On the 40th anniversary of the death of Bob Marley due to melanoma, the myth persists that people of color have a negligible risk of skin cancer despite evidence to the contrary. While the odds of developing melanoma are lower in these populations – 1 in 1,000 for Blacks and 1 in 167 for Hispanics compared to 1 in 38 for non-Hispanic Whites – they continue to face unique risks that highlight the importance of promoting awareness in this area.1
Melanoma is often diagnosed at more advanced stages in people of color, and these cases are associated with worse outcomes and survival rates compared to non-Hispanic Whites.2 Studies have also found deeper tumors, higher rates of tumor ulceration, and greater lymph node positivity in Black vs White patients with various types of melanoma.3
Thus, although recent findings suggest that ultraviolet (UV) radiation exposure may not represent a strong risk factor for melanoma for many people of color, there is a clear need to improve detection, prevention, and treatment of skin cancer in these patients.4
Dermatologist Margareth Pierre-Louis, MD, MBA, FAAD, the founder of Twin Cities Dermatology Center in Minneapolis, Minnesota, is a woman of color who specializes in multi-ethnic skin care and advocates for “Visible Wellness for All.” We interviewed Dr Pierre-Louis to learn more about issues pertaining to skin cancer in people of color as well as recommendations for the provision of multi-ethnic dermatology care.
What are some of the biggest misconceptions you have encountered regarding skin cancer in people of color?
Some of the biggest misconceptions that I have encountered are reported from my patients – that they are not at risk for skin cancer, there is no need to protect themselves from the sun and to pay attention to changing skin lesions, and there is no standard of care for their skin type or tone.
I tell my patients that by default, because they have skin, they are essentially at risk for skin cancer and that their largest body organ gives them this risk regardless of skin type or skin tone. While melanoma and nonmelanoma skin cancers are less likely to occur in skin of color, no one is immune to skin cancer. Sebaceous carcinoma, for example, the unique adnexal malignancy that can present in the skin similar to a basal cell in skin of color — spontaneously or as part of Muir-Torre Syndrome – is irrelevant to skin tone.5
Teaching our patients that everyone has a risk, whether low or high based on risk factors, and that they should remain aware of abnormal growths on the skin or symptomatic lesions, is critical for the early detection of cutaneous malignancies.
Everyone can benefit from sun protection because as skin of color ages, it also starts to appear textured and pigmented from years of UV radiation, beyond the fact that UV radiation exposure can increase the risk of skin cancer. While the UV exposure may not translate into significant wrinkles and bronzing of the skin, it can reflect an unintended older appearance. We can reduce the risk of skin cancer through healthy skincare promotion and adequate sunscreen and sunblock use.
Tell us about your mantra “Visible Wellness for All” and what that looks like in clinical practice.
Visible Wellness for All is my goal to genuinely care for every person in their skin to achieve optimal health and wellness. While we discuss diversity in dermatology and in health care, it may not reflect the understanding of how to care for all skin types and skin tones. Visible Wellness for All promotes inclusion in dermatology. It is not enough for me to be a dermatologist of a diverse background; it is more important to patients that I can successfully treat their problems and provide them with personalized and effective treatment plans.
In practice, this means that I welcome all skin types and skin tones and that my marketing reflects that. It means that I am prepared to care for everyone with the appropriate treatments and services available along with the potential adverse outcomes associated with these treatments. I train my staff to address concerns that may commonly occur when treating skin of color, such as post-inflammatory hyperpigmentation and streaking after micro-needling or laser hair removal, and hypopigmentation post cutaneous corticosteroid injections.
What are some recommendations for clinicians seeking to improve care and competency in multi-ethnic skincare?
Listen to your patients to successfully address their concerns. They are aware of what is trending in the community, and they also know their experience best. They can educate you a lot about what some of the challenges, sentiments, and misconceptions might be that are keeping them from achieving visible wellness.
I created the patient care philosophy One HEART (Hear, Examine, Assess, Reach, Teach) for Visible Wellness. Through HEART, I determine the diagnosis from a thorough exam and then take the opportunity to provide them with evidence-based options to address their problems. Because so many people may have not felt welcomed by the specialty or found a dermatologist unhelpful in the past, it is critical that dermatologists hear their patient’s concerns unfiltered in order to provide them tangible and effective solutions that they find useful.
In addition, leverage technology to help patients track their health and self-monitor skin. A telehealth solution like Miiskin, an AI-enabled app, levels the playing field by giving every patient equipped with a smartphone a tool that empowers them to evaluate their skin for changes for the early detection of worrisome lesions. The app also supports early diagnosis and intervention by keeping patients engaged and connected with us so that they can submit concerning images for evaluation or further management recommendations. Miiksin allows me to use innovation to work as a team with my patients.
Perform outreach and connect with people in the community, such as primary care clinics, aestheticians, and hair salons, which may be in need of a dermatologist to care for ethnic skin patients but might not know who to reach out to due to lack awareness of dermatologists or lack of a representation of inclusion.
Also, make sure your marketing reflects inclusion. Simple things like having photo galleries that include before and after photos of diverse patients can promote inclusion and signal that you welcome and can care for patients of diverse backgrounds. Continue to promote inclusion by reflecting diversity in dermatology at the patient, staff, and provider levels.
All patients should be welcomed and feel that the dermatology clinic they choose can care for them and provide solutions. We must be innovative and inclusive in how we engage our patients to better care for themselves through the latest medical and technological advancements.
References
1. American Cancer Society. Key statistics for melanoma skin cancer. Accessed online May 26, 2021.
2. Ferguson NN. Challenges and controversy in determining UV exposure as a risk factor for cutaneous melanoma in skin of color. JAMA Dermatol. Published online December 16, 2020. doi:10.1001/jamadermatol.2020.4615
3. Mahendraraj K, Sidhu K, Lau CS, McRoy GJ, Chamberlain RS, Smith FO. Malignant melanoma in African-Americans: a population-based clinical outcomes study involving 1106 African-American patients from the Surveillance, Epidemiology, and End Result (SEER) database (1988-2011). Medicine (Baltimore). 2017;96(15):e6258. doi:10.1097/MD.0000000000006258
4. Rodriguez T. UV exposure and melanoma risk in patients with skin of color. Published January 29, 2021. Dermatology Advisor. Accessed May 26, 2021.
5. Knackstedt T, Samie FH. Sebaceous carcinoma: a review of the scientific literature. Curr Treat Options Oncol. 2017;18(8):47. doi:10.1007/s11864-017-0490-0
