Letters to the Editor: June 2024

J Clin Aesthet Dermatol. 2024;17(6):10–12.

Beautiful Bias from ChatGPT

Dear Editor:

Since the release of ChatGPT in 2022, abilities of the large language artificial intelligence (AI) models continue to be explored. ChatGPT-4 has the capacity to generate AI-based images in response to prompts. 

Despite major advancements in technology, artificial intelligence still struggles with skin of color.^1,2 Face-analysis algorithms are less accurate for people with darker skin, and new research from Thong et al¹ suggests that AI algorithms are biased against skin with yellow and red hues.

With increasing data reflecting disparities for skin of color in artificial intelligence, it is important to understand just how far this inequity extends. When ChatGPT is prompted to “create an image of the most beautiful [man/woman/child/teenager], all images produced display subjects with Fitzpatrick Skin Type I. 

It is essential from a dermatologic perspective to consider what equating beauty with Fitzpatrick Skin Type I means. Intravenous (IV) glutathione is a compound that is increasingly being used in Asian countries to lighten the skin, importantly, this compound is lacking extensive safety data but the Food and Drug Administration (FDA) of the Philippines has issued a warning against this agent.³ The Philippines FDA reports possible adverse effects that include Stevens-Johnson syndrome, toxic epidermal necrolysis, severe abdominal pain, thyroid dysfunction, renal dysfunction, air embolism, and sepsis.³ Given the extensive use of technology among teenagers and given ChatGPT’s bias towards Fitzpatrick Skin Type I images in when prompted to generate the “most beautiful” teenager, it may be warranted for pediatric dermatologists to inform their patients and patients’ parents of the harmful effects of IV glutathione as a means of achieving skin lightening. 

Another possible consequence of ChatGPT’s definition of beauty is the emotional impact it may have on impressionable youth. The perpetuation of unrealistic beauty standards may impact children with congenital anomalies and their caregivers negatively. These children already face increased rates of bullying, teasing, and taunting from their peers, while their caregivers are also impacted emotionally.⁴ 

Given this information and the increased integration of artificial intelligence into society, it is necessary to consider methods that dermatologists can use to help their patients. As systemic inequity and power imbalances are strongly implicated in AI’s algorithmic bias,⁵ dermatologists can support their patients by being culturally competent, engaging in multidisciplinary collaboration, advocating for equity in healthcare, providing accessible care, and empowering their patients through support and education. Structural inequality necessitates action at the student, faculty, and institutional level. Organizations such as the Skin of Color Society are excellent resources that work at addressing the root causes of structural inequality and are easy for dermatologists to join. 

In conclusion, ChatGPT’s beauty bias towards images of individuals with Fitzpatrick Skin Type I is highly problematic. Not only do such responses perpetuate racial bias, uphold an ethnically homogenous standard of beauty, and devalue diverse beauty, but such responses also promote colorism, limit representation, broaden social inequity, and impede social progress. Other consequences may include a negative impact on self-esteem, particularly among teenagers and people of Asian origin. As technology continues to grow and progress, equity must advance along with it.  

With regard,

by Peter Lio, MD, and Kripa Ahuja, MS 

Affiliations. Dr. Lio is with Northwestern University’s Department of Dermatology in Chicago, Illinois. Dr. Ahuja is with Eastern Virginia Medical School in
Norfolk, Virginia.

Funding. No funding was provided for this article.

Disclosures. Dr. Lio reports research grants/funding from AbbVie, AOBiome; is on the speaker’s bureau for AbbVie, Arcutis, Eli Lilly, Galderma, Hyphens Pharma, Incyte, La Roche-Posay/L’Oreal, MyOR Diagnostics, ParentMD, Pfizer, Pierre-Fabre Dermatologie, Regeneron/Sanofi Genzyme, Verrica; reports consulting/advisory boards for Alphyn, AbbVie, Almirall, Amyris, Arcutis, ASLAN, Boston Skin Science, Bristol-Myers Squibb, Burt’s Bees, Castle Biosciences, Codex Labs, Concerto Biosci, Dermavant, Eli Lilly, Galderma, Janssen, Johnson & Johnson, Kimberly-Clark, LEO Pharma, Lipidor, L’Oreal, Merck, Micreos, MyOR Diagnostics, Regeneron/Sanofi Genzyme, Skinfix, Theraplex, UCB, Unilever, Verrica Yobee Care; stock options with Codex, Concerto Biosciences and Yobee Care. In addition, Dr. Lio has a patent pending for a Theraplex product with royalties paid and is a Board member and Scientific Advisory Committee Member of the National Eczema Association.

References

1. Thong W, Joniak P, Xiang A. Beyond Skin Tone: A Multidimensional Measure of Apparent Skin Color. Proceedings of the IEEE/CVF International Conference on Computer Vision (ICCV). 2023;4903–4913.
2. ChatGPT perpetuates racial and gender biases. AuntMinnie. Published January 2, 2024. Accessed January 2, 2024. https://www.auntminnie.com/imaging-informatics/artificial-intelligence/article/15660882/chatgpt-perpetuates-racial-and-gender-biases
3. Sonthalia S, Jha AK, Lallas A, et al. Glutathione for skin lightening: a regnant myth or evidence-based verity? Dermatol Pract Concept. 2018;8(1):15–21.
4. Vivar KL, Kruse L. The impact of pediatric skin disease on self-esteem. Int J Womens Dermatol. 2018;4(1):27–31. 
5. Walker R, Dillard-Wright J, Iradukunda F. Algorithmic bias in artificial intelligence is a problem—And the root issue is power. Nurs Outlook. 2023;71(5):102023. 

Synchronicity in Syringomas: Bilateral Cases with Distinct Clinical Profiles

Dear Editor:

Syringomas are benign tumors that originate from the intraepidermal luminal cells of eccrine sweat ducts. They often present as small, skin-colored, dome-shaped papules measuring 2 to 4mm in diameter.¹ While the periorbital region is their most common location, we highlight two unique presentations of eruptive rose-colored syringomas on bilateral upper and lower extremities, a manifestation last documented in 1982.² 

A 55-year-old male with a recent medical history of rapid heartrate controlled with aspirin and diltiazem and a family history of an unknown skin cancer type presented to the clinic with complaints of a “rash” on his inner thighs persisting for 2 to 3 years. The lesions were occasionally pruritic, and the patient had not attempted any prior treatments. On exam, multiple non-scaling, rose-colored, flat-top papules measuring 2 to 3mm were identified on the bilateral medial thighs extending to the proximal, medial upper legs (Figure 1A and 1B). The remainder of the skin elsewhere was uninvolved. The differential diagnosis included papular dermatitis, lichen planus, and guttate psoriasis. Punch biopsies of each thigh were performed and showed dilated cystic ducts within the upper dermis. Some ducts had small comma-like tails to produce a distinctive tadpole shape. Mostly, two rows of epithelial cells lined the ductal walls (Figure 1C). 

The second case involved a 77-year-old female with a medical history of Type 2 diabetes mellitus, hypertension, chronic renal insufficiency, and osteoporosis. She presented to the clinic with multiple flesh-colored papules on bilateral upper and lower eyelids and medial cheeks (Figure 2A) persisting for approximately a decade, as well as pruritic, erythematous eruptions on bilateral medial forearms (Figure 2B and 2C) that appeared one year prior. Despite previous attempts to mitigate her symptoms with hydrocortisone cream, the papules persisted. On exam, diffuse, pink-reddish, flat-top papular eruptions were observed on the bilateral medial forearms which had a different clinical morphology than the multiple white papules, some with a central pore, seen on her medial cheeks. The differential diagnosis included comedones, sebaceous hyperplasia, syringomas, and cutaneous sarcoid for the facial lesions and papular dermatitis, lichen planus, and guttate psoriasis for the forearm lesions. Punch biopsies were performed on the right and left forearm and on the right medial face. Pathology showed numerous small ducts lined by rows of epithelial cells embedded in a fibrotic stroma consistent with syringoma. 

Four major classes of syringomas have been recognized: a familial type, a form associated with Down Syndrome, a localized form, and a generalized form that encompasses multiple eruptive syringomas.¹ They develop slowly and persist indefinitely without symptoms, mainly in women. The eruptive form, initially described by Darier,³ manifests on neck, chest, abdomen, axilla, shoulders, and upper arms. Various etiologies have been proposed regarding the cause of syringomas, including sun exposure, hormonal control, corticosteroid treatment, and prolonged immunosuppressive therapy.^4,5 

Both of the aforementioned cases exemplify atypical presentations of eruptive syringomas. The first case highlights the occurrence of symmetrical lesions on the upper thighs of a male patient, a presentation not typically reported in the literature. In the second case, the previous history of facial syringomas followed by a new eruption on the bilateral forearms a decade later underscores the chronic and persistent nature of the condition. Given that neither of the individuals had risk factors for this condition, we report that both cases are consistent with eruptive, generalized syringoma, one of the rarer variants. Thorough interviews of each patient and review of their medical record could not link this variant to a “syndrome.”

These cases serve as a reminder for clinicians to remain vigilant for unusual presentations of these benign tumors, expanding our diagnostic acumen, and ultimately improving patient care.

With regard,

by Ethan Nguyen, MD; Roy Mendoza, BS; and Tiffany Dong, BS

Affiliations. Dr. Nguyen, Mr. Mendoza, and Ms. Dong are with the University of California Riverside School of Medicine in Riverside, California. Additionally, Dr. Nguyen is with Raincross Dermatology in Riverside, California.

Keywords. Bilateral syringomas, eccrine syringoma, sweat gland tumor, benign skin lesion, symmetrical lesions, eccrine ductal tumor

Funding. No funding was provided for this article.

Disclosures. The authors report no conflicts of interest relevant to the content of this article.

References:

1. Williams K, Shinkai K. Evaluation and management of the patient with multiple syringomas: A systematic review of the literature. J Am Acad Dermatol. 2016;74(6):1234–1240.
2. Van der Broek H, et al. Syringoma of the upper extremities with onset in the sixth decade. J Ame Acad Dermatol. 1982, 6:534.
3. Hashimoto K, Blum D, Fukaya T, et al. Familial Syringoma: Case History and Application of Monoclonal Anti-Eccrine Gland Antibodies. Arch Dermatol. 1985;121(6):756–760
4. Soler-Carrillo J, Estrach T and Mascaró J. Eruptive syringoma: 27 new cases and review of the literature. Journal of the European Academy of Dermatology and Venereology. 2001;15: 242–246 
5. Wallace ML, Smoller BR. Progesterone receptor positivity supports hormonal control of syringomas. J Cutan Pathol. 1995;22(5):442–445.