CONTINUING MEDICAL EDUCATION

Skin cancer in skin of color

Hugh M. Gloster, Jr, MD, and Kenneth Neal, MD
Cincinnati, Ohio

Skin cancer is less common in persons with skin of color than in light-skinned Caucasians but is often
associated with greater morbidity and mortality. Thus, it is crucial that physicians become familiar with skin
cancer in persons of color so as to maximize the likelihood of early detection of these tumors. In dark-
skinned ethnic groups, squamous cell carcinoma is most common; squamous cell carcinoma and
melanoma usually occur on nonsun-exposed sites; and ultraviolet radiation is not an important etiologic
factor for skin cancer with the exception of basal cell carcinoma. Races of intermediate pigmentation, such
as Hispanics and Asians, share epidemiologic and clinical features of dark-skinned ethnic groups and
Caucasians. Skin cancers pose a significant risk in skin of color and clinicians should focus on preventive
measures in these groups such as regular skin exams, self-examination, public education, and screening
programs. ( J Am Acad Dermatol 2006;55:741-60.)

Learning objective: At the completion of this learning activity, participants should be familiar with the
epidemiology and unique clinical features of skin cancer in skin of color and be aware of strategies to
prevent skin cancer in skin of color.

S kin cancer, the most common malignancy in

the United States, represents approximately
20% to 30% of all neoplasms in Caucasians,
2% to 4% of all neoplasms in Asians, and 1% to 2%
of all neoplasms in blacks and Asian Indians.1-12
The actual incidence is difficult to estimate because
nonmelanoma skin cancers (NMSCs) are not con-
sistently reported to most tumor registries. Further-
more, interpretation of clinical and histopathologic
differences between the races is challenging, be-
cause the total numbers of reported tumors in blacks,
Hispanics, and Asians are smaller than that in Cau-
casians. Information about the incidence of these
tumors often comes from special surveys or from
registries of select populations.
In 1978 the annual age-adjusted incidence of skin
cancer was 232 per 100,000 population in Caucasians
and 3.4 per 100,000 in blacks, indicating that
Caucasians are approximately 70 times more likely
to develop skin cancer.1,13 Since the 1960s, inci-
dences of basal cell carcinoma (BCC), squamous
From the Department of Dermatology, University of Cincinnati,
School of Medicine.
Funding sources: None.
Conflict of interest: None identified.
Reprints not available from the authors.
Correspondence to: Hugh M. Gloster, Jr, MD, Department of
Dermatology, University of Cincinnati, 9275 Montgomery Rd,
Ste 100, Cincinnati, Ohio 45242. E-mail: hgloster@yahoo.com.
0190-9622/$32.00
ª 2006 by the American Academy of Dermatology, Inc.
doi:10.1016/j.jaad.2005.08.063
Abbreviations used:
AK:
BCC:
KS:
actinic keratosis
basal cell carcinoma
Kaposi sarcoma
NMSC: nonmelanoma skin cancer
PTCH: patched
SCC: squamous cell carcinoma
UVB: ultraviolet B
UVR: ultraviolet radiation
cell carcinoma (SCC), and melanoma among pre-
dominantly white populations have increased at a
rate of 5% to 8% annually.14-16 In Japan the incidence
of BCC increased between 1976e80 and 1986e90,
yet the incidence of SCC remained constant.17
The incidence of NMSC among the Japanese is bet-
ween 1.2 and 5.4 per 100,000.18 An analysis
of the Singapore Cancer Registry revealed that the
incidence of skin cancer had increased in Chinese
Asians from approximately 6 per 100,000 in 1968 to
8.9 per 100,000 in 1997.7 In contrast, the incidence
of skin cancer has remained relatively constant in
blacks.1,4 In southeastern Arizona Hispanics, there
were no changes in the incidence of SCC or BCC from
1985 to 1996.19 Despite increasing incidence in some
races, mortality for NMSC decreased by 20% to 30%
in the United States between 1969 and 1988 in
both blacks and whites, although the decline among
blacks was less consistent than among whites.20
Mortality among blacks, however, remains dispro-
portionately high in comparison with incidence.20
NMSC mortality and incidence data may be difficult to

741
742 Gloster and Neal
interpret for blacks because of the high incidence of
Kaposi sarcoma in association with AIDS in the 1980s
and 1990s.21 The relative impact of misclassifying
AIDS-related NMSC is greater for blacks than for
whites because the incidence of non-AIDS-related
NMSC is much more frequent in whites.21
Skin cancer is less common in darkly pigmented
persons than in light-skinned Caucasians but is often
associated with increased morbidity and mortality. It
is predicted that by the year 2050, Hispanics, Asians,
and blacks will represent 50% of the US popula-
tion.22 Thus it is crucial that physicians be familiar
with skin cancer in darker skin. This article reviews
the literature to summarize the epidemiology and
unique clinical features of skin cancer in darker skin
and to emphasize the need for heightened public
awareness and earlier diagnosis and treatment of
skin cancer in people of color.
ROLE OF ULTRAVIOLET RADIATION
The low incidence of cutaneous malignancies in
darker-skinned groups is primarily a result of photo-
protection provided by increased epidermal mela-
nin, which provides an inherent sun protection
factor of up to 13.4 in blacks.2,23 Darker-skinned
groups have increased melanocyte activity and
larger, more dispersed melanosomes, in contrast to
less melanocyte activity and smaller, more grouped
melanosomes in Caucasians.2,24,25 Epidermal mela-
nin in blacks filters twice as much ultraviolet B
(UVB) radiation as does that in Causasians.2,13 Black
epidermis transmits 7.4% of UVB and 17.5% of
ultraviolet A rays, compared with 24% and 55%
in Caucasian epidermis, respectively.2,13 Dark skin
transmits less ultraviolet light because the larger,
more melanized melanosomes in the epidermis of
dark skin absorb and scatter more light energy than
the smaller, less melanized melanosomes of white
skin. The dose of ultraviolet radiation (UVR) re-
quired to produce a minimally perceptible erythema
has been estimated to be 6 to 33 times greater in
blacks than in whites.26 Deeply pigmented Melane-
sians of New Guinea have had no proven cases of
BCC and extremely rare occurrences of SCC and
melanoma in normally pigmented skin.27 The calcu-
lated incidence of NMSC among Japanese in Hawaii
is approximately 40 times less than that of whites
who live in the same area,18 probably because of the
protective effects of brown pigmentation in the
Japanese. UVR, therefore, may not be as significant
an etiologic factor in the development of skin cancer
in darker races because of protection provided by
melanin pigmentation against solar carcinogenesis.
The total ozone column has decreased signifi-
cantly over the past 20 years, resulting in an increase
J AM ACAD DERMATOL
NOVEMBER 2006
in harmful UVR at the surface of the earth.18 UVR is
the predominant predisposing factor for skin cancer
in Caucasians.28-30 Increased risks of melanoma and
NMSC have been associated with UVR from sunlight,
decreasing latitude, and decreasing level of skin
pigmentation.31 NMSCs in Caucasians most com-
monly occur on areas of skin exposed to the sun and
are primarily the result of long-term sun exposure,
whereas melanoma is strongly associated with re-
peated, intense exposure to UVR early in life.32,33
UVR is also a significant risk factor for skin cancer in
Asians. An analysis of the Singapore Cancer Registry
data from 1968 to 1997 revealed that fairer Chinese
had a twofold greater incidence of skin cancer than
did darker Malays or Indians.7 The incidence of BCC is
2 times greater among ethnic Japanese who live in
Kauai, Hawaii, than among those who live in Japan
because of more intense UVR exposure and emphasis
on outdoor activities in Hawaii.34
The association of skin cancer with UVR exposure
in blacks is unclear except for BCC.2,35 UVR plays a
significant role in the development of BCC in black
patients, since these tumors most commonly develop
on sun-exposed sites.1 Light skin color, which may
predispose less pigmented persons to actinic dam-
age, has also been associated with an increased risk
of BCC in blacks.1,2 A Howard University Hospital
study of 23 blacks with BCC and 291 blacks chosen
randomly showed that 60% of the former but only
10% of the latter had fair or olive skin.2 Other studies
have shown that the US geographical variation in
relative rates of skin cancer in blacks approaches that
in whites.36 A previous US study indicated that NMSC
incidences for blacks increased with decreasing
latitudes.37 Studies in Africa conclusively demon-
strate a higher incidence of BCC in albino blacks than
in normally pigmented black persons.38-40 However,
UVR does not appear to be as important an etiologic
factor in blacks for the development of SCC and
melanoma, which tend to occur more commonly
on non-sun-exposed sites in darkly pigmented
persons.1-4
The role UVR plays in the development of BCC and
SCC in different races and ethnic groups is illustrated
by differences in the distribution of these tumors. The
head-and-neck region is overall the most common
location of BCC in Caucasians, Asians, blacks, and
Hispanics.1,19,41-43 In a study of head-and-neck NMSC
in blacks, the scalp and nose were the most common
sites, representing 76% of tumors in Caucasians and
44% in blacks.44 In Caucasians and blacks, the ratio of
BCC to SCC was approximately 4:1 for the head and
neck. However, on covered areas, the ratio of BCC to
SCC was 1:1 in Caucasians and 1:8.5 in blacks. The
authors concluded that SCC occurred 8.5 times more
J AM ACAD DERMATOL
VOLUME 55, NUMBER 5
Fig 1. Squamous cell carcinoma on the left nasal ala of an
Asian Indian.
frequently on non-sun-exposed sites in blacks, im-
plying that UVR does not play an important role in the
development of SCC in blacks.
Despite the tendency of melanoma to develop in
non-sun-exposed sites in darker skin, there is still
evidence that exposure to solar radiation plays a
role in the development of melanoma in darker
races. One study showed similar cytotoxic damage
in cultured melanocytes from blacks and whites
who underwent exposure to simulated sunlight.2,45
Hu et al analyzed cancer registries in 6 states
(New York, New Jersey, Illinois, California, Texas,
and Florida) and found that the incidence of mel-
anoma was positively associated with the UV index
and latitude for whites, Hispanics, and blacks, yet
this correlation was statistically significant only in
white men, white women, and black men.46 These
data underscore the need for sun protection and
risk education in these populations.
Other investigators have found evidence to dis-
count the role of UVR in the development of mela-
noma. Eide and Weinstock evaluated the correlation
of melanoma incidence with UV index and latitude
within racial and ethnic groups on the basis of data
from the Surveillance, Epidemiology, and End Re-
sults (SEER) Program of the National Cancer Institute
for the years 1992 through 2001.47 The expanded
SEER program included 11 cancer registries (SEER-
11), which represented approximately 14% of the US
population. The SEER-11 data revealed that mela-
noma incidence was associated with increased UV
index and lower latitude only in whites. There was
no evidence to support the association of UV expo-
sure and melanoma incidence in blacks, Hispanics,
or Asians.
Others have even questioned the belief that
skin pigmentation protects blacks from melanoma,
since it has been shown that albinos in Africa,
in comparison with African blacks of normal pig-
mentation, do not show the same increase in
Gloster and Neal 743
Fig 2. Squamous cell carcinoma on the forehead of a
Hispanic man. Courtesy of the Cutaneous Oncology Unit,
Department of Dermatology, Hospital General de Mexico.
incidence of melanoma as seen with actinic kerato-
ses (AKs), BCC, and SCC.48
SCC
SCC is the most common cutaneous malignancy
in blacks and Asian Indians, representing 30% to
65% of skin cancers in both races, respectively
(Fig 1).1-4,6,12,49 SCC is the second most common
cutaneous neoplasm in Caucasians, accounting for
15% to 25% of skin cancers.1-4,6 In a review of 176
SCCs in black patients at Charity Hospital in Louisi-
ana, SCC was the most common cutaneous malig-
nancy overall and was 20% more common than
BCC.3 The incidence of SCC has been reported to be
17 to 150 per 100,000 in Caucasian women, 30 to 360
per 100,000 in Caucasian men, 118 per 100,000 in
Caucasian residents of Kauai, Hawaii, 23 per 100,000
in Japanese residents in Kauai, Hawaii, 21 per
100,000 in New Mexican Hispanics, 13.8 to 32.9 per
100,000 in Hispanic residents of southeastern Ari-
zona, and 3 per 100,000 in blacks (Fig 2).19,31,34,50,51
Incidence rates of SCC in Caucasians have a wide
range that correlates with the intensity of UVR at the
region of residency.
SCC is also the second most common skin cancer
in Chinese Asians and Japanese.7,52 The incidence
of SCC among Chinese Asians, which is reported to
range from 2.6 to 2.9 per 100,000, has decreased 0.9%
annually from 1968 to 1997.7 SCC accounts for 30% of
all skin cancers in Japan.52 The numbers of AKs,
a premalignant form of SCC, have increased sharply
in Japan from 1987 to 1996.52 The incidence of AK in
Japan is approximately 414 per 100,000.18,53 AKs in
the Japanese are more common among men, who
are more likely to engage in outdoor activities.54
Suzuki et al found that the presence of seborrheic
keratoses may be a risk factor for AK among
Japanese.53
SCC occurs most commonly on sun-exposed
sites of the head and neck in Caucasians and on
744 Gloster and Neal
Fig 3. Squamous cell carcinoma on sun-protected skin
of the lower leg of a black male. Courtesy of Carl
Washington, MD.
sun-protected sites in blacks1-4,31,44,50,55-57 (Fig 3),
which discredits UVR as an important etiologic factor
in the development of SCC in blacks. A review of skin
cancer cases at Howard University Hospital from
1947 to 1985 revealed 43 black patients with SCC,
making it the most common form of skin cancer in
this series.1 Sixty-five percent of patients with SCC
had lesions on non-sun-exposed skin, including the
legs, whereas 23% of SCCs in women occurred on
the anus. In a review of 524 cases of SCC in black
Africans in Nigeria, the most common site was the
lower limb, affected in 54% of cases, followed by
the head and neck.58 Fleming et al reported that of
58 cases of skin cancer in black patients, 66% were
SCCs, 61% of which developed on unexposed areas.3
A review of the Tanzania Cancer Registry in Africa
showed SCC of the skin to be the most common skin
cancer.49 Its peak was in the 40- to 49-year age group.
The site affected most often was the lower limb,
followed by the head and neck. A review of 163 cases
of SCC in blacks by Mora revealed more common
involvement of non-sun-exposed areas, including
the lower extremity and the hair-covered scalp.3
In blacks, lesions on sun-exposed areas most fre-
quently present on highly exposed skin, such as the
nose, forehead, and lower lip (Fig 4).
McCall and Chen reviewed cases of SCC in blacks
at Grady Memorial Hospital in Atlanta, Georgia, from
1996 to 2001 and found a total of 35 SCCs.56 Twenty-
four (69%) of these patients had SCC in relatively
sun-protected areas of the body such as the anogen-
ital area, the legs, and the feet. Sixty-three percent of
these patients were elderly women, and 46% of them
had involvement of the lower extremities. In this
study all SCCs on the legs of black patients occurred
in women and many of these lesions were pig-
mented (Fig 5). Three patients reported a history
of leg warming, had skin changes consistent with
erythema ab igne, and were noted to have abnormal
J AM ACAD DERMATOL
NOVEMBER 2006
Fig 4. Squamous cell carcinoma on the nose of a black
male.
Fig 5. Pigmented squamous cell carcinoma on the leg
of a black woman. Courtesy of Calvin McCall, MD.
pigmentation of perilesional skin, such as hypopig-
mented, depigmented, and hyperpigmented mac-
ules. The authors concluded that the combination
of hyperkeratotic neoplasms and mottled pigmenta-
tion of the legs of black individuals should alert the
physician to the possibility of SCC.
In blacks, SCC may present in the anogenital
area in 10% to 23% of cases.3,56,59 A review of the
Tanzania Cancer Registry in Africa showed that the
penis and the vulva were the third most affected
sites.49 In the Howard University study, 23% of SCCs
in women occurred on the anus.1 Although the
prevalence of penile SCC is approximately equal
for whites and blacks, blacks tend to present at a
younger age with a higher stage of disease and have
a shorter survival period.59
Bowen disease, or SCC in situ, is uncommon in
blacks and typically presents as a nonspecific scaly,
hyperkeratotic, sharply demarcated plaque that is
often pigmented and may be velvety, flat, or verru-
cous (Fig 6).1,2,60-62 In most series, Bowen disease
affects older persons after the 6th decade and is
slightly more common in black men than in black
women,1,62,63 although one study showed females to
be affected twice as often as males.57 As with SCC in
blacks, Bowen disease tends to develop more often
on non-sun-exposed skin, particularly the lower
extremities.1,2,57 Pigmented Bowen disease may
J AM ACAD DERMATOL
VOLUME 55, NUMBER 5
Fig 6. Pigmented Bowen’s disease on the finger of a black
woman. Courtesy of Carl Washington, MD.
mimic melanoma in dark-skinned patients.1,2
Pigmented Bowen disease has also been reported
in the anogenital region in black patients.61 In one
series, arsenic was considered as a predisposing
factor in the development of Bowen disease in
blacks, since 3 of 7 patients had histories of arsenic
exposure.63 An association of Bowen disease with
internal malignancy in blacks has been reported,57
but no such association was noted in other se-
ries.1,60,63 Invasive lesions, which are capable of
metastasis, may develop in some patients.57
The most important risk factors for the development
of SCC in blacks are chronic scarring processes and
areas of chronic inflammation.2,3,49 Chronic scarring
processes are noted in 20% to 40% of cases of SCC
in blacks.1,3,4 SCC in blacks has developed
in burn scars,1,2,64 areas of past physical or thermal
trauma,2,56,65,66 prior sites of radiation therapy,1,2,64 and
areas of chronic inflammation such as ulcers,1,2,56,64
discoid lupus erythematosus (Fig 7),1,64,67 lupus vulga-
ris,3 granuloma annulare,3 leprosy,68 lymphogranu-
loma venereum,3 osteomyelitis,2,66 and hidradenitis
suppurativa2,3 (Fig 8). In a review of 524 cases of SCC
in Nigerian blacks, the most common predisposing
factor was chronic leg ulcers, with most tumors arising
from postburn scars.34 A review of the Tanzania Cancer
Registry in Africa showed that chronic traumatic injuries
and chronic ulcers were the main predisposing factors
for SCC on the lower limb and scalp, whereas UVR was
the major risk factor for head and neck lesions.49 Risk
factors for SCC not associated with scarring or inflam-
mation include a history of albinism,1,56 human
papillomavirus,1,66 epidermodysplasia verruciformis,2
immunosuppression,2 and chemical carcinogens such
as arsenic and tar.63,66 Because of the aforementioned
predisposing factors for the development of SCC in
blacks, nonhealing ulcers or nodules adjacent to an
Gloster and Neal 745
Fig 7. Squamous cell carcinoma arising in a lesion of
discoid lupus erythematosus in a black male. Courtesy of
Carl Washington, MD.
Fig 8. Squamous cell carcinoma arising in hidradenitis
suppurativa of the perianal area of a black male. Courtesy
of Emily Fisher, MD.
area of chronic scarring or inflammation should be
subjected to biopsy to exclude malignancy. Despite
reports of SCC in blacks associated with non-UV-light
risk factors (eg, immunosuppression) and comorbidity
with other diseases (eg, discoid lupus erythematosus),
it is difficult to make firm conclusions about these risk
factors because of the isolated number of reported
cases and the lack of large series in the literature.
SCC that develops within a chronic scarring pro-
cess, the most common scenario in blacks, tends to
be more aggressive and is associated with a 20% to
40% risk of metastasis, compared with the 1% to 4%
metastatic rate of sun-induced SCC in whites.3,69
Also, SCC that occurs on non-sun-exposed sites
may have a greater potential for metastasis.1,2 The
disparity in metastatic rates of SCC between blacks
and whites may reflect the tendency for blacks to
present with more advanced disease, presumably as
a result of delays in diagnosis, or it may be related
to the presence of inherently more aggressive tu-
mors.1,2 Mora reported that mortality was greater
among patients with SCC that arose in a chronic
scarring process and was greatest among those
with perianal tumors.70 In most series, SCC in blacks
746 Gloster and Neal
is associated with mortality that ranges from 17% to
30%.1,3,4,70 Therefore, compared with sun-induced
SCC in Caucasians, SCC in blacks is associ-
ated with increased morbidity and mortality, which
underscores the essential need for earlier diag-
nosis and treatment.
BCC
BCC is the most common skin cancer in
Caucasians, Hispanics, Chinese Asians, and the
Japanese.2,7,43 In contrast, BCC represents the second
most common cutaneous malignancy in blacks and
Asian Indians.2,12 Only about 1.8% of BCCs occur in
blacks, and BCC is approximately 19 times more
common in whites.71,72 On the basis of data from 6
large medical centers, the prevalence of BCC in North
American blacks averages 1% to 2% per year.1,4,73
BCC is the most common skin tumor in Japan,
accounting for 47% of all cutaneous malignancies in
one study, a survey of 101 institutions from 1987 to
1996.52 BCC is rare in dark skin because of the
inherent photoprotection of melanin and melanoso-
mal dispersion.6,71
The incidences of BCC per 100,000 population
have been reported in different races as follows:
black men (1), black women (2), Kenyan Africans
(0.065), Chinese men (6.4), Chinese women (5.8),
Japanese (15 to 16.5), Japanese residents of Kauai,
Hawaii (29.7), Japanese residents of Okinawa (26.1),
New Mexican Hispanic women (113), New Mexican
Hispanic men (171), southeastern Arizona Hispanic
females (50), southeastern Arizona Hispanic males
(91), Caucasian men (250), Caucasian women
(212), and Caucasians in Kauai, Hawaii (185 to
340).2,7,17,19,34,51,74,75 The incidence of BCC in
Caucasians in Kauai, Hawaii, is reported to be the
highest in the United States.34
The ratio of BCC to SCC in Japan in the 1960s was
1e1.4:1,76 whereas in the 1990s the ratio increased
to 4.5:1,54 suggesting an increasing trend of BCC in
Japan. The incidence of BCC among Asian residents
of Singapore increased at a rate of 2% to 8% annually
from 1968 to 1997.7
BCC among Hispanics in southeastern Arizona
was 14 times less in incidence than that among non-
Hispanic whites.19 In 1969 a survey of southeastern
Arizona dermatology practices reported some of the
highest skin cancer rates in the world.77 Thus the
high incidences of BCC among New Mexican and
Arizona Hispanics probably reflect high rates of UVR
exposure among those who live in that region of the
United States. It is interesting that there were no
changes in the incidence of BCC among southeast-
ern Arizona Hispanics between 1985 and 1996.19
Although some studies report a higher incidence of
J AM ACAD DERMATOL
NOVEMBER 2006
BCC among black females than among black
males,41,71 others have shown a near equal incidence
between the 2 sexes.2,72 The male-to-female ratio of
BCC in Asians in 2 large series ranged from 0.94 to
0.97.43,78 In Hispanics and whites BCC tends to be
more common among males, with an even higher
male-to-female ratio in studies of white and Hispanic
populations in tropical areas.19,51,75,79
BCC represents 65% to 75% of skin cancers in
Caucasians,80 20% to 30% of skin cancers in Asian
Indians,12 12% to 35% of skin cancers in American
blacks,1,4,6,73,81,82 and 2% to 8% of skin cancers in
African blacks.38,39,83 An analysis of Singapore Can-
cer Registry data from 1968 to 1997 showed that
fairer-skinned Chinese had a 2-fold increased inci-
dence of BCC compared with darker-skinned Malays
and Indians.7 The majority of BCCs at Howard
University from 1960 to 1986 occurred in light-
complexioned, as opposed to darker, blacks.1 Thus
the incidence of BCC appears to be directly corre-
lated with the degree of pigmentation in the skin,
being most common in fair Caucasians and least
common in African blacks.
BCC is primarily related to prolonged, intens-
ive UV light exposure in Caucasians, blacks,
Hispanics, Chinese Asians, Japanese, and Asian
Indians.1-4,6,7,12,43,78 Consequently, BCC occurs
most often in persons after the 5th decade on sun-
exposed areas of the head and neck, regardless
of the degree of pigmentation of the skin.1,41,43,78
As with Caucasians, 70% to 90% of BCCs occur on
sun-exposed skin in blacks, Japanese, and Asian
Indians.1,2,12,39,41,43,73,83,84 Thus the emphasis on sun
protection should not be ignored by darkly pig-
mented persons.
BCC may occasionally occur on non-sun-exposed
sites in all races.12,42 Rarely have unusual sites, such
as the nipple, penis, anus, groin, popliteal space,
ankle, and hairy scalp, been affected.4,6,12,41,42,73,85
Some series suggest that the incidence of BCC on
covered sites is the same for Caucasians and for
blacks,1,73 although others have shown a higher
percentage of BCCs on non-sun-exposed regions in
blacks than on the same areas in whites.41,42,86 In
Caucasians 10% to 15% of BCCs arise on the trunk.6,87
BCC develops on the trunk in a similar percentage of
blacks4,6 and a slightly lower percentage of Asian
Indians.12 It is interesting that BCCs are rare on
heavily sun-exposed areas of the hands and the
dorsal portions of forearms in all ethnic groups.88
As stated previously, UVR exposure is the most
common etiologic factor for BCC in Caucasians,
blacks, Chinese Asians, Asian Indians, Japanese,
and Hispanics.1-4,6,7,12,43,78 A history of radiation
therapy may also increase the risk of BCC in black
J AM ACAD DERMATOL
VOLUME 55, NUMBER 5
Fig 9. Basal cell carcinoma on the nose of an Asian male.
patients.89,90 However, the risk of developing BCC
is much higher in previously irradiated Caucasian
patients,89,90 which emphasizes the importance
of UVR as a cofactor in the development of BCC,
since the pigmentation of black skin offers some
protection from UVR.
Other possible risk factors for BCC in blacks include
albinism,6,38,40,41,91 scars,1,41,73,92 ulcers,41,73,92,93
chronic infections,73,92 sebaceous nevus,42 arsenic
ingestion,94 immunosuppression,94 previous radiation
treatment,89 xeroderma pigmentosum,95 and trauma
(physical and thermal).1,12,72,96-98 One study showed
physical and thermal trauma to be particularly impor-
tant risk factors for BCC in Asian Indians.12 BCC that
arises in scars typically develops in sun-exposed areas
on older patients.12,97 This finding suggests a syner-
gistic role between trauma and UVR.12
The clinical presentation and histologic fea-
tures of BCC are similar in blacks, Asians, and
Caucasians.42,43,72,98,99 However, Kidd et al demon-
strated immunoperoxidase staining for carcinoembry-
onic antigen in a higher percentage of BCCs in blacks
compared with whites, indicating a greater tendency
of differentiation toward follicular, eccrine, or seba-
ceous structures.100 Most ethnic patients with BCC are
elderly and present with asymptomatic, translucent,
solitary nodules with central ulceration (Figs 9 and
10).1,41 Telangiectasias and a pearly, rolled border in
dark skin or in a pigmented tumor may be difficult to
discern. BCCs in Asians have been reported clinically
to appear brown to glossy black and have the so-called
‘‘black pearly’’ appearance, a characteristic clinical
feature of BCC in Asian races.43,78 Lesions can occur
Gloster and Neal 747
Fig 10. Basal cell carcinoma on the nose of a Hispanic
female. Courtesy of Miguel Sanchez, MD.
as nodules, plaques, papules, ulcers, or indurated or
pedunculated masses.42 In contrast to SCC, BCC is not
associated with increased morbidity in blacks in com-
parison with Caucasians.1,2
Multiple tumors, metastases, and coexisting ma-
lignancies have been reported in blacks.41 The basal
cell nevus syndrome is an autosomal dominantly
inherited genodermatosis related to a mutation in the
patched (PTCH) gene, which is linked to chromo-
some 9q22.3-q31 and functions in human beings as
both a developmental gene and a tumor suppressor
gene.101,102 The basal cell nevus syndrome has been
reported in blacks,103 yet the expression of BCC is
diminished compared with that in Caucasians owing
to the photoprotection in darker-skinned persons.1,2
Basal cell nevus syndrome is characterized by the
presence of multiple BCCs, hypertelorism, a short
fourth metacarpal, a broad nasal root, frontal bossing,
palmar or plantar pits, medulloblastomas, ectopic
calcification of the falx cerebri, bifid ribs, odonto-
genic keratocysts, and a variety of internal neoplasms
(Fig 11).104 Any black patient who presents with a
BCC, particularly multiple BCCs, should alert the
clinician to consider the basal cell nevus syndrome.
Metastatic BCC is rare in all races. The incidence of
metastatic BCC is approximately 0.0028% in general
dermatology patients and 0.1% in surgical centers.100
Only a few cases of metastatic BCC have been
reported in North American blacks.41,93,96,105-107
Preexisting conditions were present in 3 of the
4 cases, as 2 metastatic BCCs arose from long-stand-
ing venous stasis ulcers41,93 and one developed from
a gunshot wound scar of the shoulder.96
Epidemiologic evidence suggests that persons
with BCC or SCC of the skin are at elevated risk
for the development of other malignancies.108,109
A cross-sectional assessment of the association of
748 Gloster and Neal
Fig 11. Pigmented basal cell carcinoma on the trunk of
a black female with the basal cell nevus syndrome.
Fig 12. Pigmented basal cell carcinoma in a black female.
NMSC with another malignancy performed with the
data base in the Women’s Health Initiative Observa-
tional Study (93,676 women aged 50e79 years)
showed that women with a history of NMSC (n =
7,559) were 2.3 times more likely to report a history
of coexistent cancer, with breast cancer being the
most common type.110 In a subgroup analysis, black
women with NMSC were 7.46 times more likely to
report a second malignancy than were black women
without NMSC. The age-adjusted odds ratio for other
ethnic groups was 3.67 (Hispanic), 4.51 (American
Indian), and 5.64 (Asian, Pacific Islander). The au-
thors suggest multiple mechanisms that may account
for the association of NMSC with a second malig-
nancy, such as UVR-induced depression of cell-
mediated immunity, UVR-induced p53 suppressor
gene mutations, and a predisposition of certain per-
sons to p53 mutation or abnormal DNA repair capac-
ity. That black women with a history of NMSC may be
at even greater relative risk for another cancer than
are white women with NMSC may reflect underlying
ethnic immunologic differences.
Transurocanic acid is a photoreceptor in the skin
that may initiate photoimmune suppression.111
There is evidence that blacks have a higher concen-
tration of total skin urocanic acid than do whites.112
The hypothesis is that blacks have more total
urocanic acid in the skin and thus have more
J AM ACAD DERMATOL
NOVEMBER 2006
Fig 13. Pigmented basal cell carcinoma on the temple of a
Hispanic male. Courtesy of the Cutaneous Oncology Unit,
Department of Dermatology, Hospital General de Mexico.
photoimmune suppression, which increases suscep-
tibility to a second cancer.
In a review by Mora et al, 16.5% of black patients
with a BCC had a second, noncutaneous tumor, 65%
of which were lung cancer.6 Other cases of BCC
in coexistence with lung cancer have been re-
ported.100,113 Burns et al found depressed cellular
immunity by means of T-cell assay in 17 blacks with
BCC and suggested that impaired tumor immunity
and altered tumor surveillance may be important
etiologic factors for BCC in blacks that could increase
the risk of developing concurrent malignancies.114
Pigmentation is present in more than 50% of BCCs
in blacks, Hispanics, and Japanese (Figs 12 and
13).1,12,41-43,115,116 In contrast, only 6 % of BCCs in
Caucasians are pigmented.12,117-119 The presence of
pigmentation in BCC may make it difficult to differ-
entiate from other lesions, such as seborrheic kera-
toses, epidermal inclusion cysts, nevocellular nevi,
blue nevi, Bowen disease, lentigines, or malignant
melanoma.2,42,60,71 In whites, blacks, and Asians,
nodular BCC is the most common histopathologic
type of BCC.41,43,72,78,120 There may be a relatively
higher incidence of the adenoid type in blacks and
Asians.121,122 The morpheaform variety of BCC
is rare in blacks and appears less frequently
than in Caucasians.41,71,72 As with Caucasians,
morpheaform BCC usually presents in blacks as a
J AM ACAD DERMATOL
VOLUME 55, NUMBER 5
porcelain-colored plaque with indistinct, smooth
borders that may be indurated, flat or depressed,
smooth, shiny, or atrophic (Fig 14).71
MELANOMA
The incidence of malignant melanoma is increas-
ing more rapidly than that of any other cancer,123 6%
per year, making it the 6th most common cancer
in the United States.124 In 2005 melanoma will be
diagnosed in approximately 59,580 Americans.123
It is estimated that by the year 2010, melanoma will
be diagnosed in 1 in 50 persons in the United States
sometime during their lifetimes.123 Melanoma is the
third most common cutaneous malignancy in blacks,
Asians, Hispanics, and Caucasians.1,2,125 It represents
1% to 8% of all skin cancers in blacks,1,126 10% to 15%
of skin cancers in Asian Indians,12 and 19% of all skin
cancers in Japanese.52 The black-to-white ratio of
melanoma incidence in the United States is approx-
imately 1:16.127 Ages at presentation of melanoma in
members of generally darker-skinned ethnic groups
range from 50 to 70 years.52,126,128-134
The range of melanoma age-adjusted incidences
reported in the literature is slightly higher in Cauca-
sian men (8.4 to 18.9 per 100,000) than in Caucasian
women (7.6 to 12.9 per 100,000).35,125,134-138 The
incidences of melanoma are also slightly higher in
black men (0.8 to 1.5 per 100,000) than in black
women (0.6 to 0.9 per 100,000).35,125,126,135-139 Thus
melanoma is roughly 10 to 20 times more frequent in
Caucasians than in blacks.46,116,129,136
Melanoma incidences in Hispanics range from
1.2 to 4.0 per 100,000 males and 1.3 to 3.0 per
100,000 females.125,131,138,140,141 Bergfelt et al found
that fairer New Mexican Hispanics had a higher
melanoma incidence per 100,000 (1.5 in males,
2.9 in females) than darker Puerto Ricans (1.3
in males, 1.3 in females).142 Melanoma is 3 to
7 times more common in Caucasians than in
Hispanics46,116,136,140,142,143 and 1 to 4 times more
common in Hispanics than in blacks.136 The inci-
dence of melanoma among Hispanics is intermediate
between that among whites and that among blacks,
a finding that parallels their intermediate skin
pigmentation.136
In Asians, incidences are similar to those for
blacks, ranging from 0.5 to 1.5 per 100,000 for males
and females.125 Fairer-skinned Chinese in Singapore
had a higher rate (0.5 per 100,000) of melanoma than
darker Singapore Indians (0.2 per 100,000).7 The
most recent world- and age-standardized annual
incidences of melanomas in Hong Kong Chinese
were 1.1 per 100,000 in women and 1.0 per 100,000
in men.144 The California Cancer Registry (1988e93)
reported the melanoma incidence for Asians
Gloster and Neal 749
Fig 14. Morpheaform basal cell carcinoma on the nose of
a black female. Courtesy of Carl Washington, MD.
(Filipino, Chinese, Japanese, Korean, Vietnamese,
Native American, Laotian, and others) as 0.9 per
100,000 men and 0.8 per 100,000 women.125 In the
same study, incidences for Asians were comparable
to those for blacks (1.0 for men, 0.7 for women)
and lower than those for whites (17.2 for men,
11.3 for women) and Hispanics (2.8 for men, 3.0
for women).125 The incidence of melanoma in
Japanese (2.2 per 100,000) is roughly twice that of
other Asian races, and melanomas in Japanese occur
more frequently in females than in males.52,145
Recent data from the SEER program ‘‘Fast Stats’’
(1992e2001; http://seer.cancer.gov) revealed the
following age-adjusted melanoma incidences per
100,000 in different ethnic groups in the United
States: white (18.9), black (1.02), American Indian
and Alaskan Native (2.02), Asian and Pacific Islander
(1.46), and Hispanic (4.01).138
Incidence trends of melanoma vary among differ-
ent ethnic groups. The literature indicates that the
incidence of melanoma is increasing at a rate of 3% to
7% per year in Caucasian populations, and there are
strong indications from birth cohort analyses that
incidences will continue to rise in the future.21,35,146
Melanoma incidence in the United States increased
from 6.8 per 100,000 person years in 1973 to 17.3 per
100,000 person years in 1994 for males and 6.1 (1973)
to 11.6 (1994) per 100,000 person years for females.16
In Canada, the incidence of melanoma increased
by 12.5% in males and 10.35% in females from 1973
to 1987.147
Incidences for blacks, Asians, Chinese Asians,
Asian Indians, and Hawaiians have remained rela-
tively stable over the past 30 years.7,21,35,146,148 An
analysis of SEER population-based data from 1973 to
1987 showed a 12% decrease in the incidence of
invasive melanoma in blacks.129 Penello et al used
the 9 areas of the SEER program to tabulate data on
melanoma between 1973 and 1994 and found no
750 Gloster and Neal
significant increases in incidences of melanoma in
black males or females.21,35 The incidence of mela-
noma among Asian residents of Singapore remained
constant at 0.5 per 100,000 between 1968 and 1977.7
Modest increases in incidence have been noted in
Japanese (0.1% to 0.2% per year) and Hispanics of
Puerto Rican and South American descent.52,131,146
The incidence of melanoma in Puerto Ricans in-
creased from 0.92 to 1.59 per 100,000 from 1977 to
1987.131 In contrast, increases in incidence have
been substantial for Hispanics who reside in New
Mexico.146
Mortality due to melanoma has increased by
34.1% from 1973 to 1992, the third-highest increase
of all cancers.133 However, mortality trends vary
among different races. According to Swerdlow, the
mortality of melanoma is increasing at a rate of 3%
per year in Caucasians and Japanese, yet is rem-
aining relatively stable in blacks, Chinese, Indians,
Hawaiians, and Hispanics, with the exception of
Puerto Ricans, in whom there was a very slight
increase.146 Estimated percentage changes in mor-
tality from SEER data (1973e96) indicate a 1.0%
decrease for black males and no change for black
females.35 The decrease in black male melanoma
mortality may indicate an improvement in early
diagnosis and treatment. Although relatively stable,
the 5-year mortality in blacks is high, ranging from
37.5% to 85% in multiple studies.1,4,149,150 In Japa-
nese, there was a greater mortality increase per year
(3%) than incidence increase (0.1% to 0.2% per year),
which is the opposite for Caucasians, whose annual
incidence increase (3% to 6%) was greater than the
increase in mortality (3% per year).52,146,151
Risk factors for melanoma vary among Caucasians
and blacks. UVR exposure, specifically intense early
sunburns and blistering sunburns, are closely asso-
ciated with the development of melanoma in Cauca-
sians.46,123,143,152,153 Other risk factors for Caucasians
include atypical and multiple nevi, family or personal
history of melanoma, intermittent sun exposure, and
Fitzpatrick types I and II.46,123,143,152-154
In contrast, UVR does not appear to be a signif-
icant risk factor for melanoma in blacks and other
ethnic groups, who tend to develop melanoma on
non-sun-exposed sites such as palmar, plantar, and
mucosal surfaces.55 Other reported risk factors for
melanoma in blacks include albinism, burn scars,
radiation therapy, trauma, immunosuppression, and
preexisting pigmented lesions (especially on acral
and mucosal regions).2,77,149 Studies suggest that
more than 90% of blacks have at least 1 nevus.77,155
Melanocytic nevi in blacks are predominantly acral,
which may account for the high number of acral
melanoma in blacks.77,155 A family history of
J AM ACAD DERMATOL
NOVEMBER 2006
melanoma, a significant risk factor in Caucasians,
does not appear to be a major predisposing factor
in blacks.55 It is likely that other unknown factors,
perhaps immunologic and environmental, play a
role in the development of melanoma in blacks.
Although less significant than in Caucasians, UVR
may still play a role in the development of melanoma
in ethnic skin. Hu et al analyzed 6 US cancer
registries and found that there were higher mela-
noma incidences in Hispanics and blacks of both
sexes at lower latitudes of residency and with
increasing UV index, although this correlation was
statistically significant only in white men, white
women, and black men.46 Data from 9 areas of the
SEER program from 1973e94 indicated a significant
increase in age-adjusted mortality for black males
with increasing levels of surface radiation but failed
to show significantly increased incidences with in-
creasing UVB radiation exposure in blacks.21,35 No
such corresponding increase in mortality was found
for black females, possibly because males spend
more time outdoors. Also, several studies have
shown evidence that migrant populations who
move closer to the equator developed higher rates
of melanoma compared with persons in their coun-
try of origin.156-158 The most important etiologic
factors for melanoma in dark-skinned populations
remain to be documented.
In Caucasians, more than 90% of melanomas
are on sun-exposed areas of the trunk in men
and on legs in women.65,125,159 Melanomas in
blacks,125,126,128,133,136,159,160 Asians,52,125,151,161,162
Filipinos,163,164 Indonesians,165 and native Hawai-
ians166 most often arise on non-sun-exposed skin
with less pigment, particularly acral areas of the
lower extremities. Mucous membranes and acral
areas are the most common sites of melanoma in
non-Caucasians, with up to 60% to 75% of tumors
arising on the palms, soles, mucosal locations, and
subungual regions.55,133,136,159,160,161 Typically, tu-
mors present as dark, rapidly spreading patches. In
25% to 50% of cases, these tumors arise within prior
pigmented lesions.161 A review of 9,000 cases of
melanoma at Duke University between 1970 and
1996 revealed 93 cases of subungual melanoma, 12%
of which occurred in blacks, although they com-
prised less than 1% of the 9,000 cases.167 The
majority of cases presented as a pigmentation of
the nail bed (Fig 15). Oral melanomas represent
approximately 7.5% of all melanomas in Asians, and
two-thirds of these tumors arise from oral melano-
sis.161 Bellows et al found that mucosal melanoma
represented 20% of cases in 27 blacks at Charity
Hospital from 1975 to 1997.133 Among men in the
California Cancer Registry from 1988e93, melanoma
J AM ACAD DERMATOL
VOLUME 55, NUMBER 5
Fig 15. Melanoma arising in the nail bed of a black male.
Courtesy of John Kitzmiller, MD.
Fig 16. Nodular melanoma on the leg of a Hispanic male
Courtesy of Miguel Sanchez, MD.
occurred on the lower extremity for 9% of whites,
20% of Hispanics, 36% of Asians, and 50% of
blacks.125 The frequency of lower-extremity mela-
nomas in races of intermediate pigmentation tends to
fall between that of whites and that of blacks.125,161
The distribution of melanoma in Hispanics is
variable, with some studies showing similarities to
Caucasians (Fig 16),125 whereas other investigators
have found that the distribution more closely paral-
lels that of darker ethnic groups.131,136 Data from the
SEER program from 1973 to 1981 demonstrated that
Gloster and Neal 751
Fig 17. Advanced melanoma on the sole of the foot of a
Hispanic male. Courtesy of the Cutaneous Oncology Unit,
Department of Dermatology, Hospital General de Mexico.
Fig 18. Melanoma on the sole of the foot of a black male.
Courtesy of Calvin McCall, MD.
lighter-skinned New Mexican Hispanics tended to
develop melanomas on the trunk in men and on legs
in women, similar to findings for Caucasians.136 Data
from the California Cancer Registry from 1988e93
revealed that 20% of melanomas occurred on the
lower extremities in Hispanics, compared with 9% in
whites.125 In the New Mexico Tumor Registry from
1969e77, the trunk was the most common site for
both Hispanic men and women.141 In contrast,
darker Puerto Rican Hispanics developed acral tu-
mors predominantly on the lower extremities (nota-
bly the feet), similar to blacks and Japanese.131,136,168
Hispanics in the New Mexico melanoma Registry
from 1970e86 developed melanomas on acral sites
in 23% of cases, compared with 3% in Cauca-
sians.140,169 Discrepancies in distribution of melano-
mas in Hispanics are probably due to the wide
variety in the degree of pigmentation in Hispanic
people.
752 Gloster and Neal
In non-Caucasians, the plantar portion of
the foot is often the most common site, being
involved in 30% to 60% of cases (Figs 17
and 18).3,52,89,128,130,131,139,149,159,161,170-174 Thirty
percent to 70% of melanomas in blacks arise on the
sole of the foot.3,133,139,159,174 The most common
location of melanoma in Japanese is the sole of the
foot, accounting for 25% to 35% of cases.52,175,176
Other common sites reported in Japanese include
subungual areas and mucosal membranes.52,175,176
In a study of more than 1,000 melanoma patients in
Japan between 1987 and 1996, the most common site
in both males and females was the sole of the foot,52
accounting for 32% of cases.52 Krishnamurthy et al
reviewed cancer registry data in 6 different parts of
India from 1964 to 1984 and found that the sole of the
foot and internal mucous membranes were the major
anatomic sites of involvement for melanoma.148 In a
study of 43 cases of melanoma in Chinese Asians at
the University of Hong Kong from 1964 to 1982, 56%
of tumors arose on the foot, with 83% on the plantar
surface.161 Forty-seven percent of these tumors de-
veloped within a prior pigmented lesion, and 100%
of subungual tumors were on the nail bed of the
great toe or thumb. The authors concluded that the
frequency of plantar melanoma in Chinese, like
other racial groups of intermediate pigmentation,
was between those of whites and blacks. In a study
of 57 lower-extremity melanomas in Hispanic Puerto
Ricans, the foot was the most common site, partic-
ularly minimally pigmented zones of the sole, heel,
and nail bed.177 Byrd et al found that the most
common location of melanomas in black men at
Howard University between 1981 and 2000 was the
foot (38.9%), compared with 2.4% in whites.159 The
high incidence of involvement of the sole of the foot
may indicate that trauma is a significant predisposing
factor for melanoma in ethnically darker skin.2,178
Plantar involvement may be more common in black
men than in black women. Of 80 black patients with
melanoma at Charity Hospital in New Orleans since
1948, only 32% of primary lesions among women
were on the foot, compared with 73% in men.160 It is
interesting that black women also had a higher rate
of extracutaneous melanoma than did black men or
white men and women, a finding that had a negative
impact on survival rates for black women with
melanoma. Bellows et al also found that black males
were 4 times more likely than black females to
present with a cutaneous lesion.133
The predominance of plantar melanoma in non-
Caucasians may not be due to an increased incidence
in comparison with that of Caucasians but rather a
decreased incidence of melanoma at other sites.178
One study showed that US blacks and whites have
J AM ACAD DERMATOL
NOVEMBER 2006
similar melanoma incidences when it comes to the
sole of the foot.178
Acral-lentiginous melanoma (ALM) is the
most common histologic subtype in Asians and
blacks, whereas superficial spreading melanoma
(SSM) is the most frequent subtype in Cau-
casians.52,55,125,126,128,130,132,133,136,149,160,161,170,174,179
ALM represents only 2% to 8% of melanomas in
Caucasians and 35% to 90% of melanomas in blacks
and Asians.5,126,133,149,162 In a study of more than
1,000 melanoma patients in Japan between 1987 and
1996, ALM represented more than 50% of all mela-
nomas.52 However, there was an increased incidence
of SSM in Japanese from 12.3% in 1975e86 to 17.5%
in 1987e96, perhaps reflecting recent westernization
of the Japanese lifestyle (ie, more vacations to sunny
destinations, resulting in increased intermittent ex-
posure to sunlight, which may be a major risk factor
for SSM).52,151 In Chinese Asians at the University of
Hong Kong from 1964 to 1982, 52% of tumors were
ALM and 21% were SSM.161 ALM may arise in
preexisting nevi, and this phenomenon has been
documented in Asians.161,180
Singluff et al reviewed 185 patients with ALM and
found that 17% of them were black.181 In contrast,
only 0.7% of 2,274 patients with nonacral tumors
were black. The authors concluded that ALM was the
most common subtype in blacks, whereas lentigo
maligna was the least common. In the same study,
SSM was most common in Caucasians and ALM was
least common. In a study of melanoma patients at
Charity Hospital in New Orleans from 1975 to 1997,
ALM (39% in blacks, 2% in whites) was most com-
mon in blacks and SSM (18% in whites, 4% in blacks)
was most common in Caucasians.133
In Hispanics and members of some other ethnic
groups, SSM is more common overall than
ALM.125,131 However, the incidence of ALM is greater
than in Caucasians. In a study of the New Mexico
Melanoma Registry from 1970 to 1986, ALM repre-
sented 2% of melanoma in Caucasians and 15% in
Hispanics.140,169 Johnson et al found similar results
in a study of Hawaiians from 1994 to 2002, with the
incidence of ALM being 1% in Caucasians and 18%
in non-Caucasians (Japanese, Filipinos, and native
Hawaiians).166 In a review of the Puerto Rican cancer
registry from 1981e1987, SSM was most common
and ALM was second most common.131
Compared with Caucasians, blacks tend to pre-
sent with more advanced, thicker tumors and thus
tend to have a poorer prognosis, with higher mor-
tality.3,130,133,149,159,170,171,173 Multiple studies have
demonstrated that 5-year survival rates of blacks
are consistently lower than those of Caucasians
(Table I). Fleming et al reported melanoma lymph
J AM ACAD DERMATOL Gloster and Neal 753
VOLUME 55, NUMBER 5

node metastases in 11 of 13 blacks, with only 2 Table I. Prognosis of Melanoma in Blacks

patients surviving.3 Bellows et al, in a review of and Whites
melanoma at Charity Hospital in New Orleans from 5-Year Survival Rate (%)
1975e97, found that 56% of blacks presented with
Study Blacks Whites
ulcerated tumors and stage 3 and 4 disease, whereas
Fleming et al (1975)4 15 —
Caucasians were 3.6 times more likely to present
Krementz et al, Charity 21 —
without ulceration and with stage 1 or 2 disease.133
Hospital (1948e74)150
In a study of 45 black patients at the University of Reintgen et al, Duke 23 —
Capetown, the mean Breslow depth was 6.15 mm.130 University (1972e80)149
In a study of 63 black South Africans with melanoma Crowley et al, Duke 35e49 74
from 1972e85, 51% of patients presented with stage University (1980e89)5
3 or 4 disease and none of these patients survived Hudson et al (1977e91)171 26 60
beyond 38 months.174 Byrd et al found that blacks at Halder and Bang, Howard 62.5 —
Howard University presented with in situ disease in University (1988)1
39.3% of cases and stage 3 or 4 disease in 32.1% of Byrd et al, Washington Hospital 58.8 85
cases.159 In contrast, 60.4% of Caucasians presented Center (1981e2000)159
Cress and Holly, California Cancer 70 87
with in situ melanomas and 12.7% with stage 3 or
Registry (1988e93)125
4 disease.159 Hudson et al had similar results with
U.S. SEER data (1973e91)138 61e70 80e89
50% of blacks, 33% of mixed-race patients, and 4% Bellows et al, Charity Hospital 45 69
of Caucasians who presented with stage 3 or 4 (1975e97)133
tumors.171 There was also a significant difference in Swan and Hudson, University of 74 (mixed —
the primary tumor mean Breslow depth at presenta- Capetown (1980e2002)128 blacks)
tion in black (7.1 mm), mixed-race (3.6 mm), and Garsaud et al, French West Indies 44 —
white patients (3.3mm).171 Swan and Hudson at the (1976e95)139
University of Capetown found that blacks of mixed Vayer and Lefor, University of 61 —
ancestry presented with stage 3 or 4 disease in 35% of Maryland (1969e90)173
cases.128 The SEER registry from 1986e91 revealed
that the likelihood of diagnosis after metastasis was
4% for Caucasians and 14% for blacks.137 The Duke et al found that Caucasians presented with a mean tu-
University Melanoma Clinic Registry (7,500 patients mor thickness of 1.62 mm, whereas non-Caucasians
with melanoma, 79 of whom were black) found (Japanese, native Hawaiians, and Filipinos) pre-
ulceration, a known poor prognostic indicator, at the sented with a mean tumor thickness of 2.59 mm.166
primary site in 41% of blacks versus 24% of whites.5 In a study of 81 melanomas in New Mexican
On a positive note, in the same study the Duke group Hispanics, a large proportion of tumors arose on
found an improvement in survival in black patients the palms, soles, and subungual regions and tended
with melanoma from 35% (prior to 1980) to 49% to be advanced in stage and to metastasize compared
(1989 and 1990), possibly because of increased with those in whites who lived in the same area.140 In
awareness among patients and physicians.5 a review of data from the California Cancer Registry,
Plantar melanoma, the most common site of Cress and Holly showed that the likelihoods of
involvement in non-Caucasians, often has a poor diagnosis after metastasis in various races were
prognosis. Researchers based at Tulane University in 6% (Caucasian men), 4% (Caucasian women), 15%
New Orleans examined 92 ALM patients between (Hispanic men), 7% (Hispanic women), 13% (Asian
1958 and 1990 and found that all black men had men), 21% (Asian women), 12% (black men), and
foot lesions and the poorest survival rate (13% at 10 19% (black women).125 In a study of 43 melanomas
years).182 Hudson et al reviewed 85 cases of plantar in Chinese Asians at the University of Hong Kong
melanoma from 1977e91 at the University of (1964e82), 82% of volar and subungual tumors
Capetown in South Africa and found that signifi- presented at a thickness of more than 3 mm, and
cantly more blacks had metastatic disease and 37% were thicker than 9 mm.161 Taiwanese Asians
presented with deeper tumors (7.1 mm vs 3.3 mm) with melanoma were found to have a propensity
than did whites.171 The 5-year survival figures for toward presentation with advanced stages and poor
plantar melanoma in Hudson’s study was 60% for prognoses.132 Hispanics in the New Mexico Cancer
whites and 26% for blacks. Registry from 1970e86 had a higher proportion of
Other ethnic groups besides blacks tend to pre- late-stage tumors than did Caucasians.140 Finally,
sent with more advanced tumors than Caucasians. about 50% of the 1,000-plus Japanese melanoma
In a study of Hawaiians from 1994 to 2002, Johnson patients analyzed by Ishihara et al between 1987 and
754 Gloster and Neal
Fig 19. Dermatofibrosarcoma protuberans on the trunk
of a black female.
1996 presented with stage 1 or 2 disease, yet the
incidence of metastatic disease was around 30%.52
Possible causes for a poorer prognosis in non-
Caucasians include delays in diagnosis and treatment
and the frequent presence of thick primary lesions
and intrinsically more aggressive acral tumors, which
tend to present at a more advanced stage.130,133,159
Multiple investigators have found that volar and
subungual sites are usually thick and deeply invasive
by the time treatment is sought.161,183,184 Bellows
et al found that blacks with stage 1 and 2 melanoma
had a shorter survival time than did whites with the
same stages, implying that melanoma in blacks may
indeed follow a more virulent course.133 Possible
reasons for delayed diagnosis and treatment are less
accessibility to medical care and preventive screen-
ings, as well as a misconception that darker races,
particularly blacks, never develop skin cancer, which
leads to a low level of awareness and a lack of public
and physician education directed toward non-
Caucasians. Furthermore, in non-Caucasians there
is a predominance of lesions in unexpected sites
such as the palms, soles, subungual areas, mucosal
regions, and lower extremities. These areas of the
body are rarely emphasized in skin screening pro-
grams, and there may be a propensity to overlook
dark lesions in dark skin. Thus the patient and
physicians do not suspect melanomas in unusual
areas, which leads to a delay in diagnosis and
treatment and subsequent decreased survival.
Finally, normal variations in blacks, such as lon-
gitudinal melanonychia and hyperpigmented mac-
ules of the creases of the palms and soles, can make
the diagnosis of melanoma difficult.170 Clues to the
diagnosis of subungual melanoma include width
greater than 3 mm, variable pigment, rapid increase
in size, Hutchinson sign, and the presence of solitary
lesions, particularly on the thumb.170
Improved preventive strategies will allow mela-
noma to be diagnosed at an earlier stage, thus
improving survival. First, physicians and patients
should maintain a high index of suspicion for
J AM ACAD DERMATOL
NOVEMBER 2006
melanomas regardless of patient’s race or ethnic
background. Second, patients of darker-skinned
ethnicities should be encouraged to perform skin
examinations themselves and to seek regular full
skin examinations, with particular attention paid to
the palms, soles, fingers, toes, subungual areas, and
mucosal surfaces. A dermatologist skilled in differ-
entiating malignant from benign pigmented lesions
should perform full skin examinations. Current
public education programs for skin cancer and
melanoma are directed toward whites, particularly
high-risk persons with fair skin, blue eyes, and red or
blond hair. Physician training, patient education, and
public awareness campaigns should be directed to
all ethnic groups.
DERMATOFIBROSARCOMA
PROTUBERANS
Dermatofibrosarcoma protuberans (DFSP) is a
rare tumor of intermediate malignancy that accounts
for less than 0.1% of all malignancies.185 DFSP is
characterized by indolent growth and a tendency to
recur after local excision. Despite its locally aggres-
sive behavior, DFSP rarely metastasizes.185 It typi-
cally presents on the trunk or extremity of adults
between 20 and 50 years of age as a flesh-colored or
hyperpigmented, indurated plaque that with time
develops protuberant nodules (Fig 19). In blacks,
DFSP should be included in the differential diagnosis
of atypical-appearing keloids.1,2
Controversy exists as to whether DFSP is more
common in blacks.1 Garg et al concluded that it is.186
In a study of black patients at Howard University
from 1947 to 1986, DFSP accounted for 12.1% of 132
skin cancers, which represented a higher frequency
of skin cancer than melanoma.1 The authors postu-
lated that DFSP was more common in blacks than in
Caucasians, yet acknowledged that such generaliza-
tions may not be valid because of the small number
of patients in their study. Although DFSP has been
reported in all races, it is difficult to determine racial
incidences, since race is not mentioned in many of
the larger series of patients in the literature.2 Finally,
the Bednar tumor, an unusual pigmented variant of
DFSP, occurs predominantly in blacks, although it
represents less than 5% of cases of DFSP overall.2,187
KAPOSI SARCOMA
Before 1980, Kaposi sarcoma (KS) occurred most
often in Italian and Eastern European elderly men
and was rare in the United States before the onset
of the AIDS endemic in 1981.188,189 In addition, an
endemic form of KS exists in equatorial Africa, where
it represents 10% of all cancers.190 The incidence of
KS has markedly increased since the onset of the
J AM ACAD DERMATOL
VOLUME 55, NUMBER 5
AIDS epidemic, with incidence and demographic
patterns closely mimicking trends in AIDS pa-
tients.2,191 Mora and Lee reported a series of 19
blacks with KS from 1948e1983,121 none of whom
had AIDS. Their male-to-female ratio was equal,
75% of patients were at least in their 6th decade, and
almost all patients had involvement of the lower
extremity. The overall mortality was 21%. In Halder
and Barg’s review of skin cancer cases in blacks from
1947e1985, KS represented 3.8% of cutaneous neo-
plasms.1 Only one of these cases occurred before
1982 and was not associated with AIDS. In recent
years, KS is often associated with AIDS, primarily in
young homosexual males.1
Between 1972 and 1998, there were 12,162 cases
of KS, with 88% occurring in Caucasian men.191 The
incidences of KS in Caucasian men rose from 0.3 per
100,000 in the early 1980s to a peak of 8.1 per 100,000
in 1989.191 Similar incidences were noted in black
men, with a 2-year lag in comparison with Caucasian
men.191 For black men, peak rates were 8.6 per
100,000 in 1992 and 8.0 per 100,000 in 1994.191
Between 1995 and 1998, there was a precipitous fall
in KS incidences to 0.9 per 100,000 in Caucasian men
and 2.4 per 100,000 in black men,191 presumably
owing to improved treatment for AIDS patients.
Among Caucasian women, KS incidences
changed little from 1979 through 1998 (0.07 per
100,000 to 0.09 per 100,000).191 Incidences among
black women rose from 0.07 per 100,000 in 1987 to a
peak of 0.49 per 100,000 in 1996.191 According to
several studies, women have a lower incidence of KS
because of a lower risk of HIV infection and a lower
prevalence of KS type 8 herpesvirus.122,192,193
KS usually presents with painless, violaceous
plaques and nodules. The violaceous hue may
occasionally be difficult to detect in dark-skinned
persons. Increased morbidity has been documented
in blacks, who tend to have more diffuse tumors,
lower cure rates, and decreased survival rates.1,2,121
CUTANEOUS T-CELL LYMPHOMA
Mycosis fungoides is a chronic cutaneous T-cell
lymphoma that is more common in blacks than in
Caucasians, regardless of sex and age.2,194-196 Blacks
are thought to be affected twice as often as whites.196
In one series of 132 black patients with skin cancer,
mycosis fungoides represented 12.1% of all cutane-
ous neoplasms.1 The reason for the racial difference
in incidence is unknown.196 Mycosis fungoides is the
4th most common skin cancer among Japanese,
representing approximately 5% of all cutaneous
malignancies.52
The hypopigmented variant of cutaneous T-cell
lymphoma, with ill-defined, often pruritic, hypopig-
Gloster and Neal 755
Fig 20. Hypopigmented mycosis fungoides in a black
male.
mented macules and patches, tends to present in
a younger patient population than typical forms of
the disease and occurs almost exclusively in dark-
skinned persons (Fig 20).2,55,194,197,198 Up to 75%
of patients with this variant may have a history of
prolonged eczematous or psoriasiform dermatitis.1
Hypopigmented mycosis fungoides is often misdiag-
nosed because it is easily confused with other
dermatoses such as vitiligo, pityriasis alba, tinea
versicolor, hypopigmented sarcoid, and postinflam-
matory hypopigmentation.2,179 Misdiagnosis often
leads to delays in diagnosis and treatment ranging
from 7 months to 10 years from disease onset to
histologic diagnosis.199 There is usually a good
response to therapy with psoralen plus ultraviolet
A light, UVB light, and topical mechlorethamine, yet
recurrences are common.194 The overall prognosis is
good and similar to that of nonhypopigmented stage
1a mycosis fungoides.194-196
Cutaneous T-cell lymphoma may follow a more
aggressive course in blacks than in Caucasians. In a
series of patients at Howard University, there was a
44% mortality among blacks.1 Furthermore, diagno-
sis in blacks tended to occur at a later stage, empha-
sizing the need for earlier diagnosis, since early
stages of cutaneous T-cell lymphoma are more easily
treatable. Later forms of the disease with erythro-
derma and nodal involvement do not respond as
well to the usual therapeutic modalities.200
OTHER TUMORS
Many other cutaneous neoplasms have been
reported in darker skin, yet they occur so infre-
quently that their exact incidence in skin of color is
unknown. Such rare malignancies include trichilem-
mal carcinoma,201,202 Merkel cell carcinoma,27,134,203
and microcystic adnexal carcinoma.91,204,205 The an-
nual age-adjusted incidence of Merkel cell carcinoma
from 1986e1994 in blacks was 0.01 per 100,000,
compared with 0.23 per 100,000 in whites.134 In
756 Gloster and Neal
Japanese persons, Merkel cell carcinoma is not as rare
as in blacks and occurs on the face in 74% of cases.134
In contrast, Merkel cell carcinoma occurs on the face
in only 36% of cases in whites.134
CONCLUSION
Although uncommon in darker-skinned ethnic
groups, skin cancers do occur and pose a significant
health risk. People of color with skin cancer are more
likely to have greater morbidity and mortality than do
Caucasians. SCC, melanoma, cutaneous T-cell lym-
phoma, and possibly KS have a poorer prognosis in
non-Caucasians. Clinicians should consider the poten-
tial for skin cancer in people of color and should
institute preventive measures. Public education in eth-
nic communities, regular skin examinations, and self-
conducted skin examinations will permit earlier
diagnosis of skin cancer, which will decrease the
morbidity and mortality seen in many different ethnic
groups.
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