This site is intended for health professionals only

Don't feel the burn: cover up in the sun

Carol Coley
RN BSc(Hons)
Skin Cancer Nurse Specialist
Portsmouth Hospital NHS Trust

Skin cancer, particularly malignant melanoma, is a recognised health problem worldwide.(1) The National Institute for Health and Clinical Excellence states that, as the epidemiology of skin cancer and evidence from Australia suggest, in the long term the most effective way to reduce the impact of skin cancer on the population and the NHS will be through reduction of the ultraviolet (UV) radiation, particularly sun, combined with increased population awareness of signs and symptoms of skin cancer.(2)
The incidence of skin cancer has risen rapidly in the UK over the last 20 years, promoting public health organisations to try to raise awareness of the dangers of sun exposure and the need to practise sun-safe behaviour. There are more skin cancer deaths in the UK than in Australia, even though Australia has more cases of the disease.(3)
Skin cancer is the most common cancer in the UK, and its incidence is increasing. There are two main types of skin cancer" malignant melanoma (MM), the most serious type of skin cancer, and nonmelanoma skin cancer (NMSC). NMSC are squamous cell carcinoma (SCC) and basal cell carcinoma (BCC); these are more common and easier to treat. The incidence of all types of skin cancer has increased steadily over the past decade, as a result of social changes, including increased UV light exposure from both sun and artificial sources.(4) NICE points out that this estimate of 60,000 new cases of skin cancer is likely to be a significant underestimate and does not include BCCs; it suggests that the true annual incidence could be over 125,000 new cases of NMSC annually in England and Wales. NMSC accounts for 90% of all skin cancers, and there are about 5,500 cases of MM recorded in the UK each year, and more than 2,000 people die from it.(2) It is estimated that four out of five cases of skin cancer are preventable and that 80% of MMs of the skin in the UK are caused by sun exposure.(5)

Nonmelanoma skin cancer
NMSC (BCCs and SCCs) tend to affect older people. These cancers are generally found on areas of skin frequently exposed to the sun, for example the head, neck, hands and forearms. These cancers can be disfiguring and difficult to treat if extensive, but tumour growth is generally slow, over many months or years.(6)
 
Basal cell carcinoma
BCC is the most common nonmelanoma skin cancer and generally arises in sun-damaged skin but can also occur in burn scars and skin damaged by ionising radiation. BCCs are usually painless, grow slowly and rarely metastasise.
They usually start as a small round or flattened lump. The lump may be red, pale or pearly in colour. It sometimes appears as a scaly eczema-like patch on the skin or as a sore that may bleed and crust but will not heal. BCCs are most frequently seen on the face and scalp, particularly on the eyelid, behind the ear and on the inner canthus (inner corner of the eye, near the nose).(7)

Squamous cell carcinoma
SCC is more serious than BCC as it has the potential to metastasise to lymph nodes if it is left untreated. SCCs frequently appear on sun-exposed areas of the body, such as the face, neck, lips, ears, hands, shoulders and limbs, although they can occur in nonexposed sites, such as the perineum or vulva. SCCs appear as persistent red scaly spots, lumps, sores or ulcers, which may bleed easily and can be painful. The lesion might be crusty, scaly, nodular, plaque-like, verrocous, tumid or ulcerated. They can also have a hard, horny cap.(6)
The signs to watch out for with nonmelanoma skin cancers are:

  • A small lump that may be smooth or waxy.
  • A new growth or sore that will not heal.
  • A spot or mole that itches or hurts.
  • A mole that bleeds, crusts or scabs.
  • A lump with a scaly or horny top.

Treatment options for both BCCs and SCCs are surgery (excision, Mohs' [micrographic] surgery, curette and cautery, radiotherapy and photodynamic therapy [PDT]).
The treatment choice depends upon the size, site and number of lesions. New lesions and recurrence are possible, so it is important that long-term follow up is recommended and education with regard to self-examination is given.
 
Malignant melanoma
Malignant melanoma (MM) is the most serious type of skin cancer. It is a cancer that usually starts in normal- looking skin or where a mole has developed. It is far better to prevent melanoma than to treat it once it has occurred.(8)
Melanoma affects adults of all ages, and it is one of few cancers to affect young adults. It is the third most common cancer amongst 15-39 year olds and accounts for 20% of cases, with more women than men developing melanoma. If melanoma is caught early it can be treated successfully. However, if it is left it can spread to other parts of the body and may be fatal.(9)
There are several risk factors associated with the probability of developing a malignant melanoma.

Exposure to the sun
UVB, and to a lesser extent UVA, provoke skin damage and are a potential cause of skin cancer. Evidence suggests that several episodes of sunburn due to intense, intermittent sun exposure before the teen or adolescent years significantly increases the risk of developing a melanoma in later life. Coupled with changing lifestyles, foreign sunny holidays are more commonplace and greater recreational time is spent outdoors, increasing levels of UV exposure. The exposure to UVA radiation from sunbeds is also a significant risk factor for melanoma.

Age and gender
Melanoma is most common in those aged 40-60 years, and it is extremely rare in childhood. Although melanoma can affect most parts of the body, the most common site in women is on the legs, while in men it is on the trunk. Evidence shows that this is related to clothing cover and skin exposure.

Moles
The average adult will have 25 moles (pigmented lesions). Those with 50-100 moles have an increased risk of developing melanoma, as do people with atypical moles (moles that are large and irregular).

Skin type
People who burn easily are most at risk, typically people with fair, freckled skin, fair or red hair, and blue eyes. It has been estimated that white people are 40 times more likely to develop melanoma than those with coloured or black skins.

Family history
The risk of developing a melanoma is increased if more than one first-degree relative (parent, sibling or child) has been diagnosed with this cancer. Genetic factors affecting skin pigmentation such as xeroderma pigmentosum (XP) have a profound upward effect on susceptibility.

Other conditions
Pre-existing medical conditions may increase the risk of melanoma. Organ transplant patients on immunosuppressant drugs have a significantly increased risk.(10)

Treatment for malignant melanoma
The treatment for MMs depends upon the stage of the disease at diagnosis. Surgical intervention remains the only curative option available in the medical management of melanoma.(6) Complete surgical excision of the primary cutaneous lesion is always first-line management. After histological examination and staging under the microscope a wider local excision may be recommended. The staging is determined by the thickness of the melanoma, which can be measured with a microscope. The Breslow thickness scale is used to decide upon the most appropriate treatment and can give an idea of whether the melanoma may metastasise or reoccur in the future.(10)
If patients with MM are found to have lymphadenopathy they are sometimes offered a sentinel node biopsy (SNB). This is a procedure that involves identifying the first lymph node draining from the tumour by scintigraphic imaging and then removing the lymph node for histological examination to determine whether there is melanoma present in the node.(2) The SNB can only be used to give the patient and the physician a better idea of prognosis. This procedure is only being performed at some centres at present as there is still no published RCT evidence that this procedure benefits patients in terms of disease-free survival.
There are several factors that have been found to accurately predict the prognosis of patient with MM, which are:(7)

  • Breslow's thickness - this is the depth of the tumour in millimetres measured by the pathologist from the top of the granular cell layer to the deepest point of invasion. This is by far the most important prognostic indicator.
  • Ulceration - for any given thickness this worsens the prognosis.
  • Involvement of regional lymph nodes or satellite/in-transit metastases makes the prognosis worse (Stage 111). The more nodes involved (>3) and if the metastases are clinically apparent (macroscopic), the worse the prognosis.
  • Distant metastases and elevated levels of lactic dehydrogenase imply a very poor prognosis.

Protection
Everyone should protect themselves from sunburn, and in particular parents should protect their children by using a high-protective-factor sunscreen (30+ SPF, broad spectrum, waterproof on all exposed skin), and cover as much skin as possible with clothes and a broad-brimmed hat. Babies and children need extra protection from the sun, as their skin is delicate and easily damaged. Episodes of sunburn in childhood can double the risk of skin cancer, and children who are exposed to too much sun now are storing up problems for the future.(7)
In response to the fast-growing industry of tanning shops in the UK, Cancer Research UK issued guidance on the use of sunbeds. It advises that sunbeds should not be used by those who are under 16 years of age, have fair or freckly skin, burn easily, have a lot of moles, have had a skin cancer, have a family history of skin cancer, or are using medication that increases the skin's sensitivity to UV.(5) The British Association of Dermatologists states that the use of sunbeds for cosmetic tanning should be strongly discouraged, but advocates education and information about sunbeds instead of prohibition.(11)
It has also been suggested that health promotion could potentially prevent skin cancer and promote the early detection of melanoma.(12) Knowledge and attitudes play an important part in the early detection of skin cancer.(13) Nurses need to promote healthier lifestyles by raising sun awareness, educating patients on the benefits of changing sun-seeking behaviour to one of sun-avoidance, and encouraging people to adopt safe behaviours when they are in the sun.
These include:

  • Staying out of the sun at the hottest part of the day (between 11am-3pm).
  • Using sunscreen (SPF 30+) daily and applying it half an hour before going out into the sun and reapplying it regularly.
  • Wearing a hat to protect the head and the back of the neck.
  • Wearing loose-fitting, tight-weave clothing to prevent exposing the skin.
  • Changing people's views away from the tanning culture.

Conclusion
One of the main issues highlighted at the 6th World Congress on Melanoma in Vancouver in September 2005 was that the public health approach to preventing melanoma has failed in reducing the incidence of MM but that the efforts at early detection have achieved considerable success. Fatal MM is generally visible on the skin at a curable stage.
As nurses we need to be providing education for our patients about skin cancers and skin self-examination, and emphasising that the early detection of skin cancer can save lives. We need to ensure that patients understand that if they develop any new or changing lesions they need to get them checked by their doctor.
These messages need to be delivered in a positive manner, so that people are not denied outdoor leisure time but are fully aware of the associations of excessive sun exposure and skin cancer.(14)

[[NIP28_pp_81]]

References

  1. Cregan E. Mayo Clin Proc 1997;72(6):570-4.
  2. NICE. Guidance on cancer services. Improving outcomes for people with skin tumours including melanoma. London: NICE; 2006.
  3. Miles A, Waller J, Hoim S, Swanston D. Health Educ Res 2005;20(5):579.
  4. CRUK. Statistics and factsheets 2004. Available from: URL: http://www.cancerresearchuk.org/sunsmart/for professionals/ statisticsand factsheets
  5. CRUK. Skin cancer. Available from: URL: http://www.cancerresearchuk.org/sunsmart/skincancer/?version=2
  6. Buchanan P. Nurs Stand 2001;15(45):45-52.
  7. Ashton RE, Leppard B. Differential diagnosis in dermatology. 3rd ed. Oxford: Radcliffe Publishing; 2005.
  8. Turner S. Nurs Times Plus 2002;98:30.
  9. Cancerbackup. Understanding cancer of the skin. London: Cancer Backup; 2005.
  10. SWCIS. Malignant melanoma in the South West. Available from URL: http://www.swpho.nhs.uk/resource/view.aspx?RID=9083
  11. BAD. British photodermatology group consensus view on sunbeds for cosmetic tanning 2004. Available from URL: http://www.bad.org.uk/patients/skin/sunbeds
  12. Harris J. Dermatol Nurs 2000;12(5)329-33.
  13. Jackson A, et al. Br J Gen Pract 1999;49(440):199-203.
  14. Freak J. Nurs Stand 2004;18(35) 45-53.

Resources
Wessex Cancer
W:www.wessex cancer.org

Macmillan Cancer
W:www.macmillan.org.uk

British Association of Dermatologists
W:www.bad.org.uk

Cancer Research UK
W:www.cancerresearchuk.org

Cancerbackup
W:www.cancerbackup.org.uk