Skin cancer, photoprotection, and skin of color

Abstract

To the Editor:We readwith interest the article byAgbai and colleagues about skin cancers in ‘‘skin of color,’’ and commend them for bringing attention to this increasingly relevant issue. However, we are concerned about several aspects of this article, especially recommendations on photoprotection in ‘‘people of color’’ (POC). These are effectively public health messages and hence must be subjected to the same scrutiny dictated by other public health policies. Agbai and colleagues discuss skin cancers in POC, but their article is geared exclusively toward American audiences of physicians and patients. It is important that this relatively narrow context be appreciated by the wider readership of this journal and that recommendations of the authors not be generalized to all POC. Agbai and colleagues also discuss the racial categories of ‘‘whites,’’ ‘‘blacks,’’ ‘‘Hispanics,’’ and ‘‘Asians’’ as they existed in late 19th and early 20th century America. The many problems with the use of these categories in biomedical studies are beyond the scope of this article, but highly relevant here is that they are all socially rather than biologically defined groups. Americans who self-identify as ‘‘white’’ or ‘‘black’’ are highly genetically admixed and the authors’ ‘‘Asian’’ category comprises both East and SouthAsians. ThismakesPOCahighlyphenotypically and genotypically diverse category, which includes a high percentage of lightly pigmented people. Yet the main constitutional characteristic related to a high risk of UV-induced skin cancer is a low level of melanin skin pigmentation, which depends on the expression of various genes, including MC1R. Therefore, either Agbai and colleagues consider that a darker skin pigmentation defines POC, in which case they cannot rationally support the need for photoprotective measures for preventing skin cancer in POC, or they consider that POC forms a totally heterogeneous group in relation to skin pigmentation, in which case any global recommendation directed toward preventing UV-induced skin cancer in POC would therefore be irrelevant. Finally, in recommending use of sunscreen, concealing clothing, and vitamin D supplementation in POC, Agbai and colleagues are again geared toward American audiences, who can purchase these commodities cheaply and have access to some health care and public health information. However, recommendations for POC in most of the world would need to take into account peoples’ socioeconomic status and access to medical care. Furthermore, would it be realistic to advocate daily sunscreen use in most dark-skinned people living in sub-Saharan African countries? Based on the issues we have raised, we call upon Agbai and colleagues to revise their ‘‘one size fits all’’ recommendations on photoprotection in POC, which are not scientifically valid, and at worst may serve to discredit the dermatologic community, as questions become raised about potential conflicts of interests and the level of influence of the cosmetic industry within our specialty.