Race vs Ethnicity in Dermatology

In a recent editorial, Dr Williams¹ challenges the biologic validity of the concept of race, usually defined in North America and Europe in terms of skin color. He goes on to suggest that dermatologist investigators describe the subjects of their research in terms of "self-nominated ethnic group" rather than race or arbitrary classifications such as Asian/Pacific Islander.

For much of medicine, classification of patients according to externally apparent physical characteristics such as skin color is probably most relevant when the clinician is considering how signs of disease, response to treatment, and prognosis are influenced by social factors, such as access to health care, that are undeniably impacted by "race."² I would argue, however, that dermatology is the one discipline of medicine in which the relationship between race and manifestations of disease is a legitimate subject for scientific inquiry. Obviously race, defined in terms of skin color, is one of the most important factors that affect an individual's risk of developing skin cancer. Basal cell carcinoma, for example, ranks among the most common of all malignancies that occur in whites, yet is exceedingly rare in blacks. Race is also a critical factor in the response of the skin to inflammation: postinflammatory melanosis is one of the most common problems blacks present to dermatologists, while very lightly pigmented whites rarely experience it. Indeed, it is race, reflecting the quantity and distribution of melanin in the skin, that often determines whether a patient will be a suitable candidate for certain forms of dermatologic therapy—laser therapy being but one example. And the importance of race as a risk factor for cutaneous disease is not necessarily limited to diseases in which the melanin pigmentary system is known to play an essential role. Blacks are far more likely than whites to develop keloids, just as they are more susceptible to certain forms of inflammatory scalp disease such as dissecting cellulitis and its variants.

Now, if it is skin color that really concerns us as dermatologists, would it not make more sense for patients to be described using colorimetry measurements rather than observer-designated racial categories? Yes . . . and no. Without question, colorimeters have significantly enhanced our ability to make objective, quantitative statements about skin color. However, in terms of conceptual simplicity and lack of expense, racial classification as a means of communicating information about skin types remains an extremely useful if crude tool, both for the investigator and the clinician at the bedside who needs to be able to readily apply research findings to patients.

As Dr Williams points out, there is much to be gained by the examination of how skin disease is affected by ethnicity. That is not to say, however, that self-designated ethnicity is a valid substitute for race. The effects of both of these often intimately related yet very different attributes on skin disease are worthy of study.

The author has no relevant financial interest in this letter.