A Systematic Review on Skin of Color Representation in Diabetic Foot Ulceration Literature

Research Type: Level 5 - Case report, Expert opinion, Personal observation Introduction/Purpose: Diabetic foot ulcerations (DFUs) are a common complication of diabetes mellitus that can progress to hospitalization and amputations. Minority populations, such as Black and Hispanic patients, carry a greater burden of disease compared to their Caucasian counterparts as suggested by a higher prevalence of diabetes and increased rates of DFU complications like infection, amputation, and mortality. Despite the clinical presentations and outcomes of DFUs varying significantly between populations, the current literature’s representation of skin of color (SOC) is inadequate, making it more challenging to address these health disparities and exacerbating complications for vulnerable patients. This systematic review evaluates SOC representation in DFU research to identify gaps in inclusivity and report areas for improvement. Methods: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search was conducted on Medline OVID for peer-reviewed studies from 2019–2024 using keywords such as “Diabetes Mellitus,” “Skin Ulcer,” and related terms, yielding 322 results. Inclusion criteria required primary research or clinical recommendations in English, human subjects, and a focus on diabetic foot ulcerations. Two authors independently screened titles and abstracts for eligibility, resolving discrepancies with a third author. After exclusions, 65 articles remained for analysis. Extracted variables included study design and country as well as journal specialty and country affiliation. SOC representation was assessed based on references to race, skin tone, and images depicting skin. Percentages were calculated for all variables and stratified by SOC representation. Results: Publication dates of the reviewed articles were evenly distributed across the five years, peaking in 2023 and being the lowest in 2021. Study sample sizes ranged from 1 to 4,963 subjects. Most studies were conducted in China, followed by the USA and India. Journals on diabetes/endocrinology published a third of the reviewed articles whereas dermatology and orthopedics had only one article each. 80% of the studies lacked SOC representation, in that they omitted race, skin tone, and images of SOC. Almost half of the articles that did include images exclusively depicted lighter skin tones. Not one particular year, study design, journal, or country saw more SOC representation. Conclusion: This systematic review highlights critical gaps in the recent literature on DFUs. A large proportion of the studies lacked meaningful representation of SOC within the text and as images, potentially limiting our understanding of DFU manifestations across different skin tones and exacerbating health disparities. Orthopedic research, particularly in foot and ankle surgery, can promote a more comprehensive understanding of the disease process by standardizing reports of demographics and skin tone. Improving the representation of SOC patients in future research can enhance the generalizability of study findings and support a more robust approach to diagnosing and treating DFUs.