Skin Cancer in Skin of Color: Why It Is Often Caught Late

The Myth That Keeps Patients From Getting Checked

There is a persistent and dangerous myth in American culture: that skin cancer is a “white people problem.”

That melanin is protective enough. That patients with darker skin tones do not need to worry about UV damage. That they do not need skin checks. That a changing spot on the foot, nail, scalp, or mouth is probably nothing.

I hear this from patients regularly in my office, often as the explanation for why they have not seen a dermatologist in years, or ever.

The truth is more complicated and more urgent.

People of color do get skin cancer. And when they do, it is often diagnosed later, at more advanced stages, and with worse outcomes than skin cancer in lighter-skinned patients.

This disparity is not inevitable. It reflects a combination of lower public awareness, underscreening, delayed presentation, access barriers, and clinical blind spots in how skin cancer has traditionally been taught and recognized.

What the Data Actually Shows

Skin cancer is less common in patients with darker skin tones than in fair-skinned patients. That is true. Melanin does provide some natural photoprotection.

But less common does not mean rare. And it definitely does not mean impossible.

The problem is that lower incidence has contributed to lower suspicion. Patients may not check their skin. Primary care clinicians may not look carefully at palms, soles, nails, and mucosal areas. Dermatology images and education have historically overrepresented lighter skin.

The result is that skin cancer in patients of color may be missed until it is larger, deeper, symptomatic, or more advanced.

Melanoma is a clear example. Black patients are less likely to develop melanoma than white patients, but they are more likely to be diagnosed at a later stage and have lower survival rates. Stage at diagnosis is one of the most important drivers of outcome.

Hispanic, Asian, South Asian, Middle Eastern, and Indigenous patients also experience underrecognition and delayed diagnosis in different ways. These groups are often mistakenly assumed to be at negligible risk, which can delay evaluation.

The message is not fear. The message is awareness.

Types of Skin Cancer in Skin of Color

Skin cancer can look different in darker skin tones, and the most common locations may differ from what patients expect.

Acral Lentiginous Melanoma

The most commonly discussed melanoma subtype in patients of color is acral lentiginous melanoma, or ALM.

Acral melanoma occurs on the palms, soles, and under or around the nails. It is not primarily caused by UV exposure, and it often appears in areas that patients do not think to check.

This is why standard advice like “wear sunscreen” is not enough. Sunscreen matters, but it does not address acral melanoma.

ALM is rare overall, but it represents a larger proportion of melanomas in Black, Hispanic, and Asian patients compared with white patients.

The soles of the feet and nail units deserve special attention. A new dark spot on the bottom of the foot, a changing patch on the palm, or a new dark streak in the nail should not be ignored.

Subungual Melanoma and Nail Streaks

Subungual melanoma is melanoma involving the nail unit.

It can present as a dark streak in the nail, also called longitudinal melanonychia. In patients with skin of color, many dark nail streaks are benign. But a new, widening, changing, or irregular streak in an adult should be evaluated.

Warning signs include:

• A single dark streak that is new in adulthood
• A streak that is widening
• Irregular color or borders
• Pigment spreading onto the surrounding skin
• Nail splitting, bleeding, pain, or distortion
• A spot under or around the nail that does not heal

Patients may be told for years that a nail streak is “normal pigmentation.” Sometimes it is. But when it changes, it deserves a closer look.

Squamous Cell Carcinoma in Skin of Color

Squamous cell carcinoma, or SCC, can also occur in patients with darker skin tones.

In fair-skinned patients, SCC often arises from chronically sun-damaged skin or actinic keratoses. In darker skin tones, SCC may also arise in areas of chronic inflammation or injury.

This can include:

• Burn scars
• Chronic ulcers
• Non-healing wounds
• Areas of long-standing hidradenitis suppurativa
• Lupus scars
• Lichen planus scars
• Radiation scars
• Other areas of repeated trauma or inflammation

SCC arising in a chronic wound or scar is sometimes called a Marjolin ulcer.

These cancers can be missed because the area may already look abnormal from years of inflammation or scarring. A wound that changes, grows, bleeds, becomes painful, or does not heal should be evaluated.

Basal Cell Carcinoma in Skin of Color

Basal cell carcinoma, or BCC, is less common in darker skin tones than in lighter skin tones, but it does occur.

In patients of color, BCC may be pigmented. It can appear as a dark brown, blue-black, or shiny bump and may be confused with a mole, seborrheic keratosis, or other benign growth.

Warning signs include a bump that bleeds, crusts, grows, becomes shiny, does not heal, or looks different from the patient’s other spots.

What You Should Be Watching For

For patients with skin of color, I recommend watching for any new, changing, bleeding, painful, itching, or non-healing lesion anywhere on the body.

Pay special attention to:

• Palms
• Soles
• Between the toes
• Under and around the nails
• Scalp
• Lips and inside the mouth
• Genital and anal areas
• Areas of scars, chronic wounds, or inflammation

The ABCDE criteria still matter for melanoma:

A is for asymmetry.

B is for border irregularity.

C is for color variation.

D is for diameter, often greater than 6 mm, although melanomas can be smaller.

E is for evolving, meaning changing in size, shape, color, symptoms, or behavior.

For skin of color, I also emphasize the “ugly duckling” sign. If one spot looks different from all of your other spots, get it checked.

Why Skin Cancer Is Often Caught Late

Skin cancer in skin of color is often caught late for several reasons.

Patients may not know they are at risk.

Clinicians may not examine palms, soles, nails, scalp, or mucosal sites carefully.

Medical education has historically shown skin cancer mostly on lighter skin.

Some lesions are mistaken for fungus, trauma, warts, bruises, scars, or benign pigmentation.

Patients may have limited access to dermatology care.

There may be cultural or insurance barriers to preventive skin exams.

All of these factors matter. None of them are the patient’s fault.

The solution is better awareness, better screening, and a lower threshold to biopsy suspicious lesions.

Do Patients With Skin of Color Still Need Sunscreen?

Yes.

Sunscreen is still important for patients with skin of color. It helps reduce UV damage, photoaging, hyperpigmentation, melasma flares, and some UV-related skin cancers.

However, sunscreen is not the whole answer for skin cancer prevention in darker skin tones. Because some important skin cancers, including acral melanoma, occur in less sun-exposed areas, self-exams and professional skin checks matter too.

For daily use, I recommend a broad-spectrum SPF 30 or higher. For patients with melasma or post-inflammatory hyperpigmentation, a tinted sunscreen with iron oxides can be especially helpful because visible light can worsen pigmentation.

Why Full-Body Skin Exams Matter

A complete skin exam is not just a quick look at the face and arms.

For patients with skin of color, a thoughtful skin exam should include the scalp, nails, palms, soles, between the toes, and any areas of chronic wounds, scars, or inflammation.

Depending on your risk factors, your dermatologist may also ask about spots in the mouth, genital area, or other less visible sites.

Consider seeing a dermatologist for a baseline full-body skin exam, especially if you have:

• A personal or family history of skin cancer
• A changing mole or new growth
• A non-healing wound
• A dark nail streak that is new or changing
• A history of significant sun exposure
• A history of radiation, burns, chronic ulcers, or scarring skin disease
• Immunosuppression
• Many moles or atypical moles

If you have not had a dermatology visit because you assumed skin cancer was not relevant to you, please reconsider.

Early detection saves lives.

The Bottom Line

Skin cancer can affect patients of all skin tones.

In patients with skin of color, it is less common, but it is often diagnosed later. That delay can lead to worse outcomes.

The most important message is not panic. It is awareness.

Check your skin. Look at your palms, soles, nails, scalp, and areas of chronic inflammation or scarring. Do not ignore a spot just because it is not on a sun-exposed area. And see a dermatologist if something is new, changing, bleeding, painful, itching, or not healing.

Melanin is protective, but it is not immunity.

FAQ

Q: Can people with darker skin get skin cancer?

A: Yes. Skin cancer is less common in darker skin tones, but it can still occur and is often diagnosed later.

Q: What type of melanoma is more common in people of color?

A: Acral lentiginous melanoma is proportionally more common in Black, Hispanic, and Asian patients. It occurs on the palms, soles, and nail areas.

Q: Is a dark line in the nail always melanoma?

A: No. Many nail streaks in patients of color are benign. However, a new, widening, irregular, painful, bleeding, or changing nail streak should be evaluated by a dermatologist.

Q: Where should patients with skin of color check for skin cancer?

A: Check the palms, soles, between the toes, under and around the nails, scalp, mouth, lips, genital area, and any scars or chronic wounds, as well as sun-exposed areas.

Q: Do patients with skin of color need sunscreen?

A: Yes. Sunscreen helps protect against UV damage, hyperpigmentation, melasma, photoaging, and some skin cancers. It should be paired with skin self-exams and professional evaluation when needed.

Q: What does skin cancer look like in darker skin?

A: It may appear as a changing mole, dark spot, non-healing sore, bleeding bump, rough patch, dark nail streak, or a wound in a scar that does not heal.

Q: How often should patients with skin of color get a skin exam?

A: This depends on risk factors. Many patients benefit from at least a baseline full-body skin exam, and higher-risk patients may need annual or more frequent exams.

Q: When should I see a dermatologist urgently?

A: See a dermatologist if you notice a new or changing spot, a non-healing sore, a bleeding or painful lesion, a widening dark nail streak, or a wound in a scar that is not improving.