The dearth of clinical images of the cutaneous manifestations of COVID-19 in higher Fitzpatrick skin types represents a larger problem: how can dermatology diagnose diseases in darker skin if clinicians do not know what to look for?
Medicine continues to uncover more and more information regarding the effects of SARS-CoV-2, including the dermatologic symptoms and long-term effects.1 Further, data collected by the Centers for Disease Control and Prevention show that racial and ethnic minority groups are at an increased risk of infection, hospitalization, and death.2
The Dermatologist spoke with Jenna Lester, MD, about the lack of clinical images of pernio/chilblains, also known as COVID toes, and how this acute disease translates to the broader application of dermatology literature, education, and practice.
Q. What has the literature told us about the prevalence of COVID-19, and how does your study build on that from the dermatologic perspective?
A. In general, research has shown that Black and Brown people are more likely to get infected, to be hospitalized with, and to die from COVID-19.3 There was a recent study published in Lancet Public Health that demonstrated that health care workers were more likely to get COVID-19 than the general population, but in particular, Black health care workers were more likely than their White counterparts to get infected.4 To be clear, there is no genetic basis for race, which is a social construct, so there is no reason to think that this increased risk has anything to do with a genetic tendency. This disproportional impact is more likely to be caused by lack of ability to shelter in place and access to personal protective equipment.
I found it frustrating, at least in the initial stages of understanding the cutaneous manifestations of COVID-19, that we were not seeing more reports of dark skin. I thought that if after 6 or 7 months of research we found that some cutaneous manifestations were an early sign of infection in an asymptomatic case, then it was something that patients could recognize and take the necessary precautions to prevent further spread. Based on what we know about the meaning of these rashes and the very people impacted most severely by COVID-19, I wanted to look at the then-available literature to see what gaps in knowledge existed.
We performed a systematic review in which we looked at journal articles published from December 31, 2019, to May 3, 2020, that mentioned the cutaneous manifestations of COVID and that also included photographs.5 Basically, we found that there were no photos of darker skin—Fitzpatrick types V and VI—and very few of Fitzpatrick type IV (6%).
These results affirmed our hypothesis of essentially no representation of these patients in the COVID-19 literature, which concurs with the overall dearth of skin of color images in the dermatology literature, a topic I previously published on last year6 that many others have highlighted as well. There is a need for one-to-one representation to help fix the disproportionate representation of people of color: for psoriasis, eczema, or basal cell carcinoma, we need a photo of presentation in all different skin tones. If dermatologists do not know what a dermatologic disease looks like in a darker skin type, how can we recognize it in our patients?
Since that article’s publication, Dr Roxana Daneshjou and colleagues at the Stanford School of Medicine in Redwood City, CA, published a case series of seven patients with photographs of COVID toes in Fitzpatrick types III to V.7 To the best of my knowledge, there have not been any other cases series published that would suggest a deviation from our study results.5
I think the lack of clinical images partially has to do with the fact that many of these patients are not presenting to dermatologists but rather their primary care doctors. I still think that is tangentially our responsibility, because oftentimes dermatologists are asked to write chapters in internal medicine or family medicine textbooks and we provide education and information to these nondermatologic specialties who happen to be on the front lines of dermatology. I think if we, as a specialty, say this is something we should all pay attention to, it would trickle down to reach all providers.
Q. What can dermatologists do to provide better care to their patients of color both now and in the future?
A. I think we forget that we have more similarities than differences in our actual skin. As I mentioned, race is a social construct. There have been studies that suggest that there are more differences within races than across races in terms of genetics.8 So, remembering that people of color get conditions such as rosacea or psoriasis and have similar concerns is important. I think our approach to a person of color, however, is different. We should ask ourselves a number of questions:
- Has this person experienced medical trauma?
- Has this person been disregarded by a doctor in the past and is bringing that experience to me?
- What can I do to be sensitive to those experiences?
- What strategies and skills do I need to learn in order to figure out how to navigate this situation to provide the patient the best care possible?
Research has demonstrated that patients of color are more satisfied during race concordant visits, meaning their race is the same as their doctors.9,10 This is one of the reasons we should diversify our workforce. But there are 422 Black dermatologists out of more than 10,000 dermatologists in the entire country—from the looks of it now, there will never be enough Black dermatologists to take care of all the Black patients. Bearing that in mind, all of us have a responsibility to take care of all patients. A survey found 47% of dermatologists and dermatology residents reported feeling inadequately prepared to treat Black patients.11 Therefore, we need to do whatever is necessary to improve our education and to take continuing medical education courses geared towards filling gaps in our residency education, which definitely exists.
Dermatologists feeling unprepared should do whatever they would do if they encountered a disease they did not recognize: call up a friend who may have seen this more than you have or go to the literature to find the top treatments for this. You can attend conferences, such as the American Academy of Dermatology (AAD) meeting, and set out your intentions for the meeting by asking yourself where are my gaps of knowledge and what do I need to learn?
We all have the skills to overcome roadblocks in our knowledge and our education. That is a lot of what dermatology residency is about, figuring out how to learn rather than memorizing a certain set of facts. Those same skills should be employed in any patient situation where you are unsure, but I think the key is recognizing that this person deserves as good of care as you give to the patient who you know exactly how to treat them and you feel totally comfortable with them. Going that extra mile and making sure that you fill gaps in your knowledge that are needed to give that patient of color the best care possible is the key.
Q. How can dermatology evolve to provide equitable care to all patients regardless of their skin type?
A. I think that we recognize the lack of photos as a problem, and we recognize that this has implications on education and how well we are training the next generation of dermatologists.
We know that racist structures are not dismantled by individual action, and we know that these problems exist beyond one’s individual desire to make things right. So, when you have an institutional problem, there needs to be an institutional solution. There really needs to be an effort, not by just one individual dermatologist, but an academy-wide effort, to address structural racism in our specialty. This is an effort that needs to start with the leadership of the AAD prioritizing racism as something to be addressed. I believe that once the effort and momentum to do things start at that highest level, things will get fixed pretty quickly.
1. Long-hauler patients show prolonged cutaneous symptoms of COVID-19. The Dermatologist. Accessed November 2, 2020. https://www.the-dermatologist.com/news/long-hauler-patients-show-prolonged-cutaneous-symptoms-covid-19
2. Hospitalization and death by race/ethnicity. Centers for Disease Control and Prevention. August 18, 2020. Accessed November 2, 2020. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
3. Dyer O. Covid-19: Black people and other minorities are hardest hit in US. BMJ. 2020;369:m1483. doi:10.1136/bmj.m1483
4. Nguyen LH, Drew DA, Graham MS, et al. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet Public Health. 2020;5(9):E475-E483. doi:10.1016/S2468-2667(20)30164-X
5. Lester JC, Jia JL, Zhang L, Okoye GA, Linos E. Absence of skin of colour images in publications of COVID-19 skin manifestations. Br J Dermatol. Published online May 29, 2020. doi:10.1111/bjd.19258
6. Lester JC, Taylor SC, Chen MM. Under-representation of skin of colour in dermatology images: not just an educational issue. Br J Dermatol. 2019;180(6):1521-1522. doi:10.1111/bjd.17608
7. Daneshjou R, Rana J, Dickman M, Yost JM, Chiou A, Ko J. Pernio-like eruption associated with COVID-19 in skin of color. JAAD Case Rep. 2020;6(9):892-897. doi:10.1016/j.jdcr.2020.07.009
8. Chou V. How science and genetics are reshaping the race debate of the 21st century. Science in the News. April 17, 2017. Accessed November 2, 2020. http://sitn.hms.harvard.edu/flash/2017/science-genetics-reshaping-race-debate-21st-century/
9. Tanne JH. Patients are more satisfied with care from doctors of same race. BMJ. 2002;325(7372):1057.
10. Chen FM, Fryer GE Jr, Phillips RL, Wilson E, Pathman DE. Patients’ beliefs about racism, preferences for physician race, and satisfaction with care. Ann Fam Med. 2005;3(2):138-143. doi:10.1370/arm.282
11. Buster KJ, Stevents EI, Elmets CA. Dermatologic health disparities. Dermatol Clin. 2012;30(1):53-vii. doi:10.1016/j.det.2011.08.002