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Misapplication of sunscreen leaving people vulnerable to skin cancer

When applying sunscreen people miss on average 10 per cent of their face, the most common site for skin cancer, according to a study being presented at the British Association of Dermatologists' Annual Conference in Liverpool. More than 90 per cent of basal cell carcinomas, the most common cancer in the UK, occur on the head or neck, and between five and 10 per cent of all skin cancers occur on the eyelids specifically.

57 participants, male and female, were asked to apply sunscreen to their face with no further information or instructions given by the researchers from the University of Liverpool. Photos were taken of each of the participants with a UV-sensitive camera before and after the application of sunscreen, with areas covered with sunscreen appearing black due to the UV camera. These images were then segmented and analysed by a custom-designed program to judge how successful each person was at covering their whole face.

On average people missed 9.5 per cent of the whole face, with the most commonly missed areas being the eyelids, where on average 13.5 per cent of the eyelid was missed, and the medial canthal region, the area between the inner corner of the eye and the bridge of the nose which was missed by 77 per cent of participants.

The researchers then asked the participants back to repeat the experiment, this time giving extra information about skin cancers of the eyelid region. Armed with this information there was a slight improvement in the level of sunscreen coverage with 7.7% per cent of the face left unprotected.

As applying sunscreen in these areas is not necessarily practical in light of manufacturers’ warnings to keep products out of the eye, it is important to use other forms of protection such as sunglasses.

Matthew Gass of the British Association of Dermatologists said:

“As sunscreen is one of the main protections against UV damage and skin cancer it is vital that people understand how to apply it. Skin cancer is the most common type of cancer in the UK, and numbers continue to rise at a worryingly fast rate.

“We still want people to enjoy themselves outdoors, but to go back to the basics of sun protection, especially those with fair skin that burns easily, and during periods of strong sunshine either in the UK or abroad. These are to thoroughly apply and reapply sunscreen with a minimum of factor 30 and good UVA protection, to wear protective clothing such as a t-shirt or a hat, to wear sunglasses that show the CE mark and British Standard (BSEN1836), and to spend time in the shade when the sun is at its hottest between 11am and 3pm.”

Dr Kevin Hamill of the University of Liverpool, one of the researchers, said:

“It's worrying that people find it so hard to sufficiently apply sunscreen to their face, an area which is particularly at risk of skin cancer due to the amount of sun exposure it receives. Our research shows that simple health messaging can help improve this problem, and we hope that industry groups and public health campaigners can take this onboard.”

“Perhaps the most important thing to take away from this research is the importance of sunglasses. Most people consider the point of sunglasses is to protect the eyes, specifically corneas, from UV damage, and to make it easier to see in bright sunlight. However, they do more than that, they protect the highly cancer prone eyelid skin as well.”

Teenage use of sunbeds on the rise in Ireland

Rates of sunbed use amongst Irish teenagers have risen since 2014 legislation banning sunbed use by under-18s, according to a study being presented at the British Association of Dermatologists' Annual Conference in Liverpool. The researchers, from Sligo University Hospital, suggest that a lack of enforcement may be a reason for this increase.

In the current study 8.8 per cent of respondents aged 14-18 years old had used a sunbed, with the highest rate being in Dublin (13.9 per cent). A similar 2014 survey of teenagers by the same researchers prior to the legislation showed that 7.5% of respondents had used a sunbed, with a higher rate in Dublin (11.2%). Indoor tanning is associated with an increased risk of skin cancer, and the risk is higher in frequent users and in those using sunbeds at a younger age.

Over 50 per cent of those that used sunbeds experienced burning due to sunbed use, most frequently occurring on the face (33%) and chest (22%). The majority (65%) did not use protective eyewear and this resulted in eye problems in 12 per cent. Furthermore, a concerning 2 per cent of Irish teenagers are using Melanotan® to enhance tanning.

Sunburn due to the sun was reported by 90 per cent of teenagers, with 43 per cent experiencing at least five burns. Sunscreen was seldom used at home (34%) compared with when holidaying abroad (85%). The majority of teenagers believe that a tan looks healthy (70%) and makes you look more attractive (73%). Conversely, the majority also acknowledged that tanning is dangerous (77%) and associated with wrinkles (83%).

Dr Dermot McKenna of Sligo University Hospital, one of the researchers, said:

“The failure to effectively enforce sunbed legislation in Ireland is hugely worrying. Skin damage at an early age is particularly concerning. A crucial step forward was taken by bringing in this legislation, however this should not be relied on in isolation. We need to ensure that the legislation is being enforced and that on-going education is provided to ensure its success. It is disappointing that currently it is not proving effective. Of note, the current legislation does not cover home sunbed use allowing teenagers to circumvent the legislation.

“We can also see that although young people seem to be aware of the dangers of tanning this is not necessarily changing their habits, particularly in terms of protecting their skin from the sun when at home (Ireland). More effort needs to be put into changing the cultural perception of a tan as healthy and attractive, as tricky as it may be.”

Matthew Gass of the British Association of Dermatologists said:

“What this study shows is that despite generally good awareness of the dangers of excessive UV exposure Irish teenagers are still getting caught out in the sun, and are particularly lax when they’re in Ireland. An important reason for this is the desire for a tan which is considered both healthy-looking and attractive. Until this changes it’s always going to be a tricky persuading young people to make good long-term health decisions, as for many people body image and attractiveness is very closely linked to self-esteem and sense of self. Clearly this problem isn’t limited to Ireland, where there have been excellent steps taken to educate and protect people on sun awareness.”

-Ends-
Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.

The conference will be held at the ACC Liverpool from July 4th to 6th and is attended by approximately 1,300 UK and international dermatologists.

For more information please contact the media team: comms@bad.org.uk, 0207 391 6084. Website: www.bad.org.uk.

About us:
The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease. For further information about the charity, visit www.bad.org.uk

Sun protection tips:

1. Spend time in the shade during the sunniest part of the day when the sun is at its strongest, which is usually between 11am and 3pm in the summer months.
2. Avoid direct sun exposure for babies and very young children.
3. When it is not possible to limit your time in the sun, keeping yourself well covered, with a hat, T-shirt, and sunglasses, can give you additional protection.
4. Apply sunscreen liberally to exposed areas of skin. Re-apply every two hours and straight after swimming, sweating or towelling to maintain protection.

Checking for skin cancer:

There are two main types of skin cancer: non-melanoma, the most common, and melanoma, which is less common but more dangerous. The following ABCDE rules describe a few changes that might indicate a 'melanoma', which is the deadliest form of skin cancer. As skin cancers vary, you should tell your doctor about any changes to your skin, even if they are not like those mentioned here. If your GP is concerned about your skin, make sure that you are referred to a dermatologist, the most expert person to diagnose a skin cancer. Your GP can refer you via the NHS.

Asymmetry - the two halves of the area may differ in shape or colour
Border - the edges of the area may be irregular or blurred, and sometimes show notches
Colour - this may be uneven. Different shades of black, brown and pink may be seen
Diameter - most melanomas are at least 6mm in diameter. Report any change in size, shape or diameter to your doctor
Evolution – if you see progressive changes in size, shape or colour over weeks or a few months, you must seek Expert help.

If in doubt, check it out! If your GP is concerned about your skin, make sure you see a dermatologist, the most expert person to diagnose a skin cancer. Your GP can refer you via the NHS.

Non-melanoma skin cancer

Non-melanoma skin cancers can occur on any part of the body, but are most common on areas of skin that are most often exposed to the sun such as your head and neck (including lips and ears) and the backs of your hands. They can also appear where the skin has been damaged by X-rays, and on old scars, ulcers, burns and persistent wounds.

Non-melanoma skin cancers vary greatly in what they look like. They tend to appear gradually on the skin, and slowly get bigger over time. They will not go away on their own without treatment. Some possible signs include:

- A scab or sore that won’t heal. It may also bleed occasionally
- A scaly or crusty patch of skin that looks red or inflamed
- A flesh coloured, pearly lump that won’t go away and appears to be growing in size
- A lump on the skin which is getting bigger and that may be scabby
- A growth with a pearly rim surrounding a central crater, a bit like an upturned volcano

Study 1: Ultraviolet imaging reveals that areas on the face that are prone to skin cancer are disproportionately missed during sunscreen application

K. Hassanin, H. Pratt, Y. Zheng, G. Czanner, K. Hamill and A. McCormick University of Liverpool, Liverpool, Merseyside, U.K.

Use of sunscreen is an effective means of protecting skin against the harmful actions of ultraviolet (UV) radiation. Despite increasing sun awareness and sun protection usage, > 90% of basal cell carcinomas develop in sun-exposed head and neck and areas 5–10% of all skin cancers (including basal and squamous cell carcinomas and melanomas) occur on the eyelids. We hypothesized that high-risk areas, notably the eyelids and medial canthal regions, may be ineffectively covered and that provision of improved information regarding application would be an effective strategy to improve coverage. A crossover study was undertaken with 57 participant (27 male, 30 female). Participants were provided with minimal instructions and imaged with a UV-sensitive camera before and after sunscreen application. Images were processed autonomously by a custom-designed image analysis program to reduce subjectivity in segmentation. Facial landmarks were detected and images cropped respective to these landmarks so each images analysed was uniform. Images were pre-processed to remove artefacts and segmented through thresholding for regions missed. Analysis revealed a median of 9.5% of the whole face to be missed [interquartile range (range 0 – 22.2%,]; however, the proportion of the eyelid region missed was significantly higher at 13.5%, (p<0.001 Mann-Whitney test). The medial canthal region was missed by 77% of participants. Participants were invited to return for a second visit, when a new set of instructions was given with extra information pertaining to skin cancer of the eyelid region; participants were imaged as previously. Application during the second visit showed a slight overall improvement in whole face area covered (7.7%, 1.8% increase P < 0.05); however, the eyelid regions showed 3.8% increased coverage with the area missed reduced from 13.5% without information to 9.7% with (Range 0-23.5%, P < 0.05). No significant improvement in medial canthal region coverage was observed. Together these data reveal that even those who apply sunscreen are likely to be missing high-risk areas, and in turn suggest that those who believe they are protected and therefore may modify their behaviour are actually still at risk. Moreover, importantly, our data show that a simple public health announcement-type intervention could be effective at reducing risk.

Study 2: A re-evaluation of teenage sunbed use following the introduction of legislation banning use for under 18 year olds

S. Menzies, S. Daly, M. Fitzgerald and D. McKenna Sligo University Hospital, Sligo, Ireland

Indoor tanning is associated with an increased risk of skin cancer. The risk is higher in frequent users and in those using sunbeds at a younger age. In a previous study of Irish teenagers, we showed that 7.5% of respondents had used a sunbed, with a higher rate in Dublin (11.2%) [Fitzgerald M, Daly S, McKenna D et al. Ambient and sunbed ultraviolet radiation exposure: exposure rates, protection habits and attitudes of Irish teenagers aged 14–18 years before introduction of national sunbed legislation. Br J Dermatol 2015; 173 (Suppl. S1): 6]. In 2014, legislation was introduced in Ireland to ban the use of sunbeds in teenagers under the age of 18 years old. The purpose of the present study was to reassess sunbed usage among teenagers aged 14–18 years, 2 years after the introduction of the ban. We assessed (i) sunbed usage rates, (ii) sunburn history, (iii) sun-protection habits and (iv) attitudes towards sun and sunbed exposure. The same secondary schools as before were visited and the teenagers completed an anonymous questionnaire. The numbers completing the questionnaire, age and male-to-female ratio were similar to those in the original study. The results showed that more teenagers are using sunbeds following the ban (8.8%). Teenagers in Dublin continue to have a higher rate of sunbed use (13.9%) compared with other regions. After the ban there was an increase in sunbed usage in tanning shops (before 44%, after 50%) and at home (before 26%, after 41%). More teenagers were consented prior to treatment (before 9%, after 15%). The majority did not wear eye protection (65%), resulting in eye problems in 12%. In the present study, over 50% had experienced burning due to sunbed use, most frequently occurring on the face (33%) and chest (22%). A minority (2%) of teenagers used Melanotan. Sunburn due to ambient exposure was reported by 91% of teenagers, with 43% experiencing at least five burns. Sunscreen was seldom used at home (34%) compared with when holidaying abroad (85%). The majority of teenagers believe that a tan looks healthy (70%) and makes you look more attractive (73%). Conversely, the majority also acknowledged that tanning is dangerous (77%) and associated with wrinkles (83%). Our findings show that there has been no reduction of sunbed use in teenagers following the introduction of legislation banning its use in those aged < 18 years. This may be due to a lack of enforcement of the legislation, in addition to an increasing trend for sunbed use at home. Further education is needed highlighting the dangers of sunbed use and excessive sun exposure.
 

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