By Ruth Werner
Five years ago, I wrote a blog in which I shared my frustrations about being a pathology teacher who strives to be racially and ethnically inclusive in the way I educate myself and others about diseases. As we celebrate Black History Month, it seems like a good moment to provide an update on that goal.
In the original 2020 blog, I bemoaned the lack of representation of Black and Brown people in illustrations of skin diseases. This was, and continues to be, a big problem and one that many people (especially light-skinned folks) are unaware of.
Consider, for instance, the cardinal signs of inflammation we are all taught: pain, heat, redness, swelling, loss of function. Now compare them on these images of two people with folliculitis, a bacterial infection of hair shafts.
In which image is folliculitis easier to identify? Why? It’s partly because the contrast on light skin is greater, but it’s also because we aren’t taught to be aware of subtler changes.
The number of skin conditions that look completely different on different skin tones is too long to name. My point is, what we are traditionally taught about skin problems often doesn’t apply to large portions of the population!
In short, we still have a substantial problem with representation of skin that isn’t pale in medical educational materials. And because of that, many doctors (especially those who aren’t dermatologists) are undereducated in how to recognize signs of disease . . . which contributes to the barriers for people of color receiving early and effective care . . . which contributes to why we don’t see pictures of them in medical texts . . . ad infinitum.
Updates Since We Last Spoke
In the 2020 blog, I shared some resources that were attempting to bring attention to the problem. Specifically, I pointed to a project called Mind the Gap, a publication called Visual Dx, and an Instagram page called Brown Skin Matters. I have a few updates.
“Mind the Gap: A Handbook of Clinical Signs in Black and Brown Skin” is a free PDF, downloadable from the website. It has several dozen photographs of skin conditions affecting people with dark skin. However, it is a limited collection, and it has not been updated since 2020. That is disappointing, because at its beginning, it was a repository to which anyone could add images, and that is no longer the case.
“VisualDx: Essential Dermatology in Pigmented Skin” is available as a textbook from a vendor of your choice. It is also a frequently updated app with thousands of images. It is less expensive now than it was in 2020 (individual users can get it for $20.70/month, as opposed to $40) but it is still not a very practical option for massage therapists or educators.
Brown Skin Matters is still an active Instagram page where people can contribute their own photos. This is great, but the quality is not always high, there’s no search function, and it’s unclear whether these photos are labeled correctly—the disclaimer with every photograph is, “Please reference intelligently. The submitter has reported a diagnosis, but we have not independently verified this.”
The Good News
I am pleased to announce that several more resources have appeared and/or substantially expanded since 2020.
Note to Readers: looking at pictures of people with skin diseases is not everyone’s cup of tea, and these sites have some photos that show very severe cases, up close and personal. If this isn’t your jam, give it a miss! But remember, when a person gets their picture taken, it means they are receiving medical care. That helps a lot.
Skin Deep is a project hosted by an international organization called Don’t Forget the Bubbles, which is focused on education about pediatric care. The photos at Skin Deep are diverse in both skin tone and age—it’s not just children.
The Full Spectrum of Dermatology: A Diverse and Inclusive Dermatology Atlas is a repository of images available free of charge for non-commercial educational purposes. It is hosted by the Journal of Drugs in Dermatology, an academic publication.
Skin of Color Atlas is available through The Journal of the American Academy of Dermatology. These images are very intense, but they are also accompanied by the articles in which dermatologists discuss treatment options and share outcomes.
Dermatology Image Library provides good photographs broken into useful categories, but they are not shown with any explanatory information. However, they make this useful offer: “Please feel free to use any of the images showcased on this website. If you use the images, we ask that you cite both our website and the primary source of the image as references.” This site is hosted by the University of North Carolina.
The University of New Mexico also hosts a gallery of many skin conditions as they show on many different skin tones. This appears to be an ongoing project, with a mission statement and information on how to submit more images. However, I didn’t find information on permission to use the photographs.
Image Library at DermNet is a resource from New Zealand I use frequently, and they are happy to have their materials used for educational purposes.
There are more options, but I am thrilled even to provide this list. It seems that much of the educational world has awoken to the lack of representation of dark-skinned people in medical illustrations and are taking steps to be actively engaged in addressing the problem.
If you are a massage therapist or educator, this should be on your radar too. We all have the responsibility to be watchful of changes to our clients’ skin—no matter how pale or dark they are. We are skin “first responders,” and as such, we need to be educated and careful communicators about what we observe.
author bio
Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology, now in its seventh edition, which is used in massage schools worldwide. Werner is also a long-time Massage & Bodywork columnist, most notably of the Pathology Perspectives column. Werner is also ABMP’s partner on Pocket Pathology, a web-based app and quick-reference program that puts key information for nearly 200 common pathologies at your fingertips. Werner’s books are available at booksofdiscovery.com. More information about her is available at ruthwerner.com.