Diversity in Medicine

Atopic dermatitis (AD) is a chronic skin condition generally characterized by pruritic and erythematous papules and plaques.¹ While AD commonly manifests in childhood, 1 in 4 patients living with AD report adult onset of the disease.² The clinical presentation and prevalence of AD vary across age groups, skin tones, and racial and ethnic groups. Globally, AD is estimated to have a prevalence of 2.6%; however, rates vary widely by region.¹ Morphology and distribution of AD lesions also vary by population; therefore, defining one classic presentation of AD is not sufficient in diverse patient populations.³

Epidemiology

The prevalence of AD ranges from 0.2% to 24.6% worldwide, with higher rates in Africa and Oceania and lower rates in India and Northern and Eastern Europe.¹ In the United States, AD affects all racial and ethnic groups; however, prevalence and severity are increased in Black children compared with White children.⁴ In one prospective cohort study, Hispanic children and non-Hispanic Black children aged 3 years and younger had greater odds of AD persisting into mid childhood (approximately age 7 years) compared with non-Hispanic White children.^5,6

Key Clinical Features

Clinical features of AD are heterogeneous and may include differences in color, morphology, and distribution. Brown, hyperpigmented, gray, and/or violaceous plaques may predominate in patients with skin of color (SOC) compared with the erythematous plaques commonly described in lighter skin tones.^1,3 Established scoring systems for AD rely on erythema as a key diagnostic feature, but because erythema can be difficult to detect in darker skin tones, disease severity may be underestimated and diagnosis may be delayed in this population.⁴

Atopic dermatitis in SOC may manifest as lichenoid plaques,⁷ prurigo nodules,^7,8 lichenification,¹ and follicular accentuation.⁹ Lichen planus–like AD is a distinct variant characterized by lichenoid plaques with a predilection for the extensor surfaces and face in patients with darker skin tones^1,8 occurring in approximately 9% of patients in one study.¹⁰

Other key clinical features of AD in patients with SOC include pityriasis alba,¹⁰ increased risk for postinflammatory pigment alteration (including hyperpigmentation and/or hypopigmentation),¹ and greater trunk and extensor involvement.^1,11

Worth Noting

The scientific landscape for AD has grown rapidly, increasing our understanding of its pathophysiology, treatment, and social impact. Nonsteroidal treatments available for pediatric and adult patients with AD have increased in recent years, including crisaborole (approved for use in those ages ≥3 months), tacrolimus (≥2 years), and pimecrolimus (≥2 years). Injectable options include dupilumab (≥6 months), lebrikizumab (≥12 years), nemolizumab (≥12 years), and tralokinumab (≥12 years). Oral options include abrocitinib (≥12 years) and upadacitinib (≥12 years).¹² Topical options include roflumilast 0.15% cream (≥6 years)¹² and 0.05% cream (≥2-5 years),¹³ ruxolitinib 1.5% cream (≥2 years),¹⁴ and tapinarof 1% cream (≥2 years).¹²

For some patients, postinflammatory pigment alteration associated with AD has a higher impact on quality of life than the AD itself.⁷ In a study of 260 US adults with AD, the emotional impact of pigmentary changes was greatest in Black patients, with 53.3% reporting that pigment changes bothered them “a lot” or “very much.”¹⁵

Genome-wide association studies have not identified a single determinant that explains racial and ethnic differences in susceptibility to AD.⁴ Instead, social determinants of health are thought to play a role in the difference in AD prevalence and severity across groups in the United States.¹⁶

Health Disparity Highlight

In an analysis of 20 US metropolitan cities, urban and inner-city residence was associated with approximately 1.7-fold increased odds of AD.⁴ Among pediatric patients with moderate to severe AD, Black children were more likely to be exposed to tobacco smoke¹⁷ and traffic-related air pollution.¹⁸ Low socioeconomic status and low income also have been associated with moderate¹⁶ and severe¹⁹ AD. At the same education level, Black individuals in the United States receive less income than their White counterparts and have markedly less wealth at equivalent incomes.²⁰

In utero exposure to maternal stress is associated with AD.⁴ Increased IgE levels have been recorded in children who develop AD, with Black children having the highest IgE levels overall compared to other children.¹⁸

An analysis of medical records from an urban medical center in Baltimore, Maryland, from 2013 through 2018 showed that Black patients with AD were less likely to receive topical corticosteroids, topical calcineurin inhibitors, a topical phosphodiesterase 4 inhibitor, and a biologic compared to White patients with AD.²¹

Since the disproportionate burden experienced by patients with AD is not physiologic, it is imperative to address these systemic complexities and address the barriers impacting treatment availability to improve health outcomes for all patients living with AD.

Atopic dermatitis (AD) is a chronic skin condition generally characterized by pruritic and erythematous papules and plaques.¹ While AD commonly manifests in childhood, 1 in 4 patients living with AD report adult onset of the disease.² The clinical presentation and prevalence of AD vary across age groups, skin tones, and racial and ethnic groups. Globally, AD is estimated to have a prevalence of 2.6%; however, rates vary widely by region.¹ Morphology and distribution of AD lesions also vary by population; therefore, defining one classic presentation of AD is not sufficient in diverse patient populations.³

Epidemiology

The prevalence of AD ranges from 0.2% to 24.6% worldwide, with higher rates in Africa and Oceania and lower rates in India and Northern and Eastern Europe.¹ In the United States, AD affects all racial and ethnic groups; however, prevalence and severity are increased in Black children compared with White children.⁴ In one prospective cohort study, Hispanic children and non-Hispanic Black children aged 3 years and younger had greater odds of AD persisting into mid childhood (approximately age 7 years) compared with non-Hispanic White children.^5,6

Key Clinical Features

Clinical features of AD are heterogeneous and may include differences in color, morphology, and distribution. Brown, hyperpigmented, gray, and/or violaceous plaques may predominate in patients with skin of color (SOC) compared with the erythematous plaques commonly described in lighter skin tones.^1,3 Established scoring systems for AD rely on erythema as a key diagnostic feature, but because erythema can be difficult to detect in darker skin tones, disease severity may be underestimated and diagnosis may be delayed in this population.⁴

Atopic dermatitis in SOC may manifest as lichenoid plaques,⁷ prurigo nodules,^7,8 lichenification,¹ and follicular accentuation.⁹ Lichen planus–like AD is a distinct variant characterized by lichenoid plaques with a predilection for the extensor surfaces and face in patients with darker skin tones^1,8 occurring in approximately 9% of patients in one study.¹⁰

Other key clinical features of AD in patients with SOC include pityriasis alba,¹⁰ increased risk for postinflammatory pigment alteration (including hyperpigmentation and/or hypopigmentation),¹ and greater trunk and extensor involvement.^1,11

Worth Noting

The scientific landscape for AD has grown rapidly, increasing our understanding of its pathophysiology, treatment, and social impact. Nonsteroidal treatments available for pediatric and adult patients with AD have increased in recent years, including crisaborole (approved for use in those ages ≥3 months), tacrolimus (≥2 years), and pimecrolimus (≥2 years). Injectable options include dupilumab (≥6 months), lebrikizumab (≥12 years), nemolizumab (≥12 years), and tralokinumab (≥12 years). Oral options include abrocitinib (≥12 years) and upadacitinib (≥12 years).¹² Topical options include roflumilast 0.15% cream (≥6 years)¹² and 0.05% cream (≥2-5 years),¹³ ruxolitinib 1.5% cream (≥2 years),¹⁴ and tapinarof 1% cream (≥2 years).¹²

For some patients, postinflammatory pigment alteration associated with AD has a higher impact on quality of life than the AD itself.⁷ In a study of 260 US adults with AD, the emotional impact of pigmentary changes was greatest in Black patients, with 53.3% reporting that pigment changes bothered them “a lot” or “very much.”¹⁵

Genome-wide association studies have not identified a single determinant that explains racial and ethnic differences in susceptibility to AD.⁴ Instead, social determinants of health are thought to play a role in the difference in AD prevalence and severity across groups in the United States.¹⁶

Health Disparity Highlight

In an analysis of 20 US metropolitan cities, urban and inner-city residence was associated with approximately 1.7-fold increased odds of AD.⁴ Among pediatric patients with moderate to severe AD, Black children were more likely to be exposed to tobacco smoke¹⁷ and traffic-related air pollution.¹⁸ Low socioeconomic status and low income also have been associated with moderate¹⁶ and severe¹⁹ AD. At the same education level, Black individuals in the United States receive less income than their White counterparts and have markedly less wealth at equivalent incomes.²⁰

In utero exposure to maternal stress is associated with AD.⁴ Increased IgE levels have been recorded in children who develop AD, with Black children having the highest IgE levels overall compared to other children.¹⁸

An analysis of medical records from an urban medical center in Baltimore, Maryland, from 2013 through 2018 showed that Black patients with AD were less likely to receive topical corticosteroids, topical calcineurin inhibitors, a topical phosphodiesterase 4 inhibitor, and a biologic compared to White patients with AD.²¹

Since the disproportionate burden experienced by patients with AD is not physiologic, it is imperative to address these systemic complexities and address the barriers impacting treatment availability to improve health outcomes for all patients living with AD.

Atopic dermatitis (AD) is a chronic skin condition generally characterized by pruritic and erythematous papules and plaques.¹ While AD commonly manifests in childhood, 1 in 4 patients living with AD report adult onset of the disease.² The clinical presentation and prevalence of AD vary across age groups, skin tones, and racial and ethnic groups. Globally, AD is estimated to have a prevalence of 2.6%; however, rates vary widely by region.¹ Morphology and distribution of AD lesions also vary by population; therefore, defining one classic presentation of AD is not sufficient in diverse patient populations.³

Epidemiology

The prevalence of AD ranges from 0.2% to 24.6% worldwide, with higher rates in Africa and Oceania and lower rates in India and Northern and Eastern Europe.¹ In the United States, AD affects all racial and ethnic groups; however, prevalence and severity are increased in Black children compared with White children.⁴ In one prospective cohort study, Hispanic children and non-Hispanic Black children aged 3 years and younger had greater odds of AD persisting into mid childhood (approximately age 7 years) compared with non-Hispanic White children.^5,6

Key Clinical Features

Clinical features of AD are heterogeneous and may include differences in color, morphology, and distribution. Brown, hyperpigmented, gray, and/or violaceous plaques may predominate in patients with skin of color (SOC) compared with the erythematous plaques commonly described in lighter skin tones.^1,3 Established scoring systems for AD rely on erythema as a key diagnostic feature, but because erythema can be difficult to detect in darker skin tones, disease severity may be underestimated and diagnosis may be delayed in this population.⁴

Atopic dermatitis in SOC may manifest as lichenoid plaques,⁷ prurigo nodules,^7,8 lichenification,¹ and follicular accentuation.⁹ Lichen planus–like AD is a distinct variant characterized by lichenoid plaques with a predilection for the extensor surfaces and face in patients with darker skin tones^1,8 occurring in approximately 9% of patients in one study.¹⁰

Other key clinical features of AD in patients with SOC include pityriasis alba,¹⁰ increased risk for postinflammatory pigment alteration (including hyperpigmentation and/or hypopigmentation),¹ and greater trunk and extensor involvement.^1,11

Worth Noting

The scientific landscape for AD has grown rapidly, increasing our understanding of its pathophysiology, treatment, and social impact. Nonsteroidal treatments available for pediatric and adult patients with AD have increased in recent years, including crisaborole (approved for use in those ages ≥3 months), tacrolimus (≥2 years), and pimecrolimus (≥2 years). Injectable options include dupilumab (≥6 months), lebrikizumab (≥12 years), nemolizumab (≥12 years), and tralokinumab (≥12 years). Oral options include abrocitinib (≥12 years) and upadacitinib (≥12 years).¹² Topical options include roflumilast 0.15% cream (≥6 years)¹² and 0.05% cream (≥2-5 years),¹³ ruxolitinib 1.5% cream (≥2 years),¹⁴ and tapinarof 1% cream (≥2 years).¹²

For some patients, postinflammatory pigment alteration associated with AD has a higher impact on quality of life than the AD itself.⁷ In a study of 260 US adults with AD, the emotional impact of pigmentary changes was greatest in Black patients, with 53.3% reporting that pigment changes bothered them “a lot” or “very much.”¹⁵

Genome-wide association studies have not identified a single determinant that explains racial and ethnic differences in susceptibility to AD.⁴ Instead, social determinants of health are thought to play a role in the difference in AD prevalence and severity across groups in the United States.¹⁶

Health Disparity Highlight

In an analysis of 20 US metropolitan cities, urban and inner-city residence was associated with approximately 1.7-fold increased odds of AD.⁴ Among pediatric patients with moderate to severe AD, Black children were more likely to be exposed to tobacco smoke¹⁷ and traffic-related air pollution.¹⁸ Low socioeconomic status and low income also have been associated with moderate¹⁶ and severe¹⁹ AD. At the same education level, Black individuals in the United States receive less income than their White counterparts and have markedly less wealth at equivalent incomes.²⁰

In utero exposure to maternal stress is associated with AD.⁴ Increased IgE levels have been recorded in children who develop AD, with Black children having the highest IgE levels overall compared to other children.¹⁸

An analysis of medical records from an urban medical center in Baltimore, Maryland, from 2013 through 2018 showed that Black patients with AD were less likely to receive topical corticosteroids, topical calcineurin inhibitors, a topical phosphodiesterase 4 inhibitor, and a biologic compared to White patients with AD.²¹

Since the disproportionate burden experienced by patients with AD is not physiologic, it is imperative to address these systemic complexities and address the barriers impacting treatment availability to improve health outcomes for all patients living with AD.

Recognizing inflammation in darker skin tones has important implications for diagnosis and management of skin disease, particularly in patients with skin of color.¹ In this context, classification systems commonly are used—both in research and clinical practice—to standardize descriptions of skin tone across diverse populations. Fitzpatrick skin type (FST) originally was developed to classify cutaneous response to UV radiation exposure and remains one of the most widely used frameworks in dermatology.² However, FST often is used beyond its intended purpose as a proxy for differentiating skin color and race.^3,4 This mismatch risks obscuring clinically meaningful differences and limiting the accuracy of dermatologic research. Herein, we review the intended use of FST, its limitations in representing skin color and race, and considerations for more accurate characterization of skin pigmentation in clinical practice and research.

Origins and Intended Use of the FST Scale

Fitzpatrick skin type was developed by Thomas B. Fitzpatrick in the 1970s to guide UVA dosing for psoralen plus UVA therapy in patients with psoriasis.^5,6 The scale was intended to estimate an individual’s erythematous and pigmentary response to UV exposure.^6,7 Early iterations of FST largely were based on lighter skin types, reflecting its initial use in predominantly White populations, which limited representation of the full spectrum of skin tone diversity.⁵

Clinical, Educational, and Research Limitations of FST

Fitzpatrick skin type now is widely, albeit inaccurately, used in both research and clinical practice as a proxy for skin color and race,^7,8 which reflects its ease of use and the lack of standardized alternatives; however, FST does not adequately capture variability in baseline skin pigmentation, undertone, or inflammatory response. These limitations are especially pronounced in phototypes IV to VI, which encompass highly heterogeneous populations. As a result, grouping patients by FST alone to describe skin color and race may obscure important differences and limit meaningful interpretation of clinical and research findings.

Clinically, recognition of dermatologic conditions such as erythema may be more challenging in darker skin tones, in which classic visual cues are less apparent.^1,7 Relying on FST to stratify skin color may further compound diagnostic uncertainty by oversimplifying the cutaneous presentation. In addition, treatment decisions, including laser settings and assessment of pigmentary risk, often are guided by FST despite within-group variability.⁷ Further, educational frameworks that rely heavily on FST may inadequately prepare clinicians to recognize disease across diverse skin tones, contributing to delayed diagnosis and disparities in care in populations with skin of color.

The implications also extend to dermatologic research. Fitzpatrick skin type frequently is used to assess study populations; however, its limited ability to reflect true variation in pigmentation and ethnicity introduces misclassification bias.^3,7 The broad FST scale may group heterogeneous populations, obscuring differences in treatment response. As a result, studies relying on FST to represent skin color or race may have reduced generalizability across diverse populations. Importantly, these limitations are not merely conceptual but may contribute to measurable disparities in dermatologic diagnosis and outcomes.

Rethinking Skin Classification Frameworks

Despite these shortcomings, FST remains deeply embedded in dermatology. Its decades-long use has led to widespread familiarity and integration into clinical guidelines, education, and research. At the same time, the absence of a universally accepted alternative has reinforced the continued use of FST as a proxy for skin color and race.

Alternative strategies for characterizing skin pigmentation include objective measures such as spectrophotometry and melanin index assessment.⁹

Although these approaches may provide more precise quantification of pigmentation, their use may be limited by the need for specialized equipment and reduced feasibility in routine clinical settings. Other proposed approaches incorporate multidimensional factors such as pigmentation, photoreactivity, and genetic ancestry.⁴ While these techniques represent important advances, none has achieved widespread adoption yet, and each presents challenges related to feasibility and standardization.

In the absence of a single ideal system, a more nuanced approach is needed. Fitzpatrick skin type should be used in the context for which it was designed: estimating UV response. Incorporating additional descriptors, including self-identified race and ethnicity, alongside more detailed assessments of pigmentation may improve the accuracy and relevance of both clinical evaluation and research. Combining FST with more precise and inclusive frameworks represents a pragmatic step toward better reflecting patient diversity.

Recognizing inflammation in darker skin tones has important implications for diagnosis and management of skin disease, particularly in patients with skin of color.¹ In this context, classification systems commonly are used—both in research and clinical practice—to standardize descriptions of skin tone across diverse populations. Fitzpatrick skin type (FST) originally was developed to classify cutaneous response to UV radiation exposure and remains one of the most widely used frameworks in dermatology.² However, FST often is used beyond its intended purpose as a proxy for differentiating skin color and race.^3,4 This mismatch risks obscuring clinically meaningful differences and limiting the accuracy of dermatologic research. Herein, we review the intended use of FST, its limitations in representing skin color and race, and considerations for more accurate characterization of skin pigmentation in clinical practice and research.

Origins and Intended Use of the FST Scale

Fitzpatrick skin type was developed by Thomas B. Fitzpatrick in the 1970s to guide UVA dosing for psoralen plus UVA therapy in patients with psoriasis.^5,6 The scale was intended to estimate an individual’s erythematous and pigmentary response to UV exposure.^6,7 Early iterations of FST largely were based on lighter skin types, reflecting its initial use in predominantly White populations, which limited representation of the full spectrum of skin tone diversity.⁵

Clinical, Educational, and Research Limitations of FST

Fitzpatrick skin type now is widely, albeit inaccurately, used in both research and clinical practice as a proxy for skin color and race,^7,8 which reflects its ease of use and the lack of standardized alternatives; however, FST does not adequately capture variability in baseline skin pigmentation, undertone, or inflammatory response. These limitations are especially pronounced in phototypes IV to VI, which encompass highly heterogeneous populations. As a result, grouping patients by FST alone to describe skin color and race may obscure important differences and limit meaningful interpretation of clinical and research findings.

Clinically, recognition of dermatologic conditions such as erythema may be more challenging in darker skin tones, in which classic visual cues are less apparent.^1,7 Relying on FST to stratify skin color may further compound diagnostic uncertainty by oversimplifying the cutaneous presentation. In addition, treatment decisions, including laser settings and assessment of pigmentary risk, often are guided by FST despite within-group variability.⁷ Further, educational frameworks that rely heavily on FST may inadequately prepare clinicians to recognize disease across diverse skin tones, contributing to delayed diagnosis and disparities in care in populations with skin of color.

The implications also extend to dermatologic research. Fitzpatrick skin type frequently is used to assess study populations; however, its limited ability to reflect true variation in pigmentation and ethnicity introduces misclassification bias.^3,7 The broad FST scale may group heterogeneous populations, obscuring differences in treatment response. As a result, studies relying on FST to represent skin color or race may have reduced generalizability across diverse populations. Importantly, these limitations are not merely conceptual but may contribute to measurable disparities in dermatologic diagnosis and outcomes.

Rethinking Skin Classification Frameworks

Despite these shortcomings, FST remains deeply embedded in dermatology. Its decades-long use has led to widespread familiarity and integration into clinical guidelines, education, and research. At the same time, the absence of a universally accepted alternative has reinforced the continued use of FST as a proxy for skin color and race.

Alternative strategies for characterizing skin pigmentation include objective measures such as spectrophotometry and melanin index assessment.⁹

Although these approaches may provide more precise quantification of pigmentation, their use may be limited by the need for specialized equipment and reduced feasibility in routine clinical settings. Other proposed approaches incorporate multidimensional factors such as pigmentation, photoreactivity, and genetic ancestry.⁴ While these techniques represent important advances, none has achieved widespread adoption yet, and each presents challenges related to feasibility and standardization.

In the absence of a single ideal system, a more nuanced approach is needed. Fitzpatrick skin type should be used in the context for which it was designed: estimating UV response. Incorporating additional descriptors, including self-identified race and ethnicity, alongside more detailed assessments of pigmentation may improve the accuracy and relevance of both clinical evaluation and research. Combining FST with more precise and inclusive frameworks represents a pragmatic step toward better reflecting patient diversity.

Recognizing inflammation in darker skin tones has important implications for diagnosis and management of skin disease, particularly in patients with skin of color.¹ In this context, classification systems commonly are used—both in research and clinical practice—to standardize descriptions of skin tone across diverse populations. Fitzpatrick skin type (FST) originally was developed to classify cutaneous response to UV radiation exposure and remains one of the most widely used frameworks in dermatology.² However, FST often is used beyond its intended purpose as a proxy for differentiating skin color and race.^3,4 This mismatch risks obscuring clinically meaningful differences and limiting the accuracy of dermatologic research. Herein, we review the intended use of FST, its limitations in representing skin color and race, and considerations for more accurate characterization of skin pigmentation in clinical practice and research.

Origins and Intended Use of the FST Scale

Fitzpatrick skin type was developed by Thomas B. Fitzpatrick in the 1970s to guide UVA dosing for psoralen plus UVA therapy in patients with psoriasis.^5,6 The scale was intended to estimate an individual’s erythematous and pigmentary response to UV exposure.^6,7 Early iterations of FST largely were based on lighter skin types, reflecting its initial use in predominantly White populations, which limited representation of the full spectrum of skin tone diversity.⁵

Clinical, Educational, and Research Limitations of FST

Fitzpatrick skin type now is widely, albeit inaccurately, used in both research and clinical practice as a proxy for skin color and race,^7,8 which reflects its ease of use and the lack of standardized alternatives; however, FST does not adequately capture variability in baseline skin pigmentation, undertone, or inflammatory response. These limitations are especially pronounced in phototypes IV to VI, which encompass highly heterogeneous populations. As a result, grouping patients by FST alone to describe skin color and race may obscure important differences and limit meaningful interpretation of clinical and research findings.

Clinically, recognition of dermatologic conditions such as erythema may be more challenging in darker skin tones, in which classic visual cues are less apparent.^1,7 Relying on FST to stratify skin color may further compound diagnostic uncertainty by oversimplifying the cutaneous presentation. In addition, treatment decisions, including laser settings and assessment of pigmentary risk, often are guided by FST despite within-group variability.⁷ Further, educational frameworks that rely heavily on FST may inadequately prepare clinicians to recognize disease across diverse skin tones, contributing to delayed diagnosis and disparities in care in populations with skin of color.

The implications also extend to dermatologic research. Fitzpatrick skin type frequently is used to assess study populations; however, its limited ability to reflect true variation in pigmentation and ethnicity introduces misclassification bias.^3,7 The broad FST scale may group heterogeneous populations, obscuring differences in treatment response. As a result, studies relying on FST to represent skin color or race may have reduced generalizability across diverse populations. Importantly, these limitations are not merely conceptual but may contribute to measurable disparities in dermatologic diagnosis and outcomes.

Rethinking Skin Classification Frameworks

Despite these shortcomings, FST remains deeply embedded in dermatology. Its decades-long use has led to widespread familiarity and integration into clinical guidelines, education, and research. At the same time, the absence of a universally accepted alternative has reinforced the continued use of FST as a proxy for skin color and race.

Alternative strategies for characterizing skin pigmentation include objective measures such as spectrophotometry and melanin index assessment.⁹

Although these approaches may provide more precise quantification of pigmentation, their use may be limited by the need for specialized equipment and reduced feasibility in routine clinical settings. Other proposed approaches incorporate multidimensional factors such as pigmentation, photoreactivity, and genetic ancestry.⁴ While these techniques represent important advances, none has achieved widespread adoption yet, and each presents challenges related to feasibility and standardization.

In the absence of a single ideal system, a more nuanced approach is needed. Fitzpatrick skin type should be used in the context for which it was designed: estimating UV response. Incorporating additional descriptors, including self-identified race and ethnicity, alongside more detailed assessments of pigmentation may improve the accuracy and relevance of both clinical evaluation and research. Combining FST with more precise and inclusive frameworks represents a pragmatic step toward better reflecting patient diversity.

Individuals with skin of color (SOC) are disproportionately affected by hyperpigmentation disorders such as melasma and postinflammatory hyperpigmentation following sun exposure. Although epidermal melanin provides UVB protection, susceptibility to pigmentary responses from longer UVA wavelengths and visible light (VL) remains, particularly the highest energy wavelengths of blue light (BL) between 400 and 450 nm.¹ Blue light can induce immediate and persistent pigment darkening in those with Fitzpatrick skin types IV to VI, and trace amounts of near-visible UVA (NV-UVA) between 370 and 400 nm can synergize with VL to amplify pigmentation and erythema responses.²

Current photoprotection recommendations emphasize sun protection factor (SPF) ratings of 30+ and broad-spectrum labeling; however, under the US Food and Drug Administration standards, the ­broad-spectrum designation is based solely on achieving a mean critical wavelength of 370 nm or higher, which does not ensure meaningful attenuation of NV-UVA or VL wavelengths.³ Tinted sunscreens containing iron oxides (FeO) have been shown to improve protection against these ­pigment-inducing wavelengths,⁴ yet quantitative comparisons between tinted and nontinted commercial sunscreen products remain limited.

To address the gap in understanding about tinted vs nontinted commercial sunscreen products, we conducted an in vitro spectrophotometric comparative analysis. The objectives were to quantify NV-UVA and BL attenuation across products and evaluate whether formulation characteristics (eg, SPF rating, filter types and concentration, the presence and depth of tint, antioxidant content) would correlate with improved photoprotection in pigment-sensitive wavelengths. We hypothesized that formulation features such as higher SPF, inorganic filters, and the presence of tint antioxidants would be associated with superior NV-UVA and BL attenuation compared with nontinted formulations.

Methods

Sunscreen Selection—A convenience sample of 23 broad-spectrum sunscreens commercially available at drugstores was selected to reflect easily accessible options. Six sunscreen brands with tinted (n=13) and nontinted (n=10) counterpart formulations were included. Filter category (mineral and/or chemical), SPF, UV filter type and concentration, tint shade (light, medium, medium/deep, deep), number of photoprotective antioxidants (diethylhexyl syringylidenemalonate, vitamin E, vitamin C, licochalcone A, and glycyrrhetinic acid), and presence of FeO were recorded.

Substrate Preparation—Testing was performed using standardized polymethyl methacrylate (PMMA) plates. Sunscreens were mixed prior to application and applied at 1.3 mg/cm² per the European Cosmetic and Perfumery Association (COLIPA) UVA testing guidelines.⁵ Plates were reweighed to confirm dosing and dried in a dark environment for at least 15 minutes prior to testing.

Spectrophotometric Measurements—Spectral transmittance was measured from 250 to 450 nm using a spectrophotometer equipped with a xenon flash lamp (energy <0.2 J/cm²). Baseline transmission was recorded using untreated PMMA plates. Five scans were averaged per plate. Analyses focused on NV-UVA transmittance from 380 to 400 nm and peak BL transmission at 450 nm.

Mean NV-UVA transmittance was calculated as the arithmetic mean of percent transmittance measured at 1-nm increments from 380 to 400 nm (n=21). Because of the steep rise in transmittance between 380 and 400 nm and subsequent plateau into the visible range, this approach was used to approximate the area under the transmittance-wavelength curve over the specified interval, enabling direct comparison of NV-UVA penetration between formulations.

Statistical Analysis—Descriptive statistics were used to summarize transmittance values. Spearman rank correlation was used to assess associations between formulation variables and spectral attenuation. Analysis of covariance was used to evaluate the effect of FeO on transmittance while adjusting for SPF or filter type. The Mann-Whitney U test was used to compare NV-UVA and blue light transmittance between FeO-containing mineral and chemical formulations. Statistical significance was set at P<.05.

Results

Across broad-spectrum sunscreen formulations (N=23), mean SPF values were 40.4 (range, 30-70), and the mean number of antioxidants in the ingredient list was 1.5 (range, 0-4). Mean NV-UVA transmittance was 16.7% (range, 0.1%-55.0%) and mean BL transmittance was 44.3% (range, 0.3%-97.5%)(eTable 1).

The mean labeled zinc oxide (ZnO) concentration among ZnO-containing formulations (n=14) was 10.5% (range, 5.0%-21.6%), with mean NV-UVA and BL transmittance of 12.6% (range, 0.1%-55.0%) and 25.8% (range, 0.3%-67.2%), respectively. Mean NV-UVA and BL transmittance were 26.7% (range, 9.6%-55.0%) and 45.6% (range, 23.0%-67.2%) among ZnO formulations without FeO (n=5), compared with lower transmittance of 4.8% (range, 0.1%-11.5%) and 14.9% (range, 0.3%-29.5%) in ZnO formulations containing FeO (n=9).

The mean labeled titanium dioxide (TiO₂) concentration among TiO₂-containing formulations (n=14) was 9.0% (range, 3.2%-17.0%), with corresponding mean NV-UVA and BL transmittance of 9.5% (range, 0.1%-28.5%) and 22.7% (range, 0.3%-47.6%), respectively. Among TiO₂ formulations without FeO (n=4), mean NV-UVA and BL transmittance was 19.7% (range, 9.6%-28.5%) and 39.8% (range, 23.0%-47.6%), while FeO-containing TiO₂ formulations (n=10) showed lower mean NV-UVA and BL transmittance of 5.4% (range, 0.1%-11.5%) and 15.8% (range, 0.3%-29.5%), respectively. The mean labeled avobenzone concentration among avobenzone-containing formulations (n=8) was 2.9% (range, 2.5%-3%), with mean NV-UVA and BL transmittance of 24.7% (range, 10.2%-46.6%) and 79.2% (range, 53.9%-97.5%). Formulations without FeO (n=5) had mean NV-UVA and BL transmittance of 29.0% (range, 10.2%-46.6%) and 83.2% (range, 61.1%-97.5%), whereas FeO-containing products (n=3) demonstrated lower mean NV-UVA and BL transmittance of 17.5% (range, 12.5%-21.9%) and 72.6% (range, 53.9%-85.1%), respectively.

Among products containing ZnO, TiO₂, and avobenzone, the specific UV filter concentrations showed no statistically significant correlation with NV-UVA or BL transmittance (all P>.05). Iron oxide presence significantly correlated with lower NV-UVA (r=–0.67; P=.00042) and lower BL transmittance (r=–0.57; P=.0046). The number of antioxidants in the ingredient list did not correlate with NV-UVA transmittance (r=–0.28; P=.19) or BL ­transmittance (r=–0.16; P=.47). Sun protection factor was not significantly correlated with either wavelength range (Table 1).

Tint shade was treated as an ordinal variable (light, medium, medium/deep, and deep; medium was considered the universal shade). Increasing tint shade depth was significantly associated with reduced NV-UVA (r=–0.64; P=.045) and BL (r=–0.71; P=.023), suggesting a dose-response relationship wherein darker tints exhibited greater attenuation of pigment-relevant wavelengths. Among mineral filter formulations, tinted products demonstrated lower NV-UVA and BL transmittance compared with their nontinted counterparts, with deeper tints providing the greatest reduction in transmittance (eFigure 1). Similar results were observed for chemical filter formulations with greater attenuation in the NV-UVA and BL range for tinted versus nontinted products with greater variability across shade depths (eFigure 2).

After adjusting for SPF, FeO presence remained significantly associated with reduced NV-UVA (F[1,20]=26.9; P<.001) and BL transmittance (F[1,20]=11.7; P=.003). After adjusting for filter type (mineral vs chemical), FeO remained significantly associated with NV-UVA (F[1,19]=10.1; P=.004) and BL transmittance (F[1,19]=10.4; P=.005)(Table 2).

Among FeO-containing products, mineral filters demonstrated significantly lower NV-UVA transmittance compared with chemical filters (median, 5.58% [interquartile range (IQR), 0.59%-9.35%] vs 18.10% [IQR, 12.47%-21.90%]; U=0.00; P=.007). The same was true for BL transmittance (median, 15.90% [IQR, 5.00%-26.20%] vs 78.70% [IQR, 53.90%-85.10%]; U=0.00; P=.007). The differences in spectral transmittance between ­FeO-containing mineral and chemical filter ­formulations are illustrated in eFigure 3, with mineral-based ­products demonstrating lower transmittance, ­particularly across the upper NV-UVA range and across the BL range. These results indicated greater ­pigment-relevant ­photoprotection with mineral vs chemical filters (eTable 2).

Comment

Our initial hypothesis proposed that tinted sunscreens would provide greater NV-UVA and BL attenuation than nontinted formulations, and that characteristics such as inorganic filter content, SPF rating, and antioxidants would correlate with improved protection in pigment-sensitive wavelengths. Our findings partially supported this hypothesis. In this analysis, substantial variability in the NV-UVA and BL transmittance was observed despite all products meeting broad-spectrum criteria. Nontinted mineral and chemical sunscreens exhibited high transmittance in these pigment-related wavelengths, reaching values as high as 55.0% for NV-UVA and 97.5% for BL. These findings align with prior analysis demonstrating that while broad-spectrum sunscreens available in the United States may meet the current critical wavelength criteria for protection in the UVA range, they still may transmit 30% to 66% of available UVA over 2 hours between formulations with equivalent SPF label values.⁶

Recent analyses show that sunscreen recommendations in lay media rarely incorporate input from board-certified dermatologists for individuals with SOC and disproportionately favor nontinted chemical formulations, despite the high prevalence of pigmentary disorders in this population.⁷ Near-visible UVA and BL have been demonstrated to be biologically relevant pigment-inducing wavelengths, both in vitro and in vivo, particularly in individuals with SOC, yet broad-spectrum labeling does not ensure protection against these spectra.⁸ Pigmentary tints such as FeO have demonstrated enhanced attenuation in this spectral region in vivo and may provide more reliable coverage than products with broad-spectrum designation alone.^4,9 Treatment options for pigmentary disorders such as melasma tend to be palliative and costly, making optimized photoprotection a critical component of care to reduce ongoing pigmentary stimuli.¹⁰

Formulations containing FeO demonstrated significantly lower NV-UVA (P<.001) and BL transmittance (P=.003) on average; however, transmittance values ranged widely (NV-UVA: 0.10%-21.90%, BL: 0.30%-85.10%), indicating that FeO presence alone does not determine the magnitude of attenuation. Notably, among FeO-containing products, mineral filters provided significantly lower NV-UVA and BL transmittance compared with chemical filters (P=.007 for both), suggesting that filter type further modulates pigment-relevant photoprotection. Tinted formulations may improve compliance with product use by reducing the white cast and improve shade matching to find suitable options for deeper skin tones,¹¹ but the highly variable photoprotection offered raises concerns about clinical benefit. Although deeper tints showed greater attenuation, pigment concentrations and combinations are not disclosed by manufacturers as FeO is not considered an active ingredient. Darker shades are not practical across all skin tones in individuals with SOC, which underscores the need for standardized pigment metrics and shade-inclusive options.

While avobenzone and ZnO are the only US Food and Drug Administration–approved sunscreen active ingredients that extend protection beyond 360 nm,¹² both exhibited reduced attenuation beyond the longer end of the UVA spectrum. Formulation characteristics, including the concentration of ZnO, TiO₂, and/or avobenzone as well as SPF, did not correlate with NV-UVA or BL attenuation. In the adjusted analysis, FeO presence remained significantly associated with reduced transmittance after adjusting for SPF (NV-UVA: P<.001, BL: P=.003) or filter type (NV-UVA: P=.004, BL: P=.005). These findings suggest that the presence of FeO, rather than UV filters or SPF ratings, supports attenuation in the 380 to 450–nm range, indicating a functional benefit in addition to improved cosmesis.¹³ 

Although antioxidants in specific combinations have shown promise in vivo, no association was observed between the number of antioxidants present and NV-UVA or BL attenuation compared with added tint.¹⁴ This suggests that specific antioxidant combinations and their concentrations may be more relevant than the total count.

Several study limitations need to be considered in interpreting our results, including a modest number of products, controlled in vitro testing conditions, and an incomplete representation of products with pigment concentrations and shade ranges marketed to individuals with SOC across all price categories, despite our focus on affordable, commercially available options. Moreover, PMMA-based spectrophotometry does not account for skin surface heterogeneity, photodegradation, sweat, oil, friction, or application variability, which may alter real-world performance. Additionally, FeO concentrations could not be quantified beyond labeling of tint shade depth, preventing a true assessment of dose-response effects. These limitations may reduce generalizability and highlight the need for complementary in vivo studies to assess clinically relevant outcomes such as persistent pigment darkening. For this reason, caution is warranted in extrapolating these spectral findings to clinical efficacy.

Conclusion

Given the susceptibility of individuals with SOC to pigmentary disorders driven by NV-UVA and BL, our findings support further development and study of FeO-containing sunscreens that address clinically relevant wavelengths. Wide variability in photo-attenuation among tinted formulations underscores the need for evidence-based recommendations, with further studies needed to guide photoprotection strategies for populations with SOC.

Individuals with skin of color (SOC) are disproportionately affected by hyperpigmentation disorders such as melasma and postinflammatory hyperpigmentation following sun exposure. Although epidermal melanin provides UVB protection, susceptibility to pigmentary responses from longer UVA wavelengths and visible light (VL) remains, particularly the highest energy wavelengths of blue light (BL) between 400 and 450 nm.¹ Blue light can induce immediate and persistent pigment darkening in those with Fitzpatrick skin types IV to VI, and trace amounts of near-visible UVA (NV-UVA) between 370 and 400 nm can synergize with VL to amplify pigmentation and erythema responses.²

Current photoprotection recommendations emphasize sun protection factor (SPF) ratings of 30+ and broad-spectrum labeling; however, under the US Food and Drug Administration standards, the ­broad-spectrum designation is based solely on achieving a mean critical wavelength of 370 nm or higher, which does not ensure meaningful attenuation of NV-UVA or VL wavelengths.³ Tinted sunscreens containing iron oxides (FeO) have been shown to improve protection against these ­pigment-inducing wavelengths,⁴ yet quantitative comparisons between tinted and nontinted commercial sunscreen products remain limited.

To address the gap in understanding about tinted vs nontinted commercial sunscreen products, we conducted an in vitro spectrophotometric comparative analysis. The objectives were to quantify NV-UVA and BL attenuation across products and evaluate whether formulation characteristics (eg, SPF rating, filter types and concentration, the presence and depth of tint, antioxidant content) would correlate with improved photoprotection in pigment-sensitive wavelengths. We hypothesized that formulation features such as higher SPF, inorganic filters, and the presence of tint antioxidants would be associated with superior NV-UVA and BL attenuation compared with nontinted formulations.

Methods

Sunscreen Selection—A convenience sample of 23 broad-spectrum sunscreens commercially available at drugstores was selected to reflect easily accessible options. Six sunscreen brands with tinted (n=13) and nontinted (n=10) counterpart formulations were included. Filter category (mineral and/or chemical), SPF, UV filter type and concentration, tint shade (light, medium, medium/deep, deep), number of photoprotective antioxidants (diethylhexyl syringylidenemalonate, vitamin E, vitamin C, licochalcone A, and glycyrrhetinic acid), and presence of FeO were recorded.

Substrate Preparation—Testing was performed using standardized polymethyl methacrylate (PMMA) plates. Sunscreens were mixed prior to application and applied at 1.3 mg/cm² per the European Cosmetic and Perfumery Association (COLIPA) UVA testing guidelines.⁵ Plates were reweighed to confirm dosing and dried in a dark environment for at least 15 minutes prior to testing.

Spectrophotometric Measurements—Spectral transmittance was measured from 250 to 450 nm using a spectrophotometer equipped with a xenon flash lamp (energy <0.2 J/cm²). Baseline transmission was recorded using untreated PMMA plates. Five scans were averaged per plate. Analyses focused on NV-UVA transmittance from 380 to 400 nm and peak BL transmission at 450 nm.

Mean NV-UVA transmittance was calculated as the arithmetic mean of percent transmittance measured at 1-nm increments from 380 to 400 nm (n=21). Because of the steep rise in transmittance between 380 and 400 nm and subsequent plateau into the visible range, this approach was used to approximate the area under the transmittance-wavelength curve over the specified interval, enabling direct comparison of NV-UVA penetration between formulations.

Statistical Analysis—Descriptive statistics were used to summarize transmittance values. Spearman rank correlation was used to assess associations between formulation variables and spectral attenuation. Analysis of covariance was used to evaluate the effect of FeO on transmittance while adjusting for SPF or filter type. The Mann-Whitney U test was used to compare NV-UVA and blue light transmittance between FeO-containing mineral and chemical formulations. Statistical significance was set at P<.05.

Results

Across broad-spectrum sunscreen formulations (N=23), mean SPF values were 40.4 (range, 30-70), and the mean number of antioxidants in the ingredient list was 1.5 (range, 0-4). Mean NV-UVA transmittance was 16.7% (range, 0.1%-55.0%) and mean BL transmittance was 44.3% (range, 0.3%-97.5%)(eTable 1).

The mean labeled zinc oxide (ZnO) concentration among ZnO-containing formulations (n=14) was 10.5% (range, 5.0%-21.6%), with mean NV-UVA and BL transmittance of 12.6% (range, 0.1%-55.0%) and 25.8% (range, 0.3%-67.2%), respectively. Mean NV-UVA and BL transmittance were 26.7% (range, 9.6%-55.0%) and 45.6% (range, 23.0%-67.2%) among ZnO formulations without FeO (n=5), compared with lower transmittance of 4.8% (range, 0.1%-11.5%) and 14.9% (range, 0.3%-29.5%) in ZnO formulations containing FeO (n=9).

The mean labeled titanium dioxide (TiO₂) concentration among TiO₂-containing formulations (n=14) was 9.0% (range, 3.2%-17.0%), with corresponding mean NV-UVA and BL transmittance of 9.5% (range, 0.1%-28.5%) and 22.7% (range, 0.3%-47.6%), respectively. Among TiO₂ formulations without FeO (n=4), mean NV-UVA and BL transmittance was 19.7% (range, 9.6%-28.5%) and 39.8% (range, 23.0%-47.6%), while FeO-containing TiO₂ formulations (n=10) showed lower mean NV-UVA and BL transmittance of 5.4% (range, 0.1%-11.5%) and 15.8% (range, 0.3%-29.5%), respectively. The mean labeled avobenzone concentration among avobenzone-containing formulations (n=8) was 2.9% (range, 2.5%-3%), with mean NV-UVA and BL transmittance of 24.7% (range, 10.2%-46.6%) and 79.2% (range, 53.9%-97.5%). Formulations without FeO (n=5) had mean NV-UVA and BL transmittance of 29.0% (range, 10.2%-46.6%) and 83.2% (range, 61.1%-97.5%), whereas FeO-containing products (n=3) demonstrated lower mean NV-UVA and BL transmittance of 17.5% (range, 12.5%-21.9%) and 72.6% (range, 53.9%-85.1%), respectively.

Among products containing ZnO, TiO₂, and avobenzone, the specific UV filter concentrations showed no statistically significant correlation with NV-UVA or BL transmittance (all P>.05). Iron oxide presence significantly correlated with lower NV-UVA (r=–0.67; P=.00042) and lower BL transmittance (r=–0.57; P=.0046). The number of antioxidants in the ingredient list did not correlate with NV-UVA transmittance (r=–0.28; P=.19) or BL ­transmittance (r=–0.16; P=.47). Sun protection factor was not significantly correlated with either wavelength range (Table 1).

Tint shade was treated as an ordinal variable (light, medium, medium/deep, and deep; medium was considered the universal shade). Increasing tint shade depth was significantly associated with reduced NV-UVA (r=–0.64; P=.045) and BL (r=–0.71; P=.023), suggesting a dose-response relationship wherein darker tints exhibited greater attenuation of pigment-relevant wavelengths. Among mineral filter formulations, tinted products demonstrated lower NV-UVA and BL transmittance compared with their nontinted counterparts, with deeper tints providing the greatest reduction in transmittance (eFigure 1). Similar results were observed for chemical filter formulations with greater attenuation in the NV-UVA and BL range for tinted versus nontinted products with greater variability across shade depths (eFigure 2).

After adjusting for SPF, FeO presence remained significantly associated with reduced NV-UVA (F[1,20]=26.9; P<.001) and BL transmittance (F[1,20]=11.7; P=.003). After adjusting for filter type (mineral vs chemical), FeO remained significantly associated with NV-UVA (F[1,19]=10.1; P=.004) and BL transmittance (F[1,19]=10.4; P=.005)(Table 2).

Among FeO-containing products, mineral filters demonstrated significantly lower NV-UVA transmittance compared with chemical filters (median, 5.58% [interquartile range (IQR), 0.59%-9.35%] vs 18.10% [IQR, 12.47%-21.90%]; U=0.00; P=.007). The same was true for BL transmittance (median, 15.90% [IQR, 5.00%-26.20%] vs 78.70% [IQR, 53.90%-85.10%]; U=0.00; P=.007). The differences in spectral transmittance between ­FeO-containing mineral and chemical filter ­formulations are illustrated in eFigure 3, with mineral-based ­products demonstrating lower transmittance, ­particularly across the upper NV-UVA range and across the BL range. These results indicated greater ­pigment-relevant ­photoprotection with mineral vs chemical filters (eTable 2).

Comment

Our initial hypothesis proposed that tinted sunscreens would provide greater NV-UVA and BL attenuation than nontinted formulations, and that characteristics such as inorganic filter content, SPF rating, and antioxidants would correlate with improved protection in pigment-sensitive wavelengths. Our findings partially supported this hypothesis. In this analysis, substantial variability in the NV-UVA and BL transmittance was observed despite all products meeting broad-spectrum criteria. Nontinted mineral and chemical sunscreens exhibited high transmittance in these pigment-related wavelengths, reaching values as high as 55.0% for NV-UVA and 97.5% for BL. These findings align with prior analysis demonstrating that while broad-spectrum sunscreens available in the United States may meet the current critical wavelength criteria for protection in the UVA range, they still may transmit 30% to 66% of available UVA over 2 hours between formulations with equivalent SPF label values.⁶

Recent analyses show that sunscreen recommendations in lay media rarely incorporate input from board-certified dermatologists for individuals with SOC and disproportionately favor nontinted chemical formulations, despite the high prevalence of pigmentary disorders in this population.⁷ Near-visible UVA and BL have been demonstrated to be biologically relevant pigment-inducing wavelengths, both in vitro and in vivo, particularly in individuals with SOC, yet broad-spectrum labeling does not ensure protection against these spectra.⁸ Pigmentary tints such as FeO have demonstrated enhanced attenuation in this spectral region in vivo and may provide more reliable coverage than products with broad-spectrum designation alone.^4,9 Treatment options for pigmentary disorders such as melasma tend to be palliative and costly, making optimized photoprotection a critical component of care to reduce ongoing pigmentary stimuli.¹⁰

Formulations containing FeO demonstrated significantly lower NV-UVA (P<.001) and BL transmittance (P=.003) on average; however, transmittance values ranged widely (NV-UVA: 0.10%-21.90%, BL: 0.30%-85.10%), indicating that FeO presence alone does not determine the magnitude of attenuation. Notably, among FeO-containing products, mineral filters provided significantly lower NV-UVA and BL transmittance compared with chemical filters (P=.007 for both), suggesting that filter type further modulates pigment-relevant photoprotection. Tinted formulations may improve compliance with product use by reducing the white cast and improve shade matching to find suitable options for deeper skin tones,¹¹ but the highly variable photoprotection offered raises concerns about clinical benefit. Although deeper tints showed greater attenuation, pigment concentrations and combinations are not disclosed by manufacturers as FeO is not considered an active ingredient. Darker shades are not practical across all skin tones in individuals with SOC, which underscores the need for standardized pigment metrics and shade-inclusive options.

While avobenzone and ZnO are the only US Food and Drug Administration–approved sunscreen active ingredients that extend protection beyond 360 nm,¹² both exhibited reduced attenuation beyond the longer end of the UVA spectrum. Formulation characteristics, including the concentration of ZnO, TiO₂, and/or avobenzone as well as SPF, did not correlate with NV-UVA or BL attenuation. In the adjusted analysis, FeO presence remained significantly associated with reduced transmittance after adjusting for SPF (NV-UVA: P<.001, BL: P=.003) or filter type (NV-UVA: P=.004, BL: P=.005). These findings suggest that the presence of FeO, rather than UV filters or SPF ratings, supports attenuation in the 380 to 450–nm range, indicating a functional benefit in addition to improved cosmesis.¹³ 

Although antioxidants in specific combinations have shown promise in vivo, no association was observed between the number of antioxidants present and NV-UVA or BL attenuation compared with added tint.¹⁴ This suggests that specific antioxidant combinations and their concentrations may be more relevant than the total count.

Several study limitations need to be considered in interpreting our results, including a modest number of products, controlled in vitro testing conditions, and an incomplete representation of products with pigment concentrations and shade ranges marketed to individuals with SOC across all price categories, despite our focus on affordable, commercially available options. Moreover, PMMA-based spectrophotometry does not account for skin surface heterogeneity, photodegradation, sweat, oil, friction, or application variability, which may alter real-world performance. Additionally, FeO concentrations could not be quantified beyond labeling of tint shade depth, preventing a true assessment of dose-response effects. These limitations may reduce generalizability and highlight the need for complementary in vivo studies to assess clinically relevant outcomes such as persistent pigment darkening. For this reason, caution is warranted in extrapolating these spectral findings to clinical efficacy.

Conclusion

Given the susceptibility of individuals with SOC to pigmentary disorders driven by NV-UVA and BL, our findings support further development and study of FeO-containing sunscreens that address clinically relevant wavelengths. Wide variability in photo-attenuation among tinted formulations underscores the need for evidence-based recommendations, with further studies needed to guide photoprotection strategies for populations with SOC.

Individuals with skin of color (SOC) are disproportionately affected by hyperpigmentation disorders such as melasma and postinflammatory hyperpigmentation following sun exposure. Although epidermal melanin provides UVB protection, susceptibility to pigmentary responses from longer UVA wavelengths and visible light (VL) remains, particularly the highest energy wavelengths of blue light (BL) between 400 and 450 nm.¹ Blue light can induce immediate and persistent pigment darkening in those with Fitzpatrick skin types IV to VI, and trace amounts of near-visible UVA (NV-UVA) between 370 and 400 nm can synergize with VL to amplify pigmentation and erythema responses.²

Current photoprotection recommendations emphasize sun protection factor (SPF) ratings of 30+ and broad-spectrum labeling; however, under the US Food and Drug Administration standards, the ­broad-spectrum designation is based solely on achieving a mean critical wavelength of 370 nm or higher, which does not ensure meaningful attenuation of NV-UVA or VL wavelengths.³ Tinted sunscreens containing iron oxides (FeO) have been shown to improve protection against these ­pigment-inducing wavelengths,⁴ yet quantitative comparisons between tinted and nontinted commercial sunscreen products remain limited.

To address the gap in understanding about tinted vs nontinted commercial sunscreen products, we conducted an in vitro spectrophotometric comparative analysis. The objectives were to quantify NV-UVA and BL attenuation across products and evaluate whether formulation characteristics (eg, SPF rating, filter types and concentration, the presence and depth of tint, antioxidant content) would correlate with improved photoprotection in pigment-sensitive wavelengths. We hypothesized that formulation features such as higher SPF, inorganic filters, and the presence of tint antioxidants would be associated with superior NV-UVA and BL attenuation compared with nontinted formulations.

Methods

Sunscreen Selection—A convenience sample of 23 broad-spectrum sunscreens commercially available at drugstores was selected to reflect easily accessible options. Six sunscreen brands with tinted (n=13) and nontinted (n=10) counterpart formulations were included. Filter category (mineral and/or chemical), SPF, UV filter type and concentration, tint shade (light, medium, medium/deep, deep), number of photoprotective antioxidants (diethylhexyl syringylidenemalonate, vitamin E, vitamin C, licochalcone A, and glycyrrhetinic acid), and presence of FeO were recorded.

Substrate Preparation—Testing was performed using standardized polymethyl methacrylate (PMMA) plates. Sunscreens were mixed prior to application and applied at 1.3 mg/cm² per the European Cosmetic and Perfumery Association (COLIPA) UVA testing guidelines.⁵ Plates were reweighed to confirm dosing and dried in a dark environment for at least 15 minutes prior to testing.

Spectrophotometric Measurements—Spectral transmittance was measured from 250 to 450 nm using a spectrophotometer equipped with a xenon flash lamp (energy <0.2 J/cm²). Baseline transmission was recorded using untreated PMMA plates. Five scans were averaged per plate. Analyses focused on NV-UVA transmittance from 380 to 400 nm and peak BL transmission at 450 nm.

Mean NV-UVA transmittance was calculated as the arithmetic mean of percent transmittance measured at 1-nm increments from 380 to 400 nm (n=21). Because of the steep rise in transmittance between 380 and 400 nm and subsequent plateau into the visible range, this approach was used to approximate the area under the transmittance-wavelength curve over the specified interval, enabling direct comparison of NV-UVA penetration between formulations.

Statistical Analysis—Descriptive statistics were used to summarize transmittance values. Spearman rank correlation was used to assess associations between formulation variables and spectral attenuation. Analysis of covariance was used to evaluate the effect of FeO on transmittance while adjusting for SPF or filter type. The Mann-Whitney U test was used to compare NV-UVA and blue light transmittance between FeO-containing mineral and chemical formulations. Statistical significance was set at P<.05.

Results

Across broad-spectrum sunscreen formulations (N=23), mean SPF values were 40.4 (range, 30-70), and the mean number of antioxidants in the ingredient list was 1.5 (range, 0-4). Mean NV-UVA transmittance was 16.7% (range, 0.1%-55.0%) and mean BL transmittance was 44.3% (range, 0.3%-97.5%)(eTable 1).

The mean labeled zinc oxide (ZnO) concentration among ZnO-containing formulations (n=14) was 10.5% (range, 5.0%-21.6%), with mean NV-UVA and BL transmittance of 12.6% (range, 0.1%-55.0%) and 25.8% (range, 0.3%-67.2%), respectively. Mean NV-UVA and BL transmittance were 26.7% (range, 9.6%-55.0%) and 45.6% (range, 23.0%-67.2%) among ZnO formulations without FeO (n=5), compared with lower transmittance of 4.8% (range, 0.1%-11.5%) and 14.9% (range, 0.3%-29.5%) in ZnO formulations containing FeO (n=9).

The mean labeled titanium dioxide (TiO₂) concentration among TiO₂-containing formulations (n=14) was 9.0% (range, 3.2%-17.0%), with corresponding mean NV-UVA and BL transmittance of 9.5% (range, 0.1%-28.5%) and 22.7% (range, 0.3%-47.6%), respectively. Among TiO₂ formulations without FeO (n=4), mean NV-UVA and BL transmittance was 19.7% (range, 9.6%-28.5%) and 39.8% (range, 23.0%-47.6%), while FeO-containing TiO₂ formulations (n=10) showed lower mean NV-UVA and BL transmittance of 5.4% (range, 0.1%-11.5%) and 15.8% (range, 0.3%-29.5%), respectively. The mean labeled avobenzone concentration among avobenzone-containing formulations (n=8) was 2.9% (range, 2.5%-3%), with mean NV-UVA and BL transmittance of 24.7% (range, 10.2%-46.6%) and 79.2% (range, 53.9%-97.5%). Formulations without FeO (n=5) had mean NV-UVA and BL transmittance of 29.0% (range, 10.2%-46.6%) and 83.2% (range, 61.1%-97.5%), whereas FeO-containing products (n=3) demonstrated lower mean NV-UVA and BL transmittance of 17.5% (range, 12.5%-21.9%) and 72.6% (range, 53.9%-85.1%), respectively.

Among products containing ZnO, TiO₂, and avobenzone, the specific UV filter concentrations showed no statistically significant correlation with NV-UVA or BL transmittance (all P>.05). Iron oxide presence significantly correlated with lower NV-UVA (r=–0.67; P=.00042) and lower BL transmittance (r=–0.57; P=.0046). The number of antioxidants in the ingredient list did not correlate with NV-UVA transmittance (r=–0.28; P=.19) or BL ­transmittance (r=–0.16; P=.47). Sun protection factor was not significantly correlated with either wavelength range (Table 1).

Tint shade was treated as an ordinal variable (light, medium, medium/deep, and deep; medium was considered the universal shade). Increasing tint shade depth was significantly associated with reduced NV-UVA (r=–0.64; P=.045) and BL (r=–0.71; P=.023), suggesting a dose-response relationship wherein darker tints exhibited greater attenuation of pigment-relevant wavelengths. Among mineral filter formulations, tinted products demonstrated lower NV-UVA and BL transmittance compared with their nontinted counterparts, with deeper tints providing the greatest reduction in transmittance (eFigure 1). Similar results were observed for chemical filter formulations with greater attenuation in the NV-UVA and BL range for tinted versus nontinted products with greater variability across shade depths (eFigure 2).

After adjusting for SPF, FeO presence remained significantly associated with reduced NV-UVA (F[1,20]=26.9; P<.001) and BL transmittance (F[1,20]=11.7; P=.003). After adjusting for filter type (mineral vs chemical), FeO remained significantly associated with NV-UVA (F[1,19]=10.1; P=.004) and BL transmittance (F[1,19]=10.4; P=.005)(Table 2).

Among FeO-containing products, mineral filters demonstrated significantly lower NV-UVA transmittance compared with chemical filters (median, 5.58% [interquartile range (IQR), 0.59%-9.35%] vs 18.10% [IQR, 12.47%-21.90%]; U=0.00; P=.007). The same was true for BL transmittance (median, 15.90% [IQR, 5.00%-26.20%] vs 78.70% [IQR, 53.90%-85.10%]; U=0.00; P=.007). The differences in spectral transmittance between ­FeO-containing mineral and chemical filter ­formulations are illustrated in eFigure 3, with mineral-based ­products demonstrating lower transmittance, ­particularly across the upper NV-UVA range and across the BL range. These results indicated greater ­pigment-relevant ­photoprotection with mineral vs chemical filters (eTable 2).

Comment

Our initial hypothesis proposed that tinted sunscreens would provide greater NV-UVA and BL attenuation than nontinted formulations, and that characteristics such as inorganic filter content, SPF rating, and antioxidants would correlate with improved protection in pigment-sensitive wavelengths. Our findings partially supported this hypothesis. In this analysis, substantial variability in the NV-UVA and BL transmittance was observed despite all products meeting broad-spectrum criteria. Nontinted mineral and chemical sunscreens exhibited high transmittance in these pigment-related wavelengths, reaching values as high as 55.0% for NV-UVA and 97.5% for BL. These findings align with prior analysis demonstrating that while broad-spectrum sunscreens available in the United States may meet the current critical wavelength criteria for protection in the UVA range, they still may transmit 30% to 66% of available UVA over 2 hours between formulations with equivalent SPF label values.⁶

Recent analyses show that sunscreen recommendations in lay media rarely incorporate input from board-certified dermatologists for individuals with SOC and disproportionately favor nontinted chemical formulations, despite the high prevalence of pigmentary disorders in this population.⁷ Near-visible UVA and BL have been demonstrated to be biologically relevant pigment-inducing wavelengths, both in vitro and in vivo, particularly in individuals with SOC, yet broad-spectrum labeling does not ensure protection against these spectra.⁸ Pigmentary tints such as FeO have demonstrated enhanced attenuation in this spectral region in vivo and may provide more reliable coverage than products with broad-spectrum designation alone.^4,9 Treatment options for pigmentary disorders such as melasma tend to be palliative and costly, making optimized photoprotection a critical component of care to reduce ongoing pigmentary stimuli.¹⁰

Formulations containing FeO demonstrated significantly lower NV-UVA (P<.001) and BL transmittance (P=.003) on average; however, transmittance values ranged widely (NV-UVA: 0.10%-21.90%, BL: 0.30%-85.10%), indicating that FeO presence alone does not determine the magnitude of attenuation. Notably, among FeO-containing products, mineral filters provided significantly lower NV-UVA and BL transmittance compared with chemical filters (P=.007 for both), suggesting that filter type further modulates pigment-relevant photoprotection. Tinted formulations may improve compliance with product use by reducing the white cast and improve shade matching to find suitable options for deeper skin tones,¹¹ but the highly variable photoprotection offered raises concerns about clinical benefit. Although deeper tints showed greater attenuation, pigment concentrations and combinations are not disclosed by manufacturers as FeO is not considered an active ingredient. Darker shades are not practical across all skin tones in individuals with SOC, which underscores the need for standardized pigment metrics and shade-inclusive options.

While avobenzone and ZnO are the only US Food and Drug Administration–approved sunscreen active ingredients that extend protection beyond 360 nm,¹² both exhibited reduced attenuation beyond the longer end of the UVA spectrum. Formulation characteristics, including the concentration of ZnO, TiO₂, and/or avobenzone as well as SPF, did not correlate with NV-UVA or BL attenuation. In the adjusted analysis, FeO presence remained significantly associated with reduced transmittance after adjusting for SPF (NV-UVA: P<.001, BL: P=.003) or filter type (NV-UVA: P=.004, BL: P=.005). These findings suggest that the presence of FeO, rather than UV filters or SPF ratings, supports attenuation in the 380 to 450–nm range, indicating a functional benefit in addition to improved cosmesis.¹³ 

Although antioxidants in specific combinations have shown promise in vivo, no association was observed between the number of antioxidants present and NV-UVA or BL attenuation compared with added tint.¹⁴ This suggests that specific antioxidant combinations and their concentrations may be more relevant than the total count.

Several study limitations need to be considered in interpreting our results, including a modest number of products, controlled in vitro testing conditions, and an incomplete representation of products with pigment concentrations and shade ranges marketed to individuals with SOC across all price categories, despite our focus on affordable, commercially available options. Moreover, PMMA-based spectrophotometry does not account for skin surface heterogeneity, photodegradation, sweat, oil, friction, or application variability, which may alter real-world performance. Additionally, FeO concentrations could not be quantified beyond labeling of tint shade depth, preventing a true assessment of dose-response effects. These limitations may reduce generalizability and highlight the need for complementary in vivo studies to assess clinically relevant outcomes such as persistent pigment darkening. For this reason, caution is warranted in extrapolating these spectral findings to clinical efficacy.

Conclusion

Given the susceptibility of individuals with SOC to pigmentary disorders driven by NV-UVA and BL, our findings support further development and study of FeO-containing sunscreens that address clinically relevant wavelengths. Wide variability in photo-attenuation among tinted formulations underscores the need for evidence-based recommendations, with further studies needed to guide photoprotection strategies for populations with SOC.

Social drivers of health (SDH) describe the conditions in which an individual is born, grows, lives, works, and ages—all of which collectively influence their health. Examples of SDH include employment status, literacy level, education level, housing status, food access, income level, and social cohesion. Social drivers of health are critical catalysts to attaining health equity. Effectively applying an understanding of how SDH affect the care of all patients is an essential competency for physicians practicing in the modern era of rising income inequality and housing instability and increasing racial, ethnic, language, religious, and cultural diversity in the United States; however, in dermatology residency, this skill set often is developed by the hidden curriculum (ie, the informal curriculum that is based on what patient scenarios a resident happens to face) rather than one represented by formal educational objectives.²

Adding to this challenge of limited formal curricula is that caring for minoritized, marginalized, and other populations facing specific barriers can evoke feelings of frustration, helplessness, and even anger. These feelings can test the limits of a physician’s identity as a healer, leading to burnout and self-protective attitudes such as distancing (emotionally, physically, or both) from these patients.³ This is particularly relevant given that the majority (76%-79% each year from 2007-2019) of medical student matriculants come from families with incomes in the top 2 quintiles nationwide, and fewer than 6% come from the lowest quintile earners.^4,5 These data indicate that most trainees have not experienced (and may even have a hard time imagining) the degree of economic and housing instability faced by many of their low-income patients, the care of whom disproportionately falls to large academic medical centers, which sponsor dermatology training programs.⁶ Many trainees may feel uncomfortable communicating across the broad range of racial, socioeconomic, linguistic, and cultural differences they encounter during training and in practice. Structured opportunities to provide care in a supervised supportive environment combined with didactics that emphasize practical, evidence-based strategies can build empathy, improve attitudes toward patients from diverse backgrounds, and strengthen self-efficacy in challenging scenarios.³

In the past decade, there has been a push toward integrating our understanding of SDH into formal medical training.⁷ Other specialty training programs—including psychiatry,⁸ internal medicine,⁹ pediatrics,¹⁰ and family medicine¹¹—have incorporated these elements into their curricula and competency evaluations. In dermatology, as in other specialties, making and implementing effective, patient-centered care plans requires attention to the various social and structural drivers that may influence outcomes. Dermatologists therefore should be educated about SDH during their training programs and empowered to address the ways they affect patient care.

At the University of California San Francisco (UCSF)(San Francisco, California), our dermatology trainees care for patients in several hospital systems citywide, including a tertiary academic medical center with multiple locations, a county hospital, and a Veterans Affairs medical center. Given the diversity of patient populations across our training sites—including many racially and ethnically minoritized individuals, immigrants, patients with limited English proficiency, people experiencing homelessness, and sexual and gender diverse individuals—we identified a critical opportunity to enhance our training through formal didactics and hands-on experiences that integrate SDH into existing curricula and strengthen trainees’ ability to provide high-quality care to all patients.

Implementing an SDH Curriculum

In May 2020, UCSF dermatology faculty with an interest in SDH collaborated with departmental educational leadership to develop a formal SDH curriculum centered around 8 core learning objectives for residents (eTable 1). To achieve these objectives, we organized a 3-year didactic and experiential curriculum consisting of lectures (eTable 2), grand rounds sessions, journal clubs, and community engagement opportunities. Residents also spend 7 months during their training rotating at San Francisco’s city and county hospital (Zuckerberg San Francisco General Hospital [San Francisco, California]) where all faculty are members of the core SDH curriculum development team and where residents can put into practice many of the skills learned in formal didactics to develop patient-centered care plans for low-income patients, approximately 40% of whom have limited English proficiency.

To further center the importance of SDH and health equity in our training program, we developed a Health Equity Chief leadership role for senior dermatology residents. Each year, 2 to 4 residents volunteer for and serve in this role, wherein they work with core faculty to review and improve SDH curriculum elements. They also work to enhance community engagement opportunities for residents (eg, pathway programs aimed at diversifying the dermatology workforce by introducing historically excluded local high school and college students to dermatology as a career path) and improve dermatology trainees’ awareness of the history and health needs of the specific communities we serve in San Francisco. They also are prepared to become leaders in the field of health equity and to improve the care of diverse patient populations after residency. Our faculty curriculum leaders meet quarterly with our Health Equity Chiefs to review their individual and collective goals and strategize ways to improve learner and community engagement. Departmental funds are made available to support these efforts.

Leadership at our safety-net county hospital also developed a patient navigator position to improve our ability to care for patients with the most complex medical conditions and social needs. This role is held by a medical student taking a funded gap year and incorporates aspects of social work (eg, identifying barriers to care and connecting patients with resources such as transportation), quality improvement, and clinical research.¹²

Assessing Residents’ Experience of a New SDH Curriculum

Prior to curriculum implementation, we surveyed graduating UCSF dermatology residents in June 2020 to assess their familiarity with SDH and the social and medical needs of various populations facing barriers to care, their comfort level with specific challenging clinical situations, and their desire for additional training. Responses were measured using a 5-part Likert scale, with additional options for free-text response. After initiating the SDH curriculum in July 2020, we sent the same survey each year to all senior residents immediately prior to their graduation, offering a small financial incentive ($15 cash gift card) to those who completed the survey. We obtained UCSF Institutional Review Board approval to utilize these survey data to better understand and to enhance residents’ experience of the SDH curriculum.

All 8 residents invited in 2020 completed the survey assessing curriculum efficacy (100% response rate). For the 2023 and 2024 classes, data were analyzed in aggregate (n=14), with a 50% response rate. After implementation of the SDH curriculum, there was improvement in learners’ awareness of challenges faced by every patient population, from a mean (SD) of 3.12 (0.66) to 4.52 (SD, 0.69)(P<.05). Learners were more comfortable handling hypothetical clinical scenarios requiring them to identify and address specific SDH after vs before implementation of the curriculum (mean [SD], 3.5 [1.06] before vs 4.0 [1.16] after)(P>.05), though this difference was not statistically learners’ awareness of challenges faced by every patient population, from a mean (SD) of 3.12 (0.66) to 4.52 (0.69)(P<.05). Learners were more comfortable handling hypothetical clinical scenarios requiring them to identify and address specific SDH after vs before implementation of the curriculum (mean [SD], 3.5 [1.06] before vs 4.0 [1.16] after)(P>.05), though this difference was not statistically significant. Finally, many respondents expressed appreciation that our curriculum improved their ability to care for patients in complex social circumstances. Residents suggested in the free-text responses that learning more about the historical underpinnings of health disparities, opportunities for grassroots activism, and how to provide more culturally competent care of Native American populations could improve our curriculum.

Implications for Dermatology Training

Our survey results indicate that a formal SDH curriculum can improve dermatology residents’ ability to care for populations with complex social needs. We advocate for implementing SDH curricula into dermatology training programs nationwide, as has been recommended by others.^13,14 We also propose that structural competency should eventually be a key dermatologic competency as determined by the Accreditation Council for Graduate Medical Education, in line with the American Medical Association’s recommendation that structural competency is a learned skill required to end health inequity.¹⁵ The Accreditation Council for Graduate Medical Education specialty program requirements currently are being revised; interested individuals can engage in this process by submitting this suggestion for public comment (https://www.acgme.org/programs-and-institutions/programs/review-and-comment/).

Limitations of a survey include the relatively small sample size (7-8 per year) and variable response rates. In addition, we did not survey each class of residents at the beginning and end of their training; our comparisons therefore were limited by comparing different individuals with distinct backgrounds and experiences. Furthermore, we acknowledge that the experience of developing this curriculum in San Francisco may be distinct from other communities, where access to dermatologic care may vary according to both the availability of public health insurance and the treatments covered by public insurers. In San Francisco, insurance coverage is near universal, such that residents in our training program regularly care for undocumented immigrants, persons experiencing homelessness, and other populations that might find it challenging to present to dermatology clinics in other settings nationwide.

Final Thoughts

Future directions of our curriculum include exploration of novel curriculum delivery methods (including a problem-based curriculum approach and other more experiential didactics), increased opportunities for community engagement, greater focus on advocacy with an emphasis on broader social and structural policies and their downstream effects, and focusing more specifically on the history and needs of specific low-income San Francisco neighborhoods and diverse patient populations.

Social drivers of health (SDH) describe the conditions in which an individual is born, grows, lives, works, and ages—all of which collectively influence their health. Examples of SDH include employment status, literacy level, education level, housing status, food access, income level, and social cohesion. Social drivers of health are critical catalysts to attaining health equity. Effectively applying an understanding of how SDH affect the care of all patients is an essential competency for physicians practicing in the modern era of rising income inequality and housing instability and increasing racial, ethnic, language, religious, and cultural diversity in the United States; however, in dermatology residency, this skill set often is developed by the hidden curriculum (ie, the informal curriculum that is based on what patient scenarios a resident happens to face) rather than one represented by formal educational objectives.²

Adding to this challenge of limited formal curricula is that caring for minoritized, marginalized, and other populations facing specific barriers can evoke feelings of frustration, helplessness, and even anger. These feelings can test the limits of a physician’s identity as a healer, leading to burnout and self-protective attitudes such as distancing (emotionally, physically, or both) from these patients.³ This is particularly relevant given that the majority (76%-79% each year from 2007-2019) of medical student matriculants come from families with incomes in the top 2 quintiles nationwide, and fewer than 6% come from the lowest quintile earners.^4,5 These data indicate that most trainees have not experienced (and may even have a hard time imagining) the degree of economic and housing instability faced by many of their low-income patients, the care of whom disproportionately falls to large academic medical centers, which sponsor dermatology training programs.⁶ Many trainees may feel uncomfortable communicating across the broad range of racial, socioeconomic, linguistic, and cultural differences they encounter during training and in practice. Structured opportunities to provide care in a supervised supportive environment combined with didactics that emphasize practical, evidence-based strategies can build empathy, improve attitudes toward patients from diverse backgrounds, and strengthen self-efficacy in challenging scenarios.³

In the past decade, there has been a push toward integrating our understanding of SDH into formal medical training.⁷ Other specialty training programs—including psychiatry,⁸ internal medicine,⁹ pediatrics,¹⁰ and family medicine¹¹—have incorporated these elements into their curricula and competency evaluations. In dermatology, as in other specialties, making and implementing effective, patient-centered care plans requires attention to the various social and structural drivers that may influence outcomes. Dermatologists therefore should be educated about SDH during their training programs and empowered to address the ways they affect patient care.

At the University of California San Francisco (UCSF)(San Francisco, California), our dermatology trainees care for patients in several hospital systems citywide, including a tertiary academic medical center with multiple locations, a county hospital, and a Veterans Affairs medical center. Given the diversity of patient populations across our training sites—including many racially and ethnically minoritized individuals, immigrants, patients with limited English proficiency, people experiencing homelessness, and sexual and gender diverse individuals—we identified a critical opportunity to enhance our training through formal didactics and hands-on experiences that integrate SDH into existing curricula and strengthen trainees’ ability to provide high-quality care to all patients.

Implementing an SDH Curriculum

In May 2020, UCSF dermatology faculty with an interest in SDH collaborated with departmental educational leadership to develop a formal SDH curriculum centered around 8 core learning objectives for residents (eTable 1). To achieve these objectives, we organized a 3-year didactic and experiential curriculum consisting of lectures (eTable 2), grand rounds sessions, journal clubs, and community engagement opportunities. Residents also spend 7 months during their training rotating at San Francisco’s city and county hospital (Zuckerberg San Francisco General Hospital [San Francisco, California]) where all faculty are members of the core SDH curriculum development team and where residents can put into practice many of the skills learned in formal didactics to develop patient-centered care plans for low-income patients, approximately 40% of whom have limited English proficiency.

To further center the importance of SDH and health equity in our training program, we developed a Health Equity Chief leadership role for senior dermatology residents. Each year, 2 to 4 residents volunteer for and serve in this role, wherein they work with core faculty to review and improve SDH curriculum elements. They also work to enhance community engagement opportunities for residents (eg, pathway programs aimed at diversifying the dermatology workforce by introducing historically excluded local high school and college students to dermatology as a career path) and improve dermatology trainees’ awareness of the history and health needs of the specific communities we serve in San Francisco. They also are prepared to become leaders in the field of health equity and to improve the care of diverse patient populations after residency. Our faculty curriculum leaders meet quarterly with our Health Equity Chiefs to review their individual and collective goals and strategize ways to improve learner and community engagement. Departmental funds are made available to support these efforts.

Leadership at our safety-net county hospital also developed a patient navigator position to improve our ability to care for patients with the most complex medical conditions and social needs. This role is held by a medical student taking a funded gap year and incorporates aspects of social work (eg, identifying barriers to care and connecting patients with resources such as transportation), quality improvement, and clinical research.¹²

Assessing Residents’ Experience of a New SDH Curriculum

Prior to curriculum implementation, we surveyed graduating UCSF dermatology residents in June 2020 to assess their familiarity with SDH and the social and medical needs of various populations facing barriers to care, their comfort level with specific challenging clinical situations, and their desire for additional training. Responses were measured using a 5-part Likert scale, with additional options for free-text response. After initiating the SDH curriculum in July 2020, we sent the same survey each year to all senior residents immediately prior to their graduation, offering a small financial incentive ($15 cash gift card) to those who completed the survey. We obtained UCSF Institutional Review Board approval to utilize these survey data to better understand and to enhance residents’ experience of the SDH curriculum.

All 8 residents invited in 2020 completed the survey assessing curriculum efficacy (100% response rate). For the 2023 and 2024 classes, data were analyzed in aggregate (n=14), with a 50% response rate. After implementation of the SDH curriculum, there was improvement in learners’ awareness of challenges faced by every patient population, from a mean (SD) of 3.12 (0.66) to 4.52 (SD, 0.69)(P<.05). Learners were more comfortable handling hypothetical clinical scenarios requiring them to identify and address specific SDH after vs before implementation of the curriculum (mean [SD], 3.5 [1.06] before vs 4.0 [1.16] after)(P>.05), though this difference was not statistically learners’ awareness of challenges faced by every patient population, from a mean (SD) of 3.12 (0.66) to 4.52 (0.69)(P<.05). Learners were more comfortable handling hypothetical clinical scenarios requiring them to identify and address specific SDH after vs before implementation of the curriculum (mean [SD], 3.5 [1.06] before vs 4.0 [1.16] after)(P>.05), though this difference was not statistically significant. Finally, many respondents expressed appreciation that our curriculum improved their ability to care for patients in complex social circumstances. Residents suggested in the free-text responses that learning more about the historical underpinnings of health disparities, opportunities for grassroots activism, and how to provide more culturally competent care of Native American populations could improve our curriculum.

Implications for Dermatology Training

Our survey results indicate that a formal SDH curriculum can improve dermatology residents’ ability to care for populations with complex social needs. We advocate for implementing SDH curricula into dermatology training programs nationwide, as has been recommended by others.^13,14 We also propose that structural competency should eventually be a key dermatologic competency as determined by the Accreditation Council for Graduate Medical Education, in line with the American Medical Association’s recommendation that structural competency is a learned skill required to end health inequity.¹⁵ The Accreditation Council for Graduate Medical Education specialty program requirements currently are being revised; interested individuals can engage in this process by submitting this suggestion for public comment (https://www.acgme.org/programs-and-institutions/programs/review-and-comment/).

Limitations of a survey include the relatively small sample size (7-8 per year) and variable response rates. In addition, we did not survey each class of residents at the beginning and end of their training; our comparisons therefore were limited by comparing different individuals with distinct backgrounds and experiences. Furthermore, we acknowledge that the experience of developing this curriculum in San Francisco may be distinct from other communities, where access to dermatologic care may vary according to both the availability of public health insurance and the treatments covered by public insurers. In San Francisco, insurance coverage is near universal, such that residents in our training program regularly care for undocumented immigrants, persons experiencing homelessness, and other populations that might find it challenging to present to dermatology clinics in other settings nationwide.

Final Thoughts

Future directions of our curriculum include exploration of novel curriculum delivery methods (including a problem-based curriculum approach and other more experiential didactics), increased opportunities for community engagement, greater focus on advocacy with an emphasis on broader social and structural policies and their downstream effects, and focusing more specifically on the history and needs of specific low-income San Francisco neighborhoods and diverse patient populations.

Social drivers of health (SDH) describe the conditions in which an individual is born, grows, lives, works, and ages—all of which collectively influence their health. Examples of SDH include employment status, literacy level, education level, housing status, food access, income level, and social cohesion. Social drivers of health are critical catalysts to attaining health equity. Effectively applying an understanding of how SDH affect the care of all patients is an essential competency for physicians practicing in the modern era of rising income inequality and housing instability and increasing racial, ethnic, language, religious, and cultural diversity in the United States; however, in dermatology residency, this skill set often is developed by the hidden curriculum (ie, the informal curriculum that is based on what patient scenarios a resident happens to face) rather than one represented by formal educational objectives.²

Adding to this challenge of limited formal curricula is that caring for minoritized, marginalized, and other populations facing specific barriers can evoke feelings of frustration, helplessness, and even anger. These feelings can test the limits of a physician’s identity as a healer, leading to burnout and self-protective attitudes such as distancing (emotionally, physically, or both) from these patients.³ This is particularly relevant given that the majority (76%-79% each year from 2007-2019) of medical student matriculants come from families with incomes in the top 2 quintiles nationwide, and fewer than 6% come from the lowest quintile earners.^4,5 These data indicate that most trainees have not experienced (and may even have a hard time imagining) the degree of economic and housing instability faced by many of their low-income patients, the care of whom disproportionately falls to large academic medical centers, which sponsor dermatology training programs.⁶ Many trainees may feel uncomfortable communicating across the broad range of racial, socioeconomic, linguistic, and cultural differences they encounter during training and in practice. Structured opportunities to provide care in a supervised supportive environment combined with didactics that emphasize practical, evidence-based strategies can build empathy, improve attitudes toward patients from diverse backgrounds, and strengthen self-efficacy in challenging scenarios.³

In the past decade, there has been a push toward integrating our understanding of SDH into formal medical training.⁷ Other specialty training programs—including psychiatry,⁸ internal medicine,⁹ pediatrics,¹⁰ and family medicine¹¹—have incorporated these elements into their curricula and competency evaluations. In dermatology, as in other specialties, making and implementing effective, patient-centered care plans requires attention to the various social and structural drivers that may influence outcomes. Dermatologists therefore should be educated about SDH during their training programs and empowered to address the ways they affect patient care.

At the University of California San Francisco (UCSF)(San Francisco, California), our dermatology trainees care for patients in several hospital systems citywide, including a tertiary academic medical center with multiple locations, a county hospital, and a Veterans Affairs medical center. Given the diversity of patient populations across our training sites—including many racially and ethnically minoritized individuals, immigrants, patients with limited English proficiency, people experiencing homelessness, and sexual and gender diverse individuals—we identified a critical opportunity to enhance our training through formal didactics and hands-on experiences that integrate SDH into existing curricula and strengthen trainees’ ability to provide high-quality care to all patients.

Implementing an SDH Curriculum

In May 2020, UCSF dermatology faculty with an interest in SDH collaborated with departmental educational leadership to develop a formal SDH curriculum centered around 8 core learning objectives for residents (eTable 1). To achieve these objectives, we organized a 3-year didactic and experiential curriculum consisting of lectures (eTable 2), grand rounds sessions, journal clubs, and community engagement opportunities. Residents also spend 7 months during their training rotating at San Francisco’s city and county hospital (Zuckerberg San Francisco General Hospital [San Francisco, California]) where all faculty are members of the core SDH curriculum development team and where residents can put into practice many of the skills learned in formal didactics to develop patient-centered care plans for low-income patients, approximately 40% of whom have limited English proficiency.

To further center the importance of SDH and health equity in our training program, we developed a Health Equity Chief leadership role for senior dermatology residents. Each year, 2 to 4 residents volunteer for and serve in this role, wherein they work with core faculty to review and improve SDH curriculum elements. They also work to enhance community engagement opportunities for residents (eg, pathway programs aimed at diversifying the dermatology workforce by introducing historically excluded local high school and college students to dermatology as a career path) and improve dermatology trainees’ awareness of the history and health needs of the specific communities we serve in San Francisco. They also are prepared to become leaders in the field of health equity and to improve the care of diverse patient populations after residency. Our faculty curriculum leaders meet quarterly with our Health Equity Chiefs to review their individual and collective goals and strategize ways to improve learner and community engagement. Departmental funds are made available to support these efforts.

Leadership at our safety-net county hospital also developed a patient navigator position to improve our ability to care for patients with the most complex medical conditions and social needs. This role is held by a medical student taking a funded gap year and incorporates aspects of social work (eg, identifying barriers to care and connecting patients with resources such as transportation), quality improvement, and clinical research.¹²

Assessing Residents’ Experience of a New SDH Curriculum

Prior to curriculum implementation, we surveyed graduating UCSF dermatology residents in June 2020 to assess their familiarity with SDH and the social and medical needs of various populations facing barriers to care, their comfort level with specific challenging clinical situations, and their desire for additional training. Responses were measured using a 5-part Likert scale, with additional options for free-text response. After initiating the SDH curriculum in July 2020, we sent the same survey each year to all senior residents immediately prior to their graduation, offering a small financial incentive ($15 cash gift card) to those who completed the survey. We obtained UCSF Institutional Review Board approval to utilize these survey data to better understand and to enhance residents’ experience of the SDH curriculum.

All 8 residents invited in 2020 completed the survey assessing curriculum efficacy (100% response rate). For the 2023 and 2024 classes, data were analyzed in aggregate (n=14), with a 50% response rate. After implementation of the SDH curriculum, there was improvement in learners’ awareness of challenges faced by every patient population, from a mean (SD) of 3.12 (0.66) to 4.52 (SD, 0.69)(P<.05). Learners were more comfortable handling hypothetical clinical scenarios requiring them to identify and address specific SDH after vs before implementation of the curriculum (mean [SD], 3.5 [1.06] before vs 4.0 [1.16] after)(P>.05), though this difference was not statistically learners’ awareness of challenges faced by every patient population, from a mean (SD) of 3.12 (0.66) to 4.52 (0.69)(P<.05). Learners were more comfortable handling hypothetical clinical scenarios requiring them to identify and address specific SDH after vs before implementation of the curriculum (mean [SD], 3.5 [1.06] before vs 4.0 [1.16] after)(P>.05), though this difference was not statistically significant. Finally, many respondents expressed appreciation that our curriculum improved their ability to care for patients in complex social circumstances. Residents suggested in the free-text responses that learning more about the historical underpinnings of health disparities, opportunities for grassroots activism, and how to provide more culturally competent care of Native American populations could improve our curriculum.

Implications for Dermatology Training

Our survey results indicate that a formal SDH curriculum can improve dermatology residents’ ability to care for populations with complex social needs. We advocate for implementing SDH curricula into dermatology training programs nationwide, as has been recommended by others.^13,14 We also propose that structural competency should eventually be a key dermatologic competency as determined by the Accreditation Council for Graduate Medical Education, in line with the American Medical Association’s recommendation that structural competency is a learned skill required to end health inequity.¹⁵ The Accreditation Council for Graduate Medical Education specialty program requirements currently are being revised; interested individuals can engage in this process by submitting this suggestion for public comment (https://www.acgme.org/programs-and-institutions/programs/review-and-comment/).

Limitations of a survey include the relatively small sample size (7-8 per year) and variable response rates. In addition, we did not survey each class of residents at the beginning and end of their training; our comparisons therefore were limited by comparing different individuals with distinct backgrounds and experiences. Furthermore, we acknowledge that the experience of developing this curriculum in San Francisco may be distinct from other communities, where access to dermatologic care may vary according to both the availability of public health insurance and the treatments covered by public insurers. In San Francisco, insurance coverage is near universal, such that residents in our training program regularly care for undocumented immigrants, persons experiencing homelessness, and other populations that might find it challenging to present to dermatology clinics in other settings nationwide.

Final Thoughts

Future directions of our curriculum include exploration of novel curriculum delivery methods (including a problem-based curriculum approach and other more experiential didactics), increased opportunities for community engagement, greater focus on advocacy with an emphasis on broader social and structural policies and their downstream effects, and focusing more specifically on the history and needs of specific low-income San Francisco neighborhoods and diverse patient populations.

Infantile hemangioma (IH) is the most common vascular tumor of infancy, appearing within the first few weeks of life and typically reaching peak size by age 3 to 5 months.¹ It classically manifests as a raised or flat bright-red lesion in the upper dermis of the skin and/or subcutaneous tissue and can vary in number, size, shape, and location.² It is characterized by a rapid proliferative phase, especially between 5 and 8 weeks of age, followed by gradual spontaneous regression over 1 to 10 years.^1-3

Infantile hemangiomas are categorized based on depth (superficial, deep, or mixed) and distribution pattern (focal, multifocal, segmental, or indeterminate).⁴ In most cases, complete regression occurs by age 4 years, but there can be residual telangiectasia, fibrofatty tissue, and/or scarring.^1,4 About 10% to 15% of IHs result in complications that require medical intervention (eg, visual, airway, or auditory compromise; ulceration; disfigurement); ideally, these patients should be referred to a specialist by 5 weeks of age.⁴ Prompt assessment of IH severity is essential to prevent or mitigate potential complications and ultimately improve outcomes.³ Social drivers of health contribute to delayed diagnosis and management of hemangiomas, leading to increased complications in some patient populations.^5-7

Epidemiology

Infantile hemangiomas are estimated to manifest in 4.5% of infants in the United States.¹ The most common type is superficial IH, typically found on the head or neck.⁵ Risk factors in infants include female sex, White race, premature birth, and low birth weight (<1000 g).^1,3 Maternal risk factors include advanced gestational age (ie, >35 years), multiple gestations, family history of IH, tobacco use, use of progesterone therapy during pregnancy, and pre-eclampsia.^1,3

Focal IH typically manifests as a single localized lesion that can occur anywhere on the body.^2,3 In contrast, segmental IH manifests in a linear pattern and/or is distributed on a large anatomic area, most commonly on the face and less frequently the extremities and trunk.^2,3 Segmental IHs are more common in Hispanic patients and carry a higher risk for morbidity, often complicated by ulceration that can lead to functional and cosmetic challenges.⁸

Key Clinical Features

Superficial IH in patients with darker skin tones may appear as a dark-red or violaceous papule or plaque compared to bright red in lighter skin tones.⁵ Deep IH may appear as a soft, round, flesh-colored or blue-hued subcutaneous mass, the color of which may be harder to appreciate in those with darker skin tones.⁵

Worth Noting

Complications from IH may require imaging, close follow-up, systemic therapy, multidisciplinary care, and advanced health literacy and patient/family navigation. Multifocal IHs (≥5 lesions) are more likely to be associated with infantile hepatic hemangiomas.^2,3 Large (>5 cm) segmental IHs on the face and lumbosacral area require further evaluation for PHACES (posterior fossa malformation, hemangiomas, arterial anomalies, cardiac defects, eye anomalies, and sternal raphe/cleft defects) and LUMBAR (lower-body segmental IH; urogenital anomalies and ulceration; ­myelopathy; bony deformities; anorectal malformations and arterial anomalies; and renal anomalies) syndromes, which are more common in patients of Hispanic ethnicity.^2,3

The Infantile Hemangioma Referral Score is a recently validated tool that can assist primary care physicians in timely referral of IHs requiring early specialist intervention.^4,9 It takes into account the location, number, and size of the lesions and the age of the patient; these factors help to determine which IHs may be managed conservatively vs those that may require treatment to prevent ­life-threatening complications.^1-3 

Systemic corticosteroids historically have been the primary treatment for IH; however, in the past decade, propranolol oral solution (4.28 mg/mL) has become the first-line therapy for most infants requiring systemic management.¹⁰ It is the only medication approved by the US Food and Drug Administration for proliferating IH, with treatment initiation as young as 5 weeks corrected age.¹¹ As a nonselective beta-blocker, propranolol is believed to reduce IHs through vasoconstriction or by inhibition of angiogenesis.^1,4,10 

For small superficial IHs, treatment options include timolol maleate ophthalmic solution 0.5% (one drop applied twice daily to the IH) or pulsed dye laser therapy.^4,10 Surgical excision typically is avoided during infancy due to concerns about anesthetic risks and potential blood loss.^4,10 Surgery is reserved for cases involving residual fibrofatty tissue, postinvolution scarring, obstruction of vital structures, or lesions in aesthetically sensitive areas as well as when propranolol is contraindicated.^4,10

Health Disparity Highlight

Infants with skin of color and those of lower socioeconomic status (SES) face a heightened risk for delayed diagnosis and more advanced disease at the initial evaluation for IH.^5,7 Access barriers such as geographic limitations to specialty services, lack of insurance, underinsurance, and language differences impact timely diagnosis and treatment.^5,6 Implementation of telemedicine services in areas with limited access to specialists can facilitate early evaluation and risk stratification for IH.¹²

A retrospective cohort study of 804 children seen at a large academic hospital found that those of lower SES were more likely to seek care after 3 months of age than their higher-SES counterparts.⁶ Those who presented after 6 months of age also had higher IH severity scores compared to their counterparts with higher SES.⁶ Delayed access to care may cause children to miss the critical treatment window during the rapid proliferative growth phase.^6,12 However, children insured through Medicaid or the Children’s Health Insurance Program who participated in institutional care management programs (which assist in scheduling specialty care appointments within the institution) sought treatment earlier regardless of their SES, suggesting that such programs may help reduce disparities in timely access for children of lower SES.⁶ 

An epidemiologic study analyzing the demographics of children hospitalized across the United States demonstrated that Black infants with IH were more likely to belong to the lowest income quartile compared with White infants or those of other races. They also were 2 times older on average at initial presentation (1.8 vs 1.0 years), experienced longer hospitalizations (16.4 vs 13.8 days), and underwent more IH-related procedures than White infants and infants of other races (2.4, 1.9, and 2.1, respectively).⁷

These and other factors may contribute to missed windows of opportunity for timely treatment of high-risk IHs in patients with darker skin tones and/or those facing challenges stemming from social drivers of health.

Infantile hemangioma (IH) is the most common vascular tumor of infancy, appearing within the first few weeks of life and typically reaching peak size by age 3 to 5 months.¹ It classically manifests as a raised or flat bright-red lesion in the upper dermis of the skin and/or subcutaneous tissue and can vary in number, size, shape, and location.² It is characterized by a rapid proliferative phase, especially between 5 and 8 weeks of age, followed by gradual spontaneous regression over 1 to 10 years.^1-3

Infantile hemangiomas are categorized based on depth (superficial, deep, or mixed) and distribution pattern (focal, multifocal, segmental, or indeterminate).⁴ In most cases, complete regression occurs by age 4 years, but there can be residual telangiectasia, fibrofatty tissue, and/or scarring.^1,4 About 10% to 15% of IHs result in complications that require medical intervention (eg, visual, airway, or auditory compromise; ulceration; disfigurement); ideally, these patients should be referred to a specialist by 5 weeks of age.⁴ Prompt assessment of IH severity is essential to prevent or mitigate potential complications and ultimately improve outcomes.³ Social drivers of health contribute to delayed diagnosis and management of hemangiomas, leading to increased complications in some patient populations.^5-7

Epidemiology

Infantile hemangiomas are estimated to manifest in 4.5% of infants in the United States.¹ The most common type is superficial IH, typically found on the head or neck.⁵ Risk factors in infants include female sex, White race, premature birth, and low birth weight (<1000 g).^1,3 Maternal risk factors include advanced gestational age (ie, >35 years), multiple gestations, family history of IH, tobacco use, use of progesterone therapy during pregnancy, and pre-eclampsia.^1,3

Focal IH typically manifests as a single localized lesion that can occur anywhere on the body.^2,3 In contrast, segmental IH manifests in a linear pattern and/or is distributed on a large anatomic area, most commonly on the face and less frequently the extremities and trunk.^2,3 Segmental IHs are more common in Hispanic patients and carry a higher risk for morbidity, often complicated by ulceration that can lead to functional and cosmetic challenges.⁸

Key Clinical Features

Superficial IH in patients with darker skin tones may appear as a dark-red or violaceous papule or plaque compared to bright red in lighter skin tones.⁵ Deep IH may appear as a soft, round, flesh-colored or blue-hued subcutaneous mass, the color of which may be harder to appreciate in those with darker skin tones.⁵

Worth Noting

Complications from IH may require imaging, close follow-up, systemic therapy, multidisciplinary care, and advanced health literacy and patient/family navigation. Multifocal IHs (≥5 lesions) are more likely to be associated with infantile hepatic hemangiomas.^2,3 Large (>5 cm) segmental IHs on the face and lumbosacral area require further evaluation for PHACES (posterior fossa malformation, hemangiomas, arterial anomalies, cardiac defects, eye anomalies, and sternal raphe/cleft defects) and LUMBAR (lower-body segmental IH; urogenital anomalies and ulceration; ­myelopathy; bony deformities; anorectal malformations and arterial anomalies; and renal anomalies) syndromes, which are more common in patients of Hispanic ethnicity.^2,3

The Infantile Hemangioma Referral Score is a recently validated tool that can assist primary care physicians in timely referral of IHs requiring early specialist intervention.^4,9 It takes into account the location, number, and size of the lesions and the age of the patient; these factors help to determine which IHs may be managed conservatively vs those that may require treatment to prevent ­life-threatening complications.^1-3 

Systemic corticosteroids historically have been the primary treatment for IH; however, in the past decade, propranolol oral solution (4.28 mg/mL) has become the first-line therapy for most infants requiring systemic management.¹⁰ It is the only medication approved by the US Food and Drug Administration for proliferating IH, with treatment initiation as young as 5 weeks corrected age.¹¹ As a nonselective beta-blocker, propranolol is believed to reduce IHs through vasoconstriction or by inhibition of angiogenesis.^1,4,10 

For small superficial IHs, treatment options include timolol maleate ophthalmic solution 0.5% (one drop applied twice daily to the IH) or pulsed dye laser therapy.^4,10 Surgical excision typically is avoided during infancy due to concerns about anesthetic risks and potential blood loss.^4,10 Surgery is reserved for cases involving residual fibrofatty tissue, postinvolution scarring, obstruction of vital structures, or lesions in aesthetically sensitive areas as well as when propranolol is contraindicated.^4,10

Health Disparity Highlight

Infants with skin of color and those of lower socioeconomic status (SES) face a heightened risk for delayed diagnosis and more advanced disease at the initial evaluation for IH.^5,7 Access barriers such as geographic limitations to specialty services, lack of insurance, underinsurance, and language differences impact timely diagnosis and treatment.^5,6 Implementation of telemedicine services in areas with limited access to specialists can facilitate early evaluation and risk stratification for IH.¹²

A retrospective cohort study of 804 children seen at a large academic hospital found that those of lower SES were more likely to seek care after 3 months of age than their higher-SES counterparts.⁶ Those who presented after 6 months of age also had higher IH severity scores compared to their counterparts with higher SES.⁶ Delayed access to care may cause children to miss the critical treatment window during the rapid proliferative growth phase.^6,12 However, children insured through Medicaid or the Children’s Health Insurance Program who participated in institutional care management programs (which assist in scheduling specialty care appointments within the institution) sought treatment earlier regardless of their SES, suggesting that such programs may help reduce disparities in timely access for children of lower SES.⁶ 

An epidemiologic study analyzing the demographics of children hospitalized across the United States demonstrated that Black infants with IH were more likely to belong to the lowest income quartile compared with White infants or those of other races. They also were 2 times older on average at initial presentation (1.8 vs 1.0 years), experienced longer hospitalizations (16.4 vs 13.8 days), and underwent more IH-related procedures than White infants and infants of other races (2.4, 1.9, and 2.1, respectively).⁷

These and other factors may contribute to missed windows of opportunity for timely treatment of high-risk IHs in patients with darker skin tones and/or those facing challenges stemming from social drivers of health.

Infantile hemangioma (IH) is the most common vascular tumor of infancy, appearing within the first few weeks of life and typically reaching peak size by age 3 to 5 months.¹ It classically manifests as a raised or flat bright-red lesion in the upper dermis of the skin and/or subcutaneous tissue and can vary in number, size, shape, and location.² It is characterized by a rapid proliferative phase, especially between 5 and 8 weeks of age, followed by gradual spontaneous regression over 1 to 10 years.^1-3

Infantile hemangiomas are categorized based on depth (superficial, deep, or mixed) and distribution pattern (focal, multifocal, segmental, or indeterminate).⁴ In most cases, complete regression occurs by age 4 years, but there can be residual telangiectasia, fibrofatty tissue, and/or scarring.^1,4 About 10% to 15% of IHs result in complications that require medical intervention (eg, visual, airway, or auditory compromise; ulceration; disfigurement); ideally, these patients should be referred to a specialist by 5 weeks of age.⁴ Prompt assessment of IH severity is essential to prevent or mitigate potential complications and ultimately improve outcomes.³ Social drivers of health contribute to delayed diagnosis and management of hemangiomas, leading to increased complications in some patient populations.^5-7

Epidemiology

Infantile hemangiomas are estimated to manifest in 4.5% of infants in the United States.¹ The most common type is superficial IH, typically found on the head or neck.⁵ Risk factors in infants include female sex, White race, premature birth, and low birth weight (<1000 g).^1,3 Maternal risk factors include advanced gestational age (ie, >35 years), multiple gestations, family history of IH, tobacco use, use of progesterone therapy during pregnancy, and pre-eclampsia.^1,3

Focal IH typically manifests as a single localized lesion that can occur anywhere on the body.^2,3 In contrast, segmental IH manifests in a linear pattern and/or is distributed on a large anatomic area, most commonly on the face and less frequently the extremities and trunk.^2,3 Segmental IHs are more common in Hispanic patients and carry a higher risk for morbidity, often complicated by ulceration that can lead to functional and cosmetic challenges.⁸

Key Clinical Features

Superficial IH in patients with darker skin tones may appear as a dark-red or violaceous papule or plaque compared to bright red in lighter skin tones.⁵ Deep IH may appear as a soft, round, flesh-colored or blue-hued subcutaneous mass, the color of which may be harder to appreciate in those with darker skin tones.⁵

Worth Noting

Complications from IH may require imaging, close follow-up, systemic therapy, multidisciplinary care, and advanced health literacy and patient/family navigation. Multifocal IHs (≥5 lesions) are more likely to be associated with infantile hepatic hemangiomas.^2,3 Large (>5 cm) segmental IHs on the face and lumbosacral area require further evaluation for PHACES (posterior fossa malformation, hemangiomas, arterial anomalies, cardiac defects, eye anomalies, and sternal raphe/cleft defects) and LUMBAR (lower-body segmental IH; urogenital anomalies and ulceration; ­myelopathy; bony deformities; anorectal malformations and arterial anomalies; and renal anomalies) syndromes, which are more common in patients of Hispanic ethnicity.^2,3

The Infantile Hemangioma Referral Score is a recently validated tool that can assist primary care physicians in timely referral of IHs requiring early specialist intervention.^4,9 It takes into account the location, number, and size of the lesions and the age of the patient; these factors help to determine which IHs may be managed conservatively vs those that may require treatment to prevent ­life-threatening complications.^1-3 

Systemic corticosteroids historically have been the primary treatment for IH; however, in the past decade, propranolol oral solution (4.28 mg/mL) has become the first-line therapy for most infants requiring systemic management.¹⁰ It is the only medication approved by the US Food and Drug Administration for proliferating IH, with treatment initiation as young as 5 weeks corrected age.¹¹ As a nonselective beta-blocker, propranolol is believed to reduce IHs through vasoconstriction or by inhibition of angiogenesis.^1,4,10 

For small superficial IHs, treatment options include timolol maleate ophthalmic solution 0.5% (one drop applied twice daily to the IH) or pulsed dye laser therapy.^4,10 Surgical excision typically is avoided during infancy due to concerns about anesthetic risks and potential blood loss.^4,10 Surgery is reserved for cases involving residual fibrofatty tissue, postinvolution scarring, obstruction of vital structures, or lesions in aesthetically sensitive areas as well as when propranolol is contraindicated.^4,10

Health Disparity Highlight

Infants with skin of color and those of lower socioeconomic status (SES) face a heightened risk for delayed diagnosis and more advanced disease at the initial evaluation for IH.^5,7 Access barriers such as geographic limitations to specialty services, lack of insurance, underinsurance, and language differences impact timely diagnosis and treatment.^5,6 Implementation of telemedicine services in areas with limited access to specialists can facilitate early evaluation and risk stratification for IH.¹²

A retrospective cohort study of 804 children seen at a large academic hospital found that those of lower SES were more likely to seek care after 3 months of age than their higher-SES counterparts.⁶ Those who presented after 6 months of age also had higher IH severity scores compared to their counterparts with higher SES.⁶ Delayed access to care may cause children to miss the critical treatment window during the rapid proliferative growth phase.^6,12 However, children insured through Medicaid or the Children’s Health Insurance Program who participated in institutional care management programs (which assist in scheduling specialty care appointments within the institution) sought treatment earlier regardless of their SES, suggesting that such programs may help reduce disparities in timely access for children of lower SES.⁶ 

An epidemiologic study analyzing the demographics of children hospitalized across the United States demonstrated that Black infants with IH were more likely to belong to the lowest income quartile compared with White infants or those of other races. They also were 2 times older on average at initial presentation (1.8 vs 1.0 years), experienced longer hospitalizations (16.4 vs 13.8 days), and underwent more IH-related procedures than White infants and infants of other races (2.4, 1.9, and 2.1, respectively).⁷

These and other factors may contribute to missed windows of opportunity for timely treatment of high-risk IHs in patients with darker skin tones and/or those facing challenges stemming from social drivers of health.

Synthetic hair extensions are made from various plastic polymers (eg, modacrylic, vinyl chloride, and acrylonitrile) shaped into thin strands that mimic human hair and are used to add fullness, length, and manageability in individuals with textured hair.^1-3 The plastic polymers used to make synthetic hair, most notably acrylonitrile and vinyl chloride, are known to be toxic to humans.^1-4 The US Environmental Protection Agency classifies acrylonitrile as a probable carcinogen, and vinyl chloride is associated with the development of lymphoma; leukemia; and rare malignancies of the brain, liver, and lungs.^1,4 According to the Occupational Safety and Health Administration, the maximum exposure limits of vinyl chloride and acrylonitrile vapor or gas over an 8-hour period are 1 ppm (0.001 g/L) and 2 ppm (0.002 g/L), respectively.⁵ Exposure levels from wearing synthetic hair extensions easily exceed these maximums; for example, a full head of braids requires application of multiple packets of synthetic hair, resulting in continuous exposure to carcinogenic materials that can last for weeks to months at a time.¹ Furthermore, individuals as young as 3 years old can begin to style their hair with synthetic extensions, which not only leads to potentially harmful carcinogenic exposure in young children but also yields notably high levels of lifetime exposure in individuals who regularly style their hair with these products.

There currently are no regulations barring the use of potentially harmful materials from the manufacturing process for synthetic hair extensions.¹ As a result, rinsing with apple cider vinegar (ACV) is a popular remedy that many users claim can effectively remove harmful chemicals from synthetic hair.^6,7 As this is the only known remedy that aims to address this issue, we conducted a literature review of studies investigating the effects of the ACV rinse on the carcinogenicity of synthetic hair extensions.

Methods

We conducted a search of Google Scholar, JSTOR, Science Direct, the Public Library of Science, and PubMed articles indexed for MEDLINE using the terms ACV, apple cider vinegar rinse, ACV rinse, synthetic hair carcinogens, synthetic fiber carcinogens, synthetic hair extension carcinogens, modacrylic fibers, Kanekalon (a flame-retardant modacrylic fiber), acrylonitrile, and vinyl chloride fibers to identify primary research articles investigating the effects of the ACV rinse on the carcinogenicity of synthetic hair extensions for inclusion in our review. To broaden our search, we did not establish a time frame for publication of the articles included in the study. Articles investigating the ACV rinse that were unrelated to carcinogenicity and synthetic hair extensions were excluded from this study.

Results

Our initial literature search identified 270 articles, which decreased to 180 after removal of duplicates. These 180 articles were screened for relevance based on title and abstract, which yielded 6 articles. None of the 6 articles identified through our literature search discussed synthetic hair and carcinogenicity in the context of the ACV rinse and were subsequently excluded from our review (eFigure 1).

Comment

Potentially harmful chemicals and ingredients in hair care products marketed for textured hair are now established topics in public discourse among those familiar with textured hair care and maintenance^1,8; however, the discourse remains limited. Our search for scientific articles investigating the effects of the ACV rinse on the carcinogenicity of synthetic hair extensions revealed a notable deficit in the literature regarding scientific studies assessing this practice. While the likelihood that the ACV rinse effectively alters the carcinogenicity of plastic polymers found in synthetic hair extensions and improves their safety seems improbable, the deficit of empirical data evaluating this practice is concerning given both the prevalence of this remedy and the sizable demographic of patients who practice styling with synthetic hair.¹ Of the potential adverse outcomes (eg, contact dermatitis, traction alopecia) that are possible from styling with synthetic hair that have been reported in the literature, carcinogenic exposure from synthetic hair extensions is relatively absent, with the exception of a few publications,^2,3,9 despite its potential to cause serious long-term consequences for hair stylists and those who regularly use these products.

Interestingly, individuals who style their hair with synthetic hair extensions frequently tout the efficacy of the ACV rinse for removal of mostly unidentified irritants, although the effects are unverified.^6,7 While the ACV rinse may be an effective means of removing toxic chemicals from synthetic hair extensions, without verifiable data this method remains an unproven remedy whose perceived benefits could result from factors unrelated to the rinse itself. Theoretically, simply rinsing synthetic hair extensions with plain water prior to use may demonstrate similar efficacy to that of the ACV rinse. 

An additional factor worth mentioning is the lack of government regulations concerning the manufacturing practices of synthetic hair extensions. Flame-retardant materials such as trichloroethylene, polyvinyl chloride, and hexabromocyclododecane frequently are used in synthetic hair extensions despite their known adverse effects, which include reproductive organ toxicity and links to various cancers, leading to them being banned in 5 states.^1,10-12 With no federal ban on these materials, individuals using synthetic hair remain at risk.  

It is unclear what chemicals, irritants, or toxic substances the ACV rinse method could potentially remove from synthetic hair. In general, manufacturers of synthetic hair extensions are not forthcoming with information regarding materials used in the processing of their products despite public inquiries into their manufacturing practices.⁶ Although Whitehurst’s³ curriculum details the process of making synthetic polymer fibers, the overall processes by which these plastics are made to resemble human hair have not been reviewed in academic publications. Should this information be made available to the public, consumers could potentially avoid specific irritants when purchasing synthetic hair extensions.   

The most common management strategy observed in the literature for adverse outcomes attributable to synthetic hair is discontinuation of use²; however, the prevalence and cultural significance of styling with synthetic hair extensions, along with the convenience these styles offer, make this option suboptimal. The scarcity of publications concerning the management of adverse outcomes related to the use of synthetic hair extensions may explain the absence of alternative management recommendations in the literature. Notably, new synthetic hair extensions from manufacturers that exclude plastic polymers and other harmful additives are now available to the public¹³; however, these hair extensions are cost prohibitive and are less accessible compared to synthetic extensions made from modacrylic fibers (eFigures 2 and 3).^1,13-16 

Final Thoughts

The ACV rinse method is an anecdotal remedy for reducing the harm and risk of adverse outcomes and complications associated with synthetic hair extensions. Discontinued use of these components is the only remedy provided within academic literature to address the harmful ingredients found in synthetic hair extensions.² Presently, there are no known data that support or disprove the efficacy of the ACV rinse. Furthermore, no academic guidance specifically supports remedies for mitigating carcinogen exposure risks in patients who style their hair with synthetic extensions. Given the early onset of exposure to synthetic hair in pediatric populations and the substantial demographic utilizing hairstyles that incorporate synthetic hair extensions, concerns regarding potential exposure risks cannot be overstated. Dermatologists should inform their patients of the potential risks associated with styling with synthetic hair extensions, helping them make informed decisions about future styling habits and hair care choices. Lastly, future studies should investigate how, if at all, ACV rinses alter what are arguably the most harmful components of synthetic hair extensions.

Synthetic hair extensions are made from various plastic polymers (eg, modacrylic, vinyl chloride, and acrylonitrile) shaped into thin strands that mimic human hair and are used to add fullness, length, and manageability in individuals with textured hair.^1-3 The plastic polymers used to make synthetic hair, most notably acrylonitrile and vinyl chloride, are known to be toxic to humans.^1-4 The US Environmental Protection Agency classifies acrylonitrile as a probable carcinogen, and vinyl chloride is associated with the development of lymphoma; leukemia; and rare malignancies of the brain, liver, and lungs.^1,4 According to the Occupational Safety and Health Administration, the maximum exposure limits of vinyl chloride and acrylonitrile vapor or gas over an 8-hour period are 1 ppm (0.001 g/L) and 2 ppm (0.002 g/L), respectively.⁵ Exposure levels from wearing synthetic hair extensions easily exceed these maximums; for example, a full head of braids requires application of multiple packets of synthetic hair, resulting in continuous exposure to carcinogenic materials that can last for weeks to months at a time.¹ Furthermore, individuals as young as 3 years old can begin to style their hair with synthetic extensions, which not only leads to potentially harmful carcinogenic exposure in young children but also yields notably high levels of lifetime exposure in individuals who regularly style their hair with these products.

There currently are no regulations barring the use of potentially harmful materials from the manufacturing process for synthetic hair extensions.¹ As a result, rinsing with apple cider vinegar (ACV) is a popular remedy that many users claim can effectively remove harmful chemicals from synthetic hair.^6,7 As this is the only known remedy that aims to address this issue, we conducted a literature review of studies investigating the effects of the ACV rinse on the carcinogenicity of synthetic hair extensions.

Methods

We conducted a search of Google Scholar, JSTOR, Science Direct, the Public Library of Science, and PubMed articles indexed for MEDLINE using the terms ACV, apple cider vinegar rinse, ACV rinse, synthetic hair carcinogens, synthetic fiber carcinogens, synthetic hair extension carcinogens, modacrylic fibers, Kanekalon (a flame-retardant modacrylic fiber), acrylonitrile, and vinyl chloride fibers to identify primary research articles investigating the effects of the ACV rinse on the carcinogenicity of synthetic hair extensions for inclusion in our review. To broaden our search, we did not establish a time frame for publication of the articles included in the study. Articles investigating the ACV rinse that were unrelated to carcinogenicity and synthetic hair extensions were excluded from this study.

Results

Our initial literature search identified 270 articles, which decreased to 180 after removal of duplicates. These 180 articles were screened for relevance based on title and abstract, which yielded 6 articles. None of the 6 articles identified through our literature search discussed synthetic hair and carcinogenicity in the context of the ACV rinse and were subsequently excluded from our review (eFigure 1).

Comment

Potentially harmful chemicals and ingredients in hair care products marketed for textured hair are now established topics in public discourse among those familiar with textured hair care and maintenance^1,8; however, the discourse remains limited. Our search for scientific articles investigating the effects of the ACV rinse on the carcinogenicity of synthetic hair extensions revealed a notable deficit in the literature regarding scientific studies assessing this practice. While the likelihood that the ACV rinse effectively alters the carcinogenicity of plastic polymers found in synthetic hair extensions and improves their safety seems improbable, the deficit of empirical data evaluating this practice is concerning given both the prevalence of this remedy and the sizable demographic of patients who practice styling with synthetic hair.¹ Of the potential adverse outcomes (eg, contact dermatitis, traction alopecia) that are possible from styling with synthetic hair that have been reported in the literature, carcinogenic exposure from synthetic hair extensions is relatively absent, with the exception of a few publications,^2,3,9 despite its potential to cause serious long-term consequences for hair stylists and those who regularly use these products.

Interestingly, individuals who style their hair with synthetic hair extensions frequently tout the efficacy of the ACV rinse for removal of mostly unidentified irritants, although the effects are unverified.^6,7 While the ACV rinse may be an effective means of removing toxic chemicals from synthetic hair extensions, without verifiable data this method remains an unproven remedy whose perceived benefits could result from factors unrelated to the rinse itself. Theoretically, simply rinsing synthetic hair extensions with plain water prior to use may demonstrate similar efficacy to that of the ACV rinse. 

An additional factor worth mentioning is the lack of government regulations concerning the manufacturing practices of synthetic hair extensions. Flame-retardant materials such as trichloroethylene, polyvinyl chloride, and hexabromocyclododecane frequently are used in synthetic hair extensions despite their known adverse effects, which include reproductive organ toxicity and links to various cancers, leading to them being banned in 5 states.^1,10-12 With no federal ban on these materials, individuals using synthetic hair remain at risk.  

It is unclear what chemicals, irritants, or toxic substances the ACV rinse method could potentially remove from synthetic hair. In general, manufacturers of synthetic hair extensions are not forthcoming with information regarding materials used in the processing of their products despite public inquiries into their manufacturing practices.⁶ Although Whitehurst’s³ curriculum details the process of making synthetic polymer fibers, the overall processes by which these plastics are made to resemble human hair have not been reviewed in academic publications. Should this information be made available to the public, consumers could potentially avoid specific irritants when purchasing synthetic hair extensions.   

The most common management strategy observed in the literature for adverse outcomes attributable to synthetic hair is discontinuation of use²; however, the prevalence and cultural significance of styling with synthetic hair extensions, along with the convenience these styles offer, make this option suboptimal. The scarcity of publications concerning the management of adverse outcomes related to the use of synthetic hair extensions may explain the absence of alternative management recommendations in the literature. Notably, new synthetic hair extensions from manufacturers that exclude plastic polymers and other harmful additives are now available to the public¹³; however, these hair extensions are cost prohibitive and are less accessible compared to synthetic extensions made from modacrylic fibers (eFigures 2 and 3).^1,13-16 

Final Thoughts

The ACV rinse method is an anecdotal remedy for reducing the harm and risk of adverse outcomes and complications associated with synthetic hair extensions. Discontinued use of these components is the only remedy provided within academic literature to address the harmful ingredients found in synthetic hair extensions.² Presently, there are no known data that support or disprove the efficacy of the ACV rinse. Furthermore, no academic guidance specifically supports remedies for mitigating carcinogen exposure risks in patients who style their hair with synthetic extensions. Given the early onset of exposure to synthetic hair in pediatric populations and the substantial demographic utilizing hairstyles that incorporate synthetic hair extensions, concerns regarding potential exposure risks cannot be overstated. Dermatologists should inform their patients of the potential risks associated with styling with synthetic hair extensions, helping them make informed decisions about future styling habits and hair care choices. Lastly, future studies should investigate how, if at all, ACV rinses alter what are arguably the most harmful components of synthetic hair extensions.

Synthetic hair extensions are made from various plastic polymers (eg, modacrylic, vinyl chloride, and acrylonitrile) shaped into thin strands that mimic human hair and are used to add fullness, length, and manageability in individuals with textured hair.^1-3 The plastic polymers used to make synthetic hair, most notably acrylonitrile and vinyl chloride, are known to be toxic to humans.^1-4 The US Environmental Protection Agency classifies acrylonitrile as a probable carcinogen, and vinyl chloride is associated with the development of lymphoma; leukemia; and rare malignancies of the brain, liver, and lungs.^1,4 According to the Occupational Safety and Health Administration, the maximum exposure limits of vinyl chloride and acrylonitrile vapor or gas over an 8-hour period are 1 ppm (0.001 g/L) and 2 ppm (0.002 g/L), respectively.⁵ Exposure levels from wearing synthetic hair extensions easily exceed these maximums; for example, a full head of braids requires application of multiple packets of synthetic hair, resulting in continuous exposure to carcinogenic materials that can last for weeks to months at a time.¹ Furthermore, individuals as young as 3 years old can begin to style their hair with synthetic extensions, which not only leads to potentially harmful carcinogenic exposure in young children but also yields notably high levels of lifetime exposure in individuals who regularly style their hair with these products.

There currently are no regulations barring the use of potentially harmful materials from the manufacturing process for synthetic hair extensions.¹ As a result, rinsing with apple cider vinegar (ACV) is a popular remedy that many users claim can effectively remove harmful chemicals from synthetic hair.^6,7 As this is the only known remedy that aims to address this issue, we conducted a literature review of studies investigating the effects of the ACV rinse on the carcinogenicity of synthetic hair extensions.

Methods

We conducted a search of Google Scholar, JSTOR, Science Direct, the Public Library of Science, and PubMed articles indexed for MEDLINE using the terms ACV, apple cider vinegar rinse, ACV rinse, synthetic hair carcinogens, synthetic fiber carcinogens, synthetic hair extension carcinogens, modacrylic fibers, Kanekalon (a flame-retardant modacrylic fiber), acrylonitrile, and vinyl chloride fibers to identify primary research articles investigating the effects of the ACV rinse on the carcinogenicity of synthetic hair extensions for inclusion in our review. To broaden our search, we did not establish a time frame for publication of the articles included in the study. Articles investigating the ACV rinse that were unrelated to carcinogenicity and synthetic hair extensions were excluded from this study.

Results

Our initial literature search identified 270 articles, which decreased to 180 after removal of duplicates. These 180 articles were screened for relevance based on title and abstract, which yielded 6 articles. None of the 6 articles identified through our literature search discussed synthetic hair and carcinogenicity in the context of the ACV rinse and were subsequently excluded from our review (eFigure 1).

Comment

Potentially harmful chemicals and ingredients in hair care products marketed for textured hair are now established topics in public discourse among those familiar with textured hair care and maintenance^1,8; however, the discourse remains limited. Our search for scientific articles investigating the effects of the ACV rinse on the carcinogenicity of synthetic hair extensions revealed a notable deficit in the literature regarding scientific studies assessing this practice. While the likelihood that the ACV rinse effectively alters the carcinogenicity of plastic polymers found in synthetic hair extensions and improves their safety seems improbable, the deficit of empirical data evaluating this practice is concerning given both the prevalence of this remedy and the sizable demographic of patients who practice styling with synthetic hair.¹ Of the potential adverse outcomes (eg, contact dermatitis, traction alopecia) that are possible from styling with synthetic hair that have been reported in the literature, carcinogenic exposure from synthetic hair extensions is relatively absent, with the exception of a few publications,^2,3,9 despite its potential to cause serious long-term consequences for hair stylists and those who regularly use these products.

Interestingly, individuals who style their hair with synthetic hair extensions frequently tout the efficacy of the ACV rinse for removal of mostly unidentified irritants, although the effects are unverified.^6,7 While the ACV rinse may be an effective means of removing toxic chemicals from synthetic hair extensions, without verifiable data this method remains an unproven remedy whose perceived benefits could result from factors unrelated to the rinse itself. Theoretically, simply rinsing synthetic hair extensions with plain water prior to use may demonstrate similar efficacy to that of the ACV rinse. 

An additional factor worth mentioning is the lack of government regulations concerning the manufacturing practices of synthetic hair extensions. Flame-retardant materials such as trichloroethylene, polyvinyl chloride, and hexabromocyclododecane frequently are used in synthetic hair extensions despite their known adverse effects, which include reproductive organ toxicity and links to various cancers, leading to them being banned in 5 states.^1,10-12 With no federal ban on these materials, individuals using synthetic hair remain at risk.  

It is unclear what chemicals, irritants, or toxic substances the ACV rinse method could potentially remove from synthetic hair. In general, manufacturers of synthetic hair extensions are not forthcoming with information regarding materials used in the processing of their products despite public inquiries into their manufacturing practices.⁶ Although Whitehurst’s³ curriculum details the process of making synthetic polymer fibers, the overall processes by which these plastics are made to resemble human hair have not been reviewed in academic publications. Should this information be made available to the public, consumers could potentially avoid specific irritants when purchasing synthetic hair extensions.   

The most common management strategy observed in the literature for adverse outcomes attributable to synthetic hair is discontinuation of use²; however, the prevalence and cultural significance of styling with synthetic hair extensions, along with the convenience these styles offer, make this option suboptimal. The scarcity of publications concerning the management of adverse outcomes related to the use of synthetic hair extensions may explain the absence of alternative management recommendations in the literature. Notably, new synthetic hair extensions from manufacturers that exclude plastic polymers and other harmful additives are now available to the public¹³; however, these hair extensions are cost prohibitive and are less accessible compared to synthetic extensions made from modacrylic fibers (eFigures 2 and 3).^1,13-16 

Final Thoughts

The ACV rinse method is an anecdotal remedy for reducing the harm and risk of adverse outcomes and complications associated with synthetic hair extensions. Discontinued use of these components is the only remedy provided within academic literature to address the harmful ingredients found in synthetic hair extensions.² Presently, there are no known data that support or disprove the efficacy of the ACV rinse. Furthermore, no academic guidance specifically supports remedies for mitigating carcinogen exposure risks in patients who style their hair with synthetic extensions. Given the early onset of exposure to synthetic hair in pediatric populations and the substantial demographic utilizing hairstyles that incorporate synthetic hair extensions, concerns regarding potential exposure risks cannot be overstated. Dermatologists should inform their patients of the potential risks associated with styling with synthetic hair extensions, helping them make informed decisions about future styling habits and hair care choices. Lastly, future studies should investigate how, if at all, ACV rinses alter what are arguably the most harmful components of synthetic hair extensions.

The impact of pseudofolliculitis barbae (PFB) on military service members and other uniformed professionals has been a topic of recent interest due to the announcement of the US Army’s new shaving rule in July 2025.¹ The policy prohibits permanent shaving waivers, requires medical re-evaluation of shaving profiles within 90 days, and allows for administrative separation if a service member accumulates shaving exceptions totaling more than 12 months over a 24-month period.² A common skin condition triggered or worsened by shaving, PFB causes painful bumps, pustules, and hyperpigmentation most often in the beard and cheek areas and negatively impacts quality of life. It disproportionately affects 45% to 83% of men in the United States, particularly those of African, Hispanic, or Middle Eastern descent.^3,4 Genetic factors, particularly tightly coiled or coarse curly hair, can predispose individuals to PFB. The most successful treatment for PFB is to stop shaving, but this conflicts with military shaving standards and interferes with the use of protective equipment (eg, masks). Herein, we highlight the adverse impact of PFB on military career progression and provide context for clinicians who treat patients with PFB, especially as policies recently have shifted to allow nonmilitary clinicians to evaluate PFB in service members.⁵

Shaving Waivers and Advancement

Pseudofolliculitis barbae disproportionately prolongs the time to advancement of many service members, and those with PFB also are overburdened by policy changes related to shaving.⁶ In the US military, nearly 18% of the active-duty force is Black,⁷ a population that is more susceptible to PFB. Military personnel may request PFB-related accommodations, including medical shaving waivers that vary by branch. Through a formal documentation process, waivers allow service members to maintain facial hair up to one-quarter inch in length.⁵ Previously, waivers could be temporary (eg, up to 90 days) or permanent as subjectively determined based on clinician-documented disease severity. Almost 65% of US Air Force medical shaving waivers are held by Black men, and PFB is one of the most common reasons.⁶ Notably, the US Navy discontinued permanent shaving waivers in October 2019.⁸ A US Marine Corps policy issued in March 2025 now allows administrative separation of service members with PFB if symptoms do not improve after a 1-year medical shaving waiver due to “incompatibility with service.”⁹ This change reversed a 2022 policy that protected Marines from separation based on PFB.¹⁰ A Marine Corps spokesperson stated that this change aims to clarify how medical conditions can impact uniform compliance and standardize medical condition management while prioritizing compliance and duty readiness.¹

Even in the absence of policy changes, obtaining a medical shaving waiver for PFB can be challenging. Service members may have little to no access to military dermatologists who specialize in management of PFB and experience long wait times for civilian network deferment. Service members seen in civilian clinics may have restricted treatment options due to limited insurance coverage for laser hair reduction, even in the most difficult-to-manage areas (eg, neck, jawline). Expanding access to military dermatologists, civilian dermatologists who are experienced with PFB and understand the impact and necessity of military waivers, and teledermatology services could help improve and streamline care. Other challenges include the subjective nature of documenting PFB disease severity, the need for validated assessment tools, a lack of standardized policies across military branches, and stigma. A standardized approach to documentation may reduce variability in how shaving waivers are evaluated across service branches, but at a minimum, clinicians should document the diagnosis, clinical findings, severity of PFB, and the treatment used. Having a waiver would help these service members focus on mastering critical skillsets and performing duties without the time pressures, angst, and expense dedicated to caring for and managing PFB.

Clinical and Policy Barriers

Unfortunately, service members with PFB or shaving waivers often face stigma that can hinder career advancement.⁶ In a recent analysis of 9339 US Air Force personnel, those with shaving waivers experienced longer times to promotion compared to those without waivers: in the waiver group, 94.47% were enlisted and 5.53% were officers; in the nonwaiver group, 72.11% were enlisted and 27.89% were officers (P=.0003).⁶ While delays in promotion were consistent across racial groups, most of the waiver holders identified as Black (64.8%), despite this demographic group representing only a small portion of the overall cohort (12.9%).⁶ Promotion delays may be linked to perceptions of unprofessionalism and exclusion from high-profile assignments, which notably require “the highest standards of military appearance and professional conduct.”¹¹ The burden of career-limiting shaving policies falls disproportionately on military personnel with PFB who self-identify as Black. Perceptions about unprofessional appearance or job readiness often unintentionally introduce bias, unjustly restricting career advancement.⁶

Safety Equipment and Shaving Standards

Conditions that potentially affect the use of masks and chemical defense equipment extend beyond the military. Firefighters and law enforcement officers generally are required to maintain a clean-shaven face for proper fit of respirator masks; the standard is that no respirator fit test shall be conducted if hair—including stubble, beards, mustaches, or sideburns—grows between the skin and the facepiece sealing surface, and any apparel interfering with a proper seal must be altered or removed.¹² This creates challenges for uniformed professionals with PFB who must manage their condition while adhering to safety requirements. Some endure long-term pain and scarring in order to comply, while others seek waivers to treat and prevent symptoms while also facing the stigma of doing so.¹³ One of the most effective treatments for PFB is to discontinue shaving,¹⁴ which may not be feasible for those in uniformed professions with strict grooming standards. Research on mask seal effectiveness in individuals with neatly trimmed beards or PFB remains limited.⁵ Studies evaluating mask fit across facial hair types and lengths are needed, along with the development of protective equipment that accommodates career-limiting conditions such as PFB, cystic acne, and acne keloidalis nuchae. This also may encourage development of equipment that does not induce such conditions (eg, mechanical acne from friction). These efforts would promote safety, scientific innovation for dermatologic follicular-based disorders, and overall quality of life for service members as well as increase their ability to serve without stigma. These developments also would positively impact other fields that require intermittent or full-time use of masks, including health care and some food service industries.

Final Thoughts

The disproportionate impact of PFB in the military highlights the need for improved access to treatment, culturally informed care, and policies that avoid penalizing service members with tightly coiled hair and a desire to serve. We discussed PFB management strategies, clinical features, and implications across various skin tones in a previous publication.¹⁴ It is important to consider insights from individuals with PFB who are serving in the military as well as the medical personnel who care for them. Ensuring or creating effective treatment options drives innovation, and evidence-based accommodation plans can help individuals in uniformed professions avoid choosing between PFB management and their career. Promoting awareness about the impact of PFB beyond the razor is key to reducing disparities and supporting excellence among those who serve and desire to continue to do so.

The impact of pseudofolliculitis barbae (PFB) on military service members and other uniformed professionals has been a topic of recent interest due to the announcement of the US Army’s new shaving rule in July 2025.¹ The policy prohibits permanent shaving waivers, requires medical re-evaluation of shaving profiles within 90 days, and allows for administrative separation if a service member accumulates shaving exceptions totaling more than 12 months over a 24-month period.² A common skin condition triggered or worsened by shaving, PFB causes painful bumps, pustules, and hyperpigmentation most often in the beard and cheek areas and negatively impacts quality of life. It disproportionately affects 45% to 83% of men in the United States, particularly those of African, Hispanic, or Middle Eastern descent.^3,4 Genetic factors, particularly tightly coiled or coarse curly hair, can predispose individuals to PFB. The most successful treatment for PFB is to stop shaving, but this conflicts with military shaving standards and interferes with the use of protective equipment (eg, masks). Herein, we highlight the adverse impact of PFB on military career progression and provide context for clinicians who treat patients with PFB, especially as policies recently have shifted to allow nonmilitary clinicians to evaluate PFB in service members.⁵

Shaving Waivers and Advancement

Pseudofolliculitis barbae disproportionately prolongs the time to advancement of many service members, and those with PFB also are overburdened by policy changes related to shaving.⁶ In the US military, nearly 18% of the active-duty force is Black,⁷ a population that is more susceptible to PFB. Military personnel may request PFB-related accommodations, including medical shaving waivers that vary by branch. Through a formal documentation process, waivers allow service members to maintain facial hair up to one-quarter inch in length.⁵ Previously, waivers could be temporary (eg, up to 90 days) or permanent as subjectively determined based on clinician-documented disease severity. Almost 65% of US Air Force medical shaving waivers are held by Black men, and PFB is one of the most common reasons.⁶ Notably, the US Navy discontinued permanent shaving waivers in October 2019.⁸ A US Marine Corps policy issued in March 2025 now allows administrative separation of service members with PFB if symptoms do not improve after a 1-year medical shaving waiver due to “incompatibility with service.”⁹ This change reversed a 2022 policy that protected Marines from separation based on PFB.¹⁰ A Marine Corps spokesperson stated that this change aims to clarify how medical conditions can impact uniform compliance and standardize medical condition management while prioritizing compliance and duty readiness.¹

Even in the absence of policy changes, obtaining a medical shaving waiver for PFB can be challenging. Service members may have little to no access to military dermatologists who specialize in management of PFB and experience long wait times for civilian network deferment. Service members seen in civilian clinics may have restricted treatment options due to limited insurance coverage for laser hair reduction, even in the most difficult-to-manage areas (eg, neck, jawline). Expanding access to military dermatologists, civilian dermatologists who are experienced with PFB and understand the impact and necessity of military waivers, and teledermatology services could help improve and streamline care. Other challenges include the subjective nature of documenting PFB disease severity, the need for validated assessment tools, a lack of standardized policies across military branches, and stigma. A standardized approach to documentation may reduce variability in how shaving waivers are evaluated across service branches, but at a minimum, clinicians should document the diagnosis, clinical findings, severity of PFB, and the treatment used. Having a waiver would help these service members focus on mastering critical skillsets and performing duties without the time pressures, angst, and expense dedicated to caring for and managing PFB.

Clinical and Policy Barriers

Unfortunately, service members with PFB or shaving waivers often face stigma that can hinder career advancement.⁶ In a recent analysis of 9339 US Air Force personnel, those with shaving waivers experienced longer times to promotion compared to those without waivers: in the waiver group, 94.47% were enlisted and 5.53% were officers; in the nonwaiver group, 72.11% were enlisted and 27.89% were officers (P=.0003).⁶ While delays in promotion were consistent across racial groups, most of the waiver holders identified as Black (64.8%), despite this demographic group representing only a small portion of the overall cohort (12.9%).⁶ Promotion delays may be linked to perceptions of unprofessionalism and exclusion from high-profile assignments, which notably require “the highest standards of military appearance and professional conduct.”¹¹ The burden of career-limiting shaving policies falls disproportionately on military personnel with PFB who self-identify as Black. Perceptions about unprofessional appearance or job readiness often unintentionally introduce bias, unjustly restricting career advancement.⁶

Safety Equipment and Shaving Standards

Conditions that potentially affect the use of masks and chemical defense equipment extend beyond the military. Firefighters and law enforcement officers generally are required to maintain a clean-shaven face for proper fit of respirator masks; the standard is that no respirator fit test shall be conducted if hair—including stubble, beards, mustaches, or sideburns—grows between the skin and the facepiece sealing surface, and any apparel interfering with a proper seal must be altered or removed.¹² This creates challenges for uniformed professionals with PFB who must manage their condition while adhering to safety requirements. Some endure long-term pain and scarring in order to comply, while others seek waivers to treat and prevent symptoms while also facing the stigma of doing so.¹³ One of the most effective treatments for PFB is to discontinue shaving,¹⁴ which may not be feasible for those in uniformed professions with strict grooming standards. Research on mask seal effectiveness in individuals with neatly trimmed beards or PFB remains limited.⁵ Studies evaluating mask fit across facial hair types and lengths are needed, along with the development of protective equipment that accommodates career-limiting conditions such as PFB, cystic acne, and acne keloidalis nuchae. This also may encourage development of equipment that does not induce such conditions (eg, mechanical acne from friction). These efforts would promote safety, scientific innovation for dermatologic follicular-based disorders, and overall quality of life for service members as well as increase their ability to serve without stigma. These developments also would positively impact other fields that require intermittent or full-time use of masks, including health care and some food service industries.

Final Thoughts

The disproportionate impact of PFB in the military highlights the need for improved access to treatment, culturally informed care, and policies that avoid penalizing service members with tightly coiled hair and a desire to serve. We discussed PFB management strategies, clinical features, and implications across various skin tones in a previous publication.¹⁴ It is important to consider insights from individuals with PFB who are serving in the military as well as the medical personnel who care for them. Ensuring or creating effective treatment options drives innovation, and evidence-based accommodation plans can help individuals in uniformed professions avoid choosing between PFB management and their career. Promoting awareness about the impact of PFB beyond the razor is key to reducing disparities and supporting excellence among those who serve and desire to continue to do so.

The impact of pseudofolliculitis barbae (PFB) on military service members and other uniformed professionals has been a topic of recent interest due to the announcement of the US Army’s new shaving rule in July 2025.¹ The policy prohibits permanent shaving waivers, requires medical re-evaluation of shaving profiles within 90 days, and allows for administrative separation if a service member accumulates shaving exceptions totaling more than 12 months over a 24-month period.² A common skin condition triggered or worsened by shaving, PFB causes painful bumps, pustules, and hyperpigmentation most often in the beard and cheek areas and negatively impacts quality of life. It disproportionately affects 45% to 83% of men in the United States, particularly those of African, Hispanic, or Middle Eastern descent.^3,4 Genetic factors, particularly tightly coiled or coarse curly hair, can predispose individuals to PFB. The most successful treatment for PFB is to stop shaving, but this conflicts with military shaving standards and interferes with the use of protective equipment (eg, masks). Herein, we highlight the adverse impact of PFB on military career progression and provide context for clinicians who treat patients with PFB, especially as policies recently have shifted to allow nonmilitary clinicians to evaluate PFB in service members.⁵

Shaving Waivers and Advancement

Pseudofolliculitis barbae disproportionately prolongs the time to advancement of many service members, and those with PFB also are overburdened by policy changes related to shaving.⁶ In the US military, nearly 18% of the active-duty force is Black,⁷ a population that is more susceptible to PFB. Military personnel may request PFB-related accommodations, including medical shaving waivers that vary by branch. Through a formal documentation process, waivers allow service members to maintain facial hair up to one-quarter inch in length.⁵ Previously, waivers could be temporary (eg, up to 90 days) or permanent as subjectively determined based on clinician-documented disease severity. Almost 65% of US Air Force medical shaving waivers are held by Black men, and PFB is one of the most common reasons.⁶ Notably, the US Navy discontinued permanent shaving waivers in October 2019.⁸ A US Marine Corps policy issued in March 2025 now allows administrative separation of service members with PFB if symptoms do not improve after a 1-year medical shaving waiver due to “incompatibility with service.”⁹ This change reversed a 2022 policy that protected Marines from separation based on PFB.¹⁰ A Marine Corps spokesperson stated that this change aims to clarify how medical conditions can impact uniform compliance and standardize medical condition management while prioritizing compliance and duty readiness.¹

Even in the absence of policy changes, obtaining a medical shaving waiver for PFB can be challenging. Service members may have little to no access to military dermatologists who specialize in management of PFB and experience long wait times for civilian network deferment. Service members seen in civilian clinics may have restricted treatment options due to limited insurance coverage for laser hair reduction, even in the most difficult-to-manage areas (eg, neck, jawline). Expanding access to military dermatologists, civilian dermatologists who are experienced with PFB and understand the impact and necessity of military waivers, and teledermatology services could help improve and streamline care. Other challenges include the subjective nature of documenting PFB disease severity, the need for validated assessment tools, a lack of standardized policies across military branches, and stigma. A standardized approach to documentation may reduce variability in how shaving waivers are evaluated across service branches, but at a minimum, clinicians should document the diagnosis, clinical findings, severity of PFB, and the treatment used. Having a waiver would help these service members focus on mastering critical skillsets and performing duties without the time pressures, angst, and expense dedicated to caring for and managing PFB.

Clinical and Policy Barriers

Unfortunately, service members with PFB or shaving waivers often face stigma that can hinder career advancement.⁶ In a recent analysis of 9339 US Air Force personnel, those with shaving waivers experienced longer times to promotion compared to those without waivers: in the waiver group, 94.47% were enlisted and 5.53% were officers; in the nonwaiver group, 72.11% were enlisted and 27.89% were officers (P=.0003).⁶ While delays in promotion were consistent across racial groups, most of the waiver holders identified as Black (64.8%), despite this demographic group representing only a small portion of the overall cohort (12.9%).⁶ Promotion delays may be linked to perceptions of unprofessionalism and exclusion from high-profile assignments, which notably require “the highest standards of military appearance and professional conduct.”¹¹ The burden of career-limiting shaving policies falls disproportionately on military personnel with PFB who self-identify as Black. Perceptions about unprofessional appearance or job readiness often unintentionally introduce bias, unjustly restricting career advancement.⁶

Safety Equipment and Shaving Standards

Conditions that potentially affect the use of masks and chemical defense equipment extend beyond the military. Firefighters and law enforcement officers generally are required to maintain a clean-shaven face for proper fit of respirator masks; the standard is that no respirator fit test shall be conducted if hair—including stubble, beards, mustaches, or sideburns—grows between the skin and the facepiece sealing surface, and any apparel interfering with a proper seal must be altered or removed.¹² This creates challenges for uniformed professionals with PFB who must manage their condition while adhering to safety requirements. Some endure long-term pain and scarring in order to comply, while others seek waivers to treat and prevent symptoms while also facing the stigma of doing so.¹³ One of the most effective treatments for PFB is to discontinue shaving,¹⁴ which may not be feasible for those in uniformed professions with strict grooming standards. Research on mask seal effectiveness in individuals with neatly trimmed beards or PFB remains limited.⁵ Studies evaluating mask fit across facial hair types and lengths are needed, along with the development of protective equipment that accommodates career-limiting conditions such as PFB, cystic acne, and acne keloidalis nuchae. This also may encourage development of equipment that does not induce such conditions (eg, mechanical acne from friction). These efforts would promote safety, scientific innovation for dermatologic follicular-based disorders, and overall quality of life for service members as well as increase their ability to serve without stigma. These developments also would positively impact other fields that require intermittent or full-time use of masks, including health care and some food service industries.

Final Thoughts

The disproportionate impact of PFB in the military highlights the need for improved access to treatment, culturally informed care, and policies that avoid penalizing service members with tightly coiled hair and a desire to serve. We discussed PFB management strategies, clinical features, and implications across various skin tones in a previous publication.¹⁴ It is important to consider insights from individuals with PFB who are serving in the military as well as the medical personnel who care for them. Ensuring or creating effective treatment options drives innovation, and evidence-based accommodation plans can help individuals in uniformed professions avoid choosing between PFB management and their career. Promoting awareness about the impact of PFB beyond the razor is key to reducing disparities and supporting excellence among those who serve and desire to continue to do so.

As one of the most competitive specialties in medicine, dermatology presents unique challenges for residency applicants, especially following the shift in United States Medical Licensing Examination (USMLE) Step 1 scoring to a pass/fail format.^1,2 Historically, USMLE Step 1 served as a major screening metric for residency programs, with 90% of program directors in 2020 using USMLE Step 1 scores as a primary factor when deciding whether to invite applicants for interviews.¹ However, the recent transition to pass/fail has made it much harder for program directors to objectively compare applicants, particularly in dermatology. In a 2020 survey, Patrinely Jr et al² found that 77.2% of dermatology program directors agreed that this change would make it more difficult to assess candidates objectively. Consequently, research productivity has taken on greater importance as programs seek new ways to distinguish top applicants.^1,2

In response to this increased emphasis on research, dermatology applicants have substantially boosted their scholarly output over the past several years. The 2022 and 2024 results from the National Residency Matching Program’s Charting Outcomes survey demonstrated a steady rise in research metrics among applicants across various specialties, with dermatology showing one of the largest increases.^3,4 For instance, the average number of abstracts, presentations, and publications for matched allopathic dermatology applicants was 5.7 in 2007.⁵ This average increased to 20.9 in 2022³ and to 27.7 in 2024,⁴ marking an astonishing 485% increase in 17 years. Interestingly, unmatched dermatology applicants had an average of 19.0 research products in 2024, which was similar to the average of successfully matched applicants just 2 years earlier.^3,4

Engaging in research offers benefits beyond building a strong residency application. Specifically, it enhances critical thinking skills and provides hands-on experience in scientific inquiry.⁶ It allows students to explore dermatology topics of interest and address existing knowledge gaps within the specialty.⁶ Additionally, it creates opportunities to build meaningful relationships with experienced dermatologists who can guide and support students throughout their careers.⁷ Despite these benefits, the pursuit of research may be landscaped with obstacles, and the fervent race to obtain high research outputs may overshadow developmental advantages.⁸ These challenges and demands also could contribute to inequities in the residency selection process, particularly if barriers are influenced by socioeconomic and demographic disparities. As dermatology already ranks as the second least diverse specialty in medicine,⁹ research requirements that disproportionately disadvantage certain demographic groups risk further widening these concerning representation gaps rather than creating opportunities to address them.

Given these trends in research requirements and their potential impact on applicant success, understanding specific barriers to research engagement is essential for creating equitable opportunities in dermatology. In this study, we aimed to identify barriers to research engagement among dermatology applicants, analyze their relationship with demographic factors, assess their impact on specialty choice and research productivity, and provide actionable solutions to address these obstacles.

Methods

A cross-sectional survey was conducted targeting medical students applying to dermatology residency programs in the United States in the 2025 or 2026 match cycles as well as residents who applied to dermatology residency in the 2021 to 2024 match cycles. The 23-item survey was developed by adapting questions from several validated studies examining research barriers and experiences in medical education.^6,7,10,11 Specifically, the survey included questions on demographics and background; research productivity; general research barriers; conference participation accessibility; mentorship access; and quality, career impact, and support needs. Socioeconomic background was measured via a single self-reported item asking participants to select the income class that best reflected their background growing up (low-income, lower-middle, upper-middle, or high-income); no income ranges were provided.

The survey was distributed electronically via Qualtrics between November 11, 2024, and December 30, 2024, through listserves of the Dermatology Interest Group Association (sent directly to medical students) and the Association of Professors of Dermatology (forwarded to residents by program directors). There was no way to determine the number of dermatology applicants and residents reached through either listserve. The surveys were reviewed and approved by the University of Alabama at Birmingham institutional review board (IRB-300013671).

Statistical analyses were conducted using RStudio (Posit, PBC; version 2024.12.0+467). Descriptive statistics characterized participant demographics and quantified barrier scores using frequencies and proportions. We performed regression analyses to examine relationships between demographic factors and barriers using linear regression; the relationship between barriers and research productivity correlation; and the prediction of specialty change consideration using logistic regression. For all analyses, barrier scores were rated on a scale of 0 to 3 (0=not a barrier, 1=minor barrier, 2=moderate barrier, 3=major barrier); R² values were reported to indicate strength of associations, and statistical significance was set at P<.05.

Results

Participant Demographics—A total of 136 participants completed the survey. Among the respondents, 12% identified as from a background of low-income class, 28% lower-middle class, 49% upper-middle class, and 11% high-income class. Additionally, 27% of respondents identified as underrepresented in medicine (URiM). Regarding debt levels (or expected debt levels) upon graduation from medical school, 32% reported no debt, 9% reported $1000 to $49,000 in debt, 5% reported $50,000 to $99,000 in debt, 15% reported $100,000 to $199,000 in debt, 22% reported $200,000 to $299,000 in debt, and 17% reported $300,000 in debt or higher. The majority of respondents (95%) were MD candidates, and the remaining 5% were DO candidates; additionally, 5% were participants in an MD/PhD program (eTable 1).

Respondents represented various stages of training: 13.2% and 16.2% were third- and fourth-year medical students, respectively, while 6.0%, 20.1%, 18.4%, and 22.8% were postgraduate year (PGY) 1, PGY-2, PGY-3, and PGY-4, respectively. A few respondents (2.9%) were participating in a research year or reapplying to dermatology residency (eTable 2).

Research Barriers and Productivity—Respondents were presented with a list of potential barriers and asked to rate each as not a barrier, a minor barrier, a moderate barrier, or a major barrier. The most common barriers (ie, those with >50% of respondents rating them as a moderate or major) included lack of time, limited access to research opportunities, not knowing how to begin research, and lack of mentorship or support. Lack of time and not knowing where to begin research were reported most frequently as major barriers, with 32% of participants identifying them as such. In contrast, barriers such as financial costs and personal obligations were less frequently rated as major barriers (10% and 4%, respectively), although they still were identified as obstacles by many respondents. Interestingly, most respondents (58%) indicated that institutional limitations were not a barrier, but a separate and sizeable proportion (25%) of respondents considered it to be a major barrier (eFigure 1).

The distributions for all research metrics were right-skewed. The total range was 0 to 45 (median, 6) for number of publications (excluding abstracts), 0 to 33 (median, 2) for published abstracts, 0 to 40 (median, 5) for poster publications, and 0 to 20 (median, 2) for oral presentations (eTable 3).

Regression Analysis—Linear regression analysis identified significant relationships between demographic variables (socioeconomic status [SES], URiM status, and debt level) and individual research barriers. The heatmap in eFigure 2 illustrates the strength of these relationships. Higher SES was predictive of lower reported financial barriers (R²=.2317; P<.0001) and lower reported institutional limitations (R²=.0884; P=.0006). A URiM status predicted higher reported financial barriers (R²=.1097; P<.0001) and institutional limitations (R²=.04537; P=.013). Also, higher debt level predicted increased financial barriers (R²=.2099; P<.0001), institutional limitations (R²=.1258; P<.0001), and lack of mentorship (R²=.06553; P=.003).

Next, the data were evaluated for correlative relationships between individual research barriers and research productivity metrics including number of publications, published abstracts and presentations (oral and poster) and total research output. While correlations were weak or nonsignificant between barriers and most research productivity metrics (published abstracts, oral and poster presentations, and total research output), the number of publications was significantly correlated with several research barriers, including limited access to research opportunities (P=.002), not knowing how to begin research (P=.025), lack of mentorship or support (P=.011), and institutional limitations (P=.042). Higher ratings for limited access to research opportunities, not knowing where to begin research, lack of mentorship or support, and institutional limitations all were negatively correlated with total number of publications (R²=−.27, –.19, −.22, and –.18, respectively)(eFigure 3).

Logistic regression analysis examined the impact of research barriers on the likelihood of specialty change consideration. The results, presented in a forest plot, include odds ratios (ORs) and their corresponding 95% CIs and P values. Lack of time (P=.001) and not knowing where to begin research (P<.001) were the strongest predictors of specialty change consideration (OR, 6.3 and 4.7, ­respectively). Financial cost (P=.043), limited access to research opportunities (P=.006), and lack of mentorship or support (P=.001) also were significant predictors of specialty change consideration (OR, 2.2, 3.1, and 3.5, respectively). Institutional limitations and personal obligations did not predict specialty change consideration (eTable 4 and eFigure 4).

Mitigation Strategies—Mitigation strategies were ranked by respondents based on their perceived importance on a scale of 1 to 7 (1=most important, 7=least important)(eFigure 5). Respondents considered access to engaged mentors to be the most important mitigation strategy by far, with 95% ranking it in the top 3 (47% of respondents ranked it as the top most important mitigation strategy). Financial assistance was the mitigation strategy with the second highest number of respondents (28%) ranking it as the top strategy. Flexible scheduling during rotations, research training programs or discussions, and peer networking and research collaboration opportunities also were considered by respondents to be important mitigation strategies. Time management support/resources frequently was viewed as the least important mitigation strategy, with 38% of respondents ranking it last.

Comment

Our study revealed notable disparities in research barriers among dermatology applicants, with several demonstrating consistent patterns of association with SES, URiM status, and debt burden. Furthermore, the strong relationship between these barriers and decreased research productivity and specialty change consideration suggests that capable candidates may be deterred from pursuing dermatology due to surmountable obstacles rather than lack of interest or ability.

Impact of Demographic Factors on Research Barriers—All 7 general research barriers surveyed were correlated with distinct demographic predictors. Regression analyses indicated that the barrier of financial cost was significantly predicted by lower SES (R²=.2317; P<.001), URiM status (R²=.1097; P<.001), and higher debt levels (R²=.2099; P<.001)(eFigure 2). These findings are particularly concerning given the trend of dermatology applicants pursuing 1-year research fellowships, many of which are unpaid.¹² In fact, Jacobson et al¹¹ found that 71.7% (43/60) of dermatology applicants who pursued a year-long research fellowship experienced financial strain during their fellowship, with many requiring additional loans or drawing from personal savings despite already carrying substantial medical school debt of $200,000 or more. Our findings showcase how financial barriers to research disproportionately affect students from lower socioeconomic backgrounds, those who identify as URiM, and those with higher debt, creating systemic inequities in research access at a time when research productivity is increasingly vital for matching into dermatology. To address these financial barriers, institutions may consider establishing more funded research fellowships or expanding grant programs targeting students from economically disadvantaged and/or underrepresented backgrounds.

Institutional limitations (eg, the absence of a dermatology department) also was a notable barrier that was significantly predicted by lower SES (R²=.0884; P<.001) and URiM status (R²=.04537; P=.013)(eFigure 2). Students at institutions lacking dermatology programs face restricted access to mentorship and research opportunities,¹³ with our results demonstrating that these barriers disproportionately affect students from underresourced and minority groups. These limitations compound disparities in building competitive residency applications.¹⁴ The Women’s Dermatologic Society (WDS) has developed a model for addressing these institutional barriers through its summer research fellowship program for medical students who identify as URiM. By pairing students with WDS mentors who guide them through summer research projects, this initiative addresses access and mentorship gaps for students lacking dermatology departments at their home institution.¹⁵ The WDS program serves as a model for other organizations to adopt and expand, with particular attention to including students who identify as URiM as well as those from lower socioeconomic backgrounds.

Our results identified time constraints and lack of experience as notable research barriers. Higher debt levels significantly predicted both lack of time (R²=.03915; P=.021) and not knowing how to begin research (R²=.0572; P=.005)(eFigure 2). These statistical relationships may be explained by students with higher debt levels needing to prioritize paid work over unpaid research opportunities, limiting their engagement in research due to the scarcity of funded positions.¹² The data further revealed that personal obligations, particularly family care responsibilities, were significantly predicted by both lower SES (R²=.0539; P=.008) and higher debt level (R²=.03237; P=.036)(eFigure 2). These findings demonstrate how students managing academic demands alongside financial and familial responsibilities may face compounded barriers to research engagement. To address these disparities, medical schools may consider implementing protected research time within their curricula; for example, the Emory University School of Medicine (Atlanta, Georgia) has implemented a Discovery Phase program that provides students with 5 months of protected faculty-mentored research time away from academic demands between their third and fourth years of medical school.¹⁶ Integrating similarly structured research periods across medical school curricula could help ensure equitable research opportunities for all students pursuing competitive specialties such as dermatology.⁸

Access to mentorship is a critical determinant of research engagement and productivity, as mentors provide valuable guidance on navigating research processes and professional development.¹⁷ Our analysis revealed that lack of mentorship was predicted by both lower SES (R²=.039; P=.023) and higher debt level (R²=.06553; P=.003)(eFigure 2). Several organizations have developed programs to address these mentorship gaps. The Skin of Color Society pairs medical students with skin of color experts while advancing its mission of increasing diversity in dermatology.¹⁸ Similarly, the American Academy of Dermatology founded a diversity mentorship program that connects students who identify as URiM with dermatologist mentors for summer research experiences.¹⁹ Notably, the Skin of Color Society’s program allows residents to serve as mentors for medical students. Involving residents and community dermatologists as potential dermatology mentors for medical students not only distributes mentorship demands more sustainably but also increases overall access to dermatology mentors. Our findings indicate that similar programs could be expanded to include more residents and community dermatologists as mentors and to target students from disadvantaged backgrounds, those facing financial constraints, and students who identify as URiM. 

Impact of Research Barriers on Career Trajectories—Among survey participants, 35% reported considering changing their specialty choice due to research-related barriers. This substantial percentage likely stems from the escalating pressure to achieve increasingly high research output amidst a lack of sufficient support, time, or tools, as our results suggest. The specific barriers that most notably predicted specialty change consideration were lack of time and not knowing how to begin research (P=.001 and P<.001, respectively). Remarkably, our findings revealed that respondents who rated these as moderate or major barriers were 6.3 and 4.7 times more likely to consider changing their specialty choice, respectively. Respondents reporting financial cost (P=.043), limited access to research opportunities (P=.006), and lack of mentorship or support (P=.001) as at least moderate barriers also were 2.2 to 3.5 times more likely to consider a specialty change (eTable 4 and eFigure 4). Additionally, barriers such as limited access to research opportunities (R²=−.27; P=.002), lack of mentorship (R²=−.22; P=.011), not knowing how to begin research (R²=−.19; P=.025), and institutional limitations (R²=−.18; P=.042) all were associated with lower publication output according to our data (eFigure 3). These findings are especially concerning given current match statistics, where the trajectory of research productivity required for a successful dermatology match continues to rise sharply.^3,4

Alarmingly, many of the barriers we identified—linked to both reduced research output and specialty change consideration—are associated with several demographic factors. Higher debt levels predicted greater likelihood of experiencing lack of time, insufficient mentorship, and uncertainty about initiating research, while lower SES was associated with lack of mentorship. These relationships suggest that structural barriers, rather than lack of interest or ability, may create cumulative disadvantages that deter capable candidates from pursuing dermatology or impact their success in the application process.

One potential solution to address the disproportionate emphasis on research quantity would be implementing caps on reportable research products in residency applications (eg, limiting applications to a certain number of publications, abstracts, and presentations). This change could shift applicant focus toward substantive scientific contributions rather than rapid output accumulation.⁸ The need for such caps was evident in our dataset, which revealed a stark contrast: some respondents reported 30 to 40 publications, while MD/PhD respondents—who dedicate 3 to 5 years to performing quality research—averaged only 7.4 publications. Implementing a research output ceiling could help alleviate barriers for applicants facing institutional and demographic disadvantages while simultaneously boosting the scientific rigor of dermatology research.⁸

Mitigation Strategies From Applicant Feedback—Our findings emphasize the multifaceted relationship between structural barriers and demographics in dermatology research engagement. While our statistical interpretations have outlined several potential interventions, the applicants’ perspectives on mitigation strategies offer qualitative insight. Although participants did not consistently mark financial cost and lack of mentorship as major barriers (eFigure 1), financial assistance and access to engaged mentors were among the highest-ranked mitigation strategies (eFigure 5), suggesting these resources may be fundamental to overcoming multiple structural challenges. To address these needs comprehensively, we propose a multilevel approach: at the institutional level, dermatology interest groups could establish centralized databases of research opportunities, mentorship programs, and funding sources. At the national level, dermatology organizations could consider expanding grant programs, developing virtual mentorship networks, and creating opportunities for external students through remote research projects or short-term research rotations. These interventions, informed by both our statistical analyses and applicant feedback, could help create more equitable access to research opportunities in dermatology.

Limitations

A major limitation of this study was that potential dermatology candidates who were deterred by barriers and later decided on a different specialty would not be captured in our data. As these candidates may have faced substantial barriers that caused them to choose a different path, their absence from the current data may indicate that the reported results underpredict the effect size of the true population. Another limitation is the absence of a control group, such as applicants to less competitive specialties, which would provide valuable context for whether the barriers identified are unique to dermatology.

Conclusion

Our study provides compelling evidence that research barriers in dermatology residency applications intersect with demographic factors to influence research engagement and career trajectories. Our findings suggest that without targeted intervention, increasing emphasis on research productivity may exacerbate existing disparities in dermatology. Moving forward, a coordinated effort among institutions, dermatology associations, and dermatology residency programs will be fundamental to ensure that research requirements enhance rather than impede the development of a diverse, qualified dermatology workforce.

As one of the most competitive specialties in medicine, dermatology presents unique challenges for residency applicants, especially following the shift in United States Medical Licensing Examination (USMLE) Step 1 scoring to a pass/fail format.^1,2 Historically, USMLE Step 1 served as a major screening metric for residency programs, with 90% of program directors in 2020 using USMLE Step 1 scores as a primary factor when deciding whether to invite applicants for interviews.¹ However, the recent transition to pass/fail has made it much harder for program directors to objectively compare applicants, particularly in dermatology. In a 2020 survey, Patrinely Jr et al² found that 77.2% of dermatology program directors agreed that this change would make it more difficult to assess candidates objectively. Consequently, research productivity has taken on greater importance as programs seek new ways to distinguish top applicants.^1,2

In response to this increased emphasis on research, dermatology applicants have substantially boosted their scholarly output over the past several years. The 2022 and 2024 results from the National Residency Matching Program’s Charting Outcomes survey demonstrated a steady rise in research metrics among applicants across various specialties, with dermatology showing one of the largest increases.^3,4 For instance, the average number of abstracts, presentations, and publications for matched allopathic dermatology applicants was 5.7 in 2007.⁵ This average increased to 20.9 in 2022³ and to 27.7 in 2024,⁴ marking an astonishing 485% increase in 17 years. Interestingly, unmatched dermatology applicants had an average of 19.0 research products in 2024, which was similar to the average of successfully matched applicants just 2 years earlier.^3,4

Engaging in research offers benefits beyond building a strong residency application. Specifically, it enhances critical thinking skills and provides hands-on experience in scientific inquiry.⁶ It allows students to explore dermatology topics of interest and address existing knowledge gaps within the specialty.⁶ Additionally, it creates opportunities to build meaningful relationships with experienced dermatologists who can guide and support students throughout their careers.⁷ Despite these benefits, the pursuit of research may be landscaped with obstacles, and the fervent race to obtain high research outputs may overshadow developmental advantages.⁸ These challenges and demands also could contribute to inequities in the residency selection process, particularly if barriers are influenced by socioeconomic and demographic disparities. As dermatology already ranks as the second least diverse specialty in medicine,⁹ research requirements that disproportionately disadvantage certain demographic groups risk further widening these concerning representation gaps rather than creating opportunities to address them.

Given these trends in research requirements and their potential impact on applicant success, understanding specific barriers to research engagement is essential for creating equitable opportunities in dermatology. In this study, we aimed to identify barriers to research engagement among dermatology applicants, analyze their relationship with demographic factors, assess their impact on specialty choice and research productivity, and provide actionable solutions to address these obstacles.

Methods

A cross-sectional survey was conducted targeting medical students applying to dermatology residency programs in the United States in the 2025 or 2026 match cycles as well as residents who applied to dermatology residency in the 2021 to 2024 match cycles. The 23-item survey was developed by adapting questions from several validated studies examining research barriers and experiences in medical education.^6,7,10,11 Specifically, the survey included questions on demographics and background; research productivity; general research barriers; conference participation accessibility; mentorship access; and quality, career impact, and support needs. Socioeconomic background was measured via a single self-reported item asking participants to select the income class that best reflected their background growing up (low-income, lower-middle, upper-middle, or high-income); no income ranges were provided.

The survey was distributed electronically via Qualtrics between November 11, 2024, and December 30, 2024, through listserves of the Dermatology Interest Group Association (sent directly to medical students) and the Association of Professors of Dermatology (forwarded to residents by program directors). There was no way to determine the number of dermatology applicants and residents reached through either listserve. The surveys were reviewed and approved by the University of Alabama at Birmingham institutional review board (IRB-300013671).

Statistical analyses were conducted using RStudio (Posit, PBC; version 2024.12.0+467). Descriptive statistics characterized participant demographics and quantified barrier scores using frequencies and proportions. We performed regression analyses to examine relationships between demographic factors and barriers using linear regression; the relationship between barriers and research productivity correlation; and the prediction of specialty change consideration using logistic regression. For all analyses, barrier scores were rated on a scale of 0 to 3 (0=not a barrier, 1=minor barrier, 2=moderate barrier, 3=major barrier); R² values were reported to indicate strength of associations, and statistical significance was set at P<.05.

Results

Participant Demographics—A total of 136 participants completed the survey. Among the respondents, 12% identified as from a background of low-income class, 28% lower-middle class, 49% upper-middle class, and 11% high-income class. Additionally, 27% of respondents identified as underrepresented in medicine (URiM). Regarding debt levels (or expected debt levels) upon graduation from medical school, 32% reported no debt, 9% reported $1000 to $49,000 in debt, 5% reported $50,000 to $99,000 in debt, 15% reported $100,000 to $199,000 in debt, 22% reported $200,000 to $299,000 in debt, and 17% reported $300,000 in debt or higher. The majority of respondents (95%) were MD candidates, and the remaining 5% were DO candidates; additionally, 5% were participants in an MD/PhD program (eTable 1).

Respondents represented various stages of training: 13.2% and 16.2% were third- and fourth-year medical students, respectively, while 6.0%, 20.1%, 18.4%, and 22.8% were postgraduate year (PGY) 1, PGY-2, PGY-3, and PGY-4, respectively. A few respondents (2.9%) were participating in a research year or reapplying to dermatology residency (eTable 2).

Research Barriers and Productivity—Respondents were presented with a list of potential barriers and asked to rate each as not a barrier, a minor barrier, a moderate barrier, or a major barrier. The most common barriers (ie, those with >50% of respondents rating them as a moderate or major) included lack of time, limited access to research opportunities, not knowing how to begin research, and lack of mentorship or support. Lack of time and not knowing where to begin research were reported most frequently as major barriers, with 32% of participants identifying them as such. In contrast, barriers such as financial costs and personal obligations were less frequently rated as major barriers (10% and 4%, respectively), although they still were identified as obstacles by many respondents. Interestingly, most respondents (58%) indicated that institutional limitations were not a barrier, but a separate and sizeable proportion (25%) of respondents considered it to be a major barrier (eFigure 1).

The distributions for all research metrics were right-skewed. The total range was 0 to 45 (median, 6) for number of publications (excluding abstracts), 0 to 33 (median, 2) for published abstracts, 0 to 40 (median, 5) for poster publications, and 0 to 20 (median, 2) for oral presentations (eTable 3).

Regression Analysis—Linear regression analysis identified significant relationships between demographic variables (socioeconomic status [SES], URiM status, and debt level) and individual research barriers. The heatmap in eFigure 2 illustrates the strength of these relationships. Higher SES was predictive of lower reported financial barriers (R²=.2317; P<.0001) and lower reported institutional limitations (R²=.0884; P=.0006). A URiM status predicted higher reported financial barriers (R²=.1097; P<.0001) and institutional limitations (R²=.04537; P=.013). Also, higher debt level predicted increased financial barriers (R²=.2099; P<.0001), institutional limitations (R²=.1258; P<.0001), and lack of mentorship (R²=.06553; P=.003).

Next, the data were evaluated for correlative relationships between individual research barriers and research productivity metrics including number of publications, published abstracts and presentations (oral and poster) and total research output. While correlations were weak or nonsignificant between barriers and most research productivity metrics (published abstracts, oral and poster presentations, and total research output), the number of publications was significantly correlated with several research barriers, including limited access to research opportunities (P=.002), not knowing how to begin research (P=.025), lack of mentorship or support (P=.011), and institutional limitations (P=.042). Higher ratings for limited access to research opportunities, not knowing where to begin research, lack of mentorship or support, and institutional limitations all were negatively correlated with total number of publications (R²=−.27, –.19, −.22, and –.18, respectively)(eFigure 3).

Logistic regression analysis examined the impact of research barriers on the likelihood of specialty change consideration. The results, presented in a forest plot, include odds ratios (ORs) and their corresponding 95% CIs and P values. Lack of time (P=.001) and not knowing where to begin research (P<.001) were the strongest predictors of specialty change consideration (OR, 6.3 and 4.7, ­respectively). Financial cost (P=.043), limited access to research opportunities (P=.006), and lack of mentorship or support (P=.001) also were significant predictors of specialty change consideration (OR, 2.2, 3.1, and 3.5, respectively). Institutional limitations and personal obligations did not predict specialty change consideration (eTable 4 and eFigure 4).

Mitigation Strategies—Mitigation strategies were ranked by respondents based on their perceived importance on a scale of 1 to 7 (1=most important, 7=least important)(eFigure 5). Respondents considered access to engaged mentors to be the most important mitigation strategy by far, with 95% ranking it in the top 3 (47% of respondents ranked it as the top most important mitigation strategy). Financial assistance was the mitigation strategy with the second highest number of respondents (28%) ranking it as the top strategy. Flexible scheduling during rotations, research training programs or discussions, and peer networking and research collaboration opportunities also were considered by respondents to be important mitigation strategies. Time management support/resources frequently was viewed as the least important mitigation strategy, with 38% of respondents ranking it last.

Comment

Our study revealed notable disparities in research barriers among dermatology applicants, with several demonstrating consistent patterns of association with SES, URiM status, and debt burden. Furthermore, the strong relationship between these barriers and decreased research productivity and specialty change consideration suggests that capable candidates may be deterred from pursuing dermatology due to surmountable obstacles rather than lack of interest or ability.

Impact of Demographic Factors on Research Barriers—All 7 general research barriers surveyed were correlated with distinct demographic predictors. Regression analyses indicated that the barrier of financial cost was significantly predicted by lower SES (R²=.2317; P<.001), URiM status (R²=.1097; P<.001), and higher debt levels (R²=.2099; P<.001)(eFigure 2). These findings are particularly concerning given the trend of dermatology applicants pursuing 1-year research fellowships, many of which are unpaid.¹² In fact, Jacobson et al¹¹ found that 71.7% (43/60) of dermatology applicants who pursued a year-long research fellowship experienced financial strain during their fellowship, with many requiring additional loans or drawing from personal savings despite already carrying substantial medical school debt of $200,000 or more. Our findings showcase how financial barriers to research disproportionately affect students from lower socioeconomic backgrounds, those who identify as URiM, and those with higher debt, creating systemic inequities in research access at a time when research productivity is increasingly vital for matching into dermatology. To address these financial barriers, institutions may consider establishing more funded research fellowships or expanding grant programs targeting students from economically disadvantaged and/or underrepresented backgrounds.

Institutional limitations (eg, the absence of a dermatology department) also was a notable barrier that was significantly predicted by lower SES (R²=.0884; P<.001) and URiM status (R²=.04537; P=.013)(eFigure 2). Students at institutions lacking dermatology programs face restricted access to mentorship and research opportunities,¹³ with our results demonstrating that these barriers disproportionately affect students from underresourced and minority groups. These limitations compound disparities in building competitive residency applications.¹⁴ The Women’s Dermatologic Society (WDS) has developed a model for addressing these institutional barriers through its summer research fellowship program for medical students who identify as URiM. By pairing students with WDS mentors who guide them through summer research projects, this initiative addresses access and mentorship gaps for students lacking dermatology departments at their home institution.¹⁵ The WDS program serves as a model for other organizations to adopt and expand, with particular attention to including students who identify as URiM as well as those from lower socioeconomic backgrounds.

Our results identified time constraints and lack of experience as notable research barriers. Higher debt levels significantly predicted both lack of time (R²=.03915; P=.021) and not knowing how to begin research (R²=.0572; P=.005)(eFigure 2). These statistical relationships may be explained by students with higher debt levels needing to prioritize paid work over unpaid research opportunities, limiting their engagement in research due to the scarcity of funded positions.¹² The data further revealed that personal obligations, particularly family care responsibilities, were significantly predicted by both lower SES (R²=.0539; P=.008) and higher debt level (R²=.03237; P=.036)(eFigure 2). These findings demonstrate how students managing academic demands alongside financial and familial responsibilities may face compounded barriers to research engagement. To address these disparities, medical schools may consider implementing protected research time within their curricula; for example, the Emory University School of Medicine (Atlanta, Georgia) has implemented a Discovery Phase program that provides students with 5 months of protected faculty-mentored research time away from academic demands between their third and fourth years of medical school.¹⁶ Integrating similarly structured research periods across medical school curricula could help ensure equitable research opportunities for all students pursuing competitive specialties such as dermatology.⁸

Access to mentorship is a critical determinant of research engagement and productivity, as mentors provide valuable guidance on navigating research processes and professional development.¹⁷ Our analysis revealed that lack of mentorship was predicted by both lower SES (R²=.039; P=.023) and higher debt level (R²=.06553; P=.003)(eFigure 2). Several organizations have developed programs to address these mentorship gaps. The Skin of Color Society pairs medical students with skin of color experts while advancing its mission of increasing diversity in dermatology.¹⁸ Similarly, the American Academy of Dermatology founded a diversity mentorship program that connects students who identify as URiM with dermatologist mentors for summer research experiences.¹⁹ Notably, the Skin of Color Society’s program allows residents to serve as mentors for medical students. Involving residents and community dermatologists as potential dermatology mentors for medical students not only distributes mentorship demands more sustainably but also increases overall access to dermatology mentors. Our findings indicate that similar programs could be expanded to include more residents and community dermatologists as mentors and to target students from disadvantaged backgrounds, those facing financial constraints, and students who identify as URiM. 

Impact of Research Barriers on Career Trajectories—Among survey participants, 35% reported considering changing their specialty choice due to research-related barriers. This substantial percentage likely stems from the escalating pressure to achieve increasingly high research output amidst a lack of sufficient support, time, or tools, as our results suggest. The specific barriers that most notably predicted specialty change consideration were lack of time and not knowing how to begin research (P=.001 and P<.001, respectively). Remarkably, our findings revealed that respondents who rated these as moderate or major barriers were 6.3 and 4.7 times more likely to consider changing their specialty choice, respectively. Respondents reporting financial cost (P=.043), limited access to research opportunities (P=.006), and lack of mentorship or support (P=.001) as at least moderate barriers also were 2.2 to 3.5 times more likely to consider a specialty change (eTable 4 and eFigure 4). Additionally, barriers such as limited access to research opportunities (R²=−.27; P=.002), lack of mentorship (R²=−.22; P=.011), not knowing how to begin research (R²=−.19; P=.025), and institutional limitations (R²=−.18; P=.042) all were associated with lower publication output according to our data (eFigure 3). These findings are especially concerning given current match statistics, where the trajectory of research productivity required for a successful dermatology match continues to rise sharply.^3,4

Alarmingly, many of the barriers we identified—linked to both reduced research output and specialty change consideration—are associated with several demographic factors. Higher debt levels predicted greater likelihood of experiencing lack of time, insufficient mentorship, and uncertainty about initiating research, while lower SES was associated with lack of mentorship. These relationships suggest that structural barriers, rather than lack of interest or ability, may create cumulative disadvantages that deter capable candidates from pursuing dermatology or impact their success in the application process.

One potential solution to address the disproportionate emphasis on research quantity would be implementing caps on reportable research products in residency applications (eg, limiting applications to a certain number of publications, abstracts, and presentations). This change could shift applicant focus toward substantive scientific contributions rather than rapid output accumulation.⁸ The need for such caps was evident in our dataset, which revealed a stark contrast: some respondents reported 30 to 40 publications, while MD/PhD respondents—who dedicate 3 to 5 years to performing quality research—averaged only 7.4 publications. Implementing a research output ceiling could help alleviate barriers for applicants facing institutional and demographic disadvantages while simultaneously boosting the scientific rigor of dermatology research.⁸

Mitigation Strategies From Applicant Feedback—Our findings emphasize the multifaceted relationship between structural barriers and demographics in dermatology research engagement. While our statistical interpretations have outlined several potential interventions, the applicants’ perspectives on mitigation strategies offer qualitative insight. Although participants did not consistently mark financial cost and lack of mentorship as major barriers (eFigure 1), financial assistance and access to engaged mentors were among the highest-ranked mitigation strategies (eFigure 5), suggesting these resources may be fundamental to overcoming multiple structural challenges. To address these needs comprehensively, we propose a multilevel approach: at the institutional level, dermatology interest groups could establish centralized databases of research opportunities, mentorship programs, and funding sources. At the national level, dermatology organizations could consider expanding grant programs, developing virtual mentorship networks, and creating opportunities for external students through remote research projects or short-term research rotations. These interventions, informed by both our statistical analyses and applicant feedback, could help create more equitable access to research opportunities in dermatology.

Limitations

A major limitation of this study was that potential dermatology candidates who were deterred by barriers and later decided on a different specialty would not be captured in our data. As these candidates may have faced substantial barriers that caused them to choose a different path, their absence from the current data may indicate that the reported results underpredict the effect size of the true population. Another limitation is the absence of a control group, such as applicants to less competitive specialties, which would provide valuable context for whether the barriers identified are unique to dermatology.

Conclusion

Our study provides compelling evidence that research barriers in dermatology residency applications intersect with demographic factors to influence research engagement and career trajectories. Our findings suggest that without targeted intervention, increasing emphasis on research productivity may exacerbate existing disparities in dermatology. Moving forward, a coordinated effort among institutions, dermatology associations, and dermatology residency programs will be fundamental to ensure that research requirements enhance rather than impede the development of a diverse, qualified dermatology workforce.

As one of the most competitive specialties in medicine, dermatology presents unique challenges for residency applicants, especially following the shift in United States Medical Licensing Examination (USMLE) Step 1 scoring to a pass/fail format.^1,2 Historically, USMLE Step 1 served as a major screening metric for residency programs, with 90% of program directors in 2020 using USMLE Step 1 scores as a primary factor when deciding whether to invite applicants for interviews.¹ However, the recent transition to pass/fail has made it much harder for program directors to objectively compare applicants, particularly in dermatology. In a 2020 survey, Patrinely Jr et al² found that 77.2% of dermatology program directors agreed that this change would make it more difficult to assess candidates objectively. Consequently, research productivity has taken on greater importance as programs seek new ways to distinguish top applicants.^1,2

In response to this increased emphasis on research, dermatology applicants have substantially boosted their scholarly output over the past several years. The 2022 and 2024 results from the National Residency Matching Program’s Charting Outcomes survey demonstrated a steady rise in research metrics among applicants across various specialties, with dermatology showing one of the largest increases.^3,4 For instance, the average number of abstracts, presentations, and publications for matched allopathic dermatology applicants was 5.7 in 2007.⁵ This average increased to 20.9 in 2022³ and to 27.7 in 2024,⁴ marking an astonishing 485% increase in 17 years. Interestingly, unmatched dermatology applicants had an average of 19.0 research products in 2024, which was similar to the average of successfully matched applicants just 2 years earlier.^3,4

Engaging in research offers benefits beyond building a strong residency application. Specifically, it enhances critical thinking skills and provides hands-on experience in scientific inquiry.⁶ It allows students to explore dermatology topics of interest and address existing knowledge gaps within the specialty.⁶ Additionally, it creates opportunities to build meaningful relationships with experienced dermatologists who can guide and support students throughout their careers.⁷ Despite these benefits, the pursuit of research may be landscaped with obstacles, and the fervent race to obtain high research outputs may overshadow developmental advantages.⁸ These challenges and demands also could contribute to inequities in the residency selection process, particularly if barriers are influenced by socioeconomic and demographic disparities. As dermatology already ranks as the second least diverse specialty in medicine,⁹ research requirements that disproportionately disadvantage certain demographic groups risk further widening these concerning representation gaps rather than creating opportunities to address them.

Given these trends in research requirements and their potential impact on applicant success, understanding specific barriers to research engagement is essential for creating equitable opportunities in dermatology. In this study, we aimed to identify barriers to research engagement among dermatology applicants, analyze their relationship with demographic factors, assess their impact on specialty choice and research productivity, and provide actionable solutions to address these obstacles.

Methods

A cross-sectional survey was conducted targeting medical students applying to dermatology residency programs in the United States in the 2025 or 2026 match cycles as well as residents who applied to dermatology residency in the 2021 to 2024 match cycles. The 23-item survey was developed by adapting questions from several validated studies examining research barriers and experiences in medical education.^6,7,10,11 Specifically, the survey included questions on demographics and background; research productivity; general research barriers; conference participation accessibility; mentorship access; and quality, career impact, and support needs. Socioeconomic background was measured via a single self-reported item asking participants to select the income class that best reflected their background growing up (low-income, lower-middle, upper-middle, or high-income); no income ranges were provided.

The survey was distributed electronically via Qualtrics between November 11, 2024, and December 30, 2024, through listserves of the Dermatology Interest Group Association (sent directly to medical students) and the Association of Professors of Dermatology (forwarded to residents by program directors). There was no way to determine the number of dermatology applicants and residents reached through either listserve. The surveys were reviewed and approved by the University of Alabama at Birmingham institutional review board (IRB-300013671).

Statistical analyses were conducted using RStudio (Posit, PBC; version 2024.12.0+467). Descriptive statistics characterized participant demographics and quantified barrier scores using frequencies and proportions. We performed regression analyses to examine relationships between demographic factors and barriers using linear regression; the relationship between barriers and research productivity correlation; and the prediction of specialty change consideration using logistic regression. For all analyses, barrier scores were rated on a scale of 0 to 3 (0=not a barrier, 1=minor barrier, 2=moderate barrier, 3=major barrier); R² values were reported to indicate strength of associations, and statistical significance was set at P<.05.

Results

Participant Demographics—A total of 136 participants completed the survey. Among the respondents, 12% identified as from a background of low-income class, 28% lower-middle class, 49% upper-middle class, and 11% high-income class. Additionally, 27% of respondents identified as underrepresented in medicine (URiM). Regarding debt levels (or expected debt levels) upon graduation from medical school, 32% reported no debt, 9% reported $1000 to $49,000 in debt, 5% reported $50,000 to $99,000 in debt, 15% reported $100,000 to $199,000 in debt, 22% reported $200,000 to $299,000 in debt, and 17% reported $300,000 in debt or higher. The majority of respondents (95%) were MD candidates, and the remaining 5% were DO candidates; additionally, 5% were participants in an MD/PhD program (eTable 1).

Respondents represented various stages of training: 13.2% and 16.2% were third- and fourth-year medical students, respectively, while 6.0%, 20.1%, 18.4%, and 22.8% were postgraduate year (PGY) 1, PGY-2, PGY-3, and PGY-4, respectively. A few respondents (2.9%) were participating in a research year or reapplying to dermatology residency (eTable 2).

Research Barriers and Productivity—Respondents were presented with a list of potential barriers and asked to rate each as not a barrier, a minor barrier, a moderate barrier, or a major barrier. The most common barriers (ie, those with >50% of respondents rating them as a moderate or major) included lack of time, limited access to research opportunities, not knowing how to begin research, and lack of mentorship or support. Lack of time and not knowing where to begin research were reported most frequently as major barriers, with 32% of participants identifying them as such. In contrast, barriers such as financial costs and personal obligations were less frequently rated as major barriers (10% and 4%, respectively), although they still were identified as obstacles by many respondents. Interestingly, most respondents (58%) indicated that institutional limitations were not a barrier, but a separate and sizeable proportion (25%) of respondents considered it to be a major barrier (eFigure 1).

The distributions for all research metrics were right-skewed. The total range was 0 to 45 (median, 6) for number of publications (excluding abstracts), 0 to 33 (median, 2) for published abstracts, 0 to 40 (median, 5) for poster publications, and 0 to 20 (median, 2) for oral presentations (eTable 3).

Regression Analysis—Linear regression analysis identified significant relationships between demographic variables (socioeconomic status [SES], URiM status, and debt level) and individual research barriers. The heatmap in eFigure 2 illustrates the strength of these relationships. Higher SES was predictive of lower reported financial barriers (R²=.2317; P<.0001) and lower reported institutional limitations (R²=.0884; P=.0006). A URiM status predicted higher reported financial barriers (R²=.1097; P<.0001) and institutional limitations (R²=.04537; P=.013). Also, higher debt level predicted increased financial barriers (R²=.2099; P<.0001), institutional limitations (R²=.1258; P<.0001), and lack of mentorship (R²=.06553; P=.003).

Next, the data were evaluated for correlative relationships between individual research barriers and research productivity metrics including number of publications, published abstracts and presentations (oral and poster) and total research output. While correlations were weak or nonsignificant between barriers and most research productivity metrics (published abstracts, oral and poster presentations, and total research output), the number of publications was significantly correlated with several research barriers, including limited access to research opportunities (P=.002), not knowing how to begin research (P=.025), lack of mentorship or support (P=.011), and institutional limitations (P=.042). Higher ratings for limited access to research opportunities, not knowing where to begin research, lack of mentorship or support, and institutional limitations all were negatively correlated with total number of publications (R²=−.27, –.19, −.22, and –.18, respectively)(eFigure 3).

Logistic regression analysis examined the impact of research barriers on the likelihood of specialty change consideration. The results, presented in a forest plot, include odds ratios (ORs) and their corresponding 95% CIs and P values. Lack of time (P=.001) and not knowing where to begin research (P<.001) were the strongest predictors of specialty change consideration (OR, 6.3 and 4.7, ­respectively). Financial cost (P=.043), limited access to research opportunities (P=.006), and lack of mentorship or support (P=.001) also were significant predictors of specialty change consideration (OR, 2.2, 3.1, and 3.5, respectively). Institutional limitations and personal obligations did not predict specialty change consideration (eTable 4 and eFigure 4).

Mitigation Strategies—Mitigation strategies were ranked by respondents based on their perceived importance on a scale of 1 to 7 (1=most important, 7=least important)(eFigure 5). Respondents considered access to engaged mentors to be the most important mitigation strategy by far, with 95% ranking it in the top 3 (47% of respondents ranked it as the top most important mitigation strategy). Financial assistance was the mitigation strategy with the second highest number of respondents (28%) ranking it as the top strategy. Flexible scheduling during rotations, research training programs or discussions, and peer networking and research collaboration opportunities also were considered by respondents to be important mitigation strategies. Time management support/resources frequently was viewed as the least important mitigation strategy, with 38% of respondents ranking it last.

Comment

Our study revealed notable disparities in research barriers among dermatology applicants, with several demonstrating consistent patterns of association with SES, URiM status, and debt burden. Furthermore, the strong relationship between these barriers and decreased research productivity and specialty change consideration suggests that capable candidates may be deterred from pursuing dermatology due to surmountable obstacles rather than lack of interest or ability.

Impact of Demographic Factors on Research Barriers—All 7 general research barriers surveyed were correlated with distinct demographic predictors. Regression analyses indicated that the barrier of financial cost was significantly predicted by lower SES (R²=.2317; P<.001), URiM status (R²=.1097; P<.001), and higher debt levels (R²=.2099; P<.001)(eFigure 2). These findings are particularly concerning given the trend of dermatology applicants pursuing 1-year research fellowships, many of which are unpaid.¹² In fact, Jacobson et al¹¹ found that 71.7% (43/60) of dermatology applicants who pursued a year-long research fellowship experienced financial strain during their fellowship, with many requiring additional loans or drawing from personal savings despite already carrying substantial medical school debt of $200,000 or more. Our findings showcase how financial barriers to research disproportionately affect students from lower socioeconomic backgrounds, those who identify as URiM, and those with higher debt, creating systemic inequities in research access at a time when research productivity is increasingly vital for matching into dermatology. To address these financial barriers, institutions may consider establishing more funded research fellowships or expanding grant programs targeting students from economically disadvantaged and/or underrepresented backgrounds.

Institutional limitations (eg, the absence of a dermatology department) also was a notable barrier that was significantly predicted by lower SES (R²=.0884; P<.001) and URiM status (R²=.04537; P=.013)(eFigure 2). Students at institutions lacking dermatology programs face restricted access to mentorship and research opportunities,¹³ with our results demonstrating that these barriers disproportionately affect students from underresourced and minority groups. These limitations compound disparities in building competitive residency applications.¹⁴ The Women’s Dermatologic Society (WDS) has developed a model for addressing these institutional barriers through its summer research fellowship program for medical students who identify as URiM. By pairing students with WDS mentors who guide them through summer research projects, this initiative addresses access and mentorship gaps for students lacking dermatology departments at their home institution.¹⁵ The WDS program serves as a model for other organizations to adopt and expand, with particular attention to including students who identify as URiM as well as those from lower socioeconomic backgrounds.

Our results identified time constraints and lack of experience as notable research barriers. Higher debt levels significantly predicted both lack of time (R²=.03915; P=.021) and not knowing how to begin research (R²=.0572; P=.005)(eFigure 2). These statistical relationships may be explained by students with higher debt levels needing to prioritize paid work over unpaid research opportunities, limiting their engagement in research due to the scarcity of funded positions.¹² The data further revealed that personal obligations, particularly family care responsibilities, were significantly predicted by both lower SES (R²=.0539; P=.008) and higher debt level (R²=.03237; P=.036)(eFigure 2). These findings demonstrate how students managing academic demands alongside financial and familial responsibilities may face compounded barriers to research engagement. To address these disparities, medical schools may consider implementing protected research time within their curricula; for example, the Emory University School of Medicine (Atlanta, Georgia) has implemented a Discovery Phase program that provides students with 5 months of protected faculty-mentored research time away from academic demands between their third and fourth years of medical school.¹⁶ Integrating similarly structured research periods across medical school curricula could help ensure equitable research opportunities for all students pursuing competitive specialties such as dermatology.⁸

Access to mentorship is a critical determinant of research engagement and productivity, as mentors provide valuable guidance on navigating research processes and professional development.¹⁷ Our analysis revealed that lack of mentorship was predicted by both lower SES (R²=.039; P=.023) and higher debt level (R²=.06553; P=.003)(eFigure 2). Several organizations have developed programs to address these mentorship gaps. The Skin of Color Society pairs medical students with skin of color experts while advancing its mission of increasing diversity in dermatology.¹⁸ Similarly, the American Academy of Dermatology founded a diversity mentorship program that connects students who identify as URiM with dermatologist mentors for summer research experiences.¹⁹ Notably, the Skin of Color Society’s program allows residents to serve as mentors for medical students. Involving residents and community dermatologists as potential dermatology mentors for medical students not only distributes mentorship demands more sustainably but also increases overall access to dermatology mentors. Our findings indicate that similar programs could be expanded to include more residents and community dermatologists as mentors and to target students from disadvantaged backgrounds, those facing financial constraints, and students who identify as URiM. 

Impact of Research Barriers on Career Trajectories—Among survey participants, 35% reported considering changing their specialty choice due to research-related barriers. This substantial percentage likely stems from the escalating pressure to achieve increasingly high research output amidst a lack of sufficient support, time, or tools, as our results suggest. The specific barriers that most notably predicted specialty change consideration were lack of time and not knowing how to begin research (P=.001 and P<.001, respectively). Remarkably, our findings revealed that respondents who rated these as moderate or major barriers were 6.3 and 4.7 times more likely to consider changing their specialty choice, respectively. Respondents reporting financial cost (P=.043), limited access to research opportunities (P=.006), and lack of mentorship or support (P=.001) as at least moderate barriers also were 2.2 to 3.5 times more likely to consider a specialty change (eTable 4 and eFigure 4). Additionally, barriers such as limited access to research opportunities (R²=−.27; P=.002), lack of mentorship (R²=−.22; P=.011), not knowing how to begin research (R²=−.19; P=.025), and institutional limitations (R²=−.18; P=.042) all were associated with lower publication output according to our data (eFigure 3). These findings are especially concerning given current match statistics, where the trajectory of research productivity required for a successful dermatology match continues to rise sharply.^3,4

Alarmingly, many of the barriers we identified—linked to both reduced research output and specialty change consideration—are associated with several demographic factors. Higher debt levels predicted greater likelihood of experiencing lack of time, insufficient mentorship, and uncertainty about initiating research, while lower SES was associated with lack of mentorship. These relationships suggest that structural barriers, rather than lack of interest or ability, may create cumulative disadvantages that deter capable candidates from pursuing dermatology or impact their success in the application process.

One potential solution to address the disproportionate emphasis on research quantity would be implementing caps on reportable research products in residency applications (eg, limiting applications to a certain number of publications, abstracts, and presentations). This change could shift applicant focus toward substantive scientific contributions rather than rapid output accumulation.⁸ The need for such caps was evident in our dataset, which revealed a stark contrast: some respondents reported 30 to 40 publications, while MD/PhD respondents—who dedicate 3 to 5 years to performing quality research—averaged only 7.4 publications. Implementing a research output ceiling could help alleviate barriers for applicants facing institutional and demographic disadvantages while simultaneously boosting the scientific rigor of dermatology research.⁸

Mitigation Strategies From Applicant Feedback—Our findings emphasize the multifaceted relationship between structural barriers and demographics in dermatology research engagement. While our statistical interpretations have outlined several potential interventions, the applicants’ perspectives on mitigation strategies offer qualitative insight. Although participants did not consistently mark financial cost and lack of mentorship as major barriers (eFigure 1), financial assistance and access to engaged mentors were among the highest-ranked mitigation strategies (eFigure 5), suggesting these resources may be fundamental to overcoming multiple structural challenges. To address these needs comprehensively, we propose a multilevel approach: at the institutional level, dermatology interest groups could establish centralized databases of research opportunities, mentorship programs, and funding sources. At the national level, dermatology organizations could consider expanding grant programs, developing virtual mentorship networks, and creating opportunities for external students through remote research projects or short-term research rotations. These interventions, informed by both our statistical analyses and applicant feedback, could help create more equitable access to research opportunities in dermatology.

Limitations

A major limitation of this study was that potential dermatology candidates who were deterred by barriers and later decided on a different specialty would not be captured in our data. As these candidates may have faced substantial barriers that caused them to choose a different path, their absence from the current data may indicate that the reported results underpredict the effect size of the true population. Another limitation is the absence of a control group, such as applicants to less competitive specialties, which would provide valuable context for whether the barriers identified are unique to dermatology.

Conclusion

Our study provides compelling evidence that research barriers in dermatology residency applications intersect with demographic factors to influence research engagement and career trajectories. Our findings suggest that without targeted intervention, increasing emphasis on research productivity may exacerbate existing disparities in dermatology. Moving forward, a coordinated effort among institutions, dermatology associations, and dermatology residency programs will be fundamental to ensure that research requirements enhance rather than impede the development of a diverse, qualified dermatology workforce.

Cosmetic laser procedures as well as energy-based fat reduction and body-contouring devices are increasingly popular among individuals with skin of color (SOC). Innovations in cosmetic devices and procedures tailored for SOC have allowed for the optimization of outcomes in this patient population. In this article, SOC is defined as darker skin types, including Fitzpatrick skin types (FSTs) IV to VI and ethnic backgrounds such as LatinX, African American, Southeast Asian, Native American, Pacific Islander, Middle Eastern, Asian, and African. Indications for laser treatment include dermatosis papulosa nigrans (DPN), acne scars, skin rejuvenation, and hyperpigmentation. There currently are 6 procedures for nonsurgical fat reduction that are approved by the US Food and Drug Administration (FDA): high-frequency focused ultrasound, cryolipolysis, laser lipolysis, injection lipolysis, radiofrequency lipolysis, and magnetic resonance contouring (Supplementary Table S1).¹

In this review, our initial focus is cosmetic laser ­procedures, encompassing FDA-cleared indications along with the associated risks and benefits in SOC populations. Subsequently, we delve into the realms of energy-based fat reduction and body contouring, offering a comprehensive overview of these noninvasive therapies and addressing considerations for efficacy and safety in these patients.

Dermatosis Papulosa Nigra

In patients with SOC, scissor excision, curettage, or electrodesiccation are the mainstay treatments for removal of DPN (Figure 1). Curettage and electrodesiccation can cause temporary postinflammatory hyperpigmentation (PIH) in these populations, while cryotherapy is not a preferred method in patients with SOC due to the possibility of cryotherapy-induced depigmentation. In a 14-patient split-face study comparing the 532-nm potassium titanyl phosphate (KTP) laser vs electrodesiccation in FSTs IV to VI, the KTP-treated side showed an improvement rate of 96%, while the electrodesiccation side showed an improvement rate of 79%. There was a statistically significant favorable experience for KTP with regard to pain tolerability (P=.002).² Complete resolution of lesions may be seen after 3 to 4 sessions at 4-week intervals. Additionally, the 1064-nm Nd:YAG laser was assessed for treatment of DPN in 2 patients, with 70% to 90% of lesions resolved after a single treatment with no complications.³

Most dermatologists still rely on curettage and electrodesiccation instead of laser therapy to remove DPNs in patients with SOC. The use of the Nd:YAG laser is promising yet expensive for the provider both to purchase and maintain. Electrodesiccation has been used by dermatology practices for decades and can be used without permanent discoloration. To minimize the risk for PIH, we recommend application of a healing ointment such as petroleum jelly or aloe vera gel to the treated lesions as well as lightening agents for PIH and daily use of sunscreen. Overall, providers do not need to purchase an expensive laser device for DPN removal.

Acne Scars

The invention of fractional technology in the early 2000s and its favorable safety profile have changed how dermatologists treat scarring in patients with SOC.^4,5 In fact, nonablative fractional (NAF) resurfacing is a preferred treatment modality for management of acne scars in patients with SOC.⁶ In one study of the 1550-nm erbium-doped fiber laser for treatment of acne scars (3 treatments at intervals of 2-3 weeks) in 10 Japanese patients, clinical improvement was seen in all patients and no severe adverse effects were reported.⁷ In another study, 27 Korean patients with FSTs IV and V were treated with an NAF resurfacing device for acne scars. Excellent results were reported in 30% (8/27) of patients, substantial improvement in 59% (16/27), and moderate improvement in 11% (3/27).⁸ To evaluate outcomes in patients treated with NAF resurfacing, a retrospective review of 961 treatments showed a hyperpigmentation rate of 11.6% in those with FST IV and 33% in FST V.⁹

In one study of the short-pulsed nonablative Nd:YAG laser, 9 patients with FSTs I to V and 2 patients with FSTs IV to V underwent 8 treatments at 2-week intervals. Three blinded observers found a 29% improvement in the Global Acne Scar Severity score, while 89% (8/9) of patients self-reported subjective improvement in their acne scars.¹⁰

The 755-nm picosecond laser and diffractive lens array also have been shown to reduce the appearance of acne scars in patients with SOC, as shown via serial photography in a retrospective study of 56 patients with FSTs IV to VI. Transient hyperpigmentation, erythema, and edema were reported.¹¹

Nonablative laser therapy is preferred for skin rejuvenation in patients with SOC due to a reduced risk for postprocedural hyperpigmentation.¹¹ Ablative resurfacing (eg, CO₂ laser) poses major risks for postprocedural hyperpigmentation, hypopigmentation, and scar formation and therefore should be avoided in these populations.^12,13 A study involving 30 Asian patients (FSTs III-IV) demonstrated that the 1550-nm fractional laser was well tolerated, though higher treatment densities and fluences may lead to temporary adverse effects such as increased redness, swelling, and pain (P<.01).¹⁴ Furthermore, greater density was shown to cause higher levels of redness, hyperpigmentation, and swelling in comparison to higher fluence settings. Of note, patient satisfaction was markedly higher in patients who underwent treatment with higher fluence settings but not in patients with higher densities (P<.05). Postprocedural hyperpigmentation was noted in 6.7% (2/30) of patients studied.¹⁴ In another study, 8 patients with FSTs II to V were treated with either the 1064-nm long-pulsed Nd:YAG laser or the grid fractional monopolar radiofrequency laser.¹⁵ All participants experienced a significant decrease in mean wrinkle count using the Lemperle wrinkle assessment (P<.05). A significant decrease in mean wrinkle assessment score from 3.5 to 3.17 in clinical assessment and a decrease from 3.165 to 2.33 for photographic assessment was noted in patients treated with the grid laser (P<.05). A similar decrease in mean wrinkle assessment score was observed in the Nd:YAG group, with a mean decrease of 3.665 to 2.83 after 2 months for clinical assessment and 3.5 to 2.67 for photographic assessment. Among all patients in the study, 68% (6/8) experienced erythema, 25% (2/8) had a burning sensation, and 25% (2/8) experienced urticaria immediately postprocedure.¹⁵

Nonablative fractional resurfacing is preferred for the management of acne scars in patients with SOC. Adverse effects such as hyperpigmentation typically are transient, and the risk may be minimized with strict photoprotective practices following the procedure. Furthermore, avoidance of topicals containing exfoliants or α-hydroxy acids applied to the treated area following the procedure also may mitigate the risk for postprocedural hyperpigmentation.¹⁶ If hyperpigmentation does occur, use of topical melanogenesis inhibitors such as hydroquinone, kojic acid, or azelaic acid has shown some utility in practice.

Skin Rejuvenation

Nonablative fractional lasers (NAFLs) continue to be popular for treatment of photoaging. One study including 10 Asian patients (FSTs III-V) assessed the 1440-nm diode-based fractional laser for facial rejuvenation.¹⁷ After 4 sessions at 2-week intervals, 80% (8/10) of patients reported decreased skin roughness after both the second and third treatments, while 90% (9/10) had improved texture 1 month after the final procedure. Adverse effects included moderate facial edema and one case of transient hyperpigmentation.¹⁷ Another study reported a significant reduction in pore score (P<.002), with patients noting an overall improvement in skin appearance with minimal erythema, dryness, and flaking following 6 sessions at 2-week intervals using the 1440-nm diode-based fractional laser.¹⁸

The 1550-nm diode fractional laser significantly improved skin pigmentation (P<.001) and texture (P<.001) in 10 patients with FSTs II to IV following 5 sessions at 2- to 3-week intervals, with self-resolving erythema and edema posttreatment (Supplementary Table S2).¹⁹ Overall, NAFLs for the treatment of photoaging are effective with minimal adverse effects (eg, facial edema), which can be reduced with application of cold compression to the face and elevation of the head following treatment as well as the use of additional pillows during overnight sleep.

Laser Treatment for Hyperpigmentation Disorders

Melasma—The FDA recently approved fractional photothermolysis for the treatment of melasma; however, due to the risk for hyperpigmentation given its pathogenesis linked to hyperactive melanocytes, this laser is not considered a first-line therapy for melasma.²⁰ In a split-face, randomized study, 22 patients with FSTs III to V who were diagnosed with either dermal or mixed-type melasma were treated with a low-fluence Q-switched Nd:YAG laser combined with hydroquinone 2% vs hydroquinone 2% alone (Supplementary Table S3).²¹ Each patient was treated weekly for 5 consecutive weeks. The laser-treated side was found to reach an average of 92.5% improvement compared with 19.7% on the hydroquinone-only side. Three of the 22 (13.6%) patients developed mottled hypopigmentation after 5 laser treatments, and 8 (36.4%) developed confetti-type hypopigmentation. Four (18.2%) patients developed rebound hyperpigmentation, and all 22 patients experienced recurrence of melasma by 12 weeks posttreatment.²¹

First-line treatment for melasma involves the application of topical lightening agents such as hydroquinone, azelaic acid, kojic acid, retinoids, or mild topical steroids. Combining laser technology with topical medications can enhance treatment outcomes, particularly yielding positive results for patients with persistent pigmentation concerns. Notably, utilization of 650-microsecond technology with the 1064-nm Nd:YAG laser is considered superior in clinical practice, especially for patients with FSTs IV through VI.

Postinflammatory Hyperpigmentation—A retrospective evaluation of 61 patients with FSTs IV to VI with PIH treated with a 1927-nm NAFL showed a mean improvement of 43.24%, as assessed by 2 dermatologists.²² Additionally, the Nd:YAG 1064-nm 650-microsecond pulse duration laser is an emerging treatment that delivers high and low fluences between 4 J/cm² and 255 J/cm² within a single 650-microsecond pulse duration.²³ The short-pulse duration avoids overheating the skin, mitigating procedural discomfort and the risk for adverse effects commonly seen with the previous generation of low-pulsed lasers. In addition to PIH, this laser has been successfully used to treat pseudofolliculitis barbae.²⁴

Solar Lentigos—In a split-face study treating solar lentigos in Asian patients, 4 treatments with a low-pulsed KTP 532-nm laser were administered with and without a second treatment with a low-pulsed 1064-nm Nd:YAG laser.²⁵ Scoring of a modified pigment severity index and measurement of the melanin index showed that skin treated with the low-pulsed 532-nm laser alone and in combination with the low-pulsed 1064-nm Nd:YAG laser resulted in improvement at 3 months’ follow-up. However, there was no difference between the 2 sides of the face, leading the researchers to conclude that the low-pulsed 532-nm laser appears to be safe and effective for treatment of solar lentigos in Asian patients and does not require the addition of the low-pulsed 1064-nm laser.²⁵  

To avoid hyperpigmentation in patients with SOC, strict photoprotection to the treated areas should be advised. Proper cooling of the laser-treated area is required to minimize PIH, as cooling decreases tissue damage and excessive thermal injury. Test spots should be considered prior to initiation of the full laser treatment. Hydroquinone in a 4% concentration applied daily for 2 weeks preprocedure commonly is employed to reduce the risk for postprocedural hyperpigmentation in clinical practice.^26,27

Skin Tightening and Body Contouring

In general, skin-tightening and body-contouring devices are among the most sought-after procedures. Studies performed in patients with SOC are limited. Herein, we provide background on why these devices are favorable for patients with SOC and our experiences in using them. A summary of these devices can be found in Supplementary Table S4.

Radiofrequency Skin Tightening—Radiofrequency devices are utilized for skin tightening as well as mild fat reduction; they commonly are used on the abdomen, thighs, buttocks, and face.²⁸ People with SOC are more responsive to radiofrequency skin-tightening therapy due to higher baseline collagen content and dermal thickness, more sebaceous activity and skin elasticity, and more melanin content which offers protective thermal buffering.^29,30 As the radiofrequency device emits heat, penetrating deep into the dermis, it generates collagen remodeling and synthesis within 4 to 6 months posttreatment.

Nonsurgical Fat Reduction

Procedures for nonsurgical fat reduction are favorable due to minimal recovery time, manageable cost, and an in-office procedure setting. As noted previously, there are 6 FDA-indicated interventions for nonsurgical fat reduction: ultrasonography, cryolipolysis, laser lipolysis, injection lipolysis, radiofrequency lipolysis, and magnetic resonance contouring.³¹

Ultrasonography—Ultrasound devices designed for body contouring are used for skin tightening and mild fat reduction through the use of acoustic energy.³² These devices can be divided into 2 categories: high frequency and low frequency, with the high-frequency devices being the most popular. High-frequency ultrasound energy produces heat at target sites, which induces necrosis of adipocytes and stimulates collagen remodeling within the tissue matrix.³³ Tissue temperatures above 56°C stimulate adipocyte necrosis while sparing nearby nerves and vessels.²⁸ Because of the short duration of the procedure, the risk for epidermal damage is minimal. Contrary to high-frequency ultrasonography, focus-pulsed ultrasonography employs low-frequency waves to induce the mechanical disruption of adipocytes, which is generally better tolerated due to its nonthermal mechanism. The latter may be advantageous in patients with SOC due to a reduced risk for thermal injury to the epidermis. Multiple treatments often are needed at 3- to 4-week intervals, resulting in gradual improvement observed over 2 to 6 months. One study of microfocused ultrasonography in 25 Asian patients for treatment of face and neck laxity reported that skin laxity was improved or much improved in 84% (21/25) of patients following treatment.³⁴ Adverse effects were reported as mild and transient, resolving within 90 days.³⁴ Ultrasound devices also were shown to improve wrinkles, texture, and overall appearance of the skin in a 71-year-old African American woman 4 months following treatment (Figure 2). These photographs highlight the clinical utility of a microfocused ultrasound skin-tightening treatment in African American patients.

Cryolipolysis—Cryolipolysis is a noninvasive body contouring procedure that employs controlled cooling to induce subcutaneous panniculitis. Through cold-induced apoptosis of adipocytes, this procedure selectively reduces adipose tissue in localized areas such as the flank, abdomen, thighs, buttocks, back, submental area, and upper arms. The temperature used in cryolipolysis is approximately –10°C.³⁵ The lethal temperature for melanocytes is –4 °C, below which melanocyte apoptosis may be induced, resulting in depigmentation. Given the prolonged contact of the skin with a cryolipolysis device for up to 60 minutes during a body-contouring procedure, there is a risk for resultant depigmentation in darker skin types. Controlled studies are needed to fully evaluate the safety and efficacy of cryolipolysis in patients with SOC. One retrospective study of cryolipolysis applied to the abdomen and upper arm of 4122 Asian patients reported a significant (P<.05) reduction in the circumference of the abdomen and the upper-arm areas. No long-term adverse effects were reported.³⁶

Laser Lipolysis—The 1060-nm diode laser for body contouring selectively destroys adipose tissue, resulting in body contouring via thermally induced inflammation. Hyperthermic exposure for 15 minutes selectively elevates adipocyte temperature between 42°C to 47°C, which triggers apoptosis and the eventual clearance of destroyed cells from the interstitial space.³⁷ The selectivity of the 1060-nm wavelength coupled with the device’s contact cooling system preserves the overlying skin and adnexa during the procedure,³⁷ which would minimize epidermal damage that may induce dyspigmentation in patients with SOC. No notable adverse effects or dyspigmentation have been reported using this device.

Injection Lipolysis—Deoxycholic acid is an injectable adipocytolytic for the reduction of submental fat. It nonselectively lyses muscle and other adjacent nonfatty tissue. One study of 50 Indian patients demonstrated a substantial reduction of submental fat in 90% (45/50).³⁸ For each treatment, 5 mL of 30 mg/mL deoxycholic acid was injected. Serial sessions were conducted at 2-month intervals, and most (64% [32/50]) patients required 3 sessions to see a treatment effect. Adverse effects included transient swelling, lumpiness, and tenderness. A phase 2a investigation of the novel injectable small-molecule drug CBL-514 in 43 Asian and White participants found a significant improvement in the reduction in abdominal fat volume (P<.00001) and thickness (P<.0001) relative to baseline at higher doses (unit dose, 2.0 mg/cm² and 1.6 mg/cm²).³⁹ In addition to the adverse effects mentioned previously, pruritus, repeated urticaria, body rash, and fever also were reported.³⁹  

Radiofrequency Lipolysis—Radiofrequency is used for adipolysis through heat-induced apoptosis. To achieve this effect, adipose tissue must sustain a temperature of 42 °C to 45 °C for at least 15 minutes.⁴⁰ In one study, 4 treatments performed at 7-day intervals resulted in a statistically significant reduction in circumference to the treated areas of the inner and outer thighs without any reported adverse effects (P<0.001).⁴¹ Of note, there was 1 cm of distance between the applicator and the skin. The absence of direct contact with the skin is likely to reduce the risk for postprocedural complications in patients with SOC.

Magnetic Resonance Contouring—Magnetic resonance contouring with high-intensity focused electromagnetic technology is an emerging treatment modality for noninvasive body contouring. One distinguishing characteristic from other currently available noninvasive fat-­reduction therapies is that magnetic resonance may improve strength, tone, and muscle thickness.⁴² This modality is FDA approved for contouring of the buttocks and abdomen and employs electromagnetic energy to stimulate approximately 20,000 muscle contractions within a time frame of 30 minutes. Though the mechanisms causing benefits to muscular and adipose tissue have not been elucidated, current findings suggest that the contractions stimulate substantial lipolysis of adipocytes, resulting in the release of large amounts of free fatty acids that cause damage to nearby adipose tissue.⁴³ Multiple treatments are required over time to maintain effect. No major adverse effects have been reported. The likely mechanism of action of magnetic resonance contouring does not appear to pose an increased risk to patients with SOC.

Final Thoughts

One of the major roadblocks in distilling indications along with associated risks and benefits for nonsurgical cosmetic practices for patients with SOC is a void in the primary literature involving these populations. Clinical experience serves to address this deficit in combination with a thorough review of the literature. The 1064-nm Nd:YAG laser has shown clinical utility in the treatment of DPN, melanoma, and acne scars, but it poses financial constraints to the provider in comparison to modalities used for many years. Notably, NAF resurfacing is preferred for the management of acne scars in patients with SOC and continues to gain popularity for the treatment of photoaging. Regarding skin-tightening and body-contouring devices, studies performed in patients with SOC are limited and affected by factors such as small sample sizes, underrepresentation of FSTs IV through VI, short follow-up durations, and a lack of standardized outcome measures. Additionally, few studies assess pigmentary adverse effects or stratify results by skin type, which is critical given the higher risk for PIH in SOC. Ultrasound devices showed clinical utility in improvement of skin laxity, texture, and overall improvement. Patients with SOC respond well to skin-tightening devices due to the increased collagen synthesis. Regarding emerging devices for reduction of adipocytes, deoxycholic acid when injected showed notable improvement in fat reduction but also had adverse effects. As additional studies on cosmetic procedures in SOC emerge, an expansion of treatment options could be offered to this demographic group with confidence, provided proper treatment and follow-up protocols are in place.

Cosmetic laser procedures as well as energy-based fat reduction and body-contouring devices are increasingly popular among individuals with skin of color (SOC). Innovations in cosmetic devices and procedures tailored for SOC have allowed for the optimization of outcomes in this patient population. In this article, SOC is defined as darker skin types, including Fitzpatrick skin types (FSTs) IV to VI and ethnic backgrounds such as LatinX, African American, Southeast Asian, Native American, Pacific Islander, Middle Eastern, Asian, and African. Indications for laser treatment include dermatosis papulosa nigrans (DPN), acne scars, skin rejuvenation, and hyperpigmentation. There currently are 6 procedures for nonsurgical fat reduction that are approved by the US Food and Drug Administration (FDA): high-frequency focused ultrasound, cryolipolysis, laser lipolysis, injection lipolysis, radiofrequency lipolysis, and magnetic resonance contouring (Supplementary Table S1).¹

In this review, our initial focus is cosmetic laser ­procedures, encompassing FDA-cleared indications along with the associated risks and benefits in SOC populations. Subsequently, we delve into the realms of energy-based fat reduction and body contouring, offering a comprehensive overview of these noninvasive therapies and addressing considerations for efficacy and safety in these patients.

Dermatosis Papulosa Nigra

In patients with SOC, scissor excision, curettage, or electrodesiccation are the mainstay treatments for removal of DPN (Figure 1). Curettage and electrodesiccation can cause temporary postinflammatory hyperpigmentation (PIH) in these populations, while cryotherapy is not a preferred method in patients with SOC due to the possibility of cryotherapy-induced depigmentation. In a 14-patient split-face study comparing the 532-nm potassium titanyl phosphate (KTP) laser vs electrodesiccation in FSTs IV to VI, the KTP-treated side showed an improvement rate of 96%, while the electrodesiccation side showed an improvement rate of 79%. There was a statistically significant favorable experience for KTP with regard to pain tolerability (P=.002).² Complete resolution of lesions may be seen after 3 to 4 sessions at 4-week intervals. Additionally, the 1064-nm Nd:YAG laser was assessed for treatment of DPN in 2 patients, with 70% to 90% of lesions resolved after a single treatment with no complications.³

Most dermatologists still rely on curettage and electrodesiccation instead of laser therapy to remove DPNs in patients with SOC. The use of the Nd:YAG laser is promising yet expensive for the provider both to purchase and maintain. Electrodesiccation has been used by dermatology practices for decades and can be used without permanent discoloration. To minimize the risk for PIH, we recommend application of a healing ointment such as petroleum jelly or aloe vera gel to the treated lesions as well as lightening agents for PIH and daily use of sunscreen. Overall, providers do not need to purchase an expensive laser device for DPN removal.

Acne Scars

The invention of fractional technology in the early 2000s and its favorable safety profile have changed how dermatologists treat scarring in patients with SOC.^4,5 In fact, nonablative fractional (NAF) resurfacing is a preferred treatment modality for management of acne scars in patients with SOC.⁶ In one study of the 1550-nm erbium-doped fiber laser for treatment of acne scars (3 treatments at intervals of 2-3 weeks) in 10 Japanese patients, clinical improvement was seen in all patients and no severe adverse effects were reported.⁷ In another study, 27 Korean patients with FSTs IV and V were treated with an NAF resurfacing device for acne scars. Excellent results were reported in 30% (8/27) of patients, substantial improvement in 59% (16/27), and moderate improvement in 11% (3/27).⁸ To evaluate outcomes in patients treated with NAF resurfacing, a retrospective review of 961 treatments showed a hyperpigmentation rate of 11.6% in those with FST IV and 33% in FST V.⁹

In one study of the short-pulsed nonablative Nd:YAG laser, 9 patients with FSTs I to V and 2 patients with FSTs IV to V underwent 8 treatments at 2-week intervals. Three blinded observers found a 29% improvement in the Global Acne Scar Severity score, while 89% (8/9) of patients self-reported subjective improvement in their acne scars.¹⁰

The 755-nm picosecond laser and diffractive lens array also have been shown to reduce the appearance of acne scars in patients with SOC, as shown via serial photography in a retrospective study of 56 patients with FSTs IV to VI. Transient hyperpigmentation, erythema, and edema were reported.¹¹

Nonablative laser therapy is preferred for skin rejuvenation in patients with SOC due to a reduced risk for postprocedural hyperpigmentation.¹¹ Ablative resurfacing (eg, CO₂ laser) poses major risks for postprocedural hyperpigmentation, hypopigmentation, and scar formation and therefore should be avoided in these populations.^12,13 A study involving 30 Asian patients (FSTs III-IV) demonstrated that the 1550-nm fractional laser was well tolerated, though higher treatment densities and fluences may lead to temporary adverse effects such as increased redness, swelling, and pain (P<.01).¹⁴ Furthermore, greater density was shown to cause higher levels of redness, hyperpigmentation, and swelling in comparison to higher fluence settings. Of note, patient satisfaction was markedly higher in patients who underwent treatment with higher fluence settings but not in patients with higher densities (P<.05). Postprocedural hyperpigmentation was noted in 6.7% (2/30) of patients studied.¹⁴ In another study, 8 patients with FSTs II to V were treated with either the 1064-nm long-pulsed Nd:YAG laser or the grid fractional monopolar radiofrequency laser.¹⁵ All participants experienced a significant decrease in mean wrinkle count using the Lemperle wrinkle assessment (P<.05). A significant decrease in mean wrinkle assessment score from 3.5 to 3.17 in clinical assessment and a decrease from 3.165 to 2.33 for photographic assessment was noted in patients treated with the grid laser (P<.05). A similar decrease in mean wrinkle assessment score was observed in the Nd:YAG group, with a mean decrease of 3.665 to 2.83 after 2 months for clinical assessment and 3.5 to 2.67 for photographic assessment. Among all patients in the study, 68% (6/8) experienced erythema, 25% (2/8) had a burning sensation, and 25% (2/8) experienced urticaria immediately postprocedure.¹⁵

Nonablative fractional resurfacing is preferred for the management of acne scars in patients with SOC. Adverse effects such as hyperpigmentation typically are transient, and the risk may be minimized with strict photoprotective practices following the procedure. Furthermore, avoidance of topicals containing exfoliants or α-hydroxy acids applied to the treated area following the procedure also may mitigate the risk for postprocedural hyperpigmentation.¹⁶ If hyperpigmentation does occur, use of topical melanogenesis inhibitors such as hydroquinone, kojic acid, or azelaic acid has shown some utility in practice.

Skin Rejuvenation

Nonablative fractional lasers (NAFLs) continue to be popular for treatment of photoaging. One study including 10 Asian patients (FSTs III-V) assessed the 1440-nm diode-based fractional laser for facial rejuvenation.¹⁷ After 4 sessions at 2-week intervals, 80% (8/10) of patients reported decreased skin roughness after both the second and third treatments, while 90% (9/10) had improved texture 1 month after the final procedure. Adverse effects included moderate facial edema and one case of transient hyperpigmentation.¹⁷ Another study reported a significant reduction in pore score (P<.002), with patients noting an overall improvement in skin appearance with minimal erythema, dryness, and flaking following 6 sessions at 2-week intervals using the 1440-nm diode-based fractional laser.¹⁸

The 1550-nm diode fractional laser significantly improved skin pigmentation (P<.001) and texture (P<.001) in 10 patients with FSTs II to IV following 5 sessions at 2- to 3-week intervals, with self-resolving erythema and edema posttreatment (Supplementary Table S2).¹⁹ Overall, NAFLs for the treatment of photoaging are effective with minimal adverse effects (eg, facial edema), which can be reduced with application of cold compression to the face and elevation of the head following treatment as well as the use of additional pillows during overnight sleep.

Laser Treatment for Hyperpigmentation Disorders

Melasma—The FDA recently approved fractional photothermolysis for the treatment of melasma; however, due to the risk for hyperpigmentation given its pathogenesis linked to hyperactive melanocytes, this laser is not considered a first-line therapy for melasma.²⁰ In a split-face, randomized study, 22 patients with FSTs III to V who were diagnosed with either dermal or mixed-type melasma were treated with a low-fluence Q-switched Nd:YAG laser combined with hydroquinone 2% vs hydroquinone 2% alone (Supplementary Table S3).²¹ Each patient was treated weekly for 5 consecutive weeks. The laser-treated side was found to reach an average of 92.5% improvement compared with 19.7% on the hydroquinone-only side. Three of the 22 (13.6%) patients developed mottled hypopigmentation after 5 laser treatments, and 8 (36.4%) developed confetti-type hypopigmentation. Four (18.2%) patients developed rebound hyperpigmentation, and all 22 patients experienced recurrence of melasma by 12 weeks posttreatment.²¹

First-line treatment for melasma involves the application of topical lightening agents such as hydroquinone, azelaic acid, kojic acid, retinoids, or mild topical steroids. Combining laser technology with topical medications can enhance treatment outcomes, particularly yielding positive results for patients with persistent pigmentation concerns. Notably, utilization of 650-microsecond technology with the 1064-nm Nd:YAG laser is considered superior in clinical practice, especially for patients with FSTs IV through VI.

Postinflammatory Hyperpigmentation—A retrospective evaluation of 61 patients with FSTs IV to VI with PIH treated with a 1927-nm NAFL showed a mean improvement of 43.24%, as assessed by 2 dermatologists.²² Additionally, the Nd:YAG 1064-nm 650-microsecond pulse duration laser is an emerging treatment that delivers high and low fluences between 4 J/cm² and 255 J/cm² within a single 650-microsecond pulse duration.²³ The short-pulse duration avoids overheating the skin, mitigating procedural discomfort and the risk for adverse effects commonly seen with the previous generation of low-pulsed lasers. In addition to PIH, this laser has been successfully used to treat pseudofolliculitis barbae.²⁴

Solar Lentigos—In a split-face study treating solar lentigos in Asian patients, 4 treatments with a low-pulsed KTP 532-nm laser were administered with and without a second treatment with a low-pulsed 1064-nm Nd:YAG laser.²⁵ Scoring of a modified pigment severity index and measurement of the melanin index showed that skin treated with the low-pulsed 532-nm laser alone and in combination with the low-pulsed 1064-nm Nd:YAG laser resulted in improvement at 3 months’ follow-up. However, there was no difference between the 2 sides of the face, leading the researchers to conclude that the low-pulsed 532-nm laser appears to be safe and effective for treatment of solar lentigos in Asian patients and does not require the addition of the low-pulsed 1064-nm laser.²⁵  

To avoid hyperpigmentation in patients with SOC, strict photoprotection to the treated areas should be advised. Proper cooling of the laser-treated area is required to minimize PIH, as cooling decreases tissue damage and excessive thermal injury. Test spots should be considered prior to initiation of the full laser treatment. Hydroquinone in a 4% concentration applied daily for 2 weeks preprocedure commonly is employed to reduce the risk for postprocedural hyperpigmentation in clinical practice.^26,27

Skin Tightening and Body Contouring

In general, skin-tightening and body-contouring devices are among the most sought-after procedures. Studies performed in patients with SOC are limited. Herein, we provide background on why these devices are favorable for patients with SOC and our experiences in using them. A summary of these devices can be found in Supplementary Table S4.

Radiofrequency Skin Tightening—Radiofrequency devices are utilized for skin tightening as well as mild fat reduction; they commonly are used on the abdomen, thighs, buttocks, and face.²⁸ People with SOC are more responsive to radiofrequency skin-tightening therapy due to higher baseline collagen content and dermal thickness, more sebaceous activity and skin elasticity, and more melanin content which offers protective thermal buffering.^29,30 As the radiofrequency device emits heat, penetrating deep into the dermis, it generates collagen remodeling and synthesis within 4 to 6 months posttreatment.

Nonsurgical Fat Reduction

Procedures for nonsurgical fat reduction are favorable due to minimal recovery time, manageable cost, and an in-office procedure setting. As noted previously, there are 6 FDA-indicated interventions for nonsurgical fat reduction: ultrasonography, cryolipolysis, laser lipolysis, injection lipolysis, radiofrequency lipolysis, and magnetic resonance contouring.³¹

Ultrasonography—Ultrasound devices designed for body contouring are used for skin tightening and mild fat reduction through the use of acoustic energy.³² These devices can be divided into 2 categories: high frequency and low frequency, with the high-frequency devices being the most popular. High-frequency ultrasound energy produces heat at target sites, which induces necrosis of adipocytes and stimulates collagen remodeling within the tissue matrix.³³ Tissue temperatures above 56°C stimulate adipocyte necrosis while sparing nearby nerves and vessels.²⁸ Because of the short duration of the procedure, the risk for epidermal damage is minimal. Contrary to high-frequency ultrasonography, focus-pulsed ultrasonography employs low-frequency waves to induce the mechanical disruption of adipocytes, which is generally better tolerated due to its nonthermal mechanism. The latter may be advantageous in patients with SOC due to a reduced risk for thermal injury to the epidermis. Multiple treatments often are needed at 3- to 4-week intervals, resulting in gradual improvement observed over 2 to 6 months. One study of microfocused ultrasonography in 25 Asian patients for treatment of face and neck laxity reported that skin laxity was improved or much improved in 84% (21/25) of patients following treatment.³⁴ Adverse effects were reported as mild and transient, resolving within 90 days.³⁴ Ultrasound devices also were shown to improve wrinkles, texture, and overall appearance of the skin in a 71-year-old African American woman 4 months following treatment (Figure 2). These photographs highlight the clinical utility of a microfocused ultrasound skin-tightening treatment in African American patients.

Cryolipolysis—Cryolipolysis is a noninvasive body contouring procedure that employs controlled cooling to induce subcutaneous panniculitis. Through cold-induced apoptosis of adipocytes, this procedure selectively reduces adipose tissue in localized areas such as the flank, abdomen, thighs, buttocks, back, submental area, and upper arms. The temperature used in cryolipolysis is approximately –10°C.³⁵ The lethal temperature for melanocytes is –4 °C, below which melanocyte apoptosis may be induced, resulting in depigmentation. Given the prolonged contact of the skin with a cryolipolysis device for up to 60 minutes during a body-contouring procedure, there is a risk for resultant depigmentation in darker skin types. Controlled studies are needed to fully evaluate the safety and efficacy of cryolipolysis in patients with SOC. One retrospective study of cryolipolysis applied to the abdomen and upper arm of 4122 Asian patients reported a significant (P<.05) reduction in the circumference of the abdomen and the upper-arm areas. No long-term adverse effects were reported.³⁶

Laser Lipolysis—The 1060-nm diode laser for body contouring selectively destroys adipose tissue, resulting in body contouring via thermally induced inflammation. Hyperthermic exposure for 15 minutes selectively elevates adipocyte temperature between 42°C to 47°C, which triggers apoptosis and the eventual clearance of destroyed cells from the interstitial space.³⁷ The selectivity of the 1060-nm wavelength coupled with the device’s contact cooling system preserves the overlying skin and adnexa during the procedure,³⁷ which would minimize epidermal damage that may induce dyspigmentation in patients with SOC. No notable adverse effects or dyspigmentation have been reported using this device.

Injection Lipolysis—Deoxycholic acid is an injectable adipocytolytic for the reduction of submental fat. It nonselectively lyses muscle and other adjacent nonfatty tissue. One study of 50 Indian patients demonstrated a substantial reduction of submental fat in 90% (45/50).³⁸ For each treatment, 5 mL of 30 mg/mL deoxycholic acid was injected. Serial sessions were conducted at 2-month intervals, and most (64% [32/50]) patients required 3 sessions to see a treatment effect. Adverse effects included transient swelling, lumpiness, and tenderness. A phase 2a investigation of the novel injectable small-molecule drug CBL-514 in 43 Asian and White participants found a significant improvement in the reduction in abdominal fat volume (P<.00001) and thickness (P<.0001) relative to baseline at higher doses (unit dose, 2.0 mg/cm² and 1.6 mg/cm²).³⁹ In addition to the adverse effects mentioned previously, pruritus, repeated urticaria, body rash, and fever also were reported.³⁹  

Radiofrequency Lipolysis—Radiofrequency is used for adipolysis through heat-induced apoptosis. To achieve this effect, adipose tissue must sustain a temperature of 42 °C to 45 °C for at least 15 minutes.⁴⁰ In one study, 4 treatments performed at 7-day intervals resulted in a statistically significant reduction in circumference to the treated areas of the inner and outer thighs without any reported adverse effects (P<0.001).⁴¹ Of note, there was 1 cm of distance between the applicator and the skin. The absence of direct contact with the skin is likely to reduce the risk for postprocedural complications in patients with SOC.

Magnetic Resonance Contouring—Magnetic resonance contouring with high-intensity focused electromagnetic technology is an emerging treatment modality for noninvasive body contouring. One distinguishing characteristic from other currently available noninvasive fat-­reduction therapies is that magnetic resonance may improve strength, tone, and muscle thickness.⁴² This modality is FDA approved for contouring of the buttocks and abdomen and employs electromagnetic energy to stimulate approximately 20,000 muscle contractions within a time frame of 30 minutes. Though the mechanisms causing benefits to muscular and adipose tissue have not been elucidated, current findings suggest that the contractions stimulate substantial lipolysis of adipocytes, resulting in the release of large amounts of free fatty acids that cause damage to nearby adipose tissue.⁴³ Multiple treatments are required over time to maintain effect. No major adverse effects have been reported. The likely mechanism of action of magnetic resonance contouring does not appear to pose an increased risk to patients with SOC.

Final Thoughts

One of the major roadblocks in distilling indications along with associated risks and benefits for nonsurgical cosmetic practices for patients with SOC is a void in the primary literature involving these populations. Clinical experience serves to address this deficit in combination with a thorough review of the literature. The 1064-nm Nd:YAG laser has shown clinical utility in the treatment of DPN, melanoma, and acne scars, but it poses financial constraints to the provider in comparison to modalities used for many years. Notably, NAF resurfacing is preferred for the management of acne scars in patients with SOC and continues to gain popularity for the treatment of photoaging. Regarding skin-tightening and body-contouring devices, studies performed in patients with SOC are limited and affected by factors such as small sample sizes, underrepresentation of FSTs IV through VI, short follow-up durations, and a lack of standardized outcome measures. Additionally, few studies assess pigmentary adverse effects or stratify results by skin type, which is critical given the higher risk for PIH in SOC. Ultrasound devices showed clinical utility in improvement of skin laxity, texture, and overall improvement. Patients with SOC respond well to skin-tightening devices due to the increased collagen synthesis. Regarding emerging devices for reduction of adipocytes, deoxycholic acid when injected showed notable improvement in fat reduction but also had adverse effects. As additional studies on cosmetic procedures in SOC emerge, an expansion of treatment options could be offered to this demographic group with confidence, provided proper treatment and follow-up protocols are in place.

Cosmetic laser procedures as well as energy-based fat reduction and body-contouring devices are increasingly popular among individuals with skin of color (SOC). Innovations in cosmetic devices and procedures tailored for SOC have allowed for the optimization of outcomes in this patient population. In this article, SOC is defined as darker skin types, including Fitzpatrick skin types (FSTs) IV to VI and ethnic backgrounds such as LatinX, African American, Southeast Asian, Native American, Pacific Islander, Middle Eastern, Asian, and African. Indications for laser treatment include dermatosis papulosa nigrans (DPN), acne scars, skin rejuvenation, and hyperpigmentation. There currently are 6 procedures for nonsurgical fat reduction that are approved by the US Food and Drug Administration (FDA): high-frequency focused ultrasound, cryolipolysis, laser lipolysis, injection lipolysis, radiofrequency lipolysis, and magnetic resonance contouring (Supplementary Table S1).¹

In this review, our initial focus is cosmetic laser ­procedures, encompassing FDA-cleared indications along with the associated risks and benefits in SOC populations. Subsequently, we delve into the realms of energy-based fat reduction and body contouring, offering a comprehensive overview of these noninvasive therapies and addressing considerations for efficacy and safety in these patients.

Dermatosis Papulosa Nigra

In patients with SOC, scissor excision, curettage, or electrodesiccation are the mainstay treatments for removal of DPN (Figure 1). Curettage and electrodesiccation can cause temporary postinflammatory hyperpigmentation (PIH) in these populations, while cryotherapy is not a preferred method in patients with SOC due to the possibility of cryotherapy-induced depigmentation. In a 14-patient split-face study comparing the 532-nm potassium titanyl phosphate (KTP) laser vs electrodesiccation in FSTs IV to VI, the KTP-treated side showed an improvement rate of 96%, while the electrodesiccation side showed an improvement rate of 79%. There was a statistically significant favorable experience for KTP with regard to pain tolerability (P=.002).² Complete resolution of lesions may be seen after 3 to 4 sessions at 4-week intervals. Additionally, the 1064-nm Nd:YAG laser was assessed for treatment of DPN in 2 patients, with 70% to 90% of lesions resolved after a single treatment with no complications.³

Most dermatologists still rely on curettage and electrodesiccation instead of laser therapy to remove DPNs in patients with SOC. The use of the Nd:YAG laser is promising yet expensive for the provider both to purchase and maintain. Electrodesiccation has been used by dermatology practices for decades and can be used without permanent discoloration. To minimize the risk for PIH, we recommend application of a healing ointment such as petroleum jelly or aloe vera gel to the treated lesions as well as lightening agents for PIH and daily use of sunscreen. Overall, providers do not need to purchase an expensive laser device for DPN removal.

Acne Scars

The invention of fractional technology in the early 2000s and its favorable safety profile have changed how dermatologists treat scarring in patients with SOC.^4,5 In fact, nonablative fractional (NAF) resurfacing is a preferred treatment modality for management of acne scars in patients with SOC.⁶ In one study of the 1550-nm erbium-doped fiber laser for treatment of acne scars (3 treatments at intervals of 2-3 weeks) in 10 Japanese patients, clinical improvement was seen in all patients and no severe adverse effects were reported.⁷ In another study, 27 Korean patients with FSTs IV and V were treated with an NAF resurfacing device for acne scars. Excellent results were reported in 30% (8/27) of patients, substantial improvement in 59% (16/27), and moderate improvement in 11% (3/27).⁸ To evaluate outcomes in patients treated with NAF resurfacing, a retrospective review of 961 treatments showed a hyperpigmentation rate of 11.6% in those with FST IV and 33% in FST V.⁹

In one study of the short-pulsed nonablative Nd:YAG laser, 9 patients with FSTs I to V and 2 patients with FSTs IV to V underwent 8 treatments at 2-week intervals. Three blinded observers found a 29% improvement in the Global Acne Scar Severity score, while 89% (8/9) of patients self-reported subjective improvement in their acne scars.¹⁰

The 755-nm picosecond laser and diffractive lens array also have been shown to reduce the appearance of acne scars in patients with SOC, as shown via serial photography in a retrospective study of 56 patients with FSTs IV to VI. Transient hyperpigmentation, erythema, and edema were reported.¹¹

Nonablative laser therapy is preferred for skin rejuvenation in patients with SOC due to a reduced risk for postprocedural hyperpigmentation.¹¹ Ablative resurfacing (eg, CO₂ laser) poses major risks for postprocedural hyperpigmentation, hypopigmentation, and scar formation and therefore should be avoided in these populations.^12,13 A study involving 30 Asian patients (FSTs III-IV) demonstrated that the 1550-nm fractional laser was well tolerated, though higher treatment densities and fluences may lead to temporary adverse effects such as increased redness, swelling, and pain (P<.01).¹⁴ Furthermore, greater density was shown to cause higher levels of redness, hyperpigmentation, and swelling in comparison to higher fluence settings. Of note, patient satisfaction was markedly higher in patients who underwent treatment with higher fluence settings but not in patients with higher densities (P<.05). Postprocedural hyperpigmentation was noted in 6.7% (2/30) of patients studied.¹⁴ In another study, 8 patients with FSTs II to V were treated with either the 1064-nm long-pulsed Nd:YAG laser or the grid fractional monopolar radiofrequency laser.¹⁵ All participants experienced a significant decrease in mean wrinkle count using the Lemperle wrinkle assessment (P<.05). A significant decrease in mean wrinkle assessment score from 3.5 to 3.17 in clinical assessment and a decrease from 3.165 to 2.33 for photographic assessment was noted in patients treated with the grid laser (P<.05). A similar decrease in mean wrinkle assessment score was observed in the Nd:YAG group, with a mean decrease of 3.665 to 2.83 after 2 months for clinical assessment and 3.5 to 2.67 for photographic assessment. Among all patients in the study, 68% (6/8) experienced erythema, 25% (2/8) had a burning sensation, and 25% (2/8) experienced urticaria immediately postprocedure.¹⁵

Nonablative fractional resurfacing is preferred for the management of acne scars in patients with SOC. Adverse effects such as hyperpigmentation typically are transient, and the risk may be minimized with strict photoprotective practices following the procedure. Furthermore, avoidance of topicals containing exfoliants or α-hydroxy acids applied to the treated area following the procedure also may mitigate the risk for postprocedural hyperpigmentation.¹⁶ If hyperpigmentation does occur, use of topical melanogenesis inhibitors such as hydroquinone, kojic acid, or azelaic acid has shown some utility in practice.

Skin Rejuvenation

Nonablative fractional lasers (NAFLs) continue to be popular for treatment of photoaging. One study including 10 Asian patients (FSTs III-V) assessed the 1440-nm diode-based fractional laser for facial rejuvenation.¹⁷ After 4 sessions at 2-week intervals, 80% (8/10) of patients reported decreased skin roughness after both the second and third treatments, while 90% (9/10) had improved texture 1 month after the final procedure. Adverse effects included moderate facial edema and one case of transient hyperpigmentation.¹⁷ Another study reported a significant reduction in pore score (P<.002), with patients noting an overall improvement in skin appearance with minimal erythema, dryness, and flaking following 6 sessions at 2-week intervals using the 1440-nm diode-based fractional laser.¹⁸

The 1550-nm diode fractional laser significantly improved skin pigmentation (P<.001) and texture (P<.001) in 10 patients with FSTs II to IV following 5 sessions at 2- to 3-week intervals, with self-resolving erythema and edema posttreatment (Supplementary Table S2).¹⁹ Overall, NAFLs for the treatment of photoaging are effective with minimal adverse effects (eg, facial edema), which can be reduced with application of cold compression to the face and elevation of the head following treatment as well as the use of additional pillows during overnight sleep.

Laser Treatment for Hyperpigmentation Disorders

Melasma—The FDA recently approved fractional photothermolysis for the treatment of melasma; however, due to the risk for hyperpigmentation given its pathogenesis linked to hyperactive melanocytes, this laser is not considered a first-line therapy for melasma.²⁰ In a split-face, randomized study, 22 patients with FSTs III to V who were diagnosed with either dermal or mixed-type melasma were treated with a low-fluence Q-switched Nd:YAG laser combined with hydroquinone 2% vs hydroquinone 2% alone (Supplementary Table S3).²¹ Each patient was treated weekly for 5 consecutive weeks. The laser-treated side was found to reach an average of 92.5% improvement compared with 19.7% on the hydroquinone-only side. Three of the 22 (13.6%) patients developed mottled hypopigmentation after 5 laser treatments, and 8 (36.4%) developed confetti-type hypopigmentation. Four (18.2%) patients developed rebound hyperpigmentation, and all 22 patients experienced recurrence of melasma by 12 weeks posttreatment.²¹

First-line treatment for melasma involves the application of topical lightening agents such as hydroquinone, azelaic acid, kojic acid, retinoids, or mild topical steroids. Combining laser technology with topical medications can enhance treatment outcomes, particularly yielding positive results for patients with persistent pigmentation concerns. Notably, utilization of 650-microsecond technology with the 1064-nm Nd:YAG laser is considered superior in clinical practice, especially for patients with FSTs IV through VI.

Postinflammatory Hyperpigmentation—A retrospective evaluation of 61 patients with FSTs IV to VI with PIH treated with a 1927-nm NAFL showed a mean improvement of 43.24%, as assessed by 2 dermatologists.²² Additionally, the Nd:YAG 1064-nm 650-microsecond pulse duration laser is an emerging treatment that delivers high and low fluences between 4 J/cm² and 255 J/cm² within a single 650-microsecond pulse duration.²³ The short-pulse duration avoids overheating the skin, mitigating procedural discomfort and the risk for adverse effects commonly seen with the previous generation of low-pulsed lasers. In addition to PIH, this laser has been successfully used to treat pseudofolliculitis barbae.²⁴

Solar Lentigos—In a split-face study treating solar lentigos in Asian patients, 4 treatments with a low-pulsed KTP 532-nm laser were administered with and without a second treatment with a low-pulsed 1064-nm Nd:YAG laser.²⁵ Scoring of a modified pigment severity index and measurement of the melanin index showed that skin treated with the low-pulsed 532-nm laser alone and in combination with the low-pulsed 1064-nm Nd:YAG laser resulted in improvement at 3 months’ follow-up. However, there was no difference between the 2 sides of the face, leading the researchers to conclude that the low-pulsed 532-nm laser appears to be safe and effective for treatment of solar lentigos in Asian patients and does not require the addition of the low-pulsed 1064-nm laser.²⁵  

To avoid hyperpigmentation in patients with SOC, strict photoprotection to the treated areas should be advised. Proper cooling of the laser-treated area is required to minimize PIH, as cooling decreases tissue damage and excessive thermal injury. Test spots should be considered prior to initiation of the full laser treatment. Hydroquinone in a 4% concentration applied daily for 2 weeks preprocedure commonly is employed to reduce the risk for postprocedural hyperpigmentation in clinical practice.^26,27

Skin Tightening and Body Contouring

In general, skin-tightening and body-contouring devices are among the most sought-after procedures. Studies performed in patients with SOC are limited. Herein, we provide background on why these devices are favorable for patients with SOC and our experiences in using them. A summary of these devices can be found in Supplementary Table S4.

Radiofrequency Skin Tightening—Radiofrequency devices are utilized for skin tightening as well as mild fat reduction; they commonly are used on the abdomen, thighs, buttocks, and face.²⁸ People with SOC are more responsive to radiofrequency skin-tightening therapy due to higher baseline collagen content and dermal thickness, more sebaceous activity and skin elasticity, and more melanin content which offers protective thermal buffering.^29,30 As the radiofrequency device emits heat, penetrating deep into the dermis, it generates collagen remodeling and synthesis within 4 to 6 months posttreatment.

Nonsurgical Fat Reduction

Procedures for nonsurgical fat reduction are favorable due to minimal recovery time, manageable cost, and an in-office procedure setting. As noted previously, there are 6 FDA-indicated interventions for nonsurgical fat reduction: ultrasonography, cryolipolysis, laser lipolysis, injection lipolysis, radiofrequency lipolysis, and magnetic resonance contouring.³¹

Ultrasonography—Ultrasound devices designed for body contouring are used for skin tightening and mild fat reduction through the use of acoustic energy.³² These devices can be divided into 2 categories: high frequency and low frequency, with the high-frequency devices being the most popular. High-frequency ultrasound energy produces heat at target sites, which induces necrosis of adipocytes and stimulates collagen remodeling within the tissue matrix.³³ Tissue temperatures above 56°C stimulate adipocyte necrosis while sparing nearby nerves and vessels.²⁸ Because of the short duration of the procedure, the risk for epidermal damage is minimal. Contrary to high-frequency ultrasonography, focus-pulsed ultrasonography employs low-frequency waves to induce the mechanical disruption of adipocytes, which is generally better tolerated due to its nonthermal mechanism. The latter may be advantageous in patients with SOC due to a reduced risk for thermal injury to the epidermis. Multiple treatments often are needed at 3- to 4-week intervals, resulting in gradual improvement observed over 2 to 6 months. One study of microfocused ultrasonography in 25 Asian patients for treatment of face and neck laxity reported that skin laxity was improved or much improved in 84% (21/25) of patients following treatment.³⁴ Adverse effects were reported as mild and transient, resolving within 90 days.³⁴ Ultrasound devices also were shown to improve wrinkles, texture, and overall appearance of the skin in a 71-year-old African American woman 4 months following treatment (Figure 2). These photographs highlight the clinical utility of a microfocused ultrasound skin-tightening treatment in African American patients.

Cryolipolysis—Cryolipolysis is a noninvasive body contouring procedure that employs controlled cooling to induce subcutaneous panniculitis. Through cold-induced apoptosis of adipocytes, this procedure selectively reduces adipose tissue in localized areas such as the flank, abdomen, thighs, buttocks, back, submental area, and upper arms. The temperature used in cryolipolysis is approximately –10°C.³⁵ The lethal temperature for melanocytes is –4 °C, below which melanocyte apoptosis may be induced, resulting in depigmentation. Given the prolonged contact of the skin with a cryolipolysis device for up to 60 minutes during a body-contouring procedure, there is a risk for resultant depigmentation in darker skin types. Controlled studies are needed to fully evaluate the safety and efficacy of cryolipolysis in patients with SOC. One retrospective study of cryolipolysis applied to the abdomen and upper arm of 4122 Asian patients reported a significant (P<.05) reduction in the circumference of the abdomen and the upper-arm areas. No long-term adverse effects were reported.³⁶

Laser Lipolysis—The 1060-nm diode laser for body contouring selectively destroys adipose tissue, resulting in body contouring via thermally induced inflammation. Hyperthermic exposure for 15 minutes selectively elevates adipocyte temperature between 42°C to 47°C, which triggers apoptosis and the eventual clearance of destroyed cells from the interstitial space.³⁷ The selectivity of the 1060-nm wavelength coupled with the device’s contact cooling system preserves the overlying skin and adnexa during the procedure,³⁷ which would minimize epidermal damage that may induce dyspigmentation in patients with SOC. No notable adverse effects or dyspigmentation have been reported using this device.

Injection Lipolysis—Deoxycholic acid is an injectable adipocytolytic for the reduction of submental fat. It nonselectively lyses muscle and other adjacent nonfatty tissue. One study of 50 Indian patients demonstrated a substantial reduction of submental fat in 90% (45/50).³⁸ For each treatment, 5 mL of 30 mg/mL deoxycholic acid was injected. Serial sessions were conducted at 2-month intervals, and most (64% [32/50]) patients required 3 sessions to see a treatment effect. Adverse effects included transient swelling, lumpiness, and tenderness. A phase 2a investigation of the novel injectable small-molecule drug CBL-514 in 43 Asian and White participants found a significant improvement in the reduction in abdominal fat volume (P<.00001) and thickness (P<.0001) relative to baseline at higher doses (unit dose, 2.0 mg/cm² and 1.6 mg/cm²).³⁹ In addition to the adverse effects mentioned previously, pruritus, repeated urticaria, body rash, and fever also were reported.³⁹  

Radiofrequency Lipolysis—Radiofrequency is used for adipolysis through heat-induced apoptosis. To achieve this effect, adipose tissue must sustain a temperature of 42 °C to 45 °C for at least 15 minutes.⁴⁰ In one study, 4 treatments performed at 7-day intervals resulted in a statistically significant reduction in circumference to the treated areas of the inner and outer thighs without any reported adverse effects (P<0.001).⁴¹ Of note, there was 1 cm of distance between the applicator and the skin. The absence of direct contact with the skin is likely to reduce the risk for postprocedural complications in patients with SOC.

Magnetic Resonance Contouring—Magnetic resonance contouring with high-intensity focused electromagnetic technology is an emerging treatment modality for noninvasive body contouring. One distinguishing characteristic from other currently available noninvasive fat-­reduction therapies is that magnetic resonance may improve strength, tone, and muscle thickness.⁴² This modality is FDA approved for contouring of the buttocks and abdomen and employs electromagnetic energy to stimulate approximately 20,000 muscle contractions within a time frame of 30 minutes. Though the mechanisms causing benefits to muscular and adipose tissue have not been elucidated, current findings suggest that the contractions stimulate substantial lipolysis of adipocytes, resulting in the release of large amounts of free fatty acids that cause damage to nearby adipose tissue.⁴³ Multiple treatments are required over time to maintain effect. No major adverse effects have been reported. The likely mechanism of action of magnetic resonance contouring does not appear to pose an increased risk to patients with SOC.

Final Thoughts

One of the major roadblocks in distilling indications along with associated risks and benefits for nonsurgical cosmetic practices for patients with SOC is a void in the primary literature involving these populations. Clinical experience serves to address this deficit in combination with a thorough review of the literature. The 1064-nm Nd:YAG laser has shown clinical utility in the treatment of DPN, melanoma, and acne scars, but it poses financial constraints to the provider in comparison to modalities used for many years. Notably, NAF resurfacing is preferred for the management of acne scars in patients with SOC and continues to gain popularity for the treatment of photoaging. Regarding skin-tightening and body-contouring devices, studies performed in patients with SOC are limited and affected by factors such as small sample sizes, underrepresentation of FSTs IV through VI, short follow-up durations, and a lack of standardized outcome measures. Additionally, few studies assess pigmentary adverse effects or stratify results by skin type, which is critical given the higher risk for PIH in SOC. Ultrasound devices showed clinical utility in improvement of skin laxity, texture, and overall improvement. Patients with SOC respond well to skin-tightening devices due to the increased collagen synthesis. Regarding emerging devices for reduction of adipocytes, deoxycholic acid when injected showed notable improvement in fat reduction but also had adverse effects. As additional studies on cosmetic procedures in SOC emerge, an expansion of treatment options could be offered to this demographic group with confidence, provided proper treatment and follow-up protocols are in place.

The umbrella term skin of color (SOC) includes individuals identifying as Black/African, Hispanic, Asian, Native American, Middle Eastern, and Mediterranean as well as multiracial groups. While the Fitzpatrick skin typing system is not an accurate proxy for describing skin tone, SOC populations typically correspond to Fitzpatrick skin types IV to VI, and clinical researchers often report the Fitzpatrick skin type of their study populations.¹

Over the past several decades, the underrepresentation of diverse skin tones in educational resources has limited clinical training.² For example, only 10.3% of conditions featured in contemporary dermatology textbooks are shown in darker skin tones.³ This educational resource gap has spurred a transformative movement toward inclusivity in dermatologic education, research, and clinical practice. Notable examples include VisualDx⁴ and Dermatology for Skin of Color.⁵ In addition, Cutis began publishing the Dx Across the Skin Color Spectrum fact sheet series in 2022 to highlight differences in how cutaneous conditions manifest in various skin tones (https://www.mdedge.com/cutis/dx-across-skin-color-spectrum).

These resources play a critical role in advancing dermatologic knowledge, ensuring that dermatologists and other health care professionals are well equipped to diagnose and treat dermatologic conditions in SOC populations with accuracy and cultural humility. These innovations also have enhanced our understanding of how common dermatologic conditions manifest and respond to treatment in SOC populations. Herein, we highlight advances in diagnostic and therapeutic approaches for the most common concerns among SOC populations in the United States, including acne vulgaris, atopic dermatitis (AD), seborrheic dermatitis (SD), melasma, postinflammatory hyperpigmentation, psoriasis, and seborrheic keratosis.

Chief Concerns Common Among SOC Populations in the United States

Acne Vulgaris—In patients with SOC, acne frequently results in pigmentary changes and scarring that can manifest as both hypertrophic and keloidal scars.⁶ Clinical evidence from randomized controlled studies supports the use of topical dapsone gel as a safe and effective frontline treatment for acne in patients with SOC.^7,8 Notably, the US Food and Drug Administration–approved 1726-nm laser with a contact-cooling sapphire window has demonstrated safety and efficacy in the management of acne across Fitzpatrick skin types II to VI.^9-11 To manage atrophic acne scars, cutting-edge laser and radiofrequency devices including erbium-doped yttrium aluminum garnet, fractional CO₂, and picosecond lasers have been effectively employed in SOC populations. When these energy-based treatments are combined with cooling systems, they substantially reduce the risk for thermal damage in darker skin tones.^12,13

Atopic Dermatitis—While epidemiologic data indicate that Black patients experience a higher prevalence (19.3%) of AD than Asian (17.8%), White (16.1%), or Hispanic (7.8%) groups in the United States, this disparity may be influenced by factors such as access to care and environmental stressors, which require further study.^14-16 The pathogenesis of AD involves a complex interaction between skin barrier dysfunction, immune dysregulation, and environmental triggers, with patients with SOC exhibiting distinct endotypes.^14,17 For example, East Asian individuals have elevated T_H17-related cytokines and a blended T_H17/T_H2 AD-psoriasis endotype,^14,18 while Black individuals have greater T_H2 skewing and filaggrin variations and higher serum IgE levels.¹⁷ Diagnostic advancements, including a modified Eczema Area and Severity Index using grayscale rather than erythema-based assessments for patients with SOC as well as a novel SOC dermatology atlas that includes AD have increased equity in disease evaluation.^19,20 Recent clinical trials support the efficacy of topical crisaborole, topical ruxolitinib, and biologics such as dupilumab, tralokinumab, lebrikizumab, and fezakinumab for AD in SOC populations, with dupilumab also improving postinflammatory hyperpigmentation.^20-22

Seborrheic Dermatitis—Seborrheic dermatitis is common in patients with SOC, though its manifestations vary by racial/ethnic background.²³ In Black patients, petaloid SD is more prevalent and can resemble secondary syphilis, making accurate diagnosis essential to rule out potential mimickers.²⁴ Effective treatments remain limited, as current therapies often fail to address both the underlying yeast-driven inflammation and the resulting pigmentary changes that commonly affect SOC populations.²⁵ Roflumilast foam 0.3%, a phosphodiesterase 4 inhibitor, has emerged as a promising option, offering both anti-inflammatory benefits and improvements in pigmentary alterations—making it particularly valuable for treatment of SD in patients with SOC.²⁶

Melasma—Melasma is more prevalent in women with darker skin types, particularly those of African descent and those from East and Southeast Asia or Latin America.^27,28 Standard treatments including hydroquinone, retinoids, azelaic acid, kojic acid, ascorbic acid, arbutin, alpha hydroxy acids, niacinamide, and the Kligman formula (5% hydroquinone, 0.1% tretinoin, and 0.1% dexamethasone) remain therapeutic foundations in patients with SOC.²⁹ Newer alternatives that are effective in SOC populations include topical metformin 30%30; topical isobutylamido thiazolyl resorcinol or thiamidol31; and tranexamic acid cream 5%, which has comparable efficacy to hydroquinone 4% with fewer adverse effects.³² Laser therapies such as the 675-nm and 1064-nm Q-switched neodymium-doped yttrium aluminum garnet lasers, offer effective pigment reduction and are safe in darker skin tones.^33,34

Postinflammatory Hyperpigmentation—Postinflammatory hyperpigmentation, often triggered by acne in SOC populations,²³ manifests as brown, tan, or gray discoloration and is managed using similar topical agents as melasma, with the 1927-nm laser providing an additional treatment option for patients with SOC.^27,35,36

Psoriasis—In patients with SOC, psoriasis often manifests with thicker plaques, increased scaling, and greater body surface area involvement, leading to considerable quality-of-life implications.³⁷ Although prevalence is highest in White populations (3.6%), Asian (2.5%) and Hispanic/Latino (1.9%) patients experience increased disease severity, potentially explaining why psoriasis is among the top chief complaints for these racial/ ethnic groups in the United States.^23,38 Greater diversity in clinical trials has improved our understanding of the efficacy of biologics for psoriasis in SOC populations. The VISIBLE trial—the first SOC-exclusive psoriasis trial—demonstrated a Psoriasis Area and Severity Index 90 response in 57.1% (44/77) of participants receiving guselkumab vs 3.8% (1/26) of participants receiving placebo by week 16 (P<.001).³⁹ Other biologics such as risankizumab, secukinumab, and brodalumab also have shown efficacy in SOC populations.^40-42 Additionally, topical therapies such as calcipotriene-betamethasone dipropionate cream/aerosol foam and halobetasol propionatetazarotene lotion have proven effective, with minimal adverse effects and low discontinuation rates in patients with SOC.^43-46

Seborrheic Keratosis—In SOC, seborrheic keratosis (SK) often appears as a variant known as dermatosis papulosa nigra (DPN), manifesting as small, benign, hyperpigmented papules, particularly on the face and neck.⁴⁷ Dermatosis papulosa nigra is common in Black, Hispanic, and some Asian populations, with variations in color and distribution among different racial/ethnic groups.⁴⁸ For example, in Korean populations, SKs commonly affect males, and in contrast to the dark brown color common in White populations, SKs in Korean patients often appear lighter brown or sometimes pink.⁴⁹ In contrast to the verrucous and stuck-on appearance often seen in White populations, South Asian populations more often have variants including pedunculated SKs, flat SKs, and stucco keratoses.⁵⁰ High-resolution dermoscopy improves differentiation from malignant lesions; however, a sudden SK eruption in any population warrants evaluation for underlying malignancy. Cryotherapy, though effective for removal of SKs, can cause pigmentary changes in SOC populations, making laser therapy and electrosurgery preferable for these patients due to the lower risk for pigmentary sequela. If hyperpigmentation occurs, topical treatments such as hydroquinone, tretinoin, or azelaic acid can help. New laser technologies and hydrogen-peroxide–based therapies offer safer and more effective removal options while minimizing pigmentary risks in SOC populations.^47,50 While DPNs are common in patients with darker skin tones, there are limited data on optimal treatment frequency, insurance coverage, and efficacy. This literature gap hinders our understanding of treatment accessibility and economic impact on our patients.⁵¹

Final Thoughts

Innovations such as standardized scoring systems and customized therapeutic strategies for conditions including acne, pigmentary disorders, and atopic dermatitis have markedly enhanced patient care and outcomes for the most common chief concerns in SOC populations. In addition, population-specific advancements have addressed unique diagnostic and therapeutic developments in Black, Asian/Pacific Islander, and Hispanic groups, from the nuanced presentations of atopic and seborrheic dermatitis in Black patients, to those of psoriasis in Asian/Pacific Islander and Hispanic populations. Finally, updated epidemiologic studies are essential to capture the current and evolving dermatologic concerns pertinent to patients with SOC, ensuring that future clinical and research efforts align with the unique needs of these populations.

The umbrella term skin of color (SOC) includes individuals identifying as Black/African, Hispanic, Asian, Native American, Middle Eastern, and Mediterranean as well as multiracial groups. While the Fitzpatrick skin typing system is not an accurate proxy for describing skin tone, SOC populations typically correspond to Fitzpatrick skin types IV to VI, and clinical researchers often report the Fitzpatrick skin type of their study populations.¹

Over the past several decades, the underrepresentation of diverse skin tones in educational resources has limited clinical training.² For example, only 10.3% of conditions featured in contemporary dermatology textbooks are shown in darker skin tones.³ This educational resource gap has spurred a transformative movement toward inclusivity in dermatologic education, research, and clinical practice. Notable examples include VisualDx⁴ and Dermatology for Skin of Color.⁵ In addition, Cutis began publishing the Dx Across the Skin Color Spectrum fact sheet series in 2022 to highlight differences in how cutaneous conditions manifest in various skin tones (https://www.mdedge.com/cutis/dx-across-skin-color-spectrum).

These resources play a critical role in advancing dermatologic knowledge, ensuring that dermatologists and other health care professionals are well equipped to diagnose and treat dermatologic conditions in SOC populations with accuracy and cultural humility. These innovations also have enhanced our understanding of how common dermatologic conditions manifest and respond to treatment in SOC populations. Herein, we highlight advances in diagnostic and therapeutic approaches for the most common concerns among SOC populations in the United States, including acne vulgaris, atopic dermatitis (AD), seborrheic dermatitis (SD), melasma, postinflammatory hyperpigmentation, psoriasis, and seborrheic keratosis.

Chief Concerns Common Among SOC Populations in the United States

Acne Vulgaris—In patients with SOC, acne frequently results in pigmentary changes and scarring that can manifest as both hypertrophic and keloidal scars.⁶ Clinical evidence from randomized controlled studies supports the use of topical dapsone gel as a safe and effective frontline treatment for acne in patients with SOC.^7,8 Notably, the US Food and Drug Administration–approved 1726-nm laser with a contact-cooling sapphire window has demonstrated safety and efficacy in the management of acne across Fitzpatrick skin types II to VI.^9-11 To manage atrophic acne scars, cutting-edge laser and radiofrequency devices including erbium-doped yttrium aluminum garnet, fractional CO₂, and picosecond lasers have been effectively employed in SOC populations. When these energy-based treatments are combined with cooling systems, they substantially reduce the risk for thermal damage in darker skin tones.^12,13

Atopic Dermatitis—While epidemiologic data indicate that Black patients experience a higher prevalence (19.3%) of AD than Asian (17.8%), White (16.1%), or Hispanic (7.8%) groups in the United States, this disparity may be influenced by factors such as access to care and environmental stressors, which require further study.^14-16 The pathogenesis of AD involves a complex interaction between skin barrier dysfunction, immune dysregulation, and environmental triggers, with patients with SOC exhibiting distinct endotypes.^14,17 For example, East Asian individuals have elevated T_H17-related cytokines and a blended T_H17/T_H2 AD-psoriasis endotype,^14,18 while Black individuals have greater T_H2 skewing and filaggrin variations and higher serum IgE levels.¹⁷ Diagnostic advancements, including a modified Eczema Area and Severity Index using grayscale rather than erythema-based assessments for patients with SOC as well as a novel SOC dermatology atlas that includes AD have increased equity in disease evaluation.^19,20 Recent clinical trials support the efficacy of topical crisaborole, topical ruxolitinib, and biologics such as dupilumab, tralokinumab, lebrikizumab, and fezakinumab for AD in SOC populations, with dupilumab also improving postinflammatory hyperpigmentation.^20-22

Seborrheic Dermatitis—Seborrheic dermatitis is common in patients with SOC, though its manifestations vary by racial/ethnic background.²³ In Black patients, petaloid SD is more prevalent and can resemble secondary syphilis, making accurate diagnosis essential to rule out potential mimickers.²⁴ Effective treatments remain limited, as current therapies often fail to address both the underlying yeast-driven inflammation and the resulting pigmentary changes that commonly affect SOC populations.²⁵ Roflumilast foam 0.3%, a phosphodiesterase 4 inhibitor, has emerged as a promising option, offering both anti-inflammatory benefits and improvements in pigmentary alterations—making it particularly valuable for treatment of SD in patients with SOC.²⁶

Melasma—Melasma is more prevalent in women with darker skin types, particularly those of African descent and those from East and Southeast Asia or Latin America.^27,28 Standard treatments including hydroquinone, retinoids, azelaic acid, kojic acid, ascorbic acid, arbutin, alpha hydroxy acids, niacinamide, and the Kligman formula (5% hydroquinone, 0.1% tretinoin, and 0.1% dexamethasone) remain therapeutic foundations in patients with SOC.²⁹ Newer alternatives that are effective in SOC populations include topical metformin 30%30; topical isobutylamido thiazolyl resorcinol or thiamidol31; and tranexamic acid cream 5%, which has comparable efficacy to hydroquinone 4% with fewer adverse effects.³² Laser therapies such as the 675-nm and 1064-nm Q-switched neodymium-doped yttrium aluminum garnet lasers, offer effective pigment reduction and are safe in darker skin tones.^33,34

Postinflammatory Hyperpigmentation—Postinflammatory hyperpigmentation, often triggered by acne in SOC populations,²³ manifests as brown, tan, or gray discoloration and is managed using similar topical agents as melasma, with the 1927-nm laser providing an additional treatment option for patients with SOC.^27,35,36

Psoriasis—In patients with SOC, psoriasis often manifests with thicker plaques, increased scaling, and greater body surface area involvement, leading to considerable quality-of-life implications.³⁷ Although prevalence is highest in White populations (3.6%), Asian (2.5%) and Hispanic/Latino (1.9%) patients experience increased disease severity, potentially explaining why psoriasis is among the top chief complaints for these racial/ ethnic groups in the United States.^23,38 Greater diversity in clinical trials has improved our understanding of the efficacy of biologics for psoriasis in SOC populations. The VISIBLE trial—the first SOC-exclusive psoriasis trial—demonstrated a Psoriasis Area and Severity Index 90 response in 57.1% (44/77) of participants receiving guselkumab vs 3.8% (1/26) of participants receiving placebo by week 16 (P<.001).³⁹ Other biologics such as risankizumab, secukinumab, and brodalumab also have shown efficacy in SOC populations.^40-42 Additionally, topical therapies such as calcipotriene-betamethasone dipropionate cream/aerosol foam and halobetasol propionatetazarotene lotion have proven effective, with minimal adverse effects and low discontinuation rates in patients with SOC.^43-46

Seborrheic Keratosis—In SOC, seborrheic keratosis (SK) often appears as a variant known as dermatosis papulosa nigra (DPN), manifesting as small, benign, hyperpigmented papules, particularly on the face and neck.⁴⁷ Dermatosis papulosa nigra is common in Black, Hispanic, and some Asian populations, with variations in color and distribution among different racial/ethnic groups.⁴⁸ For example, in Korean populations, SKs commonly affect males, and in contrast to the dark brown color common in White populations, SKs in Korean patients often appear lighter brown or sometimes pink.⁴⁹ In contrast to the verrucous and stuck-on appearance often seen in White populations, South Asian populations more often have variants including pedunculated SKs, flat SKs, and stucco keratoses.⁵⁰ High-resolution dermoscopy improves differentiation from malignant lesions; however, a sudden SK eruption in any population warrants evaluation for underlying malignancy. Cryotherapy, though effective for removal of SKs, can cause pigmentary changes in SOC populations, making laser therapy and electrosurgery preferable for these patients due to the lower risk for pigmentary sequela. If hyperpigmentation occurs, topical treatments such as hydroquinone, tretinoin, or azelaic acid can help. New laser technologies and hydrogen-peroxide–based therapies offer safer and more effective removal options while minimizing pigmentary risks in SOC populations.^47,50 While DPNs are common in patients with darker skin tones, there are limited data on optimal treatment frequency, insurance coverage, and efficacy. This literature gap hinders our understanding of treatment accessibility and economic impact on our patients.⁵¹

Final Thoughts

Innovations such as standardized scoring systems and customized therapeutic strategies for conditions including acne, pigmentary disorders, and atopic dermatitis have markedly enhanced patient care and outcomes for the most common chief concerns in SOC populations. In addition, population-specific advancements have addressed unique diagnostic and therapeutic developments in Black, Asian/Pacific Islander, and Hispanic groups, from the nuanced presentations of atopic and seborrheic dermatitis in Black patients, to those of psoriasis in Asian/Pacific Islander and Hispanic populations. Finally, updated epidemiologic studies are essential to capture the current and evolving dermatologic concerns pertinent to patients with SOC, ensuring that future clinical and research efforts align with the unique needs of these populations.

The umbrella term skin of color (SOC) includes individuals identifying as Black/African, Hispanic, Asian, Native American, Middle Eastern, and Mediterranean as well as multiracial groups. While the Fitzpatrick skin typing system is not an accurate proxy for describing skin tone, SOC populations typically correspond to Fitzpatrick skin types IV to VI, and clinical researchers often report the Fitzpatrick skin type of their study populations.¹

Over the past several decades, the underrepresentation of diverse skin tones in educational resources has limited clinical training.² For example, only 10.3% of conditions featured in contemporary dermatology textbooks are shown in darker skin tones.³ This educational resource gap has spurred a transformative movement toward inclusivity in dermatologic education, research, and clinical practice. Notable examples include VisualDx⁴ and Dermatology for Skin of Color.⁵ In addition, Cutis began publishing the Dx Across the Skin Color Spectrum fact sheet series in 2022 to highlight differences in how cutaneous conditions manifest in various skin tones (https://www.mdedge.com/cutis/dx-across-skin-color-spectrum).

These resources play a critical role in advancing dermatologic knowledge, ensuring that dermatologists and other health care professionals are well equipped to diagnose and treat dermatologic conditions in SOC populations with accuracy and cultural humility. These innovations also have enhanced our understanding of how common dermatologic conditions manifest and respond to treatment in SOC populations. Herein, we highlight advances in diagnostic and therapeutic approaches for the most common concerns among SOC populations in the United States, including acne vulgaris, atopic dermatitis (AD), seborrheic dermatitis (SD), melasma, postinflammatory hyperpigmentation, psoriasis, and seborrheic keratosis.

Chief Concerns Common Among SOC Populations in the United States

Acne Vulgaris—In patients with SOC, acne frequently results in pigmentary changes and scarring that can manifest as both hypertrophic and keloidal scars.⁶ Clinical evidence from randomized controlled studies supports the use of topical dapsone gel as a safe and effective frontline treatment for acne in patients with SOC.^7,8 Notably, the US Food and Drug Administration–approved 1726-nm laser with a contact-cooling sapphire window has demonstrated safety and efficacy in the management of acne across Fitzpatrick skin types II to VI.^9-11 To manage atrophic acne scars, cutting-edge laser and radiofrequency devices including erbium-doped yttrium aluminum garnet, fractional CO₂, and picosecond lasers have been effectively employed in SOC populations. When these energy-based treatments are combined with cooling systems, they substantially reduce the risk for thermal damage in darker skin tones.^12,13

Atopic Dermatitis—While epidemiologic data indicate that Black patients experience a higher prevalence (19.3%) of AD than Asian (17.8%), White (16.1%), or Hispanic (7.8%) groups in the United States, this disparity may be influenced by factors such as access to care and environmental stressors, which require further study.^14-16 The pathogenesis of AD involves a complex interaction between skin barrier dysfunction, immune dysregulation, and environmental triggers, with patients with SOC exhibiting distinct endotypes.^14,17 For example, East Asian individuals have elevated T_H17-related cytokines and a blended T_H17/T_H2 AD-psoriasis endotype,^14,18 while Black individuals have greater T_H2 skewing and filaggrin variations and higher serum IgE levels.¹⁷ Diagnostic advancements, including a modified Eczema Area and Severity Index using grayscale rather than erythema-based assessments for patients with SOC as well as a novel SOC dermatology atlas that includes AD have increased equity in disease evaluation.^19,20 Recent clinical trials support the efficacy of topical crisaborole, topical ruxolitinib, and biologics such as dupilumab, tralokinumab, lebrikizumab, and fezakinumab for AD in SOC populations, with dupilumab also improving postinflammatory hyperpigmentation.^20-22

Seborrheic Dermatitis—Seborrheic dermatitis is common in patients with SOC, though its manifestations vary by racial/ethnic background.²³ In Black patients, petaloid SD is more prevalent and can resemble secondary syphilis, making accurate diagnosis essential to rule out potential mimickers.²⁴ Effective treatments remain limited, as current therapies often fail to address both the underlying yeast-driven inflammation and the resulting pigmentary changes that commonly affect SOC populations.²⁵ Roflumilast foam 0.3%, a phosphodiesterase 4 inhibitor, has emerged as a promising option, offering both anti-inflammatory benefits and improvements in pigmentary alterations—making it particularly valuable for treatment of SD in patients with SOC.²⁶

Melasma—Melasma is more prevalent in women with darker skin types, particularly those of African descent and those from East and Southeast Asia or Latin America.^27,28 Standard treatments including hydroquinone, retinoids, azelaic acid, kojic acid, ascorbic acid, arbutin, alpha hydroxy acids, niacinamide, and the Kligman formula (5% hydroquinone, 0.1% tretinoin, and 0.1% dexamethasone) remain therapeutic foundations in patients with SOC.²⁹ Newer alternatives that are effective in SOC populations include topical metformin 30%30; topical isobutylamido thiazolyl resorcinol or thiamidol31; and tranexamic acid cream 5%, which has comparable efficacy to hydroquinone 4% with fewer adverse effects.³² Laser therapies such as the 675-nm and 1064-nm Q-switched neodymium-doped yttrium aluminum garnet lasers, offer effective pigment reduction and are safe in darker skin tones.^33,34

Postinflammatory Hyperpigmentation—Postinflammatory hyperpigmentation, often triggered by acne in SOC populations,²³ manifests as brown, tan, or gray discoloration and is managed using similar topical agents as melasma, with the 1927-nm laser providing an additional treatment option for patients with SOC.^27,35,36

Psoriasis—In patients with SOC, psoriasis often manifests with thicker plaques, increased scaling, and greater body surface area involvement, leading to considerable quality-of-life implications.³⁷ Although prevalence is highest in White populations (3.6%), Asian (2.5%) and Hispanic/Latino (1.9%) patients experience increased disease severity, potentially explaining why psoriasis is among the top chief complaints for these racial/ ethnic groups in the United States.^23,38 Greater diversity in clinical trials has improved our understanding of the efficacy of biologics for psoriasis in SOC populations. The VISIBLE trial—the first SOC-exclusive psoriasis trial—demonstrated a Psoriasis Area and Severity Index 90 response in 57.1% (44/77) of participants receiving guselkumab vs 3.8% (1/26) of participants receiving placebo by week 16 (P<.001).³⁹ Other biologics such as risankizumab, secukinumab, and brodalumab also have shown efficacy in SOC populations.^40-42 Additionally, topical therapies such as calcipotriene-betamethasone dipropionate cream/aerosol foam and halobetasol propionatetazarotene lotion have proven effective, with minimal adverse effects and low discontinuation rates in patients with SOC.^43-46

Seborrheic Keratosis—In SOC, seborrheic keratosis (SK) often appears as a variant known as dermatosis papulosa nigra (DPN), manifesting as small, benign, hyperpigmented papules, particularly on the face and neck.⁴⁷ Dermatosis papulosa nigra is common in Black, Hispanic, and some Asian populations, with variations in color and distribution among different racial/ethnic groups.⁴⁸ For example, in Korean populations, SKs commonly affect males, and in contrast to the dark brown color common in White populations, SKs in Korean patients often appear lighter brown or sometimes pink.⁴⁹ In contrast to the verrucous and stuck-on appearance often seen in White populations, South Asian populations more often have variants including pedunculated SKs, flat SKs, and stucco keratoses.⁵⁰ High-resolution dermoscopy improves differentiation from malignant lesions; however, a sudden SK eruption in any population warrants evaluation for underlying malignancy. Cryotherapy, though effective for removal of SKs, can cause pigmentary changes in SOC populations, making laser therapy and electrosurgery preferable for these patients due to the lower risk for pigmentary sequela. If hyperpigmentation occurs, topical treatments such as hydroquinone, tretinoin, or azelaic acid can help. New laser technologies and hydrogen-peroxide–based therapies offer safer and more effective removal options while minimizing pigmentary risks in SOC populations.^47,50 While DPNs are common in patients with darker skin tones, there are limited data on optimal treatment frequency, insurance coverage, and efficacy. This literature gap hinders our understanding of treatment accessibility and economic impact on our patients.⁵¹

Final Thoughts

Innovations such as standardized scoring systems and customized therapeutic strategies for conditions including acne, pigmentary disorders, and atopic dermatitis have markedly enhanced patient care and outcomes for the most common chief concerns in SOC populations. In addition, population-specific advancements have addressed unique diagnostic and therapeutic developments in Black, Asian/Pacific Islander, and Hispanic groups, from the nuanced presentations of atopic and seborrheic dermatitis in Black patients, to those of psoriasis in Asian/Pacific Islander and Hispanic populations. Finally, updated epidemiologic studies are essential to capture the current and evolving dermatologic concerns pertinent to patients with SOC, ensuring that future clinical and research efforts align with the unique needs of these populations.