When it comes to brown skin, where to whom do you turn when U.S. dermatologists are more than likely to be white, inexperienced, and/or untrained in properly caring for your specific skin type?
When a black mother took her infant daughter to a white dermatologist because she had developed an odd rash, the doctor “stuttered as he fumbled for an answer,” even turning to Google for some help in determining an answer. He eventually came to the conclusion that the condition could be “eczema, psoriasis, or merely baby acne.”
Unable to find a true result, he turned to the mother and said, “I’m not confidently familiar with how certain conditions present on darker skin.”
This is what people who are not white or gender-conforming are meeting face-to-face when visiting a dermatologist.
As mentioned on InStyle, “Many doctors aren’t up to speed when it comes to caring for skin of color or concerns of trans and non-binary patients - and it all comes down to a gap in dermatology education, as people working within the field and those trying to access care.”
Just how prepared are dermatologists when it comes to treating and caring for people who exist in the margins?
A 2016 report published in the Journal of the American Academy of Dermatology found that when it comes to dermatologists in the U.S., just “3% were Black (compared to 12% of the overall national population) and 4% were Hispanic (compared to 16.3% of the overall national population).
According to Dr. Sarika Snell, a D.C.-based dermatologist, “Believe it or not, some doctors can go through their whole training without having exposure to a diverse population including certain races and ethnicities.” That even includes the skin doctors study in their textbooks, as most of them “only provide photos of skin conditions on white skin.”
"A red rash can appear a different color on a Caucasian patient versus on a patient with skin of color — clinical dermatology is not one-size-fits-all. The way you treat one condition in one race may not be the same way you treat that diagnosis and treatment in another race and I believe it’s important to gain that well-rounded education during training."
That doesn’t mean that dermatologists aren’t aware of the disconnect; it does, however, mean that much work in education still needs to be done.
Dr. Fran Cook-Bolden, a Bronx-based dermatologist who has been practicing in New York City since 1996 and a graduate of Howard University Medical School, tells InStyle, “We were actually trying to address issues pertaining to skin of color, but in a broad way.” A founding director of the Skin of Color Center in the late 1990s at New York City’s St. Luke’s-Roosevelt Hospital, Dr. Cook-Bolden recalls the horror stories her patients revealed. “They’d say, ‘I’ve gone to a white dermatologist and they said either that there’s no treatment for me or they don’t know what to do’ — but what’s disappointing is that that’s what’s still being said to patients.”
There is also a lack of knowledge when it comes to treating the LGBTQ community, as some fear or have experienced some form of discrimination. There’s also the concern of hormone treatments that the patients may be currently on or may take in the near future, how to safely perform laser hair removal treatments, how to avoid misgendering a patient, and being treated poorly. When it comes to education, there is also, “limited literature on the treatment of transgender patients relevant to dermatology.”
“You have a trans woman who has acne and you’re like, ‘OK, I have all these hormonal treatments I can give her that I normally give my teenagers for acne, but now I have to be very mindful of where we are in her treatment and what feminizing hormones she’s on.’ Or if I have a trans man who is complaining about hair loss, I’m like ‘I can’t totally take away those male hormones.’ So it has actually created some new clinical concerns and a re-thinking of our usual treatment algorithm, says York, PA-based dermatologist Dr. Patricia Oyetakin.
And in such touching and sensitive cases in dealing with the LGBTQ community, Dr. Oyetakin asks her trans patients for permission to consult their endocrinologist in order to better understand their hormonal treatment plans and to better serve them.
“In terms of the LGBTQ community today, we’re probably where we were, unfortunately, 15 to 25 years ago with skin of color,” Dr. Cook-Bolden says.
Where do we go from here?
The onus of providing notes, research, and data around caring for skin of color has historically been on HBCU medical schools like Howard University and the now-closed King/Drew Medical Centre. But though strides are being made to tackle the issue now, the question is how?
When it comes to being able to care for all skin tones, it comes down to school curriculums that are based more in inclusiveness, which could also include educating “through organizations, through regional meetings, [and] through national meetings,” Dr. Cook-Bolden says.
“We have our classic textbooks that get updated from time to time, but the textbook on the shelf today was written two to three years ago,” says Dr. Oyetakin. “So keeping up with evidence and data hot off the press, we rely heavily upon the research, because those are the things that will actually impact patient care in real time.”
According to Dr. Cook-Bolden, schools like the Icahn School of Medicine at Mt. Sinai have courses addressing racism and bias and health disparities in general, plus they also have two sessions on LGBTQ patients, including trans health. On top of that, Cornell is now holding a group lecture on addressing LGBTQ patients.
Doctors and students are also taking it upon themselves to take elective learning opportunities outside of the office and classrooms by attending regional and national conferences to gain more education on the topics.
“In our American Academy of Dermatology meetings, the number of lectures on skin of color has just grown by leaps and bounds over the years,” Dr. Cook-Bolden says. “And this year in particular, I noticed in our summer session they had a special session addressing LGBTQ patients and their concerns — and they gave that course six times over the meeting to ensure they accommodated the number of attendees that might want to get that education.”
Though the aim is to have residency programs with a mandatory focus on diversity and the opportunity to learn through professional organizations, like with many medical fields, dermatology also requires lifelong learning. This means revamping the culture of dermatology education until “attending conferences and lectures, and sharing case studies across institutions with one another for greater exposure to different skin types and ailments is the norm rather than the exception.”