Too often, Black patients get late diagnoses of deadly skin cancer

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The abundance in Black skin of melanin, the pigment that gives skin its color, offers extra protection from damaging ultraviolet rays. That makes Black people less likely than White people to get melanoma, the most dangerous skin cancer.
But that fact comes with a tragic footnote: Black people who are diagnosed with melanoma are about five times as likely as White people to die within five years.
That dramatic difference is largely the result of late diagnoses, likely caused in large part by a lack of awareness about how melanoma typically presents on Black bodies.
If we know how and where to look for the disease, in other words, fewer of us will die of it.
Reggae pioneer Bob Marley's death at the age of 36 is a cautionary tale of delayed detection. A dark spot under his toenail that Marley believed to be the result of a soccer injury was eventually diagnosed as acral lentiginous melanoma.
ALM is an aggressive cancer that usually appears as a freckle or dark brown spot or patch on the palms or the soles of the feet, or as a band running lengthwise under a nail — rather than on parts of the body that are more exposed to sunlight, where melanoma is usually found on lighter skin. Though it can occur in anyone, ALM is the most common type of malignant melanoma among people with darker skin tones.
Why does ALM often go unrecognized until it's too late? For starters, the characteristics of ALM aren't covered under the widely disseminated early detection strategy known as the ABCDEs of melanoma, which since 1985 has encouraged the public to check for moles that are: Asymmetrical; have blurry, scalloped or jagged Borders; are multi- or haphazardly Colored; are larger than 6 millimeters in Diameter (a little bigger than a pencil eraser); or Evolve in size, shape or feeling. (ALM has its own diagnostic acronym, which we'll get to below.)
Dermatologists should know to look for ALM, of course, especially when examining people of color. But it seems the medical community may not be doing a good enough job spreading the word among practitioners. A 2012 study in the journal Dermatology Clinic reported that in a recent survey, 47 percent of dermatologists and dermatology residents reported that their medical school or residency program offered inadequate training on skin conditions in Black people. It wasn't until a decade later that the American Academy of Dermatology introduced the Skin of Color Curriculum to train residents and practicing dermatologists on dermatologic conditions of the skin, hair and nails in patients with skin of color.
The problem seems to be compounded by a consistent lack of images in dermatology textbooks and a lack of skin-of-color-focused articles in top dermatology journals. (When I did a Google image search using the query 'What does skin cancer look like?' I had to scroll through 10 pages of results before a single image of a Black person appeared.)
'Because there are a dearth of images of skin cancer on dark skin, doctors and patients are less aware of what it looks like, leading to delays in recognition and treatment,' says Adewole Adamson, board-certified dermatologist and assistant professor in the department of internal medicine at Dell Medical School at the University of Texas at Austin.
Efforts are underway to address the issue. On Instagram, for example, Brown Skin Matters encourages its 118,000 followers to submit photos to create an image bank of what various dermatological conditions look like on skin of color. It was started by a mother who searched online for 'eczema on infant' and noticed that none of the images she found looked like her biracial son's symptoms. And in 2020, an international team of medical educators launched Skin Deep, a free, open-access medical education resource featuring photographs of dermatological conditions on a range of skin tones.
A lack of diversity among dermatologists may also play a role in delaying ALM diagnoses. One 2020 JAMA study shows improved patient experience when physicians shared a racial/ethnic background with their patients. Yet only 3 percent of dermatologists in the United States are Black, while Black people make up 13 percent of the population.
Regardless of the reasons for delayed ALM diagnoses, there are simple ways anyone can decrease their own risk. Early detection is key. Here's what to do:
Perform regular self-checks. The AAD recommends using a full-length mirror to check your entire body for spots, moles, discoloration, rough or dry patches, and sores that won't heal or that heal and then return. A handheld mirror will let you examine hard-to-see areas like the top of the head, back, groin, buttocks and behind the ears. (You can also enlist help from a loved one.) And ask your barber or hairdresser to tell you if they notice any new or odd-looking growths or spots on your scalp.
Check areas that usually are covered. Keep in mind that skin cancer in darker-skin populations most often develops on the soles of the feet, palms of the hands and nail beds, says Andrew Alexis, dermatologist at Weill Cornell Medicine.
In 2010, a panel of podiatrists and dermatologists developed a clinical guide to aid in early identification of melanomas on the feet and nails known as CUBED, which is detailed below.
The standard early detection strategy for spotting dangerous melanomas on the skin is not effective at detecting ALM, which typically manifests as a freckle or dark brown spot on the palms, soles of the feet or nail beds. To encourage early ALM detection, experts created the acronym CUBED.
C: Colored lesions where any part is a different color.
U: Uncertain diagnosis or a lesion without a clear clinical diagnosis.
B: Bleeding lesions on the foot or under the nail.
E: Enlargement of a lesion.
D: Delay in healing of any lesion beyond two months.
A few other things to keep in mind: Although it can occur on any toenail, ALM has a tendency to develop on the big toe, according to the AIM at Melanoma Foundation. Pay close attention to any narrow dark streaks in a nail not caused by an accident. On the surface of the foot, an ALM lesion could be flat, even as the tumor grows deep into the skin. The Foundation also cautions that thickening ALM is sometimes mistaken for a plantar wart on the sole of the foot and can make walking painful.
Keeping a close watch on your own body parts is critical, but if you use a manicurist or pedicurist, they can also be helpful in spotting abnormalities on your hands and feet and under the nails.
Find a dermatologist who is familiar with darker skin. Various institutions and individuals are working to bring dermatologists up to speed when it comes to communities of color. The Skin of Color Society is a member organization with a directory of physicians and board-certified dermatologists promoting awareness in skin-of-color dermatology. And there are a growing number of academic 'ethnic skin centers' in the U.S. that focus on the care and research of conditions common among people of color, preparing residents to treat skin of color and educating the medical community and public.
Protect your skin from the sun. Recognizing that Black people tend to get melanomas on body parts that solar rays don't typically reach is important, but dark-skinned people still must protect themselves from direct sunlight. Even the darkest skin has a natural sun protection factor of only 13, according to the Dermatology Education Foundation — while the AAD recommends correct consistent use of broad-spectrum, water-resistant sunscreen with an SPF of at least 30.
For some people of color, sunscreen is a hard sell. 'The acceptance of sunscreen use by people with skin of color has been at least in part affected by challenges finding sunscreen formulations that do not leave a visible cast,' Alexis says. Sunscreen can manifest on darker complexions as a white overtone that makes skin look like a powdered doughnut — but some are better than others in this respect. In a Consumer Reports evaluation, 83 people with olive to deep-brown complexions were asked to judge the look and feel of 21 sunscreens on their skin. The participants found several products that absorbed quickly and did not make their skin look chalky or ashy, including Black Girl Sunscreen Kids Spray & Play SPF 50 and Supergoop Play Everyday Lotion SPF 50.
Of course, limiting your skin's exposure to the sun, by either staying in the shade or wearing protective clothing, can also mitigate the risk of developing skin cancer.
Consumer Reports is an independent, nonprofit organization that works side by side with consumers to create a fairer, safer and healthier world. CR does not endorse products or services, and does not accept advertising. Read more at ConsumerReports.org.

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