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168: Misdiagnosis of Chronic Skin Conditions In Skin of Color w/ Dr. Hope Mitchell

Did you know that inflammation shows up differently on skin of color than on white skin? As a result, people of color are often misdiagnosed, because their doctors have not been trained in the different ways skin conditions can present on different skin tones.

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A native of Brooklyn, New York, Dr. Hope Mitchell attended the University of Rochester and graduated with a Bachelor of Arts in Biology.

She obtained her doctorate of medicine from The Medical College of Ohio (MCO). She also completed an internship in Internal Medicine and a Pathology Fellowship while at MCO and a residency in Dermatology at Henry Ford Hospital in Detroit, Michigan.

Dr. Mitchell is certified by the American Board of Dermatology and is a fellow of the American Academy of Dermatology.

Dr. Mitchell is an Ohio and Michigan board-certified medical and cosmetic dermatologist and the founder & CEO of Mitchell Dermatology.

With over 25 years of experience in the medical field, she is an accomplished, highly qualified dermatologist and entrepreneur. She has extensive experience in general dermatologic education and treatment, acne/complexion treatment, skin cancer diagnosis, treatment and surgery, as well as cosmetic injectables.

Dr. Mitchell has subspecialty interest in hair loss, eczema, hyperpigmentation, skin cancer prevention, and skincare consultations. She is an advocate for mentorship, education and diversity in medicine and dermatology.

Dr. Mitchell is a wife and mother of four young adult children.

Join us as we talk about how chronic skin conditions are often misdiagnosed in people of color.

Has your skin condition ever been misdiagnosed? Tell me about it in the comments!

In this episode:

  • How not learning about skin conditions on skin of color can be problematic in getting an accurate diagnosis
  • How does inflammation present in different skin colors?
  • Do patients end up suffering because necessary tests are not run?
  • What should people keep in mind when trying to determine whether what they're seeing on their skin is hyperpigmentation or inflammation?
  • What is the connection between itching and inflammation?
  • How does psoriasis show up in skin of color?

Quotes

“What I find in my practice is that a lot of patients that I start to see that seek me out because I am a black dermatologist have told me that either they were misdiagnosed, that's what led them to see me. They just didn't feel that their diagnosis was accurate. Or they were told initially that the diagnosis that they had, and they may not have been given a diagnosis, was nothing to worry about.” [3:38]

“The other thing that I think throws off the doctor is that inflammation looks very different. It looks very different in skin of color. And so where we've been trained that red looks like inflammation, in skin of color inflammation looks more gray, it looks dark, it may look purple-ish, it may look dark brown.” [5:25]

Links

Find Dr. Mitchell online

Healthy Skin Show ep. 151: How Eczema Changed My Life (So I Could Help Others) w/ Rakhi Roy, MS, RD, LDN

Follow Dr. Mitchell on Instagram | Instagram

168: Misdiagnosis of Chronic Skin Conditions In Skin of Color w/ Dr. Hope Mitchell FULL TRANSCRIPT

Jennifer: Thank you so much, Dr. Mitchell, for being here. I really appreciate it.

Dr. Mitchell: Oh, I'm so excited to be here. Thanks for having me.

Jennifer: Well, I think today our conversation is going to be one that is much needed and to help support people who are listening to this where the rashes don't show up the way that everyone else's do. So, I just want to give some context here. One really incredible thing, and incredible, I'm not sure is a good way to describe it, but one really, really incredible fact that I learned is that a lot of the textbooks for dermatology display pictures of basically lighter or white skin tones when it comes to chronic skin issues. And the way that those issues like eczema and psoriasis, for example, show up in people who have darker skin tones, more melanin in their skin, it doesn't look the same way. And so they're oftentimes… And I've seen this in clients where they are misdiagnosed, they are blown off by their symptoms because it doesn't present. Considering that black + Hispanic children tend towards more severe eczema that lasts longer in life compared to white children, this is a big quality of life deal!

Jennifer: My skin gets red, my friend, and actually she's been on the show, you guys have listened to Rakhi Roy on the show, her skin turns gray. And she's of Indian descent. And so I'm really appreciative that you're willing to come on the show and talk about this whole issue, because I think it's really important that we support every single person regardless of where they are, what they look like to make sure that they're getting accurate diagnosis. So do you want to give everybody a little bit more context since you're a dermatologist and you actually see this in practice?

Dr. Mitchell: Absolutely. You bring up several great points. I am a board-certified dermatologist and I was trained on some of these very textbooks that you talk about in terms of learning diagnoses, but not really learning them on all skin types. When you look into the book and you look up a certain diagnosis, what we found was according to the textbook, most of those conditions occurred in white skin, because that's what we saw. But when you fast forward into the reality of clinical practice, we actually see these skin conditions on all skin types, every patient of color, including black people. So that may be Latin X, it may be Indian, it may be Asian, it may be Mexican, but we do see it. And just think about the impact that if you train at a program that doesn't have a lot of black patients or patients of color, what that impact can be on that dermatologist.

Dr. Mitchell: I mean, now you have a scenario where you've had textbooks that didn't show you skin of color. You've had clinics that didn't show you skin of color and what that does to your ability to be able to diagnose skin conditions in skin of color when you're in practice. Fortunately, myself being skin of color, I was able to have living examples of how these rashes can affect different skin colors and I also trained in Detroit, Michigan. And so I was able to see lots of different skin types and different skin tones, and so I feel very comfortable. But what I find in my practice is that a lot of patients that I start to see that seek me out because I am a black dermatologist have told me that either they were misdiagnosed, that's what led them to see me. They just didn't feel that their diagnosis was accurate. Or they were told initially that the diagnosis that they had, and they may not have been given a diagnosis, was nothing to worry about. “This is nothing to worry about.”

Dr. Mitchell: Or thirdly, there was a delay in the diagnosis and the problem, the rash such as psoriasis or eczema, it extended. And so you have a patient that is frustrated. You have a patient whose quality of life has been greatly decreased because either there has been a misdiagnosis or delay in diagnosis. And I think what happens… I know that we're talking more about rashes, but I even see it in skin cancer in skin of color.

Jennifer: Really?

Dr. Mitchell: We also see that concern there where I have patients that come in and they're told, “You don't have to worry, you don't get skin cancer because you have darker skin type.” So I have had patients that have told me that, and I think that-

Jennifer: Wow.

Dr. Mitchell: … that's unfortunate.

Jennifer: Yeah.

Dr. Mitchell: And I think that what we have to do is we have to start to educate not only the patient about these conditions, but the primary care doctors as well because I think a lot of the patients that I'm seeing, they're starting with the primary care doctor. So they're starting with their family doctor, their internist, and they're presenting to them with these rashes and with these lesions that they're not comfortable with.

Dr. Mitchell: The other thing that I think throws off the doctor is that inflammation looks very different. It looks very different in skin of color. And so where we've been trained that red looks like inflammation, in skin of color inflammation looks more gray, it looks dark, it may look purple-ish, it may look dark brown.

Jennifer: So almost like hyperpigmentation-

Dr. Mitchell: Almost like-

Jennifer: … in a sense?

Dr. Mitchell:  … hyperpigmentation.

Jennifer: Okay.

Dr. Mitchell: Absolutely. Where you would be thinking, unless the patient said to you, “I'm really itchy. This is very uncomfortable.” You would be thinking that they're on the tail end of their problem, that the problem has resolved and that they're left with pigmentation. But the patient is insisting, “I'm uncomfortable. This is how my rash, this is how my problem starts. It starts out looking this color.” And I think that a lot of times the patient itself, the patient themselves, they may even feel like I'm not quite sure if this is my rash or not. And so I think learning that and understanding that skin problems that have inflammation can look differently on skin of color is very, very important.

Jennifer: Yeah.

Dr. Mitchell: Very important. Mm-hmm (affirmative).

Jennifer: It Makes me think too that if you go into, say a dermatologist or your primary care, whomever and like you were saying, it looks like you're past, you're over the hump, but in-

Dr. Mitchell: Yes.

Jennifer: … reality you have a staph infection.

Dr. Mitchell: Yeah.

Jennifer: And they may say, “Oh, well, you don't need a culture. You don't need whatever.” So do you see that a lot of times then a necessary culture may be overlooked or not done and thus that patient just suffers?

Dr. Mitchell: I think you bring up a good point. I think that there can be open skin where there could be a secondary infection involved, especially in patients that have more widespread rash or very itchy rash. I would hope that if there was enough discharge or enough inflammation or open skin that the doctor would not miss doing a culture, but I definitely think it's important to do. I have had patients that have come to me where I have found MRSA in the skin.

Jennifer: Oh, wow.

Dr. Mitchell: So I definitely think the consideration is important because there are times when we do have to prescribe oral antibiotics on top of their treatment plan. Mm-hmm (affirmative).

Jennifer: Yeah, because that can be serious. I mean, you can end up… MRSA's no joke. You don't mess with MRSA.

Dr. Mitchell: It's no joke. Uh-uh (negative).

Jennifer: No.

Dr. Mitchell: No.

Jennifer: So, for someone… Let's talk to just the patient right now. So you have a patient in front of them. You want to educate them on what does inflammation look like in their skin. What are the warning signs. Because like you're saying, most of us, I think we all grow up with this idea that red equals inflammation, but that's not really quite the case-

Dr. Mitchell: Mm-hmm (affirmative).

Jennifer: … actually now. It's just sobering and really important for us all to know. So what are some of the signs that you see when you're like, “Oh, that's inflammation. That's actually not just some hyperpigmentation.” What are some things that people should be on the lookout for?

Dr. Mitchell: For me, the number one thing that I educate my patients about that would be inflammation is just the itch. It's the itch. I educate them that, almost like with a cold sore, when you educate that patient because sometimes they don't know. And I'll say, “A cold sore can be preceded by itching. It doesn't have to be a burn or a tingle that you normally think of with cold sores.” The same with eczema. The moment your skin feels different, just that itch because we don't know if it's the itch that rashes or the rash that itches. So there are times where we don't know which one comes first.

Dr. Mitchell: And so, I educate the patient that the moment you start to feel that itch let's really ramp up and make sure that we're not skipping out on our topical treatment, our topical creams. Because we want to get the patient to a point where they don't need to use their topical creams, right? We want to educate them enough that maybe dietary changes, skincare changes, using the proper cleansers and the proper moisturizers that lock that moisture into their skin, the proper detergents, whatever it is. We want to have a comprehensive discussion about that. And so we are hopeful, we are optimistic that we can get to a point where you're doing the day-to-day things, and you may have your intermittent flare-ups because this is a chronic condition. And so if you're doing everything correctly, there's no changes, and you start with that itch, then that should prompt you instead of scratching and rubbing or ignoring it to get your medication on your skin immediately. So incorporate that or go up to twice daily if you've only been using it once daily.

Dr. Mitchell: Definitely as the season changes, as the weather changes, we may start to use our moisturizers more than once or twice a day. I think a lot of us get comfortable when we have eczema in the summer months, we may not be real consistent with using our hydrating products, our moisturizing lotions or creams. Some of us may have converted to lotions instead of those creams, and so I like to recommend, “If you start to see that your skin is drier, let's ramp back up and pick up ointments that feel heavier, creams that feel heavier that can lock that in moisture in.” So those are probably the two things that I'll say, “The moment you feel the itch, let's jump on that. And then as the season changes, especially going from the warmer to cooler months, let's transition into those heavier creams and let's make sure we're getting them on morning and night.” I like to take the approach that we want to be proactive and preventative.

Jennifer: And can I ask you a question? Because you brought up a really interesting point that I don't think I've ever asked anyone in the history of this show. What is the connection between the itching and inflammation? Is there something specific about that because that honestly never occurred to me before?

Dr. Mitchell: Yeah. In terms of the itch, we thought that there was a connection to the histamine receptor and mass cells and all of that. And what we're finding is that that's not the case. We're finding more that there is a step in the inflammatory cascade where there are inflammatory or inflammation or lymphocyte type cells that seem to set off a pathway. And the studies are really impressive to the point that now we have biologics or injectables that target that pathway for eczema, and there are a few more that are set to be approved to be released in the next year or two. So right now we have dupilumab, which is an injectable medication which targets a specific pathway in the inflammation pathway that causes eczema. And so we definitely know that there is a connection. We definitely know that a lot of patients have a genetic predisposition, but we're learning more and more beyond genetics, which is very exciting.

Jennifer: That is very exciting. It is really interesting, all of the research, and I like to be kind of… I just always say, “I'm medication agnostic.” I'm like, “You have to decide what's appropriate for you because we all have our own feelings about different things. And so I, I think it's important for people to weigh all of the options and educate themselves and decide for themselves what the best way is in conjunction with their doctor.”

Dr. Mitchell: Mm-hmm (affirmative).

Jennifer: And so, I think the research on a lot of these biologics is actually quite fascinating because it-

Dr. Mitchell: It's quite fascinating.

Jennifer: Yeah. It shows us how… I always say to people, I'm like, “You don't understand, inflammation is such a huge driver of eczema.” So if you don't.. If you don't know what's… We have this inflammation, you go, “I have inflammation?” And then the question is, “Well, what's causing the inflammation?” And it's like “Well, I don't know, my skin's itchy.” I'm like, “Well, maybe there's something else.” And that's where I like to dig. That's kind of like my sandbox. But it's super cool to know that that's the case. So I wanted to ask you a question.

Dr. Mitchell: It's a partnership.

Jennifer: It is.

Dr. Mitchell: It's a partnership.

Jennifer: It is.

Dr. Mitchell: It's a partnership. I absolutely will talk to my patients about seeing the nutritionist. I talked to my patients about working with an allergist, if appropriate.

Jennifer: Yes.

Dr. Mitchell: So I think it's very, very important. We have to educate our patients about every facet of this condition.

Jennifer: Yeah.

Dr. Mitchell: And so, it's important. Yeah.

Jennifer: Can I ask you about psoriasis? Does the inflammation show up in the same way as it does in psoriasis in skin of color or are there things that, say someone who is of Indian descent or who may have a black skin tone, are there things that tend to get missed or overlooked that might cause someone to not get diagnosed correctly? Because psoriasis is a big deal, it's considered, for the most part, an autoimmune disease. And I think it's important, you should know if you have an autoimmune disease.

Dr. Mitchell: Mm-hmm (affirmative).

Jennifer: So, are there any things that you find from research or just from your experience that maybe they're hallmark things that just get overlooked or missed?

Dr. Mitchell: Okay. So bringing up an excellent point, but remember, as with a lot of conditions, there is going to be the classic presentation, right?

Jennifer: True.

Dr. Mitchell: And so that textbook presentation may say psoriasis is on the elbows and knees and-

Jennifer: Mm-hmm (affirmative).

Dr. Mitchell: … it's a thick scaly plaque, right, or buildup. Sometimes in the scalp we can see it. But let's think about those cases where it's not that classic presentation. Psoriasis can start out looking pretty much like dry skin, right? So can eczema. And until we have either some progression or we take the time to really get a detailed history it may be overlooked.

Dr. Mitchell: Now as we grow up and we become adults, the distribution of eczema and psoriasis may not be the classic distribution that we think of where we think of eczema as being in the folds, right, the arm creases, the neck creases, behind the knees. And we think of psoriasis as being more of an extensor type of rash, on the knees, on the elbows. We can't rely on that as our patients become adults because that distribution can change.

Dr. Mitchell: And not only the distribution, but the presentation of the rash. And so we may look at these patients and we can simply see dry skin. We may see some hyperpigmentation, some discoloration, but as you dive into the history we may find that there is a genetic predisposition for one over the other. We may find that they actually have quite a bit more symptoms than what it appears, they're very uncomfortable, they're very itchy. And so that puts us in tune with the fact that we're dealing with more than just dry skin as we think about it. So it's our job to really be detectives. I think of us dermatologists as being detectives.

Jennifer: Absolutely.

Dr. Mitchell: It's our job to ask, we ask a lot of questions. And even if we don't have a lot of clinical manifestation of the problem, it's still our job to be able to educate our patients about what we really believe is going on.

Jennifer: Can I ask you a question too with that? Because I think that it's not just… I always think of the patient and the doctor or whomever they're working with, it's a partnership. It really is because-

Dr. Mitchell: Mm-hmm (affirmative). Mm-hmm (affirmative).

Jennifer: … you're not a mind reader. You don't know their history. If someone hasn't sat and really thought about it or kind of lined up, okay, I'm going to make sure to tell someone. Because that's what I… I go to the clients sometimes and I'm like, “Okay, so you need to tell the doctor, this, this, this, this, and this. Write it down so you remember to say it.” Because I think sometimes people… We don't go to school to learn how to express what's wrong with us in a very intelligent manner. Plus, there's a limited amount of time to do that. So are there things that maybe people should think about before they walk into the dermatologist's office or their doctor's office, especially if they do have darker skin tones or skin of color and things that might be important to think about and say, do I have this and this, and this? Is this true for me? And then have that list ready to go so that way they can also more effectively convey that information and make sure that it doesn't get left out.

Dr. Mitchell: And definitely as we see any doctor, any skin type, we should be prepared for the visit. So preparation for the visit means that we should know our history. We should know how long we've been dealing with the problem. We should have an idea or bring the list, bring a photograph of your prescriptions, bring in the medications that you're currently using, that you have used. Because as with any consultation, the more information you can bring to the table the better the provider can assist you.

Dr. Mitchell: But if you're in the appointment and you don't know what you've tried, what you fail, what products you're using, we're not going to have a very productive appointment. We may end up re-prescribing something that you tried and didn't work for you. And as the doctor and as any provider, we don't want our patients to feel like we didn't help them. They came to the appointment, they've waited to see us. They're excited about getting help. We're excited about helping our patients, but we don't have all of the information that we need to be able to do our best job. And so when you come into the appointment it is very important that you know these things.

Jennifer: Mm-hmm (affirmative).

Dr. Mitchell: Now, in terms of skin type or skin tone, I think it's really important that we understand, are we using lotions, are we using creams, how often, what soaps are we using? Because what we have found is that there may be a lower level of ceramides in black skin. And so ceramides would be a component of basically the skin that helps to keep the barrier protected, and to protect the skin from bacteria and irritants and allergens that are floating around from being able to attack the skin. And if the skin barrier is not strong or if the skin barrier is disrupted, excuse me, the skin can not provide the adequate protection needed. And so, I really love to know when my patients come in what products they're using, what moisturizers, are they lotions or are they creams. And I think that the more information we have, I think the better the appointment will go.

Jennifer: Yeah. And I think it's also important too. I always encourage people, make notes ahead of time, succinct notes-

Dr. Mitchell: Mm-hmm (affirmative).

Jennifer: … on a piece of paper because it's really easy to get real flustered and forget to say something. And then you walk out and you're like, but, but, and then the doctor has to go onto the next patient and it's a little too late. So it's really important, sit and think about all of the symptoms. And then also the other thing that I recommend… Because I came to recognize that I had eczema and the way my eczema showed up, I had different symptoms than other people. And so when people just go, “Well, I have eczema.” I'm like, “Well, tell me about your eczema. Tell me all of the ways that it shows up. How does it feel? What's the experience?” Because just saying, “I have this,” the way it shows up for one person may be different for another person.

Dr. Mitchell: Mm-hmm (affirmative).

Jennifer: And I think it's important to really… And I also tell people too, I don't know if it helps you at all, to also look at if you have these flares that seem to happen in a cycle, start to look at a calendar and see, maybe for women, is it connected with their cycle?

Dr. Mitchell: Mm-hmm (affirmative).

Jennifer: Start to take a look at that because there can be patterns. And if you can do a little investigation ahead of time, they can then provide their doctor with that information and just help, help dig.

Dr. Mitchell: And that's part of my consultation when I see patients is I do recommend that they journal. I do recommend that every day they think about their skin and if they break out or something happens, stop, look, and listen.

Jennifer: Yeah.

Dr. Mitchell: Look at your skin, listen to your body, think about what you may have done that was different for you and just write it down. Even if you don't go further at that particular moment, write it down and as we start to see more connections we might be able to figure out what could really be a true trigger based on those notes.

Jennifer: Can I ask you one final question? And I think just because of your experience, I think you might have some great words of wisdom. But for practitioners who are listening and maybe they… Look, everybody's guilty of, we've learned what we've learned, but we can always do better. We can always learn and do better. They're listening to this. They're like, “I want to serve all of my patients better.” What words of advice or pearls would you share with them if they have someone come into their office who is a person of color and maybe in the past they've like, “I don't know what this is.” Or they just sort of… Is there any pearls you could share with them in these final moments that might help them serve their patients?

Dr. Mitchell: Absolutely. Always show compassion. So always stop and listen to what the patient has to say. I know that we're busy, it may not be something that we're comfortable with, but I would say, hear them out. So first show them compassion, let them know that you care. And then the second step is be okay, be authentic. It's okay to say, “I'm not comfortable with answering that. I don't know. I don't understand. That's not where my training is.” And number three, “What I think would be best for you is that we get you into the hands of a board certified dermatologist who can further help you with this condition.” It's okay to say, “I'm not sure, this is not where I've trained.” It's not okay to falsely reassure a patient and tell them that it's okay or to just continuously give them topical steroids or creams that may be putting a band-aid on the situation, but are not really giving them the solutions to help them keep that problem under a longer term control.

Jennifer: Yeah. And I think too, there's also going to be more and more textbooks coming out as well that will also help educate everyone about-

Dr. Mitchell: Mm-hmm (affirmative).

Jennifer: Even too, and this is sort of an aside, but I think I read a lot of research that has said, “Oh, rosacea only happens in lighter skin tones.” That is not true.

Dr. Mitchell: Right. Not true. Not true at all. And I love to do consults on the phone. I've had doctors that have called me and said, “This is what I'm thinking.” And so I would also say, connect with a dermatologist and be willing to call on behalf of the patient. A quick call could really change the quality of life of that patient. And so, we support our primary care physicians and we want to do more to educate and to keep the partnership.

Jennifer: Yeah.

Dr. Mitchell: But most importantly, we want to work together for the good of the patient.

Jennifer: Yeah. Yeah. I think it's going to be a really interesting time over the next few years to see how things really shift and change because it's important that all patients, regardless of what skin tone they have are getting the same type of care and investigation, not just, “Oh, it looks fine, looks fine.” And yet they're suffering. It's really important. So, if you have a rash and you've not felt well heard, I think it's time to find someone else. And too, Dr. Mitchell has her own practice, by the way. Where are you located, Dr. Mitchell?

Dr. Mitchell: I'm located in Ohio. My practice is, Mitchell Dermatology, where I am the founder and CEO. I've been in practice since 1998. And I see lots of medical dermatology in the office. I can be found very easily on Instagram, my handle is @drhopemitchell, and you can also reach out to me by email [email protected]

Jennifer: Yes. And I will tell you guys, I found Dr. Mitchell on Instagram. I love everything that she posts, so you should definitely go follow her there. She's got a lot of great content. And for those of you, I want to just put the bug in your ear. If you've been dealing with hair loss, she's also got a lot of great content on that as well. So she's a good knowledgeable resource to tune into on that. And hopefully we can have you back, Dr. Mitchell. This was such a pleasure and an honor to have you here. And thank you so much.

Dr. Mitchell: Thank you for having me. I really enjoyed this.

“The other thing that I think throws off the doctor is that inflammation looks very different. It looks very different in skin of color. And so where we've been trained that red looks like inflammation, in skin of color inflammation looks more gray, it looks dark, it may look purple-ish, it may look dark brown.”


Jennifer Fugo, MS, CNS

Jennifer Fugo, MS, CNS is an integrative Clinical Nutritionist and the founder of Skinterrupt. She works with women who are fed up with chronic gut and skin rash issues discover the root causes and create a plan to get them back to a fuller, richer life.


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