Identifying dermatological emergencies in patients with skin of colour: Insights from Australian emergency medicine practitioners

Abstract

Many dermatological conditions can be managed in an outpatient setting; however, some are life-threatening emergencies requiring prompt diagnosis and management. Textbook images of dermatological conditions primarily showcase manifestations on light skin, leading to a significant underrepresentation of patients with skin of colour (SOC).^{1, 2} Previous research has revealed that common skin conditions may possess distinct variations in patients with SOC^{3, 4} yet this remains largely unexplored within the realm of dermatological emergencies. Given doctors in the emergency department are likely to encounter such presentations before dermatologist consultation, providing comprehensive education in this domain is crucial. The objective of this study is to evaluate and address the knowledge gaps and preferences for further education initiatives among emergency medicine practitioners in diagnosing dermatological emergencies in patients with SOC, with the overarching goal of enhancing patient care across diverse populations.

An online survey and quiz were distributed among emergency medicine practitioners in Victoria, Australia from February to October 2023. The survey gathered information regarding participant demographics, confidence in diagnosing dermatological emergencies in individuals with SOC and attitudes towards current training formats. The quiz comprised clinical images of dermatological emergencies in four separate patients with SOC, accompanied by multiple-choice questions. A total of 76 doctors participated in the survey, including 17 junior doctors (22%), 18 registrars (24%) and 41 consultants (54%).

Our quiz findings indicate variations in response accuracy across different questions, highlighting existing uncertainty among emergency medicine practitioners in diagnosing dermatological emergencies specific to SOC. Question 1 showed an image of lower limb cellulitis in an adult with Fitzpatrick skin type (FST) 6 for which 36% of respondents selected the correct answer. Background pigmentation masking erythema in darker skin tones may have contributed to the low amount of correct responses.⁵ Question 2 showed an image of eczema herpeticum in a child with FST 3 for which 78% of respondents selected the correct answer. The appearance of monomorphic vesicles and punched-out erosions in this condition is less influenced by alterations in the background skin pigmentation, potentially contributing to the observed high rate of accurate responses.

Question 3 showed an image of psoriatic erythroderma in an adult with FST 6 for which 45% of respondents selected the correct answer. Psoriatic plaques in SOC have a violaceous hue compared with salmon-pink plaques observed in light skin³ which may have caused difficulty identifying the correct answer. Question 4 showed an image of toxic epidermal necrolysis (TEN) in an adult with FST 5 for which 74% of respondents selected the correct answer. Epidermal detachment revealing pink flesh underneath is a recognised feature of this widely known dermatological emergency, likely resulting in a high rate of correct responses.

Our quiz results support that skin lesions with features such as vesiculation and epidermal detachment, which are less likely to be hidden by background pigmentation, can make the associated conditions easier to diagnose. In contrast, identifying violaceous hues as erythema seems to pose a challenge. A comprehensive patient history remains crucial to arrive at the correct diagnosis.

Although most doctors reported approximately one-third of their patients to have SOC, 72% expressed low confidence in managing dermatological emergencies in this group. For TEN, erythroderma and pemphigus vulgaris, only 39%, 20% and 21% of respondents, respectively, reported receiving adequate training. Despite this significant finding, 99% of respondents emphasised the necessity for increased teaching and training dedicated to the subject with only 5% having received related teaching in the preceding 12 months.

Regarding preferred training modes, nearly half of the respondents (47%) indicated a preference for online modules, followed by webinars (34%) and bedside teaching (30%). The majority of doctors (74%) advocated for the inclusion of SOC dermatoses in fellowship examinations. Consequently, augmenting trainee curricula with relevant learning objectives and offering continuing medical education courses for consultants could generate considerable interest. Additionally, the creation of a repository containing high-quality images depicting dermatological emergencies in SOC may be useful. Dissemination of images through social media platforms such as ‘Brown Skin Matters’ or publication of Atlases showcasing conditions across various skin tones could improve awareness.

The need for enhanced education concerning dermatological emergencies in patients with SOC is substantiated by the observed demand for increased knowledge among emergency medicine practitioners. Addressing this imperative warrants the collaborative engagement of the entire dermatology community. Concerted efforts to bridge existing knowledge disparities will ensure equitable healthcare for patients from culturally diverse communities.

The authors declare no conflicts of interest.

Ethics Approval was obtained from the University of Melbourne Ethics Committee (Ref 2023-22851-39725-6).