PEOPLE OF COLOR

Dark skin

Here’s the problem with dermatology education -- it only addresses White people's skin. However, the majority of Americans are not Caucasian. Imagine not knowing how to diagnose problems with  the heart, lungs or colon in the majority of the population! Why do we treat the skin differently? And more importantly, what can we do about it? I don’t pretend to have all the answers, but I wanted to provide some helpful resources below, and offer some of my thoughts on the topic. 

• • • The online resource VisualDx has a great repository of images. 

    • Mind the Gap is a free online handbook covering dark skin.  

Here are some of the conditions that are more commonly seen in people  with dark skin

• • • Keloids are much more common in people of color. Wounds normally heal themselves by constructing a collagen mesh (scar). Sometimes the collagen production spirals out of control, for reasons we don’t understand, and the scar grows beyond the margins of the original cut. Keloids are big, puffy and shiny. Do not remove them surgically, as this angers the keloid, and it will grow even more. 

    • Dermal Melanocytosis (Mongolian Spots) are dark gray-blue birthmarks in babies of color. They occur whenever melanocytes are trapped within the dermis, instead of the epidermis. But don’t worry too much about them, the dermis will eventually replenish, and the spot should disappear within a few years. They look pretty similar to bruises, however, mongolian spots tend to look more homogenous than bruises. History and close inspection are vital.

Here are some of the challenges with examining dark skin.

• • • Cyanosis is less obvious, but it is still possible to spot central cyanosis (in the face) because here the epidermis is thinnest and the vasculature is densest. The tongue should always have a healthy pink color. 

    • Erythema can be tougher to spot on dark skin. Here’s a handy trick to help you spot cellulitis. With cellulitis, there is swelling. And with swelling, the skin is pulled taut, making it shiny! And when that swelling dies down, the skin takes a duller, scratchy appearance.

    • Bruises are a little harder to appreciate, especially in the later stages where the bruise turns from blue to yellow.

    • The little finger devices that monitor oxygen saturation have a tougher time with dark skin. The results they provide are likely to be thrown off by about 2-3% and are overall less reliable.

    • A good rule of thumb is to compare the patient to a family member or to an old photograph

Physical exam findings that are NOT affected by having dark skin. These “anatomical loopholes” can provide you with information even if the skin is withholding.

• • • The conjunctiva should have a pink rim, regardless of race. See my Iron Deficiency Anemia section for more information. This is a helpful tool to diagnose anemia. 

    • The sclera should be white (they are the “whites of the eyes” after all). But this rule of thumb isn’t absolute.  Many people of color have yellow or muddy brown discoloration of their sclerae, and this is a normal finding that is due to increased deposition of fat. So before you cry icterus, compare their eyes to family or an old photograph. 

    • The tongue should always have a healthy pink hue. It turns pale in anemia, and dusky with cyanosis.