Conference Coverage

The case for a new skin typing system



The Fitzpatrick Skin Typing system could use a makeover.

dermatologist and cosmetic and laser fellow in the department of dermatology at Massachusetts General Hospital

Dr. Karen C. Kagha

Even though the popular classification system added skin types V and VI in 1988 to the first iteration established in 1975, it was never intended for categorizing skin color, according to Karen C. Kagha, MD.

“This topic is going to become more relevant in our clinical practices, especially when you look at the current population trends in the U.S.,” Dr. Kagha, MD, a dermatologist and cosmetic and laser fellow in the department of dermatology at Massachusetts General Hospital and a research fellow at Wellman Center for Photomedicine, both in Boston, said during a virtual course on laser and aesthetic skin therapy. “Minority groups continue to increase. According to the U.S. Census Bureau, by the year 2050, we can expect that the majority of the population will be of non-European descent.”

The original intent of the Fitzpatrick Skin Typing (FST) system was to establish a minimal erythema dose, or likelihood to burn for patients receiving phototherapy, she continued. However, a recently published survey of 141 board-certified dermatologists and trainees found that 31% of respondents said that they used the Fitzpatrick Skin Typing System to describe the patient’s race or ethnicity, 47% used it to describe the patients’ constitutive skin color, and 22% used it in both scenarios.

“There also have been inconsistencies reported with the Fitzpatrick Skin Typing System,” Dr. Kagha said during the meeting, which was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. “Some studies show that there are inconsistent correlations between self-reported Fitzpatrick Skin Type and burn risk, and between self-reported FST and physician-reported FST. This means that some patients self-identify differently from how their physicians identify them.” There have also been some inconsistent correlations between race and objective measures of pigmentation, and also between race and self-reported FST.

Several classification systems have surfaced to try to bridge some of these gaps, including the Fanous classification, the Roberts Skin Type Classification System, and the Lancer Ethnicity Scale. Some of these have focused more on expanding the racial and ethnic categories to help predict response to procedures, she said, while others have focused more on hyperpigmentation, photoaging, and risk of scarring. “Others have suggested having different color matching systems to expand on a number of color-matched hues with regard to hyperpigmentation or race,” Dr. Kagha added. “In spite of all these efforts, it seems that the FST system remains the most widely used classification system in dermatology. I think that’s likely because we haven’t established a new consensus on a different system to use.”

She went on to postulate that there is likely “an infinite number of skin colors that are also impacted by geographic and cultural factors. Perhaps we should restructure how we think about skin typing. We need to establish a new consensus on skin typing, one that respects the variability in skin color but also one that’s clear, concise, objective, practical, and can be universally accepted.”

Dr. Kagha concluded her remarks by encouraging dermatologists to become more comfortable with treating all skin types. “This is going to be in line with the current population trends in the U.S., and also in line with the patients that we serve. Finally, I think we as physicians are in a unique position. Our patients’ frustrations and unsolved mysteries can drive our passion and our patient-centered innovation. For me, a common theme and a common source of frustration that I’ve seen in patients with increased melanin in their skin is figuring out how to effectively remove or prevent unwanted marks or unwanted pigment without disturbing the baseline pigment.”

Dr. Kagha reported having no financial disclosures.

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