Dermatology for Skin of Color
Aug 24, 2021 Cassie Tomlin, illustration by Janna Morton
Dermatology suffers from a race gap. Skin conditions, and skin symptoms caused by medical conditions, look different on people of different races. But many physicians are trained to recognize dermatological issues only on light complexions—meaning non-white patients are often undiagnosed or misdiagnosed and can miss out on critical and time-sensitive treatment. Moreover, patients and physicians lack awareness about skin diseases that predominantly affect people of color and the ways cosmetic procedures should be performed on them to avoid adverse effects.
A focus on physician training and treatment gaps aims to correct disparities in care, says Jasmine Onyeka Obioha, MD, a Cedars-Sinai dermatologist. Obioha is specially trained in how to treat the diverse complexions of Black, Asian and Latino patients. Here, she outlines what patients need to know about their skin—and the importance of finding a provider experienced in treating a broad range of people.
Conditions to Watch For
Medical textbooks largely feature images of disease only on white skin. “The exclusion is problematic since primary care physicians diagnose many conditions, at least initially, by sight,” Obioha explains. Even common issues like psoriasis, which causes itchy, scaly patches, often go undetected in patients of color: On darker skin, scales and patches can show up purple or gray, not red or pink like on white skin. While psoriasis can’t be cured, diagnosis can lead to relief with medications, such as injections and creams, or light therapy.
Alopecia, a condition marked by hair loss, is among the most common dermatological diagnoses for Black patients. One under-researched form of this type of hair loss—central centrifugal cicatricial alopecia (CCCA)—almost exclusively impacts Black women and is often mistaken for female-pattern hair loss, a less damaging condition. CCCA can be treated when caught early—but causes irreversible hair loss if left unchecked.
More complex conditions get overlooked, too, with severe consequences. An aggressive type of mycosis fungoides, the most common form of lymphoma (a type of cancer) on the skin, is more common in Black, Latino, Middle Eastern and Asian populations. In Black patients, the condition often goes undetected longer, and they’re less likely to survive the disease than white patients. Recognizing symptoms—such as thicker skin and early-stage patches and lesions that can look yellow or gray on darker skin—is important to stopping the progression of lymphoma, Obioha says.
It’s part of a bigger problem—patients of color often don’t get the right care for their skin.”
- Jasmine Onyeka Obioha, MD
Black people are less likely than other populations to develop skin cancer and, as a result, may be screened less often and with less scrutiny. But Black and Latino patients are at higher risk for acral melanoma, a skin cancer of the hands and feet that isn’t necessarily caused by sun exposure.
Obioha notes that infrequent checkups, paired with less awareness about skin cancer risk for patients of color, means these patients get diagnosed later, when prognosis is worse.
“It’s important for patients of all ethnic backgrounds to get regular skin checks and for dermatologists to check the palms of the hands and the bottoms of feet thoroughly,” Obioha adds.
Care with Cosmetic Procedures
Cosmetic procedures were on the rise in the pandemic—but such practices can have poor results for patients of color, according to Obioha. Skin that’s rich in melanin pigment is more likely to scar or darken after being inflamed by procedures like chemical peels, laser facials and hair removal. But such procedures are safe and appropriate for people of color when performed with the right techniques and equipment.
Even mole and skin tag removal carries a risk of side effects on pigmented skin: Liquid nitrogen used to freeze off a benign growth can leave a light spot in its wake. As an alternative for people of color, Obioha considers electrocautery, a technique that uses heat to remove the growth, which is less likely to leave a mark.
“Not every procedure we do in lighter skin is good for darker skin, so patients have to be really intentional in seeing someone who is experienced with a diverse patient group,” Obioha says.
Obioha notes that her Cedars-Sinai dermatology colleagues are adept and actively attuned to the nuances of treating darker skin types.
“Race does affect medical care,” she says, “and right now, a lot of directed efforts are calling attention to disparities and how we play a role in correcting them as we practice medicine.”
Better Hair Help
Only 3% of dermatologists in the U.S. are Black, and the field generally lacks understanding about cultural differences in caring for people of color, Obioha says. One fraught factor, especially for Black women: hair. Even simple dandruff treatment often fails when physicians make insensitive prescriptions.
“Dandruff can be treated with shampoo, but if physicians say to use it three times a week, patients won’t use it at all—the overwhelming majority of Black women wash their hair no more than once a week,” she says. “Physicians need to understand these complexities and nuances for ethnic skin and hair so patients don’t immediately lose confidence in them.”
Obioha also sees many Black patients for styling-related hair loss and tailors recommendations based on her own experiences, rather than recommending a patient abandon hairstyling entirely.
“Hair loss is already such an emotional condition to open up about with someone you’ve never met,” she says. “That level of connection and cultural competence is hard to achieve if you don’t have that foundation.”