10.5826/dpc.1304S1a311S
Introduction: Individuals with melanin-rich skin account for the majority of the world's population. However, literature data regarding dermoscopic characteristics of skin cancer in skin of color (SoC) are scarce. The dermoscopic characteristics of cutaneous tumors might differ among skin types due to heterogeneity in composition and pigmentation.
Objectives: To summarize literature data on the dermoscopic findings of skin neoplasms according to the skin color and race.
Methods:  The literature search was performed using the PubMed database up to December 30, 2022, and was conducted with the use of terms referring to dermoscopy, race (Caucasians, Hispanics, Asians, and Black/African), and skin cancer types (basal cell carcinoma [BCC], squamous cell carcinoma [SCC], keratoacanthoma, Bowen disease, and melanoma).
Results: In total, 30 race-specific records were included. Nine SoC records for BCCs (2 BCC studies in Hispanics, 1 BCC study in Black individuals, and 6 BCC studies in Asians), 9 SoC records for SCCs ( 1 SCC study in Hispanics ,1 SCC study in Black individuals and 7 SCCs in Asian population), and 8 SoC records for melanoma (2 melanoma studies in Hispanics, 1  in Blacks, and 5  in Asians) were compared with 4 records that involved only a Caucasian population, according to their participant section as well as with studies on dermoscopy characteristics without focusing on race origins and phototype of the patient.
Conclusion: Based on a review of studies including Caucasians, Hispanics, Asians and Blacks /Africans, SoC patients present with more frequent and unique dermatoscopy features of skin cancers. 
text/xml
2160-9381
3542
en
Zoe Apalla
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Blacks
Race-Specific and Skin of Color Dermatoscopic Characteristics of Skin Cancer: A Literature Review
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Review
2023-10-04
2023-05-14
2023-10-04
2023-11-27
e2023311S
Dermatol Pract Concept
Introduction: Individuals with melanin-rich skin account for the majority of the world's population. However, literature data regarding dermoscopic characteristics of skin cancer in skin of color (SoC) are scarce. The dermoscopic characteristics of cutaneous tumors might differ among skin types due to heterogeneity in composition and pigmentation.
Objectives: To summarize literature data on the dermoscopic findings of skin neoplasms according to the skin color and race.
Methods:  The literature search was performed using the PubMed database up to December 30, 2022, and was conducted with the use of terms referring to dermoscopy, race (Caucasians, Hispanics, Asians, and Black/African), and skin cancer types (basal cell carcinoma [BCC], squamous cell carcinoma [SCC], keratoacanthoma, Bowen disease, and melanoma).
Results: In total, 30 race-specific records were included. Nine SoC records for BCCs (2 BCC studies in Hispanics, 1 BCC study in Black individuals, and 6 BCC studies in Asians), 9 SoC records for SCCs ( 1 SCC study in Hispanics ,1 SCC study in Black individuals and 7 SCCs in Asian population), and 8 SoC records for melanoma (2 melanoma studies in Hispanics, 1  in Blacks, and 5  in Asians) were compared with 4 records that involved only a Caucasian population, according to their participant section as well as with studies on dermoscopy characteristics without focusing on race origins and phototype of the patient.
Conclusion: Based on a review of studies including Caucasians, Hispanics, Asians and Blacks /Africans, SoC patients present with more frequent and unique dermatoscopy features of skin cancers. 
Zoe Apalla
2023/10/04
10.5826/dpc.1304S1a311S
e2023311S
Second Dermatology Department, School of Health Sciences, Aristotle University of Thessaloniki, Greece
2160-9381
Blacks
en
e2023311S
Muizzuddin N, Hellemans L, Van Overloop L, Corstjens H, Declercq L, Maes D. Structural and functional differences in barrier properties of African American, Caucasian and East Asian skin. J DermatolSci 2010;59:123–8.
Race-Specific and Skin of Color Dermatoscopic Characteristics of Skin Cancer: A Literature Review
https://dpcj.org/index.php/dpc/article/download/3542/2348
   Race-Specific and Skin of Color Dermatoscopic
 Characteristics of Skin Cancer: A Literature Review
                     Emmanouil Karampinis1, Aimilios Lallas2, Elizabeth Lazaridou1,
                                   Enzo Errichetti3, Zoe Apalla1


1 Second Dermatology Department, School of Health Sciences, Aristotle University of Thessaloniki, Greece
2 First Dermatology Department, School of Health Sciences, Aristotle University of Thessaloniki, Greece
3 Institute of Dermatology, Santa Maria della Misericordia University Hospital, Udine, Italy



Key words: dermatoscopy, skin of color, basal cell carcinoma, squamous cell carcinoma, keratoacanthoma, Bowen’s disease, melanoma,
Caucasians, Hispanics, Asians, Blacks
Citation: Karampinis E, Lallas A, Lazaridou E, Errichetti E, Apalla Z. Race-Specific and Skin of Color Dermatoscopic Characteristics of
Skin Cancer: A Literature Review. Dermatol Pract Concept. 2023;13(4)S1:e2023311S. DOI: https://doi.org/10.5826/dpc.1304S1a311S
Accepted: September 18, 2023; Published: October 2023
Copyright: ©2023 Karampinis 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: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Emmanouil Karampinis MD,MSc, Phd, Second Dermatology Department, School of Health Sciences, Aristotle
University of Thessaloniki, Greece. Naxos Island, Cyclades, tel: 6980420401 Email: emankarampinis@gmail.com




  ABSTRACT             Introduction: Individuals with melanin-rich skin account for the majority of the world's population.
                       However, literature data regarding dermatoscopic characteristics of skin cancer in skin of color (SoC)
                       are scarce. The dermatoscopic characteristics of cutaneous tumors might differ among skin types due
                       to heterogeneity in composition and pigmentation.
                       Objectives: To summarize literature data on the dermatoscopic findings of skin neoplasms, according
                       to the skin color and race.
                       Methods: The literature search was performed using PubMed database up to December 30, 2022
                       and was conducted with the use of terms referring to dermatoscopy, race (Caucasians, Hispanics,
                       Asians, and Black/African) and skin cancer types (BCC, SCC, keratoacanthoma, Bowen’s disease and
                       melanoma).
                       Results: In total, 30 race-specific records were included. 9 SoC records for BCCs (2 BCC studies in
                       Hispanics, 1 BCC study in Black individuals and 6 BCC studies in Asians ), 9 SoC records for SCCs
                       ( 1 SCC study in Hispanics ,1 SCC study in Black individuals and 7 SCCs in Asian population) and
                       8 SoC records for melanoma (2 melanoma studies in Hispanics, 1 melanoma study in Blacks and 5
                       melanoma studies in Asians) were compared with 4 records that involved only Caucasian population,
                       according to their participant section as well as with studies on dermatoscopy characteristics without
                       focusing on race origins and phototype of the patient. In Hispanics and in both fair and dark-skinned
                       Asians, BCCs were more often pigmented or at least with pigmented structures on dermoscopy.




Review | Dermatol Pract Concept. 2023;13(4)S1:e2023311S                                                                                   1
                      S­ quamous cell carcinoma (SCC) and keratoacanthoma were the least studied in SoC patients. Bowen’s
                       disease in SoC patients can be pigmented in a higher frequency compared to Caucasians, with glomer-
                       ular vessels and a squamous surface being the most common dermatoscopic findings. The most fre-
                       quent pattern of melanomas in SoC individuals were the parallel ridge pattern in palmoplantar region.
                      Conclusion: Based on a review of studies including Caucasians, Hispanics, Asians and Blacks /­Africans,
                      SoC patients present with more frequent and unique dermatoscopy features of skin cancers.




Introduction                                                          The aim of our study is to investigate available data from
                                                                   studies on the dermatoscopic characteristics on skin cancers
Skin of Color (SoC) is a term used to define individuals with      in SoC populations, compare them with the findings in white
melanin-rich skin that might belong to several races, includ-      skin and summarize the evidence on dermatoscopic patterns
ing those of Hispanic/Latino, Asian, African, Native Ameri-        and structures of common skin cancers in SoC.
can, Pacific Island origin, as well as mixtures of the different
races [1]. In dermatology research, SoC patients seem to be
                                                                   Methodology
neglected to some extent, since most research has been con-
ducted in white-skin populations. The underrated education         A literature review was performed using the PubMed data-
of medical students and trainees on SoC populations [2], the       base and included a search for articles in the English language
limited availability of images of skin diseases in SoC for ed-     from inception to December 2022. Search terms included
ucational and research purposes and the focus of artificial        “dermoscopy,” and “dermatoscopy,” combined with terms
intelligence and machine learning on white skin, broaden the       referring to different races, namely “Caucasians, “Hispan-
gap [3]. It has been shown that most skin cancers in individ-      ics” “Asians” “Blacks” and “Africans” and skin cancer types,
uals of SoC are diagnosed late, due to the health inequity and     namely “basal cell carcinoma”, “squamous cell carcinoma”,
the lack of access to healthcare and dermatology care [2]. In      “Bowen’s disease”, “keratoacanthoma” and “melanoma”. In
the last years, SoC dermatology has attracted more attention       case of Hispanic and Asian populations we further added
as a result of the lack of relevant information and the subse-     investigation using countries with Hispanic and Asian resi-
quent difficulties the dermatologists are facing when dealing      dents- for example Mexico, Argentina, Chile, Uruguay and
with SoC individuals. Indeed, the search of ‘skin of color”        Peru and Japan, China, Korea, India. The inclusive criteria
term in Pubmed results in 21,324 studies, with the 5,139           involved studies that provided dermoscopy details of skin
(approximately 24%) of them published in the last three            cancer specifically reported for a particular race. However,
years (2020-2022).                                                 we excluded case reports and case series or studies focusing
    Dermatoscopy is a precious tool for dermatologists,            on the dermoscopy of rare subtypes or presentations of skin
enabling an assessment of skin lesions based on patterns,          cancer, as well as skin cancer occurring in specific locations
structures, signs and colors and significantly facilitating the    such as the nail. We found 158 studies on dermoscopy of
clinicaldiagnosis. In SoC, different color backgrounds and         BCC, 11 of which provided detailed information on the race
patterns typical of darker phototypes maybe alter the dermo-       of the included population and were included in this review.
scopic aspect, as compared to white skin [4]. The combina-         The search for SCC, keratoacanthoma and Bowen’s disease
tion between ‘skin of colour” and ‘dermatoscopy” Pubmed            revealed 147 results, with 9 being suitable for inclusion. The
search results in 680 articles with limited research in the der-   search for melanoma revealed 675 results, of which 10 were
matoscopy of skin cancer in SoC patients.                          suitable for the review. As a results, 30 race-specific records
    An additional limitation is that SoC is often considered       were included in this review.
as a group, while in fact it consists of significantly heteroge-
nous populations in terms of skin color. Therefore, it would       Results
be more informative to describe each study population in
more details. For instance, Caucasians are the not-Hispanic,       Dermatoscopy of BCC
white-skinned individuals of European origin, blacks are           Caucasians
not-Hispanic individuals of African origin and Hispan-             Although the majority of dermatoscopy studies have been
ics are the individuals from Mexico, Puerto Rico, Cuba,            performed on Caucasians, most studies do not provide clear
­Spanish-speaking countries of Central and South America,          information on the race of the included population. Two
Spanish-speaking Caribbean Island nations, and other His-          studies clarified that the included population consisted ex-
panic civilizations                                                clusively of Caucasian individuals [5,6]. In this population,



2                                                                          Review | Dermatol Pract Concept. 2023;13(4)S1:e2023311S
the most common BCC type was the nodular, followed by             such as Indians, macroscopic and dermatoscopic features
superficial. The most frequent dermatoscopic features in          of pigmentation were more frequent. Ulceration, blue-white
nodular BCCs were arborising vessels and ulceration. Cor-         veil, and branching vessels were significantly associated with
respondingly, the most common dermatoscopic features              nodular BCCs, while maple leaf-like areas, red/white struc-
of superficial BCC were multiple small erosions and small         tureless areas, multiple small erosions and spoke-wheel areas
fine superficial telangiectasias [5]. Only 10% of the BCCs        were noted in superficial BCCs [16,17].
were pigmented, contrary to the high incidence of pigmented
BCCs (pBCCs) in other populations [7]. In nodular pBCC            Blacks
the most prevalent dermatoscopic criterion was blue-gray          BCCs scarcely affect black individuals, mostly in the back-
ovoid nests, often in association with arborising vessels. The    ground of albinism and Gorlin syndrome. BCCs in Blacks
most common dermatoscopic features of superficial pBCC            are less common than SCCs and were more frequently met-
were maple leaf-like areas, spoke-wheel areas and concentric      astatic. It has been reported that the morphea-like BCC is
structures, whilst blue-gray ovoid nests were absent [5].         rare [10]. Dermatoscopically, pigmented subtypes are simi-
                                                                  lar to the ones seen in Caucasians (maple-leaf areas, spoke-
Hispanics                                                         wheel areas, etc). Reticular pigmentation can be observed in
Interestingly, BCCs in Hispanic individuals tend to be more       the surrounding uninvolved skin, more intense around the
often located on the right part of the body [8], with the         lesion with central hypopigmentation [18].
presence of pigmentation being twice as common as in Cau-
casians [9]. Regarding BCC type, the most common were             Dermatoscopy of SCC
nodular and superficial, however nodular subtype in His-          Caucasians
panics is less frequent compared to Caucasians. Hispanic          In the Caucasian population, we can literally observe all
individuals have a higher frequency of invasive BCC than          SCC subtypes. In terms of dermatoscopy studies related to
Caucasians [10]. Due to the higher percentage of pigmented        SCC, the majority come from Australia, Austria, Greece,
lesions, BCCs in Hispanic frequently display the classic der-     Italy or they are multi-country based. The most common
matoscopic features of pigmented subtypes. For example,           dermatoscopic features of SCC include the presence of kera-
nodular BCCs present blue-gray ovoid nests and/or blue-           tin, white scales, blood spots, white circles, white structure-
gray non-aggregated globules, along with branching vessels        less areas and white halos [19]. Bowen's disease is usually
and shiny white structures, whilst superficial BCCs exhibit       non-pigmented and in dermatoscopy often displays glomer-
brown colored structures (e.g maple-leaf like areas) and/or       ular and dotted vessels, white scales, and small erosions [20].
erosions and/or radial linear structures [11]. In a study per-    Keratoacanthoma is dermatoscopically characterized by a
formed in a Mexican population, the main dermatoscopic            crateriform morphology the characteristic mass of keratin
finding for nodular BCC was blue-gray ovoid nests, whilst         surrounded by elongated and sometimes thick telangiecta-
for pBCCs were the shortened vessels, the gray-blue ovoid         sias or hairpin-like vessels, as well as by white circles, white
nests and the maple-leaf like areas. Regarding infiltrating       halos and white structureless areas. In general, the discrimi-
BCC, branching and truncated vessels were more common             nation of a keratoacanthoma and a well-differentiated SCC
and for the superficial BCCs the spoke-wheel areas and            on the clinical and dermatoscopic basis is very challenging.
shortened vessels were mostly seen [12]. It is of particular      However, it has been suggested that the presence of keratin
importance to mention that in Hispanic populations a blue-        and white background color may indicate keratoacanthoma,
white veil is often described in BCCs [13].                       whilst mixed color favors an invasive cSCC [21]. Poorly dif-
                                                                  ferentiated SCCs are dermatoscopically characterized by a
Asians                                                            predominant red color, resulting from the presence of dense
In populations with Fitzpatrick ranging from III to IV (e.g.,     neo-vascularization and/or hemorrhage [19].
Japanese), BCCs are usually clinically pigmented or at least
with pigmented structures on dermatoscopy. In general,            Hispanics
BCCs in this population present similar dermatoscopic fea-        Very limited literature data report on dermatoscopic features
tures as in Caucasians [14]. Arborising vessels are the pre-      of SCC in Hispanic population. The dermatoscopic features
dominant morphologic vessel type. The presence of other           are similar to those described in white individuals, but
vesseltypes is of low diagnostic value in this population [15].   there is a higher incidence of the pigmented variants [11].
In addition, a low sensitivity of dermatoscopy in BCCs diag-      Pigmented Bowen’s disease appears with asymmetric struc-
nosis was recorded when the lesions involved the trunk and        tureless, brown areas, gray, brown or blue dots in linear
extremities and were hypo- or non-pigmented [15]. In pop-         arrangement usually at the periphery of the lesion and tor-
ulations with Fitzpatrick phototype ranging from IV to V,         tuous vessels [22]. Keratoacanthoma presents with the same



Review | Dermatol Pract Concept. 2023;13(4)S1:e2023311S                                                                         3
dermatoscopic presentation as in Caucasians [11]. Patients in     dermatoscopically show irregular dots, gray color and re-
this population more often than Caucasians can present with       gression and in almost 50% they present dermatoscopic cri-
pigmented SCC that dermatoscopically has radially arranged        teria of a lentigo maligna [29]. In palmoplantar melanomas
brown lines and brown dots aligned in a linear fashion [11].      the two most common patterns were irregular diffuse pig-
                                                                  mentation and parallel ridge pattern [30]. A hyperpigmented
Asians                                                            follicular opening, annular-granular pattern, pigmented
Concerning light-colored Asian populations, glomerular            rhomboidal structures, obliterated hair follicles, as well as
vessels plus a scaly surface were the most common derma-          increased density of the vascular network, red rhomboidal
toscopic findings in Bowen’s disease [23]. BD had also a          structures, target-like patterns, and pigmentation are lentigo
high probability of detecting pigmentation in dermatoscopy        maligna characteristics [31].
[23] The three most frequent dermatoscopic findings of pig-
mented BD included structureless pigmentation and pigment         Hispanics
streaks combined with scaling [24]. Common dermatoscopic          As in Caucasians, superficial melanoma is the most com-
findings for non-pigmented BD were glomerular vessels,            mon subtype [32]. Dermatoscopic features of melanomas in
scales, a pinkish-white network, dotted vessels, hairpin ves-     Hispanics are similar to Caucasians; however, more derma-
sels, and pinkish-white structureless areas [24]. Scarce case     toscopic studies are needed in this population to determine
reports show that the main dermatoscopic features of SCC          frequency of specific melanoma patterns and any specific
subtypes are similar to those seen in Caucasians. In the dark-    dermatoscopic signs. Dermatoscopy signs such as blue white
skinned Asian population, the vast majority of BD are also        veil, white shiny structures and milky red areas increased are
pigmented [25]. A combination of pigmented structures as-         more frequent in thick melanomas [32]. Biaxial asymmetry
sociated with BD is often observed and includes structureless     is the most common dermatoscopic finding in in situ and
brown hyperkeratotic area, homogeneous areas of different         invasive melanoma [33].
shades (focal/multifocal), brown to blue-gray dots/globules
(in a peripheral clustered or linear arrangement), and brown      Asians
to blue-grey peppering [25]. Keratoacanthoma presents with        In Asian population, there is a high incidence of site-specific
the same dermatoscopic image (corneal plug and/or ulcer-          melanomas such as palmoplantar melanomas [34]. Mela-
ation), while SCC presents with the same main features as in      nomas in trunk and limbs may appear dermatoscopically
Caucasians, but with an increased likelihood of presenting        with an asymmetric colorful pattern, blotches, blue-white
its specific characteristics, as radially arranged brown lines    veil, atypical pigment network, irregular peripheral streaks,
and brown dots [11].                                              atypical vascular pattern, ulceration, atypical dots/globules
                                                                  bright white lines and regression structures [15,34]. Palmo-
Blacks                                                            plantar melanomas are typified by a parallel ridge pattern
SCCs in black individuals are often superficial, discrete, hard   and irregular diffuse pigmentation [35].
lesions with an indurated, rounded, and raised base [26].
The dermatoscopic features observed are similar to those          Blacks
described in Caucasians, but there is a higher incidence of       The most frequent melanoma type in this population is pal-
pigmented variants [18].Dermatoscopically, loss of the nor-       moplantar melanoma that shows a parallel ridge pattern,
mal pigmented network surrounding the squamous cell car-          while loss of pigmentation around the lesion itself may be
cinoma lesion can be observed [18].                               present, creating a hypomelanotic “halo” [18].
                                                                     A summary of the most common dermatoscopic features
Dermatoscopy of Melanoma                                          observed in skin cancer subtypes (BCC, SCC, and mela-
Caucasians                                                        noma) among patients with Skin of Colour is presented in
                                                                  Table 1.
Melanoma is mostly studied in Caucasian populations.
Melanomas in situ are characterized by dermatoscopic fea-
tures such as irregular hyperpigmented areas, atypical net-       Discussion
work, and gray structures, and less commonly radial lines,
multiform vessels, and polygonal structures [27]. Both in         SoC is a descriptive term frequently used in studies reporting
situ and invasive melanomas often display irregular blotch,       on dark-skinned, or in non-Caucasians individuals, in gen-
atypical network and gray or blue structures [27]. Atypical       eral. Skin color outweighs other vague terms that do not focus
network, blue-white veil, irregular globules and dots, pseu-      on the type, tone or characteristics of the skin [1]. However,
dopods or striae, and the blue-black veil can distinguish mel-    even nowadays there is not a clear categorization of the char-
anoma from other tumors [28]. Melanomas in the neck area          acteristics of the skin of color individuals. The Fitzpatrick



4                                                                          Review | Dermatol Pract Concept. 2023;13(4)S1:e2023311S
Table 1. Summarizes the most frequent dermatoscopic characteristics of skin cancer subtypes (BCC,
                        SCC and melanoma) in Skin of Colour patients.
    Skin cancer in skin of
           colour                                               Dermatoscopy characteristics
 BCC in Hispanics                 • the chance of pigmentation for BCC is twice as common as in white patients.
                                  • the main dermatoscopic finding for nodular BCC was blue-gray ovoid nests.
                                  • The main dermatoscopic feature for pBCCs were the shortened vessels, the gray-blue
                                    ovoid nests and the maple-leaf like regions.
                                  • In superficial BCCs the spoke-wheel areas and shortened vessels were mostly seen.
                                  • A blue-white veil subtype of BCCs can be observed.
 BCC in Asians                    III – IV phototype populations
                                  • The majority BCCs are pigmented or at least with pigmented structures in
                                     dermatoscopy
                                  • Similar dermatoscopic features and approach as that of Caucasians
                                  • Branching vessels as the dominant vascular pattern. The presence of other vascular
                                     formations has a low diagnostic value in this population
                                  IV-VI phototype populations
                                  • Ulceration, blue-white veil, and branching vessels are significantly associated with
                                     nodular BCC
                                  • Maple leaf-like areas, the red-white structureless areas, multiple small erosions, and
                                     radial wheel areas were noted in the surface BCCs
 BCC in Blacks/Africans           • Pigmented subtypes with characteristic structures that are also observed in white
                                    populations (maple-like leaves, radial wheel structures, etc.) are reported.
                                  • Reticular pigmentation can be observed in the surrounding uninvolved skin, more
                                    intense around the lesion and central hypopigmentation.
 SCC in Hispanics                 • Very limited literature on SCC in this population and on its dermatoscopic features
                                  • The dermoscopic features observed are similar to those described in white subjects, but
                                    there is a higher incidence of pigmented variants
 SCC in Asians                    III – IV phototype populations
                                  • Glomerular vessels plus a squamous surface were the most common dermoscopic
                                     findings of BD
                                  • High probability of detecting pigmentation dermatoscopically
                                  • Common dermatoscopic findings for pigmented BD included dotted vessels, hairpin
                                     vessels, a pink-white network, and a pink-white structureless area.
                                  IV-VI phototype populations
                                  • A combination of pigmented structures associated with Bowen's disease is often seen
 SCC in Blacks/Africans           • The dermoscopic features observed are similar to those described in white individuals,
                                    but there is a higher incidence of melanocytic variants.
                                  • Dermatoscopically, loss of the normal pigmented network surrounding the lesion of
                                    squamous cell carcinoma can be observed.
 Melanoma in Hispanics            • Dermatoscopic features of melanomas in Hispanics are similar to those in Caucasians;
                                  • Dermatoscopic features such as whitish blue veil, bright white structures and milky red
                                    areas were reported
 Melanoma in Asians               • Usually, melanomas of specific location
                                  • They may appear dermatoscopically with an asymmetric colorful pattern, blotches,
                                    blue-white veils. atypical pigment networks, irregular peripheral striae, atypical vascular
                                    patterns, ulcer, atypical dots/balls bright white lines and hypopigmented structures
                                  • The most common vascular pattern seen in melanoma was linear and irregular vessels.
 Melanoma in Blacks/Africans      • High incidence of palmoplantar melanomas that show a parallel ridge pattern
                                  • There may be loss of pigmentation surrounding the lesion itself, creating a
                                    hypopigmented “halo”



phototype system assesses the minimum erythema dosage             the comparison cards of the Taylor hyperpigmentation scale,
for fair-skinned patients. However, studies presented many        [38] there is still no consensusonhow to evaluate skin color
limitations, as far as Asian population is concerned [36].        patients. As a result, many studies have significant limita-
From the combination of race and Fitzpatrick system [37] to       tions due to lack of important information.



Review | Dermatol Pract Concept. 2023;13(4)S1:e2023311S                                                                       5
    Furthermore, in every SoC study should provide detailed        in Caucasians [18]. In studies investigating dermoscopy of
information on the characteristics of the included popula-         BCCs in Caucasian [5], Hispanic [12], Indian [17] and Black
tion. Usually, studies follow the definition of CDC and inter-     populations [18], certain similarities but also important dif-
pret ethnicity as 1 of 2 categories—Hispanic/Latino and not        ferences in the frequency of dermatoscopic structures were
Hispanic/Latino—and race as 1 of 5 categories: American            found. Grey-blue ovoid nests were seen in 50% of BCCs in
Indian/Alaskan Native, Asian, Black/African American, Na-          Black population [18], 40.6 % of nodular BCCs in Indian
tive Hawaiian/from pacific island and white [39]. As for their     population, 58% of nodular BCCs in Hispanics and 50% of
skin type, most Hispanics range from IV to VI, whereasre-          nodular BCCs in in Caucasians [5]. Milia-like cysts, a typical
garding the Asians, there is a wider range, for example from       structure of seborrheic keratosis, were observed in 37.5%
III to IV in the Chinese and Japanese and from types IV to V       of nodular BCCs in the Indian population [17]. Maple leaf
in Indians and Pakistanis [40]. However, this skin categori-       like areas were observed in 50% of BCCs in Black individ-
zation has many limitations and should not be considered as        uals, 92.5% of superficial BCCs in Indian individuals, 43%
a standard deviation, due to the variability between the races     of pigmented BCCs in Hispanics and 37.7 % of superficial
that occurred by immigration and race combinations [41].           BCCs in Caucasians. Ulceration was found in 53.2% of nod-
    The dermatoscopic characteristics of skin cancers had          ular BCCs Caucasians and in 84.3% of nodular BCCs in
been studied more on white populations. There are many             Indians. Another frequency difference was observed regard-
possible reasons for this discrepancy. First, this is definitely   ing the spoke wheel like structures, which appeared with a
related to the high incidence of skin cancers in this popu-        percentage of 18.2% in the superficial BCCs in Caucasians,
lation (with the exception of acral lentigious melanoma to         while the respective percentage in Indians was 55.5%.
Asians and Blacks). However, limited access of some other             SCC and keratoacanthoma were the least studied cuta-
populations to medical assistance may also contribute. Fur-        neous neoplasm in SoC individuals. Case series including the
thermore, the role of limited financial resources and the lack     frequency of dermatoscopic characteristics concerning His-
of investments in scientific groups working in developing          panic and Indian populations were limited in the number of
countries may have resulted in limited production of publi-        participants. As a result, the comparison between them and the
cations from these countries. An attempt to bridge this gap        Caucasian studies that have numerous subjects would not lead
has recently been made with more studies on the dermatos-          to a safe conclusion. However, in studies describing Bowen’s
copy of skin lesions in SoC patients, making this section a        disease in SoC, the authors found that the lesions were often
field of great interest.                                           pigmented and displayed glomerular vessels and a scaly surface
    Considering that the skin of white and black individu-         in dermatoscopy [23–25]. As for the Japanese and a Cauca-
als presents differences, it is essential to fill this knowledge   sians (Europe country based) study, the scales and the glomer-
gap. The melanosomes that are responsible for the skin color       ular vessels were the dominant findings in the classic Bowen’s
are of different stage, organization and endurance amongst         diseases, reaching a 94% and 97% respectively for the Asians
the races. In people of African descent, melanosomes are           and 90% and 90% respectively for the Caucasians [20,23].
scattered throughout the epidermis, in contrast to non-sun-­          The most of the SoC melanoma studies focus on the acral
exposed white skin, where melanosomes are confined to the          lentiginous melanoma of the sole. These melanomas in SoC
basal layer and absent in the upper epidermal layers [42].         patients have many similarities with melanomas in Cauca-
Larger keratinocyte size, greater keratinocyte density, re-        sians in dermatoscopy. Specifically, the parallel ridge pattern
duced proteolytic activity, increased fibroblast number and        in palmoplantar areas is the most frequent dermatoscopic
slow desquamation rates are found in black skin, as well as        pattern. In a study focusing on Black individuals [18], all
a higher number of cell layers consisting the stratum cor-         cases (100%) displayed a structureless pattern with multiple
neum than a thinner stratum corneum in people of Asian             shades of different colours, while 75% of them had also the
descent [43]. Taking into account the aforementioned dif-          typical parallel ridge pattern. In a study conducted in Cauca-
ferences, it is expected that the skin cancer arising in differ-   sians, irregular diffuse pigmentation was found in 60% and
ent skin types would possibly differ in terms of frequency,        parallel-ridge pattern in 53% of the lesions, whilst polychro-
qualitative and quantitative dermatoscopic, mostly emerging        mia and existence of an abrupt edge were also melanoma
from the heterogeneity of pigmentation.                            indicators. [30].
    Compared to Caucasians, in Hispanics and Asians,                  The limitations of the study are connected mainly with
BCCs were more often pigmented, or at least display pig-           the unclear and often confusing correlation between races
mented dermatoscopic structures, such as maple-leaf likes          and skin tones. Races (especially Hispanic and Asian) en-
and spoke-wheel areas. In black individuals, a characteristic      compass also "light skin type" (mainly phototype III), so the
in the background of the BCC was detected, namely an in-           analysis may be affected by the mixture of fair and dark skin
tense pigment network, which is not a typical characteristic       types (which are classically phototypes IV-VI) for such racial



6                                                                          Review | Dermatol Pract Concept. 2023;13(4)S1:e2023311S
groups. Moreover, it is crucial to consider the specific focal                    histopathologic variants of basal cell carcinoma. Int J Dermatol
points of certain studies which may be centered on a partic-                      2013;52:718–21.
                                                                            13.   Quiñones-Venegas R, Paniagua-Santos JE, Guevara-Gutierrez E,
ular characteristic (for example the association of dermatos-
                                                                                  Esteban-Salerni G, Gonzalez-Ramirez RA, Tlacuilo-Parra A.
copy characteristics and histology type [5]), rather than the
                                                                                  Basal cell carcinoma, blue-white variant: Dermatoscopic findings
race of the patients, potentially affecting the results.                          in 32 cases. Indian J Dermatol VenereolLeprol2021;87:29.
                                                                            14.   TAKENOUCHI T. Key points in dermoscopic diagnosis of basal

Conclusions                                                                       cell carcinoma and seborrheic keratosis in Japanese. J Dermatol
                                                                                  2011;38:59–65.
                                                                            15.   SAKAKIBARA A, KAMIJIMA M, SHIBATA S, YASUE S, KONO
There is limited data concerning dermatoscopy of skin cancer
                                                                                  M, TOMITA Y. Dermoscopic evaluation of vascular structures
in SoC patients. In this review, we have highlighted the most
                                                                                  of various skin tumors in Japanese patients. J Dermatol 2010;
frequent and unique dermatoscopy features of skin cancers,                        37:316–22.
based on a review of studies including Caucasians, Hispan-                  16.   Vinay K, Ankad BS, Narayan R V, et al. A multicentric study on
ics, Asians and Blacks /Africans. Further studies focusing on                     dermoscopic patterns and clinical-dermoscopic-histological cor-
the combination of race and phototype are needed, in which                        relates of basal cell carcinoma in Indian skin. Clin Exp Dermatol
                                                                                  2022;47:1982–90.
dermatoscopic features described in Caucasian populations
                                                                            17.   Behera B, Kumari R, Thappa DM, Gochhait D, Srinivas BH,
should be re-evaluated about their significance in SoC.
                                                                                  Ayyanar P. Dermoscopic features of basal cell carcinoma in skin
                                                                                  of color: A retrospective cross-sectional study from Puducherry,
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