Brykyta Shelton found herself standing in the checkout line at a big-box retailer, uncomfortably aware of a woman staring at her sandaled feet.
Shelton had been on medication for months for what his doctor said was toenail fungus, but one nail still looked gross.
After Shelton finished his shopping, the woman pulled him aside and said that, while she wasn’t a doctor, she thought Shelton was dealing with something more serious than fungus.
“He’s like: ‘I know I’m just a random stranger, but please, somebody else check this out,'” says Shelton, who lives in a Maryland suburb of Washington, D.C.
Shelton, now 42, took the advice.
Initial lab work did not yield a clear diagnosis, but her new doctor said he was confident she had acral lentiginous melanoma, a form of skin cancer. Additional testing proved him right. Although rare, it is the most common subtype of melanoma in black people like Shelton. It’s the disease that killed reggae star Bob Marley at the age of 36, and it’s often found on skin less frequently exposed to the sun, such as the hands, soles of the feet, and under the nails. Researchers don’t understand what causes acral lentiginous melanoma, and they don’t know how to prevent it. It is often overlooked or misdiagnosed in skin tests.
Skin cancer, in general, is often missed or misdiagnosed in black patients.
Historically, black people and those with dark skin have been left out of efforts to fight skin cancer. Long neglected by sunscreen manufacturers and a medical community lagging behind in diversity and cultural competence — recognizing patients’ traditions, beliefs and values — many are not informed about sun protection or how to check their skin for signs of damage or cancer.
To be sure, skin cancer rates are lower for people with darker skin tones. Melanoma is more than 20 times more common in whites than African Americans, with an overall lifetime risk of 1 in 38 for whites compared to 1 in 1,000 for blacks. Melanin provides some protection against sun damage, so people who have more of it – those with dark skin – are better protected than those with fair skin.
But overall, black patients are more likely to be diagnosed with more advanced forms of skin cancer and have higher mortality rates, said Dr. Janine Luke, with the Skin of Color Society, a nonprofit that works to educate doctors and the public about skin health.
According to a report by the Centers for Disease Control and Prevention, the five-year melanoma survival rate among non-Hispanic blacks is 66%, compared to 90% for non-Hispanic whites. According to the American Cancer Society, 1 in 3 black men or women diagnosed with melanoma in the United States die from the disease, compared to at least 1 in 7 for non-Hispanic whites.
Given the perceived disparity in outcomes, Skin of Color Society President Dr. Valerie Harvey said two areas of research are needed: studying educational initiatives to see if awareness can lead to earlier diagnosis and improved survival; and determining risk factors for dark-skinned patients, particularly those with less sun exposure, for developing melanoma.
Improving cultural competence and diversity within dermatology is only one step toward improving diagnosis and outcomes. According to recent data, fewer than 3% of dermatologists nationwide are black. Orthopedics is the only medical specialty with a small fraction.
Dermatology has traditionally been one of the most competitive specialties in medicine, says Dr. Michelle Henry, a clinical instructor of dermatology at Weill Cornell Medicine. In addition to rigorous academic requirements, admission to dermatology programs also depends on connections with mentors and extensive networking, which can be costly. And that, Henry said, has created barriers for traditionally black medical students who want to pursue dermatology.
“There are so many barriers that make it difficult for many students of color to do what they need to do in such an uber-exclusive and small space,” she said.
Recent initiatives are beginning to work to help students overcome these barriers, says Dr. Susan Taylor, MD, vice chair of the Department of Dermatology at the University of Pennsylvania and founder of the Color Society. American Academy of Dermatology initiatives include holistic review of residency applications, mentorship, and programs to increase interest in and prepare high school students for college and medical school.
Medical app company VisualDX is working to reduce disparities in medicine through Project Impact by creating a catalog of images that reflect different diseases in different skin tones. Skin cancer can look different on fair skin than on dark skin, and because doctors may only be trained to image fair-skinned people, the chance of misdiagnosing dark-skinned people increases.
The sunscreen industry has also changed.
Jorge Martinez-Bonilla, senior vice president and partner at C+R Research, a market research firm in Chicago, said the medical community’s failure to provide adequate skin care for people with black skin is due to the lack of availability of sunscreen to meet patient needs, especially for black people.
“What it did is it pushed black entrepreneurs from one day to the next to come up with their own solutions and their own products,” Martinez-Bonilla said. “Not just from a lack of availability, but because these people know their needs best.”
Katonya Breaux is one of those entrepreneurs. She wasn’t thrilled when, in her 30s and 40s, she noticed moles appearing on her face and neck like she had seen on older family members growing up. He assumed it was just part of aging. But her dermatologist said it was sun damage.
“I was literally shocked. I was like: ‘But I’m black,'” she says, adding that she had no experience with sunscreen growing up. “It was so foreign to me. I believed we didn’t need it.”
After struggling to find a sunscreen that didn’t leave a residue or feel like it was burning her skin, she worked with a chemist who helped her create a tinted mineral-based sunscreen. At first, she intended it only for her personal use, but she eventually launched Ansan Cosmetics. The Los Angeles-based company teaches skin care and sells products designed for consumers with dark skin.
Shontay Lundy has also struggled to find a sunscreen that “doesn’t give my skin a blue, purple or other color cast.” Until, he said, “I realized it didn’t exist.”
So, in 2016, she created products that left no residue, eventually launching Black Girl Sunscreen.
Education is fundamental to his company’s advertising, Lundy said. “Our mission is to help people of all ages and skin colors take their skin health seriously and protect themselves from sun damage with the right sunscreen products.”
Shelton, whose cancer diagnosis came from a chance encounter in a store checkout line, said she has become an advocate for skin self-exams and sunscreen and is now known as the “sunblock lady” at her local pool. The type of skin cancer she got may not have been from sun exposure, but it raised her awareness of skin damage and other types of skin cancer.
Doctors have since successfully removed the tumor from her toe and she has been cancer free through chemotherapy and radiation. But the experience was traumatic.
“It’s life-changing,” he said.
Still, he said, he has resumed an active and full life. He said he will be forever grateful to the stranger who pulled him aside that day, as well as the doctor who disbelieved the first set of labs that came back, choosing instead to trust his instincts to begin treatment immediately.
Skin Cancer Avoidance Tips for All Skin Tones
• Avoid direct sunlight, especially between 10 am and 4 pm Keep children completely out of the sun.
• Use a broad-spectrum sunscreen with an SPF of 30 or higher every day. Reapply every two hours or after swimming or activity/sweating.
• Do not leave sunscreen in the car, as temperature fluctuations can cause it to break down and become less effective.
• Wear clothing that covers arms and legs.
• Wear a wide-brimmed hat to protect the face, ears and neck.
• Wear UV-blocking sunglasses.
• Avoid indoor tanning beds.
• Check the skin from head to toe every month. Look for dark spots or patches, or growths that are growing, bleeding or changing; Sores that are slow to heal, or heal and come back; patches of skin that feel rough and dry; and dark lines under or around fingernails or toenails. Be diligent to check nail beds, palms, soles of feet, head, lower legs, groin, and other places that get little sun. Contact a doctor if you have any concerns.
• See a board-certified dermatologist at least once a year for a full-body exam.
Sources: Skin Cancer Foundation, American Academy of Dermatology, Dr. Janine Luke, Dr. Michelle Henry, Katonia Breaux
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