Diagnosing cancer in Black skin
Knowing the differences in presentation, confidence to request biopsy both key to improving patient outcomes (1,400 words, 7 minutes)
Knowing the differences in the presentation of skin cancers in the range of skin types and having biopsies taken when there is suspicion of cancer is essential for achieving good outcomes, said Dr. Joël Claveau during a presentation at the 9th annual Skin Spectrum Summit on October 21, 2023.
Dr. Claveau is a dermatologist specializing in diagnosing and treating melanoma and skin cancers and an Associate Professor with the Department of Medicine at Laval University in Quebec City.
He noted that basal cell carcinoma is the most common skin cancer overall but is very rare in Black skin types. If a Black patient has a lesion that persists for more than three months, especially if it is papular and red with some black dots and occasionally bleeds, the physician should consider basal cell carcinoma, Dr. Claveau said.
Squamous cell carcinomas are more common in Black skin types than in lighter skin types but can be challenging to diagnose, Dr. Claveau said, explaining these cancers often “look like ulcers, and they often appear on the legs in chronic wounds.”
He recommended that physicians consider a biopsy if a leg ulcer in a Black patient does not resolve after standard skin ulcer care.
Often, patients will go to a skin ulcer clinic, but the signs of cancer will be overlooked, he said. “Watch for pigment at the periphery [of the ulcer]. This can be a sign of melanoma.”
In Black patients, Dr. Claveau explained, melanoma most frequently occurs on the acral skin on the hands and feet, including the nails. “Also, an even more rare melanoma is mucous membrane melanoma.”
“Do not forget to look on the hands and feet and nails” during a patient examination, he said. “Don’t hesitate to biopsy if you have a suspicious lesion; it’s difficult to biopsy hands and feet. So ask for a dermatologist plastic surgeon [to perform the biopsy] if you’re unfamiliar with those biopsies.”
Dr. Claveau cautioned that not every lesion that is dark on feet and hands is melanoma. He noted that dermoscopy is valuable for differentiating cancer from pigmented nevi.
Bottom line: Awareness of the differences in skin cancer presentation between skin types and confidence in knowing when to biopsy suspicious lesions can improve outcomes for patients with skin of colour.
Reviewing the literature on skin cancer in skin of colour
Skin of colour representation in dermoscopy studies distinguishing benign from malignant skin lesions: A scoping review
This study evaluated participant diversity in studies examining dermoscopic features distinguishing benign from malignant skin lesions. The authors searched PubMed for articles discussing dermoscopic features of melanoma, squamous cell carcinoma, and basal cell carcinoma up to Ja. 3, 2023.
Among 159 included studies, only eight (5.0%) reported subject race and ethnicity, with 7/8 studies including White patients. Only one study explicitly included Black, Native American, or Pacific Islander patients; two included Hispanic patients, and four included Asian patients. Phototype was reported in 21/159 (13.2%) studies, with most including participants with phototypes I-III, fewer including phototypes IV-V, and none including phototype VI. Nationality was disclosed in 12/159 (7.5%) studies.
The researchers also examined a subset of 19 studies that included acral lentiginous melanoma. Of those, three (15.8%) studies reported race and ethnicity, four (21.1%) reported phototype, and most patients were White or light-skinned.
None of the 20 most-cited studies reported race or ethnicity, one reported phototype, and one reported patient nationality.
Acral lentiginous melanoma incidence by sex, race, ethnicity, and stage in the United States, 2010-2019
Researchers examined the incidence rates of acral lentiginous melanoma (ALM) compared to all other melanoma types, using data from the U.S. Centers for Disease Control and Prevention’s National Program of Cancer Registries and the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program.
The investigators found ALM incidence rates were significantly lower among non-Hispanic Black persons (1.8 per 1,000,000), non-Hispanic Asian/Pacific Islander (API) persons (1.7 per 1,000,000); and Hispanic Black, American Indian/Alaska Native (AI/AN), and API persons (1.5 per 1,000,000) compared to non-Hispanic White persons (2.3 per 1,000,000). Rates were significantly higher among Hispanic White persons (2.8 per 1,000,000) than non-Hispanic White persons. For all other melanoma types, incidence rates were significantly higher among non-Hispanic White persons compared to persons in the other racial and ethnic categories. The percentage of ALM melanomas ranged from 0.8% among non-Hispanic White persons to 19.1% among Hispanic Black, AI/AN, and API persons.
Skin cancer in non-White solid organ transplant recipients: Mayo Clinic experience
This study aimed to describe the characteristics and outcomes of non-White patients who developed skin cancer following solid organ transplantation.
Researchers conducted a retrospective chart review of non-White solid organ transplant recipients (SOTRs) at the Mayo Clinic who underwent transplantation between Nov. 1987 and April 2020 and subsequently developed skin cancer.
They identified 32 non-White SOTRs who developed skin cancer in the posttransplant period. Among these, 46.9% were Hispanic/Latinx, 25% were American Indian/Alaskan Native, 21.9% were Asian, and 6.3% were Black/African American. Four patients had a history of non-melanoma skin cancer pretransplant. Looking at types of skin cancer, 21 (65.6%) patients developed squamous cell carcinoma, 15 (46.9%) developed basal cell carcinoma, five (15.6%) developed melanoma, and two (6.3%) developed sebaceous carcinoma. The median time from transplant to first posttransplant skin cancer was 7.8 years.
Association of Fitzpatrick skin type with metastatic risk from uveal melanoma in 854 consecutive patients at a single center
Researchers conducted a retrospective detailed review of patient charts for Fitzpatrick skin type (type I- white, II-fair, III-average, IV-light brown, V-brown, VI-black), clinical details of the patient and the uveal melanoma, tumour cytogenetic classification according to The Cancer Genome Atlas (TCGA), and outcome of melanoma-related metastasis and death.
There were 97 patients with Fitzpatrick skin type I, 665 with type II, 79 with type III, 11 with type IV, two with type V, and none with type VI. When the researchers compared skin types I to II and III to V, they found significant differences in mean age at presentation (64.1 vs. 58.5 vs. 49.8 years, p<0.001), presence of ocular melanocytosis (3% vs. 3% vs. 10%, p=0.01), visual acuity <20/200 at presentation (6% vs. 7% vs. 13%, p=0.03), genetic results showing TCGA group B tumours (11% vs. 14% vs. 26%, p=0.01) or TCGA group D tumours (22% vs. 11% vs. 9%, p=0.01), 10-year incidence of melanoma-related metastasis (25% vs. 15% vs. 14%, p=0.02) and 10-year incidence of melanoma-related death (9% vs. 3% vs. 4%, p=0.04). FST significantly predicted melanoma-related metastasis (p=0.02, Hazard ratio 2.3).
The authors conclude that Fitzpatrick skin type may predict melanoma-related metastasis in uveal melanoma, with metastasis and TCGA Group D tumours being more common in patients with Fitzpatrick skin type I.
VIDEO: Skin cancer awareness in skin of colour
Seattle-based dermatologist Dr. Daniel Sugai describes subungual melanoma and the appearance of non-melanoma skin cancers in skin of colour.
At the intersection of skin and society
Pfizer Canada and the Skin Spectrum Summit are pleased to announce the winners of the new Canadian Skin of Colour & Diversity Scholarship program, which aims to improve dermatological care for underrepresented populations, including those with deeper skin tones, Indigenous Peoples, and other racialized individuals.
Dermatology residents Dr. Nickoo Merati from McGill University and Dr. Muskaan Sachdeva from the University of Toronto have been selected as this year’s scholarship winners by an independent committee of dermatologists across Canada. The two winning residents will each receive $20,000 to fund their innovative projects to help support advances in dermatologic care in Canada.
“It is heartening to see the impressive applications we received for this scholarship program. This speaks to the high calibre of resident dermatologists in this country and their commitment and desire to enact positive change,” said Dr. Marissa Joseph, chair of the steering committee for the Canadian Skin of Colour & Diversity Scholarship. “Currently, there is a disparity in the diagnosis, understanding and treatment of certain skin conditions in Canada. We hope to address these care gaps with this new scholarship, the first of its kind in this country.”
Dr. Merati’s project addresses the lack of research on atopic dermatitis, or eczema, within Indigenous communities. Dr. Merati says her project was inspired by her work with Cree youth in northern Quebec and Indigenous communities in rural Saskatchewan, where she witnessed how a lack of access to care can cause eczema to progress into a debilitating disease.
Dr. Sachdeva’s proposal seeks to tackle the lack of representation of skin of colour in dermatology medical education. With her funding, she will introduce an innovative ethnodermatology course into the University of Toronto (UofT) undergraduate curriculum. Dr. Sachdeva initially delved into this area while researching that highlighted disparities and knowledge gaps in treating patients with skin of colour, especially with psoriasis and atopic dermatitis.
Dr. Merati and Dr. Sachdeva will each share the outcomes of their projects at the 2024 Skin Spectrum Summit annual conference in Toronto on October 5, 2024.
“At Pfizer, we firmly believe fostering diversity leads to a more comprehensive understanding of patient needs,” said Frédéric Lavoie, Inflammation and Immunology Lead for Pfizer Canada. “This is why we are so proud to support the Canadian Skin of Colour and Diversity Scholarship. The program aligns perfectly with our core company values and provides vital resources needed to support education, amplify diverse voices, and ignite important change.”
“This scholarship is an opportunity to provide these future leaders with the resources they need to improve dermatological care for everyone in this country,” said Mitchell Shannon, CEO and Publisher of Chronicle Companies and Conference Secretariat of Skin Spectrum Summit. “Based on the quality of the applications we received, there’s no doubt in my mind that the future of dermatology in Canada is bright and filled with diversity, equity and inclusivity.”
Pfizer Canada and the Skin Spectrum Summit are pleased to support the Canadian Skin of Colour and Diversity Scholarship again in 2024. Details will be available in spring 2024 here: www.skinofcolourscholarship.com.
October 28 is National Prescription Drug Take Back Day in the U.S.
October 29 is World Psoriasis Day
October 29 is International Day of Care and Support
Skin Spectrum Weekly’s 9th annual Skin Spectrum Summit coverage continues with Dr. Jonathan Shapero’s presentation on laser treatments in patients with richly pigmented skin.
The Great Lakes ImmunoDermatology Exchange (GLIDE) 5.0 meeting will be held at the Queen’s Landing Hotel in Niagara-on-the-Lake, Ont. from Oct. 27-28, 2023. This meeting focuses on new concepts, therapeutic options, and real-world practice issues in immunodermatology.
Registration opens soon for the 2023 Indigenous Skin Spectrum Summit. First held in March 2021, the Indigenous Skin Spectrum Summit is a special session of the Skin Spectrum Summit addressing specific challenges in treating Canada’s Indigenous community. This year’s virtual meeting will be held on November 25, 2023. Watch this site for more details.
If you like Skin Spectrum Weekly, why not check out Chronicle’s other publications, podcasts, and portal?
Established in 1995, The Chronicle of Skin & Allergy is a scientific newspaper providing news and information on practical therapeutics and clinical progress in dermatologic medicine. The latest issue features:
Drs. Irina Turchin (Fredericton, N.B.), Ron Vender (Hamilton, Ont.), and Ashley O’Toole (Peterborough, Ont.) discuss advances in psoriasis treatment.
Dr. Joel DeKoven (Toronto) details the most common contact allergens based on North American Contact Dermatitis Group data.
An essay from Dr. Fabian Rodriguez-Bolanosi (Toronto) submitted to the 2022 Dermatology Industry Taskforce on Inclusion, Diversity and Equity (DiTiDE) short essay contest. Dr. Rodriguez-Bolanosi wrote about his experience working with Black women in the hair clinic.
Plus regular features, including the popular column “Vender on Psoriasis” by dermatologist Dr. Ron Vender
Read a recent digital edition of The Chronicle of Skin & Allergy here. To apply for a complimentary* subscription or to receive a sample copy, please email firstname.lastname@example.org with your contact information.
The Women in Dermatology e-newsletter updates new findings concerning dermatologic issues that affect women and the female dermatologists who care for them. Read the current issue here.
Season two of the Yadav on Acne podcast with Dr. Geeta Yadav has launched. Listen to the new season here. In episode three, Dr. Yadav gives insight into the prevalence and risk factors of acne scarring, combining microneedling with isotretinoin and dermaplaning.
And if you’re looking for a web destination for all things derm, visit derm.city, “Where Dermatology Lives.” Please like, rate, review, and share it with your colleagues.