New Study Examines How Dedicated Dermatology Textbooks Represent Skin of Colour

A new research letter published in the Archives of Dermatological Research has turned the spotlight on an often overlooked corner of medical publishing: the textbooks that are specifically dedicated to ethnic dermatology and skin of colour. The study, led by Melody Li and William Liu of the University of British Columbia together with Jincheng Shi of the University of Ottawa, asks a deceptively simple question with far-reaching consequences for patient care. If the reference books that clinicians reach for when diagnosing conditions in patients with darker skin do not themselves represent a full spectrum of skin tones, then even the most well-intentioned educational resources may fall short of their purpose. The work arrives at a moment when the dermatology community worldwide is grappling with how deeply visual biases are embedded in its teaching materials.

The stakes of this question are anatomical as much as they are social. Dermatology is perhaps the most visually dependent specialty in medicine. A diagnosis of erythema, for example, relies on the recognition of redness, yet redness manifests very differently on pale skin than on deeply pigmented skin, where inflammation may appear violaceous, hyperpigmented, or nearly invisible to the untrained eye. Conditions as common as acne, eczema, psoriasis, and cutaneous lupus can present with subtle colour cues that vary systematically with the amount and distribution of melanin in the epidermis. Melanoma, too, may look markedly different on dark skin, and acral lentiginous melanoma, which arises on the palms, soles, and nail beds, disproportionately affects people with darker complexions. A clinician trained predominantly on images of light skin is therefore at a measurable diagnostic disadvantage when treating the majority of the world’s population, most of whom have intermediate to deeply pigmented skin.

The authors of the new study frame their inquiry within a growing body of literature that has documented persistent representation gaps in mainstream dermatology education. A widely cited 2021 analysis by Adelekun, Onyekaba, and Lipoff published in the Journal of the American Academy of Dermatology evaluated skin colour in dermatology textbooks and found that images of dark skin were substantially underrepresented relative to the composition of the population. That analysis echoed and extended earlier concerns raised by researchers and trainees who noticed that the visual canon of the specialty, accumulated over decades of publishing, skewed overwhelmingly toward lighter complexions. Subsequent work has examined the problem at multiple levels, from medical school curricula to residency training programs to the published literature itself, and has repeatedly found the same pattern: darker skin tones appear less often, appear later in training materials, and appear with less clinical variety.

One response to those documented gaps has been the creation and proliferation of dedicated textbooks on ethnic dermatology and skin of colour. These volumes were conceived precisely to correct the imbalance in general references, assembling clinical photography, pathophysiology, and treatment guidance relevant to patients with richly pigmented skin. There are now several well-established texts in this niche, some of them now in multiple editions, and they have become standard resources for dermatology residents and practicing clinicians who want to improve their diagnostic acumen across the full range of human skin. Given that these books exist specifically to serve populations that general textbooks have underserved, the new research letter poses an important internal question: do these dedicated resources themselves deliver balanced representation across the spectrum of darker skin tones, or do they too have blind spots?

The study, published as a research letter in volume 318 of Archives of Dermatological Research, was designed and conducted by a team spanning two Canadian institutions. Li and Liu, based at the University of British Columbia’s Faculty of Medicine and its Department of Dermatology and Skin Science, carried out the material preparation, data collection, and analysis, while Shi, of the Division of Dermatology at The Ottawa Hospital and the University of Ottawa, contributed to the conception and design of the study. According to the author contributions published with the article, all three authors participated in developing the study concept, commented on earlier versions of the manuscript, and approved the final text. The article was received in October 2025, revised in September 2026, and published on 23 September 2026, following peer review at the long-running dermatological research journal.

Methodologically, research letters in this field typically follow a content-analysis approach: the investigators identify the relevant textbooks, catalog the clinical images they contain, and classify those images by skin tone, often using an established classification system such as the Fitzpatrick scale or the more gradated tools developed specifically to reduce the tendency of observers to lump all darker skin into a single category. Finer-grained classification matters, because treating skin of colour as a monolith can obscure the distinct needs of patients across a wide range of pigmentation levels, from light brown to deep ebony tones. The detailed classification scheme used in the study, along with the underlying data, is provided within the manuscript and its supplementary information files, allowing readers to examine the criteria the authors applied and to replicate or extend the analysis.

Whatever the precise distribution the authors report, the conceptual significance of auditing dedicated textbooks is easy to articulate. Representation gaps in medical imagery are not merely cosmetic. Studies of clinical decision-making suggest that visual pattern recognition is a core component of diagnostic expertise, and that expertise is built through repeated exposure to examples. If a trainee sees twenty images of psoriasis on light skin and two on dark skin, the mental template that forms will be calibrated accordingly. The consequences are tangible: delays in diagnosis, misdiagnosis, and disproportionate disease burden among patients with darker skin have all been documented for conditions ranging from inflammatory disorders to skin cancer. Canadian survey data published in 2022 by Mahmood and colleagues on skin of colour representation in postgraduate dermatology education underscored that trainees themselves perceive these gaps in their formal programs.

The new study also connects to a broader reform movement that has gained momentum in the past several years. Syder and colleagues published a two-part analysis in the Journal of the American Academy of Dermatology documenting gaps in skin of colour content across medical school, residency, and continuing education, describing curricula that treat pigmented skin as an occasional special case rather than an integral part of dermatologic practice. Wilson and colleagues, writing in the International Journal of Women’s Dermatology, analyzed diversity content in the dermatologic literature and issued what they called a call to action, urging journals, educators, and publishers to treat equitable visual representation as a basic quality standard rather than an aspirational goal. Chang and Lipner catalogued resources for skin of colour images to help educators find better material. Against that backdrop, auditing the dedicated textbooks themselves is a logical next step, because these books are the very resources educators turn to when they try to close the gap.

The researchers report that they have no relevant financial or non-financial interests to disclose, and the study was conducted without external funding, which the authors state in their declarations. That independence matters in a conversation that touches on publishing industries with commercial stakes in their back catalogs. Publishers of medical textbooks face real costs in commissioning new clinical photography, obtaining patient consent, and reprinting new editions, and critics have noted that these economic realities can slow the pace at which visual content is refreshed. Independent audits such as this one provide the empirical evidence base that educators, professional societies, and publishers can use to prioritize where new imagery is most needed and to track progress over time.

For clinicians, educators, and patients, the message of the study is ultimately constructive. The existence of dedicated ethnic and skin of colour dermatology textbooks represents real progress in a specialty that for most of its modern history centered its visual teaching on a narrow slice of humanity. Auditing those texts is not an indictment of them but a way of ensuring that the tools built to correct one imbalance do not quietly introduce another. As dermatology’s global patient population continues to demand equitable, expert care, the granularity with which textbooks represent the full spectrum of skin tones will increasingly be seen as a marker of educational quality. The new research letter in Archives of Dermatological Research, available through its publisher with the data supplied in the manuscript and supplementary files, gives the field a rigorous, transparent framework for holding its own most specialized resources to that standard.

Subject of Research: Skin colour representation in dedicated ethnic and skin of colour dermatology textbooks

Article Title: Skin colour representation in dedicated ethnic and skin of colour dermatology textbooks

Article References: Li, M., Liu, W., & Shi, J. (2026). Skin colour representation in dedicated ethnic and skin of colour dermatology textbooks. Archives of Dermatological Research, 318(1), Article 475. https://doi.org/10.1007/s00403-026-04979-9

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04979-9

Keywords: dermatology, skin of colour, medical education, textbooks, health equity, clinical imaging, diagnosis, representation, skin pigmentation, research letter, medical publishing, curriculum gaps