Basal Cell Carcinoma in Skin of Color
April 2012 | Volume 11 | Issue 4 | Original Article | 484 | Copyright © 2012
Non-melanoma skin cancer most commonly affects Caucasians, and only rarely affects darker-skinned individuals. However, skin cancer in these groups is associated with greater morbidity and mortality. Ultraviolet radiation is the major etiologic factor in basal cell carcinoma (BCC) and likely plays a pivotal role in the development of other forms of skin cancer. Yet it is commonly thought among patients as well as physicians that darker pigmentation inherently affords complete protection from skin cancer development. This low index of suspicion results in delayed diagnoses and poorer outcomes. This review follows a detailed computer search that cross-matched the diagnosis of BCC with skin color type in a large commercial dermatopathology facility. The reported skin types, all Fitzpatrick skin types IV, V, and VI, and histories were confirmed. A predominance of pigmented BCCs was found in sun-exposed areas of these older individuals. Although less common in darker-skinned ethnic groups, BCC does occur and can pose significant morbidity. Thus, it is essential that dermatologists are familiar with the epidemiology and clinical presentation of all cutaneous malignancies in darker skin so that these patients are fully aware of risks as well as prevention of the disease.
J Drugs Dermatol. 2012;11(4):484-486.
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Non-melanoma skin cancer (NMSC), and specifically basal cell carcinoma (BCC), is less common in persons of skin of color than in lighter-skinned individuals. However, these cancers are often associated with more morbidity and mortality in this population as treatment may be delayed. Squamous cell carcinoma (SCC) and melanoma may be seen in darker-skinned groups and more often appear on non-sun exposed sites, whereas BCC most often develops in a similar sun-exposed distribution as in their lighter-skinned counterparts. Therefore, ultraviolet radiation (UVR) is likely an important etiologic factor in the development of BCCs, and less so in SCCs and melanomas in this patient population.1
It is predicted that by the year 2050, Hispanics, Asians, and blacks will represent 50% of the US population.1 This demographic and the fact that skin cancer is generally a curable disease makes it difficult to ignore the increased morbidity and mortality rates seen in darker-skinned individuals with skin cancer. This disparity can be attributed to various reasons, most importantly, socioeconomic and cultural differences among various ethnic groups. For example, it is commonly thought that there is no risk in developing sun-induced skin cancers due to their darker pigmentation. Also, most educational information regarding skin cancer and its prevention is directed towards Caucasian groups.
Studies have shown that Caucasians and Hispanics were more likely to report having used sunscreen lotions than African Americans. Caucasians performed self-skin examination more than Hispanics and African Americans, although African Americans were less confident in their ability to identify a suspicious lesion and less likely to follow up with a dermatologist regarding their findings.3 African Americans were also most likely to cite cost and inadequate insurance as an obstacle to dermatologic care.4
Contributing to these socioeconomic and cultural factors is that many physicians lack experience in diagnosing and treating skin cancer in skin of color. The fact that skin cancer can occur in all skin types is typically not stressed in medical training. With a low degree of suspicion, there is an increased risk of a delayed diagnosis. Also, total body skin examinations are often not performed in patients with skin of color.
A computer search was performed cross-matching the diagnosis of basal cell carcinoma with skin color type in a large commercial dermatopathology facility. The reported skin types and histories were confirmed. Follow up was performed to more accurately determine ethnicity and skin type in ambiguous cases. The slides of all patients were reviewed for confirmation of diagnosis, histologic subtype of basal cell carcinoma, presence of actinic elastosis, and presence of pigment within the tumor.
All of the eleven patients reviewed were of Fitzpatrick skin type IV, V, or VI, and were age 50 or older at the time of their initial biopsy (see Table 1). Seven of the 11 patients were aged 70 or older at their presentation. This is in concordance with studies