Culturally Conscious Skincare​

Why Hispanic and Black Patients Don’t Get the Dermatological Care They Need

Non-Hispanic white patients are twice as likely to visit a dermatologist for a concern regarding their skin condition than Hispanic and Black patients, according to a national study completed by Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center. This disparity is compounded by the fact that many skin conditions are more common in skin of color.

Conditions that are equally prevalent among all people may manifest differently on skin of color and require unique management and treatment. There is a crucial need to address the disparity in dermatologic care delivery and its utilization among the rising population of African Americans, Asians, and Hispanic Americans in the United States. Recognizing the need to address the disparities in dermatologic care and service utilization among rising populations of African Americans, Asians, and Hispanic Americans in the United States, Sheena D. Franklin designed the first integrative, culturally conscious, and holistic digital skincare and dermatology clinic for women, Kep’t Health.

The Journey to Kep’t Health

Franklin’s journey as a patient and experience as a healthcare lobbyist led her to the idea of Kep’t Health. In search of a treatment for her acne and severe post-inflammatory hyperpigmentation, a condition more common among people of color, it took her two and a half years to find the right skincare specialists who could meet her health needs and heal her skin.

As a lobbyist for a large healthcare company, Franklin’s work for an innovation team gave her a front-row seat to the burgeoning digital health and technology landscape, diverse state and federal healthcare policies, and distinct roles of various stakeholders in healthcare. This insight, combined with her experience as a patient, led her to discover the lack of a holistic and culturally competent dermatology platform. Her conversations with several women with dermatologic conditions confirmed that women sought but struggled to find a suitable licensed professional. Like her, women were searching for providers who understood acknowledged differences in skin and hair while also practicing integrative dermatology to solve the root cause of skin issues.

Addressing Disparities in Dermatology Care

Research substantiates that nonwhite patients are willing to seek medical care, but barriers often prevent them from accessing necessary dermatologic care. Low health literacy, high costs of care, and lack of cultural competency are critical barriers these patients face. These barriers are often compounded by the shortage of dermatologists in these communities and few dermatologists accepting Medicaid insurance. With the expansion of teledermatology services, ethnic minorities and patients of low socioeconomic status can have better access and outcomes. Some studies even revealed that teledermatology doubled the number of Medicaid patients receiving dermatologic care while electronic consultations served more underserved and underinsured groups than conventional referrals.

Biggest Achievements to Date

However, unlike most teledermatology platforms that are extensions of primary care-based telemedicine, Franklin is creating a more purposeful and standalone teledermatology platform rooted in inclusive A.I. Her platform’s primary goal is to redefine how women, specifically women of color, experience dermatologic care. She is designing a teledermatology clinic around the whole patient journey by considering the patient’s prior experiences to establish a continuum of care. Her platform aims to use artificial intelligence (A.I.) to support dermatologists in addressing the underlying causes of skin conditions and optimize skin health. Kep’t Health’s mission is to change how all women experience skincare while simultaneously acknowledging that women of color face additional systemic challenges.

The Education and Training Gap

Racial and ethnic minorities have historically been underrepresented in medical research. This lack of representation has led to an absolute scarcity in robust fundamental dermatologic studies examining skin of color.8 The reality is that many skin conditions vary in their presentation and on the molecular level, resulting in treatment failure and poorer outcomes. For example, studies have found that African Americans, in whom atopic dermatitis is more prevalent, tend to require higher doses of corticosteroids, likely due to underlying molecular differences that increase inflammation. These differences are rarely discussed in dermatology textbooks and are further exacerbated by the lack of representative images of common and severe skin disorders affecting skin of color. In particular, scientific literature has documented apparent differences in the presentation, complications, and treatment of acne in African Americans, yet textbooks barely discuss acne in dark-skinned individuals.

“Medical schools don’t often offer a curriculum on treating skin of color or holistic approaches to treating skin conditions. Unless practitioners have a personal interest in practicing integrative dermatology, treating skin of color, and actively seeking out diverse cities to gain this experience, they will rarely receive this training or understand the importance of specialized care​”

Creating a Culturally Conscious and Inclusive Database

Consequently, the uncertainty in clinical diagnosis and unfamiliarity with skin of color can adversely impact the physician-patient relationship perpetuating stereotypes, patient mistrust in the healthcare system, and low-quality care. A.I. technology can help support practitioners’ limited exposure to training and education in surrounding skin of color by facilitating inclusion and representation. However, this is only possible if the images used to train the software are curated mindfully. Franklin believes that by taking the time to build and continuously test a diverse image dataset, she can minimize the issues of generalizability that can perpetuate systematic bias. Still, A.I. facilitated image analysis is only one part of the puzzle. Franklin asserts that practitioner input and patient perspectives will make Kep’t Health’s database more comprehensive and distinct from other AI-based skincare platforms.

“We want to work together to build a system that involves everyone in the design and their perspectives. We want to, first and foremost, foster collaboration and support shared-decision making.”

Given the disparity in care that women and racial minorities face, it is essential to establish respect, dignity, understanding, and trust between the practitioner and patient. Communication plays a crucial role in facilitating the recognition of patients’ concerns, goals, and desires and ultimately incorporating patient preferences and values in the choice of therapy.

Franklin wants to help patients find the right practitioner and believes that enabling communication and collaboration over time through asynchronous technology will support this effort. She envisions moving beyond A.I. to build a comprehensive approach to care using technology to help break down barriers to access and overcome social stigma. While a primary goal is to minimize misdiagnosis, she also aims to alleviate patient fear surrounding costly and harmful incorrect treatments.

“Our skin changes throughout our lives, for example, with age and significant life experiences like pregnancy or cancer. If we can provide women with quality specialized care, they will continue to seek care because we have built that trust and peace of mind they seek. We want to create a lasting relationship with our patients so that they feel comfortable returning to us when they are in need​”

Time and other physician constraints are often at the crux of this issue. Franklin explained that unless the condition is severe, most dermatologists rarely have the time in their packed schedules, despite their desire, to work with a patient for an extended period to determine and resolve the root cause of seemingly more straightforward conditions like acne. Kep’t Health technology will capture and analyze personal data points and AI-facilitated image analysis to give providers a complete picture of their patients. These unique data points will include the patient’s feelings around long-term treatments, their preference for taking supplements over prescription medications, and their understanding of general dermatology terminology. Franklin hopes that this asynchronous data capture will ultimately help doctors make more informed decisions by removing the conscious and unconscious bias stemming from a lack of communication and medical education on skin of color.

Women’s Health Tech Challenge (WHTC) and Beyond

Goodwin Procter LLP chose Kep’t Health’s novel dermatology-focused telehealth platform as a recipient of the grand prize of $10,000 (USD) from over 120 applicants representing 24 countries at the WHTC. The mission of the WHTC is to identify and accelerate technologies that address unmet needs in women’s health. The Challenge is an essential element of The Women’s Health Tech Initiative, which aims to drive women’s health innovation through events, mentorship, networking, and thought leadership. For Franklin, it was a unique opportunity for her startup to gain exposure and credibility, which led to building meaningful partnerships and receiving some investments.

“Goodwin is committed to improving the lives of all women through our Women’s Health + Wellness practice, making key connections and providing strategic, business and legal advice to the women’s health and wellness industry. Sheena Franklin is a visionary entrepreneur who is transforming skin care for all women,” added Delphine O’Rourke, Partner at Goodwin.

Being primarily a telemedicine platform, the newfound partnership with Goodwin has been as beneficial as the monetary award they received. With telehealth standards varying by state, Goodwin has been invaluable in helping Kep’t Health keep abreast of the different rules and regulations related to telehealth practices. This knowledge has guided their launch strategy in terms of determining where to launch first. Ultimately, Goodwin is providing crucial guidance and foresight on how Kep’t Health can effectively establish its platform and provide care in new states.

“Our goal is to be the skin health doctor of this generation. We want to empower women to take control of their skin and overall health and wellness on their terms!”

Acutely aware of the many barriers women face in accessing healthcare, Franklin also hopes that her platform will fundamentally change the way women experience healthcare and the broader healthcare system. To this end, she has established a subscription plan that will allow patients to sidestep the need for private insurance by giving them flexibility in how they pay for their healthcare. Finally, with the COVID-19 pandemic having accelerated the acceptance of telemedicine, Franklin is diligently preparing for Kep’t Health’s launch later this year. She is also looking forward to sharing the critical research data they have collected to help transform the dermatology landscape.

“Kep’t Health is a way to reclaim the narrative from consumer marketing, which has mainly focused on products and the need to be beautiful, and refocus the conversation on our skin health and how it serves as a critical indicator of our internal health.”

The HITLAB Women’s Health Tech Initiative is excited to announce the Women’s Health Tech Innovators Showcase will take place on June 3rd, 2021. Tune in to hear 30 visionary FemTech founders deliver rapid-fire pitches. It is free to register.

About the Author

Avantika Pathak is pursuing a doctorate in pharmacy at the USC School of Pharmacy.

About HITLAB

HITLAB is an impact-first organization that offers digital health research, teaching, and advisory services to improve health delivery around the world.

At HITLAB, we believe technology and health can work together to improve the quality of health delivery and healthcare worldwide. We use rigorous research and evidence-based methods to identify the best digital health solutions for each of our partners.

References:

1. Tripathi R, Knusel KD, Ezaldein HH, Scott JF, Bordeaux JS. Association of Demographic and Socioeconomic Characteristics With Differences in Use of Outpatient Dermatology Services in the United States. JAMA Dermatol. 2018 Nov 1;154(11):1286–1291.
2. Taylor SC. Epidemiology of skin diseases in people of color. Cutis. 2003 Apr;71(4):271–5. PMID: 12729089.
3. Ebede T, Papier A. Disparities in dermatology educational resources. J Am Acad Dermatol. 2006 Oct;55(4):687–90.
4. Frey WH. New Projections Point to a Majority Minority Nation in 2044. Brookings. 2014 Dec 12. https://www.brookings.edu/blog/the-avenue/2014/12/12/new-projections-point-to-a-majority-minority-nation-in-2044/
5. Bray JK, Cline A, McMichael AJ, Feldman SR. Differences in healthcare barriers based on racial and/or ethnic background for patients with psoriasis. J Dermatolog Treat. 2019 Nov 25:1–5.
6. Mulcahy A, Mehrotra A, Edison K, Uscher-Pines L. Variation in dermatologist visits by sociodemographic characteristics. J Am Acad Dermatol. 2017 May;76(5):918–924.
7. Wang RF, Trinidad J, Lawrence J, Pootrakul L, Forrest LA, Goist K, Levine E, Nair S, Rizer M, Thomas A, Wexler R, Kaffenberger BH. Improved patient access and outcomes with the integration of an eConsult program (teledermatology) within a large academic medical center. J Am Acad Dermatol. 2020 Dec;83(6):1633–1638.
8. Buster KJ, Stevens EI, Elmets CA. Dermatologic health disparities. Dermatol Clin. 2012;30(1):53-viii.
9. Espinosa ML, Lio P. Skin issues that affect patients with skin of color. Dermatology Times. 2019 Feb 5; 40(2). https://www.dermatologytimes.com/view/skin-and-disparity-issues-affect-patients-color
10. Lester JC, Taylor SC, Chren MM. Under-representation of skin of colour in dermatology images: not just an educational issue. Br J Dermatol. 2019 Jun;180(6):1521–1522.
11. Gomolin A, Netchiporouk E, Gniadecki R, Litvinov IV. Artificial Intelligence Applications in Dermatology: Where Do We Stand?. Front Med (Lausanne). 2020;7:100. Published 2020 Mar 31.
12. Perlman KL, Klein EJ, Park JH. Racial disparities in dermatology training: the impact on black patients. Cutis. 2020 Dec;106(6):300–301.
13. Cices A, Alexis AF. Patient-focused Solutions in Rosacea Management: Treatment Challenges in Special Patient Groups. J Drugs Dermatol. 2019 Jul 1;18(7):608–612.
14. Sanchez D, McLean EO, Maymone MBC, Granados NM, Vashi NA. Patient-provider comparison of dermatology vocabulary understanding: a cross-sectional study in patients from minority ethnic groups. Arch Dermatol Res. 2020 Aug;312(6):407–412.