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Here are some publications arising from our 2021 meeting by some of our distinguished speakers.

The Skin of Colour Training Day UK: training the medical workforce in ethnic dermatology

O. Jagun, P. Banerjee, D. Thompson, M. Taylor 

Clinical and Experimental Dermatology, Volume 47, Issue 2, 1 February
2022, Pages 245–246
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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.

Structural and functional differences in skin of

C. Iwuala, S. C. Taylor

Clinical and Experimental Dermatology, Volume 47, Issue 2, 1 February
2022, Pages 247–250
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The term ‘skin of colour’ (SOC), refers to individuals of African, Latinx, Asian, Native Hawaiian, Pacific Islander and Indigenous descent. These individuals typically have darker skin tones compared with white individuals and they often present with unique disorders of the skin or with common disorders that have a unique appearance. Certain skin conditions commonly associated with SOC patients, in contrast to individuals with lighter skin tones, are explained by structural and functional differences between this population and the white population. Variations in functional differences between these two groups are dependent on structural differences in melanosomes, stratum corneum, epidermis and dermis. Understanding the structural distinctions between white populations and SOC populations will provide insight into common disorders in SOC patients, including hyperpigmentation, hypopigmentation, dry skin, scaliness, xerosis, sensitive skin and keloids. Furthermore, understanding structural and functional skin difference will encourage more research regarding aetiology of disease and therapeutic interventions.

Differential diagnosis and management of

J. Yoo

Clinical and Experimental Dermatology, Volume 47, Issue 2, 1 February
2022, Pages 251–258, 
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There is an increasing recognition of ethnic dermatology to reflect the increase in skin of colour (SOC) populations in the UK. Hyperpigmentary disorder is one of the commonest skin concerns in SOC but there has been limited training available in this field of dermatology. Variations in skin colour are genetically determined by the amount of melanin content, the eumelanin/pheomelanin ratio and the size of melanosomes, but is also influenced by other factors such as hormones and extrinsic factors such as ultraviolet radiation. Hyperpigmentation is a broad term to describe increased pigmentation in the skin, and making a correct diagnosis is an important first step in the successful management of hyperpigmentary disorders. A systematic approach based on the disease pathogenesis (e.g. reactive vs. nonreactive, increased melanin vs. increased number of cells or epidermal vs. dermal pigmentation) aided by a detailed history and clinical examination is the best way to diagnose a hyperpigmentary disorder. Based on its pathogenesis, management can be planned. For epidermal hyperpigmentation caused by increased melanin, topical skin‐lightening agents targeting inhibition of tyrosinase or melanosome transfer and promotion of keratinocyte turnover can be used. Hydroquinone‐containing cream is the gold‐standard treatment for epidermal hyperpigmentation. Alternative treatments include laser toning or chemical peels. However, increased dermal pigmentation is more challenging to target with topical treatments. If hyperpigmentation is due to increased numbers of melanocytes or keratinocytes, high‐fluence laser is the most appropriate treatment method.

Acne and rosacea in skin of colour

T. Maruthappu, M. Taylor

Clinical and Experimental Dermatology, Volume 47, Issue 2, 1 February 2022,
Pages 259–263, 
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Acne and rosacea are common inflammatory skin conditions present in numerous racial and ethnic groups. There are distinct differences in clinical presentation, exacerbating factors, potential triggers and consequences of both conditions in individuals with skin of colour (SOC), classified as Fitzpatrick skin types III–VI. For example, acne can be complicated by the development of postinflammatory hyperpigmentation and keloid scarring in SOC, and this can influence treatment choice. Although rosacea is reported less frequently in SOC, this may be the result of delayed diagnosis or late presentation due to the difficulty in discerning the classic features of erythema in darker skin tones. In such cases, additional clues in the medical history and clinical examination may assist in making the diagnosis. This review aims to summarize nuances in both the diagnosis and management of these two common skin conditions in patients with SOC to support clinicians in providing an individualized treatment approach.

Skin lightening: causes and complications 

M. Sommerlad

Clinical and Experimental Dermatology, Volume 47, Issue 2, 1 February 2022,
Pages 264–270, 
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Skin bleaching, also known as skin lightening, is the deliberate lightening of an individual's skin tone without medical supervision. The causes are complex, multifactorial and often intertwined, although the unifying themes centre around a belief that lighter skin denotes an individual of higher status, socioeconomic background or physical beauty, than their darker‐skinned counterpart. Skin lightening is achieved using agents that block the production of melanin and often contain drugs such as hydroquinone, superpotent topical steroids or mercury. These drugs can cause serious local and systemic complication. Skin‐lightening compounds are illegal in most countries throughout the world; however the industry is worth billions of dollars annually, and the agents can be easily obtained by individuals seeking to lighten their skin. Dermatologists are in a unique position to identify those at risk of using skin‐bleaching agents, manage complications and give advice on the physiological variation in pigmentation and how to avoid using skin‐lightening agents to treat dermatological conditions. To manage the belief that lighter skin is better, societal level change is required to ensure that people of all skin tones are represented in the media.

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