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CLINICAL EVALUATION OF SKIN OF COLOR AND SKIN INTEGRITY
MAINTENANCE: AN INTEGRATIVE REVIEW ON HEALTH EQUITY
Shirley Rangel Gomes1
Ângela Carlos Do Amaral2
Thiago Aliprandi Lima3
Abstract: Objective: To analyze current scientic evidence on the morphological characteristics
of black skin and discuss how these specicities inuence clinical assessment and skin integrity
maintenance strategies in nursing practice. Materials and Methods: Integrative literature review
conducted in PubMed, SciELO, and LILACS databases, with a temporal cut-off from 2020 to 2025.
The selection followed the PRISMA protocol, resulting in 18 analyzed sources (articles and academic
works). Results: Black skin presents a more compact stratum corneum, thick dermis with hyper-
reactive broblasts, and larger, dispersed melanosomes. These features provide UV protection but
increase the risk of post-inammatory hyperpigmentation (PIH) and keloids. It was identied that
the Fitzpatrick Scale has limitations in detecting inammatory erythema (“invisible erythema”),
recommending the adoption of technologies such as Alternative Light Source (ALS) and ancestry
scales. Conclusion: Maintaining the integrity of black skin requires mastery of ethnodermatology.
Professional practice must overcome the Eurocentric standard and institutional racism, integrating
sensory and technological methods to ensure health equity and patient safety.
Keywords: African Continental Ancestry Group; Morphology; Dermatology; Professional Practice;
Nursing.
1 Nurse - UFF. Master’s in Professional Nursing Care - UFF. PhD candidate in Public Health -
Integralize.
2 Nurse - UERJ. Specialist in Clinical Podiatry - UERJ.
3 Nurse - UERJ. Specialist in Clinical Podiatry - UERJ.
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INTRODUCTION
In Brazil, the black population (both black and mixed-race) continues to bemajority,
representing more than55,5% do total, according to data based on the 2022 IBGE Census (Alchorne,
2024)However, these people have different possibilities of access to health care, not only due to the
availability of public health care, but also due to knowledge of the specicities involved in diseases
that are difcult to diagnose in skin with a higher concentration of melanin.
The skin is the largest organ in the human body, and rIt covers the entire organism, forming
a protective barrier against external aggressions. Its integrity varies according to several factors.
intrinsic(age, genetics, nutrition, diseases such as diabetes/circulatory problems, incontinence, reduced
mobility) andextrinsic(pressure, shear, friction, humidity, temperature, chemicals, trauma, surgery,
radiation therapy, smoking, pollution, stress)These elements affect the skin barrier, compromise
healing, and can lead to problems such as pressure sores, infections, and premature aging, impacting
skin health.Lopes et al.., 2021).
According to Da Silvaet al.(2022) the study of black skin is an important and complex
topic in the eld of dermatology, and it is essential to know the structural, biological and functional
differences in relation to light skin in order to ensure that professionals provide improved, adequate
and comprehensive care to the Brazilian population.
Nurses play a crucial role in contemporary clinical practice, basing their interventions on an
understanding of the biological particularities of each patient. According to COFEN Resolution No.
626/2020, aesthetic nurses have the autonomy to perform injectable and technological procedures,
provided they are based on safety and technical excellence. In the management of patients with
high phototypes, detailed knowledge of skin morphology is indispensable; as pointed out by...
Chichester (2024)Black skin has specic characteristics, such as higher dermal density and broblast
reactivity, which require personalized protocols to avoid complications such as post-inammatory
hyperpigmentation.
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In this context, the application of Baumann’s Classication (2020) allows the nurse to make
a prescription ofhome careIt is necessary to identify sensitivity and pigmentation variables that are
crucial for the success of invasive procedures and for maintaining an intact skin barrier.
In the Brazilian context, characterized by a high degree of miscegenation, it becomes
imperative that nurses master the morphological characteristics of pigmented skin to ensure patient
safety and treatment effectiveness. Recent literature, such as the works of...Litteret al. (2021) and
updates ofBaumann (2024)This reinforces the idea that maintaining skin integrity in Black skin
requires a specialized approach to the skin barrier and dermal density.
Based on this literary gap,The guiding question arose.”What are the main morphological
characteristics of black skin described in recent literature, and how do they inuence the assessment
and maintenance of skin and mucous membrane integrity?”
Thus, the aim of this study is to analyze the current scientic evidence on the morphological
characteristics of black skin and to discuss how these particularities inuence clinical assessment and
strategies for maintaining skin and mucous membrane integrity in professional practice.
MATERIALS AND METHODS
This research is characterized as an Integrative Literature Review (ILR). To ensure
methodological rigor and transparency in data reporting, the steps were conducted in accordance
with the PRISMA protocol guidelines for integrative reviews (Mendes; Silveira; Galvão, 2021). The
research was structured in six stages: 1) Development of the guiding question; 2) Literature search or
sampling; 3) Data collection; 4) Critical analysis of the included studies; 5) Discussion of the results;
6) Presentation of the review/synthesis of knowledge.
The search strategy and descriptors were performed in the PubMed, SciELO, and LILACS
databases. For the selection of articles, the Health Sciences Descriptors (DeCS) combined with
Boolean operators were used (ANDandORBlack SkinANDMorphology; NursingANDSkin Integrity;
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Black SkinAND Skin Barrier ANDAesthetics. The inclusion criteria were original and review articles
published between 2020 and 2025, available in full in Portuguese, English, or Spanish, that specically
address the histological and physiological characteristics and evaluation of black and mixed-race skin.
The exclusion criteria were isolated case reports or abstracts from congresses and studies that focused
exclusively on serious pathologies (such as advanced skin cancer) without correlation to aesthetics or
skin integrity, and articles published before 2020.
Table 1: Distribution of Review Sources
Category Amount Main Authors
Scientic Articles 13 Addor, Alchorne, Baumann (2), Chichester, Cohen, Da
Silva, Limandjja, Lopes, Mendes, Miot, Taylor, Thawabteh.
Books / Chapters 2 Alexis & Barbosa; Baumann (Cosmetic Dermatology).
Monographs / Dissertations 2Oliveira; Sousa.
Institutional Guidelines 1 Brazilian Society of Dermatology (SBD).
Source: The authors, 2025
RESULTS AND DISCUSSION
The results obtained through the integrative review indicate that nursing care for the Black
population is frequently compromised by a gap in technical-scientic training, which tends to use
light skin as a universal reference standard. The analysis of the 18 selected sources allowed the
structuring of knowledge into axes that highlight everything from cutaneous microstructure to the
impacts of institutional racism on diagnostic accuracy. In the rst axis, focused on morphophysiology,
the data corroborate that Black skin has unique characteristics that confer both adaptive advantages
and specic vulnerabilities, summarized in Table 2.
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Table 2: Thematic areas, main ndings, and application in professional practice.
Morphophysiology and Pigmentation of Black Skin
Analysis of scientic evidence reveals that the particularities of black skin reside primarily
in the organization of the melano-epidermal unit and the structure of the dermis. Unlike light skin,
where melanosomes are small and clustered, in black skin these organelles are larger, denser, and
individually distributed throughout the cytoplasm of keratinocytes (Alchorne; Abreu, 2024). This
individualized dispersion, combined with a slower degradation of melanin in the upper layers of the
epidermis, provides natural protection against ultraviolet (UV) radiation, but predisposes to a more
intense and persistent inammatory response.
As highlighted by Miot et al. (2021), melanogenic activity is extremely reactive to external
stimuli. Any injury to skin integrity, whether from trauma, chemical agents, or radiation, can trigger an
inammatory cascade that results in Post-Inammatory Hyperpigmentation (PIH). This phenomenon
is exacerbated by the sensitivity of black skin to visible light, which acts synergistically with UV in
maintaining pigmentary disorders such as melasma (Thawabteh).et al.., 2023).
In addition to pigmentation, dermal morphology presents unique characteristics: a thicker
dermis, with compact collagen bundles and larger, more active broblasts. While this structure delays
Thematic Axis Key Findings Application in Professional Practice
1. Morphophysiology
and Pigmentation
Larger, isolated melanosomes with
slow degradation; dermis rich in
collagen and reactive broblasts.
Monitor hyperpigmentation early;
understand that natural protection does
not eliminate the need for lters against
visible light.
2. Clinical Assessment
and Scales
The Fitzpatrick Scale fails to predict
erythema; colorimetric or ancestry-
based assessment is needed.
Replace purely visual inspection with
palpation (heat and edema) and the
patient’s genetic history.
3. Maintaining Integrity Higher rate of water loss (TEWL);
specic microbiota; high risk of
keloids and folliculitis.
Prescribe moisturizers that reinforce the
lipid barrier; avoid ablative procedures
without prior skin preparation.
4. Education and Society Structural racism generates a
diagnostic “void”; textbooks omit
the dermatology of black skin.
Humanized practice; active search for
specic literature to avoid diagnostic
and therapeutic negligence.
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the visible signs of photoaging (wrinkles), it signicantly increases the risk of hypertrophic scarring
and keloids (Limandjja).et al.Therefore, understanding this morphophysiology is the rst step towards
a professional practice that knows how to differentiate physiological aging from inammatory
pathology, respecting the recovery time and biological reactivity of this phototype.
Thus, the analysis of the pThe morphological and physiological differences between black
skin and white skin are highlighted, with an emphasis on how these differences impact clinical
diagnoses and wound healing, summarized in Table 3.
Table 3. Comparative summary of the morphological and physiological characteristics of black skin
compared to white skin.
Features Black Skin White Skin
Stratum Corneum Greater intercellular cohesion (cells
more “closed together”).
Reduced cellular cohesion.
Eczema/Lesions Papular and lichenied (dry/hard)
appearance.
Moist and spongy appearance.
Water Loss Greater (greater tendency to xerosis/
dryness).
Reduced transepidermal hair loss.
Melanocytes Same quantity. Same quantity.
Melanossomos Larger, not aggregated, and slow to
degrade.
Smaller, aggregated, and rapidly
degrading.
Dermis Thicker, more compact, and richer in
ber.
Thinner in comparison.
Fibroblasts Larger, more numerous, and highly
reactive.
Smaller and fewer in number.
Healing Tendency to develop keloids and
hypertrophic scars.
Healing is generally normal.
Aging Delayed process (less atrophy). Earlier atrophy process.
Source: Alchorne (2024); Chichester (2024); Oliveira (2023);Thawabteh (2023) Limandjja (2020)
Therefore, professionals who assist the Black population must be able to identify phototypes
and specic skin characteristics, integrating the principles of...ethnodermatologyThis area is
fundamental in contemporary healthcare because it recognizes that the skin should not be treated
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under a single, supercial approach.universal standard, focusing on the particularities of skin with
high phototypes. These characteristics have historically been underrepresented in textbooks and
academic curricula, which reinforces the need for updated guidelines for maintaining the integrity of
this tissue (SBD, 2025).
Clinical Assessment and Rating Scales
Dermatological and aesthetic professional practice has historically been guided by the
Fitzpatrick Scale, developed in 1975 with the primary purpose of evaluating the cutaneous response
to phototherapy in light skin. However, recent literature indicates that this metric is insufcient and
sometimes inaccurate for the evaluation of black skin. According to Cohen et al. (2023), excessive
reliance on scales based on visual perception of color can lead to underdiagnosis of inammatory
conditions, since erythema, a classic sign of inammation, becomes visually “masked” by the high
concentration of melanin (invisible erythema).
Baumann’s studyet al.(2020) corroborates this limitation, demonstrating that objective
measurements of color and erythema often do not coincide with subjective visual classication. This
implies that clinical assessment in high phototype skin must transcend vision, incorporating touch
and technology. Palpation to detect temperature variations (local heat) and edema becomes essential
to identify early inammatory processes that are not chromatically evident.
Given this scenario, the transition to models such as the Colorimetric Scale and the recognition
of ethnoancestry are fundamental (Alexis; Barbosa, 2024). As argued by Tayloret al.(2021), replacing
or supplementing the Fitzpatrick Scale with methods that consider genetic ancestry allows for more
reliable prediction of the risk of post-procedure complications, overcoming the limitations of systems
based solely on visual observation from the 1990s.
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Assessment scales for skin phototypes, ethnicity, and ancestry.
The Fitzpatrick Skin Tone Scale was created in 1975. It classies skin according to its ability
to tan and its tendency to burn under sun exposure.Visual representation of the skin tones that make
up the Fitzpatrick scale, ranging from type I (lightest and most sensitive skin) to type VI (deep black
skin), shown in Figure 1, and the description of the phototypes in Table 2.
Figure 1:Chromatic representation of the phototypes of the Fitzpatrick Scale (I to VI). The progressive
increase in melanin is observed, which acts as a natural barrier but can mask initial inammatory
signs. Source: Prepared by the authors (2025).
Table 1:Description of the Phototypes of the Fitzpatrick scale
Phototype Clinical Characteristics Reaction to the Sun
IVery fair skin, light eyes, freckles. It always burns, never tans. Extremely
sensitive.
II Fair skin, light or brown eyes. Burns easily, tans very little. Sensitive.
III Light to light brown skin. Burns moderately, tans gradually. Normal
sensitivity.
IV Medium brown skin (Mediterranean). It burns lightly, tans easily. Not very sensitive.
In Dark brown (tan) skin. Rarely burns, tans deeply and thoroughly.
Durable.
WE Black skin. Never burns, deep pigmentation. Very
resistant.
Fonte: Alchorne (2024)
The Lancer Ancestry Scale (LES) has recently been revalidated in contemporary studies to
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predict the inammatory response. Unlike simple observation, its application is based on the family
tree, and it is considered a more robust metric for mixed skin types than the purely phenotypic systems
of previous decades (Taylor).et al.(…, 2021). When using the LES Type, you must identify the origin
of the four grandparents (two paternal and two maternal), as described in Table 2. After identication,
perform the calculation (Lancer Mean), add the numbers corresponding to the four grandparents and
divide the result by 4, as in the following example:
THE =Paternal Grandmother + Paternal Grandfather + Maternal Grandmother + Maternal
Grandfather / 4
Example: If a person has 2 grandparents of German origin (Type 2) and 2 grandparents of
South American Indigenous origin (Type 4): 2 + 2 + 4 + 4 = 12 12 / 4 = 3 therefore, the nal result is
LES III.
Table 2. Lancer Ancestry Scale - Identication of each grandparent’s score
Score Geographic Origin / Ancestry
1Celtic, Nordic or Northern European (Very fair skin, high sensitivity).
2 Central Europe, Eastern Europe or Germany (Fair skin, but less sensitive than type 1).
3Mediterranean, Southern Europe, European Jews or Native Americans (“Golden” skin).
4Asian (China, Japan, Korea, Thailand), Sephardic Jews, or Indigenous peoples of Central/
South America.
5African (Central, East, West), Arab, Middle Eastern or Ethiopian.
Source: Cohen et al. (2023)
The application of ancestry scales, such as the Lancer Ethnicity Scale (LES), has been
reafrmed in the literature (Cohen et al., 2023) as an essential tool to mitigate the risks of post-
inammatory hyperpigmentation in patients with high phototypes undergoing thermal procedures.
Although the original scale was created in the 1990s, recent scientic literature, such as
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the review by Addor (2021), has focused on validating its correlation with the exposome concept,
adapting the classication of sun damage to a molecular understanding that includes visible light and
pollution, critical factors for hyperpigmentation in black skin.
Table 3. Glogau Scale
Type Classication Common Age Typical Characteristics
ILive 20-30 years old No wrinkles; minimal pigmentary changes; no keratoses.
II Moderate 30-40 years old Wrinkles only appear with movement; premature senile
lentigines; visible pores.
III Advanced 40-50+ years Wrinkles at rest; evident dyschromias; telangiectasias.
IV Grave 60-70+ years Only wrinkles; yellowish/grayish skin; possible
precancerous lesions.
Source: (Alchorne; Abreu, 2024)
Baumann’s Classication (Skin Types). Focuses on skin behavior for skincare routines. It
analyzes four variables: Oiliness vs. Dryness (Oily vs. Dry); Sensitivity vs. Resistance (Sensitive vs.
Resistant); Pigmentation vs. Tendency to Spots (Pigmented vs. Non-pigmented); and Elasticity vs.
Tendency to Wrinkles (Tight vs. Wrinkled).
Unlike the Fitzpatrick scale (which focuses on color and UV), the Baumann scale helps treat
specic problems such as xerosis by identifying the type.D(Dryness) to treat transepidermal water
loss and hyper-reactivity that contributes to the identication of the typeP(Pigmented), crucial to
prevent any inammation from turning into a dark spot.
Technological Innovations: Alternative Light Source (ALS) and the Visualization of Subtle Le-
sions
Given the limitations of subjective visual scales, recent literature points to the use of
Alternative Light Source (ALS) as a game-changer in the assessment of black skin. ALS uses specic
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wavelengths that, by interacting with the optical properties of tissues, allow the identication of what
naked-eye inspection misses due to the chromatic barrier of melanin.
In skin with a high concentration of pigment (phototypes IV to VI), the detection of
hematomas, ecchymosis, and initial inammation is challenging, as the epidermal pigment masks the
classic coloration of extravasated blood or vascular congestion. However, under specic wavelengths
(generally between 415nm and 450nm), hemoglobin absorbs light intensely, causing “subtle lesions”
to appear as dark, contrasting areas.
For nurses, this technology is crucial in preventing pressure injuries (PIs). Since non-
blanchable erythema (stage 1) is often “invisible” in dark skin, ALS allows visualization of deep
tissue damage before skin integrity is compromised. Incorporating this tool into nursing consultations
mitigates the risk of underdiagnosis and promotes equitable care, ensuring that care is not neglected
due to biological factors.
Other specic scales
• Fanous Scale: Based on racial and geographic categories (Nordic, European,
Mediterranean, Indo-Pakistani, African, and Asian), widely used in plastic surgery and
laser treatment planning.
• Taylor Scale: A visual system (color cards) created specically to assess hyperpigmentation
in dark skin, helping to monitor the treatment of blemishes.
Maintenance of Skin and Mucosal Integrity
Maintaining the integrity of black skin requires a deep understanding of its hydration
dynamics and microbiological protection. Although it presents a more compact stratum corneum,
studies indicate that this skin may have lower levels of ceramides and a higher Transepidermal
Water Loss (TEWL) rate compared to other phototypes (Baumann, 2024). This characteristic results
in a greater predisposition to xerosis (dryness), which in black skin manifests visually as an ashy
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appearance, compromising the barrier function and facilitating the entry of pathogens. In this situation,
the appearance of the skin as a pressure injury of unidentiable grade can lead to misdiagnosis. As
advocated by the clinical need for intense hydration cited by Baumann (2024), superhydration is
fundamental in these situations.
Integrity is also inuenced by the balance of the microbiota. According to Lopeset al.(2021),
external factors, such as the use of occlusives (diapers or tight clothing) and inadequate hygiene,
alter the pH and resident ora, increasing the risk of dermatitis and fungal infections. In black skin,
any imbalance that leads to inammation is a potential trigger for hyperpigmentation. Therefore,
maintaining integrity should not focus solely on cleansing, but on preserving the hydrolipidic mantle
through synthetic cleansers and moisturizers that mimic the natural lipid barrier (Chichester).et al..,
2024).
Furthermore, maintaining skin integrity in individuals with high phototypes should include
preventing specic complications such as pseudofolliculitis and keloids. Proper management requires
professionals to avoid excessive mechanical and chemical trauma. As observed by Oliveira (2023),
efcient photoprotection is a pillar of integrity, as radiation not only causes cellular damage but also
degrades components of the extracellular matrix that maintain skin resilience. Thus, professional
practice should be guided by a “preventive minimalism” protocol: high hydration, photoprotection
against visible light, and interventions that minimize the risk of an exacerbated inammatory
response. Lopes (2021) reported on hygiene to maintain the inguinal microbiota with an acidic pH to
prevent opportunistic infections in skin fold areas.
Education, Health and Society: The Impact of Underrepresentation
The effectiveness of professional practice in maintaining the integrity of Black skin is
directly inuenced by academic training and the sociopolitical context. The literature indicates that
biological invisibility in health curricula is a form of...rInstitutional racism. As demonstrated by Da
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Silvaet al. (2022), science and health textbooks have historically omitted or treated pathologies in
black skin only peripherally, which consolidates a Eurocentric learning bias. This pedagogical “gap”
results in professionals who, although technically qualied, feel insecure or fail to diagnose erythema
and lesions in high phototypes.
This educational gap is exacerbated by the implications of structural racism on public health.
According to Sousa (2025))Institutional racism manifests itself in the lesser clinical attention given
to Black bodies and the underestimation of their dermatological complaints. Neglect in recognizing
an initial dermatitis, for example, can evolve into complex wounds or severe hyperpigmentation,
irreversibly compromising skin integrity. Therefore, ethnodermatology should not be seen merely as
an aesthetic subspecialty, but as a tool for social justice and equitable healthcare.
In this sense, the guidelines of the Brazilian Society of Dermatology (SBD, 2025) reinforce
the need for continuing education that includes ethnic diversity at all levels. Maintaining physical
integrity depends on the professional’s ability to recognize the Black patient as a subject of rights,
whose physiology requires specic, not general, protocols. Deconstructing the “universal standard”
of beauty and health is, therefore, a prerequisite for clinical care to be truly inclusive and efcient.
CONCLUSION
This integrative review concluded that maintaining the integrity of black skin transcends
the application of conventional protocols, requiring a specialized clinical approach grounded in
the particularities of ethnodermatology. The morphological evidence analyzed, such as the greater
compaction of the stratum corneum, the dense dermis, and the high melanocytic reactivity, conrms
that, although this tissue possesses superior mechanical resilience, it presents a marked inammatory
vulnerability that can compromise healthcare outcomes.
It has been identied that one of the greatest challenges for professional practice is
the obsolescence of strictly visual assessment scales, such as the Fitzpatrick scale, when used in
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isolation. Recognizing “invisible erythema” and adopting sensory (palpation for heat and edema)
and technological methods, such as Alternative Light Source (ALS) for identifying subtle lesions and
hidden hematomas, are urgent steps to mitigate underdiagnosis. Furthermore, skin barrier management
in Black skin should be personalized, combating graying xerosis and protecting the microbiome to
prevent post-inammatory hyperpigmentation and keloids.
Finally, the study emphasizes that technical excellence in nursing is inseparable from social
awareness. Combating institutional racism, manifested in the historical underrepresentation of
dermatology for Black skin in health curricula, is a basic premise for a practice guided by equity.
It is hoped that this review will serve as a guide for health and aesthetics professionals, fostering a
practice that respects biological uniqueness and promotes, in a comprehensive way, the safety, health,
and dignity of the Black population.
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