cancer down the line."
SOCS also says that many people with darker skin have misconceptions about potential cures for skin conditions "and spend considerable financial resources on ineffectual non-prescription, folk or home therapies."
"For some people, cocoa butter fixes everything. That's a common cultural thing with African-Americans," McMichael said. "The problem is that cocoa butter has fragrances and other chemicals in it and can be very irritating. It can be a good moisturizer, that's basically what it is, but some people will slather it on just about anything, and they shouldn't."
But people of color aren't the only ones who should be better acquainted with the conditions associated with pigmented skin, McMichael said. Medical providers – especially family physicians, who are frequently the first providers to be presented with skin problems, and dermatologists – need to be more aware of these issues.
That's because this country is becoming more, well, colorful. As of 2016, five states – Hawaii, New Mexico, California, Texas and Nevada – and the District of Columbia had minority-majority populations (less than 50 percent non-Hispanic whites), and it is estimated that the nation's population as a whole will become minority-majority before 2050.
"This means that many of us are going to be dealing with patients of all ethnicities, even ones we're not necessarily familiar with," McMichael said. "We'll have to be versatile, to take into consideration how their pigmentation or cultural practices affect their particular problem and how it can best be addressed."
The field of dermatology would benefit, she added, if it were more diverse, as it currently ranks near the very bottom among medical disciplines in terms of minority representation.
"There are efforts by the American College of Dermatology to improve that," McMichael said. "That's not to have more minority dermatologists who'd just see minority patients. It would ideally mean there'd be more dermatologists aware of and sensitive to the factors involved with skin and hair conditions in people with skin of color and how to properly identify and treat them."