Dermatology is a visual field. In many cases, a skilled physician can make a diagnosis based solely on what something looks like. But there’s a glaring gap in dermatology education: Many physicians are trained on what diseases look like on white patients only. In fact, a study published in the Journal of the American Academy of Dermatology found that only 4 to 18 percent of the images in dermatology textbooks show black or brown skin. Some books don’t have a single example of acne, psoriasis, or dermatitis on dark skin.

A physician who has been trained to recognize eczema by how it looks on white skin may struggle to recognize this common disease when it looks different on black and brown skin, Kassahun Bicha, MD, FAAP, told Bottom Line Health.

Commonly missed conditions

Part of the diagnostic dilemma is that darker skin may not look red when it is inflamed or irritated. This simple difference can affect the diagnosis of a variety of issues:

  • Cellulitis can look purplish or brown.
  • Eczema can look brown, violet, or gray. Further, darker-skinned people with eczema are more likely to develop bumps on their arms, legs, and torso, as well as dark, bumpy circles under the eyes—something not often seen in white patients.
  • Psoriasis, usually red or pink on white skin, is often salmon-colored with a silvery-white scale on brown skin. It can be dark brown or violet with a gray scale on black skin.
  • Melanoma. People with darker skin often develop melanoma lesions on the soles of their feet, palms of the hand, fingernails, toenails, or inside the mouth. A dermatologist who is looking for lesions on sun-exposed skin can easily miss these, which may help explain why skin cancer is often diagnosed late and has a poor prognosis in people with black or brown skin.

Several skin conditions are more common in Black and Brown patients:

  • Post-inflammatory hyperpigmentation consists of darkened patches of skin located at the site of previous inflammation or injury.
  • Pseudofolliculitis barbae occurs when hairs either leave the hair follicle and curl back into the skin or penetrate the skin before leaving the hair follicle. The body reacts by causing inflammation and bumps.
  • Melasma appears as brown-gray patches of skin on and around the cheeks, lips, chin, nose, and forehead
  • Acne keloidalis nuchae is a long-term inflammatory condition that leads to inflamed plaques and papules on the head or neck.
  • Dermatosis paulosa nigra causes benign skin growths on the neck and face that may be skin-colored or hyperpigmented.
  • Keloids. People with darker skin are more prone to develop these raised scars.
  • Vitiligo affects people of any skin color, but the white or lightened patches it causes are more obvious on darker skin, making the condition more distressing.

Improve care

When it comes to skin health, Black and Brown patients need to be proactive, informed, and persistent to get the right diagnoses and
treatments.

  • When researching skin conditions online, look for photos of skin conditions on your own skin color. (See the sidebar for several websites to try.)
  • Don’t settle for the first diagnosis you get. If you’re unsure about a diagnosis or a treatment isn’t working, get a second (or third) opinion.
  • There are a growing number of dermatology practices that specialize in Black and Brown skin. Try the doctor finder feature on the Skin of Color Society website https://skinofcolorsociety.org.
  • If you can’t find a local provider, consider a doctor who offers video appointments that you can do over the phone or computer.
  • Once you find a dermatologist that you trust, undergo routine skin checks.
  • Ask your hairdresser or barber to tell you if they notice any suspicious spots. He or she may be the first person to spot evidence of skin cancer on your scalp, neck, or face.
  • Use a broad-spectrum, water-resistant sunscreen of at least SPF 30 every day.

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