German dermatology and its problems with dark skin

Illustration by Abbysoul

Dermatology faces a challenge with dark skin, which has different needs than light skin. Common conditions like acne, age spots, and melanomas manifest differently on dark skin than on light skin. Nevertheless, dermatologists are trained to diagnose precisely these conditions on light skin.

Dermatology, as a medical subspecialty, deals with the structure and function of the skin, skin care and pigmentation, as well as the diagnosis and treatment of skin diseases. Skin experts know that the care and treatment needs of people with dark skin differ from those of people with lighter skin. However, there is a lack of, or incomplete, representation of dark skin types in dermatology. Both light and dark-skinned people can experience the same symptoms, but they can appear differently. Dark or black skin is hardly addressed in textbooks. There are very few photographs showing the effects of skin diseases on people with dark skin. The risk of misdiagnosis is high.

The misconception surrounding dark skin is worrying, as studies focus almost exclusively on conditions like tumors, moles, and melanomas on lighter skin. Skin changes on dark or black skin are harder to detect and, due to natural UV protection, are also much less common than in people with lighter skin. Furthermore, many people with dark skin often have insufficient access to the healthcare system due to social circumstances. As a result, they fall through the cracks of the medical system, and their skin changes go unnoticed.

A good example of this flawed development is the Google Health app, which barely considers dark skin types. Google's explanation is that the entire field of dermatology has a problem with the availability of data on people with dark or black skin. Only about 3.5 percent of the underlying images showed patients with Fitzpatrick classifications V and VI, which encompass dark to black skin. The skin classification I to VI, based on UV sensitivity, is named after dermatologist Dr. Thomas Fitzpatrick, who began classifying human skin in 1975.

While dark-skinned people are less prone to malignant melanomas and sunburn due to natural UV protection, they are more susceptible to inflammation and certain types of skin injuries, such as keloids. Keloids are raised, sometimes intensely itchy scars. The darker the skin, the greater the risk of keloid formation. These conditions can lead to depigmentation, meaning lighter patches of skin. Depigmentation is also a problem associated with acne, a skin condition that affects dark-skinned people more often than those with lighter skin. German dermatologist and Woman of Color Ephsona Shencoru recognized this issue and runs the blog https://www.thequestionnaire-official.com/lessons1 to raise awareness about darker skin types.

With appropriate medical research, skin diseases such as acne, inflammatory processes, and melanomas are usually very treatable. However, the situation is different for people with dark to black skin, as they are underrepresented in dermatology. Studies predominantly focus on skin diseases in light-skinned individuals; photographic documentation of skin changes on dark or black skin is scarce. Therefore, it is difficult for people with dark skin to find dermatologists who understand their skin's needs and can correctly diagnose and treat changes or diseases.

While people with dark skin are less frequently affected by malignant melanoma and hyperpigmentation, when this skin disease does occur, the mortality rate is significantly higher than in people with lighter skin. This is due to a lack of relevant studies and photographic documentation that could provide guidance for an initial self-assessment. Dermatologist Jenna Lester recognized this problem and pioneered the "Skin of Color" Dermatology Clinic.