Risks mistakes after tick bites: Missing pictures of dark people

In August last year, the Tick Center launched the Tick Check, where the aim is to assess suspected tick bites with quick advice on further measures against the tick-borne disease Lyme disease. In case of infection by the bacteria, it is important to start treatment at an early stage to reduce the risk of developing serious disease. One of the first things to notice is a rash, called erythema migrans (EM).

– The tick check service has become popular, we have received around 500 photos from a total of 300 people who have had a rash. However, we have experienced a notable lack of images of rashes in people with darker skin tones. It is a pervasive problem that applies to other types of skin infections as well, says adviser Harald Reiso at the Flea Center to NTB.

– We do not think it is a matter of the tick going after lighter skin tones to a greater extent. It is more likely that a rash is more visible on paler skin, and that it is then easier to detect and get assessed, says Reiso.

Consequently, many people may have undiagnosed Lyme disease in the skin.

Global phenomenon

A quick search online reveals a general lack of photo documentation of rashes on darker skin tones. Dermatologist Jenna Lester searched the medical literature for pictures of rashes on dark skin to better help her dark-skinned patients. She couldn’t find a single picture anywhere.

– We do not teach (and possibly do not learn) skin colour, Lester writes in his analysis in the British Journal of Dermatology (BJD) about the phenomenon in general.

Last December, the Johns Hopkins Medicine Lyme Disease Research Center published research showing large disparities in the diagnosis and treatment of Lyme disease between black and white patients.

While 52.1 percent of the white patients were diagnosed due to rash only, this applied to only 18.6 percent of the dark-skinned patients.

Lead author behind the study, John Aucott, believes this is about a lack of knowledge and awareness both in the healthcare system and society, and not least that it is not taught how to identify Lyme disease in patients with darker skin.

Aucott warned that the problem will grow globally as infected ticks spread.

Artificial intelligence

Each year, approximately 7,000 Norwegians get a Lyme disease rash. Those cases that develop systemic disease and late manifestations must be reported. Last year, 570 cases of Lyme borreliosis were registered in Norway. The hope is to reduce the number of cases through early diagnosis and treatment.

One of the moves in Norway is to further develop Flåttschekk.no and use artificial intelligence (AI) for automatic image recognition of the Lyme disease rash. But then many and varied images are needed to get a reliable AI service. The tick center therefore encourages everyone who gets a rash after a tick bite, both young and old, women and men, people with light skin and dark skin, to register photos.

– In order for our future image recognition app to function optimally, we are dependent on obtaining a varied selection of images, says Reiso.

The American researchers at John Hopkins began with the same plan in 2021, but determined that there were major challenges.

– The biggest of which is to compensate for the general lack of available images of rashes on dark skin tones. The computer cannot learn to recognize a Lyme disease rash on dark skin if it does not have the necessary basis, wrote Aucott, who, among thousands of rash images, had then only found a dozen images of dark skin.

Structural discrimination

Professor of migration and health services at Oslo Met, Jonas Debesay, says there is a lack of global knowledge and awareness that disease can progress differently in people with different skin colours. He explains that it entails a form of discrimination and racism that is often difficult to spot: structural racism.

– This type of racism appears through routines, guidelines and decisions in organisations, but also through social and political perceptions in society, he says.

– So it is not reluctance or willful discrimination that creates health inequality among minority patients. Most likely it happens as a result of a lack of mapping of needs and provision for a more heterogeneous user group, says Debesay.

Some of the lack of rash images can perhaps be explained by the fact that ethnic minorities are not infected to the same extent, because they do not have the same culture for traveling in forests and fields, or that they make up a smaller proportion of the population in the coastal areas particularly exposed to ticks.

– But as the years go by, more people will get “Norwegian habits” and the tick will spread. And if more people are bitten, it is important that we have a system in place that catches all cases at an early stage, says Debesay.