Melanoma is far more deadly in Black men, who may get skin cancer in unexpected places such as fingernails and the bottoms of their feet, according to a study of more than 205,000 cases.

Researchers have long known that men overall have a higher risk of being diagnosed and dying of the disease than women do. But the new study is the largest evaluation to date to explore how the location, stage and prognosis of melanoma in men varies by race.

While melanoma is far more common in white men, the study showed that Black men are 26% more likely to die of the disease. Although only about 2.5% of the more than 200,000 men in the study were Black, they had a much lower survival rate than that of White men.

“I think this is significant,” said Ali Hendi, a specialist in skin cancer surgery in Chevy Chase, Md., who did not participate in the study. “This study doesn’t give us the answer as to why, but it sheds light on the numbers.”

The study, published Tuesday in the Journal of the American Academy of Dermatology, found the following trends:

• Among Black men with melanoma, 48.6% are diagnosed at late stages of the disease, when it is harder to treat, compared with 21.1% among White men. Late-stage diagnoses occur in 39.6% of Hispanic men, in 37.6% of Asian men and in 29.1% of Native American men. If detected early, the five-year survival rate for melanoma is 99%. But a late diagnosis changes those odds dramatically. Once melanoma has spread to distant parts of the body, the five-year relative survival rate is about 32%.

• The location of melanomas on the body varied starkly by race. The data showed that 50.7% of Black men with melanoma have it on their lower extremities. Fewer than 10% of white men with the disease had it on their lower bodies. Among white men, most cases were on the trunk (35.5%) or head and neck (25.7%). By comparison, only 12.6% of cases in Black men were on the trunk and 9.8% on the head.

• Melanoma in Black men is often found in areas not typically exposed to the sun, such as the soles of the feet, toes, toenails, fingers, fingernail beds and palms.

• More than 75% of White men live five years or more after a melanoma diagnosis. Only 51.7% of Black men do.

The study underscores the importance of increasing public education for doctors and patients to be on the lookout for melanoma, even in Black patients where it rarely occurs, said Jeremy Brauer, physician and clinical associate professor of dermatology at NYU Langone Health, who was not connected to the study.

Brauer noted that doctors are often trained to identify skin cancers on White skin and may not know how the disease shows up differently in different races.

“This disproportionate and unfortunate rate of death means we have to try to be much more preventative,” Brauer said.

The study’s researchers compared diagnosis data from the National Cancer Database from 2004 to 2018 in white, Black, Asian, American Indian/Alaska Native, and Hispanic men.

“The purpose of our study was to dive deeper into why we are seeing these differences in survival rates and the factors that may be driving this,” said co-author Ashley Wysong, physician and chair of dermatology at the University of Nebraska Medical Center.

Nearly 1 in 5 Black melanoma patients have a subtype called acral lentiginous melanoma, a more deadly form of the disease. By comparison, less than 1% of White men had this subtype.

“It’s not related to sun exposure,” said Robert Brodell, professor of pathology and dermatology at the University of Mississippi Medical Center, who was not involved in the study. “It seems to have a different natural history, and a poorer prognosis, though late diagnosis is a component of that.”

It often appears as a black dot under the fingernail that’s growing or changing, Brodell said.

Melanomas on the fingers, toes, palms and soles of the feet are often mistaken for warts, fungus or other benign conditions, Wysong said, and ignored by patients. “They can look like flat, pink, gray, brown or black lesions.”

“Most people don’t think of skin cancers in their nails or on their hands and feet,” Wysong said. “So we see delays in diagnosis because of the location. It’s hard to see. Most people don’t know what a nail melanoma looks like.”

Late diagnosis explains only part of the reason melanoma is more deadly in Black men. Although the study controlled for factors such as income, insurance, access to health care and education level, those variables “don’t fully explain why Black men would have a 26% higher death rate than Whites,” Wysong said. “It does suggest that there are biological factors at work.”

The number of new invasive melanoma cases diagnosed annually has increased by 27% in the past decade. In 2023, 97,610 cases of invasive melanoma are expected to be diagnosed in the United States; of those, 58,120 will be in men and 39,490 in women, according to the Skin Cancer Foundation. Also this year, 7,990 people are expected to die of melanoma, 5,420 of them men.

Because the majority of melanomas originate with sun damage to skin cells, dermatologists continue to stress vigilant sun protection. Wysong added that men tend to resist the very things that could save their lives – wearing hats, sun screen and protective clothing, avoiding the sun, and regularly seeing a dermatologist.

Experts advise annual skin checks at the doctor and monthly personal checks of your body. You can enlist the help of a partner or friend to look at your back and other places where you don’t have good visibility. Check the soles of your feet, palms, nail beds and between your toes. And you can ask your barber or hair stylists to speak up about any lesions or changes on your scalp.

If you notice anything new, changing, failing to heal or bleeding, see a dermatologist.

“Melanoma is totally asymptomatic,” Brodell said. “Unless you notice a changing mole, you won’t be bothered by it.”