Updated: Jul 25
“Eliminating biases and establishing a new foundation of education based on diversity is integral to achieving health equity and improving the trust between a doctor and their patient.”
Author: Varsa Murugesu
(a) Images obtained from articles depicting the cutaneous symptoms of COVID-19 (b) Skin colour of the patients corresponding to the images in (a), determined by selecting an area of the skin unaffected by the rash and adjusted for unwanted lighting conditions such as overexposure 
Within the last 20 years, diagnosing illnesses and infections has become drastically easier and more accessible through the advancements of technology. With the internet at most people’s disposal, self-diagnosing a new rash is just a few taps away on your smartphone. But what happens when you can’t find a reasonable diagnosis for your symptom? As you scroll through hundreds of images on Google, none of the pictures match the rash you see on your arm. So, you decide to book an appointment with the dermatologist. However, even the dermatologist doesn’t seem entirely confident with the diagnosis they give you. This is the case for many Black, Indigenous, and people of colour (BIPOC) who wake up one day with a skin condition that not many health professionals are able to accurately diagnose due to difference in comparison with the field’s ‘normal’ skin tone.
Our Current Situation
In light of the current coronavirus pandemic, identifying symptoms has become increasingly important. Recognizing signs is key to diagnosing the condition quickly and getting the appropriate treatment. However, the latest studies show that COVID affects BIPOC disproportionally . With information about the virus continually being updated, it is vital to know some symptoms that can help identify the virus faster: cutaneous presentations are easier to identify than physiological ones that manifest as coughs or fevers; Coronavirus may be harder to identify in BIPOC populations; and people with darker skin may have to look for different criteria which results in a delay of diagnosis as well as treatment .
Second-year UK medical student Malone Mukwende addresses this issue through his book, Mind the Gap (yet to be released), after seeing Black families being asked if their lips turned blue as a symptom of COVID-19 . “These are not useful descriptors for a Black patient, and as a result, their care is compromised from the first point of contact,” he states . Identifying clinical signs that affect skin in people of colour is especially important during a pandemic as it could help to identify physiologically asymptomatic patients . For example, skin rash is one of the symptoms of the coronavirus . However, if you do a quick google search of “COVID skin rash”, most of the images show rashes on white skin (see Figure 1).
A recent study conducted by Lester et al. involved a systematic literature review of all articles related to COVID published between the end of December and early May . They discovered that most of the clinical images that demonstrated cutaneous symptoms of COVID were from individuals with lighter skin (see Figure 2) .
Screenshot of the results from a Google search of the words “Covid skin rash” 
The Scope of the Issue
This problem doesn’t only exist in the diagnosis of coronavirus; several other skin conditions also feature white skin as the blueprint example for symptoms of the condition . Skin cancer is an example of this. It is widely believed that skin cancer mostly affects White people, with sunburn being something to avoid . However, everyone’s skin can get sunburnt and skin cancer is not the only resultant of UV radiation . For example, melanoma is a type of skin cancer that is more aggressive in BIPOC populations . The symptoms present themselves differently to White people than to BIPOC . Melanomas are commonly known to cause moles that change in shape in areas where the sun is exposed to the skin in White people . However, in BIPOC, symptoms show up in odd areas including the fingernails, toenails, in the mouth, and on palms . These symptoms are seen in the later stages of the condition, which is further harmful as there is already a preconceived notion that darker skin correlates to protection from UV rays .
After Ellen Buchanon Weiss noticed a rash on her adopted one-year-old son’s back, she immediately turned to the Internet to find any information . She discovered that a lot of the images, including those on Mayo Clinic, didn’t feature any with brown skin . In order to help solve the lack of representation, she opened up an Instagram account aimed at helping others who might be in the same situation with reference photos of skin conditions on brown and black skin . Her account, BrownSkinMatters, now has a little over 62k followers and continues to grow with every post featuring a new condition that is also reviewed by a physician for accuracy . One of her posts, for example, highlights the hive condition on dark skin, which appears to manifest as tiny raised little bumps as opposed to the raised blotchy red bumps exhibited on white skin . In the comments section, two followers express their appreciation of the post, stating that they couldn’t find the right explanation for the symptom for years until they found the post . However, it should be noted that these posts are not meant to replace an actual diagnosis but to act more as a guide/reference.
A Pakistani-Canadian woman named Aisha told TheMighty.com of an incident where she had a doctor’s appointment about her skin irritation but was dismissed with the doctor prescribing her shampoo for psoriasis . Following the order didn’t help Aisha as her symptoms remained and she even developed red patches . Canadian medical student Michael Mackley also recalls in a twitter thread about his interaction with a Black patient: upon being assigned a new patient and going over the chart and symptoms, Mackley automatically diagnosed his patient with liver disease . However, he realized that this diagnosis was only made based on the physical findings of white skin. Upon entering the patient’s room, he realized his patient was Black . He admits that as a result of the lack of exposure to physical findings of all skin colours and his own assumptions, Mackley was unable to give an accurate diagnosis . Dermatology involves a lot of pattern recognition — if the foundation of medical education does not include all skin colours, this increases the health disparities that already exist.
The Importance of Representation
These examples serve to address a bigger picture: medical schools do not educate their students enough to recognize skin abnormalities in darker skin, which inadvertently creates a bias . Adequate training and education is the key to eliminating this bias. In an article with The Mighty.com, dermatology professor Mckinley-Grant explains that medical training usually does not include photographs of darker skin . According to a study published in 2019, it was stated that 47% of dermatologists expressed their feelings of having inadequate training to diagnose diseases that appear in skin of colour . Grant also advises that healthcare and medical professionals need to be trained in more diverse and inclusive environments where they can be exposed to more BIPOC patients . In addition to this, she also recommends attending symposiums to learn more about various cultures . Medical schools could also strive to increase the number of lectures that are taught by experts in skin of colour. Lastly, further research is mandatory to improve early detection and treatment of BIPOC skin conditions. By doing so, it eliminates many of the worry and confusion associated with having an illness and enhances their quality of life.
It is especially important to solve this problem as the integration of artificial intelligence in all aspects of healthcare relies heavily on input from humans. If the information that goes into making the algorithms is based predominantly on lighter skin, it could prove harmful to those who have darker skin, leading to delayed treatment and negative impact on doctor-patient relationships. Eliminating biases and establishing a new foundation of education based on diversity is integral to achieving health equity and improving the trust between a doctor and their patient.
Williams Thottungal & Majd Al-Aarg
Header Image by Mika Baumeister .@mbaumi from Unsplash
Lester J, Jia J, Zhang L, Okoye G, Linos E. Absence of images of skin of colour in publications of COVID‐19 skin manifestations. British Journal of Dermatology [Internet]. 2020 [cited 5 August 2020]; https://doi.org/10.1111/bjd.19258
Mind the Gap: a handbook of clinical signs on black and brown skin [Internet]. Sgul.ac.uk. 2020 [cited 22 July 2020]. Available from: https://www.sgul.ac.uk/news/mind-the-gap-a-handbook-of-clinical-signs-on-black-and-brown-skin
Lester J, Taylor S, Chren M. Under‐representation of skin of colour in dermatology images: not just an educational issue. British Journal of Dermatology [Internet]. 2019 [cited 5 August 2020];180(6):1521-1522. https://doi-org.proxy.bib.uottawa.ca/10.1111/bjd.17608
www.sciencedaily.com [Internet]. Skin cancer rare — but more deadly — in people with darker skin. ScienceDaily. 2020 [cited 14 August 2020]. Available from: https://www.sciencedaily.com/releases/2006/07/060727100422.htm#:~:text=Researchers%20say%20that%20dark%2Dskinned,leads%20to%20disproportionately%20more%20deaths
www.cancer.org [Internet]. Signs of melanoma skin cancer | symptoms of melanoma. American Cancer Society. 2020 [cited 5 August 2020]. Available from: https://www.cancer.org/cancer/melanoma-skin-cancer/detection-diagnosis-staging/signs-and-symptoms.html#:~:text=Spread%20of%20pigment%20from%20the,of%20a%20lump%20or%20bump
Gupta A, Bharadwaj M, Mehrotra R. Skin Cancer Concerns in People of Color: Risk Factors and Prevention. Asian Pacific journal of cancer prevention [Internet]. 2016 [cited 17 August 2020];17(12):5257–5264. Available from: doi:10.22034/APJCP.2016.17.12.5257
www.npr.org [Internet]. Diagnostic gaps: skin comes in many shades and so do rashes [Internet]. NPR. 2020 [cited 20 July 2020]. Available from: https://www.npr.org/sections/health-shots/2019/11/04/774910915/diagnostic-gaps-skin-comes-in-many-shades-and-so-do-rashes
Metraux J. For BIPOC people, bias is a barrier to treatment for skin conditions [Internet]. The Mighty. 2020 [cited 5 August 2020]. Available from: https://themighty.com/2020/07/black-brown-skin-treatment-bias/
Mackley M. I am a third-year medical student. Yesterday, I was assigned a new patient. I hadn’t met them yet, but knew they had presented with liver-related symptoms. In preparation for morning rounds, I flipped through their chart and checked their lab work. [Internet, Twitter]. 2020 Jun 11 [cited 14 August 2020]. Available from: https://twitter.com/MichaelMackley/status/1271245408573034496
Google Images. COVID skin rash [Internet screenshot]. 2020 [cited 2020 Aug 17]. Available from: https://www.google.com/search?q=covid+skin+rash&newwindow=1&rlz=1C1CHBF_en-GBGB862GB862&sxsrf=ALeKk01Oj0_VHw268zOesEkcLJHJ6uL8lQ:1598560350834&source=lnms&tbm=isch&sa=X&ved=2ahUKEwiE5vOunbzrAhWCQs0KHcFgDQ4Q_AUoAXoECCAQAw&biw=1920&bih=937