Analysis

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

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
The Fitzpatrick scale categorises skin tone from I to VI Picture: Shutterstock

A letter published earlier this year in the

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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
The Fitzpatrick scale categorises skin tone from I to VI Picture: Shutterstock

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

A clinical handbook of signs and
symptoms in black and brown skin

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.

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.

Neesha Oozageer Gunowa: ‘Pay attention
to the terms you use’

‘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.’

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.

Malone Mukwende: ‘We were leaving out
a group of patients in our learning’

‘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.’

Diversity in clinical teaching: what is required?

The Nursing and Midwifery Council (NMC) says it is up to individual universities to develop nurse education programmes that meet the needs of their local communities.

COVID-19 highlights the importance of
protected characteristics when providing care
Picture: iStock

But the NMC makes clear through its education framework that all courses must have an ‘open and honest learning culture that respects equality and diversity’.

NMC executive director of professional practice Geraldine Walters says: ‘A core expectation of all nursing and midwifery professionals is the ability to provide individualised care that respects a person’s needs and preferences, which includes their culture, values and beliefs. So it’s important that education programmes give students the opportunity to develop this skill.’

She adds: ‘The COVID-19 pandemic has only highlighted just how crucial it is for health and care professionals to understand the way in which protected characteristics, such as race, gender, sexual orientation and religious beliefs, can affect a person’s experience when receiving care.’

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.

Lucy Moorhead: ‘Patients with darker skin
often present at a later stage of disease’

‘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.’

Assessing darker skin: tips for nurses

The severity of eczema is often
underestimated when seen on darker skin
Picture: Skin Deep
  • Do your homework, advises dermatology nurse specialist Alice Slater, and learn about darker skin. ‘Read, get advice, teach yourself. And know your limitations. If something doesn’t look right, get help. There’s always someone you can ask’
  • Simply looking at the skin is not enough, says clinical nurse specialist in paediatric dermatology Maria Akinde. ‘Touch the skin and feel it. When there is significant inflammation, it’s not just the colour that changes, you notice there’s an increased temperature on the skin too.’ Julia Wheeler of the British Dermatological Nursing Group agrees: ‘When assessing the skin, it’s not just about appearance, it’s about looking at other, wider issues’
  • Mind your language Using terms such as ‘red spots’ may not be appropriate. ‘If you don’t see red spots in someone of a different skin tone, then that can affect your ability to offer individualised care,’ says Ms Akinde. ‘You won’t see the redness because it won’t present as that’
  • Be alert and lower your threshold for intervention, says Ms Wheeler. If you are less used to assessing very dark skin you may find it more difficult than assessing a fair skin type. ‘You need to be more cautious and perhaps more vigilant’
  • Tailor topical treatment regimens, says consultant nurse Lucy Moorhead. ‘Be mindful when you are devising any treatment plans that you are looking at the patient from a holistic basis that takes into account any variations that may occur’
  • Treat the person in front of you In truly individualised care no assumptions are made; each patient is assessed and treated according to need, not age, gender or skin tone. Person-centred care is ‘not protocol driven’, says associate professor Laura Stumidlo, of Coventry University

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.

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.

Despite treatment, psoriasis may leave
darker or light spots on treated skin
Picture: Skin Deep

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.’

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.’


Daniel Allen is a health journalist
Additional reporting by Kimberley Hackett


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