As a medical student interested in a career in dermatology, Nneamaka Ezekwe, MD, quickly realized that the textbooks — particularly the collections of images of various skin conditions known as atlases — didn’t include photos of people with skin like hers.
“Kodachrome is the word we use to describe pictures of disease that are used as a supplemental learning aid to trainees,” says Ezekwe, now a dermatology resident at the University of Colorado School of Medicine. “These atlases have great kodachromes of diseases in lighter skin complexions. Erythema, which means redness of the skin, can be easily perceived in a lighter skin tone but may be harder to perceive and can be a subtle finding in darker skin tones. There is a spectrum of skin tones. My darker complexion is one skin tone, and there are complexions representative of Hispanic Latinos and people from the Middle East — you can’t box everybody into one bubble and say, ‘This is what it looks like.’ We need to show the whole spectrum.”
Gathering inclusive images
After Ezekwe graduated from medical school at the University of Mississippi and began working as a research fellow at the Henry Ford Department of Dermatology in Detroit, Michigan, she was excited to be part of an effort to create a more inclusive atlas that includes kodachromes of such conditions as vitiligo, hidradenitis suppurativa, and sarcoidosis in an array of different skin tones.
“We tried to stay away from the conventional skin scale that we use as dermatologists, because it was never meant to categorize skin color. It was only supposed to be used as a scale of how easily people can burn or tan,” Ezekwe says. “It’s not an accurate measurement of your skin complexion or the spectrum of skin colors.”
For their book, “The Full Spectrum of Dermatology: A Diverse and Inclusive Atlas,” editors Misty Eleryan, MD, MS, and Adam Friedman, MD, compiled more than 650 images of more than 85 commonly seen dermatological conditions in an array of skin tones. Displayed side by side, the images are intended to advance education among health care practitioners and to visually teach them to recognize various skin conditions in different skin tones.
The book was released in August 2021, and the publisher sent a free copy to every trainee in every dermatology department in the country. The editors also created a free online database of inclusive dermatology images to which providers can refer.
Right place, right time
As a research fellow, Ezekwe says, she was “in the right place at the right time” to be picked to work on the atlas project. She was one of the principal photographers who contributed images of various skin conditions to the book.
“They picked departments of dermatology across the country that are known to have patients with a plethora of skin colors,” she says. “Henry Ford is a well-known dermatology department that tends to see a multitude of diverse patients because of its geographic location and the providers who are there. The editors reached out to us and said, ‘Would you be interested in working on this atlas?’
"My job was to find the patients in clinic, verify diagnosis with the provider, adequately consent, and take professional, studio-style pictures. From there, we would submit pictures and receive feedback by an in-house medical photographer weekly. We would meet regularly with the editors and advisory council to review cases and provide feedback as needed.”
Overcoming barriers
It was surprisingly easy to get patients to participate, she says, as many understood how photos of their conditions could help dermatologists make diagnoses in a population that has barriers to treatment. Many patients from ethnic backgrounds underrepresented in medicine have a distrust of the health care system, Ezekwe says, and many feel they aren’t treated with respect when they go to see a doctor. Compound those factors with conditions that are more difficult to detect in darker skin, and potentially dangerous skin conditions can get misdiagnosed — or never diagnosed at all.
“It's fairly easy to get shuffled around in the health care system, and then a diagnosis that could have been made in two months is now delayed to six years,” she says. “Patients from different ethnic groups want to serve as teachers so that their experience doesn’t happen to other patients. I received that comment from many patients when I was taking their pictures.”
Bridging the gap
“The Full Spectrum of Dermatology” is currently being used in her program at the CU School of Medicine, Ezekwe says, and she hears regularly from residents and other trainees across the country about how useful the atlas has been in their training.
'The Full Spectrum of Dermatology' was released in 2021.
The positive feedback, she says, shows that the atlas is slowly achieving its goal of making dermatology more equitable and inclusive.
“Obviously, one atlas can’t address disparities of health care in general,” she says, “but I do think this atlas can help to bridge the gap in helping to train providers to make common diagnoses. Even for primary care doctors, if they were able to pick up even one diagnosis that they didn’t know, but they now know because they saw it in a book, that can help that patient, and in certain cases, lower their threshold to refer for further management to a dermatologist.”
