The Doctor Treating Skin Of Color
Dermatologists presented with a new patient have a number of symptoms to look at in order to diagnose. Does the patient have a rash, bumps, or scaling skin? Is there redness, inflammation, or ulceration? For rare conditions a doctor may have never seen in person before, it’s likely that they were trained on photos of the conditions—or can turn to colleagues who may themselves have photos.
But in people with darker, melanin-rich skin, the same skin conditions can look drastically different, or be harder to spot at all—and historically, there have been fewer photos of these conditions on darker-skinned patients. And for these patients, detection and diagnosis can be life-saving: people of color get less melanoma, for example, but are also less likely to survive it.
Dermatologist Jenna Lester, who started one of the few clinics in the country to focus on such patients, explains the need for more dermatologists trained to diagnose and treat people with darker skin tones—and why the difference can be both life-saving and life-altering.
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Jenna Lester is an assistant professor of Dermatology at the University of California-San Francisco Medical School in San Francisco, California.
IRA FLATOW: This is Science Friday. I’m Ira Flatow. Have you made an appointment to see your dermatologist recently? Maybe get a skin cancer screening or check out that inflammation? If you’re a person of color, someone with darker, melanin-rich skin, it’s statistically likely that your dermatologist is not. And while that shouldn’t matter, it’s also likely that they trained on photos that were more likely to be from light-skinned patients, and in such an intensely visual field where redness and discoloration are important symptoms, what consequences does this lack of diversity in both practitioners and data have for the patients?
My next guest has asked both these questions, and in response, opened one of the few clinics in the country that specializes in patients with melanin-rich skin– skin of color, the technical term. Dr. Jenna Lester, Assistant Professor of Dermatology, University of California San Francisco Medical School, and Director of their Skin of Color Clinic joins me here at KQED.
JENNA LESTER: Hello.
IRA FLATOW: So what drove you to open this clinic?
JENNA LESTER: A number of factors. When I was a resident, I would always be struck by the reaction that patients of color would have when I’d walk through the room. They pretty much uniformly would say, wow, I’ve never had a black dermatologist before. I feel like you’re going to understand my skin. Especially if it was someone with a hair concern, they would say, you know, dermatologist x told me to use this on my hair and told me to wash my hair every day, something that if you’ve ever come in contact with a black woman, you know that that’s not something that we do. It just spurred me to– well, first of all, I realized what a big issue that was, and made me want to create a place where these patients felt comfortable.
IRA FLATOW: Do dermatologists– are they able to recognize the differences in the skin of people who have darker skin? I mean, when you get trained–
JENNA LESTER: Yeah.
IRA FLATOW: –does the training help you?
JENNA LESTER: I think the training does help, and I think that’s one of the things that I want to focus on is education because studies have shown that close to half of graduating dermatology residents don’t feel comfortable diagnosing skin conditions in skin of color. And I think that has a lot to do with exposure. Part of it depends on where you trained. If you trained in an area of the country that’s less diverse as opposed to a place that has a lot of racial and ethnic diversity, you may have had differential exposure to these things in the clinic, and so then you rely more on photographs that you look at from textbooks, et cetera. So I think that is sort of the crux of the issue.
IRA FLATOW: Is there any bias in the photographs?
JENNA LESTER: So I have found that there is. We took, along with a group of medical students, took a look at photographs in common teaching textbooks and teaching slide sets and found that about a third of those images were of darker skin tones. And you may think, OK, well a third. That’s probably enough. But if you consider that many dermatologists need to know rashes that they may have never seen in real life, you realize how much more important those photos become. And I would say we need one to one representation of every skin condition in every different skin color. That would be ideal.
IRA FLATOW: Mhm. Our number, 800-844-724-8255. You can also tweet us @scifri. Why is this training deficiency so important for the patient outcome?
JENNA LESTER: Well, there are several disparities in dermatology in general but across all specialties in medicine. And I think education on these, the differences and what color looks like in different colored skin is really important. Addressing those disparities and not contributing to delays in care and making patients feel comfortable and that you’re informed and know what you’re talking about.
IRA FLATOW: Mhm. How differently do skin conditions present when your skin is darker? In something like psoriasis, for example.
JENNA LESTER: Yeah. That’s a great question. So there’s a concept called simultaneous contrast, which it comes from color theory and was first described in the mid-1800s. And that’s the concept that color is dynamic, and so the color surrounding anything in particular that you’re looking at really affects how it hits your eye. And so erythema, or redness, inflammation in the skin, when we see it, we describe it as red or pink. And in darker skin, it can actually look more, what we say in dermatology, violaceous or purple, sometimes dark blue. And if your eye’s not trained to see that, then you miss it.
IRA FLATOW: Mhm. So it’s harder. You really have to be trained to see that.
JENNA LESTER: Yes. And I think repetition is the greatest teacher, so if you don’t see this over and over and over again, in situations where there’s time pressure, where you don’t have enough information or you have incomplete information, you have to make decisions quickly, this is something that you might miss.
IRA FLATOW: Well, so then, should people with darker skin themselves be more cognizant of changes in their skin? Because they might not feel that they need to.
JENNA LESTER: Yeah. I think many are, and what I’ve heard from patients is they come to the doctor and are told nothing’s wrong sometimes. I do also think that there is education that we as dermatologists need to give our patients about the fact that skin cancer, while it’s less common in patients with darker skin, still happens. And when African-American patients, for example, when they present with melanoma are more likely to have advanced disease and are more likely to present with nodal metastases or spread to other parts of the body.
IRA FLATOW: Is that because they’ve waited so long?
JENNA LESTER: Yeah, I think it’s because they waited. Maybe they’ve been told skin cancer’s not something that can happen to you. And in patients with darker skin, these are more likely to happen on areas of the body like the palms of the hands or the soles of the feet. Maybe you don’t look in those areas as much.
IRA FLATOW: Right. I think people think that if you have a darker skin color, that the melanin protects you. Is that a mythology?
JENNA LESTER: That’s not a mythology. That’s absolutely true and we see that in the incidence of different skin cancers. And oftentimes, skin cancers that patients of color get are not related to UV or sun exposure. But I still think that if you have skin, you can get skin cancer. I think that’s kind of the bottom line.
IRA FLATOW: So you have opened up a clinic.
JENNA LESTER: Yes.
IRA FLATOW: And do you see people coming to you who are sort of refugees from other doctors or other clinics?
JENNA LESTER: Patients do travel from far to come see me, and I think that happens for a number of reasons. They want reassurance that the path that they’re on is the right one. They’ve maybe had a bad experience. And I think a lot of people are just– they want their doctors to look like them, I think, in a lot of situations, so it’s quite powerful.
IRA FLATOW: Is there any part that you see misdiagnosed more often on the body than anything else?
JENNA LESTER: You mean any part of the body–
IRA FLATOW: Yes.
JENNA LESTER: –where there’s a misdiagnosis?
IRA FLATOW: Face, hair, shoulders.
JENNA LESTER: Yeah, I actually see a fair number of patients who come in with issues of hair loss and things that– a particular condition where we can give a patient a name, we can do a biopsy, we can make a diagnosis and start them on the road to treatment maybe was brushed off before and said, you know, there’s nothing we can really do about this so just sort of deal with it.
IRA FLATOW: I have a tweet from Chidi who says, are people with darker skin more prone to certain skin problems? If so, what are they?
JENNA LESTER: That’s an excellent question, and I think largely, that’s something we’re still discovering. There’s a condition that a provider at UCSF, Haley Naik, is working a lot on called hidradenitis suppurativa. We think that there are racial, ethnic differences in that particular condition. But a lot of these studies haven’t been done, and so we’re working to figure that out.
IRA FLATOW: Mhm. We’ve talked about skin cancer, melanoma.
JENNA LESTER: Mhm.
IRA FLATOW: Are there any other kinds of skin conditions where identifying it correctly could be a life or death situation?
JENNA LESTER: Yeah, so a particular example that comes to mind is something called toxic epidermal necrolysis.
IRA FLATOW: Say that again?
JENNA LESTER: Toxic Epidermal Necrolysis, or TEN for short, and this is one of the severe dermatological emergencies. People think dermatologists don’t treat life-threatening conditions, and to the contrary, this is one that dermatologists can have a life-saving impact. And a patient in my medical training– I trained at many different institutions– a patient with darker skin sat in the emergency room for 8 or 10 hours because the redness, which can be subtle in patients with darker skin, that’s the sort of hallmark feature of this condition was missed in this person.
IRA FLATOW: What about jaundice, right? Skin get yellower from jaundice. Could this be missed with people who have darker skin?
JENNA LESTER: It could be missed. I think places where you could still look are the sclera of the eyes, the palms of the hands, but oftentimes, jaundice doesn’t reach those areas until it’s pretty far advanced.
IRA FLATOW: Wow, that’s interesting. In your clinic, what do you need? What that you don’t have– I have a blank check question, I don’t have the real blank check. If you had a blank check and you needed to buy equipment or a better test for something, what do we really need?
JENNA LESTER: Yeah. I think I would need a medical photographer.
IRA FLATOW: Ooh.
JENNA LESTER: I need someone who could set up and take photographs of literally every single thing that I ever saw during the day, because part of the huge issue is this disparities in the existence of photos. People are interested in including these in their talks, but they don’t exist in the numbers, side by side with the photos of lighter skin, and we need really good photos.
IRA FLATOW: But there are doctors manuals of skin diseases. They’re not good enough is what you’re saying.
JENNA LESTER: I say they could be better.
IRA FLATOW: They could be better.
JENNA LESTER: They definitely could be better. And there are atlases of patients with skin of color, but they’re separate. And if you’re a dermatology resident, say, in San Francisco who’s struggling to pay your rent and also eat and doing all these other things, buying a separate textbook is really something you can’t do. And I think it also signifies that this is not something that should be part of the mainstream of dermatology. We have to have a separate book for it. You need to take an extra step to learn about this. So it’s optional.
IRA FLATOW: And you need to collect more data from people, right?
JENNA LESTER: Yeah.
IRA FLATOW: Are they willing to volunteer?
JENNA LESTER: I think that’s a tenuous question because there is a history, there is a legacy in our country of mistreatment and experimentation that a lot of people remember. And there are some very well-known examples, but I think people also have personal examples where they’re hesitant to do that.
IRA FLATOW: So, if they’re hesitant to come to you as a doctor or a dermatologist, they may be hesitant to go to another–
JENNA LESTER: Exactly.
IRA FLATOW: –kind of doctor and miss out on a different disease. Have you ever referred a patient?
JENNA LESTER: Oh, all the time. My 10-minute appointments often extend to 20 and 30 minutes when I get into blood pressure control and other things these patients should be doing because they do see me as someone that they want to tell all of their problems to and I see it as an opportunity. Any interaction someone has with the medical system is an opportunity where they either turn towards care or away from care. And so I see myself as a gateway for a lot of patients.
IRA FLATOW: So what do you say to people? And we have a large audience. I have two million people listening.
JENNA LESTER: Mhm.
IRA FLATOW: What’s your message to them about going to see– they can’t all come to your clinic.
JENNA LESTER: Right.
IRA FLATOW: What’s your message? Or to doctors who might be listening, we need to have more clinics of your type opening?
JENNA LESTER: I think that doctors should– we all have a responsibility to care for all patients. Sure, maybe black patients or patients of color want to see me. There’s not enough of me and there’s not enough of doctors that look like me. So, as a medical community, I think we all have a responsibility to fill the gaps in our knowledge and to educate ourselves. This is a field of lifelong learning. It never stops. So you have a responsibility to all of your patients to do this so that you can adequately diagnose them, treat them, give them the right medications that work for their particular condition.
IRA FLATOW: I’m Ira Flatow. This is Science Friday from WNYC Studios, talking with Jenna Lester, Assistant Professor of Dermatology at the UC San Francisco Medical School. Is this a topic of discussion at medical school conventions or dermatology conventions? Do doctors realize this?
JENNA LESTER: I think this is something that more and more people are realizing and it’s catching more attraction. I think, as we talk about diversity in the specialty of dermatology, dermatology is the second-least diverse specialty. So I think this sort of goes hand in hand with the issues and the conversations that happen around diversity of our workforce.
IRA FLATOW: Because I know of cases where there have been cases of melanoma, for example, and I know people who have been diagnosed with melanoma, but it was not the typical five, six, seven variations that you’re supposed to look for.
JENNA LESTER: Mhm.
IRA FLATOW: It was something totally different.
JENNA LESTER: Mhm.
IRA FLATOW: And when I talked to a doctor about this, he said, you know, we couldn’t list everything that will show up in patients, so we just list the most common types.
JENNA LESTER: Mhm.
IRA FLATOW: It seems like what you’re saying is the same sort of thing that’s happening here.
JENNA LESTER: Yeah, I think education is central to this because what I think of when I diagnose melanoma often, patients say, oh, this one has changed. And these are often patients who have been told since they were younger, skin cancer is something you should get. You should wear sunscreen. You should stay out of the sun. These are the signs that you look for. So, when subtle changes are something that’s picked up on, you have to think that education is at the basis of that.
IRA FLATOW: Yeah. Let’s see if we have time for a call before we go. Octavia in Decatur, Alabama. Hi, welcome to Science Friday.
OCTAVIA: Hi, how are you all?
IRA FLATOW: Hi there. Fine. Go ahead.
OCTAVIA: OK, so my question is, I have a doctor– a dermatologist that’s India– and his skin is really dark. And a lot of the patients that I see coming in and out of his office are darker– you know, people of Indian descent and African-Americans. So, I’m just kind of wondering, how closely related are our skin makeups? Because I know, with me, he always hits the nail on the head, so is our skin makeup related?
JENNA LESTER: That’s a really good question, and I think, overall, there are more similarities than differences. A lot of the differences have to do with skin tone, and so in dermatology, we have something called the Fitzpatrick scale that was developed as a way to determine someone’s likelihood of developing skin cancer but has also become a proxy or a stand-in for skin tone. And so it goes from 1 to 6, and 6 is the darkest and 1 is the lightest. And so there are people of different ethnicities that would fit into the same skin tone, so I think a lot of that sort of draws the similarities between the skin as well.
IRA FLATOW: So where do you professionally go from here?
JENNA LESTER: Oh, professionally.
IRA FLATOW: Are you going to expand the clinic, or?
JENNA LESTER: So a research program is something that I’m developing now. I’m also developing curriculum, trying to teach the next generation of physicians how to care for patients with all different skin tones. I think education is the way to have sort of a reverberating impact since, as I said, I don’t think there will ever be enough doctors of color to see all the patients of color that want to see them. So that’s the goal.
IRA FLATOW: Well, I hope we’ve made a dent in the education process today.
JENNA LESTER: Yes, I hope so, too.
IRA FLATOW: Dr. Jenna Lester, Assistant Professor of Dermatology at the University of California San Francisco Medical School. Thank you–
JENNA LESTER: Thank you for having me.
IRA FLATOW: –for taking time to be with us today.