The Fitzpatrick scale wasn’t designed for darker skin—types V and VI were added later based on constitutive pigmentation or presumed ethnicity, not measured biology.
That limitation is central to a new JAMA Dermatology viewpoint by Rashmi Sarkar, MD, and Hitaishi Mehta, MD, who examine how the term “skin of color” (SOC) has evolved over the past two decades. The authors note that the term advanced equity by reshaping education, imagery, and research priorities. But they argue it is now often used as a catch-all that can simultaneously imply skin tone, racial identity, ancestry, and social experience, depending on context.
That breadth, they suggest, can obscure clinically meaningful differences: patients with similar Fitzpatrick types may differ in melanin distribution, UV sensitivity, pigmentary genetics, and treatment response. In this way, SOC can function as an imprecise clinical descriptor even as it remains valuable for framing equity.
The authors describe SOC as serving both as an equity framework and a clinical shorthand—roles that may not always align as dermatology moves toward more individualized care.
They propose a more granular approach that separates SOC into four components: pigment phenotype (measured using tools such as ITA, Melanin Index, or Monk Skin Tone), ancestry and ethnogeographic background, sociocultural context (including colorism, stigma, and access), and pigment-linked clinical risk modifiers such as postinflammatory hyperpigmentation or keloid tendency. The goal is not to eliminate SOC, but to move beyond using it as a stand-in for multiple distinct factors.
The authors note that these tools remain underused, in part because they require workflow integration, training, and institutional endorsement. They also acknowledge the tension in refining a term that has been important for visibility in dermatology.
In practice, they suggest that when SOC is used in clinical or research contexts, clinicians clarify which dimension—pigment phenotype, ancestry, sociocultural context, or risk profile—is most relevant, rather than relying on the umbrella term alone.
The authors declared having no competing interests.
Source: JAMA Dermatology
