The psychosocial burden of hyperpigmentation in fitzpatrick skin types IV to VI

Rehet Chugh; Kenneth Treasure; Merisa Adelman; Selina Chang; Naif Hebo; Mildred Min

doi:10.18203/issn.2455-4529.IntJResDermatol20254132

Authors

Rehet Chugh Burrell College of Osteopathic Medicine, Las Cruces, New Mexico, USA
Kenneth Treasure Burrell College of Osteopathic Medicine, Las Cruces, New Mexico, USA
Merisa Adelman Chicago College of Osteopathic Medicine, Downers Grove, Illinois, USA
Selina Chang University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
Naif Hebo University of Arizona College of Medicine Phoenix, Phoenix, Arizona, USA
Mildred Min Kettering Health Network, Department of Internal Medicine, Kettering, Ohio, USA

DOI:

https://doi.org/10.18203/issn.2455-4529.IntJResDermatol20254132

Keywords:

Hyperpigmentation, Skin of color, Psychosocial, Quality of life, PIH, Melasma

Abstract

Hyperpigmentation, which includes conditions like post-inflammatory hyperpigmentation (PIH) and melasma, disproportionately affects individuals with Fitzpatrick skin types IV-VI. Although medically benign, hyperpigmentation can cause significant emotional and social distress. Despite growing awareness of dermatologic disparities, research exploring the psychosocial burden of hyperpigmentation among individuals with Fitzpatrick skin types IV-VI remains limited. This review synthesizes existing literature on the psychosocial impacts associated with hyperpigmentation, focusing on individuals with melanin-rich skin. Studies reveal consistent associations between hyperpigmentation and diminished self-esteem, anxiety, depression, and social withdrawal. In many cases, the psychosocial toll was disproportionately greater than the clinical severity of the hyperpigmentation. Cultural beliefs, including colorism and societal beauty standards that favor fair skin, were found to influence how patients perceive their hyperpigmentation, pursue treatment and engage with healthcare providers. There was a notable lack of inclusive clinical studies, culturally sensitive care models and dermatological mental health care. In addition, physicians receive limited medical training on skin of color, further contributing to misdiagnosis and inappropriate treatment. Addressing these gaps involves a multifactorial approach including increasing representation amongst dermatological research, developing inclusive educational resources for physicians, incorporating culturally sensitive care, and launching public health campaigns promoting skin health and inclusivity. Recognizing both the clinical and psychological severity associated with hyperpigmentation allows for greater patient-centered care, fostering patient trust, engagement, and treatment compliance.

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References

Moolla S, Miller-Monthrope Y. Dermatology: how to manage facial hyperpigmentation in skin of colour. Drugs Context. 2022;11:10.7573/dic.2021-11-2. DOI: https://doi.org/10.7573/dic.2021-11-2

Gupta V, Sharma VK. Skin typing: Fitzpatrick grading and others. Clin Dermatol. 2019;37:430-6. DOI: https://doi.org/10.1016/j.clindermatol.2019.07.010

Davis SA, Narahari S, Feldman SR, Huang W, Pichardo-Geisinger RO, McMichael AJ. Top dermatologic conditions in patients of color: an analysis of nationally representative data. J Drugs Dermatol. 2012;11:466-73.

Kaufman BP, Aman T, Alexis AF. Postinflammatory hyperpigmentation: epidemiology, clinical presentation, pathogenesis and treatment. Am J Clin Dermatol. 2018;19:489-503. DOI: https://doi.org/10.1007/s40257-017-0333-6

Ogbechie-Godec OA, Elbuluk N. Melasma: an up-to-date comprehensive review. Dermatol Ther (Heidelb). 2017;7:305-18. DOI: https://doi.org/10.1007/s13555-017-0194-1

Jafferany M. Psychodermatology: a guide to understanding common psychocutaneous disorders. Prim Care Companion J Clin Psychiatry. 2007;9:203-13. DOI: https://doi.org/10.4088/PCC.v09n0306

Garg A, Chren MM, Sands LP. Psychological stress perturbs epidermal permeability barrier homeostasis: implications for the pathogenesis of stress-associated skin disorders. Arch Dermatol. 2001;137:53-9. DOI: https://doi.org/10.1001/archderm.137.1.53

Cartwright MM, Kamen T, Desai SR. The psychosocial burden of skin disease and dermatology care insights among skin of color consumers. J Drugs Dermatol. 2023;22:1027-33. DOI: https://doi.org/10.36849/JDD.7713

Riley PA. Melanin. Int J Biochem Cell Biol. 1997;29:1235-9. DOI: https://doi.org/10.1016/S1357-2725(97)00013-7

Yamaguchi Y, Hearing VJ. Physiological factors that regulate skin pigmentation. Biofactors. 2009;35:193-9. DOI: https://doi.org/10.1002/biof.29

Elbuluk N, Grimes P, Chien A, Hamzavi I, Alexis A, Taylor S, et al. The pathogenesis and management of acne-induced post-inflammatory hyperpigmentation. Am J Clin Dermatol. 2021;22:829-36. DOI: https://doi.org/10.1007/s40257-021-00633-4

Perez-Bernal A, Munoz-Perez MA, Camacho F. Management of facial hyperpigmentation. Am J Clin Dermatol. 2000;1:261-8. DOI: https://doi.org/10.2165/00128071-200001050-00001

Nolan BV, Feldman SR. Dermatologic medication adherence. Dermatol Clin. 2009;27:113-20. DOI: https://doi.org/10.1016/j.det.2008.11.006

Mar K, Khalid B, Maazi M, Ahmed R, Wang OJE, Khosravi-Hafshejani T. Treatment of post-inflammatory hyperpigmentation in skin of colour: a systematic review. J Cutan Med Surg. 2024;28:473-80. DOI: https://doi.org/10.1177/12034754241265716

Davis EC, Callender VD. Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol. 2010;3:20-31.

Rossi AM, Perez MI. Treatment of hyperpigmentation. Facial Plast Surg Clin North Am. 2011;19:313-24. DOI: https://doi.org/10.1016/j.fsc.2011.05.010

Khalkhal E, Razzaghi M, Rostami-Nejad M, Rezaei-Tavirani M, Heidari Beigvand H, Rezaei Tavirani M. Evaluation of laser effects on the human body after laser therapy. J Lasers Med Sci. 2020;11:91-97. DOI: https://doi.org/10.15171/jlms.2020.15

Sharma AN, Patel BC. Laser fitzpatrick skin type recommendations. StatPearls. 2025.

Darji K, Varade R, West D, Armbrecht ES, Guo MA. Psychosocial impact of postinflammatory hyperpigmentation in patients with acne vulgaris. J Clin Aesthet Dermatol. 2017;10:18-23.

Balkrishnan R, McMichael AJ, Camacho FT, Saltzberg F, Housman TS, Grummer S, et al. Development and validation of a health-related quality of life instrument for women with melasma. Br J Dermatol. 2003;149:572-7. DOI: https://doi.org/10.1046/j.1365-2133.2003.05419.x

Platsidaki E, Efstathiou V, Markantoni V, Kouris A, Kontochristopoulos G, Nikolaidou E, et al. Self-Esteem, Depression, Anxiety and Quality of Life in Patients with Melasma Living in a Sunny Mediterranean Area: Results from a Prospective Cross-Sectional Study. Dermatol Ther (Heidelb). 2023;13:1127-36. DOI: https://doi.org/10.1007/s13555-023-00915-1

Mahajan VK, Patil A, Blicharz L, Kassir M, Konnikov N, Gold MH, et al. Medical therapies for melasma. J Cosmet Dermatol. 2022;21:3707-28. DOI: https://doi.org/10.1111/jocd.15242

Charles CAD, McLean SK. Body image disturbance and skin bleaching. Br J Psychol. 2017;108:783-96. DOI: https://doi.org/10.1111/bjop.12241

Daftary K, Poondru S, Patel N, Shramuk M, Muhammad L, Kundu RV. Colorism attitudes and use of skin lightening agents in the United States. Int J Womens Dermatol. 2023;9:e092. DOI: https://doi.org/10.1097/JW9.0000000000000092

Sommerlad M. Skin lightening: causes and complications. Clin Exp Dermatol. 2022;47:264-70. DOI: https://doi.org/10.1111/ced.14972

Dlova NC, Hamed SH, Tsoka-Gwegweni J, Grobler A. Skin lightening practices: an epidemiological study of South African women of African and Indian ancestries. Br J Dermatol. 2015;173:2-9. DOI: https://doi.org/10.1111/bjd.13556

Jacobs M, Levine S, Abney K, Davids L. Fifty shades of African lightness: a bio-psychosocial review of the global phenomenon of skin lightening practices. J Public Health Afr. 2016;7:552. DOI: https://doi.org/10.4081/jphia.2016.552

Mpofana N, Chibi B, Gqaleni N, Hussein A, Finlayson AJ, Kgarosi K, et al. Melasma in people with darker skin types: a scoping review protocol on prevalence, treatment options for melasma and impact on quality of life. Syst Rev. 2023;12:139. DOI: https://doi.org/10.1186/s13643-023-02300-7

Ghale RA, Nasimi M, Alidoost S, Talebi M, Ghale RA, Rahmani M, et al. Melasma and its effect on quality of life: a cross-sectional perspective. Dermatol Pract Concept. 2025;15:1.

Wilson BN, Sun M, Ashbaugh AG, Ohri S, Yeh C, Murrell DF, et al. Assessment of skin of color and diversity and inclusion content of dermatologic published literature: An analysis and call to action. Int J Womens Dermatol. 2021;7:391-97. DOI: https://doi.org/10.1016/j.ijwd.2021.04.001

Mineroff J, Nguyen JK, Jagdeo J. Racial and ethnic underrepresentation in dermatology clinical trials. J Am Acad Dermatol. 2023;89:293-300. DOI: https://doi.org/10.1016/j.jaad.2023.04.011

Chren MM. The Skindex instruments to measure the effects of skin disease on quality of life. Dermatol Clin. 2012;30:231-6. DOI: https://doi.org/10.1016/j.det.2011.11.003

El Fakir S, Baybay H, Bendahhou K, Obtel M, Benchat L, Mernissi FZ, et al. Validation of the Skindex-16 questionnaire in patients with skin diseases in Morocco. J Dermatol Treat. 2014;25:106-9. DOI: https://doi.org/10.3109/09546634.2012.681016

McKesey J, Berger TG, Lim HW, McMichael AJ, Torres A, Pandya AG. Cultural competence for the 21st century dermatologist practicing in the United States. J Am Acad Dermatol. 2017;77:1159-69. DOI: https://doi.org/10.1016/j.jaad.2017.07.057

Gorbatenko-Roth K, Prose N, Kundu RV, Patterson S. Assessment of black patients' perception of their dermatology care. JAMA Dermatol. 2019;155:1129-34. DOI: https://doi.org/10.1001/jamadermatol.2019.2063

Cao S, Thomas R, Mansour M, Ramirez JL, Hile G, Castanedo-Tardan MP, et al. Patient perspectives towards skin of color clinics: results from a survey study. Int J Womens Dermatol. 2024;10:e182. DOI: https://doi.org/10.1097/JW9.0000000000000182

Alghofaili A, Alolayan S, Alhowail A, Mobark MA, Alderaibi S, Almogbel Y. The effect of depression on treatment adherence among a sample of saudi patients diagnosed with acne vulgaris. Clin Cosmet Investig Dermatol. 2021;14:1497-1506. DOI: https://doi.org/10.2147/CCID.S335007