Objective
This systemic review assesses skin tone representation in images of dermatomyositis rashes in medical education literature.
Methods
A review of 59 dermatology, 11 neurology, 10 neuromuscular, 7 rheumatology, and 6 internal medicine textbooks published between 2011 and 2021 and 3 online image databases (UpToDate, VisualDx, and DermNet NZ) that were available through an online medical school library was performed. After extracting images, images with poor lighting or unclear rashes were removed. Authors graded skin tone independently on the Massey and Martin Skin Colour Scale (MMSCS) from 1 (very light) to 10 (very dark). The median score was taken for a final score, grouped within MMSCS 1–2, 3–4, 5–7, or 8–10. Inter-rater reliability was assessed using Kendall’s coefficient of concordance (W).
Results
621 images were extracted after reviewing 93 textbooks and 3 online databases. Of the 561 images analyzed, 73.1% of images represented MMSCS 1–2, followed by 3–4 (13.4%), 5–7 (11.8%), and 8–10 (1.8%). Inter-rater reliability was high (W = 0.835). Of the images in MMSCS 5–10, 59.2% were in online databases and 80.6% of textbook images were in dermatology books.
Conclusions
Patients with lighter skin tones were represented in a higher number of dermatomyositis-related educational materials compared with patients with darker skin tones. Our findings add to current research implicating that darker skin tones are underrepresented in cutaneous educational materials, specifically for dermatomyositis. This leads to the inability to properly characterize skin involvement in dermatomyositis and may lead to inappropriate exclusion from clinical trials due to erroneous skin scoring.
