Content style guide - Make content about skin symptoms more inclusive

This guidance will help you make written content and imagery of skin symptoms inclusive for people with various skin tones and people with a visual impairment.

How to make written content about skin symptoms more inclusive

On the NHS website, skin symptoms are mostly described in terms of how they appear on white skin.

While some skin symptoms (such as itchiness) are the same for everyone, other symptoms may differ depending on people's skin tones.

When a person's skin tone is not represented in our content, they do not have the same opportunity to recognise symptoms and understand what they need to do next.

Prioritise symptoms that affect everyone equally

When you list symptoms, start with the ones that affect everyone equally. Depending on the condition these might be:

  • shape and size (of a rash, spot, or affected area)
  • if or how it spreads on the body
  • texture (for example, smooth, blisters, rough or scabs)
  • location on the body
  • how it feels (for example, itchy, hot or painful)
  • other symptoms (such as a high temperature)
  • skin colour changes

Explain when a symptom may look different on various skin tones

A key symptom that's likely to differ on various skin tones is a change in skin colour.

For example, a rash that looks red when it appears on white skin may not look red when it appears on skin that's brown or black.

If a change in skin colour does not affect everyone equally, make this clear.

Example

Impetigo starts with red sores or blisters, but the redness may be harder to see on brown and black skin.

If possible, be specific about how a symptom may appear differently on a range of skin tones. We recognise this can be difficult because of a lack of medical sources on which to base this information.

See our list of medical sources for symptoms on various skin tones and the research insights on this page.

Describe skin tone as white, brown and black

The NHS website team working on skin symptom content has been researching and testing different terms for skin tones.

From the research done so far, we've found "brown and black skin" and "white skin" tested better than "dark skin", "darker skin" or "light skin" as a way to describe skin tones.

Based on these learnings, we've started using the term "brown and black skin" instead of "dark skin" or "darker skin", but we're keen to hear from other teams working on skin symptom content.

Read the research insights on this page.

Include descriptions of how skin feels, if possible

Non-visual symptoms are especially useful for people who have a visual impairment.

Example

The scarlet fever rash feels like sandpaper and starts on the chest and tummy.

Read the research insights on this page.

How to make images of skin symptoms more inclusive

Images on the NHS website mostly show skin symptoms on white skin, but some symptoms can look different on various skin tones.

When a person's skin tone is not represented in our images, they do not have the same opportunity to recognise symptoms and understand what they need to do next.

We're working on additional guidance about when and how to use images.

Include images of symptoms on a variety of skin tones, if possible

The NHS website team working on skin symptom content has been researching and testing images of skin symptoms on a variety of skin tones.

From the research done so far, we know that people find multiple images of the same symptom on different skin tones useful.

We're still testing the best way to display multiple images that's accessible for both sighted people and people with a visual impairment.

Describe skin tone in alt-text

The NHS website team also looked into how to talk about skin tone in alternative text (alt-text) of images of skin symptoms.

Alt-text is a short text description of an image for people who cannot see the image.

We've been using the terms "white", "light brown", "medium brown" and "dark brown" to describe skin tone in alt-text, rather than just saying "white", "brown" or "black".

We've found being specific about the person's skin tone in the image helps people with a visual impairment.

We're still researching how best to describe skin tone in alt-text.

Example

Yellowing of the white part of the eye and the skin under the person's eyebrows. Shown on dark brown skin.

(Alt-text on NHS website jaundice page)

Read more about how to use alternative text for images in content in our accessibility guidance.

Consider providing a long description

As well as writing good alt-text, we've found that long descriptions of images are useful for people who have a visual impairment.

Long descriptions are designed to be used with complex images where short alt-text cannot convey all the information in the image.

We're still testing the use of long descriptions in content about skin symptoms.

Research insights

Explaining when a symptom may look different on various skin tones

NHS website research found people with brown or black skin appreciated content that clearly stated that a symptom may appear differently on various skin tones.

Describing skin tone as white, brown and black

1-to-1 interviews

The NHS website team asked 6 people with brown or black skin which of these 2 versions they preferred (in content about chickenpox):

  • "the spots can be hard to see on brown and black skin"
  • "the spots can be hard to see on dark skin"

5 out of the 6 people preferred the term "brown and black skin" instead of "dark skin" saying it's more:

  • helpful
  • direct
  • specific
  • useful in capturing a range of skin tones

They said "dark skin" was:

  • vague
  • subjective
  • unclear

Survey findings

The NHS website team found people with brown or black skin preferred the terms "light brown", "medium brown" and "dark brown" to describe skin tones, rather than less specific terms such as "light skin", "dark skin" or "darker skin".

We use the terms "light brown", "medium brown" and "dark brown" to describe skin tone in alt-text only. See the section on describing skin tone in alt-text on this page.

Including descriptions of how skin feels

NHS website research found people who have a visual impairment find it particularly useful when we include descriptions of how skin feels when you touch it, as this helps them know what to feel for on their own skin or someone else's skin.

Next steps

We're still looking into issues related to describing skin symptoms on various skin tones, including:

  • the best way to label skin tone in alt-text
  • if we're describing how skin symptoms appear on various skin tones, which skin tone to mention first
  • if a skin symptom about a change to skin colour looks the same on all skin tones, should we say this explicitly

Medical sources for symptoms on various skin tones

Would you like to contribute to this guidance?

Please let us know how this has worked for you and, in particular, if you have research findings to share. This will help us improve it for everyone.

Before you start, you will need a GitHub account. It's an open forum where we collect feedback.

If you have any questions, you can message us on Slack. You will need a Slack account if you do not have one. Or you can contact us by email.

Updated: June 2021