By Marianne Matthews
When Amy McMichael, MD, first joined the dermatology department at Wake Forest Baptist Medical Center, she wanted to do a research project on psoriasis in African Americans. One of her colleagues at the time—an epidemiologist and family practice physician—was puzzled by her topic because he was convinced that African American patients don’t get psoriasis.
“That was within the first couple of years that I came here, and I realized, ‘I’ve got a lot of work to do,’?” McMichael says.
In fact, it was some 20 years ago, and McMichael hasn’t stopped working since. In a sense, she is still debunking that psoriasis myth in her ongoing quest to educate physicians, patients, and decision-makers on Capitol Hill about important issues associated with the treatment of skin of color.
As professor and chair of the Department of Dermatology at Wake Forest, McMichael leads a team that cares for approximately 45,000 patients a year. She personally sees as many as 35 patients a day, several times a week. And, she runs clinical trials on alopecia, seborrheic dermatitis, psoriasis, and other conditions that affect the scalp. What’s more, McMichael presently serves as the president of the Skin of Color Society (SOCS), a professional dermatologic organization dedicated to promoting awareness of and excellence within this special interest area of dermatology.
A dedicated physician and researcher, McMichael’s deepest calling is as an educator and mentor. She is most passionate about giving back to the next generation and about teaching others how to approach the art of medicine. At Wake Forest, she oversees nine residents a year and calls her work with them her “biggest and most important accomplishment” during her tenure there.
“I try to impart to them how to think about patients with skin of color, and how you might treat them differently than someone who is very fair with the same skin disease; why you might recommend one thing for them and something else for someone who is not very pigmented; and culturally, what might work and what might not work for their conditions,” McMichael says.
By all accounts, she is doing a stellar job at motivating young doctors. “Each week I observe Dr McMichael’s unique combination of academic excellence, clinical expertise, and genuine compassion for her patients. She is an outstanding teacher. Working with her in clinic is a phenomenal learning experience,” says Rechelle Tull, a third-year medical student at Wake Forest University School of Medicine.
Changing Demographics, Need for Training
The time has come for the dermatology community to embrace diversity. The fact is, treating skin of color will soon be commonplace for dermatologists, rather than a niche or special interest. By 2060, 31% of the US population will be Hispanic, 15% African American or black, and 8.2% Asian, according to US Census Bureau projections.
“More and more, we’re all going to have to know how to address these patients. As educators, we need to be more aware about teaching how to treat everyone,” McMichael says.
Pigmentary diseases, inflammatory diseases that cause pigmentation problems, and hair loss are among the key medical dermatological concerns for skin of color patients, McMichael says. A team at Wake Forest looked at National Ambulatory Survey data and found, for example, that African Americans ranked acne, eczema, psoriasis, and alopecia among their top 10 dermatologic concerns.
While young dermatologists will certainly encounter these diseases in their training, how each condition is effectively treated in skin of color patients versus fair-skinned patients can be quite different. Moreover, some diseases, like psoriasis, do not even look the same in the two patient populations, which is why it is often misdiagnosed in skin of color patients.
As with the general population, cosmetic dermatology is becoming more of an interest with skin of color patients, too. Here again, McMichael says the right training is critical. “We need to be judicious about when and how to perform these cosmetic procedures, and make sure we’re not causing more damage like scarring and pigmentation alteration,” McMichael says.
“If you’re not experienced with skin of color, you can actually do things that can be quite harmful. It’s important to really know your stuff when addressing skin of color, especially with lasers and also fillers and Botox,” McMichael says. “You do approach the face differently, because the face ages differently when you are deeply pigmented versus fair. So there are different ways you want to address making the person look more youthful or relaxed.”
While there have been early pioneers, prior to the establishment of SOCS in 2004 there was no coalition or coordinated effort to push the field forward. But over the past decade, interest has grown and the skin of color movement has made slow, steady progress.
Currently, McMichael says, there is a “collision of things” happening simultaneously which is helping to bring better treatments and drive greater awareness about skin of color concerns. For example, several major institutions have opened skin of color centers, including the Henry Ford Multicultural Dermatology Clinic, Northwestern University’s Center for Ethnic Skin, and Johns Hopkins Ethnic Skin Program. Each institution has identified its own unique goals, with some more involved in research, others in patient care, McMichael says. The momentum is building, and McMichael anticipates that more centers will undoubtedly debut in the near future.
At the same time, the American Academy of Dermatology (AAD) created a diversity task force some years ago with a mentorship program. “The AAD recognizes that it is the group that needs to spearhead the training of more doctors who have this interest, and who are doctors with skin of color to make sure that our group of doctors looks like the patients that come to see us,” McMichael says.
Then there is SOCS, which has grown from just a 20-physician group to an international organization. “As an organization, we are focused on how to deliver the best care possible, how to increase access to the care that we’re delivering, and how to get around complications and side effects that we run into when we treat skin of color patients,” McMichael says.
The organization is also advocating on behalf of patients on Capitol Hill. In the fall of 2015, for example, McMichael joined forces with the National Psoriasis Foundation to educate members of Congress about what psoriasis is and help persuade them to increase federal funding for psoriatic disease research in the skin of color patient population.
In general, McMichael says, research grants for skin of color projects have been few and far between, calling it an “amazingly underserved” area. “Even basic research needs to be done in people with pigmentation—or with these models—because we really don’t have a good platform of research looking at diseases in skin of color.”
More Work to Be Done
While various groups have made strides in advancing the skin of color agenda, each operates independently and one group is not necessarily always informed about the others’ activities. McMichael sees a need to document the progress made to date. To that end, she and her student, Rechelle Tull, are working on a project to compile and evaluate the clinical, educational, and research efforts of all skin of color groups.
McMichael views the end product as a sort of compendium that will bring the various factions together in a more cohesive manner and ultimately, foster collaboration. “It’s a matter of getting the word out about what’s going on, documenting what’s important and what’s happened over the years, and a way for all of us to be on the same page and level of understanding about where we need to go from here,” McMichael says.
There’s no doubt that McMichael knows where she needs to go from here. With another year remaining in her term as president of SOCS, she is focused on three key goals: working with Congress to raise funds for research; developing grassroots programs for patients; and raising awareness through the media.
“Getting in front of Congress about a number of different topics regarding skin of color treatment and research is going to be very important,” McMichael says.
Patient advocacy efforts are critical, too. She wants to find more feasible ways for SOCS to help patients in their own communities. For example, she might build on an existing school-based program led by a SOCS member in Chicago or create brand-new initiatives. “Before I leave, I’d like to see an actual program up and running with the Skin of Color moniker so you can just get the paperwork and start the program any place in the country.”
Finally, spreading the word is a top priority. SOCS held its first media day in New York City in December 2015, and the event was an overwhelming success. McMichael foresees the organization engaging more actively with the media to raise awareness and also to dispel the many myths surrounding skin of color.
For more than 2 decades, McMichael has unfailingly dedicated herself to a singular mission: advancing the understanding of and treatment of skin of color.
While she shows no signs of letting up anytime soon, perhaps her greatest contribution lies in inspiring others to follow in her footsteps. “I view Dr McMichael as my mentor because she is the complete representation of the physician I aim to be,” Tull says. Mission accomplished, Dr McMichael.
Marianne Matthews is a contributing writer for Plastic Surgery Practice magazine. She can be reached via [email protected].