Abstract
Keywords
Disparities in dermatological outcomes for patients with skin of color may be exacerbated by the lack of inclusion in educational materials. Educational resources used to teach medical trainees, especially textbooks, must represent all skin types. The importance of inclusivity in dermatology is a topic that has been receiving much-needed attention in recent years. Past studies reviewed skin type diversity in general medical textbooks and dermatology textbooks. Representation of skin of color was reported as low as 4%. 1,2 Skin of color has been defined as Fitzpatrick phototypes IV-VI. 3 An additional study reviewed representation in updated dermatology texts and have found as little as 1% differences to skin of color representation. 4 This paper aims to evaluate the changes, if any, in the representation of skin of color in core dermatology textbooks throughout multiple textbook editions.
The textbooks used in this study were selected based on the criteria used in the previous study, 4 alongside “General dermatology books” outlined by the American Academy of Dermatology. Images were divided based on their Fitzpatrick skin type. 3 Light skin represented Fitzpatrick types I-IV, dark skin represented Fitzpatrick types V-VI, and the indeterminate category was given to any image in which a skin type could not be given. Images were excluded if they were black-and-white pictures, histology, repeated images, diagnostic procedures, dermoscopy, or had no skin pathology in the image. A total of 26 textbooks were independently screened by two reviewers (A.A. and E.A), and 37,416 dermatologic images were reviewed for skin phototype. The data collected showed an average of 11.5% dark skin images across the textbooks, with an average of 1.3% increase in dark skin images between the first and last editions of each textbook reviewed (Table 1). These results show an overall but still overwhelmingly small increase in the number of images of darker skin in the textbooks. Despite this increase, the actual percentage of darker skin images has decreased in many of the textbooks reviewed.
Images of Different Skin Phototypes in Dermatology Textbook Over Multiple Editions.
Abbreviations: Dark, skin phototype V-VI; Light, skin phototype I-IV.
aRepresents the change (%) in dark images between textbook editions
Representation in skin of color remains an issue in dermatology. As more individuals continue to advocate for the inclusivity of skin of color in various dermatology materials, there will hopefully be a shift towards a diverse and inclusive dermatology curriculum. 5 While our results showed an overall increase in darker skin representation across dermatology textbooks, the gaps in the tools used to educate clinicians on the presentation of skin disease remain highlighted. This increase suggests that advocacy for skin representation is being recognized as an unmet need. Recommendations to address the issues discussed in this paper include further research into diversity in dermatology education, advocating for increased physician awareness regarding this lack of representation, and educating physicians on the health inequities that may result from a lack of said representation.
Limitations of this study include the exclusion of online-only materials and textbooks without revised editions. Despite these limitations, our findings provide valuable information on the current state of inclusivity in dermatology. A further comprehensive investigation of all dermatology textbooks is needed to confirm whether our findings are consistent with other dermatology textbooks.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
