Skin cancer is the most common cancer in Caucasians. It does occur in people of colour, although the relative risk is low. Skin cancer in skin of colour is associated with increased morbidity and mortality due to late presentation, atypical presentation, late treatment, and refusal of treatment (for example amputation).
Prevention and increased surveillance are essential, by means of regular skin exams by clinicians, self-examination, public education, and screening programmes.
Patients should seek medical attention for a non-healing ulcer (three weeks), new moles, changing moles, and changing lesions (oozing, bleeding, crusting).
Risk factors for skin cancer are increased sun exposure, especially to fair-skinned individuals, skin conditions that result in scarring or chronic inflammation, burn scars and post-radiation therapy.
Ultraviolet (UV) chronic exposure is a risk factor for nonmelanoma skin cancer (basal cell carcinoma [BCC], squamous cell carcinoma [SCC] and actinic keratosis [AK]), melanoma and photoaging.
Actinic keratoses
This is the proliferation of cytologic atypical keratinocytes in the dermal-epidermal junction zone. The risk of progression to SCC increases with the increase in the number of AKs.
Management of widespread AK
- Destructive therapies: Cryotherapy, surgery, dermabrasion, laser
- Topical therapies: 5-Fluorouracil, imiquimod, diclofenac
- Chemical peels
- Photodynamic therapy.
Albinism
This is a lack of pigment or pigment dilution due to a defect in the synthesis of melanin leading to a congenital absence of pigment in the skin and eyes.
Cancer risk is 23.4% in this group, increasing with age, due to cumulative exposure to UV radiation and inability to tan. SCC is more common than BCC here and occurs more commonly on the head. Melanoma is rare.
Xeroderma pigmentosum
This is a rare inherited disease that causes extreme sensitivity to the sun’s UV rays. Without sun protection, the skin and eyes are severely damaged. These patients develop freckles at an early age and the sun damage leads to the early onset of cancer of the skin and eye.
SCC
This cancer is more common in people of colour and is not always in sun-exposed areas. It is more common in the lower legs, the anogenital region, and the head and neck.
Risk factors include scarring (discoid lupus erythematosus, leprosy, burns), non-healing ulcers, radiation therapy, organ transplant recipients, albinism, and patients with xeroderma pigmentosum.
Weakened immunity
Patients with depressed immunity, such as organ transplant patients or those with HIV are at risk for SCC, Kaposi sarcoma, BCC, and melanoma.
BCC
This condition is less prevalent than SCC. Exposure to UV light is a major aetiological factor
Predisposing factors include fair skin and albinism, xeroderma pigmentosum, trauma and long-term ulceration, radiation therapy, arsenic ingestion, nevus sebaceous, basal cell nevus syndrome, and immunosuppression.
It is more common in females over 50, on the lower legs. The skin in these patients is usually pigmented.
Melanoma in the skin of colour
Melanoma is the third most common type of skin cancer in all racial groups, and the most deadly. It is 5-18 times less common than in Caucasians. The aetiology is undetermined in the skin of colour. Areas of involvement include hands and feet (acral lentiginous) including under the nails (misdiagnosed as warts or fungal infection)and mucous membranes.
There is a good chance of survival if detected early. Decreased survival is due to aggressive disease, late presentation and wrong diagnosis.
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