Dermatology is the branch of medicine concerned with the skin, hair, and nails as well as the conditions associated with them. Basic knowledge of dermatology is essential for every physician, as approximately 50% of skin-related consultations are initially assessed by non-dermatologists. In the United States, the most common conditions seen by dermatologists include acne, actinic keratoses, non-melanoma skin cancers, benign tumors, and contact dermatitis. Skin lesions may be primary or secondary. Primary lesions (e.g., macules and papules) appear as a direct result of a disease process. Secondary lesions (e.g., scales and ulcers) may develop from primary lesions or result from external trauma (e.g., infections, scratching). Dermatological conditions can often be diagnosed based on patient history and physical examination but confirming the diagnosis may require laboratory testing or biopsy. Dermatological diseases are managed with medication (topical and systemic) and procedures such as surgery, cryoablation, radiotherapy, or phototherapy. Conservative treatment with topical agents is the treatment of choice for most dermatological conditions, with systemic medication and/or surgery being employed only if necessary. The prevalence, manifestations, and treatment of dermatological conditions in skin of color may vary depending on skin tone and genetic inheritance.
- History of present illness
- Past medical history: Underlying diseases may be responsible for skin findings (e.g., erythema nodosum in chronic bowel disease).
- Drug history: Many drugs have cutaneous adverse and side effects. Be aware of potential drug interactions.
- Review of systems: e.g., diabetes, rheumatic diseases, infections, and endocrine disorders (e.g., hyperthyroidism)
- Family history: e.g., Café au lait spots in young children may be part of an inherited disease such as neurofibromatosis.
- Social history
- Complete skin assessment: Examine the skin (including the hands, mouth, and scalp) and nails for signs of dermatological conditions.
- Examination techniques
- Confirmation of diagnosis: may require biopsy for histopathological examination (see “ ” below) and/or laboratory studies
The hands, mouth, scalp, and nails should not be overlooked during a dermatological examination.
- Determine the type of lesion: See primary skin lesions, secondary skin lesions, and complex skin lesions below.
- Record lesion characteristics
|Alterations of the nails|
|Clinical findings||Clinical examples||Possible underlying disease|
White, grey, or yellowish color with dullness and crumbling of the nail
(horizontal lines of discoloration)
|Alterations of the hands|
|Clinical findings||Clinical examples||Possible underlying disease|
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|Overview of most common primary skin lesions |
|Primary Lesions||Description||Cross-section||Clinical example|
|Patch (dermatology)|| |
|Nodule (dermatology)|| |
|Overview of most common secondary skin lesions |
|Secondary Lesions||Description||Illustration||Clinical example|
|Excoriation (scratch marks)|
|Overview of complex skin lesions |
|Complex lesions||Description||Clinical example|
|Purpura (a subtype of hematoma that does not blanch upon the application of pressure)||Nonpalpable purpura|| |
|Palpable purpura|| |
|Histopathologic finding||Characteristics||Examples of associated conditions|
|Hypergranulosis|| || |
|Hyperkeratosis|| || |
Overview of treatment
- Topical medications
- Systemic medications
Types of topical preparations 
- Lotions, foams, and gels
Topical steroids are the most frequently used topical treatment in dermatology.
- “Skin of color” refers to skin with a higher degree of pigmentation than that traditionally associated with Northern European heritage.
- Skin tone is a spectrum that does not necessarily correspond to the skin tones traditionally associated with race.
- Genetic inheritance can play a more important role in the manifestation of dermatological conditions than skin tone.
- It is important to recognize with regard to the concept of “race” still in use by the US Census Bureau that there is no foundation for a scientific concept of race as a specific genetic, phenotypical, ancestral, or ethnic trait that distinguishes all members of one population from those of another.
- Western medicine has traditionally focused on the presentation of light-skinned individuals, leading to underrepresentation in dermatological resources of cutaneous manifestations in individuals with skin of color.
- Changing demographics and increased representation of historically marginalized populations have raised awareness for the need and importance of thoroughly understanding skin of color.
- The incidence and prevalence of dermatological conditions in individuals with skin of color depend to a high degree on skin tone and differ from those seen in light-skinned individuals for a variety of reasons:
- Underrecognition due to poor dermatological training in diagnosing cutaneous conditions in individuals with skin of color.
- Factors that are influenced by different lifestyle and cultural practices
- Genetic inheritance
|Dermatological conditions that are more common in individuals with skin of color |
|Heritage||Condition(s) with higher prevalence|
|American Indian|| |
Skin color depends on the degree of pigmentation with (contained in melanosomes, which are synthesized in melanocytes), other pigments (i.e., hemoglobin, oxyhemoglobin, and carotenoids), and melanocyte activity, all of which are determined by genetic heritage. For more information on melanin, see “ ” in “ .”
- Differences in skin pigmentation are mainly due to differences in melanocytic activity.
Skin layer composition varies between different skin colors.
Stratum corneum (SC)
- The darker the skin, the more cell layers and greater intercellular cohesion it will have.
- Thickness: similar in all skin colors
- Lipid content: is highest in individuals with Southeast and East Asian heritage, followed by those with Hispanic and African heritage
- Barrier function (greater transepidermal fluid loss): African heritage > Hispanic heritage > Southeast and East Asian heritage
- The greater the amount and size of fibroblasts, small collagen fibers, and macrophages, the higher the risk of keloid formation and scarring
- Stratum corneum (SC)
- Skin appendages: larger sebaceous glands → increased sebum production (African heritage > Southeast and East Asian heritage > Hispanic heritage)
Clinical presentation 
- Dermatological symptoms may be subtle or have a characteristic appearance depending on skin pigmentation.
|Overview of dermatological symptoms in skin of color|
|Skin hemorrhages|| |
- Specific conditions may appear uniquely in individuals with skin of color 
|Distinguishing features of specific conditions in individuals with skin of color |
|Atopic dermatitis|| |
|Basal cell carcinoma|| |
- The prevalence, manifestations, and treatment of dermatological conditions may vary depending on skin tone and genetic inheritance.
- Lack of familiarity with the manifestations of dermatological conditions in individuals with skin of color may lead to a delay or failure to properly recognize, diagnose, and treat dermatological conditions in these patient groups.
- Keep the following recommendations in mind regarding patients with skin of color to ensure proper diagnosis and treatment:
- Appreciate the diversity of skin tones and consider the characteristics of every patient's skin individually.
- Familiarize yourself with differences in disease manifestations, epidemiology, and treatment of dermatological conditions that depend on skin color.
- Familiarize yourself with and be sensitive to differences that depend on skin color and/or ethnicity in skincare (e.g., dandruff products), cosmetic use (e.g., skin bleaching products), and cultural practices (e.g., tattooing, hair extensions).
- Familiarize yourself with the preferred terms for describing skin tones and those that should be avoided.
- Raise awareness for common misconceptions regarding skin of color (e.g., that people of color do not require sunscreen, do not get sunburnt, and do not get skin cancer).
- Perform a complete skin assessment upon initial presentation and familiarize yourself with the patient's normal skin tone to better recognize irregularities and lesions.
- Use a and be open about pertinent gaps in knowledge, involving the patient in helping to close them.
- Be aware of the history of racism and its consequences also in health care, but refrain from making assumptions (e.g., regarding social status) based on skin color (see also “ ”).
Treatment considerations 
- Skin reactivity to certain therapies differs among skin types.
- The darker the skin, the greater the risk of postinflammatory hyperpigmentation and postinflammatory hypopigmentation
- Lifestyle and personal care practices (e.g., frequency of hair washing) may affect the practicality of certain therapies (e.g., treatment of seborrheic dermatitis on the scalp with a topical steroid oil applied nightly may be more practical than an antifungal shampoo for individuals who wash their hair every few weeks).