To the Editor: By 2060, nonwhite individuals will make up 56% of the US population.1Colby S.L. Ortman J.M. Projections of the Size and Composition of the U.S. Population: 2014 to 2060, Current Population Reports. U.S. Census Bureau, 2014Google Scholar The incidence of skin cancers is rising in this growing population.2Loh T.Y. Ortiz A. Goldenberg A. Jiang B. Prevalence and clinical characteristics of nonmelanoma skin cancers among Hispanic and Asian patients compared with white patients in the United States: a 5-year, single-institution retrospective review.Dermatol Surg. 2016; 42: 639-645Crossref PubMed Scopus (24) Google Scholar,3Loh T.Y. Ortiz A. Goldenberg A. Jiang B. Incidence and clinical characteristics of nonmelanoma skin cancers among Hispanic and Asian patients in the US: a 5-year, single institution retrospective review.J Am Acad Dermatol. 2015; 72: AB186Google Scholar Nonwhite patients with skin cancer suffer from increased morbidity and mortality and are often diagnosed later compared to their white counterparts.4Higgins S. Nazemi A. Feinstein S. Chow M. Wysong A. Review of nonmelanoma skin cancer in African Americans, Hispanics, and Asians.Dermatol Surg. 2018; 44: 903-910Crossref PubMed Scopus (28) Google Scholar,5Higgins S. Nazemi A. Feinstein S. Chow M. Wysong A. Clinical presentations of melanoma in African Americans, Hispanics, and Asians.Dermatol Surg. 2019; 45: 791-801Crossref PubMed Scopus (15) Google Scholar Cancer prevention efforts should include all at-risk patients. The goal of this study was to analyze all social media posts from major dermatology organizations during Skin Cancer Awareness Month, evaluate the diversity of skin color in images, and identify the type of prevention strategies highlighted. We selected 10 organizations with skin cancer prevention efforts: (1) American Academy of Dermatology, (2) American College of Mohs Surgeons, (3) American Society of Dermatologic Surgeons, (4) Center of Disease Control and Prevention, (5) Melanoma Research Alliance, (6) Melanoma Research Foundation, (7) National Cancer Institute, (8) National Comprehensive Cancer Network, (9) Skin Cancer Foundation, and (10) The American Melanoma Foundation. We identified social media handles on Facebook, Instagram, and Twitter and extracted all English and Spanish posts between May 1 and May 31, 2020, that included the topic of skin cancer prevention (Table I). Images were coded for (1) Fitzpatrick type of at-risk individuals or depicted skin cancers, (2) behavioral intervention displayed (sunscreen, hat, shade, protective clothing, tanning avoidance, full-body skin examination, sunglasses), and (3) anatomic location of depicted skin cancers. An at-risk individual was defined as either an individual implementing a specific behavior aimed at skin cancer prevention or an image of an individual associated with text suggesting that he or she was at risk. A given image could have promoted multiple behaviors and/or received multiple Fitzpatrick scores (if multiple skin cancers and/or at-risk individuals were shown). Two independent raters, SKG and VR, independently coded each post. Discrepancies were resolved by a third independent rater, JL.Table ITotal number of relevant posts by nonprofit organization and social media handleTotal postsFacebookInstagramTwitter∗All of the nonprofit organizations were most active on Twitter.Total postsAmerican Academy of Dermatology21162966American College of Mohs Surgeons64091155American Society of Dermatologic Surgeons0121123Centers for Disease Control and Prevention0000Melanoma Research Foundation8317111211Melanoma Research Alliance115299315National Cancer Institute0101National Comprehensive Cancer Network1034Skin Cancer Foundation11254884The American Melanoma Foundation0000Total18186592859∗ All of the nonprofit organizations were most active on Twitter. Open table in a new tab A total of 1329 posts were extracted, and 859 met inclusion criteria. Of these 859 posts, 659 Fitzpatrick scores were assigned: 62 for depicted skin cancers and 597 to at-risk individuals. All 62 skin cancers had background Fitzpatrick I or II skin. Only 3.2% (2/62) were on non–ultraviolet radiation–mediated sites (palmoplantar, mucosal, or nail). Of all the at-risk individuals depicted (N = 597), 435 (72.9%) had Fitzpatrick I/II skin, 105 (17.6%) had Fitzpatrick III/IV skin, and 57 (9.5%) had Fitzpatrick V/VI skin. The types of skin cancer prevention behaviors promoted included sunscreen, hats, shade, protective clothing, tanning avoidance, full-body skin examinations, and sunglasses. Table II displays the Fitzpatrick breakdown by each specific behavior promoted in the images.Table IIFitzpatrick score distribution by specific behavior promoted in images, n/total (%)Fitzpatrick I/IIFitzpatrick III/IVFitzpatrick V/VISunscreen∗There were 109 images where sunscreen was specifically being promoted; 64 Fitzpatrick scores were assigned across the 109 images.48/64 (75)4/64 (6.3)12/64 (18.8)Hats†There were 146 images where hat use was specifically being promoted; 187 Fitzpatrick scores were assigned across the 146 images.119/187 (63.6)59/187 (31.6)9/187 (4.8)Shade‡There were 147 images where shade use was specifically being promoted; 178 Fitzpatrick scores were assigned across the 147 images.104/178 (58.4)62/178 (34.8)12/178 (6.7)Protective clothing§There were 84 images where protective clothing use was specifically being promoted; 124 Fitzpatrick scores were assigned across the 84 images.74/124 (59.7)42/124 (33.9)8/124 (6.5)Tanning avoidance‖There were 161 images where tanning avoidance was specifically being promoted; 196 Fitzpatrick scores were assigned across the 161 images.121/196 (61.7)63/196 (32.1)12/196 (6.1)Full-body skin examination¶There were 102 images where full-body skin examinations were specifically being promoted; 87 Fitzpatrick scores were assigned across the 102 images.64/87 (73.6)18/87 (20.7)5/87 (5.7)Sunglasses#There were 105 images where sunglasses use was specifically being promoted; 134 Fitzpatrick scores were assigned across the 105 images.89/134 (66.4)38/134 (28.4)7/134 (5.2)No behaviorThere were 412 images where no behavioral intervention was specifically being promoted; 242 Fitzpatrick scores were assigned across the 412 images.166/242 (68.6)49/242 (20.2)27/242 (11.2)∗ There were 109 images where sunscreen was specifically being promoted; 64 Fitzpatrick scores were assigned across the 109 images.† There were 146 images where hat use was specifically being promoted; 187 Fitzpatrick scores were assigned across the 146 images.‡ There were 147 images where shade use was specifically being promoted; 178 Fitzpatrick scores were assigned across the 147 images.§ There were 84 images where protective clothing use was specifically being promoted; 124 Fitzpatrick scores were assigned across the 84 images.‖ There were 161 images where tanning avoidance was specifically being promoted; 196 Fitzpatrick scores were assigned across the 161 images.¶ There were 102 images where full-body skin examinations were specifically being promoted; 87 Fitzpatrick scores were assigned across the 102 images.# There were 105 images where sunglasses use was specifically being promoted; 134 Fitzpatrick scores were assigned across the 105 images.∗∗ There were 412 images where no behavioral intervention was specifically being promoted; 242 Fitzpatrick scores were assigned across the 412 images. Open table in a new tab In the text analysis, we found that 1.7% (15/859) of posts had captions specifically mentioning skin cancer in skin of color. Our analysis of social media posts by major dermatologic organizations show a gap in cancer prevention messages. Current skin cancer prevention efforts on social media do not include images of diverse patients, nor do they reflect clinical nuances in presentation. Skin cancer awareness efforts must reflect current demographic trends, which, in turn, redefine populations at risk for skin cancer to increasingly include patients with skin of color.