Recognising how conditions present on darker skin: is nurse training colour-blind?

Darker skin tones are often not included in clinical resources – including for COVID-19 – and this can have disastrous effects on outcomes

• With black and minority ethnic people being more severely affected by COVID-19, the lack of representation of darker skin in studies of symptoms could have serious consequences for outcomes
• There is a recognised lack of training and clinical information on how to diagnose and treat other conditions in darker skin, and some nurses report they have learned from experience
• Tips on how to assess darker skin, plus the resources available that cover all skin types

A letter published earlier this year in the British Journal of Dermatology reported on a literature review of articles describing ‘cutaneous manifestations’ of COVID-19.

The articles included in the review showed 130 images of patients’ skin, none of which represented skin classified as types V and VI on the Fitzpatrick scale – brown, or dark brown or black.

Images of white skin dominate articles about COVID-19 symptoms

The paucity of photographs of COVID-19 manifestations on darker skin is a problem, said the authors of the letter: ‘Given the racial disparities in COVID-19 infections and associated deaths, it is important that all manifestations of this disease contain broad representations of different races and ethnicities.’

Across the 46 articles that met the review’s inclusion criteria, 120 of the images (92%) were of skin types I to III on the scale, which categorises skin from pale (type I) to dark brown or black (type VI).

Dermatology nurses have long recognised that darker skin does not appear as much as it should in clinical teaching or in textbooks. They also know the potentially severe consequences of that deficit on health outcomes.

Read more dermatology articles

British Dermatological Nursing Group (BDNG) educational development nurse Julia Wheeler says: ‘My role in the BDNG is to put together resources for our members to teach them about different skin conditions and how they present.

‘You try to get the best image you can that identifies most clearly the concern the patient has – for example, inflammation in darker skin tones. But when I search for images, I struggle.’

Skin Deep: diversity in skin tones shown in diagnostic resources

Recently there have been indications that things may be changing. A new project called Skin Deep aims to improve diversity in images of children’s skin in medical education. It provides a free resource that helps healthcare staff identify skin conditions in children with different skin tones.

• RELATED: Nurse contributors wanted for project showing skin conditions in BAME children

And August saw the launch of Mind the Gap, a clinical handbook of signs and symptoms in black and brown skin, with an accompanying website.

Medical student Malone Mukwende, of St George’s, University of London, compiled the handbook because he had noticed a lack of teaching about darker skin during his time in medical school.

‘It was problematic because it was almost like we were leaving out a group of patients in our learning,’ he says. ‘It felt as though we were going to qualify and go out into the world and we wouldn’t be fully equipped.’

Mind the Gap, which is aimed primarily at medical students but is relevant to all health professionals, has received international attention.

Mr Mukwende says that demonstrates how the lack of diversity in clinical teaching is a worldwide problem.

‘Colour-blindness’ in dermatology can result in poorer outcomes

The consequences of this ‘colour-blindness’ can be severe, says Neesha Oozageer Gunowa, a senior lecturer in nursing at Kingston University and St George’s, University of London.

‘I did a literature review to investigate outcomes in people with darker skin tones,’ she says. ‘And there is evidence to suggest that people with darker skin tones are more likely to get severe pressure injuries and ulcers.’

• RELATED: Kawasaki-like syndrome more likely to affect black children, study suggests

So what should nurses be looking for when treating patients with darker skin tones?

‘There is no set standard,’ she says. ‘It’s more about acknowledging that there is a difference.’ Terminology is important too, she says. An over-reliance on terms such as ‘redness’ when describing inflamed skin means a whole population group may be excluded.

Maria Akinde is a clinical nurse specialist in paediatric dermatology at St Thomas’ Hospital, London. The centre she works in serves a diverse patient population so its nurses and doctors are familiar with managing skin conditions in people of colour.

‘But going back to my undergraduate training, we didn’t have much in terms of diversity in dermatology when identifying certain characteristics or conditions.

‘And nor when it came to other skin conditions, such as ulcers or changes to the skin that weren’t necessarily a dermatology issue – I don’t recall having that training.’

Formal dermatology training often excludes darker skin

Like many other dermatology nurses, she has taught herself about skin issues in darker skin through a mixture of experience and a commitment to learning.

But lack of formal training remains a concern, Ms Akinde says. If clinical teaching does not embrace diversity, conditions that present differently in particular patient groups will remain an ‘other’ – something perceived as peripheral or unusual.

‘It needs to be integrated rather than “We do X, Y and Z, and, oh, this as well”.

‘The population is changing and as it changes, people need to be able to identify the way different conditions manifest on the skin because it can have a severe impact on health outcomes.’

• RELATED: Challenges of identifying eczema in darkly pigmented skin

Like Ms Akinde, Alice Slater, a dermatology nurse specialist at Homerton University Hospitals NHS Foundation Trust, can recall no formal clinical education relating to darker shades of skin, either in her initial nurse training or as a postgraduate.

‘You build up your knowledge mainly through clinical practice,’ says Ms Slater. ‘There’s only a limited amount you can get from a textbook.

‘Therefore if you work in an area with an ethnically diverse population you do build up experience.’

In fact, she says, given the area of east London in which she works, with its high black and minority ethnic population, she is more used to treating patients with dark skin than white.

Dermatology treatments may vary according to skin colour

Diversity in relation to dermatology is not only about recognising different manifestations of the same condition but also considering different treatments.

‘From a nursing perspective there are nuances,’ Ms Slater says. ‘For example, with eczema black skin tends to be drier and therefore needs a greasier moisturiser than white skin.’

Lucy Moorhead, a consultant nurse in inflammatory skin disease at Guy’s and St Thomas’ NHS Foundation Trust, highlights the potentially serious consequences of failing to acknowledge that skin issues can appear differently in people of different skin colours.

Ms Moorhead, who has worked in dermatology for more than 20 years, says: ‘What would look like erythema – redness – on whiter skin can look just like darker patches on darker skin, and very often you would only see erythema if disease is very severe.

‘So in eczema, for example, there is often an underestimation of its severity in patients with darker skin.’

High mortality rates for melanoma

Ms Moorhead also points to a recent blog about skin cancer by consultant dermatologist Thrivi Maruthappu on the British Skin Foundation website, which highlights a poorer prognosis in people of colour.

‘Often patients with darker skin present at a later stage of disease and healthcare professionals are perhaps not used to seeing skin cancer in darker skin or there’s a presumption that it doesn’t affect people with darker skin,’ she says.

• RELATED: Nurses need to improve their knowledge of skin cancer

Dr Maruthappu writes: ‘Studies have shown that there is a 2-3 times increase in mortality rates in melanoma presenting in skin of colour and these individuals were more likely to present with stage IV (advanced) melanoma.’

In addition, says Ms Moorhead, sun protection creams are often designed for lighter skin and can be less cosmetically acceptable for people of colour because of their ashy residue.

For some conditions, treatments may be judged as successful by the nurse but not by the patient. With psoriasis, for example, treatment may leave darker or light spots on treated skin. ‘We’re delighted because, from our point of view the psoriasis has gone,’ Ms Moorhead says. ‘There are no raised or scaly plaques. But you can still see where the areas are because there is marked post-inflammatory hyper- or hypopigmentation, which is just as visible to the patient as the actual skin disease.’

Diversity in nurse education – technology and innovation

Recent debates about the lack of diversity in clinical teaching have had a medical rather than a nursing focus.

While there is always room for improvement, is nursing education really so colour-blind in terms of how its practitioners are prepared and how they practise?

Nurse educator Laura Strumidlo, an associate professor at Coventry University, says that diversity was a significant element of her own nurse training 30 years ago.

‘I was taught about how people would present and to be aware that with certain skin colours you could miss things that might have grave results in terms of patient outcomes.’

And these days, technology and innovation are helping to keep diversity at the forefront of nursing students’ education, she says. Mannequins and even a glucometer blood-testing ‘hand’ in different skin tones, alongside videos, online interactive anatomy workbooks and role play with actors are all used to help reflect the breadth of the patient population.

The importance of sharing best practice

And the students themselves are also ‘a great resource’, says Ms Strumidlo. ‘They challenge us – and rightly so. If certain groups are feeling under-represented we absolutely must work with them to say our perception is that we were covering these things but if that’s your perception we clearly need to signpost more. If we’re not doing it in a way students remember, then that’s a worry.’

• RELATED: Maintaining skin health in older people

When it comes to nursing courses delivering an appropriately diverse curriculum, she says: ‘I don’t know if it’s guidance that’s needed, more sharing of good practice. What Health Education England and some NHS workstreams have been good at has been hooking up best practice around the country, and that’s what I would welcome.’

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Daniel Allen is a health journalist
Additional reporting by Kimberley Hackett

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Further information

• Black & Brown Skin/Mind the Gap
• Brown Skin Matters
• British Dermatological Nursing Group
• DermNet NZ
• Skin Deep