Inflammatory dermatoses, pigment variation, and delayed recognition of skin cancer in people with dark skin were the central themes at the European Academy of Dermatology and Venereology (EADV) Congress.

Much of the current dermatologic teaching and published evidence is based on observations in people with lighter skin, which can lead to missed or delayed recognition of diseases in those with darker skin tones.

Case Study

Ophelia Entsir Dadzie highlighted that dermatologic pattern recognition has historically been based on studies in light-skinned individuals. She emphasized that a focused and uninterrupted clinical history remains the most reliable foundation for diagnosis.

She described a 51-year-old man from the Democratic Republic of the Congo who presented with facial swelling, nodules, and papules but no fever or neurologic symptoms. The initial evaluation was centered on infectious diseases, such as leprosy and tuberculosis. 

However, histologic examination revealed blister-like structures consistent with a granulomatous reaction to fillers such as silicone.

The treating physician responded, “But he cannot have had fillers; he is Black!”

When asked, the patient explained that he had received injections in Ukraine years earlier to treat acne scarring.

Clinicians should assess the characteristic papules and nodules and carefully examine the pigmentation patterns of acne vulgaris. Hyperpigmented lesions are often indicative of active rather than late-stage inflammation.

In the differential diagnosis of people with dark skin, facial Afro-Caribbean childhood eruption, also known as childhood granulomatous periorificial dermatitis, should be considered. This condition is characterized by granulomatous lesions in the perioral region.

Dadzie emphasized the importance of assessing the patients and their skin conditions holistically, and of expanding the clinical spectrum of differential diagnoses to encompass darker-pigmented skin.

Cancer Diagnosis

Another challenge in clinical practice is the detection of skin cancer in individuals with dark skin. Melanomas are often identified only at a late stage, contributing to high morbidity and mortality despite their low incidence. Ibrahima Traoré, MD, MSc, PhD, director of the Clinique Dermatologique de Donka at Donka National Hospital in Conakry, Guinea, noted that a false sense of security plays a role, as skin cancer is still widely associated with white skin. Melanomas in people with dark skin also arise more often on acral or mucosal sites or present as variants with different pigmentation, further delaying recognition. Acral lentiginous melanoma is a type of melanoma that develops on the palms of the hands, soles of the feet, and under the nails.

Other skin cancers, including squamous cell carcinoma, may present on the dark skin as hyperkeratosis or mimic chronic inflammatory lesions, thereby increasing the risk for misclassification as ulcers.

How can skin cancer be detected in individuals with dark skin in daily clinical practice? Clinicians should conduct careful clinical examinations that include the palms, soles, and nails, in addition to the rest of the body surface, as subtle pigment changes are often difficult to detect.

Dermoscopy increases the accuracy of visual assessment, and specific training in dermoscopy for darkly pigmented skin helps clinicians recognize the features characteristic of these skin types, such as pigmented basal cell carcinoma.

Clinical algorithms also support the early detection of cancer. When applied correctly and extended to include acral, mucosal, and amelanotic lesions, the asymmetry, border, color, diameter, and evolving rule can improve diagnostic accuracy.

An adapted version for people with dark skin is needed because the rule was developed for individuals with light skin tones. Traoré advised lowering the threshold for histologic assessment and biopsying any lesion that looks even slightly suspicious.

Correctly classifying inflammatory dermatoses and skin cancers in individuals with dark skin remains challenging in clinical settings, which are oriented toward lighter skin types. Clinicians should understand how disease presentation diverges from the classic patterns in dark skin.

Targeted training in dark-pigmented skin can improve clinicians’ skills and build confidence, helping ensure that these skin types are no longer viewed as uncommon.

This story was translated from Coliquio, part of the Medscape Professional Network.