Laser Fitzpatrick Skin Type Recommendations

Issues of Concern

Objective Determination of Fitzpatrick Skin Types

Given the relative ease of implementation of Fitzpatrick skin typing, it is understandable why this classification system has been so widely applied. However, numerous studies have criticized this system on scientific grounds, and validated objective alternatives have been sought to achieve a comparable prediction of ultraviolet (UV) sensitivity.[4] Methods, including the Wood’s lamp for quantification of cutaneous eumelanin and pheomelanin, have been implemented; however, both have been unsuccessful in differentiating Fitzpatrick skin types higher than level II.[4]

Currently, spectrophotometers are the primary tool for estimating melanin density in the epidermis and for evaluating the accuracy of self-reported skin types.[4] Spectrophotometers are able to distinguish darkening caused by increased melanin from erythema as a result of inflammation or increased hemoglobin, allowing for a more reliable estimation of the true Fitzpatrick skin type.[5] Spectrophotometers have also been used to distinguish constitutive skin color (baseline skin color in body areas not exposed to light) from facultative skin color (skin color in body areas where light-induced pigmentation changes are seen).[4] Specifically, all 6 Fitzpatrick skin types can be discerned using a reflectance spectrophotometer across the 450-615 nm wavelength range.[4] Unfortunately, this tool is not perfect, and the high costs of personnel and equipment may prevent widespread adoption.

Inconsistencies with Self-Reporting and Ethnic Skin

It is important to highlight that the Fitzpatrick skin type is a classification intended to reflect sun sensitivity and not a proxy for racial or phenotypic features. The description of the skin by color – white, brown, black – was meant to denote complexion rather than a self-identification of ethnic origin.[6] For example, a cross-sectional survey of an ethnically diverse population showed self-reported pigmentary phenotypes and race were significant but incomplete predictors of Fitzpatrick skin types.[7]

The difficulty in assessing ethnic skin with the current Fitzpatrick skin type system can be traced to the origin of skin types V and VI. When these additional types were created in 1988, the initial intention was to place all Black individuals in the Type VI category. However, people with mixed heritage or races who identify as black often self-report in a variety of categories, ranging from type IV to type VI.[8] Though the reasons for this are multifaceted, the concept of labeling one’s skin reaction to the sun as tanning or burning lacks reliability, as these words have different meanings to different people. Specifically, participants with skin of color have been shown to report fewer painful burns or tanning episodes, or to have a limited understanding of tanning.[8][9] The functionality of Fitzpatrick skin typing in ethnic skin is also under question. In a population-based study of 2691 participants, this classification system correlated with sun sensitivity among non-Hispanic white and Hispanic participants but not among black participants.[2] In response, multiple scales limited to single ethnic groups have been developed, including a Japanese Skin Type scale by Kawada and a scale for individuals of African descent by Willis and Earles, to more accurately classify the nuances of ethnic skin.[10]

Laser Therapy in Ethnic Skin

Structural and functional differences between darkly pigmented and lightly pigmented skin are important considerations when performing laser or light-based procedures. In general, darker skin types possess increased epidermal melanin, larger and more widely distributed melanosomes, and reactive fibroblasts.[11] Higher Fitzpatrick skin types are therefore associated with these biological characteristics, leading to increased melanin content and epidermal distribution. Increased melanin concentration provides greater protection against ultraviolet radiation, resulting in less pronounced and delayed signs of photoaging.[12]

There are several factors to consider when treating individuals with Fitzpatrick skin types IV through VI. Melanin in the epidermis acts as a chromophore, absorbing more laser energy and increasing the risk of adverse events from epidermal injury in those with darkly pigmented skin. To circumvent this risk, longer-wavelength lasers are recommended. Deeper penetration of the laser allows for an increased ratio of the temperature of the hair bulb to the temperature of the epidermis, leading to follicular destruction with little epidermal damage.[13] Similarly, lower fluences and longer pulse durations (laser hair removal) or lower treatment densities (laser resurfacing) are suggested for darker-skinned individuals to decrease the risk of thermal injury to the epidermis.[13] Pre- and post-treatment with bleaching agents (eg, hydroquinone cream) has been shown to reduce the risk of post-inflammatory hyperpigmentation, particularly after laser resurfacing.[14] Cooling of the epidermis at pre- or post-treatment times can also prevent pigmentary abnormalities, with the most common modalities involving contact or cryogen spray cooling.

With regard to laser or light-based procedures, the risk of postprocedural hyperpigmentation or hypopigmentation is higher in patients with Fitzpatrick skin types IV through VI. In general, dyschromia is among the most common reasons that individuals with skin of color consult dermatologists, as injury or inflammation can alter pigment production.[15] In addition to the aforementioned recommendations, classification systems, such as the Laser Ethnicity Scale, have been developed to better predict healing efficacy and time in patients undergoing laser procedures.[16]

Clinical Significance

Fitzpatrick skin types have long been the favored method of classifying an individual’s skin color based on their specific reactions to sun exposure. Clinically, these designations have been employed to estimate dosages, assess cancer risk, or guide counseling (Figures 1 & 2). However, this system has been recognized as ineffectual in certain populations, especially those with darker, non-Caucasian ethnic skin. These individuals are at greater risk of post-procedural pigmentary and scarring-related adverse effects. Thus, the accurate determination of Fitzpatrick skin types has important therapeutic consequences. Numerous attempts have been made to develop objective methods for determining an individual’s skin type; although none are yet considered a gold standard, reflectance spectrophotometers constitute an efficient, noninvasive alternative with a proven record of success.

Nursing, Allied Health, and Interprofessional Team Interventions

While the determination of Fitzpatrick skin types is typically performed by a physician, the administration of laser treatments may involve multiple healthcare workers. Physicians, physician assistants, nurse practitioners, nurses, and medical assistants are involved in laser treatments, and an interprofessional team approach is essential to prevent and mitigate pre-, intra-, and post-treatment complications. Detailed education on side effects, careful management of expectations, and thorough counseling on results are essential interprofessional team interventions that improve outcomes for patients across all Fitzpatrick skin types.