Melanin-Rich Skin Deserves Specialist Care: Common Misdiagnoses I See in Cape Town
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Cape Town is a city celebrated for its diversity — a blend of cultures, histories, and complexions. As a dermatologist practicing here, I’m grateful to work with patients from all walks of life. But I’ve also seen how this diversity presents a unique challenge in medicine: melanin-rich skin is often misdiagnosed, undertreated, or treated inappropriately — especially in generalist settings where dermatological expertise is limited.
This is not just an aesthetic concern. These misdiagnoses can impact quality of life, delay serious diagnoses like skin cancer, and result in permanent skin damage. In this post, I’d like to share some of the most common skin conditions I see mismanaged in patients of colour — and how tailored dermatology can make all the difference.
Understanding the Science of Melanin
Melanin is more than pigment — it’s a sophisticated biological shield. Rich in eumelanin, darker skin types have a natural resilience against sun damage and ageing, but they’re also more reactive to inflammation, injury, and chemical irritation.
What this means in practice:
- Hyperpigmentation and hypopigmentation are more common.
- Keloids and scarring tendencies are higher.
- Redness and rashes don’t always appear red.
- And most importantly, “standard” treatments may be too aggressive or simply ineffective.
As a dermatologist in Cape Town, my training and experience allow me to anticipate these differences — and treat accordingly.
1. Hyperpigmentation: The Aftermath, Not the Cause
Post-inflammatory hyperpigmentation (PIH) is one of the leading concerns that bring melanin-rich patients to my clinic. It can be triggered by acne, eczema, friction, harsh products, or even an insect bite.
Too often, patients are given bleaching creams, strong exfoliants, or laser therapy without first addressing the inflammation or trauma that caused the pigmentation. The result? Skin barrier damage, rebound pigmentation, or even chemical burns.
My approach is different:
✅ I calm inflammation first.
✅ Support the skin barrier.
✅ Then strategically introduce pigment-correcting agents under careful supervision.
2. Acne in Melanin-Rich Skin: Not Just About the Breakouts
Acne is one of the most emotionally distressing conditions I see in patients of all ages. But in melanin-rich skin, the marks it leaves behind can be even more troubling than the pimples themselves.
A misstep in treatment can result in:
- Worsened dark marks
- Skin lightening or bleaching
- Increased scarring
- Keloid formation
What works in one skin type doesn’t necessarily apply to another. I often adjust dosages, swap out harsh actives for gentler ones, and combine treatment with antioxidants, pigmentation control, and barrier support.
It's not about following a formula — it’s about formulating one just for you.
3. Eczema, Psoriasis, and Atopic Dermatitis: Misdiagnosed and Misunderstood
In lighter skin, eczema tends to appear red, flaky, and inflamed. In darker skin, it may look purple, dark brown, or ashen — and this leads to frequent misdiagnosis. I’ve seen patients who lived with undiagnosed eczema for years, told it was “dry skin” or “a cosmetic concern.”
The same goes for psoriasis, which can appear less scaly and more hyperpigmented in skin of colour.
Delays in treatment can lead to:
- Severe skin thickening
- Secondary infections
- Chronic discomfort
- Emotional distress
Diagnosis requires a trained eye — and time spent listening to the patient's experience, not just examining the skin.
4. Keloids & Raised Scars: Prevention is Better Than Cure
Patients with darker skin types are far more likely to develop keloids — raised, fibrous scars that grow beyond the boundaries of the original wound. Sadly, I see many cases where patients received piercings, surgeries, or even cosmetic procedures without being warned of this risk.
Once a keloid forms, treatment becomes complex and long-term, involving corticosteroid injections, silicone dressings, laser therapy, and sometimes surgical excision.
Whenever I see a patient who’s prone to keloids, I tailor a treatment strategy that focuses on prevention — or early intervention when signs of abnormal scarring begin.
5. Pigment Disorders Like Vitiligo and Pityriasis Versicolor
Pigment loss can be especially distressing in patients with melanin-rich skin, as the contrast is often more visible. Yet vitiligo and fungal-related pigment changes are frequently misidentified — or worse, dismissed as cosmetic.
At my Cape Town practice, we offer Wood's lamp assessments, dermoscopic imaging, and biopsy when necessary to get to the root of the problem. Because skin changes aren’t always superficial — they’re often signals of deeper immune, fungal, or metabolic issues.
6. The Problem With Bleaching Creams and Unregulated Treatments
There’s an entire industry built around colourism — and many patients fall victim to over-the-counter bleaching creams or imported products that contain mercury, corticosteroids, or unregulated hydroquinone.
These agents can thin the skin, trigger steroid acne, and worsen pigmentation over time.
Education is key. I spend time helping patients understand the difference between lightening and restoring even skin tone — and guide them toward products that are safe, effective, and backed by science.
7. Skin Cancer Can Still Happen in Melanin-Rich Skin
Yes, people with darker skin have a natural SPF of around 13 — but skin cancer can still occur, especially in areas not exposed to the sun (soles, palms, nails, and genitals). Unfortunately, because it’s considered “rare,” it’s often diagnosed late.
At my practice, I perform AI-assisted total body mole mapping and conduct comprehensive skin cancer screenings for all patients — regardless of skin tone. Early detection saves lives.
Final Thoughts: Why You Deserve Specialist Dermatology
Caring for melanin-rich skin is not just about clinical knowledge — it’s about cultural understanding, nuance, and respect. When you walk into my practice, I don’t just see a condition — I see your story, your concerns, and your goals.
Dermatology should be inclusive, informed, and deeply personal.
And in a city as beautifully diverse as Cape Town, that’s more important than ever.
🔹 Book your consultation today
📍 28 Brookdale Avenue, Pinelands, Cape Town
🔗 dermatologist.capetown
— Dr Altaaf Parker
MBChB (UCT) | FCDerm (SA) Summa Cum Laude | Specialist Dermatologist & Hair Transplant Surgeon