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Evidence Based Strategies: Recognizing Pediatric Rashes Across Skin Tones

Column Author: Sydney Rogers, MD| Pediatric Resident

Column Editor: Kathleen Berg, MD, FAAP| Medical Director, Office of Evidence-Based Practice, Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Rashes are a common chief complaint in pediatrics. Although these conditions are frequently benign and self-limiting, some can be evidence of serious infectious, allergic, rheumatologic, or neurocutaneous disorders, or even non-accidental injuries, that require early intervention. In many cases, accurate diagnosis depends heavily on recognizing a rash based on its appearance and the patient’s history.

It is important to understand that rashes can present differently across various skin tones. For example, a rash that appears red on light skin may look purplish or hypopigmented on darker complexions. Despite this, most medical textbooks and online resources predominantly feature images of dermatologic conditions on lighter skin tones.

One study reviewed over 4,000 images from widely used medical textbooks — including the Atlas of Human Anatomy, Bates’ Guide to Physical Examination and History Taking, Clinically Oriented Anatomy, and Gray’s Anatomy for Students. Despite the U.S. racial demographics being approximately 62% white, 20% Black, and 17% other people of color, the textbooks featured dermatologic images on 75% light skin, 21% medium skin, and only 4.5% dark skin tones.1 Other studies have reported similar representation. From 2006 to 2020, the proportion of images in dermatology textbooks portraying darker skin tones remained consistent, 4%-18% of images depending on the textbook.2,3 Perhaps most concerning is a disparity based on diagnosis, with a disproportionate representation of darker skin tones in images depicting signs of sexually transmitted infections or non-accidental trauma.2,4

This underrepresentation of darker skin tones has real clinical consequences. A study conducted in Australia assessed health care professionals’ ability to identify pediatric dermatologic conditions on darker skin tones. Participants scored an average of just 50%, and only 11% met the passing threshold of 80%.5 Studies focused on specific dermatologic diagnoses are also revealing. While patients of color with systemic lupus erythematosus are at greater risk of severe complications, their images are less frequently found in textbooks, journals and online image libraries.6 In a review of 93 textbooks and three online image databases, images of dermatomyositis in those with darker skin tone were underrepresented compared to those with lighter skin tone.7 Evidence also suggests that patients with dark complexions may not be diagnosed with or treated for dermatomyositis as quickly as those with light complexions.8 While this delay is likely multifactorial and causation cannot be applied to the textbook images, or lack thereof, it highlights the importance of diagnostic tools that work for all skin types.

To address these gaps, multiple resources are available that can help clinicians identify rashes, including showing how the conditions may appear on darker skin tones:

Red Book Atlas of Pediatric Infectious Diseases:

This is an image companion to the Red Book, with hundreds of detailed images for pediatric infectious disease diagnoses. It provides additional information for each diagnosis by discussing clinical manifestations, etiology, epidemiology, diagnostic testing recommendations and treatment.9

VisualDx:

This clinical decision support tool helps practitioners build a differential diagnosis. It features thousands of peer-reviewed images, many of which can be filtered by skin tone, allowing clinicians to see how conditions may appear on different complexions.10

Skin Deep:

Skin Deep is a free, open-access online database of photographs of medical conditions in a range of skin tones that can be used by health care professionals but also the general public. Images can be sorted by description, diagnosis, and even body part. There is also a quiz to help you test your knowledge of the appearance of skin conditions on differing skin types.11

Brown Skin Matters (Instagram):

This Instagram is a social media account that provides photos of different skin conditions on darker skin tones. Many of the photos are user submissions. The goal of the Instagram account is to provide reference photos for dermatologic conditions on skin of color.12

References:

  1. Louie P, Wilkes R. Representations of race and skin tone in medical textbook imagery. Soc Sci Med. 2018;202:38-42. doi:10.1016/j.socscimed.2018.02.023
  2. Kaundinya T, Kundu RV. Diversity of skin images in medical texts: recommendations for student advocacy in medical education. J Med Educ Curric Dev. 2021;8:23821205211025855. doi:10.1177/23821205211025855
  3. Adelekun A, Onyekaba G, Lipoff JB. Skin color in dermatology textbooks: an updated evaluation and analysis. J Am Acad Dermatol. 2021;84(1):194-196. doi:10.1016/j.jaad.2020.04.084
  4. Huntsman A, Pavek A, Shen N, et al. An analysis of the diversity of skin colour representation in paediatric nursing practitioner textbooks. J Adv Nurs. Published online November 9, 2024. doi:10.1111/jan.16614
  5. Shanmugavadivel D, Liu JF, Buonsenso D, Davis T, Roland D. Assessing healthcare professionals’ identification of paediatric dermatological conditions in darker skin tones. Children (Basel). 2022;9(11):1749. doi:10.3390/children9111749
  6. Rana A, Witt A, Jones H, Mwanthi M, Murray J, Zickuhr L. Representation of skin colors in images of patients with lupus. Arthritis Care Res (Hoboken). 2022;74(11):1835-1841. doi:10.1002/acr.24712
  7. Babool S, Bhai SF, Sanderson C, Salter A, Christopher-Stine L. Racial disparities in skin tone representation of dermatomyositis rashes: a systematic review. Rheumatology (Oxford). 2022;61(6):2255-2261. doi:10.1093/rheumatology/keab809
  8. Weisleder H, Valle A, Xie X, Mahmood S. Racial disparities in diagnosis and treatment of patients with dermatomyositis of different skin tones. J Clin Rheumatol. 2024;30(1):8-11. doi:10.1097/RHU.0000000000002031
  9. Baker CJ, ed. Red Book Atlas of Pediatric Infectious Diseases. American Academy of Pediatrics; 2020. doi:10.1542/9781610023511
  10. VisualDx. Accessed May 26, 2025. https://www.visualdx.com
  11. Don’t Forget the Bubbles. Skin Deep. Accessed May 26, 2025. https://dftbskindeep.com
  12. Brown Skin Matters Instagram page. Instagram. Accessed May 26, 2025. https://www.instagram.com/brownskinmatters/?hl=en
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Evidence Based Strategies: Recognizing Pediatric Rashes Across Skin Tones