Black Skin, The Fitzpatrick Scale & Modernising Medical Language
Skin of colour is still underrepresented in the medical field, and studies like those carried out by Dr. Paul Leighton and his team at the Centre of Evidence Based Dermatology push for change.
A part II, if you will, on our short, sweet, but vital series in conversation with CEBD (Centre of Evidence Based Dermatology). If you haven’t read the interview feature already, Black Skin Directory have discussed the essential work the research centre are doing to enlighten clinicians, the NHS and BAME communities on changes needed for black individuals to be involved in clinical research.
Read Involving Black People in Clinical Research .
A change is needed in the world of dermatology as many medical textbooks and teachings fail to recognise skin conditions on black and brown skin. Certain conditions are prevalent in BAME communities, such as psoriasis, eczema and melasma, yet medical teaching still falls back on representing these conditions predominantly on white or lighter skin tones - ignoring that these conditions often look completely different on different skin tones. Much work is needed to change how Black and Brown skin is represented, how BAME communities work with medical practitioners and how clinical research becomes more inclusive to ensure that underrepresented communities are presented and catered too.
In part II of our conversations with CEBD, we spoke to Dr Paul Leighton, Associate Professor of Applied Health Services Research, on the developments in the last year, their work around the Fitzpatrick Scale, medical descriptors and the actions as a community we need to consider.
In conversation with CEBD
Nateisha Scott (NS): Last year, BSD and CEBD came together to discuss clinical research and the lack of skin of colour in dermatology. Have you seen an improvement in inclusivity since then?
Paul Leighton (PL): I have to start by saying that the work we do, especially for improving language, education and skin of colour visibility, is trying to broaden the debate and bring a voice to the individuals who have lived an experience of disproportionately. The work is never complete, and we’re constantly working with the NHS to make permanent changes, hopefully. But, one element of change that we hope to make headway with is the conversation around the Fitzpatrick Scale and how people of colour see and aptly describe their skin when inflammed.
NS: Let’s dive into the Fitzpatrick scale. What is that you’re trying to change?
PL: In recent years, clinicians and medical experts have been investigating the use and disparities with the scale and its clear indication that it doesn’t cater to Black and Brown skin types. Focusing predominantly on White skin, it leaves out a vast proportion of skin tones today. Considering its integral position in dermatology, it shows severe inequalities. Don’t get me wrong; changes are happening. Google released the Monk Skin Tone Scale, and the British Association of Dermatologists have created the Eumelanin Skin Tone Scale, which measures the amount of light reflected from the skin as opposed to just perceived skin colour. But, this is generated by clinicians without any input from the public. The public voice is needed, and that was our survey's point.
NS: How is the Fitzpatrick scale used in dermatology today?
PL: Well, I have to start by saying that the Fitzpatrick Scale was never meant to be used for what it is today. It was originally designed to measure photosensitivity, what happens when an individual’s skin is exposed to UV light, linking this to a scale from I to VI (lighter to darker) skin tones to help determine types of medical treatments and cancer risk. But now, it’s used to measure skin tones in skincare, makeup and aesthetic treatments, like laser hair removal. The Fitzpatrick Scale is now the norm.
Representation of the Fitzpatrick Scale
NS: From your Fitzpatrick Scale survey, what was the outcome?
PL: The survey was launched on social media for two months in May 2021, gathering 1,300 responses to demonstrate inconsistencies in the scale. We asked those who participated, “Is your skin tone represented?” and to position themselves on the scale. The results essentially stated that from the pictorial version of the scale (as opposed to the written scale), 61% described themselves as White so that they could be seen on the scale, and that phototype I was the most selected. Only 40% of Black-African and Caribbean participants could see their skin tone on the scale.
We also noticed that individuals were identifying their skin tone in-between the “official” scale of I to VI in skin tones, showcasing valid concerns around the limitations in using the Fitzpatrick Scale to identify and describe skin colour.
NS: Your results clearly indicate the inadequacy of the current scale?
PL: Completely, the Fitzpatrick scale is too blunt a tool to measure the complexity of skin colour. We also surveyed the use of language and how individuals understand and describe inflammation and redness (erythema) - a clear sign of trauma and distress to the skin. An overwhelming number of participants, of different ethnic backgrounds and skin colour, categorised their skin as red, pink or dark red. With additional notes to follow up:
“It’s hard to choose my ‘own’ words because we live within a context where white skin is the norm and mine is ‘othered’, so when I search for words, it’s other (white) people’s words that come to mind. If you ask Caucasian people how they would describe the colour of their skin, for example, they probably won’t use food.”
“Red... But only because white Doctors have described it as such.”
“You can only appreciate the redness if looking under good light or sunlight.”
We know that not all skin goes red, especially for those with Black and Brown skin, and this again is a failing of the medical system and language used in broader society. You aren’t to know different if you’ve been taught or conditioned to one type of language, so changes are needed not only in scales like the Fitzpatrick but also with the medical experts, textbooks and communities in adopting a new and inclusive language around the skin of colour.
The danger in not recognising the nuances of how different conditions present in different skin tones, is that conditions go unobserved for longer by medical practitioners, clinic researchers and patients, leading to phenomena such as skin cancer not being recognised in Black and Brown skin until it reaches a critical stage. Hence, skin cancer is more common in lighter and White skin tones, but more fatal when present in Black and Brown skin tones.
Above, graph shows the responses of participants from different ethnic groups when trying to place themselves on the pictorial Fitzpatrick Scale.
NS: What can be done for better inclusivity of skin of colour in dermatology?
PL: Communities can adopt a more descriptive and accurate depiction of language is essential for change on a grander scale. Inflamed skin can also be dark brown, and purple as examples of how skin can appear in colours other than red or pink. Change at this level is essential for familiarity and to normalise such descriptors across medical practices, not just dermatology.
With only 5% of medical textbooks and 20% of dermatology textbooks visually showcasing disease and skin conditions in skin of colour, this has to change, especially when there are conditions more prevalent in Black and Brown skin than in White skin (and vice versa). There is still work to be done, but at CEBD we bring these survey findings to the NHS with the aim to publish in dermatology journals and to showcase to the masses the need for change.
We know that change doesn’t happen overnight, but one step at a time is the consistency we need to see that skin colour is accurately represented. Whether that is through involving ourselves in clinical research to understand better how our skin responds to new products and treatments or taking part in critical surveys to help educate our medical industry.