The medical community is not immune to racism. As a result, a growing percentage of the US population may be receiving inferior health care. That’s not only morally unacceptable, it’s bad business. In 2020, 52.2% of children in the US were minorities according the US Census. By 2044, 50.3% of all Americans will be “non-white.”

Despite the trend, like other industries, dermatology is plagued by structural racism, according to Dr. Susan Taylor, MD.

Taylor was one of several speakers at the Skin of Color Society’s Fifth Annual Media Day, which was held virtually last month.

“Structural racism, and the way it manifests within the health care system, as well as the communities where we practice, should be of concern to every physician because of the implications on public health,” observed Taylor.

She noted that the dermatology workforce currently comprises 7.2% Black and Latinx dermatologists, while the proportion of representation in the general population is 29.1%. To help rectify the imbalance, Taylor suggested four action items:

• Increase under-represented residents in medicine.
• Increasing funding for research fellowships for students.
• Build a pipeline of students from high school to college to medical students to mentor to support and to inspire them to enter medicine, specifically dermatology.
• Education. Many dermatologists feel their education is inadequate related to skin of color.

“We have called for dermatology education to include curricula that incorporate concepts of anti-racism implicit bias, cultural humility, health disparities and skin of color education and integrate them into all aspects of learning,” she said.

Dr. Rebecca Vasquez, MD noted that if a physician is uncomfortable serving diverse communities, or if the physician is not providing services that meet the unique social, cultural or even linguistic needs of her patients, it could affect clinical decision making.

“And that can affect my communication. I may talk faster. That can lead to shorter visits, less patient-centered care,” she explained. “We really need to acknowledge the history of discrimination, segregation and medical experimentation on the Black community and other groups in this country.”

The Skin of Color Society is changing that narrative by encouraging skin of color medical students to consider dermatology. SOCS is mentoring more of these students and offering more opportunities to them. The goal is to create a pipeline of dermatologists to improve patient care. According to SOCS President Dr. Donald Glass, MD, SOCS is partnering with VisualDx on #ProjectIMPACT, a global community dedicated to reducing healthcare bias in skin of color. The program includes education, information and shared resources to drive awareness of medical treatment disparities. #ProjectIMPACT is geared to physicians as well as the general public.

Dr. Valerie Harvey, MD noted that living in disadvantaged environments leads to worse medical outcomes. She said that psoriasis is more severe among racial and ethnic minorities. For example, Black Medicare patients with psoriasis are 70% less likely to receive biologic treatments. Similarly, a recent study revealed racial/ethnic, sex and insurance-based disparities in healthcare use and treatment for acne. According to Harvey, Medicaid patients are less likely than commercially insured patients to be prescribed topical and oral acne treatments. Black patients with acne are also less likely to receive systemic treatments.


More Education with L’Oréal’s Support

Finally, Harvey said Black, Hispanic and Asian patients with melanoma are 2-4 times more likely to present with metastases. Furthermore, these patients are twice as likely to have delays in diagnosis of 41-60 days, and three times as likely to have delays of 60-90 days.

“Early diagnosis is a crucial part of saving lives,” noted Harvey.

To help the medical community get up-to-speed on this fast-growing segment of the population, SOCS launched Dermatology E-Learning + Equity Platform (DEEP), a first-of-its-kind online learning management system that will enable members and non-members alike to learn straight from the experts at their own pace through dermatology educational webinars and practice management content. The program is made possible by a grant from L’Oréal’s dermatological beauty brands—SkinCeuticals, La Roche-Posay and CeraVe.

According to SOCS, DEEP will be a nimble resource that will offer emerging and highly relevant expert content. Dermatology education courses, spanning a wide array of skin of color dermatology topics, will be taught by SOCS experts, and practice management courses will be taught by leading subject matter experts. Initially, the course catalog includes lessons on keloids and hypertrophic scarring, an overview of hair disorders and non-scarring hair and scalp disorders in skin of color patients.


Hair Care Issues

Dr. Crystal Aguh, MD will teach the hair disorders course. Aguh was also on-hand during SOCS Media Day to detail some of the hair care issues that affect skin of color patients. She noted that 64% of dermatologists report that their understanding of hair care practices come nearly exclusively from personal experience, which creates great variability and delivery of care.

“That’s why so many patients want to see someone who looks just like them,” said Aguh. “Tightly curled hair is the most fragile hair type.”

She noted that regular use of harsh chemicals can lead to Acquired Trichorrhexis Nodosa, a defect in the hair shaft characterized by thickening or weak points (nodes) that cause the hair to break easily.

During Q&A, Aguh told reporters sodium lauryl sulfate (SLS) is fine for those with very straight hair that gets greasy very easily.

“But for dry-prone, curly hair, washing the hair even once with a shampoo containing this ingredient could lead to hair breakage in someone with curly hair,” asserted Aguh.
She recommended the following regimen for curly damaged hair:

• Apply light protein treatment to dry or damp hair. Cover with shower cap or heating source for 30 minutes.
• Wash hair once weekly with sulfate-free or gentle sulfate shampoo.
• Deep condition with every shampoo. Follow deep conditioning with moisturizing rinse-out conditioner.
• Add leave-in conditioner after washing, at least three times a week.
• End washing session with light oil. Detangle, air dry overnight in twisted sections. Style for week.

The estimated time for this regimen? Four to eight hours.

Dr. Candrice R. Heath, MD detailed more hair disorders in skin of color. Traction Alopecia is the result of chronic tension. Although it can happen to anyone, there is increased risk for those with tightly-coiled hair.

“Hair is breaking faster than it grows,” explained Heath. “Naomi Campbell lost her hair due to overuse of hair extensions. I tell my patients to change their hair care habits before they lead to permanent hair loss.”

She tried to dispel myths surrounding hair supplements. For example, Heath pointed out biotin deficiency, inherited or acquired, is very rare in the US. Furthermore, high dose biotin does not improve hair loss. and can interfere with cardiac troponin tests. This interference can make it difficult for medical staff to assess abnormalities such as thyroid disease or elevated cardiac troponin levels.

“Are you having a heart attack or not?” she explained.


Pigmentary Disorders

The amount, density and distribution of melanin are the primary determinants of the variability of human skin color. Differences in melanosome size, density and aggregation correlate closely with skin color, explained Dr. Janiene Luke, MD. Furthermore, there is no racial differences in the number of melanocytes between races. The ratio of keratinocytes to melanocytes in the epidermis is 36:1.

“As beauty standards continue to evolve, we’re trying to look at beauty through a more inclusive lens,” said Luke. “This should be reflected not only in the medications and the products that we research and develop, but in the images we select and the stories that we tell. We struggle with this, not only in the United States, but around the world with issues of racism and/or colorism.”

According to Luke, pigmentary disorders remain a common concern among people of color. For example:

• Hyperpigmentation is the No. 1 aesthetic concern of Latin type patients, making up 80% of Latin patient concerns visiting aesthetic dermatologists.
• Facial Aging Dyschromia is the No. 1 aesthetic concern of East Asian type patients. Luke noted that flawless skin tone is of utmost importance for Chinese Asian women, especially as they start aging.
• Post-Inflammatory Hyperpigmentation (PIH) is the No. 1 aesthetic concern of West Asian and African type patients, with 19.9% prevalence. PIH accounts for as much as 70% of African-type patients’ visits to aesthetic dermatologist for pigmentation issues.Luke added that post-acne scarring and dyschromia may distress patients more than the actual acne.

Common pigmentation disorders are hypopigmentation (vitiligo and post-inflammatory hypopigmentation) and hyperpigmentation (melasma and post-inflammatory hyperpigmentation).
Dr. Seemal Desai, MD is particularly passionate about vitiligo.

“There is a profound amount of psychological impact that is associated with vitiligo,” he noted. “More and more in the past few years, thanks to many of our media partners, there’s been a lot more attention in the public sphere on vitiligo and the psychological impact of the disease.”

Vitiligo treatments include topical therapies, oral steroids, light treatment, JAK (janus kinase) inhibitors, psychological therapy and combination modalities. Although there are no FDA-approved treatments to improve vitiligo, Desai said medical science is on the cusp of some revolutionary vitiligo treatments, especially regarding JAK inhibitors.

“Most importantly, I always assess the goal of the patients,” explained Desai. “Are they seeking treatments on their face because they are self-conscious about the way people look at them? Perhaps they’re not really worried about the covered areas of their bodies. Or, they may be more bothered by their hands or even the genital area.”

Desai said hyperpigmentation and melasma is due to genetic, hormonal and vascular factors, as well as UV and visible light exposure.

In treating hyperpigmentation, dermatologists have several targets:

• Inhibit melanogenesis with hydroquinone, arbutin, kojic acid, azelaic acid, licorice extract, ascorbic acid, resorcinol, retinoids.
• Inhibit melanosome transfer with niacinamide, soy and retinoids.
• Accelerate skin turnover with retinoids and alpha-hydroxy acids.
• Protect skin from UV rays and other inflammatory stimulants, including broad-spectrum SPF, ascorbic acid, vitamin E, cysteamine, niacinamide, ferulic acid, iron oxides and resveratrol.

Desai also said there is a global epidemic in skin bleaching.