Christina Lewis, MN, RN, NPCertified Dermatology Nurse

UCLA Arthur Ashe Student Health and Wellness Center

May 31, 2012

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Identify questions to review when presented with a student that has a concern about possible skin cancer

Compare and contrast the three most common types of skin cancer

Explain how UV exposure can affect the skin and how it may affect the Vitamin D levels of the average college student

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Skin cancer is the most common form of cancer in the United States.

2003 there was more than one million new cases of skin cancer in US and 9,800 will die of the disease (Scarlett, 2003)

Incidence of skin cancer has doubled each decade since the 1930’s (Wolf, 2003)

Who to screen? No randomized studies. Discuss changes in behaviors with whom?

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Increase to 75% proportion of persons who use at least one protective measure that may reduce risk of skin cancer: ◦ avoid sun between 10-4◦ wear sun protective clothing◦ use sunscreen with SPF of at least 15◦ avoid artificial sources of UV light.

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- Family history of skin cancer- Personal history of skin cancer- Number of blistering sunburns in the

student’s lifetime-Tanning bed use-Where they grew up-Changes to any area of the skin and when

the changes were noted. Including changes in areas of past burns and keloids

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Basal Cell-more common with intermittent “recreational” exposure. Unclear if sunscreen prevents BCC. Metastasis rate is less than 0.1%

Squamous Cell-more common with continuous sun exposure such as outdoor workers. “regular sunscreen can prevent SCC” (Lin, et al. 2003). Metastasis rate is 2-6%

Melanoma-more common with intermittent “recreational” exposure. Unclear if sunscreen prevents melanoma (Lin, et al 2003)

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Dermnet images11

Appears “black, pearly” Pigmentation is present in >50%. Compared

to 5% in whites. (Bigler, et al, 1996) BCC occurs most commonly after the 5th

decade (Maguire-Elsen, 2011)

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Predisposing Factors◦ Precursor lesions (actinic keratosis, Bowen disease) ◦ Ultraviolet radiation exposure ◦ Ionizing radiation exposure ◦ Exposure to environmental carcinogens- Arsenic,

Insecticides and herbicides, smoking/alcohol assoc with oral SCC

◦ Immunosuppression ◦ Scars ◦ Burns or long-term heat exposure ◦ Chronic scarring or inflammatory dermatoses discoid

lupus, pilonidal cyst, hidradenitis superativa ◦ Human papillomavirus infection (HPV 16-head and

neck, HPV 5)◦ Genodermatoses (albinism, xeroderma pigmentosum,

porokeratosis, epidermolysis bullosa)

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Fitzpatrick Color Atlas 16

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Surgical excision Cryotherapy-97-99% cure rate in BCC Mohs micrographic surgery Topical chemotherapy (5-FU, interferon,

retinoids) Systemic chemotherapy Laser therapy Electrodessication and Curettage Curettage (for BCC only) Photodynamic therapy-uses light, oxygen and a

photosensitizing chemical

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• Different incidence, site distribution, stage at diagnosis, and histological type. Acral lentiginous melanoma is more frequent (Cress, Holly, 1997)

Lower extremity:◦ Hispanics-20%◦ Asians-36%◦ Blacks-50%◦ Nonhispanic whites-9% • Trunk is in all males but only in

nonhispanic whites among females. (Weir, 2011)

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Male Hispanics in Florida had a 20% higher incidence than male Hispanics in the U.S. Female Hispanics in Florida had a lower rate than other areas of U.S. Female Blacks had 60% higher incidence than the U.S cohort. Total of 109,633 pts in study.(Rouhani, 2010)

Mucosa, palms, soles and nail beds are equally frequent in whites and blacks and have remained constant unlike melanomas in other body areas. (Wolff, 2008)

Melanoma education to ethnic people may be improved by using skin cancer photographs of early melanoma in people with dark skin, providing guidance on how to inspect hands and feet for suspicious moles.(Robinson, 2011)

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UV accounts for approximately 93% of skin cancers (Gallagher, 2010)

UV light is addicting. UV light releases endorphins

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UVA penetrates the stratum corneum but is poorly absorbed by DNA◦ Has a longer wavelength◦ Accounts for about 95% of UV rays that reach the

earth◦ More efficient than UVB in immediate and delayed

pigment darkening and delayed tanning. (Korak, 2011) UVB-partially penetrates the stratum corneum

and is absorbed by DNA◦ Primarily associated with erythema and sunburn◦ Can cause immunosuppression and

photocarcinogenesis

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Ultraviolet radiation makes chemical change in DNA

Change in DNA causes muta-tion of P53

Mutation alters function of the gene

Gene function leads to a new cell phenotype

The abnormal cell expands into a clone

The clone becomes the target of further DNA damage

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◦ Latitude◦ Altitude◦ Ozone-UVB◦ Season/cloudiness◦ Exposure time◦ Time of the day◦ Sunscreen ◦ Shade◦ Tanning bed◦ Herbal preparations◦ Low fat diet◦ Behavioral Therapy

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Latitudes above 35o have little UVB exposure◦ Albuquerque, N.M.35◦ Birmingham, Ala.33◦ Bismarck, N.D.46◦ Boston, Mass.42◦ Charlotte, N.C.35◦ Chicago, Ill.41◦ Minneapolis, Minn.44◦ Nashville, Tenn.36◦ New York, N.Y.40◦ Philadelphia, Pa.39◦ Salt Lake City, Utah40

Squamous cell carcinoma appears to double with each 8-10 degree decline in latitude

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Affects UVB more than UVA

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UVB is somewhat blocked by the ozone

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In the summer, UVA is 96.5% of the UV rays that reach the earth and UVB is 3.5%

Seasonal change accounts for about 1/5 of a change in Vitamin D production (Perez-Lopez, 2010)

Clouds affect UVB more than UVA

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High school white students who never wore sunscreen when out in sun >1 hr, increased from 57.5%to 69.4% from 1999-2009 (Jones, 2012)

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UV is strongest between 10 am and 4 pm 2/3 of the UV radiation comes between 10

am and 2 pm

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Used most common in women, less common in black women. SPF 30 protects from 97% of UVB

People in the U.S. only apply about 25% of the recommended sunscreen (Thieden, et al, 2005)

Nambour (Queensland) sunscreen trial-first randomized clinical trial with regular sunscreen users and control group

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17 approved agents in the U.S. (Maguire-Elsen, 2011)

Blocking sunscreen reflect UV rays zinc oxide and titanium dioxide. Scatter

UV light. Good for sensitive skin, not skin of color.

Chemical sunscreens absorb the UV rays◦ Chemical sun blocks only block narrow regions of

the UV spectrum so they are used together. Most block UVB.

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◦ “Broad spectrum” means UVA and UVB protection◦ Skin cancer/skin aging alert on sunscreens <15◦ Capped SPF value of 50+◦ “Sunblock”, “sweatproof”, and “waterproof” can

not be used.◦ Clear time frames for “water resistant” (40

minutes) and “very water resistant” (80 minutes)◦ New Drug Facts box◦ Will include “do not use on damaged or broken

skin”

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UVA is not filtered by window glass (UVB is) 50% of exposure to UVA occurs in the shade Shade use-most common in women-less

common in white women Hat with brim, long sleeves Clothing to the ankles-most common in men Sunglasses with UV-absorbing lenses Darker colors are slightly more protective.

◦ Plain white cotton T-shirt has about SPF 7◦ Dark green T-shirt has about SPF 10

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In the past, because UVA did not cause sunburn, only tanning, it was not considered harmful to skin.

Tanning bed regular and early (high school and college) use increases risk of skin cancer.

Tanning 4 times a year increases risk of non-melanoma cancer by 15% and melanoma by 11% (Sun & Skin News, 2011)

One tanning session a year in high school increased risk of BCC by 10%. (Zhang)

6.7% of high school males and 25.4% of females use indoor tanning.(MMRW 2010)

WHO recommended minors be prohibited. 36 states have put into law as of April, 2012.

No protective benefit to getting an artificial tan before exposure to natural light (Miyamura, 2011)

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Herbs and herbal preparations protect from UV exposure generally through their antioxidant activity

Plant peptides protect skin proteins (our natural sun blockers). Topical application of sesame oil blocks 30% of UV rays. Coconut, peanut, olive and cottonseed oil block about 20%, mineral oil does not block UV.

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Proanthocyanidin-grape seed (DNA mutation inhibitor)

Resveratol -grapes, wine, cranberries, peanuts

Quercetin-many fruits and vegetables-is the most common flavonol

Apigenin-cumin, fruit, and vegetables (carrots), marigolds

Silymarin-milk thistle Curcumin-tumeric

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Vitamin E-(tocopherol)-in wheat germ, pumpkin seeds.

Vitamin C-rosehip seed extractCarotonoids-(sea buckthorn, fruit oil [ie Avocado oil],

fish oil). Fish oil may increase sun protective effect in some cases up to SPF 5.

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◦ Green tea and black tea◦ Aloe vera◦ Walnut extract◦ Krameria triandra (Kameria triandra root extract)◦ Borage oil◦ Evening primrose oil◦ Tea tree oil (increases blood flow only)◦ Porphyra (red algae)

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Low fat diets. High fat diets shorten the time between UV exposure and tumor formation

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Vitamin D insufficiency (range being 20 or 30) is common among:◦ Elderly◦ Institutionalized◦ Dark skinned◦ Wearing of protective clothing or consistent use of

sunscreen causing limited effective sun exposure◦ Obese◦ Malabsorption issues (Dawson-Hughes, 2012)

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7-dehydrocholesterol

Diet/supplementsUV light skin

Cholecalciferol (Vitamin D3)

Ergocalciferol (Vitamin D2)

Liver

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Grant (2009) supported sun exposure. “Although a few thousand extra deaths per year might occur from melanoma and skin cancer, the avoided premature death rate could be near 400,000/year.”

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Recommendation for short (15 minute) sun exposure, outdoor sport and leisure activities is needed as a vitamin D rich diet generally provides only about 10% of the needed vitamin D (Perez-Lopez, 2010)

The difference in the sunlight can be made up with supplements.

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◦ Correlates with reduced risk of about 14 types of cancer including Hodgkin lymphoma, colon, breast and prostate cancer, and colon cancer

◦ Correlates with reduced incidence and/or mortality rates of type 2 DM, coronary heart disease, and congestive heart failure

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International Agency for Research on Cancer (IARC) concluded that data does not support any form of intentional UV exposure

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Uptodate recommends for high risk (dark skin/sunscreen/protective clothes users) measurement of serum 250HD is useful but for regular low risk adults, suggest they take 600-800 iu/day

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Main questions to review with patients:◦ Family history of skin cancer◦ Personal history of skin cancer or biopsies and

results◦ Number of blistering sunburns in the patient’s

lifetime, tanning bed use◦ Any changes or specific skin concerns the patient

has noted.◦ Students of color, location and presentation of

melanoma.

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Three most common skin cancer◦ Basal cell◦ Squamous cell◦ Melanoma

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Correlation of UV exposure and skin cancer Sunscreen and other interventions to

decrease UV exposure (concern about possible low Vitamin D)

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Bigler, C et al. “Pigmented basal cell carcinoma in Hispanics” j am acad dermatol 34:751-2.

Buller, DB, et al. “Prevalence of sunburn, sun protection and indoor tanning behaviors among Americans: review from national surveys and case studies in 3 states” j am acad dermatol. 2011, Nov,65(5 Suppl 1) S114-23.

Center for Disease Control and Prevention. “Preventing Skin Cancer” MMWR Morb Mortal Wkly. Oct 17, 2003, 52(RR15);1-12.

Center for Disease Control and Prevention. “Sunburn and Sun Protective Behaviors Among Adults Aged 18-29 Years-United States, 2000-2012”. MMWR Morb Mortal Wkly. May 11, 2012, 61(18); 317-322

Crest, R, Holly E. “Incidence of Cutaneous Melanoma among non-Hispanic whites, Hispanics, Asians, and Blacks: an analysis of California Cancer Registry Data 1998-1993” Cancer Cause Control. 1997 Mar;8(2):246-52.

Dawson-Hughes, B “Treatment of vitamin d deficiency in adults” uptoDate 2012 www.uptodate.com.

Gallagher, RP, et al “Ultraviolet radiation” Chronic dis Can. 2010;29 Suppl 1:51-68.

Grant, W. “In Defense of the Sun” Dermatoendocrinol. 2009 Jul-Aug:1(4):207-214.

Jones, SE, et al, “Trends in sunscreen use among us high school students: 1999-2000” j Adolesc Health 2012 Mar,50(3):304-7.

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Korac, R and Khambholia, K. “Potential of herbs in/skin protection from Ultraviolent Radiation” Pharmacogn Rev. 2011 Jul-Dec;5(10): 164-173.

Lin, JS, Ederm M. et al. “Behavioral counseling to prevent skin cancer: Systemic evidence to review to update the 2003 U.S. Preventative Services Task Force Recommendation”

Maguire-Elsen, M. :”Food and Drug Administration’s final ruling on sunscreens” Journal of the Deermatology Nurses’ Association. 2011, October 3(5):255-9.

Miyamura, et al. “The deceptive nature of UVA tanning versus the modest protective effects of UVB tanning on human skin” Pigment Cell and Melanoma Research. 24(1), 136-7

MMRW Surveill Summ 2010;59: 1-142) Murphy, et, al. “Predictors of Serum Vitamin D

levels in African American and European American Men in Chicago” Am J Mens Health. 2012 Mar 8.

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Perez-Lopez, et al. “Vitamin D and adolescent health” Adolescent Health, Medicine, and Therapeutics. 2010 (1):1-8.

Pichon, L, et al. “Measuring skin cancer risk in /African Americans: is the Fitzpatrick skin type classification Scale Culturally Sensitive”. Eth Dis. 2010 Spring:20(2):174-9.

Porcia, T. “Skin Cancer in Skin of Color” Dematol Nurs. 2009 Jul-aug;21(4): 170-178.

Rouhani, P., et al. “Increasing rates of melanoma among nonwhites in Florida compared with the United States” Arch Dermatol. 2010 Jul;146(7):741-6.

Robinson, et al. “Melanoma knowledge, perception and awareness in ethnic minorities in Chicago: recommendations regarding education” Psychooncology. 2011 Mar;20(3):313-20.

Scarlett, WL. “Ultraviolet radiation: sun exposure, tanning beds, and vitamin D levels. What you need to know and how to decrease the risk of sun cancer” J Am Osteopath Assoc 2003 Aug, 103(8)271-5.

Sun & Skin News. 2011, winter, 28(4). www.SkinCancer.org. Thieden, et al. “Sunscreen use related to UV exposure, age, sex, and

occupation based on personal dosimeter readings and sun –exposure behavior diaries” Archives of Dermatology. 2005, 141(8):967-973.

Weir, et al. “Melanoma in adolescents and young adults (ages 15-39 years): United States, 1999-2006” J Am Acad Dermatol. 2011 Nov;65(5 Spppl 1):S38-49

Wolff, et al. Fitzpatrick Dermatology, 7th edition, 2008. Chapter 112. Carcinogenesis: ultraviolet radiation

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American Academy of Dermatology-www.add.org

CDC.gov/cancers/skin Sunwise program www.epa.gov SkinCancerNet www.skincarephysicians.com/skincancernet/

skin_of_color.html http://www.skincancer.org/skin-cancer-infor

mation/basal-cell-carcinoma http://www.dermnet.com/images/Basal-Cell-

Carcinoma-Face/photos/2

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