Spotting signs of skin cancer in the pharmacy

With incidences of skin cancer on the rise, pharmacists can play an important role in advising patients on when to seek specialist help, says Dr Juber Hafiji

Key learning points

• Skin cancer is the most common cancer and the second most common cause of death in young adults

• Risk factors to look out for include a history of excess UV exposure, sunbed use and having lived in a hot climate

• Bleeding and itching are unreliable signs that a mole has become a melanoma

There has been a sharp rise in the rates of skin cancer in the UK over the past 40 years. An ageing population, widespread use of immunosuppressive treatments, an unregulated sunbed industry and ease of travel to sunny climates are some of the reasons. Patients who are concerned about a lesion may struggle to see their GP
in a timely fashion. Patients will often ask a pharmacist for advice.

The scale of the problem

Skin cancer is the most common cancer and the second most common cause of death in young adults. Skin cancers are divided broadly into two groups: non-melanoma skin cancers (NMSC) and melanoma.

Within the NMSC group, basal cell carcinomas (BCC) account for 80% of cases,¹ with the remainder predominantly being squamous cell carcinomata (SCC). Some 132,000 new NMSCs  were reported in the UK in 2014 and over 15,419 new cases of melanoma in the same year – a 400% increase over 30 years.² There are several risk factors for developing skin cancer. These include exposure to UV radiation, fair skin,
advancing age, immunosuppressive medication, personal or family history
and occupational history.

BCC

BCC is the most common form of cancer in humans.³ They are sometimes referred to as ‘rodent ulcers’, reflecting their slow growth with local invasion into the skin and deeper tissues. They typically present as non-healing pearly pink or skin-coloured lesions with rolled edges that bleed and crust. More than 80% occur in the head and neck region.⁴

They can also develop as red patches mimicking eczema or a fungal infection; or be skin coloured or even pigmented mimicking a melanoma. The overall prognosis is excellent as the risk of distant spread is exceptionally rare. Guidance from the National Institute of Health and Care Excellence (NICE) stipulates that all suspected BCCs should be referred routinely to dermatology services.

SCC

SCCs account for 20% of skin cancers and around 500 preventable deaths annually.  They usually present as rapidly growing (weeks to months) lesions that are typically tender, can be ulcerated with a keratin horn and often occur in heavily sun-damaged skin. 

They can also occur at a site of previous damage to the skin, for example, irriadiation, scarring and areas of inflammation. Usual sites include sun-exposed areas such as the head and neck, dorsum of hands, forearms and lower legs.  All suspected SCCs should be referred urgently to secondary care via the two-week wait.

Melanoma

Differentiating melanomas from harmless moles can be difficult and requires specialist training and experience.  There are four subtypes of melanoma. Some 50% of the superficial spreading melanomas arise from pre-existing moles. Nodular melanomas usually present as blue-black nodules or can occasionally be red-pink.

They often grow rapidly and present late.  Lentigo maligna is a type of surface melanoma that usually occurs in the elderly as a very slow-growing pigmented patch.  They can turn into lentigo maligna melanoma, which is invasive. Acral lentiginous melanomas occur on the palms and soles and under the nail.  Hutchinson’s sign – extension of pigment to the adjacent skin – is very suspicious for melanoma.

Clinical assessment

A detailed history and full skin examination are important. Risk factors include a history of excess UV exposure (especially in childhood), sunbed use, personal or family history of skin cancer, history of immunosuppression and having lived in a hot climate.  Self-examination and taking baseline photographs should be encouraged.

Moles can occur at any age, with many being familial and associated with a fairer skin. It is not uncommon for moles to change in pregnancy. Rarely, melanoma can be familial. You should have a high index of suspicion for moles that change on the backs of males and the lower limbs of females.  Also, remember the ‘ugly duckling’ sign – the mole that stands out from others. Melanomas grow slowly (within months), so bleeding and itching are unreliable symptoms.

It is helpful to assess pigmented lesions using the ABCDE approach (see below). Patients should be educated on this checklist. Mackie’s seven-point checklist (see below) can help spot early invasive melanoma^2,5 Any lesion scoring more than three points warrants referral via the two-week wait pathway.  Table 3 below shows the key points when seeing a patient with suspected skin cancer.

The ABCDE approach

A Asymmetry

B Border irregularity

C Colour – three or more colours or one colour that is different from the rest

D Diameter greater than 7mm

E Evolution – persistent growth of a new or pigmented lesion

Mackie’s seven-point checklist

Major signs (score 2 points each):

a) change in size
b) change in shape
c) change in colour

Minor signs (score 1 point each):

a) inflammation
b) bleeding or crusting
c) diameter greater than 7mm
d) sensory change

Tips for protecting your skin from the sun

One of the major risk factors for developing skin cancer is ultraviolet exposure.

Acute intermittent blistering episodes of sun burn, especially in childhood, can increase the risk of melanoma. This is in contrast with NMSCs where it is the chronic cumulative exposure of sun over many years which increases the risk of an individual developing NMSCs later in life.

Pharmacists are well placed to provide sun protection advice to all ages groups in the community and encourage those bonafide sun worshippers to alter their behaviours. Here are 10 sun smart tips to share with your patients:

1. Limit the amount of time you are out in the sun between 11-3pm. This is when the suns rays are most intense so seek shade when out and about.
2. When going on holiday, remember the closer the holiday destination is to the equator, the greater the exposure of UVA and UVB to the skin and the greater the risk of sun damage and being burnt.
3. Clothes are the best form of sun protection. If possible, wear long sleeved shirts and trousers. Dark, tightly woven clothing provides greater protection than white loosely woven clothing. Look for the Ultraviolet Protection Factor (UPF) on the garment label.
4. Wear a wide brimmed hat and sun glasses with lenses that have 99%-100% UV absorption providing optimal protection to the eyes and surrounding skin.
5. Use sunscreen every day, even if it is cloudy.
6. Choose a broad spectrum sunscreen that protects against Ultraviolet A and Ultraviolet B (UVA and UVB) radiation – Minimum SPF 30.
7. Use sufficient quantities of sunscreen and apply 30 minutes before going out in the sun. Apply every two hours and hourly if swimming or sweatng during physical activity.
8. Use a lip balm with sun protection factor (SPF) 30.
9. Be careful around water and sand as these surfaces reflect sunlight causing extra sun damage to the skin.
10. Remember UV Exposure not only increases the risk of skin cancer but also causes photoageing. So if you still want to look young with good looking skin in later life, slip on a shirt, slip into the shade, slop on sunscreen, slap on a hat and wrap on sunglasses!

Helpful resources and information to suggest to your patients:

http://www.bad.org.uk/for-the-public

http://www.britishskinfoundation.org.uk/Community.aspx

http://www.pcds.org.uk/

https://www.dermnetnz.org/topics/

Dr Juber Hafiji is a consultant dermatologist, dermatological and Mohs micrographic surgeon and a British Skin Foundation spokesperson.

References 

1. Baxter JM, Patel AN, Varma S. Facial basal cell carcinomata. BMJ 2012; 345:37-42
2. Cancer Research UK. Skin cancer incidence statistics. Cancer Research UK. cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/skin-cancer/incidence
3. Levell NJ, Igali L, Wright KA et al. Basal cell carcinoma epidemiology in the UK: the elephant in the room. Clin Exp Dermatol 2013; 38:367-369.
4. Newlands C, Currie R, Memon A et al. Non-melanoma skin cancer: United Kingdom National Mulitidiscplinary Guidelines. J Laryngol Otol 2016;130(S2):S125-S132.
5. Walter FM, Prevost AT, Vasconcelos J et al. Using the 7-point checklist as a diagnostic aid for pigmented skin lesions in general practice: a diagnostic validation study. Br J Gen Pract 2013; 63:e345-353.