It is with great pleasure that we introduce this special Skin of Colour issue following our first virtual Annual Skin of Colour Training Day, which took place on 29 January 2021. The event was hosted in collaboration with the recently formed British Association of Dermatologists
(BAD) Skin Diversity Sub-Committee and The Dowling Club.
Skin of colour (SOC) is an umbrella term used to describe individuals with ’non’ white (Fitzpatrick IV–VI) skin types. These skin types are prone to hyperpigmentation and scarring.1 Although imperfect and vague, the term is often used in the literature to describe people from various racial and ethnic groups including those of African descent as well as Asian
(Indian subcontinent, East Asia, Southeast Asia), Middle Eastern, Native Americans and Hispanics.2 ‘Healthy skin for all’ has been the motto of BAD since 1920. The impact of globalization has caused a change in the demographic landscape of the UK in the past 100 years, leading to an ethnic make-up of 85.42% white and 14.58% nonwhite (7.10% Asian,
3.48% black, 2.25% mixed, 1.03% other and 0.72% Chinese), according to the 2011 census.3 In London alone, where 13.4% of the entire UK population live, 40.2% of residents identify as nonwhite,3 and it is estimated that by 2056, the nonwhite population in the UK will increase to 31%.4 As such, training needs to reflect this change to ensure that dermatologists are well equipped in treating skin of colour.
Several surveys in Western countries (UK, USA and Australia) experiencing similar demographic shifts have highlighted a need for better training and exposure to
dermatological conditions in SOC. In 2013, Salam and Dadzie found that by the end of their training, 54% of dermatology trainees in the UK did not feel competent in managing SOC conditions.5 The majority of those who felt competent were trainees from the West Midlands
and London, areas with significant nonwhite populations, leaving those trainees working in less ethnically diverse areas at a disadvantage, potentially compounded by the underrepresentation of SOC images in dermatology textbooks.5–7 Furthermore, a 2020 UK survey showed that 86% of dermatologists felt inadequately trained in managing hyperpigmentation.8 These surveys highlight an increased need for more training for both dermatologists and trainees in managing SOC conditions, with one survey proposing more structured teaching with a special focus on pigmentary and hair/scalp disorders
with outcome measures incorporated into the training curriculum.5
With 23% of higher specialty trainees seeking consultant jobs outside their deaneries and the majority of dermatologists working in urban areas with greater ethnic admixtures, it is imperative that dermatologists are well equipped to manage skin conditions in a changing population, in order to ensure adequate patient care.7 This is crucial because the classic dermatology descriptions of rashes, which use terms applicable to white skin, may have no bearing for darker skin, thus leading to delays in diagnosis. Lester et al.9 published an anecdotal report of the suboptimal care of patient with toxic epidermal necrolysis who
waited several hours in the emergency room before the emergent nature of their condition was recognized, owing to the lack of the characteristic erythema more easily seen in white skin but can be very subtle in darker skin types. Such near misses and/or misdiagnoses
may increase not just morbidity but mortality for patients with SOC.
In recent years, the BAD has been working to diversify dermatology education in all work streams. The killing of George Floyd in May 2020 sparked the worldwide ‘Black Lives Matter’ protest, which created public interest in the work of the BAD in addressing diversity.
Medical students from around the country petitioned to have better representation of Black and Minority Ethnic (BAME) skin types in dermatology resources, which was swiftly addressed by the BAD, who updated the Dermatology Handbook for Medical Students and Junior Doctors, with more SOC images. They also included additional sections on pigmentary disorders and keloid scars. The BAD continues to undertake projects to improve diversity in all its workstreams.
One such workstream was education, for which we collaborated to bring about the first Virtual Annual Skin of Colour Training Day. The event was very successful, with almost 300 delegates in attendance, and included an expert faculty of international and national speakers in Dermatology, Paediatrics and Oculoplastics.
It was important that we started with the basics in highlighting some of the structural and functional differences in fibroblasts, hair follicles and melanocytes in SOC that often account for its unique pathologies. Prevalence studies in the UK have shown some differences in the most commonly seen skin diseases in Asian and African/Afro-Caribbean people, which tend to include more inflammatory dermatoses (e.g. eczema, psoriasis, acne, seborrheoic keratosis and itchy skin) compared with those for white skin, which tend to include more lesional disease (e.g. basal cell carcinomas, seborrhoeic keratoses, actinic keratoses, eczema and benign moles). Dermatological conditions may vary in type, severity and clinical appearance in SOC.10
As the Trainee Dermatology Curriculum is updated in 2021 to include ethnic dermatology, we hope that our training day will help trainees and consultants alike to gain competence in this much needed area. It is important that all doctors are adequately trained so that the burden of treating patients with SOC does not lie solely with doctors of colour, which runs the risk of
limiting career opportunities, as evidenced by a recent US survey in which 72% of the 7.5% of dermatology residents interested in SOC were people of colour themselves.11
In trying to encourage participation in this small but growing field, numerous resources are available, including textbooks such as Ethnic Dermatology: Principles and Practice (Dadzie, Petit and Alexis) and Dermatology for Skin of Colour (Taylor and Kelly), along with the Skin of Color Society in the US (open to international members) and their annual Skin of Color Update meeting in the summer.
We would like to recognize the efforts of Dr Ophelia Dadzie in highlighting SOC as a subspeciality to be considered in the UK and for organizing the biannual international ethnic skin and hair conference up until 2014. As the UK population continues to grow, we continue to do our part in the huge work of achieving ‘healthy skin for all’. Hence, we aim to return with
the second Virtual Annual Skin of Colour Training Day in January 2022.
O. Jagun,1 P. Banerjee,2 D. Thompson3 and M. Taylor4
1. Department of Dermatology, East Kent Hospitals University Foundation Trust, Kent, UK;
2 . Department of Dermatology, Lewisham and Greenwich NHS Trust and St John’s Institute of Dermatology, Guy’s Hospital, London, UK;
3. Department of Dermatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK and
4. Department of Dermatology, Imperial College Healthcare NHS Trust, London, UK
E-mail: oluwadamilola.jagun@nhs.net
References
1 Taylor SC, Cook-Boden F. Defining skin of color. Cutis 2002; 69: 435–7.
2 Taylor SC. Skin of color: biology, structure, function, and implications for dermatologic disease. J Am Acad Dermatol 2002; 46: S41–62. http://dx.doi.org/10.1067/mjd.2002. 120790
3 UK Government. Regional ethnic diversity. Available at: https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethnicity/national-and-regional-populations/regional-ethnic-diversity/latest (accessed 24 June
2021).
4 Coleman D. Projections of the ethnic minority populations of the United Kingdom 2006–56. Popul Dev Rev 2010; 36: 441–86.
5 Salam A, Dadzie OE. Dermatology training in the U.K.: does it reflect the changing demographics of our population. Br J Dermatol 2013; 169: 1360–2.
6 Royal College of Physicians. Focus on Physicians: 2018–19 census (UK consultants and higher specialty trainees). Available at: https://www.rcplondon.ac.uk/projects/outputs/focus-physicians-2018-19-census-uk-consultantsand-higher-specialty-trainees (accessed 24 June 2021).
7 Adelekun A, Onyekaba G, Lipoff J. Skin colour in dermatology textbooks: an updated evaluation and analysis. J Am Acad Dermatol 2021; 84: 194–6.
8 Ma Y, Millette D, Nalluri R, Yoo J. UK-based dermatologist online survey on the current practice and training in the management of melasma and postinflammatory hyperpigmentation. Clin Exp Dermatol 2020; 45: 483–4.
9 Lester JC, Taylor SC, Chren M-M. Under-representation of skin of colour in dermatology images: not just an educational issue. Br J Dermatol 2019; 180: 1521–2. http://dx.doi.org/10.1111/bjd.17608
10 Banner A, Dinsey M, Ezzedine K, Dadzie OE. The spectrum of skin diseases occurring in a multiethnic population in north-west London, U.K.: findings from a cross-sectional descriptive study. Br J Dermatol 2017; 176: 523–5.
11 Okoji UK, Lipoff JB. Demographics of US dermatology residents interested in skin of color: an analysis of website profiles. J Am Acad Dermatol 2020. http://dx.doi.org/10.1016/j.jaad.2020.09.092