Photographs courtesy of Richard P. Usatine, MD (Figure A), and Tizita Yosef Kidane, MD (Figure B).
THE COMPARISON
A Nodular basal cell carcinoma (BCC) with a pearly rolled border, central pigmentation, and telangiectasia on the forehead of an 80-year-old Hispanic woman (light skin tone).
B Nodular BCC on the cheek of a 64-year-old Black man. The dark nonhealing ulcer had a subtle, pearly, rolled border and no visible telangiectasia.
Basal cell carcinoma is most prevalent in individuals with lighter skin tones and rarely affects those with darker skin tones. Unfortunately, the lower incidence and lack of surveillance frequently result in a delayed diagnosis and increased morbidity for the skin of color population.1
Epidemiology
Basal cell carcinoma is the most common skin cancer in White, Asian, and Hispanic individuals and the second most common in Black individuals. Squamous cell carcinoma is the most common skin cancer in Black individuals.2
Although BCCs are rare in individuals with darker skin tones, they most often develop in sun-exposed areas of the head and neck region.1 In one study in an academic urban medical center, BCCs were more likely to occur in lightly pigmented vs darkly pigmented Black individuals.3
Key clinical features in people with darker skin tones
The classic BCC manifestation of a pearly papule with rolled borders and telangiectasia may not be seen in the skin of color population, especially among those with darker skin tones.4 In patient A, a Hispanic woman, these features are present along with hyperpigmentation. More than 50% of BCCs are pigmented in patients with skin of color vs only 5% in White individuals.5-7 The incidence of a pigmented BCC is twice as frequent in Hispanic individuals (Figure, A) as in non-Hispanic White individuals.7 Any skin cancer can present with ulcerations, so while this is not specific to BCC, it is a reason to consider biopsy.
Worth noting
Pigmented BCC can mimic melanoma clinically and even when viewed with a dermatoscope, but such a suspicious lesion should prompt the clinician to perform a biopsy regardless of the type of suspected cancer. With experience and training, however, physicians can use dermoscopy to help make this distinction.
Note that skin of color is found in a heterogeneous population with a spectrum of skin tones and genetic/ ethnic variability. In my practice in San Antonio (R.P.U.), BCC is uncommon in Black patients and relatively common in Hispanic patients with lighter skin tones (Figure, A). There is speculation that a lower incidence of BCC in the skin of color population leads to a low index of suspicion, which contributes to delayed diagnoses with poorer outcomes. 1 There are no firm data to support this because the rare occurrence of BCC in darker skin tones makes this a challenge to study.
Health disparity highlight
In general, barriers to health care include poverty, lack of education, lack of health insurance, and systemic racism. One study on keratinocyte skin cancers including BCC and SCC found that these cancers were more costly to treat and required more health care resources, such as ambulatory visits and medication costs, in non-Hispanic Black and Hispanic White patients compared to non- Hispanic White patients.8
Final thoughts
Efforts are needed to achieve health equity through education of patients and health care providers about the appearance of BCC in skin of color with the goal of earlier diagnosis. Any nonhealing ulcer on the skin (Figure, B) should prompt consideration of skin cancer regardless of skin color.