I invite you to read the previous articles:

Part 1: Facial Aging: Aesthetic Treatments for Every Decade of Life in Skin of Color

Part 2: Improving Aesthetics Care: Key Strategies for Dermatology NPs Treating Skin of Color

‍

What is Skin Phototyping?

In dermatology, skin typing is used for the study of photodermatology and procedural dermatology. More specifically, skin phototyping has been used to classify the skin based on how it responds to ultraviolet light. Before the 1960s, the skin phototype was based on the clinical assessment of skin color. However, that practice was later deemed to be flawed, prompting Thomas B. Fitzpatrick, MD, PhD (1975) to develop a classification system where skin phototyping was based on ethnicity and one’s susceptibility to sunburn and tan. This evaluation system was then used to determine the initial dose of phototherapy (Gupta & Sharma, 2019).

Phototherapy is the use of ultraviolet B (UVB; the most common), ultraviolet A (UVA), or visible light (VL) to medically treat various skin conditions. Exposing the skin to a specific wavelength will trigger a biological reaction that can reduce inflammation, decrease skin cell growth, and improve immune functions.

‍

Skin Color

Skin color can be classified as either constitutive or facultative. Constitutive skin color is determined by genetics, specifically the levels, types, and distribution of melanin in the epidermis, and remains unaffected by external or internal influences. In contrast, facultative skin color develops due to environmental factors, such as sun exposure, or hormonal changes, leading to increased melanin production (Gupta & Sharma, 2019).

Although skin phototype and skin color may seem similar, they are distinct concepts. Skin color—whether black, brown, or white—is influenced by multiple pigments, including melanin, hemoglobin (both oxygenated and deoxygenated), bilirubin, and carotenoids. However, melanin is the primary pigment responsible for UV protection. Additional biological mechanisms also contribute to skin photoprotection. Notably, there isn’t always a direct correlation between skin phototype and skin color, particularly in darker skin tones (Gupta & Sharma, 2019).

‍

Melanin

Skin color is primarily determined by the content and type of epidermal melanin, which can be classified into two main types: eumelanin and pheomelanin. Eumelanin, which is darker in color, is predominant in individuals with more deeply pigmented skin. It provides superior photoprotection by effectively filtering UV light and acting as a free radical scavenger. In contrast, pheomelanin, which is lighter in color and more prevalent in fair-skinned individuals, is a less effective UV filter. Instead of offering strong protection, pheomelanin can act as an endogenous photosensitizer, generating superoxide anions that contribute to oxidative stress.

Beyond melanin itself, certain intermediate products in the melanogenesis pathway also play a role in photoprotection. For example, 5,6-dihydroxyindole, an intermediate in melanin synthesis, helps inhibit lipid peroxidation and shields keratinocytes from UV-induced apoptosis. Additionally, other biochemical mechanisms—including cutaneous antioxidant enzymes, DNA repair systems, and extracellular matrix homeostasis—contribute to the skin’s overall defense against UV damage, even though they do not directly influence pigmentation (Gupta & Sharma, 2019).

‍

‍

Who is Thomas Fitzpatrick?

Thomas B. Fitzpatrick, MD, PhD is recognized as one of the leading dermatologists of our time. He dedicated his career at the University of Oregon (Head of Dermatology) before being recruited to Harvard Medical School’s Department of Dermatology and Massachusetts General Hospital’s Dermatology Service as the youngest (age 39) Professor and Chairman of the Department of Dermatology (1959 – 1987), respectively. As a result of his commitment, he is described as the father of modern academic dermatology (Parrish, 2003).

He started researching pigmentation of the skin during World War II when he served in the Army Chemical Center. He was a member of more than 20 professional organizations, served as the president of the Society for Investigative Dermatology, and founded the Dermatology Foundation.  He traveled to Japan frequently to train other dermatologists and as a result, received the Order of the Rising Sun (1987) award. Most notably, he continued to treat difficult cases until his death at the age of 83 and is known for never refusing to see any patient (Parrish, 2003).

‍

Dr. Fitzpatrick was instrumental in the creation of several landmark publications and discoveries including:

-The first multiauthor dermatology textbook (and 4 subsequent editions) in the United States

-The Color Atlas of Dermatology

-Over 250 original scientific publications related to pigmentation, aging, and disorders of the skin

-Cutaneous markers of neurological disorders

-Naming of the melanosome

-Application of the electron microscope in dermatology

-Defining the clinical and microscopic characteristics of early melanoma and widespread screening

-Quantitative studies of sunscreen and the promotion of widespread use in the US and Europe

-Oral psoralen photochemotherapy (PUVA)

‍

Fitzpatrick’s Early Work

Fitzpatrick first classified skin types I to III using the results of an Australian sunscreen study (1972) (Pathak, 2004). Three years later, clinicians needed a way to classify the skin to identify the initial dose of UVA for the use of photochemotherapy in the treatment of psoriasis for patients with white skin. They soon realized they needed a better assessment system to reduce the risk of phototoxic reactions to UVA in all skin types. After realizing that using hair and eye color were not a reliable trait, they developed a classification system based on the patient’s history of sunburn and tanning. Specifically, they evaluated the patient’s response during the first 45 to 60 minutes of unprotected sun exposure (Gupta & Sharma, 2019). In contrast, phototypes V (brown skin) and VI (black skin) were added based on skin color rather than the patient’s reaction to the sun. The subjective assessment of skin phototyping has led to several criticisms of Fitzpatrick skin phototyping system.

‍

The Problems with the Original Skin Typing System

Recall, that Fitzpatrick initially needed a classification system to identify the initial dose of UVA for photochemotherapy or the minimal erythema dose. The minimal Erythema Dose (MED) refers to the smallest amount of ultraviolet (UV) radiation required to produce a perceptible redness (erythema) on the skin within 24 hours after exposure. It is commonly used in dermatology and photobiology to measure individual skin sensitivity to UV radiation and to assess the effectiveness of photoprotection, such as sunscreen or melanin content in the skin (Gupta & Sharma, 2019).

‍

Minimal Erythema Dose (MED)

MED varies based on skin type, melanin levels, and environmental factors. Individuals with darker skin typically have a higher MED due to greater melanin protection, while those with lighter skin have a lower MED and burn more easily. The Fitzpatrick skin phototyping system was introduced as a faster way to calculate MED, which requires a solar simulator. Solar simulators are not readily available and are time-consuming to use. However, discrepancies have been discovered between the MED and self-reported histories (Gupta & Sharma, 2019).

‍

Skin Cancer

Although the Fitzpatrick classification of skin phototyping has been associated with skin cancer risk, it does not provide a quantitative measure of that risk. Additionally, its effectiveness in predicting postinflammatory hyperpigmentation (PIH) following cosmetic procedures has been questioned. To address these limitations, several alternative skin typing systems have been developed, which are discussed later in this article (Gupta & Sharma, 2019).

‍

‍

Doubts Persist

How someone’s skin is classified can vary depending on whether the patient or the provider assesses the response to the questions. While the assessment includes three categories (genetic predisposition, reaction to sun exposure, and tanning habits) with a total of 10 questions, over time, clinicians have focused on only two of the questions and either asked or assumed the patients’ history of sunburning and tanning. However, studies show that respondents tend to answer just one of those questions: sunburning or tanning. Additionally, the way the question is asked varies amongst clinicians, which elicits a variety of answers from the same patient (Gupta & Sharma, 2019). Doubts persist on whether patients consider one or multiple sun exposures and if the Fitzpatrick skin phototyping system is based on constitutive or facultative skin color. Further, given that Fitzpatrick skin types V and VI were based on skin color alone, it doesn’t consider the fact that deeper skin tones can have reactivity to sunlight and that those reactions can vary widely depending on ethnicity (Gupta &Sharma, 2019).

‍

Cosmetic Procedures in Skin of Color: Risk Reduction

When it comes to recommending an appropriate cosmetic treatment or procedure, it’s important to understand that patients with deeper skin tones are at higher risk for developing postinflammatory pigmentary alterations, scarring, and keloids. Below are skin classification scales that consider racial and genetic backgrounds to predict the risk of postoperative complications (Alexis et al., 2024; Gupta & Sharma, 2019).

‍

Pigment Protection Factor (PPF) and Skin Color Measurement

Pigment Protection Factor (PPF) is an objective measure of skin phototype that can be calculated in seconds using diffuse remittance spectroscopy. Unlike the Fitzpatrick classification, which relies on self-reported sunburn and tanning tendencies as detailed previously, PPF directly quantifies UV sensitivity by assessing the dose required to induce erythema and pigmentation. Studies show that PPF correlates more accurately with both sunburn and tanning responses, making it a more reliable indicator across all skin tones, including darker skin (Gupta & Sharma, 2019).

Skin color measurement techniques, such as spectrophotometry and reflectance analysis, offer further precision in assessing phototypes. While these methods align with clinician-assessed Fitzpatrick types, they remain primarily research tools due to cost and accessibility (Gupta & Sharma, 2019).

‍

‍

Selecting Safe Cosmetic Procedures in Skin of Color

I recently published an article on my recommendations for dermatology textbooks for skin of color, highlighting over ten essential medical texts that should be on the required reading list for nursing and medical schools. Despite the collection, there remains a significant gap, particularly in wound care, pediatric dermatology, and cosmetic dermatology.

One standout resource is Procedures in Cosmetic Dermatology: Cosmetic Procedures in Skin of Color by Dr. Andrew F. Alexis, a leader in dermatology. Alexis et al. (2024) offers evidence-based techniques for treating conditions like melasma, hyperpigmentation, and keloids, making this book an invaluable resource for dermatology nurse practitioners committed to safe and effective aesthetic care for all skin tones (Alexis et al., 2024). To minimize post-procedure complications, the authors recommend collecting a thorough history that includes asking about hypertrophic scarring, keloids, and hyperpigmentation before performing cosmetic procedures. When it comes to skin typing, the authors recommend the Roberts Skin Typing System, a four-part approach that evaluates phototype, hyperpigmentation, photoaging, and scarring through ancestral and clinical history and visual examination (Alexis et al., 2024).

‍

The Roberts Skin Type Classification System

The Roberts Skin Type Classification System is a comprehensive tool designed to assess an individual's risk of adverse skin reactions following cosmetic procedures and inflammatory skin conditions. Unlike traditional skin typing methods, this system integrates four key indices—skin phototype, photoaging severity, hyper/hypopigmentation risk, and scarring propensity—to predict potential complications and guide personalized treatment plans. By evaluating these factors, clinicians can proactively identify patients at risk for post-inflammatory hyperpigmentation (PIH), scarring, or other sequelae, allowing for tailored interventions that minimize complications. This classification is particularly valuable for individuals with darker skin tones, who may be more prone to PIH and scarring. Additionally, it serves as a predictive model for treatment response, enabling practitioners to optimize outcomes by selecting the most suitable cosmetic procedures and pre/post-treatment care. By incorporating ancestral background, clinical history, and test site reactions, the Roberts system provides a multidimensional approach to skin assessment, enhancing both safety and efficacy in dermatologic and aesthetic treatments (Roberts, 2008, 2009).

‍

Alternative Skin Typing Systems for Improved Risk Assessment

Several skin typing systems go beyond the Fitzpatrick scale by incorporating ancestry, pigmentation tendencies, and post-procedure risks to enhance treatment planning:

• Lancer Ethnicity Scale: Considers racial and ancestral background alongside Fitzpatrick phototypes to guide laser resurfacing treatments.

• Fanous Skin Classification: Accounts for ancestral origin and skin color to predict procedural risks and expected outcomes.

• Goldman World Classification Scale: Includes ancestry, Fitzpatrick type, and patient-reported tendencies for postinflammatory hyperpigmentation.

• Taylor Hyperpigmentation Scale: Uses a set of 15 color cards with varying pigmentation levels to visually assess and track hyperpigmentation severity, though results may vary between raters.

• Roberts Skin Type Classification: A four-part system incorporating Fitzpatrick phototype, Glogau photoaging scale, hyperpigmentation risk, and scarring tendency to predict post-procedure responses and optimize treatment planning (Gupta & Sharma, 2019; Roberts, 2009).

‍

‍

Key Takeaways

When it comes to classifying the skin, you should consider comprehensive data including, but not limited to, skin color, genetic background, ethnicity, environmental factors, and hormonal changes. Multiple contributing factors have yet to be identified when it comes to how the skin will respond to various stimuli. In the meantime, consider the benefits of using objective skin typing methods such as pigment protection factors or skin color measurements to better predict the outcome of cosmetic procedures like lasers, Intense Pulsed Light, and chemical peels (Gupta & Sharma, 2019; Taylor et al., 2006).

‍

Nursing Implications & Recommendations for DNP Projects and PhD Research in Nursing

Advancing skin classification systems requires nursing-driven research that integrates comprehensive dermatologic assessments with patient-centered care. Future DNP projects can focus on developing clinical guidelines and policies that incorporate skin color, genetic background, ethnicity, environmental influences, and hormonal changes to improve patient safety and procedural outcomes. PhD-level research can further explore the complex interactions that influence skin responses to stimuli, filling critical gaps in dermatologic nursing science.

Additionally, objective skin typing methods—such as pigment protection factors (PPF) and skin color measurements—offer a data-driven approach to predicting patient responses to cosmetic procedures like lasers, intense pulsed light (IPL), and chemical peels. Nurse researchers can evaluate the clinical utility of these methods, ensuring they are equitable, accessible, and effective for diverse patient populations. Expanding nursing-led investigations in this field can enhance dermatologic care, reduce disparities, and optimize patient outcomes in both aesthetic and medical dermatology.

‍

Words of Encouragement

The future of dermatology is bright, with cutting-edge technologies paving the way for more precise, personalized, and effective skin assessments. By integrating science, innovation, and clinical expertise, we can ensure better patient outcomes, particularly for those with diverse skin tones who have been historically underrepresented in research. Keep pushing boundaries, exploring new methodologies, and advocating for inclusive and evidence-based dermatologic care in nursing education, research, and clinical practice.

‍

References

Alexis, A. F., Dover, J. S., & Alam, M. (Eds.). (2024). Cosmetic Procedures in Skin of Color. Elsevier.

Gupta, V., & Sharma, V. K. (2019). Skin typing: Fitzpatrick grading and others. Clinics in Dermatology, 37(5), 430–436.

Parrish JA. Thomas B. Fitzpatrick, MD, PhD 1919-2003). Arch Dermatol. 2003;139(12):1613.

Pathak M. A. (2004). In memory of Thomas Bernhard Fitzpatrick. The Journal of investigative dermatology, 122(2), xx–xxi.

Roberts W. E. (2008). The Roberts Skin Type Classification System. Journal of Drugs in Dermatology D JDD, 7(5), 452–456.

Roberts W. E. (2009). Skin type classification systems old and new. Dermatologic clinics, 27(4), 529–viii.

Taylor, S., Westerhof, W., Im, S., & Lim, J. (2006). Noninvasive techniques for the evaluation of skin color. Journal of the American Academy of Dermatology, 54(5 Suppl 2), S282–S290.

‍

‍

Kimberly Madison, DNP, AGPCNP-BC, WCC

I am a Board-Certified Nurse Practitioner, educator, and author dedicated to advancing dermatology nursing education and research with an emphasis on skin of color. As the founder of Mahogany Dermatology Nursing | Education | Research, I aim to expand access to dermatology research, business acumen, and innovation using artificial intelligence and augmented reality while also leading professional groups and mentoring clinicians. Through engaging and informative social media content and peer-reviewed research, I empower nurses and healthcare professionals to excel in dermatology and improve patient care.

‍