Dermatology for Skin of Colour: Why Specialist Experience Matters

Dermatology for skin of colour

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By Dr Mary Sommerlad | Consultant Dermatologist, Dermasurge Harley Street

A patient with brown or Black skin often arrives at a dermatology consultation having been round the houses. A rash treated as one condition for months before being correctly identified. Acne cleared successfully, leaving dark marks that nobody warned them about and nobody offered to treat. A laser session elsewhere that lightened an area of skin permanently. A hairline that has been receding gradually while being told it is simply how their hair grows.

None of that reflects a separate branch of medicine. Dermatology is one specialty, and the underlying conditions are the same conditions. What differs is how they present, how easily they are recognised, and how carefully treatment has to be chosen so that it resolves the problem without creating a pigmentary one. Experience across the full range of skin tones is what makes that difference, and it is a reasonable thing to ask about before booking.

How conditions appear differently across skin tones

Most dermatology teaching, and the overwhelming majority of clinical images published in textbooks and online, show conditions on fair skin. The vocabulary follows suit. Inflammation is described as redness, and redness is exactly what is hardest to see when there is more melanin in the skin.

In richly pigmented skin, inflammation more often reads as violet, deep brown, grey or simply as a change in texture. Psoriasis plaques may look purple or grey-brown rather than salmon-pink, and the scale can be more obvious than the colour beneath it. Atopic eczema commonly appears on the extensor surfaces rather than the flexures, may be more follicular in pattern, and frequently leaves darker or lighter patches once the inflammation settles, which patients understandably mistake for the condition itself continuing. Rosacea is well documented in brown and Black skin but is diagnosed far less often, partly because the background flushing is difficult to see.

The practical consequence is that assessment relies more on what the skin feels like, how it is distributed, what the patient describes, and on features other than colour. That is a matter of experience and of deliberately looking for the right things, and it is why a diagnosis that has never quite fitted is worth a second opinion.

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The cost of a delayed or incorrect diagnosis

Delay has consequences that go beyond the frustration of the wait. Inflammation that continues for longer leaves more pigmentation behind, so the mark left by the condition becomes a longer problem than the condition. Acne treated late has more opportunity to scar. Scalp conditions that scar are the clearest example of all, because hair follicles lost to scarring inflammation do not come back, and treatment can only preserve what remains.

The same pattern applies at the serious end. Skin cancer occurs in all skin tones and is less common in richly pigmented skin, but it is diagnosed at a later stage more often. In brown and Black skin, melanoma arises disproportionately on the palms, the soles, under the nails and in the mouth, sites that neither patients nor clinicians examine routinely. A new dark streak under a nail, a changing pigmented patch on a sole, or a sore that does not heal all warrant assessment regardless of skin tone.

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Pigmentation: the thread running through it

If there is one theme that connects most consultations in this area, it is pigmentation. Skin with more melanin responds to almost any insult, whether inflammatory, chemical or thermal, by producing more of it.

Post-inflammatory hyperpigmentation

Post-inflammatory hyperpigmentation is the dark mark left behind after inflammation has settled. It follows acne, eczema, a shaving bump, an insect bite, a burn or an over-aggressive treatment. It is the single most common reason patients with skin of colour attend a dermatology clinic, and it is frequently what the patient came about, even when a different condition is the underlying cause.

Two things follow. First, the primary condition has to be controlled properly, because there is no point treating marks while new inflammation keeps producing them. Second, the marks themselves respond to treatment, though they take patience. Topical pigment-regulating agents, sun protection used consistently, carefully selected chemical peels and appropriately chosen laser or light-based treatments all have a place. Progress is measured over months rather than weeks, and it varies from person to person. Our detailed guide to hyperpigmentation in darker skin tones covers how the different types are told apart and treated safely.

Melasma

Melasma is a distinct pigmentary condition, typically appearing as symmetrical brown or grey-brown patches across the cheeks, forehead and upper lip. It is more common in women, is influenced by hormones and by sun and visible light exposure, and it is chronic and recurrent by nature.

Melasma is also unforgiving of the wrong approach. Aggressive treatment, particularly heat-generating devices used without appropriate settings, can make it worse rather than better. Management is a long-term programme combining rigorous photoprotection, including protection against visible light, with topical treatment, and with procedural treatment used selectively and conservatively. Our melasma treatment in London page sets out the approach, and there is further background on our pigmentation page.

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Conditions where experience changes the plan

Acne and acne scarring

Acne itself is the same condition in all skin tones. The consequences are weighted differently. In richly pigmented skin the marks left behind often distress the patient more than the active spots, and keloid or raised scarring is more common on the jawline, chest and back. Treating acne early and adequately is therefore doubly important, and the plan should address the pigmentation from the outset rather than treating it as an afterthought. Read more on our acne treatment in London page.

Eczema

Atopic eczema is common across all populations and is often more severe and more persistent in Black and South Asian patients. Because the redness is harder to see, severity is routinely underestimated, and it is not unusual for a patient to be treated as mild when the picture described by their symptoms is anything but. Pigment change after a flare, both darker and lighter, is common and settles slowly once the eczema is genuinely controlled. Our article on how eczema appears across different skin tones covers the presentation in detail, and our adult eczema treatment article covers management.

Hair and scalp concerns

Hair and scalp conditions are a significant part of this work and are often the most neglected. Traction alopecia, caused by sustained tension from certain styles, is preventable and reversible early, and permanent once the follicles have scarred. Central centrifugal cicatricial alopecia causes gradual, scarring loss from the crown outwards and needs early recognition. Seborrhoeic dermatitis and scalp psoriasis interact with washing frequency and styling routines in ways that a treatment plan has to accommodate to be workable. A useful consultation asks about styling practices in detail and adapts around them rather than issuing instructions that no one would realistically follow.

Keloid and hypertrophic scarring

Raised scarring is more common in richly pigmented skin, and it changes the calculation before any procedure that breaks the skin, including mole removal and minor surgery. It should be discussed before the procedure rather than managed after it, and the site, technique and aftercare plan all shift accordingly. Our scar clinic covers the treatment options.

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Treatment plans that minimise pigmentation change

The technical part of this is straightforward to state and requires discipline to apply. Almost every intervention carries a risk of causing pigmentation change, in either direction, and the higher the melanin content of the skin, the higher that risk.

• Device and wavelength selection. Longer wavelengths that pass more safely around epidermal melanin are generally preferred in darker phototypes. For laser hair removal, the Nd:YAG 1064nm platform is the recognised choice for richly pigmented skin, where devices designed for fair skin carry a real risk of burns and pigment loss.
• Conservative settings and test patches. A test patch, with an interval before the full treatment, is standard practice rather than an optional extra. Starting conservatively and building slowly produces better outcomes than starting at settings intended for fair skin.
• Preparing the skin. Priming with appropriate topical agents before a procedure, and settling any active inflammation first, reduces the chance of post-procedure pigmentation.
• Peel choice and depth. Superficial and medium peels can work well when the agent, the strength and the number of passes are matched to the skin. Deeper peels carry a higher pigmentary risk and are chosen selectively.
• Photoprotection. Daily broad-spectrum sun protection, including cover against visible light, is part of the treatment rather than an add-on. Modern tinted formulations designed for deeper skin tones make this genuinely practical.
• Aftercare that anticipates the risk. Clear instructions, prompt review if pigmentation appears, and early treatment of any change rather than waiting for it to fade on its own.

Sometimes the right recommendation is to do less, or to treat medically rather than with a device. A consultant dermatologist is well placed to say so, since the assessment and the treatment come from the same person. Our article on Q-switched laser for pigmentation explains where device treatment does and does not fit.

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Why choose Dermasurge Clinic

Dermasurge is a consultant-led dermatology clinic on Harley Street. Assessment and treatment are carried out by consultant dermatologists on the GMC specialist register.

Dr Mary Sommerlad is a consultant dermatologist with a particular focus on facial pigmentary and inflammatory conditions, skin of colour dermatology, laser dermatology and paediatric dermatology. She trained in dermatology in London at the Royal London and the Royal Free, which gave her experience of managing skin disease across all skin types and tones, and she has worked to advance education and competence in skin of colour dermatology in the UK through academic publication, research and lecturing, including at the British Association of Dermatologists Annual Meeting, the European Academy of Dermatology and Venereology, the World Congress of Dermatology and the UK Skin of Colour meeting. She holds MBBS (Lond), FRCP(Derm)(UK) and DCH (RCPCH), is an international fellow of the American Academy of Dermatology, and is an ambassador for the British Skin Foundation.

She practises alongside Dr Hiba Injibar, consultant dermatologist and founder of Dermasurge, who trained and practised in Lebanon and Saudi Arabia before establishing the clinic in London and holds a fellowship in laser dermatologic surgery from the Washington Institute of Dermatologic Laser Surgery.

Medical and cosmetic dermatology sit under one roof, with on-site M22, Q-switched and other laser platforms, so device selection is made by the dermatologist who has assessed the skin rather than dictated by whichever machine happens to be available. Treatment plans are evidence-based, personalised, and built around what is realistic for the individual in front of us. You can read more about the team on our meet the team page, or see how we compare with other London practices in our guide to the best dermatologists in London.

An assessment with a consultant dermatologist is required to reach a diagnosis and determine which treatments are appropriate for your skin.

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Frequently asked questions

What does skin of colour mean in a dermatology context?

It is a broad, practical term covering richly pigmented skin, including Black, South Asian, East and South East Asian, Middle Eastern, Hispanic and mixed heritage skin, usually corresponding to Fitzpatrick phototypes IV to VI. It describes a range rather than a category, and the point of using it is to flag the higher likelihood of pigmentary responses, not to place patients in a separate stream of care.

Are laser treatments safe on Black and brown skin?

Many are, when the wavelength, the settings and the operator are right. Longer-wavelength devices such as the Nd:YAG 1064nm are used for richly pigmented skin, and a test patch before full treatment is standard. Risk arises when devices designed for fair skin are used at unsuitable settings, which can cause burns and lasting pigment change. Suitability is determined at consultation, and responses vary from person to person.

Why do dark marks appear after my spots clear?

That is post-inflammatory hyperpigmentation, the skin producing extra melanin in response to inflammation. It is a normal response rather than scarring, and it fades, though it often takes months. Treatment works best when the underlying acne or eczema is properly controlled first, then topical pigment-regulating treatment and consistent sun protection are added, with peels or laser considered selectively.

Do I need to wear sunscreen if I have deeply pigmented skin?

Yes. Melanin provides some natural protection, but not enough to prevent pigmentary change, and visible light as well as ultraviolet drives conditions such as melasma. Daily broad-spectrum protection with cover against visible light is a working part of any pigmentation treatment plan. Tinted formulations designed for deeper skin tones avoid the white cast that puts many people off.

How do I know whether a dermatologist has experience with my skin type?

Ask directly. It is a fair question at the point of booking, and a reasonable clinic will answer it plainly. Useful things to ask about are experience treating your specific condition in your skin type, which devices the clinic uses and why, whether test patching is routine, and how the plan handles the risk of pigmentation change.

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Book a consultation

If a diagnosis has never quite fitted, if pigmentation has been left untreated after the original condition settled, or if you want a plan built by someone who assesses skin of colour routinely, a consultation is the place to start. The aim is a plan that treats the condition and protects the skin’s pigment at the same time.

To arrange a personalised assessment with a consultant dermatologist, book a consultation at Dermasurge Clinic. You can find out more about the clinic at dermasurge.co.uk.

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