Clinical Reference / Dermatopathology: Practical & Conceptual / Jul – Sep 2010 | Vol. 16, No. 3 / “Skin of color”: Racism in medicine for profit

“Skin of color”: Racism in medicine for profit

Jul – Sep 2010 | Vol. 16, No. 3
Ackerman, A. Bernard; Goldblum, Elyse; Yun, Jasmine

Dedication

For Rabbi Jack Stern, Jr.
who, in the 1950s, exhorted his congregants to fight racism wherever it be found,
a plea heeded then and now by one of his disciples
Bernie Ackerman

Contents

Preface

Foreword

Part I: Perspective historical

Parlance pertinent to “colored people” and variations on that designation derisive

Evolution of the notion of “skin of color”

Part II: Authenticity medical of “skin of color”

Definition and exegesis of terms

Justifications offered for creation of a discipline dedicated to “skin of color”

-To generate research about “racial” differences in skin and hair

-To resolve controversies about “racial” differences in (a) skin and (b) skin diseases

-To provide better treatments for “skin of color”

-To produce a literature about “skin of color”

-To give expression to altruism as a “person of color”

Fallacies inherent in the notion of “skin of color” from a vantage medical

Part III: Legitimacy ethical of “skin of color”

Ramifications of institutionalized racism in medicine

Profit from racism in medicine

Fallacies inherent in the notion of “skin of color” from a vantage ethical

Afterword

Acknowledgments

Preface

Seemingly out of nowhere in 1998, came the phrase “skin of color” and since then it has taken hold firmly in the mind of American dermatologists and in the parlance of them. The number of courses didactic devoted to that topic at the annual meeting of the American Academy of Dermatology (AAD) has risen from none in 2000 to seven accredited for Continuing Medical Education (CME) in 2007. Among the offerings listed in the “AAD Scientific Program, 65th Annual Meeting” are ones titled, “Aesthetics and Cosmetic Surgical Procedures in Darker Racial Ethnic Groups,” “Practical Approaches to Skin of Color Patients,” “Skin Cancer in Skin of Color,” “Ethnic Hair,” “Cosmetic Treatments in Ethnic Skin,” “Issues and Approaches in Skin of Color,” and “Treatment Considerations for Ethnic Hair and Scalp Disorders.” The subject of “skin of color,” much en vogue and gaining popularity ever-increasing, appears with predictability in journals various of dermatology, in courses and symposia given for CME, such as the one at the San Diego Marriott Hotel and Marina on July 26, 2006, captioned, “Natural Considerations for Skin of Color,” to say nothing of derivatives numerous of the first “Skin of Color Center” established in an “academic institution,” that being in 1998 at the St. Luke’s/Roosevelt Medical Center in New York City. The year 2004 saw the birth of the “Skin of Color Society.” An entire supplement to the Journal of the American Academy of Dermatology in 2002 was devoted to issues germane to “Skin of Color,” it being titled, “Colloquium on race/ethnicity/skin color.” So popular in 2007 is the theme of “skin of color” that the journal, Cutis, in nearly every monthly issue of it, invites submission of manuscripts for publication given specifically to “Highlighting Skin of Color.”

Some sense for the raison d’être and dynamic of the field of “skin of color” can be gleaned from these lines in 2003 of Susan C. Taylor, M.D. (Taylor SC. Brown skin: Dr. Susan Taylor’s prescription for flawless skin, hair, and nails. New York City: Amistad, 2003, page 5), perhaps the proponent foremost and most prolific of “skin of color”:

“To better serve my patients and deepen the scientific understanding of color, in 1998 I became director of the Skin of Color Center at St. Luke’s Hospital Center in New York City. When I helped establish the Skin of Color Center, it was the first such center of its kind. As the number of people of color in the United States has steadily grown to 24 percent of the population (Blacks constitute 12 percent, Hispanics 10 percent), the need for medical information and expertise specific to pigmented skin has grown. At the center – where about 90 percent of people are of color – a cadre of highly regarded dermatologists is clarifying the differences between skin of color and white skin. This groundbreaking work will soon lead to better treatments for skin of color and greater choices for you and all women of color.”

Parenthetically, it is to “women of color” that the cosmetic industry appeals as it creates more and more products designed specifically for needs it creates for them. We undertake in this work to explore comprehensively the phenomenon of efflorescence of activities in the service of “skin of color,” to attempt to explain the reasons for it, and to subject to scrutiny the matter of differences morphologic and biologic in skin, other than the fact of color and the implications for function of the integument as a consequence of that difference, as well as to assess critically the issues of “race” in general and of the place, if any, for “race” in medicine, those considerations being a preliminary requisite to coming to a judgment reasoned about the validity medically and the legitimacy ethically of “skin of color.” Because of limitations serious of the very concept of “race,” as will become apparent on perusal of the first few pages in Part II of this work, that word when employed throughout the text will be framed always by quotation marks.

This endeavor of ours is presented in such a way as to enable a reader to come to his/her own conclusions about each of the issues just mentioned, that desideratum being facilitated by presenting, as fully as possible and in their own words, the positions various of advocates and enthusiasts of the concept of “skin of color,” that being followed, in every instance, by our own vantage of those same matters. In that way, we have sought earnestly to set forth in fashion “fair and balanced” perspectives conflicting. You decide!

For more than three centuries, the United States of America was unable to be true to its own ideals because of the matter of “race,” the color of skin of many people who lived on its shores preventing those persons from being treated as human beings. Even after slavery was abolished by Abraham Lincoln, Woodrow Wilson, who came originally from Virginia, instituted during the course of his presidency segregated toilet facilities in the nation’s capital, Washington, D.C. Until the Civil Rights Movement of the 1960s, galvanized in large measure by Reverend Martin Luther King, Jr., “blacks” in the south of the country endured segregation – continuous and merciless – in every aspect of life. In regard to medicine, they were cared for mostly by black physicians who had done their training at the black medical schools of Howard and of Meharry; when seen uncommonly by a white physician, they were secluded in a waiting room for “colored” only and when hospitalized were admitted either to a strictly “colored hospital” or to a segregated ward in a city or county hospital. The lynching in 1955 of Emmett Till, a young “Negro” boy said to have whistled at a “white” woman in Mississippi, so revolted many Americans of all strata of society that not long thereafter, “Jim Crow laws,” universal in southern states, no longer would be tolerated, they being overturned by law. In short, it was not so long ago in the United States that the color of a man’s skin prevented him from being treated as a man, let alone a citizen.

Americans were slow to come to the realization of how destructive to everyone concerned was this fixation on color. Lincoln in the 19th century and King, Jr. in the 20th alerted their fellow Americans to how erosive that obsession was to human dignity of those who were “white,” as much as to those who were “black.” Leaders of the Civil Rights Movement championed the cause of a society color blind, one in which merit, not the color of skin, was the sole and ultimate arbiter.

Now, in the 21st century, some among us, paradoxically and ironically, mostly those who in that shameful past were referred to as “colored people” and who, moreover, are physicians, have reintroduced race to the culture of medicine in the form of a discipline they named “Skin of Color.” We in this Arbeit deny the proposition that there is a place in medicine for distinctions based on the color of skin. At the same time we affirm that, for purposes practical, skin is skin, whether normal or diseased, and to segregate on the basis of its color is inherently racist. Those principles animate the pages of this endeavor, one that is consummately “politically incorrect,” and it is they that galvanized us to undertake it. We are pleased and proud to have done what we believe to be socially conscionable correct.
A. Bernard Ackerman, M.D.
Jasmine Yun, M.D.
September 2008
New York City

Foreword

“Distinctions of race, nationality, color, and creed are unknown within the portals of the temple of Aesculapius.” W. Osler [1]

All human beings possess the very same organs, skin being one of them. Disciplines like internal medicine and general pathology are dedicated largely to diagnosis of disease in those organs diverse, and it is evident to practitioners of those specialties that the color of the skin of a patient whose other organs also are being assessed in no way is germane to their purpose. Of course, as is the case near always for statements declarative in medicine, there are exceptions, one notable being management of hypertension in persons whose skin has a particular color, to wit, that of Africans and African-Americans. Despite that reality, cardiologists have yet to create a niche, nor will they ever, dedicated specifically to “heart of color.” In analogy to cardiology, dermatology is the study of skin; it is not the study of “skin of color,” nor does the color of skin change in any way the actuality of the patient as person or of the disease as object for diagnosis. Nowhere is that more apparent than in dermatopathology, i.e., pathology of the skin, where diagnoses with exactness turn not a whit on the color of skin, only on the findings histopathologic themselves. What is true for microscopy conventional applies equally to other methods utilized for diagnosis of skin diseases, e.g., electron microscopy, immunofluorescence, immunohistochemistry, and molecular biology; efficacy of them is not influenced in any way by the color of skin. Once again a caveat obvious is in order: diseases inflammatory present themselves differently in “white” skin vis-à-vis “black” skin by virtue of erythema, i.e., redness, being visualized much more readily on a background white than on one black.

If the assertions just made are true, what justification can there possibly be for the field spawned recently of “skin of color”? In this monograph, we will set forth the facts as directly and dispassionately as possible, each reader being encouraged to decide on the basis of the “facts” the legitimacy of the notion of “skin of color.” In coming to a determination about that, it might be worthwhile now to contemplate a hypothetical as follows: If, say, psoriasis, fungal disease, and melanoma were much more common in whites, would that justify the creation of a special province given to “skin of non-color”?

Part I: Perspective historical

Parlance pertinent to “colored people” and variations on that designation derisive

We call attention now to the irony of the term “skin of color” being propagated largely by persons who, by their own definition, qualify them as having “skin of color,” Susan C. Taylor, Jeannine Downie, Rebat Halder, Fran Cook-Bolden, Victoria Holloway, Valerie Callender, and Eliot Battle, Jr. being exemplars of that. A mere one generation ago, the moniker “colored” was rejected by African-Americans because of connotations of it deprecatory, derogatory, and demeaning. Listen to the words of Winbush written in 2003 pertinent to the fate of the word “colored” as descriptive of “colored people” in the lingo of that people itself, to say nothing of its use by the “white” majority in the society:

“One irony of an epithet is that its use can evolve from being a term of pride to one of derision. ‘Colored’ for example was the most common designation that Africans in America used to refer to themselves until the early part of the nineteenth century…‘Black’ replaced ‘negro’ as a symbol of racial pride and ‘colored’ not only fell into disrepute but also became a term of derision and ‘fighting words’ for most blacks along with its close etymological cousin, ‘Negro.’” [2]

Reverend Jesse Jackson, one of the most visible and vocal successors of Martin Luther King, rejects not only “colored” and “Negro,” but “Black” as terms for identifying his people, he being quoted about the matter thus:

“Announcing the switch to African American, Jesse Jackson said, ‘Just as we were called colored, but were not that, and then Negro, but not that, to be called Black is just as baseless.’”[3]

The evolution and devolution of the terms “colored,” “people of color,” and “colored people,” among others of a vein similar can be chronicled as follows.

From the time that African slaves were imported to help establish permanent English settlements in America there had been reference to them by virtue of their color [4]. The first group of Africans to arrive in Virginia in 1619 was designated by John Rolfe in his journal as “negars” [5]. The derivation of that word is traced to the Latin niger, meaning black. When exactly the term niger evolved into “nigger”, with its connotations disparaging and negative, is unclear [6]. By the 18th century, Americans of African descent were contemptuous of that epithet, conveying as it did an undeniable sense of inferiority solely because of race and the characteristics of the stereotype implied by it. In reaction to that term of denigration, African-Americans began to refer to themselves as “negroes” [7], the word negro in Spanish meaning black. Not until the 18th century did “negro” became adopted as a term used by Anglo-American to refer to all persons of African descent, it being a moniker more genteel than “nigger,” but a denomination demeaning nevertheless, based as it was on character racial alone.

During the 18th century, various names were employed to identify African-Americans who no longer were slaves, among those being “free man of color,” “free woman of color,” and “colored man” or “colored woman.” Records of African-Americans from Tazewell County’s Law Order Books of 1820 characterized a black slave applying for permission to obtain freedom in Virginia as a “man of color” [8]. The term “free persons of color” appears in the Assembly of 1840 in an act that made it unconstitutional to prevent “free persons of color” from carrying arms.[9]

During the 17th and 18th centuries, there was a severe shortage of slaves to satisfy the growing needs of the colonies for laborers. In order to increase the supply, the colonists used English criminals banished to America as indentured servants. Working alongside the African slaves on farms resulted in intermarriage and eventual mixing of the races [10]. Children of mixed heritage were referred to by names revealing of skin color, among those being mulattoes, quadroons, octoroons, and high yellow. By 1860, approximately 10% of the more than 400,000 slaves in the South were mulatto, most of them being progeny of a master and his slaves. It was believed generally that “more than two centuries of race mixing had produced a population of Negroes more racially mixed than pure” [11]. Mulattoes were given preferential treatment because of the lighter tone of their skin. Slave owners propagated erroneous perceptions about lighter-skinned African-Americans that resulted in class distinction and employment bias in regard to African-Americans. Mulattoes were considered to be “third class” and of higher status than slaves with very dark skin. Those prejudicial attitudes were adopted by many African-Americans and some of them endure to this day.

In the early 1900s, “The Colored American” and “Voice of the Negro” were titles of magazines, they typifying images that African-Americans had of themselves. By the end of the century, magazines subscribed to mostly by African-Americans would be captioned “Ebony” and “Essence.” In 1910, the National Association for the Advancement of Colored People, known colloquially as NAACP, was established not only to protect the rights of African-Americans, but to advocate for legal and economic justice in regard to civil rights. Despite attempts by some members over the years to change the word “colored” to a term more acceptable, the title of the organization remains as it was originally, it being a reminder poignant of the work that the NAACP has done to advance both the cause of a people oppressed because of color and of a society that would fulfill its promise by being color blind. [12]

During the Harlem Renaissance of the 1920s, New York City was a magnet for African-American artists and intellectuals producing African-centered music, art, and literature of the time. It was in Harlem that African-American musicals flourished as a new form of theater, one which afforded an opportunity for African-Americans to perform on stage. Depictions stereotypical still prevailed; however, light-skinned African-Americans were given preference for parts and African-Americans were relegated often to roles as docile servants.

By 1960, the term “Negro” was considered offensive by African-Americans because of its association with slavery. During the Civil Rights and Black Power movements of the 1960s, the term “Black” became a symbol for unity, militancy, and pride of African-Americans. Reverend Jesse Jackson, a civil rights activist who, like his mentor, Martin Luther King, Jr., was a Christian minister, led the campaign to change the nomenclature from “Negro” to “Black.” At the same time, the Black Power movement rejected civil rights values of integration and assimilation, and developed in their stead the concept of an autonomous “Black” community. That idea served to galvanize a movement among African-Americans to crusade for equal opportunity, political and economic. The Black Power movement also helped to instill a sense of identity and pride in African-Americans, just as had been the intent of Marcus Garvey who, in Detroit in the 1920s, sought to do the same with his “Back to Africa” movement, it being a seed germinative for what became known as the Black Muslims.

During the 1980s, controversy reigned over preference for the term by which persons of descent from Africa chose to be identified, to wit, African-American or Black. Now Reverend Jesse Jackson championed replacing “Black” with “African American.” He advanced his position in these words: “To be called African Americans has cultural integrity. We are not descended from slaves, nor up from slavery, but rather Africans who were enslaved.”[12] Moreover, he argued thus: “Black does not describe our situation. In my household there are seven people and none of us have the same complexion. We are of African American heritage.” [12] His call for cultural identity served to heighten consciousness of blackness and to remind African-Americans of the conditions exploitive that brought them to America.

Today the generic phrase, “people of color,” has emerged as an alternative to African-American and Black. Curiously it is reminiscent of the discarded term “colored people.” In times past, “colored people” meant African-Americans, whereas today the designation “people of color” refers to all human beings other than Caucasians (as if Caucasians lack skin of color). The Skin of Color Society, established in 2004, is an organization of dermatologists who consider “skin of color” to be advantageous to their purposes [13]. Perhaps it will be worthwhile for them and for all of us, in historical perspective, to reflect on whether racism is any less inherent in “skin of color” than it was in “people of color.”

Terminology embodied in old prejudicial concepts such as “skin of color,” continues to divide people based on color of skin. These purely discriminatory words that are part of the American lexicon need to be eliminated in order for racist attitudes towards African-Americans to desist.

We aver that “purely discriminatory words” such as “skin of color” must be eschewed if racist attitudes in general are to be discarded and every person is to be judged according to merit and never, ever, on the basis of the color of skin.

The evolution of the notion of “skin of color”

It was in 1998 that Susan C. Taylor founded the Skin of Color Center of St. Luke’s-Roosevelt Hospital Center which, in her own words, “addresses the unique needs of patients with pigmented skin, hair and nails.” She went on to advise about the mission of that center as follows:

“The center specializes in the diagnosis and treatment of skin conditions that are common or of particular concern in individuals of color, including, but not limited to, African-Americans, Asians, and Latinos.” [14]

In a series of articles about “skin of color” published in the journal, Cutis, Taylor and Cook-Bolden, dermatologists both, defined “skin of color” as skin of “those of the Black and Asian races, as well as those reporting Latino or Hispanic ethnicity.” They acknowledged that “by this definition, people with skin of color are of various racial and ethnic backgrounds.” [15]

In the nine years ensuing, “skin of color” has become a mantra chanted not only by propagandists for it, such as Taylor and Cook-Bolden, and the Skin of Color Center in New York City, but by the Center for Ethnic Skin of Northwestern University Feinberg School of Medicine in Chicago, the Cultura Skin of Color Training Institute in Washington, D.C., the Skin of Color Society, units dedicated to the subject in departments of dermatology, seminars given to the matter sponsored by the cosmetic industry, books and articles devoted to it by dermatologists whose audience is both laypersons and physicians, and courses about it offered by the American Academy of Dermatology, as well as by other well known societies and organizations in dermatology. Since 2002, Cutis has hosted an ongoing series captioned, “Highlighting Skin of Color.” Entire issues of it and of other journals, such as Dermatology Clinics in October 2003 and Journal of Drugs in Dermatology in January 2007, have focused on “skin of color.” So attractive, appealing, and politically correct has become the notion of “skin of color” that in less than a decade a reader of a journal of clinical dermatology can expect to encounter at least one piece pertinent to the topic.

Not every title for volumes various dedicated to the general subject of “skin of color” bears that very phrase; some books about the matter are captioned “Brown skin” and “Ethnic skin.” The number of those productions is burgeoning.

Part II: Authenticity Medical

Definition and exegesis of terms

Skin

“1. the integument of an animal stripped from the body, and usually dressed or tanned (with or without the hair), or intended for this purpose; a hide, pelt, or fur. 2. the continuous flexible integument forming the usual external covering of an animal body, also one or other of the separate layers of which this is composed, the derma or epidermis.”[16]

“1 a (1): the integument of an animal (as a fur-bearing mammal or a bird) separated from the body usually with its hair or feathers. 2a: the external limiting tissue layer of an animal body; especially : the 2-layered covering of a vertebrate body consisting of an outer epidermis and an inner dermis”[17]

The authors of a leading text current of dermatology define skin as “[being] composed of three layers: epidermis, dermis, and subcutaneous tissue (panniculus).” They go on to state the following: “The epidermis, the outermost layer, is formed by an ordered arrangement of cells called keratinocytes, whose basic function is to synthesize keratin, a filamentous protein that serves a protective function. The dermis is the middle layer. Its principal constituent is the fibrillar structural protein collagen. The dermis lies on the panniculus, which is composed of lobules of lipocytes.” [18]

In actuality, the skin of a human consists of (1) epidermis with which adnexal structures epithelial (hair follicles, sebaceous units, apocrine units, and eccrine units) are continuous and (2) dermis within which are housed adnexal structures non-epithelial (blood/lymphatic vessels, nerves, and smooth muscles), as well as ones epithelial. The subcutaneous fat, known also as the panniculus adiposus and as the hypoderm, is not part of the skin, that truth being communicated clearly by the words themselves, namely, subcutaneous (below the skin) and hypoderm (below the skin); in the construct of anatomy and of general pathology, the subcutaneous fat is considered to be soft tissue, not skin. As an organ vital to life, the skin fulfills many functions, chief among them being a barrier against elements noxious, a vehicle for proprioception, and a resource for modulation immunologic. In addition, the skin, especially that of the face, serves a role esthetic, as well as being a vehicle for communication by way of expression of feelings. Moreover, the skin stores lipids and water, participates in the synthesis of vitamin D3, excretes urea, and absorbs/diffuses oxygen, nitrogen, and carbon dioxide.

The epidermis is composed overwhelmingly of keratinocytes, but also of melanocytes and Langerhans’ cells. Keratinocytes, by virtue of a process termed maturation, are responsible for cornification that takes the form of an outermost stratum corneum that provides skin, and thereby the human organism, with a defense against agents external at the same time that it prevents loss of fluid internal. Melanocytes situated at the base of the epidermis produce melanin, a brown-black pigment that is transferred to keratinocytes in the epidermis, it serving to protect the dermis from damaging ultraviolet rays of the sun. Langerhans’ cells positioned in the middle of the epidermis present antigens to lymphocytes and by virtue of that participate in responses immunologic of the body.

Of

“1. used as a function word to indicate a point of reckoning. 2a. used as a function word to indicate origin or derivation <a man of noble birth> b — used as a function word to indicate the cause, motive, or reason <died of flu> c : BY <plays of Shakespeare> d : on the part of <very kind of you> e : occurring in <a fish of the western Atlantic>3. used as a function word to indicate the component material, parts, or elements or the contents <throne of gold> <cup of water>
4 a. used as a function word to indicate the whole that includes the part denoted by the preceding word <most of the army> b — used as a function word to indicate a whole or quantity from which a part is removed or expended <gave of his time>”
[19]

This is what Stephen Silver, a dermatologist practicing in Connecticut, queried and then advised about “of” in the phrase “skin of color” in a letter of 2003 to the editor of Cutis:

“Something may be the ‘color of…,’ but can anything be ‘of color’? Obviously, all skin must be of some color, or else it would not be visible. The term ‘skin of color’ is ridiculous if taken literally…It was disheartening to find an article in your journal [15] that attempts not only to define but also justify the term ‘skin of color.’ These are thankless tasks, because the term is utter nonsense.”[20]

We are in synchrony complete with those sentiments of Silver.

Color

“1. the quality or attribute in virtue of which objects present different appearances to the eye, when considered with regard only to the kind of light reflected from their surfaces. 2. a particular hue or tint, being one of the constituents into white or ‘colourless’ light can be decomposed, the series of which constitutes the spectrum; also any mixture of these. In speaking of the colours of objects, black and white, in which rays of light are respectively wholly absorbed and wholly reflected, are included.”[21]

“1 a: a phenomenon of light (as red, brown, pink, or gray) or visual perception that enables one to differentiate otherwise identical objects b (1): the aspect of the appearance of objects and light sources that may be described in terms of hue, lightness, and saturation for objects and hue, brightness, and saturation for light sources <the changing color of the sky> “ [22]

When one looks at an object, it appears to have the color of the light (with specific wavelengths) that leaves the object in the direction of the eye. Light directed toward an opaque surface is either (a) reflected “specularly” (as in the manner of a mirror), (b) scattered, (c) absorbed, or (d) a combination of these. Hence, objects opaque that do not reflect specularly (non-mirrored objects with a rough surface) possess color which is determined by the wavelengths of light they scatter versus the ones they absorb. If an object scatters all wavelengths, it appears white or colorless to the viewer. If it absorbs all wavelengths, it appears black.[23]

Skin in every healthy human being, irrespective of “race,” has color. The skin of a Sicilian may be very dark and, conversely, the skin of an Egyptian may be very light. All skin, except for albinos and in those with vitiligo universal, contains melanin. That being so, all skin displays color. Even those persons with albinism and widespread vitiligo are not colorless; their skin does not scatter all wavelengths of light. A pink hue in skin albinotic or vitiliginous sometimes is discernible because of the effects of hemoglobin in red blood cells housed in vascular channels of the superficial plexus situated in the upper part of the dermis. The role of light in regard to color is captured succinctly in these lines of Elizam Escobar, a Puerto Rican political activist and artist:

“Rigorously speaking, color is something that depends on light. Indeed, color itself is within light. It exists and it does not exist….But what if we use instead the term ‘colorless people’ to express our concept of the ‘white’ dominant class? I fear that this term would be considered ‘reverse racism’ or ‘anti-white.’ So a better solution would be to say that all peoples are ‘people of color,’ that there are no colorless people. In such a case, ‘color’ is neither a privilege nor a stigma, but a commonality.”[24]

These thoughts of Escobar are very much to the point in regard to the matter of “skin of color.” Needless to say, we share the opinion of Escobar in regard to color of people (if not his proclivity for the phrase “people of color”).

“Skin of color”

“Patients who are considered to have skin of color would include those of the Black and Asian races, as well as those reporting Latino or Hispanic ethnicity. By this definition, people with skin of color are of various racial and ethnic backgrounds. According to US Census statistics, those individuals who are considered to be of Latino or Hispanic ethnicity are as follows: Mexican/Mexican American/Chicano, Puerto Rican, Cuban, South or Central American, or other Spanish culture. Those individuals classified as “Black” include: African, Caribbean Black, and African Americans. Asians are defined as those individuals from the Far East, Southeast Asia, and the Indian subcontinent (Asian Indian, Japanese, Chinese, Korean, Filipino, Vietnamese, Burmese, Hmong, Pakistani and Thai), and Native Hawaiian or other Pacific Islanders (Samoan and Guamanian). Finally, Native Americans include those individuals of the various tribes of the continental United States and Alaska.” [15]

“The United States is becoming a country in which the majority of its citizens will no longer have white skin, but instead pigmented skin, also referred to as skin of color. These people will be of diverse racial and ethnic backgrounds and primarily will include African Americans, Hispanics, and Asians, as well as individuals from these groups who have intermarried.”[25]

“In this book, I use the term ‘skin of color’ interchangeably with the terms ‘black skin,’ ‘brown skin,’ ‘African-American skin,’ ‘Hispanic skin,’ and ‘pigmented skin.’ “Skin of color’ is defined as skin that contains increased amounts of melanin as compared to white skin. The amount of melanin among different women of color can vary dramatically. Scientists have estimated that people of African descent have some thirty-five different hues or shades of skin tone. If you think about the members of your family and extended family, you’ll recognize that there are probably even more shades than that!”[26]

“If your family has roots in Africa, Asia, the Caribbean, Latin American, the Indian subcontinent, the Middle East, the Mediterranean, or the South Pacific or is Native American, Beautiful Skin of Color unlocks the particular secrets of your skin and provides the answers you’ve been searching for. You deserve them….There’s plenty of research, and a great deal of speculation, about how different cultures evolved. We’re not going to jump into that. But if your family history includes people from Africa, Asia, the Caribbean, the Indian subcontinent, Latin America, the Mediterranean including Greece and Italy, and anywhere in the Middle East, Turkey, or the South Pacific or if you are Native American, you have genes and cells that react similarly to genes in the darkest skin of color.”[27]

“Most skin diseases occur in all types of people, regardless of their skin color (pigment). Certain skin problems are more common among people with darker skin tones. A wide range of racial and ethnic groups, including Africans-Americans, Asians, Hispanics/Latinos, and Native Americans, constitute people who have skin of color.”[28]

“There are many racial and ethnic groups that may be categorized as people with skin of color. These include Asians, African-Americans, Afro-Caribbeans and Africans, as well as Hispanics and Native Americans. Within each of these ethnic and racial groups, there are subgroups.” [29]

“Founded in February 1999, the Skin of Color Center of St. Luke’s and Roosevelt Hospitals addresses the unique needs of patients with pigmented skin, hair, and nails. The Center specializes in the diagnosis and treatment of skin conditions that are common or of particular concern to individuals of color, including, but not limited to, African-Americans, Asians and Latinos. A full staff of board-certified dermatologists with expertise in the skin of color provides individualized and culturally sensitive care.”[30]

It seems that for Taylor and compatriots of her just quoted, “skin of color” applies to all persons on planet Earth who are not “white,” but nowhere do they characterize that latter integument as “skin of non color” or as “skin colorless,” nor do they address a single syllable to criteria by which a person fails to qualify as having “skin of color.” And more remarkable still is their omission of any effort on their part to quantify how much color is necessary for skin to be “of color.” Surely coming from the “Indian subcontinent” is not enough to ensure eligibility for inclusion in “skin of color”; how simplistic is the notion of origin geographic alone in conveying anything meaningful about the color of skin is captured by the novelist, Mohsin Hamid, who has the protagonist of his most recent work speak these lines: “How did I know you were American? No, not by the color of your skin; we have a range of complexions in this country [Pakistan] and yours occurs often among the people of our northwest frontier.” [31]. The matter is placed in perspective proper by these words of Aldo Morrone in a chapter by him devoted to the subject of “Anthropology of skin colors”:

“We know today that race does not determine the color of skin, and that the color of the skin does not define a race. We can clearly assert that a ‘caucasive race’ does not exist, just as a ‘black race’ does not exist, and that the color of the skin of an individual depends on the interaction of various biological, genetic, environmental, and cultural factors. Moreover, we must emphasize the fact that ‘black skin’ is not black, just as a ‘white skin’ is not white, and that certainly a ‘yellow skin’ does not exist. In fact, the different colors of skin rather represent variations in the red spectrum.”[32]

And how simplistic it is to lump together the potpourri of “Asians, African-Americans, Afro-Caribbeans, and Africans, as well as Hispanics and Native Americans” as “people with skin of color,” the colors of them ranging from very light to very dark, i.e., black, to say nothing of the mish-mash of Africans, African Americans, and Afro-Caribbeans, and the separation erroneous of Native Americans from Asians. That notion simplistic is given the lie by Morrone in these lines:

“In Africa there are populations with extremely varied somatic traits, morphology and skin color. The continent houses tall, thin individuals in Kenya (Nilotics), small people in Congo (pygmies), and others in South Africa. Thus, African physical stereotypes are extremely diverse as their ancestors from South-East Asia. Despite the diversity of the African population, there is a tendency to classify them into one category of human race (African/black/Negroid) for the purpose of isolating them from the European or mid-Eastern populations (European/white/Caucasoid). In fact, the ‘Africans’ of Somalia look much more similar to the inhabitants of Saudi Arabia or Iran – countries near Somalia – than, for example, to the Ghanians on the west African coast. Likewise, the Iranians and the Saudis are more similar to the Somalis than the Norwegians. Thus, associating the Ghanians and the Somalis on the one hand and the Saudis and the Norwegians on the other creates an artificial model which is contradicted by all empirical studies of human biology.” [32]

More important still is the inference rightly of Escobar that there is a not-so-subtle scent of racism in the term “skin of color,” it excluding people solely because of reputed lack of color. The absurdity of the idea of “skin of color” is revealed undisguisedly in this exchange of correspondence between one of us (JY) and the current director of the Skin of Color Center of St. Luke’s Roosevelt Medical Center:

From Jasmine Yun, M.D., to Andrew Alexis, M.D.:

Dear Dr. Alexis,

My name is Jasmine Yun, and I am a dermatologist here in New York City. I have now had the opportunity to review the brochure that describes the Skin of Color Center at St. Luke’s Roosevelt Medical Center and have a question about it for you.  It is not made clear who, exactly, qualifies as a person of color, i.e., one with “skin of color.”  How dark does a patient’s skin have to be in order for me to refer him/her to the Skin of Color Center?  Does a swarthy Caucasian qualify?

Thank you in advance for a response.

Sincerely,
Jasmine Yun, MD

From Dr. Alexis to Dr. Yun:

All patients are welcome! In no way is our practice limited to specific ethnic groups. Thank you for your interest!
Best regards,
Andrew

From Dr. Yun to Dr. Alexis:

Dear Dr. Alexis,

Thank you for the rapid response to my letter.

In your missive to me you wrote that all patients are welcome to the Skin of Color Center.  If that is the case, why is there a need for a Center devoted specifically to “skin of color”?  In short, if all patients are welcome, why the need for a Skin of Color Center and not simply a dermatology clinic for patients of all color of skin?

Thank you once again in advance.

Sincerely,
Jasmine Yun, M.D.

From Dr. Alexis to Dr. Yun:

The Skin of Color Center is part of the Dept. of Dermatology at St. Luke’s-Roosevelt Hospital. We have faculty members that treat all types of patients and each dermatologist has his/her own areas of clinical/research interest. The reason for the center is to provide specialized care for skin of color (culturally competent care that includes expertise in treating conditions that are more common or of particular concern in darker-skinned populations – e.g. dyschromias, follicular disorders, keloids, various alopecias, etc.). It also serves to conduct clinical research on the above skin disorders. As you know, research in this area is limited so we are committed to improving the care of these disorders and making advances in our understanding of them.

I hope this answers your question.

Best regards,
Andrew F. Alexis, M.D., M.P.H., Director, Skin of Color Center, St. Luke’s-Roosevelt Hospital

 

Sad to say, the replies of Dr. Alexis do not answer the questions posed by Dr. Yun.

Medicine

“1) the science and art of diagnosing, treating, curing, and preventing disease, relieving pain, and improving and preserving health. 2) the branch of this science and art that makes use of drugs, diet, etc., as distinguished especially from surgery and obstetrics. 3) any drug or other substance used in treating disease, healing, or relieving pain.”[33]

Medicine, the law, and the ministry constitute the three professions classic, those being vocations requiring advanced education and training, as well as certain skills intellectual, utilized primarily in the service to others and not chiefly for gain financial, in contrast to commerce, i.e., business. It is undeniable that beginning in the years following the Second World War, the profession of medicine as practiced in the United States became progressively a business; the language of the profession, was supplanted by the parlance of business: physicians became “providers,” patients were referred to as “consumers,” “customers,” and “clients,” fees were designated “prices,” and courtesies were called “discounts.” Perhaps no specialty in medicine embraced business more enthusiastically than did dermatology. It was in that milieu commercial that “skin of color” was conceived and spawned, and very soon became the cottage industry it is today.

Race

“1) a group of persons, animals, or plants, connected by a common descent or origin. 2) a limited group of persons descended from a common ancestor. 3) a tribe, nation, or people, regarded as of common stock. 4) one of the great divisions of mankind, having certain physical properties in common.”[34]

“2 a: a family, tribe, people, or nation belonging to the same stock b: a class or kind of people unified by shared interests, habits, or characteristics. 3 a: an actually or potentially interbreeding group within a species; also : a taxonomic category (as a subspecies) representing such a group b:breed c: a category of humankind that shares certain distinctive physical traits” [35] 

If the first definition provided by the Oxford English Dictionary is to be accepted and if all men and women on the globe are descended from one couple, then all humans are members of a single race.

Since the introduction of the term “race” in the eighteenth century by Georges Louis Leclerc de Buffon and the first classification of humans predicated on the color of skin and other traits physical in the mid-nineteenth century by the German anthropologist, Johann Friedrich Blumenbach, that word has been used to identify groups of people very different culturally from one another. Blumenbach classified “races” on the basis of attributes inherent in the discipline of physical anthropology, this being some of what he wrote in 1865 about the matter:

“Five principal varieties of mankind may be reckoned… Caucasian, Mongolian, Ethiopian, American, Malay… I have taken the name of this [Caucasian] variety from Mount Caucasus, both because its neighbourhood, and especially its southern slope, produces the most beautiful race of men.”[36]

In short, the thinking about “race” of Blumenbach patently was racist. Within the same treatise, Blumenbach also presented the opinions of his fellow German anthropologist, Christoph Meiners, who, he said, “refers all nations to two stocks: (1) handsome, (2) ugly; the first white, the latter dark.” According to Blumenbach, Meiners “includes in the handsome stock the Celts, Sarmatians, and oriental nations,” whereas, “the ugly stock embraces all the rest of mankind.” Meiners was a racist unabashed.

It goes without saying that we are appalled and disgusted by the precepts advocated by Blumenbach and Meiners, as we trust is everyone who reads the lines written by them. How astonishing it is that those statements became the basis for the modern-day concept of “race.”

The idea seminal of Blumenbach concerning “race” and promulgated by him more than 140 years ago has been accepted widely by anthropologists and physicians, as well as by politicians. Lord Byron, in 1915, was among the first to put the issue in perspective stark, he doing that in these words:

“No branches of historical inquiry have suffered more from fanciful speculation than those which relate to the origin and attributes of the races of mankind. The differentiation of these races began in prehistoric darkness, and the more obscure a subject is, so more the fascinating.” [37]

The subject of race remains much debated to this day, but evidence is mounting increasingly that the concept of it put forth originally by physical anthropologists may have no legitimacy genetically. Recent studies of the human genome have generated data that indicates variation between individuals accounts for 93-95% of genetic variability, “differences among major groups (‘races’) constitute only 3 to 5%.” [38] In spite of such data compelling, the concept of “race” continues to be accepted and perpetuated in many quarters, and is employed near universally today by scientists in general and physicians in particular—despite the fact of its being fictitious. Listen to the words of Montagu [37] in that regard, sentiments with which we agree wholeheartedly:

“The idea of ‘race’ represents one of the most dangerous myths of our time, and one of the most tragic…Today, many of us believe in ‘race.’ ‘Race’ is the witchcraft of our time. The means by which we exorcise demons. It is the contemporary myth. Man’s worst dangerous myth.”

The opinion of Montagu was seconded recently by Aldo Morrone [39] who wrote as follows:

“‘Race’ should have disappeared in the 1950s and 1960s, when scientists passed from studying pure genetic variations as a response to studying genetic variations as a response to the forces of evolution. But the concept of race, along with racism, did not die.”

Morrone went on to say that, “Race, in other words, does not determine skin color and vice versa.”

The word “race,” by virtue of implications of it and inferences from it, is fraught with charge emotional, having as it does connotations complex both psychological and political. Nowhere is that more evident than in the use today in the media, both in newspapers and on television, of the expression “the N word,” “N” substituting for “nigger” which is deemed currently to be incorrect politically even if it is being invoked to decry how unacceptable was the employment derogatorily of it in the past. The status of the word “nigger” today is appraised in the Fourth Edition of Webster’s New World College Dictionary thus:

Nig-ger (nig ar) n. [Dial. Or Slang] Negro

USAGE—originally simply a dialectal variant of Negro, the term nigger is today acceptable only in black English; in all other contexts it is now generally regarded as virtually taboo because of the legacy of racial hatred that underlies the history of its use among whites, and its continuing use among a minority of speakers as a viciously hostile epithet.

We learn from the author[s] of this definition of the existence of “black English.” Let it be known that the authors of the book you hold in your hands seek to write and speak, not “white English” or “yellow English,” but proper English!

“Race” has even become an impediment to communication among scholars in different fields and in the very same discipline. That being the case, for purposes of our endeavor here, the term “race,” as we have alerted to previously, will be used strictly throughout the rest of this work in reference to certain major groups of people as they have been separated from one another conventionally for the last nearly 150 years. Because we consider that categorization not only to be simplistic but inaccurate, we enclose the word race partially by quotation marks in order to convey, unreservedly, our own reservations profound about it.

Racism

“1. the belief that there are characteristics, abilities, or qualities specific to each race. 2. discrimination against or antagonism towards other races.”[40]

“1. a belief that race is the primary determinant of human traits and capacities and that racial differences produce an inherent superiority of a particular race. 2. racial prejudice or discrimination”[41]

Racism is defined in different ways, ranging from a belief that certain human characteristics are determined by “race” to a belief in the superiority, moral or biological, of one “race” or ethnic group over others. Racism, irrespective of the definitions various of it, often is associated with (a) preferences for one’s own ethnic group (ethnocentrism), (b) fear of differences among peoples (xenophobia), and (c) proscriptions against intermarriage and interbreeding (miscegenation). Constitutional laws prohibiting miscegenation in 16 states of the union were overturned only recently, i.e., in 1967, in Loving vs. Virginia. Racism has been used to justify discrimination social, segregation racial, and violence destructive, including genocide. Although it is obvious that “race” and “racism” are very different concepts, it merits reminding that those who initiated the idea of “race,” namely, Blumenbach and Meiners, were racists unabashedly and unashamedly.

The subjects of race and of racism are intertwined inextricably, as Alan Goodman, an anthropologist dedicated to the principle that “the concept of race is completely obsolete and should have been discarded at the beginning of the last [20th] century,” [42] observed and conveyed in these lines:

“Even acknowledging that the idea of race is a legend we will not eradicate racism. Until researchers, even in good faith, go on using the concept of race without clearly defining it, they will sustain the idea of race on a biological basis, thus misleading public opinion and encouraging racist attitudes.”

Racism, in practice, segregates by virtue of decisions and policies predicated on considerations of “race” for the purpose of the subordination of certain persons. Racism that has become institutionalized may be covert and subtle, it then being less identifiable and, therefore, much more dangerous by virtue of becoming less condemnable than when overt undisguisedly, as was the case of apartheid in South Africa prior to the assumption of the reins of government by Nelson Mandela.

Racism occurs in medicine. As recently as 2003, this is what Judith Kaplan and Trude Bennett had to say about that particular subject in the Journal of the American Medical Association:

“To write about race/ethnicity so that it does not stigmatize and does not imply a we/they dichotomy between health professionals and populations of color is challenging. Language both reflects and shapes belief and understanding. Authors need to be thoughtful and deliberate in writing about race/ethnicity to avoid reinforcing stereotypes about racial/ethnic groups or assumptions differences between groups.” [43]

“Skin of color,” as a concept, is racist because it segregates, albeit in a manner imprecise shockingly, based entirely on considerations of “race,” excluding from the group so designated those who are different “racially” only by virtue of their having less color (even though no effort is made by the segregationists to quantify what they mean by color, just as it was for white South Africans, especially Afrikaners, who divided all skin as being “white,” “black,” or “colored”). The irony of American physicians “of color” thinking in the 21st century like white South Africans in the long period viciously prejudicial known as apartheid should not escape notice or be given short shrift.

Profit

“1.Advantage; gain; benefit. 2.Financial or monetary gain obtained from the use of capital in a transaction or series of transactions. 3.The sum remaining after all costs, direct and indirect, are deducted from the income of a business, the selling price, etc.”[44] 

Although the word “profit” denotes gain, the connotation usual of it is gain financial. In medicine, the most noble and learned of all professions, the purpose overarching should be gain healthful, physically and psychological, of a patient. A physician is compensated for ministrations to a patient, but gain financial for the physician is not supposed to be the motivation primary for the practice of medicine. The patient must profit, and the issue that engages us here is who profits maximally from “skin of color”—physicians, centers for “skin of color,” pharmaceutical and cosmetic companies, or patients?

Ethnic

“1. relating to a group of people having a common national or cultural tradition. 2. referring to origin by birth rather than by present nationality”[45]

“2a. of or relating to large groups of people classed according to common racial, national, tribal, religious, linguistic, or cultural origin or background <ethnic minorities> <ethnic enclaves> b : being a member of a specified ethnic group <an ethnic German> “[46]

“Merriam-Webster’s definition of ‘ethnic’ is clear. Its etymology is ‘from Greek ethnikos national, gentile, from ethnos nation, people; akin according to common racial, national, tribal, religious, linguistic, or cultural origin or background.’ This definition has no consideration for the amount of pigment visible in the epidermis as a unifying feature but relates to the social bonding and associations of groups. Our definition should be as clear too, though it is entirely not.”[47] 

As early as 1998, Johnson, Moy, and White titled a volume by them “Ethnic skin,” and gave their reason for crafting it as follows:

“This book provides a practical look at dermatologic disease in patients of different ethnic groups (Black, Asian, Hispanic) and tries to point out the effect of ethnicity on dermatologic disease.”[48]

This is how Halder and Nootheti, dermatologists both, define “ethnic skin”:

“For the purposes of this article, ‘ethnic skin’ is defined as non-Caucasian darker skin types: Fitzpatrick skin types IV, V, and VI. Asia can be subdivided into South Asia, which includes the subcontinent region of Pakistan, India, and Sri Lanka; Southeast Asia, which includes the regions of Malaysia, Singapore, and Indonesia; and East Asia, which includes Japan and China. Also included in non-Caucasian skin are members of the black race. The black race can be divided into subcategories: Africans, Afro-Caribbeans, and African Americans, which is a composite of a number of different races, including West African, Caucasian, and Native American. Hispanics, another group included in the non-Caucasian category, are categorized as European Hispanics, who are lighter in color, and Central American, South American, and Mexican Hispanics, who are darker in color.”[49]

For Johnson, Moy, and White, and for Halder and Nootheti, as with Taylor, Cook-Bolden, Halder, Holloway, and Callender in regard to “skin of color,” “ethnic skin” refers to the integument of all peoples in the world except for that of Caucasians “lighter in color,” those qualifying as having “ethnic skin” actually representing a hodge-podge of peoples, among them “non-Caucasian” of “darker skin types” said to be “lighter in color” and “Mexican Hispanics” who are “darker in color.” Apart from being racist, that classification of human beings according to the color of skin includes, fallaciously, “members of the black race” who are divided arbitrarily into the subcategories “Africans, Afro-Caribbeans, and African Americans, which is a composite of a number of different races, including West African, Caucasian, and Native American.” The pseudoscience of Halder and Nootheti rivals that of Blumenbach and Meiners.

In English, “ethnic skin” makes no sense at all, it meaning skin that is ethnic, which is amusing in its illogic. If one could query directly the skin of an African or of an Indian about the character essential of the person’s own integument, unlikely, in the extreme, would the response be, “I’m ethnic!”

People

“1. human beings in general or considered collectively. 2. (the people) the mass of citizens; the populace. 3. (one’s people) one’s relatives, or one’s employees or supporters. 4. (pl. peoples) treated as sing. or pl. the members of a particular nation, community, or ethnic group.” [50]

“As apoplitical dermatologist-scientists we all know that except for totally vitiliginous persons or tyrosinase-negative albinos the entire human race is one of ‘people of color.’ ” [51]

There are countless peoples in this world, a people being a group of persons who constitute “a community, tribe, race, or nation.” And true it is that some of those peoples differentiate themselves from other peoples by the color of skin, the designation chosen for that purpose almost always being denigrating and racist, e.g., “nigger,” “whitey,” “redskin,” and “yellow belly.” No people is exempt from that tendency, but physicians should eschew tenaciously any such inclination, they being the stewards of all peoples, independent of the color of their skin. Time was, not so many years ago, when the epithet, “colored people” was recognized universally as being a reference denigrating uttered by persons who, consciously or unwittingly, were racist; are the phrases “people of color,” “women of color,” and “skin of color” any less disparaging, and are those who employ them any less bigoted? Note that the word “denigrate” derives from the Latin denigratus, to blacken.

Fig 1

Classification of Skin Phototypes
SPT Reaction of Moderate Sun Exposure Skin Color
I Burn and no tan Pale white
II Burn and minimal tan Pale White
III Burn then tan well White
IV Tan, no burn Light tan
V Tan, no burn Brown
VI Tan, no burn Dark brown

Figure 1. Reproduced from: Fitzpatrick TB, Ortonne J. Normal skin color and general considerations of pigmentary disorders. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, eds. Fitzpatrick’s Dermatology in General Medicine. New York, NY: McGraw-Hill, 2003:820.

Constitutive skin color (also called basic skin color) is the genetically determined skin color (light brown, medium brown, and dark brown) or absence of color (white) in skin unexposed to solar irradiation; this is found in habitually sun-shielded areas such as the buttocks, and inner upper arms. Facultative skin color is the skin color that results from an increase in the intensity of skin color as a result of ultraviolet radiation (UVR) exposure and reflects genetically predetermined capacity of the skin to darken in response to UVR. ‘White’ people are dissimilar in their ability to tan. This is the basic premise of the system of skin phototypes. The phenotype (hair and eye color) is not a reliable guide to sunburn sensitivity because the “white” population is a mix of various skin phototypes: although persons with white skin with freckling and red hair have a limited or no capacity to tan, this failure to tan can also be present in persons who have brown eyes and dark hair. Because of the unreliability of the phenotype, a system of skin phenotypes (SPT) was developed, in 1975, to provide a basis for estimating the dose of UVA in the use of psoralen photochemotherapy.” [52] (Fig 1)

Regarding “skin of color” and Fitzpatrick skin phototypes, Taylor had this to say:

“Skin of color is commonly defined as Fitzpatrick skin phototypes IV to VI. It should be noted that the Fitzpatrick scale describes the response of different skin types to UV light rather than the actual color of the skin.”[53]

Independent of the motive of Fitzpatrick for constructing a classification of “skin phototypes,” it is obvious that his system is predicated on notions naïve, such as “white” skin being the result of “absence of color” and “skin color,” in all nuances of it, being characterized, simply and simplistically, as “pale white,” “white,” “light tan,” “brown,” and “dark brown.” What, pray tell, is “pale white” (white as the ultimate paleness) and “light tan” (tan being a yellowish-brown color and, by definition, lighter in hue than brown unmodified)? In short, it will not be long before the Fitzpatrick Skin Phototype Classification, like his “epidermal-melanin unit” (what he should have referred to was a melanocyte-keratinocytes unit), his (along with Clark) histogenetic classification of melanoma as lentigo maligna, superficial spreading, acrolentiginous, and nodular (what really is a classification anatomic was claimed wrongly by them to be “histogenetic”; and, moreover, morphologically, i.e., clinically and histopathologically, melanomas have the very same attributes irrespective of site), and his (along with Clark) dysplastic nevus and dysplastic nevus syndrome (what is called “dysplastic nevus,” after three decades, has yet to be characterized morphologically, it actually being more than one type of melanocytic nevus, and the so-called syndrome does not qualify as a syndrome because instead of consisting of a constellation of signs and symptoms typifying a particular condition, it is but a single finding, i.e., lots of nevi purported to be of a single type) will be “history,” consigned to the scrapheap of notions ill-conceived about melanocytes, melanin, nevi, and melanomas that emanated first from the department of dermatology at Harvard and then from the one at the University of Pennsylvania during the last 35 years of the 20th century.

The Taylor Hyperpigmentation Scale

“The Taylor Hyperpigmentation Scale is a new visual scale developed to provide an inexpensive and convenient method to assess skin color and monitor the improvement of hyperpigmentation following therapy. The tool consists of 15 uniquely colored plastic cards spanning the full range of skin hues and is applicable to individuals with Fitzpatrick skin types I to VI. Each card contains 10 bands of increasingly darker gradations of skin hue that represent progressive levels of hyperpigmentation… In the study, skin color and an area of hyperpigmentation in 30 subjects of white, African American, Asian, or Hispanic ancestry (approximately 5 from each of the 6 skin types) were evaluated by 10 investigators. The results of the study revealed significant variation among intraindividual and interindividual ratings by investigators of skin hue (P < .0001) and hyperpigmentation (P = .0008); however, most investigators rated the scale as useful and easy to use, and 60% stated they would use it in clinical practice to document the response of hyperpigmentation to therapeutic agents.”[54]

Taylor devised her method for the purpose expressed by her of assessing “skin color” and of monitoring “improvement of hyperpigmentation following therapy.” Irrespective of the motivation for such a scale, the idea of grading color of skin according to “10 bands of increasingly darker gradations of skin hue” is as simplistic as the schema of Fitzpatrick for characterizing “skin color,” to wit, “pale white,” “white,” “light tan,” “brown,” and “dark brown.” Taylor’s “Hyperpigmentation Scale” has no better chance of standing the test of time than does Fitzpatrick’s “Skin Phototype Classification” (or his “skin types”). Moreover, the “scale” of Taylor is entirely unnecessary; a measuring stick for assessing hyperpigmentation is built in to every person, the “control” being the individual’s normal skin and the “analyzer” of it being retinae attached to the brain of a dermatologist.

Justifications offered for creation of a discipline dedicated to “skin of color”

Proponents of the notion of “skin of color” have written reams about the subject. What follows now are the arguments they proffer, assertively and repeatedly, on behalf of the legitimacy of a field dedicated specifically to “skin of color”:

  • To generate research about “racial” differences in skin and hair
  • To resolve controversies about “racial” differences in (a) skin and (b) skin diseases
  • To provide better treatments for “skin of color”
  • To produce a literature about “skin of color”
  • To give expression to altruism as a “person of color”

Let us now examine the authenticity of each of those contentions.

To generate research about “racial” differences in skin and hair

“There is not a wealth of data on racial and ethnic differences in skin and hair structure, physiology, and function. What studies do exist involve small patient populations and often have methodologic flaws….

…There is a paucity of well-controlled studies on people with skin of color. Most studies evaluate differences between fair-skinned persons of European ancestry and African/African-American persons. Obviously further research is needed for people with skin of color who will shortly constitute the majority of people in this world.”[55]

“Speakers described a history of scarce information on cutaneous diseases in skin of color, problems with the data that do exist, and inappropriate use of dermatologic data. Basic descriptive data on the structure and function of skin in people of color is needed.” [56]

In this book, I answer the types of questions I frequently hear not only from the various television interviewers, magazine editors, and fellow dermatologists who seek facts about skin of color but also from the many patients I see at the Skin of Color Center at St. Luke’s-Roosevelt Hospital in New York, where I serve as director. At the center, a team of renowned dermatologists and physicians conducts pioneering research on the differences between [sic] brown, black, and white skin.”[57]

“The spectrum of cutaneous diseases occurring in people of color is broad. Many skin diseases (e.g., acne vulgaris; pigmentary disorders; eczematous dermatitis; infections caused by bacteria, fungi, or viruses) are common to most people of color—blacks, Asians, Hispanic/Latinos, and Native Americans. Over recent years, diseases of more cosmetic concern—pigmentary disorders (e.g., melasma, post-inflammatory pigmentation), AKN/scalp and facial folliculitis, keloids, alopecias, and photoaging—have emerged. Identification of cutaneous diseases affecting these rapidly growing populations will help us to focus our research and clinical resources appropriately.”[58]

“Although some research to enhance understanding of ethnic skin has been undertaken, significant work remains to be performed in the area of ethnic skin disorders to properly manage dermatoses in the non-Caucasian population.”[59]

“The section …[on skin of color in Cutis] will present basic scientific research that will expand the knowledge of the structure, function, and biology of skin of color, and inspire further research. This section on skin of color will describe the science o skin of color as it pertains to the following individuals: Mexican/Mexican-American/Chicano, Puerto Rican, Cuban, South or Central American, or those from other Spanish cultures; African, Caribbean Black, and African Americans; individuals from the Far East, Southeast Asia, and the Indian subcontinent (Asian Indian, Japanese, Chinese, Korean, Filipino, Vietnamese, Burmese, Hmong, Pakistani, Thai), Native Hawaiian or other Pacific Islanders (Samoan and Guamanian); and Native Americans.”[60]

“Conflicting data have been published on the inherent differences in skin surface properties among various ethnic groups, though there is a widespread perception that differences exist.”[61]

“As the population of people of color grows in the United States and globally, more research will need to be initiated to understand skin of color and to help design treatments and skin care products to meet the needs of people with skin of color. Achieving a more comprehensive understanding of skin of color offers exciting new opportunities for clinical practice and research in dermatology.”[62]

Obvious physical differences exist among human populations, in hair color, texture, skin color, and facial features. Although all humans are members of the same species, understanding the causes of the skin diseases may hinge on the structural and physiologic variations that exist among different ethnic groups in skin and hair.”

“This change necessitates the need to understand the differences in the structure and function of skin of color, the presentation of disease, and treatment management of disorders of the hair and skin.”[63]

“Although data from some of these seminal studies are conflicting or are based on small populations, they form an essential foundation for continuing research.”[64] 

“One of the authors recently completed a review on the epidemiology of skin disease in people of color…Whereas quality data could be found for a few of the disorders reported (e.g. melanoma, nonmelanoma skin cancer, psoriasis), no quality data was available for the majority of the cases reported.”[65]

More research is needed to understand skin of color and to deliver improved treatments and skin care products designed to meet the special needs of patients of color.”[66]

“Highlighting Skin of Color. Articles to assist clinicians in the diagnosis and treatment of patients with skin of color and to present basic scientific research that will expand the knowledge of the structure, function, and biology of darker skin types.”[67]

Our conclusion based on the evidence

During the latter half of the 20th century, studies numerous were undertaken in an effort to demonstrate differences structural and physiological between “black” and “white” skin, those investigations being conducted in a manner shoddy at best. Toward the end of seeking to correct that deficiency egregious, a conference was convened in 2000 at the National Institute of Arthritis and Musculoskeletal and Skin Diseases where a committee of dermatologists “clearly outlined research direction pertaining to cutaneous diseases in individuals with skin of color.” [68] Since then, much ink has been spilled about the need for more basic and clinical research in order to illuminate purported differences fundamental between “white skin” and “skin of color.” Despite the cascade of words on behalf of that goal, little work actually has been performed in pursuit of the aims stated avidly and often. What little has been done not only is paltry, but is no more meritorious scientifically than that which went before. And yet the urgings of the cheerleaders for more research goes on undiminished despite the utter lack of accomplishment in that regard.

In brief, despite protestations to the contrary, much of the research devoted to the subject of differences in skin of different “races” has been inconsistent in regard both to quality of design and to assessment of matters rudimentary. Many studies consisted of but tiny populations (most with fewer than 50 persons in toto) and employed methodologies either wholly subjective or extremely unconventional, e.g., olfaction used to measure apocrine gland function and tape strippings utilized to gauge “spontaneous” desquamation. How can there be anything but “controversy regarding whether there are clinically important differences in sebaceous gland activity, stratum corneum lipids, and barrier function between skin of color and white skin” in the matter of “ashy skin,” as Taylor calls it, when there is no agreed on definition of what really constitutes “ashy skin.” In order to justify a place for “skin of color” in the galaxy of dermatology, proponents of such a subspecialty trumpet the need for “basic descriptive data on the structure and function of skin in people of color,” and then they proceed to criticize those studies that have been undertaken because the results of them are not in synchrony with a condition fictitious, i.e., “ashy skin.”

In addition to these limitations serious, only a few studies set forth with any degree of precision the method whereby a particular individual was determined to have “skin of color,” which itself went undefined in a manner cogent. This is what Unaeze and Bigby found by virtue of their analysis of how “race/ethnicity” was determined by authors of articles pertinent to medicine in which that particular issue was a consideration:

“Although race/ethnicity was mentioned in 41% of cases reported in the JAAD in 2004, the method used for race/ethnicity identification and reason for mentioning race/ethnicity was provided in only a minority of reports.”[69]

A reader can only wonder worriedly about whether criteria for “race/ethnicity” were furnished by a person’s own perception of his/her color or whether it was the investigator who assigned color to a particular person. Nowhere is it mentioned if an individual with “skin of color” had dark skin or light skin, the latter hue at times resulting doubtlessly from a mix of “races” being present in a single individual. It is difficult to compare apples and oranges if some “oranges” are one-quarter red.

In addition, the studies on “skin of color” are restricted mostly to skin of “blacks” and “whites.” Only a few studies have examined the hair of Asians, including Native Americans, and only a handful of articles describe the efficacy of different therapies on diseases of the skin of Asians and Hispanic/Latinos, e.g., retinoids in acne vulgaris in Chinese vis-à-vis Dominicans (many of whom are of a mix of “races”). Griffiths, for example, reported on the observation that “retinoids are well tolerated in [Asian] patient populations, with the main side effect being a reaction that manifests as erythema, scaling, or burning, occurring to the same degree as in white skin.” [70] Just as is true for studies on “black” skin, investigations of persons with so-called skin of color other than “black” employ only small numbers of patients. For purposes practical, all of those studies demonstrate that Asians and Latinos have skin similar to that of both “whites” and “blacks.” As but one example of that, Gloster had this to say in his assessment of skin cancer in persons with “skin of color”:

“Races of intermediate pigmentation, such as Hispanic/Latinos and Asians, share epidemiologic and clinical features of dark-skinned ethnic groups and Caucasians.” [71]

Sewon Kang, professor of dermatology at University of Michigan and member of the Board of Directors of the Skin of Color Society, was kind enough to share with one of us (JY) in mid-March of 2007 his view of the state of research conducted by that Society. This is the exchange of correspondence:

From Jasmine Yun, M.D., to Sewon Kang, M.D.:
”Dear Dr. Kang:

Hello, my name is Jasmine Yun, and I am a dermatopathology fellow at SUNY Downstate intrigued by “skin of color,” the majority of the patients seen at Downstate having “black” skin. I am also preparing a presentation for the dermatology and pathology residents so I would very appreciate any information you could extend.

I am familiar with your articles about “skin of color” and am aware of your emphasis on the importance of research in regard to elucidating aspects of “skin of color.”  What do you consider to be the major advances of the investigations carried out in this regard since “skin of color” became a discipline in the year 2000?  I would be grateful to hear about them from you.  In particular, apart from the amount of melanin in the epidermis and the structure of the follicle, as well as the hair made by it, do you know of proven differences between skin of “whites” and “skin of color?”

Thank you in advance for your consideration.

Sincerely,

Jasmine Yun”

From Dr. Kang to Dr. Yun:

“Dear Dr. Yun,

Thanks for your email. SOC is a relatively new organization run by people who want to promote better dermatologic care and research for those with pigmented skin. Not sure I’d call it a new discipline.  Anyhow, because of its relative infancy, I’m not sure we have made any significant progress thus far.  We do have our annual meetings a day before the AAD, and we are finalizing a research grant program to give out to those with good ideas.  We are hopeful that young people like you will become involved in the growth of our society.

Best wishes,
Sewon Kang, M.D.
Professor of Dermatology
Director of Clinical Research UnitUniversity of Michigan Medical Center”
(email correspondence from Sewon Kang, March 19, 2007)

To resolve controversies about “racial” differences in skin

Despite the plea incessant on the part of advocates of “skin of color” for the conduct of more research designed to reveal differences among skin of different colors in different “races,” the evidence gathered to date by students of just such investigations is unambiguous: the actual differences are negligible. Listen to the words of the researchers themselves about that matter:

Structure and function:

“[It] shows that aging black skin has many features of aging white skin. Blacks may not necessarily need to be excluded from future chronologic aging studies because it is feared that this process differs markedly in them.”

“With the exception of the vascularity in the aged adult group, the above features are similar to those seen in aging white skin, and suggest that chronologic aging in white and black skin is similar.”[72]

“Most authors who studied the histologic and ultrastructural features of black skin agree that there are no structural differences other than the ‘packaging’ and the number of the melanosomes.”[73]

“Initial impressions are that actinic dyspigmentation and melasma in Asian skin probably respond as well to tretinoin as do these conditions in white skin.”[74]

“In summary, we were unable to detect any difference in skin thickness between black and white women.”[75]

“Variation between individual members of a racial or ethnic group may at times assume greater importance than interracial variation in its impact on health and disease.”

“It is well established that there are no racial differences in the number of melanocytes.”[76]

“Although the actual number of melanocytes may vary in different individuals from one anatomic site to another, there has been no evidence of differences in the number of melanocytes between races.”

“Blacks with dark skin have large, nonaggregated melanosomes, whereas light-skinned blacks have a combination of large, nonaggregated and smaller aggregated melanosomes.”

“Although obvious differences exist among human populations, little data exist in defining ethnic and racial differences in skin and hair structure and physiology.”[77]

“Racial variability in skin function is an area in which data often conflict.” [78]

“It seems reasonable to attribute this increase in textural properties to sun damage due to decreased melanin content.”

“Although the scientific data both support and dispute the hypothesis that skin of certain ethnic origins is somehow physiologically different from the skin of other ethnic groups, many physicians and consumers believe a difference exists…

…Results showed differences in photodamage and hyperpigmentation between the two ethnic groups tested, but no significant differences between the two groups were seen in the results of instrumental measurements for sebum, pH, corneometry (skin moisture), or transepidermal water loss (barrier function).”[79]

“Clearly, there are differences in the epidermal melanin content; these differences lead to differences in the prevalence and type of pigmentary disorders in skin of color compared with white skin.”[80]

“Other studies could not find differences in the stratum corneum properties between black and white skin. Despite differences in age, anatomic areas of skin roughness, scaliness, and stratum corneum hydration, there were no significant differences between black and white skin. Skin hydration and roughness or scaliness were similar between different races.”

“To investigate the racial differences in skin function, various biophysical   parameters have been studied. Transepidermal water loss…[was] studied in whites, Hispanics and blacks under basal conditions. The data showed no differences in transepidermal water loss between race or sites without tape stripping.”

“Although obvious differences exist among human populations, little data exists in defining ethnic and racial differences in skin and hair structure and physiology…

…In summary, although several studies tend to suggest differences in barrier properties and lipid composition between black and white skin, conclusive evidence for these differences have not been demonstrated.” [81]

“The controversy regarding whether there are clinically important differences in sebaceous gland activity, stratum corneum lipids, and barrier function between skin of color and white skin is illustrated by studies of a condition known as ashy skin.”[82]

“Not surprisingly, the overall correlation between race and objective measures of color is poor, as this outcome reflects the heterogeneity of pigmentation among members of the same racial self-designation. Pigmentation reflects genetic factors, which may be expressed variably across members of a single self-identified racial group.”[83]

“Findings relating to the lipid content of the skin barrier in individuals with skin of color are conflicting.”

“The comparative vulnerability of the skin barrier to irritants in black and white individuals also is controversial.”

“Similar to other controversies regarding the understanding of skin of color, assessments of racial differences in skin sensitivity and risk of irritation have been numerous and conflicting.”[84] 

“There is no real difference in the sebum production of any specific nationality of people.”[85]

No differences in transepidermal water loss baseline values between Blacks, Caucasians, and Hispanics have been reported; similar results have been observed in a study performed on Chinese, Indians, and Malays. Our data support these observations.”[86]

Patch Tests:

“Except for p-phenylenediamine, we found no epidemiologic evidence for a significant difference in prevalence of contact dermatitis between black and white skin. Further experimental and prospective clinical studies are warranted to examine the ongoing controversies on the differences between the skin of the two racial groups.”[87]

“In this test population, we found no differences in the overall response rate to allergens… Our understanding of how race and ethnicity affect the incidence and character of allergy to topical agents is limited. Our study is the largest to date to examine the effects of such factors….the overall demographic and clinical data do appear to support the idea that the prevalence of allergic contact dermatitis between black and white individuals is essentially the same. Our data also support the idea that the overall sensitization rates and distribution of disease are also similar.”[88]

Hair:

“Chemical analysis has shown no major biochemical differences between the various racial groups.”

“The Africans hairs differed in being tightly coiled and having a flattened cross-sectional appearance compared with the oval and circular appearance of the Caucasian and Asian hairs, respectively.”[89] 

“Hair follicles in blacks are curved and sit at an oblique angle, with the concavity toward the epidermis.” [90]

“Black hair has an elliptical shape, whereas Asians have round shaped, straight hair; the hair in whites is intermediate.”

“In a comparative study of different racial and ethnic groups, there was no significant difference in the thickness of the cuticle, scale size, and shape, and cortical cells of whites compared with blacks.”[91]

Our conclusion based on the evidence:

For all the hoopla about the need for a discipline devoted to “skin of color” in order to resolve controversies about “racial” differences in skin and in skin diseases, not a single matter germane to those subjects has been illuminated by champions of that cause.

Bernett Johnson, Jr., a dermatologist, got it mostly right in his chapter given to “Differences in skin type” in a work titled “Ethnic skin” [92] where, in a mere two pages of a total of 290, he caught the essence of his theme, namely, that differences between “races” in regard to normal skin and hair are minuscule. This is what he wrote: “Ethnic skin dermatoses are those that occur in people of different ethnic backgrounds (i.e., black, white, Asian, and Hispanic) and are modified as influenced by the characteristic differences in ethnic skin, such as pigment; follicular response, curved, flat hair; and fibroblast activity.” Although we reject the idea of “ethnic skin” and of “ethnic skin dermatoses” (and the concept that black, white, Asian, and Hispanic represent a set of like types), we acknowledge unreservedly that there are some differences among peoples in regard to quantity of melanin in the epidermis consequent to differences in capability of melanocytes to produce it, as well as differences in the character of hair shafts secondary to differences in the shape of hair follicles and the orientation of them. When one considers the extraordinary number of similarities in normal skin and hair of human beings the world over, the differences mentioned by Johnson are trifling in the extreme. Although in those two pages Johnson extracted the essence of “differences in skin” of different peoples, in his chapter following given to “Histologic differences,” he oversimplifies vastly by dividing all colors of skin into two just categories: “black skin” and “nonblack skin.”

In their enthusiasm to justify the legitimacy of a field dedicated to “skin of color,” partisans on behalf of it are given to spin data generated by “research” to suit their own prejudgments. Nowhere is that illustrated more graphically than in the chapter of Oresago, Pallai, and Richards captioned, “Structure and function of skin and hair in pigmented races” [91]. What follows is how those authors equivocate (highlighted by emphases in bold and comments by us) in regard to differences between “pigmented skin” and skin purportedly not pigmented:

“The numbers of cell layers [of the stratum corneum] appear to be increased in black skin, although the mean thickness of stratum corneum is the same in both races.”

“A difference in the pH gradient has also been reported between black and white skin” [in a single study only]

“Berardesca et al. found that marked differences between races exist in skin bio-physical parameters. They concluded that these differences are mainly related to the protective role of melanin present in races with darker skin.” [the reason for the alleged differences is acknowledged to be the amount of melanin]

“It has been suggested that the lipid content of black skin may be higher than that of Caucasian skin.”

“Studies from Elias’ group suggest that there may be lipid differences in the dark vs. lighter skin.”

“Overall, the morphology and structure of epidermis is similar between different skin types, although some racial differences in epidermal structure have been demonstrated … [the differences in most of the considerations in the Table are not significant, e.g., ‘stratum corneum layers’ (17 in whites and 22 in blacks) and, more important, some structures listed do not exist, e.g., ‘stratum lucidum,’ which refers to the lowermost part of the stratum corneum on volar skin which fails to take the stain].

“The distribution of melanosomes and skin tone appears to be correlated.”

“Some subtle differences have been reported in the literature between the dermal structures of black and white skin.” [so subtle as to be meaningless]

“The ratio of sebaceous gland to sweat glands is believed to be higher in blacks and the sweat glands in darker skin are believed to be larger, providing better tolerance to hot climates.”

“Other indirect evidence indicates similarities between black and white skin with regard to sebum and sweat secretion. If there is a racial difference in the sebum levels, one can assume a racial differences in the control of bacterial, viral, and other infections (because sebum and sweat contribute to the acid-protective mantle of the skin). Both blacks and whites have a similar rate of cutaneous infections, suggesting that there may not be a racial difference in sebum and sweat secretion between these two racial groups.” [91]

Perhaps no subject is more illustrative of the murkiness that permeates discussion of differences between “black” and “white” skin than the matter of “ashy skin.” Johnson et al., in their book given to “Ethnic Skin” published in 1998, had this to say about “ashiness”:

“People who have dark skin become ‘ashy’ white when their skin is dry and scaly. This same scaling occurs in nonblack skin but is clinically inapparent. Because the ‘ashy’ color is considered unacceptable by some, many blacks use oils and/or petrolatum to mask it. This in turn leads to oil folliculitis and appears to adversely affect acne.”      [48]

And this is what Downie and Cook-Bolden wrote about “ashy skin” in their volume of 2004 about “Beautiful Skin of Color”:

“If you are African-American or Caribbean-American, you were probably a toddler when you first heard your mother say, ‘Oh, baby, your skin is so ashy. Let me put something on it.’ We’ve heard the term ashy skin forever. For many, ashy skin is an everyday occurrence, particularly during the dry, cold winter months. Although ashy skin isn’t life-threatening, it can make you uncomfortable, itchy, and self-conscious…

Basically, ashy skin is dry skin.”[27]

Susan C. Taylor mentions “ashiness” briefly in her volume titled, “Brown Skin” issued in 2003[93] and she addresses that subject further in a piece in Cutis in 2005 headed, “Understanding skin physiology” in persons of “skin of color.” This is what she wrote on pages 302 and 303:

“The controversy regarding whether there are clinically important differences in sebaceous gland activity, stratum corneum lipids, and barrier function between skin of color and white skin is illustrated by studies of a condition known as ashy skin. Ashy skin can appear on the neck or body, though it is more prevalent in areas of friction and on extensor points. It can be elicited by rubbing or scratching, even following application of emollients. Ashy skin frequently is identified with patients of darker skin; however, little is known about the pathogenesis of ashy skin… Specific differences between the etiology of ashy skin and normal dry skin need to be clarified. With white skin, the type of dryness that causes ashiness likely is attributable to disrupted skin barrier function, which leads to abnormal stratum corneum water content and abnormal desquamation, reduced generation of natural moisturizing factor, and changes in stratum corneum lipids. Decreased epidermal hydration unrelated to seasonal changes in humidity typically is the result of exposure to chemicals, such as surfactants, that can strip the skin of lipids and disrupt the skin barrier. In addition, dry skin is well documented as asymptomatic [sic] of endogenous factors such as diabetes and chronic kidney disease. Psychological stress and aging also can affect skin barrier stability… Ashy skin is considered by some dermatologists simply to be normal dry skin that is more apparent in patients with skin of color because of differences in reflectance properties.”[93]

The last sentence of Taylor just quoted contains a statement that accords with the assessment of Johnson et al. and of Downie and Cook-Bolden that “ashy skin” is nothing other than “dry skin,” which is skin slightly scaly by virtue of factors physiologic, not pathologic. In sum and in short, the notions of “ashy skin” and “ashiness” derive from the lore of “black people” and are written about mostly in works pertinent to so-called skin of color, it being thought of by those said to exhibit that change peculiar and by dermatologists in general to be a property only of “black” skin when, in reality, as Johnson et al. state rightly, the “same scaling occurs in nonblack skin but is clinically inapparent.” In brief, the difference alleged between “blacks” and “whites, i.e., “ashy skin,” is no difference at all! All “races” of people can have xerotic skin; this dermatosis is not limited to “black” people.

The upshot of all of the studies of “skin of color,” no matter the design of them, is clear, i.e., although much data are conflicting in regard to differences in structure and function of “black” and “white” skin, a fact acknowledged by Berardesco and Maibach who stated that “Racial variability in skin function is an area in which data often conflict.”[94], it can be concluded with a high degree of confidence that there are very few actual differences between them. Even Taylor, the most vocal spokesperson for “skin of color,” concedes in her review comprehensive of the subject that “few definitive conclusions about racial and ethnic differences in skin structure, physiology, and dermatologic disorders can be made.” She proceeds to qualify that by saying “the literature does support a racial/ethnic differential in epidermal melanin content and melanosome dispersion, and in black persons compared with fair-skinned persons, and differences in hair structure and fibroblast structure.”[95] Even if all of what Taylor avers is true (although differences in capability of fibroblasts for synthesizing collagen among different peoples does not in itself establish differences in “fibroblast structure” among the “races”), the evidence on behalf of distinctions of consequence among skin of different “colors” is rivetingly underwhelming.

What, then, are the real differences between “black” and “white” skin and hair? They seem to be these:

1.   Amount of epidermal melanin, and size and arrangement of melanosomes

Although there is no difference in the number of melanocytes in persons of different “races,” there certainly are differences in the amount of melanin present in the epidermis of them, it being responsible in large measure for different colors of skin. In “whites” who are fair-skinned, melanosomes are small and aggregated inside a membrane enveloping of them. Melanosomes of Asians also are aggregated, but are organized more compactly than those in fair-skinned “whites.” Dark-skinned “blacks” have large melanosomes that are not at all aggregated. “Blacks” who are less dark-skinned tend to have a combination of large melanosomes nonaggregated and small melanosomes aggregated. For nearly 40 years, it has been an article of faith that different sizes and patterns of aggregation of melanosomes correlate with colors of skin of ranges various.[96]

2.   Structure of hair follicles and hair shafts

The components of the hair follicle of all human beings, regardless of the color of those persons, are the same, namely, a bulb, a stem, and an isthmus, the latter being continuous with infundibular epidermis. All follicles possess in their bulb a matrix whose cells mature to become, from outside in, outer sheath, inner sheath, and hair. Matrical cells are joined by melanocytes that sport dendrites prominently. Whereas the bulb of hair follicles in Asians is perpendicular to surface epidermis, that of Caucasians is oriented oblique slightly, and that of black Africans is aligned somewhat parallel to the surface of the skin. That orientation is thought to account for the straight hair of Asians and the coiled hair of Africans.

The hair of persons of different races has been shown to be different in structure. Hair shafts of “whites” when viewed in cross-section are oval. The diameter of hair in “whites” tends to be smaller than that in Asians, including Native Americans, whose hair shafts are round. Those attributes morphologic also are thought to reflect the orientation of the bulb of follicles as it appears in sections of normal tissue prepared routinely. [97,98]

To resolve controversies about “racial” differences in skin diseases

“Acne vulgaris is the most common dermatosis seen in black individuals, accounting for 27% of the dermatoses. This is not different from white individuals.”[99]

“Keloids are common as a sporadic condition, but not as a familial disorder. . . A hereditary component in keloid etiology has been considered, mainly based on the higher occurrence in darker-skinned races.”[100]

“Pseudofolliculitis barbae, also known as pili incarnati, folliculitis barbae traumatica, and sycosis barbae, is a common dermatologic condition affecting men and women of African American and Hispanic origin who have tightly coiled hair. It occurs in Caucasian men, but only infrequently.”[101]

“As noted earlier, many of the cutaneous diseases reported in the various surveys for blacks have remained the same throughout the 20th century; these diseases include acne vulgaris, eczema, seborrheic dermatitis, fungal infections, urticaria, contact dermatitis, and warts,” opened the author. She also wrote as follows: “Kenney also listed the diseases he found occurring frequently in blacks; these diseases included pigmentary changes (hypopigmentation, hyperpigmentation), dermatosis papulosa nigra, pseudofolliculitis of the beard, dermatitis papillaris capillitii, and perifolliulitis abscedens et suffodiens (dissecting cellulitis of the scalp). All these diseases remain common in blacks.”[102]

“In summary, acne is the most common dermatologic disorder seen in ethnic skin.”[103]

“Speaking today at the American Academy of Dermatology’s (Academy) skin academy 2005, dermatologist Eliot F. Battle, M.D., assistant clinical professor of dermatology at Howard University in Washington, D.C., addressed a variety of conditions that are common in people with skin of color and how to treat them. ‘Skin of Color reacts differently from Caucasian skin to almost all medical and cosmetic dermatologic treatments,’ said Dr. Battle. ‘It’s more sensitive and it’s more prone to problems of discoloration and scars.’”[104] 

“Most skin diseases occur in all types of people, regardless of their skin color (pigment). Certain skin problems are more common among people with darker skin tones.“[105]

Our conclusion based on the evidence

In brief, every disease dermatologic encountered in one “race” is met with in all other “races.” No skin disease is a province of a single “race” alone. The results of all studies epidemiological concerning skin diseases corroborate the assertions just made. Furthermore, the diseases most common in “blacks” (e.g., acne, seborrheic dermatitis, and allergic contact dermatitis) are also the ones most common in Asians, Latinos, and “whites.” Even Halder, an advocate vocal and vigorous of the notion of “ethnic skin,” acknowledges that reality in these words:

“Acne vulgaris is the most common dermatosis encountered the general population and in ethnic groups. It accounts for approximately 27% of the dermatoses seen in black individuals. It is also the most common dermatologic disease in the Latino population and the second most common dermatologic disease in the Asian population.” [106]

We understand, full well, that a number of skin diseases are more prevalent in some “races” than in others. For example, Spitz’ nevus seems to be less common in “blacks” than in “whites,” whereas keloids are more common in “blacks” and in Latinos than in “whites.” But both Spitz’ nevi and keloids can occur in persons of skin of any color—and they do. For example, this is what Shaffer et al had to say about the matter of keloids:

“Most researchers agree that keloidal scars occur in all races but are more common in black patients.” [107]

In her book, Brown Skin, Taylor [108] devotes pages to the subjects of acne, eczema, melasma, post-inflammatory hyperpigmentation, scars, keloids, and alopecia—each of those maladies being found not only in “brown” skin, but in “white” and “black” skin. No disease is the territory of “brown skin” alone.

We also are very much aware that the appearance clinical of a particular skin disease may differ in some respects among “races.” For instance, it is established that the lesions of certain conditions such as sarcoidosis, lichen planus, and secondary syphilis tend to assume configurations annular more often in “blacks” than in “whites.” [109,110] Such variations genetic are to be expected and in no way gainsay the argument that sarcoidosis is diagnosable by employing the same criteria morphologic for it, i.e., those clinical and histopathologic, in “blacks” and “whites” – and that is as true equally for lichen planus and secondary syphilis as it is for all diseases of the skin. It is true, too, as has been remarked on previously, that the color red in the form of erythema is modified by the background on which it occurs. A bright red plaque of psoriasis on the leg of someone “white” does not have that very same appearance on the leg of someone “black,” it being violaceous in the latter circumstance as a consequence of the cast of the backdrop of darker normal skin. It seems, too, that there may be a greater tendency to infundibulocentricity of papules produced by rubbing the skin hard and long (lichen simplex chronicus) in “blacks” than in “whites.” In the total scheme of things in regard to skin of persons of different “races,” however, these differences are piddling. Surely those distinctions minor do not justify creation of a new subspecialty, to wit, “skin of color.”

We also are mindful highly of the tendency of darker skin to develop even darker blotches consequent to inflammation of any cause, as disparate as acne vulgaris and trauma accidental or purposeful, such as by piercing of types different, that phenomenon being termed medically “post-inflammatory hyperpigmentation.” Sometimes the very same processes inflammatory may result in hypopigmentation. In some individuals with dark skin, an inflammatory disease, such as lupus erythematosus, can end with both hyperpigmentation and hypopigmentation concurrently. Those alterations in pigmentation often are disquieting in the extreme to the person who bears them, posing as they do problems overt cosmetically. Perhaps no disease wreaks as much havoc on the psyche of an Indian or Pakistani as vitiligo; not only is the depigmentation unsightly, but the condition is regarded generally as being leprosy and the person affected is made an outcast. In short, these are issues serious that must be addressed and managed in a manner most effective, at the same time that heed careful is paid to not inflicting harm even greater by therapy injudicious that creates new changes pigmentary.

It cannot be emphasized too strongly that all that has just been said about post-inflammatory hyper and hypopigmentation is applicable, albeit less dramatically, to individuals with “light-colored” skin.

To provide better treatments for “skin of color”

“An individual’s ethnic background can and does modify the presentation and severity of disease. Ethnicity can also modify the patients’ response to a treatment regimen just in the basis of the individual’s inherited characteristics. This is especially true in skin disease. Diagnosing and recognizing skin disorders in individuals whose skin color is not white requires an understanding of how ethnicity modifies disease and how treatment should be tailored to be most effective in various ethnic groups.”[111]

“At the [Skin of Color] Center, where about 90 percent of patients are of color – a cadre of highly regarded dermatologists are clarifying the differences between skin of color and white skin. This groundbreaking work will soon lead to better treatments for skin of color and greater choices for you and all women of color…Through the center’s work, my work at Society Hill Dermatology (www.societyhilldermatology.com) in Philadelphia, and through his book, I hope as a health-care practitioner to make a significant contribution to the science of dermatology.”[112]

“This understanding of epidemiology [of diseases in skin of color] is important in advancing therapies for the diseases and in allocating resources to dermatologic education and research.”[113]

“The section [on skin of color in Cutis] will assist clinicians in the diagnosis and treatment of patients with skin of color.”[114]

“Dr. Eliot Battle: ‘The newer treatments that are available like safer cosmeceuticals, prescription medications, aesthetic services and ‘color-blind’ lasers mean that there are more options than ever before for helping people with skin of color keep their skin, hair, and nails healthy.’”[115]

“Physician and patient interest in the use of natural ingredients for skin care, as well as the treatment of skin diseases, is increasing in parallel with the rise in well-controlled studies of these ingredients.”[116]

“The Skin of Color Center serves as a rich base for scientific endeavors designed to further understand diseases which affect skin of color, and has developed new ethical drug and cosmetic treatments for skin of color.”[117]

Our conclusion based on the evidence

As a general principle, all diseases of the skin are treated the same way with the same therapies, irrespective of the color of the skin of the person who bears that disease. That applies equally to inflammatory diseases such as acne vulgaris, psoriasis, and lupus erythematosus, neoplastic diseases such as carcinomas, lymphomas, and melanomas, and cysts of different kinds.

The very same principle just enunciated also applies to maladies of the skin that have particular import psychologically because of the compromises wrought esthetically, chief among those being “post-inflammatory hyperpigmentation” and “post-inflammatory hypopigmentation,” those changes pigmentary are being more pronounced the more dark is the hue of the surrounding normal skin. Sad to say, treatment of post-inflammatory alterations pigmentary is not effective consistently in persons of any color skin, the reason being that melanin displaced from the epidermis then resides in macrophages stationed in the upper part of the dermis, they being resistant to all kinds of therapy, including lasers of different kinds. Furthermore, care must be taken in management that more harm than good is not inflicted; there is always the possibility that the medications employed may worsen the situation by increasing, rather than reducing, blotchiness. The method current best effective from the standpoint of cosmesis is camouflage by make-up.

To produce a literature about “skin of color”

The need for this series [on Skin of Color] arose from an analysis of the changing demographics of the US population.”

“Cutis is taking one additional step in educating the dermatology community about issues related to skin of color: our new series, Highlighting Skin of Color, is designed to significantly increase the dermatologic literature on this issue. The section will assist clinicians in the diagnosis and treatment of patients with skin of color; present basic scientific research that will expand the knowledge of structure, function, and biology of skin of color; and inspire further research. This section of Cutis will describe the science of skin of color…”[118]

“In the past few years, increasing attention has been given to skin disease in individuals with skin of color (also termed ethnic skin, racial skin, black skin, or pigmented skin). We will attempt to identify those individuals with skin of color. We use this article as an introduction to a recurring series that will address cutaneous disease affecting these individuals.”[119]

“The mission of the Skin of Color Society is as follows: […] To promote an increase in the body of dermatological literature related to skin of color.”[120]

“In addition to the increased scientific understanding of skin of color, there is a need for increased cultural understanding among all healthcare providers. This understanding may take the form of becoming knowledgeable of the religious, cultural, and dietary practices and norms of patients as well as becoming competent in foreign languages.”[121]

An illustration graphic of the pension for publishing about “skin of color” having run amok appears in the March issue for 2007 of the journal “Skin & Aging” in an article by McMichael under the general heading of “Treating patients of color,” it being titled, “Special considerations to keep in mind when treating seborrheic dermatitis.” [122] This is some of what McMichael claimed at the outset about seborrheic dermatitis as it occurred in “patients of color”:

“This article will focus on treating seborrheic dermatitis with an emphasis on considerations for treating patients of color. While many of us already know a lot about seborrheic dermatitis, this article will discuss some of the things that may not typically be associated with seborrheic dermatitis, such as hair breakage, traction alopecia, scarring alopecia, and some other pigmentary disorders.”[122]

Seborrheic dermatitis is an inflammatory disease of the skin, in particular a spongiotic process affiliated with an infiltrate of lymphocytes around venules dilated markedly of the superficial plexus, slight epidermal hyperplasia in company with loci of spongiosis, and mounds of parakeratosis that house globules of serum and sometimes a few neutrophils, those hillocks being situated at the lips of ostia of infundibula. Never, ever, does seborrheic dermatitis affect the hair follicle itself, and, therefore, never, ever, is it “associated” authentically with “hair breakage” and/or “traction alopecia,” those latter phenomenon, if present, being induced wholly factitiously, that is, by the patient twisting hairs back and forth until they break off and/or pulling hairs from their socket. Should hyper- or hypopigmentation be present at sites of seborrheic dermatitis, it is post-inflammatory in nature, as is expected in any process long-standing in which lymphocytes produce chemicals that cause melanin to be lost from epidermal keratinocytes into macrophages in the papillary dermis.

In sum, the article by McMichael was crafted in the service of the scheme artificial of “skin of color” and the message of it is misleading because it is wrong, as the second part of this sentence by her conveys undeniably: “It [hair breakage problems] often occurs in localized areas because of itching from seborrheic dermatitis, but breakage also can be diffuse from severe hair shaft damage.” This “contribution” of McMichael follows on the urgings of Taylor to produce a literature about “skin of color.” All-too-often, however, the effort is misguided because the motivation for it is ill-conceived and, paradoxically, the results presented give the lie to the notion of “skin of color.” Thus far, the “literature” generated on behalf of the legitimacy of “skin of color” is mere “smoke and mirrors” – nothing more.

To give expression to altruism as a “person of color”

“As a Black woman, my desire is to benefit the lives of people of color. To best serve the increasing numbers of patients of color, the field of dermatology will need to broaden its focus to include knowledge about pigmented skin, and develop better technologies and products to treat it. . . This book is my gift to you. I hope that in accepting it, you’ll start to take the health of your skin, nails, and hair as seriously as I do.”[123]

“’Dark skin is a blessing as it relates to sun damage and aging,’ says Susan C. Taylor, M.D., director of the Skin of Color Center in New York and author of Brown Skin: Dr. Susan Taylor’s Prescription for Flawless Skin, Hair and Nails (HarperCollins, 2003). ‘A 50-year-old woman of color often looks 40, while a white woman of the same age might look 10 years older than her real age.” But, the dermatologist continues, “skin of color can cause significant problems, as well.’”[124]

“We are committed to the important task of furthering the understanding of the science of skin of color.”

“We look forward to an informative and enlightening exchange of information during the coming years. We trust that this recurring series will serve to further the understanding of skin of color for all practitioners.”[125]

“When you look good, you feel good. It’s one of the funny things about life. You feel more confident when your skin glows and is free of blemishes, and your hair is healthy, manageable, and stylish…And that’s why we wrote Beautiful Skin of Color. We want to give you the knowledge and the information you need to look your best.”[126]

“It’s important for people of color to see a dermatologist who understand their skin’s unique needs, said Dr. Battle.”[127]

Using emerging findings in the areas of skin of color and active natural ingredients to treat changing patient populations will be an ongoing challenge and a source of satisfaction for dermatologists.”[128]

Our conclusion based on the evidence

We exhort our fellow physicians, dermatologists among them, to banish from their thinking about themselves and about their patients the matter of color of skin, and, instead, to focus on the commonalities of human beings irrespective of the color of the skin of them. In the analysis ultimate, as we have endeavored to convince readers throughout his work, skin is skin and diseases of skin are fundamentally the same regardless of a person’s color. That being true, it is not necessary for a dermatologist when caring for a patient to conceive of himself/herself as a Black man/Black woman or White man/White woman; the patient should be cared for as a human being who happens to have a skin disease, the “blackness” or “whiteness” of the skin itself being an irrelevancy in terms of diagnosis and management.

If skin is skin, as in reality it is, and if all diseases of skin occur in persons of all colors of skin, then it is not necessary for “the field of dermatology” to “broaden its focus to include knowledge about pigmented skin.” Dermatology is the study of skin disease, which means skin of every shade of color, no matter the amount of the pigment in it.

Fallacies inherent in the notion of “skin of color” from a vantage medical

“Skin color is but one of many physical features used to differentiate races and, because of its extreme variability, is in itself not particularly important.”

“It is an offense against scientific clarity to blur the distinction between race and skin pigmentation. The hybrid term ‘skin of color,’ part euphemism and part science, attempts to refer to both simultaneously and thereby confounds the two. It is obviously a wastebasket term, because everyone except light-skinned Caucasians may be said to have ‘skin of color.’”[129]

“There is no firm delineation between people who are ‘black’ or ‘of color,’ or, for that matter, ‘white’….We need to write with scientific clarity to make our statements believable. There is no acceptable scientific definition of the term ‘skin of color’ because we live with a continuum of racial color and features.”[130]

“The real answers about skin of color are deeply embedded in the very essence of your being. Skin of color has a unique cellular makeup and a special protein structure. The cells and the skin structure create and replenish the healthful color.”[131]

“For me, African American, Puerto Rican American, Indian American, or Native American are labels that a bit more helpful than a specific color, which seems almost always inaccurate as a descriptor of an individual. Dermatologists are biologists of the skin and should prefer for medical use labels that help them understand the physiology of a person’s skin. All the rest is for the social scientists, philosophers, and politicians.”[132]

“Because skin color has been so adaptive and labile, it has only very limited value in the determination of phylogenetic relationships amongst the human populations of the world. An appreciation of this reality should be prerequisite for the future design of studies in which the goal is to compare skin features amongst the different groups.”

“All peoples of this planet have basic skin color, and all of them have their own particular ethnicity. Beyond that, this subject tends to become most enigmatic.”[133]

“Although the question raised was how should we express the race of people of African descent, a better question is whether we should refer to patients’ race at all? The answer is a resounding ‘NO!’ Doing so perpetuates the myth that racially classifying patients somehow aids our ability to diagnose, treat, and relate to them. The practice should be abandoned for the following reasons: 1) Racial classification lacks genetic and anthropologic credibility; 2) The origin and practice of racial classification is inherently racist; 3) Racial classification is more often a hindrance than an aid to diagnosis and treatment.”[134]

“There are no human populations that have truly white or truly black skin.”[135]

“The reporting of race/ethnicity in the medical literature has been controversial… Opponents argue that racial classification lacks genetic and anthropologic credibility, the origin and the practice of racial classification is inherently racist, and racial classification is more a often a hindrance than an aid to diagnosis and treatment.”[136]

“External features, although impressive, are not necessarily markers of other traits or even response to disease—they may be proxies of variable accuracy. For example, although people of African ancestry are reported to have higher mean blood pressures than white Americans, this race-linked association falls flat when one considers that the mean blood pressure in parts of Europe is significantly higher than that of African Americans. . . Current evidence suggests that for common diseases in populations, environmental factors are more important disease determinants than genetic traits. It is now also known that many previous associations of race with disease, like assessments of intellect, were in fact confounded by nurture (e.g., socioeconomic status). Race is not a quantifiable biologic entity, and there is more variation within than between groups, yet its social effects are not insignificant. While race has been used to do untold harm—and as a South African, the experience is recent—its use in dermatology is a vexed question. . . Even indigenous Africans in Africa display variations in hair form. I agree with Bigby et al that race should be abandoned, and whilst it is a useful, albeit nonspecific, surrogate for hair form, its use suggests a lack of rigor on our part.”[137]

Our conclusion based on the evidence:

The concept of “skin of color” is flawed irreparably in every respect: conceptually, linguistically, and scientifically. Conceptually, it runs counter to principles fundamental to a society that would be equitable scrupulously based on merit unwaveringly, and free entirely of any taint of bias predicated on the color of skin. Linguistically, there is no such thing as “skin of color” or of “ethnic skin”; there is color of skin and that subject certainly is a legitimate arena for study. Scientifically, so-called skin of color has been shown, even by advocates passionate of the notion of it, to be a red herring. No studies have demonstrated in a manner repeatable that stratum corneum thickness, transepidermal water loss, sebaceous gland activity, or any other parameters measurable in “blacks” is different from that in “whites.” Differences between two individuals random of any “race” can be expected to occur with a rate of confidence greater than differences between an individual “black” and an individual “white.” Apart from differences in the amount of melanin contained in the epidermis, the size and arrangement of melanosomes, and the structure and orientation of hair follicles, including the shape of hair shafts, the skin of human beings is the same irrespective of “race.” And apart from the incidence of a few skin diseases being different among the “races,” black individuals having a proclivity for keloids being the example quintessential of that, all diseases of the skin occur in all “races.”

Those dermatologists responsible for generating and propagating the concept of “skin of color” and for the industry that derived from it are virtually all “people of color,” as are those who staff “Skin of Color Centers.” It has become an article of faith, perpetuated by those same persons, that “black” dermatologists are better able to diagnose and manage “black skin” than are “white” dermatologists (although no one would be so incorrect politically, and so wrong scientifically, to advise that “white” dermatologists are more facile at diagnosing and managing “white” skin than are “black” dermatologists). Just as no one rational would claim that “black” nephrologists are more able to deal with kidney disease in “black” patients, so, too, should the very same logic be applicable to skin. A qualified dermatologist, no matter the color of his/her skin, is able to handle problems pertinent to skin of all colors.

Part III: Legitimacy ethical of “skin of color”

Ramifications of institutionalized racism in medicine

Racism is abhorrent in general and nowhere is it more unacceptable than in medicine. The physician is the steward of the health of Man—all human beings—no matter the race. It is this universality of medicine as a profession that distinguishes it from all others and that endows the physician with a privilege not granted to others. That catholicism of medicine is witnessed today in the association formed by “Physicians without Borders,” the absence of boundaries applying not only to ones geographic, but to those of race, religion, and nationality. Anything that compromises in any manner the mindset of physicians in regard to neutrality in the care of patients is a violation of a code sacred. Racism, no matter how subtle, or even unintended, is a violation intolerable. The quotations that follow convey a message that transcends medicine, but that are relevant to medicine. A physician should be a citizen of the world, prepared to minister to the physical and emotional needs of every patient as human being, no matter the color, faith, or nationality. That being so, race is irrelevant to the mission of a physician.

“One of my theories is that the hearts of men are about alike, no matter what their skin color.

Mark Twain

“The true student [of medicine] is a citizen of the world, the allegiance of whose soul, at any rate, is too precious to be restricted to a single country. The great minds, the great works, transcend all limitations of time, of language and of race, and the scholar can never feel initiated into the company of the elect until he can approach all of life’s problems from the cosmopolitan standpoint.”[138] 

“God is not merely interested in the freedom of brown men, yellow men, red men and black men. He is interested in the freedom of the whole human race.”

Segregation is the adultery of an illicit intercourse between injustice and immorality. [139]

“I look forward confidently to the day when all who work for a living will be one with no thought to their separateness as Negroes, Jews, Italians or any other distinctions. This will be the day when we bring into full realization the American dream — a dream yet unfulfilled. A dream of equality of opportunity, of privilege and property widely distributed; a dream of a land where men will not take necessities from the many to give luxuries to the few; a dream of a land where men will not argue that the color of a man’s skin determines the content of his character; a dream of a nation where all our gifts and resources are held not for ourselves alone, but as instruments of service for the rest of humanity; the dream of a country where every man will respect the dignity and worth of the human personality.”

“Now, I say to you today my friends, even though we face the difficulties of today and tomorrow, I still have a dream. It is a dream deeply rooted in the American dream. I have a dream that one day this nation will rise up and live out the true meaning of its creed: – ‘We hold these truths to be self-evident, that all men are created equal.’“I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character.[140]

Until justice is blind to color, until education is unaware of race, until opportunity is unconcerned with the color of men’s skins, emancipation will be a proclamation but not a fact.” [141]

“Until the philosophy which holds one race superior and another inferior is finally and permanently discredited and abandoned, everywhere is war and until there are no longer first-class and second-class citizens of any nation, until the color of a man’s skin is of no more significance than the color of his eyes. And until the basic human rights are equally guaranteed to all without regard to race, there is war. And until that day, the dream of lasting peace, world citizenship, rule of international morality, will remain but a fleeting illusion to be pursued, but never attained… now everywhere is war.” [142]

“Institutional racism is common in society and medicine in the United States; arbitrary race grouping is part of such racism. . . Race taxons have been “medicalized”; that is, race groupings have been legitimized by their use in medical literature and practice as acceptable descriptive labels that are integral to the proper diagnosis and treatment of disease in humans. Assumptions about disease that are made because a race has been assigned can result in important negative consequences for individual patients and inaccurate genetic inferences for populations. . . However, ethnic boundaries are dynamic and imprecise, and it is dangerous to assume that any person possesses a certain health variable just because that person is a member of a particular ethnic group.” [143]

We may have different religions, different languages, different colored skin, but we all belong to one human race.” [144]

“In a Darwinian population, there is great variation around a mean value. This variation has reality, while mean value is simply an abstraction. One must treat each individual on the basis of his or her own unique abilities, and not the basis of the group’s mean value.” [145]

“The human race cannot be subdivided or compartmentalized like zoological species. There is no fixed number of human ‘types.’ If we look at people from distant regions, for example, Norway, Nigeria, and Vietnam it is clear that they do not resemble each other. But what do these differences mean? A couple of centuries ago, different people were thought to be the descendants of Noah’s children, who had moved to the four corners of the earth and multiplied. Today, however, there is no reason to think that in a certain era there were people living only near Oslo, Lagos, or Saigon; nor any reason to believe that the most extreme variations of humanity represent a primordial purity. As far as we know, there have always been people distributed in all parts of the Old World.”[146]

“These disciplines show that human race taxonomy has no scientific basis. Race is thus a flawed social construct that reflects concepts created from prevailing social perceptions without scientific evidence. Despite there being no scientific basis for race in research, race taxons continue to be legitimized by their use in the medical literature as acceptable descriptive labels that are integral to proper diagnosis and treatment of disease in humans.” [147]

Profit from Racism in Medicine

“Pharmaceutical companies various provide ‘unrestricted grants’ for research in the field of ‘skin of color’ in the hope of ‘cashing in’ on the $1.7 billion African-American hair-care industry and the $490 million ethnic cosmetics and skin care industry.” [148]

“The aesthetic industry is gradually experiencing the pressure of new expectiations and demands from a changing demographic consumer base. We anticipate that the Cultura Skin of Color Training Institute will be a major resource to explore the emerging cosmetic needs of people of color.”[149]

“Although the scientific data both support and dispute the hypothesis that skin of certain ethnic origins is somehow physiologically different from the skin of other ethnic groups, many physicians and consumers believe a difference exists. This belief may be in part due to marketing efforts for products designed to meet the perceived needs of specific ethnic groups. One area that has seen tremendous market growth in the last decade is the antiaging skin care market.”[150]

Anne Eggers, Vice-President of Sales at Galderma Laboratories, L.P. presents an unrestricted grant to Susan C. Taylor, President, and Valerie Callender, Treasurer of the Skin of Color Society” at the Skin of Color Society Event in New York, July 2004. [151]

“She [Susan C. Taylor] thanked the audience and speakers for attending the symposium [Skin of Color Society Scientific Symposium 2005], and gratefully acknowledged the sponsors, including Galderma, L’Oreal, and Skin Medica at the Gold level, Allergan, Fujisawa, Medicis, Connetics, and Novartis at the Silver level, and Aventis, Bioglan, Doak, and Health Point at the Bronze level.” [152]

“Like many dermatologists before them, they [dermatologist advocates of “skin of color”] also write self-help beauty books and appear in medical segments on television programs like ‘Good Morning America’ and the ‘Today’ show. They are attracting a growing clientele of actors, newscasters, politicians, members of Middle Eastern nobility and Southeast Asian entrepreneurs. Their increasing prominence reflects a rising interest among black, Asian, and Hispanic consumers in cosmetic treatments and calls attention to the fact that these consumers need expert care.”[153]

“In 2004, sales of black hair- care products exceeded $1.7 billion, according to a report by Mintel International Group, a consumer research company. And that doesn’t include the synthetic and human hair additions that are also extremely popular.”

“Today L’Oreal, Alberto-Culver, and Proctor & Gamble are the top three sellers of black hair-care products, Mintel said.”[154]

Profit from creation of a subspecialty devoted to “skin of color” comes in many forms, to wit, gain financial, promotion professional, and attention personal being chief among them. If money were not to be made from “skin of color,” L’Oreal and Johnson & Johnson would not be investing in it so heavily by generating products ostensibly suited to those with “darker” color skin, by sponsoring symposia, seminars, by publishing materials dedicated to matters pertinent to skin of color, and underwriting fellowships in the “discipline” of skin of color.

Although the profit motive is obvious when it comes to cosmetic and pharmaceutical companies, it surely is at play, too, albeit more subtly, when it comes to “Skin of Color Centers” and to private practices of dermatologists who cater to the carriage trade of “people of color.” There is no disguising that reality, as some of those dermatologists acknowledge in their own words, both in the literature of the profession, such as Susan C. Taylor who, in Cutis in 2005 on page 254, wrote of the need to “design treatments and skin care products to meet the needs of people with skin of color,” and in the media, for example, in the edition of The New York Times in 2005 where several dermatologists were reported to speak glowingly of the business of skin of color.[155]

Some dermatologists “of color” have become famous, even icons, by virtue of their promotion of “skin of color,” that reputation gaining them not only fame with invitations galore to be spokespersons for “skin of color” to organizations professional and to the laity, but fortune as well.

A journal such as Cutis has a stake financial in “skin of color,” it being a major vehicle to publications numerous about the subject, entire issues even being given to it, and featuring in many an issue a section “Highlighting Skin of Color.” The editor of that journal serves also as chairman of the department of dermatology that gave birth to the first “Skin of Color Center,” namely, St. Luke’s/Roosevelt Medical Center in New York City.

In short, there is much profit for dermatologists and for industry from “Skin of Color,” but yet to be determined is whether there truly is profit, except perhaps psychologically, for patients. Of course the importance of the emotional and spiritual are not to be minimized, but those benefits, if they exist at all, never are propounded as being the raison d’être of those who champion “skin of color”! And of the purported benefits are an illusion consequent to the efficacy of marketing and promotion, then what is claimed to be salutary is just chicanery.

Fallacies Inherent in the Notion of “Skin of Color” from a Vantage Ethical

Five reasons have been cited by the proponents of “skin of color” as being the ones chiefly motivating of it, they being as follows:

  1. To generate research about “racial” differences in skin and hair
  2. To resolve controversies about “racial” differences in (a) skin and (b) skin diseases
  3. To provide better treatments for “skin of color”
  4. To produce a literature about “skin of color”
  5. To give expression to altruism as a “person of color”

There is no small number of definitions of “ethical,” ranging from “having a system of moral standards or values” to “conforming to the standards of conduct of a given profession or group.” Let us examine briefly the ethicality of “skin of color” using those two definitions in order to assess the five justifications given by proponents for the establishment in the first place of such a field.

  1. Advocates of “skin of color” acknowledge that there has been no research illuminating of “‘racial’ differences in skin and hair” since the creation nearly a decade ago of a branch of dermatology called “skin of color.” Moreover, except for considerations relevant to the quantity of melanin in the epidermis, the character and distribution of melanosomes, and the structure and orientation of the hair follicle, including the shape of the shaft of it, there are no proven differences significant between “skin of color” and “skin of non-color” (“black skin” and “non-black skin”).
  2. Partisans of “skin of color” admit that no controversies of consequence concerning “racial” differences in skin and in skin diseases have been resolved by virtue of endeavors of “Skin of Color Centers” and activities of the “Skin of Color Society.”
  3. No new treatments efficacious have come from pharmaceutical and cosmetic companies for diseases of the skin or for conditions physiological, such as “ashiness,” although innumerable preparations are being touted by industry as being tailor-made for “people of color” in general and for “women of color” in particular.
  4. A literature certainly has been produced germane to “skin of color,” but it is devoid of originality and of substance; much ink has been spilled and many trees have been felled in pursuit of that desideratum, but knowledge of the skin and of skin disease of so-called people of color has not been advanced a whit by virtue of the introduction in 1998 of a field reserved for “skin of color.”
  5. There are reasons various for engagement in the subject of “skin of color,” but altruism probably is not the one most motivating.

If the five assessments just offered are accurate, then the reasons stated for forging a subspecialty of “skin of color” fail to pass muster as conforming to “a system of moral standards or values” on one hand and as being in synchrony with “the standards of conduct of a given profession or group” on the other. Most important of all, the separation arbitrarily of patients on the basis alone of the color of their skin is racist and racism is unethical, no matter the color of the skin of those who practice it.

Other colleagues have called attention to the politicization of medicine by dint of enterprises such as “skin of color.” This is part of what Stephen E. Silver, a dermatologist practicing in Connecticut, wrote in 2003 in a “Letter to the Editor” of Cutis [156] in response to an article that he characterized as “disheartening” by Susan C. Taylor and Fran Cook-Bolden:

“It is unfortunate that we, as a nation, are so neurotically preoccupied with race and skin color that we cannot even communicate about these subjects without using euphemisms. The term skin of color is a symptom of this malady. Gleaming with political correctness and bearing all the hallmarks of bureaucratic doublespeak, such a term can only lead us backwards into confusion. The term is political and should not be given scientific legitimacy. Rather than try to define it, the medical profession should give it a wide berth. There is nothing inherently wrong with the occasional euphemism, but the use of obfuscatory language, no matter how benevolent the intention, has no place in scientific discourse.” [156]

We agree with every syllable uttered by Silver, deeming as we do “skin of color” to be a deviation from proper use of language, but much more important from conduct of a profession, predicated as it is on racism.

Afterword

“The origin and practice of racial classification is dehumanizing and is inherently racist.”[157]

This work of ours is titled, “Skin of color: Racism in medicine for profit” and in it we have sought to convince by suasion logical that the idea of “skin of color” is egregiously flawed, conceptually, linguistically, and scientifically, that at core it is racist for which there is no place under any circumstance, especially in medicine, and that the motives for it are gain of kinds various, not the least being financial.

Nowhere in this endeavor do we state, imply, or intend to convey in any way that those who initiated, propagandized, and propagate to this day the thesis of “skin of color” are mean-spirited in their racism or even that they mean to be racists, but that does not mitigate their being racists, they excluding from consideration in the discipline they espouse only persons deemed by them to have “white” skin, which, significantly, they never define. Nor do we mean to communicate the impression that all who are proponents of “skin of color” and of “ethnic skin” seek profit for themselves; some of those advocates clearly are energized by aspirations lofty, even though we consider segregation of human beings according to color of skin to be misguided, no matter how well intended the motivation for it may be.

In our view, not only is the construct designated “skin of color” racist, but it is pseudoscience, purporting as it does to be rooted in a system of “knowledge derived from observation, study, and experimentation carried on in order to determine the nature of principles of what is being studied,” but, in actuality having no scientific basis or application.

If the statements just made by us are true, then it is obvious that an end should be brought post haste to the sham and shame of “skin of color.” Centers devoted to it should be encouraged to disband volitionally, articles written about it for publication, save those that decry it, should be rejected, and courses, seminars, and symposia dedicated to it should be discouraged. If what we have set forth in this volume is thought to be untrue, then debate vibrantly intellectual, incisively logical, and consummately civil should commence, it being free entirely of the platitudes, rationalizations, and justifications sophistic that for the past decade have been the fare served up by devotees of it. That we have sought earnestly to solicit the opinions of supporters of “skin of color” and to provide them a forum for clarification of issues knotty should be evident from the correspondence with Drs. Alexis and Kang published in this work.

In fact, there has been practically no reasoned argument about the issues raised here concerning “skin of color.” Criticisms of that phrase and of the concepts galvanizing of it, such as those raised by the dermatologists S. Silvers and M. Elgart in Cutis in 2003, never are addressed in a manner scholarly and academic, but in a fashion designed to obfuscate, distract, and diffuse pique. The lines of meringue that follow offered by Susan C. Taylor in response to the judgments harsh of Silvers and of Elgart are stereotypical of a method meant to neutralize offense rather than to engage vigorously in a collision of ideas:

 Letter to the Editor of Cutis from Stephen E. Silver, MD

Dear Cutis:

It was disheartening to find an article in your journal (Taylor SC, Cook-Bolden F. Defining skin of color. Cutis. 2002;69:435-437) that attempts not only to define but also to justify the term skin of color. These are thankless tasks, because the term is utter nonsense.

Something may be the “color of . . . ,” but can anything be “of color”? Obviously, all skin must be of some color, or else it would not be visible. The term skin of color is ridiculous if taken literally. It is a euphemism.

The word colored was originally regarded as a polite way of referring to African Americans. It probably came into use in the mid 19th century—an era famous for its verbal niceties—and was used as such by Abraham Lincoln in 1860. Eventually, this term was further refined and by the 20th century was changed to the slightly more elegant people of color, much the way a green hat might become a hat of green. Race was the real issue, and an individual’s actual skin color had little to do with it.

The main point is that colored and people of color are not descriptive terms but are clearly euphemisms related to race. What these terms really mean is “nonwhite,” which actually means non-Caucasian—the term used by the US Census Bureau. There are dark-skinned Caucasians just as there are light skinned African Americans and Asians. Nevertheless, once one has designated all non-Caucasians as “people of color,” it is but a short grammatical mis-step to describing their skin as “skin of color.”

Skin color is tangible and measurable. This is not true of the biological concept of race, which has been fraught with serious problems since Johann Blumenbach, the father of modern anthropology, first introduced it in 1776. Chief among these problems has been the controversy over whether race as such really exists or whether it is simply a classification device, providing a frame within which various groups of mankind may be arranged. These abstractions, however convenient, are misleading when confused with living populations. Races grade into each other, and the physical traits by which they are characterized show considerable overlap. Skin color is but one of many physical features used to differentiate races and, because of its extreme variability, is in itself not particularly important. Craniofacial features and hair structure generally are considered much more significant indicators of race. Many anthropologists believe that the concept of race is so unproductive and inexact, so apt to perpetuate confusion and engender discord, that it should be dropped altogether.

It is extremely important for everyone, not just scientists, to recognize the inherent difference between race and skin color. Dermatologists know that certain predispositions, such as the tendency towards postinflammatory hyperpigmentation, have more to do with skin color than race. They also recognize that conditions such as pseudofolliculitis barbae are related more closely to race than skin color.

It is an offense against scientific clarity to blur the distinction between race and skin pigmentation. The hybrid term skin of color, part euphemism and part science, attempts to refer to both simultaneously and thereby confounds the two. It is obviously a wastebasket term, because everyone except light-skinned Caucasians may be said to have “skin of color.” To add to the confusion, the term also includes light-skinned Caucasians of Latino or Hispanic background, whose only distinguishing feature is their ethnicity.

If it is appropriate in certain situations to provide racial identification, let me recommend the following:

– The term white or Euro-American should be used with the understanding that it designates a member of the Caucasian race and does not mean white literally, but rather a wide range of pinkish tan.

– The term black or Afro-American should be used with the understanding that it designates a member of the Negro race and does not mean black literally, but all shades of brown, ranging from very light to very dark.

– Those individuals who are neither clearly “black” nor clearly “white” should be designated by their national or regional origin. This includes, primarily, Mongol or Mongoloid—words that are inherently so ambiguous as to be worthless. People may be referred to as Pakistani, Native American, Mexican, North African, etc. The use of national or regional terms here circumvents the issue of race entirely, which is a distinct advantage.

The term light-skinned or dark-skinned, if pertinent, may be used as an adjective preceding any of the above. The term color should be used to mean precisely that and should never be used to intimate an individual’s race or ethnicity. I believe the above designations will offend no one.

It is unfortunate that we, as a nation, are so neurotically preoccupied with race and skin color that we cannot even communicate about these subjects without using euphemisms. The term skin of color is a symptom of this malady. Gleaming with political correctness and bearing all the hallmarks of bureaucratic doublespeak, such a term can only lead us backwards into confusion. The term is political and should not be given scientific legitimacy. Rather than try to define it, the medical profession should give it wide berth. There is nothing inherently wrong with the occasional euphemism, but the use of obfuscatory language, no matter how benevolent the intention, has no place in scientific discourse.

Sincerely,
Stephen E. Silver, MD, PC
Waterford, Connecticut

Letter to the Editor of Cutis from Mervyn L. Elgart, MD

Dear Cutis:

I have a great deal of difficulty with concepts such as race and ethnicity as they appear in scientific journals. When I went to grammar school, 5 terms were used to define race: white, black, brown (Indian), yellow, and red (American Indian, what we now call Native American). In the article “Defining Skin of Color” (Taylor SC, Cook-Bolden F. Cutis. 2002;69:435-437) these groups are cut down to 3: black, white, and yellow. These differences were based on skin color and, to some extent, on geography. However, when people began to travel more extensively, relationships became somewhat blurred. In my youth, interracial marriage was rare, but it has become much more common. I now see many shades of yellow and brown. It is difficult to know how to categorize these individuals.

The increasing incidence of shades between the absolute colors of the major races indicates that interracial marriage and crossover are increasing and racial barriers are decreasing. There is no firm delineation between people who are “black” or “of color,” or, for that matter, “white.” Is a Swede with Fitzpatrick skin type I a Caucasian? What about an Italian with Fitzpatrick skin type III or a Greek with Fitzpatrick skin type IV? No pure definitions exist. Studies done in the United States, where crossover is more common, may be of little relevance. Racial classification often is based on either the author’s or, worse, the individual’s perception. Therefore, we should do studies in countries where crossover is much less common, such as Japan, China, India, or Africa, to obtain information about how cutaneous disease manifests in “pure” groups of people with specific skin colors. From this information, we need to evaluate skin color classifications in our patients in the United States to determine how they may evolve.

The article “Defining Skin of Color” tries to define these classifications but comes up with a political rather than a scientific definition. I am hard pressed to define the terms Chicano, Latino, or even African American. Is a Vietnamese person one whose parents were both Vietnamese, or is he or she still a “person of color” if the father is a white American soldier? There was a concept prevalent in the pre-1950 American South in which a person who was one-eighth black (an octoroon) was still considered black, while one who was one-sixteenth black was considered white. The same criterion was used in Hitler’s Germany for people with a Jewish background. One-eighth Jewish was enough to be sent to the concentration camps. These are political not scientific definitions.

We need to write with scientific clarity to make our statements believable. There is no acceptable scientific definition of the term skin of color because we live with a continuum of racial colors and features.

Sincerely,
Mervyn L. Elgart, MD
University Dermatology Associates, PLLC
Washington, DC

Response from Susan C. Taylor, MD to Drs. Silver and Elgart

It is with great excitement that I respond to the 2 letters to the editor by Drs. Silver and Elgart concerning the article, “Defining Skin of Color.” I welcome and encourage a discourse on this issue. The fundamental question of whether scientists should attempt to identify and define differences in mankind, in this case for the purpose of understanding and advancing knowledge of cutaneous disease, is at the heart of the matter. If it is deemed valuable to categorize mankind, what is the optimal system to employ? We at the Skin of Color Center grapple with these questions on a daily basis. Based on these letters to the editor, my colleagues apparently share this struggle.

Both colleagues accurately point out that the biological concept of race is fraught with many problems. In addition, they accurately state that no pure racial or ethnic definitions exist. Furthermore, as mankind becomes more homogeneous through intermingling of the races, the ethnic distinctions that do exist become increasingly blurred. Race has been and still is used as a marker of several different physical features, including skin color. Does it make more sense to define skin based on race and ethnicity or on the actual hue of the skin? Or, are both systems inadequate? As Dr. Silver indicates, postinflammatory hyperpigmentation is related most closely to skin color, but most of our patients with this cutaneous disease are of African, Asian, or Hispanic descent. Dr. Silver also correctly points out that pseudofolliculitis barbae may have more to do with race than actual skin color. However, most of our patients with this disorder have Fitzpatrick skin types IV to VI. Here, we clearly see that skin color and race are almost inextricably intertwined; they are confounding variables. The term skin of color, as imperfect as it has proven to be, is an attempt to include within one easily understandable phrase many individuals who share similar characteristics and diseases. The term, furthermore, is used at our center to bring together patients, clinicians, and scientists interested in investigating and treating diseases such as postinflammatory hyperpigmentation and pseudofolliculitis barbae.

I applaud Dr. Silver’s attempt to create an identification system for mankind that is based on race. In fact, I wrote the following response to an inquiry from the editor of the Journal of the American Academy of Dermatology regarding the use of the term African American in case reports (personal communication):

“ . . . Currently, the term African American appears to be the preferable term in the dermatology literature. However, this term is a misnomer for those individuals of African descent described in the literature who reside or have resided in a Caribbean, European or an African nation. Although no term will address all of the issues related to the appropriate nomenclature for these individuals, I propose the use of the term black in the dermatology literature for the identification of subjects or patients of African descent. This term is not intended to pertain to the color black, but instead black meaning ‘ . . . of, pertaining to, or belonging to those individuals whose ancestors originated from the continent of Africa.’ ”

As Dr. Elgart states, “ . . . we live with a continuum of racial colors and features.” However, the question remains as to how we as dermatologists can best understand and treat differences in cutaneous disease among these individuals without a mechanism to define their differences. Is it valuable to place individuals from several different racial and ethnic groups under one umbrella term, such as skin of color, for the purpose of understanding and advancing the knowledge of cutaneous disease? We at the Skin of Color Center believe that the answer is a resounding “yes.”

Finally, to assume that such terms have no political impact is to ignore the reality that numerous studies by biomedical scientists in many fields have repeatedly shown that “people of color” suffer disparities in their access to healthcare, as well as in the quality of healthcare they receive. I thank Drs. Silver and Elgart for their comments and perspective.

Sincerely,
Susan C. Taylor, MD
Director, Skin of Color Center
St. Luke’s Roosevelt Hospital Center
New York, New York

Apart from the criticisms by Drs. Silvers and Elgart in letters to an editor, there has been practically no resistance at all by dermatologists to the notion of “skin of color,” an exception notable and recent being by Gary Brauner in a chapter by him titled The impact of skin disease in “ethnic skin.” [158] This is how Brauner began his piece:

“The pursuit of Science requires focus and refinement, and must always be kept separate from sociopolitical desires and agendas, which serve only to confuse the issues of such pursuit. This author, therefore, takes umbrage from [sic] the intellectual dishonesty in the present day use of such a nomenclature for ‘ethnic’ and ‘skin of color.’… In her landmark supplement to the Journal of the American Academy of Dermatology in 2002, Taylor attempted to classify what she meant as ‘people of skin of color’ in the following confusing array […] of a huge genetically and phenotypically diverse population.” [158]

Brauner then proceeded to criticize the mish-mash of peoples considered by Taylor to qualify as having “skin of color.”

The idea of “skin of color” has been fostered fervently by organized dermatology, especially by the American Academy of Dermatology. Its voice, in company with that of industry and partisans of “skin of color,” has bestowed legitimacy on a field that has neither earned it nor defended in fashion scholarly the reason for its very being.

If proponents of “skin of color” truly have conviction about the authenticity of that subject as an arena legitimate for study and inquiry learned, then it is long past due for them to produce work substantial about matters pertinent to it, to respond to criticisms in a manner thoughtful, profound, and instructive, and to eschew determinedly anything resembling vaguely pseudoscience served up with the consistency of cotton candy. In short, it is time for message, not more massage.

There is no place in general for a double standard and particularly not in medicine. Consider a hypothetical! A group of pale-skinned “Caucasian” dermatologists open a “Skin of Non-Color Center” in affiliation with a medical school in a major metropolis of the United States. What would be the response of the Reverend Al Sharpton and the Reverend Jesse Jackson? They would cry “racism,” organize protest marches, and have the center closed down. And yet when groups of dermatologists “of color” found a “Skin of Color Center” linked to a university medical in a major American city, it is greeted universally with approval and applause. That inconsistency is incompatible with the principles guiding of that remarkable experiment in democracy known as the United States of America. In short, if the goose “colored people” is unacceptable, so, too, it should be for the gander “people of skin of color”; if the goose “Skin of Non-Color Center” is offensive, so, too, it should be for “Skin of Color Center.”

It is collision of ideas that enables medicine as a discipline to advance, it is expression forthright of opinions different, even diametric, in a setting public that permits a society to be open, free, and democratic, and it is propositions such as ours, as nettling as they may be, that ensures attention proper be paid to the most crucial of all subjects, to wit, one standard and one alone as a basis for interaction with fellow human beings—individuals each with dignity no matter their color. That is what this undertaking by us really is about.

Summary

In 1998 the concept of “skin of color” was introduced to the field of dermatology, and since then, it has been received with approval and applause. Our analysis shows that there is no authenticity of that subject as an arena legitimate for study and inquiry learned, and it is long past due for the proponents of “skin of color” to produce work substantial about matters pertinent to it. Recent studies of the human genome have generated data that indicates that we, across all “races” and “colors,” are genetically more indistinguishable than we are different. We in this Arbeit deny the proposition that there is a place in medicine for distinctions based on the color of skin. At the same time, we affirm that, for purposes practical, skin is skin, whether normal or diseased, and to segregate on the basis of its color is racist. To institutionalize racism within the “color-blind” portals of medicine is inherently wrong.

Bernard Ackerman, M.D., was director emeritus of the Ackerman Academy of Dermatopathology. Jasmine Yun, M.D., was a fellow in dermatopathology at the same Institute. She is now a Clinical Assistant Professor of Dermatology at the Keck School of Medicine at the University of Southern California in Los Angeles. Ms. Goldblum is a medical student at Sophie Davis School of Biomedical Education of New York City. This article was reviewed by …. Contact corresponding author via email: jasmineyun@hotmail.com

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