A 76-year-old Black woman presents to the clinic for evaluation of a bump on her face that she first noticed about a year ago. She reports that the bump has been growing slowly; she denies itching, burning, pain, or any other associated symptoms. The patient denies any known trauma to the area. She has no personal or family history of skin cancers or skin diseases. On physical examination, the patient’s skin type is VI on the Fitzpatrick scale; she has a small soft 0.5- x 0.5-cm skin-colored papule on the upper-cutaneous lip. No other significant skin findings are noted.
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Basal cell carcinoma (BCC) may present differently in people with different skin tones. Clinicians must have a high index of suspicion for any new growths in patients with darker Fitzpatrick types. Patient counseling about sun protection, the ABCDEs of melanoma, and concerning signs and symptoms of nonmelanoma skin cancer that would warrant urgent evaluation is also essential.
The incidence of skin cancer is estimated to be approximately 2% in Black patients; however, patients with darker skin tones have disproportionately higher morbidity and mortality rates than patients with lighter skin tones.1 The reason for this pattern is thought to be multifactorial and at least in part because of delayed diagnosis and treatment.1 A recent review of nonmelanoma skin cancers in people of color discussed African American race as an independent risk factor for BCC metastasis in some studies.2 Additionally, BCC is more likely to be pigmented in these patients (50% in Black patients compared with 5% to 6% in White patients).2
Clinicians must actively seek out photographs of nonmelanoma skin cancers in patients of color, as the majority of published photos of these malignancies are of White patients. Familiarizing oneself with how skin cancer can present in various skin tones will hopefully prevent delayed diagnosis and improve outcomes for people of color.1,2
Nicole Papac, MD, is a dermatology resident at the University of Oklahoma Health Sciences Center in Oklahoma City. Her interests include skin cancer, pediatric dermatology, and chronic autoimmune dermatologic conditions. Pamela S. Allen, MD, is an associate professor and chair at the University of Oklahoma Health Sciences Center Department of Dermatology. She serves as the director of the residency program and cosmetics. Dr. Allen is the founder and director of the Mark Allen Everett, MD, Skin of Color Symposium of the OU Department of Dermatology.
1. Gloster HM Jr, Neal K. Skin cancer in skin of color. J Am Acad Dermatol. 2006;55(5):741-760; quiz 761-4. doi:10.1016/j.jaad.2005.08.063
2. Higgins S, Nazemi A, Chow M, Wysong A. Review of nonmelanoma skin cancer in African Americans, Hispanics, and Asians. Dermatol Surg. 2018;44(7):903-910. doi:10.1097/DSS.0000000000001547.