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Source: PEXELS via Pixabay
Underrepresentation of Dark Skin in Medical Literature
Recently, a medical illustration of a fetus in utero went viral. It was one of the first depictions many people had seen of a darker-skinned baby in a medical context. Chidiebere Ibe is the Nigerian medical student behind this revolutionary illustration and many more. In an interview with NBC News, Ibe stated, “I made a deliberate action to constantly advocate that there be inclusion of Black people in medical literature.”
Skin diversity in medical textbooks is low. A 2019 study noted that about 4.5% of images in these textbooks depicted dark skin. In 2018, a publication titled “Skin manifestations of tick bites in humans” contained only photos of light skin.
This can have life-threatening consequences. Dermatologists have difficulty identifying melanoma on darker-skinned patients. In about 25% of cases, doctors only diagnosed the cancer in Black people after it had spread to the lymph nodes. At this stage, melanoma is much more difficult to treat. The five-year melanoma survival rate is 92% for white adults and 67% for Black adults.
Research and Training Lags
LaShyra Nolen, a Black medical student, published in the New England Journal of Medicine her experience of learning about Borrelia burgdorferi in her microbiology course. B. burgdorferi is the bacteria that causes Lyme disease.
Nolen learned about Lyme disease and visual symptoms to look for in patients. Her professor showed images of an erythema migrans (EM) rash on primarily light/white skin. When Nolen asked what an EM rash looked like on darker skin, the response left her less than satisfied. Nolen recalls the professor stating, “Stage 1 Lyme disease is hard to see in patients who are not white, so therefore we don’t depend on rash recognition or diagnosis.”
An EM rash is an important marker since most Lyme disease symptoms are non-specific (headaches, fatigue, fever, etc.). Proper identification of an EM rash can lead to early testing and treatment. Black people are more likely to be diagnosed with Lyme disease out of tick season, suggesting a delayed diagnosis. They are also more likely to be diagnosed when they experience disseminated symptoms like arthritis.
Researchers are unsure if the late diagnosis of Lyme disease in Black patients can solely be attributed to difficulty identifying the EM rash, or if other aspects of implicit biases are involved. However, it is an important consideration.
A Devastating Case Study
The results of delayed diagnosis can be devastating, as documented in a 2019 case study following a young Black man’s journey with Lyme disease.
The patient sought treatment for fatigue, chills, and a bug bite rash that manifested two weeks after a family camping trip. Originally doctors did not associate the patient’s rash with Lyme disease.
After misdiagnoses and several trips to the emergency room, the patient eventually received an ELISA serology test for Lyme disease and tested positive. He was diagnosed with meningitis and atypical Bell’s palsy and received a 10-day course of doxycycline.
He returned to the emergency room with noise and photo sensitivity, continued atypical Bell’s palsy and weakness and tenderness in several areas of his body. A further treatment of intravenous ceftriaxone was administered for 21 days, and yet the patient continued to experience many of the same symptoms.
Eight months after treatment he still had fatigue, headaches and weakness. Here the published case report ends with a diagnosis of post-treatment Lyme disease.
Conclusion
More research and training on identifying skin manifestations of Lyme disease and other vector-borne disease on dark skin is desperately needed. The case study mentioned above is free to access and contains a photograph of EM rash on dark skin. Further photos of EM rash on a variety of skin tones can be found on this CDC page. The report from future doctor LaShyra Nolen points out the spotlight diverse medical trainees and providers can bring to areas where research and training are missing. With more representation, we can provide better care.
Resources
Mann, D. (2021, October 15). Lyme disease often spotted at later stage in Black patients. U.S. News & World Report. https://www.usnews.com/news/health-news/articles/2021-10-15/lyme-disease-often-spotted-at-later-stage-in-black-patients
Fix, A. D. et al. (2000). Racial differences in reported Lyme disease incidence. American Journal of Epidemiology, 152(8), 756-759. 10.1093/aje/152.7.756 https://academic.oup.com/aje/article/152/8/756/126833
Haddad Jr., V. et al. (2018). Skin manifestations of tick bites in humans. Anais Brasilieiros de Dermatologia, 93(2), 251-255. 10.1590/abd1806-4841.20186378 https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC5916399/
American Academy of Dermatology Association. (n.d.). Signs of Lyme disease that appear on your skin. https://www.aad.org/public/diseases/a-z/lyme-disease-signs
Centers for Disease Control and Prevention. (2020, October 9). Lyme disease rashes and look-alikes. https://www.cdc.gov/lyme/signs_symptoms/rashes.html
Centers for Disease Control and Prevention. (2021, January 15). Lyme disease signs and symptoms. https://www.cdc.gov/lyme/signs_symptoms/index.html#:~:text=Erythema%20migrans%20(EM)%20rash%20(,80%20percent%20of%20infected%20persons
Adams, C. (2021, December 10). Meet the student bringing Black illustrations to the medical field. NBC News. https://www.nbcnews.com/news/nbcblk/meet-student-bringing-black-illustrations-medical-field-rcna8277
Adelekun, A. et al. (2020). Skin color in dermatology textbooks: An updated evaluation and analysis. Research Letter, 84(1), P194-P196. 10.1016/j.jaad.2020.04.084 https://www.jaad.org/article/S0190-9622(20)30700-3/fulltext
Sandoiu, A. (2021, July 30). Visual representation of darker skin is key. Medical News Today. https://www.medicalnewstoday.com/articles/disparities-in-dermatology-visual-representation-of-darker-skin-is-key#1
Ly, D. P. (2021). Black-white differences in the clinical manifestations and timing of initial Lyme disease diagnoses. Journal of General Internal Medicine, 2021. 10.1007/s11606-021-07129-1 https://link.springer.com/article/10.1007/s11606-021-07129-1
cited in:
Lyme disease often diagnosed later among Black patients. (2021, October 14). https://consumer.healthday.com/black-patients-experience-delays-in-lyme-disease-diagnosis-2655252337.html
Nolen, L. (2020). How medical education is missing the bull’s-eye. New England Journal of Medicine, 382, 2489-2491. 10.1056/NEJMp1915891 https://www.nejm.org/doi/10.1056/NEJMp1915891
Dennison, R. et al. (2019). Lyme disease with erythema migrans and seventh nerve palsy in an African-American man. Cureus, 11(12), e6509. 10.7759/cureus.6509 https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC6988734/