Skin Cancer in Darker Skin: Why It's Different, Often Missed, and How to Protect Yourself

When we picture skin cancer, the image that usually comes to mind is a rough, red, scaly patch on the arm of a fair-skinned person who has spent years in the sun. We've all seen the public service announcements, the sunscreen ads, and the warnings about blistering sunburns. But what if the cancer doesn't look red? What if it shows up on the bottom of your foot or under your fingernail? What if you've been told your entire life that the melanin in your skin protects you from the sun?

For millions of people with Skin of Color—a term that includes Black, Hispanic, Asian, and Indigenous individuals—this is the confusing reality. While having more melanin does provide a natural SPF, it is not a suit of armor. The truth is, skin cancer in darker skin often behaves like a completely different disease than in lighter skin. It hides in plain sight, appears in places the sun never shines, and is frequently mistaken for something harmless, like a wart, a scar, or a bruise.

Because of this, when a person with dark skin finally gets a diagnosis, the cancer is often far more advanced and harder to treat. This article will pull back the curtain on this dangerous knowledge gap. We'll explore why these disparities exist, what skin cancer actually looks like in Skin of Color, and—most importantly—what you can do to protect yourself and your loved ones.

The Melanin Myth: Why Protection Isn't Perfect

Let's start with the science of the skin, explained simply. Your skin has several layers, but the most important for this discussion is the epidermis, the top layer you can see and touch. Scattered throughout the base of the epidermis are cells called melanocytes. Think of melanocytes as tiny, individual factories. Their job is to produce melanin, which is the pigment that gives your skin, hair, and eyes their color.

Melanin is like a natural, built-in umbrella. When the sun's ultraviolet rays hit your skin, the melanin absorbs that radiation and turns it into harmless heat. This prevents the UV rays from penetrating deeper and damaging the DNA of your skin cells. People with darker skin have melanocytes that are much more active and produce larger quantities of melanin.

This is a fantastic biological advantage. It explains why the overall rate of skin cancer is much lower in people with darker complexions compared to those with very fair skin.

However, this is where the myth becomes dangerous. While melanin is great at blocking UV rays, it doesn't block them entirely. You can still get a sunburn. You can still accumulate DNA damage in your skin cells over time. And most importantly, not all skin cancer is caused by the sun. This is the critical piece of information that often gets left out of the conversation. There are other powerful forces at play, and in Skin of Color, those forces are often the main drivers of the disease.

A Different Kind of Cancer in Different Places

This is the most important takeaway in this entire article: when skin cancer occurs in people with darker skin, it does not follow the same rulebook. It has different causes, it appears in different locations, and it can look completely different.

Location, Location, Location

On white skin, about nine out of ten melanomas are directly linked to sun exposure and are found on areas that get a lot of sun: the back, the chest, the face, and the legs. The thinking is simple: more sun equals more risk.

In Black, Asian, and Hispanic populations, this logic flips. The vast majority of skin cancers, especially the most dangerous type called melanoma, are found on areas that rarely, if ever, see the sun. We call these "acral" surfaces. This includes:

• The palms of the hands

• The soles of the feet

• The nail beds (under and around the fingernails and toenails)

• The mucous membranes (inside the mouth, nose, and genital area)

This isn't a small statistical blip. For example, in a significant number of melanomas found in Black patients, the tumor is located on the foot. This isn't a sun-driven cancer. It's a completely different beast, and scientists are still working to fully understand why these areas are so vulnerable in people with darker skin. Theories include trauma, pressure, or chronic inflammation, but no single cause has been definitively proven.

What Skin Cancer Actually Looks Like on Darker Skin

Because the standard educational materials—the posters in the doctor's office, the photos in medical textbooks, the images used to train artificial intelligence—are overwhelmingly filled with pictures of white skin, both patients and doctors are often looking for the wrong thing.

If you're looking for a red, flaky patch on a dark brown or black skin tone, you're likely going to miss it. Inflammation that looks red on white skin often appears as a darker purple, gray, or hyperpigmented patch on darker skin.

Here is a breakdown of what to watch for instead of relying on the "red = danger" rule.

For the most common skin cancers, Basal Cell Carcinoma and Squamous Cell Carcinoma:

• What to look for: Instead of a red, scaly patch, look for a growth that is darker than the surrounding skin. It might look like a sore that doesn't heal, only to scab up and then bleed again. It could also appear as a raised, firm growth that might look like a scar—shiny and tight—but with a pearly border. Sometimes, it might just look like a patch of skin that feels rough to the touch, like sandpaper, but looks brown or black rather than red.
  

For Melanoma, the deadliest form of skin cancer:

Forget the "ugly duckling" rule for a moment, where you compare a mole to its neighbors. On the soles of the feet or palms of the hands, you're not looking for an odd mole out. You're looking for a new or changing spot.

• On the feet and hands: Look for a spot that is flat or slightly raised. The color is key. It might be a brown or black patch that looks like a stain. It could be a growth that resembles a wart but has dark pigment in it. A very common presentation is a dark streak or band that appears under the fingernail or toenail. This is often mistaken for a bruise.

  • The Nail Trick: A bruise under the nail, caused by stubbing your toe or dropping something on it, will typically grow out with the nail over a few weeks or months. You can watch the line of the bruise move forward as the nail grows. A cancerous streak, on the other hand, will not move. It may also get wider, or the pigment may spread from the nail onto the surrounding skin fold (a very serious sign called Hutchinson's sign).

• In the mouth: Look for a dark, flat, painless patch on the gums, the roof of the mouth, or the inside of the cheek. This is not a normal freckle.

The Danger of the Knowledge Void

This lack of awareness creates a perfect storm of late diagnosis.

First, there's patient delay. You notice a strange dark spot on the bottom of your foot. It doesn't hurt. You think, "I must have stepped on something," or "It's just a planters wart." Since you've never been told that skin cancer can look like this, you file it away as a minor nuisance. Months pass. It changes. It starts to hurt or bleed. Only then do you decide to see a doctor.

Second, there's provider delay. You go to a general practitioner with a dark spot under your nail. The doctor, who also likely trained using textbooks with pictures of light-skinned patients, might look at it and say, "Oh, it's just a bruise. Did you jam your finger?" Or they might see a rough patch on your heel and prescribe a cream for a wart or a fungal infection. By the time a correct diagnosis is made by a dermatologist, the cancer has had months or years to grow deeper.

This is why the outcomes are so stark. A diagnosis at a later stage means the cancer is thicker and has had more of a chance to spread to lymph nodes or other organs, making it much harder to treat successfully.

Who Is Really at Risk?

It's important to be clear: anyone with skin can get skin cancer. However, there are specific factors that increase the risk for people with darker skin.

• Personal or Family History: If you've had skin cancer before, or if a close family member has, your risk is higher. This is especially true for melanoma.

• Immune Suppression: People who have undergone organ transplants or are on medications that suppress the immune system are at a much higher risk for Squamous Cell Carcinoma.

• History of Radiation: Previous radiation treatment for other cancers can increase the risk of developing skin cancer in the exact area that was treated.

• Chronic Inflammation or Scars: Cancers can sometimes arise in areas of chronic skin problems, old burn scars, or areas with persistent inflammation. This is another theory for why the feet, which endure constant friction and pressure, are a common site.

• Genetic Syndromes: Certain rare inherited conditions can make a person more susceptible to skin cancer, but these are not common.

How Skin Cancer Is Treated: A Look Under the Hood

If you or a loved one is diagnosed, the treatment will depend entirely on the type of skin cancer, its size, and how deep it has grown. The goal is always to remove the cancer completely while preserving as much healthy tissue and function as possible.

Because skin cancer in people of color is often found on sensitive areas like the hands, feet, and face, treatment must be precise.

Surgery: The Front Line of Defense

For most skin cancers that haven't spread, surgery is the primary treatment.

• Simple Excision: This is exactly what it sounds like. The doctor numbs the area and cuts out the tumor along with a small rim of healthy-looking skin around it. This rim is called a "margin" and acts as a safety buffer to ensure no stray cancer cells are left behind. The skin is then stitched back together. The sample is sent to a lab to confirm the margins are clear. It's a quick procedure, usually done in the doctor's office. The main drawback is a permanent scar, and there is a small chance the margins aren't clear, requiring another surgery.

• Mohs Surgery: This is a more advanced and precise technique, often used for cancers on the face, hands, or feet where saving healthy tissue is critical for function and appearance. The surgeon acts as both the doctor and the pathologist. They remove the visible tumor, then a very thin layer of tissue from the base and edges. While the patient waits, they stain the tissue and look at it under a microscope right there in the office. If they see any cancer cells at the edges of that layer, they know exactly where to go back and remove just a bit more tissue from that specific spot. This process is repeated layer by layer until no cancer cells are seen. The benefit is a very high cure rate and maximum preservation of healthy skin. The trade-off is that it's a longer procedure and requires a specially trained surgeon, so it may not be available in every clinic.

Other Treatment Options

• Curettage and Electrodesiccation: This is often used for small, low-risk Basal Cell or Squamous Cell Carcinomas. The doctor scrapes away the cancer with a sharp, ring-shaped tool called a curette. Then, they use an electric needle to cauterize the base of the wound to stop bleeding and kill any remaining cancer cells. This process may be repeated a couple of times. It's quick and effective for superficial cancers, but it's not precise enough for aggressive or deep tumors, or for cancers in critical locations like the foot. The healing process leaves a white, flat scar.

• Radiation: For patients who cannot undergo surgery due to other health problems, or for tumors in locations where surgery would be very disfiguring, radiation therapy is an option. High-energy beams, like X-rays, are targeted at the tumor to kill the cancer cells. Treatment is spread out over several weeks, with short daily sessions. It's effective, but it can cause side effects like skin irritation, fatigue, and changes in skin color in the treated area, which can be a major concern for someone with darker skin.

• Topical Chemotherapy and Immunotherapy: For very superficial skin cancers confined to the top layer of skin, doctors may prescribe a cream. One common one is 5-fluorouracil (5-FU) , a chemotherapy cream. The patient applies it at home for several weeks. It works by killing rapidly dividing cells, which cancer cells are. The skin will become very red, inflamed, and crusty as it heals—this is a sign it's working. Another cream is imiquimod, which stimulates your own immune system to attack the cancer. A major warning for both creams is that they cause a significant, sometimes painful, local skin reaction. They are only for very superficial cancers and are not a treatment for invasive melanoma or deep tumors.

If Cancer Spreads: Systemic Therapy

If a melanoma has spread to the lymph nodes or other organs, treatment becomes more complex and involves the whole body. This is where immunotherapy and targeted therapy come in.

• Immunotherapy: These powerful drugs work by "taking the brakes off" your body's own immune system, allowing your T-cells (a type of white blood cell) to recognize and attack the cancer anywhere in the body. It can be incredibly effective, leading to long-term remission for some people. However, because it revs up the entire immune system, side effects can be serious and affect any organ. You might experience inflammation of the lungs (pneumonitis), the colon (colitis causing severe diarrhea), the liver, or the skin. Patients on immunotherapy need to be closely monitored.

• Targeted Therapy: About half of all melanomas have a specific mutation in a gene called BRAF. This mutation is like a switch stuck in the "on" position, telling the cancer cells to grow uncontrollably. Targeted therapy uses pills that specifically block that mutant protein, turning the switch "off." These drugs can cause rapid shrinkage of tumors. The downside is that the cancer can eventually figure out a way around the blockade and start growing again. Side effects are different from chemotherapy and can include fever, joint pain, and sun sensitivity.

Prevention and Early Detection: Your Action Plan

You don't need to be a dermatologist to protect yourself. You just need to be a good observer of your own body.

1. Know Your Areas of Risk: Pay special attention to your palms, the spaces between your toes, the soles of your feet, and your nails. Look under your nails and at the skin around them. Use a hand mirror to check the bottoms of your feet, or ask a partner or family member to help you.

2. Look for Change, Not Just "Bad" Moles: You are looking for anything new, changing, or unusual. That means:

   • A new dark spot on your skin, especially on your hands or feet.

   • A sore that just won't heal after a month.

   • A dark streak under a nail that wasn't caused by trauma.

   • A spot that itches, bleeds, or is painful.

   • A firm, raised growth that feels different from the surrounding skin.

3. Sun Protection Still Matters: Yes, most cancers in SOC aren't on sun-exposed skin. But some are. And sun protection will prevent the premature aging and hyperpigmentation that many people of color struggle with. Use a broad-spectrum sunscreen with SPF 30 or higher on all exposed skin when you're outside for long periods. This includes your face, neck, hands, and ears.

4. See a Dermatologist: If you notice something that concerns you, don't just ask your general doctor about it during your physical. Ask for a referral to a board-certified dermatologist. When you make the appointment, it's perfectly okay to ask the scheduler if the dermatologist has experience treating skin of color. A specialist is your best resource.

Pros and Cons: A Quick Reality Check

• Pros of Melanin: Provides natural, built-in sun protection, significantly lowering the overall risk of sun-induced skin cancers.

• Cons of the Knowledge Gap: Leads to a false sense of security. Public health messaging and medical training have historically ignored SOC, leading to late-stage diagnoses and worse outcomes.

• Pros of Vigilance: Self-examination is a powerful tool. Because SOC cancers often appear in hidden, non-sun-exposed areas, you have the power to notice them if you know what to look for.

• Cons of Atypical Presentation: The "red flag" signs are different. Relying on standard ABCDE rules for moles (Asymmetry, Border, Color, Diameter, Evolving) can be misleading, especially for acral melanomas which often don't fit this mold.

Who Should Be Most Vigilant?

Everyone should be aware, but this message is most critical for:

• People of African, Hispanic, Asian, and Indigenous descent.

• Anyone with a personal or family history of skin cancer.

• Individuals taking immunosuppressive medications.

• People who notice any new or changing spot on their hands, feet, or nails.

Final words

The story of skin cancer in darker skin is a story of disparity, but it doesn't have to be a story of tragedy. The danger is real, but it is not invisible. By understanding that this disease plays by a different set of rules on melanin-rich skin, you can take back control.

The next generation deserves a world where the images in medical textbooks and the results of AI tools reflect the full spectrum of humanity. But for today, the most powerful tool is knowledge. The best protection is not just sunscreen—it is awareness. It is the willingness to look closely at your own body, to question a spot that seems out of place, and to advocate for yourself until you get the answers you need. Your skin, in all its beautiful shades, is worth it.