Not Just Skin Deep: Reshaping Equity in Dermatology

Even as dermatology evolves and makes progress in skin of color education, one of its most pressing problems remains unsolved: patients with richly pigmented skin, particularly Black individuals, continue to face disparities. Addressing these gaps is not just about representation; it is a scientific imperative. Without representative data and training, the risk of diagnostic errors and misinformation remains high.

As someone with brown skin, the journey to understand my complexion has been deeply personal. I began my dermatology career as a medical assistant in a dermatology clinic that expanded beyond medical and cosmetic and featured a research clinic. This role and practice sparked my commitment to improving skin health in underserved communities, an effort that continues to guide my work. Online resources have empowered me and many others to better understand our skin. However, when it comes to chronic skin conditions like psoriasis, atopic dermatitis, acne, and post-inflammatory hyperpigmentation, many still lack a reference point. Educational materials and clinical images overwhelmingly feature lighter skin tones. Many dermatologists are also not trained to recognize how these conditions present in richly pigmented skin, leading to delayed treatment.

My goal with this article is to bring more awareness to these issues, not only for providers, but for biologic coordinators and medical assistants who work alongside providers. Staying informed empowers us to better support both patients and providers. I have learned that engaging with pharmaceutical reps, asking thoughtful questions, and staying current on treatment updates make a major difference. As medical assistants and coordinators, we know patients will ask us questions when a provider steps out of the room. Patients frequently call us for lab results, authorizations, and guidance, especially when their concerns have not been fully addressed. For many of these racially diverse patients, this knowledge is crucial because, in many cases, they are not getting the answers they need anywhere else.

Bridging Gaps in Dermatology Research

Historically, dermatology research has overlooked non-light skin tones, creating critical differences in how chronic skin conditions manifest and respond to treatment. Recent clinical trials are beginning to shift this narrative, placing greater emphasis on patients with visibly darker skin. The VISIBLE study conducted by Johnson and Johnson in 2024 is one of the first large scale psoriasis studies focused specifically on skin of color. It demonstrated that biologics like Tremfya are equally effective in medium to rich skin tones, directly addressing the long standing lack of representation in clinical trials. Participants included 11.4 percent Black, 44.5 percent Hispanic and Latino, and 29.9 percent Asian individuals. While a step forward, Black representation remained disproportionately low given the prevalence of psoriasis among Black patients. In the VISIBLE study, 57 percent of participants with plaque psoriasis achieved at least 90 percent skin clearance by Week 16, meeting one of the study’s co-primary endpoints. Additionally, 71.9 percent of participants with scalp psoriasis achieved full skin clearance, reinforcing Tremfya’s efficacy across racially diverse patient groups.

Eli Lilly has launched one of the first eczema trials tailored specifically to people of color, focusing on how lebrikizumab (Ebglyss) performs in skin of color. In this first of its kind trial, 89 percent of participants with moderate to severe eczema saw visibly clearer skin by Week 16, a strong indication of lebrikizumab’s effectiveness in underrepresented populations.

Putting Equity at the Center of Research

Another major obstacle in dermatology for Black patients is the data blind spots in research that account for variation in skin types. For decades, dermatology trials have overwhelmingly featured White participants, creating a massive knowledge gap in how certain conditions present in Black and Brown patients and how different treatments can affect them. This underrepresentation is not accidental. It is the result of systemic and logistical barriers that have remained entrenched over generations.

Disparities in the prescription of biologic therapies remain a significant issue in dermatology, particularly for patients with psoriasis. A study published in the Journal of the American Academy of Dermatology found that Black and Hispanic patients with psoriasis were less likely to receive biologic therapies compared to White patients, underscoring how systemic healthcare inequalities impact access to advanced treatments. These disparities stem from limited access and systemic inequities. Black and Brown patients are more likely to be underinsured or on public insurance plans, which often impose more restrictive prior authorization requirements for biologics. Additionally, dermatology clinics in predominantly Black and Hispanic communities tend to be fewer in number. Provider bias also contributes, whether through assumptions about a patient’s ability to afford a biologic or the belief that certain skin conditions are less severe in darker skin tones. Black individuals represent only 3% to 5% of participants in dermatology clinical trials, a striking disparity given the significant burden of chronic skin disease in communities of color. In one national survey, only 14% of Black respondents said they would “definitely” participate in a clinical trial, compared to 33% of White respondents, highlighting the role of deep-rooted mistrust and fear of exploitation in deterring participation.

Addressing these disparities requires systemic change, but there are also immediate steps that can be taken to move in the right direction. Healthcare providers should take the time to fully educate patients about biologics, addressing common concerns about efficacy and safety while presenting data from inclusive clinical trials that specifically studied Black and Brown patients. Equally important is the role of biologic coordinators, who should be up to date on the latest research and insurance policies so they can help providers navigate prior authorizations and ensure patients receive timely access to treatment. Biologic coordinators can use pharma lunches, rep visits, and industry events to not only learn about new treatment options but also advocate for the lack of visibility for more diverse patient populations, filling clinical evidence gaps.

Medical Mistrust and Misdiagnosis

Medical mistrust is also a significant factor. A study published in JAMA Network Open found that Black participants had the highest levels of medical mistrust among racial groups surveyed, which has significant implications for how they engage with healthcare systems, including participation in clinical trials. Similarly, research published in the Journal of General Internal Medicine found that Black patients’ satisfaction with dermatologic care could improve if clinicians received enhanced training in cultural competency and skin of color. When patients do not have confidence in their medical care, they are less likely to try new treatments, including biologics, based on the belief that these treatments were not developed or tested with people like them in mind.

Misdiagnosis in dermatology is a significant issue for patients with deeply pigmented skin, leading to delays in proper treatment and worse health outcomes. The National Eczema Association reports that eczema disproportionately affects Black children (20 percent) compared to White (16 percent) and Hispanic (8 percent) children, yet it is frequently misdiagnosed due to its distinct presentation in darker skin tones. Similarly, a study published in the Postgraduate Medical Journal found that dermatologists and healthcare providers misdiagnosed common dermatological conditions at alarming rates: 100 percent for eczema, 80 percent for psoriasis, and 60 percent for melanoma, when assessing images of these conditions in patients with skin of color. The lack of diversity in medical education and clinical resources plays a critical role. Research from the Association of American Medical Colleges further highlights this problem, showing that treating physicians are less likely to accurately diagnose conditions such as lichen planus and psoriasis in patients with dark skin. These findings reinforce the urgent need for inclusive training, better resources, and more diverse medical imagery.

When dermatologists can point to studies that specifically include Black and Brown participants, it builds trust and makes patients more likely to consider treatment. Telling patients, “It works for all skin tones,” rings hollow. They need evidence that their skin was studied and that their unique concerns were factored in the development of these medications.

Additionally, economic and structural challenges play a role in patients from historically marginalized groups. According to the Commonwealth Fund, Black Americans report higher levels of skepticism toward medical research due to past unethical practices and a lack of transparent communication between healthcare professionals and patients. With limited inclusion in trials, providers continue to be trained primarily on White skin, which reinforces disengagement and inadequate treatment options for patients of color.

Sunscreen and PIH in Skin of Color

Once patients have their eczema and psoriasis cleared with biologics or topical steroids, they are often left with post-inflammatory hyperpigmentation (PIH) and residual discoloration. Sunscreen is the most important step in treating pigmentation, especially in those with deeper complexions, because without it, other treatments are significantly less effective. Providers need to initiate clear, direct conversations about sun protection, particularly when addressing pigmentation concerns. Broad-spectrum sunscreens with SPF 30 or higher are essential, and tinted sunscreens containing iron oxides offer critical protection against visible light, wavelengths that penetrate deeper and can worsen this condition in melanated skin.

One major challenge is misinformation. Many individuals with richly pigmented skin have been told they do not need UV protection, often due to the cultural belief that melanin provides sufficient protection. When discussing sun protection with patients, it is important to recommend brands that offer cosmetically elegant options for skin of color. Many sunblocks leave a white cast, which can make them unappealing and discourage consistent use.

Larger brands like EltaMD, La Roche-Posay, and Neutrogena now offer formulations that work well on deeper tones, while Supergoop!’s Unseen Sunscreen SPF 40 provides a completely invisible finish suitable for all skin types. Additionally, smaller brands founded with skin of color in mind, such as Fenty Skin, Bolden, Kinlò, and EleVen, have created broad-spectrum formulations that avoid the white cast while still delivering effective UV protection.

Alongside sunscreen, some providers recommend topical treatments to further address PIH. One such option is Cyspera (cysteamine), which reduces melanin production by inhibiting tyrosinase and peroxidase. Unlike hydroquinone, Cyspera does not trigger pigment deposits or structural skin changes associated with exogenous ochronosis, making it a safer, longer-term treatment for hyperpigmentation, especially in patients with dark skin. Importantly, Cyspera is also available without a prescription. A 16-week randomized, double-blinded, vehicle-controlled trial demonstrated that the cysteamine-isobionicamide complex significantly improved postinflammatory hyperpigmentation, with a 47.3% reduction in MASI scores and enhanced skin tone as measured by objective tools like the Mexameter® and VISIA analysis. Advanced imaging techniques confirmed decreased pigment deposition at the cellular level. Importantly, patients reported improved quality of life, and the treatment was well-tolerated with only mild, transient side effects.

Final Thoughts

Dermatology is evolving, but there is still a long way to go. Clinical trials that include Fitzpatrick skin types III to VI are no longer a milestone; they must be the baseline. True equity means consistently including at least 20 to 30 percent of participants from diversified racial groups, especially Black patients.

Beyond trials, dermatology education must change. Many providers were trained using resources that centered only on lighter skin tones, leaving them underprepared to care for patients with pigmented skin. That gap results in diagnostic inaccuracy, mistrust, and inadequate treatment, and patients should not have to rely on luck to find someone who understands their skin.

As a medical assistant and biologic coordinator, I have seen how much our work shapes the patient experience. We frequently serve as the link between clinical decisions and patient confidence, between diagnosis and access. In this role, staying knowledgeable is not optional, it is how we advocate. When we can confidently explain treatment options and point to clinical data that reflect our patients, we help them feel seen and heard.

These conversations, whether about sun protection or trial access, are part of a larger truth: equity must be embedded at every level of dermatologic care. That includes clinical research, medical education, and everyday patient interactions. When equity drives every decision, dermatology becomes a field where equity is not just a goal, it is the foundation of excellence.

References

1. Thompson HS, Manning M, Mitchell J, et al. Factors associated with racial/ethnic group–based medical mistrust and perspectives on COVID-19 vaccine trial participation and vaccine uptake in the US. JAMA Netw Open. 2021;4(5):e2111629. doi:10.1001/jamanetworkopen.2021.11629
2. Shwe S, Nguyen C, Bhutani T. Racial disparities in clinical trials of biologic treatments for psoriatic arthritis. J Am Acad Dermatol. Published online August 2021. doi:10.1016/j.jaad.2021.08.038
3. Balch B. Why are so many Black patients dying of skin cancer? Association of American Medical Colleges (AAMC). https://www.aamc.org/news/why-are-so-many-black-patients-dying-skin-cancer. Accessed May 7, 2025.
4. Ongoro G, Avestruz Z, Stover S. Skin inclusion: addressing deficits in medical education to promote diversity in dermatological diagnosis and treatment. Clin Cosmet Investig Dermatol. 2023;16:3481-3485. doi:10.2147/CCID.S433718
5. Hostetter M, Klein S. Understanding and ameliorating medical mistrust among Black Americans. The Commonwealth Fund. https://www.commonwealthfund.org/publications/newsletter-article/2021/jan/medical-mistrust-among-black-americans. Accessed May 7, 2025.
6. Eli Lilly and Company. More than two-thirds of people with atopic dermatitis and skin of color experienced skin improvement in a first-of-its-kind lebrikizumab study. Eli Lilly and Company. https://investor.lilly.com/news-releases/news-release-details/more-two-thirds-people-atopic-dermatitis-and-skin-color. Accessed May 7, 2025.
7. Liu RTL, Tsai TF, Lai YJ, Ng CY. Efficacy and safety of cysteamine-isobionicamide complex in postinflammatory hyperpigmentation: a 16-week, randomized, double-blinded, vehicle-controlled trial. Dermatol Sin. 2023;41(4):222-230. doi:10.4103/ds.ds-d-23-00184