Skin of colour in the Dermatology SCE: what gets tested and how to revise it

How skin of colour is tested in the Dermatology SCE: the presentations that look different in darker skin, the conditions that are more common, and how to build pattern recognition.

Skin of colour is part of the SCE blueprint, and for good reason: a large proportion of patients have richly pigmented skin, and many conditions look different from the textbook images of fair skin that candidates revise from. Recognising those differences is both good medicine and reliable exam marks.

Why it matters in the exam

Erythema is far harder to see in darker skin, where inflammation often appears violaceous, grey or simply as hyperpigmentation rather than red. If your mental model of a condition is built only on its appearance in fair skin, the same disease in skin of colour can read as a different diagnosis. Examiners know this, and they test it.

Presentations that look different

• Inflammation often appears violaceous or grey rather than red, so erythroderma and drug eruptions can be subtle.
• Post-inflammatory hyperpigmentation and hypopigmentation are prominent and a common reason for presentation in their own right.
• Eczema and psoriasis may show follicular accentuation, prominent lichenification and marked pigmentary change.
• Lichen planus and lupus can leave striking pigmentary sequelae.
• Pityriasis versicolor and vitiligo stand out because of the contrast against pigmented skin.

Conditions that are more common or distinctive

• Keloids and hypertrophic scars.
• Pseudofolliculitis barbae and acne keloidalis nuchae.
• Central centrifugal cicatricial alopecia and traction alopecia, strongly linked to hair-care practices.
• Melasma and dermatosis papulosa nigra.
• Lichen planus pigmentosus and confluent and reticulated papillomatosis.

Hair and scalp

Hair and scalp disease in skin of colour is high yield. Know central centrifugal cicatricial alopecia, traction alopecia and acne keloidalis nuchae, including their typical distribution and the role of hair-care and styling practices, because these come up as both diagnosis and management questions.

How to revise it

• Use image resources that show diverse skin tones, because most textbooks underrepresent them. DermNet and dedicated projects such as Skin Deep are good starting points.
• Practise image questions that include richly pigmented skin so recognition becomes automatic.
• Learn the pigmentary sequelae of common inflammatory conditions, as these are frequently the intended answer.

Sources & further reading

• DermNet - dermatology reference and image library
• Skin Deep - diverse dermatology image library
• British Association of Dermatologists - patient information and guidelines

For educational use only. Check current official guidance.