Academy emphasizes recommendations to educate about skin cancers in people of color

Henry Lim, MD

Henry Lim, MD, chair of the AAD Photoprotection for Skin of Color Workgroup, talks with a Forum attendee following the session Saturday.

Lost in the emphasis on diagnosing and treating melanoma among Caucasians is the threat to people with skin of color, in whom all types of skin cancers are often overlooked. The Academy has stepped up its efforts to educate both dermatologists and the public about these dangers through a paper published online in January and a Forum presented Saturday.

“Skin Cancer and Photoprotection in Skin of Color: Recommendations for Prevention, Education, and Early Diagnosis” reviewed research about the dangers of skin cancers for people of color, emphasized the need for earlier detection of cancers, and expanded on those recommendations.

“We know that people of color can develop skin cancer, so they have to continue to practice photoprotection and take vitamin D supplements, and when they do a self-exam, they need to examine the entire skin surface, including the palms and the soles,” said Henry Lim, MD, chair of the AAD Photoprotection for Skin of Color Workgroup and director of Saturday’s session.

“That is the same message we need to give to clinicians, that many skin cancers in people of color tend to occur on the soles and also in the oral cavity. When we do an examination in this group of patients, that is what we need to do.”

The Academy’s recommendations were first published online in the Journal of the American Academy of Dermatology Jan. 25 in the paper “Skin Cancer and Photoprotection in People of Color: A Review and Recommendations for Physicians and the Public.”

The recommendations for patients include wearing sun-protective clothing, hats to shade the face, shoes that cover the entire foot, and sunglasses with UV-absorbing lenses, avoiding exposure to tanning beds or lamps, and performing monthly self-examinations of the skin, paying close attention to subungal skin, palms, soles, and mucous membranes. Other recommendations:

  • Apply broad spectrum sunscreen with an SPF >30.
  • Apply sunscreen to dry skin 15-30 minutes before going outdoors, and reapply every two hours and after perspiring or swimming.
  • Sunscreens with no inorganic filters (titanium dioxide and zinc oxide) are generally better accepted by people of color.

Physicians should tell people of color about those recommendations, but also evaluate and biopsy changing pigmented lesions, nonhealing ulcers, hyperkeratotic or poorly healing lesions in chronic DLE lesions or in scars, and typical-appearing keloidal plaques or those with growth or development with no history of trauma.

Included in the paper are Institute of Medicine recommendations for vitamin D: 400 IU/day for children 0-12 months; 600 IU/day for those ages 1-70; 800 IU/day for those age 71 and over.

Dr. Lim, chairman and C.S. Livingood Chair of the department of dermatology at Henry Ford Hospital, Detroit, opened Saturday’s Forum by looking at the effects of sunlight on skin of color. Studies show that 70 minutes of UVA1 exposure leads to pigmentation of skin that fades rapidly over two weeks, but pigmentation from visible light is sustained during two weeks following exposure.

“Weeks later you can see the persistence of pigment alterations, especially in darker skinned individuals. The significance is that visible light may have a role on conditions aggravated by sun exposure, such as melasma, especially in dark-skinned individuals,” he said, adding that chemical UV filters are not sufficient to protect the skin from the effect of visible light.

Diane Jackson-Richards, MD, director of the Multicultural Dermatology Center at Henry Ford Hospital, presented the results of several surveys showing that there is a “lack of research involving structure and lack of studies on epidemiology, presentation, and therapeutics in skin of color.”

Complicating this lack of research is the lack of awareness among people of color that darker skin does not protect them from skin cancers, and so they do not avoid sun exposure or perform self-exams.

“Although skin cancer is much less prevalent in people of color, it’s often associated with increased morbidity and mortality due to presenting at a more advanced stage,” Dr. Jackson-Richards said. “Increased education and awareness is needed.”

Hugh M. Gloster, Jr. MD, professor of dermatology and director of dermatologic surgery at the University of Cincinnati, also addressed the need for physicians to perform more thorough exams to detect cancers earlier and improve outcomes.

“Although uncommon in people of color, skin cancers do occur and pose a significant risk,” Dr. Gloster said. “People of color with skin cancer are more likely to have greater morbidity and mortality than Caucasians.

Also in people of color, squamous cell carcinomas and melanoma are most common and usually occur on areas of the skin not exposed to the sun. UV radiation is not an important etiologic factor in skin cancer, except for basal cell carcinomas.

“Clinicians should consider the potential for skin cancer in people of color and should institute the same preventive measures used for Caucasians,” Dr. Gloster said, adding that early diagnosis can lead to decreased morbidity and mortality.

Vincent DeLeo, MD, chairman of the department of dermatology at St. Luke’s and Roosevelt Hospital and Beth Israel Medical Center, New York, discussed the importance of sunscreens.

Sunscreens are important in preventing sunburn, cancer, and photoaging in skin types IV-VI, he said. FDA rules now allow labeling with warnings that spending time in the sun increases the risk of skin cancer and skin aging, and that using sunscreen can help prevent both, as well as sunburn.

“I think this is a great step forward in educating our patients,” Dr. DeLeo said. “This is the first time it is recognized that sunscreen protects against cancer and skin aging.”

He also discussed how much sunscreen should be used. A family of four experiencing heavy sun exposure should use one bottle of sunscreen in two days, but studies show families only use 1-1/2 bottles of sunscreen a year.

“Persons of color are not taught how much sunscreen to use and how frequently they should reapply it,” Dr. DeLeo said. “It should be reapplied every two hours, or use higher SPF than think you need to.”

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