Alexandra Montgomery and Tue “Felix” Nguyen

Skin of Color Dermatology: Exploring Skin Cancer Disparities in Ethnic Populations

By Marie Vu, Alexandra Montgomery and Tue “Felix” Nguyen

kin of color (SOC) dermatology is a subset of dermatology which treats skin, hair and nail conditions in individuals of African American, Asian, Hispanic/Latino, Native Indian or Pacific Islander descent. With a diverse ethnic population that continues to grow, demographics in the United States are shifting. These changes underscore the importance of a thorough understanding of SOC dermatology, although attention to addressing these needs has increased in recent years. There are cutaneous diseases that are more prevalent, present differently or are inadequately understood in people of color. More specifically, skin cancer plays an impactful role when assessing disparities within SOC dermatology due to its increased prevalence and malignant potential.

The three most common types of skin cancer are basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and melanoma. Each of these skin cancers have characteristic features that doctors and patients can look for, but some of these classic signs are often not present when these cancers arise in SOC, which can make early detection more difficult and can negatively impact prognosis.

Basal cell carcinoma is the most common skin cancer in Caucasians, Asians and Hispanics, and the second most common in African Americans.1 In fair skin, this cancer typically looks like a flesh-colored or “pearly pink” bump, often with raised edges, visible blood vessels and commonly with an open sore in the center. In SOC, BCC may lack its characteristic pink hue and visible blood vessels, and instead may contain extra melanin, giving the lesion a darker appearance.

Squamous cell carcinoma is the most common skin cancer in African Americans, and the second most common in Caucasians, Hispanics

Sand Asians. The typical appearance of this cancer in fair skin can vary from scaly pink-to-red patches to thickened, crusted plaques or nodules. Like BCC, the appearance of SCC in darker skin is often brown or black rather than pink due to excess pigmentation. In Caucasians, SCC usually appears in areas that have been chronically exposed to the sun, like the face and upper body. However, in patients of color, it can often occur in areas without much sun exposure, such as the lower legs or the genital region, and may be more often related to chronic wounds or additional underlying disease.1 Melanoma is the least common type of skin cancer, but is the most dangerous due to its ability to spread to other organs. It primarily affects Caucasians, however, the diagnosis of melanoma in SOC is often associated with poorer clinical outcomes. Melanomas are often irregularly shaped and may have different shades of pigmentation within a single lesion. The common “warning signs” to detect melanoma include lesions that exhibit asymmetry, irregular borders, color changes, a diameter greater than six millimeters and a spot that has significantly changed over time. An important difference between the development of melanoma in people of color and in Caucasians is location. While melanomas most often present on the trunk in Caucasians, melanomas often develop in unusual locations such as the lower extremities, palms, soles, nails and mucosal surfaces in African American, Hispanic and Asian populations.2 Though SOC individuals are less likely to develop skin cancer, there is increased morbidity and mortality in such populations when compared to Caucasians.3 An epidemiological review showed a 5-year survival rate of 70% for SOC patients while Caucasian patients had a significant in-

crease of 92%.4,5,6 The cause of this notable disparity is multifactorial. One reason for increased mortality in SOC patients is late detection of skin cancers. As discussed previously, symptoms are not easily visible, as they present differently in people of color. In addition, SOC patients may not fully understand their risk for skin cancer as there is a false belief that darker skin is protected from UV rays.7 While increased melanin and dispersed melanosomes absorb and deflect UV rays more efficiently, it is still possible for people of color to develop skin cancer.8 Another reason for increased mortality is attributed to lack of access to medical care. SOC patients have the least percentage of medical coverage, thus decreasing access to required care and accounting for poorer prognosis. Other factors to consider are the lack of resources available in the past decades of medical training, which provide insight on evaluating skin cancer lesions in SOC individuals. This poses diagnostic challenges, including identifying specific characteristics like variation of color in lesions.9

There has been increasing recognition of the need for more representation of people of color in the field of dermatology. A study found that African American and Hispanic patients are less likely to receive outpatient dermatological treatments compared to Caucasians.10 Potential resources that can help minimize this health disparity and improve visibility include dermatology free-clinics. In San Antonio, two free dermatology clinics that exist are Travis Park Dermatology Clinic and Haven For Hope. Both clinics are student and faculty-led clinics supported by the University of Texas at San Antonio Health Science Center, which provide free dermatologic care to people of all backgrounds — including those who are homeless and uninsured. Many people within these communities are people of color. According to a 2019 Racial Indicator Equity Report in San Antonio, 22.5% of African Americans and 21.3% of Hispanics live in poverty compared to 11.2% of the Caucasian population.11 As a result, free clinics can help not only provide quality skin care to these marginalized communities but also educate patients about how to properly take care of their skin to minimize the occurrence of preventable skin diseases. Additionally, from the provider’s perspective, treating melanated skin further improves education for medical students and residents by exposing them to the morphologic differences of common skin conditions that are often misdiagnosed in people of color.

SOC dermatology has become more prevalent in recent years, changing the landscape of how providers practice medicine and address disparities. While there are many unique cutaneous conditions which affect people of color, skin cancer remains an important topic due to its vast prevalence and malignant potential. The increased morbidity and mortality associated with skin cancer in SOC individuals can be attributed to many factors. Public awareness of skin cancer education and prevention, combined with increased accessibility to care and comprehensive medical training for providers, may be the key to a timely diagnosis and treatment. References 1. Higgins S, Nazemi A, Chow M, Wysong A. Review of Nonmelanoma Skin

Cancer in African Americans, Hispanics, and Asians. Dermatologic Surg. 2019;44(7):903-910. doi: 10.1097/DSS.0000000000001547. 2. Higgins S, Nazemi A, Feinstein S, Chow M, Wysong A. Clinical Presentations of Melanoma in African Americans, Hispanics, and Asians. Dermatol

Surg. 2019 Jun;45(6):791-801. doi: 10.1097/DSS.0000000000001759.

PMID: 30614836. 3. Cancer Facts and Figures 202. American Cancer Society. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf.

Accessed October 30, 2021. 4. Merrill SJ, Subramanian M, Godar DE. Worldwide cutaneous malignant melanoma incidences analyzed by sex, age, and skin type over time (19552007): Is HPV infection of androgenic hair follicular melanocytes a risk factor for developing melanoma exclusively in people of European-ancestry?

Dermatoendocrinol. 2016 Jul;8(1):e1215391. doi: 10.1080/19381980. 2016.1215391. PMID: 27588159 5. Wu XC, Eide MJ, King J, Saraiya M, Huang Y, Wiggins C, Barnholtz-Sloan

JS, Martin N, Cokkinides V, Miller J, Patel P, Ekwueme DU, Kim J. Racial and ethnic variations in incidence and survival of cutaneous melanoma in the United States, 1999-2006. J Am Acad Dermatol. 2011 Nov;65(5 Suppl 1):S26-37. doi: 10.1016/j.jaad.2011.05.034. PMID: 22018064. 6. Gohara MA. Skin cancer in skins of color. J Drugs Dermatol. 2008

May;7(5):441-5. PMID: 18505135. 7. Jacobsen AA, Galvan A, Lachapelle CC, Wohl CB, Kirsner RS, Strasswimmer J. Defining the Need for Skin Cancer Prevention Education in Uninsured, Minority, and Immigrant Communities. JAMA Dermatol. 2016

Dec;152(12):1342-1347. doi: 10.1001/jamadermatol.2016.3156. PMID: 27626892. 8. Cummins DL, Cummins JM, Pantle H, Silverman MA, Leonard AL,

Chanmugam A. Cutaneous malignant melanoma. Mayo Clin Proc. 2006

Apr;81(4):500-7. doi: 10.4065/81.4.500. PMID: 16610570. 9. Agbai ON, Buster K, Sanchez M, Hernandez C, Kundu RV, Chiu M,

Roberts WE, Draelos ZD, Bhushan R, Taylor SC, Lim HW. Skin cancer and photoprotection in people of color: a review and recommendations for physicians and the public. J Am Acad Dermatol. 2014 Apr;70(4):748-762. doi: 10.1016/j.jaad.2013.11.038. PMID: 24485530. 10.Tripathi R, Knusel KD, Ezaldein HH, Scott JF, Bordeaux JS. Association of Demographic and Socioeconomic Characteristics With Differences in

Use of Outpatient Dermatology Services in the United States. JAMA Dermatol. 2018;154(11):1286–1291. doi:10.1001/jamadermatol.2018.3114 11.City of San Antonio Office of Equity. 2019 Racial Equity Indicator Report.

A Report by City of San Antonio Office of Equity, San Antonio, TX. 2019;16.

Marie Vu, Alexandra Montgomery and Tue “Felix” Nguyen are medical students at UT Health San Antonio who are interested in dermatology. They all serve as officers for the medical school’s Dermatology Interest Group.