To the Editor: Cutaneous pathology appears significantly different on disparate skin tones. Access to educational materials illustrating pathology across all skin tones plays a crucial role in developing pattern recognition skills and improving diagnostic confidence.1Rimoin L. Altieri L. Craft N. Krasne S. Kellman P.J. Training pattern recognition of skin lesion morphology, configuration, and distribution.J Am Acad Dermatol. 2015; 72: 489-495Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar,2Fourniquet E. Garvie K. Beiter K. Exposure to dermatological pathology on skin of color increases physician and student confidence in diagnosing pathology in patients of color.FASEB J. 2019; 33: 606.18Google Scholar Given the increasingly diverse patient population and known dermatologic health disparities,3Buster K.J. Stevens E.I. Elmets C.A. Dermatologic health disparities.Dermatol Clin. 2012; 30: 53-59Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar we aimed to assess the prevalence of dark skin images in widely used contemporary print and web-based dermatology resources. Eight commonly used resources (6 textbooks and 2 web-based resources) and 65 conditions were selected for review. For each condition, images were categorized as light skin images, dark skin images (DSIs) (Fitzpatrick phototypes V or VI), or indeterminate (because of extent of disease involvement, image frame, or lighting). Of the 15,445 images across all resources, 19.5% were DSIs. Online resources had a greater representation of DSIs (22.1%) compared to printed texts (10.3%) (Table I). For online resources, VisualDx had a greater representation of DSIs (28.5%) compared to DermNet NZ (2.8%). DSI representation varied based on dermatologic conditions. Disorders of Langerhans cells and macrophages had the greatest representation of DSIs (36.8%), whereas neoplasms of the skin (10.6%) and adnexal diseases (12.3%) had the lowest (Table II). These discrepancies are not consistently reflective of the incidence and prevalence in the population; overall, there is disproportionately lower representation when comparing the proportion of DSIs to epidemiologic data. However, the high representation of DSIs in conditions such as sarcoidosis and syphilis may be reflective of a disproportionate incidence in dark-skinned individuals.Table IExtent of illustration of dark skin in commonly used dermatologic learning resources for the 65 common dermatologic conditions included in this studyLearning resourcesTotal, nLight, nDark, nIndeterminate, nDark, %Printed texts346930673564610.3 Dermatology, 4th editionBolognia4Bolognia J. Schaffer J. Cerroni L. Dermatology (4th ed.). Elsevier, Amsterdam, The Netherlands2018Google Scholar748634991513.2 Andrews' Diseases of the Skin, 13th editionJames5James W. Elston D. Treat J. Rosenbach M. Neuhaus I. Andrews' diseases of the skin (13th ed.). Elsevier, Amsterdam, The Netherlands2019Google Scholar37229574319.9 Fitzpatrick's Dermatology, 9th editionKang6Kang S. (2019). Fitzpatrick's Dermatology, Ninth Edition, 2-Volume Set (Fitzpatricks Dermatology in General Medicine) (9th ed.). New York: McGraw-Hill Education/Medical.Google Scholar516428781015.1 Rook's Textbook of Dermatology, 8th editionBurns7Burns T, Breathnach S, Cox N, & Griffiths C. (2010). Rook's Textbook of Dermatology (8th ed.). Hoboken: Wiley-Blackwell.Google Scholar54449340117.4 Clinical Dermatology: A Color Guide to Diagnosis and Therapy, 6th editionHabif8Habif TP. (2015). Clinical Dermatology E-Book: A Color Guide to Diagnosis and Therapy (6th ed.). Mosby.Google Scholar8638223924.5 Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology, 8th editionWolff9Wolff K, Johnson AR, Saavedra A, & Roh E. (2017). Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology (8th ed.). New York: McGraw-Hill Education/Medical.Google Scholar4263952656.1Online resources11,976926926525522.1 VisualDx9007641725692128.5 DermNet NZ2969285283342.8Total15,44512,336300810119.5 Open table in a new tab Table IIExtent of illustration of dark skin in common dermatologic conditions across all dermatologic learning resources (printed texts and online resources) and available incidence and prevalence epidemiologic data for these dermatologic conditionsDermatologic conditions and diagnosesTotal images, nDark skin images, nDark skin images, %Disease incidence/prevalence for general populationDisease incidence/prevalence by race/ethnicityDisorders of Langerhans cells and macrophages47317436.8 Sarcoidosis20111657.77.6-8.8 per 100,000 incidence (general population)17.8-46 per 100,000 incidence (African American) Xanthoma1955226.71%-4% prevalence (general population)No reliable figures available Necrobiosis lipoidica7767.80.3%-1.2% prevalence (general population with diabetes)No reliable figures availableInfections, infestations, and bites4095101024.7 Syphilis43625959.43-18.7 per 100,000 incidence (general population)8.4-28.1 per 100,000 incidence (African American) Pityriasis versicolor1665533.11.1% prevalence (general population in Sweden)No determined difference based on ethnicity Tinea52615329.121.3 per 100,000 prevalence (general population)17.8 per 100,000 prevalence (African American) Varicella1985628.34.1 per 100,000 incidence (general population)7.8 per 100,000 incidence (African American) Herpes zoster2617026.812.4% prevalence (general population aged 60+ years)8% prevalence (African American) Molluscum2225323.9<5% prevalence (general pediatric population); 33% prevalence (patients with HIV)2-4 odds ratio of prevalence (not white compared to white) Impetigo2425723.61080-2220 per 100,000 incidence (general pediatric population)No reliable figures available Warts4049523.537.3% incidence (general male population)45.7% incidence (African American male patients) Scabies3106220221-281 per 100,000 prevalence (general population)No determined difference based on ethnicity Insect bite1672615.6No reliable figures availableNo determined difference based on ethnicity Measles1111614.40.02-0.04 per 100,000 incidence (general population)0.04 per 100,000 incidence (minority populations) Candidiasis2463514.2No reliable figures availableNo determined difference based on ethnicity Herpes simplex3625013.847.8% prevalence (HSV1); 11.9% prevalence (HSV2) (general population)58.5% prevalence (HSV1); 34.6% prevalence (HSV2) (African American) Cellulitis1131513.3200.3 per 100,000 incidence (general population)200.6 per 100,000 incidence (African American) Erysipelas7756.5249 per 100,000 incidence (general population)No determined difference based on ethnicity Erythema infectiosum5511.890% prevalence of seropositivity (general population aged 60+ years)No determined difference based on ethnicity Erythema migrans12221.627.0 per 100,000 incidence (general population)4.8 per 100,000 incidence (African American) Rubella4600<0.01 per 100,000 incidence (general population)9% of cases were in African American patients Roseola310077% prevalence of seropositivity (general population aged 24 months)No determined difference based on ethnicityRheumatologic and systemic dermatologic diseases199648824.4 Vitiligo28810937.80.2 per 100,000 prevalence (general population)No reliable figures available Scleroderma/morphea31910131.724.2 per 100,000 prevalence (general population)31.5 per 100,000 prevalence (African American) Alopecia1765330.12.1% lifetime incidence (general population)1.77 odds ratio of incidence (African American compared to white) Cutaneous lupus erythematosus45011425.34.2 per 100,000 incidence (general population)119 per 100,000 incidence (African American) Systemic lupus erythematosus2204721.42.9 per 100,000 incidence (general population)7.2 per 100,000 incidence (African American) Granuloma annulare2214319.50.1%-0.4% prevalence (general population seeking dermatology consultations)No determined difference based on ethnicity Lichen sclerosis et atrophicus232198.2100-330 per 100,000 incidence (general population of US Armed Forces)1.4 per 100,000 prevalence (dermatology consultations of African American patients) Erythema nodosum9022.20.38%-0.5% prevalence (general population)No reliable figures availablePapulosquamous and eczematous dermatoses284559620.9 Lichen simplex chronicus10048484.04%-12% prevalence (general population)No determined difference based on ethnicity Pityriasis rosea1898142.9172.2 per 100,000 incidence (general population)2 odds ratio of incidence (African American individuals compared to the rest of the population) Erythroderma1414632.60.9-2 per 100,000 prevalence (general population)No reliable figures available Ichthyosis2206027.30.5 per 100,000 prevalence (general population)No reliable figures available Seborrheic dermatitis1393726.61%-11.6% prevalence (general population)0.36-0.39 odds ratio of prevalence (light brown and black skin compared to white skin) Lichen planus3598523.71.27% prevalence (general population)No reliable figures available Psoriasis5189919.13.2% prevalence (general adult population)1.9% prevalence (African American) Stasis dermatitis1312015.36%-7% prevalence (general population aged 50+ years)No determined difference based on ethnicity Atopic dermatitis1512013.20.2%-24.6% prevalence (general population)1.7 odds ratio of prevalence (African American compared to European American individuals) Erythema annulare centrifugum1111311.71 per 100,000 incidence (general population)No reliable figures available Contact dermatitis7568511.220% prevalence (general population)No determined difference based on ethnicity Cheilitis3725.40.7% prevalence (general population)17% incidence (individuals with dark skin tones)Urticarias, erythemas, purpuras, and vascular disorders121819215.8 Erythema multiforme26263240.01%-1% incidence (general population)No reliable figures available Drug eruptions4226615.6180-700 per 100,000 prevalence (general population of hospitalized patients)No reliable figures available Vasculitis2113114.7200 per 100,000 incidence (general population)No reliable figures available Infantile hemangioma1671710.24.5% incidence (general population)3.5% incidence (African American) Urticaria156159.60.23% prevalence (general population)0.29% prevalence (African American)Vesicobullous diseases3695615.2 Bullous pemphigoid1533019.612 per 100,000 prevalence (general population)15.4 per 100,000 prevalence (African Americans) Dermatitis herpetiformis741216.210-11.2 per 100,000 prevalence (general population)No reliable figures available Pemphigus vulgaris142149.90.42-0.68 per 100,000 prevalence (general population)No reliable figures availableAdnexal diseases118014512.3 Keratosis pilaris952425.340%-80% prevalence (general population)No determined difference based on ethnicity Miliaria1152622.630% incidence (general population)No reliable figures available Acne vulgaris5696411.214.3%-24% prevalence (general population)37% prevalence (African American women) Folliculitis220219.5No reliable figures availableNo reliable figures available Rosacea181105.55.496% prevalence (general population of dermatology patients)10% prevalence (skin of color)Neoplasms of the skin326934710.6 Neurofibroma1194840.333.3 per 100,000 prevalence (general population)No determined difference based on ethnicity Cutaneous T-cell lymphoma300108361.07 per 100,000 incidence (general population)1.15 per 100,000 incidence (African American) Kaposi sarcoma2014723.40.6 per 100,000 incidence (general population)2.96 per 100,000 incidence (African American) Seborrheic keratosis203209.990% prevalence (general population aged 60+ years)No reliable figures available Squamous cell carcinoma/keratoacanthoma363328.8296-497 per 100,000 incidence (general population)3 per 100,000 incidence (African American) Benign melanocytic nevus791587.395% prevalence (general population)0.12 odds ratio of incidence (Fitzpatrick V versus I and II) Dermatofibroma1715.9No reliable figures availableNo reliable figures available Melanoma620243.922 per 100,000 incidence (general population)0.9 per 100,000 incidence (African American) Basal cell carcinoma38192.4226-353 per 100,000 incidence (general population)0.06 odds ratio of prevalence (African American compared to white) Actinic keratosis2740011%-26% incidence (general population)No reliable figures availableTotal15,445300820.1HSV, Herpes simplex virus. Open table in a new tab HSV, Herpes simplex virus. This analysis underscores variations in DSI representation among learning resources and dermatologic conditions. The lower representation of DSIs in textbooks may relate to the limited space, need to show classic cases, and reuse of images. Online resources have more flexibility to add images to their database, allowing for a more comprehensive illustration of pathology. Accordingly, VisualDx shows pathology on dark skin in a remarkably high proportion compared to other resources. Our data show an exceedingly low representation of DSIs in neoplasms of the skin, which is consistent with prior studies.10Louie P. Wilkes R. Representations of race and skin tone in medical textbook imagery.Soc Sci Med. 2018; 202: 38-42Crossref PubMed Scopus (67) Google Scholar Although the incidence of most skin cancers is lower in individuals with dark skin, these patients often have worse clinical outcomes, including disproportionately higher morbidity and mortality.3Buster K.J. Stevens E.I. Elmets C.A. Dermatologic health disparities.Dermatol Clin. 2012; 30: 53-59Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar,11Davis S.A. Narahari S. Feldman S.R. Huang W. Pichardo-Geisinger R.O. McMichael A.J. Top dermatologic conditions in patients of color: an analysis of nationally representative data.J Drugs Dermatol. 2012; 11: 466-473PubMed Google Scholar Consequently, rather than reflecting the incidence of disease in the patient population, educational materials must comprehensively illustrate all pathology in patients of a spectrum of skin tones. This includes presentations that trainees may be unlikely to encounter through the course of their clinical training. Images should be supplemented with clinical pearls for conditions harder to diagnose in darker skin tones, although this should not replace high-quality photographs. This study is limited by the inherent subjective nature of designating skin tone, the omission of individuals of racial/ethnic minorities with lighter skin tone, and the inability to directly link DSI representation and patient outcomes. Increased effort and guidance pertaining specifically to photographing skin of color are needed, given the challenges of photographing pathology on dark skin. With the gap in availability of DSIs in dermatology educational materials, online resources may play a role in providing more exposure to pathology on dark skin. Skin of color matters: A call to actionJournal of the American Academy of DermatologyVol. 84Issue 6PreviewTo the Editor: We read Alvarado et al's recent study1 on the representation of dark skin images of common dermatologic conditions in educational resources with great interest. Cultural competency in health care delivery is fundamental in reducing health care disparities and providing unbiased care. Ultimately, cultural competency will help us connect with our patients and foster a better patient–provider relationship. Although the US population is becoming more diverse, our educational resources continue to lag behind, as evidenced by studies that shed light on the limited representation of skin of color images in dermatology educational resources. Full-Text PDF