Dermatological Atlas of Black Skin
By Dr. Coyle Connolly and Dr. Joseph Bikowski
Merit Publishing International
96 pp $49.95

I work as a primary care medic at a community clinic, and it's not every day that I stumble across a reference book that changes the way I view patient concerns. Just such an epiphany came recently during a complex dermatology appointment with an Afro-Brazilian patient. A cluster of small bumps on her cheek and a pale patch below it could have been symptoms of any of several skin conditions, from impetigo to a fungal infection to contact dermatitis. For help, I turned to the clinic's small library and found the answer in a slim but remarkable diagnostic manual, Dermatological Atlas of Black Skin.

The Atlas is not extensive. It covers just 32 skin disorders as they appear on dark-skinned patients, with a special emphasis on people of African descent. Accessible to both the clinician and the lay reader, the Atlas explains the cause of each disorder and includes diagnoses, basic treatment options, and a discussion of the special needs of black and dark-skinned patients. Large-format color photos show skin lesions at high magnification, making it less likely that the medical practitioner will miss details critical to an accurate diagnosis.

But what makes this modest book so important is that until recently, reference works to help properly diagnose common dermatological problems for patients with dark skin have been difficult to find. Thumb through most any of the classic dermatology texts, and you'll find that most of the images show only light-skinned subjects. When dark skin appears, it is generally used to depict tropical skin diseases or disorders, such as vitiligo and sickle cell anemia, which are found almost exclusively in darker-skinned people. In dermatological canon, in other words, white skin is considered the standard.

As the book well illustrates, however, a number of common diseases show up quite differently on black skin. Take the fungal skin infection tinea versicolor. As the Latin name suggests, the affected skin turns the "opposite color." As a rule, dermatology texts illustrate this condition with a photo of a Caucasian patient, showing dark reddish rings on pale skin. On dark-skinned patients, however, the affected area turns lighter, taking the form of small pale patches.

Atopic dermatitis, or eczema, is another example. On dark skin, eczema's telltale bumps often look different from those on light skin. In an interview, co-author and dermatologist Coyle Connolly notes, "The clinician may well wonder, 'What is this? An infection? Little warts?' For trained dermatologists, the answer should be easy. But the family practitioner or pediatrician -- especially one who has very few dark-skinned patients -- might easily mistake it."

In other cases, the practitioner may miss the diagnosis entirely. A clinician can, for example, spot a scabies infestation on white skin fairly easily: The pinhead-size blisters are usually rosy or red. But on dark skin, scabies lesions are often indistinguishable in color from the surrounding area. If a dark-skinned patient complains of itching, the practitioner needs to look for other clues, such as altered skin texture and rash location.

Left untreated, even benign skin disorders like scabies can cause extreme discomfort, and with others, such as psoriasis, early detection can mean the difference between a fairly limited condition and a painful chronic one. Worse yet, syphilis, a systemic disease that may surface in the form of skin lesions, damages the organs and can prove fatal if not treated. In other cases, overmedication can be a problem. A dark-skinned person may come to a clinic seeking urgent medical treatment for normal and benign skin variations. An inexperienced doctor might prescribe unnecessary medication -- from steroids to antifungals to antibiotics -- and possibly damage the patient's skin or overall health.

Dermatology is the most visual of medical specialties, and dermatological problems are among the most difficult to diagnose. Dermatologists learn to recognize patterns and to differentiate between skin conditions by seeing hundreds of cases, yet many medical practitioners have far less exposure. While skin-related complaints account for 15 percent of all general practitioners' appointments, most medical students devote only a tiny fraction of their training to the study of dermatology. Still less time is devoted to recognizing problems as they appear on a variety of skin types.

Necessity was the mother of invention for Atlas co-author Connolly. After completing his medical training in the early 1980s, he began clinical rotations in Philadelphia. "Most of my patients were black or Latino," he recalls. "I realized right away there was a need for photographs and a knowledgebase about deeply pigmented skin." Connolly began compiling a manual for first-year students, general physicians, and pediatricians. Through experience, he knew it would benefit patients too: "When you can show patients a picture and say, 'This is what you've got,' it helps them bond with their doctor and trust the diagnosis."

The only reference book comparable to this one is Black and White Skin Diseases, published in 1995. Although this earlier Atlas is more comprehensive, the photos it uses to illustrate the text are small, and at $189 it is a costly book for most low-income clinics or medical students.

One would expect that Connolly and Joseph Bikowski's book would find a ready clientele in the United States and South Africa, where blacks make up about 13 percent and 75 percent of the population, respectively, or Brazil, with more than 72 million citizens of African descent. Marketing the Atlas has not been easy, however, according to Merit Publishing's Jean Evers. Designed to be the flagship volume of Merit's new "Skin of Color" series, the book has been picked up by only a fraction of medical schools in the United States -- where Merit expected high sales -- and orders from distributors in South Africa, a relatively wealthy African country, have only trickled in.

Apparently, it is chiefly in doctors' offices and community health centers that this reference manual is getting a real workout. In the primary care clinic where I work, the pages of the Atlas are dog-eared from use.

-- Diana Reiss-Koncar is a medic at the Berkeley Free Clinic in Berkeley, California. She is also a freelance health writer and illustrator whose work has appeared in Hippocrates, Consumer Health Interactive, and numerous other outlets.

First published June 12, 2002
Last updated October 27, 2008
Copyright © 2002 Consumer Health Interactive

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