Am Fam Physician. 2023;107(1):26-34
Related editorial: Improving Diversity, Equity, and Inclusion in AFP
Patient information: See related handout on common skin conditions in skin of color.
Published online October 12, 2022.
Author disclosure: No relevant financial relationships.
Individuals with skin of color represent a diverse population of racial and ethnic backgrounds, including but not limited to Black or African American, American Indian or Alaska Native, Asian American or Pacific Islander, Hispanic or Latino, and Middle Eastern or North African. Dermatologic health disparities exist in part because of systemic racism and are exacerbated by inadequate physician training and a lack of high-quality research on skin diagnoses that disproportionately affect people with skin of color. These conditions, which include postinflammatory hyperpigmentation, keloids, dermatosis papulosa nigra, pseudofolliculitis barbae, and acne keloidalis nuchae, are usually diagnosed clinically and not associated with an underlying systemic disease. They can have significant impacts on mental health and quality of life and are often underdiagnosed or undertreated in skin of color. Hydroquinone 4% is considered the standard treatment for postinflammatory hyperpigmentation. Standard treatment for keloids includes combination intralesional therapy with triamcinolone and fluorouracil. If treatment is preferred for dermatosis papulosa nigra, options include scissor excision, cryotherapy, curettage, electrodesiccation, and laser therapies. Shaving cessation is the best initial treatment for pseudofolliculitis barbae. Individuals with acne keloidalis nuchae should avoid frequent close shaves or short haircuts on the nuchal area of the scalp.
Individuals with skin of color make up 40.9% of the U.S. population, and this is expected to increase to 59.5% by 2060.1 Skin conditions account for 12.4% of all diagnoses seen by family physicians,2–12 highlighting the importance of educating physicians on common dermatologic conditions in skin of color (Table 13–10,13,14). Although other skin conditions such as atopic dermatitis, psoriasis, and cellulitis can present differently in skin of color, this article focuses on five common diagnoses that disproportionately affect this population and can have a substantial impact on mental health and quality of life: postinflammatory hyperpigmentation, keloids, dermatosis papulosa nigra, pseudofolliculitis barbae, and acne keloidalis nuchae.
| Despite increased reporting of race and ethnicity in dermatology clinical trials, the percentage of non-White participants has not changed over the past 10 years. |
| An analysis of dermatologic textbooks showed that Fitzpatrick skin types V and VI are dramatically underrepresented compared with U.S. demographics. The one exception is sexually transmitted infections; skin of color represents 47% to 58% of images depicting these infections. |
| A systematic review of 36 articles evaluating cutaneous manifestations of COVID-19 showed that 120 out of 130 images (92%) represented patients with Fitzpatrick skin types I to III, with no images representing skin types V or VI. |
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Broad-spectrum, water-based sunscreen (SPF of 30 or higher) should be used to prevent postinflammatory hyperpigmentation.27–29 | C | Expert opinion |
| First-line topical therapies for postinflammatory hyperpigmentation include hydroquinone 4% and triple combination therapy with fluocinolone 0.01%/hydroquinone 4%/tretinoin 0.05% (Tri-Luma).31–33 | C | Expert opinion |
| First-line treatment for keloids is weekly or biweekly administration of intralesional triamcinolone and fluorouracil for six to eight weeks.41,42 | B | Randomized controlled trial with 150 patients and a comparative study with 102 patients |
| First-line treatment for pseudofolliculitis barbae is cessation of shaving for at least eight weeks.48,49 | C | Expert opinion |
| Laser treatment appears to be most effective for improving acne keloidalis nuchae.54,55 | B | Systematic review with 85 patients and a small randomized controlled trial |
| Condition | Prevalence in skin of color | Onset | Features |
|---|---|---|---|
| Acanthosis nigricans | 5.5% to 34.2% | Adolescence | Irregularly defined, hyperpigmented, velvety patches, usually on the posterior neck, axilla, and groin |
| Acne keloidalis nuchae | 0.5% to 13.6% | Postadolescence | Keloid-like papules and plaques and cicatricial alopecia of the nuchal and occipital scalp |
| Atopic dermatitis | 7.8% to 19.3% | Early childhood | Erythematous or hyperpigmented, pruritic, scaly patches |
| Dermatosis papulosa nigra | 33% | Adolescence | Hyperpigmented, filiform or sessile papules, usually on the face and neck |
| Hidradenitis suppurativa | 0.05% to 4% | Adolescence | Nodules and abscesses in intertriginous areas |
| Keloids | 8.5% | Adolescence | Firm, rubbery, proliferative nodules |
| Melasma | 9% to 50% | Postadolescence | Gray-brown patches, usually on the face |
| Postinflammatory hyperpigmentation | 65% | Any age | Irregular hyperpigmented macules or patches |
| Prurigo nodularis | 8.8% | Postadolescence | Firm, pruritic nodules, usually on the arms and legs |
| Pseudofolliculitis barbae | 45% to 83% | Adolescence | Erythematous or hyperpigmented, firm papules and pustules, usually on the jaw and upper neck areas |
| Traction alopecia | 1% to 37% | Early childhood | Symmetrical hair loss around the scalp line |
The wide spectrum of skin color is commonly classified using Fitzpatrick skin phototypes I to VI (Table 2).2,3,13–18 This classification was first proposed in 1975 and relies on the subjective determination of an individual's propensity for photodermatitis (sunburn) based on skin color. Importantly, this classification system should not be used as a surrogate marker for race and ethnicity.15,16 In this article, skin of color refers to a diverse population of racial and ethnic backgrounds, including but not limited to those who identify as Black or African American, American Indian or Alaska Native, Asian American, Pacific Islander, Hispanic or Latino, and Middle Eastern or North African.
| Type | Example | Possible skin conditions |
|---|---|---|
| I | Melanoma | |
| II | Melanoma | |
| III | Dermatosis papulosa nigra Postinflammatory hyperpigmentation | |
| IV | Dermatosis papulosa nigra Postinflammatory hyperpigmentation | |
| V | Acne keloidalis nuchae Dermatosis papulosa nigra Keloids Postinflammatory hyperpigmentation Pseudofolliculitis barbae | |
| VI | Acne keloidalis nuchae Dermatosis papulosa nigra Keloids Postinflammatory hyperpigmentation Pseudofolliculitis barbae |
Dermatologic Health Disparities
Factors that contribute to dermatologic disparities include systemic racism, lack of high-quality evidence-based research on dermatologic conditions affecting skin of color, and lack of physician education on the treatment and diagnosis of these conditions.19 For example, melanoma and nonmelanoma skin cancers are less prevalent in patients with skin of color, but these patients clinically present with more advanced disease (16% vs. 5%) and have a lower five-year survival rate (66.2% vs. 90.1%) compared with White patients.20 Black patients are less likely to receive treatment for acne, atopic dermatitis, and psoriasis compared with White patients.21
Despite increased reporting of race and ethnicity in dermatology clinical trials, the percentage of non-White participants has not changed over the past 10 years.22 A 2020 systematic review evaluating cutaneous manifestations of COVID-19 showed that 120 out of 130 images (92%) from 36 articles represented patients with Fitzpatrick skin types I to III, with no images representing types V or VI.23 An analysis of dermatologic textbooks showed that skin types V and VI are dramatically underrepresented compared with U.S. demographics (with less than 14% of textbook images representing skin types V and VI).24 The one exception is sexually transmitted infections; skin of color represents 47% to 58% of images depicting these infections, compared with 28% of non–sexually transmitted infections.25
A 2011 survey showed that 47% of dermatologists report inadequate training on skin conditions common in Black patients.26 Medical students receive an average of only 16 to 22 total hours of dermatology training, and fewer than 40% of primary care residents feel that their medical school adequately prepared them to manage common skin conditions.26
Expanding dermatologic medical education and enhancing research funding directly related to common conditions in skin of color are key to reducing dermatologic health disparities.
Postinflammatory Hyperpigmentation
Postinflammatory hyperpigmentation is a reactive hypermelanosis that occurs after endogenous inflammation or external injury (Figure 1) and is most noticeable in Fitzpatrick skin types III to VI (90% of cases).14 The first step in treatment is identifying the underlying etiology of the injury or inflammation to prevent further damage.14 Endogenous causes include inflammatory conditions such as acne vulgaris (47.4% to 65.3% of cases), pseudofolliculitis barbae, atopic dermatitis, lichen planus, psoriasis, and contact dermatitis. Causative external injuries include insect bites, chemical peels, cryotherapy, and laser surgery. Use of a broad-spectrum (ultraviolet A and B protection), water-based sunscreen with a sun protection factor (SPF) of 30 or higher can reduce the incidence of postinflammatory hyperpigmentation.27–29 Sunscreen that blocks visible light, such as iron oxide sunscreen, can be especially helpful for patients with skin types III to VI.27,30
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