Diagnostic Challenges: Discussing Complex Dermatology Cases in Skin of Color

At the 2025 SDPA Annual Summer Dermatology Conference in Washington, DC, Ginette Okoye, MD, a nationally recognized expert in skin of color dermatology and chair of dermatology at Howard University College of Medicine, led a session titled 'Diagnostic Dilemmas: Complex Cases in Skin of Color.' The talk highlighted the often-overlooked complexities that arise when dermatologic conditions present in richly-pigmented skin, where subtle visual cues can be masked or misinterpreted.

Through a series of real-world case studies, Okoye guided attendees through diagnostic challenges related to inflammatory, pigmentary, infectious, and autoimmune diseases—many of which are known to mimic one another in those with skin of color. Those viewing her session were given ways to identify key differences in how common and uncommon dermatologic conditions appear in darker skin tones, as well as ways that standard diagnostic assumptions can lead to delayed or missed diagnoses.

“This was an 11 year old who came to us,” Okoye explained. “He had a 6-month history of this discoloration on his face, especially on his eyelids, and what he what he and his family called a ‘rash’ on the back of his hands that was previously diagnosed as eczema. He'd been treated with topical steroids, but the rash on the hands never improved, and the hyperpigmentation or dispigmentation on the face seem to be spreading to them. He was never itchy. He never had any systemic symptoms. When we did our review of systems, he had a known history of asthma…I did some muscle strength testing, and his muscle strength was a 1 out of 5.”

Okoye noted that the child had significant muscle weakness, in addition to this hyperpigmentation on the upper eyelid and this hypopigmentation in the nasolabial folds that she had observed.

“So what's our differential diagnosis for this young man?” Okoye said. “Before I knew about the muscle weakness, looking at him, I thought maybe some seborrheic dermatitis. He got hypopigmentation in the nasolabial folds, but there was no scale there. I thought about dermatomyositis briefly, because whenever I see something going on on the eyelids and on the knuckles, I always think of dermatomyositis. I would like you to do that as well…I really honed in on dermatomyositis. I just want to talk to you about assessing proximal muscle weakness, because this child did have juvenile dermatomyositis.”

Typically, the weakness experienced by patients with dermatomyositis is in the proximal muscles such as the shoulder girdle, the thighs, and the quadriceps. Okoye added that a quick test for proximal muscle weakness is to ask the patient to stand from a sitting position without assistance, without touching the table and without holding on to anybody.

Okoye also highlighted that the risk of cancer in patients with dermatomyositis is 4 to 5 times higher than people without dermatomyositis, especially among those over the age of 45. She noted that in children, this is not as much of an issue, but Okoye did add that risk continues up to about 5 years following diagnosis. Therefore, such patients should be screened at diagnosis and yearly for the next 5 years at least.

Examples like these during Okoye's session emphasized the importance of pattern recognition, thoughtful clinical assessment, and the strategic implementation of biopsies and laboratory testing to reach accurate conclusions. Okoye addressed common diagnostic errors that disproportionately affect patients with skin of color and offered practical strategies to avoid these pitfalls.

Beyond clinical recognition, the session underscored the importance of culturally competent communication—an essential tool for building trust and improving diagnostic accuracy in diverse patient populations. Okoye encouraged those in attendance to adopt a more inclusive diagnostic lens, adding that they should refine their clinical judgment by incorporating both visual nuance and a patient-centered approach. By the conclusion of the talk, dermatology PAs and others in attendance walked away knowing more about the diagnosis and management of complex presentations in skin of color.

For any further information on this subject or related topics highlighted at the 2025 SDPA Conference, view the latest conference coverage.

The quotes used in this summary were edited for the purposes of clarity.