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Taking photos and relying on images to make accurate diagnoses is a cornerstone of dermatology residency training, but this only works when all skin tones are represented in the medical literature, says Adam J. Friedman, MD, FAAD, chair of dermatology at George Washington University in Washington, DC. Here, Dr. Friedman discusses what was lacking in medical education in terms of images across skin tones and how a new atlas aims to fill the void.

Why are photos so important in dermatology?

Adam Friedman, MD: Education is point A, and effective clinical care is point B. Given that dermatology is a visual field that relies on pattern recognition and taking an organized approach to formulating a differential diagnosis based on what you are seeing, photos are incredibly important.

Where have medical education resources traditionally fallen short?

Dr. Friedman: There are great resources, textbooks, and patient education sites out there, and I want recognize the foundation and work by those before me. We have many atlases; some focus on specific disease states or appendages like nails and hair, and some even cover specific skin tones, but what was missing is one textbook that coveres the gamut of all skin tones and marries pattern recognition with the understanding that skin can be so beautifully diverse, and that diversity can translate to different clinical presentations.

Without seeing how skin tone can impact clinical presentation, even with a feature as common as erythema, it’s impossible to tap into the bare basics of residency training: describe what you see and use this description to generate a reasonable differential diagnosis.

What is The Full Spectrum of Dermatology: A Diverse and Inclusive Atlas?

Dr. Friedman: First off, this project was an incredible opportunity to partner with one of my former residents, Misty Eleryan, MD, MS on a topic about which we are both exceedingly passionate: inclusivity in dermatology. The unique format—side-by-side images of different skin tones for different diseases—will hopefully ensure that a patient never hears, “I don’t know how to manage your skin tone” and a resident will never have a hard time finding an image of a condition in a different skin tone for a lecture, thus assuring that the dermatologist is an expert in hair, skin, and nails for all. We want the atlas to inspire others to do similar projects and take the images in the atlas and build a massive repository so people can go online for free and take what photos they need.

How do some common skin conditions manifest across skin tones?

Dr. Friedman: With erythema, we think of pink or red, but in darker skin tones, it could be dark purple, brown, black, or off-white with all presentations unified by being still very active. If the erythema is mistaken for post-inflammatory changes, the patient will not be managed correctly. Seborrheic dermatitis is a good example. It is classically portrayed as red, greasy, and scaly. In darker skin, it’s off-white or faint pink, and people miss this diagnosis because it doesn’t fit the mold. If you don’t have the proper resources, you won’t recognize it or know what to look for.

Is there a need to quantify skin tones in artificial intelligence (AI) tools?

Dr. Friedman: An AI tool is only as good as the algorithm and what you feed it. If you are not providing a diverse and plentiful spectrum of inclusive images, it’s more than not helpful; it could be harmful. These algorithms are based on predominately lighter skin, so they won’t work unless they contain examples of all skin pantones.

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