Skin type classification systems: Cosmetic consideration and planning for procedures

Abstract

This mixing of ethnicities leads to a significant evolution in the world demographics as we continue to diversify at unprecedented levels. We are developing new skin types at a rapid rate. The U.S. Census Bureau statistics in 2000 lists six race categories with 57 possible combinations ( 2 ). To classify a person by skin color is obsolete. Skin color is a complex subject. There are many factors which determine the appearance of skin color. Nordlund et al. state that a number of chemicals contribute to skin color . A major determinant of skin color is melanin, its quantity, type, distribution, and location of melanin within the epidermis and dermis. Other significant determinants are capillary blood flow, chromophores such as carotene or lycopene, and collagen within the dermis ( 4 ). To that end, we understand that we are dealing with biologically separate structures i.e., keratinocyte, melanocytes, collagen, ground substance, blood vessels and these all may have an individual or cumulative effect on skin color and also “the aesthetic” of the post-procedure skin appearance. Historically we have identified patient at risk for untoward procedures by their Fitzpatrick skin phototype. The Fitzpatrick skin type classification system has been the gold standard in communicating skin type ( 5 ). It is by definition, however, a “phototype” limited to describing the predilection for burning and tanning only. It does not address the predilection for hyperpigmentation and scarring. Hyperpigmentation and scarring are the two most common complications from skin injury and insult in cosmetic procedures in diverse skin types. They are followed by prolonged erythema, hypopigmentation, and keloid formation. While many skin type classifications have been proposed, the Roberts skin type classification system is unique in its focus on four elements, which include hyperpigmentation and scarring. Though not as user friendly as the Fitzpatrick scale because it encompasses more parameters, it is a tool to communicate important data needed for safe outcomes ( 6 ).