Severity outcome measures in patients with skin of color: Gaps in current scoring systems and opportunities for improvement

Scoring systems are imperative in dermatology to objectively measure disease severity, allowing clinicians to measure treatment response and deliver appropriate therapy. Disease characteristics differ markedly across skin of color populations, introducing interrater variability and limiting the validity of existing scoring tools that have been developed in predominantly White cohorts. Therefore, this review evaluates the limitations of conventional scoring systems in minority racial and ethnic groups to highlight best practices and where further development, adaption, and validation of outcome measures will be of benefit. Erythema-dependent indices demonstrate reduced reliability in darker skin types, where inflammation may appear violaceous or gray rather than red. Pigmentary and scarring sequelae remain underrepresented in existing measures, leading to the underestimation of disease severity and treatment outcomes in these groups. Broader inclusion of diverse racial and ethnic groups in tool development, Fitzpatrick skin type-stratified validation, pigment-independent objective measures, and incorporation of digital tools are of priority to ensure equitable and accurate dermatologic assessment worldwide.