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onmelanoma Skin Cancer in Persons of Colorrooke A. Jackson, MD

Skin cancer is the most common form of cancer in the United States. Although skin canceris less common in persons of color than in Caucasians, the rates of morbidity and mortalityassociated with skin cancer often are significantly greater in darker-skinned ethnic groups.This article reviews special considerations in the approach and management of nonmela-noma skin cancer in patients of color.Semin Cutan Med Surg 28:93-95 © 2009 Elsevier Inc. All rights reserved.

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kin cancer is the most common form of cancer in theUnited States.1 Histologic studies of darker skin reveal

arger and more heavily melanized epidermal melanocytesompared with those in Caucasian skin.2 These larger mela-ocytes allow dark skin to filter up to twice as much ultravi-let B (UVB) radiation than white skin,3 resulting in an esti-ated sun protection factor of 13.1 in black skin.4 These

nique features of ethnic skin serve to protect it against ac-inic damage, making sun-induced skin cancers less preva-ent.

Although skin cancer is less common in persons of colorhan in Caucasians, it has an increased incidence of morbid-ty and mortality,5,6 raising public health concerns. Currentublic-awareness skin cancer campaigns focus on Cauca-ians in high-risk groups. Most physicians do not immedi-tely associate skin cancer with persons of color. However,he incidence of nonmelanoma skin cancer (NMSC) in mostthnic groups is increasing, suggesting that there are factorsther than UV exposure that play a role in the development ofkin cancer in persons of color.7 According to the 2000 cen-us, 50% of the US population will be nonwhite by the year050.8 This changing demographic, combined with the dis-arate skin cancer mortality rates in persons of color, makes

t imperative that physicians become familiar with skin can-er in persons of color so they may better educate their pa-ients on prevention and early detection.

asal Cell Carcinoma (BCC)he classic presentation of a solitary pearly papule witholled borders and central ulceration may occur in personsolor, but pearly borders and surrounding telangiectasia may

kin Wellness Center of Chicago, Chicago, IL.ddress reprint requests should be addressed to Brooke Jackson, MD, Med-

ical Director, Skin Wellness Center of Chicago, SC111 N Wabash Ave.,

eSte. 1116, Chicago, IL 60602-3126. http://www.skinwellnesscenter.org.

085-5629/09/$-see front matter © 2009 Elsevier Inc. All rights reserved.oi:10.1016/j.sder.2009.04.010

e difficult to appreciate in darker skin tones (Fig. 1). Al-hough BCC does occur in sun-exposed areas; in skin ofolor, it is seen with increasing frequency at nonsun-exposedites9 and often presents in an atypical manner,10 makingiagnosis challenging. Physicians should therefore consideraking a biopsy of any suspicious or nonhealing lesion inersons of color. Histologically, pigmented BCC occurs morerequently in persons of color.9 The differential diagnosis ofCC in persons of color includes blue nevus, seborrheic ker-tosis, lupus erythematosus, trauma (curling iron burn), sar-oid, and nevus sebaceous (Fig. 2).

Studies11 have documented the correlation of BCC in Af-ican Americans to UV light exposure; however, persons ofolor often have a false sense of security with regard to aware-ess of skin cancer risk and tend not to follow sun-protectionuidelines proposed in skin cancer campaigns aimed at high-isk patients.12 Persons of color also have an increased inci-ence of medical conditions,13 such as diabetes, hyperten-ion and lupus, necessitating the use of photosensitizingedications. These combined factors support the need for

etter counseling, patient education, and perhaps a distinctkin cancer awareness campaign directed toward skin ofolor.

quamous Cellarcinoma (SCC)

CC is the most common cutaneous malignancy in Africanmericans14 and the second most common cutaneous malig-ancy in Caucasian, Japanese, and Chinese patients (BCCeing the most common NMSC in the latter).15 Althoughctinic keratoses, the precursor lesions to SCC, are seen com-only in Caucasians and Japanese patients,16 they tend not to

ccur in African Americans.17 SCC, which occurs in sun-xposed and nonsun-exposed areas with equal frequency inaucasians, is 8.5 times more likely to occur in nonsun-

xposed areas of African Americans, in areas such as the

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94 B. Jackson

ower extremity and anogenital region,18,19 suggesting thatV radiation plays less of a role in the development of SCC infrican Americans. Mortality rates of African Americans withCC are as high as 29% and may be related to delayed diag-osis of tumors in nonsun-exposed areas as well as poten-ially more biologically aggressive tumors.20 Although Bowenisease (SCC in situ) is less common in African AmericansFigs. 3 and 4), it often occurs on the lower extremity as ayperkeratotic plaque.Risk factors for SCC in persons of color include chronic

nflammatory and scarring processes, such as lupus, radia-ion sites, burn scars, hidradenitis suppurativa, and cutane-

igure 1 BCC in an 80-year-old male African-American golfer.

igure 2 Nodular pigmented BCC on the scalp of an African

merican woman. F

us ulcers.14 The decreased survival rate of SCC in Africanmericans warrants vigilant surveillance and biopsy of anyonhealing lesion associated with a chronic inflammatoryrocess. Patients with cutaneous chronic inflammatory dis-ase should be counseled regarding their increased risk forCC and advised to seek medical attention for any nonheal-ng lesion.

ypopigmentedycosis Fungoides

ypopigmented mycosis fungoides, a variant of cutaneous-cell lymphoma, occurs almost exclusively in persons ofolor and almost twice as often in African Americans than in

igure 3 Bowen disease of the right lower extremity of an Africanmerican woman.

igure 4 Patch stage hypopigmented mycosis fungoides.

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Nonmelanoma skin cancer in persons of color 95

aucasians.21 It presents as ill-defined hypopigmentedatches in patients who often have an eczematous historyFig. 4). The differential diagnoses of hypopigmented myco-is fungoides include Tinea versicolor, Pityriasis alba, Tineaorporis, vitiligo, and postinflammatory hypopigmentation.iopsy should be considered in patients of color unrespon-ive to standard therapies for the aforementioned conditionsr who have an unexplained exacerbation of their diseaserocess. Diagnosis often requires several serial biopsies.

reatment ofMSC in Persons of Color

reatment options do not differ from those used in Caucasianatients; however, because of the increased risk of keloidormation in persons of color,22,23 caution must be taken toinimize tension on surgical wound closures. Erythematousypertrophic scars in light-complexioned persons of colorskin types 1IV) may be treated with the pulsed dye laser.his author uses Cynosure 595 nm, 10-mm spot, 0.5-msulse duration and fluences of 3-6 J, with fading witnessed into -3 treatments. When treating precancerous lesions, this

uthor avoids use of liquid nitrogen in persons of color inavor of imiquimod in effort to avoid posttreatment loss ofigment associated with liquid nitrogen.

onclusionskin cancer does occur in persons of color, although lessommonly than in Caucasians. Persons of color are moreikely to die from their disease when compared with theiraucasian counterparts. This disparity may be attributable toelayed diagnosis as well as more biologically aggressive tu-ors. Little is known regarding the sun-protective behaviors

f persons of color, many of whom have a false sense ofecurity regarding their skin cancer risks. Public awarenesskin cancer campaigns directed at persons of color should beonsidered and physicians treating these patients shouldonsider skin cancer surveillance and counseling as they doith Caucasian patients.

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6. Suzuki T, Ueda M, Naruse K, et al: Incidence of actinic keratosis ofJapanese in Kasai city, Hyogo. J Dermatol Sci 16:74-78, 1997

7. Hale EK, Jorizzo JL, Nehal KS, et al: Current concepts in the manage-ment of actinic keratoses. J Drugs Dermatol 3:S3-X16, 2004 (suppl)

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1. Akaraphanth R, Douglass MC, Lim HW: Hypopigmented mycosis fun-goides: Treatment and a 61/2 year follow up of 9 patients. J Am AcadDermatol 42:33-39, 2000

2. LeFlore IC: Misconceptions regarding elective plastic surgery in theblack patient. J Natl Med Assoc 72:947-948, 1980

3. Arnold HL, Franer FH: Keloids; etiology and management by excision

and intensive prophylactic radiation. Arch Dermatol 80:772, 1959