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Doctor Op-Ed Evolving the Understanding of Skin Type to Embrace Real Diversity

Medically reviewed by Raechele Cochran Gathers, MD — By Jenny Yu, MD FACS on September 23, 2022Share on PinterestLeire Cavia/Stocksy United (top right); ohlamour studio/Stocksy UnitedIn almost any major city in the U.S., you can look out on a crowded street and see a breadth of diversity that would have been unheard of just a hundred years ago. America has often been called a “melting pot” due to its history of immigration and the variety of cultures and traditions that have found a home on its shores. Still, to truly honor the varied people who make their lives here, we must see them first. This begins with how we talk about, understand, and classify skin tone, from the medical community to skin care and beyond.

What are the Fitzpatrick Skin Types

As it stands now, much of the collective understanding of skin tone is dictated by the Fitzpatrick Skin Types (FST). If you’ve been to a dermatologist, you may be familiar with them. The Fitzpatrick Skin Type (FST) scale was developed in 1972 by Thomas Fitzpatrick as a means to determine the likelihood that different shades of skin would or wouldn’t burn with exposure to sunlight or during phototherapy. During the invention of the scale, Fitzpatrick’s patients were originally white people, rendering a scale of I to IV that reflects lighter skin tones. In 1988, V and VI were added to include darker skin tones. The 6 types denote the amount of melanin that’s present in the skin. This determines how likely the skin will burn with exposure to UV radiation, including sun and other forms of light therapy. Type I has the least amount of melanin and is most likely to burn, while Type VI burn tendency is less due to more melanin present. The FST is used in various clinical settings for:procedures such as laserstattoo removalschemical peelsdeveloping skin care productsassessing skin cancer risk

The limitations of the Fitzpatrick Skin Types

While the FST is still widely used in the medical community, it has limitations that shouldn’t be ignored. First, it involves a subjective, self-reported survey. Questions within the FST related to sunburn, frequency of tanning, and more can be easily misinterpreted. Studies have shown that there is lack of reliability with responses to these specific questions, especially as it relates to different cultures and races. Second, the FST does not address the more nuanced skin reactions to phototherapy—like irritation, tenderness, and itching—that can be more pronounced in darker skin tones. According to 2020 research, there are special considerations needed when treating skin of color. For instance, the National Psoriasis Foundation notes that darker skin tones may require higher doses of phototherapy, and that many practitioners may be uncomfortable doing so due to inexperience with these skin types. To do so, the questions could be revised to address the entire spectrum of reactions that present in varying degrees on different skin types.

Influence beyond the doctor s office

The FST is a commonly used standard in clinical settings to discuss various skin tones, from pale to dark. These 6 skin types or tones are widely adopted even outside of the clinical setting. FST skin tones were used by tech companies as the data set for building the algorithm in products and services such as Google Search and Photos, according to an article by Reuters. However, having only 6 skin types created challenges and limitations for AI and machine learning. On top of that, the article noted that having four categories for white skin and one each for black and brown skin disregards diversity among people of color. As a result, Google is adopting the Monk Skin Tone Scale. It’s an expanded scale that’s more reflective of actual skin tone diversity.Share on PinterestBrazilian photographer Angelica Dass at the ‘The Nature of Color’ exhibition preview, American Museum of Natural History, New York, USA – 03 Mar 2020. By Vanessa Carvalho/Shutterstock In her Humanae project, Brazilian artist Angélica Dass paired thousands of photos of varying skin tones with the Pantone Color System (PCS), designed to standardize colors for identification and matching in printed materials. Dass’ work is challenging how we think of skin tones and ethnicity.

Confusing color and race

How did a clinical scale originally intended to determine skin’s reaction to sunlight become the standard for identifying skin tone, often conflated to determine ethnicity and race? An anonymous survey of dermatologists conducted by Dr. Susan Taylor and colleagues, 31 percent said they used FST to describe the patient’s race or ethnicity. Pew Research has reported that half of the U.S. population will be of non-European descent by 2050. Furthermore, the U.S. Census Bureau notes that the percentage of people who reported multiple races has increased more than any other single-race group, from 2.9 percent of the population (9 million people) in 2010 to 10.2 percent of the population (33.8 million people) in 2020.

Updating how we see skin tone

As the distinction of skin tones blur, we need to expand our thinking outside of the use of the FST alone. We need to recognize its original intention and take the knowledge of what we’ve learned within skin health to develop better ways to discuss skin tones. Clinically, this work has been ongoing. However, we need to translate and apply these learnings for use in skin care product development, therapies, and medical education. Both clinically and culturally, we need to take the opportunity to look at the FST with a new perspective as well. Jenny Yu joins the Healthline Medical Affairs Team with experience in clinical research, education, and clinical practice. She has experience in clinical operations, research processes, and innovation. Her passion is to educate in the realm of conditions, prevention and wellness. Her role with the Medical Integrity Team is to ensure accurate and consistent medical content in the strategic growth of Healthline. Last medically reviewed on September 23, 2022

How we vetted this article

SourcesHistoryHealthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.Jones N, et al. (2021). 2020 Census Illuminates Racial and Ethnic Composition of the Country.
census.gov/library/stories/2021/08/improved-race-ethnicity-measures-reveal-united-states-population-much-more-multiracial.htmlNational Psoriasis Foundation. (2021). Psoriasis and Skin of Color.
psoriasis.org/advance/diagnosing-psoriasis-in-skin-of-color/Paresh D. (2020). Exclusive: Google searches for new measure of skin tones to curb bias in products.
reuters.com/article/ctech-us-tech-fitzpatrick-exclusive-idCAKCN2DU0UA-OCATCPassel JS, et al. (2008). Pew Research. U.S. Population Projections: 2005-2050.
pewresearch.org/hispanic/2008/02/11/us-population-projections-2005-2050/Sharma AN, et al. (2022). Laser Fitzpatrick Skin Type Recommendations.
ncbi.nlm.nih.gov/books/NBK557626/Ware OR, et al. (2020). Phototherapy in Skin of Color.
sciencedirect.com/science/article/abs/pii/S0733863519300853?via%3DihubWare OR, et al. (2020). Racial Limitations of Fitzpatrick Skin Type.
cdn.mdedge.com/files/s3fs-public/Ware%20SOC%20CT105002077.PDFOur experts continually monitor the health and wellness space, and we update our articles when new information becomes available. Current Version Sep 23, 2022 By Jenny Yu Edited By Crystal Hoshaw Medically Reviewed By Raechele Cochran Gathers, MD Share this articleMedically reviewed by Raechele Cochran Gathers, MD — By Jenny Yu, MD FACS on September 23, 2022

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