Investigating demographic differences in women’s dermatologic concerns: a large urban cohort study

Abstract

Background:

Few studies have comprehensively assessed dermatologic conditions in women, particularly among different racial and ethnic groups.

Objective:

This study characterizes common dermatologic diagnoses in adult women (acne), emphasizing conditions disproportionately affecting women of color (WOC) (hidradenitis suppurativa [HS], hypertrophic scars, and scarring and nonscarring alopecia).

Methods:

This retrospective cohort study analyzed data from Northwestern Medicine’s Enterprise Data Warehouse, covering 637,124 patient visits from 2018 to 2021. The dataset included 212,223 unique patients, with 398,431 visits by women. Patient demographics (age, race, and ethnicity) and clinical data (diagnoses, treatments) were analyzed using logistic and linear regression.

Results:

Women accounted for 62.5% of dermatologic visits. Women were significantly more likely than men to present with acne, HS, and scarring and nonscarring alopecia. White women represented 77.4% of women, while WOC (Black, Asian, and Hispanic) comprised 16.3%. Acne was the most common diagnosis among women under 30. WOC were younger on average (44.6 years) compared with white patients (50.9 years) and had higher odds of alopecia, hypertrophic scars, acne, and HS. Cosmetic procedures were less frequent among WOC.

Limitations:

Findings may have limited generalizability due to being conducted within a single medical system.

Conclusion:

Women, and specifically WOC, are disproportionately impacted by many common dermatologic conditions. These conditions have significant morbidity, which is heightened by complications like hyperpigmentation and scarring in the skin of the color population. Accurate and timely diagnosis is necessary to improve women’s dermatology outcomes.

What is known about this subject in regard to women and their families?

• Patients with skin of color are disproportionately affected by acne, alopecia, hidradenitis suppurativa (HS), and hypertrophic scars.

• These conditions have a significant impact on patient quality-of-life, often affecting women more than men.

What is new from this article as messages for women and their families?

• This retrospective cohort study found that women had higher odds of acne, HS, alopecia, and hypertrophic scars compared with men, and women of color had higher odds compared with white women.

• Women of color represent a growing segment of dermatology patients, particularly in younger age groups.

• Cosmetic procedures were more common among white women, with women of color underrepresented despite national trends showing increasing utilization.

Introduction

Limited studies have investigated the dermatologic concerns of women, and even fewer focus on women of color (WOC). Women compose over 60% of dermatology visits, and patients with skin of color, commonly defined as Fitzpatrick skin types IV through VI, represent a growing population in the United States.^1,2 Significant healthcare disparities exist in dermatologic care, contributing to delayed diagnoses, limited treatment options, and poorer outcomes, particularly among women, and racial and ethnic minority populations.^3,4 This study aimed to identify the most common diagnoses among women of different ages, races, and ethnicities who receive dermatological care in a large urban healthcare system.

Materials and methods

Patient population

This retrospective cohort study utilized data from Northwestern Medicine’s Enterprise Data Warehouse, encompassing 637,124 patient visits from 2018 to 2021. The dataset included 212,223 unique patients from 4,129 zip codes across 18 clinic locations. Of these visits, 398,431 were by women aged 18 years and older. Collected demographic information included age, sex, race, ethnicity, zip code, and marital status. Medical data comprised primary and secondary dermatologic diagnoses, prescribed medications, and concurrent chronic conditions, with diagnoses coded using International Classification of Disease 10th revision codes.

Analysis

The analysis used Stata/SE 17.0. Student t tests compared age and number of visits between men and women, while χ² tests examined race and ethnicity. Logistic regression calculated odds ratios (ORs) for selected conditions, and linear regression explored relationships between gender, age, prescribed treatments, and dermatologic diagnoses.

Ethical approval

This retrospective cohort study was approved by the Northwestern University Institutional Review Board (Protocol Number: RK04072022). The requirement for the Health Insurance Portability and Accountablity Act authorization was waived given minimal risk to included individuals. Protected health information was protected in accordance with institutional guidelines and applicable regulations. All data were de-identified before analysis to ensure patient confidentiality.

Results

Of the cohort, most visits were by women (62.5% [398,431/637,124]). In comparison to men, women were significantly more likely to be diagnosed with acne, hidradenitis suppurativa (HS), and scarring and nonscarring alopecia (P < .0001). Gender did not have a statistically significant relationship with hypertrophic scars. Additionally, women were more likely to receive cosmetic procedures than men (P < .0001).

When analyzing according to female patient demographics, white women represented the largest group, making up 48.4% (308,495/637,124) of total patient visits and 77.4% of all visits by women (308,495/398,431). Black, Asian, and Hispanic patients (WOC) made up 6.3% (25,085/398,431), 3.9% (15,709/398,431), and 6.0% (24,084/398,431) of all visits by women, respectively (Table 1). American Indian or Alaskan Native and Native Hawaiian or other Pacific Islander patients composed 0.23% (925/398,431) and 0.16% (653/398,431) of women, respectively (Table 1). The remainder of the women responded “unknown,” “other,” or declined to respond. This study focused on Black, Asian, Hispanic, and white patients due to their greater representation in the dataset.

Table 1.

Demographic Data 2018-2021

	Women Number (% of women)	Men Number (% of men)	P value
Total visits	398,431 (62.5% total visits)	238,693 (37.5% total visits)	<.0001
Mean age at appointment	49.4	53.4	<.0001
Black	25,085 (6.3%)	9,047 (3.8%)	<.0001
Asian	15,709 (3.9%)	8,968 (3.7%)	<.0001
Hispanic	24,084 (6.0%)	12,587 (5.2%)	<.0001
White	308,495 (77.4%)	187,945 (78.7%)	<.0001
American Indian or Alaskan Native	925 (0.23%)	575 (0.24%)	.486
Native Hawaiian or Other Pacific Islander	653 (0.17%)	354 (0.15%)	.069

Statistical significance of demographic information calculated using student t test for patient age and total visits, and χ² tests for race/ ethnicity.

Black, Asian, and Hispanic women saw significantly higher odds of acne, scarring, and nonscarring alopecia, and hypertrophic scars compared with non-Black, Asian, and Hispanic women (Table 2, P < .0001). Black women saw markedly elevated odds for scarring alopecia and HS (OR = 6.454-7.619, 8.090-9.662, respectively) compared with non-Black women. Among WOC, acne was the most common diagnosis, and on average, WOC had higher odds of acne compared with non-WOC (P < .0001) (Figure 1 and Table 2). Asian women had the highest excess risk for acne (OR = 1.772-1.943, P < .0001). White patients had greater odds of receiving cosmetic procedures in comparison to nonwhite patients (OR = 1.270-1.358, P < .0001) (Table 2).

Table 2.

Odds of selected dermatologic diagnoses in women across racial and ethnic groups, 2018-2021

		95% Confidence interval
	Odds ratio	Lower	Upper	P value
Acne
Black	1.451	1.394	1.510	<.0001
Asian	1.856	1.772	1.943	<.0001
Hispanic	1.600	1.538	1.665	<.0001
White	0.538	0.526	0.551	<.0001
Cosmetic procedures
Black	0.314	0.287	0.343	<.0001
Asian	0.777	0.721	0.837	<.0001
Hispanic	0.550	0.513	0.589	<.0001
White	1.313	1.270	1.358	<.0001
Hidradenitis suppurativa
Black	8.841	8.090	9.662	<.0001
Asian	0.943	0.754	1.179	.605
Hispanic	2.356	2.077	2.673	<.0001
White	0.215	0.197	0.234	<.0001
Hypertrophic skin disorders
Black	3.674	3.406	3.963	<.0001
Asian	2.760	2.497	3.047	<.0001
Hispanic	1.618	1.461	1.792	<.0001
White	0.314	0.296	0.333	<.0001
Nonscarring alopecia
Black	2.723	2.573	2.882	<.0001
Asian	2.158	2.003	2.326	<.0001
Hispanic	2.260	2.126	2.403	<.0001
White	0.392	0.376	0.408	<.0001
Scarring alopecia
Black	7.013	6.454	7.619	<.0001
Asian	0.475	0.360	0.627	<.0001
Hispanic	1.104	0.947	1.287	<.0001
White	0.350	0.324	0.378	<.0001

Odds ratios calculated comparing rates of diagnoses for selected dermatologic conditions within each racial/ethnic group in comparison to all other patients not in that racial/ethnic group.

Fig. 1.

Top 10 dermatological diagnoses in women of color according to patient-reported racial/ethnic group, 2018-2021. Legend: Ten most common dermatologic diagnoses according to racial and ethnic groups represented in the study.

When analyzing visits by age, WOC were younger (average age 44.6 years compared with 50.9 years for white patients, P < .0001). The younger cohort of patients had a higher percentage of WOC (25.6% in patients younger than 30 years) compared with older patients (9.5% of women over 80 years old) (Figure 2). Linear regression modeling revealed that HS, scarring alopecia, hypertrophic scars, and acne were associated with younger age, while nonscarring alopecia was associated with increased age (Figure 3, P < .0001). HS, scarring alopecia, hypertrophic scars, and acne were more likely to result in a prescribed treatment during the visit compared with other diagnoses (P < .0001).

Fig. 2.

Number of women of each racial and ethnic group according to patient age, 2018-2021. Legend: Number of dermatology patient visits for each racial/ ethnic group according to patient age within 10-year age ranges.

Fig. 3.

Most common dermatologic diagnoses according to patient age, 2018-2021. Legend: Distribution of most common dermatologic diagnoses, based on International Classification of Disease 10th revision codes, as a percentage of total patients within each 10-year age group.

Discussion

Our study, in line with existing literature, found that acne, HS, scarring and nonscarring alopecia, and hypertrophic scars (including keloid scars) are more prevalent in skin of color.^3,5 Most patients in our cohort were in their thirties, with 20.2% of visits from women aged 30 to 39.

Our study population skewed more white and had a higher percentage of women than the Chicago population data.⁶ However, younger patients receiving dermatologic care in this healthcare system were more racially and ethnically diverse than their older counterparts and therefore appeared more representative of the wider metropolitan area.⁶ It remains unclear whether this diversity is due to cultural differences in healthcare utilization among young WOC or improved access to dermatological care.

Acne

Acne was a top diagnosis in our cohort, affecting women across all races and ethnicities. While up to 85% of adolescents experience acne during their teenage years, women are more likely than men to continue experiencing acne into adulthood, particularly between the ages of 20 and 49.⁷ Acne has significant morbidity, with impacts on quality of life comparable to chronic conditions like epilepsy, asthma, diabetes, or arthritis.^8,9 Research shows that women, especially those with acne scars, are more affected by acne’s impact on quality of life than men.^9,10

Consistent with national data, acne was the most common diagnosis among WOC, with higher odds of acne diagnosis found in all skin of color groups.³ Treating acne in skin of color patients is challenging due to the increased risk of postinflammatory hyperpigmentation and keloid scarring, which can last longer than the original lesion and persist for up to several years.^11,12 Acne management in skin of color patients is further complicated by limitations in access to care. Black and Hispanic patients are less likely to see a dermatologist for acne, and Black patients are less likely to be treated with prescription topical or oral medication.¹³ Timely identification of acne severity is necessary to avoid undertreatment and prevent postinflammatory hyperpigmentation and scarring.¹² Given the higher rates of acne in WOC and their increased risk of scarring, careful management is essential to reduce morbidity.

Hidradenitis suppurativa

HS is a chronic skin condition that disproportionately affects skin of color and is often associated with significant physical and psychosocial comorbidities. HS is more common in Black and biracial patients and is twice as likely to present in women in comparison to men.¹⁴ Patients self-report higher levels of embarrassment and self-consciousness and limit social activities due to their HS.¹⁴ Risk factors for HS include tobacco use, metabolic syndrome, and obesity, with affected individuals showing higher rates of substance use and unemployment.¹⁴

Patients with HS may experience frustration because their condition is often underdiagnosed or misdiagnosed.¹⁵ Inaccurate diagnoses may be explained by a large proportion of HS patients managed by nondermatologists, with 65% of dermatologist-diagnosed HS patients presenting with milder cases in comparison to only 35% diagnosed by nondermatologists.¹⁵ HS visits with a dermatologist are more likely to recommend medical or procedural interventions than nondermatologist management.¹⁵ Earlier recognition and management may lead to improved patient clinical and psychosocial outcomes.

Scarring and nonscarring alopecia

Nonscarring alopecia is very common, with the most common form, androgenic alopecia, affecting 70% of men and 50% of women by age 50.¹⁶ In comparison, scarring alopecia makes up approximately 7% of patients presenting with hair loss concerns.¹⁷ Given its permanence, early detection and management of scarring alopecia are crucial to prevent future scarring and preserve hair. While all alopecia has significant impacts on quality of life, scarring alopecia has a greater impact on anxiety, depression, self-esteem, and loneliness.¹⁸

Alopecia is often underdiagnosed and undertreated in individuals with skin of color.¹⁹ Differences in both hair structure and hairstyling practices make Black women susceptible to alopecia.²⁰ Central centrifugal cicatricial alopecia is the most common form of scarring alopecia in women of African descent. However, there is a tendency to overdiagnose central centrifugal cicatricial alopecia in Black women, potentially missing other coexisting alopecias.²¹ To ensure early detection at the community level, studies recommend training hair stylists and cosmetologists to identify early signs of hair loss in WOC, as many forms of alopecia begin on the vertex scalp, which may be difficult for patients to monitor themselves.²⁰

Hypertrophic and keloid scars

Keloid scars are a result of abnormal wound healing following cutaneous injuries such as acne, trauma, surgery, or burns.^22–24 Keloids present both a cosmetic and functional concern, often manifesting on the chest, face, and arms, causing limited mobility, pruritus, and pain.^23,24 They can lead to significant physical and psychological impairment, with studies showing a link between facial keloids and psychological distress, and mobility-restricting keloids and perceived suffering.²⁴

Keloids are equally prevalent across sexes; however, they are 15× more common in skin of color, specifically people of African, Hispanic, and Asian descent.²³ Risk factors for developing new keloids include keloid manipulation, infection, history of rheumatic disorders, multiple keloids at different sites, and a disease duration of 15 years.²⁵ Hypertrophic scarring has been found to have a genetic predisposition, explaining increased prevalence within families, twins, and ethnic groups.²⁶

Cosmetic procedures

In our cohort, cosmetic procedures were primarily performed on white women (only 7.5% of cosmetic procedures involved WOC). In contrast, national data from 2017 show that 32% of all cosmetic procedures performed were on skin of color patients.²⁷ Other research indicates that patients with darker skin tones are less prone to sun damage and therefore show clinical signs of aging 10 to 20 years later than lighter skin-toned patients, potentially leading to decreased interest in cosmetic procedures.²⁸ Additionally, people of color are more prone to adverse effects such as bruising, hyper/hypo pigmentation, and scarring.²⁹ Anatomical differences, beauty ideals, and other biological and cultural differences may influence the use of cosmetic procedures, necessitating practitioner knowledge of the specific needs of skin of color patients.²⁷

Skin of color education

Education on dermatologic conditions affecting skin of color and their presentation across skin tones is limited, from preclinical medical school training, extending through fellowship.³⁰ By 2050, the skin of color population is projected to make up 51% of the US population, meaning WOC could comprise nearly half of female dermatology patients.¹ This growing patient group and their predisposition to many common conditions highlight the need for better education on skin of color.

Limitations

A limitation of this study is that it only includes patients from a single healthcare system in one Midwest metro land area. The data was limited to existing data available in electronic medical records. The use of International Classification of Disease 10th revision codes limits diagnostic nuance and may have reduced diagnostic specificity due to code consolidation during analysis.

Conclusion

Women represented nearly two-thirds of the dermatology visits in this study. Although the overall WOC cohort was smaller, their numbers are expected to rise, with younger patient groups already showing an increase in WOC.¹ Women seek dermatology treatment across their lifetime and are predisposed to common dermatologic concerns with significant physical and psychological morbidity. Additionally, WOC face higher risks of delayed diagnosis and poorer outcomes due to scarring and hyperpigmentation.

This study aimed to identify the dermatologic conditions that most significantly affect women and explain their associated morbidity. Future research should prioritize improving timely and accurate diagnoses for women and specifically women of color, especially by enhancing education on skin of color.

Conflicts of interest

None.

Funding

None.

Study approval

This retrospective cohort study was approved by the Northwestern University Institutional Review Board (Protocol Number: RK04072022).

Author contributions

CG and RK conceived the study. CG collected data. CG performed statistical analysis and drafted the manuscript. All authors contributed to data interpretation, revised the manuscript critically, and approved the final version.

Acknowledgements

The authors gratefully acknowledge the Feinberg School of Medicine Area of Scholarly Concentration program for supporting the research process. Specifically, the authors express gratitude to the Northwestern Enterprise Data Warehouse for their assistance in data acquisition.