Skin Type Classification: A Decennial Perspective

The intent of this brief communication is to revisit the Roberts Skin Type Classification System published by Journal of Drugs in Dermatology (JDD) in 2008 with a 2018 lens and provide additional information for its wider acceptance and implementation. The key points of this communication are that the 2010 US census indicates rapid growth of the multiple race population up 30-50% from the 2000 census,¹ cosmetic procedures have increased from 9.5 million to 12.8 million over the same 10 year period,² and cosmetic procedures in SOC patients have increased 6% over the same 10 year period.² We have come very far in our knowledge of skin safety and colorblind technology, however, as we experience rapid globalization and increasing diversity of traditionally diverse populations, this classification system is even more relevant now than it was 10 years ago.³ What standard are we using to predict our diverse patient outcomes to skin insult, injury, and inflammation? Why do we still use the limited Fitzpatrick Phototype System to communicate safety when the system does not address dyspigmentation and scarring, the most frequent complications in ill-fated skin trauma?⁴ The Skin of Color Society asked these questions of it participants in 2006. Dr. Eliott Battle and Dr. Susan Taylor led the discussion. Most of the existing Skintype scales at that time were based on phototype, burning reactions, race, or ethnicity. After attending that meeting and learning there was nothing to adequately describe the tool we needed, I took a crack at coming up with a system I believed was simple, colorblind, not ethnicity based, and effective. After designing the system, I presented it to the Skin of Color Society Post-Inflammatory Hyperpigmentation workgroup, it was embraced, and I pursued a validation process. The article was published in the JDD in 2008. After presenting the classification system at different international conferences, many of our colleagues in India, Africa, and Asia adopted this system into their diverse practices. The system has been clinically validated as helpful in prevention of procedural misadventures. We here in the United States have been late adopters and inexplicably wed to the Fitzpatrick Phototype system. The Roberts System is an outcome-based scale that measures skin responses to insult, injury, and inflammation. This system is colorblind, genderblind, and nationality/race blind. It is completely dependent on how the skin behaves when facing an environmental stimulus. The stimulus can be thermal, laser, incision, inflammatory, cryogenic, or chemically induced. This is achieved by examination of the skin and review of the patient history and ancestry. To classify an individual with the Roberts System, 3 steps are used: 1) Review ancestral history 2) review clinical history, and 3) visual examination of the patient’s skin. These steps can be easily accomplished during a routine full body skin examination. I recommend the Skin Type be assigned on that initial examination because it will be helpful in planning medical, surgical, and cosmetic/aesthetic procedures. Procedural test sites may be used to gather more information regarding skin response. To be inclusive and build on the work done by Thomas Fitzpatrick (Phototypes) and Richard Glogau (Photoaging),⁵ the Roberts Scale incorporates the quantification of 4 elements: a) skin phototype, b) skin pigmentation, c) skin photoaging, d) skin scarring. Each element is assigned an alpha numeric based on the clinical history and examination. These alpha numerics are placed in a serial series and the 4 serial alpha numerics constitute the individuals skin type.Clinical ExampleA patient with visually white skin that hypopigments with trauma, has moderate photoaging, and develops keloids would have the following scale FZ 2, H0, G2 , S4.Shifting DemographicData on race have been collected since the first US census in 1790.6 In census 2000, for the first time, individuals were presented with the option to self-identify with more than one race, and this continued with the 2010 census. An individual’s response to the race question is based upon self-identification; The 2000 and 2010 data for specific race combination groups were compared.7People who reported White as well as Black or African American, a population that grew by over one million people, increased by 134%. People who reported White as well as Asian, a population that grew by about three-quarters of a million people, increased by 87 percent.6 These two groups exhibited significant growth in size and proportion from 2000 to 2010. Among people who reported more than one race in 2010, the vast majority (92%) reported exactly two races. An additional 7.5% of people who reported multiple races reported three races, and less than 1.0% reported four or more races.⁷Cosmetic ProceduresData citing overall skin insult, injury, and inflammation are hard to find. However ASAPS has excellent data in cosmetic procedures both surgical and nonsurgical. Complications may arise in both groups without informed awareness of at risk skintype characteristics. These ASAP statistics give us the scope of the possibility of potential complications. Cosmetic procedures have increased by 39% from 2011 to 2015 with surgical procedures up 17% and nonsurgical procedures up 44%. Combined surgical and nonsurgical procedures in the United States