Lack of Physician Training in How to Treat Skin of Color Can Put Minorities at Risk for Poor Care
With cosmetic procedures in high demand during the pandemic, Cedars-Sinai dermatologist Jasmine Obioha, MD, has seen an unfortunate side effect: botched treatments for patients of color.
When performed improperly, procedures such as chemical peels and laser hair removal can inflame and darken melanin-rich skin of color.
“I’ve had patients come to me for complications from cosmetic treatments done at medispas or even by dermatologists,” Obioha said. “It’s part of a bigger problem–disparities in healthcare affecting patients of color, and dermatology is no exception.”
The culprit? Few physicians receive training for treating skin of color.
A large part of dermatology education involves visual recognition. Physicians must identify conditions from photos of skin in textbooks or shared in the classroom. But most of the patients in those images are white and only 4.5% of the images show dark skin, according to a 2018 review of general medicine textbooks in the journal Social Science and Medicine.
As a result, medical students and residents often don’t learn about skin conditions experienced primarily by patients of color, appropriate treatments or cultural practices.
“If you’re not properly trained, you won’t recognize certain conditions, know what to look for or how to communicate effectively,” said Obioha, who attended a residency program that addressed these healthcare gaps while treating patients from a diverse community.
Obioha advises patients to call before booking an appointment at a dermatologist’s office and ask if the specialist has experience treating skin of color.
Botching Cosmetic Treatments
Laser treatments and chemical peels can do serious damage to darker skin if not handled by an expert who understands melanin-rich skin and how to treat it without doing harm.
Deep chemical peels should be avoided on darker skin, but gentler, more superficial ones are fine and won’t cause “hyperpigmentation,” or deepening of color. Lasers with special frequencies and micro-needling can be done safely on darker skin to remove scarring or tighten or refresh the appearance.
“Laser resurfacing technology has improved and there are more options for all skin types, so it helps to see a specialist who’s aware of the latest developments,” Obioha said.
She also cautions that liquid nitrogen treatments to freeze and remove moles and other benign growths can leave light spots on skin of color.
“Pigment cells in darker skin are sensitive to temperature,” Obioha said. “I’d recommend another approach using electrocautery–burning off the benign growth–which carries less risk.”
Knowing What to Look For
A range of skin conditions manifest differently in darker skin. Psoriasis, a common skin disorder that produces salmon-colored patches on light skin, creates deep purple patches on darker skin. The opposite is true for a complex blood cancer called “mycosis fungoides” that causes red scaly patches in light skin and lighter-hued patches in dark skin.
Other conditions primarily seen in dark skin look similar to other more common conditions and can be misdiagnosed, with serious consequences. A type of hair loss that occurs mostly in African Americans, called central centrifugal cicatricial alopecia, affects the top of the scalp and resembles female pattern hair loss. But the treatments and prognoses are very different. If left undiagnosed, this form of alopecia can lead to scarring and irreversible hair loss.
“Imagine permanently losing your hair only to learn that it could’ve been avoided with the right diagnosis,” Obioha said.
Navigating Cultural Sensitivities
Sometimes physicians make the right diagnosis but fail to prescribe the treatment in a way that would resonate with a patient of color.
“I can’t count the number of patients I’ve seen with dandruff whose dermatologist or primary care physician prescribed them a clinical shampoo to use three times a week and didn’t touch it,” Obioha said.
That’s because the overwhelming majority of Black women wash their hair once a week or every other week since the texture makes it more fragile, Obioha said. They might not trust a physician who doesn’t understand their hair or prescribes a treatment plan that fits their lifestyle.
Or if a Black woman is suffering from hair loss related to styling and must stop wearing extensions or a weave–human or synthetic hair that’s glued or sewn onto natural hair–their physician needs to handle that conversation with great sensitivity, Obioha said. These hair styles can be a big part of a woman’s self-image, and Obioha suggests that physicians can encourage a patient if they also provide guidance for hair styling alternatives. Otherwise, patients might not follow their care plan, she said.
“Physicians need to grasp the nuances of ethnic skin and hair. Otherwise patients will lose confidence in them,” Obioha said.
Read more on the Cedars-Sinai Blog: Curb Your Risk of Skin Cancer at https://www.cedars-sinai.org/newsroom/why-skin-issues-in-patients-of-color-are-neglected-mistreated/