In the last few years there has been increased awareness of deficits in dermatology training when it comes to skin of colour (SoC). Any user of Tele-Derm will have noted the significant number of requests for advice in patients with SoC posted. Especially from the Northern Territory, North Queensland and Western Australia. Images of skin conditions in popular texts are usually of light skin. It is well known the clinical features of common dermatoses can differ in darker skin.
A recent article in the Australasian Journal of Dermatology (Identifying dermatological emergencies in patients with skin of colour: Insights from Australian emergency medicine practitioners, published online May 31, 2024) addresses the uncommon but important issue of dermatological emergencies in SoC. These will first present to general practitioners or emergency doctors. The authors pose the question ‘what are the knowledge gaps and preferences for further education among emergency medical practitioners in diagnosing dermatological emergencies in patients with SoC’?
They addressed this by surveying emergency medicine practitioners in Victoria.
They state they “gathered information regarding participant demographics, confidence in diagnosing dermatological emergencies in individuals with SOC and attitudes towards current training formats. The quiz comprised clinical images of dermatological emergencies in four separate patients with SOC, accompanied by multiple-choice questions. A total of 76 doctors participated in the survey, including 17 junior doctors (22%), 18 registrars (24%) and 41 consultants (54%).”
The emergencies illustrated were cellulitis of the lower limb, eczema herpeticum in a child, psoriatic erythroderma and toxic epidermal necrolysis in an adult. Interestingly the respondents had by far the most difficulty with diagnosing cellulitis and erythroderma. This is because darker skin masks the erythema of cellulitis. Psoriasis in dark skin looks distinctly violaceous rather than the salmon pink we see in the fair skinned. In both conditions the correct diagnosis was made by far fewer than half the clinicians.
The two blistering conditions were correctly identified by around 80% of the participants. This stands to reason as grouped , monomorphic vesicles and superficial erosions of eczema herpeticum and the widespread denuded skin with flaccid bullae are readily identifiable regardless of skin tone.
This certainly reflects my experience where I am far more likely to need to biopsy to diagnose conditions such as eczema, psoriasis or lichen planus in SoC than in Caucasians.
The surveyed practitioners felt that around one third of their patient load had SoC. Less than a third felt they had received adequate training in managing presentations such as toxic epidermal necrolysis, erythroderma or pemphigus. I suspect however that not a few of them would not have been confident regardless of skin colour in managing these uncommon conditions.
99% agreed that they needed increased training in the area. Worryingly only 5% had received any teaching in the area in the last 12 months.
Preferred methods of education were noteworthy. Around half preferred on line modules, one third wanted webinars and a similar number expressed a desire for bedside teaching. The latter would be hard to achieve as these presentations are rare and dermatologists are thin on the ground in accident and emergency!
To me it is noteworthy that ACRRM has been a pioneer in online education. They were delivering on line education and satellite-based live educational events at least 25 years ago.
Around 75% felt SoC dermatoses should be included in the fellowship exams. The authors argue that this would require adjusting trainee curricula, offering CME and creating resources of high quality images of skin conditions in SoC.
There is a significant amount of material available in this area, see https://cdn.bad.org.uk/uploads/2022/02/29200007/Educational-Resources-for-Clinicians-on-Skin-of-Colour-in-Dermatology-2020.pdf.
However, most textbooks certainly have more fair than dark skin in their clinical images.
Although this is a small study and the results by no means unexpected, they drive home an important point. Skin disease is a diagnostic and management challenge in skin of colour. The shortcomings in training in this area need to be addressed. Online education will remain vital to delivering same. I suspect that ready access to dermatologist review either online or in person is also crucial. Having said that image-based diagnosis in SoC is definitely more challenging in SoC.
Dr Jim Muir