Renowned dermatologists Dr. Peter Lio and Dr. Fabrizio Galimberti discuss current dermatology trends—covering diagnosis, disease management, treatment considerations, and innovative ways that dermatologists can partner with pharmaceutical leaders to support patient care.

“What keeps me up at night thinking about dermatology is actually all the things that are going on in dermatology: So many new things coming up, new conditions, new ways to treat conditions. Unfortunately, sometimes I feel like the more I learn about the new stuff, perhaps I'm forgetting about some of the stuff that I learned in the past. So how do I keep on refreshing my memory? We talked about repetition earlier…What I envision something like Top Derm can do for me and for anybody is the ability to repeat, to see those images—the ability to repeat, repeat, repeat.”

—Fabrizio Galimberti, MD, PhD, Dermatology, University of Miami, physician advisor for Top Derm

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Melyssa Nocar [00:00:09] Hello and welcome to our Market Trends discussion powered by Top Derm. In case you might be asking, “What is Top Derm?”, it’s the latest Level Ex medical mobile game release, specifically a dermatology knowledge game made for dermatologists. But we'll get into that a little bit more later in the discussion. My name is Melyssa Nocar, Senior Vice President, Marketing at Level Ex. I'm delighted to be joined today by Dr. Peter Lio and Dr. Fabrizio Galimberti, both practicing dermatologists and key advisors throughout the development of Top Derm. Today, we will lean in and focus on trends surrounding diagnosis, disease management, treatment considerations, and innovative ways that pharmaceutical companies can partner with dermatologists to support patient care. To get us started, I'd like to ground us in dermatology market growth and some of the driving and restraining factors.

The global dermatological drug market size is projected to reach 63.99 billion by 2027.1 To name a few drivers, research points to a rise in dermatological diseases, awareness of various skin conditions, increased personal care spending, as well as a growing geriatric population.2 Perhaps you can share how you are experiencing some of these driving factors within your own practices and directly with patient care?

Dr. Galimberti [00:01:40] First of all, I'm very happy to be here talking to you about this today. This is a very interesting topic because—let's look at it from the positive. First of all, we live longer. Perhaps we have more problems the longer we live. But nonetheless, we do live longer, and as we live longer, we need more medications. Now, the medication is skyrocketing, in many cases, because we have newer medications. There are much smarter medications. They're directed. They're designed to do a specific job. Sometimes the combination, especially of those medications, can cost up to millions of dollars. We can prolong the life of a melanoma patient in metastatic melanoma patients with combination drugs that can cost millions of dollars. So, the cost of healthcare is increasing, but it's not necessarily a bad thing because it also means that we have significantly better medications available out there. That, unfortunately, does present a little bit of an issue. We have a conundrum: we are getting great medications, but we also have medications that are very expensive. We need to find a way to not only promote access to these medications, but perhaps to find a way to use them better, to know who we should use them for, and when we should use them. That most likely will help not only reach our patients and help our patients, but perhaps also reduce the cost of healthcare.

Dr. Lio [00:03:03] I agree, and it's so important because dermatology care is a very important aspect of medicine. Part of the problem is that we're outnumbered quite a bit by our patients and by other physicians. Dermatology is a very small group, probably around 1% of physicians, so even if we optimize everything, it can still be very difficult to deliver the best care in an equitable way. Part of the mission, therefore, is to continue to refine and improve and optimize our care approaches, but also to teach because it is part of our job to empower our primary care physicians and primary care practitioners who are on the front line so that they can help do what they have to do for their local population and perhaps, just as importantly, know the proper patients to refer and when.

Despite the positive outlook, it is important to note the restraining factors that are underlying this dynamic and how healthcare stakeholders are meeting the challenges. Top of mind are health equity, health literacy concerns, which can lead to diminished product adoption, and for disease and condition management, unwanted side effects from improper use.3 Going into 2022 and beyond, what are some restraining factors that you are anticipating and how are you thinking about meeting patients where they are? Dr. Galimberti, if you wouldn't mind starting on this one as well.

Dr. Galimberti [00:04:28] The way that we approach technology and the way that we approach medicine has drastically changed since the advent of COVID. Literally a few years ago, we probably wouldn't have met via Zoom; we would have had this conversation perhaps in person. We would have recorded it in different ways. Now, teledermatology is something that is real now. We might not see 100% of our patients get teledermatology, but it does allow us to see patients that are far away, patients that perhaps, as Dr. Lio emphasized, that might be very far. We are greatly outnumbered by our patients, even though not necessarily in the cities; in the major metropolitan cities, there are large numbers of dermatologists, but rural areas still struggle with a single dermatologist for many, many months. I think that the way that we're going to approach the next few years is going to really use technology to [not only] improve the relationship between dermatologists but other providers as well and patients. So really kind of coordinated care. And in many cases, coordination of the care not only will lead to better results, but it will lead to faster and perhaps cheaper ways to use healthcare dollars. I do want to emphasize again that even though there are a lot of concerns about healthcare in the future, there are so many positive things that are happening now.

Dr. Lio [00:05:49] It's a given that for any patient that we're treating, we explain that there's a process, that there's some back and forth where we have to give and take in terms of getting to the heart of the problem and getting the best treatment for their disease. And one of the hard parts for us is understanding how we can optimize that. Technology can also help us get closer to precision or personalized medicine where we can actually get the right treatment for the right patient, both in terms of efficacy, but also in terms of minimizing those side effects. And that's a big part of what I'm excited about in terms of better biomarkers and better understanding so that we can really leverage the tools that we do have.

You both advised on content development for Top Derm. A little background for our viewers: Top Derm helps dermatologists strengthen their knowledge and their ability to visually identify skin conditions across subspecialties through challenges pulled from evidence-based research. Dr. Lio, let's start with you on this question. In your experience, how does Top Derm reflect some of these market trends and their associated driving and restraining factors?

Dr. Lio [00:07:02] There are a few things coming together with Top Derm: The first is the leveraging of technology just in and of itself to improve education and ideally, ultimately, clinical outcomes. Now, that's a little ways away to prove that what we're doing here will affect clinical outcomes, but that's how everything is being built with that in mind to help patients. The second piece is that we can actually really leverage some of the key facts of using a game format, a mobile game format, to enhance and improve this experience. We can do things in this format that you literally can't do any other way—in a lecture setting, in a podcast, even in a SIM type setting; in a place like a hospital or a SIM center, we have a lot of limitations. Part of that is temporal. You can only be in there. You can rent the room for an hour. The lecture can only go so long; people start falling asleep. But with a game, you can break things up into bite sizes and have people being able to engage in that material in a way that potentially can even adapt to their needs, to fine tune to their needs, and do exactly as much repetition as they need to get those learning points and learning goals across. And I think that's part of what's really exciting, that we can use these new technology tools in ways that I think truly were not available before.

Dr. Galimberti [00:08:20] I agree 100%. I think the other strength that we have here is that we live in a time of information overload. We have access to probably too much information in the sense that there are thousands of papers probably published every month. We cannot read them all. But using this type of approach, an approach like Top Derm, down the line, perhaps we can kind of really draw the conclusions from the major papers through CMEs so we can stay updated using our app whenever we want to, wherever we want to.

Melyssa Nocar [00:08:52] That's great. Also something we had talked about last week when we were connecting is just around telemedicine and telederm as a means for diagnosis without physical touch. Did you want to touch on any of those experiences as well?

Dr. Galimberti [00:09:11] Yes. That's very important. Teledermatology, as I said, increases access, but at the same time, it’s a very different experience. Now, it could be very or fairly complicated for a few elderly patients who may not use Zoom on a daily basis, but nonetheless, it is a way to reach the patient. However, there is a barrier; there is a screen in between us. We cannot establish—the same way that we establish relations in the clinic, we’re going to struggle to do that on the screen. At the same time, we cannot touch our patients, so we need to learn how to diagnose through a screen. For some conditions that might be relatively simple and easy, but for other ones that might be challenging. So using the screen to learn might actually recapitulate the situation that we will see in our teledermatology clinics.

That's a perfect segue into diagnosis and diagnostic process improvements. What types of strategies are you and your colleagues using to mitigate error in different clinical settings? Also related, how can pharma partners support dermatologists and diagnostic process improvements?

Dr. Lio [00:10:18] We know that the secret of learning is repetition, right? That's the key. And with diagnosis, that is really the secret. I remember when I was a medical student, I was completely blown away by watching a patient in the emergency department who was being seen by a number of different specialists for a whole bunch of problems. I remember the distinguished cardiology professor was talking about their heart problem and then they showed the rash, and the cardiologist said, “I have no idea. Get dermatology down here.” And the dermatologist came down and kind of blew everyone's mind and just looked and in one moment knew exactly what it was. Well, how did she do that? I think she did that in part because she had repetition. She had exposure to presentation after presentation and in different aspects of the body and different skin types and in a different subtle presentation. That's really how I think we learn. So what I'm excited about is the ability to not only get that repetition, but also to be able to make subtle and important changes in repetition and that presentation to really help patients get that care, even if they don't look like the textbook picture. This way the clinicians who are seeing them will be ready. They'll be exposed to so many different variations and so many different ranges of possibilities that they are going to be empowered to make those diagnoses.

Dr. Galimberti [00:11:39] Repetition is key. And the other thing that is key in the healthcare system nowadays is communication. Even though we're in 2021, we all share a smartphone. Sometimes electronic medical records, EMRs, don't cross communicate, and that can be an issue. So for me, one of the things that I'm looking for in the future is actually to remove this barrier of communication. Different practices, different specialties might not share the level of communication, and that is going to impact the patient. Perhaps pharma can try to bring different specialties together with multidisciplinary events. They could at least bring together, not necessarily international, but at least local dermatologists, with local cardiologists, with local GI doctors, because we know now that dermatology is not just about the skin. A lot of what we see in dermatology starts from the inside.

Let's move on to some industry trends. In the US, psoriasis, atopic dermatitis, and acne hold the biggest market share for dermatology.4 There's been an uptick in pipeline products for acne and new emerging therapies for psoriasis.5 We're also seeing treatment options in special populations such as women of childbearing age.6 So when it comes to some of the new and emerging therapies, as well as treatment options in special populations, what therapies or therapeutic areas even are you monitoring?

Dr. Galimberti [00:13:12] Sure. For me, this is a very exciting time for dermatology. We're really at the beginning of a new phase of dermatology with new targets. New personalized medicine is not quite yet truly personalized, but it's approaching that. We're starting to understand better the molecular biology that is behind inflammatory chronic conditions. So to me, the biggest trend that we're going to have down the line, in just the next few months, if not years, is going to be the advent of tablets that are going to perhaps substitute injections or injectable biologics. To me, that's a very exciting point. The other thing that makes me curious about dermatology and what's going to happen in dermatology over the next few years or so is something that Dr. Lio mentioned earlier. It's the biomarkers. Can we really start using biomarkers more effectively in predicting which patients will benefit from a treatment? Moreover, one thing that we don't do so well at this point in dermatology, but other specialties have done in the past, is perhaps think about how different conditions, or the same condition rather, is treated in different ethnic populations. For example, in cardiology, there are some medications that we know African-American patients might respond better [to] or might benefit more [from] than Caucasian patients. In dermatology, we're not really quite there, perhaps because our clinical trials are smaller in number of patients compared to cardiology, but we're getting there, and that's very exciting.

Dr. Lio [00:14:38] I'm a little biased because my focus is atopic dermatitis, so I've been really watching the atopic dermatitis space, and we are on the cusp of just an incredible number of new treatments, at least five or six major ones in the next year and even more in the pipeline. This is going to be a huge breakthrough for patients who—I really feel strongly that there's a ton of morbidity, suffering, and unmet need. This is going to change the narrative a little bit for a lot of them. But the issue is how do we wield these new tools correctly? How do we figure out what to do with them? And the way I know this is going to be a problem is because even I, who’ve been following many of these drugs from their inception, from phase one and phase two, I feel like I know them already. They're old friends in a way, but even I'm confused about how I'm going to put these to use. Part of our job is going to be educating not only about the basics, because you can know all the ins and outs of the trials and all the different aspects of the molecule. But still, to put that to use clinically, there is an enormous translational gap. What we're going to need is some really good guidance and understanding and digestion, if you will, about, OK, here's where we think this will fit best until, as Dr. Galimberti made a point, until we have those biomarkers to help us say, OK, this is really the right one for this patient, and this is the right one for that patient. Because we're not there yet, we're going to need to use our clinical wisdom and experience and pull that together. Another way to approach that is through really innovative educational endeavors.

Dr. Galimberti [00:16:01] Can I add one thing that I think is important to keep in mind? We talk very often about the art of medicine, and part of the art of medicine is this at this point. We have a lot of medications that are perhaps interchangeable at least at first sight, the art of medicine coming, choosing that. But it would be nice if the art of medicine and the science of medicine came to get a little bit closer when it's time to choose which medication to use for our patients. We have a little sprinkle of knowledge on that, but only time will give us significantly more, and that will help us help our patients much, much more.

Expanding on precision medicine, let's discuss diversity, equity, and inclusion as it relates to dermatology. Underdiagnosis and misdiagnosis in patients with darker skin tones is highlighted across the literature. I read recently that it is estimated that a five year melanoma survival rate for African-American patients is only 67% versus 92% for Caucasian patients.7 And textbooks have been shown to only represent 4-18% of darker skin tones.8 Let's unpack this important issue. Where are you seeing this disparity in your practice and in the scientific literature? And what can dermatologists as well as medical societies do to address the issue at scale?

Dr. Lio [00:17:27] One of the hardest parts is that some of the discrepancies and disparities you pointed out are complicated and they're multifaceted. Part of our job is to work on each aspect where there is disparity. Certainly some of that is in the educational differences. What you see in a textbook often does under-represent what we're seeing in real life. Part of it is that real life has changed. We know that—and I'm happy to say that—diversity in the United States is continuing to improve and increase, so that actually has to be reflected in what we're doing clinically and what we're seeing clinically. But obviously, that wasn't necessarily the case 50 or 100 years ago when some of the original textbooks were getting established. So part of it is the dynamic environment, and then part of it may be some of the differences between different groups. The melanoma point is very striking. Is that due to disparity in care? It certainly could be. We have to answer that question. But is it possible that patients with more richly pigmented skin actually get different types of melanoma—so when melanoma does come out, maybe it is more aggressive? That may be true, too. And there may be both. Neither of these are mutually exclusive, but it does make the problem very, very difficult. And I'm personally pretty excited about the really positive energy that people are putting into this. I think dermatologists have been, in my experience so far, really excited and eager to try to meet these problems head on and try to work on the disparity. We're seeing a lot of interest around this area, including many, many talks and webinars, and at our academy meeting, with more sessions really focusing on the specialized needs of skin color. Part of the issue with this topic is that there are some important differences just by having more deeply pigmented skin. So, for example, with atopic dermatitis, again, my bias, because that's what I'm so interested in, we know that it is actually harder to appreciate erythema, the redness in darker skin types, so that, again, that's a real problem and a real aspect of having more richly pigmented skin. That is not necessarily an inequity. It's just a reality of something we have to do. So it is our job to acknowledge that, to educate [on] that, and to make sure we're giving extra special care for patients that have darker skin tones so we can get them the proper diagnosis, the proper severity and, of course, the proper treatment.

Dr. Galimberti [00:19:40] I agree this is a multisystem issue and multisystem problem that is difficult to address with a single answer. Dermatology has been trying really hard over the last few years... to be successful in becoming a more inclusive specialty. Inclusive does not just mean seeing patients from all over the world. Inclusive also means that dermatologists ourselves are becoming more diverse...Thinking about melanoma, we use the term melanoma as if any melanoma was the same, but personalized medicine also means understanding and not every melanoma is the same. So once we have the technology to do that, and that’s not an easy step, that is not a single step approach, then not only are we going to be able to tell you exactly which type of melanoma we had, but we're going to be able to understand why is the mortality difference so low; is it just access, or is there more to that? Perhaps there are medications that will work better for those types of melanoma. It's a very complex process, but nonetheless has been addressed in multiple ways. Of course, diversity and inclusiveness of the specialty is one of the foremost important conditions because sometimes I do have dark skin patients who [tell] me, “Listen, I didn't know if I wanted to come and see you because I was looking for somebody that looks like me, understanding me better.” And that's true. I understand that point. Having a more diverse force of dermatologists would definitely help with this.

Top Derm is designed to support dermatologists in the care of underrepresented populations. How does Top Derm equip you and fellow dermatologists to demonstrate best practices in early diagnosis and long-term management strategies of dermatologic conditions for patients with darker skin tones?

Dr. Lio [00:21:31] What's so exciting is that we went in thinking about this from the very beginning. From the first meetings years ago I had around those tables, this was part of the DNA of Top Derm. That really is something I'm quite proud of—that this has been from the get go. What also is really exciting is that we see that some of the disparity happens in... the teaching images in textbooks, and there is an inherent limitation to that, not only because of what has been happening in the past in terms of the photographs taken, but also it turns out that there are some socioeconomic disparities. Perhaps some of the patients who are being seen, they favor patients with lighter skin tones. So, again, this is being reflected in what's in the books. How do we get around that? Well, one way that's really neat to me, and worth talking about, that's very different than anything I've seen before, is the ability to render images, to do artistically rendered images in all different types of skin tones, things that maybe either don't exist at all or more likely don't exist enough. So we can actually do more of these things and bring them to the attention of dermatologists so they can see them, and then we can actually manipulate different variables. Maybe there is a reasonably good picture of lichen planus on the wrist of a darker skinned patient, but what about a more widespread variant? What about things that happen in areas where we might not have a photograph, including more sensitive areas where people are often less apt to take a photograph in the first place? Now, with the power of the great artists at Level Ex, and the rendering engine, we can actually demonstrate those in a way that I think really meets the clinical need to see those cases, but can give us everything we want and need.

Dr. Galimberti [00:23:08] I had just a little story to add to this, a personal experience. I'm interested in inflammatory conditions, and, for example, I always thought that dermatomyositis was something that I found very interesting. And it does have a characteristic rash, that heliotrope rash. But I'll be honest with you, it doesn’t matter how many times I've seen it in books, the first time that I met a dark skinned patient who had a very faint erythema on the eyelids, I basically missed it. If you're not trained to see that, it's going to be very hard for you to see. And really, Top Derm can help with the availability of images; as Dr. Lio said, maybe these images are available; maybe there’s only one. Different lights, different moments, slightly different skin tone, especially erythema, can be difficult to capture. So Top Derm will give us this level of education that right now many of us are missing.

As we think about post pandemic considerations—the topic of all topics—including the return of in-person gatherings and events, pharmaceutical leaders are seeking new ways to innovate their awareness and engagement programs and strategies. Remaining partner neutral, of course, are there any recent examples of well executed awareness or engagement experiences that you might like to highlight? And most importantly, as we look ahead, are there any thoughts you might add, around how pharmaceutical leaders can continue to strengthen their partnerships with dermatologists?

Dr. Lio [00:24:40] Yes, thank you. I think this is a complex problem, and I do like to believe that things are going to keep getting better, and we're going to learn from this terrible experience of the pandemic. And I'm hopeful that some of the messages we're going to take home will be that the meetings of the future are going to have to be a little bit higher yield. We're going to have to really focus on the human interaction aspect of it, maybe even the destination aspect of it. I think smaller, more intimate meetings are going to be the norm because to some degree, Zoom and other teleplatforms have really answered the call for many of the things that we used to do, say at a large sort of impersonal type meeting. If you don't really get to talk to the speaker, and you don't really get to have a small group and chat... you've flown somewhere; you've gone out to a dinner for not much. So I'm hopeful that we're going to be able to take the best of both worlds. We're going to be able to still do plenty of big, good learning, educational initiatives that can be done remotely to save people time, energy, and save the environment, too. You don’t have to fly people on a plane or do all this kind of stuff and stay in a hotel. But I'd also like to think that we can capitalize on the magic of being close with other people and that face-to-face contact and spontaneity and the kinds of things that people create. There is a powerful spark when everyone's together in a room. But I think I think we're going to hopefully see things that are really angling towards that to get the most out of it. And the same goes for companies trying to get their message out. It's one thing to do endless Zoom videos, right? It's another to bring people together in a small group to discuss. And it's still another, I think, to be able to have a game where you have something totally unique, totally new, that can be another way to access people's thoughts and really get their opinions and and experiences through this mobile experience on something like Top Derm, which I think is really exciting.

Dr. Galimberti [00:26:30] I agree 100%. I think in the future, things will be slightly different. Perhaps having a hybrid system will enable physicians to really pick the type of meeting that they want to experience. Are you somebody that prefers to have human interaction in person, or are you somebody that prefers to hear the data via Zoom? And both are going to be fine. We get a chance to choose which one we want to do. So it's going to be an exciting change in how we see meetings in the future. In terms of how pharma companies have perhaps approached this, there seems to be a good trend in trying to involve physicians early on, many physicians early on, in the development of new medications, just as a way to get every physician involved on an emotional level in how these medications are changing. How are they coming to the market? For example, there are pharmaceutical companies that enable physicians to actually see the manufacturing side of medication. So you get a chance to see how these medications are made. So sure, we know that there are injectables; we know that there are syringes. But how is this made? What does the process really entail? And that really gives you an idea of how powerful our medicines have become, how intelligent we're becoming designing medicines. And I think that creates a partnership that enforces how physicians see themselves—at the forefront of medicine and not just dispensers of medications.

As we close, I am going to put you both on the spot. I would love for each of you to share just one thing that is keeping you up at night as you think about the future of dermatology, and if relevant, how can Level Ex support those needs with our game mechanics?

Dr. Lio [00:28:18] I do worry a lot about the fact that we're being kind of elbowed out by other practitioners who are not focused on dermatology. I think because, as we kind of started this discussion with “we are outnumbered,” we really don't have the ability to meet the need, for example, for skin screening. Skin screening is a really important thing that we do. It's still somewhat controversial. There's not actually formal nationalized guidelines for skin screening, but most of us feel like it's pretty important. However, if everybody in the US said we've got to get skin screening, even if we said it just once a year, we're finished. Our waiting lists are already so long. So I do worry about getting the proper care to those in need. And I worry that, you know, it's funny because people will say, “Oh, you're enriching yourself with seeing all these patients.” It's like, well, we have a problem in medicine that is very different from other areas of technology or things like that. They call it Baumol's cost disease, where no matter how efficient I get, at the end of the day, you still have to see me. I still have to go room to room. I have to shake your hand and sign your prescription. So where a big computer can sell six billion copies of their device or their software, we really have to do it 1:1. So the way I think we get hopefully a little piece of myself, my teaching, my approach, my thinking about disease out there—if I can't do it personally—is to teach and educate. So I'm curious and excited that we can try to find new ways to do this and get that out there to get the people who are in need better, because I wish I could, but I can't see everybody.

Dr. Galimberti [00:29:50] What keeps me up at night thinking about dermatology is actually all the things that are going on in dermatology: So many new things coming up, new conditions, new ways to treat conditions. Unfortunately, sometimes I feel like the more I learn about the new stuff, perhaps I'm forgetting about some of the stuff that I learned in the past. So how do I keep on refreshing my memory? We talked about repetition, repetition, repetition earlier. And that's true. That's really the key to that. So what I envision something like Top Derm can do for me and for anybody is the ability to repeat, to see those images (might be new images), but nonetheless the ability to repeat, repeat, repeat. And that's hopefully going to help me sleep a little bit more. So I know that I can keep up and not forget what I learned in the past and perhaps even learn something new while I do that.

Melyssa Nocar [00:30:38] Excellent. All great points. I appreciate those insights so much. Looking forward to bringing some of these details back to the team, in fact, and thinking through unique ways we can bring them to life with our pharma partners over the coming months. Thank you, both of you, for the great discussion today. It's been an absolute pleasure speaking with both of you. Looking forward to seeing many of our viewers at the AAD Summer Meeting in a couple of weeks. And to our viewers, thanks for tuning in today.

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