COVID-19-Related Skin Changes: The Hidden Racism in Documentation

Graeme M. Lipper, MD


July 27, 2020

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Belatedly, the disproportionate impact of COVID-19 on patients of color is getting attention. By now, we've read the headlines. Black people in the United States make up about 13% of the population but account for almost three times (34%) as many deaths. This story repeats — in other countries and in other minority communities.

Early detection is critical both to initiate supportive care and to isolate affected individuals and limit spread. Skin manifestations of COVID-19, especially those that occur early in the disease (eg, vesicular eruptions) or have prognostic significance (livedo, retiform purpura, necrosis), are critical to this goal of early recognition.

In this context, a recent systematic literature review looked at all articles describing skin manifestations associated with COVID-19. The investigators identified 46 articles published between March and May 2020 which included a total of 130 clinical images.

Their findings are striking:

  • 92% of the published images of COVID-associated skin manifestations were in Fitzpatrick skin types I-III.

  • Only 6% of COVID skin lesions included in the articles were in patients with skin type IV.

  • None showed COVID skin lesions in skin types V or VI.

  • Only six of the articles reported race and ethnicity demographics. In those, 91% of the patients were White and 9% were Hispanic.


These results reveal a critical lack of representative clinical images of COVID-associated skin manifestations in patients of color. This deficiency is made all the more egregious given the fact that patients of color, including those who are Black, Latinx, and Native American, have been especially hard hit by the COVID-19 pandemic and suffer disproportionate disease-related morbidity and mortality.

As the study authors point out, skin manifestations in people of color often differ significantly from findings in white skin (for example, look at the figure depicting the rash typical of Kawasaki disease in a dark-skinned child compared with a light-skinned child). It is not a stretch to suggest that skin manifestations associated with COVID-19 may look very different in darker skin.

Figure. Kawasaki disease in a dark- and a light-skinned child.

These investigators have identified a damning lack of images of COVID-19–associated skin manifestations in patients with darker skin. This isn't a new phenomenon. Almost half of dermatologists feel that they've had insufficient exposure to skin disease in darker skin types. Skin of color remains underrepresented in medical journals.

Like other forms of passive, institutional racism, this deficiency will only be improved if dermatologists and dermatology publications actively seek out COVID-associated skin manifestations in patients of color and prioritize sharing these images. A medical student in the United Kingdom has gotten the ball rolling, compiling a handbook of clinical signs in black and brown skin as part of a student-staff partnership at St George's Hospital and the University of London. Mind the Gap is looking for a publisher.

Graeme M. Lipper, MD, is a clinical assistant professor at the University of Vermont Medical College in Burlington, Vermont, and a partner at Advanced DermCare in Danbury, Connecticut.

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