{'fraction_non_alphanumeric': 0.0188065939168795, 'fraction_numerical': 0.016484792198746226, 'mean_word_length': 5.607361963190184, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Skin of color in dermatology: analysis of representation in dermatologic journals

Skin of color in dermatology: analysis of representation in dermatologic journals Dear Editor, In dermatology, diagnosis of skin disease depends on pattern recognition of specific features shaped by the canvas of underlying skin color. Despite visual cues gained from skin tone, skin of color (SoC) continues to be underrepresented in dermatology textbooks and medical school examination resources, potentially impairing the knowledge base of trainees. Limited exposure to cutaneous pathology on SoC may delay accurate diagnosis, leading to worsened patient outcomes and highlighting the importance of this topic. The current study aimed to evaluate representation of SoC in dermatologic journals in order to characterize diversity in another key educational resource. Photographs in three dermatology journals, JAMA Dermatology, Journal of the American Academy of Dermatology (JAAD), and Journal of the European Academy of Dermatology and Venereology (JEADV) were reviewed from January 2018 to December 2020. Consistent with previous study methodology, photographs showing background skin color and dermatologic disease were classified as light (Fitzpatrick I-IV), dark (V or VI), or indeterminate if a definitive decision could not be made. The following were excluded: images of histology, dermoscopy, and procedures, as well as black-and-white and repeated images. Only articles published in printed sections of the journals were reviewed; online-only articles and advertisements were excluded. Overall, our study revealed similar representation of SoC compared to previous analyses of dermatology textbooks in 2006 and 2020 (Table 1). The proportion of images containing Fitzpatrick V or VI phototypes was comparable between journals, comprising 12.8, 13.5, and 18.4% of total photos in JAMA Dermatology, JAAD, and JEADV, respectively. Interestingly, subanalysis of journal data by year revealed notable improvement from 2018 to 2019, which was relatively maintained in 2020 for JAMA Dermatology and JAAD but decreased in JEADV; however, despite this decrease, JEADV had the highest representation of darker skin phototypes in 2020 and overall. Although representation in dermatology journals appears similarly low compared to other educational resources, we were encouraged by the increased inclusion of SoC in 2019 compared to 2018, which was relatively maintained through 2020. This increase could be a result of previous studies demonstrating the consequences of insufficient representation in dermatology and improving awareness of negative implications that may arise in SoC because of delayed or incorrect diagnosis. These results also align with studies demonstrating improved inclusion of SoC in dermatology clinical trials, an important source of images in publications. The timely improvement of SoC representation in journals compared to textbooks reflects the dynamic nature of this academic resource, adaptable through monthly issues, that has taken action to increase the publication of SoC topics. Despite decreased SoC representation in JEADV from 2019 to 2020, JEADV had the greatest inclusion of SoC images. This difference may be because of earlier or heightened awareness of SoC representation in European journals or higher emphasis on the publication of skin conditions more commonly seen in SoC. Differences in SoC representation across journals appeared to converge in 2020 as JAMA Dermatology and JAAD maintained the gains made in 2019. Limitations of the current study include the collective analysis of images by each individual journal rather than analysis by article type or skin condition. This was done to provide direct comparison to previous studies of dermatology textbooks; however, future research of SoC representation in journals should assess representation across these variables. As the US population continues to diversify, it is important to continue to strive for inclusion and awareness of SoC in major educational resources to improve the knowledge base of trainees. Continued improvement is necessary to better patient outcomes in dermatology and bridge the gap toward achievement of equitable care. Table 1 Skin phototypes in images of dermatology journals and textbooks