Exploring Diagnostic Accuracy and Clinical Reasoning of Dermatological Lesions in Podiatry Students

A recent study highlighted the challenges health care professionals face in diagnosing dermatologic conditions in patients with darker skin tones, placing a particular emphasis on the ability of pre-registration podiatry students to identify skin conditions.

Published in the Journal of Foot and Ankle Research, the study¹ also identified key variations in the clinical presentation of common skin conditions across different Fitzpatrick phototypes, emphasizing the need for a more inclusive curriculum and training for health care providers.

Image Credit: © Orlando Bellini - stock.adobe.com

Background and Methods

The study builds on existing evidence that non-White patients often experience delays or inaccuracies in dermatologic diagnoses. These disparities are rooted in differences in clinical presentations and a lack of representation of skin of color in medical textbooks and online resources.²

To explore these issues, researchers adopted a mixed-methods approach, combining a pictorial survey assessing diagnostic accuracy with focus groups designed to probe confidence levels and clinical reasoning.

The research team developed a pictorial survey featuring 6 images of inflammatory skin conditions—psoriasis and eczema—across 3 grouped Fitzpatrick phototypes: light, medium, and dark skin tones. These images were paired with a set of diagnostic options, and focus groups provided qualitative insights into participants' diagnostic approaches and challenges.

Findings

The study revealed several significant findings about the accuracy and challenges in diagnosing dermatologic conditions in patients with different skin tones.

Participants demonstrated the highest accuracy for light skin phototypes, followed by medium, with the lowest accuracy for dark skin phototypes. Common errors included misidentifying hyperpigmentation in darker skin tones and mistaking erythema for other conditions in medium-toned skin.

Additionally, participants reported lower confidence levels when diagnosing conditions in darker skin tones. Focus group discussions highlighted the role of limited exposure to diverse images during medical training as a critical barrier.

An analysis of leading medical textbooks showed a significant underrepresentation of skin of color, with only 4.5% of images depicting darker skin tones. Researchers noted similar gaps in online resources and slide decks used in medical education, further limiting exposure for health care professionals.

Delays or inaccuracies in diagnosis for patients with darker skin tones can lead to worse prognoses, including advanced disease states and decreased survival rates in cases like melanoma.

Conclusions

The study's findings are limited by its focus on a single specialty (podiatry) and geographic region (England). Expanding the research to include a broader participant pool and additional specialties would provide a more comprehensive understanding of these disparities. Moreover, longitudinal studies could evaluate the long-term impact of curriculum changes on diagnostic accuracy and patient outcomes.

Moving forward, study authors Otter et al recommended diversifying medical education, enhanced training resources, and more. They wrote that medical schools should prioritize decolonizing curricula by incorporating more diverse images and case studies into training materials. Further studies should explore similar diagnostic challenges in other specialties and develop interventions to address systemic biases.

"Based on our reviews of the literature this research is the first mixed-method study that seeks to investigate the dermatological diagnostic ability of podiatry students on different skin tones and therefore could be used as a starting point to explore this important topic further, both within and external to podiatric education," wrote Otter et al.

References

1. Otter S, Whitham D, Melotto G, et al. Investigating pre-registration podiatry students approaches to identifying dermatology conditions in different skin tones: a mixed methods protocol. J Foot Ankle Res. November 30, 2024. https://doi.org/10.1002/jfa2.70015
2. Narla S, Heath CR, Alexis A, Silverberg JI. Racial disparities in dermatology. Arch Dermatol Res. 2023;315(5):1215-1223. doi:10.1007/s00403-022-02507-z