When you Google common skin conditions like keratosis pilaris (KP), rosacea, eczema and psoriasis, you’re probably flooded with images of these conditions on white or fair skin tones. Additionally, most textbook photos and studies doctors examine in school tend to be of lighter skin rather than skin of color. Every dermatologist’s experience is different, so it’s important to find an expert that can identify these conditions on any skin tone.
“Patients with pigmented skin may find it hard to find representative pictures of their condition on Google—80 percent of Google pictures of skin conditions are of lighter-skinned people,” says New York dermatologist Elaine Kung, MD. Additionally, “depending on where the dermatologist has trained or is practicing, they may have limited exposure to patients with darker skin types,” says Dr. Kung. “For example, a friend who moved to Virginia texted me that she called a few dermatology offices in her area inquiring if they feel comfortable treating an Asian person’s brown spots with a laser. She was disappointed to find out that most of them do not.”
Similarly, while Montclair, NJ dermatologist Jeanine B. Downie, MD has trained and practiced in New York City, friends in other states, like Idaho and Iowa, don’t see as many patients with skin of color, so diagnosis can be challenging. “There needs to be more skin of color training in all residencies so that different skin conditions are not misdiagnosed and mistreated,” she says. Furthermore, “dermatologists need to do research if they realize they’re weaker in a certain area,” says Dr. Downie. “They need to attend more CME-type dermatologic conferences and make sure that they’re trained in the areas they think they’re weaker in because we don’t need weak doctors ever at all.”
According to Dr. Kung, dermatologists who have practiced in major metropolitan areas like New York City and Chicago, like herself, are the best experts to ask as they’re more familiar with a wide range of skin tones. “Many times, patients will come to see me and they tell me they have shingles and it’s psoriasis. They tell me they have acne and it’s KP. They tell me they have a fungus and it is eczema,” says Dr. Downie. “So if patients tried to treat something over the counter for more than a week, and it’s not treatable, then they should go see a board-certified dermatologist.”
Miami dermatologist Anna Chacon, MD says eczema can present very differently in people of color. “Due to the redness’ potential to be hidden on darker skin, it is frequently hard to figure out,” says Dr. Chacon. “Eczema may instead appear as a dark brown, purple or ashen gray color. This can lead to delayed or incorrect diagnoses.” Hallandale Beach, FL dermatologist Dr. Bertha Baum says affected areas may also appear as thick, scaly patches that are darker than the surrounding skin. Dr. Downie notes that it can also be more papular than what we commonly see on light skin types. Some other signs of eczema include itching, dry skin and a rash, says Dr. Chacon.
“In people with darker skin tones, psoriasis can appear as dark patches or thickened, scaly plaques that may be mistaken for eczema or other skin conditions,” says Dr. Baum. She notes that the usual redness of the condition is often less apparent on skin of color. Dr. Downie says the often silvery scales could appear a deep eggplant color.
“Acne lesions can appear darker or redder on skin of color due to increased melanin production. Additionally, post-inflammatory hyperpigmentation (PIH) can be more common and more severe in people with darker skin tones, leading to long-lasting dark marks after acne clears,” says Dr. Baum. Dr. Downie notes that often patients come in concerned about acne, but it turns out to be dark spots.
“Skin cancers do look different in skin of color versus lighter skin types,” says Dr. Downie. “If you have a non-healing pimple or a non-healing wound, you should check it to make sure that it’s not a skin cancer with the board-certified dermatologist.”
Rosacea often presents as a flush of pink and red on those with lighter skin tones, but Dr. Downie says it can appear more violet and purple on darker skin tones. “On dark and black skin, it may be challenging to recognize the flushing or blushing associated with rosacea. Keep an eye out for additional symptoms of the illness,” says Dr. Chacon. “Rosacea is a common skin disorder that makes your face look flushed and has visible blood vessels. Moreover, it could result in tiny, pus-filled pimples.”
Dr. Downie says KP may look like a generalized rash on skin of color. While KP tends to appear as white or red bumps on lighter skin, they may be brown or flesh-colored on darker skin tones, says Dr. Chacon. It frequently appears as raised, darker lumps on the upper arms, butt and thighs.