As a young, healthy African American, Joshua Paschal didn’t think he could get melanoma. The deadliest form of skin cancer is rare among African-Americans, so he wasn’t worried when a tiny dark spot appeared on the sole of his right foot early last year.
“It was as small as a dot that you would do with a pen,” Paschal, 20, a sophomore at the University of Kentucky, told TODAY.
“I didn’t care too much about it because I thought it was a blood blister. I kept playing football and working out and it would grow in small increments.”
By the time he went home last summer, the black spot — located under his big toe — grew to the size of a dime and became surrounded by smaller “satellite” dots. Paschal also felt it sting when he ran or stood for a while.
Thinking it could be a plantar wart, the football player first consulted a podiatrist. But he was quickly sent to a dermatologist for a biopsy. The diagnosis: melanoma.
Skin cancer on the sole of the foot is more aggressive
It’s not unusual to have moles — or nevi, in medical terminology — anywhere on the body, including the soles of the feet and palms of the hands, said Dr. Vishal Patel, assistant professor of dermatology at the George Washington University School of Medicine & Health Sciences, and director of the Cutaneous Oncology Program at the GW Cancer Center in Washington, D.C.
Though, just because you have a spot underneath your foot doesn’t automatically mean it’s a cause for concern. But skin cancer can lurk there.
Melanoma on the extremities — nails, hands and feet — is the rarest subtype of the skin cancer, accounting for less than 5 percent of all melanomas, Patel said. But it makes up about a third of all the melanomas that African Americans, Indians, Asians and other people with darker skin develop, which is a ten-fold increase compared to the general population, he noted.
“Patients say, ‘I have dark skin, I don’t have to worry about melanoma.’ This answer is no, this is exactly the type of melanoma we worry about,” Patel said.
This type of cancer — called acral lentiginous melanoma — tends to be more aggressive than other melanomas. It can also be harder to detect because the skin on the palms and soles is thicker than on other parts of the body, which can change how the moles look both to the eye and when a pathologist is doing a biopsy, Patel said.
Plus, many people just don’t check underneath their feet for any suspicious spots.
“Patients come to see me [for a skin check], they get completely naked and they leave their socks on. They don’t think we have to look between your toes, on the soles of your feet,” Patel said. “A good dermatologist should be looking everywhere — where the sun don’t shine, basically.”
Sun exposure can still mutate moles on the soles and palms, but that’s not the main driver of acral lentiginous melanoma. It can be genetically driven or develop for other, unknown reasons.
The spots tend appear in the rear and front of the sole — areas where the foot gets the most stress when a person walks or runs, according to a 2016 analysis by Japanese researchers, published in The New England Journal of Medicine.
It’s theoretically possible, but it’s not something most runners have to worry about, Patel said.
Paschal, the University of Kentucky student, underwent three surgeries to remove the cancer from his foot. Doctors used a skin graft from his calf to repair the missing tissue in his sole. A biopsy of the lymph nodes in his groin revealed a trace amount of cancer cells, so Paschal has been undergoing immunotherapy since August and has several treatments left.
He returned to playing football in November, though he had to learn how to run on his right foot again. It has healed, but parts of it feel numb, Paschal said. He gets skin checks, an ultrasound and a PET scan every three months.
“I feel like [my faith] is what’s keeping everything together, it’s keeping me positive,” he said.
"Whatever you see on your skin that looks irregular, you should get that checked," Paschal said, adding that he hopes to raise awareness of skin cancer by sharing his story.
What to look for:
Remember the ABCDE’s of melanoma. They apply to spots on the palms and soles, too.
Report any changes to your doctor. Because acral lentiginous melanoma is more aggressive, dermatologists have a lower threshold for wanting to biopsy any suspicious spots, Patel said.
Report a blister or any lesion that’s not healing anywhere on your body.
Melanoma lesions are generally painless, but they can be painful if ulcerated or if they press on a nerve.
Think of you and your dermatologist as a team, Patel advised. Actively scan your body between appointments and take pictures of your moles to keep track of changes and show to your physician. Bring any spots that concern you to your doctor’s attention. Working together can boost the chances of catching melanoma in its earliest stages.