Inez Dover listened carefully while her longtime Brigham dermatologist, Jennifer Lin, MD, asked a series of questions over the phone about a hot, prickly rash that Dover had discovered on her body recently. One of her doctor’s first inquiries: What color was the lesion?
“Some of it was red and some of it was brown,” Dover recalled. “I was thinking, aren’t rashes supposed to be all red? Or pink? But Dr. Lin said, ‘Yes, that’s OK. It’s because of your complexion.’ She explained that, because I am a woman of color, a rash would look like that on my skin. And when she prescribed medication for it, she advised me not to use it for too long because it could lighten my skin.”
Dover, who is African American, remembers the interaction as a refreshing departure from other experiences she’s had as a person of color in the health care system.
“The disproportionate way people of color are treated and dehumanized in the health care system is a major concern for me,” she said. “As a Black woman, I have had negative experiences with physicians, and when I was choosing a dermatologist, it was critically important that I selected someone who understands women of color’s skin. It’s a change-maker.”
To help address the historic disparities, frustrations and indignities that patients of color like Dover have experienced in trying to obtain care for skin and hair disorders, a group of Brigham dermatologists came together in 2011 to create the Skin of Color Dermatology Program. Staffed by a team of four attending dermatologists, the program provides individualized, culturally sensitive care to patients of color.
“As doctors, we see everyone as equivalent. Everyone is someone I want to help. In some ways, we’re colorblind when we’re examining our patients, and yet in dermatology, we do have to pay attention to color, acknowledge and celebrate it,” said Lin, one of the program’s founding co-directors. “Being part of a program that creates the space to do that is a real privilege for me, especially as someone who has lived with having skin of color myself.”
‘Skin Is Skin, but Skin Is Not Skin’
The Skin of Color program has grown steadily over the year, now offering specialized services at two locations: 221 Longwood Ave. in Boston and 850 Boylston St. in Chestnut Hill. In addition to patient care, the program provides education and training opportunities for dermatology residents. And as its momentum continues to build, the team is beginning to explore research opportunities to help grow the number of studies focusing on skin of color.
“Skin is skin, but skin is not skin. There are differences in the way different skin tones respond to injury and certain skin diseases,” said Deborah Scott, MD, also a founding co-director of the program. “You might think, why do we need a dedicated program for this? In an ideal world, we wouldn’t. But it’s not an ideal world, and it’s important for us to not only be able to treat patients appropriately but also to ensure our trainees are prepared to care for all skin types after they complete their training and go out into the world.”
Dover, who began seeing Lin before the Skin of Color program formed, said she has been continually impressed with her dermatologist’s thoughtful, personalized and patient-centered approach.
“Dr. Lin is the best. She is very detailed and explicit in her explanations, and her bedside manner is impeccable,” said Dover, a retired educator, ordained minister and grandmother of three. “Whatever recommendations she makes for me, she’s always thinking about my background and what differences might be seen in my complexion.”
Acknowledging the Gaps
Chronic diseases such as discoid lupus and sarcoidosis, both of which cause skin inflammation, are more common in darker skin types, particularly among people of African descent. Meanwhile, many treatments for skin conditions, including lasers and certain ointments, can affect darker skin tones differently than lighter ones.
Some disorders can be more noticeable, and devastating, on people with darker skin — including conditions such as hyperpigmentation and vitiligo, which respectively cause an excess or loss of skin pigment.
“When patients have a skin disease, it’s often not their choice whether they disclose it or not. It is particularly true with vitiligo, which can be quite noticeable,” said Kristina Liu, MD, MHS, a dermatologist in the Skin of Color program and director of the Vitiligo Clinic. “There is a lot of misunderstanding about the disease, and vitiligo patients with skin of color experience much higher levels of stigma and distress.”
Scott and Lin co-founded the Skin of Color program with former colleague Vaneeta Sheth, MD, after seeing these conditions and needs addressed inadequately, or sometimes not at all, by existing systems of care.
“I’m African American, and when I first started practicing 30 years ago, I would see patients who said another dermatologist sent them to me because their dermatologist didn’t know how to treat their hair. I thought that was appalling,” said Scott, who also serves as director of the Laser & Skin Health Center and co-director of the Hair Loss Clinic. “I certainly knew how to treat patients whose hair didn’t look like mine. That’s what triggered my specialization in hair, actually. It wasn’t that I was particularly interested in the topic as much as I felt I needed to be a resource for patients who were being ignored or having their issues minimized.”
While dermatology practice and education has evolved considerably since then, there is a continued need to address gaps and inequities through a program like Skin of Color.
“I am not someone who thinks that you can only care for patients who look like you. That’s not our goal at all. In fact, this is a clinic that should be obsolete. Every dermatologist has the ability to care for patients with darker skin,” said Lin, who also serves as co-director of the Melanoma Risk and Prevention Clinic. “But for now, there’s value in having a dedicated clinic where patients feel comfortable that the people taking care of them have had some extra training and a special interest in caring for skin of color.”
Part of the challenge lies in dermatology education, as geography and local demographics often determine the patient populations residents are exposed to during training. That is, residents who train in clinics that see mostly white patients often don’t get experience in how skin and hair disorders may appear in patients of color. Compounding the issue is the fact that photographs used in medical textbooks often depict lesions and disorders on white skin by default.
To help ensure trainees have more exposure to caring for patients of color, Skin of Color dermatologist Sotonye Imadojemu, MD, leads one of the program’s resident clinics to provide dedicated time for dermatology trainees to learn about caring for patients with skin of color.
“It’s been really well-received by the residents so far, and one important point to note is that it’s not an elective. It’s part of the general dermatology training experience, just like any other clinic,” Imadojemu said. “We deliberately did not want to make it seem like skin of color was a specialized niche.”
Imadojemu, who is dual board-certified in internal medicine and dermatology and is director of the Cutaneous Sarcoidosis and Granulomatous Diseases Clinic, said contributing to the field in this way and being part of the Skin of Color team has been a rewarding experience.
“I can’t even count how many times patients say, ‘I’m so happy to see you,’” she said. “It feels like my presence as a Black doctor is filling a need in the community. It’s not necessarily specific to being a Skin of Color dermatologist, but rather just being a doctor — helping people heal, making an impact on educating the next generation of dermatologists and reshaping the way we think about skin of color in dermatology.”