Dermatoscopy for BCCs in skin of colour
Visual features of common skin cancer not obvious to the eye in darker skin types (Issue #501, 1,500 words, 8 minutes)
Common features of basal cell carcinomas (BCCs), such as translucency and telangiectasias, are not as evident in patients with darker skin and may require a dermatoscope for clinical observation, Dr. Megan MacGillivray told delegates at the First Indigenous Skin Spectrum Global Summit on April 5 in Montreal. Pigmented BCCs are more common in patients of colour.
Dr. MacGillivray is the founder of the FullCircleDerm Virtual Acne Clinic based in Barrie, Ont., and runs the skin cancer biopsy clinic and an Indigenous health-focused clinic at the Royal Victoria Regional Hospital in Barrie.
BCC typically presents as a translucent papulonodule with prominent telangiectasias, as noted by Dr. MacGillivray. But in patients with more pigmented skin, including Indigenous patients, the translucency and telangiectasias are not as apparent. A dermatoscope can help diagnose BCC in patients of colour.
A pigmented BCC is usually a nodular or superficial type of BCC containing varying amounts of melanin pigment, said Dr. MacGillivray. The mechanism for increased pigmentation is unclear; however, in patients with darker skin, more than half of BCCs exhibit pigment. The BCC can present as brown or even almost black and can resemble a melanoma.
Dr. MacGillivray provided the example of a 68-year-old female Indigenous patient with a lesion near her left upper nasolabial fold, which the patient thought was a pimple. The lesion presented as a skin-coloured papule with no visible blood vessels. However, by using a dermatoscope, Dr. MacGillivray was able to see arborizing telangiectasias and some fine grey dots, characteristic of pigmented BCC, which was confirmed by a biopsy. The patient was surprised by the diagnosis, as she knew nobody with skin cancer. Dr. MacGillivray cautioned that the diagnosis of BCC is not as common in darker-skinned patients.
Pigmented BCC may also present with pigmented leaf-like structures, spoke wheel structures, or concentric structures, said Dr. MacGillivray.
Bottom Line: Common features of BCCs, such as translucency and telangiectasias, are not as obvious in patients with darker skin. A dermatoscope can help physicians see those features and diagnose BCC. Pigmented BCCs are more common in patients of colour.
From the literature on skin cancer in skin of colour
Non-melanoma skin cancer: Dermatoscopic diagnostic clues in Mexican individuals based on Fitzpatrick skin phototypes
This study aimed to investigate dermatoscopic clues that support the accurate diagnosis of non-melanoma skin cancer among Mexican individuals. Researchers included 53 patients diagnosed with non-melanoma skin cancer, aged 39 to 89 years, who visited an academic dermatology department for skin examinations. Two certified dermatologists evaluated at least three dermatoscopy images for each lesion. Investigators took biopsies to confirm the preliminary diagnosis. Most patients were classified as phototype III.
Researchers found that patients with phototype IV were diagnosed at a younger age. Basal cell carcinomas were the most common subtype of cancer. Nodular and ulcerated tumours were the most prevalent morphology. The dermatoscopic examination revealed that 60% of the lesions were pigmented, with a predominance of polymorphic vascular patterns. Squamous cell carcinomas exhibited monomorphic vascular structures. Blood vessel arrangements and specific patterns were primarily radial in both skin types III and IV.
The authors conclude that in the Mexican population, patients with non-melanoma skin cancer tend to be under 60 years of age at diagnosis. Although prominent reticular lines were distinctive of the ulcerated lesions, finding any pathognomonic pigmentary feature for non-melanoma skin cancer subtypes or locations was impossible. A polymorphic pattern of blood vessels, with a predominance of linear vessels, typically indicates the presence of Basal cell carcinoma. In contrast, a monomorphic pattern with a predominance of comma vessels is more suggestive of squamous cell carcinoma.
Squamous cell carcinoma: A clinical and histopathological review of a South African tertiary dermatology unit
In this paper, researchers describe the clinical, histopathological, and risk profile characteristics of cutaneous squamous cell carcinoma (CSCC) in a South African cohort, identifying patterns that can inform local clinical practice and guide future research priorities.
They conducted a retrospective data analysis of patients seen at Tygerberg Academic Hospital in Parow, Cape Town, between Sept. 1, 2019 and Aug. 31, 2020. The authors extracted demographic and clinical data from medical records. Two study evaluators used predetermined criteria to review the histopathological features in skin biopsies. Risk stratification of lesions followed the guidelines of the National Comprehensive Cancer Network.
Over one year, 113 CSCCs were diagnosed in 83 patients. Participants were primarily Fitzpatrick skin phototype I (65.1%) and male (60.2%), with a median age of 73 years and a male-to-female ratio of 1.51:1. Some 15.6% of participants had skin phototype III or higher. The BCC-to-CSCC incidence ratio was 1.71:1. Most lesions had been present for more than six months (87.6%) and were located on the head and neck (59.3%). Punch biopsies diagnosed 62.8% of lesions. Histologically, 63.7% were well differentiated, and 40.7% were invasive. Conventional CSCCs comprised 75.2% of lesions; 5.3% were the high-risk acantholytic subtype. Researchers found a high recurrence risk in 77.0% of lesions.
Keratoacanthoma in a patient with skin of colour
The case report investigates a 63-year-old African American female who presented to a family medicine clinic with a one-year history of a progressively enlarging nodule on her right shin.
Clinical examination revealed a seven-millimetre dome-shaped, hyperpigmented, well-defined, scaly, rough papule with central umbilication and a keratin plug.
Histopathological analysis of an excisional biopsy confirmed the diagnosis of keratoacanthoma with clear margins.
The study authors write that due to the significant overlap in gross appearance and dermoscopic features of keratoacanthomas and malignant squamous cell carcinomas, it is imperative to fully excise similarly presenting lesions and send them for microscopic analysis. Even with histologic examination, differentiating keratoacanthomas from squamous cell carcinomas can be challenging. Therefore, the priority of contemporary research lies in developing new methods to distinguish between the two conditions, allowing for the more conservative management of self-limited, benign keratoacanthoma, thereby avoiding invasive removal and associated morbidity.
They note this research is significant for patients with skin of colour who are more likely to experience post-operative complications such as proinflammatory hyperpigmentation, hypertrophic scars, and keloids, but are also at risk of squamous cell carcinoma.
At the intersection of skin and society
A pair of reports out of British Columbia are detailing the complex, expensive and under-resourced process of repatriating Indigenous historical items or remains back to their homes, reports CBC News.
The studies, developed in partnership between the First Peoples' Cultural Council and K'yuu Enterprise Corporation, call for changes that include the creation of a centralized body to facilitate the work, a repatriation accreditation program for museums and other institutions, and "substantial" funding and support from the provincial and federal governments.
Gretchen Fox, an anthropologist and the Council's acting heritage manager, said the growing interest in the moral and ethical requirement for repatriation demonstrates the need for resources to establish steps that can be applied in B.C. and other jurisdictions.
“There was a need for a way forward, or a road map—what's involved in repatriation, what's the history of it?” she said.
“To have a really good understanding and documentation of what's been lost, where these ancestors and belongings are held today, and what kind of work specifically is involved in locating them.”
One report, titled “From Stealing to Healing: Repatriation and B.C. First Nations,” shares critical research identifying over 2,500 Ancestors and 100,000 Belongings, from B.C. alone, currently held in 229 colonial institutions worldwide. The report includes a timeline that presents more than 100 years of removal and repatriation in B.C. and shares more recent repatriation experiences from 16 Nations. The positive impact of repatriation in communities is immeasurable and is vital for healing and cultural revitalization.
The other report, “The Repatriation Cost Analysis: A Framework and Model,” describes the steps taken to identify and estimate the costs of First Nations-led repatriation from the beginning planning stages to long-term caretaking after Ancestors and Belongings are repatriated. It presents a cost model with the flexibility to account for various stages of readiness, the number of items to be returned, and diversity across B.C. First Nations communities. It is a tool for communities to identify their resources and needs, enabling them to move forward with their repatriation projects.
“The First Peoples’ Cultural Council is so grateful to the community experts who so generously shared their knowledge and expertise with all of us,” said Tracey Herbert, CEO of the First Peoples’ Cultural Council, in a release from the Council. “This groundbreaking research reveals that First Nations–led repatriation is a moral and ethical imperative to mitigate historical and ongoing cultural appropriation. The reports create an opportunity to work together and invest in British Columbia’s collective heritage.”
This week
July is UV Awareness Month
July 9 is Nunavut Day
July 10 is Chronic Disease Day
Something to think about in the week ahead . . .
—Hal Borland, (1900 – 1978), U.S. author
Next week
Saskatoon-based pathologist Dr. Archana Kakadekar discusses structural skin differences between skin types and the role of collaboration between clinical and laboratory physicians in improving patient outcomes.
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