Mastering fine strokes across the dermatologic palette

Past Academy President Seemal R. Desai, MD, FAAD, said pigmentary disorders are among the most common reasons patients with skin of color seek dermatologic care. Although some conditions may be more prominent in certain populations, he said there is considerable overlap across ethnic groups. What often differs are clinical presentations and treatment approaches.

“An important point to remember is that we should not think of ‘skin of color’ as a single group. There is tremendous biological and clinical diversity within and between populations,” said Dr. Desai, who is founder and medical director of Innovative Dermatology and a clinical associate professor of dermatology at the University of Texas Southwestern School of Medicine in Dallas.

Commonalities in diagnostic dermatology

Melasma is particularly common in individuals with darker phototypes, including many patients of Hispanic/Latino, South Asian, Southeast Asian, and Middle Eastern ancestry. Similarly, post-inflammatory hyperpigmentation (PIH) is also extremely common in patients with skin of color, said Dr. Desai. It can occur from acne, eczema, psoriasis, injury, or almost any inflammatory skin condition.

Seemal R. Desai, MD, FAADAccording to Dr. Desai, PIH and disorders of increased pigmentation are particularly important clinical concerns among patients of African descent. In South Asian populations, dermatologists frequently encounter melasma, PIH, lichen planus pigmentosus, and other acquired hyperpigmentation disorders. In East and Southeast Asian populations, melasma and PIH are routine in addition to certain acquired dermal pigmentary disorders, he said.

“Hispanic/Latino patients also have a high burden of melasma and PIH,” Dr. Desai said. “Vitiligo occurs across all ethnicities. It is not necessarily more common in people with darker skin, but the contrast between depigmented and normally pigmented skin can make the disease particularly visible and psychologically impactful in patients with more deeply pigmented skin.”

Cause and effect

Although these conditions can occur in all skin types, Nada Elbuluk, MD, FAAD, said there may be biologic and physical characteristics of skin and hair in people of color that can affect the presentation and treatment of these conditions. She said effective treatment rests in the hands of experienced dermatologists.

Nada Elbuluk, MD, FAADDr. Elbuluk is a professor of clinical dermatology at the University of Southern California Keck School of Medicine in Los Angeles. She also directed the 2026 AAD Innovation Academy session, Skin of Color Primer, which focused on dermatologic conditions in skin of color.

“Dermatologists are trained to treat all these conditions, but the degree of training in treating these conditions in all skin colors may vary depending on where the person trains, the patient populations in that area, and the didactic learning provided to the trainees,” Dr. Elbuluk said. “Some academic centers have dedicated skin of color clinics or programs, while others attempt to prioritize this in their educational curriculum. With that said, this is a very important area of education for all trainees and dermatologists, and one that merits continued medical education so that one is comfortable with diagnosing and treating all dermatologic conditions across diverse populations.”

One size doesn’t fit all

Looks alone don’t always tell the story of dermatologic conditions, said Tina Bhutani, MD, FAAD, an associate clinical professor of dermatology at the University of California San Francisco. Psoriasis, for example, may be common in many dermatology practices; however, it looks different on various skin tones.

Tina Bhutani, MD, FAAD“Psoriasis may appear as thicker plaques, more violaceous and brown in color, and may involve more scalp involvement in individuals with skin of color,” Dr. Bhutani said. “As a result, people with skin of color may also experience a diagnostic delay for skin disease up to three times longer than those with lighter skin tones.”

The severity of the disease is also disproportionate among ethnicities, she said, and ranges from mild to moderate versus severe to very severe. Dr. Bhutani said patients who are Asian or Hispanic have significantly more severe psoriasis at presentation than white individuals.

Then there’s the matter of inequity in receiving treatment. According to Dr. Bhutani, Black patients are offered biologics almost 69% less often than white patients.

“The barriers include patient-level factors (such as unfamiliarity with biologics or needle aversion), prescriber-level factors, cost, and organizational/formulary restrictions,” she said.

Trial by design

Dr. Bhutani said clinical trials are rarely inclusive and must be comprised of intentional trial design for people with skin of color rather than passive enrollment.

“Better assessment tools improve evaluation across skin tones,” she said. “Future dermatology trials should treat diversity as a scientific requirement, not an optional goal.

According to Dr. Elbuluk, more studies are beginning to consider PIH as a clinical endpoint in evaluating acne treatments in skin of color. More cultural competency recommendations are being made for how to treat seborrheic dermatitis in skin of color to account for different hair types and grooming practices, she said, and rosacea treatments are beginning to be evaluated in more diverse populations to ensure study results are relevant across skin colors.

Choosy considerations yield natural looks

Cheryl M. Burgess, MD, FAAD, said people with skin of color often have specific aesthetic goals and may prioritize subtle enhancement and preservation of their ethnic identity rather than dramatic changes. That’s always a conversation dermatologists should have with patients.

Cheryl M. Burgess, MD, FAAD“Successful cosmetic outcomes depend heavily on communication,” said Dr. Burgess, who is founder, medical director, and president of the Center for Dermatology and Dermatologic Surgery, PC, in Washington, D.C. “Patients with skin of color often show delayed wrinkle formation, more volume preservation, and more dyschromia-related aging changes as well as uneven tone, skin laxity, perioral hyperpigmentation, and undereye hollowing.”

She said the most successful outcomes occur when dermatologists respect ethnic features, understand melanin biology, minimize inflammation, and prioritize long-term skin health alongside aesthetic enhancement.

Energy-based devices and cosmetic procedures can be highly successful in treating patients with skin of color when performed carefully. Dr. Burgess said important principles and considerations include:

• Lower-fluence settings
• Conservative treatment parameters
• Test spots when appropriate
• Avoidance of unnecessary thermal injury

“Safer approaches may include superficial chemical peels, nonablative fractional lasers, radiofrequency or microfocused ultrasound skin lifting/tightening, microneedling, and thulium 1927 nm, 650 nm microsecond, or 755 nm picosecond lasers for pigmentation,” she said.

More than skin deep

People with skin of color have varying diagnostic and treatment needs related to hair disorders too, said Amy McMichael, MD, FAAD. Dr. McMichael, who is a professor of dermatology at Wake Forest School of Medicine in Winston-Salem, North Carolina, often trains dermatologists in addressing nonscarring alopecia.

Amy McMichael, MD, FAADThe most common nonscarring alopecias include hair fragility (also known as breakage), androgenetic alopecia, and alopecia areata. Management of each requires understanding the interaction among them all. Dr. McMichael recommends the use of trichoscopy to conduct physical examination, labs to determine underlying abnormalities (iron, thyroid, nutrition, etc.), and in-depth patient conversations to assess at-home hair routines, treatments (dyes, braids, extensions), and products.

Depending on the diagnosis and treatment plan for those with hair breakage, Dr. McMichael said she often instructs patients to “give hair a rest.”

“I tell patients with hair breakage to consider stopping chemical relaxer and/or color for six to 12 months, placing a hair weave that is not tight and will allow continued hair care, losing the braids or wig and opting for natural hair — and to not straighten with heat,” she said. “It might also involve serial trimming of hair every six to eight weeks, using heat protectant products on the hair before styling, or adding a layered moisturizing regimen, which starts with moisturizing shampoo and conditioner.”

Most important, Dr. McMichael said, is to advise patients that treating hair fragility and breakage can be a long process, and they shouldn’t be discouraged if improvement doesn’t occur immediately.

Lessons learned

Dr. Desai said that understanding skin of color is an essential component of good dermatologic care. It’s not about learning a different set of diseases, he said, it’s about recognizing how common diseases can look different, understanding how treatments can behave differently, and appreciating the patient’s experience of their disease.

“Pigmentary changes, for example, can have a profound psychosocial impact, and patients often tell us that discoloration can be as concerning — or more concerning — than the original inflammatory disease that caused it,” Dr. Desai said. “The goal should be equitable, individualized care: the right diagnosis for the right patient with the right treatment, all while minimizing treatment-induced pigmentary complications.”