Skin cancer is always a risk, but it can go unnoticed on the skin

Brykita Shelton was in the checkout line at a department store when she felt uncomfortable because a woman in front of her was staring at her feet.

Shelton was taking medication for toenail fungus that his doctor said, but one of his nails looked really bad.

After paying, the woman approached Shelton and told him that although he wasn’t a doctor, she thought his foot was more serious than a fungus.

“She told me, ‘I know I’m a stranger to you, but please have someone else look at you,'” said Shelton, who lives in a Maryland suburb in the Washington, D.C., area.

Shelton, now 42, followed the advice.

Initial lab tests did not yield a clear diagnosis, but her new doctor assured her that she had acral lentiginous melanoma, a form of skin cancer.

Subsequent tests proved him right. Although rare, it is the most common subtype of melanoma in black people like Shelton. It’s a disease that killed reggae star Bob Marley at the age of 36, and it usually occurs on skin with less sun exposure, such as the hands, soles of the feet, and under the nails.

Researchers don’t understand what causes acral lentiginous melanoma and don’t know how to prevent it. It is often missed or misdiagnosed in skin tests.

Skin cancer, in general, is often missed or misdiagnosed in dark-skinned patients.

Historically, African Americans and people with darker skin have been left out of efforts to fight skin cancer. For too long, sunscreen manufacturers and a medical community lacking knowledge of diversity and cultural competence—acknowledging the patient’s roots, beliefs, and values—have ignored segments of the population when reporting on sun protection or how to get your skin checked for damage or cancer.

It is true that people with darker skin tones have lower rates of skin cancer. Melanoma is 20 times more common in whites than African Americans, with an overall risk of 1 in 38 in whites, compared to 1 in 1,000 in blacks. Melanin provides some protection against sun damage, so people with more melanin—those with darker skin—are better protected than those with lighter skin.

But in general, black patients are more likely to develop later-stage skin cancers and have higher mortality rates, according to Dr. Janine Luke of the Skin of Color Society, a nonprofit organization that works to educate physicians and the general public about skin health.

According to a report by the Centers for Disease Control and Prevention (CDC), the five-year melanoma survival rate among non-Hispanic blacks is 66%, compared to 90% for non-Hispanic whites. And the American Cancer Society says 1 in 3 black men or women diagnosed with melanoma in the U.S. die from the disease, compared to 1 in 7 for non-Hispanic whites.

Given the known 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 longer survival; and determine risk factors for dark-skinned patients, particularly those with less sun exposure, who develop melanoma.

Improving cultural competence and diversity within dermatology is only one step in improving diagnosis and outcomes. According to recent data, less than 3% of dermatologists in the country are black. Orthopedics is the only medical specialty with a lower percentage.

Dermatology has traditionally been one of the most competitive specialties in medicine, says Dr. Michelle Henry, 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 an extensive network of contacts. And that, according to Henry, has traditionally created barriers for black medical students who want to pursue dermatology.

“There are many barriers that make things difficult for many students of color in such an exclusive and small space,” she added.

Recent initiatives to help students overcome those barriers are starting to pay off, according to Dr. Susan Taylor, vice president of diversity, equity and inclusion at the University of Pennsylvania’s department of dermatology and founder of the Skin of Color Society. American Academy of Dermatology (AAD) initiatives include a holistic review of residency applications, mentorships, and programs to engage high school students and prepare them for college and medical school.

Medical app company VisualDX seeks to reduce disparities in medicine through Project Impact, creating catalogs of images that reflect different diseases on different skin tones. Skin cancer can look different in light skin than in dark skin, and because doctors may only be trained in the presentation of light skin, there is an increased chance of misdiagnosis in people with dark skin.

The sunscreen industry has also changed.

Jorge Martinez-Bonilla, vice president and partner at C+R Research, a Chicago-based market research firm, said the medical community’s failure to provide adequate skin care for black people reflects the lack of availability of sunscreens that meet the needs of patients, particularly African Americans.

“It pushed black entrepreneurs to create their own solutions and their own products, from one day to the next,” Martinez-Bonilla said. “Not just because of a lack of product, but because they are the people who know their needs best.”

Katonya Breaux is one of those business women. He was surprised when, in his 30s and 40s, he noticed moles growing on his face and neck similar to those he had seen on his older family members as children. He thinks it’s part of aging. But her dermatologist told her it was sun damage.

“I was literally shocked. I thought: ‘But I’m black,'” he said, adding that he had never used sun protection in his life. “It was something strange for me. I thought we didn’t need it.”

After being frustrated in her search for a residue-free sunscreen that wouldn’t make her skin feel burnt, she worked with a chemist who helped her develop a mineral-based sunscreen. At first, he intended it only for his personal use, but eventually he launched Ansan Cosmetics. The Los Angeles-based company educates on skin care and sells products designed for dark-skinned consumers.

Shonte Lundy was also looking for a sunscreen that “wouldn’t leave my skin blue, purple, or any other cast.” Until “I realize it doesn’t exist”.

So, in 2016, it developed products that leave no residue, finally launching Black Girl Sunscreen.

Lundy stresses that education is fundamental to his company’s marketing. “Our mission is to equip people of all ages and skin colors with the right sun protection products so they can take their skin health seriously and protect themselves from sun damage.”

Shelton, whose cancer diagnosis came from a chance encounter in a store checkout line, said she became a fan of skin self-exams and sun protection and now everyone knows her as the “sunscreen lady” at her local pool. The type of skin cancer she suffered from may not have been caused by sun exposure, but it raised her awareness of skin damage and other types of skin cancer.

She is cancer free after doctors successfully removed the tumor from her toe and underwent chemotherapy and radiotherapy. But the experience was traumatic.

“It changed my life,” he said.

But she also says she’s back to a full and active life. He will always be grateful to the stranger who spoke to him that day, as well as to the doctor who disbelieved the first set of lab tests, choosing instead to trust his instincts to begin treatment immediately.

Tips to Avoid Skin Cancer for All Skin Tones

  • Avoid direct sunlight, especially between 10 am and 4 pm.
  • Use a broad-spectrum sunscreen with an SPF of 30 or higher every day. Reapply every two hours or after swimming or sweaty activity.
  • Do not leave sunscreen in the car, as temperature fluctuations can cause it to break down and lose effectiveness.
  • Wear clothing that covers your arms and legs.
  • Wear a wide-brimmed hat to protect your face, ears and neck.
  • Wear sunglasses with UV filters.
  • Avoid indoor tanning beds.
  • Check the skin from head to toe every month. Look for dark spots or patches, or shapes that grow, bleed or change shape; 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. Carefully check your nail beds (the skin under the nails), your palms, the soles of your feet, your head, lower legs, groin, and other places that get little sun. Contact a doctor if you have any concerns.
  • Make an appointment with a dermatologist at least once a year for a full-body exam.

Sources: Skin Cancer Foundation, American Academy of Dermatology Janine Luke, Dr. Michelle Henry, Katoni Breaux.

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