{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,8]],"date-time":"2026-06-08T03:51:33Z","timestamp":1780890693863,"version":"3.54.1"},"reference-count":16,"publisher":"Oxford University Press (OUP)","issue":"4","license":[{"start":{"date-parts":[[2025,10,6]],"date-time":"2025-10-06T00:00:00Z","timestamp":1759708800000},"content-version":"vor","delay-in-days":278,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,9,13]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Objectives<\/jats:title>\n                  <jats:p>Cutaneous manifestations of systemic autoimmune rheumatic disease\u2013interstitial lung disease (SARD-ILD) are clinically useful diagnostic features that can support early diagnosis and management. However, medical education resources often lack diversity in representing skin tones, which lead to inequities in healthcare delivery. Our study aimed to quantify the proportion of skin tones represented in medical literature that depict cutaneous features relevant to SARD-ILD.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>A structured search of medical resources was conducted with the support of North Bristol NHS Trust Library and Knowledge Service. We systemically reviewed images of cutaneous signs associated with SSc, DM and vasculitis. Images that did not depict these conditions were excluded. Each image was assigned a Monk Skin Tone (MST) Scale score (1\u201310). A chi-square goodness-of-fit analysis was used to establish whether the distribution of images was equal.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Sixteen e-resources and 26 textbooks were analysed, yielding 790 images: there were 190 depicting SSc, 401 DM and 199 vasculitis. The chi-square indicated a significantly unequal distribution of images across skin tones (P\u2009&amp;lt;\u20090.001), a pattern that persisted across all conditions. Furthermore, there was no significant improvement in skin tone representation from 2009 to 2022 (median skin tone category 1\u20132).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>There is persistent underrepresentation of people of global majority in educational resources, despite evidence of higher disease prevalence and severity among individuals with darker skin tones. Increasing the inclusion of diverse skin tones in medical imagery is essential to enhancing diagnostic accuracy, reducing health disparities, and improving clinical outcomes.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/rap\/rkaf114","type":"journal-article","created":{"date-parts":[[2025,10,6]],"date-time":"2025-10-06T13:30:26Z","timestamp":1759757426000},"source":"Crossref","is-referenced-by-count":1,"title":["Analysis of the representation of skin tone diversity amongst medical resources illustrating dermatological manifestations of dermatomyositis, systemic sclerosis and vasculitis"],"prefix":"10.1093","volume":"9","author":[{"given":"Stacey","family":"Kihumba","sequence":"first","affiliation":[{"name":"Bristol Medical School, University of Bristol , Bristol,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9787-0739","authenticated-orcid":false,"given":"Giles","family":"Dixon","sequence":"additional","affiliation":[{"name":"Bristol Interstitial Lung Disease (BILD) Service, North Bristol NHS Trust , Bristol,","place":["UK"]},{"name":"Department of Clinical & Biomedical Sciences, University of Exeter , Exeter,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8683-3358","authenticated-orcid":false,"given":"Matthew","family":"Wells","sequence":"additional","affiliation":[{"name":"Bristol Interstitial Lung Disease (BILD) Service, North Bristol NHS Trust , Bristol,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0352-665X","authenticated-orcid":false,"given":"Sarah","family":"Rudd","sequence":"additional","affiliation":[{"name":"Library and Knowledge Service, North Bristol NHS Trust , Bristol,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3368-095X","authenticated-orcid":false,"given":"Jo","family":"Hardy","sequence":"additional","affiliation":[{"name":"Bristol Interstitial Lung Disease (BILD) Service, North Bristol NHS Trust , Bristol,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Harsha","family":"Gunawardena","sequence":"additional","affiliation":[{"name":"Bristol Interstitial Lung Disease (BILD) Service, North Bristol NHS Trust , Bristol,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2793-2364","authenticated-orcid":false,"given":"John D","family":"Pauling","sequence":"additional","affiliation":[{"name":"Bristol Interstitial Lung Disease (BILD) Service, North Bristol NHS Trust , Bristol,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8230-175X","authenticated-orcid":false,"given":"Huzaifa","family":"Adamali","sequence":"additional","affiliation":[{"name":"Bristol Interstitial Lung Disease (BILD) Service, North Bristol NHS Trust , Bristol,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3067-7349","authenticated-orcid":false,"given":"Shaney L","family":"Barratt","sequence":"additional","affiliation":[{"name":"Bristol Interstitial Lung Disease (BILD) Service, North Bristol NHS Trust , Bristol,","place":["UK"]},{"name":"Academic Respiratory Unit, Bristol Medical School, University of Bristol , Bristol,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2025,10,6]]},"reference":[{"key":"2025101706115467600_rkaf114-B1","doi-asserted-by":"crossref","first-page":"1152","DOI":"10.1016\/j.rmed.2009.02.009","article-title":"Ascertainment of collagen vascular disease in patients presenting with interstitial lung disease","volume":"103","author":"Mittoo","year":"2009","journal-title":"Respir Med"},{"key":"2025101706115467600_rkaf114-B2","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1016\/j.socscimed.2018.02.023","article-title":"Representations of race and skin tone in medical textbook imagery","volume":"202","author":"Louie","year":"2018","journal-title":"Soc Sci Med"},{"key":"2025101706115467600_rkaf114-B3","doi-asserted-by":"crossref","first-page":"950","DOI":"10.1016\/j.jaad.2021.03.088","article-title":"Representation and misdiagnosis of dark skin in a large-scale visual diagnostic 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1)","article-title":"Incidence, prevalence & mortality in idiopathic inflammatory myopathies & associated interstitial lung disease in England: a national cohort using routinely collected administrative data","author":"Hannah","year":"2023","journal-title":"Ann Rheumatic Dis"},{"key":"2025101706115467600_rkaf114-B8","doi-asserted-by":"crossref","first-page":"e232427","DOI":"10.1001\/jamanetworkopen.2023.2427","article-title":"Evaluation of pulmonary fibrosis outcomes by race and ethnicity in US adults","volume":"6","author":"Adegunsoye","year":"2023","journal-title":"JAMA Netw Open"},{"key":"2025101706115467600_rkaf114-B9","doi-asserted-by":"crossref","first-page":"1684","DOI":"10.1093\/rheumatology\/kez486","article-title":"Racial differences in systemic sclerosis disease presentation: a European Scleroderma Trials and Research group study","volume":"59","author":"Jaeger","year":"2020","journal-title":"Rheumatology 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