A dermatology for every skin type

It happens every day: People with darker skin tone are treated differently based on a superficial characteristic. That bias extends to the various ways dermatologic diseases are treated in those with darker skin tone. Clinicians, educators, and researchers at Yale are working to address such disparities in the diagnosis, treatment, and research of skin conditions.

“Dermatology is so visual,” said Christine Ko, MD, professor of dermatology and pathology. “The perception of color can really affect each case that we see.” A key determinant in diagnosing skin disease is not race, however, but the actual hue of the skin. “It’s analogous to when you choose paint color,” Ko said—“the color looks different in different settings. It’s just how our eyes perceive things. The background skin color that surrounds a rash or tumor can affect the way we see that rash or tumor and can potentially adversely impact our making the right diagnosis.”

Traditionally, medical training has provided limited exposure to symptoms of skin diseases (such as skin lesions) as they manifest in darker skin tones. “When it comes to learning about skin manifestations of different diseases in diverse populations, we need to broaden the lens considering the rapidly changing demographic of our patient population,” said Beverley Sheares, MD, MS, associate professor of pediatrics (pulmonary) and leader of the School of Medicine’s Health Equity Thread. “If medical students who will be our next generation of doctors don’t recognize disease in nonwhite skin, diagnoses are delayed, appropriate treatment is delayed, excess morbidity and mortality will result, and disparate outcomes continue to occur.”

The keys to reducing disparities in dermatologic outcomes, she said, are broader representation of people of color during medical training, larger representation of this population in clinical trials, and wider access to dermatologists with the requisite experience to recognize and treat diseases in different skin tones. “Today’s students will be well served by some of the efforts that are being made now to present a diversity of images and learn about skin of color,” Sheares said. “Students need to understand the myriad ways diseases of the skin present based on the hue of the skin. We also must continue the work of dispelling longstanding myths relating race to skin conditions, including skin thickness, as these myths lead to poorer care and increased morbidity for patients of color.”

Skin cancer is one example. People of all skin hues are susceptible to melanoma, but while darker skin tone does offer some protection, it does not render immunity to the condition. “Patients themselves don’t think they are able to get skin cancer,” said Ko. Yet a particular kind of melanoma—acral lentiginous melanoma—can occur in patients with darker skin tones in areas that don’t get much sun exposure, such as the palms of the hands, the soles of the feet, and under the nails. Transplant patients are also at higher risk of skin cancer than non-immunosuppressed patients, and this group includes transplant patients with darker skin tones. As recommended by the American Society of Transplantation and the American Academy of Dermatology, all transplant patients at Yale New Haven Hospital are now screened for skin cancer regardless of their external appearance.

“This is where awareness and appropriate training come together to benefit patients, but one has to know how to look, where to look, and know how to interpret what one is seeing,” Sheares said. “And that should be the focus of medical education.”

At Yale School of Medicine, there is a push to change how medical trainees see their patients from day one. “Having exposure to the wide spectrum of skin tones is an area of interest for students and our faculty,” said Sheares. “It is a priority for them as the population is getting more diverse, and they will be the physicians and a critically important part of medical education.”

In an effort spearheaded by Mary Tomayko, MD, PhD, associate professor of dermatology and of pathology, and director of dermatology medical student education, presentations included in the first-year dermatology module for medical students are now illustrated with at least two pictures of each condition: one from a patient with lighter skin and one from a patient with darker skin.

Some skin diseases are more commonly associated with darker-skinned people. For example, sarcoidosis, a potentially disfiguring skin disorder, has traditionally been described with race as a risk factor. “If a patient has an unknown rash, [sarcoidosis] is a disease that tends to be considered,” said William Damsky, MD, PhD, assistant professor in dermatology and dermatopathology.

Sarcoidosis symptoms can also be more distressing to people with darker skin tone because they have higher levels of post-inflammatory hyper pigmentation, which can make spots the disease causes more apparent. “Patients are often told that there is little that can be done to address the pigmentary alteration,” Damsky said, “and while there is some truth to that, just brushing that piece aside leads to more frustration.”

No therapy to treat sarcoidosis symptoms has been approved by the Food and Drug Administration (FDA) other than prednisone, a steroid that has many serious side effects. But turn on the television, and commercials for psoriasis medications abound: Otezla, Humira, Tremfya, Taltz, Skyrizi, Cosentyx, Stelara, to name a few. While psoriasis, a common chronic autoimmune disorder that often affects Caucasians and causes inflamed and scaly skin, can be serious and can profoundly affect the lives of individuals who have it, “We have more than a dozen highly effective therapies for it,” Damsky said. “In sarcoidosis, we have none.”

Damsky is part of a team of Yale researchers who have come up with a novel treatment for sarcoidosis. His research mentor, Brett King, MD, PhD, associate professor of dermatology, pioneered the use of Janus kinase, or JAK, inhibitors, a group of FDA-approved therapies for rheumatoid arthritis, for use in such intractable skin diseases as vitiligo, alopecia areata, and eczema. During Damsky’s residency, he and King discovered that one JAK inhibitor, tofacitinib (Xeljanz), appeared to be effective in treating sarcoidosis symptoms when used off-label.

“Dr. King had a patient with sarcoidosis, which led to red and brown bumps and scars on much of her face and body, and also led to hair loss,” Damsky recalled. “Just about every other therapy for sarcoidosis had failed. She was treated with Xeljanz, and all of her sarcoidosis went away.” The research was published in The New England Journal of Medicine in 2018, and the team is working on a clinical trial to further examine the findings.

In the United States, people with darker skin color are more likely to develop sarcoidosis than people with lighter skin. This difference does not hold true globally, and the reason is not yet well understood.

“It is incumbent on medical educators, clinicians, and researchers to not only better understand dermatologic disparities, but also to increase our awareness of the systems that produced the disparities and focus on how we can we actually close the gap,” Sheares said. “We have been studying the social determinants of health for decades, but the disparities still exist. We are at a point where we are beginning to examine the impact of some of the structural determinants of health so that we are all working on a larger scale to achieve health equity for all patients.”