As the globe shrinks via mobile technologies that allow people from many different cultures to interact instantaneously, the nuances of “ethnic diversity” become ever more apparent. Certainly, as we erase geographic borders, dermatologists are treating a much wider range of skin types. A loose terminology is developing in response to the changing patient mix.
Ethnic skin is a term used to identify or classify specific skin types associated with heritage, geography, and genetic links. People of Asian, African, Caribbean, and South American descent generally have darker skin tones than European Caucasian models, but not always. By this definition, we all have ethnic skin, driven by tribal gene pools, from pale Nordic to ebony equatorial.
The term people of color has become a more-global descriptor that applies to those of any ethnicity with darker skin tones. So while we all have ethnic skin, we're not all people of color.
Why is this important? Because the proportion of nonwhites in the United States is 29% now and is expected to reach 48% by 2050.
We need to understand more about ethnic skin and skin conditions of people of color because we are mixing together genetically like never before, creating new skin tones everyday. And we are finding that skin disease presents very differently on darker skin tones than that of lighter skin tones.
Darker skin is different from lighter skin because it has more melanin. This is the natural benefit of darker skin, which, as a result, generally ages gracefully, with less wrinkling. With melanin’s built-in SPF, there’s an overall decreased risk of skin cancer in people of color. However, people of African descent have a higher incidence than whites of melanoma that involves the palms and soles. Moreover, these cases of melanoma are often diagnosed late, resulting in poor prognosis and outcome.
Darker skin tones are also prone to more visible scarring, particularly from acne and surface wounds. This condition, hyperpigmentation, results when melanocytes in the inflamed area become stimulated by sun exposure, which darkens the skin, making scars more prominent. In my practice, scarring is one of the biggest concerns of my patients.
Besides scarring, dark skin tones can develop visible texture changes. Depressions on the skin surface (pits or divots) or raised scars (keloids) can be observed in all ethnic skin types. Because of the tendency to hyperpigmentation, raised scars are visibly more pronounced in darker skin tones.
Although most inflammatory and scarring skin diseases cause hyperpigmentation in darker skin tones, there are certain inflammatory diseases that are common in all skin types that actually cause lightening of skin tones, known as hypopigmentation. Two such examples are tinea versicolor and seborrheic dermatitis. With tinea versicolor, numerous small, white spots typically appear on the chest or back while sparing the face. It is a disease that characteristically affects young, healthy people. The spots don’t tan, so they appear more obvious in summer months. Tinea versicolor is caused by a superficial yeast infection of the skin and is fairly easy to treat.
In contrast, while seborrheic dermatitis can affect young, healthy people, it most commonly affects middle aged and older individuals. Also, unlike tinea versicolor, severe and persistent cases of seborrheic dermatitis are common in patients with underlying neurologic disease and immune deficiencies. The affected skin in darker-skinned patients is light pink in color, with a light to heavy, greasy scale, characteristically on the face and chest. These patches don’t tan, so affected areas appear more visible in the summer.
These are just a few examples of common skin conditions in people of color. Like with other organ systems, there are some skin diseases that demonstrate no differences among various ethnic groups. However, dermatologists and leading medical associations have an opportunity to update and share information on skin diseases that cause different appearances in people of color so that we can properly diagnose and effectively treat them. This will no doubt help to prepare all physicians to treat patients of all ethnicities, including the increasing number of people of color worldwide.
The more we learn now, the better prepared we will be to deliver quality care for the future.