When she was pregnant with her first child in 2011, Destiny McAfee developed a skin condition. She would itch until wounds and lesions appeared, and eventually, dark spots would speckle her skin.
With her second and third pregnancies, it got even worse. She became so self-conscious because of the dark spots that she would wear pants and long sleeves even on the hottest summer days.
For years, McAfee, 30, a FedEx package handler in Columbus, Ohio, has been trying to figure out what's wrong. She has seen multiple dermatologists and tried everything she can think of: creams, ointments, sensitive soap, oatmeal baths.
Eventually a doctor diagnosed her with borderline eczema, although McAfee finds little solace in that. There is still no cure for her skin condition, and besides, she said, what good is a borderline diagnosis anyway?
"It's just a really weird mystery that I would love to figure out," McAfee told TODAY.
It's true that many women develop rashes during pregnancy — although not often as severe as McAfee's — and that there is not always a clear explanation or treatment. But there may be another underlying reason as to why doctors have struggled to diagnose McAfee, a Black woman: People of color have a striking disadvantage when it comes to dermatology.
Black skin is often left out of clinical teachings ...
Recently doctors and medical students have been raising awareness of a longtime problem: the lack of images of Black skin in medical literature, including dermatology textbooks.
One medical student in London has even taken action to change that.
Malone Mukwende was in his first year of medical school when he realized that there were no depictions of dark skin in his textbooks or lessons. He teamed up with two staff members to create a guide, "Mind the Gap," that shows how clinical conditions appear on dark skin, in hopes it will help both future and current doctors better diagnose Black patients.
Mukwende, 20, told NBC News that people in his own community are "almost having a distrust for health care professionals because they have heard stories of misdiagnosis or had been misdiagnosed."
There is also a popular social media account, Brown Skin Matters, that aims to highlight the lack of reference photos of dermatological conditions on skin of color.
And nearly 200,000 people have signed an online petition to encourage medical schools to include photos of non-white skin in their clinical teachings. The petition, which originated in the U.K., points out that "clinical descriptions such as erythematous, pallor and rubor are not typical of all patients and students are often not taught otherwise."
... and it could have dire consequences in the COVID-19 era
The lack of diversity in dermatology teachings could prove all the more tragic during the coronavirus pandemic, since skin rashes have emerged as a symptom of COVID-19.
Dermatologist Jenna Lester told the health news website STAT that when she learned that rashes on the skin and toes were a symptom of the virus, she began to look for photos of what that looked like in Black people so that she would recognize it in her patients. But she found nothing.
“I was frustrated because we know COVID-19 is disproportionately impacting communities of color,” she told the website. “I felt like I was seeing a disparity being built right before my eyes.”
Lester and three other dermatologists published a research letter in the British Journal of Dermatology in late May that highlights the lack of images of skin manifestations of COVID-19 in people of color. They looked at literature describing the skin manifestations related to the virus and found that 92% of the associated images were of patients with the Fitzpatrick skin types I-III — in other words, people with white skin. Six percent of the images showed people with Fitzpatrick skin type IV, which describes people with an olive skin tone. There were no clinical images that depicted Fitzpatrick skin types V or VI, which describe people with brown and Black skin, respectively. (The remaining 2% of images could not be classified.)
The doctors wrote that this is problematic because skin disease often presents differently in different skin colors.
"Given the racial disparities in COVID‐19 infections and associated deaths, it is important that all manifestations of this disease contain broad representation of people of different races and ethnicities, as any clue, if recognized, could contribute to early diagnosis and potentially better health outcomes," they wrote.
While the pandemic may be shining a stark light on the lack of diversity in dermatological teachings — and systemic racism in health care as a whole — these problems are hardly new.
Medscape pointed to a 2012 report in which nearly half of dermatologists say they've had insufficient exposure to skin disease in darker skin types. And the under-representation of darker skin in medical journals has been well documented, too.
Black dermatology patients grasp for solutions
It's not a stretch to say patients feel the effects of those inadequacies. In fact, many Black patients, like McAfee, say they've struggled to find a dermatologist who understands their skin. (Only about 3% of dermatologists are Black, according to a 2016 study in the Journal of the American Academy of Dermatology.)
Akira Brooks, 29, recently tweeted the joy she felt when she finally found a Black dermatologist. She told TODAY that she had previously seen white dermatologists, but she felt they didn't understand how to treat her skin problems, including hyper-pigmentation and inflammation.
"They treat our skin how they treat white skin and that's really unfair," she said, adding that she feels she's in better hands with a Black dermatologist.
For McAfee, the solution may not be so simple. After years of testing and no solution, she's not sure there's a cure out there for her skin woes.
Besides, she said, even if she were to find a Black dermatologist, "it would be hard for them to help me if what they've learned is only on Caucasian skin."