Dark Skin Is Underrepresented In Medicine. Here's How a Student Is Changing That

Malone Mukwende, a second-year medical student at St. George’s University in London, had a realization: His medical textbooks sorely lacked representation for people of color.

So together with two of his professors, Mukwende created a guidebook called Mind the Gap: A Handbook of Clinical Signs in Black and Brown Skin. The book aims to train medical providers on how to diagnose certain conditions in skin-of-color. 

“I noticed a lack of teaching about darker skin tones, and how certain symptoms appear differently in those who aren’t white,” Mukwende said in a July 22 interview with the Washington Post. "My hope is that the handbook will become a staple resource in medical settings around the world."

The handbook explores how numerous conditions—from jaundice and eczema to meningitis—appear on darker skin tones. It is not yet published or available to the public.

“It is important that medical providers know how to diagnose conditions in skin-of-color since this will directly improve health disparities,” Ginette A. Okoye, MD, FAAD, professor and chair of the department of dermatology at Howard University College of Medicine, tells Verywell.

Challenges for Medical Providers 

Because there are over 4,000 possible skin diagnoses, misdiagnosing one skin condition for another isn’t uncommon. In addition, conditions present differently on skin-of-color, making misdiagnosis even more likely to the untrained eye. For example, the following skin conditions can appear differently on darker skin:

• Eczema
• Psoriasis
• Skin cancer 
• Pityriasis rosea 

“I have seen many Black patients with a skin lymphoma (cancer) called mycosis fungoides who were misdiagnosed as eczema for years,” Okoye says. “For some of these patients, that delay in diagnosis meant the difference between life and death.”

More Than Just a Skin Issue 

In "Mind The Gap," Mukwende and the his co-authors discuss the clinical presentation of conditions beyond traditional skin disorders, such as inflammatory conditions and conditions that cause cyanosis.

Inflammatory Conditions

In Kawasaki disease, a rare inflammatory disease mostly affecting children, darker skin may not show the obvious red rash that presents on white skin.

“In skin of color—particularly tan, brown, or dark brown—inflammation appears to be more gray or violaceous (violet) in color, which gives an entirely different clinical picture,” Charles E. Crutchfield III, MD, clinical professor of dermatology at the University of Minnesota Medical School, tells Verywell. 

He says that in addition to the color, the structure of certain skin conditions can also appear different on skin-of color.

"Pityriasis rosea can appear [as] flat scaling oval patches on white skin, but in brown skin, there are not flat oval patches with scale, they are bumps in the same distribution,” he says. 

Cyanosis 

Cyanosis is a sign that your blood doesn’t have enough oxygen. It’s typically identified as a bluish color around the lips, nail beds, or the eyes. However, in people with darker skin, cyanosis may look gray or whitish, while the areas around the eyes can appear gray or bluish.

Many medical conditions that cause breathing problems—such as pneumonia, asthma, and even the COVID-19—can lead to cyanosis. Not recognizing cyanosis could mean a dangerous delay in care that can result in poor health outcomes. 

Skin Color Can Impact Treatment 

Skin condition treatments among people of color may require different approaches or dosages than treatments for those with light skin.

“One of our common treatments in dermatology is phototherapy, where we use measured doses of ultraviolet light to treat skin conditions like psoriasis, eczema and vitiligo," Okoye says. "Patients with skin of color require higher doses of phototherapy to achieve results."

Providers treating skin-of-color must also consider the effects of inflammation, which Dr. Crutchfield says can change the shade of skin color.

"Often, when I'm treating patients of color, especially with acne or psoriasis, I tell them that we will treat the active inflammation, but we also have additional medicines to treat the discoloration,” he says. 

Recommendations for Patients 

Board-certified dermatologists who can treat skin-of-color exist, but it’s important to do your own research.

“You want somebody with experience, so take a look at their website," Crutchfield says. "See if they have pictures of people of color on their website and sections that talk about skin color treatment or specialize in it."

Okoye encourages patients to be upfront with their requests.

“Patients with skin-of-color express feelings of mistrust regarding their diagnoses and treatment if their provider does not seem to be familiar with treating diseases in skin of color," she says. “It is okay to respectfully ask your provider if they are comfortable with diagnosing and treating skin-of-color."

The Find a Doctor Database offered by the Skin of Color Society can help you find care that is right for you.

December 6, 2021: A previous version of this article misspelled the last name of Malone Mukwende, the medical student behind the guidebook.