Basal Cell Carcinoma in Skin of Color
April 2012 | Volume 11 | Issue 4 | Original Article | 484 | Copyright © April 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.
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