The American Journal of Nursing (AJN)Visual Representation of Clinical Conditions Across Skin Tones in Nursing Textbooks: A Quantitative Image Analysis

Analysis of 1,116 images across 13 foundational nursing textbooks found only 7% depicted dark skin, and just 10% of clinical-condition photos showed dark skin. Cellulitis, melanoma, and allergic reactions were rarely shown on dark skin at all.

Key Clinical Considerations

• Conditions diagnosed by visual cues, erythema, cyanosis, stage 1 pressure injury, jaundice, present differently on darker skin and are routinely missed when nurses train only on light-skin imagery
• Graphic illustrations were even more skewed: only 2% depicted dark skin, normalizing light skin as the clinical default
• Nearly half of all photos showed no identifiable clinical condition, further shrinking learning exposure to actual disease presentation on any skin tone
• Underrecognition contributes to diagnostic delays and worse outcomes for patients of color, a documented patient safety issue

Practice Applications

• Assess for warmth, induration, and tenderness alongside color when ruling out cellulitis or stage 1 PI on darker skin
• Compare the suspect area to surrounding skin and the patient’s baseline rather than to a textbook image
• Document skin changes using descriptors like violaceous, hyperpigmented, or dusky, not just “red” or “pink”
• Consult open-access resources like Mind the Gap or VisualDx when textbook references fall short