Dermatology: Practical and Conceptual Commentary | Dermatol Pract Concept. 2023;13(2):e2023090 1 Nail Dermatologist and Patient Educational Content Lacks Adequate Skin of Color Representation: Implications for Care Julianne M. Falotico1, Shari R. Lipner2 1 Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA 2 Weill Cornell Medicine, Department of Dermatology, New York, NY, USA Citation: Falotico JM, Lipner SR. Nail Dermatologist and Patient Educational Content Lacks Adequate Skin of Color Representation: Implications for Care. Dermatol Pract Concept. 2023;13(2):e2023090. DOI: https://doi.org/10.5826/dpc.1302a90 Accepted: September 22, 2022; Published: April 2023 Copyright: ©2023 Falotico et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: Ms. Falotico has no conflicts of interest. Dr. Lipner has served as a consultant for Ortho Dermatologics, Verrica, Hoth Therapeutics, BelleTorus Corporation, and Hexima. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Shari R. Lipner MD, PhD 1305 York Avenue, NY, NY 10021. Phone: 646-962-3376 Fax: 646-962-0033 Email: shl9032@med.cornell.edu Skin of color (SoC) representation in dermatology educa- tional content is lacking, which has been recognized only re- cently [1]. Poor inclusion of SoC images in training materials may contribute to delays and missed diagnoses in SoC pa- tients [2], which can have significant implications for care. In an analysis of trends of SoC representation in dermatology textbooks over time [3], on average, there were only 11.5% of Fitzpatrick skin type V-VI images across 26 dermatology textbooks, with an overall 1.3% average increase in repre- sentation with later textbook editions. In this commentary, we corroborate these findings of limited SoC representation specifically for nail diseases in dermatology textbooks, re- view other learning modalities, and highlight resources for SoC images. In an analysis of 1288 nail images of 34 nail conditions across nine dermatology and nail-specialty textbooks [4], only 4% of images overall represented skin types V-VI, with no V-VI representation for 47.1% (16/34) of nail conditions. The mean proportion of V–VI nail images per textbook was 6.6% (range 0.9%–23.5%). Compared to all dermatology images [3], nail-specific images had less V-VI representation in 80% (4/5) of textbooks (Table 1). Therefore, nail con- ditions lack adequate SoC representation in dermatology textbooks. In a Google image analysis of the same 34 nail con- ditions [5], categorizing the first 50 images per condi- tion by Fitzpatrick skin type, only 8% of 1700 images demonstrated V-VI skin types. The highest proportion of V-VI images were found for anonychia (36%) and longitudinal melanonychia (22%), with no V-VI images for onychomycosis, despite it being the most common nail disease encountered in clinical practice [6]. There- fore, public education images of nail pathology in SoC patients are lacking. In addition, in a systematic review of 182 onychomy- cosis clinical trials (1988– 2020) [7], only 5.4% (8/149) of 2 Commentary | Dermatol Pract Concept. 2023;13(2):e2023090 participant images depicted skin types V-VI. There was a de- crease in the proportion of V-VI onychomycosis images from 15.7% to 2.1% between 1996 and 2020. Therefore, there is a need to recruit diverse patient populations in nail clinical trials and depict images of participants with darker Fitzpat- rick skin types in publications. Taken together, these findings highlight inadequate demonstration of nail pathology in SoC for both dermatol- ogist and patient education. There is limited nail training during dermatology residency [8], and the lack of adequate representation of nail pathology across all skin types in dif- ferent educational platforms further compounds this prob- lem. Therefore, we encourage dermatology residents and attendings to supplement their learning with resources that prioritize SoC education and/or have sections specific to SoC, such as websites for VisualDx, Skin Deep, and the Skin of Color Society [9]. While the need to diversify physician and patient der- matological content has been recognized, there is a lag in implementing change, particularly for nail content. Failure to sufficiently portray educational SoC nail images may re- sult in worse outcomes for this patient population. There- fore, dermatology residency programs should use dedicated SoC resources to demonstrate nail pathology during didactic lectures, and dermatologists who review online medical web- sites should advocate for increased diversity specifically for nail content. References 1. Adelekun A, Onyekaba G, Lipoff JB. Skin color in dermatology textbooks: an updated evaluation and analysis. J Am Acad Der- matol. 2021;84(1):194-196. DOI: 10.1016/j.jaad.2020.04.084. PMID: 32335181. 2. Lester J, Taylor S, Chren M. Under-representation of skin of colour in dermatology images: not just an educational issue. Br J Dermatol. 2019;180(6):1521-1522. DOI: 10.1111 /bjd.17608. PMID: 31157429. 3. Abduelmula A, Akuffo-Addo E, Joseph M. The Progression of Skin Color Diversity and Representation in Dermatology Text- books. J Cutan Med Surg. 2022;26(5):523-525. DOI: 10.1177 /12034754221099668. PMID: 35544370. 4. Falotico JM, Lipner SR. Lack of skin of color images of nail conditions in dermatology textbooks. Int J Dermatol. 2023;62(1):e48-e50. DOI: 10.1111/ijd.16028. PMID: 34865217. 5. Falotico JM, Lipner SR. Few skin of color images in Google image searches of nail conditions. Int J Dermatol. 2023;62(3):e153-e155. DOI: 10.1111/ijd.16121. PMID: 35119690. 6. Lipner SR, Scher RK. Onychomycosis: Clinical overview and diagnosis. J J Am Acad Dermatol. 2019;80(4):835-851. DOI: 10.1016/j.jaad.2018.03.062. PMID: 29959961. 7. Chang MJ, Qiu Y, Lipner SR. Race reporting and representation in onychomycosis clinical trials: A systematic review. Mycoses. 2021; 64(8):954-966. DOI: 10.1111/myc.13262. PMID: 33655595. 8. Hare AQ, Rich P. Clinical and educational gaps in diagno- sis of nail disorders. Dermatol Clin. 2016;34(3):269-273. DOI: 10.1016/j.det.2016.02.002. PMID: 27363883. 9. Chang MJ, Lipner SR. Resources for skin of color images. J Am Acad Dermatol. 2021;84(6):e275-e277. DOI: 10.1016/j .jaad.2021.01.040. PMID: 33484764. Table 1. Proportion of Fitzpatrick skin type V-VI images for all dermatology images and nail-specific images in five dermatology textbooks. Textbook All dermatology images [3] Nail images [4] Jean Bolognia et al., eds. Dermatology. 4th ed. Elsevier; 2018. 13.53 5.9 Klaus Wolff et al., eds. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. 8th ed. McGraw-Hill Education; 2017. 7.64 6.7 Thomas P. Habif. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 6th ed. Saunders; 2015. 4.88 1.4 Christopher E. M. Griffiths et al., eds. Rook’s Textbook of Dermatology. 8th ed. John Wiley & Sons, Ltd; 2010 9.56 5.9 Brian J. Hall, John C. Hall, eds. Sauer’s Manual of Skin Diseases. 11th ed. Wolters Kluwer; 2017. 15.99 23.5