Skin Cancer in Skin of Color: An Update on Current Facts, Trends, and Misconceptions

February 2013 | Volume 12 | Issue 2 | Original Article | 194 | Copyright © February 2013


Claire Battie PharmD,a Mona Gohara MD,b Michèle Verschoore MD,a and Wendy Roberts MDc

aL'Oréal Research and Innovation, Asnières, France bDepartment of Dermatology, Yale University School of Medicine, New Haven, CT cDesert Dermatology Skin Institute, Rancho Mirage, CA

Abstract
For many fair-skinned individuals around the world, skin cancer is the leading malignancy. Although skin cancer comprises only 1% to 2% of all malignancies in those with darker complexions, the mortality rates in this subgroup are substantially higher when compared with their Caucasian counterparts. This discrepancy is largely as a result of delayed detection/treatment, and a false perception among patient and physician that brown skin confers complete protection against skin cancer. Recent studies show that 65% of surveyed African Americans never wore sunscreen, despite living in sunny climates, and that more than 60% of minority respondents erroneously believed that they were not at risk for skin cancer.

Dark skin offers some protection from ultraviolet (UV) light. However, there is considerable heterogeneity in skin of color, a phenomenon that is accentuated by mixed heritage. Ethnicity does not confer skin type anymore. People of color do experience sunburn, and from a biological point of view, all skin types appear to be sensitive to UV-induced DNA damage, with an inverse relationship between skin color and sensitivity to UV light.

Our population is changing rapidly, and within the next few decades minority populations will become the majority. It is therefore imperative to educate both physicians and patients on the perceived immunity against cutaneous malignancies, the need for sun protection, and the clinical signs of skin cancer in non-Caucasian people, so that future unnecessary mortality can be avoided.

J Drugs Dermatol. 2013;12(2):194-198.

INTRODUCTION

For people of color, skin cancer may not be top of mind as a significant health threat. However, while uncommon in darker complexions, skin cancer does occur and can be deadly when diagnosis is delayed.
Delayed diagnosis can result from a false conception that people of color do not get skin cancer, a lack of access to medical care, or both. As we raise awareness, it is equally important to remember that ethnicity does not confer skin type. African Americans, Asians, Hispanics, Middle Easterners, Asian Pacific Islanders, Native Americans, or any other ethnic minority can have Fitzpatrick skin phototypes ≤III and live with the false notion that they are immune to skin cancer, when in reality, they may be at a comparable risk to Caucasians.
By the year 2050, 50% of the US population will consist of minority populations.1 It is essential that we educate both physicians and patients on skin cancer and skin of color so that unnecessary mortality can be prevented. We need to spread the message that this disease does not discriminate.

Skin Cancer and Skin of Color

Differences exist in the epidemiology, clinical presentation, and prognosis of skin cancers in skin-of-color populations (Figure 1).2
Basal cell carcinoma is the most common skin cancer in Caucasians, Hispanics, Chinese Asians, and Japanese Asians, while squamous cell carcinoma is the most common skin cancer in African Americans and Asian Indians.3 Basal cell carcinoma is most likely to occur on the head and neck in people of color because sun exposure is the most common predisposing factor. Squamous cell carcinoma, on the other hand, occurs in sites of chronic inflammation or scarring, and is more likely to metastasize in this clinical setting (Figure 2).4
Melanoma is the third most common type of skin cancer among all racial groups. Obviously the incidence of melanoma is higher in Caucasians than in African Americans, but a recent epidemiological review published by the American Academy of Dermatology showed that the 5-year survival rate for African Americans (78%) was significantly lower than that of whites (92%).5 The high percentage of advanced and thicker melanomas among non-Caucasians highlights the need to raise the awareness about skin cancer in skin of color. Studies also reveal that the incidence of melanoma is increasing in Hispanics of Puerto Rican and Mexican descent.6,7 The role of ultraviolet (UV) light in the development of melanoma in brown skin has not been clearly elucidated. Despite the tendency of melanoma to develop on non–sun-exposed sites in
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