FROM THE ACADEMYSkin cancer and photoprotection in people of

FROM THE ACADEMY
Skin cancer and photoprotection in people of color:
A review and recommendations for
physicians and the public
Oma N. Agbai, MD,
a
Kesha Buster, MD,
b
Miguel Sanchez, MD,
c
Claudia Hernandez, MD,
d
Roopal V. Kundu, MD,
e
Melvin Chiu, MD,
f
Wendy E. Roberts, MD,
g
Zoe D. Draelos, MD,
h
Reva Bhushan, PhD,
i

Susan C. Taylor, MD,
j
and Henry W. Lim, MD
a
Detroit, Michigan; Wichita, Kansas; New York, New York;
Chicago and Schaumburg, Illinois;
Los Angeles and Rancho Mirage, California; High Point, North
Carolina; and Philadelphia, Pennsylvania
From
D
D
D
m
C
D
M
C
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A
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748
Skin cancer is less prevalent in people of color than in the white
population. However, when skin cancer
occurs in non-whites, it often presents at a more advanced
stage, and thus the prognosis is worse compared
with white patients. The increased morbidity and mortality
associated with skin cancer in patients of color
compared with white patients may be because of the lack of
awareness, diagnoses at a more advanced
stage, and socioeconomic factors such as access to care barriers.
Physician promotion of skin cancer
prevention strategies for all patients, regardless of ethnic
background and socioeconomic status, can lead to
timely diagnosis and treatment. Public education campaigns
should be expanded to target communities of
color to promote self-skin examination and stress importance of
photoprotection, avoidance of tanning bed
use, and early skin cancer detection and treatment. These
measures should result in reduction or earlier
detection of cutaneous malignancies in all communities.
Furthermore, promotion of photoprotection
practices may reduce other adverse effects of ultraviolet
exposure including photoaging and ultraviolet-
related disorders of pigmentation. ( J Am Acad Dermatol
2014;70:748-62.)
Key words: basal cell carcinoma; Bowen disease;
dermatofibrosarcoma protuberans; dyspigmentation;
melanoma; Merkel cell carcinoma; mycosis fungoides; people of
color; photoprotection; radiation; skin
cancer; skin of color; squamous cell carcinoma; sun protection;
sunscreen; ultraviolet.
DEFINITIONS
Abbreviations used:

BCC: basal cell carcinoma
DFSP: dermatofibrosarcoma protuberans
MED: minimal erythema dose
MF: mycosis fungoides
MM: malignant melanoma
NMSC: nonmelanoma skin cancer
POC: people of color
SCC: squamous cell carcinoma
SEER: Surveillance, Epidemiology, and End
Results
SPF: sun-protection factor
UV: ultraviolet
Whites: Non-Hispanic individuals of European
descent
Blacks: Non-Hispanic individuals of African
descent
Hispanics: Individuals who trace their origin or
descent to Mexico, Puerto Rico, Cuba, Spanish-
speaking Central and South American countries,
Spanish-speaking island nations of the Caribbean,
and other Spanish cultures. Origin can be considered
as the heritage, nationality group, lineage, or country
of the person or the person’s parents or ancestors
before their arrival in the United States. People who
the Multicultural Dermatology Center, Department of
ermatology, Henry Ford Hospital, Detroit
a
; Department of
ermatology, Via Christi Clinic, Wichita
b

; Department of
ermatology, New York University Medical Centerc; Depart-
ent of Dermatology, University of Illinois College of Medicine,
hicago
d
; Northwestern Center for Ethnic Skin, Department of
ermatology, Northwestern University Feinberg School of
edicine, Chicagoe; Division of Dermatology, University of
alifornia Los Angeles Medical Centerf; Desert Dermatology
ncho Mirage
g
; Dermatology Consulting Services, High Point
h
;
merican Academy of Dermatology, Schaumburgi; and Society
ill Dermatology and Cosmetic Center, Philadelphia.j
Funding sources: None.
The authors’ conflict of interest/disclosure statements appear at
the end of the article.
Accepted for publication November 26, 2013.
Reprint requests: Reva Bhushan, PhD, Department of

Evidence-based Research, American Academy of
Dermatology, 930 E Woodfield Rd, Schaumburg, IL 60173.
E-mail: [email protected]
Published online January 30, 2014.
0190-9622/$36.00
� 2014 by the American Academy of Dermatology, Inc.
http://dx.doi.org/10.1016/j.jaad.2013.11.038
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Delta:1_surname
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mailto:[email protected]
http://dx.doi.org/10.1016/j.jaad.2013.11.038
J AM ACAD DERMATOL
VOLUME 70, NUMBER 4
Agbai et al 749
identify their origin as Hispanic or Latino may be of
any race. This definition of Hispanic fully excludes
the Portuguese, Brazilians, or anyone from any other
country that speaks Portuguese.1

Asians: Individuals having origins in any of the
original peoples of East Asia, Southeast Asia, or the
Indian subcontinent, including, for example,
Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and
Vietnam.1
INTRODUCTION
Malignant melanoma (MM) and nonmelanoma
skin cancer (NMSC) account for 40% of all neoplasms
in whites, making it the most common malignancy in
the United States.2 Skin cancer is most common in
whites and in people living in equatorial latitudes.3
The incidence of both MM and NMSC remains
significantly lower in people of color (POC) when
compared with whites as they are seen in about 5%
of Hispanics, 4% of Asians, and 2% of blacks.4,5 Even
so, multiple reports have demonstrated heightened
morbidity and mortality in minority populations,
6-8
raising public health concerns in these groups.
Although there are data detailing incidence of skin
cancer in POC, these data are limited. In addition to
skin cancer, factors such as photoaging, pigmentary
disorders induced or exacerbated by ultraviolet (UV)
exposure, and sunburn must be considered in POC.
It is estimated that black, Hispanic, and Asian
Americans will comprise approximately 50% of the
US population by the year 2050.4 These evolving
demographics, elevated rates of skin cancer
morbidity and mortality in POC, and limited clinical

data on additional adverse effects of UV exposure in
this population mandate that physicians develop
familiarity with the concept of optimized photo-
protection for POC. An understanding of the varying
clinical presentations of UV-related skin cancers in
POC, in addition to relevant topics in photoaging and
UV-related disorders of pigmentation, is necessary
for adequate management of photoprotection in
POC.
BIOLOGICAL BASIS OF SKIN
CARCINOGENESIS AND PHOTOAGING IN
POC
Few studies have been performed to thoroughly
evaluate biological differences between differing
ethnic skin types. Skin color is primarily determined
by the presence of melanin. Jimbow et al9 reported
that dark skin has larger melanocytes that produce
more melanin and melanosomes are distributed
individually in keratinocytes rather than in aggre-
gates. The rarity of cutaneous malignancy in
populations of darker complexions is secondary to
photoprotection from a higher amount of epidermal
melanin, which filters at least twice as much UV
radiation as the epidermis of whites.10 In an in vitro
study performed by Kaidbey et al,11 the amount of
UV radiation reaching the papillary dermis of whites
was greater than that of blacks by approximately
5-fold. The authors proposed that larger and more
melanized melanosomes observed in POC absorbed
more energy than the melanosomes in white skin,
which were smaller, less dense, and lightly mela-
nized. Furthermore, the authors estimated that the
epidermis of blacks has an intrinsic sun-protection
factor (SPF) of 13.4, whereas light skin has an SPF of

3.3.11 Therefore, exposure to UV radiation plays a
lesser role in heightening the risk for skin cancer in
populations of darker complexions.
Damage to DNA secondary to UV radiation is a
major factor in cutaneous photocarcinogenesis and
photoaging. However, the correlation of ethnicity
and degree of sensitivity to UV rays has not been
elucidated. Tadokoro et al12 performed a study
evaluating the correlations between melanin content
and degree of UVA- and UVB-induced DNA damage
in normal-appearing skin of various ethnic groups.
DNA damage was found to be most severe in
qualitatively light skin. Baseline skin pigmentation
and extent of DNA damage were inversely related, as
individuals of darker skin tones were able to repair
UVA-/UVB-induced DNA damage more rapidly than
subjects with fair skin. Even low exposure to
UVA/UVB radiation induced some appreciable
DNA damage in all skin types, dispelling the myth
that those with very dark skin are completely im-
mune to UVA-/UVB-induced DNA damage.12
Indeed, NMSC and MM do occur in POC, despite
the low relative risk.13 Because of the limited
research on skin cancer in POC, there are few
resources providing insight on evaluating darkly
pigmented lesions in POC. Frequently atypical
presentations, together with constitutive dark
pigmentation, pose diagnostic challenges in the
identification of characteristics such as variation in
color within the lesions. Furthermore, certain skin
cancers that are pigmented in POC may not be
pigmented in whites (such as basal cell carcinoma,
which is more likely to be pigmented in darker skin
types); therefore, a high index of suspicion in POC is

necessary in making the diagnosis.
5
BASAL CELL CARCINOMA
Basal cell carcinoma (BCC) is the most prevalent
skin cancer found in whites, Asians, and Hispanics.14
Hispanics are more likely to be given a diagnosis of
multiple BCC rather than a single squamous cell
Fig 1. Nonmelanoma skin cancers in people of color. Pigmented
basal cell carcinoma in
elderly Hispanic man (right lateral orbital rim) (A); middle-
aged Asian woman (right cheek)
(B); middle-aged Hispanic man (right forehead) (C); and
middle-aged Hispanic man (left nasal
ala) (D). Hypopigmented mycosis fungoides in Hispanic man
(back) (E) and black man (lower
aspect of back) (F). G, Metastatic squamous cell carcinoma in
black man (right parietal scalp,
courtesy of Dr Marc Silverstein, Sacramento, CA).
J AM ACAD DERMATOL
APRIL 2014
750 Agbai et al
carcinoma (SCC).15 In contrast to Hispanic popula-
tions, BCC is the second most common skin malig-
nancy in blacks after SCC.4,5
The clinical spectrum of disease in BCC shows
many parallels among blacks, whites, Asians, and

Hispanics. The classic clinical presentation of a solitary
pearly papule with central ulceration and rolled
borders may be seen in POC, but may pose challenges
in the physical examination as the characteristic pearly
borders and telangiectasia may not be clinically as
apparent in dark skin types (Fig 1). In whites, the
majority of patients presenting with BCC are of
advancedage([50years),mostcommonlypresenting
with asymptomatic solitary translucent nodules with
central ulceration.14 Pigmentation is present in over
50% of tumors in POC,4,16 whereas only 5% of BCCs
affecting whites have been shown to be pigmented. In
Asians, BCCs frequently present as brown to black
papules, or have a ‘‘black pearly’’ appearance.17 The
clinical presentation of BCCs in Asian skin ranges from
nodules to papules, plaques, and ulcers.18 With
regards to anatomic distribution, there are significant
similarities between POC and whites. Approximately
80% of BCCs in POC were found in the head and
neck,19 as has been shown in whites.14 Differential
diagnosis for BCC in POC includes seborrheic kera-
tosis, blue nevus, trauma, lupus erythematosus, nevus
sebaceous, sarcoidosis, and melanoma.20 Metastasis in
BCC is rare in all skin types.14
BCC in blacks
Although quite rare, BCC has been reported in the
black population. In a report from Howard
University (Washington, DC) from 1960 through
1986, most BCCs were seen in blacks of fairer skin
complexion in comparison with those with darker
complexions.19 From this, one may conclude that the
incidence of BCC may correlate directly with the
degree of skin pigmentation, as it is most frequently
diagnosed in whites of fairer complexions, and more

rarely diagnosed in blacks. A study of skin cancer
prevalence was conducted by Asuquo et al21 in a
Nigerian teaching hospital between the years of 2000
and 2004. Of 63 cases of skin cancer, BCC was
diagnosed in 8% (n = 5) of the cases; 66.7% of the
BCC were on the head and neck, and 33.3% on the
upper limb. All of these lesions were nodular. BCC
was diagnosed only in albinos in this study.21 In a
review of 128 black patients with 148 BCCs, Mora
and Burris3 (New Orleans, LA) found that the
average age of examination (not necessarily onset)
was 59 years, with lesions most commonly located
on head and neck. Only 2 of these patients had
albinism.
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Agbai et al 751
The incidence of BCC in non-sun-exposed skin is
equal between whites and blacks.22 Diverse pre-
sentations and locations of BCCs have been found in
blacks, ranging from superficial BCC to perianal
BCC.3,11 BCCs in blacks are often pigmented, and
there are reports of BCCs that have arisen in scars,
which rarely proceeded to metastasize.3,4,23
BCC in Hispanics
One of the most common neoplasms diagnosed in
Hispanics is pigmented BCC.16 Hispanics studied
demonstrated significantly lower incidence rates of
BCC than non-Hispanic whites regardless of
gender.24 Still, a high index of suspicion should be

maintained in evaluating pigmented lesions in
Hispanics, as BCCs have a propensity to be pig-
mented in Hispanic populations and may be mis-
diagnosed as melanomas.16 In a study performed by
Bigler et al16 (Albuquerque, NM), the incidence of
pigmented BCC in Hispanics was found to be twice
that of white patients.
Compared with whites, Hispanics with NMSC
were shown to have fewer tumors per individual,
and fewer Hispanics had more than 1 tumor.24 A
registry of skin cancers in New Mexico between the
years of 1964 and 1992 showed an average of 1.8
tumors per individual with NMSC among Hispanics,
compared with 2.2 tumors per individual with NMSC
in whites. Of these, BCC was more common than
SCC by 6.6-fold in both Hispanics and whites.24
BCC in Asians
Although NMSC is not common in Asians, it is not
extremely rare. In a study by Cheng et al25 studying
incidence of NMSC between 1990 and 1999 in Hong
Kong, China, the incidence of BCC was 0.32 and 0.92
per 100,000 population. Pigmented BCC was the
most common NMSC diagnosed, found in approxi-
mately 60% of Chinese patients with skin cancer in
the study.25 Multiple or subsequent skin cancers and
subtypes of new cancers were seen less often in the
Chinese group when compared with the white
group.25 Similarly, Sng et al26 reported an increase
of skin cancers including BCC, SCC, and MM, in
Singapore between the years of 1998 and 2006. The
extremities were the most common sites affected by
Bowen disease (SCC in situ).27 There is an increased
incidence of NMSC in Japanese living in Kauai,

Hawaii, which may be secondary to heightened
intensity of year-round UV radiation and popularity
of outdoor activities, as reviewed by Lee and Lim.28
SQUAMOUS CELL CARCINOMA
SCC comprises approximately 20% of all skin
cancers. With MM excluded, approximately 75% of
all deaths from skin cancers are caused by SCC.
29
In
blacks and Asian Indians, SCC is the most commonly
diagnosed skin cancer. It is the second most
commonly diagnosed skin cancer in Hispanics, East
Asians (including Japanese and Chinese patients),
and whites.5,30 Although actinic keratoses are most
commonly diagnosed in white and Japanese pa-
tients,31 they are very rare in blacks.32
Riskfactorsfor SCCinPOCincludechronicscarring
and inflammatory processes including hidradenitis
suppurativa, lupus erythematosus, scars caused by
chemical and thermal burns, skin ulcers, and sites of
previous radiation.33,34 Immunocompromised pa-
tients, including organ transplant recipients, also
demonstrate a heightened risk for SCC.35 Among
blacks, the greatest predisposing factors for devel-
oping SCC include chronic scarring and/or inflamma-
tory processes that are observed in 20% to 40% of
reported cases.4 In addition, the human papilloma-
virus has been linked to the development of SCC,
particularly in immunocompromised patients.36 One
retrospective study detected human papillomavirus
DNA in skin samples of 4.7% of controls, 90.5% of
benign warts, 60.4% of precancerous lesions, 59.7% of

SCC, and 27.8% of BCC, suggesting a link between
viral infection and the development of NMSC.37
Definitive studies have not been performed on the
relationship between human papillomavirus infection
and NMSC in POC.
SCCs are characteristically firm, superficial, w ell-
demarcated papules or plaques that emerge from a
rounded, indurated, and elevated base.29 In POC,
SCC is most commonly found in areas that are not
typically exposed to the sun, such as the lower
extremities and anus. In fact, lower extremity and
anogenital SCCs were seen in 15% of SCCs in blacks
in a study conducted by Halder and Bang19 in
Washington, DC. This is a sharp contrast to the white
population, in whom SCCs are characteristically seen
in chronically sun-exposed skin.19
SCC in blacks
Among black patients given the diagnosis of
SCC, the peak incidence was shown to be in the
fifth decade on the lower limbs, followed by the
head and neck and then the genitals. The scalp and
lip are more often implicated in black women than
in men.38 Chronic trauma, ulcers, and scars are the
most significant predisposing factors for SCCs in the
lower limb and on the scalp, as reported by Amir
et al38 (Dar es Salaam, Tanzania) in a study of SCC
in Tanzanian patients, where UV radiation was
found to be the primary factor predisposing pa-
tients to increased risk of SCC in the head and neck.
In a study done in Tanzania, smegma of the

J AM ACAD DERMATOL
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752 Agbai et al
uncircumcised penis was also reported as a risk
factor for the majority of cases of SCC developing
on the penis in blacks.38 The majority of SCC on the
penis were found to be SCC in situ upon histologic
analysis in a study performed by Hubbell et al39
(New Orleans, LA).
SCC was the most common skin cancer reported
in a Nigerian teaching hospital between 2000 and
2004 by Asuquo et al,
21
where the lower limb was
the most commonly affected anatomic site. SCC
manifesting as Marjolin ulcer associated with trau-
matic injury of the limb was diagnosed in 7
patients, and associated with a history of burn in
1 patient. SCC involved the external genitalia in 9
patients, 3 of whom had genital warts. The anus
was affected in 4 female cases. There were no
lesions involving the head and neck regions, and
all patients in this study presented with chronic
ulcers.21
Several cases of the emergence of SCC within
scars of chronic discoid lupus erythematosus in black
patients have been reported. Caruso et al40 reported
a heightened propensity for SCC to metastasize in
black Canadian patients with discoid lupus erythe-

matosus. Sun exposure of hypopigmented lesions of
discoid lupus erythematosus may have been a
predisposing factor.
In blacks, Bowen disease (SCC in situ) typically
presents as scaly hyperkeratotic pigmented pla-
ques, and may be misdiagnosed as MM. In contrast,
Bowen disease lesions are rarely pigmented
outside of the groin in whites.41 Black women
are affected twice as often as black men, and most
frequently in skin that is not sun exposed.19 In a
study performed by Mora et al42 in New Orleans,
LA, evolution to SCC was noted in 5 of 19 black
patients with Bowen disease, leading to death in 3
of these patients. The most common area affected
was the lower extremity.42 Mortality of SCC in
blacks is as high as 29%, secondary not only to
delays in diagnosis and treatment, but also to more
aggressive biologic behavior of SCC in this popu-
lation.41,43 In blacks, SCC that develops within a
chronic scarring process tends to be more aggres-
sive and is associated with a 20% to 40% risk of
metastasis. In contrast, the rate of metastatic trans-
formation of sun-induced SCC in blacks is approx-
imately 1% to 4%.4 In a case series on SCC in blacks
performed by Mora and Perniciaro
33
(New Orleans,
LA), the highest mortality was observed in cases of
perianal SCC. Although most patients with primary
SCC have a very good prognosis, the 10-year
survival is less than 20% in patients with regional
lymph node metastasis, and less than 10% in
patients with distant metastasis.29

SCC in Asians
Bowen disease and pigmented BCCs are not
uncommonly diagnosed in Asians. Because of their
pigmented appearance, as in blacks, these may be
misdiagnosed as MM.25 Although NMSC is uncom-
mon, it is not rare in the Chinese population in Hong
Kong. Cheng et al25 (Hong Kong, China) reported
that the incidence of SCC in 1990 was 0.16 per
100,000 population, and in 1999, 0.34. Similarly, in a
case-control study performed by Chen et al44 in
Taiwan evaluating the association between UV radi-
ation exposure from the sun and risk for develop-
ment of SCC by gender, exposure at a young age
(15-24 years) and cumulative sun exposure were
significantly associated with heightened risk of SCC
in a dose-related pattern. Cumulative sun exposure
was found to be more closely related to increased
risk of SCC in women, whereas sun exposure at an
early age showed more relevance to SCC risk in
men.44 Skin reactions such as redness, burn, and
suntan after 2 hours of sun exposure in childhood
and adolescence were not associated with increased
risk for SCC.44
In a study on skin cancer incidence between 1986
and 1997 among Asians living in Singapore, 2650
BCCs were reported. There was a general increase in
skin cancer incidence from 6 per 100,000 person-
years (from 1968-1972) to 8.9 per 100,000 person-
years (1993-1997). The incidence of BCC increased
approximately 3% yearly. Age-standardized inci-
dence rates for BCC were greatest in fair-skinned
Chinese, followed by Malays and Indians. This trend
was also noted for SCC and cutaneous MM.

45
MALIGNANT MELANOMA
MM is the deadliest type of skin cancer found
across all races and ethnicities. Many melanoma cases
are diagnosed in nonhospital settings and thus may
be underreported to central cancer registries, which
traditionally collect the majority of cases from hospi-
tals.46 This could lead to significant underreporting of
MM and resultant underestimation of the incidence of
melanoma.47 The National Cancer Institute, Division
of Cancer Control and Population Sciences,
Surveillance Research Program, Cancer Statistics
Branch (Bethesda, MD) reports that the incidence
of cutaneous MM increased by approximately 6%
yearly in the 1970s, slowed to a 3% yearly increase
between 1981 and 2000, and has since stabilized.48
Since the late 1980s, the incidence of MM has
increased significantly among Hispanics in
California, increasing an average of 1.8% yearly in
male Hispanics between 1988 and 2001, and 7.3%
average yearly between 1996 and 2001.49 In a study
conducted by Bergfelt et al,50 the incidence of MM
Fig 2. Melanomas in people of color. A, Lentigo maligna in
middle-aged Hispanic woman
(vermilion upper and lower lips). Melanoma in middle-aged
black woman (right fourth toe)
(B); Hispanic woman (left fifth toe) (C); middle-aged Hispanic
man (left plantar foot) (D);
elderly Hispanic man (right cheek) (E); and Asian woman (side
of left leg) (F).

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Agbai et al 753
among Hispanics in Puerto Rico and New Mexico
(race not specified) was greater than in US blacks by
1.6- to 3.7-fold. There was a close correlation in
anatomic distribution of MM among whites and
Hispanics in New Mexico in both men and women.
The most common MM distribution in Hispanics from
Puerto Rico was the leg, as was seen in black
Americans.50 In another study, Vazquez-Botet et al51
reported that nearly half of MM in Hispanic patients in
Puerto Rico were found on the extremities, especially
the feet, similar to black and Japanese patients.
Superficial spreading melanoma was the most com-
mon histologic type, followed by acral lentiginous,
nodular, and lentigo maligna melanomas.51 More
recently, Wu et al52 (New Orleans, LA) reported that
incidence rates of MM in the United States were
notably higher in females than males in white and
Hispanic populations younger than 50 years, and in
Asian/Pacific Islanders younger than 40 years. The
median age of white and black patients was greater
(59-63 years) when compared with Hispanics, Asian/
Pacific Islanders, and American Indians/Alaskan
Natives (52-56 years).52 Histologically, acral lentigi-
nous melanoma was the most common subtype in
blacks, whereas superficial spreading melanoma was
most commonly diagnosed in all other ethnic groups
studied.52 Incidence rates of acral lentiginous
melanoma were, however, highest in Hispanics.
Non-whites demonstrated an increased propensity
to present with more advanced MM when compared

with whites.52
Typically, MM presents as a dark macule or patch
and may have a history of rapid spreading. Suspicion
for subungual melanomas is raised when a pig-
mented band wider than 3 mm is observed on the
nail, extension of pigment to proximal nail fold
(Hutchinson sign) and there is pigment variation,
rapid growth in size, and the observation of solitary
lesions.4 Subungual melanoma is most common on
the thumb and first toe. In populations of color, the
plantar foot is most commonly affected (Fig 2),53 as it
is implicated in 30% to 40% of cases.54 Melanomas
found in the oral cavity comprise approximately 7.5%
of all melanomas in Asians, where approximately
60% of these develop from lesions of oral melanosis.
The greatest risk factors for the development of MM
in whites include periods of high intermittent sunlight
exposure (as in sunbathing and indoor tanning), and
large cumulative doses of UV radiation from chronic
exposure (as seen in outdoor workers).55 Factors in
the host that may increase susceptibility to develop-
ment of melanoma include a large number of nevi, the
presence of dysplastic nevi, freckles, fair complexion,
red or blonde hair, and family history of MM.55
J AM ACAD DERMATOL
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754 Agbai et al
Contrarily, in blacks and Asians, UVradiation does not
appear to be a major risk factor, as the majority of
melanomas are found in skin that is not typically sun

exposed, including palmar, plantar, and subungual
skin, and mucous membranes.56 In POC, the risk
factors for MM have not been identified, but may be
unrelated to sun exposure.57 Specifically, as acral
melanomas are identified with similar rates at different
latitudes and in varying racial groups, and as they tend
to be diagnosed in anatomic sites that are not typically
sun exposed, their origin may be unrelated to sun
exposure.28
MM in blacks
In black Americans, acral lentiginous melanoma is
the most common and deadly form of MM.56,58 Not
uncommonly it is misdiagnosed and managed as a
tinea nigra, or even talon noir. In a retrospective
study performed at Tulane University School of
Medicine (New Orleans, LA)58 from 1958 to 1990,
82 patients (including 27 white men, 29 white
women, 18 black men, and 8 black women) with a
diagnosis of acral lentiginous melanoma were fol-
lowed up, and the study showed a trend toward
reduced survival in black men. A direct correlation
between decreased survival and increased Clark
level was also observed. As previously mentioned,
the overall incidence of melanoma in the black
population is lower than that of whites. Additional
types of melanoma found in black Americans
include superficial spreading and nodular types.
13
Acral lentiginous melanoma has a poor prognosis
secondary to its propensity for deep invasion at
presentation, with 5-year survival lower than 50%.59

In a study of skin cancers in a teaching hospital in
Nigeria between 2000 and 2004, MM of the skin
represented 8% (n = 5) of the 63 histologically
diagnosed cutaneous malignancies. All of these
MMs were plantar. Three of the 5 cases were
clinically advanced nodular melanomas, whereas 2
were ulcerated superficial spreading melanomas.21
MM in Hispanics
Pipitone et al60 (Maywood, IL) proposed that
Hispanics had a propensity to present with more
advanced disease secondary to the combination of a
belief that they are not at risk to sunburn and/or
develop skin cancer. Skin cancer prevention mea-
sures are typically directed toward non-Hispanic
whites, where skin self-examination and sun protec-
tion are emphasized.13 Feun et al61 (Miami, FL)
reviewed 54 melanoma cases in Hispanic patients;
the majority of melanomas were located on the
trunk, arm, shoulder, leg, and hip. Although 70% of
these patients presented with local disease, 26%
presented with regional and distant lesions. In this
study, Hispanics given the diagnosis of melanomas
had better treatment outcomes and survival than
non-Hispanics.61 This contradicts a handful of other
studies that have demonstrated poorer survival in
Hispanic populations.57,62,63
MM in Asians
In Asian populations, the sole of the foot is the
most common site for MM.28 This is typically acral
lentiginous melanoma.28 As in blacks and Hispanics,
MMs in Asians have a propensity to be diagnosed at a
late stage in comparison with whites.57 In a study

done in Taiwan, factors such as age over 55 years,
male gender, tumor thickness, and tumor ulceration
were generally predictive of a poorer prognosis.64 In
a study done in Japan, loss of the p53 gene though
deletion mutation was associated with more aggres-
sive subtypes of MM.65
Although in whites, number of melanocytic nevi is
directly proportional to risk of developing MM,66 this
may not be the case in POC. The density of
melanocytic nevi is significantly lower in POC than
in whites.66 Gallagher et al66 (Vancouver, British
Columbia, Canada) found that nevus density in
Asians was unrelated to skin color or tendency to
burn. These findings may indicate a lack of correla-
tion between nevi density and MM in POC; however,
further research is needed to clarify this point.
Survival in MM across ethnicities
The 5-year survival for melanoma in Hispanic and
black populations has been shown to be consistently
lower than in whites.6,53,67 When compared with
whites, black and Hispanic populations have a pro-
pensity to present with thicker tumors that are more
advanced, therefore leading to a worse prognosis. In
reviewing several melanoma cases in California,
Cockburn et al49 demonstrated that diagnosis of
tumors with a thickness greater than 1.5 mm upon
presentation increased at 11.6% yearly and 8.9%
yearly in Hispanic males and females, respectively.
Hu et al62 performed a retrospective analysis of case
series in the Florida Cancer Data System, showing
that late-stage melanomas were most commonly
diagnosed in black and Hispanic patients, at rates
of 52% and 26%, respectively. In contrast, late-stage

MM was diagnosed at a rate of 16% in white
populations.62 In reviewing MM cases in California,
blacks are have a higher rate of death in comparison
with their white counterparts after adjusting for sex,
age, stage, histology, anatomic site, socioeconomic
status, and treatment.68 Therefore, the lower survival
for blacks with MM is not fully accounted for by
discrepancies in socioeconomic standing or access to
J AM ACAD DERMATOL
VOLUME 70, NUMBER 4
Agbai et al 755
adequate medical care. This leads to a conclusion
that more aggressive primary and secondary preven-
tion measures are needed for the diagnosis and
control of MM across all races, including groups
that have a lower risk of developing MM.69
MYCOSIS FUNGOIDES
Mycosis fungoides (MF) is more commonly diag-
nosed in whites than in POC. However, incidence
and prognosis vary significantly based on race.
Weinstock and Gardstein70 used the US
Surveillance, Epidemiology, and End Results (SEER)
program of the National Cancer Institute to study the
incidence of MF in blacks, whites, and Asians in the
United States from 1973 to 1992. After adjusting for
age, blacks had a higher incidence of MF than whites,
with an incidence rate ratio of 1.6. The incidence of
MF in Asians was lower than that of whites, with an
incidence rate ratio of 0.6. Furthermore, blacks with
MF had a worse prognosis than whites, with a

mortality ratio of 2.4 compared with whites. In
contrast, the mortality ratio of Asians compared
with whites was 0.5. The cause for these differences
in incidence and mortality are unknown.70 In a more
recent study, Criscione and Weinstock71 used the
SEER database to study incidence of cutaneous T-cell
lymphoma in whites and blacks between 1973 and
2002. The incidence was 9.0 per 1 million person-
years in blacks, whereas incidence of cutaneous
T-cell lymphoma was 6.1 per 1 million person-years
in whites.
MF typically presents as erythematous or
hyperpigmented patches in individuals of darker
complexion.13 Hypopigmented MF is diagnosed
almost exclusively in POC. It typically presents as
poorly defined hypopigmented patches
(Fig 1).20,72,73 Distribution is typically more central
than acral, and mild pruritus is often present.13
Differential diagnosis includes pityriasis alba, tinea
versicolor, vitiligo, postinflammatory hypopigmenta-
tion, and tinea corporis. Biopsy should be done in
cases unresponsive to treatment for the aforemen-
tioned conditions, or in patients who exhibit wors-
ened disease despite treatment. Multiple biopsy
specimens are often needed to confirm the diag-
nosis.20 Immunohistochemical analysis often reveals
a relative loss of the CD7 antigen.
74
OTHER SKIN CANCERS
There is limited information on other skin cancers
diagnosed in POC. Dermatofibrosarcoma protuber-

ans (DFSP) is a slow-growing spindled cell neoplasm
located in the dermis or subcutaneous tissue. It can
present as a rare pigmented form that comprises up to
5% of DFSP. The pigmented variant occurs primarily
in blacks. DFSP most commonly presents on the
trunk, followed by the upper and lower extremities
and the head and neck. Clinically it may resemble a
keloid, raising suspicion for keloidlike lesions in
blacks that have no clear history of trauma.41 One
study conducted in Nigeria reported 5 DFSP in 63 skin
cancers diagnosed between 2000 and 2004. Three of
these presented with recurrent lesions, and positive
margin in 1 patient after initial excision.
21
Pigmented
DFSP may be histologically distinguished from the
common variant through the presence of a dendritic
cells containing melanin. DFSP tend to have a high
local recurrence rate, though there have been reports
of distant metastases. Wide excision and close clinical
follow-up are indicated.13
Merkel cell carcinoma occurs at a rate of 0.2 and
0.01 per 100,000 in whites and blacks, respectively.
Increased sun exposure corresponds with increased
incidence, as the face is the most commonly affected
site.75 Merkel cell carcinoma is rarely seen in Asians,
though there have been case reports associating
Merkel cell carcinoma with other skin cancers such
as Bowen disease.76
PHOTOAGING AND UV-RELATED
DYSPIGMENTATION IN POC

Although skin cancers pose the greatest mortality
risk when discussing the need for photoprotection in
POC, additional adverse effects of UVexposure, such
as photoaging and UV-related exacerbation of
pigmentation disorders, must be considered. Up to
95% of the visible signs of aging are a result of
exposure to the sun, which starts in childhood and
persists throughout life. Clinical signs of photoaging
apparent in white skin may be less noticeable in POC
of comparable age groups, implying a role of skin
color in photoprotection.77 Despite the protective
effects of darker skin on photoaging, signs of pho-
toaging are still prevalent in POC. Dyspigmentation
is more commonly seen in POC, whereas wrinkling
is more prevalent in whites. As pigmentation disor-
ders such as postinflammatory hyperpigmentation
and melasma are generally more prevalent in POC,
photoprotection may prevent worsening and recur-
rence of these conditions.77
Kotrajaras and Kligman78 (Bangkok, Thailand)
reported that significant photodamage manifested
as dermal collagen and elastin damage, epidermal
atypia and atrophy, and disorders of pigmentation
are not uncommonly seen in POC. Similarly, other
studies have observed that pigmentary changes may
be more common than skin wrinkling with regards to
photoaging among Asians.79,80 Chan et al81 (Hong
Kong, China) observed that moderate to severe
wrinkling becomes evident at around 50 years in
J AM ACAD DERMATOL
APRIL 2014

756 Agbai et al
Asians, 1 or 2 decades later than in age-matched
whites.
Chung et al82 (Seoul, South Korea) performed a
study evaluating the type and severity of photo-
damage in Koreans and observed that women had a
propensity to have more wrinkles than men.
Seborrheic keratosis was the major pigmentary
lesion observed in sun-exposed skin of men,
whereas hyperpigmented macules were more often
seen in women. Although cigarette smoking was
found to be an independent risk factor for wrinkles,
this was not so for dyspigmentation.82 There was no
correlation between constitutive skin color and
development of wrinkles or dyspigmentation. The
authors concluded that wrinkling and pigmentary
changes are significant manifestations of photoaging
in Koreans.
82
Additional cutaneous manifestations of photoag-
ing in ethnic skin include development of benign
lesions such as solar lentigines and dermatosis
papulosa nigra.81,83
SUN-PROTECTION BELIEFS AND
PRACTICES IN POC
Although POC are most commonly categorized
into skin phototypes IV to VI, it should be noted that
ethnic skin colors can span the entire spectrum of
skin phototypes.84 Skin examination and photo-
protection practices differ between ethnic groups
as whites and Hispanics have a greater propensity to

use sunscreen than blacks.69 In addition, whites are
more likely to perform skin self-examinations than
Hispanics. Although blacks and Hispanics show
similar practices in performance of skin self-
examinations, blacks tend to follow up with derma-
tologists less frequently.13 One survey study showed
that blacks who self-reported experiencing severe
sunburns were 7 times less likely to use sunscreen
than their white counterparts who reported experi-
encing severe sunburns. Among those surveyed who
had severe sunburns in other ethnic groups (eg,
Mexican American, other Hispanic, and other races),
there was no such difference in sunscreen use.85
Although UV radiation exposure continues to
become a more significant causative factor for skin
cancer in blacks, discussion of their UV radiation-
protection practices remains inadequate. Hall and
Rogers86 (Atlanta, GA) analyzed the National Health
Interview Survey performed in 1992 (n = 1583), in
which approximately 6% of blacks reported marked
sensitivity to sunlight with occurrence of severe
sunburn, whereas 9% reported mild burning. Of
the subjects studied, 53% self-reported a high likeli-
hood of wearing protective clothing, sunscreens, or
seeking shade. Factors such as educational
background, age, and sunburn history contributed
to a tendency toward better photoprotection habits
with sunscreens.86 Similarly, Buster et al87
(Birmingham, AL) evaluated a cross-sectional survey
data from the National Cancer Institute to evaluate
cancer-related knowledge, attitudes, and behaviors.
There were 1246 respondents, including whites,
blacks, and Hispanics. Blacks perceived their likeli-
hood of developing skin cancer in the future as low,

and were less likely than whites to recognize that
behavior and lifestyle influence the risk of devel-
oping skin cancer. Furthermore, blacks and
Hispanics were more likely to believe that skin
cancer is associated with pain or another symptom.
Blacks less frequently viewed regular skin examina-
tions as necessary for early detection of skin cancer,
and both blacks and Hispanics were more likely to
believe that little can be done to decrease the risk of
developing skin cancer.87
In a survey performed by the Skin of Color Center
in New York, NY, blacks and Hispanics self-reported
low sunscreen use, secondary to misconceptions
that it is unnecessary to use sun protection to prevent
photoaging or skin cancers.77 If used at all, sun-
screens were generally insufficiently applied and not
reapplied frequently enough. Sanclemente et al88
(Medellin, Colombia) performed a study evaluating
sun-protection behavior, skin phenotype , and min-
imal erythema dose (MED) in 911 high school
students in Colombia. There was significant vari-
ability in MEDs among the different phototypes
represented in the population, as individuals with
fairer skin appeared to respond to UV radiation
similar to their darker-skinned colleagues, and
some students with darker skin responded similar
to what would be expected from someone of lighter
skin. This suggested a lack of predictability of MEDs
based on skin phototype. In this population, only
10% of students who completed the associated
questionnaire reported use of sunscreens or prac-
ticed photoprotection.
88

Studies have shown that educational intervention
may be helpful in improving photoprotection prac-
tices. In a study performed by Kundu et al89
(Chicago, IL), POC (n = 93) were given instruction
on how to identify potentially abnormal moles in
cutaneous self-examination. Races represented in
the study included Asian/Pacific Islander (21.5%),
black American (59.1%), Hispanic (15.1%), and
multiracial or ‘‘mixed’’ (4.3%). The investigators
used self-report questionnaires evaluating attitudes,
practices, and beliefs before, immediately after, and
3 months after the educational intervention.89 In all,
21% self-reported a skin phenotype that sometimes
burns, and 32% reported at least 1 blistering sunburn
Table I. Recommendations for photoprotection and early
detection of skin cancer in people of color
n Seek shade whenever possible.
n Wear sun-protective clothing.
n Wear a wide-brimmed hat to shade the face and neck, and
shoes that cover the entire foot.
n Wear sunglasses with ultraviolet-absorbing lenses.
n Apply broad-spectrum sunscreen with a sun-protection factor
of 30 or greater. Sunscreens without inorganic filters
(titanium dioxide and zinc oxide) are generally better accepted
by people of color because of their better cosmesis on
dark skin.
n Apply sunscreen to dry skin 15 to 30 minutes before going
outdoors. When outdoors, reapply every 2 hours to all exposed

skin, and after perspiring or swimming.
n Avoid exposure to indoor tanning beds/lamps.
n Take vitamin D supplement.
n Perform monthly self-skin examinations, paying close
attention to subungual skin, palms, soles, mucous membranes,
groin. and perianal area.
Table II. Recommendations for physicians for people of color
n Educate patients:
People of color are at risk for developing skin cancer.
Practice sun-protective behaviors.
Perform monthly self-skin examinations for those with multiple
nevi, or history of skin cancers.
Avoid tanning salons.
Obtain regular skin examination by a dermatologist.
n Perform a thorough skin examination including areas
infrequently exposed to the sun, such as palms, soles, oral
mucosa,
groin, and perianal area. Regularly ask patients to remove shoes
and socks for skin examination.
n Monitor changes in pigmented lesions, including those of
mucosal, palmar, plantar, interdigital spaces, and subungual
surfaces.
n Advise vitamin D supplementation as indicated.
n Refer to dermatologists:
Changing pigmented lesions.
Nonhealing ulcers.
Hyperkeratotic or poorly healing lesions in chronic lesions such
as those of discoid lupus erythematosus, or in scars.
Atypical appearing keloidal plaques, or those with

growth/development with no history of trauma.
J AM ACAD DERMATOL
VOLUME 70, NUMBER 4
Agbai et al 757
in the past. Of the original 93 subjects, 71 returned for
follow-up evaluation after 3 months. Improved
knowledge of MM as a skin cancer, and of concern-
ing signs for melanoma was observed after the
educational intervention. Furthermore, awareness
of MM risk was shown to improve and was main-
tained at 3 months. Practices such as performance of
monthly self-skin checks, particularly of palms,
soles, and periungual skin, dramatically improved
after the intervention.89
VITAMIN D AND PHOTOPROTECTION
Vitamin D has been shown to be beneficial for
bone health, and has been reported to have other
potential health effects, including reduction of colo-
rectal cancer, and reduction in cardiovascular dis-
ease.90 Therefore, the question of whether or not
rigorous photoprotection increases the risk of
vitamin D deficiency is an important one.
Individual variables such as amount of skin pigmen-
tation play a role in determining vitamin D produc-
tion. There has been an emergence of vitamin D
deficiency and rickets in dark-skinned patients in
northern latitudes of the United States and United
Kingdom. Meanwhile, similar populations in their
countries of origin did not have this problem, which
has led to suspicion that increased skin pigmentation
may predispose dark-skinned patients to have
vitamin D deficiency in certain geographic loca-
tions.91 Because POC, especially those of darker

skin, may have a higher risk for vitamin D insuffi-
ciency secondary to higher skin melanin content,92
vitamin D supplementation should be recommen-
ded as part of a photoprotection regimen for POC.
Although there have been studies demonstrating
decreased serum vitamin D levels in patients with
photosensitivity practicing rigorous photoprotec-
tion,93-95 regular use of sunscreens did not result in
inadequate serum vitamin D level.95-97 It should be
Table III. Melanoma, basal cell carcinoma, squamous cell
carcinoma, and Bowen disease in people of color
Skin cancer Pertinent demographics Physical presentation
Differential diagnosis in POC Anatomic distribution Major risk
factors in POC
Melanoma Median age of diagnosis in all
races ranges from 52-63 y
Skin: Dark macules or
patches with history of
rapid spreading
Nail: Pigmented band [3
mm on the nail
Oral mucosa: Oral
melanomas can rise from
lesions of oral melanosis
Tinea nigra palmaris, talon
noir, pigmented BCC

Commonly in lower
extremities and plantar
feet
UV radiation NOT a major risk
factor
Risk factors for melanoma in
POC unknown
BCC Most prevalent skin cancer in
Hispanics14; second most
common in blacks (in
whom SCC is the most
common)4,5
Typical: Asymptomatic
solitary translucent
nodules with pearly
borders, rolled borders,
and telangiectasia14
POC: Pigmentation in over
half of cases; brown/black
papules can also present
as nodules, plaques, and
ulcers
4,16,18
Seborrheic keratosis, blue
nevus, trauma, lupus
erythematosus, nevus
sebaceous, sarcoidosis,
and melanoma5,18

Head and neck most
common in both whites
and POC
15,19
Family history of skin cancer,
Fitzpatrick skin type I, and
the presence of actinic
keratoses, solar lentigines,
leukoderma, and elastosis
rhomboidalis nuchae, UV
radiation
SCC Most common skin cancer in
blacks and Asian Indians;
second most common in
Hispanics, East Asians, and
whites (second to BCC); in
blacks: peak incidence in
forties
Range between well-
demarcated scaling pink
plaques; firm, superficial,
well-demarcated papules/
nodules emerging from
round, indurated elevated
base; granulomatous or
verrucous lesions; and
nonhealing ulcers
Lesions can be
hypopigmented or
hyperpigmented

Actinic keratosis, nummular
eczema, inflamed
seborrheic keratosis,
verruca vulgaris
Typically on the face in white
skin; in POC, not
uncommon in areas not
typically exposed to the
sun, including lower
extremities and anus
Lower limb/scalp SCC:
Chronic scarring and
inflammatory processes
including hydradenitis
suppurativa, lupus
erythematosus, chemical/
thermal burns, chronic skin
ulcers, chronic trauma sites
of previous radiation;
immunocompromised
patients also at risk
Head/neck SCC: UV radiation
Bowen disease Black women affected twice
as often as black men
Scaly hyperkeratotic
pigmented plaques
resembling seborrheic
keratoses
Seborrheic keratoses,
pigmented BCC, superficial

BCC, malignant melanoma,
or nonspecific pigmented
hyperkeratotic lesions
Areas not typically exposed
to the sun: including groin
and extremities
See SCC
BCC, Basal cell carcinoma; POC, people of color; SCC,
squamous cell carcinoma; UV, ultraviolet.
J
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M
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J AM ACAD DERMATOL
VOLUME 70, NUMBER 4
Agbai et al 759
noted that most of the vitamin D photoprotection
studies were done in predominantly white popula-
tion, raising a question to their applicability to the
broader population. A guideline to follow would be
Institute of Medicine recommendations of 400 IU of
vitamin D daily for infants up to 1 year old, 600 IU for
individuals between 1 and 70 years old, and 800 IU
for those older than 70 years.98 The National
Institutes of Health provided a listing of food sources
of vitamin D, including but not limited to cod liver
oil, salmon, tuna, swordfish, and vitamin Defortified

dairy products.99
THE SPF AND RECOMMENDATIONS FOR
CLINICAL PRACTICE
A recent survey performed by Pourciau et al100
demonstrated a general belief among leaders in
photodermatology that photoprotection counseling
is warranted in POC. Still, there is a general lack of
strong data supporting recommendations on SPF
requirements for specific skin phototypes. It is
known that a given sunscreen may demonstrate
different SPF value in varying skin colors, as demon-
strated by Damian et al101 (Sydney, Australia) in
1999. Using a xenon arc lamp with an emission
spectrum simulating the UVA and UVB wavelengths
of natural sunlight, the investigators found testing a
sunscreen product in fair-skinned individuals (who
had low MED) yielded higher SPF values compared
with testing the same product in dark-skinned sub-
jects (with higher MEDs). Because commercial
testing of SPF is mandated to be done in fair-
skinned individuals,102 SPF values of sunscreens on
dark skin therefore may be lower that the SPF values
stated in the label.101
Similar to the message on photoprotection for the
general population, POC should also be advised to
use a daily broad-spectrum sunscreen of at least SPF
30, and practice sun-protective behavior such as
seeking shade and use of protective clothing, wide-
brimmed hat, and sunglasses (Table I). Sunscreens
should be applied liberally and reapplied every 2
hours while outdoors. Furthermore, patients should
be advised to avoid tanning salons and intentional

tanning with natural sunlight. A thorough skin
examination, including examination of nails, oral
cavity, gums, palms, soles, groin, and perianal area
should be performed regularly by a dermatologist;
for those older than 50 years, yearly examination is
appropriate. Pigmented lesions on gums and streaks
in nails are normal in POC, but should be monitored
regularly for changes as malignant transformation
can occur. For patients with history of skin NMSC or
melanoma, or multiple nevi, monthly self-skin ex-
amination is appropriate. Primary care physicians
should be educated on high-risk sites for MM, such as
palms and soles (Tables II and III). Efforts are needed
to take the diversity in culture, beliefs, and language
across ethnicities into account so that photoprotec-
tion education can reach the target population of
color.
Wendy E. Roberts, MD, serves as a consultant for
Allergan Medical, L’Oreal, La Roche-Posay, and NeoStrata,
for which she receives honoraria. She also sits on the
advisory board and consults for SkinMedica, for which she
receives honoraria. She receives stock options from
TopMD. She consults for Theraplex, for which she receives
no compensation.
In 2013, Susan Taylor, MD, held seats on the
advisory boards of Allergan, Beiersdorf, Inc, Excaliard
Pharmaceuticals, and Unilever, for which she receives
honoraria. She serves as a consultant for Curel Skincare,
Pfizer, Schlesinger Associates, and Viviscal. Dr Taylor
founded T2 Skincare for which she receives other
financial benefit and serves in other roles. She receives
grants as an investigator for Hisamitsu Pharmaceutical,
Medicis Pharmaceuticals, Noven Pharmaceuticals, and
Pfizer. Dr Taylor has received honoraria as a speaker

from Allergan, Johnson & Johnson, Kao USA, Merz
Pharmaceuticals, and Neostrata.
2012 found Dr Taylor serving as a consultant
for Schlesinger Associates and Pfizer for which she
received honoraria. She sat on the advisory board for
Allergan, Beiersdorf and Excaliard Pharmaceuticals, for
which she received honoraria. Dr Taylor founded T2
Skincare for which she received other financial benefit
and served in other roles. She is an investigator for
Pfizer, Medicis, Noven, and Hisamitsu, for which she
receives honoraria. She contracted for Medscape/
WebMD for which she received honoraria. She served
as a speaker for Merz Pharmaceuticals and Allergan for
which she received honoraria. She receives no compen-
sation for her role at the Philadelphia Life Sciences
Institute.
In 2011, Dr Taylor was awarded grants as an
investigator for Medicis and Noven Pharmaceuticals.
She received honoraria for speaking from Elsevier and
Johnson & Johnson. Dr Taylor sat on the advisory board
for Merz Pharmaceuticals and Beiersdorf and received
honoraria for her support. She served as a consultant
and received a consulting fee from Tria Beauty and
Johnson & Johnson Dr. Taylor has received honoraria as
researcher from Johnson & Johnson and Beiersdorf.
Henry W. Lim, MD, serves as a consultant for Ferndale
and La Roche-Posay for which he receives honoraria.
Roopal V. Kundu, MD, had no relevant conflict of
interest to disclose. Her department receives compensa-
tion for pharmaceutical sponsored research that does not
benefit her directly.

Oma N. Agbai, MD, Kesha Buster, MD, Miguel Sanchez,
MD, Claudia Hernandez, MD, Melvin Chiu, MD, FAAD,
Zoe D. Draelos, MD, and Reva Bhushan, PhD, had no
relevant conflicts of interest to disclose.
J AM ACAD DERMATOL
APRIL 2014
760 Agbai et al
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Unit 5 Assignment Contract Terms Template
LAW204 – Business Law I
Quoted Definition with Citation
Definition (in your own words)
Example
Offer

Acceptance
Bilateral Contract
Unilateral Contract
Promissory Estoppel
References
Due Date: 11:59 p.m. EST, Sunday of Unit 5
Points: 100
Overview:

Regardless of whether you own a business or are a stakeholder
in a business,
understanding basic contract terms is important. Businesses
enter into contracts with
many areas, from shipping to suppliers to customers. As a
business owner or manager
knowledge of these basic terms will assist you in the day to day
operations of the
business, regardless of the field.
Instructions:
• Fill in the attached template.
• For each term, define the term with citation to authority,
define the term in your
own words and provide an example of each term.
Requirements:
• Use APA format for non-legal sources such as the textbook.
Use Bluebook
citation format for any legal citations.
• Submit a Word document using the template.
• Maximum two pages in length, excluding the Reference page.
Be sure to read the criteria below by which your work will be
evaluated before
you write and again after you write.
LAW204 – Business Law I

Contract Terms
Evaluation Rubric for Contract Terms Assignment
CRITERIA Deficient Needs
Improvement
Proficient Exemplary
0 – 44 Points 45 – 59 Points 60 – 74
Points
75 Points
Contract
Terms
Does not
concisely and
clearly defines
most terms.
Somewhat
concisely and
clearly defines
some terms.
Mostly
concisely,
succinctly,
and clearly
defines most

terms.
Concisely,
succinctly, and
clearly defines
each term.
0 – 5 points 6 – 7 points 8 – 9 points 10 points
Paper Length More than 2
pages
n/a n/a 2 pages or less
0 – 8 points 9 – 11 points 12 – 14
points
15 points
Clear and
Professional
Writing and
APA/Bluebook
Format
Errors impede
professional
presentation;
guidelines not
followed.
Significant errors
that do not
impede
professional

presentation.
Few errors
that do not
impede
professional
presentation.
Writing and
format are
clear,
professional,
APA/Bluebook
compliant, and
error free.
Overview:Instructions:Requirements:Evaluation Rubric for
Contract Terms Assignment

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