711110

research-article2017
CMSXXX10.1177/1203475417711110Journal of Cutaneous Medicine and SurgeryOgunyemi and Miller-Monthrope

Medical Letter

Journal of Cutaneous Medicine and Surgery

The State of Ethnic Dermatology 2017, Vol. 21(5) 464­–466

© The Author(s) 2017
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DOI: 10.1177/1203475417711110
https://doi.org/10.1177/1203475417711110
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Boluwaji Ogunyemi1 and Yvette Miller-Monthrope2

Abstract
Approximately 30% of Canadians will be members of a visible minority by 2031. When dermatology became an independent
medical discipline in the late 18th and early 19th centuries, most residents of Canada and the United States were of Northern
European descent. Morphology and descriptions of dermatoses are based on patients with light skin. Skin of colour dermatology
refers to a unique field in dermatology dedicated to the diagnosis and management of disorders that are more prevalent in
patients with moderately to richly pigmented skin. Important differences in the presentation of common dermatoses such
as seborrheic dermatitis and acne exist in patients with darker skin types. The effect of traditional treatments for common
and uncommon dermatoses is also an important consideration in managing patients with skin of colour. Such treatments may
result in adverse effects such as postinflammatory hyperpigmentation or keloid scarring at a higher rate. Most respondents
from a 2013 UK study of dermatology residents and consultants agreed that individuals with ‘ethnic skin’ had specific and
unique dermatological problems. The Royal College of Physician and Surgeons of Canada’s Objectives of Training in Dermatology
states that residents must demonstrate the requisite knowledge, skills, and attitudes for effective patient-centred care and
service to a diverse population. Future steps include creating a national society of dermatologists interested in clinical and
academic aspects of ethnic dermatology. As well, presentations on skin of colour dermatology could be encouraged at major
Canadian dermatology meetings.

Keywords
skin of colour, medical education, hair disorders, pigmentation disorders, diversity

Defining Ethnic Dermatology management, or counselling for a dermatologic condition. For

Canada, along with the United States and many Western
European countries, is witnessing an ever-increasing presence
of immigrants and visible minorities. Approximately 30% of
Canadians will be members of a visible minority by 2031. In
Vancouver and Toronto, it is projected that 3 in every 5 resi-
dents will be a member of a visible minority by this time.1
When dermatology became an independent medical disci-
pline in the late 18th and early 19th centuries, most residents
of Canada and the United States were of Northern European
descent. It is not surprising, then, that morphology and descrip-
tions of dermatoses are based on patients with light skin.2
Skin of colour dermatology refers to a unique field in der-
matology dedicated to the diagnosis and management of dis-
orders that are more prevalent in patients with moderately to
richly pigmented skin.3
Formal educational opportunities in skin of colour derma-
tology in Canada are being grossly outpaced by this nation’s
increasing ethnically and cutaneously diverse population.
In the United Kingdom, ethnic dermatology is preferred
over skin of colour dermatology because it is felt that this term
emphasises patient grooming and other practices that may be
related to culture as well as to the clinical presentation,
example, understanding hair-grooming practices such as
employing braids and cornrows that are much common among
women of African ancestry is important in assessing for risk
factors for traction alopecia. Similarly, central centrifugal
cicatricial alopecia, formerly known as “hot comb alopecia,”
is much more common among those with Afro-textured hair
and is also thought to be partially related to hair-grooming
practices.2
Pigment incontinence proves more common and more
florid in patients with darker skin types, making postin-
flammatory hyperpigmentation of particular concern in
these populations. Pigmentation and complexion, as it
related to achieving an “even” skin tone, is of tremendous
1
Department of Dermatology and Skin Science, University of British
Columbia, Vancouver, BC, Canada
2
Division of Dermatology, Department of Medicine, University of
Toronto, Toronto, ON, Canada
Corresponding Author:
Boluwaji Ogunyemi, The Skin Care Centre, 835 West 10th Avenue,
Vancouver, British Columbia V5Z 4E8, Canada.
Email: b.ogunyemi@mun.ca
Ogunyemi and Miller-Monthrope 465
cosmetic importance in many patients with continental
origin of Asia or Africa.2
Ethnic Dermatology and Dermatology
Education
Residents of the United Kingdom have documented that eth-
nic dermatology is a field worthy of devoted clinical effort. A
2013 UK-based study of dermatology trainees and recently
licensed consultant dermatologists reported that only 17 of
78 respondents (22%) had formal teaching sessions or lec-
tures focused on ethnic dermatology as part of their training
program.4 Most respondents (74/78, 95%) agreed that indi-
viduals with ‘ethnic skin’ had specific and unique dermato-
logical problems. Most respondents (55/78; 71%) were of
the opinion that formal outcomes related to ethnic dermatol-
ogy should be incorporated into the dermatology training
curriculum in the United Kingdom. Importantly, only half of
these respondents (38/78) respondents thought they were or
would become competent in treating conditions pertinent to
the United Kingdom’s ethnic population after completion of
their residency training program.
Predating this investigation in the United Kingdom was a
similar study based in the United States that described training
in skin of colour dermatology in allopathic dermatology resi-
dency programs. This 2008 study by Nijhawan et al5 relies on
survey responses from chief residents and program directors
to document the skin of colour dermatology curriculum in
US-based allopathic dermatology residency programs. It was
discovered that 52.4% of chief residents and 65.9% of pro-
gram directors reported having lectures focusing on diseases
in ethnic skin incorporated into their curricula. Only 30.2% of
chief residents and 12.2% of program directors reported a spe-
cific rotation in which residents gained experience specifically
in treating patients with ethnic skin.
Whether residents in dermatology training in Canada
postgraduate residency programs feel prepared to practice in
patients of varying skin types remains to be seen.
Ethnic dermatology cannot be reduced to committing to
memory a number of diagnoses with increased prevalence in
particular skin types. There is evidence that the severity of
atopic dermatitis in dark-skinned patients of African ancestry
is greatly underestimated compared to fair-skinned children,
largely due to clinicians’ decreased ability to perceive ery-
thema in the former. As erythema proves difficult to assess
reliably in patients, Vachiramon et al6 recommend that physi-
cians rely more on the report of the families when it comes to
children with heavily pigmented skin in determining severity
of eczema so as to avoid undertreating. Important differences
in the presentation of common dermatoses such as psoriasis,
seborrheic dermatitis, and acne vulgaris exist in patients with
darker skin types. This is also the case in less common der-
matoses such as mycosis fungoides. The effect of traditional
treatments for common and uncommon dermatoses is also an
important consideration in managing patients with skin of
colour. Such treatments may result in adverse effects such as
postinflammatory hyperpigmentation or keloid scarring at a
higher rate than in patients with fair skin.
We assert that increasing the presence of skin of colour
dermatology in Canadian dermatology programs would
allow residents to more completely fulfill our certifying
body’s requirement in cultural competency. The Royal
College of Physician and Surgeons of Canada’s Objectives of
Training in Dermatology states that “residents must demon-
strate the requisite knowledge, skills, and attitudes for effec-
tive patient-centred care and service to a diverse population.
In all aspects of specialist practice, the graduate must be able
to address issues of gender, sexual orientation, age, culture,
ethnicity and ethics in a professional manner.”7 Competency
in hair-grooming practices and their association with alope-
cia, particularly in patients with Afro-textured hair, would be
in keeping with this objective.
The State of Ethnic Dermatology in
North America
While there are several clinics dedicated to skin of colour
dermatology across the United States, there remains a pau-
city of such facilities in Canada.
A recent investigation by Rechelle Tull and Skin of Color
Society President and North Carolina–based dermatologist
Amy McMichael describes 9 dermatologist-led multicultural
skin centres in the United States.8 These centres are located
in New York, Miami, Detroit, Chicago, Baltimore, Boston,
Iowa City, Hampton, Virginia, and Washington, DC. The
clinical and research interests at these institutions include
melasma, central centrifugal cicatricial alopecia, acne keloi-
dalis nuchae, keloids, pigmentation disorders such as vitil-
igo, and skin cancer in skin of colour populations. Each of
these centres has an average of 3.4 dermatologists, ranging
from 1 to 6.
Furthermore, compared to established fields of dermatol-
ogy areas such as paediatric dermatology and surgical der-
matology or more focused areas of interest and expertise,
including immunodermatology and wound healing, derma-
tology residents and consultants alike may be less likely to
classify ethnic dermatology as such.
However, there is evidence of an increasing appetite for
education in ethnic dermatology in Canada. The first annual
Skin Spectrum Summit—Canadian Conference on
Ethnodermatology was held in 2015 in Toronto. Attendees
included family physicians, dermatology residents, and con-
sultant dermatologists. In 2016, the conference expanded to
2 additional sites: Montreal and Vancouver. As well,
Women’s College Hospital has an ethnic skin and hair clinic
that has been run by faculty in the Division of Dermatology
at the University of Toronto.
With increasing globalisation and ethnic diversity in our
nation, there will be a greater need for Canadian dermatolo-
gists to be equipped with skills in diagnosis, management,
466 Journal of Cutaneous Medicine and Surgery 21(5)

and counselling of individuals from every ethnic background
in a culturally competent manner.
To meet this need, future steps include creating a national
society of dermatologists and trainees interested in clinical
and academic aspects of ethnic dermatology, perhaps akin to
4. Salam A, Dadzie OE. Dermatology training in the U.K.: does
the Skin of Color Society of the United States. As well, pre-
sentations on skin of colour dermatology could be encour-
aged at major Canadian dermatology meetings such as the
Canadian Dermatology Association annual general meeting.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
References
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