J Clin Aesthet Dermatol. 2024;17(12):18–22.
by Anisha Bhanot, MD; Jamalje Bassue, MD; Sherifat Ademola, MD; Brigitte Sallee, MD; and Pamela Allen, MD
Drs. Bhanot, Sallee, and Allen are with the The University of Oklahoma Department of Dermatology in Norman, Oklahoma. Dr. Bassue is with the Tulane School of Medicine in New Orleans, Louisiana. Dr. Ademola is with the Boston Medical Center in Boston, Massachusetts.
FUNDING: No funding was provided for this article.
DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.
ABSTRACT: Objective: The authors sought to compare the results in Fitzpatrick Skin Type (FST) reporting among providers, trainees, and patients. They discussed the implications of discordance in FST reporting among these groups.
Methods: This survey-based study was offered to all adult patients (18 years or older), dermatology residents, and dermatology faculty providers at University of Oklahoma Dermatology Clinic in Oklahoma City, Oklahoma. Deidentified information from the patient survey, provider-assigned FST, and provider credentials were consolidated, and data was analyzed by a biostatistician.
Results: The provider-assigned FST was more accurate than the patient’s own estimation of their own ability to tan versus burn. The patient’s race played an important factor in a discrepancy between provider and patient described FST. Additionally, provider years in practice increased the odds of any discrepancy existing.
Limitations: This study was conducted at one clinic location encompassing only the immediate geographic population.
Conclusion: Despite being the most used skin tone classification system in dermatology, the FST system has many limitations. The classification system needs to be reevaluated or replaced with methods that more accurately, appropriately, and reliably describe skin tones and skin photo reactivity. Education is necessary for current trainees to avoid erroneous use of classifications such as the FST.
Keywords: Fitzpatrick skin type, phototype, melanin index, skin tone
Introduction
The Fitzpatrick Skin Type (FST) scale was developed and subsequently introduced into clinical practice in 1975 by dermatologist Thomas B. Fitzpatrick, MD, PhD, and colleagues. The creation of the scale allowed for a provider estimation of initial dosage of ultraviolet A (UVA) radiation in the treatment of psoriasis and atopic dermatitis in non-Hispanic White patients. The dosage required for appropriate photochemotherapy topical psoralen (P) plus (UVA) therapy (PUVA) was shown to approximate the patient’s tendency to either burn or tan when their unprotected skin is exposed to UV radiation.1
The scale has since been expanded from its original niche role and has become a pillar of dermatologic care. In modern practice, phototypes are determined by patient responses to a series of questions that allow the patient to qualify the reaction of their skin when exposed to specified quanta of sunlight.2
Guided by these responses, it is the provider’s responsibility to categorize patients into six phototypes (phototype I to VI). On the extremes of the spectrum lie phototypes I (always burns, never tans) and phototype VI (never burns, always tans).
It is commonplace for providers to assume patient FST based solely on patient phenotype (the overall pigmentation of the skin). For example, phototypes V and VI are commonly assigned to patients with darker skin—traditionally those belonging to groups of Asian and African origin. However, a more nuanced approach to the application of the FST is required since racial and ethnic phenotypes fail to consistently correspond to predicted skin phototypes.3
Afterall, it was Fitzpatrick himself in 1988 who concluded that race and ethnicity are merely social constructs, a far cry from the objectivity observed in biological phenomenon.4
This results in the potential for discordance between provider determined FST and the patient’s understanding of their own tendency to burn and to tan. Moreover, the literature suggests that patients belonging to racial and ethnic groups traditionally associated with darker phototypes tend to have higher levels of discordance between more subjective determinations and more objective determinations of melanin index.5 This highlights a potential gap in equitable dermatologic care—one that can lead to false assumptions about patient risk for adverse dermatologic outcomes.
The intent of this study is to determine the severity of discordance that exists in phototype determination and what measures can be implemented to reduce this discordance. The results of such a study may be used to adjust our clinical practice with the ultimate goal of providing patient care that is more effective and more equitable.
Methods
Overview. This study was conducted following the approval of an institutional review board. This study population comprised 479 individual adult outpatient visits (ages 18 or older) to the University of Oklahoma Health Physicians Dermatology Clinic in Oklahoma City, Oklahoma.
Survey creation. Patient survey. A voluntary patient survey was created to collect patient information regarding patient demographics and skin reaction to the sun (ie, burning versus tanning; intensity of redness, irritation, tenderness, itching, and darkening).
Provider survey. A provider survey was distributed to physician assistants, resident physicians, and attending physicians. This survey recorded the years of practice, level of training, and demographics of the providers.
Data collection. This voluntary survey was offered to all patients upon their arrival to the clinic check-in desks. Consenting patients had a patient information identifier sticker affixed to the completed survey. Exclusion criteria included patients under the age of 18, incarcerated individuals, patients with intellectual disability, and patients who opted not to participate. A total of 472 patients completed the survey.
Collected data were password-protected and accessible only with the use of an encrypted device. The patient information identifier sticker was used to gather the patient’s self-assigned FST as well as their provider-assigned FST. At the conclusion of data collection, patient information was deidentified. Collected data were verified, consolidated, then analyzed by a biostatistician in the University of Oklahoma Hudson College of Public Health.
Results
Four-hundred and seventy two (N=472) patients completed the survey (66% female, 34% male) (Figure 1). Patients represented all age ranges from 18 to 75 years and older (Figure 2). Patients self-identified as 63 percent White (non-Hispanic), 21 percent Black, six percent Latino or Hispanic, six percent Asian Indian, three percent Asian, and one percent American Indian/Alaska Native (Figure 3). Twenty providers completed surveys (45% female, 55% male) (Figure 4); representing 60 percent ages 25 to 34, 25 percent ages 35 to 44, 10 percent ages 65 to 74, and 5 percent ages 45 to 54 (Figure 5). Providers self-identified as 85 percent White (non-Hispanic), 1.5 percent Black, 1.5 percent Latino or Hispanic, and 1.5 percent Asian Indian (Figure 6). Provider years in practice were reported as follows: 75 percent (0 years), 15 percent (6-10 years), 5 percent (11-20 years), and 10 percent (21+ years) (Figure 7). Provider level of training was reported as 55 percent residents, 35 percent board-certified dermatologists, and 10 percent advanced practice providers (Figure 8).
General findings. Overall, there was some degree of discordance observed between provider-assigned FST and answers to questions provided by participants.
Patients tended to report higher instances of tanning and burning when compared to the provider-assigned-FST. This corresponded in a mean difference of 0.51 points on the FST scale. This value suggests that our providers generally underestimated the ability of patients to sunburn.
Additionally, the mean differences between provider-assigned FSTs and patient responses to questions 6a (sunburns), 6b (sun tans), and 7 (skin tone at end of winter) were smaller than the differences between question 1 (historical question of patient estimated FST) and questions 6a (sunburns), 6b (sun tans), and 7 (skin tone at end of winter). This finding suggests that the provider-assigned FST was more accurate than the patient’s own estimation of their ability to tan versus burn and their color of natural untanned skin at end of winter.
Data analysis indicated that there was a near-perfect correlation between patients’ responses to question 1 and question 2e (patient reporting any skin darkening with sun exposure). However, there was discordance between patient and provider responses to question 1 and every other component of question 2. The major implication of this finding is that patients more accurately report changes in skin color/tone but struggled to accurately report redness, irritation, tenderness, and itching.
Effects of patient demographics on discrepancy. Racial and ethnic identity had varying degrees of discrepancy between provider and patient derived FST. One striking example of this was observed in patients who self-identified as Latino or Hispanic ethnicity. There was a small odds ratio of finding a discrepancy in this ethnic category [OR=0.262 (95% CI: 0.078, 0.88; p=0.0303)] when patients were asked about their tendency to tan/burn. Otherwise stated, being of Hispanic ethnicity serves as a protective factor from discrepancies in FST determination—specifically when patients were asked in the context of tanning versus burning. Conversely, the odds of this discrepancy between patient and provider FST were higher among Whites (OR=1.359) and Asian Indians (OR=1.623).
Racial and ethnic identity would again serve as a protective factor, this time for Black patients, when analyzing the likelihood of discordance among provider-assigned FST, patient perception of tanning versus burning, and patient estimation of FST. Patients identifying as Black had a small odds ratio of discrepancy in this analysis [OR=0.18 (95% CI: 0.055, 0.587; p=0.0045)] (Figure 9).
Although analyzed in detail, other patient demographic factors lost significance due to smaller group sample sizes.
Effects of provider demographics on discrepancy. Provider demographics also played an important role in the presence of a discrepancy. Analysis of provider demographics and the likelihood of a discrepancy between provider assigned FST, patient perception of tanning versus burning, and patient estimation of FST indicated that more provider years in practice increased the odds of any discrepancy existing. Notably, providers with 10 or more years of experience had higher reporting discrepancies when compared to providers with fewer than five years of experience [OR=3.054 (95% CI: 1.468, 6.354; p=0.0342]. However, provider characteristics such as age, gender, or personal FST were not significant in predicting the odds of any FST reporting discrepancy.
Discussion
The misuse of the FST as a surrogate for racial/ethnical identity has recently been met with criticism by dermatologists many calling for the development of more clinically and culturally applicable skin type assessment strategies.6 The results of this study highlight the degree of discordance between patient and provider understanding of the FST.
While analyzing the results of our study, some trends were readily identifiable. Unsurprisingly, the subjective determination of FST by providers solely based on skin tone failed to consistently correspond with patient-determined FST. This is particularly problematic because the FST is often used to approximate skin cancer risk and risk of cancer recurrence; predict risk of dermatologic complications from other iatrogenic procedures; and guide the efficacy and safety of cosmetic procedures, among other things.3,7,8
FST as a surrogate for race/ethnicity. Recent surveys suggest that one-third of academic dermatologists and dermatology trainees erroneously adopt the use of FST as a descriptor of race in clinical documentation. This use of the FST scale as a surrogate for skin color is largely because to date, no globally adopted, objective, consistent, and practical method for stratifying and describing skin color exists.6,7 Efforts are underway to produce such a method.9 Until then, clinicians must exercise caution when using FST to guide clinical practice, understanding that the most appropriate use of the scale involves a thorough sun-exposure-response history from the patient themselves rather than a provider-based assessment of patient skin color.
Terminology. Accompanying the criticism of the FST are suggestions for its improvement by methods such as employing the use of terminology on screening questionnaires that is more culturally relevant and/or clarifying survey options to patients. It was Eilers et al5 who suggested the adoption of terms such as “becoming darker” versus “tanning,” “skin irritation,” and “skin burning.”10
Our study supports the use of alternative terminology that is more culturally relevant. For example, our data shows a near-perfect correlation between patient-derived FST and patient-estimated ability to “darken” with sun exposure. This indicates that within our patient population, the use of terminology such as “tanning” in FST questionnaires may be deleterious to patients who simply do not strongly relate to the concept of a tan. Patients may be unconsciously directed towards lighter phototypes because, to their knowledge, they have never experienced a “tan.” There may be some merit in replacing terms like “tanning” with other culturally relevant descriptors in patient-completed questionnaires. In clinical scenarios where FST is used to guide practice decisions, time should also be allotted for providers to appropriately answer or clarify any questions posed by patients about their skin reactivity. Such changes in terminology and clarification of otherwise confusing terminology have demonstrated some effectiveness in follow ups to large-scale, multination research.10 More studies can help determine the most appropriate terminology to employ in local clinic questionnaires that can reduce these incongruencies in our patient populations.
Limitations. The findings reported in this manuscript serve as an initiator of discourse around the use of the FST within clinic systems in Oklahoma. As such, respondents in this study represent a geographically and regionally limited sample. While traditionally seen as a study-limitation, further analysis reveals a double-edged sword. Limited geographic sample sizes may incur an advantage in study designs such as ours. With larger variations in geography comes variations to sun exposure (geographic latitude); and the effects of subjectivity imparted by terminology such as ethnicity, race, darken, lighten, skin tones, and other culturally significant terminology become magnified. The geographic limitations imposed by FST research encourages our support of deployment of similar studies in other regions.
Conclusion
It is without surprise that the results of our study support more recent calls for updated methods of skin type assessment. The incongruencies between provider-determined FST and our patient’s understanding of their burn/tan risk highlight the problems faced when utilizing the scale as a surrogate solely to describe patient skin color.
Until better methods for stratifying skin color and sun exposure are developed, extreme caution must be used to prevent the misuse and overgeneralization of the FST scale. Even with its inherent flaws, the accuracy of the tool can be bolstered when used appropriately. Trainees should be reminded that it is patient-guided responses that ultimately determine FST. This, alone, should be used to guide clinical decision making when necessary.
Additionally, we support the optimization of current FST questionnaires by adopting terminology that minimizes the risk of confusion on behalf of the patient. The goal of such an adoption would be improved accuracy of patient skin-type reporting and better clinical outcomes. This will be culturally and regionally specific and may require a multidisciplinary approach to gather insight into behaviors of specific patient populations.
References
- Fitzpatrick TB. Soleil et peau. J Med Esthet. 1975;2:33–34.
- Ravnbak MH. Objective determination of fitzpatrick skin type. Dan Med Bull. 2010;57(8):B4153.
- Fasugba O, Gardner A, Smyth W. The fitzpatrick skin type scale: a reliability and validity study in women undergoing radiation therapy for breast cancer. J Wound Care. 2014;23(7):358–368.
- Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988;124(6):869–871.
- Eilers S, Bach DQ, Gaber R, et al. Accuracy of self-report in assessing Fitzpatrick skin phototypes I through VI. JAMA Dermatol. 2013;149(11):1289–1294.
- Okoji UK, Taylor SC, Lipoff JB. Equity in skin typing: why it is time to replace the fitzpatrick scale. Br J Dermatol. 2021;185(1):198–199.
- Ware OR, Dawson JE, Shinohara MM, et al. Racial limitations of fitzpatrick skin type. Cutis. 2020;105(2):77–80.
- Gogia R, Binstock M, Hirose R, et al. Fitzpatrick skin phototype is an independent predictor of squamous cell carcinoma risk after solid organ transplantation. J Am Acad Dermatol. 2013;68(4):585–591.
- Taylor SC, Arsonnaud S, Czernielewski J. The taylor hyperpigmentation scale: a new visual assessment tool for the evaluation of skin color and pigmentation. Cutis. 2005;76(4):270–274.
- Trakatelli M, Bylaite-Bucinskiene M, Correia O, et al. Clinical assessment of skin phototypes: watch your words! Eur J Dermatol. 2017;27(6):615–619.