A major contributing factor to morbidity and mortality in people with diabetes is inadequate foot care and its associated complications (NHS England, 2017). Approximately 60,000 people with diabetes present with diabetic foot ulceration (DFU) every year in England, and the 5-year mortality rate for these patients is around 50% (NHS Digital, 2023). Relevant assessment and proactive foot care has the potential to ease the burden of diabetic feet, increase quality of life for patients and reduce healthcare costs (Abraham et al, 2022). Therefore, a thorough foot examination is essential to detect the disease early (Mishra et al, 2017).
However, the challenges of assessing the skin of patients with dark skin tones is widely acknowledged (Fletcher, 2022), and failure to recognise early signs of disease can have significant consequences, leading to more serious stages of ulceration (Black and Simende, 2020). Variable knowledge around assessment exists, as well as a lack of confidence in assessing patients with dark skin tones (Enwezor, 2021). In particular, evidence shows that discrepancies in wound care exist in many areas due to variation in skin tone (Oozageer Gunowa et al, 2017). This is due to a lack of accurate assessment and early identification, and evidence-based practice is needed is needed to ensure that patients receive the best possible care.
Establishing baseline skin tone
It is important to determine an individual’s baseline skin tone as part of the initial skin inspection and holistic wound assessment, so that any changes to the person’s skin can be monitored regularly and identified early (Dhoonmoon et al, 2021). Skin changes in people with dark skin tones fail to be observed quickly enough on a global scale, and this is usually due to a lack of accurate assessment and early identification (Wounds International, 2023).
A validated classification tool, such as the skin tone tool (Figure 1; adapted from Ho and Robinson, 2015), should be used to determine and describe an individual’s skin tone. It is paramount that clinicians avoid using metaphors or similes when describing skin tone, such as comparing skin tones to foods – especially those that were fuelled and continue to fuel the slave trade (e.g. cocoa and coffee). Therefore, the skin tone tool supports clinicians to use respectful language when establishing baseline skin tone. It is also more effective than asking patients to describe their own skin using terms that could be subjective and potentially harmful (Dhoonmoon et al, 2023). Particularly in cultures where there may be bias towards light skin, or colourism is an issue, this may affect how patients view and describe their own skin tone (Everett et al, 2012). Furthermore, skin tone usually differs across different areas of the body; therefore, a patient’s tone needs to be selected that most closely matches their upper inside arm.
Assessment and diagnosis of diabetic foot in dark skin tones
In DFUs, changes in colour and pigmentation in people with dark skin tones may be difficult to spot; therefore, diagnosing infection or ischemia in these individuals can be challenging (Dhoonmoon et al, 2021). In addition, any initial ‘redness’ seen on light skin may not be present in dark skin and thus be missed in the initial assessment.
It is very easy to miss erythema in dark skin since it can be difficult to predict exactly what colour erythema will look like in varying skin tones. Therefore, clinicians should use other cardinal signs — e.g. warmth and swelling (Wang et al, 2020; Figure 2) — and ask patients about symptoms that may not be visible (e.g. pain or feeling unwell).
Where access to a clinician is limited (e.g. in rural/remote areas), clinicians must advise patients with diabetes to check their entire foot, including the underside, with a mirror on a regular basis, noting any redness, changes in colour or bleeding between their toes (Khunkaew et al, 2019). Clinicians also need to bear in mind that age-related pigmentation may be misdiagnosed in dark skin tones — it is not uncommon for dark skin to present with age-related dark patches on the soles of the feet (Figure 3). Therefore, full use of the senses — especially touch and hearing — is valuable in assessment of all patients. Clinicians need to ask the patient about their skin and listen to their perspective about what they consider to be a problem — e.g. tightness and changes in feeling. Further tips for assessment in dark skin tones are shown in Box 1.
Influence of cultural considerations and practices on foot care
Across the globe, there may be variations in practice depending on local cultural and geographical factors. Clinicians need to be culturally aware and recognise that different climates and cultures may have to be considered in different areas (Dhoonmoon et al, 2023).
Climate can affect wounds and dressings, especially in parts of the world where the climate is hot and humid. Moreover, many hot and humid countries have a barefoot culture; however, walking barefoot on hot surfaces (e.g. sand) can cause people to injure their feet and develop foot ulcers (Harkin, 2010), and this is particularly the case if they have diabetes. Clinicians need to encourage patients to wear appropriate, properly fitted footwear, to avoid shoes that are too small, tight or rub against a specific area of the foot, and to avoid walking barefoot on hot surfaces and indoors, where feet can be exposed to potential trauma — e.g. splinters from hardwood flooring (Harkin, 2010; Gulf Diabetic Foot Working Group, 2017).
The importance of individualised care
A ‘one size fits all’ approach fails to cater to the needs of individual people; therefore, implementation of personalised treatment plans based on skin tones is essential. Care needs to be tailored to the individual patient in a way that considers their distinctive needs, concerns and circumstances (WUWHS, 2020). Since dark skin tones present unique challenges in the assessment, diagnosis and management of DFUs, the need for individualised care is even more urgent in this patient population. Furthermore, it will likely ensure the early identification of complications and improve outcomes for patients.
Inclusive language and raising patient awareness
Inclusive, person-first language sets the right tone from the outset and can help patients to maintain a positive outlook. It is important for clinicians to avoid thinking of dark skin tones as ‘difficult’ or ‘challenging’, and to use respectful, simple, professional and neutral language when communicating with patients (Box 2; Dhoonmoon et al, 2023). When using skin tone descriptors, clinicians must use clear and up-to-date language. There is a difference between skin tones and ethnicity, and not all black people have dark skin tones. Clinicians need to use terms like ‘brown’ or ‘black’ to describe skin tones rather than ‘darker’, which implies that white skin is the baseline or norm.
Clinicians should also aim to support patients to familiarise themselves with their own skin, so that they can notice any changes and take action, especially if they are at risk of foot damage (Dhoonmoon et al, 2023). Evidence shows that involving patients in their treatment and explaining the rationale for a particular dressing/treatment option has the potential to radically improve patient outcomes (Sandy-Hodgetts et al, 2022).
Addressing biases and improving diabetic foot care practices
It is evident that there is a lack of research in relation to skin care that involves patients with dark skin tones, lack of diversity in clinical photos and case studies, and lack of black or brown teaching aids in clinical settings (Nursing Times, 2021). Moreover, white bias in education has been identified, with information and illustrative images overwhelmingly focused on white skin, and this has contributed to a lack of knowledge of assessment and diagnosis in dark skin tones (Mukwende, 2020; Oozageer Gunowa, 2022). Ongoing education and training for healthcare professionals on the relevance of skin tones to their individual specialties will further improve diabetic foot care practices. Further aims for the future in the field of diabetic foot care includes the need to (Dhoonmoon et al, 2023):
Build evidence and research in wounds in a range of skin tones
Increase awareness around signs and symptoms in a range of wound types — not just pressure ulcers
Improve inclusive care, cultural awareness and outcomes for all patients.
Conclusion
Individuals living with diabetes are at an increased risk of developing chronic DFUs, which significantly impact patient quality of life and cause financial stress for healthcare systems. It is evident that systematic change is required to eradicate health inequalities, disparities and biases that affect people with dark skin tones. Ultimately, it is the clinician’s responsibility to keep in mind that language is constantly evolving, and to foster an environment in which patients feel supported and safe in communicating and reporting changes to their own skin.
It is important to note that assessing diabetic foot complications in dark skin tone can be challenging due to the limited visibility of certain skin changes, such as early signs of erythema or ischaemia. Therefore, clinicians should be vigilant, rely on a combination of clinical signs and symptoms, and consider an assessment tool, such as the skin tone tool described in this article, to provide tailored, individual assessment. Cultural sensitivity and effective communication with the patient are also crucial to ensure accurate assessment and diagnosis
