A new addition to Canada's authoritative pharmacy resource aims to give pharmacists the knowledge they need to better diagnose and treat dermatological conditions for people of colour.
There's a critical lack of diversity in education and literature on dermatological conditions, explains Ravina Sanghera, clinical associate professor in the Faculty of Pharmacy and Pharmaceutical Sciences.
"There's data showcasing that those with different skin tones, because they are not being diagnosed accurately or face delays in diagnosis, are actually having increased morbidity or impact from their disease."
Sanghera and Parbeer Grewal, a clinical professor from the Faculty of Medicine & Dentistry, are looking to change that.
To address the knowledge gap and give health-care professionals the information they need to treat all patients effectively, Sanghera and Grewal are co-authors of "Dermatological Considerations in Skin of Colour," a new chapter in the Compendium of Pharmaceuticals and Specialties, the main reference used by pharmacists across the country.
The new chapter includes information on how common dermatological conditions may present or be managed differently in skin of colour. As a visual aid, it also features a more diverse range of photos depicting these conditions on various skin tones, as well as links to other helpful resources and databases with additional information.
"We weren't having these conversations visibly in how we talked about therapeutics and treatment and assessment, especially when it came to racialized groups," says Sanghera. "So this is a first of its kind."
Improving diagnosis in dermatology
As a practising clinician, Sanghera has seen the devastating effects that inaccurate or delayed diagnoses stemming from these health-care inequities can have on patients.
She remembers one patient with eczema, a condition that's typically relatively minor and managed with moisturizers or steroid creams. However, because the patient was unable to see a specialist for a long time, his eczema "was so severe that he could barely walk, and there was profuse swelling in his legs."
"The amount of pain he was in was not something that's normally seen with that skin condition, but it had just progressed so much."
Another patient, who had previously received an eczema diagnosis, came into Grewal's clinic for treatment. When they took a biopsy, they discovered that the South Asian man had been misdiagnosed by his original practitioner.
"It was actually a quite invasive melanoma," says Grewal. "Somebody who came in to get a cream was diagnosed as having a severe form of skin cancer."
"We need to be in tune to these inequities so we can provide tailored care and increase access to care sooner, because these are modifiable factors," says Sanghera.
More than skin deep
Along with highlighting existing inequities with the aim of getting patients diagnosed more rapidly and accurately, the new chapter also provides guidance on a more inclusive approach to care that integrates cultural factors and relevant context into any recommendations, she explains.
"When we develop care plans, we need to be integrating patients' beliefs, values and experiences with the health system," she says. "We need to create inclusive environments where patients feel comfortable seeking care for their skin condition."
For example, she explains, some cultural practices such as hair oiling or cupping can exacerbate certain skin conditions. However, if the practices are important to the patient, a recommendation to stop them altogether may not be the most appropriate choice. Instead, clinicians should find a way to tailor their recommendations and care plan to the specific patient and their needs.
She also notes that many skin conditions can cause either a loss or gain in pigmentation, which can add complexity to conversations with patients. Sanghera recalls an infant who had a severe diaper rash. When she discussed the treatment with the child's parents, she found they were concerned about the rash healing but were equally distressed about the potential longer-lasting impact of the white patches that had developed on their child.
"I had to work with them and explain that it will take time to heal and repigment," says Sanghera. "That's very different counselling and a very different conversation than just, 'You have a diaper rash, let's treat it with zinc oxide.'"
Additional factors in dermatology-related health inequity among racialized populations include issues like lack of access to clean water or affordable moisturizers in some communities, distrust of the health-care system because of negative experiences, and the fact that many common dermatology scoring tools such as SCORAD and EASI tend to underestimate disease severity in skin of colour, Sanghera says.
The reception to the new chapter has been positive so far, she notes. She and Grewal have been invited to present components of it at professional conferences. The co-authors also have their sights set on educating the next generation of practitioners so they can treat skin of colour more confidently, with Sanghera instructing pharmacy students and Grewal teaching dermatology and medical residents.
