Skin is a spectrum: Learn to recognize different presentations and improve diagnosis

Learning to recognize conditions in skin of color is imperative to providing equitable care; however, medical education resources are falling short. Fewer than 40% of primary care residents report feeling that their medical school provided adequate dermatologic training in skin of color.

Below are examples of different presentations of the same disease. The greater representation we have in our educational resources, the better prepared we will be to take care of all of patients who walk into our exam rooms.


Livedo Reticularis

Livedo reticularis is a skin finding caused by decreased blood flow to the skin or impaired outflow in the dermal venous plexus and stagnation of the blood within these vessels. Etiologic categories include vasospasm, vessel wall dysfunction, and vascular flow compromise as in coagulopathies. It may be physiologic, a primary disease (as in idiopathic cases), medication- induced, or secondary to disorders such as antiphospholipid antibody syndrome, vasculopathies, autoimmune connective tissue disorders, or infection. A workup for underlying disease is often indicated.

These side-by-side comparisons highlight how variably erythema presents in different skin colors. In lighter skin colors, livedo reticulitis presents as a lacy or reticular pink-to-violet pattern. In darker skin colors, the pattern may appear deep red, maroon, violaceous, or brown.


Kawasaki Disease

Kawasaki disease, also known as mucocutaneous lymph node syndrome, is a type of vasculitis that primarily affects infants and children. There is a typical series of findings. I learned the “CRASH and burn” mnemonic, which stands for:

  • conjunctivital injection
  • rash
  • adenopathy
  • strawberry tongue
  • hand and foot edema
  • and high fever (the “burn”)

Skin findings are nonspecific. Skin findings typically occur on the trunk and extremities with a predilection for the lower abdomen, groin, perineum, and buttocks. Desquamation often occurs. Coronary artery aneurysm can develop in 20%-25% of untreated patients. Workup includes echocardiography to rule out coronary artery aneurysm along with CBC, CMP, ESR, CRP and urinalysis. Treatment is aimed at decreasing the risk of developing cardiac abnormalities and includes IVIG and/or aspirin (one of the few exceptions to giving aspirin to children with a suspected virus).

The side-by-side photos display the desquamative erythematous truncal rash, which may be subtler in darker skin colors.


Tinea Versicolor

Tinea versicolor, also known as pityriasis versicolor, is an overgrowth of Malassezia yeast, which is part of our normal skin flora. Tinea versicolor is an incredibly common diagnosis and is a perfect example of how the same disease can present very differently in different skin types.

The rash can present as multiple erythematous, hypo- or hyperpigmented papules and macules with a fine scale. It is common during the summer months and more often affects patients in warm and humid climates. Topical antifungals are usually an effective treatment, with skin pigmentation resolving in a few months. Some patients with hypopigmentation may be concerned they have vitiligo and are reassured to know that this is something totally different and treatable.


For More Skin of Color Images

These are just a few examples of how the same condition can appear very differently on different skin types. To see more images of conditions on skin of color, VisualDx has curated its clinical image collection to sort by skin pigmentation so that you can quickly find examples that match your patients’ presentations—a great way to make your patients feel understood.

I’d like to recommend the resources curated by Project IMPACT, an initiative by VisualDx to reduce healthcare bias by sharing of information. Materials include a list of free digital resources for healthcare professionals as well as websites to share with patients.

My hope is that it becomes easier to find images in all skin colors for every condition and that skin of color is better represented in medical school curricula.


Bloom R, Burgin S. Livedo reticularis. In: Goldsmith LA, editor. VisualDx Visual Clinical Decision Support Tool [online]. Rochester, NY: Logical Images; 2022. Available from

Buster KJ, Stevens EI, Elmets CA. Dermatologic health disparities. Dermatol Clin. 2012;30(1):53-viii.doi:10.1016/j.det.2011.08.002. PMID: 22117867; PMCID: PMC3742002.

Nurmohamed S, Tan B, Burgin S. Tinea versicolor. In: Goldsmith LA, editor. VisualDx Visual Clinical Decision Support Tool [online]. Rochester, NY: Logical Images; 2022. Available from

Werbel T, Burgin S. Kawasaki disease. In: Goldsmith LA, editor. VisualDx Visual Clinical Decision Support Tool [online]. Rochester, NY: Logical Images; 2022. Available from

Zhu F, Ang JY. 2021 update on the clinical management and diagnosis of Kawasaki disease. Curr Infect Dis Rep. 2021;23(3):3. doi: 10.1007/s11908-021-00746-1. Epub 2021 Feb 6. PMID: 35194409; PMCID: PMC8851597.

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