Skin of Color: Understanding the gaps in medical education that result in delayed or misdiagnoses

There have traditionally been missed opportunities to educate doctors on how to effectively diagnose and manage patients with skin of color. This ranges from not being properly trained to look for clues other than hues of pink or red, to not understanding the impact that missed diagnoses can have resulting in discoloration and dyspigmentation that follows any inflammation, to effectively managing scalp and hair concerns by not making the effort to understand the wide range of normal hair practices. The following is a short list of some of the more common scenarios that present in my practice.

Acne:

 

The basis of acne is clogged pores.  When these persist they can become inflamed and result in worsening of acne and the potential for scarring. 

The clogged pore stage of acne can be understood by recognizing that whiteheads are closed comedones and can be felt as a small bumps under the skin.  Open comedones, traditionally referred to as blackheads, are open pores filled with keratin. 

The inflamed stage of acne on lighter skin types can appear pink. In darker skin types the pink hue is not readily apparent.  If it worsens it can appear dusky or discolored. The goal is to catch acne before it gets to this point.  The main reason to catch it early is that if the inflammation persists, it's harder to avoid discoloration afterwards that can last for months. 

Looking for other clues to detect the inflamed acne stage?  Feel your skin! If those small bumps or clogged pores are enlarging or becoming inflamed they will feel larger, somewhat ‘juicy’ or fluctuant as they often are purulent or filled with pus.  They can be tender or sensitive to touch.  I encourage medical students and residents to touch or feel the acne to get a sense of how deep it is.  This is important to understand the skin on a 3 dimensional level and also to truly understand different skin types and how they present with acne. 

The most frustrating aspect of acne in darker skin types is that it often is caught or treated later in its course and can result in significant discoloration that can last months.  The key to avoiding this is appropriately diagnosing the stage of acne and starting treatment early. It is also important to integrate topicals that include ingredients that address the potential for discoloration early on such as retinoids and azaleic acid. 

 

Sunburn:

 

I find it frustrating that there is a misconception that darker skin does not burn in the sun.  Although it may be less likely to, it absolutely can burn and does.  It is also a common missed diagnosis.  I have had patients referred to me by their primaries or urgent care centers saying “my skin hurts” and their doctors cannot figure out why.  The red or pink may not be obvious but the skin discomfort is definitely your first clue. 

The other main feature is that the skin will be swollen with the skin marking lines less noticeable.  There can be a dusky or darker hue to the skin as well.  As it resolves the skin will shed or peel quite a bit.  It is important to manage this stage carefully by keeping the skin well hydrated with products such as white petrolatum because it is very common to see patchy discoloration that lasts months again if not managed appropriately.

 

Hair loss:

 

There are a multitude of reasons for hair loss but one version should be understood or highlighted simply because the hair loss may be the end result of inflammation that went untreated, unrecognized or missed entirely. 

 

Central centrifugal scarring alopecia and frontal fibrosing alopecia are types of scarring hair loss that actually may start in many cases as inflammation around the based of the hair follicle.  This inflammation if it goes unrecognized will result in scarring hair loss.  This is frustrating because once the hair loss occurs it can be permanent. 

 

Other clues that the inflammation is present if the pink is not readily apparent are flaking or scaling around the base of individual hair follilces and itching.  Another common symptom I find in many of my hair loss patients is that they feel a sensitive or ‘bogginess’ to their scalp.  Sometimes they will say that even when their hair is not pulled back they feel like they just ‘very aware’ of their hair or scalp. 

 

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