J Clin Aesthet Dermatol. 2025;18(5–6 Suppl 1):28–29.
by Archana M. Sangha, MMS, PA-C
Ms. Sangha is a senior medical science liaison for Incyte Corporation in Wilmington, Delaware. Prior to that, she spent over a decade as a dermatology PA specializing in general, surgical, and cosmetic dermatology. She is a fellow of the American Academy of Physician Assistants in Alexandria, Virginia. She is also a Past President of the Society of Dermatology Physician Assistants.
FUNDING: No funding was provided for this article.
DISCLOSURES: Ms. Sangha is an employee of Incyte Corporation in Wilmington, Delaware.
Recently, I was at the pediatrician’s office with my five-year-old daughter who has seasonal allergies. With the pollen count this year being much higher than usual, it wasn’t surprising that my daughter’s allergies were more severe. However, the reason for our visit was an evaluation of unilateral, severe, periorbital edema with newly appearing erythema for two days. There was no discharge, change in vision, photosensitivity or pain. Upon clinical examination, the pediatrician was unable to visualize the erythema on the Fitzpatrick Type V skin of my daughter. I used a pen light to point out the telangiectasis and the subtle pink hue, which is one representation of erythema in patients with skin of color (SOC).
We left the office with a diagnosis of seasonal allergies and after my insistence, a prescription for an oral antibiotic to be used “only if things worsened.” Within 12 hours, my daughter had crusting, spreading erythema, and periorbital edema, which now impacted her ability to open her eye. I started the oral antibiotic and within 24 hours, her symptoms were 80 percent resolved. Since then, my daughter has made a full recovery with no complications.
This incident reminded me what a privilege it is to practice dermatology and to know how to recognize signs of impending infection in different skin types. This skill helped me easily advocate for appropriate care of my daughter. However, it also made me keenly aware of the large gap among healthcare providers (HCPs) in recognizing the tell-tale signs of infection in patients with SOC.
This article will highlight five pearls to efficiently and effectively aide in diagnosing skin infections in patients with SOC.
1. Recognize erythema and/or discoloration. In richly pigmented skin, while it can appear pink or red, it can also present as violaceous, hyperpigmented (ie, brown-dark brown), or gray.1 A practice pearl is to compare the affected skin to unaffected skin. (ie, compare the skin on the unaffected eyelid to that of the affected eyelid).
In a post-hoc analysis by Johnson et al,2 the authors examined 350 chronic wounds to determine if clinical signs and symptoms (CSS) such as erythema could accurately predict infection in varying skin types or if fluorescence imaging of wounds could help diagnostic accuracy. Patients were grouped into three groups (low, medium, high) based on Fitzpatrick Skin Phototype Classification (FSPC). The low group consisted of Fitzpatrick Types I and II, medium were Types III and IV, and high were Types V and VI. The results showed that despite comparable bacterial loads, erythema was reported less frequently with increased FSPC score. Those with a low FSPC score had erythema reported 13.4 percent versus those with a high score had it reported only 2.3 percent.2
Sensitivity in this study was defined as the ability to predict high bacterial loads. Based on CSS alone, the sensitivity was significantly lower in the low FSPC group versus the high FSPC group (14.0% vs. 2.9% respectively). When wound fluorescence and CSS were combined, sensitivity significantly increased across all groups. Of interest, this combination resulted in a 12-fold higher sensitivity for the high FSPC group. These findings highlight the disparities that exist among accurate wound diagnosis in SOC. They also bring to light a potential solution of incorporating fluorescence wound imaging to improve diagnostic acumen in SOC.2
2. Edema and warmth. Here it’s important to not only look but touch the skin. Is there warmth? Are there changes in the skin contours due to edema? Is the skin taut or shiny?7
3. Textural skin changes. Are skin pores more prominent or more widely spaced when compared to unaffected skin? This can be a subtle indication of edema in SOC.7 Are there any blisters or bullae present? Are there any “punched out” lesions with violaceous margins? These can be indicative of a bacterial and or viral etiology.8
4. Pain, tenderness, and/or pruritis. Is there discomfort in the affected area? Is it worsened with touch? Does the patient report itch? Are there excoriations visible?
In an article by Chiu,3 he discusses that pathogens such as viruses, bacteria, parasites, and fungi are able to cause pain, itch, and/or analgesic responses. While the exact mechanisms for why some pathogens bind to nociceptors (pain) and others bind to pruriceptors (itch) neurons is unknown, we know that pathogens have preferences
(Table 1).3
5. Systemic symptoms. Does the patient appear ill? Do they have a fever? What about nausea, vomiting, or diarrhea?9
Each of these signs and symptoms should serve as a piece of the puzzle to aide healthcare professionals (HCPs) in making an accurate diagnosis. The absence of one or two criteria should not lessen your index of suspicion of skin infection from your differential diagnosis.
Timely and accurate diagnosis of skin infections is important for optimal patient outcomes.
Studies have shown that Black patients often suffer increased morbidity and mortality rates from postoperative wound infections4 and pressure ulcers5 compared to white patients. While reasons for this are multifactorial and include socioeconomic status, gender, and comorbidities, one must also consider the possibility of delayed diagnosis in Black patients.
The need for clinician education materials that are inclusive of all skin types is essential for improving early and accurate diagnosis in patients with SOC. In a 2022 global survey of over 200 wound care–treating HCPs, over 60 percent reported they were unaware of educational resources for wound care in different skin tones.6 Additionally, it was noted that of the existing educational materials, nearly 90 percent were examples in Fitzpatrick Skin Types I and II.6
Being aware of the nuances of skin infection presentation in patients with SOC is an important first step in shortening the disparity gap.
References
- Finlay AY, Griffiths TW, Belmo S, Chowdhury MMU. Br J Dermatol. 2021;185(6):1240–1241
- Johnson J, Johnson AR, Andersen CA, et al. Skin pigmentation impacts the clinical diagnosis of wound infection: imaging of bacterial burden to overcome diagnostic limitations. J Racial Ethn Health Disparities. 2024;11(2):1045–1055.
- Chiu IM. Infection, pain, and itch. Neurosci Bull. 2017;34(1):109–119.
- Brooks Carthon JM, Jarrín O, Sloane D, Kutney-Lee A. Variations in postoperative complications according to race, ethnicity, and sex in older adults. J Am Geriatr Soc. 2013;61(9):1499–1507.
- Bazargan-Hejazi S, Ambriz M, Ullah S, et al. Trends and racial disparity in primary pressure ulcer hospitalizations outcomes in the US from 2005 to 2014. Medicine (Baltimore). 2023;102(40):e35307.
- Dhoonmoon L, Fletcher J. Assessing skin tones in practice: results of an international survey. Wounds Int. 2022;13(2):6–9.
- British Association of Dermatologists. Skin of Colour. Accessed May 2025. https://www.skinhealthinfo.org.uk/support-resources/skin-of-colour/.
- Nardi NM, Schaefer TJ. Impetigo. (Updated 2023 Jul 31). In: StatPearls (Internet). Treasure Island (FL): StatPearls Publishing; 2025 Jan.
- Ki V and Rotstein C. Bacterial skin and soft tissue infections in adults: A review of their epidemiology, pathogenesis, diagnosis, treatment and site of care. Can J Infect Dis Med Microbiol. 2008 Mar;19(2):173–184.