The appearance of changes in the skin, such as rashes and bruises, can vary significantly across different skin tones, making it essential for healthcare professionals to have a nuanced understanding of how these conditions present in diverse populations. This knowledge not only ensures accurate diagnosis and treatment, but can also save lives, particularly in cases of serious conditions like meningitis, sepsis, or abuse.
Here, we discuss why this awareness is so important, provide detailed examples of how conditions manifest differently on various skin tones, and discuss what both healthcare professionals and parents should look out for.
The need for inclusive healthcare awareness
Health inequalities and misdiagnoses
One of the most significant barriers to equitable healthcare is a lack of training in recognising symptoms on brown and black skin tones. Many medical textbooks and training materials disproportionately feature lighter skin tones, leading to gaps in understanding among healthcare workers. This can result in delayed diagnoses, misdiagnoses, and unequal treatment for individuals with darker skin.
For example, a 2020 report by the British Association of Dermatologists highlighted that skin conditions in people with darker skin tones are often underdiagnosed or mistaken for other issues, due to limited exposure among healthcare professionals to varied presentations of conditions.
Building trust and confidence
For parents and patients, particularly from Black, Asian, and ethnic minority groups, a lack of confidence in their GP’s ability to recognise symptoms accurately on their skin can deter them from seeking timely medical advice. Bridging this gap fosters trust and ensures everyone receives high-quality care.
How rashes appear on different skin tones
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Meningitis rash
A meningitis rash is often described as a purplish-red pinpoint rash that does not fade under pressure. However, this description favours lighter skin tones. On brown and black skin tones, the rash may not appear as vividly purple or red. Instead, it may present as dark brown, black, or purplish spots that blend with the skin’s natural pigmentation.
What to look for:
- Healthcare workers: Use the “glass test” (pressing a glass against the rash to check if it fades) regardless of skin tone. Focus on less pigmented areas such as palms, soles, or inside the mouth.
- Parents: Observe for any unusual or persistent spots, even if the coloration is subtle, and seek immediate medical help if suspected.
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Eczema
Eczema can appear as red, inflamed patches on lighter skin tones, but on black and brown skin tones, it may present as greyish, purplish, or dark brown patches. These variations often lead to underdiagnosis or mistaken diagnoses, such as fungal infections.
What to look for:
- Healthcare workers: Be aware that inflammation may look less “red” on darker skin and more dusky or hyperpigmented. Focus on areas prone to eczema, such as creases of the elbows and knees.
- Parents: Monitor for dry, scaly patches or areas where the child is persistently scratching.
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Bruising
Bruising typically progresses from red to purple to green and yellow as it heals. On brown and black skin, bruises might initially appear as deep purple, black, or bluish patches and can be harder to spot in the early stages.
What to look for:
- Healthcare workers: Pay attention to areas that are tender or painful upon examination, even if visual cues are subtle.
- Parents: Be alert to areas of swelling or unexplained pain, as these may indicate hidden bruising.
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Psoriasis
Psoriasis often manifests as raised, scaly plaques that are red or pink on lighter skin. On black and brown skin, these plaques might appear purple, grey, or dark brown, and scaling may be more prominent.
What to look for:
- Healthcare workers: Assess texture and scaling in affected areas rather than relying solely on redness.
- Parents: Check for flaky or rough patches that may not be visibly red.
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Cyanosis
Cyanosis, a bluish discolouration of the skin due to lack of oxygen, is easily noticeable on lighter skin tones. On black and brown skin tones, cyanosis may appear as a greyish or whitish hue, particularly around the lips, gums, and nail beds.
What to look for:
- Healthcare workers: Inspect mucous membranes and nail beds carefully for changes in colour.
- Parents: Note any unusual pale or grey discoloration and seek immediate medical attention.
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Erythema (skin redness)
On lighter skin tones, erythema appears as a pronounced red flush. On darker skin, the redness may be subtle or manifest as warmth and swelling rather than an overt colour change.
What to look for:
- Healthcare workers: Use palpation to detect heat or swelling in affected areas.
- Parents: Be aware of persistent swelling or tenderness, even if redness isn’t visible.
Importance for parents and healthcare workers
For parents:
Understanding how symptoms present on your child’s skin tone will empower you to act quickly and confidently when something seems wrong.
For healthcare professionals:
Equipping GPs, nurses, healthcare assistants and other healthcare workers with knowledge about diverse skin presentations is critical to reducing health disparities. It allows for more accurate diagnoses, prevents misdiagnoses, and ensures equitable healthcare delivery.
Educate your peers: Skin changes on different skin tones
Recognising and understanding how rashes and bruises present across different skin tones is not just a matter of medical accuracy – it’s a matter of healthcare equity. By incorporating diverse visual references, leveraging NHS guidelines, and fostering open communication with parents, healthcare professionals can ensure that all patients, regardless of their skin tone, receive timely and effective care. This commitment to inclusivity in medicine is vital for improving outcomes and building trust in healthcare systems.
Let’s move forward with the collective goal of ensuring that no child or adult is overlooked or misdiagnosed because their symptoms didn’t “fit the textbook” image.
