The research, led by Ou Jia Emilie Wang and Quinn Stewart of the Faculty of Medicine at the University of British Columbia together with Jincheng Shi of the Division of Dermatology at The Ottawa Hospital and the University of Ottawa, was structured as a research letter but carries the weight of a large-scale audit. Two independent reviewers went through the figure collections of seven textbooks that are widely used in dermatologic surgery training, classifying every image by Fitzpatrick skin type and recording the associated diagnoses, procedures, and pigmentation findings. The Fitzpatrick scale, originally developed in 1975 to standardize responses to ultraviolet light, remains the dominant classification framework in dermatology despite well-documented limitations, and its six-category spectrum from type I, pale skin that always burns, to type VI, deeply pigmented skin that never burns, provided the study’s core metric.

The aggregate figure of 8.7 percent conceals a steeper drop-off in the subspecialties where visual pattern recognition matters most. Images depicting skin of colour were scarcest in Mohs micrographic surgery, the tissue-sparing technique for skin cancer removal, where they accounted for just 1.5 percent of figures. Facial reconstruction fared worst of all at 0.6 percent, followed by tumour imagery at 2.4 percent and wound care at 3.2 percent. These are precisely the domains in which surgeons must judge erythema, margins of inflammation, postoperative pigmentary change, and scarring patterns against a baseline that differs fundamentally from the pale skin that dominates the literature.

The clinical stakes of this visual deficit are not abstract. In highly pigmented skin, erythema may appear subtle or violaceous rather than bright red, making the early recognition of infection, flap ischemia, or allergic contact reactions considerably harder for a trainee who has never seen these presentations. Post-inflammatory hyperpigmentation and hypopigmentation, both common sequelae of surgical trauma in skin of colour, follow different courses and respond to different interventions than in lighter skin. Keloidal scarring, which occurs disproportionately in genetically darker skin, demands different surgical planning and adjunctive therapy. A recent systematic review of post-inflammatory hyperpigmentation treatment in skin of colour, cited by the authors, underscores how much of the evidence base itself is built on studies that under-recruit darker-skinned patients, compounding the textbook gap at every level of the educational pipeline.

The consequences extend into oncology. Acral lentiginous melanoma, the subtype that arises on the palms, soles, and nail apparatus, occurs at similar rates across populations but is disproportionately represented among people with darker skin, precisely because ultraviolet-driven melanomas are rarer there. Yet because educational imagery overwhelmingly shows melanoma on light skin, delayed diagnosis of acral lesions remains a documented driver of the survival gap, with population-level analyses from the United States showing worse outcomes for this subtype dating back decades. When a surgical textbook shows a trainee one hundred examples of melanoma and only a handful on brown or Black skin, the pattern-matching machinery of clinical judgment is calibrated accordingly.

The authors also flagged a structural problem that goes beyond simple counts: the near-total absence of standardized Fitzpatrick skin type labelling in the figures themselves. Without explicit labelling, readers cannot reliably identify which images depict which skin types, cannot gauge representation in any given chapter, and cannot use the images for calibrated self-testing. The lack of standardized annotation limits the educational value of whatever diverse imagery does exist and makes it difficult for publishers to track progress over time. In effect, the audit found both a quantitative shortfall and a qualitative infrastructure problem, since even the minority of skin-of-colour images are not systematically curated, tagged, or indexed for teaching purposes.

The new study builds on and extends a growing body of audit literature. A widely cited 2021 cross-sectional analysis published in the Journal of the American Academy of Dermatology by Alvarado and Feng found similar underrepresentation of dark skin in educational resources for common dermatologic conditions, helping to catalyze a wave of similar audits across journals, board review materials, and medical school curricula. The present analysis is notable for focusing specifically on dermatologic surgery, a procedural discipline in which the visual baseline matters not only for diagnosis but for intraoperative decision-making, and for its sheer scale, with more than three thousand figures classified by two independent reviewers rather than sampled or estimated.

The disparities documented in the textbooks mirror documented inequities in care. A 2025 comprehensive review of disparities in surgical site infection diagnosis and management in highly pigmented skin tones, cited in the study, describes how delayed recognition of infection in darker skin contributes to worse outcomes, while work on Mohs micrographic surgery in skin of colour has highlighted both the technical adaptations required and the scarcity of guidance available to surgeons. Educational materials are not the sole cause of such disparities, but they are a modifiable upstream factor: a resident who trains exclusively on images of light skin enters practice with a systematically skewed prior, and no amount of individual goodwill fully compensates for a curriculum that never showed them the relevant presentations.

The authors argue that deliberate, structured inclusion of skin of colour in surgical dermatology resources is necessary to support diagnostic accuracy and promote more equitable care. In practice, that means commissioning and licensing clinical photography that represents the full Fitzpatrick spectrum, standardizing skin type labelling across figures, and prioritizing the subspecialty areas where the deficit is most acute, particularly facial reconstruction and Mohs surgery. Some publishers and educational platforms have begun such initiatives in response to earlier audits, but the new data suggest that the field’s foundational textbooks, the reference works against which trainees are examined, have not yet caught up. The study’s authors received no external funding for the analysis and declare no competing interests.

As dermatology confronts a demographic reality in which the majority of the global population has pigmented skin, and as populations in North America and Europe grow increasingly diverse, the visual canon of the specialty is under pressure to change. The message of this audit is quantitative and unambiguous: out of 3,334 images across seven authoritative textbooks, fewer than three hundred showed the skin types carried by most of humanity. Closing that gap will require more than good intentions; it will require the same systematic curation, labelling, and editorial accountability that the field applies to its evidence base, so that the next generation of surgeons learns to read every skin the way it has long been trained to read one.

Subject of Research: Representation of skin of colour in dermatologic surgery textbook imagery

Article Title: Skin of colour representation in dermatologic surgery textbooks: an image analysis

Article References: Wang, O. J. E., Stewart, Q., & Shi, J. (2026). Skin of colour representation in dermatologic surgery textbooks: an image analysis. Archives of Dermatological Research, 318(1), Article 385. https://doi.org/10.1007/s00403-026-04853-8

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04853-8

Keywords: dermatologic surgery, skin of colour, Fitzpatrick skin type, medical education, health equity, Mohs surgery, textbook imagery, facial reconstruction, post-inflammatory hyperpigmentation, diagnostic disparity, dermatology training, wound care

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