Representation of Skin Colors in Images of Patients With Lupus

Abstract

Objective Lupus presents earlier and more severely among patients with skin of color (SOC), and this population experiences worse outcomes. Providers rely on medical education materials when developing skills to care for patients, yet these resources historically underrepresent patients with SOC and marginalize vulnerable populations. In this study, we investigated if this publication bias extends to images depicting patients with lupus. Methods We reviewed published images of patients with lupus from rheumatology, dermatology, and internal medicine textbooks and medical journals, SOC atlases, online image libraries, UpToDate, and Google Images. We selected materials published from 2014 to 2019 that were available through our university's online medical library. We used the search terms “lupus” and “lupus rash” to identify images. We rated the skin color in each image using the New Immigrant Survey Skin Color Scale and categorized them as light, medium, or dark. We compared the frequencies of published skin tones with chi‐square and odds ratio analyses. Results We assessed the skin tone of 1,417 images. The significant majority (56.4%) of the images represented light skin (χ2 = 490.14, P < 0.001). After SOC atlases, journals were the most inclusive of images depicting dark skin tones. The specialty of dermatology was most inclusive of medium and darker skin tones. Conclusion Published images of lupus underrepresent patients with SOC, which may limit providers' ability to deliver care to the patients who are at greatest risk for complications.

Assessment and Identification of Skin Disorders in Skin of Color

“…12 Researchers also found significant disparity in images in dermatologic and medical textbooks and journals that may be contributing to disparity in skin injury identification in DST. 13,14 More diversity in these images is needed to help guide HCPs to properly characterize skin lesions in patients with DST.…”

“…This potential disparity was echoed in a study conducted that compared the ability of forensic pathologists to identify blunt trauma injuries in DST versus light skin tones where researchers found fewer injuries identified in DST as compared to White victims 12. Researchers also found significant disparity in images in dermatologic and medical textbooks and journals that may be contributing to disparity in skin injury identification in DST 13,14. More diversity in these images is needed to help guide HCPs to properly characterize skin lesions in patients with DST.…”

Health care practitioners’ confidence assessing lupus-related rashes in patients of color

“…Medical education contributes to the health disparities experienced among P-SOC with lupus. Educational materials underrepresent P-SOC, 4 a bias extending to resources specific to lupus, 5 and training programs contain few curricula dedicated to cutaneous findings in P-SOC. 6 These resources and learning experiences prepare practitioners to care for patients, and they impart unconscious biases while creating deficiencies in clinical skills when they exclude P-SOC.…”

Racial Disparities in Diagnosis and Treatment of Patients With Dermatomyositis of Different Skin Tones

“…6 In a meta-analysis of published materials of more than 1400 images depicting patients with lupus, a significant majority represented light skin. 7 Similarly, a recent meta-analysis of DM rash images in medical education literature also demonstrated a significant underrepresentation of darker skin tones. 8 In a survey study designed to assess provider confidence in the detection of cutaneous manifestations of lupus in minority patients, physicians from rheumatology, dermatology, and internal medicine were found to have statistically significantly lower confidence levels in assessing lupus-related cutaneous findings in patients of color when compared with patients of fair skin tones.…”

“…In a study of general medicine textbooks analyzing more than 4000 images, only 4.5% represented dark skin 6 . In a meta-analysis of published materials of more than 1400 images depicting patients with lupus, a significant majority represented light skin 7 . Similarly, a recent meta-analysis of DM rash images in medical education literature also demonstrated a significant underrepresentation of darker skin tones 8 .…”