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Can I have help? FROM THE ACADEMY Skin cancer and photoprotection in people of color: A review and recommendations for physicians and the public Oma N. Agbai, MD, a Kesha Buster, MD, b Miguel Sanchez, MD, c Claudia Hernandez, MD, d Roopal V. Kundu, MD, e Melvin Chiu, MD, f Wendy E. Roberts, MD, g Zoe D. Draelos, MD, h Reva Bhushan, PhD, i Susan C. Taylor, MD, j and Henry W. Lim, MD a Detroit, Michigan; Wichita, Kansas; New York, New York; Chicago and Schaumburg, Illinois; Los Angeles and Rancho Mirage, California; High Point, North Carolina; and Philadelphia, Pennsylvania From D D D m C D M C Ra A H 748 Skin cancer is less prevalent in people of color than in the white population. However, when skin cancer occurs in non-whites, it often presents at a more advanced stage, and thus the prognosis is worse compared with white patients. The increased morbidity and mortality associated with skin cancer in patients of color compared with white patients may be because of the lack of awareness, diagnoses at a more advanced stage, and socioeconomic factors such as access to care barriers. Physician promotion of skin cancer prevention strategies for all patients, regardless of ethnic background and socioeconomic status, can lead to timely diagnosis and treatment. Public education campaigns should be expanded to target communities of color to promote self-skin examination and stress importance of photoprotection, avoidance of tanning bed use, and early skin cancer detection and treatment. These measures should result in reduction or earlier detection of cutaneous malignancies in all communities. Furthermore, promotion of photoprotection practices may reduce other adverse effects of ultraviolet exposure including photoaging and ultraviolet- related disorders of pigmentation. ( J Am Acad Dermatol 2014;70:748-62.) Key words: basal cell carcinoma; Bowen disease; dermatofibrosarcoma protuberans; dyspigmentation; melanoma; Merkel cell carcinoma; mycosis fungoides; people of color; photoprotection; radiation; skin cancer; skin of color; squamous cell carcinoma; sun protection; sunscreen; ultraviolet. DEFINITIONS Abbreviations used: BCC: basal cell carcinoma DFSP: dermatofibrosarcoma protuberans MED: minimal erythema dose MF: mycosis fungoides MM: malignant melanoma NMSC: nonmelanoma skin cancer POC: people of color SCC: squamous cell carcinoma SEER: Surveillance, Epidemiology, and End Results SPF: sun-protection factor UV: ultraviolet Whites: Non-Hispanic individuals of European descent Blacks: Non-Hispanic individuals of African descent Hispanics: Individuals who trace their origin or descent to Mexico, Puerto Rico, Cuba, Spanish- speaking Central and South American countries, Spanish-speaking island nations of the Caribbean, and other Spanish cultures. Origin can be considered as the heritage, nationality group, lineage, or country of the person or the person’s parents or ancestors before their arrival in the United States. People who the Multicultural Dermatology Center, Department of ermatology, Henry Ford Hospital, Detroit a ; Department of ermatology, Via Christi Clinic, Wichita b ; Department of ermatology, New York University Medical Centerc; Depart- ent of Dermatology, University of Illinois College of Medicine, hicago d ; Northwestern Center for Ethnic Skin, Department of ermatology, Northwestern University Feinberg School of edicine, Chicagoe; Division of Dermatology, University of alifornia Los Angeles Medical Centerf; Desert Dermatology ncho Mirage g ; Dermatology Consulting Services, High Point h ; merican Academy of Dermatology, Schaumburgi; and Society ill Dermatology and Cosmetic Center, Philadelphia.j Funding sources: None. The authors’ conflict of interest/disclosure statements appear at the end of the article. Accepted for publication November 26, 2013. Reprint requests: Reva Bhushan, PhD, Department of Evidence-based Research, American Academy of Dermatology, 930 E Woodfield Rd, Schaumburg, IL 60173. E-mail: [email protected] Published online January 30, 2014. 0190-9622/$36.00 � 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2013.11.038 Delta:1_given name Delta:1_surname Delta:1_given name Delta:1_surname Delta:1_given name Delta:1_surname Delta:1_given name Delta:1_surname Delta:1_given name Delta:1_surname Delta:1_given name mailto:[email protected] http://dx.doi.org/10.1016/j.jaad.2013.11.038 J AM ACAD DERMATOL VOLUME 70, NUMBER 4 Agbai et al 749 identify their origin as Hispanic or Latino may be of any race. This definition of Hispanic fully excludes the Portuguese, Brazilians, or anyone from any other country that speaks Portuguese.1 Asians: Individuals having origins in any of the original peoples of East Asia, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.1 INTRODUCTION Malignant melanoma (MM) and nonmelanoma skin cancer (NMSC) account for 40% of all neoplasms in whites, making it the most common malignancy in the United States.2 Skin cancer is most common in whites and in people living in equatorial latitudes.3 The incidence of both MM and NMSC remains significantly lower in people of color (POC) when compared with whites as they are seen in about 5% of Hispanics, 4% of Asians, and 2% of blacks.4,5 Even so, multiple reports have demonstrated heightened morbidity and mortality in minority populations, 6-8 raising public health concerns in these groups. Although there are data detailing incidence of skin cancer in POC, these data are limited. In addition to skin cancer, factors such as photoaging, pigmentary disorders induced or exacerbated by ultraviolet (UV) exposure, and sunburn must be considered in POC. It is estimated that black, Hispanic, and Asian Americans will comprise approximately 50% of the US population by the year 2050.4 These evolving demographics, elevated rates of skin cancer morbidity and mortality in POC, and limited clinical data on additional adverse effects of UV exposure in this population mandate that physicians develop familiarity with the concept of optimized photo- protection for POC. An understanding of the varying clinical presentations of UV-related skin cancers in POC, in addition to relevant topics in photoaging and UV-related disorders of pigmentation, is necessary for adequate management of photoprotection in POC. BIOLOGICAL BASIS OF SKIN CARCINOGENESIS AND PHOTOAGING IN POC Few studies have been performed to thoroughly evaluate biological differences between differing ethnic skin types. Skin color is primarily determined by the presence of melanin. Jimbow et al9 reported that dark skin has larger melanocytes that produce more melanin and melanosomes are distributed individually in keratinocytes rather than in aggre- gates. The rarity of cutaneous malignancy in populations of darker complexions is secondary to photoprotection from a higher amount of epidermal melanin, which filters at least twice as much UV radiation as the epidermis of whites.10 In an in vitro study performed by Kaidbey et al,11 the amount of UV radiation reaching the papillary dermis of whites was greater than that of blacks by approximately 5-fold. The authors proposed that larger and more melanized melanosomes observed in POC absorbed more energy than the melanosomes in white skin, which were smaller, less dense, and lightly mela- nized. Furthermore, the authors estimated that the epidermis of blacks has an intrinsic sun-protection factor (SPF) of 13.4, whereas light skin has an SPF of 3.3.11 Therefore, exposure to UV radiation plays a lesser role in heightening the risk for skin cancer in populations of darker complexions. Damage to DNA secondary to UV radiation is a major factor in cutaneous photocarcinogenesis and photoaging. However, the correlation of ethnicity and degree of sensitivity to UV rays has not been elucidated. Tadokoro et al12 performed a study evaluating the correlations between melanin content and degree of UVA- and UVB-induced DNA damage in normal-appearing skin of various ethnic groups. DNA damage was found to be most severe in qualitatively light skin. Baseline skin pigmentation and extent of DNA damage were inversely related, as individuals of darker skin tones were able to repair UVA-/UVB-induced DNA damage more rapidly than subjects with fair skin. Even low exposure to UVA/UVB radiation induced some appreciable DNA damage in all skin types, dispelling the myth that those with very dark skin are completely im- mune to UVA-/UVB-induced DNA damage.12 Indeed, NMSC and MM do occur in POC, despite the low relative risk.13 Because of the limited research on skin cancer in POC, there are few resources providing insight on evaluating darkly pigmented lesions in POC. Frequently atypical presentations, together with constitutive dark pigmentation, pose diagnostic challenges in the identification of characteristics such as variation in color within the lesions. Furthermore, certain skin cancers that are pigmented in POC may not be pigmented in whites (such as basal cell carcinoma, which is more likely to be pigmented in darker skin types); therefore, a high index of suspicion in POC is necessary in making the diagnosis. 5 BASAL CELL CARCINOMA Basal cell carcinoma (BCC) is the most prevalent skin cancer found in whites, Asians, and Hispanics.14 Hispanics are more likely to be given a diagnosis of multiple BCC rather than a single squamous cell Fig 1. Nonmelanoma skin cancers in people of color. Pigmented basal cell carcinoma in elderly Hispanic man (right lateral orbital rim) (A); middle-aged Asian woman (right cheek) (B); middle-aged Hispanic man (right forehead) (C); and middle-aged Hispanic man (left nasal ala) (D). Hypopigmented mycosis fungoides in Hispanic man (back) (E) and black man (lower aspect of back) (F). G, Metastatic squamous cell carcinoma in black man (right parietal scalp, courtesy of Dr Marc Silverstein, Sacramento, CA). J AM ACAD DERMATOL APRIL 2014 750 Agbai et al carcinoma (SCC).15 In contrast to Hispanic popula- tions, BCC is the second most common skin malig- nancy in blacks after SCC.4,5 The clinical spectrum of disease in BCC shows many parallels among blacks, whites, Asians, and Hispanics. The classic clinical presentation of a solitary pearly papule with central ulceration and rolled borders may be seen in POC, but may pose challenges in the physical examination as the characteristic pearly borders and telangiectasia may not be clinically as apparent in dark skin types (Fig 1). In whites, the majority of patients presenting with BCC are of advancedage([50years),mostcommonlypresenting with asymptomatic solitary translucent nodules with central ulceration.14 Pigmentation is present in over 50% of tumors in POC,4,16 whereas only 5% of BCCs affecting whites have been shown to be pigmented. In Asians, BCCs frequently present as brown to black papules, or have a ‘‘black pearly’’ appearance.17 The clinical presentation of BCCs in Asian skin ranges from nodules to papules, plaques, and ulcers.18 With regards to anatomic distribution, there are significant similarities between POC and whites. Approximately 80% of BCCs in POC were found in the head and neck,19 as has been shown in whites.14 Differential diagnosis for BCC in POC includes seborrheic kera- tosis, blue nevus, trauma, lupus erythematosus, nevus sebaceous, sarcoidosis, and melanoma.20 Metastasis in BCC is rare in all skin types.14 BCC in blacks Although quite rare, BCC has been reported in the black population. In a report from Howard University (Washington, DC) from 1960 through 1986, most BCCs were seen in blacks of fairer skin complexion in comparison with those with darker complexions.19 From this, one may conclude that the incidence of BCC may correlate directly with the degree of skin pigmentation, as it is most frequently diagnosed in whites of fairer complexions, and more rarely diagnosed in blacks. A study of skin cancer prevalence was conducted by Asuquo et al21 in a Nigerian teaching hospital between the years of 2000 and 2004. Of 63 cases of skin cancer, BCC was diagnosed in 8% (n = 5) of the cases; 66.7% of the BCC were on the head and neck, and 33.3% on the upper limb. All of these lesions were nodular. BCC was diagnosed only in albinos in this study.21 In a review of 128 black patients with 148 BCCs, Mora and Burris3 (New Orleans, LA) found that the average age of examination (not necessarily onset) was 59 years, with lesions most commonly located on head and neck. Only 2 of these patients had albinism. J AM ACAD DERMATOL VOLUME 70, NUMBER 4 Agbai et al 751 The incidence of BCC in non-sun-exposed skin is equal between whites and blacks.22 Diverse pre- sentations and locations of BCCs have been found in blacks, ranging from superficial BCC to perianal BCC.3,11 BCCs in blacks are often pigmented, and there are reports of BCCs that have arisen in scars, which rarely proceeded to metastasize.3,4,23 BCC in Hispanics One of the most common neoplasms diagnosed in Hispanics is pigmented BCC.16 Hispanics studied demonstrated significantly lower incidence rates of BCC than non-Hispanic whites regardless of gender.24 Still, a high index of suspicion should be maintained in evaluating pigmented lesions in Hispanics, as BCCs have a propensity to be pig- mented in Hispanic populations and may be mis- diagnosed as melanomas.16 In a study performed by Bigler et al16 (Albuquerque, NM), the incidence of pigmented BCC in Hispanics was found to be twice that of white patients. Compared with whites, Hispanics with NMSC were shown to have fewer tumors per individual, and fewer Hispanics had more than 1 tumor.24 A registry of skin cancers in New Mexico between the years of 1964 and 1992 showed an average of 1.8 tumors per individual with NMSC among Hispanics, compared with 2.2 tumors per individual with NMSC in whites. Of these, BCC was more common than SCC by 6.6-fold in both Hispanics and whites.24 BCC in Asians Although NMSC is not common in Asians, it is not extremely rare. In a study by Cheng et al25 studying incidence of NMSC between 1990 and 1999 in Hong Kong, China, the incidence of BCC was 0.32 and 0.92 per 100,000 population. Pigmented BCC was the most common NMSC diagnosed, found in approxi- mately 60% of Chinese patients with skin cancer in the study.25 Multiple or subsequent skin cancers and subtypes of new cancers were seen less often in the Chinese group when compared with the white group.25 Similarly, Sng et al26 reported an increase of skin cancers including BCC, SCC, and MM, in Singapore between the years of 1998 and 2006. The extremities were the most common sites affected by Bowen disease (SCC in situ).27 There is an increased incidence of NMSC in Japanese living in Kauai, Hawaii, which may be secondary to heightened intensity of year-round UV radiation and popularity of outdoor activities, as reviewed by Lee and Lim.28 SQUAMOUS CELL CARCINOMA SCC comprises approximately 20% of all skin cancers. With MM excluded, approximately 75% of all deaths from skin cancers are caused by SCC. 29 In blacks and Asian Indians, SCC is the most commonly diagnosed skin cancer. It is the second most commonly diagnosed skin cancer in Hispanics, East Asians (including Japanese and Chinese patients), and whites.5,30 Although actinic keratoses are most commonly diagnosed in white and Japanese pa- tients,31 they are very rare in blacks.32 Riskfactorsfor SCCinPOCincludechronicscarring and inflammatory processes including hidradenitis suppurativa, lupus erythematosus, scars caused by chemical and thermal burns, skin ulcers, and sites of previous radiation.33,34 Immunocompromised pa- tients, including organ transplant recipients, also demonstrate a heightened risk for SCC.35 Among blacks, the greatest predisposing factors for devel- oping SCC include chronic scarring and/or inflamma- tory processes that are observed in 20% to 40% of reported cases.4 In addition, the human papilloma- virus has been linked to the development of SCC, particularly in immunocompromised patients.36 One retrospective study detected human papillomavirus DNA in skin samples of 4.7% of controls, 90.5% of benign warts, 60.4% of precancerous lesions, 59.7% of SCC, and 27.8% of BCC, suggesting a link between viral infection and the development of NMSC.37 Definitive studies have not been performed on the relationship between human papillomavirus infection and NMSC in POC. SCCs are characteristically firm, superficial, well- demarcated papules or plaques that emerge from a rounded, indurated, and elevated base.29 In POC, SCC is most commonly found in areas that are not typically exposed to the sun, such as the lower extremities and anus. In fact, lower extremity and anogenital SCCs were seen in 15% of SCCs in blacks in a study conducted by Halder and Bang19 in Washington, DC. This is a sharp contrast to the white population, in whom SCCs are characteristically seen in chronically sun-exposed skin.19 SCC in blacks Among black patients given the diagnosis of SCC, the peak incidence was shown to be in the fifth decade on the lower limbs, followed by the head and neck and then the genitals. The scalp and lip are more often implicated in black women than in men.38 Chronic trauma, ulcers, and scars are the most significant predisposing factors for SCCs in the lower limb and on the scalp, as reported by Amir et al38 (Dar es Salaam, Tanzania) in a study of SCC in Tanzanian patients, where UV radiation was found to be the primary factor predisposing pa- tients to increased risk of SCC in the head and neck. In a study done in Tanzania, smegma of the J AM ACAD DERMATOL APRIL 2014 752 Agbai et al uncircumcised penis was also reported as a risk factor for the majority of cases of SCC developing on the penis in blacks.38 The majority of SCC on the penis were found to be SCC in situ upon histologic analysis in a study performed by Hubbell et al39 (New Orleans, LA). SCC was the most common skin cancer reported in a Nigerian teaching hospital between 2000 and 2004 by Asuquo et al, 21 where the lower limb was the most commonly affected anatomic site. SCC manifesting as Marjolin ulcer associated with trau- matic injury of the limb was diagnosed in 7 patients, and associated with a history of burn in 1 patient. SCC involved the external genitalia in 9 patients, 3 of whom had genital warts. The anus was affected in 4 female cases. There were no lesions involving the head and neck regions, and all patients in this study presented with chronic ulcers.21 Several cases of the emergence of SCC within scars of chronic discoid lupus erythematosus in black patients have been reported. Caruso et al40 reported a heightened propensity for SCC to metastasize in black Canadian patients with discoid lupus erythe- matosus. Sun exposure of hypopigmented lesions of discoid lupus erythematosus may have been a predisposing factor. In blacks, Bowen disease (SCC in situ) typically presents as scaly hyperkeratotic pigmented pla- ques, and may be misdiagnosed as MM. In contrast, Bowen disease lesions are rarely pigmented outside of the groin in whites.41 Black women are affected twice as often as black men, and most frequently in skin that is not sun exposed.19 In a study performed by Mora et al42 in New Orleans, LA, evolution to SCC was noted in 5 of 19 black patients with Bowen disease, leading to death in 3 of these patients. The most common area affected was the lower extremity.42 Mortality of SCC in blacks is as high as 29%, secondary not only to delays in diagnosis and treatment, but also to more aggressive biologic behavior of SCC in this popu- lation.41,43 In blacks, SCC that develops within a chronic scarring process tends to be more aggres- sive and is associated with a 20% to 40% risk of metastasis. In contrast, the rate of metastatic trans- formation of sun-induced SCC in blacks is approx- imately 1% to 4%.4 In a case series on SCC in blacks performed by Mora and Perniciaro 33 (New Orleans, LA), the highest mortality was observed in cases of perianal SCC. Although most patients with primary SCC have a very good prognosis, the 10-year survival is less than 20% in patients with regional lymph node metastasis, and less than 10% in patients with distant metastasis.29 SCC in Asians Bowen disease and pigmented BCCs are not uncommonly diagnosed in Asians. Because of their pigmented appearance, as in blacks, these may be misdiagnosed as MM.25 Although NMSC is uncom- mon, it is not rare in the Chinese population in Hong Kong. Cheng et al25 (Hong Kong, China) reported that the incidence of SCC in 1990 was 0.16 per 100,000 population, and in 1999, 0.34. Similarly, in a case-control study performed by Chen et al44 in Taiwan evaluating the association between UV radi- ation exposure from the sun and risk for develop- ment of SCC by gender, exposure at a young age (15-24 years) and cumulative sun exposure were significantly associated with heightened risk of SCC in a dose-related pattern. Cumulative sun exposure was found to be more closely related to increased risk of SCC in women, whereas sun exposure at an early age showed more relevance to SCC risk in men.44 Skin reactions such as redness, burn, and suntan after 2 hours of sun exposure in childhood and adolescence were not associated with increased risk for SCC.44 In a study on skin cancer incidence between 1986 and 1997 among Asians living in Singapore, 2650 BCCs were reported. There was a general increase in skin cancer incidence from 6 per 100,000 person- years (from 1968-1972) to 8.9 per 100,000 person- years (1993-1997). The incidence of BCC increased approximately 3% yearly. Age-standardized inci- dence rates for BCC were greatest in fair-skinned Chinese, followed by Malays and Indians. This trend was also noted for SCC and cutaneous MM. 45 MALIGNANT MELANOMA MM is the deadliest type of skin cancer found across all races and ethnicities. Many melanoma cases are diagnosed in nonhospital settings and thus may be underreported to central cancer registries, which traditionally collect the majority of cases from hospi- tals.46 This could lead to significant underreporting of MM and resultant underestimation of the incidence of melanoma.47 The National Cancer Institute, Division of Cancer Control and Population Sciences, Surveillance Research Program, Cancer Statistics Branch (Bethesda, MD) reports that the incidence of cutaneous MM increased by approximately 6% yearly in the 1970s, slowed to a 3% yearly increase between 1981 and 2000, and has since stabilized.48 Since the late 1980s, the incidence of MM has increased significantly among Hispanics in California, increasing an average of 1.8% yearly in male Hispanics between 1988 and 2001, and 7.3% average yearly between 1996 and 2001.49 In a study conducted by Bergfelt et al,50 the incidence of MM Fig 2. Melanomas in people of color. A, Lentigo maligna in middle-aged Hispanic woman (vermilion upper and lower lips). Melanoma in middle-aged black woman (right fourth toe) (B); Hispanic woman (left fifth toe) (C); middle-aged Hispanic man (left plantar foot) (D); elderly Hispanic man (right cheek) (E); and Asian woman (side of left leg) (F). J AM ACAD DERMATOL VOLUME 70, NUMBER 4 Agbai et al 753 among Hispanics in Puerto Rico and New Mexico (race not specified) was greater than in US blacks by 1.6- to 3.7-fold. There was a close correlation in anatomic distribution of MM among whites and Hispanics in New Mexico in both men and women. The most common MM distribution in Hispanics from Puerto Rico was the leg, as was seen in black Americans.50 In another study, Vazquez-Botet et al51 reported that nearly half of MM in Hispanic patients in Puerto Rico were found on the extremities, especially the feet, similar to black and Japanese patients. Superficial spreading melanoma was the most com- mon histologic type, followed by acral lentiginous, nodular, and lentigo maligna melanomas.51 More recently, Wu et al52 (New Orleans, LA) reported that incidence rates of MM in the United States were notably higher in females than males in white and Hispanic populations younger than 50 years, and in Asian/Pacific Islanders younger than 40 years. The median age of white and black patients was greater (59-63 years) when compared with Hispanics, Asian/ Pacific Islanders, and American Indians/Alaskan Natives (52-56 years).52 Histologically, acral lentigi- nous melanoma was the most common subtype in blacks, whereas superficial spreading melanoma was most commonly diagnosed in all other ethnic groups studied.52 Incidence rates of acral lentiginous melanoma were, however, highest in Hispanics. Non-whites demonstrated an increased propensity to present with more advanced MM when compared with whites.52 Typically, MM presents as a dark macule or patch and may have a history of rapid spreading. Suspicion for subungual melanomas is raised when a pig- mented band wider than 3 mm is observed on the nail, extension of pigment to proximal nail fold (Hutchinson sign) and there is pigment variation, rapid growth in size, and the observation of solitary lesions.4 Subungual melanoma is most common on the thumb and first toe. In populations of color, the plantar foot is most commonly affected (Fig 2),53 as it is implicated in 30% to 40% of cases.54 Melanomas found in the oral cavity comprise approximately 7.5% of all melanomas in Asians, where approximately 60% of these develop from lesions of oral melanosis. The greatest risk factors for the development of MM in whites include periods of high intermittent sunlight exposure (as in sunbathing and indoor tanning), and large cumulative doses of UV radiation from chronic exposure (as seen in outdoor workers).55 Factors in the host that may increase susceptibility to develop- ment of melanoma include a large number of nevi, the presence of dysplastic nevi, freckles, fair complexion, red or blonde hair, and family history of MM.55 J AM ACAD DERMATOL APRIL 2014 754 Agbai et al Contrarily, in blacks and Asians, UVradiation does not appear to be a major risk factor, as the majority of melanomas are found in skin that is not typically sun exposed, including palmar, plantar, and subungual skin, and mucous membranes.56 In POC, the risk factors for MM have not been identified, but may be unrelated to sun exposure.57 Specifically, as acral melanomas are identified with similar rates at different latitudes and in varying racial groups, and as they tend to be diagnosed in anatomic sites that are not typically sun exposed, their origin may be unrelated to sun exposure.28 MM in blacks In black Americans, acral lentiginous melanoma is the most common and deadly form of MM.56,58 Not uncommonly it is misdiagnosed and managed as a tinea nigra, or even talon noir. In a retrospective study performed at Tulane University School of Medicine (New Orleans, LA)58 from 1958 to 1990, 82 patients (including 27 white men, 29 white women, 18 black men, and 8 black women) with a diagnosis of acral lentiginous melanoma were fol- lowed up, and the study showed a trend toward reduced survival in black men. A direct correlation between decreased survival and increased Clark level was also observed. As previously mentioned, the overall incidence of melanoma in the black population is lower than that of whites. Additional types of melanoma found in black Americans include superficial spreading and nodular types. 13 Acral lentiginous melanoma has a poor prognosis secondary to its propensity for deep invasion at presentation, with 5-year survival lower than 50%.59 In a study of skin cancers in a teaching hospital in Nigeria between 2000 and 2004, MM of the skin represented 8% (n = 5) of the 63 histologically diagnosed cutaneous malignancies. All of these MMs were plantar. Three of the 5 cases were clinically advanced nodular melanomas, whereas 2 were ulcerated superficial spreading melanomas.21 MM in Hispanics Pipitone et al60 (Maywood, IL) proposed that Hispanics had a propensity to present with more advanced disease secondary to the combination of a belief that they are not at risk to sunburn and/or develop skin cancer. Skin cancer prevention mea- sures are typically directed toward non-Hispanic whites, where skin self-examination and sun protec- tion are emphasized.13 Feun et al61 (Miami, FL) reviewed 54 melanoma cases in Hispanic patients; the majority of melanomas were located on the trunk, arm, shoulder, leg, and hip. Although 70% of these patients presented with local disease, 26% presented with regional and distant lesions. In this study, Hispanics given the diagnosis of melanomas had better treatment outcomes and survival than non-Hispanics.61 This contradicts a handful of other studies that have demonstrated poorer survival in Hispanic populations.57,62,63 MM in Asians In Asian populations, the sole of the foot is the most common site for MM.28 This is typically acral lentiginous melanoma.28 As in blacks and Hispanics, MMs in Asians have a propensity to be diagnosed at a late stage in comparison with whites.57 In a study done in Taiwan, factors such as age over 55 years, male gender, tumor thickness, and tumor ulceration were generally predictive of a poorer prognosis.64 In a study done in Japan, loss of the p53 gene though deletion mutation was associated with more aggres- sive subtypes of MM.65 Although in whites, number of melanocytic nevi is directly proportional to risk of developing MM,66 this may not be the case in POC. The density of melanocytic nevi is significantly lower in POC than in whites.66 Gallagher et al66 (Vancouver, British Columbia, Canada) found that nevus density in Asians was unrelated to skin color or tendency to burn. These findings may …