Skin Cancer in Skin of Color

Porcia T. Bradford

Dermatology Nursing. 2009;21(4):170-77; 206.

Abstract and Introduction

Abstract

Skin cancers in skin of color often present atypically or with advanced stage in comparison to Caucasian patients. Health care providers must maintain a high index of suspicion when examining skin lesions in skin of color.

Objectives
This continuing nursing educational (CNE) activity is designed for nurses and other health care providers who care for and educate patients and their families about skin cancer in skin of color. For those wishing to obtain contact hour credit, an evaluation follows. After studying the information presented in this article, the nurse will be able to:
1. Discuss the incidence of skin cancer in skin of color.
2. Identify the features of basal and squamous cell cancers in skin of color.
3. Describe the occurrence of melanoma in skin of color.
4. Define the characteristics of cutaneous T-cell lymphoma and Kaposi sarcoma in skin of color.

Introduction

Skin cancer is the most common malignancy in the United States and represents approximately 35% to 45% of all neoplasms in Caucasians (Ridky, 2007), 4% to 5% in Hispanics, 2% to 4% in Asians, and 1% to 2% in Blacks (Gloster & Neal, 2006; Halder & Bridgeman-Shah, 1995). The incidence of skin cancer has been increasing among Caucasians (Ridky, 2007), but remains relatively low in people of color. Data have been limited for non-White populations, making accurate determination of incidence and mortality difficult.

The low incidence of skin cancers in darker-skinned groups is primarily a result of photo-protection provided by increased epidermal melanin, which filters twice as much ultraviolet (UV) radiation as does that in the epidermis of Caucasians (Montagna & Carlisle, 1991). The larger, more melanized melanosomes of darker-skinned groups absorb and scatter more energy than do the smaller melanosomes of Caucasians (Brenner & Hearing, 2008). Hence, UV radiation, the most important predisposing factor for skin cancer in Caucasians, plays a lesser role in people of color.

When skin cancer occurs in people of color, patients often present with an advanced stage, and thus, worse prognosis in comparison to Caucasian patients (Cormier et al., 2006; Hu, Sora-Vento, Parker, & Kirsner, 2006). Furthermore, certain types of skin cancer, such as dermatofibrosarcoma protuberans, predominate in people of color (Halder & Bridgeman-Shah, 1995). The anatomic distribution may or may not be different from that seen in Caucasians, depending on the specific type of skin cancer. Treatment is generally the same among all racial groups.

Predictions estimate that by the year 2050, Hispanics, Asians, and Blacks will represent approximately 50% of the U.S. population (Gloster & Neal, 2006; U.S. Census Bureau, Population Division, 2000). Hence, given the often atypical clinical presentation, the difficulty in detecting certain features such as color variegation in dark skin, and pigmentation of some skin cancers that are usually not pigmented in Caucasians, a high degree of suspicion must be maintained by physicians and other health care providers when examining skin lesions in people of color (Halder & Bridgeman-Shah, 1995). In this review, the differences in risk factors, clinical presentation, and mortality associated with skin cancers in Blacks, Asians, and Hispanics compared to Caucasians will be discussed. Forms of skin cancers that can present atypically in skin of color will be included and consist of basal cell cancer, squamous cell cancer, melanoma, cutaneous T-cell lymphoma, Kaposi sarcoma, and dermatofibrosarcoma protuberans.

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Table 1. Basal Cell Cancer Features in Caucasians and People of Color
	Caucasians	People of Color
Frequency of Disease	Most common skin cancer	Most common skin cancer in Hispanics and Asians
Risk Factors	Sun exposure, fair skin, previous radiation therapy, and genetic disorders (albinism, nevoid basal cell carcinoma syndrome, xeroderma pigmentosum)	Sun exposure, scars, ulcers, previous radiation therapy, and genetic disorders (albinism, nevoid basal cell carcinoma syndrome, xeroderma pigmentosum)
Typical Clinical Presentation	Translucent, solitary nodule with central ulceration and telangiectasias	Pigmented BCC, with "black, pearly appearance" common
Anatomic Distribution	Head and neck regions	Head and neck regions

Table 2. Squamous Cell Cancer Features in Caucasians and People of Color
	Caucasians	People of Color
Frequency of Disease	2nd most common skin cancer	Most common skin cancer in Blacks; 2nd most common in Hispanics and Asians
Risk Factors	Sun exposure, fair skin, immunosuppression, human papillomavirus infections, scarring	Chronic scarring/inflammation from burns, leg ulcers, radiation, lupus, immuno-suppression, human papillomavirus
Typical Clinical Presentation	Superficial lesion arising from indurated, rounded, elevated base	Sore that will not heal (bleeding or developing a crust)
Anatomic Distribution	Sun exposed areas (head and neck, hands)	Skin infrequently exposed to the sun (legs)

Table 3. Melanoma Features in Caucasians and People of Color
	Caucasians	People of Color
Frequency of Disease	3rd most common skin cancer; incidence increasing	3rd most common skin cancer; incidence increasing in Hispanics
Risk Factors	Sun exposure, fair skin, family history, increased number of nevi, dysplastic nevi	Sun exposure; unknown for acral melanoma
Typical Clinical Presentation	Dark, rapidly spreading macules or patches a rising from pigmented nevi	Dark, rapidly spreading macules or patches a rising from pigmented nevi; rapidly changing pigmented band on the nail (Hutchinson's sign)
Anatomic Distribution	Often on trunk or lower legs	Often on palmar, plantar, and subungual areas (acral melanoma)

Table 4. Cutaneous T-Cell Lymphoma Features in Caucasians and People of Color
	Caucasians	People of Color
Patterns of Disease	Most common cutaneous lymphoma	Most common cutaneous lymphoma; Blacks twice as likely to be affected
Risk Factors	Largely unknown	HTLV-1 endemic in Caribbean, Japan, sub-Saharan Africa, and South America
Clinical Presentation	Erythematous, slightly scaling, annular, or arcuate patches	Hypopigmented lesions presenting as macules or patches with ill-defined borders and no or minimal scaling
Anatomic Distribution	Involves sun-shielded trunk "bathing suit distribution"	Involves sun-shielded trunk "bathing suit distribution"

Table 5. Kaposi Sarcoma Features in Caucasians and People of Color
	Caucasians	People of Color
Patterns of Disease	One of the most common cutaneous soft-tissue sarcomas	Blacks have higher incidence rates of KS than Caucasians;Asians have a much lower incidence
Risk Factors	Mediterranean and Ashkenazi Jew background; immunosuppression (organ transplants); AIDS; HHV-8	Endemic KS in Africa; immunosuppression (organ transplants); AIDS; HHV-8
Clinical Presentation	Painless, violaceous macules, nodules, or plaques	Painless, violaceous macules, nodules, or plaques; violaceous hue may be difficult to detect in darker-skinned populations
Anatomic Distribution	Commonly on lower extremities	Commonly on lower extremities

Table 6. Dermatofibrosarcoma Protuberans Features in Caucasians and People of Color
	Caucasians	People of Color
Patterns of Disease	Rare	Approximately 10% of all skin cancers in Blacks; Blacks have higher incidence than other groups
Risk Factors	Unknown	Unknown
Clinical Presentation	Violaceous, red-brown, or flesh-colored indurated plaque that with time develops protuberant nodules	Violaceous, red-brown, or flesh-colored indurated plaque that with time develops protuberant nodules
Anatomic Distribution	Trunk or extremities	Trunk or extremities

Table 7. Recommendations for Patients and Clinicians for Preventing Skin Cancer in Skin of Color
Recommendations for Patients
Perform routine skin examinations and report any new and/or changes of existing skin lesions to health care providers.
Sunscreen (sun protection factor 30 or greater) should be applied to skin, regardless of complexion, during periods of prolonged exposure, especially d u ring peak hours of sunlight (10 a.m.–2 p. m.).
Wear sunglasses with UV-absorbing lenses.
Avoid tanning booths.
Recommendations for Clinicians
Pigmented lesions in skin of color, particularly those of mucosal, palmar, plantar, and subungual surfaces, should be monitored closely and biopsied if any enlargement or ulceration is noted.
Hyperkeratotic or poorly healing lesions in people of color with chronic discoid lupus erythematosus should be biopsied.
Nonhealing ulcers of significant duration on skin of color, regardless of original etiology, should be biopsied.
Atypical-appearing keloids and those keloids appearing in atypical nontraumatized locations on skin of color or in nontension areas should be evaluated.
CTCL should be included in the differential diagnosis of diffuse hypopigmentation disorders of people of color.

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