10.5826/dpc.1302a90
text/xml
2160-9381
2680
en
Shari R. Lipner
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Nail Dermatologist and Patient Educational Content Lacks Adequate Skin of Color Representation: Implications for Care 
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Commentary
2023-04-29
2022-07-02
2023-04-29
2023-05-31
e2023090
Dermatol Pract Concept
Shari R. Lipner
2023/04/29
10.5826/dpc.1302a90
e2023090
Weill Cornell Medicine, Department of Dermatology, New York, NY, USA
2160-9381
en
e2023090
Chang MJ, Lipner SR. Resources for skin of color images. Journal of the American Academy of Dermatology. 2021;84(6):e275-e277.
Nail Dermatologist and Patient Educational Content Lacks Adequate Skin of Color Representation: Implications for Care 
https://dpcj.org/index.php/dpc/article/download/2680/2109
           Nail Dermatologist and Patient Educational
             Content Lacks Adequate Skin of Color
             Representation: Implications for Care
                                         Julianne M. Falotico1, Shari R. Lipner2


1 Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
2 Weill Cornell Medicine, Department of Dermatology, New York, NY, USA



Citation: Falotico JM, Lipner SR. Nail Dermatologist and Patient Educational Content Lacks Adequate Skin of Color Representation:
Implications for Care. Dermatol Pract Concept. 2023;13(2):e2023090. DOI: https://doi.org/10.5826/dpc.1302a90
Accepted: September 22, 2022; Published: April 2023
Copyright: ©2023 Falotico et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: Ms. Falotico has no conflicts of interest. Dr. Lipner has served as a consultant for Ortho Dermatologics, Verrica,
Hoth Therapeutics, BelleTorus Corporation, and Hexima.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Shari R. Lipner MD, PhD 1305 York Avenue, NY, NY 10021. Phone: 646-962-3376 Fax: 646-962-0033
Email: shl9032@med.cornell.edu



Skin of color (SoC) representation in dermatology educa-                 The mean proportion of V–VI nail images per textbook was
tional content is lacking, which has been recognized only re-            6.6% (range 0.9%–23.5%). Compared to all dermatology
cently [1]. Poor inclusion of SoC images in training materials           images [3], nail-specific images had less V-VI representation
may contribute to delays and missed diagnoses in SoC pa-                 in 80% (4/5) of textbooks (Table 1). Therefore, nail con-
tients [2], which can have significant implications for care. In         ditions lack adequate SoC representation in dermatology
an analysis of trends of SoC representation in dermatology               textbooks.
textbooks over time [3], on average, there were only 11.5%                    In a Google image analysis of the same 34 nail con-
of Fitzpatrick skin type V-VI images across 26 dermatology               ditions [5], categorizing the first 50 images per condi-
textbooks, with an overall 1.3% average increase in repre-               tion by Fitzpatrick skin type, only 8% of 1700 images
sentation with later textbook editions. In this commentary,              demonstrated V-VI skin types. The highest proportion
we corroborate these findings of limited SoC representation              of V-VI images were found for anonychia (36%) and
specifically for nail diseases in dermatology textbooks, re-             longitudinal melanonychia (22%), with no V-VI images
view other learning modalities, and highlight resources for              for onychomycosis, despite it being the most common
SoC images.                                                              nail disease encountered in clinical practice [6]. There-
    In an analysis of 1288 nail images of 34 nail conditions             fore, public education images of nail pathology in SoC
across nine dermatology and nail-specialty textbooks [4],                ­patients are lacking.
only 4% of images overall represented skin types V-VI, with                   In addition, in a systematic review of 182 onychomy-
no V-VI representation for 47.1% (16/34) of nail conditions.             cosis clinical trials (1988– 2020) [7], only 5.4% (8/149) of




Commentary | Dermatol Pract Concept. 2023;13(2):e2023090                                                                                  1
Table 1. Proportion of Fitzpatrick skin type V-VI images for all dermatology images and nail-specific
                               images in five dermatology textbooks.
                                                                                               All dermatology          Nail images
                                       Textbook                                                   images [3]                 [4]
 Jean Bolognia et al., eds. Dermatology. 4th ed. Elsevier; 2018.                                     13.53                    5.9
 Klaus Wolff et al., eds. Fitzpatrick’s Color Atlas and Synopsis of Clinical                           7.64                   6.7
 Dermatology. 8th ed. McGraw-Hill Education; 2017.
 Thomas P. Habif. Clinical Dermatology: A Color Guide to Diagnosis and Therapy.                        4.88                   1.4
 6th ed. Saunders; 2015.
 Christopher E. M. Griffiths et al., eds. Rook’s Textbook of Dermatology. 8th ed.                      9.56                   5.9
 John Wiley & Sons, Ltd; 2010
 Brian J. Hall, John C. Hall, eds. Sauer’s Manual of Skin Diseases. 11th ed. Wolters                 15.99                  23.5
 Kluwer; 2017.



participant images depicted skin types V-VI. There was a de-       References
crease in the proportion of V-VI onychomycosis images from
15.7% to 2.1% between 1996 and 2020. Therefore, there is           1. Adelekun A, Onyekaba G, Lipoff JB. Skin color in dermatology
                                                                      textbooks: an updated evaluation and analysis. J Am Acad Der-
a need to recruit diverse patient populations in nail clinical
                                                                      matol. 2021;84(1):194-196. DOI: 10.1016/j.jaad.2020.04.084.
trials and depict images of participants with darker Fitzpat-
                                                                      PMID: 32335181.
rick skin types in publications.                                   2. Lester J, Taylor S, Chren M. Under-representation of skin of
    Taken together, these findings highlight inadequate               colour in dermatology images: not just an educational issue.
demonstration of nail pathology in SoC for both dermatol-               Br J Dermatol. 2019;180(6):1521-1522. DOI: 10.1111
ogist and patient education. There is limited nail training             /bjd.17608. PMID: 31157429.
                                                                   3.   Abduelmula A, Akuffo-Addo E, Joseph M. The Progression of
during dermatology residency [8], and the lack of adequate
                                                                        Skin Color Diversity and Representation in Dermatology Text-
representation of nail pathology across all skin types in dif-
                                                                        books. J Cutan Med Surg. 2022;26(5):523-525. DOI: 10.1177
ferent educational platforms further compounds this prob-               /12034754221099668. PMID: 35544370.
lem. Therefore, we encourage dermatology residents and             4.   Falotico JM, Lipner SR. Lack of skin of color images of
attendings to supplement their learning with resources that             nail conditions in dermatology textbooks. Int J Dermatol.
prioritize SoC education and/or have sections specific to               2023;62(1):e48-e50. DOI: 10.1111/ijd.16028. PMID: 34865217.
                                                                   5.   Falotico JM, Lipner SR. Few skin of color images in Google image
SoC, such as websites for VisualDx, Skin Deep, and the Skin
                                                                        searches of nail conditions. Int J Dermatol. 2023;62(3):e153-e155.
of Color Society [9].
                                                                        DOI: 10.1111/ijd.16121. PMID: 35119690.
    While the need to diversify physician and patient der-         6.   Lipner SR, Scher RK. Onychomycosis: Clinical overview
matological content has been recognized, there is a lag in              and diagnosis. J J Am Acad Dermatol. 2019;80(4):835-851.
implementing change, particularly for nail content. Failure             DOI: 10.1016/j.jaad.2018.03.062. PMID: 29959961.
to sufficiently portray educational SoC nail images may re-        7.   Chang MJ, Qiu Y, Lipner SR. Race reporting and representation in
                                                                        onychomycosis clinical trials: A systematic review. Mycoses. 2021;
sult in worse outcomes for this patient population. There-
                                                                        64(8):954-966. DOI: 10.1111/myc.13262. PMID: 33655595.
fore, dermatology residency programs should use dedicated
                                                                   8.   Hare AQ, Rich P. Clinical and educational gaps in diagno-
SoC resources to demonstrate nail pathology during didactic           sis of nail disorders. Dermatol Clin. 2016;34(3):269-273.
lectures, and dermatologists who review online medical web-           DOI: 10.1016/j.det.2016.02.002. PMID: 27363883.
sites should advocate for increased diversity specifically for     9. Chang MJ, Lipner SR. Resources for skin of color images. J
nail content.                                                         Am Acad Dermatol. 2021;84(6):e275-e277. DOI: 10.1016/j
                                                                      .jaad.2021.01.040. PMID: 33484764.




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