Leandra Barnes, MD, was a third-year medical student rotating through a dermatology elective when she encountered a patient with hidradenitis suppurativa -- a condition that causes painful lumps deep in the skin and, without treatment, can lead to dangerous infection and even disability.
Though Barnes had never heard the name of it, she immediately recognized hidradenitis suppurativa. Friends and family members back home in Georgia and Alabama had struggled with the condition, which disproportionately affects Black women. But no one she knew had known it fell within a concrete diagnosis and had a recommended set of treatment options. They had missed out on getting appropriate care, Barnes realized.
While skin comes in many different shades, dermatologists in the United States are overwhelmingly white -- only about 3% are Black and about 4% are Hispanic -- and mostly trained to treat white skin. That leads to frequent misdiagnoses and lack of adequate treatment for people of color, according to a 2020 report by the New York Times.
As the largest organ in the body, skin plays a critical role in protecting us from external threats, regulating our internal temperature, sensing the world around us, and ensuring the growth of healthy hair and nails (both appendages of the skin).
Before starting medical school, Barnes hadn't thought much about dermatology. But during that third-year elective she began to imagine the good she could do by dedicating her career to helping close those kinds of health care access gaps. She decided to specialize in researching and treating a broad range of dermatological conditions, including hidradenitis suppurativa, skin cancer and others that more commonly impact people of color.
Now as a Stanford Health Care dermatologist, Barnes is in the throes of launching Stanford Medicine's first Skin of Color program. The initiative, to which Barnes is already dedicating half of her patient visits, is designed to provide a welcoming environment for patients and culturally sensitive treatment of diverse skin conditions, while also advancing research, training and advocacy aimed at addressing health care disparities in dermatology. We caught up with her to discuss her inspiration and goals for the program.
This interview has been edited for clarity and brevity.
What does dermatology mean to you?
When I started medical school, I had perhaps written dermatology off as "Oh, it's just mainly cosmetics." But it's so much more than that. We deal with everything from life-threatening issues such as skin cancer and systemic autoimmune conditions to things that affect patients' physical comfort, self-perception and sense of belonging. There's a huge range of mental and physical health issues that we take into account.
We deal with everything from life-threatening issues such as skin cancer and systemic autoimmune conditions to things that affect patients' physical comfort, self-perception and sense of belonging.
Leandra Barnes
Growing up, I personally didn't even know that dermatology would serve me or people who look like me. So being able to change that perception and encourage people to seek the help they deserve from medical providers is really important to me.
What made you feel that dermatology wasn't something that might serve you?
A lot of the campaigns for skin cancer screening tend to be targeted to people with fairer skin who are most likely to badly burn when they go out in the sun. While it's certainly important to target those people, it's also critical to consider that people with darker skin shades also suffer from skin cancer.
Actually, even though they may beless likely to get skin cancer, Black and Hispanic patients are also much more likely to be diagnosed late, and to die from that cancer. Despite that, when I was younger, I didn't know that I needed to think about my risk for skin cancer and I had no idea what the signs of it would be. None of the providers I saw encouraged me to think about it.
I also had an experience in college where I went to a dermatologist because I was losing hair. I now know that it was because of iron deficiency, probably in addition to stress and lack of sleep. But the dermatologist fixated on how often I washed my hair and pegged that as the cause. As a Black woman, I wash my hair weekly or every two weeks -- too much more than that would cause it to get very dry and literally start to break off.
Now that I'm a dermatologist, I know that there are so many factors that can impact your hair health.
Leandra Barnes
Now that I'm a dermatologist, I know that there are so many factors that can impact your hair health: iron deficiency; vitamin D, B12 and zinc levels, your thyroid health. There are also forms of scarring hair loss that are driven by the immune system. Those are all factors that the person who saw me probably should also have thought of, but sometimes it's just easier to blame a patient.
Unfortunately, there are a lot of conditions in dermatology where there's a stigma involved and a potential to blame the patient. I just love being the one in the room who can say, "This is not your fault. There are things we can do, so let's work together to address this."
And now you're launching your own Skin of Color program. What are the goals of the program?
The program has four pillars: culturally dexterous care, research, teaching and community outreach that emphasizes advocacy. We want to make sure, first of all, that we are creating a safe space for patients to seek care. Whether the patient might be Black, Hispanic or Latino, Asian, American Indian, Hawaiian and Pacific Islander or another ethnic or racial minority, they know they are seeing dermatologists who focus on issues as they affect that individual patient.
We also want to keep advancing research on conditions that have been underinvestigated because they affect populations of people who are underrepresented in research. We also want to provide teaching and training to make sure new and current doctors are learning about and recognizing conditions in darker skin tones.
We also want to provide teaching and training to make sure new and current doctors are learning about and recognizing conditions in darker skin tones.
Leandra Barnes
Our last pillar, outreach with advocacy, involves visiting community centers, such as hair and nail salons, to encourage service providers to be on the lookout for certain symptoms and to let people know that there are specialists available who can serve them if they are having a problem. It also means eventually becoming a source of advocacy against policies that could be harmful to our patients.
What kind of harmful policies have you come across that you could imagine incorporating into your advocacy?
Step therapy -- a cost-containment strategy used by insurance policies-- is a really tricky thing for me right now. It's a policy that can require a patient to try a lower-cost medication before "stepping up" to what I've originally prescribed only after the lower-cost medication is shown not to work. Sometimes it requires me to prescribe a drug that has side effects I don't want my patients to experience.
This is a challenge with all patients but, when it comes to vulnerable groups, it just adds another barrier that could make patients less trusting and more likely to give up on pursuing care. It also tends to really affect conditions like hidradenitis suppurativa, where awareness is lacking, and there are limited FDA-approved medications -- meaning it's harder to get insurance companies to sign off on them.
There are also cases where insurance won't cover a certain treatment because it's considered "cosmetic." It's important to look at what we define as cosmetic and who is bearing the impact of not having that covered. For example, things like melasma and vitiligo -- which both can cause patches of skin discoloration on the face and disproportionately impact people with dark skin tones -- are often classified as cosmetic, whereas something like rosacea -- which causes reddened patches and sometimes pimples on the face and can be more readily diagnosed in fair-skinned people -- typically is not.
Why is Stanford Medicine a good place to launch a Skin of Color program?
Having been here since 2013, I've really seen how Stanford is fertile soil. Even if something doesn't exist yet, there are always a lot of people who are passionate and want to help you take a new idea and run with it. There's also a strong emphasis on minimizing health care inequities. It's very aligned with my values in that way, so it's honestly a perfect place to be doing this.
Photo: Emily Moskal
