Representation of Fitzpatrick skin phototype in dermatology surgical textbooks

Given the importance of skin of color (SoC) representation in dermatologic education and training, this study quantified representation of Fitzpatrick skin phototypes (FST) in core dermatology surgery textbooks. Images within Surgery of the Skin: Procedural Dermatology, Dermatologic Surgery, and Facial Reconstruction after Mohs Surgery were categorized according to the Fitzpatrick skin phototype (FST) depicted and the dermatologic surgery topic addressed. 1501 images were analyzed, with only 5.6% of the images categorized as FST IV-VI representing SoC. Several topics (11/29, 37.9%) identified did not include images with SoC. Increasing access to high-quality images of SoC can enhance appreciation of various skin conditions, especially those predominant in SoC, by dermatologic trainees and clinicians.


Introduction
The United States is becoming more diverse, yet dermatology textbooks have not reflected this [1]. Studies show that skin of color (SoC) is under-represented in visual and textual medical content, with as little as 4.0-18.0% representation in dermatology textbooks [2]. Given the importance of SoC representation in education and training, this study quantified representation of Fitzpatrick skin phototypes (FST) in core dermatology surgery textbooks.

Methods
All patient photographs in Surgery of the Skin: Procedural Dermatology, Dermatologic Surgery, and Facial Reconstruction after Mohs Surgery were recorded and independently reviewed by two authors. Images were rated according to FST scale (skin types I-VI). Types I-III and IV-VI were designated as non-SoC and SoC, respectively. Animated images, those where discerning skin type was challenging (e.g. images of cadavers or mucosa), depersonalized schematic diagrams, images of internal organs, and duplicate images were excluded. FST was assessed without consulting the figure captions.

Results
Analysis yielded 1501 images. Images were organized into 29 categories ranging from surgical techniques to specific images for skin cancer removal (Table 1). 443/1501 (29.5%) images assessed depicted surgical procedures involving various flaps, comprising the largest portion of the images. Of the images assessed, the majority were classified as depicting skin with FST III (993/1501, 66.2%). 84/1501 (5.6%) images were classified as SoC as represented by FST IV-VI ( Fig. 1). Dyspigmentation and keloids had the greatest number of SoC images, with 1/5 (20%) and 14/16 (87.5%) images respectively. Several topics (11/29, 37.9%) did not include images with SoC.

Discussion
This study demonstrated SoC is underrepresented in dermatologic surgery textbooks. Inclusion of images of SoC is critical to ensure trainee exposure and equitable treatment outcomes for these patients, specifically within laser and cosmetic procedures [3]. Despite only 5.2% of cosmetic images depicting SoC, these patients are known to experience increased inflammation, scarring, and hyperpigmentation  after procedures such as chemical peels, laser, and hair removal [4]. Images of keloids and dyspigmentation comprised approximately 1.4% of the total images assessedsuggesting their inclusion was not of central importance, despite being common conditions faced by those with SoC.
Other dermatology surgical topics such as acne, hidradenitis suppurativa, hair, and nail surgery, are pertinent to SoC populations, but photos were underrepresented in surgical textbooks. Consequently, the exclusion of SoC from these textbooks may perpetuate poorer outcomes and heighten already present health disparities, as exposure by learners and trainees is limited.
Limitations include the use of three dermatologic surgery textbooks. Future studies should expand the methodology to include a greater number of textbooks. Further, FST was originally designed to assess a patient's risk of burning with sun exposure rather than as a proxy for SoC. However, given there is no other standard classification system, FST is commonly used in clinical practice and academia [5].

Conclusion
Exposure to SoC in dermatology textbooks is critical. Increasing access to high-quality images of SoC can enhance appreciation of various skin conditions, especially those predominant in SoC, by trainees and clinicians. Given the current gap, trainees are encouraged to seek out textbooks and medical education that are inclusive of SoC.
Author contributions DCPF and CD were responsible for all data collection and image review. JJ was responsible for the creation of the manuscript and the associated figures. All authors reviewed the manuscript thoroughly and participated in hypothesis generation, methodology, and the completion of the project.
Funding The author(s) received no financial support for the research, authorship, or publication of this article.
Data availability Data is available upon request.