Takeaway

More information about skin of color can help fill the vacuum of knowledge that exists. And improved awareness may help people with dark skin tones receive better, and earlier, care. 

This column is a companionpiece to the feature “Skin Cancer: A Closer Look” in this issue of Massage & Bodywork (page 32). I chose to address the topic of skin of color on its own because as an educator I have been discouraged and frequently frustrated by the dearth of information and images available about skin conditions that affect people of color, and this subject needs a full discussion.

I am not the only one who has noticed this void. In recent years, several organizations and resources have come to wrestle with this problem, and links to them can be found at the end of this column. They are not specific to skin cancer, but they do begin to fill the vacuum of knowledge that might help people with dark skin tones receive better care from their physicians.

Terminology to Help

To approach the topic of skin cancer and skin of color, we must establish some terminology. Much of the writing about skin issues on non-White skin uses the term skin of color, but what does that mean?

Technically, skin of color should encompass every human who doesn’t have albinism: We all have pigment in our skin. But some of us have more pigment than others. Melanin is pigment, produced by melanocytes located deep in the epidermis. Melanin absorbs harmful ultraviolet (UV) rays, preventing damage to deeper tissues. This provides some—but not complete—protection from some types of skin cancer. People with skin of color have more melanin than non-Hispanic White people.

Skin of color has been defined by Western researchers to refer to people of African, Asian (including Indian), Native American, Middle Eastern, and Hispanic backgrounds. A close reading of this list reveals some important missing groups: indigenous peoples of Central and South America, for instance, or those from Australia and New Zealand, along with Pacific Islanders and Inuit people. Further, bear in mind that people from the Mediterranean often have darker skin than some of these other groups. As a descriptor, I find that the term skin of color is not useful, but it is the accepted language.

Another labeling system for skin color is the Fitzpatrick Skin Tone Scale. This is the work of American dermatologist Thomas B. Fitzpatrick, who created the scale in 1975. His purpose was to clarify who, regardless of race or ethnicity, was most at risk for skin damage related to UV radiation (Image 1).

Fitzpatrick found that people with Types I and II skin are most likely to sustain damage from UV radiation, regardless of their ethnic or racial heritage. This is useful, because it takes race identification or assignment (and all its accompanying cultural judgments) out of the equation (see “Race vs. Ethnicity”).

Unfortunately, over time the use of the Fitzpatrick Skin Tone Scale has been distorted to oversimplify connections between skin color and ethnicity, so it has lost some of its effectiveness as an analytical or predictive tool.

Physiologically, the main difference between people with dark skin and those with light skin is how much melanin they produce. How does this difference come about? Do people with dark skin have more melanocytes, or bigger melanocytes, or do their melanocytes just produce more melanin? Surprisingly, the answer to that question isn’t always clear.

Regardless of how many, or how big, or how active our melanocytes are, two truths have emerged from studies of skin cancer risk for people with skin of color:

• People with dark skin get skin cancer less often than people with light skin. 

• People with dark skin are more likely to be diagnosed at an advanced stage, and more likely to die from skin cancer, compared to people with light skin.

We see evidence of this fact in the photographs in the “Skin Cancer: A Closer Look” article (page 32). Almost without exception, if a person of color had skin cancer, they were photographed at a more advanced stage than a White person with the same condition. This isn’t a matter of my cherry-picking images. It’s a simple fact: People with skin of color are diagnosed later, and consequently photographed later, compared to White people. 

As a result, they have riskier, more complicated, and less successful treatment experiences compared to White people. Two key statistics cited in that article support this: Cutaneous squamous cell carcinoma is 10 times more likely to metastasize in Black patients, and the five-year survival rate for White people diagnosed with melanoma is 93 percent, but for Black people, it is 71 percent. 

This is not because skin cancer is more aggressive in some people than others. It is, in part, a reflection of disparities in health-care access and skin cancer awareness in both patients and health-care providers.

How MTs Can Help

As skin observers and advocates for good self-care, it is our responsibility to be aware of this: The risks connected to late diagnosis and treatment are greater for our clients with dark skin than for our White clients. But why would this be true?

A few issues contribute to this problem:

• Subtle changes in skin tone, especially when the skin gets darker, can be hard to track on dark skin, especially when they occur in places that are hard to see, like between the toes or on the sole of the foot. (And acral lentiginous skin cancer, which has this pattern, is the most common form of melanoma among people of color.)

• People with skin of color often don’t recognize themselves as being at risk for skin cancer, and so they may not make a habit of using sunscreen, wearing protective clothing, or doing full-body skin checks. Awareness of the risks of skin cancer within this population is low compared to White people.

• People with skin of color may have less access to medical care, and/or they may feel less heard, less understood, or taken less seriously by the medical community—which is, in fact, the case—partly because . . .

• Medical providers often are under-educated about skin cancer and other skin problems in people with skin of color. This problem is made worse by having limited resources in medical education that address this issue. 

It all boils down to two main issues: health-care access and awareness. People with skin of color (and all people, for that matter) need to be able to access care from educated providers who take their concerns seriously. And those providers and their patients need to become more aware of the risks, early signs, and the importance of preventive measures for skin cancer. If those changes took place, I believe skin cancer outcomes would not stand out as an example of systemic racism in our health-care system. 

What Do We Do with This Information? 

We become advocates for excellent skin cancer vigilance and prevention. We become educated about what skin cancer looks like, not just on White skin, but on all skin tones. We encourage all our clients, of every skin tone, to use good preventive measures against skin cancer. And we speak up—carefully—when we see changes on our clients that require attention. That communication must be done with some care, a topic that is addressed in “Skin Cancer: A Closer Look.” 

In addition to the resources listed, there are three good resources that collect images of skin diseases on skin of color. While these resources don’t focus on cancer specifically, the whole topic of skin diseases as they present on dark skin is hugely underaddressed, and I want to encourage all massage therapists to bookmark and use these resources regularly:

• Brown Skin Matters: brownskinmatters.com

• Mind the Gap: blackandbrownskin.co.uk/mindthegap

• Skin Deep: dftbskindeep.com/diagnoses-gallery

In my opinion, every person who has skin—regardless of its tone—should have some knowledge on skin cancer. Because our main interface with clients is by way of their skin, and because we are also self-care advocates, massage therapists have the opportunity, and possibly even the obligation, to observe, make note, and educate clients about skin cancer and its risks. Through our early detection, we can participate in bringing the number of advanced skin cancer cases down. 

Race vs. Ethnicity

The term race is often used to describe groups of people who are divided by inherited physical characteristics, like skin tone, eye color, hair texture, and so on. However, race can also be described as a purely social or political construct: a convenient way to identify who is “in” and who is “out” of a particular group—especially when establishing hierarchies of power. When we look at our genetic blueprints, we find more variation within self-identified racial groups than between them (according to the National Human Genome Research Institute), so the term race as a way to make genetic distinctions becomes a bit meaningless. I personally promote the idea that while we have rich diversity in physical (as well as mental, cultural, and other ways of self-expression) differences, ultimately there is only one race: the human race. So how do we describe our obvious differences in skin colors, which is necessary when discussing skin cancer?

Ethnicity is a term that refers to groups who are identified by shared and inherited cultural practices and traditions, often linked to geographic regions. Some people suggest ethnicity is a better term than race to categorize humans, because it has less political baggage. 

Race and ethnicity are not synonymous, and neither one captures the concept of skin tone—which is a relevant identifier, at least in the context of skin cancer. I personally choose ethnicity to refer to distinctions between groups, because race has a long tradition of being used as a way to subjugate certain people, and I want to avoid falling into that linguistic trap.