Diversity and Equity in Dermatology

In November 2020, Practical Dermatology® hosted a virtual roundtable discussion on Diversity and Inclusion in Dermatology. This discussion was supported by L’Oreal Dermatological Beauty brands CeraVe, La Roche-Posay and SkinCeuticals. A panel of dermatologists and industry executives discussed the challenges facing the field due to a lack of diversity in physician and industry representation, clinical trials, and more. From the effects on patient care to treatment outcomes, they share personal insights about the issues, what needs to change, and opportunities to makes those changes a reality that will improve access to dermatology for people of all races and ethnicities.

In part 1 of this 2-part series, a panel of dermatologists and industry professionals discuss why diversity in race and ethnicity is important in dermatology in everything from clinical trials to physician and industry representation.

The COVID-19 pandemic has brought attention to existing racial disparities in health care. Lack of diversity in the medical workforce, including dermatology, has been well documented.^1-3 Roundtable participants agree that lack of diversity of race and ethnicity in the physician and industry workforce has many negative consequences, including an impact on patient care, and concur that the inequity must be addressed and corrected. The lack of representation of minority physicians and patients with skin of colors is one such issue that the group agrees must be addressed in order to move the specialty forward and ensure best outcomes for all patients.

“We, as the leaders in the industry, need to help other people to understand that diversity is not in dermatology at all. Only three percent of dermatologists are African-American across the country,” says Jeanine Downie, MD, a dermatologist in New Jersey. She notes that there is also a lack of representation in some of the bigger pharmaceutical companies in terms of African-Americans, Asian Americans, Latino Americans at the lower rungs as well as at the higher levels. “I think that can be improved upon as well as looking at the decision-makers for clinical trials, the decision-makers for who writes what paper, who gets up on the podium—all of that.”

Dr. Downie has vast experience—more than 25 of her 73 peer-reviewed articles have been on skin of color. She has been the primary investigator for 40 clinical trials since 2003. But, she says, she’s had to fight her way into many clinical trials. She explains that diversity in those performing the trials as well as those participating in them is extremely important. “I think that we should obviously be testing on all skin types and that we should open up the floor to more diversity,” Dr. Downie adds.

The Benefits of Diverse Representation of Skin Types and Ethnic Backgrounds in Medical Research

Corey Hartman, MD, a dermatologist in Birmingham, AL, says that it’s critical that all different skin types and ethnic backgrounds are represented in clinical trials in order to understand how all products interact with different populations. Including multiple races and ethnicities shows companies are interested in having those patients be part of the overall strategy for how these products will be used and who will use them in the long run.

“Part of the reason why it’s so difficult to get African-Americans, in particular, into studies is because of the history of medicine in this country and the instances of being taken advantage of and used throughout the years. That makes us less likely to participate or volunteer for clinical trials in the first place. So it becomes sort of a self-defeating, self-fulfilling prophecy, if you will, where people don’t want to participate, so no one participates,” Dr. Hartman says. “And at this point, the history is so deep, some of those wounds are so fresh, and it’s on the minds of a lot of people. So it really is going to take a concerted effort on the part of the people who are doing the research to go out and recruit these patients so that they can participate and also recruit Black doctors to conduct the trials so that you have participation at every level.”

He adds that it should be common sense for companies to ensure inclusion on the participant and physician level. Otherwise, there’s a strong possibility that at the end of the trial, the FDA will not approve a drug or device because there weren’t enough people of color included in the trial.

“If you just do it right from the start, you’ll save yourself a lot of trouble—it just makes sense. Not to mention the fact that going forward, the quote-unquote minority will become the majority,” Dr. Hartman explains. “So you’re shooting yourself in the foot financially. You’re shooting yourself in the foot from a moral perspective, an ethical perspective.”

Seemal R. Desai, MD agrees and emphasizes that from a political advocacy perspective, the need for diversity in clinical trials goes beyond FDA approvals to bigger-picture issues of drug policy and research funding needs. “I see this all the time from the advocacy perspective whether it’s through my involvement with clinical research, the FDA or when I’m in Washington with congressional work. You can’t say we have a diversity problem, or a clinical scenario issue, or a drug development issue unless you have outcomes data and numerical statistical objective ways to support that,” Dr. Desai explains. “And the only way to support that is to get more patients of color into clinical trials so that you have the numbers to give definitive objective data. For example, in psoriasis and skin of color, we see morbidity and more issues with chronic psoriatic arthritis along with additional skin sequelae of a typically non-scarring skin disease.” The only way to improve from a long-term health care perspective is to get outcomes data to support those claims. Practicing board-certified dermatologists already know those claims are valid, but no one’s going to listen without the clinical data. Dr. Desai notes that this is where things like DataDerm, the American Academy of Dermatology’s module for collecting data from electronic medical records, have value. Having one repository to pull information like the number of skin of color patients who were diagnosed with melanoma can show that a significantly higher number of skin of color patients are being diagnosed with melanoma than the Surveillance, Epidemiology, and End Results (SEER) show. This information can be used to advocate for more melanoma research funding.

From an industry perspective, lack of diversity in subjects in clinical trials not only ups the risk for not winning FDA approval, but can lead to a smaller potential customer base long-term and a lack of understanding of all potential treatment outcomes.

“Clearly one of the things we do in clinical trials is look at safety and efficacy. We have populations that are racially different—diverse ethnicities—and in some cases, in some disease areas, they do respond differently to the treatment that you’re giving them, whether it’s from a safety perspective or an efficacy perspective,” says Chudy Nduaka DVM, PHD, DABT, Therapeutic Area Head, Dermatology, US Medical Affairs, Abbvie. “So if you finish your trial and put the drug on the market and you have not tested it in these populations, you may end up with a very different effect in those populations that you have not tested when it comes to market. And that’s not the place to start looking at the differences that could come about from the drug treatment—the right place is in a controlled clinical trial. That’s why it’s so important as we do these trials, that we make sure that we have diverse representation.”

Clinical trials are designed to show safety and efficacy, which are the basic requirements for FDA approval, but they really don’t call out vigilance or observation of particular consequences in populations that are known to react atypically to different treatments, adds Jonah Shacknai, Executive Chairman, Dermaforce Partners, parent company of SkinBetter Science. So in addition to diversifying representation in trials, it’s also important to look at trial design and be vigilant for effects that may be particular to one population or another represented in a study.

“There’s really inadequate attention paid to it so we can win the battle having greater representation in clinical trials, but still lose the war if we’re not looking for those discrete events that may be particular to certain communities. And if we just wait for them to fall through the cracks and have to do a retrospective analysis of data, or engage in post-marketing surveillance to try to answer a question, we’ve really failed from conception,” Mr. Shacknai says.

Stephanie Manson Brown, MBBS, MRCS, MFPM, Vice President, Head of Clinical Development, Aesthetic Medicine at Allergan Aesthetics, an AbbVie Company, says there’s massive room for improvement in clinical trials, including in the aesthetics space. And although it can be argued that the makeup of clinical trial participants for aesthetic trials being predominately white women reflects the current market for cosmetic procedures, according data from the American Society of Plastic Surgery, this is short-sighted. Dr. Manson Brown explains that it’s a self-perpetuating vicious circle—if you’re not studying a more diverse patient population, the same issues will persist. (See the sidebar What Does a Diverse Clinical Trial Look Like?)

Physician and Researcher Representation Matters

In order to achieve better diversity in clinical trial subjects, the first step may be to ensure diversity among clinical trial investigators. Mr. Shacknai recalls time spent earlier in his career on the National Institute of Arthritis and Musculoskeletel and Skin Diseases (NIAMS) Advisory Council to the National Institutes of Health (NIH). Although he believes NIAMS is a relatively progressive institute that has promoted significant dermatologic research, he remembers being struck that there seemed to be no special interest in studying dermatologic diseases in populations other than Caucasians—Fitzpatrick skin types I through III.

“I don’t think it was deliberate, but if you look at the composition of the advisory board that I served on, there was very little diverse representation. And among the investigators whose grants we were reviewing, there was even less diversity, less representation from different groups,” Mr. Shacknai notes. “So there’s no question that this begins at a more basic level, because of a lack of representation and diversity in the sciences, in dermatologic research. If the investigators themselves are unrepresentative of the population, it’s quite probable that their interests will likewise be unrepresentative of the population.”

The fact that the clinical investigators and researchers have such poor representation among persons of color is definitely a factor. In clinical research that is not industry sponsored, in particular, there’s been so little representation.

Dr. Desai points to the need for diversity in the patient population that investigators serve. Without diversity among those leading clinical trials, diversity in clinical trial subjects will not be adequate.

“For example, I practice in Dallas; a very large portion of my practice is skin of color. Inherently, I am biased in our clinical trials that I am involved in because I have a higher proportion of skin of color patients in my census, that is my practice. I live in a very urban area and that’s what I have designed my practice to do. But Mary down the street from me, who may be excellent at treating skin of color dermatologic disease and does a lot of skin of color trials, may not have the right patient population to even recruit those subjects. This has come up recently in a lot of the atopic dermatitis work I’ve been involved in, because clearly atopic dermatitis is a disease that affects underrepresented minorities to a significant degree,” Dr. Desai explains.

Companies have to be very selective about which CROs they use, because as a part of site selection processes the CRO knows how to vet an investigator and the patient population of that investigator for the trial. They need to understand that a practice in a certain area may not have a diverse enough patient population. In certain geographies, it is not possible to recruit patients who are genuinely representative of a national population. They will represent locally, and we have to compensate for that by going to other places, Mr. Shacknai adds.

Work being done across the field seeks to connect industry to minority physicians or health care providers who are interested in being clinical investigators. For example, Dr. Hartman says the Dermatology Section of the National Medical Association offers a research component to bridge that gap between industry and member. The Skin of Color Society also helps to connect companies with investigators of diverse races.

“You can go to one place and not have to reinvent the wheel, and know that you’re going to recruit high-quality investigators, physicians who have theses built-in patient populations that you’re looking for to get the patients that you need in the studies,” Dr. Hartman says.

Companies and CROs need to be aware of and take advantage of existing resources.

“At this point in time, it’s beyond anything that’s even remotely excusable for ignorance, not to have awareness of the need for diversity in clinical trials and in investigators,” Mr. Shacknai adds.

Dr. Manson Brown also points out another important benefit of having diversity in clinical investigators. One of the barriers for patients from a diverse or an underrepresented background to participate in clinical trials often is mistrust, as Dr. Hartman also noted. “There’s plenty of data out there to demonstrate that patients have better health outcomes when they’re treated by a doctor they can identify with. They’re going to have a better trust in their doctor. Therefore, if they see a doctor who’s participating in a trial, then they’re more likely to have trust in participating in that trial,” she says. (See the sidebar Overcoming Participant Recruitment Challenges.)

A Diverse Workforce: The Benefit to Patient Care

Noting the importance of addressing issues of diversity and inclusion, Dr. Downie shares her recent experience being asked to review a piece from International Journal of Women’s Dermatology, “talking about meaningful reforms in terms of diversity, and in it, it says, as physicians, we carry privileged status in a trusted voice that engenders a greater responsibility to meet the demands for the moment.

“I think that should be changed to ‘as physicians, some of us carry privileged status.’ And then it should say that skin of color physicians, unfortunately, may not. Because as a black physician, I have to contend with the fact that my color will bring me discrimination and bias, because I walk in the room and my race walks in the room before I walk in the room. So many times, and it’s not intentional, but people will call me the wrong name of somebody that they’ve seen me with, or that I might not even be friendly with, that’s an African-American physician or industry,” she explains. “It’s necessary to realize that all this implicit bias exists. Health care disparities are a form of racism, and it’s time to focus on the health care disparities within the dermatological industry and try to cure these things.

“As a skin of color physician, I’m very passionate about this. If we don’t deal with this, it’s just going to keep growing and getting worse, and it’s the elephant in the room because a lot of majority doctors, they do treat me with respect, the majority of doctors in my industry. They absolutely do,” she says. “But every single doctor on this panel will say that they feel like we need to be on more panels at conferences, we need to be listened to, and we need to be co-authors and co-investigators and basically totally co-exist—be an integral part of the dermatologic experience.”

Dr. Desai agrees, saying that this is a reason why it’s so important to empower and mentor current residents to help continue to take the lead on these issues going forward, encouraging more inclusion of dermatologists of various ethnic and racial groups to be on panels, to do research.

“Young dermatologists who are the next wave of our specialty, probably don’t even know some of the opportunities that are out there. I think it’s our job to continue to mentor and expose them to as many of those as we can,” Dr. Desai says.

To make meaningful change, roundtable participants say, really requires outreach to students in medical schools to recruit them into dermatology residencies, because the number of minority dermatologists in the US is very low. It has been reported that approximately three percent of dermatologists in the US are Black, and 4.2 percent are Hispanic, compared with 12.8 and 16.3 percent, respectively, of the total population.^1,2 Race demographics of US medical school applicants and matriculants also fail to reflect the general population. There is significant underrepresentation of racial and ethnic minorities. In fact, in 2014, dermatology residents in the US were 68.8 percent white, 3.9 percent Black, 6.7 percent Hispanic, 20.3 percent Asian, 0.2 percent Native American/Alaskan Native, 0.2 percent Native Hawaiian/Pacific Islander, 1.9 percent multiracial, and 4.8 other/unknown.^1-3

“We should look back to see how we can devise programs that will help medical students thinking about careers in dermatology, especially the minority medical students,” Dr. Nduaka adds.

In fact, the Skin of Color Society has taken a lead on the Diversity Pipeline Initiative to guide underrepresented minorities at a much earlier age. The Initiative includes reaching students on the high school level to encourage them to pick a career in medicine so that they can prepare to be the best candidates they can be in college in order to get into medical school, explains Dr. Desai.

Unless you know what’s involved, what the opportunities are, and what they can then translate to, you can miss out, says Dr. Manson Brown. Joint initiatives with industry to help with education and to help bring that awareness and understanding as to what it pertains to being involved in clinical trials, and really, what the opportunities are, are vital.

Having representation in the office is always going to impact a patient of color’s perception of how that physician is equipped to handle his/her particular needs. But another part of the equation, especially when talking about aesthetic procedures, is marketing, the group agrees. As mentioned with regard to clinical trials representation, the data currently suggests that the target audience for most cosmetic procedures today is Caucasian women, because they spend the most and are the most likely to participate. But that may be a reflection of marketing. In reality, many other patients out there are interested in these procedures, as well. “If you only see commercials with 25-year-old white women, talking about their cheeks and their lips, then that’s all that you’re going to think that this product is geared for, aimed for, and can be productive and successful in,” explains Dr. Hartman.

Dr. Downie agrees, describing how a recent Juvéderm campaign that included women with brown skin, a Black woman, and an older white woman with gray hair has bought many new different patients into her office. “My Black patients feel like it’s marketed to them, my white patients feel like it’s marketed to them. I think there’s somebody that looks like she could be Latina in there, I mean, so that is to me a great aesthetic commercial that’s brought in more patients,” she says.

There’s no question that industry has done a poor job representing a diverse population in marketing and advertising and that there is a significant effort now underway to correct this and be more representative.

Rhonda Peebles, Head of US Dermatology, UCB echoes the call for diversification across the industry. “Not as my role at UCB and in medical dermatology, but as a patient, I can tell you that there is a feeling when you’re sitting in the waiting room, wondering if they know why you’re there, or if they see beauty, the way that you need them to, or you’d like them to, or you want them to. I can tell you that I did not feel comfortable in going to a dermatologist office until I visited Dr. Downie, because I actually saw her at a meeting and said, ‘That’s someone who probably would understand my goals, and that’s someone who looks like me.’” Without that connection, she saw no ads with patients who looked like her or reason for her to know that a dermatologist would understand her goals.

Improving Training and Education

With relatively few minority dermatologists in the United States, there are a lot more patients with skin of color in the US than there are dermatologists. Industry has a key role to play in modeling what patients should look like and feel like, but what happens when someone successfully wants an aesthetic procedure, they show up in the waiting room, and they’re feeling different because the staff and other patients in the office are not representative of what their community looks like?

This is a comprehensive issue, and as noted earlier, it requires systemic changes to introduce children to the option of medicine at an early age, to connect in high school to put them on a path to do well, to get into a good college, to get into medical school, to seek out a dermatology residency. But changes in dermatology training programs are also needed.

“If we just look at our little microcosm of this, it’s industry, but it’s also the dermatology community, and we have to sensitize people that if they expect to get patients who are diverse—and it’s good for business to do that, it’s economically good for them—they have to be able to treat people appropriately and respectfully and make them feel welcomed no matter what they look like,” Mr. Shacknai says. “I’d like to think as an industry, we’re doing better, but there’s also a piece of this that falls on the practitioner. Particularly those practitioners who may not have adequate sensitivity to the needs of communities other than their own, to make people feel comfortable. It starts in the waiting room, it starts with having a staff that looks like everybody in the community, and it ends with an understanding of cultural sensitivity of beauty.”

He says this is one of the reasons Allergan Aesthetics and Skinbetter Science have launched a new long-term, educational initiative—DREAM: Driving Racial Equity in Aesthetic Medicine—to further the principles of racial and ethnic diversity, inclusion, respect and understanding in the fields of dermatology and plastic surgery. “We’re trying to educate physicians and the media in particular, that there are different perceptions of beauty, and that a white physician cannot look at an Asian patient or a Black patient and say, this is the way I’m going to treat you, because this is the prototype of what a white woman is supposed to look like,” he explains.

We need to shift the mindset—there’s not a common set of goals for all ethnicities and race, say Dr. Manson Brown. Aesthetic treatment goals should include preserving racial and ethnic features. And that starts with research and trials and physician training.

”I think we need to be making sure that we’re designing clinical trials to ensure that we are looking at indications that complete different diverse patient populations, rather than going for one indication that is more beneficial for white females. It’s really important that we need to be looking at all the different needs of our patient population,” she says. (See the sidebar Is it Time to Rethink the Fitzpatrick Skin Types and Other Clinical Trial Measurements?)

In addition to failing to foster sensitivity to all patients, there are repercussions to inadequate training programs and research that don’t include a broad range of skin types. Many people are not trained on what various skin conditions look like in skin of color, says Dr. Downie, which can lead to misdiagnosis.

“I believe that part of the initiative of DREAM is to educate doctors, because right now there seems to be a diversity problem also in the dermatology books. It can’t just be white skin except for syphilis and keloids and sexually transmitted diseases, because that has such negative undertones,” she explains.

The DREAM Initiative is sponsoring the development of “The Full Spectrum of Dermatologic Disease: A Diverse and Inclusive Atlas,” a comprehensive textbook photo atlas that will present the characteristics of skin conditions across the full range of skin types. The text will be disseminated to residents, faculty, and program libraries and will be available as a resource for clinical practitioners worldwide.

This is such a vital issue, Melissa Kanchanapoomi Levin, MD says. “One of the biggest reasons why I wanted to train in New York is because I wanted to train in a patient population that spanned all different skin types. But unfortunately so much of our country doesn’t allow for seeing all these different skin types, so having more comprehensive Kodachromes, which are photos that we use in dermatology to learn, is something that’s so important. It needs to be prioritized at the residency level,” Dr. Levin explains. There is also a need to develop a curriculum for aesthetic dermatology. She says this is significant deficit in the field. She encourages the development or deepening of an aesthetic dermatology curriculum that actually teaches young dermatologists how to identify different definitions of beauty, and how to then deliver those aesthetic goals.

“I continually learn from my patients, because I have a big patient population that comes from Asia, and their beauty definitions are completely different. I’m learning to deliver that and also training my eye. It needs to be an ongoing curriculum that dermatologists, particularly those who are committed to cosmetic dermatology, continually train ourselves on, because definitions of beauty do change over time. I think we have a long way to go, but I think what you’re starting with the DREAM initiative at the residency level is very needed,” she says.

There is additional encouraging news on the horizon. The AAD will be launching the first ever skin of color curriculum, which will be an A to Z skin of color educational module-based system for residents. And the Skin of Color Society is also working on an initiative that specifically tackles these issues, such as how to look for erythema and redness in a patient with skin of color.

“I think a lot of that work is starting to be done…in a way it’s fantastic that we’re all working on all of these things together, but it’s also a travesty that there even needs to be a book about skin of color dermatologic disease. We should not even be at the point of needing a dedicated curriculum for this, because this should just be so second nature and part of what we do, that there should be no reason that we’re this excited about an entire curriculum from the AAD, or a book, or a chapter. And so hopefully 20 years from now, it’ll be so mainstream, it’s part of every already thing that’s out there,” Dr. Desai says.