Original Article

Updating the Fitzpatrick Classification: The Skin Color

and Ethnicity Scale
William Coleman, MD,* Kavita Mariwalla, MD,† and Pearl Grimes, MD‡
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BACKGROUND There has been a significant increase in submissions to scientific journals addressing a broad spectrum
of medical and surgical conditions in subjects grouped under the classification of “Skin of Color.” Authors, reviewers, and
editors have struggled with accurate terminology.
OBJECTIVE To update the Fitzpatrick scale to make it more accurate in stratifying various shades of skin color.
MATERIALS AND METHODS A thorough literature review was performed using PubMed and Embase to assess existing
skin color scales, and an extensive internet search was conducted using makeup foundation ranges as a starting point for
skin tone matching.
RESULTS The research resulted in a consensus that Fitzpatrick types 4 and 5 ratings were the most confusing in that
these included a broad range of skin types with different responses to solar radiation, lasers, surgery, and cosmetic
products. The authors reached a consensus that subdividing skin types 4 and 5 into “A” and “B” better defined them. The
new scale that resulted was labeled the SCE scale (for Skin Color Ethnicity).
CONCLUSION This new updated SCE scale should assist authors in better reporting scientific data in skin of color.

T here has been a significant increase in submissions to

scientific journals addressing a broad spectrum of
medical and surgical conditions in subjects grouped
under the classification of “Skin of Color.” Authors, re-
viewers, and editors have struggled with accurate termi-
nology when constructing and reviewing these manuscripts
and whether indeed the patients who may share a genetic or
cultural background should be classified as one considering
the range of melanin pigment that can exist in any one
group. By the year 2050, recent data from the US Census
Bureau suggests that most people in the United States will be
skin of color populations including those self-identifying as
Latino, Asian, and African American.1 It should be noted
that there are inherent problems with the US Census Bureau
classification categories. Multiple scientific investigations
document differences in disease susceptibility, presentation,
morbidity, and mortality rates in different populations
throughout the world.2 Hence, there exists an urgent need
for the dermatology/medical literature to objectively de-
scribe and more accurately classify multihued diverse racial/
ethnic groups and skin types in a reproducible and consis-
tent way.
From the *Coleman Center for Cosmetic Dermatologic Surgery, Metairie, Louisiana;
†
Mariwalla Dermatology, West Islip, New York; ‡ Vitiligo and Pigmentation Institute
of Southern California, Los Angeles, California
Pearl Grimes is a Consultant, Investigator, and Shareholder of Versicolor
Technologies LLC; Consultant and Investigator for Incyte, L’Oreal.
Address correspondence and reprint requests to: William Coleman, MD, Coleman
Center for Cosmetic Dermatologic Surgery, 4425 Conlin Street, Metairie, LA 70006,
or e-mail: wc@drcoleman.net
© 2023 by the American Society for Dermatologic Surgery, Inc. Published by
Wolters Kluwer Health, Inc. All rights reserved.
Dermatol Surg 2023;49:725–731
http://dx.doi.org/10.1097/DSS.0000000000003860
In the realm of dermatology, incorrect assessment of a
person’s skin tone could lead to miscalculation of risk
factors including cancer risk and potential for scarring or
keloid formation, dyschromia, and poor outcomes from
aesthetic procedures.
Lexicons commonly used in the lay press, social science
publications, national databases, and the US Census Bureau
to delineate diverse populations can be confusing and may
not conform to the necessary rigors needed for peer
reviewed medical and surgical publications. For instance,
the term Asian categorizes a major segment of the global
population as a single group, despite the strikingly diverse
skin color of the Asian continent; shades of pigmentation
range from very fair (Russia) to skin deeply pigmented
(Indian subcontinent). Similarly, recently popularized terms
such as “melanated” skin can also confuse the public to
assume that fair skin lacks melanin. Adding to this is the
migration of people across the globe and the disparity that
can exist when a patient identifies as one ethnic group
culturally, but has a skin phototype that does not correlate
with that group. Racial and ethnic intermarriage is
widespread with very few individuals having a genome
from a single geographic location. Despite the ready
availability of genetic research, most individuals have very
little idea what their genetic ancestry is, and so, self-selecting
an ethnicity may be incorrect.5,6 Maternal haplogroups and
other genetic markers have confirmed worldwide genetic
admixing of previously separate populations.7 As popula-
tions migrate and racial and ethnic intermarriage continues,
ethnicity is no longer a good predictor of skin behavior with
dermatologic procedures. Although patients may select a
specific ethnicity based on the culture practiced in their
home, as an objective measurement, this can be very
variable and unreliable. Moreover, multiple skin tones

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Figure 1. First degree cousins who identify as primarily South
Asian although their skin phototypes are markedly different. This
highlights the need to update the current skin phototype grading
system to properly assess risk when performing procedures and
when classifying groups for study outcomes.
exist, which makes the act of self-selecting a skin tone based
on a color chart alone also problematic.
An example of this is seen in Figure 1, which shows 2 first
degree cousins who identify as primarily South Asian,
although their skin phototypes are markedly different. This
highlights the need to update the current skin phototype
grading system to properly assess risk when performing
procedures and when classifying groups for study
outcomes.
In the late 1970s, Coleman and colleagues4 studied the
distribution of nevi and melanoma in “black” patients with
TABLE 1. Other Skin Color Classifications
Name Method
Sharma Questionnaire and
spectrophotometry
Fanous Visual
Roberts Visual
Taylor hyperpigmentation scale Visual
Lancer ethnicity scale Visual/History
Goldman world classification History
726 DERMATOLOGIC SURGERY • August 2023 • Volume 49 • Number 8
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a wide range of skin color, demonstrating that lighter
skinned “black” subjects had a higher risk of total body nevi
and melanoma, whereas darker-skinned “black” subjects
had far fewer nevi and a higher risk of palmar and plantar
melanoma. The correlation of skin cancer risk in individuals
with fair skin has subsequently become well established.
When studying a population based on self-reported
ethnicity or geography, it is important for the researcher to
provide accurate skin type information.
The Fitzpatrick Skin Phototype Classification was de-
veloped in 1975 to demonstrate the correlation of skin cancer
and skin color and to assess an individual’s susceptibility to
sun burning and calculate the initial doses for phototherapy.
Over time, the Fitzpatrick scale has become synonymous with
skin classifications of race/ethnicity, even though this was not
the intended use.3 When constructing a cohort, physicians are
more accurate in stratifying subjects by Fitzpatrick skin type
than allowing patients to self-identify their skin type, which
has been shown to be quite inaccurate.6 In recent years, the
Fitzpatrick scale has been criticized as flawed, especially in
types IV and V. Because the original scale was devised to
predict skin cancer, it failed to properly stratify skin color for
other tendencies such as keloids, suitability for certain lasers,
and even the assessment of aging parameters.7–10
Several modifications have been proposed to the
Fitzpatrick scale to better incorporate darker skin types.
However, none of these have been comprehensive enough
for authors and researchers to widely adopt them11–16
(Table 1). This has left the original Fitzpatrick scale, with its
imperfections, as the primary approach to defining differ-
ences in skin color.
This article presents a proposed updated skin color scale
to more clearly demonstrate the ratings of various skin types
and including an appendix of directed clinical questions to
better subdivide patient groups. The goal is to expand the
classification of patient populations so that practitioners
and researchers can better report predisposition to disease
and risk factors for adverse events related to skin type, and
thus more precisely predict anticipated results of treatment
for patients. Examples of visual scales that can be used by
patients and physicians is also included.
Measurement Approach Types
Spectrophotometry Modified Fitzpatrick
Visual 6 Geographic types
Grades scarring and Scarring: 6
hyperpigmentation Hyperpigmentation:
7
Match skin to cue cards 15 different hues
Geographic 5
Geographic plus sunburn history 5 plus 3 subtypes
www.dermatologicsurgery.org
 TABLE 2. Racial/Ethnic, Clinical and Colorimetry Features of the Skin Color and Ethnicity Scale (SCE Scale)
Racial/Ethnic Aging, Scarring, and Colorimetry (Melanin Index)
Skin Type Homeland Hyperpigmentation (Spectrophotometer)
Skin Type I Northern Europe Minimal pigmentary changes Courage Khazaka Database;
Always burns, never develops a England, Scotland, Keratoses Grimes PE VPI Database17
tan or darkening of the skin Ireland Coarse and Fine wrinkles 0–100
(painful burn at 24 h and no tan at Baltic/Nordic Countries Laxity Eilers: 9,000 6 10
7 d) Sallowness
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Multiple Nevi
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Increased occurrence of
premalignant and malignant skin
lesions (including actinic
keratoses, basal cell carcinoma,
squamous cell carcinoma, and
melanoma)
Lentigenes and actinic damage
Skin Type II Northern Europe Minimal pigmentary changes 100–150
Easily burns, then develops a light Central Europe Keratoses Eilers: 8,500 6 10
tan or light darkening (painful burn Eastern Europe Coarse and Fine wrinkles
at 24 h and a light tan at 7 d) Baltic/Nordic Countries Laxity
Sallowness
Multiple Nevi
Increased occurrence of
premalignant and malignant skin
lesions (including actinic
keratoses, basal cell carcinoma,
squamous cell carcinoma, and
melanoma)
Lentigenes and actinic damage
Skin Type III Southern Europe Visible dyschromia 150–250
Mild burning, tenderness, or Central Europe Fewer keratoses compared to I Eilers: 8,200 6 10
itching, skin irritation in sun- Eastern Europe and II
exposed skin, then develops a Mediterranean Laxity
medium tan or skin becomes Americas Sallowness
slightly darker in sun-exposed East Asia Fewer Nevi
sites India Increased occurrence of
premalignant and malignant skin
lesions (including actinic
keratoses, basal cell carcinoma,
squamous cell carcinoma, and
melanoma)
Some have lentigenes
Skin Type IV A and B Central America No keratoses 50–400
Minimal skin irritation, minimal South America Mild to Moderate pigmentary Eilers: 6,200 6 10
tenderness, itching, or redness in North America changes with aging
sun-exposed areas, then Philippines Minimal wrinkling
develops a deep tan or skin Polynesia Few nevi
becomes darker in sun-exposed Vietnam Occasional lentigenes (some
areas (no skin irritation, North India palmar and plantar)
tenderness, or itching at 24 h and East Asia Propensity for keloid and scarring
a tan or darker skin at 7 d) Mediterranean Jowl formation
Africa
China
Korea
Japan
Thailand
North Africa
Middle East

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 TABLE 2. Racial/Ethnic, Clinical and Colorimetry Features of the Skin Color and Ethnicity Scale (SCE Scale) (Continued)
Racial/Ethnic Aging, Scarring, and Colorimetry (Melanin Index)
Skin Type Homeland Hyperpigmentation (Spectrophotometer)
Skin Type V Afro Caribbean Prominent jowls 350–475
A and B Central Africa Few rhytides Eilers: 5,000 6 10
Occasional skin irritation, East Africa Marionette Lines
tenderness, or itching in sun- West Africa Moderate hyperpigmentation
exposed skin, then develops South Africa with aging
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moderate or significantly darker South India Propensity for keloid and scarring
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skin in sun-exposed sites in Polynesia No keratose

temperate climates; sunburn Australia
uncommon Eritrea
Ethiopia
North Africa
Middle East
Skin Type VI Afro Caribbean Jowl formation 450–825
No skin irritation, tenderness, or Central Africa Few rhytides Eilers: 4,000 6 10
itching in sun-exposed skin, no East Africa Marionette Lines
noticeable change in skin in sun- West Africa Deeply pigmented skin
exposed sites in temperate South Africa Hyperpigmentation with aging
climates; sunburn uncommon South India Propensity for keloid and scarring
Polynesia No keratose
Australia

Methods and Results In addition to the scale, it is important to assess the

The 3 authors, who have a combined experience of over 80
years in research on skin of color, had numerous virtual
research meetings over 12 months to devise a new scale. A
systematic literature review was performed using PubMed
and Embase (2005–2023) to assess existing skin color scales
(queried “skin of color” “skin color scales” and “Fitzpa-
trick”). An extensive Google search was conducted using
makeup foundation ranges as a starting point for skin tone
matching and potentially insight into cutoff points for
classification. This research and comments from other skin
of color experts confirmed our opinion that Fitzpatrick
types 4 and 5 ratings were the most confusing in that these
included too broad of a range of skin types with different
responses to solar radiation, lasers, surgery, and cosmetic
products. Therefore, it made sense to subdivide skin types 4
and 5 into “A” and “B” to better define them in a new scale.
Additional clinical identifiers such a freckling, pore size, and
other parameters were added to allow researchers to use the
scale more easily (Table 2). These verbal definitions were
combined with a range of photographs to demonstrate the
range of skin color seen within each type. To obtain high-
quality images, Jouer Cosmetics was approached and gave
permission to modify the visual graphic they offer
consumers for color matching makeup foundations into a
color collage for this study. Figure 2 demonstrates the new
scale visually. The finished scale was labeled the SCE scale
(for Skin Color and Ethnicity). Next, numerous photos of
various skin hues were compared with the new scale
pictured in Figure 2. A wide range of skin colors and
genders were rated using the new scale and are demon-
strated in Figure 3.
accompanying clinical assessments such as freckling, nevi,
and scarring to aid in proper cohort placement.
Discussion
The increasing diversity within the United States presents a
multitude of challenges to the practicing dermatologist. Not
only must physicians recognize skin disease in varying skin
tones, but also counsel and guide patients on important
matters including sun protection, benefits of treatment and
risk of unintended consequences of medical therapies, plus
cosmetic, and surgical procedures. The limitations of how we
currently classify diverse patient populations has become
apparent in the last decade and may impact certain types of
studies. Although traditionally the Fitzpatrick scale has been
used to classify pigmentation of the patient population, this
scale was devised for a narrow scope of pigmentation and
disease state (fair skin photodamage). In this article, we
propose an expansion of the Fitzpatrick scale to include a
broader range of skin pigment and to consider disease states
other than photodamage that can be related to skin type. We
have added a clinical assessment of pore size, tendency of
freckling, presence of nevi, and potential for hypertrophic and
keloidal scarring to increase the use of the scale for skin of
color. Not only does the A and B subgrouping in our updated
scale help to stratify groups in phototypes 4 to 5, it can clarify
misconceptions about sunburn risk. It can also help to grade
wrinkle severity as those in subgroup A of 5 are more likely to
behave like subgroup B of 4. The result is a spectrum of risk
that mirrors what we see. Rather than arbitrary question sets
based on sun exposure, the SCE score can create better data
sets for lasers, peels, and other cosmetic procedures. Looking
forward, a more precise color scale should assist in ongoing

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Figure 2. The Skin Color Ethnicity (SCE) Scale dem-

onstrated visually using color charts. (Modified by
permission of Jouer Cosmetics).

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Figure 3. A wide range of skin colors and genders were rated using the new scale and are demonstrated here (Humanae collage
created by artist Angelica Dass and used with permission to demonstrate the variety of skin tones present globally). The authors
propose a new classification system of skin phototypes and present it below each photo in the collage to demonstrate its use among
all patients.

research into artificial intelligence in dermatology such as that
developed by sociologist Ellis Monk, Phd in collaboration
with Google.18,19
Conclusion
This new updated SCE scale should assist authors in better
reporting scientific data in skin of color. Hopefully large
databases such as SEER and the U.S. Census will also adopt
this more precise approach. Currently, validation of this
scale with a larger panel of dermatologists is underway.
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