Skin cancer is a risk regardless of skin tone. But it can be missed in people with dark skin.

Skin cancer is a risk regardless of skin tone. But it can be missed in people with dark skin.

Brykyta Shelton stood at the checkout line at a major retailer, uncomfortably aware that a woman in front of her was staring at her sandaled feet.

Shelton had been taking medication for months for what her doctor described as toenail fungus, but one nail still looked gross.

After Shelton completed her purchase, the woman pulled her aside and said that even though she wasn't a doctor, she thought Shelton was dealing with something more serious than mushrooms.

"She says, 'I know I'm just a random stranger, but please, let someone else check it out,'" said Shelton, who lives in the Maryland suburbs of Washington, D.C

Shelton, now 42, took the advice.

Initial lab work didn't yield a clear diagnosis, but her new doctor said he was confident she had acral lentiginous melanoma, a form of skin cancer. Further tests proved him right. Although rare, it is the most common subtype of melanoma in black people, like Shelton. It's the disease that Reggae star Bob Marley killed at age 36 and is most commonly found on skin that is less frequently exposed to the sun, such as the hands, soles of the feet, and under the nails. Researchers don't understand what causes acral lentiginous melanoma and they don't know how to prevent it. It is often missed or misdiagnosed during skin examinations.

Skin cancer in general is often overlooked or misdiagnosed in black patients.

Historically, Black and dark-skinned people have been excluded from efforts to combat skin cancer. Long neglected by sunscreen manufacturers and a medical community that lags behind in diversity and cultural competency — recognizing a patient's heritage, beliefs and values ​​— many have been uninformed about the safety of the sun or how to examine their skin for signs of damage or cancer.

Certainly, skin cancer rates are lower in people with darker skin. Melanoma is more than 20 times that common among whites as well as African Americans, with an overall life risk of 1 in 38 for whites compared to 1 in 1,000 for blacks. Melanin provides some protection against sun damage, so people with more of it - those with darker skin - are better protected than those with lighter skin.

But overall, Black patients are more likely to be diagnosed with various forms of skin cancer at more advanced stages and have higher mortality rates, she said Dr. Janiene Luke with the Skin of color society a nonprofit organization that educates physicians and the public about skin health.

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

Given the known differences in results, Dr. Valerie Harvey, president of the Skin of Color Society, said two areas of research are needed: studying educational initiatives to see whether awareness could lead to earlier diagnosis and improved survival; and determining risk factors in patients with dark skin, particularly factors that lead to the occurrence of melanoma in places less exposed to the sun.

Improving cultural competency and diversity within dermatology is just one step toward improving diagnosis and outcomes. According to that latest data, less than 3% of dermatologists nationwide are Black. Orthopedics is the only medical specialty with a lower proportion.

Dermatology has traditionally been one of the most competitive specialties in medicine, said Dr. Michelle Heinrich a clinical trainer in dermatology Weill-Cornell medicine. In addition to rigorous academic requirements, admission to dermatology programs also depends on connection to mentors and extensive networking, which can be expensive. And that, Henry said, has traditionally created barriers for Black medical students wanting to study dermatology.

“There are so many barriers that make it difficult for many students of color to do the things they need to do in such an over-exclusive and small space,” she said.

Recent initiatives to help students overcome these barriers are beginning to work, said Dr. Susan Taylor, Vice Chair of Diversity, Equity and Inclusion in the Department of Dermatology at the University of Pennsylvania and founder of the Skin of Color Society. Initiatives from the American Academy of Dermatology This includes holistic residency application reviews, mentoring, and programs to increase the interest of high school students and prepare them for college and medical school.

Medical app companies VisualDX works to reduce inequalities in medicine through Project impact by creating a catalog of images that reflect different diseases in different skin tones. Skin cancer can look different on lighter skin than on darker skin, and because doctors may only have been trained on depictions of light skin, the likelihood of misdiagnosis increases in people with darker skin.

Something has also happened in the sun protection industry.

Jorge Martinez-Bonilla Senior vice president and partner at a market research firm in Chicago C+R research said the failure within the medical community to provide adequate skin care for people with dark skin reflects the lack of availability of sunscreen to meet the needs of patients, particularly for Black people.

“This has led to Black entrepreneurs being pushed from one day to the next to develop their own solutions and their own products,” Martínez-Bonilla said. “Not just for lack of availability, but because they know their needs best.”

Katonya Breaux is one of these entrepreneurs. She wasn't thrilled when, in her 30s and 40s, she noticed that she was developing moles on her face and neck, similar to those she had seen on older family members when she was growing up. She assumed it was just part of aging. But her dermatologist said it was sun damage.

"I was literally shocked. I was like, 'But I'm black,'" she said, adding that she had no experience with sunscreen growing up. "It was so foreign to me. I thought we just didn't need it."

After struggling to find a sunscreen that didn't leave a residue or feel like it was burning her skin, she worked with a chemist who helped her create a mineral-based tinted sunscreen. At first she intended it only for her personal use, but eventually she launched Sun cosmetics. The Los Angeles-based company educates about skin care and sells products for darker-skinned consumers.

Shontay Lundy I also struggled to find a sunscreen that “didn’t leave my skin blue, purple, or any other colored tint.” Until she said, “I realized it doesn’t exist.”

So in 2016 she developed products that left no residue and finally brought them to market Sunscreen for black girls.

Education is essential to promoting her business, Lundy said. “Our mission is to equip people of all ages and skin colors with the right sun protection products so they can take their skin health seriously and protect themselves from sun damage.”

Shelton, whose chance encounter at a store checkout led to her cancer diagnosis, said she has become an evangelist for skin self-tests and sunscreen and is now known at her local pool as "the sunscreen lady." The type of skin cancer she had may not have been due to sun exposure, but it raised her awareness about skin damage and other types of skin cancer.

She has been cancer-free since the doctor successfully removed the tumor on her toe and she underwent chemotherapy and radiation. But the experience was traumatic.

“It’s life-changing,” she said.

Still, she said, she has resumed an active and fulfilling life. She said she will forever be grateful to the stranger who pulled her aside that day, as well as the doctor who didn't believe the first labs that came back and instead chose to trust his instincts to begin treatment immediately.

Skin cancer prevention tips for all skin tones

• Avoid direct sun, especially between 10 a.m. and 4 p.m. Keep babies completely out of the sun.

• Use a broad-spectrum sunscreen with an SPF of 30 or higher every day. Reapply every two hours or after swimming or activity/sweating.

• Do not leave sunscreen in the car as temperature changes can cause it to break down and lose its effectiveness.

• Wear clothing that covers arms and legs.

• Wear a wide-brimmed hat to protect your face, ears and neck.

• Wear UV-blocking sunglasses.

• Avoid indoor tanning beds.

• Examine the skin from head to toe every month. Look for dark spots or patches or growths that are growing, bleeding, or changing; wounds that heal slowly or heal and return; patches of skin that feel rough and dry; and dark lines under or around fingernails or toenails. Carefully inspect nail beds, palms, soles, head, lower legs, groin, and other areas that receive little sun. Contact a doctor if you have any concerns.

• See a board-certified dermatologist at least once a year for a full-body exam.

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

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