Representation of Skin Colors in Images of Patients With Lupus

Lupus presents earlier and more severely among patients with skin of color (SOC), and this population experiences worse outcomes. Providers rely on medical education materials when developing skills to care for patients, yet these resources historically underrepresent patients with SOC and marginalize vulnerable populations. In this study, we investigated if this publication bias extends to images depicting patients with lupus. We reviewed published images of patients with lupus from rheumatology, dermatology, and internal medicine textbooks and medical journals, SOC atlases, online image libraries, UpToDate, and Google Images. We selected materials published from 2014 to 2019 that were available through our university's online medical library. We used the search terms “lupus” and “lupus rash” to identify images. We rated the skin color in each image using the New Immigrant Survey Skin Color Scale and categorized them as light, medium, or dark. We compared the frequencies of published skin tones with chi‐square and odds ratio analyses. We assessed the skin tone of 1,417 images. The significant majority (56.4%) of the images represented light skin (χ2= 490.14, P< 0.001). After SOC atlases, journals were the most inclusive of images depicting dark skin tones. The specialty of dermatology was most inclusive of medium and darker skin tones. Published images of lupus underrepresent patients with SOC, which may limit providers' ability to deliver care to the patients who are at greatest risk for complications.