Christal Malcolm, 46, spent more than a decade trying to find relief from her alopecia — a skin disease that causes hair loss.
Malcolm experienced severe itchiness and inflammation on her scalp, which bled. She turned to wigs to hide her lesions and avoided looking in mirrors. For many years, she struggled with depression due to the condition. Her type of alopecia — central centrifugal cicatricial alopecia — has no cure.
“The first dermatologist I saw said to me, ‘You’re like the fourth or fifth patient that I’ve seen today with this’ … There isn’t really much we can do,” said Malcolm, who is a surgical administrative assistant at Toronto’s Women’s College Hospital. “Unfortunately, I think a lot of people just kind of [think of it] as more of a cosmetic issue than anything else.”
For Black individuals like Malcolm, this experience is not unique. Many racialized Canadians — who account for more than a quarter of Canada’s population — have trouble finding health-care professionals who know how to diagnose conditions and diseases that present differently on their skin.
Some medical professionals say their education is to blame. Medical training programs in Canada primarily focus on how skin diseases present on white skin, they say.
“In several health-care textbooks, there’s limited information related to Black people’s skin,” said Bukola Salami, a researcher and professor at the Cumming School of Medicine at the University of Calgary.
“[I]n several health-care professions you can graduate with just the general knowledge of people’s health, without any particular knowledge of people that have experienced inequities, such as Black populations,” said Salami, a registered nurse whose research focuses on Black and racialized peoples’ health.
Language matters
Dr. Marissa Joseph, a paediatrician and dermatologist, has treated hundreds of children for eczema.
“[Eczema] really affects kids’ lives. It disturbs their sleep. Ask any parent. [Their] kid is itchy, [so] they can’t concentrate at school,” said Joseph, who practices at The Hospital for Sick Children in Toronto. “They’re dysregulated.”
In Joseph’s observation, Black kids are less likely than white kids to get the help they need for eczema, because the disease presents differently in each group.
For white people, eczema appears as a red, itchy rash. For Black people, eczema dries out the skin, which can result in a bumpy texture that looks grey or purple, a condition called hyperpigmentation.
Canadian health-care workers tend to be better at identifying eczema on white skin, says Joseph, who is also medical director of the Ricky Kanee Schachter Dermatology Centre at Women’s College Hospital. On referral forms, a white child with a severe case of eczema would have a description “red rash all over 90 per cent of the body,” which would be treated as urgent.
But a Black child with the same severity of eczema may be treated as non-urgent, because they present with dryness and hyperpigmentation, says Joseph. This patient would be more likely to end up on a long waitlist, which, in Joseph’s practice, is about 15 months.
“The language that referring providers use to tell me why I need to see a patient is really important,” she said. It “really affects the time in which they will be seen.”
A 2024 study published in the leading science journal Nature found dermatologists and primary care physicians were able to diagnose skin diseases 38 per cent and 19 per cent of time, respectively. But both were four percentage points less accurate when diagnosing skin diseases on dark skin.
‘It’s not extra’
Most education in paediatric and dermatology training programs focuses on how skin diseases look on white skin — not on brown or Black skin, says Joseph, who obtained her medical degree from Dalhousie University and completed a dermatology residency at the University of Toronto.
Salami agrees. To rectify this issue, some medical professors include a supplementary book on diagnosing and treating health conditions for racialized people, she says.
“When I went to nursing school, honestly, I didn’t see any Black skin on my nursing textbook,” said Salami, who obtained her nursing degrees from the University of Windsor.
A 2023 UK study in the journal Advances in Health Sciences Education found medical students were more confident diagnosing diseases on white skin than darker skin.
“These findings highlight the need to improve teaching resources to include a greater diversity of skin colours exhibiting clinical signs, to improve students’ knowledge and confidence, and ultimately, to avoid patients being misdiagnosed due to the colour of their skin,” the study says.
Joseph says supplementary materials are not enough.
“In my view, we have to embed what skin disease looks like across the skin spectrum in all of our key core teaching elements. It’s not extra stuff. It’s changing the stuff we have,” she said.
Over time, she has noticed “there has been significant movement towards including skin disease presentations across all skin types in medical textbooks, atlases and websites.”
Race and health
For Malcolm, who has a scarring form of alopecia, permanent hair loss was inevitable.
It is important that medical professionals are trained to acknowledge the loss caused by this condition, says Joseph, as this can inform their care.
“This is not just a question of making beautiful people more beautiful. This is a question of disfigurement,” said Joseph. “Hair for many people is important. But for Black women, I would say that, at least in the patients that I see in my own personal experience, it’s a cultural expression.”
More Black health-care professional organizations have formed since 2020, such as the Black Physicians of Canada and Alberta Black Therapist Network — a development Salami attributes at least in part to the Black Lives Matter movement.
But not all progress is recent. Salami says she has seen great improvement in care for racialized patients since she first started practising as a nurse more than two decades ago.
“The Public Health Agency of Canada, ten years ago, did not have racism or race as a social determinant of health,” said Salami. Today, the agency acknowledges race as a social determinant of health, which incentivizes more research and educational material specific to racialized groups.
At this point in her career, promoting health literacy in both medical and racialized communities has become a priority for Joseph, who has been practising for nearly 15 years.
“Empowerment for the patient is very important,” she said. “With the right tools, with the right knowledge, they can advocate for themselves and have important conversations with their health-care providers.”
Malcolm, who has become a hair loss mentor and a health advocate for Black women, says participating in many events on health-care for Black populations with Black health-care workers made her path to healing possible.
“I think as a Black woman, our needs are so unique, and I feel like there are gaps within the health-care sector,” she said. Events with Black health professionals are “an amazing time where we can just learn and network and feel comfortable to share our issues and concerns, but also be educated and supported without judgement.”
A previous version of this article incorrectly included that part of Bukola Salami’s nursing education was completed at the University of Toronto.
