Learn to recognize dermatologic changes in patients of color with rheumatic disease

Everything you learned about recognizing dermatologic manifestations of rheumatologic diseases in medical school, residency, and fellowship is off the mark. Not wrong, just incomplete.

Most textbook or lecture descriptions and images of lupus, scleroderma, psoriasis, and other cutaneous signs of rheumatologic diseases as well as post inflammatory hyperpigmentation are based on patients of largely European descent who have light-colored skin. And white skin is only one subset of the human color palette that clinicians see every day.

“When we think of scleroderma, we’re all taught to picture a 40/50-year-old Caucasian female with skin thickening who also has Raynaud’s,” explained Lisa Zickuhr, MD, Assistant Professor of Medicine within the Division of Rheumatology at Washington University School of Medicine. “But if your patient has a darker skin tone, you may not notice the early changes of Raynaud’s because it doesn’t match what you were taught to look for. In patients with darker skin tones, Raynaud’s may look dusky as opposed to going through the triphasic color changes of white, blue, then red.”

Dr. Zickuhr will moderate a session exploring the challenges of recognizing symptomatic changes in skin of color titled Picture It: Skin Findings in Patients of Color with Rheumatic Disease. The session, which will be held from 2 – 2:30 p.m. ET Saturday, Nov. 6, will also review techniques to improve recognition and diagnosis in skin of color.

“Medicine, generally speaking, is pattern recognition,” Dr. Zickuhr said. “That holds especially true for fields like rheumatology where clinical diagnosis is so central to what we do. Rheumatology doesn’t have a lot of gold standard lab tests, it’s all about the history and physical exam, making what you are trained to see and interpret matter. Yes, you can train your eyes to see patterns in all skin tones on your own, but that’s extra work and more difficult than if you learned the foundation to recognize patterns across various skin tones during medical school, residency, and fellowship.”

It’s not just about recognizing patterns, it’s about improving diagnostic skills and patient outcomes, she said. Patients of color disproportionately suffer from the skin manifestations of lupus and many other rheumatic diseases. Many factors contribute to this disparity, some of which are beyond the rheumatologist’s ability to change. But it is possible to improve clinicians’ skills and comforts in assessing rashes and other skin changes in patients of color.

A patient’s underlying skin tone can affect the cutaneous manifestations of rheumatic diseases as diverse as cutaneous lupus, dermatomyositis, sarcoidosis, rheumatoid arthritis, systemic sclerosis, and many others. Patients of color who have scleroderma, for example, tend to develop symptoms at an earlier age and have more severe disease than similar white patients. Patients of color are more likely to have interstitial lung disease and pulmonary hypertension.

“Patients of color with scleroderma are probably going to have more severe disease and more significant disease. Likewise with lupus,” Dr. Zickuhr said. “Race and ethnicity have important influences in how diseases manifest overall, including in the skin.”

Just as artificial intelligence systems that are trained on incomplete data sets are less likely to reach the appropriate conclusions when assessing more complete data, rheumatology clinicians trained to recognize signs and symptoms in light colored skin could miss those same markers in skin of color.

“I’ve had this experience with my own patients,” Dr. Zickuhr said. “They’ve had to teach me what to look for because I was not taught how to approach cutaneous manifestations among patients with skin of color in my own training. The first step is acknowledging that you have a clinical deficiency. That can open a door leading to new learning that will benefit the care you are providing to patients.”