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 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.
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.
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.
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 melanoma2,5 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
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):
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:
Helpful resources and information to suggest to your patients:
Dr Juber Hafiji is a consultant dermatologist, dermatological and Mohs micrographic surgeon and a British Skin Foundation spokesperson.