Race and Medicine
Race and Medicine
Disclosures: The researchers report no relevant financial disclosures.
April 07, 2021
3 min read

Darker skin tones 'significantly underrepresented' in major rheumatology image banks

Disclosures: The researchers report no relevant financial disclosures.
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Darker skin tones are “significantly underrepresented” in rheumatology clinical image banks, including the American College of Rheumatology Image Library and The New England Journal of Medicine Images in Clinical Medicine, according to data.

“Rheumatic diseases disproportionately impact racial and ethnic minorities, and disparities in health outcomes are prevalent,” Adrienne Strait, BA, of the University of California, San Francisco School of Medicine, and colleagues wrote in Arthritis Care & Research. “Clinical images are a key tool in rheumatology education. For example, cutaneous manifestations are common extra-articular findings of rheumatic disease. Therefore, education in identifying skin rashes and lesions is a core part of rheumatology training.”

Darker skin tones are “significantly underrepresented” in rheumatology clinical image banks, according to data. Data derived from Strait A, et al. Arthritis Care Res. 2021;doi:10.1002/acr.24602.

“Morphology and appearance of skin conditions vary depending on the skin phototype of an individual, thus trainee exposure to educational materials that highlight patients of diverse racial and ethnic backgrounds is important,” they added. “Given evidence that the underrepresentation of racial and ethnic minorities in medical education resources may perpetuate health care disparities, it is imperative to characterize better the current representation of racial and ethnic minority groups in rheumatology educational materials so that trainees learn how to recognize disease in all their patients, not just some.”

To analyze the representation of darker skin color in clinical images among the major rheumatology training resources, Strait and colleagues examined four sources — the ACR Image Library, UpToDate, The New England Journal of Medicine Images in Clinical Medicine and Clinical Cases, and the 9th edition of Kelley’s Textbook of Rheumatology. For The New England Journal of Medicine, the researchers filtered their results by “rheumatology.” Black-and-white pictures, images demonstrating diagnostic and therapeutic procedures, those taken through a dermatoscope, images focusing on mucous membranes and pictures of eyes were excluded.

Adrienne Strait

Strait and colleagues used Fitzpatrick’s skin phototypes to independently code images demonstrating visible skin as either “light,” defined as skin types I to IV; “dark,” defined as skin types V to VI; or “indeterminate.” In addition, the researchers compared the representation of dark skin in clinical images to that of Asian, Native American and Black individuals in the U.S. population, based on census data, and among U.S. lupus cases.

Strait and colleagues gathered and analyzed 1,043 images, included 538 from the ACR, 265 from UpToDate, 85 from The New England Journal of Medicine and 155 from Kelley’s Textbook of Rheumatology.

According to the researchers, 13.4% portrayed dark skin, while 84% demonstrated light skin and 2.6% were indeterminate. This, despite U.S. census figures showing Asian, Native American and Black individuals comprising 20.6% of the population (X2 = 32.8; P < .001), the researchers wrote.

Dark skin was “underrepresented considerably more” in images of patients with systemic lupus erythematosus, they added. According to the researchers, Asian, Native American and Black individuals represent approximately 44.2% of all prevalent SLE cases in the United States. Yet, overall representation of dark skin in SLE images was only 22.6% (X2 = 20; P < .001).

“Images of people with darker skin tones are significantly underrepresented in major rheumatology clinical educational resources, including among rheumatic diseases such as SLE that disproportionately affect racial and ethnic minority groups,” Strait told Healio Rheumatology. “This highlights an opportunity to improve the diversity and equity of representation of dark skin tones in rheumatology curricula in order to better equip trainees to recognize cutaneous manifestations of rheumatic disease in all their patients, not just some.”

To improve racial and ethnic representation in clinical images, the researchers proposed the following steps:

  • Education resource editors should improve the representation of dark skin color in images of all rheumatic diseases, starting with those that are most commonly associated with skin manifestations, including SLE, vasculitis, inflammatory myopathies, systemic sclerosis, sarcoidosis and psoriasis;
  • Educators in academic rheumatology programs should collaborate to improve diversity of patient representation in curricular resources used at the undergraduate and graduate levels;
  • An ACR taskforce could improve racial and ethnic diversity represented in the ACR Image Library and other resources; and
  • Speakers at rheumatology conferences should use their platform to educate attendees about presentations of rheumatic diseases in individuals of color.

“Underrepresentation of dark skin tones among educational materials may perpetuate health disparities by increasing the risk for misdiagnosis or diagnostic delay when diseases present in people with skin of color,” Strait said. “In addition, it may contribute to implicit bias and structural racism present in medical education by promoting white-only models of disease. We should work together to develop more equitable educational tools.”