With sun awareness week just last month and the weather improving as we move into the summer months, Julie Van Onselen, a dermatology lecturer practitioner with a clinical background in dermatology and nursing, advises on sun awareness, photoprotection and skin cancer risks for general practice nursing.
In day-to-day practice, nurses have a responsibility to identify skin lesions of concern and understand the risks of skin cancer. Nurses should also be able to educate patients on photoprotection, promote sun safety and recommend sunscreens.
Skin cancer risks
Since 1990, there has been a 135% increase in melanoma and skin cancer incidence.1 In the UK, in 2015-17, 16,202 new cases of melanoma were diagnosed, which equates to 44 per day.1 New cases of non-melanoma skin cancer (basal cell and squamous cell carcinoma) in the same period amounted to 151,739.1
Excessive exposure to Ultraviolet (UV) light during childhood increases the risk of skin cancer (melanoma and non-melanoma) in adulthood. Five severe cases of sunburn will increase this risk to 80%.2 With melanoma accounting for 4% of all skin cancer cases, it is the fifth most common cancer in the UK.1
There is currently no national screening programme for skin cancer.
Identifying lesions of concern
Patients will frequently seek advice from nurses if they are worried about a changing mole or skin lesion. Nurses should assess the patient’s concern, examine the mole/skin lesions (ideally with a dermatoscope) and ask the following questions:
- Why are you worried about this skin lesion/mole?
- How long have you had the skin lesion/mole?
- Has it grown – recent /gradual growth?
- Has it changed in size and shape –recent/gradual?
- Has it changed colour?
- Is it a pink lesion?
- Has the lesion/mole been inflamed, itchy, or has it bled?
The ABCDE is an acronym, as a check list for identifying changes: A= asymmetry, B= border (uneven), C= colour (changes/more than one colour), D= diameter ( >5mm), E=evolution (new or growing lesion).3
A clinical history to identify skin cancer risk factors should be included with the assessment:
- Phototype – based on the Fitzpatrick skin typing4 – most vulnerable, type 1 Red hair, fair skin and freckles, always burns when exposed to sunlight (see box 1 below).
- A personal or family history of skin cancer.
- History, frequency and gravity of sunburn under 18.
- Medication – light sensitising drugs, hormone treatment.
- Photodermatoses /photoaggrevated skin conditions.
- Patients who are immunocompromised (including transplant patients) -higher risk of squamous cell carcinoma.
- The use of tanning /sunbeds.
- Lifestyle/leisure which results in prolonged sun exposure.
Skin type Typical features Tanning ability I Pale white skin, blue/green eyes, blond/red hair Always burns, does not tan II Fair skin, blue eyes Burns easily, tans poorly III Darker white skin Tans after initial burn IV Light brown skin Burns minimally, tans easily V Brown skin Rarely burns, tans darkly easily VI Dark brown or black skin Never burns, always tans darkly Fitzpatrick skin type
The Williams assessment5, is a tool that identifies skin cancer risk, based on the questions below.
- What was your natural hair colour aged 15 years old?
- Did you have freckles as a child?
- How many raised moles do you have on your forearms?
- Did you have any severe episodes of blistering sunburn as a child?
- Did you live in a sunny climate?
- Have you ever had skin cancer?
- Do you have any relatives who have had skin cancer? (Non-melanoma/melanoma?)
The clinical history, assessment of risk and examination, will raise pointers for concern. These include recent changes in size, shape, colour and growth (ABCDE), a new unexplained lesion – mole or scab that won’t heal.
The gold standard for clinical examination should be a complete body skin check with dermoscopy; however, this is not feasible in many clinical practices.
A good clinical practice should be an examination of the mole/lesion of concern in the context of the whole limb/trunk. This is crucial to identify the ‘Ugly duckling’ – a mole/lesion stands out as different. Patients should be reassured if the mole/lesion is normal or referred to advice and guidance dermatology service. For a lesion of concern, patients should be directed to the two-week wait cancer referral service.
Sun safety, photoprotection and sunscreens
Exposure to UVA and UVB results in DNA damage contributing to the development of skin cancer. UVB is responsible for sunburn. UVA causes oxidative stress, a significant factor in skin ageing, and visible light aggravates skin pigment. Photoprotection and sunscreens are vital in reducing UV damage.
General sun safety advice includes using photoprotection (sunscreens) and wearing photoprotective clothing and glasses. It is also essential to avoid sun exposure in the hottest part of the day and never expose infants under three to direct sunlight.
Sunscreens are mineral (inorganic) or chemical (organic), with different modes of action. Mineral-based sunscreens work by reflective diffraction, whilst chemical products work by selective photon absorption. Both types have good efficacy, photostability and good protection (at an SPF 30+ with added UVA protection). Children and vulnerable adults (phototype, immunosuppression or past skin cancer) are recommended to use SPF 50.
Vitamin D is obtained from sun exposure, food and supplements, and is beneficial to health. However, sunbathing, tanning or burning should not be necessary to make sufficient vitamin D to obtain health benefits.1 Brief exposure of 5-10 minutes is enough to synthesise vitamin D for most individuals. Vitamin D supplementation is the safer and better advice for people who have or potentially may have low vitamin D.8
Skin cancer incidents are expected to continue rising, with a peak in incidents predicted between 2021 and 2029.
Non-melanoma skin cancers are caused by repetitive sun exposure or burning and photodamage, whilst sunburn increases the risk of melanoma.
Photoprotection is vital to prevent and reduce all types of skin cancers. All healthcare professionals should give sun safety and photoprotection advice and guidance.
1. Cancer Research UK. Melanoma skin cancer. 2021: https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/melanoma-skin-cancer/incidence#heading-Five [accessed 25 May 2021]
2. Wu, S., Han, J., laden, f. & Qureshi, A. A. long-term ultraviolet flux, other potential risk factors, and skin cancer risk: a cohort study. Cancer Epidemiol Biomark.2014 ; 23, 1080–1089
3. Tsao H, Olazagasti J, Cordoro K. Early detection of melanoma: reviewing the ABCDEs. Journal Am Acd Dermatol.2015; 72(4):717-23.
4. Fitzpatrick, T.B The validity and practicality of sun-reactive skin types I through VI. Archives of Dermatology. 1988; 124 (6): 869–871,
5. Williams L, Shors AR, Barlow WE. Identifying Persons at Highest Risk of Melanoma Using Self-Assessed Risk Factors. J Clin Exp Dermatolo Res. 2011; 2(6)1000129
6. Cancer Research UK. Sun, UV and safety. 2021. https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/sun-uv-and-cancer [accessed 25 May 2021]
7. PrescQIPP Sunscreens. Bulletin 138 2016. Available: https://www.prescqipp.info/our-resources/bulletins/bulletin-138-sunscreens/ [accessed 25 May 2021]
8. Reid, S. M., Robinson, M, Kerr, A. C. & Ibbotson, S. H. Prevalence and predictors of low vitamin D status in patients referred to a tertiary photo- diagnostic service: a retrospective study. Photodermatol. Photoimmunol. Photomed. 2021; 28, 91–96