When you Google common skin conditions such as keratosis pilaris (KP), rosacea, eczema and psoriasis, you’re probably flooded with images of these conditions on white skin. “Patients with pigmented skin may find it hard to find representative pictures of their condition—80 percent of Google pictures of skin conditions are of lighter-skinned people,” says New York dermatologist Elaine Kung, MD.
That gap often extends into the exam room, too. “Depending on where the dermatologist has trained or is practicing, they may have limited exposure to patients with darker skin types,” says Dr. Kung. “A friend who moved to Virginia texted me that she called a few dermatology offices inquiring if they feel comfortable treating an Asian person’s brown spots with a laser. She was disappointed to find out that most of them do not.”
The result is frequent misdiagnosis, says Montclair, NJ dermatologist Jeanine B. Downie, MD. “Many times, patients will come to see me, and they tell me they have shingles and it’s actually psoriasis. They tell me they have acne and it’s KP,” she says. “If patients tried to treat something over the counter for more than a week, and it’s not treatable, they should go see a board-certified dermatologist.”
That’s why we asked seven board-certified dermatologists to break down exactly how common skin conditions present differently on skin of color, so you know what to look for and when to get help.
What to Look For, Condition by Condition
While many common skin conditions have the same underlying biology, they don’t necessarily have the same appearance, says Bellevue, WA dermatologist Jenny Liu, MD. “I often tell patients that in skin of color, diseases that present as red or pink may instead present as brown hyperpigmentation,” says West Islip, NY dermatologist Kavita Mariwalla, MD. “Melanin is very sensitive and presents as reactionary patterns—in other words, hypopigmentation and hyperpigmentation.” Dr. Liu adds that common rashes may look more papular on skin of color.
Other signs worth seeing a dermatologist for, says Dr. Liu, include changes in skin texture—scaling, roughness, thickening, tiny bumps, swelling or warmth—even when redness isn’t obvious. Areas that become darker, gray-purple or lighter than the surrounding skin, as well as symptoms like itching, burning, tenderness or pain, also warrant a visit.
Because these symptoms can be less obvious, Dr. Mariwalla always advises patients with skin of color to advocate for themselves. She notes that “culturally, many people do not seek dermatologic care because they did not grow up with family members who sought dermatologic care,” and urges anyone with concerns to schedule an appointment with a board-certified dermatologist.
Eczema
“Due to the redness’ potential to be hidden on darker skin, it is frequently hard to figure out,” says Miami dermatologist Anna Chacon, MD. “Eczema may instead appear as a dark brown, purple or ashen gray color. This can lead to delayed or incorrect diagnoses.”
Hallandale Beach, FL dermatologist Bertha Baum, MD, says affected areas may also appear as thick, scaly patches that are darker than the surrounding skin. Dr. Downie notes that eczema can also be more papular than what we commonly see on light skin types. Other signs include itching, dry skin and a rash, says Dr. Chacon. Following a flare, patients of color often tend to develop significant post-inflammatory hyperpigmentation.
Psoriasis
“Psoriasis plaques may appear more violaceous or dark brown with a thicker scale, making them less obviously inflamed,” says Dr. Liu. Dr. Downie notes the often silvery scales could even appear a deep eggplant color. These dark patches or thickened, scaly plaques may be mistaken for eczema or other skin conditions, warns Dr. Baum.
Acne
“Acne lesions can appear darker or redder on skin of color due to increased melanin production. Additionally, post-inflammatory hyperpigmentation can be more common and more severe in people with darker skin tones, leading to long-lasting dark marks after acne clears,” says Dr. Baum.
“Acne is frequently accompanied by post-inflammatory hyperpigmentation, which can persist for months after the pimples resolve,” says Dr. Liu. Dr. Downie notes that often patients come in concerned about acne, but it turns out to be dark spots. Dr. Mariwalla says acne should be treated more aggressively in patients with skin of color because of the increased risk of post-inflammatory hyperpigmentation: “For many people of color, those marks look just as bad as the original acne so they feel like their routine has not worked.”
Melasma
“Melasma often affects patients with medium to deeper skin tones and can be particularly persistent because pigment-producing cells are highly reactive to hormones, UV light, visible light and inflammation,” says Dr. Liu. Clinically, melasma may present differently in patients with melanin-rich skin, particularly because with melasma, as well as acne and rosacea, inflammation can stimulate more melanin production, resulting in hyperpigmentation, explains Monroe, LA dermatologist Janine Hopkins, MD.
Skin Cancer
“Skin cancers do look different in skin of color versus lighter skin types,” says Dr. Downie. “If you have a non-healing pimple or a non-healing wound, you should check it to make sure that it’s not a skin cancer with a board-certified dermatologist,” she urges.
Rosacea
“Rosacea is a common skin disorder that makes your face look flushed and has visible blood vessels. Moreover, it could result in tiny, pus-filled pimples,” says Dr. Chacon. Rosacea often presents as a flush of pink and red on those with lighter skin tones, but Dr. Downie says it can appear more violet and purple on darker skin tones. “On dark and black skin, it may be challenging to recognize the flushing or blushing associated with rosacea. Keep an eye out for additional symptoms of the illness,” says Dr. Chacon.
Keloid
Anyone can get a keloid, but doctors say they are more common in skin of color. Dr. Mariwalla notes that keloids often appear on the ears, chest and upper back. They can present in a range of colors, including pink, purple, red and brown. Keloid scars result from trauma to the skin, creating an excessive scar formation, explains Dr. Hopkins. Dr. Liu notes that things like piercings, surgery, acne and even minor skin injuries can result in keloids.
Keratosis Pilaris (KP)
Dr. Downie says KP may look like a generalized rash on skin of color. While KP tends to appear as white or red bumps on lighter skin, they may be brown or flesh-colored on darker skin tones, says Dr. Chacon. It frequently appears as raised, darker bumps on the upper arms, butt and thighs.
Razor Bumps (Pseudofolliculitis Barbae)
“Pseudofolliculitis barbae (aka razor bumps) is a frustrating skin condition often seen on the neck or on the back of the scalp in men of color due to shaving,” says Dr. Hopkins. “This chronic acneiform breakout can lead to scarring around irritated hair follicles.” On fair skin, it tends to present as red bumps, while on skin of color, it can be red but more often is a darker brown.
