The US Census Bureau has estimated that half of the US population will be of non-European descent by 2050.8 As racial and ethnic distinctions continue to be blurred, attempts to include all nonwhite skin types under the umbrella term skin of color becomes increasingly problematic. The true number of skin colors is unknown but likely is infinite, as Brazilian artist Angélica Dass has demonstrated with her photographic project “Humanae” (Figure). Given this shift in demographics and the limitations of the FST, alternative methods of describing skin color must be developed.
The results of our survey suggest that approximately one-third to half of academic dermatologists/dermatology trainees use FST to describe race/ethnicity and/or constitutive skin color. This misuse of FST may occur more frequently among physicians who do not identify as having skin of color. Additionally, misuse of FST in academic settings may be problematic and confusing for medical students who may learn to use this common dermatologic tool outside of its original intent.
We acknowledge that the conundrum of how to classify individuals with nonwhite skin or skin of color is not simply answered. Several alternative skin classification models have been proposed to improve the sensitivity and specificity of identifying patients with skin of color (Table). Refining FST classification is one approach. Employing terms such as skin irritation, tenderness, itching, or skin becoming darker from sun exposure rather than painful burn or tanning may result in better identification.1,4 A study conducted in India modified the FST questionnaire to acknowledge cultural behaviors.15 Because lighter skin is culturally valued in this population, patient experience with purposeful sun exposure was limited; thus, the questionnaire was modified to remove questions on the use of tanning booths and/or creams as well as sun exposure and instead included more objective questions regarding dark brown eye color, black and dark brown hair color, and dark brown skin color.15 Other studies have suggested that patient-reported photosensitivity assessed via a questionnaire is a valid measure for assessing FST but is associated with an overestimation of skin color, known as “the dark shift.”20
Sharma et al15 utilized reflectance spectrophotometry as an objective measure of melanin and skin erythema. The melanin index consistently showed a positive correlation with FSTs as opposed to the erythema index, which correlated poorly.15 Although reflectance spectrometry accurately identifies skin color in patients with nonwhite skin,21,22 it is an impractical and cost-prohibitive tool for daily practice. A more practical tool for the clinical setting would be a visual color scale with skin hues spanning FST types I to VI, including bands of increasingly darker gradations that would be particularly useful in assessing skin of color. Once such tool is the Taylor Hyperpigmentation Scale.17 Although currently not widely available, this tool could be further refined with additional skin hues.
Other investigators have criticized the various limitations of FST, including physician vs patient assessment, interview vs questionnaire, and phrasing of questions on skin type.23 Our findings suggest that medical providers should be cognizant of conflating race and ethnicity with FST. Two authors of this report (O.R.W. and J.E.D.) are medical students with skin of color and frequently have observed the addition of FST to the medical records of patients who were not receiving phototherapy as a proxy for race. We believe that more culturally appropriate and clinically relevant methods for describing skin of color need to be developed and, in the interim, the original intent of FST should be emphasized and incorporated in medical school and resident education.
The authors thank Adewole Adamson, MD (Austin, Texas), for discussion and feedback.