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Patients and providers often don't recognise skin cancer on darker skin. Medical school faculty and students are trying to change that. As a dermatologist practicing in Detroit, Michigan, a city where the population is more than 80% people of colour, Meena Moossavi has seen how health inequities have disproportionately harmed her patients. At times, her patients of colour have come to her with late-stage skin cancer that she believes may have been better treated if it had been detected earlier. Because of a lack of awareness of the risks of skin cancer among Black people and clinicians’ lack of experience diagnosing skin conditions in people with darker skin, melanoma for Black patients can go untreated far longer than when it’s identified for White patients, Moossavi explains in this article.

This article in the American Journal of Nursing provides basic information about the assessment of dark skin tone and calls for action in academia and professional practice to ensure the performance of effective skin assessments in all patients.

Around 1 in 5 children have eczema (also known as atopic eczema or atopic dermatitis). They typically have inflamed and dry, itchy skin. During flare-ups (periods of worsening symptoms), their skin becomes vulnerable to cracks, bleeding and infection. Eczema impacts quality of life; it can impair sleep, ability to concentrate at school, self-confidence and mood. The condition is usually long-term (chronic), although it improves, or even clears completely, in some children as they get older. Even so, it is one of the most common reasons for children and young people to seek medical care. Community pharmacists and GPs are the first port of call and, while there is no cure, treatments can soothe sore skin, reduce itching, improve the appearance of the eczema, and reduce infections. The first part of this National Institute for Health and Care Research (NIHR) Collection brings together major NIHR studies on the prevention and treatment of eczema. Research has explored the effectiveness and/or safety of emollients (moisturisers), anti-inflammatory steroid creams, immunosuppressants (medicines that dampen the body’s imbalanced immune response), and more. Many of the studies directly address treatment uncertainties identified by patients and healthcare professionals in an NIHR-funded James Lind Alliance priority setting partnership. The second part of this Collection explores recent NIHR evidence on the support children and their families need to understand and self-manage their eczema effectively. And finally, the Collection signposts ongoing NIHR research which aims to improve the quality of life of children with eczema in future. The information is intended for pharmacists, GPs and others who deliver and commission primary care services; it could be used to help patients and their families understand more about research into eczema care.

Skin cancer is one of the most common cancers worldwide, with one in five people in the US expected to receive a skin cancer diagnosis during their lifetime. Detecting and treating skin cancers early is key to improving survival rates. This blog for The Medical Futurist looks at the emergence of skin-checking algorithms and how they will assist dermatologists in swift diagnosis. It reviews research into the effectiveness of algorithms in detecting cancer, and examines the issues of regulation, accessibility and the accuracy of smartphone apps.

In this article for Forbes, Dana Brownlee looks at individuals who are promoting inclusion in healthcare in practical, tangible ways. She looks at the work of Nigerian medical illustrator Chidiebere Ibe, who is depicting black skin in his medical illustrations, and of Toby Meisenheimer, who developed a business selling plasters of different skin tones. She highlights the importance of individuals who disrupt the norms of healthcare to make it more representative of the populations it serves. She also talks about the dangers to patient safety caused by lack of representation, particularly in fields such as dermatology that rely on images of skin for accurate diagnosis.

This webpage by the British Association of Dermatologists contains a selection of resources about skin cancer and sun safety for patients. it describes the different types of skin cancer, how to get moles checked and how to stay safe in the sun.

Potassium permanganate is routinely used in the NHS as a dilute solution to treat weeping and blistering skin conditions, such as acute  weeping/infected eczema and leg ulcers. It is not licensed as a medicine. Supplied in concentrated forms, either as a ‘tablet’ or a solution, it  requires dilution before it is used as a soak or in the bath. These concentrated forms resemble an oral tablet or juice drink and if ingested are highly toxic; causing rapid swelling and bleeding of the lips and tongue, gross oropharyngeal oedema, local tissue necrosis, stridor, and gastrointestinal ulceration. Ingestion can be fatal due to gastrointestinal haemorrhage, acute respiratory distress syndrome and/or multiorgan failure. Even dilute solutions can be toxic if swallowed. A Patient Safety Alert issued in 20142 highlighted incidents where patients had inadvertently ingested the concentrated form, and the risks in relation to terminology and presenting tablets or solution in receptacles that imply they are for oral ingestion, such as plastic cups or jugs. A review of the National Reporting and Learning System over a two-year period identified that incidents of ingestion are still occurring. One  report described an older patient dying from aspiration pneumonia and extensive laryngeal swelling after ingesting potassium permanganate tablets left by her bedside. Review of the other 34 incidents identified key themes: healthcare staff administering potassium permanganate orally patients taking potassium permanganate orally at home, or when left on a bedside locker potassium permanganate incorrectly prescribed as oral medication. The British Association of Dermatologists (BAD) ‘Recommendations to minimise risk of harm from potassium permanganate soaks’ includes advice on formulary management, prescribing, dispensing, storage, preparation and use, and waste.

Getting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings. One in four people in England and Wales see their GP about a dermatological condition, such as eczema, psoriasis or skin cancer, every year. This leads to more than 3.5 million outpatient and day surgery appointments annually. The GIRFT dermatology report makes 23 recommendations to help patients get faster and more equal access to care, including addressing the dermatology workforce shortage. You will need a FutureNHS account to view this report, or you can watch a short video summary which includes key recommendations.

A blog highlighting the barriers in healthcare faced by patients due to the colour of their skin. The COVID-19 pandemic has brought to the forefront health inequalities relating to the colour of a patient’s skin. However, this is not a new issue and patients have always faced barriers in healthcare due to the colour of their skin. Impacting factors can include explicit racial bias, which includes discrimination and prejudice; implicit racial bias; missing data; lack of trust; and reduced access.[1] These can lead to misdiagnoses and delays in treatment, which can ultimately cause harm and preventable death. Dangerous gaps in training Medical training has, to date, primarily centred on diagnosis in white-skinned individuals, leading to conditions being overlooked in darker skin. Lack of understanding on how changes from the norm may manifest in individuals with darker skin could mean that early developing illness is missed.[2] In a column for The Guardian, doctor Neil Singh highlights that during his medical training it was almost always assumed that his patients would be white.[3] He argues that this prejudice is harmful and can be deadly when it comes to dangerous skin conditions. A lack of diverse imagery In dermatology, where images are critical for diagnoses, the lack of images of darker skin poses a barrier to proper treatment and medical education.[4] A study in the journal Social Science and Medicine found that only 4.5% of images in medical textbooks feature dark-coloured skin, which makes it difficult for doctors to learn how to diagnose people of all skin tones.[5] Skin conditions that involve redness or pinkness in light skin can be subtler or harder to see in dark skin, and doctors who haven’t been adequately trained with such images are prone to misdiagnose their patients.[4] Dermatologists say the lack of images is one reason why many conditions, including cancer, can go misdiagnosed or underdiagnosed in darker-skinned patients. As a result, the five-year melanoma survival rate for black patients is just 70% compared with 94% for white patients.[4] Midwifery: monitoring wellbeing An example of where skin issues are prevalent is in midwifery, where skin assessment is important in monitoring mothers’ wellbeing – looking for changes in skin appearance using visual and tactile cues that might indicate deviation from normality.[2] Although visual signals are more readily discernible in women with light skin tones, they may be more challenging to detect in women with darker skin.[2] It is therefore crucial that midwives are educated to assess and recognise skin changes in all skin tones so that they can care for women with confidence using clinical judgement.[3] Maureen Raynor reports that ‘we need midwives to be colour aware instead of colour blind’ to help improve treatment of their patients.[2] Pulse oximeters and false readings Another example where skin colour plays a role in potential poor treatment is in pulse oximeter testing. In a study, the three tested pulse oximeters overestimated arterial oxygen saturation during hypoxia in dark skin participants.[6] These false readings could lead to health deterioration and lack of necessary treatment. This has been evident during the COVID-19 pandemic, where pulse oximeters have been seen to overestimate oxygen levels in black patients. NHS England is issuing updated guidance, advising patients from Black, Asian and other minority ethnic groups to continue using pulse oximeters, but to seek advice from a healthcare professional.[7] Experts believe the potential inaccuracies in pulse oximeters may be a contributing factor to some of the deaths in dark-skinned COVID-19 patients.[7] An increasing awareness of the need for change To address biases concerning the colour of a patient’s skin, in some cases clinics have been set up where people can see dermatologists who have greater knowledge around darker skin tones. In the United States, major cities now have such ‘skin of colour clinics’, many operating under the name ‘ethnic dermatology’.[3] A petition exists urging the UK General Medical Council to require that medical schools include a diverse representation of skin tones in their teaching.[3] Moreover, the handbook ‘Mind the Gap’ has been produced to educate and raise awareness of how clinical signs and symptoms can present differently on darker skin.[8] Concerned members of the general public have also contributed to this issue – Ellen Buchanan Weiss has established the website ‘Brown Skin Matters’, which provides interested parents and doctors with a collection of images showing how skin conditions can present differently in richly pigmented skin. Final thoughts In conclusion, patients with darker skin experience a greater chance of misdiagnosis than white patients, with higher odds of suffering increased harm from diagnostic errors.[5] This is due to lack of education and medical training, non-representative images and available resources, as well as systemic racism. Much has been done in the way of improving this situation, but a wider movement will be needed to ensure that darker-skinned patients receive equal treatment to white-skinned patients. References: Epstein H. Why the Color of Your Skin Can Affect the Quality of Your Diagnosis. The Society to Improve Diagnosis in Medicine (SIDM) 2018. Raynor M, Essat Z, Menage D et al. Decolonising Midwifery Education Part 1: How Colour Aware Are You When Assessing Women With Darker Skin Tones in Midwifery Practice? The Practising Midwife 2021; 24(6). Singh N. Decolonising dermatology: why black and brown skin need better treatment. The Guardian 2020. McFarling U. Dermatology faces a reckoning: Lack of darker skin in textbooks and journals harms care for patients of color, Stat News 2020. Simmons T. I’m a Black Woman and My Skin Cancer Was Misdiagnosed for Nearly 10 Years. Prevention 2021. Bickler P, Feiner J, Severinghaus J. Effects of Skin Pigmentation on Pulse Oximeter Accuracy at Low Saturation. Anesthesiology 2005; 102, 715–719. Elahi A. Covid: Pulse oxygen monitors work less well on darker skin, experts say. BBC News 2021. Mukwende M, Tamonv P, Turner M. Mind the Gap: A handbook of clinical signs in Black and Brown skin, 2020.

This study, published in the British Medical Journal, found that current algorithm based smartphone apps cannot be relied on to detect all cases of melanoma or other skin cancers. Test performance is likely to be poorer than reported here when used in clinically relevant populations and by the intended users of the apps. The current regulatory process for awarding the CE (Conformit Europenne) marking for algorithm based apps does not provide adequate protection to the public.

Little information is available about the effect of childhood atopic dermatitis (AD) on family function. The aim of this study was to identify the areas of family life most affected and their perceived importance. Intensive qualitative interviews with 34 families were conducted and 11 basic problem areas were identified.