The color of human skin is primarily determined by the presence of melanin, a pigment that provides some protection from the harmful effects of ultraviolet (UV) radiation. In people with darker skin tones, larger melanocytes produce more melanin, which offers greater defense against sun damage. This natural protection, however, does not make people of color immune to skin cancer, a misconception that often leads to delayed diagnoses and poorer outcomes. One in five Americans will develop skin cancer in their lifetime, emphasizing the importance of awareness and prevention.
This blog explores the complexity of skin cancer in people of color (POC), the risks they face, the types of cancers most common among them, and the need for greater awareness and preventive measures.
Introduction
Skin cancer is a significant health concern worldwide, affecting people of all skin tones. While it is often associated with fair skin, skin cancer can also occur in people with darker skin tones, including Black people. In fact, skin cancer in Black people is often diagnosed at a later stage, making it more challenging to treat. This article aims to provide an overview of skin cancer in Black people, including its risk factors, warning signs, detection methods, treatment options, and the importance of vitamin D for skin health.
The Protective Role of Melanin
Melanin, the pigment responsible for skin color, plays a vital role in protecting the skin from UV radiation. Darker skin has an intrinsic sun protection factor (SPF) of around 13.4, whereas lighter skin has an SPF of just 3.3 (Kaidbey et al., 1979). The superior photoprotection provided by melanin is due to its ability to absorb and deflect UV light. Higher amounts of epidermal melanin filter at least twice as much UV radiation as lighter skin, contributing to lower skin cancer rates among POC (Brenner and Hearing, 2008).
However, despite this natural protection, people of color are not immune to skin cancer. UV radiation, ionizing radiation, pollutants, and other environmental factors still pose significant risks, making it crucial to dispel the myth that darker skin is entirely shielded from cancer. While non-melanoma skin cancers are more common, melanoma skin cancer is more serious and has a higher mortality rate.
Risk Factors and Causes
Several risk factors contribute to the development of skin cancer in Black people. While melanin provides some natural protection against UV radiation, it is not a guarantee against skin cancer. Prolonged exposure to UV radiation can still cause damage to the skin, leading to skin cancer. Additionally, certain genetic conditions, such as albinism, can increase the risk of skin cancer in Black people. A family history of skin cancer can also elevate an individual’s risk of developing the disease.
People with weakened immune systems, such as those with HIV/AIDS, are more susceptible to skin cancer. Certain medications, such as those used to treat high blood pressure, can also increase the risk. Understanding these risk factors is crucial for prevention and early detection.
Does UV radiation play a role in these cancers that turn up in spots where “the sun doesn’t shine”?
Yes, UV radiation does play a role in skin cancer, even in cases where the cancer appears in areas that are not typically exposed to the sun, such as the palms, soles, and under the nails—often referred to as “the sun doesn’t shine” areas. However, in these cases, the relationship between UV exposure and skin cancer is less direct, and other factors may be involved.
For people of color (POC), melanoma and other skin cancers frequently arise in less sun-exposed areas. This type of melanoma is known as acral lentiginous melanoma, and it is more common in people with darker skin. While UV radiation is a primary factor in many skin cancers, particularly in sun-exposed areas, acral lentiginous melanoma and some other forms that develop in these “hidden” areas are not solely linked to UV exposure. These cancers may be driven by other factors, such as:
1. Genetics and Immune Factors: Genetic mutations, immune system issues, or chronic inflammation can contribute to the development of skin cancers in these locations.
2. Chronic Injury or Trauma: Repeated injury or scarring in these areas can lead to squamous cell carcinoma (SCC) or melanoma. Chronic inflammation or conditions like scars or ulcers can predispose skin to cancer in these non-sun-exposed regions.
Thus, while UV radiation is the main culprit for skin cancer in exposed skin, cancers in areas less affected by sunlight may be influenced by a combination of genetic, environmental, and trauma-related factors, and their occurrence highlights the importance of thorough skin checks in all areas of the body, regardless of sun exposure.
How common is skin cancer in people of color?
Skin cancer is less common in people of color (POC) compared to those with lighter skin tones, but it still poses a significant health risk. The incidence of skin cancer in POC is much lower due to the protective effect of higher melanin levels, which helps shield the skin from ultraviolet (UV) radiation. However, the disease can and does occur in all skin types.
While skin cancer is less common among non-Hispanic white patients, other groups such as Black and Hispanic patients typically experience worse outcomes due to later-stage diagnoses.
For instance:
Melanoma, the deadliest form of skin cancer, is less frequent in people of color, but when it does occur, it often has worse outcomes due to delayed diagnosis. In the U.S., melanoma incidence rates are highest among whites, followed by American Indian/Alaska Native, Hispanic, Asian/Pacific Islander, and black populations.
Non-melanoma skin cancers, such as squamous cell carcinoma (SCC) and basal cell carcinoma (BCC), are also less common in POC, but SCC is the most common skin cancer among African Americans and Asian Indians, often presenting in areas of chronic inflammation or scarring rather than sun-exposed skin.
While overall rates of skin cancer are lower in POC, the outcomes are often more severe due to later-stage diagnoses and reduced awareness about the risks.
The Misconception of Immunity to Skin Cancers
One of the most dangerous myths is that people with darker skin are immune to skin cancer. This false belief contributes to delayed diagnoses, often resulting in the disease being discovered at a more advanced stage when treatment is more challenging. While it is true that skin cancer incidence is lower in POC compared to those with lighter skin, POC are more likely to die from skin cancer when it does occur. Studies have shown that the five-year survival rate for melanoma, the deadliest form of skin cancer, is 70% in non-white populations, compared to 92% in whites (Wu et al., 2011; Gohara, 2008).
Skin cancer begins in the melanocytes, specifically referring to malignant melanoma, which originates in these pigment-producing cells. Individuals of color face challenges in recognizing melanoma due to its tendency to develop in less pigmented areas of the skin, often leading to delayed diagnoses and misdiagnoses.
Early detection is critical to improving survival rates. However, skin cancer in POC often presents in less obvious areas, such as the palms, soles, under the nails, and in mucous membranes, where it is easily overlooked or mistaken for other conditions (Madankumar et al., 2016). These hidden locations, combined with a lack of awareness, contribute to poorer outcomes for POC.
The Rising Risk of Skin Cancer Among People with Darker Skin Tones
The incidence of skin cancer in people of color, while lower than in whites, is increasing. Whites have the highest rates of melanoma, followed by American Indian/Alaska Native, Hispanic, Asian/Pacific Islander, and black populations (CDC Statistics, 2016). Over the past decade, melanoma incidence rates have risen by an average of 1.4% annually (CDC Statistics, 2016). This trend highlights the growing need for skin cancer awareness in POC as demographic shifts occur.
As the minority population in the U.S. continues to grow, the impact of skin cancer on these groups is becoming more significant. By 2050, it is estimated that African Americans, Hispanics, and Asians will make up approximately 50% of the U.S. population (Gloster and Neal, 2006). Unfortunately, skin cancer rates in these populations are also rising, particularly in states like California, Texas, and Florida, where sun exposure is high (Mann D, 2016).
Types of Skin Cancer Common Among Dark Skin People
Squamous Cell Carcinoma (SCC):
Squamous cell carcinoma is the most common type of skin cancer in African Americans and Asian Indians. It accounts for 30% to 65% of skin cancers in POC, compared to 15% to 25% in whites (Gloster and Neal, 2006). SCC often develops in areas of chronic scarring or inflammation and can occur in non-sun-exposed areas, particularly in Asians. Among African Americans, SCC is more likely to develop on the legs, buttocks, and feet (Halder and Bridgeman-Shah, 1995). While SCC is less aggressive than melanoma, it can still be dangerous, especially if diagnosed late.Basal Cell Carcinoma (BCC):
Basal cell carcinoma is the second most common type of skin cancer in POC, contributing to 20% to 30% of skin cancers in these groups, compared to 65% to 75% in whites (Gloster and Neal, 2006). BCC is typically caused by UV exposure and often appears as pearly or flesh-colored growths on sun-exposed areas of the skin. Although it rarely metastasizes, BCC can cause significant disfigurement. BCC is more common among lighter-skinned individuals, but pigmented forms of BCC are more prevalent in Hispanics and Asians, leading to diagnostic challenges (Bigler et al., 1996).Malignant Melanoma (MM):
Although melanoma accounts for less than 1% of skin cancer cases, it causes the majority of skin cancer-related deaths. Melanoma is more difficult to detect in POC because it frequently arises in less pigmented areas such as the palms, soles, and under the nails. These locations make melanoma more likely to be misdiagnosed or ignored, contributing to its higher mortality rate in POC (Tucker and Goldstein, 2003). Melanoma is often diagnosed at later stages in POC, particularly in blacks, Hispanics, and Asians, making early detection crucial for improving survival rates.
Warning Signs and Detection
Detecting skin cancer early is crucial for effective treatment. Here are some warning signs to look out for:
New or changing moles: Moles that change in size, shape, or color can be a sign of skin cancer.
Sores that don’t heal: Sores that don’t heal or go away can be a sign of skin cancer.
Bleeding or oozing: Bleeding or oozing from a mole or sore can be a sign of skin cancer.
Itching or pain: Itching or pain in a mole or sore can be a sign of skin cancer.
The ABCDE rule can help identify potential skin cancers:
A: Asymmetry: One half of the mole doesn’t match the other.
B: Border: The edges are irregular, ragged, or blurred.
C: Color: The color is not uniform and may include shades of brown or black, or sometimes patches of pink, red, white, or blue.
D: Diameter: The spot is larger than 6 millimeters across (about ¼ inch – the size of a pencil eraser), although melanomas can sometimes be smaller than this.
E: Evolving: The mole is changing in size, shape, or color.
If you notice any of these warning signs, consult a dermatologist for a thorough examination.
While all types of skin cancer are less common in people of color, their outcomes are dramatically worse. What accounts for this gap?
While skin cancer is less common in people of color, the outcomes are often far worse, and several factors contribute to this disparity:
1. Delayed Diagnosis: In people of color, skin cancer often develops in less obvious areas, such as the palms, soles, nails, and mucous membranes. These are places where people are less likely to notice changes, and healthcare providers may not thoroughly examine these areas during routine visits. As a result, skin cancers are typically detected at more advanced stages when they are harder to treat.
2. Lack of Awareness: Many people of color believe that their darker skin protects them from skin cancer, leading to a false sense of security. This misconception delays preventive measures like sun protection and skin checks, contributing to the late diagnosis of skin cancer. Additionally, POC are less likely to be educated about skin cancer risks by healthcare providers.
3. Underrepresentation in Research and Public Health Campaigns: There is limited research focused on skin cancer in people of color, which leads to gaps in understanding how the disease manifests in these populations. Moreover, public health campaigns about skin cancer tend to target lighter-skinned individuals, leaving people of color less informed about their risks.
4. Healthcare Access and Socioeconomic Barriers: People of color often face barriers to accessing healthcare, including fewer screenings and limited access to dermatologists. This reduces opportunities for early detection and timely treatment. Socioeconomic factors, such as lack of insurance or financial difficulties, can further delay medical attention, resulting in poorer outcomes.
These factors combined lead to higher mortality rates in people of color, despite the lower overall incidence of skin cancer. Addressing these issues through education, improved access to healthcare, and targeted public health campaigns can help close this gap.
Recommendations for prevention and early detection of skin cancer in people of color
Preventing and detecting skin cancer early in people of color starts with education and awareness. One of the most important steps is using broad-spectrum sunscreen with at least SPF 30, even for those with darker skin tones, as UV damage can affect everyone. Regular self-examinations are key—checking your skin from head to toe each month, especially less obvious areas like palms, soles, nails, and inside the mouth, can help spot early signs. It’s also essential to visit a dermatologist regularly, even if there are no obvious concerns. By taking these simple actions, people of color can protect themselves and catch potential issues early when they are most treatable. Early detection saves lives, and everyone, no matter their skin tone, deserves to stay safe from the dangers of skin cancer.
The Role of Healthcare Providers and Public Education
Health care providers play a critical role in raising awareness of skin cancer risks among people of color. Studies have shown that POC often receive little to no education about the risks and prevention of skin cancer from their doctors (Kim et al., 2009). This gap in communication can be deadly, as many POC continue to believe that their darker skin protects them completely from UV damage.
Physicians should be vigilant in performing thorough skin examinations, particularly in areas where melanoma is more likely to develop in POC, such as the soles of the feet, palms, nails, and mucous membranes. Encouraging patients to perform monthly self-examinations and educating them about the early signs of skin cancer can help improve early detection rates. In addition, public education campaigns should target communities of color to raise awareness about sun protection, the importance of using sunscreen, and the dangers of tanning beds.
Prevention and Early Detection Strategies
Prevention is the most effective way to reduce the risk of skin cancer in POC. Here are some key recommendations:
Sun Protection: People of color should use broad-spectrum sunscreen with an SPF of at least 30 daily, even on cloudy days. Sunscreens with active ingredients like zinc oxide, titanium dioxide, or avobenzone are particularly effective at protecting against both UVA and UVB rays. Sunscreen should be applied 30 minutes before going outside and reapplied every two hours while outdoors.
Avoid Tanning Beds: Tanning beds are a significant risk factor for skin cancer. The UV radiation emitted by these devices can cause DNA damage that leads to skin cancer, regardless of skin color.
Self-Examinations: Regular self-examinations are essential for early detection of skin cancer. POC should carefully examine their skin from head to toe every month, paying close attention to unusual moles, sores, lumps, or changes in the appearance of existing skin lesions.
Regular Check-ups: Physicians should perform comprehensive skin examinations during routine visits, particularly for high-risk individuals. Regular monitoring of nails, palms, soles, and mucous membranes is crucial for early detection of melanoma.
Treatment Options
Treatment options for skin cancer in Black people depend on the type and stage of the disease. These may include:
Surgery: Surgical removal of the tumor is often the first line of treatment for skin cancer.
Radiation therapy: Radiation therapy can be used to treat skin cancer that has spread to other parts of the body.
Chemotherapy: Chemotherapy can be used to treat skin cancer that has spread to other parts of the body.
Immunotherapy: Immunotherapy can be used to stimulate the immune system to fight skin cancer.
Each treatment option has its benefits and potential side effects, and the best approach depends on the individual case. Consulting with a healthcare provider can help determine the most appropriate treatment plan.
Vitamin D and Skin Health
Vitamin D is essential for skin health, and people with darker skin tones are often at risk of vitamin D deficiency. Vitamin D helps to regulate skin cell growth, prevent skin cancer, and reduce inflammation. People with darker skin tones can get vitamin D through:
Sunlight: While it’s essential to protect the skin from UV radiation, some sunlight can help boost vitamin D levels.
Supplements: Vitamin D supplements can help boost levels, especially during the winter months.
Food: Fatty fish, such as salmon, and fortified dairy products are rich in vitamin D.
It’s essential to consult a healthcare provider before taking any supplements to ensure you’re getting the right amount of vitamin D for your skin health. By maintaining adequate vitamin D levels, you can support overall skin health and potentially reduce the risk of skin cancer.
The Need for More Research
Despite the rising incidence of skin cancer in POC, there is limited research on the disease in these populations (Buster et al., 2012). Few resources exist for evaluating darkly pigmented lesions, which poses diagnostic challenges for clinicians. With changing demographics and increasing diversity, it is critical to conduct more studies on cutaneous malignancies in ethnic populations. These studies will help improve our understanding of how skin cancer affects POC and develop more effective prevention and treatment strategies.
Conclusion
Skin cancer in people of color is a growing public health issue that requires immediate attention. While melanin provides some protection against UV radiation, it is not foolproof, and POC remain at risk of developing skin cancer. The misconceptions surrounding immunity to skin cancer in POC contribute to delayed diagnoses and poorer outcomes. It is essential for healthcare providers and public health campaigns to raise awareness about skin cancer risks in POC, promote early detection, and emphasize the importance of preventive measures such as sun protection and regular skin examinations.
By addressing these challenges, we can improve skin cancer outcomes for people of all skin tones and reduce the burden of this preventable disease.