# Skin Tone Representation of Early Lyme Disease in Medical Education Resources: Gaps and Implications for Equity

## TL;DR

Medical education resources often lack images of Lyme disease on dark skin, which could lead to delayed diagnoses and health inequities.

## Contribution

This study reveals a gap in the representation of skin tone diversity in Lyme disease educational materials used in U.S. medical schools.

## Key findings

- Only 12.5% of resources included images of erythema migrans on dark skin.
- Dark-skinned images were only found in web-based resources published after 2020.
- The lack of representation contrasts with U.S. demographics, suggesting potential for health inequities.

## Abstract

Cutaneous Lyme disease presents differently in light versus dark skin, and delayed diagnosis can increase outcome severity. Insufficient exposure to manifestations of Lyme disease in dark skin during medical training may contribute to health inequities due to late or missed diagnoses. It remains unclear how Lyme disease, specifically, is represented in commonly used medical training materials. To inform curricula updates, we identified primary educational resources used for teaching dermatology at top-tier U.S. medical schools and assessed the representation of erythema migrans on light and dark skin in these materials.

In this cross-sectional content analysis, commonly used training resources for 50 top U.S. medical schools were identified by reviewing websites and syllabi and contacting schools when information was unavailable. Resource images were categorized as “light-skinned” or “dark-skinned” using the Fitzpatrick scale (I-III vs IV-VI). Proportions and counts of light-skinned and dark-skinned images were compared to U.S. demographics, resource format (print-/web-based), and age of publication (pre-/post-2020).

Sixteen resources, containing 47 erythema migrans images, were identified. Two of 16 (12.5%) resources included dark-skinned images; both were web-based resources. None of the print resources or those published before 2020 included dark-skinned images. The proportions of light-skinned (n = 44, 93.6%) and dark-skinned (n = 3, 6.4%) images were significantly different from U.S. demographics (p = .03).

Among commonly used medical student resources, few contain images of erythema migrans on dark skin; these were only found in web-based resources published since 2020. This differential representation has the potential to contribute to inequitable diagnosis and treatment across racial groups.