Skin tone representation in preclinical dermatology education: A cross-sectional curricular audit

Dermatologic diagnosis is fundamentally visual, yet minimally melanated skin has historically predominated in educational imagery used for medical training. The limited representation of brown and black skin in dermatologic preclinical education may contribute to delayed recognition of disease and reduced diagnosis confidence among trainees and physicians caring for patients with skin of color. Promoting visual equity within medical student preclinical education therefore represents an important step toward improving health outcomes in patients of color. In this cross-sectional study, preclinical dermatology and rheumatology teaching materials at the University of California, San Diego were systematically examined using a standardized image-based protocol. Clinical images were classified according to the Massey-Martin New Immigrant Survey Skin Color Scale and collapsed into three analytic groups: Light/White, Medium/Brown, and Dark/Black. These groups were further analyzed by instructional week and disease category. Across 507 clinical images, lighter skin tones predominated: light/white (n = 304, 60%), medium/brown (n = 147, 29%), and dark/black (n = 56, 11%), a distribution that deviated significantly from equal representation (χ² = 186.26, p < 0.001). Disease-level stratification revealed underrepresentation of dark/black skin tones across all analyzed disease categories. These findings highlight persistent gaps in skin tone diversity within preclinical curricula and demonstrate the feasibility of a standardized, reproducible framework for evaluating visual representation in dermatologic education. Establishing scalable equity audits across medical schools may enable institutional benchmarking and ultimately contribute to more equitable dermatologic diagnosis and care.