Updating The Fitzpatrick Classification The Skin.1

Original Article
Updating the Fitzpatrick Classification: The Skin Color

and Ethnicity Scale
William Coleman, MD,* Kavita Mariwalla, MD,† and Pearl Grimes, MD‡
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BACKGROUND There has been a significant increase in submissions to scientific journals addressing a broad spectrum
of medical and surgical conditions in subjects grouped under the classification of “Skin of Color.” Authors, reviewers, and
editors have struggled with accurate terminology.
OBJECTIVE To update the Fitzpatrick scale to make it more accurate in stratifying various shades of skin color.
MATERIALS AND METHODS A thorough literature review was performed using PubMed and Embase to assess existing
skin color scales, and an extensive internet search was conducted using makeup foundation ranges as a starting point for
skin tone matching.
RESULTS The research resulted in a consensus that Fitzpatrick types 4 and 5 ratings were the most confusing in that
these included a broad range of skin types with different responses to solar radiation, lasers, surgery, and cosmetic
products. The authors reached a consensus that subdividing skin types 4 and 5 into “A” and “B” better defined them. The
new scale that resulted was labeled the SCE scale (for Skin Color Ethnicity).
CONCLUSION This new updated SCE scale should assist authors in better reporting scientific data in skin of color.
T here has been a significant increase in submissions to

scientific journals addressing a broad spectrum of
medical and surgical conditions in subjects grouped
under the classification of “Skin of Color.” Authors, re-
In the realm of dermatology, incorrect assessment of a
person’s skin tone could lead to miscalculation of risk
factors including cancer risk and potential for scarring or
keloid formation, dyschromia, and poor outcomes from
viewers, and editors have struggled with accurate termi- aesthetic procedures.
nology when constructing and reviewing these manuscripts Lexicons commonly used in the lay press, social science
and whether indeed the patients who may share a genetic or publications, national databases, and the US Census Bureau
cultural background should be classified as one considering to delineate diverse populations can be confusing and may
the range of melanin pigment that can exist in any one not conform to the necessary rigors needed for peer
group. By the year 2050, recent data from the US Census reviewed medical and surgical publications. For instance,
Bureau suggests that most people in the United States will be the term Asian categorizes a major segment of the global
skin of color populations including those self-identifying as population as a single group, despite the strikingly diverse
Latino, Asian, and African American.1 It should be noted skin color of the Asian continent; shades of pigmentation
that there are inherent problems with the US Census Bureau range from very fair (Russia) to skin deeply pigmented
classification categories. Multiple scientific investigations (Indian subcontinent). Similarly, recently popularized terms
document differences in disease susceptibility, presentation, such as “melanated” skin can also confuse the public to
morbidity, and mortality rates in different populations assume that fair skin lacks melanin. Adding to this is the
throughout the world.2 Hence, there exists an urgent need migration of people across the globe and the disparity that
for the dermatology/medical literature to objectively de- can exist when a patient identifies as one ethnic group
scribe and more accurately classify multihued diverse racial/ culturally, but has a skin phototype that does not correlate
ethnic groups and skin types in a reproducible and consis- with that group. Racial and ethnic intermarriage is
tent way. widespread with very few individuals having a genome
from a single geographic location. Despite the ready
availability of genetic research, most individuals have very
From the *Coleman Center for Cosmetic Dermatologic Surgery, Metairie, Louisiana;
little idea what their genetic ancestry is, and so, self-selecting
†
Mariwalla Dermatology, West Islip, New York; ‡ Vitiligo and Pigmentation Institute an ethnicity may be incorrect.5,6 Maternal haplogroups and
of Southern California, Los Angeles, California other genetic markers have confirmed worldwide genetic
Pearl Grimes is a Consultant, Investigator, and Shareholder of Versicolor admixing of previously separate populations.7 As popula-
Technologies LLC; Consultant and Investigator for Incyte, L’Oreal.
Address correspondence and reprint requests to: William Coleman, MD, Coleman
tions migrate and racial and ethnic intermarriage continues,
Center for Cosmetic Dermatologic Surgery, 4425 Conlin Street, Metairie, LA 70006, ethnicity is no longer a good predictor of skin behavior with
or e-mail: [email protected] dermatologic procedures. Although patients may select a
© 2023 by the American Society for Dermatologic Surgery, Inc. Published by specific ethnicity based on the culture practiced in their
Wolters Kluwer Health, Inc. All rights reserved.
Dermatol Surg 2023;49:725–731
home, as an objective measurement, this can be very
http://dx.doi.org/10.1097/DSS.0000000000003860 variable and unreliable. Moreover, multiple skin tones
Updating the Fitzpatrick Classification • Coleman et al www.dermatologicsurgery.org 725
© 2023 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
a wide range of skin color, demonstrating that lighter
skinned “black” subjects had a higher risk of total body nevi
and melanoma, whereas darker-skinned “black” subjects
had far fewer nevi and a higher risk of palmar and plantar
melanoma. The correlation of skin cancer risk in individuals
with fair skin has subsequently become well established.
When studying a population based on self-reported
ethnicity or geography, it is important for the researcher to
provide accurate skin type information.
The Fitzpatrick Skin Phototype Classification was de-

veloped in 1975 to demonstrate the correlation of skin cancer

and skin color and to assess an individual’s susceptibility to
sun burning and calculate the initial doses for phototherapy.
Over time, the Fitzpatrick scale has become synonymous with
skin classifications of race/ethnicity, even though this was not
the intended use.3 When constructing a cohort, physicians are
more accurate in stratifying subjects by Fitzpatrick skin type
than allowing patients to self-identify their skin type, which
has been shown to be quite inaccurate.6 In recent years, the
Fitzpatrick scale has been criticized as flawed, especially in
types IV and V. Because the original scale was devised to
predict skin cancer, it failed to properly stratify skin color for
other tendencies such as keloids, suitability for certain lasers,
and even the assessment of aging parameters.7–10
Figure 1. First degree cousins who identify as primarily South Several modifications have been proposed to the
Asian although their skin phototypes are markedly different. This Fitzpatrick scale to better incorporate darker skin types.
highlights the need to update the current skin phototype grading However, none of these have been comprehensive enough
system to properly assess risk when performing procedures and for authors and researchers to widely adopt them11–16
when classifying groups for study outcomes. (Table 1). This has left the original Fitzpatrick scale, with its
imperfections, as the primary approach to defining differ-
exist, which makes the act of self-selecting a skin tone based ences in skin color.
on a color chart alone also problematic. This article presents a proposed updated skin color scale
An example of this is seen in Figure 1, which shows 2 first to more clearly demonstrate the ratings of various skin types
degree cousins who identify as primarily South Asian, and including an appendix of directed clinical questions to
although their skin phototypes are markedly different. This better subdivide patient groups. The goal is to expand the
highlights the need to update the current skin phototype classification of patient populations so that practitioners
grading system to properly assess risk when performing and researchers can better report predisposition to disease
procedures and when classifying groups for study and risk factors for adverse events related to skin type, and
outcomes. thus more precisely predict anticipated results of treatment
In the late 1970s, Coleman and colleagues4 studied the for patients. Examples of visual scales that can be used by
distribution of nevi and melanoma in “black” patients with patients and physicians is also included.
TABLE 1. Other Skin Color Classifications

Name Method Measurement Approach Types
Sharma Questionnaire and Spectrophotometry Modified Fitzpatrick
spectrophotometry
Fanous Visual Visual 6 Geographic types
Roberts Visual Grades scarring and Scarring: 6
hyperpigmentation Hyperpigmentation:
7
Taylor hyperpigmentation scale Visual Match skin to cue cards 15 different hues
Lancer ethnicity scale Visual/History Geographic 5
Goldman world classification History Geographic plus sunburn history 5 plus 3 subtypes
726 DERMATOLOGIC SURGERY • August 2023 • Volume 49 • Number 8 www.dermatologicsurgery.org
TABLE 2. Racial/Ethnic, Clinical and Colorimetry Features of the Skin Color and Ethnicity Scale (SCE Scale)
Racial/Ethnic Aging, Scarring, and Colorimetry (Melanin Index)
Skin Type Homeland Hyperpigmentation (Spectrophotometer)
Skin Type I Northern Europe Minimal pigmentary changes Courage Khazaka Database;
Always burns, never develops a England, Scotland, Keratoses Grimes PE VPI Database17
tan or darkening of the skin Ireland Coarse and Fine wrinkles 0–100
(painful burn at 24 h and no tan at Baltic/Nordic Countries Laxity Eilers: 9,000 6 10
7 d) Sallowness
Multiple Nevi
Increased occurrence of
premalignant and malignant skin
lesions (including actinic
keratoses, basal cell carcinoma,
squamous cell carcinoma, and
melanoma)
Lentigenes and actinic damage
Skin Type II Northern Europe Minimal pigmentary changes 100–150
Easily burns, then develops a light Central Europe Keratoses Eilers: 8,500 6 10
tan or light darkening (painful burn Eastern Europe Coarse and Fine wrinkles
at 24 h and a light tan at 7 d) Baltic/Nordic Countries Laxity
Sallowness
Multiple Nevi
Increased occurrence of
melanoma)
Lentigenes and actinic damage
Skin Type III Southern Europe Visible dyschromia 150–250
Mild burning, tenderness, or Central Europe Fewer keratoses compared to I Eilers: 8,200 6 10
itching, skin irritation in sun- Eastern Europe and II
exposed skin, then develops a Mediterranean Laxity
medium tan or skin becomes Americas Sallowness
slightly darker in sun-exposed East Asia Fewer Nevi
sites India Increased occurrence of
melanoma)
Some have lentigenes
Skin Type IV A and B Central America No keratoses 50–400
Minimal skin irritation, minimal South America Mild to Moderate pigmentary Eilers: 6,200 6 10
tenderness, itching, or redness in North America changes with aging
sun-exposed areas, then Philippines Minimal wrinkling
develops a deep tan or skin Polynesia Few nevi
becomes darker in sun-exposed Vietnam Occasional lentigenes (some
areas (no skin irritation, North India palmar and plantar)
tenderness, or itching at 24 h and East Asia Propensity for keloid and scarring
a tan or darker skin at 7 d) Mediterranean Jowl formation
Africa
China
Korea
Japan
Thailand
North Africa
Middle East
TABLE 2. Racial/Ethnic, Clinical and Colorimetry Features of the Skin Color and Ethnicity Scale (SCE Scale) (Continued)
Racial/Ethnic Aging, Scarring, and Colorimetry (Melanin Index)
Skin Type Homeland Hyperpigmentation (Spectrophotometer)
Skin Type V Afro Caribbean Prominent jowls 350–475
A and B Central Africa Few rhytides Eilers: 5,000 6 10
Occasional skin irritation, East Africa Marionette Lines
tenderness, or itching in sun- West Africa Moderate hyperpigmentation
exposed skin, then develops South Africa with aging
moderate or significantly darker South India Propensity for keloid and scarring
skin in sun-exposed sites in Polynesia No keratose

temperate climates; sunburn Australia
uncommon Eritrea
Ethiopia
North Africa
Middle East
Skin Type VI Afro Caribbean Jowl formation 450–825
No skin irritation, tenderness, or Central Africa Few rhytides Eilers: 4,000 6 10
itching in sun-exposed skin, no East Africa Marionette Lines
noticeable change in skin in sun- West Africa Deeply pigmented skin
exposed sites in temperate South Africa Hyperpigmentation with aging
climates; sunburn uncommon South India Propensity for keloid and scarring
Polynesia No keratose
Australia
Methods and Results In addition to the scale, it is important to assess the

The 3 authors, who have a combined experience of over 80 accompanying clinical assessments such as freckling, nevi,
years in research on skin of color, had numerous virtual and scarring to aid in proper cohort placement.
research meetings over 12 months to devise a new scale. A
Discussion
systematic literature review was performed using PubMed
The increasing diversity within the United States presents a
and Embase (2005–2023) to assess existing skin color scales
multitude of challenges to the practicing dermatologist. Not
(queried “skin of color” “skin color scales” and “Fitzpa-
only must physicians recognize skin disease in varying skin
trick”). An extensive Google search was conducted using tones, but also counsel and guide patients on important
makeup foundation ranges as a starting point for skin tone matters including sun protection, benefits of treatment and
matching and potentially insight into cutoff points for risk of unintended consequences of medical therapies, plus
classification. This research and comments from other skin cosmetic, and surgical procedures. The limitations of how we
of color experts confirmed our opinion that Fitzpatrick currently classify diverse patient populations has become
types 4 and 5 ratings were the most confusing in that these apparent in the last decade and may impact certain types of
included too broad of a range of skin types with different studies. Although traditionally the Fitzpatrick scale has been
responses to solar radiation, lasers, surgery, and cosmetic used to classify pigmentation of the patient population, this
products. Therefore, it made sense to subdivide skin types 4 scale was devised for a narrow scope of pigmentation and
and 5 into “A” and “B” to better define them in a new scale. disease state (fair skin photodamage). In this article, we
Additional clinical identifiers such a freckling, pore size, and propose an expansion of the Fitzpatrick scale to include a
other parameters were added to allow researchers to use the broader range of skin pigment and to consider disease states
scale more easily (Table 2). These verbal definitions were other than photodamage that can be related to skin type. We
combined with a range of photographs to demonstrate the have added a clinical assessment of pore size, tendency of
range of skin color seen within each type. To obtain high- freckling, presence of nevi, and potential for hypertrophic and
quality images, Jouer Cosmetics was approached and gave keloidal scarring to increase the use of the scale for skin of
permission to modify the visual graphic they offer color. Not only does the A and B subgrouping in our updated
consumers for color matching makeup foundations into a scale help to stratify groups in phototypes 4 to 5, it can clarify
color collage for this study. Figure 2 demonstrates the new misconceptions about sunburn risk. It can also help to grade
scale visually. The finished scale was labeled the SCE scale wrinkle severity as those in subgroup A of 5 are more likely to
(for Skin Color and Ethnicity). Next, numerous photos of behave like subgroup B of 4. The result is a spectrum of risk
various skin hues were compared with the new scale that mirrors what we see. Rather than arbitrary question sets
pictured in Figure 2. A wide range of skin colors and based on sun exposure, the SCE score can create better data
genders were rated using the new scale and are demon- sets for lasers, peels, and other cosmetic procedures. Looking
strated in Figure 3. forward, a more precise color scale should assist in ongoing
Figure 2. The Skin Color Ethnicity (SCE) Scale dem-

onstrated visually using color charts. (Modified by
permission of Jouer Cosmetics).
Figure 3. A wide range of skin colors and genders were rated using the new scale and are demonstrated here (Humanae collage
created by artist Angelica Dass and used with permission to demonstrate the variety of skin tones present globally). The authors
propose a new classification system of skin phototypes and present it below each photo in the collage to demonstrate its use among
all patients.
research into artificial intelligence in dermatology such as that 2. Karimkhani C, Dellavalle RP, Coffeng LE, Flohr C, et al. Global
developed by sociologist Ellis Monk, Phd in collaboration skin diease morbidity and mortality: update from the global
burden of disease study 2013. JAMA Dermatol 2017;153:
with Google.18,19 406–12.
3. Fitzpatrick T. The validity and practicality of sun-reactive skin types I
Conclusion through VI. Arch Dermatol 1988;124:869–71.
4. Coleman WP, Gately LE, Krementz AB, Reed RJ, Krementz ET. Nevi,
This new updated SCE scale should assist authors in better
lentigines, and melanomas in blacks. Arch Dermatol 1980;116:
reporting scientific data in skin of color. Hopefully large 548–51.
databases such as SEER and the U.S. Census will also adopt 5. He S, McCulloch C, Boscardin J, Chren MM, et al. Self-reported
this more precise approach. Currently, validation of this pigmentary phenotypes and race are significant but incomplete pre-
scale with a larger panel of dermatologists is underway. dictors of Fitzpatrick skin phototype in an ethnically diverse pop-
ulation. J Am Acad Dermatol 2014;71:731–7.
6. Eilers S, Bach D, Gaber R, Blatt H, et al. Accuracy of self-report in
References assessing Fitzpatrick skin phototypes I through VI. JAMA Dermatol
1. https://www.census.gov/newsroom/releases/archives/population/ 2013;149:1289–94.
cb12-243.html 7. https://www.23andme.com/ancestry-composition-guide
8. Sommers M, Fargo J, Regueira Y, Brown K, et al. Are the Fitzpatrick 13. Roberts W. The Roberts skin type classification system. J Drugs
skin phototypes valid for cancer risk assessment in a racially and Dermatol 2008;7:452–6.
ethnically diverse sample of women? Ethn Dis 2019;29:505–12. 14. Taylor S, Arsonnaud S, Czernielewski J. The Taylor hyperpigmenta-
9. Pichon L, Landrine H, Corral I, Hao Y, et al. Measuring skin cancer tion scale: a new visual assessment tool for the evaluation of skin color
risk in African Americans: is the Fitzpatrick skin type classification and pigmentation. Cutis 2008;76:270–4.
culturally sensitive? Ethn Dis 2010;20:174–9. 15. Wolbarsht ML, Urbach F. Letter to the editor. Lasers Surg Med 1999;
10. Ware OR, Dawson JE, Shinohara MM, Taylor SC. Racial limitations 25:105–6.
of Fitzpatrick skin type. Cutis 2020;21:77–80. 16. Goldman M. Universal classification of skin type. In: Shiffman M,
11. Sharma V, Gupta V, Jangid B, Pathak M. Modification of the Fitz- Mirrafati S, Lam S, editors. Simplified Facial Rejuvenation. New
patrick system of skin phototype classification for the Indian pop- York: Springer; 2008; pp. 47–50.
ulation, and its correlation with narrowband diffuse reflectance 17. Grimes P. Aesthetics and Cosmetic Surgery for Darker Skin Types in.
spectrophotometry. Clin Exp Dermatol 2018;43:274–80. Philadelphia, PA: Lippincott Williams and Wilkins; 2007.
12. Fanous N. A new patient classification for laser resurfacing and peels: 18. Rojas N. Teaching algorithms about skin tones. The Harvard Gazette.
predicting responses, risks, and results. Aesthet Plast Surg 2002;26: July 5, 2022.
99–104. 19. https://skintone.google/get-started

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Original Article

Updating the Fitzpatrick Classification: The Skin Color

T here has been a significant increase in submissions to

Updating the Fitzpatrick Classification • Coleman et al www.dermatologicsurgery.org 725

The Fitzpatrick Skin Phototype Classification was de-

veloped in 1975 to demonstrate the correlation of skin cancer

TABLE 1. Other Skin Color Classifications

726 DERMATOLOGIC SURGERY • August 2023 • Volume 49 • Number 8 www.dermatologicsurgery.org

Updating the Fitzpatrick Classification • Coleman et al www.dermatologicsurgery.org 727

skin in sun-exposed sites in Polynesia No keratose

Methods and Results In addition to the scale, it is important to assess the

728 DERMATOLOGIC SURGERY • August 2023 • Volume 49 • Number 8 www.dermatologicsurgery.org

Figure 2. The Skin Color Ethnicity (SCE) Scale dem-

Updating the Fitzpatrick Classification • Coleman et al www.dermatologicsurgery.org 729

730 DERMATOLOGIC SURGERY • August 2023 • Volume 49 • Number 8 www.dermatologicsurgery.org

Updating the Fitzpatrick Classification • Coleman et al www.dermatologicsurgery.org 731

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