Setting the bar for skin of colour expertise - why it matters in legal proceedings
Almost one in five people in England and Wales identifies as belonging to a Black, Asian, mixed or other ethnic group, according to the 2021 Census. This diversity has important implications for dermatology, particularly when recognising and interpreting clinical signs in patients with different levels of skin pigmentation.
For legal practitioners involved in clinical negligence claims, personal injury litigation or other cases requiring dermatological evidence, an important question arises: does the medical expert have the knowledge and experience needed to recognise dermatological conditions across the full spectrum of pigmentation?
Why skin pigmentation matters
In dermatology, skin of colour (SOC) refers to a diverse range of skin pigmentation rather than a single skin type or ethnic group. Higher levels of epidermal melanin (richly pigmented skin) can influence how certain clinical signs appear, potentially making them more difficult to recognise.
Erythema, a common sign of inflammation, illustrates the issue. In lighter skin, it typically appears red or pink. In more richly pigmented skin, however, the same inflammatory process may present as subtle darkening or violaceous, greyish or brownish discolouration.
The underlying inflammation has not necessarily changed; its visible appearance may simply be different because of the optical properties of skin. If a clinician is unfamiliar with these variations, an important diagnostic sign may be overlooked, potentially resulting in a missed or delayed diagnosis.
For legal practitioners, this raises a significant question when considering the adequacy of clinical assessment and the reliability of subsequent expert evidence.
What constitutes expertise in skin of colour (SOC) dermatology?
TLA expert Dr Ophelia Entsir Dadzie, Consultant Dermatologist and Dermatopathologist, has tackled this issue head on in a new paper/publication in the British Journal of Dermatology. Written with Dr Antoine Petit, a retired consultant dermatologist from Saint-Louis University Hospital in Paris, it considers what should constitute expertise in SOC dermatology and how such expertise should be recognised and maintained as the field develops.
The authors propose three key components of expertise:
Knowledge: A comprehensive understanding of dermatology across the full spectrum of skin pigmentation, including relevant disciplines such as dermatopathology.
Experience: Appropriate training, mentorship and sustained clinical exposure to patients with diverse skin pigmentation, enabling clinicians to recognise and interpret presentations that may differ from conventional descriptions.
Contribution: A meaningful contribution to the development of the field through research, teaching, guideline development or professional leadership.
The authors are clear that expertise should not be inferred from a clinician's ethnicity or skin colour. Lived experience may offer valuable insight, but it is not a substitute for relevant training, clinical experience, continuing professional development and scholarly contribution.
They also recognise that SOC dermatology is not geographically or culturally uniform. Regional, environmental and cultural factors can influence clinical presentations and practice, meaning that expertise may take different, complementary forms. Maintaining expertise also requires objectivity, up-to-date knowledge and awareness of potential conflicts of interest.
What does this mean when instructing a medical expert?
For solicitors and barristers, the implications are practical. When a case involves a patient with darker or richly pigmented skin, it may be necessary to consider whether the proposed dermatological expert has the relevant knowledge and experience to interpret the clinical findings reliably.
Being a qualified dermatologist does not answer every question about an expert's suitability for a particular case. Equally, an expert's own skin colour or ethnicity should not be treated as evidence of specialist competence.
Instead, practitioners should consider the nature of the issues in dispute and whether the expert's training, clinical experience and knowledge are appropriate to the questions they have been asked to address.
Depending on the circumstances, relevant questions may include:
Does the expert have experience recognising dermatological conditions across different levels of skin pigmentation?
Are they familiar with how pigmentation can affect the visibility and interpretation of clinical signs?
Have they considered whether conventional clinical descriptions are applicable to the patient's presentation?
Can they explain the basis of their interpretation and identify any relevant limitations in the available evidence?
These considerations may be particularly important where the interpretation of a clinical sign is central to the alleged breach of duty, the timing of diagnosis, causation or the assessment of injury.
Recognising the limitations of traditional clinical descriptions
The authors also draw attention to the historical development of dermatology. Many traditional clinical descriptions and diagnostic frameworks were developed predominantly in Europe in the eighteenth and nineteenth centuries, based on observations of lighter skin.
As a result, familiar diagnostic descriptions may not always translate directly to patients with more richly pigmented skin. This does not mean that every difference in presentation is attributable to pigmentation. Rather, clinicians must distinguish between changes in the visibility of clinical signs and differences that may have other explanations.
For legal practitioners, this distinction matters when evaluating expert opinions. An explanation based on conventional descriptions of a condition should be considered in the context of the patient's actual presentation, including whether skin pigmentation may have influenced what was visible and how it was interpreted.
A more informed approach to expert evidence
The central message is not that SOC dermatology should be treated as an entirely separate discipline, or that every case involving a patient with richly pigmented skin requires a specialist in this field. It is that dermatological expertise must be appropriate to the clinical questions being addressed.
For medico-legal practitioners, this means looking beyond professional titles and considering the specific knowledge, experience and critical understanding that underpin an expert's opinion. Where skin pigmentation may affect the recognition or interpretation of clinical signs, these factors should form part of the assessment of the expert's suitability and the evidence they provide.
Ultimately, reliable expert evidence depends on the ability to recognise and interpret disease across the full spectrum of human skin pigmentation. A more informed approach to SOC dermatology can help legal practitioners ask the right questions when instructing experts and evaluating the evidence on which clinical negligence and other medico-legal claims may turn.
Dr Dadzie is a consultant dermatologist at the Hillingdon Hospitals NHS Foundation Trust and a trained dermatopathologist and previous lead of the Dermatopathology Service at The North West London Pathology Center, a joint venture across three London NHS trusts.
Read Dr Dadzie's full Consultant Spotlight here.