Seeing Beyond the Surface: Detecting Skin Cancer in Darker Complexions

Skin cancer is the most common type of cancer. Risk factors include increased UV exposure, immunosuppression, chemical exposures, genetic syndromes, and lighter skin phototype. But skin cancer can occur in people with dark skin, too. And while the risk of developing skin cancer may be lower in individuals with darker skin color, diagnosis is often delayed in these patients, resulting in higher morbidity and mortality. Health care professionals need proficiency in detecting skin cancer in all skin colors.

See below for images and information on different types of skin cancer and detection of skin cancer in darker skin colors. Click through to VisualDx for more pictures and information.

Basal cell carcinoma

Impact of darker skin color on clinical presentation:

The classic appearance of BCC – a pearly papule with rolled borders and telangiectasias – may be difficult to visualize and appear less conspicuous. Examine closely for presence of brown, dark brown, black, blue, and/or glossy pigmentation.

Cutaneous squamous cell carcinoma

  • Cutaneous squamous cell carcinoma (SCC) is the second most common skin cancer.
  • SCCs can occur anywhere but most often appear on chronically sun-damaged skin of the head, neck, forearms, and dorsal hands.
  • In people with darker skin, 30%-40% of SCCs develop within scars and chronic nonhealing ulcers (compared with 2% in people with lighter skin).

Impact of darker skin color on clinical presentation:

The classic appearance of BCC – a pearly papule with rolled borders and telangiectasias – may be difficult to visualize and appear less conspicuous. Examine closely for presence of brown, dark brown, black, blue, and/or glossy pigmentation.

Melanoma

  • Melanoma is an aggressive malignancy of pigment-producing cells known as melanocytes. Subtypes are superficial spreading melanoma, nodular melanoma, lentigo maligna melanoma, and acral lentiginous melanoma (ALM).
  • ALM occurs in all races and ethnicities with a similar incidence but is disproportionately represented compared with other melanoma subtypes among individuals with darker skin colors.
  • ALM typically occurs in minimally sun-exposed areas such as the palms, soles, and distal digits and beneath nail beds.

Impact of darker skin color on clinical presentation:

Periungual pigment associated with a primary nail apparatus melanoma (Hutchinson sign) may be subtler and masked in darker skin colors.

Cutaneous T-cell lymphoma

  • Cutaneous T-cell lymphomas (CTCLs) are a heterogeneous group of neoplasms. Mycosis fungoides (MF) is the most common type.
  • MF is mostly seen in older adults (median age at presentation is 50-55 years), although it can occur at any age.
  • In the United States, individuals of African descent have twice the incidence of MF compared with those of Northern European descent, though this difference decreases with age.

Impact of darker skin color on clinical presentation:

Erythema may be subtle, or it may appear pink, violaceous, or grayish. Sometimes, active plaques may appear dark brown.

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