Understanding Dermatologic Care in Skin of Color: Limitations in Education and Research, Clinical Considerations, and Patient Counseling

Dermatologic care encompasses all skin types, yet patients with darker skin pigmentation have historically been underrepresented in research, education, and clinical training. As a result, clinicians working in the field of dermatology have lower confidence in recognizing, diagnosing, and providing effective treatment plans and education for patients with diverse skin tones.

Dermatology clinicians should strive to improve competency and take additional steps to get the proper education and training to provide more equitable dermatologic care. With a lack of variation in pigmentation seen in research and education, health care providers need proper guidance around how to counsel patients and tailor treatment regimens backed by understanding of how different conditions and adverse drug effects can present in skin of color.

Skin Phototypes and Differentiating Skin Pigmentation

For effective dermatologic counseling, it is important to understand variations in skin tone. The Fitzpatrick skin phototype classification system is commonly used in practice and categorizes skin based on its response to ultraviolet (UV) exposure. The scale ranges from Type I (fair skin that burns easily and does not tan) to Type VI (deeply pigmented skin that rarely burns and tans easily).¹ This system has its shortcomings, as it was originally developed to guide safe UV exposure in psoriasis treatment, primarily in Caucasian populations, highlighting the limitations in its ability to capture the complexity and diversity of skin tones seen in darker skin phototypes. Of note, skin phototypes V and VI were later added to this system based off a patient’s baseline pigmentation rather than their true UV response. This led to the assumption that these skin types never or rarely burn, which is misleading, as emerging evidence suggests these skin types can burn more than previously thought.² Relying on this scale may lead to misinformation, and clinicians should think beyond it when evaluating skin of color.

It is also important to distinguish between constitutive and facultative skin color. Constitutive pigmentation describes an individual’s genetically determined baseline melanin levels, whereas facultative pigmentation refers to skin changes due to external influences such as UV exposure, hormonal changes, chronic conditions, or medications.² Distinguishing between these 2 is clinically relevant, as patients with darker pigmentation, either from their genetic baseline or from external factors, may be at an increased risk for pigmentary disorders. Understanding these fundamentals can help providers better counsel patients on potential adverse effects such as post-inflammatory hyperpigmentation (PIH) and tailor treatment strategies appropriately.

Structural Bias in Dermatologic Education and Research

There is growing need for attention on the lack of education and research surrounding dermatologic conditions in patients with darker skin pigmentation. Many skin conditions present differently in those with skin of color, yet providers may exhibit a lower level of confidence when diagnosing and managing these patients.³ These gaps can be attributed to insufficient diversity in medical education, including textbooks, conferences, and online resources.⁴ This gap must be addressed to prevent suboptimal health outcomes for individuals with skin of color.

Another contributing factor to disparities in dermatologic care is the structural bias in clinical trials and research for most medications. To ensure the efficacy and safety of different drugs, representation in clinical trials is essential. Currently, 75% of research participants are White, compared to 11% who are Hispanic, 8% African-American, and 6% Asian, demonstrating that racial minorities remain inadequately represented in many studies.⁵ Due to this, there may not be sufficient data to fully capture differences in treatment response and adverse effects in patients with various skin tones.⁵ Therefore, broadening diversity in clinical trials is important to improve treatment strategies and reduce disparities in dermatologic care.

As a result of these disparities, delayed diagnoses and misdiagnoses are common, further prolonging treatment and ultimately leading to patient distress, unnecessary testing, excessive biopsies, and reduced trust in the patient-provider relationship.³ Patients with darker skin pigmentation may be at increased risk for complications such as PIH or hypopigmentation, especially when conditions are not appropriately managed. It is important to consider the limited testing of medications in patients with darker skin tones when discussing medication regimens that are reported to have minimal adverse effects but that have not been adequately studied across diverse populations. These challenges show the importance of improving education to ultimately reduce disparities in dermatologic outcomes.

There are ongoing efforts to address structural bias in dermatologic education and research, including the development of more inclusive dermatology textbooks, increased representation in clinical trials, and growing educational outreach through dermatologists on social media platforms, all of which are important steps toward reducing disparities and improving outcomes for patients with skin of color.

What Is PIH?

Multiple dermatologic conditions may be more prevalent or present differently in skin of color, including melasma, keloids, acne, and exogenous ochronosis. Among these, PIH is one of the most frequently encountered and results from an exaggerated pigmentary response. Although increased melanin can be a protective factor from UV damage, individuals with darker skin tones may be more susceptible to developing PIH.

PIH presents on the skin as dark spots or patches and can be most severe in African American, Hispanic, Middle Eastern, Pacific Islander, Native American, and Asian populations. These discolorations are from excess melanin production seen with a variety of conditions, including acne, sun exposure, or epithelial injury. PIH is a commonly encountered pigmentary disorder affecting individuals primarily with skin types on Fitzpatrick levels III through VI. As previously discussed, even though darker skin tones can have a lower risk of photodamage from excessive UV radiation, the exposure to sun can aggravate this condition, causing uneven skin tone. This hyperpigmentation is seen in dermatologic diagnoses such as atopic dermatitis, allergies, injuries, or cosmetic procedures.⁶

The mechanism behind PIH involves an initial irritation, injury, or inflammation to the basal layer of the epidermis, leading to stimulated melanocyte activity and deposition within the epidermis or dermis. Because darker skin tones already have a higher baseline melanocyte activity, there may be an increase in reactive pigment production. In comparison, dermatologic irritation can present primarily as erythema in lighter skin tones. At the cellular level, the initial inflammation that occurs releases cytokines, specifically IL-1, IL-6, tumor necrosis factor (TNF), prostaglandins, and leukotrienes.⁶ All of these are signals to the body that stimulate melanin production and increase the transfer of pigment to skin cells.⁶

Recent study findings suggest that individuals with darker skin may be more prone to inflammation with increased inflammatory markers, like IL-6, when compared to Mexican and lighter skinned non-Hispanic populations. Additional research comparing Japanese and African American individuals found that pro-inflammatory markers, including IL-6, C-reactive protein, and fibrinogen were consistently lower in the Japanese population. These findings support the idea that individuals with darker skin may be more susceptible to inflammatory processes, which can be the main trigger for the development of PIH. This increased tendency for inflammation could also suggest individuals with melanin-rich skin are more prone to inflammatory conditions like acne and atopic dermatitis, which are common contributors to PIH.⁶

How to Treat Hyperpigmentation Disorders

There are several approaches to treating hyperpigmentation disorders, with the most effective treatments targeting underlying inflammation that drives pigment production. Discolorations are seen at both the epidermal and dermal layer and can determine how to proceed with treatment management. In the epidermal layer, the discoloration is more temporary and easier to treat as skin turnover happens more frequently and can be promoted through products like tretinoin. However, when hyperpigmentation is occurring at the dermal layer, it is affecting a deeper layer of skin where turnover happens at a much slower rate. In addition, this excess melanin is being taken up by macrophages responding to the inflammation. Macrophages do not break down melanin efficiently, which can make the hyperpigmentation permanent or much more difficult to clear. Study findings suggest that darker skin types have more macrophages and fibroblasts, which could explain the susceptibility to discoloration and keloids.⁶

There is a fine line when treating hyperpigmentation in these populations, as interventions must reduce pigment without triggering additional inflammation. Common treatments include topical depigmenting agents, oral medications like tranexamic acid, chemical peels, and laser technology. However, laser procedures must be used with caution, as they can induce inflammation and potentially worsen the underlying condition.⁶ Among resurfacing options, studies have shown erbium-based lasers may offer a safer alternative with a lower risk of pigmentary complications because they cause less thermal injury to surrounding tissue.⁷ Given that melanocyte stimulation primarily occurs within the basal layer of the epidermis, caution should be utilized with shorter wavelength devices, as these penetrate the skin more superficially and can increase the risk of hyperpigmentation. However, careful consideration is still advised in darker skin types due to the ongoing risk of PIH.⁷ Pre- and post-treatment with topical corticosteroids have been shown to further reduce this risk by suppressing inflammation.⁶

Topical agents with both depigmenting and anti-inflammatory properties are typically the preferred management with pigmentation disorders. Azelaic acid is an effective option as it inhibits inflammatory markers like IL-1B, IL-6, and TNF-α.^1,6 Other agents, like kojic acid and N-acteyl glucosamine, offer similar benefits.^1,6 Retinoids may also improve hyperpigmentation by accelerating epidermal turnover, but should be introduced carefully, as irritation or excessive use can provoke inflammation and potentially worsen PIH.⁶ Hydroquinone is another effective treatment, but requires careful counseling as this can cause another pigmentation disorder that disproportionately affects darker skin populations, called exogenous ochronosis. This can be a complication of long-term use of hydroquinone and presents as a blue-black pigmentation.⁸ Lastly,oraltranexamic acid has emerged as a promising new treatment which may reduce melanocyte stimulation and abnormal pigmentation.⁹

Vitamin D deficiency is another important component to pigmentation disorders. Vitamin D deficiency is common in individuals with darker skin tones due to reduced cutaneous synthesis. Evidence suggests that vitamin D supplementation may play a role in improving microvascular endothelial function that help manage inflammation and reduce oxidative stress, which may be relevant considering the higher rates of Vitamin D deficiency observed in individuals with darker skin.⁶ Therefore, correcting this deficiency may indirectly improve inflammatory drivers of hyperpigmentation. Treatment requires a balanced approach that minimizes inflammation while addressing excess pigment, with careful consideration of the specific risks in skin of color.

Counseling Considerations

Effective patient education and counseling require understanding how skin of color can present differently in certain diseases and respond differently with various treatments. Clinicians must understand different skin reactions to a variety of conditions and medications to effectively counsel patients and ensure better outcomes. Explaining to patients that they may have a greater propensity for inflammation helps them exercise caution knowing they can be at an increased risk for PIH. Additionally, effectively educating patients to minimize skin irritating behaviors, such as picking at acne lesions, scratching, or misusing topical medications is important. These factors can exacerbate inflammation and increase the likelihood of hyperpigmentation.

No matter the phototype on the Fitzpatrick Scale, photoprotection is a critical component of management for all skin types. Lack of sun protection can lead to DNA damage and can worsen inflammation from oxidative stress. Daily use of broad-spectrum sunscreen with a sun protection factor of at least 30 should be encouraged.⁶

It is also important to set appropriate expectations with patients. Explain that pigmentary changes, particularly those involving the dermis layer, may take months or years to improve, and, in some cases, may not fully resolve. Emphasizing patience and adherence to treatment plans can improve outcomes and reduce patient frustration.

Patients also need to be educated on the proper use and potential adverse effects of topical therapies. Counseling should include guidance on appropriate duration of use, gradual introduction of new medications, and early recognition of irritation to minimize adverse effects. When considering cosmetic treatments like chemical peels or laser therapy, clinicians should exercise the utmost caution in patients with darker skin tones due to the risk of rebound or worsening hyperpigmentation. It is important to ensure that patients understand these risks prior to treatment.

Improving awareness of how dermatologic conditions and medications affect patients across diverse skin tones is an important step toward more equitable dermatologic care. Clinicians need to be able to recognize variations in presentation, identify medication-induced pigmentary changes, and provide individualized treatment plans. Incorporating more diversity into medical education and research is a necessary step toward reducing disparities and improving dermatologic outcomes. At the end of the day, clinicians are responsible for advocating for their patients and owe it to patients to promote more patient-centered dermatologic care.

The Pharmacist’s Role

Pharmacists are uniquely positioned to address gaps in dermatologic care for patients with skin of color through accessible, front-line patient interactions. In community settings, pharmacists frequently assist patients in selecting OTC therapies for acne, hyperpigmentation, and other inflammatory skin conditions. Given the increased risk of PIH in these populations, pharmacists should prioritize recommending products that minimize irritation, such as gentle cleansers, non-comedogenic moisturizers, and gradual introduction of active ingredients such as topical retinoids or chemical exfoliants.^10,11

In addition to product selection, pharmacists play a critical role in patient counseling by setting realistic expectations regarding treatment timelines and emphasizing adherence. Hyperpigmentation disorders, particularly those involving the dermis, may take several months to improve, and premature discontinuation of therapy can limit treatment success.¹⁰ Pharmacists should educate patients on proper application techniques, including starting with lower frequencies for potentially irritating agents and using adjunctive moisturizers to reduce skin barrier disruption.¹¹

Pharmacists are also well positioned to monitor for medication-induced dermatologic adverse effects. Certain medications, including topical retinoids, benzoyl peroxide, and chemical peels, may increase irritation and exacerbate pigmentary changes if not used appropriately.¹⁰ Early identification of irritation and timely intervention can help prevent worsening of PIH. Additionally, pharmacists should reinforce the importance of daily photoprotection with broad spectrum sunscreen, as UV exposure can worsen hyperpigmentation even in individuals with darker skin tones.¹¹

Beyond direct patient care, pharmacists have a role in advancing health equity by staying informed about differences in dermatologic disease presentation across diverse populations and incorporating this knowledge into clinical decision making. Increasing awareness of these variations, advocating for inclusive research, and tailoring patient education accordingly are essential steps toward reducing disparities in dermatologic outcomes. By leveraging their accessibility and medication expertise, pharmacists can significantly improve the management of dermatologic conditions in patients with skin of color.

REFERENCES

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8. Ishack S, Lipner SR. Exogenous ochronosis associated with hydroquinone: a systematic review. Int J Dermatol. 2022;61(6):675-684. doi:10.1111/ijd.15878

9. Kim HJ, Moon SH, Cho SH, Lee JD, Kim HS. Efficacy and safety of tranexamic acid in melasma: a meta-analysis and systematic review. Acta Derm Venereol. 2017;97(7):776-781. doi:10.32400/00015555-2668

10. Davis EC, Callender VD. Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol. 2010;3(7):20-31.

11. Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis. 2007;80(5):387-394.