May is National Skin Cancer Awareness Month. We should feel proud that as a society, we have learned so much over the last generation about preventing, diagnosing, and treating skin cancer. However, research reveals that skin cancer awareness and education specific for African American skin is lacking. Most people are under the wrong impression that African Americans can’t get skin cancer. The good news is that skin cancer in the African American population is relatively low. The bad news, however, is that most African Americans suffer a significant delay in the diagnosis of the disease which results in greater difficulty in treating and curing the disease.
We know there is a direct relationship between early diagnosis, treatment options, and how effective these options will be. Besides the general lack of awareness of the risk of skin cancer, another huge factor that contributes to the delayed diagnosis of skin cancer in African Americans is that it often looks different from what we traditionally see in common skin cancers in white skin. As a result, many early signs of skin cancer are missed.
My hope is that by providing information on the signs and symptoms of skin cancer in African Americans, more people will seek proper screening, diagnosis, and treatment.
Let’s start with some basic information on the three major types of skin cancer.
- Basal cell carcinoma (BCC) comes from blips of intense sun exposure, usually as a result of vacationing.
- Squamous cell carcinoma (SCC) is the result of cumulative sun exposure–the type of exposure that is common with sun-worshippers as well as farmers and others who work outside. SCC is capable of metastasizing which means the cancer can reach the blood stream and spread throughout the body.
- Malignant melanoma is commonly referred to as melanoma. This is the deadly type that doesn’t play fair. Melanoma can occur anywhere on your body in any shape, color, or form.
In whites, BCC is the most common type of skin cancer, followed by SCC and then melanoma. In African American populations, the first two are reversed; SCC is the most common, then BCC, and then melanoma.
Out of 100,000 whites around 230 to 240 will develop SCC compared to only 3 or 4 instances in African Americans. Yet the few African Americans who do develop it are often diagnosed late. Late diagnosis of SCC may be fatal because SCC can metastasize. I have found that by the time African Americans are diagnosed with SCC the disease has usually advanced to the point where I must treat it more aggressively and extensively. This is also true of melanoma.
I ask myself, with so few instances of skin cancer in African Americans how can we improve such a low cure rate? I believe the answer is in greater education and awareness of skin cancer in African American skin. I explain to my African American patients that if they develop skin cancer, it may likely not look like the traditional textbook descriptions and pictures.
It’s important to know if your lifestyle, physiology, or genetics increase your skin cancer risk. You also need to know what signs to look for and where on your body these changes may occur. I will explain how signs of skin cancer in African Americans differ from those in whites.
Risk factors for BCC and SCC in everyone include chronic exposure to UVB light, previous radiation exposure (eg from a medical treatment), trauma such as an injury to the skin or nails, congenital or inherited susceptibility, immuno-suppression (eg diseases like AIDS or cancer), the human papilloma virus (commonly known as genital warts), and exposure to chemical carcinogens such as hydroquinone (a skin lightener) or formaldehyde (a popular preservative in nail polish and other cosmetic products).
I want you to be aware, but not alarmed, that potential chemical carcinogens are things that may be found in cosmetic products. For example, hydroquinone was under recent investigation and while the data wasn’t strong enough to confirm a direct causal link, you should only use hydroquinone in concentrations of 3% or higher under the direct guidance and supervision of a doctor. Although I use hydroquinone in my practice, I provide patients with a detailed explanation of the risks and benefits of the drug and monitor them frequently for potential side effects.
In whites, BCC and SCC generally occur on the area of the body exposed to direct sun light. In African Americans, however, skin cancer tends to occur on areas of the body that are traditionally covered, such as the underarms and the perianal area. On white skin I look for red or pale scaly areas as signs of skin cancer. On darker skin tones, I look for scaly moles and raw patches.
Most typical skin checks for BCC and SCC aren’t concerned with dark moles. But on African American skin, BCC and SCC can look like a simple dark mole, and consequently, the cancer is missed on exam by the untrained eye. This is exactly why African Americans are usually diagnosed only after the disease has advanced to more dangerous stages.
When we look at melanoma compared to BCC and SCC, we note that the cause of melanoma remains less understood than that for BCC and SCC. Risk factors for melanoma include genetics, family history (especially if you have first-degree relatives who have had melanoma), UV light exposure, repeated childhood blistering sunburns, lighter skin tone, and immunosuppression. In addition, it is well recognized that skin trauma, especially injured nail beds, may plant the seed for melanoma. Therefore, if you stub your toe and develop a dark blood spot under the nail, it is important for you to keep a close eye on it to make sure that it clears up in a month or two. If it does not, you should see a dermatologist to make sure that melanoma has not developed in the same spot as a result of the injury. Be comforted by the fact that this is rarely the case. But unfortunately, for unexplained reasons, melanoma likes to grow on the feet in African Americans more so than on other parts of the body. Remember: when it comes to melanoma, there are still a lot of unknowns.
On lighter skin tones, the most common places melanoma occurs are on the back, chest, and legs. For African Americans, the most common places are the legs and feet, especially the soles of the feet where there is neither color nor sun exposure.
When I diagnose skin cancer, I want it to be superficial (ie, limited to the outermost layer of the skin) because these cancers have the have highest cure rate. Unfortunately, this is rare with African Americans because late diagnosis is rarely superficial. Education and awareness will make a difference in the outcome and cure rate.
When it comes to diagnosing and treating skin cancer in African American patients, I have several rules I follow. First, if during a skin exam I see an odd lesion and I can’t name it, I biopsy it! Second, I recommend that just like with our baseline exams for breast cancer, colon cancer, etc, everyone should also get a baseline full body skin check by a dermatologist. Let your risk factors for skin cancer, as discussed above, be your guideline on how soon you should be seen by a dermatologist. When choosing a dermatologist, do not be shy to ask if he or she examines and treats a lot of patients of color, as you now know that skin cancer often looks different in darker skin tones. By all means, become familiar with your own skin; know what moles and markings you have and use them as a baseline for assessment. You should repeat this full body check every 4 to 5 years depending on the results of your baseline skin exam. You and your doctor need increased suspicion for skin cancer. For the reasons I mentioned above, skin cancer may not even be on your physician’s radar. Finally, while the internet is an amazing resource for information, don’t rely on it for your skin cancer information and education. The traditional descriptions of skin cancer you find online are not necessarily true for your skin. Let’s make this May a National Skin Cancer Awareness (and Education) Month for us all!