Skin of color

From dermoscopedia
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 Author(s): Richard Usatine, Rachel Manci
Description This chapter describes the dermoscopy in skin of color and explaint Fitzpatrick's skin types
Author(s) Rachel Manci · Richard Usatine
Responsible author Richard Usatine→ send e-mail
Status open
Status update August 25, 2023
Status by Ralph P. Braun

This chapter describes the dermoscopy in skin of color and explaint Fitzpatrick's skin types

It has the following subchapters:

Importance of Dermoscopy in Skin of Color

Individuals with skin of color (SOC) are defined by the Skin of Color Society as those individuals of Hispanic/Latino, Asian, African, Native American, Pacific Island descent, and mixtures thereof. All too often skin cancers are detected late in persons of skin of color due to many factors including health inequity, poverty, lack of access to education and healthcare. Another factor is that skin cancer is less common in darker-skinned persons and the lack of worry that a skin growth is cancer may lead to delays in diagnosis. Even the preventive messages about sun and skin cancer are more directed to lighter skinned persons.

Review of Fitzpatrick Skin Types

The Fitzpatrick skin type system was developed in 1975 by Dr. Thomas Fitzpatrick. It was originally used as a basis to determine the proper ultraviolet A dose for the newly developed photochemotherapy treatment of severe generalized psoriasis in patients with white skin. [1]

Today, the system has been expanded to also include those with brown and black skin. The system characterizes skin types by visible color and the tendency to tan and/or burn in response to ultraviolet light exposure, which is greatly determined by the amount of melanin pigmentation within the skin. [2] There are six Fitzpatrick skin types today, ranked on a scale of 1 to 6, with one being the lightest skin tone and six being the darkest skin tone (Table 1). This system is widely used to evaluate skin cancer risk. [3]

Table 1. Fitzpatrick skin types

Fitzpatrick skin typing is easy to use and widely accepted, but has several limitations. Most notably, this system has incited criticism due to its subjective nature. [3] Trained dermatologists are more accurate in their self-report of Fitzpatrick skin type compared to the general population, but high variability still exists. [3] In an attempt to negate this subjectivity, several objective measures have been developed. These objective measures include pigment protection factor (which utilizes diffuse remittance spectroscopy), spectrophotometry, and colorimetric analysis.

Those with lighter skin phenotypes have less melanin pigmentation and are more likely to burn from ultraviolet light exposure. Therefore, these individuals more easily and quickly accumulate a mutational burden in the skin, which increases susceptibility to cutaneous malignancies. [3] Patients with lighter skin, specifically those with Fitzpatrick skin types 1-3, are also more likely to experience skin sensitivity in response to the application of skincare products. [4]

In contrast, those of darker skin phenotypes have a greater melanin concentration and are better able to withstand ultraviolet light exposure. These individuals are more likely to tan than burn, and are overall less likely to develop cutaneous malignancies induced by ultraviolet light. [3] Additionally, those with darker skin types are more likely to develop post-inflammatory hyperpigmentation. [5]

It is the goal of this full chapter to describe and provide examples of dermoscopy in skin of color (Fitzpatrick skin types 4-6)

Many studies have demonstrated that melanomas in persons of skin of color are diagnosed at more advanced stages and have a worse prognosis than melanomas in non-Hispanic whites. [6] [7] [8] [9] [10]

Dermoscopy has been proven to increase the sensitivity and specificity of cancer detection especially in light skinned individuals. Unfortunately, many of the studies have included very few persons with darker skin types (skin of color). The most comprehensive article on skin cancer in skin of color does not even have the words dermoscopy or dermatoscope in the article. [11] However, nevi, lentigines, and melanomas in skin of color have been analyzed as far back as the 1970’s prior to dermoscopy. [12]

In one prospective study of dermoscopic nevus patterns in skin of color, Lallas, et al. analyzed 300 nevi from persons with skin type V and VI. [13] The majority of nevi in skin type V revealed a reticular pattern with dark brown color, whereas persons with skin type VI possessed more nevi showing a structureless pattern with black, blue and grey colors. [13] In another similar prospective study, Tuma et al. reported that nevi in patients with skin types V and VI had a color distribution pattern with a tendency for central hyperpigmentation. [14]

Dermoscopic patterns in acral melanocytic lesions in the United States in skin of color was analyzed by Madankumar, et al. [15] They confirmed that melanocytic lesions of the palms and soles are common in skin of color. However, there were no melanomas found in over 1000 patients, so they were unable to make any conclusions about the predictive value of various dermoscopic patterns for diagnosing acral melanoma in skin of color. [15]

De Giorgi, et al. utilized dermoscopy to analyze 100 pigmented cutaneous lesions in non-white patients. [16] This analysis included Clark nevi, seborrheic keratoses, blue nevi, dermatofibromas, and melanomas. [16] They determined that the use of dermoscopy in nonwhite populations remains the same as in white populations, since single dermoscopic features such as a pigmented network, streaks, globules, blue-white veil, and milia-like cysts were easily identified during dermoscopic exam. [16] Therefore, more research promoting the use of dermoscopy in skin of color patients will be useful in making this practice more commonplace in this population.

Fortunately, more attention is being paid to the issue of skin of color in general as increasing attention is being paid to the systemic racism in the US and around the world. This is a time to collaborate to put together what we know about dermoscopy in skin of color and to begin doing research to advance our knowledge of this area.

Simultaneously, the dermatology world is beginning to look at how to be more inclusive of doctors of skin of color. [17] [18] [19] [20] [21] This can break down some barriers to healthcare for people of color.

Of course, our goal in Dermoscopedia is to see that all dermatologists and other health-care providers caring for people’s skin are competent and confident dermoscopists with the full spectrum of human skin.

Please visit these sub-chapters on SOC after completing this section below


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  2. Sharma & Patel: Laser Fitzpatrick Skin Type Recommendations. ' 2021;. PMID: 32491558.
  3. 3.0 3.1 3.2 3.3 3.4 Holm-Schou et al.: Skin cancer phototype: A new classification directly related to skin cancer and based on responses from 2869 individuals. Photodermatol Photoimmunol Photomed 2019;35:116-123. PMID: 30312498. DOI.
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  10. Hu et al.: Comparison of stage at diagnosis of melanoma among Hispanic, black, and white patients in Miami-Dade County, Florida. Arch Dermatol 2006;142:704-8. PMID: 16785372. DOI.
  11. Gloster & Neal: Skin cancer in skin of color. J Am Acad Dermatol 2006;55:741-60; quiz 761-4. PMID: 17052479. DOI.
  12. Coleman et al.: Nevi, lentigines, and melanomas in blacks. Arch Dermatol 1980;116:548-51. PMID: 7377786.
  13. 13.0 13.1 Lallas et al.: Dermoscopic nevus patterns in skin of colour: a prospective, cross-sectional, morphological study in individuals with skin type V and VI. J Eur Acad Dermatol Venereol 2014;28:1469-74. PMID: 24237599. DOI.
  14. Tuma et al.: Dermoscopy of black skin: A cross-sectional study of clinical and dermoscopic features of melanocytic lesions in individuals with type V/VI skin compared to those with type I/II skin. J Am Acad Dermatol 2015;73:114-9. PMID: 25982540. DOI.
  15. 15.0 15.1 Madankumar et al.: Acral melanocytic lesions in the United States: Prevalence, awareness, and dermoscopic patterns in skin-of-color and non-Hispanic white patients. J Am Acad Dermatol 2016;74:724-30.e1. PMID: 26803347. DOI.
  16. 16.0 16.1 16.2 de Giorgi et al.: Dermoscopy in black people. Br J Dermatol 2006;155:695-9. PMID: 16965417. DOI.
  17. Van Voorhees & Enos: Diversity in Dermatology Residency Programs. J Investig Dermatol Symp Proc 2017;18:S46-S49. PMID: 28941493. DOI.
  18. Pritchett et al.: Diversity in dermatology: Roadmap for improvement. J Am Acad Dermatol 2018;79:337-341. PMID: 29653209. DOI.
  19. Granstein et al.: Diversity in Dermatology-A Call for Action. JAMA Dermatol 2017;153:499-500. PMID: 28423151. DOI.
  20. Pandya et al.: Increasing racial and ethnic diversity in dermatology: A call to action. J Am Acad Dermatol 2016;74:584-7. PMID: 26774427. DOI.
  21. Bray et al.: Publication rates on the topic of racial and ethnic diversity in dermatology versus other specialties. Dermatol Online J 2020;26:. PMID: 32609444.
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