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Skin cancer and photoprotection in people of color:
A review and recommendations for
physicians and the public
Oma N. Agbai, MD,
Kesha Buster, MD,
Miguel Sanchez, MD,
Claudia Hernandez, MD,
Roopal V. Kundu, MD,
Melvin Chiu, MD,
Wendy E. Roberts, MD,
Zoe D. Draelos, MD,
Reva Bhushan, PhD,
Susan C. Taylor, MD,
and Henry W. Lim, MD
Detroit, Michigan; Wichita, Kansas; New York, New York; Chicago and Schaumburg, Illinois;
Los Angeles and Rancho Mirage, California; High Point, North Carolina; and Philadelphia, Pennsylvania
Skin cancer is less prevalent in people of color than in the white population. However, when skin cancer
occurs in non-whites, it often presents at a more advanced stage, and thus the prognosis is worse compared
with white patients. The increased morbidity and mortality associated with skin cancer in patients of color
compared with white patients may be because of the lack of awareness, diagnoses at a more advanced
stage, and socioeconomic factors such as access to care barriers. Physician promotion of skin cancer
prevention strategies for all patients, regardless of ethnic background and socioeconomic status, can lead to
timely diagnosis and treatment. Public education campaigns should be expanded to target communities of
color to promote self-skin examination and stress importance of photoprotection, avoidance of tanning bed
use, and early skin cancer detection and treatment. These measures should result in reduction or earlier
detection of cutaneous malignancies in all communities. Furthermore, promotion of photoprotection
practices may reduce other adverse effects of ultraviolet exposure including photoaging and ultraviolet-
related disorders of pigmentation. ( J Am Acad Dermatol 2014;70:748-62.)
Key words: basal cell carcinoma; Bowen disease; dermatofibrosarcoma protuberans; dyspigmentation;
melanoma; Merkel cell carcinoma; mycosis fungoides; people of color; photoprotection; radiation; skin
cancer; skin of color; squamous cell carcinoma; sun protection; sunscreen; ultraviolet.
Abbreviations used:
BCC: basal cell carcinoma
DFSP: dermatofibrosarcoma protuberans
MED: minimal erythema dose
MF: mycosis fungoides
MM: malignant melanoma
NMSC: nonmelanoma skin cancer
POC: people of color
SCC: squamous cell carcinoma
SEER: Surveillance, Epidemiology, and End
SPF: sun-protection factor
UV: ultraviolet
Whites: Non-Hispanic individuals of European
Blacks: Non-Hispanic individuals of African
Hispanics: Individuals who trace their origin or
descent to Mexico, Puerto Rico, Cuba, Spanish-
speaking Central and South American countries,
Spanish-speaking island nations of the Caribbean,
and other Spanish cultures. Origin can be considered
as the heritage, nationality group, lineage, or country
of the person or the person’s parents or ancestors
before their arrival in the United States. People who
the Multicultural Dermatology Center, Department of
ermatology, Henry Ford Hospital, Detroit
; Department of
ermatology, Via Christi Clinic, Wichita
; Department of
ermatology, New York University Medical Centerc; Depart-
ent of Dermatology, University of Illinois College of Medicine,
; Northwestern Center for Ethnic Skin, Department of
ermatology, Northwestern University Feinberg School of
edicine, Chicagoe; Division of Dermatology, University of
alifornia Los Angeles Medical Centerf; Desert Dermatology
ncho Mirage
; Dermatology Consulting Services, High Point
merican Academy of Dermatology, Schaumburgi; and Society
ill Dermatology and Cosmetic Center, Philadelphia.j
Funding sources: None.
The authors’ conflict of interest/disclosure statements appear at
the end of the article.
Accepted for publication November 26, 2013.
Reprint requests: Reva Bhushan, PhD, Department of
Evidence-based Research, American Academy of
Dermatology, 930 E Woodfield Rd, Schaumburg, IL 60173.
E-mail: [email protected]
Published online January 30, 2014.
� 2014 by the American Academy of Dermatology, Inc.
Delta:1_given name
Delta:1_given name
Delta:1_given name
Delta:1_given name
Delta:1_given name
Delta:1_given name
mailto:[email protected]
Agbai et al 749
identify their origin as Hispanic or Latino may be of
any race. This definition of Hispanic fully excludes
the Portuguese, Brazilians, or anyone from any other
country that speaks Portuguese.1
Asians: Individuals having origins in any of the
original peoples of East Asia, Southeast Asia, or the
Indian subcontinent, including, for example,
Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and
Malignant melanoma (MM) and nonmelanoma
skin cancer (NMSC) account for 40% of all neoplasms
in whites, making it the most common malignancy in
the United States.2 Skin cancer is most common in
whites and in people living in equatorial latitudes.3
The incidence of both MM and NMSC remains
significantly lower in people of color (POC) when
compared with whites as they are seen in about 5%
of Hispanics, 4% of Asians, and 2% of blacks.4,5 Even
so, multiple reports have demonstrated heightened
morbidity and mortality in minority populations,
raising public health concerns in these groups.
Although there are data detailing incidence of skin
cancer in POC, these data are limited. In addition to
skin cancer, factors such as photoaging, pigmentary
disorders induced or exacerbated by ultraviolet (UV)
exposure, and sunburn must be considered in POC.
It is estimated that black, Hispanic, and Asian
Americans will comprise approximately 50% of the
US population by the year 2050.4 These evolving
demographics, elevated rates of skin cancer
morbidity and mortality in POC, and limited clinical
data on additional adverse effects of UV exposure in
this population mandate that physicians develop
familiarity with the concept of optimized photo-
protection for POC. An understanding of the varying
clinical presentations of UV-related skin cancers in
POC, in addition to relevant topics in photoaging and
UV-related disorders of pigmentation, is necessary
for adequate management of photoprotection in
Few studies have been performed to thoroughly
evaluate biological differences between differing
ethnic skin types. Skin color is primarily determined
by the presence of melanin. Jimbow et al9 reported
that dark skin has larger melanocytes that produce
more melanin and melanosomes are distributed
individually in keratinocytes rather than in aggre-
gates. The rarity of cutaneous malignancy in
populations of darker complexions is secondary to
photoprotection from a higher amount of epidermal
melanin, which filters at least twice as much UV
radiation as the epidermis of whites.10 In an in vitro
study performed by Kaidbey et al,11 the amount of
UV radiation reaching the papillary dermis of whites
was greater than that of blacks by approximately
5-fold. The authors proposed that larger and more
melanized melanosomes observed in POC absorbed
more energy than the melanosomes in white skin,
which were smaller, less dense, and lightly mela-
nized. Furthermore, the authors estimated that the
epidermis of blacks has an intrinsic sun-protection
factor (SPF) of 13.4, whereas light skin has an SPF of
3.3.11 Therefore, exposure to UV radiation plays a
lesser role in heightening the risk for skin cancer in
populations of darker complexions.
Damage to DNA secondary to UV radiation is a
major factor in cutaneous photocarcinogenesis and
photoaging. However, the correlation of ethnicity
and degree of sensitivity to UV rays has not been
elucidated. Tadokoro et al12 performed a study
evaluating the correlations between melanin content
and degree of UVA- and UVB-induced DNA damage
in normal-appearing skin of various ethnic groups.
DNA damage was found to be most severe in
qualitatively light skin. Baseline skin pigmentation
and extent of DNA damage were inversely related, as
individuals of darker skin tones were able to repair
UVA-/UVB-induced DNA damage more rapidly than
subjects with fair skin. Even low exposure to
UVA/UVB radiation induced some appreciable
DNA damage in all skin types, dispelling the myth
that those with very dark skin are completely im-
mune to UVA-/UVB-induced DNA damage.12
Indeed, NMSC and MM do occur in POC, despite
the low relative risk.13 Because of the limited
research on skin cancer in POC, there are few
resources providing insight on evaluating darkly
pigmented lesions in POC. Frequently atypical
presentations, together with constitutive dark
pigmentation, pose diagnostic challenges in the
identification of characteristics such as variation in
color within the lesions. Furthermore, certain skin
cancers that are pigmented in POC may not be
pigmented in whites (such as basal cell carcinoma,
which is more likely to be pigmented in darker skin
types); therefore, a high index of suspicion in POC is
necessary in making the diagnosis.
Basal cell carcinoma (BCC) is the most prevalent
skin cancer found in whites, Asians, and Hispanics.14
Hispanics are more likely to be given a diagnosis of
multiple BCC rather than a single squamous cell
Fig 1. Nonmelanoma skin cancers in people of color. Pigmented basal cell carcinoma in
elderly Hispanic man (right lateral orbital rim) (A); middle-aged Asian woman (right cheek)
(B); middle-aged Hispanic man (right forehead) (C); and middle-aged Hispanic man (left nasal
ala) (D). Hypopigmented mycosis fungoides in Hispanic man (back) (E) and black man (lower
aspect of back) (F). G, Metastatic squamous cell carcinoma in black man (right parietal scalp,
courtesy of Dr Marc Silverstein, Sacramento, CA).
APRIL 2014
750 Agbai et al
carcinoma (SCC).15 In contrast to Hispanic popula-
tions, BCC is the second most common skin malig-
nancy in blacks after SCC.4,5
The clinical spectrum of disease in BCC shows
many parallels among blacks, whites, Asians, and
Hispanics. The classic clinical presentation of a solitary
pearly papule with central ulceration and rolled
borders may be seen in POC, but may pose challenges
in the physical examination as the characteristic pearly
borders and telangiectasia may not be clinically as
apparent in dark skin types (Fig 1). In whites, the
majority of patients presenting with BCC are of
with asymptomatic solitary translucent nodules with
central ulceration.14 Pigmentation is present in over
50% of tumors in POC,4,16 whereas only 5% of BCCs
affecting whites have been shown to be pigmented. In
Asians, BCCs frequently present as brown to black
papules, or have a ‘‘black pearly’’ appearance.17 The
clinical presentation of BCCs in Asian skin ranges from
nodules to papules, plaques, and ulcers.18 With
regards to anatomic distribution, there are significant
similarities between POC and whites. Approximately
80% of BCCs in POC were found in the head and
neck,19 as has been shown in whites.14 Differential
diagnosis for BCC in POC includes seborrheic kera-
tosis, blue nevus, trauma, lupus erythematosus, nevus
sebaceous, sarcoidosis, and melanoma.20 Metastasis in
BCC is rare in all skin types.14
BCC in blacks
Although quite rare, BCC has been reported in the
black population. In a report from Howard
University (Washington, DC) from 1960 through
1986, most BCCs were seen in blacks of fairer skin
complexion in comparison with those with darker
complexions.19 From this, one may conclude that the
incidence of BCC may correlate directly with the
degree of skin pigmentation, as it is most frequently
diagnosed in whites of fairer complexions, and more
rarely diagnosed in blacks. A study of skin cancer
prevalence was conducted by Asuquo et al21 in a
Nigerian teaching hospital between the years of 2000
and 2004. Of 63 cases of skin cancer, BCC was
diagnosed in 8% (n = 5) of the cases; 66.7% of the
BCC were on the head and neck, and 33.3% on the
upper limb. All of these lesions were nodular. BCC
was diagnosed only in albinos in this study.21 In a
review of 128 black patients with 148 BCCs, Mora
and Burris3 (New Orleans, LA) found that the
average age of examination (not necessarily onset)
was 59 years, with lesions most commonly located
on head and neck. Only 2 of these patients had
Agbai et al 751
The incidence of BCC in non-sun-exposed skin is
equal between whites and blacks.22 Diverse pre-
sentations and locations of BCCs have been found in
blacks, ranging from superficial BCC to perianal
BCC.3,11 BCCs in blacks are often pigmented, and
there are reports of BCCs that have arisen in scars,
which rarely proceeded to metastasize.3,4,23
BCC in Hispanics
One of the most common neoplasms diagnosed in
Hispanics is pigmented BCC.16 Hispanics studied
demonstrated significantly lower incidence rates of
BCC than non-Hispanic whites regardless of
gender.24 Still, a high index of suspicion should be
maintained in evaluating pigmented lesions in
Hispanics, as BCCs have a propensity to be pig-
mented in Hispanic populations and may be mis-
diagnosed as melanomas.16 In a study performed by
Bigler et al16 (Albuquerque, NM), the incidence of
pigmented BCC in Hispanics was found to be twice
that of white patients.
Compared with whites, Hispanics with NMSC
were shown to have fewer tumors per individual,
and fewer Hispanics had more than 1 tumor.24 A
registry of skin cancers in New Mexico between the
years of 1964 and 1992 showed an average of 1.8
tumors per individual with NMSC among Hispanics,
compared with 2.2 tumors per individual with NMSC
in whites. Of these, BCC was more common than
SCC by 6.6-fold in both Hispanics and whites.24
BCC in Asians
Although NMSC is not common in Asians, it is not
extremely rare. In a study by Cheng et al25 studying
incidence of NMSC between 1990 and 1999 in Hong
Kong, China, the incidence of BCC was 0.32 and 0.92
per 100,000 population. Pigmented BCC was the
most common NMSC diagnosed, found in approxi-
mately 60% of Chinese patients with skin cancer in
the study.25 Multiple or subsequent skin cancers and
subtypes of new cancers were seen less often in the
Chinese group when compared with the white
group.25 Similarly, Sng et al26 reported an increase
of skin cancers including BCC, SCC, and MM, in
Singapore between the years of 1998 and 2006. The
extremities were the most common sites affected by
Bowen disease (SCC in situ).27 There is an increased
incidence of NMSC in Japanese living in Kauai,
Hawaii, which may be secondary to heightened
intensity of year-round UV radiation and popularity
of outdoor activities, as reviewed by Lee and Lim.28
SCC comprises approximately 20% of all skin
cancers. With MM excluded, approximately 75% of
all deaths from skin cancers are caused by SCC.
blacks and Asian Indians, SCC is the most commonly
diagnosed skin cancer. It is the second most
commonly diagnosed skin cancer in Hispanics, East
Asians (including Japanese and Chinese patients),
and whites.5,30 Although actinic keratoses are most
commonly diagnosed in white and Japanese pa-
tients,31 they are very rare in blacks.32
Riskfactorsfor SCCinPOCincludechronicscarring
and inflammatory processes including hidradenitis
suppurativa, lupus erythematosus, scars caused by
chemical and thermal burns, skin ulcers, and sites of
previous radiation.33,34 Immunocompromised pa-
tients, including organ transplant recipients, also
demonstrate a heightened risk for SCC.35 Among
blacks, the greatest predisposing factors for devel-
oping SCC include chronic scarring and/or inflamma-
tory processes that are observed in 20% to 40% of
reported cases.4 In addition, the human papilloma-
virus has been linked to the development of SCC,
particularly in immunocompromised patients.36 One
retrospective study detected human papillomavirus
DNA in skin samples of 4.7% of controls, 90.5% of
benign warts, 60.4% of precancerous lesions, 59.7% of
SCC, and 27.8% of BCC, suggesting a link between
viral infection and the development of NMSC.37
Definitive studies have not been performed on the
relationship between human papillomavirus infection
and NMSC in POC.
SCCs are characteristically firm, superficial, well-
demarcated papules or plaques that emerge from a
rounded, indurated, and elevated base.29 In POC,
SCC is most commonly found in areas that are not
typically exposed to the sun, such as the lower
extremities and anus. In fact, lower extremity and
anogenital SCCs were seen in 15% of SCCs in blacks
in a study conducted by Halder and Bang19 in
Washington, DC. This is a sharp contrast to the white
population, in whom SCCs are characteristically seen
in chronically sun-exposed skin.19
SCC in blacks
Among black patients given the diagnosis of
SCC, the peak incidence was shown to be in the
fifth decade on the lower limbs, followed by the
head and neck and then the genitals. The scalp and
lip are more often implicated in black women than
in men.38 Chronic trauma, ulcers, and scars are the
most significant predisposing factors for SCCs in the
lower limb and on the scalp, as reported by Amir
et al38 (Dar es Salaam, Tanzania) in a study of SCC
in Tanzanian patients, where UV radiation was
found to be the primary factor predisposing pa-
tients to increased risk of SCC in the head and neck.
In a study done in Tanzania, smegma of the
APRIL 2014
752 Agbai et al
uncircumcised penis was also reported as a risk
factor for the majority of cases of SCC developing
on the penis in blacks.38 The majority of SCC on the
penis were found to be SCC in situ upon histologic
analysis in a study performed by Hubbell et al39
(New Orleans, LA).
SCC was the most common skin cancer reported
in a Nigerian teaching hospital between 2000 and
2004 by Asuquo et al,
where the lower limb was
the most commonly affected anatomic site. SCC
manifesting as Marjolin ulcer associated with trau-
matic injury of the limb was diagnosed in 7
patients, and associated with a history of burn in
1 patient. SCC involved the external genitalia in 9
patients, 3 of whom had genital warts. The anus
was affected in 4 female cases. There were no
lesions involving the head and neck regions, and
all patients in this study presented with chronic
Several cases of the emergence of SCC within
scars of chronic discoid lupus erythematosus in black
patients have been reported. Caruso et al40 reported
a heightened propensity for SCC to metastasize in
black Canadian patients with discoid lupus erythe-
matosus. Sun exposure of hypopigmented lesions of
discoid lupus erythematosus may have been a
predisposing factor.
In blacks, Bowen disease (SCC in situ) typically
presents as scaly hyperkeratotic pigmented pla-
ques, and may be misdiagnosed as MM. In contrast,
Bowen disease lesions are rarely pigmented
outside of the groin in whites.41 Black women
are affected twice as often as black men, and most
frequently in skin that is not sun exposed.19 In a
study performed by Mora et al42 in New Orleans,
LA, evolution to SCC was noted in 5 of 19 black
patients with Bowen disease, leading to death in 3
of these patients. The most common area affected
was the lower extremity.42 Mortality of SCC in
blacks is as high as 29%, secondary not only to
delays in diagnosis and treatment, but also to more
aggressive biologic behavior of SCC in this popu-
lation.41,43 In blacks, SCC that develops within a
chronic scarring process tends to be more aggres-
sive and is associated with a 20% to 40% risk of
metastasis. In contrast, the rate of metastatic trans-
formation of sun-induced SCC in blacks is approx-
imately 1% to 4%.4 In a case series on SCC in blacks
performed by Mora and Perniciaro
(New Orleans,
LA), the highest mortality was observed in cases of
perianal SCC. Although most patients with primary
SCC have a very good prognosis, the 10-year
survival is less than 20% in patients with regional
lymph node metastasis, and less than 10% in
patients with distant metastasis.29
SCC in Asians
Bowen disease and pigmented BCCs are not
uncommonly diagnosed in Asians. Because of their
pigmented appearance, as in blacks, these may be
misdiagnosed as MM.25 Although NMSC is uncom-
mon, it is not rare in the Chinese population in Hong
Kong. Cheng et al25 (Hong Kong, China) reported
that the incidence of SCC in 1990 was 0.16 per
100,000 population, and in 1999, 0.34. Similarly, in a
case-control study performed by Chen et al44 in
Taiwan evaluating the association between UV radi-
ation exposure from the sun and risk for develop-
ment of SCC by gender, exposure at a young age
(15-24 years) and cumulative sun exposure were
significantly associated with heightened risk of SCC
in a dose-related pattern. Cumulative sun exposure
was found to be more closely related to increased
risk of SCC in women, whereas sun exposure at an
early age showed more relevance to SCC risk in
men.44 Skin reactions such as redness, burn, and
suntan after 2 hours of sun exposure in childhood
and adolescence were not associated with increased
risk for SCC.44
In a study on skin cancer incidence between 1986
and 1997 among Asians living in Singapore, 2650
BCCs were reported. There was a general increase in
skin cancer incidence from 6 per 100,000 person-
years (from 1968-1972) to 8.9 per 100,000 person-
years (1993-1997). The incidence of BCC increased
approximately 3% yearly. Age-standardized inci-
dence rates for BCC were greatest in fair-skinned
Chinese, followed by Malays and Indians. This trend
was also noted for SCC and cutaneous MM.
MM is the deadliest type of skin cancer found
across all races and ethnicities. Many melanoma cases
are diagnosed in nonhospital settings and thus may
be underreported to central cancer registries, which
traditionally collect the majority of cases from hospi-
tals.46 This could lead to significant underreporting of
MM and resultant underestimation of the incidence of
melanoma.47 The National Cancer Institute, Division
of Cancer Control and Population Sciences,
Surveillance Research Program, Cancer Statistics
Branch (Bethesda, MD) reports that the incidence
of cutaneous MM increased by approximately 6%
yearly in the 1970s, slowed to a 3% yearly increase
between 1981 and 2000, and has since stabilized.48
Since the late 1980s, the incidence of MM has
increased significantly among Hispanics in
California, increasing an average of 1.8% yearly in
male Hispanics between 1988 and 2001, and 7.3%
average yearly between 1996 and 2001.49 In a study
conducted by Bergfelt et al,50 the incidence of MM
Fig 2. Melanomas in people of color. A, Lentigo maligna in middle-aged Hispanic woman
(vermilion upper and lower lips). Melanoma in middle-aged black woman (right fourth toe)
(B); Hispanic woman (left fifth toe) (C); middle-aged Hispanic man (left plantar foot) (D);
elderly Hispanic man (right cheek) (E); and Asian woman (side of left leg) (F).
Agbai et al 753
among Hispanics in Puerto Rico and New Mexico
(race not specified) was greater than in US blacks by
1.6- to 3.7-fold. There was a close correlation in
anatomic distribution of MM among whites and
Hispanics in New Mexico in both men and women.
The most common MM distribution in Hispanics from
Puerto Rico was the leg, as was seen in black
Americans.50 In another study, Vazquez-Botet et al51
reported that nearly half of MM in Hispanic patients in
Puerto Rico were found on the extremities, especially
the feet, similar to black and Japanese patients.
Superficial spreading melanoma was the most com-
mon histologic type, followed by acral lentiginous,
nodular, and lentigo maligna melanomas.51 More
recently, Wu et al52 (New Orleans, LA) reported that
incidence rates of MM in the United States were
notably higher in females than males in white and
Hispanic populations younger than 50 years, and in
Asian/Pacific Islanders younger than 40 years. The
median age of white and black patients was greater
(59-63 years) when compared with Hispanics, Asian/
Pacific Islanders, and American Indians/Alaskan
Natives (52-56 years).52 Histologically, acral lentigi-
nous melanoma was the most common subtype in
blacks, whereas superficial spreading melanoma was
most commonly diagnosed in all other ethnic groups
studied.52 Incidence rates of acral lentiginous
melanoma were, however, highest in Hispanics.
Non-whites demonstrated an increased propensity
to present with more advanced MM when compared
with whites.52
Typically, MM presents as a dark macule or patch
and may have a history of rapid spreading. Suspicion
for subungual melanomas is raised when a pig-
mented band wider than 3 mm is observed on the
nail, extension of pigment to proximal nail fold
(Hutchinson sign) and there is pigment variation,
rapid growth in size, and the observation of solitary
lesions.4 Subungual melanoma is most common on
the thumb and first toe. In populations of color, the
plantar foot is most commonly affected (Fig 2),53 as it
is implicated in 30% to 40% of cases.54 Melanomas
found in the oral cavity comprise approximately 7.5%
of all melanomas in Asians, where approximately
60% of these develop from lesions of oral melanosis.
The greatest risk factors for the development of MM
in whites include periods of high intermittent sunlight
exposure (as in sunbathing and indoor tanning), and
large cumulative doses of UV radiation from chronic
exposure (as seen in outdoor workers).55 Factors in
the host that may increase susceptibility to develop-
ment of melanoma include a large number of nevi, the
presence of dysplastic nevi, freckles, fair complexion,
red or blonde hair, and family history of MM.55
APRIL 2014
754 Agbai et al
Contrarily, in blacks and Asians, UVradiation does not
appear to be a major risk factor, as the majority of
melanomas are found in skin that is not typically sun
exposed, including palmar, plantar, and subungual
skin, and mucous membranes.56 In POC, the risk
factors for MM have not been identified, but may be
unrelated to sun exposure.57 Specifically, as acral
melanomas are identified with similar rates at different
latitudes and in varying racial groups, and as they tend
to be diagnosed in anatomic sites that are not typically
sun exposed, their origin may be unrelated to sun
MM in blacks
In black Americans, acral lentiginous melanoma is
the most common and deadly form of MM.56,58 Not
uncommonly it is misdiagnosed and managed as a
tinea nigra, or even talon noir. In a retrospective
study performed at Tulane University School of
Medicine (New Orleans, LA)58 from 1958 to 1990,
82 patients (including 27 white men, 29 white
women, 18 black men, and 8 black women) with a
diagnosis of acral lentiginous melanoma were fol-
lowed up, and the study showed a trend toward
reduced survival in black men. A direct correlation
between decreased survival and increased Clark
level was also observed. As previously mentioned,
the overall incidence of melanoma in the black
population is lower than that of whites. Additional
types of melanoma found in black Americans
include superficial spreading and nodular types.
Acral lentiginous melanoma has a poor prognosis
secondary to its propensity for deep invasion at
presentation, with 5-year survival lower than 50%.59
In a study of skin cancers in a teaching hospital in
Nigeria between 2000 and 2004, MM of the skin
represented 8% (n = 5) of the 63 histologically
diagnosed cutaneous malignancies. All of these
MMs were plantar. Three of the 5 cases were
clinically advanced nodular melanomas, whereas 2
were ulcerated superficial spreading melanomas.21
MM in Hispanics
Pipitone et al60 (Maywood, IL) proposed that
Hispanics had a propensity to present with more
advanced disease secondary to the combination of a
belief that they are not at risk to sunburn and/or
develop skin cancer. Skin cancer prevention mea-
sures are typically directed toward non-Hispanic
whites, where skin self-examination and sun protec-
tion are emphasized.13 Feun et al61 (Miami, FL)
reviewed 54 melanoma cases in Hispanic patients;
the majority of melanomas were located on the
trunk, arm, shoulder, leg, and hip. Although 70% of
these patients presented with local disease, 26%
presented with regional and distant lesions. In this
study, Hispanics given the diagnosis of melanomas
had better treatment outcomes and survival than
non-Hispanics.61 This contradicts a handful of other
studies that have demonstrated poorer survival in
Hispanic populations.57,62,63
MM in Asians
In Asian populations, the sole of the foot is the
most common site for MM.28 This is typically acral
lentiginous melanoma.28 As in blacks and Hispanics,
MMs in Asians have a propensity to be diagnosed at a
late stage in comparison with whites.57 In a study
done in Taiwan, factors such as age over 55 years,
male gender, tumor thickness, and tumor ulceration
were generally predictive of a poorer prognosis.64 In
a study done in Japan, loss of the p53 gene though
deletion mutation was associated with more aggres-
sive subtypes of MM.65
Although in whites, number of melanocytic nevi is
directly proportional to risk of developing MM,66 this
may not be the case in POC. The density of
melanocytic nevi is significantly lower in POC than
in whites.66 Gallagher et al66 (Vancouver, British
Columbia, Canada) found that nevus density in
Asians was unrelated to skin color or tendency to
burn. These findings may …

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