Pigment International

: 2022  |  Volume : 9  |  Issue : 1  |  Page : 1--3

Pigmentary disorders: paradigms in a multicultural society

Monisha Gupta1, Brent J Doolan2,  
1 Department of Dermatology, Liverpool Hospital, Sydney, New South Wales; Pigmentary Disorders Clinic, The Skin Hospital, Westmead and Darlinghurst, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Western Sydney University, New South Wales, Australia
2 Department of Dermatology, Liverpool Hospital, Sydney, New South Wales; Department of Medical Oncology, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia

Correspondence Address:
Dr. Monisha Gupta
Department of Dermatology, Liverpool Hospital, Sydney, New South Wales, Pincode/Postcode: 2170

How to cite this article:
Gupta M, Doolan BJ. Pigmentary disorders: paradigms in a multicultural society.Pigment Int 2022;9:1-3

How to cite this URL:
Gupta M, Doolan BJ. Pigmentary disorders: paradigms in a multicultural society. Pigment Int [serial online] 2022 [cited 2022 Dec 5 ];9:1-3
Available from: https://www.pigmentinternational.com/text.asp?2022/9/1/1/345301

Full Text

The face of the human race is changing and is taking on a distinctive brownish hue. India and China together constitute 2.6 billion of the current world population of 7.9 billion.

According to the United Nations population statistics, in the last decade, the population growth has been maximum in these countries though about two-thirds of the future growth is expected to occur in Africa.[1] Not only is the population of people of color growing, they are no longer segregated but now constitute the largest number of migrants around the world. According to data from the Australian Bureau of Statistics, within the top 10 countries of birth for Australian residents was India, China, Philippines, Vietnam, Malaysia, and Sri Lanka, all of which have people with darker skin color.[2] The traditionally white societies are having to learn to adapt to a growing multiethnic population, which poses unique challenges to the dermatologists not equipped to recognize and treat conditions across a spectrum of skin colors.

 Service gap

One hundred years ago, Johnson & Johnson invented the Band-Aid in a beige shade. They have produced over 100 billion Band-Aids but only recently have they started making their products to match different skin tones to “embrace the beauty of diverse skin.”[3] Cosmetic products, especially foundations for a true match across all skin colors are not readily available in Australian supermarkets and pharmacies. A petition calling for Australia’s leading supermarkets to stock beauty products that cater to all skin colors has been launched recently as a response to perceived racial discrimination, labeled as unfair and exclusive by the customer launching the petition and those within the beauty industry.[4]

Globally, sunscreens are advertised and sold on the basis of their sun protection factor, which is a measure of the product’s ability to protect against ultraviolet B (UVB) spectrum of the solar radiation. UVA and UVB are relevant for protection against skin cancer. However, visible light is more important for pigmentary disorders requiring a tinted product with iron oxide. The distinction between sunscreen for skin cancer and sunscreen for hyperpigmentation is not visible in the marketing strategy as yet.

Historically, we have tried to categorize skin through the use of questionnaires, such as the Fitzpatrick scoring system, which is based on a patient’s skin color and response to sun exposure. Even though this questionnaire is still commonly used in practice today, it does not adequately represent all skin types, excluding many Black patients and overestimating the number of Black patients with a type IV Fitzpatrick skin rating.[5] Other commonly used scoring systems such as the Eczema Area and Severity Index and the Psoriasis Area and Severity Index have also been reported as imprecise scoring systems in patients with darker skin, as the erythema in darker skin types is harder to assess especially by the untrained eye.[6] Furthermore, the persisting postinflammatory hyperpigmentation in people of color remains a cause of concern for the patient, reflected in high Dermatology Life Quality Index scores but not captured by the severity scores. This underassessment of the severity of their disease in turn disadvantages them from accessing medications such as biologic agents, which in countries like Australia are determined by the severity scores.

 Understanding clinical competency

There are significant differences in the presentation of dermatologic disorders based on each major racial and ethnic group.[7] Common conditions may have different morphologies, for example, follicular eczema, lichenified psoriasis, photodermatoses like lichen nitidus actinicus, lichenoid reactions to hair color ingredients, and significant postinflammatory dyspigmentation from acne vulgaris and other inflammatory conditions. Other conditions may be more common, for example, discoid lupus and sarcoidosis. Tropical infections such as leprosy, leishmaniasis, and cutaneous tuberculosis result in delayed diagnosis and poorer outcomes with increased complications in patients presenting to dermatologists unfamiliar with these conditions.

Cosmetic treatments also differ with high rates of irritancy to topicals, different settings for laser devices, and higher risk of scarring. The cultural, ethnic, and racial norms for beauty and proportions also differ, requiring understanding of these by the cosmetic physician to deliver satisfactory treatment outcomes through identifying patient concerns, for example, the shape of the eyes and jaws in South-East Asians, whereas uneven skin color and “dark circles” in those from the Indian subcontinent maybe chief cosmetic concerns.

 Health disparities due to ethnicity

Many studies show that there are significant racial and ethnic disparities in receiving newly approved medications, as well as accessing standard of care medical therapies for patients with skin of color. Demographic, socioeconomic factors, and comorbidities may all contribute to the difference, but the color of skin appears to be an overarching factor in unequitable access to health care. This is further compounded by the lack of proficiency in the English language. Navigating a health system designed with the presumption of universal understanding of the language creates a barrier to access and compliance in those from a non-English speaking background.

Interestingly, cultural competency is a topic that continues to arise when reviewing critical factors in the optimal care of patients with skin of color. For example, within South-East Asian culture, the psychosocial impact of vitiligo for a woman is greater than that in a man of similar background. Her chances for marriage are slim and she agonizes over the chances of passing on this stigma to her child.

Though the western world grapples with the rising incidence of melanoma from sun-seeking behavior of the young population including the use of tanning devices and culturally driven tanning behaviors, whitening creams have become a billion-dollar industry in African, South and South-East Asian countries. At the heart of this perception lies the role of media and cultural perceptions. The western media speaks about how “Kate and Will returned from a holiday in Hawaii, looking fit and tanned….” implying good health associated with a tanned appearance.[8] In the West being tanned suggests that one is rich enough to afford a tropical holiday in the middle of winter. In tropical countries, being light skin implies being privileged enough to not have to work outdoors and get tanned. However, in Victorian times pale skin was prized by nobility, it was Coco Chanel in the mid-1920s who made a tanned appearance trendy and a symbol of privilege, fashion, leisure, and liberation. The historical, cultural, and media influences mold medicine that dermatologists need to be sensitized to.

 The shortfalls within institutional policy and education

It is surprising that despite Australia’s indigenous population, the interest in skin of color has only been quite recent and triggered by the multiracial immigrant population.[2] In a survey among Australian dermatology residents (registrars), both trainees and fellows admitted to their lack of confidence in treating patients with skin of color.[9],[10] An audit of Australia’s first pigmentary disorders clinic assessing patient satisfaction, clearly demonstrates a gap in service that needs to be met within the multiethnic, multicultural Australia.[11]

There is a clear under-representation of skin of color in dermatology images and textbooks, both traditional textbooks and recent reports of coronavirus disease 2019 and cutaneous manifestations in the journals.

Mind the Gap by medical student, Malone Mukwende, is the first step in addressing the difference by producing a resource which shows how clinical signs appear on darker skin.[12] Dermnet NZ, the world’s largest online authoritative resource in dermatology, is also working toward inclusivity in skin color in text and images. Major dermatology journals also fail to include adequate articles and images representing skin conditions in a diverse skin color.

Under-representation of patients with skin of color is also a big issue in the dermatological clinical trials that provide efficacy and safety for new drugs that are then used in clinical practice. The difference lies not only in the color of skin whereby trial data cannot be simply extrapolated from a nonrepresentative Caucasian sample, but also in the genetics, pharmacokinetics, lifestyle, etc.

 Implementing change to accommodate patients with skin of color

A positive relationship between people with skin of color and their treating physician improves health outcomes for patients. The mandatory use of interpreter services for patients with limited English proficiency, the provision of information in the patient’s preferred language to improve health literacy would align with the rights of patients. Inclusion of cultural competency in medical training and including presentations across different ethnicities and color by training and examining bodies would be a step in the right direction. Diversity in research and trials should be addressed to provide for more tailored treatment for individuals.There has been a call to journal editors to reconsider publishing clinical trials that are not representative of global diversity. It has also been suggested that including ∼16% or higher skin of color content in publications will promote equitable dermatology care for our diverse patient population.[13]

As the field of dermatology moves toward personalized patient care, race and ethnicity have become significant topics of clinical conversation. We need to move forward in strengthening patient trust in the healthcare system and aim to reduce healthcare disparities to provide equitable dermatology care for all.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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11Doolan BJ, Weaich M, Gupta M. An analysis of patient satisfaction in a pigmentary disorders clinic from a quaternary referral service. Australas J Dermatol 2021;62:e109-10.
12BME Medics. Interview with Malone Mukwende: mind the gap, 2020. Available at https://www.bmemedics.co.uk/post/interview-with-malone-mukwende-mind-the-gap. [Accessed June 7, 2021].
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