Overview & epidemiology

Overall incidence of all skin cancer types is lower in skin of colour than in white populations — but outcomes are substantially worse, driven predominantly by later-stage presentation (with some evidence of a residual stage-for-stage difference).
Disparities driven by:
- Under-recognition by clinicians and patients.
- Less routine sun-protection / surveillance behaviour.
- Over-representation of clinically aggressive subtypes (acral / mucosal melanoma, Marjolin SCC, post-burn / scar SCC).
- Late presentation; advanced stage at diagnosis.
- Reduced access to specialist dermatology / skin oncology services in some communities.

Melanoma in skin of colour

Acral lentiginous melanoma (ALM) — the dominant melanoma subtype in skin of colour; up to ~30–50% of all melanomas in patients of African, Asian or Hispanic descent (vs ~5% in white populations; proportions vary across cohorts — older series quoted higher figures). See monograph.
Subungual melanoma — disproportionately common in skin of colour. See monograph.
Mucosal melanoma — over-represented; oral, anorectal, vulvovaginal sites. See monograph.
Conventional sun-exposed superficial spreading melanoma is much less common.
UV is not a major driver of these subtypes; melanoma in skin of colour is not preventable through photoprotection alone — patient education and clinician awareness are essential.
Overall melanoma 5-year survival in Black patients in published US series is ~67% (vs ~94% in white patients) — almost entirely attributable to advanced stage at diagnosis.

cSCC is the commonest skin cancer in Black patients (in contrast to BCC commonest in white populations).
Distinct distribution and substrate:
- Marjolin-spectrum cSCC in chronic burn scars, ulcers, sinus tracts (HS, osteomyelitis), discoid lupus erythematosus — see Marjolin's ulcer, HS-cSCC, DLE-SCC.
- Lower-limb lesions on areas of chronic injury, lichen planus, lupus profundus.
- Anogenital cSCC (HPV-driven) over-represented; see VIN, AIN.
- Genital, oral and acral SCC at sites without significant UV exposure.
Behaviour — frequently more aggressive than UV-driven cSCC in white populations; higher rate of metastasis (10–40% in some series).

Less common but well-described.
Distinctive features:
- Pigmented BCC — much more common (~50% of BCCs in skin of colour vs ~6% in white populations); blue-grey to black "pearly" papules with arborising vessels.
- Dermoscopy — leaf-like areas, blue-grey ovoid nests, arborising vessels.
- Differential — pigmented seborrhoeic keratosis, melanoma, naevus.

Disproportionately affects Black populations from HIV-endemic and HHV-8-endemic regions of sub-Saharan Africa, the Caribbean and parts of South America.
UK Black African patients are over-represented in HIV-associated and AIDS-associated Kaposi sarcoma cohorts.
See Kaposi sarcoma.

Acne keloidalis nuchae — chronic scarring folliculitis on the posterior occiput / neck of Black men; long-standing disease has reported SCC arising at the site.
Dissecting cellulitis of the scalp / hidradenitis suppurativa — over-represented in Black populations; long-standing disease carries Marjolin-spectrum SCC risk.
Dermatosis papulosa nigra — multiple small black papules on the face; benign seborrhoeic-keratosis variant; not malignant.
Adult T-cell leukaemia/lymphoma (HTLV-1) — over-represented in UK Caribbean diaspora; see monograph.
Discoid lupus erythematosus — over-represented in Black populations; long-standing scarring DLE carries SCC risk; see DLE-SCC.

Clinical examination:
- Full skin examination including palms, soles, between the toes, mucosae, anogenital and nail unit — these are the high-risk sites in skin of colour and are commonly missed in routine surveillance.
- Examine inside chronic ulcers, scars, lichen planus and HS lesions for any change.
- Examine the oral cavity in any patient with concerning facial / mucosal pigmentation.
Patient education:
- Counter the myth that "skin cancer doesn't happen in dark skin".
- Counsel about acral, nail, mucosal and chronic-wound skin cancers.
- Specific photoprotection education — even in skin of colour, photoprotection prevents some cancers and most photoaging.
Diagnostic / referral patterns:
- Low threshold for biopsy of any acral pigmented lesion in skin of colour.
- Low threshold for biopsy of any chronic ulcer / change in long-standing inflammatory disease.
- Engage diverse imaging libraries when teaching; many UK dermatology atlases under-represent skin of colour.
Service development:
- Recruit clinical photography of skin lesions in diverse skin tones.
- Train clinicians in dermoscopic features of pigmented lesions in skin of colour (parallel ridge / furrow patterns, etc.).
- Address known healthcare disparities — referral times, language access, community engagement.