Australian Analysis Calls for Diversity in Dermatological Research

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A recent analysis highlighting diversity in dermatology addressed the lack of research and clinical trials involving those with skin of color (SOC). The Australian analysis stated that darker skin differs “substantially” in biology, structure, and function compared to lighter skin.¹ “A diverse participant pool is crucial for understanding human variation and disease pathology,” the researchers wrote.²

The analysis found that dermatology data sets historically tend to be biased towards those with European ancestry, with notable contributing factors to this including physician, investigator, industry, and patient-related barriers.³ Researchers cited the light skin model specifically as a physician-related barrier, which they stated evokes clinical uncertainty when conditions present differently in darker skin, despite the noted addition of SOC to the Australian dermatology training curriculum in 2017.⁴

Underrepresentation and its Effect on Clinical Diagnosing

The analysis found that Australia has the highest melanoma incidence globally, with 36.6 cases per 100,000 people.⁵ It found that rates are notably higher for non-Indigenous Australians (30.4 per 100,000) compared to Aboriginal and Torres Strait Islanders (14.1 per 100,000). Melanoma often presents at advanced stages in people with SOC, with acral lentiginous melanoma being the most common subtype in SOC, which can lead to misdiagnosis due to its unusual presentation.^6-7

“Without conscious effort to incorporate all skin types in research studies, the unique manifestations, risk factors and treatment for melanoma in SOC will remain unknown, whilst mortality rates in these minority populations continue to rise,” the analysis stated.

The analysis noted anAustralian Centre of Excellence in Melanoma Imaging and Diagnosis (ACEMID) study is working to enhance early melanoma detection using 3D body photography and artificial intelligence (AI). However, they found the study's recruitment has not specifically targeted SOC, leading to underrepresentation. The analysis stated that participants were recruited across 15 metropolitan and regional Australian sites through referrals, social media, traditional media, and previous skin cancer studies, without actively targeting those with SOC. In a subanalysis from 2 Brisbane sites, only 4% of participants were from SOC, compared to 30% in the general Australian population. The SOC participants were primarily of Chinese, Aboriginal, Torres Strait Islander, and Indian descent.⁸

Classification Systems

The analysis recognized that various classification systems exist to classify skin color, such as the Fitzpatrick skin type (FST), which defines 6 categories based on self-reported sunburn and tanning reactions. They also noted the Taylor Hyperpigmentation Scale (THS), which assesses skin color against different toned cards, and the Individual Typology Angle (ITA), which quantifies pigmentation using a chromameter.⁹ In the above study, lighter skin types (FST I-III) were more common among SOC participants, indicating a potential bias in recruitment and data collection.

“Given the apparent skew of the SOC population towards lighter skin tones (FST I–III), untargeted recruitment fails to obtain participants with darker skin (FST IV–VI) and subsequently limits data analysis,” the analysis stated.

Conclusion

The analysis suggested that physician, investigator, industry, and patient-related barriers could explain why SOC is underrepresented in dermatology research and clinical trials. As dermatological manifestations differ in darker skin, researchers stated that physicians may underestimate disease severity and less frequently recommend clinical trials to their patients. “On an industry level, images of darker skin are seldom integrated into public health campaigns, which is likely to lower perceptions of melanoma risk for patients with SOC,” researchers stated.

The analysis suggested that these barriers can be overcome through education on systemic failures and building relationships with leaders of minority communities. They stated that empowering stakeholders such as physicians, investigators, and patients with SOC with knowledge of melanoma in darker skin could improve mortality outcomes and data quality overall, possibly facilitating the development of AI models with diagnostic accuracy for all skin types. “Through active engagement of people with SOC, the absence of diversity in current data sets will improve, ensuring a fairer and more equitable future of dermatological research,” researchers wrote.

References

1. Rodrigues M. Importance of skin of colour dermatology in the primary care setting in Australia. Aust J Gen Pract. 2023;52(10):665-667. doi:10.31128/AJGP-01-23-6681
2. Susanto A, Nathan V , Janda M, et al. Diversifying dermatology: Improving skin of colour representation. Australas J Dermatol. 2024. https://doi.org/10.1111/ajd.14356
3. Cobb CBC, Heath CR, Byrd AS, et al. The skin of color society's meeting the challenge summit, 2022: Diversity in dermatology clinical trials proceedings [published correction appears in JAMA Dermatol. 2023 Jul 1;159(7):793. doi: 10.1001/jamadermatol.2023.2286]. JAMA Dermatol. 2023;159(7):757-762. doi:10.1001/jamadermatol.2023.1285
4. Rodrigues MA, Ross AL, Gilmore S, et al. Australian dermatologists' perspective on skin of colour: Results of a national survey. Australas J Dermatol. 2018;59(1):e23-e30. doi:10.1111/ajd.12556
5. Skin cancer statistics: World cancer research fund international. WCRF International. June 26, 2024. Accessed July 29, 2024. https://www.wcrf.org/cancer-trends/skin-cancer-statistics/.
6. Roder D, Currow D. Cancer in aboriginal and Torres Strait Islander people of Australia. Asian Pac J Cancer Prev. 2009. 10(5):729-33.
7. Madankumar R, Gumaste PV, Martires K, et al. Acral melanocytic lesions in the United States: Prevalence, awareness, and dermoscopic patterns in skin-of-color and non-Hispanic white patients. J Am Acad Dermatol. 2016;74(4):724-30.e1. doi:10.1016/j.jaad.2015.11.035
8. Koh U, Cust AE, Fernández-Peñas P, et al. ACEMID cohort study: protocol of a prospective cohort study using 3D total body photography for melanoma imaging and diagnosis. BMJ Open. 2023;13(9):e072788. Published 2023 Sep 28. doi:10.1136/bmjopen-2023-072788
9. Gribbin H, Lee RC, Betz-Stablein B, Soyer HP. Response to 'The essential role of dermatology publications in enhancing professional diversity, equity and inclusion'. Br J Dermatol. 2022;187(2):276-277. doi:10.1111/bjd.21629