INTRODUCTION
Skin of color is defined as Fitzpatrick skin types (FST) IV, V, or VI in individuals of Hispanic/ Latino, African, or Asian descent. Over the next two decades, people of color will comprise over half of the United States population.1 Data show increased utilization of Mohs micrographic surgery (MMS) in African Americans at 44.2%, which far exceeds Caucasian patients at only 9.6%.2
Located in the Bronx, NY, our institution serves one of the most diverse populations in the nation. Forty-four percent of the population is Black and 56% is Hispanic/ Latino. Despite the low incidence of skin cancer in reported in Hispanics (5%) and African Americans (2%) in the literature,3 our institution performs over 100 cases of MMS in individuals with skin of color annually. Compared to numbers reported in the literature, our case load is high. In 10-year single institution retrospective review, Gupta and colleagues report 17 cases of basal cell carcinoma in African Americans.4 In a 5-year single institution retrospective study, Loh and colleagues identified 115 Hispanic patients with non-melanoma skin cancer (NMSC).5 Perper and colleagues published one of the largest studies of NMSC in Hispanics. However, 91% of Hispanic patients included in their study were white.6 This is in contrast to our patient population. All patients we classify as skin of color undergoing MMS have skin types III through VI of Hispanic, African, and Asian descent. Herein we share our experience, clinical pearls, and guidance for performing MMS in skin of color.
Tumor Identification and Extirpation
MMS is the gold standard for the treatment of keratinocyte carcinoma. Pigmented variants are more common in skin of color. Depending on the clinical scenario, pigment may be friend or foe to intraoperative identification of tumor borders. Hyperpigmentation associated with lichen simplex chronicus or postinflammatory hyperpigmentation may be observed in association with cutaneous tumors in skin of color (Figures 1 and 2). This is not surprising as chronic inflammatory processes account for up to 40% of squamous cell carcinoma cases (SCC) in African Americans.3 In these cases, it is difficult to differentiate background hyperpigmentation from pigmented tumors and we recommend dermoscopy as an aid. SCC arising at sites of chronic scarring and inflammation is inherently more aggressive and contributes to the higher rates of disease specific death from SCC in African American patients.3
Located in the Bronx, NY, our institution serves one of the most diverse populations in the nation. Forty-four percent of the population is Black and 56% is Hispanic/ Latino. Despite the low incidence of skin cancer in reported in Hispanics (5%) and African Americans (2%) in the literature,3 our institution performs over 100 cases of MMS in individuals with skin of color annually. Compared to numbers reported in the literature, our case load is high. In 10-year single institution retrospective review, Gupta and colleagues report 17 cases of basal cell carcinoma in African Americans.4 In a 5-year single institution retrospective study, Loh and colleagues identified 115 Hispanic patients with non-melanoma skin cancer (NMSC).5 Perper and colleagues published one of the largest studies of NMSC in Hispanics. However, 91% of Hispanic patients included in their study were white.6 This is in contrast to our patient population. All patients we classify as skin of color undergoing MMS have skin types III through VI of Hispanic, African, and Asian descent. Herein we share our experience, clinical pearls, and guidance for performing MMS in skin of color.
Tumor Identification and Extirpation
MMS is the gold standard for the treatment of keratinocyte carcinoma. Pigmented variants are more common in skin of color. Depending on the clinical scenario, pigment may be friend or foe to intraoperative identification of tumor borders. Hyperpigmentation associated with lichen simplex chronicus or postinflammatory hyperpigmentation may be observed in association with cutaneous tumors in skin of color (Figures 1 and 2). This is not surprising as chronic inflammatory processes account for up to 40% of squamous cell carcinoma cases (SCC) in African Americans.3 In these cases, it is difficult to differentiate background hyperpigmentation from pigmented tumors and we recommend dermoscopy as an aid. SCC arising at sites of chronic scarring and inflammation is inherently more aggressive and contributes to the higher rates of disease specific death from SCC in African American patients.3
