Is Acral Lentiginous Melanoma Common In Filipinos?

When it comes to our physical well-being, we could all learn a thing or two from Santa Claus. As chaotic as things get, we should make sure we check everything twice—and being as thorough and meticulous as possible about tracking changes in our skin. (Not sure if it’s changed? Check it again.) To say that skin cancer is no joke is an understatement, and most of us could likely do better when it comes to checking our skin for moles and melanomas, perhaps particularly people of color. Acral lentiginous melanoma (ALM) is one of the most common types of melanoma for people with darker skin and it’s important that we check everywhere for it. When your doctor or dermatologist says to look all over, they mean it — underarms, palms, bottoms of feet, and yes, between your toes.

You may have never considered checking these places before, but trust it’s just as important to look there as it is to scan the tops of your thighs and backs of your legs. Even though it may not necessarily show up between the toes more than in other places, it’s an oft-overlooked spot, and when caught early, there can be a better chance of surviving ALM. We consulted board-certified dermatologists on why it’s important to check between the toes, and how you should know to check.

What is acral lentiginous melanoma?

“Acral lentiginous melanoma, or ALM, is a type of melanoma that develops on the palms, soles, or under finger or toenails,” says Hope Mitchell, MD, a board-certified dermatologist based in Ohio. “This form of skin cancer can arise from a pre-existing mole or appear as a new growth on otherwise normal-appearing skin.” According to Elizabeth Hale, MD, a board-certified dermatologist based in New York City and vice president of the Skin Cancer Foundation, ALM is one of the rarest types of melanoma with one of the worst prognoses.

Board-certified dermatologist Ada Atilano-Bautista, MD, FPDS, head dermatologist at Profero Ageless Aesthetics in Quezon City, says that “ALM occurs regardless of sun exposure, and unlike many other melanomas, it is not strongly linked to UV rays. It is the most common melanoma subtype in darker skin tones, specifically those of African, Asian, and Hispanic descent.”

Often, ALM is found in locations you may not often think to look—like underneath the feet, in between toes, and underneath nails—which can cause the delay in diagnosis. “Early detection is key because if you find a melanoma while it is still confined to the superficial layers of the skin, it is almost always completely curable. Once it starts to get thicker and larger and invade into the skin, that’s when it develops the potential to metastasize and the cure rate drops precipitously,” explains Hale. The Skin Cancer Foundation has several photos of acral lentiginous melanoma available for reference.

Hale reminds us that singer Bob Marley died from a melanoma that was found under his toenail but was not diagnosed until it was too late, because it was originally written off as trauma or a bruise from his years of playing soccer. “I often use this story as an example because it shows that anyone can get skin cancer, even if you have darker skin; if you don’t treat melanoma, it can be fatal; and you need to go in for a skin examination to have a dermatologist inspect those areas that you don’t check on yourself.”

What’s the link between ALM and people with darker skin tones?

It’s not necessarily accurate to say that ALM is more common in darker skin because melanoma, in general, is more common in fairer skin, according to New York-based board-certified dermatologist, skin cancer specialist, and founder of OptiSkin, Orit Markowitz.

However, when melanoma is found in darker skin tones, the most common type is ALM. “ALM is the leading cause of melanoma in people with darker skin. Although the cause of acral lentiginous melanoma is unknown, it does not appear to stem from sun exposure,” explains Mitchell.

Hale theorizes that ALM is more common in darker skin because the palms of your hands and soles of your feet tend to have less melanin. “But this assumption doesn’t completely line up, because the bottoms of your hands and feet don’t get much sun exposure,” she says. “For this reason, ALM is most likely a combination of having less melanin in those areas as well as other unknown factors.”

“The problem is that because patients with darker skin aren’t necessarily used to visiting a dermatologist for an annual skin check, skin cancer [may not be] on their radar,” Hale continues. Lack of emphasis in examining darker skin tones can lead down a bad road, and consequently, a lot of times these patients don’t get their melanoma in front of the doctor until it is more advanced and dangerous.

Are Filipinos prone to it?

“Filipinos are actually less likely to develop skin cancer compared to Caucasians, but we still see a lot of cases in our clinics,” explains Dr. Atilano-Bautista. “We need to correct the myth that we protected because of our darker skin tone. We can still get skin cancer.”

Melanomas caused by UV exposure are relatively rare in darker skin tones, such as Filipinos’, because of the protective role of melanin, she explains. “Instead, non-UV related subtypes like ALM dominate.”

According to Atilano-Bautista, other types of skin cancer such as basal cell carcinoma and squamous cell carcinoma are more common in Filipinos. “But when we see [any] case of melanoma, that’s the one that we fear the most because it’s the deadliest kind,” she says.

Why should we check between our toes for skin cancer?

While melanoma can be caught early with proper monitoring, it can also be unpredictable: If you’re not armed with proper knowledge and performing regular skin checks, melanoma can sometimes be like that “friend” who wakes you up at 3 a.m. on a Tuesday night to go check out a new 24-hour nightclub: It knows no boundaries and has no regard for the plans you’ve made for your life. “There have been reports of melanoma between [the] toes, in [the] eyes, in [the] mouth, on [the] nails. In these occurrences, melanoma is very deadly when caught late and that is why it’s so important that your dermatologist does a very thorough exam—and I don’t mean a spin and twirl, they need to look at every inch of the body,” says Markowitz.

Skin cancer can present itself anywhere on the body, and while self-examinations are great and highly encouraged, you should definitely get yourself checked by a board-certified dermatologist in those hard-to-reach areas like between the toes, behind the ears, and on the scalp—you know, the places you can’t see, anyway.

But again, that doesn’t mean you can’t do some inspection yourself, either. When caught and treated early, skin cancers can be curable, and in those early stages of skin cancer development, no one is better than you at seeing changes in your skin. According to Hale, ALM presents as a hyperpigmented, irregular patch of skin that you might initially believe is a bruise. “I would say that any new or changing spot on the soles of the feet, toes, under the nails, or palms should be evaluated if they exhibit what is known as the ABCDEs: asymmetry, border irregularity, color variation, increasing diameter, or any type of evolution or change.”

Dr. Atilano-Bautista shares that it’s critical to consult a board-certified dermatologist who uses a dermatoscope, a non-invasive tool to check for clues that can help with early detection of melanoma. “It reveals things not visible to the naked eye, and can determine which lesions require biopsy,” she explains.

“When Filipinos consult about something that turns out to be melanoma, it’s usually at a later stage, because they were not aware of it, as it’s not too common for us,” Dr. Atilano-Bautista adds. “But that’s what makes it deadly, when it’s not detected early.”

On top of your regular visits to the dermatologist, take notes, keep track of changes monthly, and if something is alarming, call your doctor and let them know ASAP. It’s a simple but powerful way to look at yourself, that might just save your life.