Human skin is an amazing and vital part of the body. It is the largest organ and accounts for around 16% of body weight. It reacts to pressure, transmits sensation and responds to touch; it regulates our body temperature, regenerates daily and, importantly, it is the first thing that others see when they look at us. The skin's melanin content dictates the pigment of the skin, and it is often this that defines what others see. Sadly, variation in pigment also needs to be understood in the context of racism, prejudice and discrimination.
Wound care, tissue viability and dermatology are all important areas of clinical care delivery that have skin as their focus. Breaks in the skin or wounds affect many people; indeed, in 2012/13, some 2.2 million patients presented to a health professional with a wound (Guest et al, 2015). Wounds impact significantly on an individual's quality of life and their day-to-day functioning; they are often painful, and require cleansing, dressing and reviewing by a range of health professionals.
Recent attention towards the skin, energised by the ‘Black Lives Matter’ movement, may have prompted a watershed moment and encouraged us to make a tangible difference to a range of fundamental areas of clinical care, not least the care of patients' skin. Indeed, to this end, Malone Mukwende, a second-year medical student at St George's, University of London, has created a handbook entitled ‘Mind the Gap’, to show how disease appears on darker skin. This handbook is awaiting publication and was developed in response to the author being taught predominantly about the diagnosis of conditions in white patients.
I am an academic with considerable experience in the area of wound care, and recent work within my institution to decolonise the curriculum has highlighted to me an urgent need to decolonise my area of expertise—wound care. Following a decolonising session I helped to facilitate, I reflected on my involvement in wound care over the years and had to acknowledge that my delivery of education in this area has tended to have a ‘white skin’ bias, not through any conscious intent but influenced by the limited resources available, my lack of insight that this was an issue and, to an extent, a genuine fear of offending someone if the wrong language was used. Any search of wound-care textbooks, online resources, publications and wound images available on the internet reveals an almost complete absence of images of wounds on black or brown skin and scant attention to differences in presentation; this is despite Black, Asian and minority ethnic groups making up 14% of the UK population (UK Government, 2018).
Wound-care education for health professionals of all disciplines teaches the recognition of a variety of diagnostic indicators that aid in wound assessment. These indicators support decisions about the wound type, level of bacteria, perfusion and the condition of the surrounding skin. However, all of these indicators are fundamentally linked to the pigment of the patient's skin and, as such, may not be apparent for those whose skin is not white. Such indicators include erythema, cyanosis, inflammation, discolouration, blanching and scarring, among others. The presentation of wound-specific diagnostic indicators will be considerably different on black and brown skin; yet, this barely, if ever, gets a mention, even within reputable textbooks.
If we are to fully equip health professionals to care for all, irrespective of race, we need to address this considerable oversight in the wound-care curriculum. We need to work together to ensure that educational resources that support the provision of optimal care for the body's largest organ truly reflect the diversity of the population.