©DR Z HUSAIN 2021
This article has been posted with permission of the author. Dr Z Husain is a UK based GP.
It is a truth, yet to be universally acknowledged, that the same rash can look very different in different skin tones and colours. Sadly, this truth is not well represented in medical educational material (1).
Medical photography in mainstream textbooks and educational material can lack the diversity in
appearance seen in practice.
There are concerns that this disparity could be cemented further by design in artificial intelligence programs used for diagnosis, due to the lack of reference material of skin conditions in non-white skin (2) (3). There have been some positive moves to address the educational deficit. An online handbook showing common conditions in different skin tones was recently produced by Malone Mukwende, a medical student at a London medical school, and a group of doctors (4). ‘Brown Skin Matters’ a website (5), Twitter (6) and Instagram page (7), is a resource where individuals and parents can submit photographs of their own rashes and skin conditions to form an online reference guide ‘addressing the lack of reference photos of dermatological conditions on non-white skin’. This was created after Ellen Buchanan Weiss noticed she had difficulty googling reference photographs of rashes on brown skin for her baby, and realised many other parents would have the same problem (8). She teamed up with a primary care doctor (GP) to produce the community project. While initially aimed at parents, it has been increasingly used as a resource by healthcare professionals (9).
The lack of reference material filters through in medical education, as LaShyra Nolen, a US medical
student, found as she listened thoughtfully through a medical school lecture on Lyme disease where
Erythema Migrans was only shown on white skin, and questions from the students on how it would
appear in pigmented skin were not adequately addressed.
She reflected in a twitter thread (10), and later an article in the New England Journal of medicine (11), her concerns on whether she and her fellow students would be equipped with the knowledge to recognise Erythema Migrans in a patient with darker skin tones, when they had only seen images of Erythema Migrans in white skin. The extensive comments and responses to her thread and article revealed she was far from alone in her concerns.
Erythema Migrans, when present, is diagnostic of Lyme disease (12), and is an indicator to start treatment.
However, it can come in a variety of guises (13) and may only be visible after exposure to heat (14). The ‘Bull’s eye’ appearance, with central clearing, is often quoted, but more recent studies suggest that this appearance may only contribute to 20-30% of Erythema Migrans rashes (15). Up to 70-80% of the time they may have the ‘non-classical’ appearance, which can include being uniform in colour – often depicted as red or pink in tone (16).
To complicate matters, most educational material, be it in textbooks, research papers or online, depict Erythema Migrans in white skin, generally of northern European origin complexion, where the ‘erythema’, or redness, is relatively easy to see, and relatively easily captured by cameras (17).
Erythema Migrans in darker and more varied skin tones is rarely available in educational material. If present, there may only be one or few examples, losing the variety of appearances that can be encountered in the consultation room and beyond, and not representing the full spectrum of skin tones (18).
This is problematic.
There is an old saying in medicine, ‘the eyes can not recognise what the mind does not know’. This saying impresses the importance of having a database of knowledge in your mind’s eye, thus gaining the ability to recognise what you see, rather than leave a diagnostic clue unrecognised because it was unknown to you. If the variety of appearances of the diagnostic rash in the full spectrum of skin tones is not covered in educational and reference material, like LaShyra Nolen noted, how can that doctor learn to recognise it? And how can artificial intelligence ‘learn’ to diagnose it? The appearance is not automatically transferable in the mind from its appearance in white skin to more melanated tones. The rash looks different. To assume that this knowledge will somehow be picked up by individual doctors through ‘everyday exposure’ defeats the purpose of medical education. After all, it is the prepared mind that can make a diagnosis.
The sad possible consequence is that Erythema Migrans in those with darker skin is less likely to be recognised by the patient and the treating doctor. This in turn could lead to a delayed diagnosis of Lyme disease, with the subsequent delay in treatment, and thus greater likelihood of developing disseminated disease.
An American study published in 2000 demonstrates this risk (19). The researchers hypothesised that Black and White residents living in the same mainly rural areas endemic of Lyme disease would have similar rates of infection. Instead, they found that White patients were more likely to be diagnosed with Erythema Migrans, and less likely to be diagnosed with arthritis (a sign of disseminated Lyme disease, and a complication of untreated disease), while the reverse was true for Black patients. The authors of the study proposed that Erythema Migrans may be more likely to be recognised in those with white skin, while under recognised in those with darker skin. Early diagnosis would mean a White person was more likely to receive timely treatment, thus less likely to develop complications of untreated infection. Meanwhile, a Black patient’s rash would be left unrecognised, their Lyme disease untreated, and more likely to develop complications. The authors also considered a possible ‘bias of diagnosis by health providers who believe that Lyme disease is relatively rare in African Americans’.
Broadly, the challenges in diagnosing Erythema Migrans in melanated skin appear to be threefold:
1 – Lack of reference and educational material in the full spectrum of skin tones and colours.
2 – Camera technology that lacks colour accuracy for non-white skin (3).
3 – Healthcare bias, where Lyme disease is assumed to be predominantly seen in White people, despite an individual’s risk factors for infection (19).
Medical knowledge has expanded at great speed in the last century. The scientific community need to ensure the basics are right and gaps are addressed, so that further development happens on a strong and reliable foundation. The Shades of Lyme project by ILADS is a welcome addition in attempting to address the lack of reference material for the skin signs of Lyme Disease in the full spectrum of skin tones. There is much work to be done to improve the educational landscape in medical photography.
1. BAD and minority ethnic group inclusivity. British Association of Dermatologists. [Online] [Cited:
7 February 2021.] https://www.bad.org.uk/healthcare-professionals/inclusivity-andrepresentation .
2. PRICHEP, DEENA. Diagnostic Gaps: Skin Comes In Many Shades And So Do Rashes. NPR. [Online]
4 11 2019. [Cited: 7 2 2021.] https://www.npr.org/sections/healthshots/2019/11/04/774910915/diagnostic-gaps-skin-comes-in-many-shades-and-so-do-rashes.
3. Singh, Neil. Decolonising dermatology: why black and brown skin need better treatment.
Guardian Newspaper. [Online] 13 8 2020. [Cited: 7 2 2021.]
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9. Most dermatologists are trained primarily on white skin. That’s a big problem. Advisory Board.
[Online] 9 9 2020. [Cited: 7 2 2021.] https://www.advisory.com/daily-briefing/2020/09/09/skincolor.
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11. How Medical Education Is Missing the Bull’s-eye. Nolen, LaShyra. 382, 25 6 2020, New England
Journal of Medicine, pp. 2489-2491. https://www.nejm.org/doi/full/10.1056/NEJMp1915891
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13. DOES EVERYONE GET THE TELLTALE BULLSEYE RASH? Bay Area Lyme Foundation. [Online] 12 9
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2 2021.] https://www.bad.org.uk/healthcare-professionals/inclusivity-andrepresentation/erythema-in-skin-of-colour .
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