10.5826/dpc.1202a75
Background: Minimal knowledge exists regarding skin cancers in Black individuals, which may adversely affect patient care.
Objectives: To describe clinical features and risk factors of skin cancers in Black individuals. &nbsp;
Methods: Retrospective study of Black individuals diagnosed with skin cancer between January 2000 and January 2020 at our institution.
Results: 38,589 patients were diagnosed with skin cancer, of which 165 were Black. &nbsp;One-hundred-thirteen of these Black individuals were diagnosed with melanoma, 35 with squamous cell carcinoma (SCC), and 17 with basal cell carcinoma (BCC). Most melanomas (80.0%, n=90) were of the acral subtype; 75% (6 of 8 cases with dermoscopic images) displayed a parallel ridge pattern (PRP). The surrounding uninvolved background skin was visible in 7 cases, all demonstrating a PRP. This disappeared adjacent to most of the melanoma lesions (n=4, 57.1%) – creating a peripheral hypopigmented “halo”. The nonmelanoma skin cancers were pigmented and had similar dermoscopic features as reported in predominantly white populations. Most SCCs (n=5, 71.4%) had a hypopigmented “halo” and most BCCs (n=10, 55.6%) had an accentuated reticular network adjacent to the lesions. Most (80.0%, n=28) SCC patients had a chronic inflammatory condition. Two BCC patients (16.7%) had Gorlin syndrome.
Conclusions: Skin cancers are pigmented in Black individuals. In both ALMs and SCCs, we noted a peripheral rim of hypopigmentation between the lesions and the surrounding uninvolved background skin, while BCCs had accentuation of the background pigmentation adjacent to the lesions. Most acral melanomas displayed a PRP, which was also seen in surrounding uninvolved background skin. &nbsp;
text/xml
2160-9381
1902
en
Ashfaq Marghoob
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
dermoscopy
Features of Skin Cancer in Black Individuals: A Single-Institution Retrospective Cohort Study
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-05-02
2021-07-21
2022-05-02
2022-05-24
e2022075
Dermatol Pract Concept
Background: Minimal knowledge exists regarding skin cancers in Black individuals, which may adversely affect patient care.
Objectives: To describe clinical features and risk factors of skin cancers in Black individuals. &nbsp;
Methods: Retrospective study of Black individuals diagnosed with skin cancer between January 2000 and January 2020 at our institution.
Results: 38,589 patients were diagnosed with skin cancer, of which 165 were Black. &nbsp;One-hundred-thirteen of these Black individuals were diagnosed with melanoma, 35 with squamous cell carcinoma (SCC), and 17 with basal cell carcinoma (BCC). Most melanomas (80.0%, n=90) were of the acral subtype; 75% (6 of 8 cases with dermoscopic images) displayed a parallel ridge pattern (PRP). The surrounding uninvolved background skin was visible in 7 cases, all demonstrating a PRP. This disappeared adjacent to most of the melanoma lesions (n=4, 57.1%) – creating a peripheral hypopigmented “halo”. The nonmelanoma skin cancers were pigmented and had similar dermoscopic features as reported in predominantly white populations. Most SCCs (n=5, 71.4%) had a hypopigmented “halo” and most BCCs (n=10, 55.6%) had an accentuated reticular network adjacent to the lesions. Most (80.0%, n=28) SCC patients had a chronic inflammatory condition. Two BCC patients (16.7%) had Gorlin syndrome.
Conclusions: Skin cancers are pigmented in Black individuals. In both ALMs and SCCs, we noted a peripheral rim of hypopigmentation between the lesions and the surrounding uninvolved background skin, while BCCs had accentuation of the background pigmentation adjacent to the lesions. Most acral melanomas displayed a PRP, which was also seen in surrounding uninvolved background skin. &nbsp;
Ashfaq Marghoob
2022/05/02
10.5826/dpc.1202a75
e2022075
Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
2160-9381
dermoscopy
en
e2022075
Features of Skin Cancer in Black Individuals: A Single-Institution Retrospective Cohort Study
https://dpcj.org/index.php/dpc/article/download/1902/1586
      Features of Skin Cancer in Black Individuals:
     A Single-Institution Retrospective Cohort Study
          Rachel N Manci1,2, Megan Dauscher1, Michael A Marchetti1, Richard Usatine3,
                 Veronica Rotemberg1, Stephen W Dusza1, Ashfaq A Marghoob1


1 Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
2 Cooper Medical School of Rowan University, Camden, NJ, USA
3 University of Texas Health, San Antonio, TX, USA



Key words: skin cancer, skin of color, ethnic skin, dermoscopy
Citation: Manci R, Dauscher M, Marchetti MA et al. Features of skin cancer in black individuals: a single-institution retrospective cohort
study. Dermatol Pract Concept. 2022;12(2):e2022075. DOI: https://doi.org/10.5826/dpc.1202a75
Accepted: October 8, 2021; Published: April 2022
Copyright: ©2022 Manci et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: Supported in part by Memorial Sloan Kettering Cancer Center’s NIH/National Cancer Institute Cancer Center support grant P30
CA008748.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Ashfaq Marghoob, M. Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center,
New York, NY, USA. E-mail: marghooa@mskcc.org




  ABSTRACT             Introduction: Minimal knowledge exists regarding skin cancers in Black individuals, which may ad-
                       versely affect patient care.
                       Objectives: To describe clinical features and risk factors of skin cancers in Black individuals.
                       Methods: Retrospective study of Black individuals diagnosed with skin cancer between January 2000
                       and January 2020 at our institution.
                       Results: 38,589 patients were diagnosed with skin cancer, of which 165 were Black individuals.
                       One-hundred-thirteen of these Black individuals were diagnosed with melanoma, 35 with squamous cell
                       carcinoma (SCC), and 17 with basal cell carcinoma (BCC). Most melanomas (80.0%, n = 90) were of
                       the acral subtype; 75% (6 of 8 cases with dermoscopic images) displayed a parallel ridge pattern (PRP).
                       The surrounding uninvolved background skin was visible in 7 cases, all demonstrating a PRP. This dis-
                       appeared adjacent to most of the melanoma lesions (n = 4, 57.1%). creating a peripheral ­hypopigmented
                       “halo”. The nonmelanoma skin cancers were pigmented and had similar dermoscopic features as report-
                       ed in predominantly White populations. Most SCCs (n = 5, 71.4%) had a hypopigmented “halo” and
                       most BCCs (n = 10, 55.6%) had an accentuated reticular network adjacent to the lesions.
                       Conclusions: Skin cancers are pigmented in Black individuals. In both acral melanomas and SCCs, we
                       noted a peripheral rim of hypopigmentation between the lesions and the surrounding uninvolved back-
                       ground skin, while BCCs had accentuation of the background pigmentation adjacent to the lesions. Most
                       acral melanomas displayed a PRP, which was also seen in surrounding uninvolved ­background skin.




Original Article | Dermatol Pract Concept. 2022;12(2):e2022075                                                                               1
Introduction                                                         All lesions selected for biopsy by the dermatology ser-
                                                                  vice undergo clinical and dermoscopic imaging. Thus, we
Skin cancer is the most common malignancy worldwide and           cross-referenced all 165 cases with our image database to
its incidence is expected to increase [1,2]. Although much is     conduct a subset analysis on available images. Most patients
known about the presentation of skin cancer in fair skin indi-    (n = 146) were referred to MSKCC after a biopsy was per-
viduals, there is a paucity of data regarding disease morphol-    formed by a community-based practitioner, and therefore did
ogy and contributing risk factors among those with darker         not have images in our database. There were clinical and der-
skin [2-5]. This is likely secondary to the relatively higher     moscopic images of 37 lesions from 19 patients (11 melano-
incidence of skin cancer in those with fair skin, as well as      mas from 11 patients, 8 SCCs from 3 patients, and 18 BCCs
disparities related to systemic racism in healthcare systems.     from 5 patients). We evaluated images for standard dermo-
    It is essential for healthcare providers to assess skin le-   scopic features [8-13]. We also evaluated the surrounding
sions with consideration of skin types. Experience has shown      uninvolved background skin to identify dermoscopic struc-
that skin cancer risk factors and morphology are not the          tures or patterns present in this surrounding skin.
same across all skin types, but there have been few stud-            To analyze melanoma cases, we utilized the World Health
ies specifically examining Black individuals [6,7]. This void     Organization melanoma classification algorithm as a basis
increases the risk of missed diagnoses, and simultaneously        for subtype classification [14].
may increase morbidity through the unnecessary biopsies of           Frequencies, relative frequencies, means, standard devia-
benign skin lesions.                                              tions (SD), and ranges were used to describe the distribution
                                                                  of characteristics and dermoscopic features of skin cancers.

Objectives
                                                                  Results
To address these knowledge gaps, we sought to describe the
clinical and dermoscopic features of skin cancers in Black
                                                                  Overall Results
patients that were seen at Memorial Sloan Kettering Can-
cer Center (MSKCC). Additionally, we identified skin cancer       Our search yielded a total of 165 Black patients diagnosed
risk factors and features of early disease.                       with BCC, SCC, or melanoma between January 1st, 2000
                                                                  and January 1st, 2020. The average age at diagnosis was 58.9
                                                                  years (SD = 3.2) and 59% (n = 96) were female. One hun-
Methods
                                                                  dred and thirteen patients (68.5%) were diagnosed with mel-
This study was approved by the Institutional Review Board         anoma, 35 (21.2%) with SCC, and 17 (10.3%) with BCC.
at MSKCC and adhered to the Helsinki declaration. We
conducted a retrospective review of Black patients with bi-       Acral Lentiginous Melanomas (ALM)
opsy-confirmed basal cell carcinoma (BCC), squamous cell          The majority of melanomas were acral (80.0% of all mela-
carcinoma (SCC), or melanoma seen at MSKCC between                noma cases, n = 90), with 83.4% (n = 75) occurring on plan-
January 1st, 2000, and January 1st 2020. We identified pa-        tar surfaces, 13.3% (n = 12) in nail units, and 3.3% (n = 3)
tients with billing record ICD diagnostic codes for these         on palmar surfaces. The average age at diagnosis was 61.7
skin cancers (n = 38,948). At our institution, race/ethnicity     years (SD = 13.0) and 52.2% (n = 47) were male.
information is collected from all patients, and we selected          Most plantar ALMs were invasive (Table 1) and half of
those who self-identified as Black (n = 359). Racial informa-     these cases were classified as AJCC 8th edition stage IV mel-
tion was missing from 344 cases and these were excluded.          anoma at the time of initial biopsy. All dermoscopic images
We screened medical records and included Black patients           (n = 8) had structureless areas with multiple colors and most
who received treatment for skin cancers at our institu-           had a parallel ridge pattern (PRP) (Table 2). The surrounding
tion (n = 165). We conducted a review of medical records          uninvolved background skin was visible in 7 of these cases, all
through January 2020 and recorded demographic informa-            demonstrating a PRP and most also demonstrating a fibrillar
tion, medical history, and skin cancer risk factors, including    pattern (Figure 1). Four of these cases (57.1%) demonstrated a
a history of cancer genetic syndromes, large congenital nevi,     peripheral hypopigmented “halo” (Figure 1). Additionally, dif-
HPV infection, trauma, burns, and immunocompromised               fuse plantar lentigines were found in 5 of these cases (71.4%).
states. Additionally, we recorded the pathology diagnosis            Half of the nail unit ALMs were invasive (Table) and
and anatomic location of each cancer. We excluded those           two-thirds (n = 8) were classified as AJCC 8th edition stage
who did not receive treatment at our institution (n = 194)        IV melanoma at time of initial biopsy. There were der-
since they did not have complete reports within our medical       moscopic images of 3 nail-unit melanomas, all of which
record system.                                                    were heavily pigmented (Table 2). The melanoma-in-situs



2                                                                     Original Article | Dermatol Pract Concept. 2022;12(2):e2022075
                                             Table 1. Melanoma Characteristics
    Melanoma                                         Depth of invasion (mm)                                   Mitotic index (mit/
     subtype           In-situ versus Invasive       Mean (median, range)             Ulceration Y/N           mm2) Mean (SD)

                           n (%)         n (%)
                          in-situ      invasive                                   n (%) yes      n (%) no

 Plantar               27 (36.00)     48 (64.00)          5.84 (4, 0.75-55)       37 (49.33) 38 (50.67)            5.03 (5.91)
 ALM
 (n=75)

 Nail-unit ALM          6 (50.00)      6 (50.00)          3.15 (2.9, 1.6-5)        4 (33.33)     8 (66.67)         4.00 (4.30)
 (n=12)

 Palmar                 1 (33.33)      2 (66.67)         5.25 (5.25, 3.5-7)        1 (33.33)     2 (66.67)         1.50 (0.71)
 ALM
 (n=3)

 Other melanomas          1 (5.26)    18 (94.74)         7.31 (4.5, 0.4-20)        3 (15.79)    16 (84.21)         5.25 (6.70)
 on non-acral and
 non-mucosal
 surfaces
 (n=19)

The pathologic characteristics of the melanomas observed in our Black patient population. ALM = acral lentiginous melanoma



                                     Table 2. Dermoscopic Features of Melanomas
                                         Dermoscopic Features                                                 Prevalence: n (%)
 Acral lentiginous melanoma cases on the soles (n=8)
 Structureless areas with multiple shades of brown, blue, black, and pink colors                                  8 (100.00)
 Parallel ridge pattern                                                                                            6 (75.00)
 Ulceration                                                                                                        2 (25.00)
 Atypical fibrillar pattern                                                                                        2 (25.00)
 Parallel ridge pattern of surrounding skin*                                                                      7 (100.00)
 Fibrillar pattern of surrounding skin*                                                                            4 (57.14)
 Peripheral hypopigmentation*                                                                                      4 (57.14)
 Diffuse plantar lentigines*                                                                                       5 (71.43)
 Acral lentiginous melanoma cases on the nail-unit (n=3)
 Hutchinson sign (pigmentation of the nail fold)                                                                  3 (100.00)
 Brown-to-black parallel lines on the nail plate with irregular spacing, thickness, and disruption                3 (100.00)
 of parallelism
 Band involving more than 2/3 of the nail plate                                                                    2 (66.67)
 Nail dystrophy                                                                                                    1 (33.33)



(n = 2) demonstrated micro-Hutchinson sign and brown to                  None of these patients had a family history of melanoma
black parallel lines on the nail plate with irregular spac-          or had received testing for germline mutations increasing
ing, thickness, and disruption of parallelism (Figure 2).            melanoma risk.
The invasive melanoma (n = 1) demonstrated Hutchin-
son sign, pigmentation of the entire nail plate, and nail            Melanomas, Not Otherwise Specified
dystrophy (Figure 2).                                                Nineteen (16.8%) melanoma cases were on non-acral cuta-
    There were only 3 palmar ALMs, 2 of which were in-               neous surfaces, and the average age at diagnosis was 54.7
vasive (Table 1) and classified as AJCC 8th edition stage IV         years (SD = 18.2). Twelve (63.2%) of these patients were fe-
melanoma at the time of initial biopsy. There were no dermo-         male. Two-thirds of these cases presented as AJCC 8th edition
scopic images of these ALMs.                                         stage IV melanoma (Table 1).



Original Article | Dermatol Pract Concept. 2022;12(2):e2022075                                                                    3
                                                                               Most cases occurred on the lower extremities (31.6%,
                                                                           n = 6) and back (26.3%, n = 5). The most common subtype
                                                                           was spindle cell and/or epithelioid (36.8%, n = 7). One pa-
                                                                           tient developed a dermal primary melanoma within a giant
                                                                           congenital nevus and no other risk factors were identified.
                                                                           There were no clinical or dermoscopic images.
                                                                               Other melanoma subtypes included mucosal (n = 8,
                                                                           7.1%), ocular (n = 4, 3.5%), and metastatic with unknown
                                                                           primary lesion (n = 6, 5.3%). Mucosal melanomas were
                                                                           located on the anus (n = 3), nasopharynx (n = 2), vagina
                                                                           (n = 2), and vulva (n = 1). No clinical or dermoscopic images
                                                                           were available.


                                                                           Squamous Cell Carcinomas
                                                                           There were 29 Black individuals with 35 SCCs, and the av-
                                                                           erage age at diagnosis was 56 years (SD = 16). Most cases
                                                                           (71.4%, n = 25) were invasive. Most SCCs were located on
                                                                           anogenital surfaces (n = 11), lower extremities (n = 7), or the
                                                                           head and neck (n = 6). Known SCC risk factors were identified
                                                                           in 80% of patients (n = 28), including active HIV infection
                                                                           (n = 11), chronic wounds (n = 4), prior radiation to the area
                                                                           (n = 2), psoriasis (n = 2), hidradenitis suppurativa (n = 1), and
                                                                           lichen simplex chronicus (n = 1). HPV testing was conducted
Figure 1. Acral melanoma on the sole of the foot. The normal back-         in 8 total cases, of which 7 were positive for high-risk HPV,
ground skin surrounding the acral melanomas had noticeable pig-            located on the anogenital region (n = 3) and nail unit (n = 4).
mentation demonstrating a parallel ridge pattern (solid oval). There
                                                                               There were dermoscopic images of 8 SCCs, many of
was loss of the pigmentation and dermoscopic patterns surrounding
                                                                           which were heavily pigmented (Table 3). In the surrounding
the lesion itself, generating a hypopigmented “halo” around the ac-
ral lentiginous melanoma on the plantar surface. This “halo” was           uninvolved background skin, half had a pigmented reticular
seen in 57.1% (n = 5) of plantar melanoma cases and was most               network and an associated “halo” effect (Figure 3); the other
evident in cases with the most heavily pigmented surrounding skin.         half had patchy hyperpigmentation.




Figure 2. Nail melanoma cases. (A,B) The dermoscopic images of two melanoma-in-situ cases that demonstrate micro-Hutchinson sign and
brown to black parallel lines on the nail plate with irregular spacing, thickness, and disruption of parallelism. (C) The clinical image of an in-
vasive melanoma case that demonstrates and easily visible Hutchinson sign, diffuse pigmentation of the whole nail plate, and nail dystrophy.




4                                                                               Original Article | Dermatol Pract Concept. 2022;12(2):e2022075
     Table 3. Dermoscopic Features of Non-Melanoma Skin Cancers (Basal Cell Carcinomas And
                                   Squamous Cell Carcinomas).
                                   DERMOSCOPIC FEATURES                                            PREVALENCE: n (%)
 Pigmented squamous cell carcinoma cases (n=3)
 Adherent scales with pigment                                                                            3 (100.00)
 Peripheral hypopigmentation, loss of pigmented network seen in surrounding skin                         3 (100.00)
 White circles                                                                                           1 (33.33)
 Milky-red areas                                                                                         1 (33.33)
 Non-pigmented squamous cell carcinoma cases (n=4)
 Adherent white scale                                                                                    4 (100.00)
 White circles                                                                                           3 (75.00)
 Ulceration                                                                                              3 (75.00)
 Peripheral hypopigmentation, loss of pigmented network seen in surrounding skin                         2 (50.00)
 Dotted vessels                                                                                          2 (50.00)
 Serpentine vessels                                                                                      1 (25.00)
 Shiny white strands                                                                                     1 (25.00)
 Peripheral islands of hyperpigmentation                                                                 1 (25.00)
 Nail unit squamous cell carcinoma case (n=1)
 Heavy pigmentation of the nail plate                                                                    1 (100.00)
 Nail dystrophy                                                                                          1 (100.00)
 Subungual hyperkeratosis                                                                                1 (100.00)
 Basal cell carcinoma cases (n=18)
 Loss of normal background pigmentation and network                                                      13 (72.22)
 Milky red area                                                                                          12 (66.67)
 Accentuated normal background pigmentation network surrounding the lesion itself                        10 (55.56)
 Leaf-like areas                                                                                         9 (50.00)
 Blue-gray ovoid nests                                                                                   9 (50.00)
 Multiple blue-gray dots and globules                                                                    9 (50.00)
 Shiny white blotches and strands                                                                        9 (50.00)
 Central hypopigmentation                                                                                6 (33.33)
 Spoke-wheel like structures                                                                            4/18 (22.22)
 Scale and/or crust                                                                                     2/18 (11.11)
 MAY globules                                                                                           1/18 (5.56)
 Milky white areas                                                                                      1/18 (5.56)
 Ulceration                                                                                             1/18 (5.56)
 Peripheral hypopigmentation                                                                            1/18 (5.56)


Basal Cell Carcinomas                                               Dermoscopic images were available for 18 BCCs (from 5
There were 15 Black individuals with 17 BCCs that were di-       patients), all of which were pigmented (Table 3). The surround-
agnosed and treated at our institution and the average age at    ing uninvolved background skin was assessed in 15 cases. All
diagnosis was 54.4 years (SD = 21.6). Most lesions were lo-      cases had a pigmented reticular network, and 11 cases (73.3%)
cated on the head and neck (n = 12). Pigmentation was noted      had an accentuated network adjacent to the lesion (Figure 4).
on the pathology report of 6 cases (35.3%). Pathologic sub-
types included combined nodular and infiltrative (n = 6), mi-
                                                                 Conclusions
cronodular (n = 3), nodular (n = 3), superficial (n = 1), and
combined superficial and nodular (n = 1). Two patients had       Over a 20-year period, only a small proportion of our skin
Gorlin syndrome, and no other risk factors were observed.        cancer patients were Black individuals; this is likely due to




Original Article | Dermatol Pract Concept. 2022;12(2):e2022075                                                                5
                                                                     Figure 4. Accentuated pigmented network surrounding the basal
                                                                     cell carcinoma lesion. The pigmentation network observed in the
                                                                     normal skin (dashed oval) was accentuated surrounding the basal
                                                                     cell carcinoma lesion itself (solid oval). This was observed in 55.6%
                                                                     (n = 10) of the basal cell carcinoma cases.



Figure 3. Loss of normal pigmented network surrounding the squa-     that MSKCC is a tertiary cancer center and therefore it is
mous cell carcinoma lesion. Note the pigmented network seen in the
                                                                     more likely to see advanced cases.
normal skin surrounding the pigmented squamous cell carcinoma
(solid ovals) and the loss of network just adjacent to the lesion        It is interesting to note that 90.6% (n = 102) of melano-
(dashed ovals). This was observed in 4 cases (57.1%).
                                                                     mas in our population were ALM, mucosal, or ocular sub-
                                                                     types, all of which have not been associated with ultraviolet
the overall low incidence of skin cancer in this population          radiation (UVR) exposure. Superficial spreading and lentigo
and also secondary to disparities in access to healthcare facil-     maligna melanomas are most closely associated with UVR
ities [15]. Reports have suggested that skin cancers are found       exposure; these subtypes accounted for only 2 of our cases
at more advanced stages in Black people compared to white            (1.8%), suggesting that UVR likely plays little to no role in
individuals – possibly due to differences in screening, skin         the pathogenesis of melanoma in Black individuals [20-22].
cancer knowledge, healthcare access, or cancer types across          As suggested by a recent systematic review, photoprotection
populations [16,17]. However, before recommending for or             will likely provide minimal benefit [20].
against screening or public education efforts to possibly ad-            We were unable to identify any major risk factors in
dress these disparities, it is imperative to discern the features    Black individuals. Benign pigmented macules and mottled
of skin cancers in Black patients and determine whether              hyperpigmentation on acral surfaces are suggested risk
these features can differentiate benign from malignant le-           factors, but approximately 50% of Black individuals have
sions in asymptomatic Black individuals.                             these features [23-25]. While many of our patients had dif-
    It has been reported that melanomas in Black individuals         fuse pigmented macules on the plantar surfaces, it is unlikely
are diagnosed at locally advanced stages with higher rates           that this is a risk factor given the high prevalence of this
of metastases [18]. While overarching gross statistics reveal        finding and the low prevalence of melanoma in Black indi-
that melanoma thickness is greater in Blacks compared to             viduals [23,25].
Whites, the difference narrows when the comparison focuses               The PRP has been suggested to have high sensitivity and
on ALMs, the most common subtype in Blacks [18,19]. An               specificity for early ALM in Caucasian and Asian popula-
analysis of the SEER database revealed that the average depth        tions, but it has not been validated in individuals of other
across all subtypes for Caucasians and African Americans             races/ethnicities [26]. While the majority of our plantar mel-
was 1.09 mm and 2.02 mm, respectively; when stratifying              anoma cases demonstrated the PRP, these individuals also
for subtype, the average depth of ALMs was 2.05 mm and               had the PRP in surrounding uninvolved background skin. A
2.28 mm, respectively [19]. Our review revealed a high pro-          limitation of this finding is that the clinically uninvolved skin
portion of advanced cases, but it is important to underscore         displaying the PRP was not biopsied. Therefore, it is possible



6                                                                         Original Article | Dermatol Pract Concept. 2022;12(2):e2022075
that this PRP may represent subclinical extension of the mel-      to be more sensitive to UVR. There is a known association
anomas, though we believe this is unlikely since the PRP was       between skin tone and BCC risk, of which Black individuals
diffusely present in the surrounding uninvolved background         with lighter complexions are more likely to develop BCCs
skin in the majority of our cases. Additionally, the PRP has       [35]. Two of our patients had Gorlin syndrome, but no other
been described in benign ethnic pigmented macules [27,28].         risk factors were observed.
Therefore, this knowledge adds credence that the PRP may              Pigmented BCCs are quite rare overall but are the most
lack discriminatory power in Black individuals; if used, it        prevalent type in Black populations [34,36]. All of our dermos-
may lead to an escalation of unnecessary biopsies [29]. Fu-        copy images were heavily pigmented, and the features were
ture studies analyzing the PRP in Black individuals may ben-       consistent with those known for pigmented BCCs. We ob-
efit from acquiring dermoscopy images of contralateral volar       served reticular pigmentation in the surrounding uninvolved
surfaces. Regarding other dermoscopic features observed in         background skin, and 55.6% (n = 10) of cases had a hyperpig-
our ALM cases, the presence of structureless areas with mul-       mented network adjacent to the lesion. Central hypopigmenta-
tiple colors proved most useful, but this was not helpful in       tion was seen in 33.3% (n = 6) of cases. These features are not
differentiation of in-situ and invasive disease, since cases of    to be confused with those of a dermatofibroma, a pigment net-
all stages exhibited this feature.                                 work and central scar-like white patch [37]. It is important to
    A novel feature we identified was a hypopigmented “halo”       note that no cases were associated with significant morbidity.
surrounding 57.1% (n = 4) of the plantar melanoma lesions,            Our study is limited since it is a retrospective analysis
all of which were melanoma in-situ cases. Further studies with     of a single tertiary cancer center. Referral bias is likely the
larger sample sizes would be helpful in identifying whether        reason for the high proportion of advanced disease cases.
this is a sensitive and specific feature for early diagnosis.      It is also important to consider other socioeconomic limita-
    Early detection also remains a challenge for nail-matrix       tions that may hinder the ability of some Black patients to
melanomas, since patients of color often have benign pig-          seek care at MSKCC. We observed that BCCs and SCCs are
mented nail bands [30]. To better understand how to differ-        pigmented and demonstrate similar dermoscopic features
entiate these benign from malignant lesions, we need data          to those reported in predominately White populations. Our
comparing ethnic pigmented nail bands and nail-matrix mel-         study brings into question the ability of the PRP to distin-
anomas. While we await such studies, reassuring factors in-        guish ALM from benign acral lesions. It has been reported
clude the involvement of multiple nails and stability over time.   that the PRP can be present in benign pigmented macules
    Regarding the other melanoma subtypes, no identifiable         on volar surfaces, and we also observed this pattern in the
risk factors were found. One patient developed a dermal mel-       surrounding uninvolved background skin, brining into ques-
anoma within a giant congenital nevus; dermoscopy will not         tion the reliability of this feature for differentiating benign
be useful in the early identification of these dermal lesions.     and malignant lesions in Black patients. Future research is
    Regarding squamous cell carcinomas (SCC), UVR expo-            needed to elucidate whether the rim of peripheral hypopig-
sure is the most common risk factor for the development of         mentation that we observed around the ALMs can assist in
SCC in those with fair skin, but trauma and inflammatory           the differentiation of ALMs and benign pigmented macules.
processes predominate the pathogenesis in Black popula-               Black individuals deserve equal care, which does not
tions, a trend also observed in our population [1,2,31-33].        necessarily mean the same care. Instead, it means that Black
Most Black patients had SCCs on non-sun exposed areas,             individuals deserve customized care based on the features
which is consistent with other literature reports, suggesting      most useful at discriminating benign from malignant lesions.
photoprotection will likely have little to no benefit [31,32].     Towards this end, a better understanding of the clinical, mor-
    SCCs in Black individuals are often superficial, discrete,     phologic, and dermoscopic features of skin cancers in those
hard lesions arising from an indurated, rounded, elevated          with darker skin is required.
base [31,32]. The dermoscopic features observed in our
images were similar to those described in white individu-
als, but there was a higher incidence of pigmented variants
                                                                   References
[8,10,31,33]. We observed a similar “halo” pattern as was           1. Gordon R. Skin cancer: an overview of epidemiology and
described for plantar ALMs, but a larger study is needed to            risk factors. Semin Oncol Nurs. 2013;29(3):160-169. DOI:
validate the predictive importance of this result.                     10.1016/j.soncn.2013.06.002. PMID: 23958214.
                                                                    2. Gloster HM Jr, Neal K. Skin cancer in skin of color. J Am
    Finally, in terms of our basal cell carcinomas (BCC), The
                                                                       Acad Dermatol. 2006;55(5):741-764. DOI: 10.1016/j.
majority of BCCs (70.6%) occurred on the head and neck
                                                                       jaad.2005.08.063. PMID: 17052479.
region, suggesting UVR may play some role in the pathogen-          3. Buster KJ, Stevens EI, Eelmets CA. Dermatologic health dis-
esis [34]. The low incidence of BCC in Black individuals sug-          parities. Dermatol Clin. 2012;30(1):53-viii. DOI: 10.1016/j.
gests that other factors must predispose certain individuals           det.2011.08.002. PMID: 22117867. PMCID: PMC3742002.



Original Article | Dermatol Pract Concept. 2022;12(2):e2022075                                                                   7
 4. Lawson CN, Hollinger J, Sethi S, et al. Updates in the under-       18. Cormier JN, Xing Y, Ding M, et al. Ethnic differences among
    standing and treatments of skin and hair disorders in women             patients with cutaneous melanoma. Arch Intern Med 2006;
    of color. Int J Womens Dermatol. 2017;3(1 Suppl):S12-S37.               166(17):1907-1914.      DOI:       10.1001/archinte.166.17.1907.
    DOI: 10.1016/j.ijwd.2017.02.006. PMID: 28492036; PMCID:                 PMID: 17000949.
    PMC5419061.                                                         19. Mahendraraj K, Sidhu K, Lau CSM, McRoy GJ, Chamberlain
 5. Alexis AF, Sergay AB, Taylor SC. Common dermatologic dis-               RS, Smith FO. Malignant Melanoma in African-Americans: A
    orders in skin of color: a comparative practice survey. Cutis.          Population-Based Clinical Outcomes Study Involving 1106 Afri-
    2007;80(5):387-394. PMID: 18189024.                                     can-American Patients from the Surveillance, Epidemiology, and
 6. Hogue L, Harvey VM. Basal Cell Carcinoma, Squamous Cell                 End Result (SEER) Database (1988-2011). Medicine (Baltimore).
    Carcinoma, and Cutaneous Melanoma in Skin of Color Pa-                  2017;96(15):e6258. DOI: 10.1097/MD.0000000000006258.
    tients. Dermatol Clin. 2019;37(4):519-526. DOI: 10.1016/j.              PMID: 28403068. PMCID: PMC5403065..
    det.2019.05.009. PMID: 31466591.                                    20. Lopes FCPS, Sleiman MG, Sebastian K, Bogucka R, Jacobs EA,
 7. Ezenwa E, Stein JA, Krueger L. Dermoscopic features of neo-             Adamson AS. UV Exposure and the Risk of Cutaneous Mela-
    plasms in skin of color: A review. Int J Women Dermatol.                noma in Skin of Color: A Systematic Review. JAMA Dermatol.
    2021;7(2):145-151. DOI: 10.1016/j.ijwd.2020.11.009. PMID:               2021;157(2):213-219. DOI: 10.1001/jamadermatol.2020.4616.
    33937480. PMCID: PMC8072485.                                            PMID: 33325988.
 8. Kato J, Horimoto K, Sato S, Minowa T, Uhara H. Dermoscopy of        21. Whiteman DC, Pavan WJ, Bastian BC. The melanomas: a syn-
    Melanoma and Non-melanoma Skin Cancers. Front Med (Lau-                 thesis of epidemiological, clinical, histopathological, genetic, and
    sanne). 2019;6:180. DOI: 10.3389/fmed.2019.00180. PMID:                 biological aspects, supporting distinct subtypes, causal path-
    31497603. PMCID: PMC6712997.                                            ways, and cells of origin. Pigment Cell Melanoma Res. 2011;
 9. dermoscopedia contributors – Ash Marghoob, Natalia Jaimes. Basal        24(5):879-897. DOI: 10.1111/j.1755-148X.2011.00880.x.
    cell carcinoma. dermoscopedia. June 8, 2019, 11:10 UTC. Avail-          PMID: 21707960. PMCID: PMC3395885.
    able from https://dermoscopedia.org/w/index.php?title=Basal_cell_   22. Hayward N, Wilmott J, Waddell N, et al. Whole-ge-
    carcinoma&oldid=16531. Accessed January 25, 2021.                         nome landscapes of major melanoma subtypes. Nature.
10. dermoscopedia contributors - Florentina Dimitriou, Theresa                2017;545(7653):175-180. DOI: 10.1038/nature22071. PMID:
    Deinlein, Iris Zalaudek. Squamous cell carcinoma. dermosco-               28467829.
    pedia. November 27, 2020, 17:18 UTC. Available from https://        23.   Coleman WP 3rd, Gately LE 3rd, Krementz AB, Reed RJ,
    dermoscopedia.org/w/index.php?title=Squamous_cell_carci-                  Krementz ET. Nevi, lentigines, and melanomas in blacks. Arch
    noma&oldid=17536. Accessed January 25, 2021.                              Dermatol. 1980;116(5):548-551. PMID: 7377786.
11. dermoscopedia contributors – Luc Thomas, Amelie Boespflug.          24.   Lewis MG. Malignant melanoma in Uganda. (The relationship
    SCC. dermoscopedia. September 19, 2018, 10:32 UTC. Available              between pigmentation and malignant melanoma on the soles
    from     https://dermoscopedia.org/w/index.php?title=SCC&ol-              of the feet). Br J Cancer. 1967; 2(3):483-495. DOI: 10.1038/
    did=13642. Accessed January 12, 2021                                      bjc.1967.56. PMID: 6054282. PMCID: PMC2008026.
12. Lallas A, Kyrgidis A, Koga H, et al. The BRAAFF checklist: a        25.   Palicka GA, Rhodes AR. Acral Melanocytic Nevi: Prevalence
    new dermoscopic algorithm for diagnosing acral melanoma. Br               and Distribution of Gross Morphologic Features in White and
    J Dermatol. 2015;173(4):1041-1049. DOI: 10.1111/bjd.14045.                Black Adults. Arch Dermato.l 2010;146(10):1085–1094. DOI:
    PMID: 26211689.                                                           10.1001/archdermatol.2010.299. PMID: 20956637.
13. Starace M, Alessandrini A, Brandi N, Piraccini BM. Use of Nail      26.   Phan A, Dalle S, Touzet S, Ronger-Savlé S, Balme B, Thomas
    Dermoscopy in the Management of Melanonychia: Review.                     L. Dermoscopic features of acral lentiginous melanoma in a
    Dermatol Pract Concept 2019; 9(1):38-43. DOI: 10.5826/                    large series of 110 cases in a white population. Br J Dermatol.
    dpc.0901a10. PMID: 30775147. PMCID: PMC6368078.                           2010;162(4):765-71. DOI: 10.1111/j.1365-2133.2009.09594.x.
14. Elder DE, Bastian BC, Cree IA, Massi D, Scolyer RA. The 2018              PMID: 19922528.
    World Health Organization Classification of Cutaneous, Muco-        27.   Phan A, Dalle S, Marcilly MC, Bergues JP, Thomas L. Benign
    sal, and Uveal Melanoma: Detailed Analysis of 9 Distinct Sub-             dermoscopic parallel ridge pattern variants. Arch Dermatol.
    types Defined by Their Evolutionary Pathway. Arch Pathol Lab              2011;147(5):634. DOI: 10.1001/archdermatol.2011.47. PMID:
    Med. 2020;144(4):500-522. DOI: 10.5858/arpa.2019-0561-RA.                 21576594.
    PMID: 32057276.                                                     28.   Saida T, Miyazaki A, Oguchi S, et al. Significance of Dermo-
15. Manuel JI. Racial/Ethnic and Gender Disparities in Health                 scopic Patterns in Detecting Malignant Melanoma on Acral
    Care Use and Access. Health Serv Res. 2018;53(3):1407-1429.               Volar Skin: Results of a Multicenter Study in Japan. Arch
    DOI: 10.1111/1475-6773.12705. PMID: 28480588. PMCID:                      Dermatol. 2004;140(10):1233–1238. DOI: 10.1001/arch-
    PMC5980371.                                                               derm.140.10.1233. PMID: 15492186.
16. Halder RM, Bridgeman-Shah S. Skin cancer in Afri-                   29.   Ishihara Y, Saida T, Miyazaki A, et al. Early acral melanoma
    can     Americans.     Cancer.     1995;75(2    Suppl):667-673.           in situ: correlation between the parallel ridge pattern on der-
    DOI:          10.1002/1097-0142(19950115)75:2+<667::aid-cn-               moscopy and microscopic features. Am J Dermatopathol.
    cr2820751409>3.0.co;2-i. PMID: 7804993.                                   2006;28(1):21-27. DOI: 10.1097/01.dad.0000187931.05030.
17. Agbai ON, Buster K, Sanchez M, et al. Skin cancer and photo-              a0. PMID: 16456320.
    protection in people of color: a review and recommendations for     30.   Ruben BS. Pigmented lesions of the nail unit: clinical and his-
    physicians and the public. J Am Acad Dermato.l 2014; 70(4):748-           topathologic features. Semin Cutan Med Surg. 2010;29(3):148-
    762. DOI: 10.1016/j.jaad.2013.11.038. PMID: 24485530.                     158. DOI: 10.1016/j.sder.2010.06.008. PMID: 21051008.




8                                                                             Original Article | Dermatol Pract Concept. 2022;12(2):e2022075
31. Bradford PT. Skin cancer in skin of color. Dermatol Nurs.            10-Year Retrospective Review at a Single Academic Institu-
    2009;21(4):170-7, 206; quiz 178. PMID: 19691228. PMCID:              tion. Dermatol Surg. 2019;45(5):660-665. DOI: 10.1097/
    PMC2757062.                                                          DSS.0000000000001744. PMID: 30614839.
32. Alam M, Ratner D. Cutaneous squamous-cell carci-                 35. Beckenstein MS, Windle BH. Basal cell carcinoma in black pa-
    noma. N Engl J Med. 2001;344(13):975-983. DOI: 10.1056/              tients: the need to include it in the differential diagnosis. Ann
    NEJM200103293441306. PMID: 11274625.                                 Plast Surg. 1995;35(5):546-548. DOI: 10.1097/00000637-
33. Morais PM, Schettini APM, Rocha JA, Silva Júnior RCD. Pig-           199511000-00020. PMID: 8579279.
    mented squamous cell carcinoma: case report and importance       36. Nouri K. Skin cancer. New York, NY, USA: McGraw-Hill Med-
    of differential diagnosis. An Bras Dermatol. 2018;93(1):96-98.       ical; 2008.
    DOI: 10.1590/abd1806-4841.20186757. PMID: 29641705.              37. Kelati A, Aqil N, Baybay H, Gallouj S, Mernissi FZ. Beyond
    PMCID: PMC5871370.                                                   classic dermoscopic patterns of dermatofibromas: a prospective
34. Gupta R, Gordon SL, Council ML, Hurst EA. Clinical Char-             research study. J Med Case Rep. 2017;11(1):266. DOI: 10.1186/
    acteristics of Basal Cell Carcinoma in African Americans: A          s13256-017-1429-6. PMID: 28927449. PMCID: PMC5605998.




Original Article | Dermatol Pract Concept. 2022;12(2):e2022075                                                                          9
