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Response to IARC's reclassification of sunbeds

Nina Goad of the British Association of Dermatologists: “We know that ultraviolet radiation (UVR) causes skin cancer, and sunbeds create a tan by emitting UVR, so we welcome the recognition that sunbeds are carcinogenic. 


It is high time that steps were taken to regulate the industry, to prevent children using sunbeds, and to ensure that sunbeds are subject to health warnings like other known carcinogens. At the moment, many salons are free to advertise somewhat spurious health ‘benefits’ of using sunbeds, but offer no advice on health risks. Hopefully, categorizing sunbeds as a known carcinogen will prompt the government to introduce compulsory health warnings on tanning beds.


Recent research shows that  many sunbeds are not maintained, emit worryingly high levels of UV, and are not subject to any safety checks.”

The International Agency for Research on Cancer (IARC) has moved sunbeds (UV tanning beds) up to the highest cancer risk category—group 1—‘carcinogenic to humans’. The use of sunlamps and sunbeds was until now classified as "probably carcinogenic to humans" (group 2A). For full Special Report see The Lancet: http://press.thelancet.com/tlosunbeds.pdf  

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Shocking safety standards in sunbed parlours, research reveals

A high number of tanning parlours have shockingly poor standards of practice and a severe lack of staff training, including the provision of sunbeds designed for medical use only, a report due to be released at the British Association of Dermatologists’ annual conference this week will reveal.

332 tanning salons in Northern Ireland took part in a survey over an eight week period in July and August 2007, and the results have raised serious concerns about safety within the sunbed industry.

Types of sunbed and safety

Staggeringly, over a quarter of premises used ‘type 4’ sunbeds which are designed for medical use and not for cosmetic tanning, according to European and international standards*. It is possible that many others are using sunbeds that emit high levels of UV, as almost two thirds (62%) of salons did not know what level of ultraviolet (UV) radiation their sunbeds produced.

39 percent of the premises reported that devices were not regularly tested. The date of the last inspection of fixed electrical installations was unknown in over a third (34%) of premises, while 18 percent of premises did not even know the manufacturer of the sunbeds in their salons. In 71 percent of the tanning salons the operating manual for the sunbeds was unavailable.

This raises serious concerns that improperly maintained or faulty machines could produce high levels of ultraviolet (UV) radiation, cause burning to the skin and potentially lead to skin cancer.

High risk users

Worryingly, the study found little evidence of children being prohibited from using sunbeds. Only half (51%) vetted clients with regard to age. Where premises allowed minors to use sunbeds, almost three quarters (71%) did not require parents or guardians to sign a consent form. Furthermore, over 15 percent of staff received no age awareness training. 
In one fifth (20%) of the salons skin type was not even discussed with customers. In the salons where skin type was discussed, it was left to the client to determine their own skin type in 13 percent of cases.

In a recent study, only 40 percent of the indigenous population of Northern Ireland felt they were skin type I and II (naturally fair skinned) with over 30 percent typing themselves as type V or VI (dark Asian or black skinned)1 whereas in fact Northern Ireland has a predominantly fair-skinned population.

Dr Art O’Hagan, Consultant Dermatologist explained: “Previous studies have shown poor comprehension of personal skin types, and relying on clients to have knowledge of their own skin type is an unsafe mode of skin type vetting. Furthermore, asking about skin types was a somewhat purposeless exercise, since only 44 percent of customers with skin type 1 (people with very pale skin who are at greater risk of burning and skin cancer) were subsequently advised against using the sunbeds. More shockingly, only 31 percent of cases advised patients not to use a sunbed if they had a history of skin cancer.”

Hygiene, facilities and staff training

In a quarter (24%) of salons, the staff were offered no training at all on the risks of UV exposure. 
39 percent of salons had coin operated devices, allowing the use of devices without staff supervision.

Basic hygiene standards in many of the salons that took part in the survey were particularly low. Only three quarters (75%) of salons reported that staff cleaned the sunbeds after usage, with others expecting clients to clean the sunbeds themselves, while almost a quarter (22%) failed to sanitise their eye protection wear after usage.

Worryingly, there was a charge for eye protection in 38 percent of cases. Furthermore, over 30 percent of the goggles were not CE marked therefore did not conform to a mandatory marking in the European Economic area and did not offer sufficient protection.

Interestingly over three quarters (79%) of premises were not members of the Sunbed Association, which shows that any code of conduct applied by the association does not apply to the majority of salons.

Local councils in Northern Ireland have prohibited the use of sunbeds in local council premises however the survey’s results have shown that private parlours continue to run with worryingly poor standards of operation.

The tanning industry in Northern Ireland continues to grow despite most of the population having a predominant skin type that increases their risks of skin cancer. In particular, the use of sunbeds seems to be prevalent in younger girls.3

Rebecca Freeman at the British Association of Dermatologists said: “This survey has shown that there is a serious lack of regulation within the sunbed industry, and self regulation is clearly not working. Children are able to access sunbeds in a shockingly high number of salons, which is a real worry. One in five salons do not consider the client’s skin type, yet people with skin type 1, which is pale and burns easily, are particularly at risk of serious and permanent skin damage from sunbed use. Likewise, less than a third of salons advise people against using a sunbed if they have a history of skin cancer. This survey implies salons are not protecting their clients sufficiently. There is a great need for improved public education and strong regulation of sunbed salons to ensure that those who do choose to use sunbeds are fully aware of the risks.”

Possible effects of sunbed use include premature skin ageing, increased skin fragility, cataracts and skin 
Cancer.4,5

Summary of results

Sunbed and Safety 
• 27% of premises used ‘type 4’ sunbeds. 
• 62% of salons did not know what level of ultraviolet (UV) radiation their sunbeds produced. 
• 39% of the premises reported that devices were not regularly tested. 
• 34% of premises did not know the date of their last fixed electrical installations inspection. 
• 18% of premises did not know the manufacturer of the sunbeds in their salons. 
• In 71% of the tanning salons the operating manual for the sunbeds was unavailable.

Age 
• 85% of salons claimed to use questionnaires to tailor their advice to customers. 
• All salons who participated were asked about age, however only 51% vetted clients with regard to age 
• 71% of the premises that allowed minors to use their sunbeds did not require parents or guardians to sign a consent form. 
• Over 15% of staff were offered no age awareness training.

Skin Type 
• 20% of the salons skin type was not discussed with customers. 
• In the salons where skin type was discussed, it was left to the client to determine their own skin type in 13% of cases.
• Only 44% of customers with skin type 1 (people with very pale skin who are at greater risk of burning and skin cancer) were advised against using the sunbeds.
• Only 31% of cases advised patients not to use a sunbed if they had a history of skin cancer.

Staff Training 
• 24% of salons, the staff were offered no training at all on the risks of UV exposure. 
• 79% of premises were not members of the Sunbed Association. 
• 16% of parlours advertised the health benefits of artificial UV sources. 
• 39% had coin operated devices allowing the use of devices without supervision of staff. 
• 9% of clients were advised not to use sunbeds within 48 hours of last usage.

Hygiene 
• Only 75% of salons reported that staff cleaned the sunbeds after usage. 
• Only 78% sanitised their eye protection wear after usage. 
• There was a charge for eye protection in 38% of cases. 
• Over 30% of the goggles were not CE marked therefore did not conform to a mandatory marking in the European Economic area.

Facts about skin cancer

• There are three main types of skin cancer: malignant melanoma – the deadliest but least common, squamous cell carcinoma (SCC) and basal cell carcinoma (BCC).
• BCC and SCC are collectively known as ‘non-melanoma skin cancer’. BCC is the most common skin cancer. 
• In the UK, more than 100,000 new cases of skin cancer are diagnosed annually, making it the most common cancer. Of these, more than 10,000 are melanoma.
• There are over 2,300 deaths from skin cancer annually in the UK. 
• The annual incidence of melanoma worldwide is increasing faster than that of any other cancer. 
• In just 30 years, cases of melanoma across Great Britain have quadrupled in men and tripled in women. 
• Melanoma is more common in women than men, but there is a faster rate of increase in men and more men die from the disease, possibly due to late detection.
• In as many as 4 out of 5 cases, skin cancer is preventable, so follow the British Association of Dermatologists’ sun safety tips:
You don't have to avoid the sun all year, and some sunshine can be good for you as it helps the body to produce vitamin D, but taking a few steps when out and about in the summer sun or when on a sunshine holiday will help to protect you from sunburn and the risk of skin cancer, particularly if you are pale skinned.
• Protect the skin with clothing, including a hat, T shirt and UV protective sunglasses 
• Spend time in the shade between 11am and 3pm when it’s sunny 
• Use a sunscreen of at least SPF 30 (SPF 50 for children or people with pale skin) which also has high UVA protection
• Keep babies and young children out of direct sunlight 
• The British Association of Dermatologists recommends that you tell your doctor about any changes to a mole – if your GP is concerned about your skin, make sure you see a Consultant Dermatologist (on the GMC register of specialists), the most expert person to diagnose a skin cancer. Your GP can refer you via the NHS.
Sunscreens should not be used as an alternative to clothing and shade, rather they offer additional protection. No sunscreen will provide 100% protection.

-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 Scottish Exhibition & Conference Centre, Glasgow from July 7th to 10th 2009, and is attended by UK and worldwide dermatologists and dermatology nurses.

“Public at risk – a survey of sunbed parlour operating practices in Northern Ireland”. AH O’Hagan1, C Devereux1, A Devlin2, G O’Callaghan2, B Furey2, G McElwee2,4, G McEvoy2, J Caughey2, L McPeak2, L Fitzsimmons2, L Smart2, N McMahon2, P Loan2, S Martin2, S Gordon2,4, T Crossan2, A Gavin3. 
1Craigavon Area Hospital, 2Sun Bed Working Group (NIMSIG), 3Northern Ireland Cancer Registry, 4Ulster Cancer Foundation.

Other references: 
* The French regulations for ultraviolet radiation sunbeds; J. P. Cesarini, Radiation Protection Dosimetry 
Vol 91, Nos 1-3, pp 205-207, 2000. 
1 Gavin A. Personal Communication, Sept 2008 
2 Northern Ireland Statistics and Research Agency. NI Census 2001, Key Statistics.www.nisra.gov.uk/census/census2001output/keystatistics/keystatrepl.html
3 Ting W, Schultz K, Cac NN, Peterson M, Walling HW. Tanning bed exposure increases the risk of malignant melanoma. Int J Dermatol. 2007; 46:1253-57
4 Sunbeds; Hawk JLM, Radiat Prot Dosimetry, 2000; 91:143–5. 
5 Epidemiology of chronic disease risks in relation to ultraviolet radiation exposure; Swerdlow AJ, Radiat Prot Dosimetry 2000; 91:19–23

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.

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Media reports lead to better skin cancer detection

Media coverage of skin cancer advice and sun awareness campaigns may have generated a 47 percent increase in diagnoses of melanoma in just one year, according to research due to be released at the British Association of Dermatologists’ Annual Conference next week.

A team of dermatologists in Portsmouth examined data about referrals to their hospital dermatology department for suspected skin cancers, and correlated this with the numbers of tumours that were subsequently confirmed as skin cancers. They then investigated press reports from the same time periods and surveyed local GPs to try to explain their observations.

Skin cancer increase

The researchers found that since 2000, summer referrals between April and September are on average 41 percent higher than during the preceding winter months (October to March).

The largest increase was in summer 2008, when referrals were 64 percent higher than the preceding winter and 41 percent higher than summer 2007.

Local cancer network data from 2007 and 2008 showed a similar rise across the region, excluding the possibility that this particular dermatology department was seeing a disproportionate number of referrals compared to other clinics.

However, it was not just referrals that increased but also actual diagnoses of skin cancers. Pathology data comparing the year October to September 2006/7 to 2007/08 confirms an increase of 47 percent for melanomas (the least common but most dangerous type of skin cancer)  and 15 percent for squamous cell carcinomas (the second most dangerous type of skin cancer) diagnosed by the dermatology department.

Media reports

The team then searched selected national and local media for coverage relating to skin cancer during the same time frame. In summer 2008, 10 articles were identified locally, featuring six personal accounts from case studies. In contrast, the team could find no local reports about skin cancer in 2007.                                                                     

The team also identified an increase in national media reports on skin cancer in 2008 compared to 2007.

A survey of local GPs revealed that 93 percent felt they were seeing more patients concerned about skin cancer than five years ago, with just over half (53 percent) noticing a specific increase in 2008.

A third of the GPs said that patients concerns were specifically prompted by media coverage in 2008 and a third felt that the 2008 media coverage had increased referrals from within their practice.

Nina Goad of the British Association of Dermatologists said: “In recent years a number of charities have been working hard to raise awareness of skin cancer. The national Sun Awareness campaign in particular focuses on early detection of skin cancer, teaching people how to check their skin and what signs to look out for. In 2008, the campaign received its highest level of media coverage to date, and it is so encouraging to think this might be making a difference and contributing to a 48 percent increase in melanoma diagnoses.

“We know that charities working to promote sun safety messages have helped to teach people about skin cancer prevention, such as wearing sunscreen, so it’s great to know that our media work around checking the skin are also proving successful in picking up skin cancers that might otherwise have gone undiagnosed.

“The fact that it is not just referrals that have increased, but also actual diagnosed cases of skin cancers, shows that media work is not just driving people to see their doctors unnecessarily – it is helping to detect skin cancers that if left undiagnosed could in fact kill people. Early diagnosis is crucial with melanoma, and this proves how helpful the media have been to our campaign.”

Dr Ann Lonsdale-Eccles, dermatologist at Portsmouth Hospitals Trust and one of the study’s authors, said: “Our results confirm an increase in urgent skin cancer referrals over the last eight years.  We found marked seasonal variation which has been attributed in part to targeted public awareness campaigns in spring. We observed a particularly large increase in referrals and confirmed cancers in 2008, which we feel may be related to increased media reports at that time.”

-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 Scottish Exhibition & Conference Centre, Glasgow from July 7th to 10th 2009, and is attended by UK and worldwide dermatologists and dermatology nurses.

Two-week wait skin cancer referrals – referral patterns, cancer incidence and the media
Ann Lonsdale-Eccles1, Jan Croker1, Chris Slade2, Steve Traer1, Jonathan Hayes1, Rachel Humphries1, Gemma Rainger1, Dierdre McCormick1, Stephen Keohane1
1Portsmouth Hospitals Trust, Portsmouth, United Kingdom, 2Hampshire Primary Care Trust, Eastleigh, United Kingdom

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.

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Urgent need for routine skin cancer checks, research reveals

One in 14 transplant patients attending a routine skin cancer screening clinic were found to have skin cancer, according to research due to be released at the British Association of Dermatologists’ Annual Conference next week, highlighting the urgent need for routine skin cancer checks to be part of transplant clinics across the UK.

Patients were offered an annual skin surveillance appointment, arranged to coincide with a transplant follow-up appointment where possible, at a one stop transplant-dermatology surveillance clinic in Manchester, which was set up in 2006.

Over a one year period, 404 patients were reviewed in this transplant-skin cancer surveillance clinic. Seven percent were found to have non-melanoma skin cancer (basal cell carcinoma or squamous cell carcinoma). A further five percent of patients were found to have pre-cancerous skin lesions.

Three–quarters (76%) of those with skin cancer were diagnosed with basal cell carcinoma, with the rest (24%) diagnosed with squamous cell carcinoma.

Kidney transplant recipients are much more likely to develop skin cancer than people who have not received a transplant. 30 percent of UK renal (kidney) transplant recipients (RTRs) will go on to develop non-melanoma skin cancer, the most common type, within 10 years. This is because immunosuppressive drugs that prevent the body rejecting the transplanted organ, also increase the risk of skin cancer.

A recent study* found that only 66 percent of centres managing kidney transplant patients provide annual skin cancer surveillance. In contrast, 97 percent of centres in Australia offer skin cancer screening. Furthermore, of UK centres offering surveillance, only 59 percent provide full skin examination. However, 20 percent of non-melanoma skin cancers in UK kidney transplant patients arise on body sites covered by clothes.

Nina Goad of the British Association of Dermatologists said: “This was a routine screening service – so a lot of the patients would not have been aware that they had a suspicious lesion on their skin. The high number of skin cancers picked up through this service shows how vital routine screening is for such high risk people, because these cancers could easily have gone undetected otherwise.

“There appears to be something of a ‘postcode lottery’ regarding whether or not transplant patients receive screening for skin cancer. The clinic in Manchester seems to provide an ideal one stop service for patients, aiming to combine routine skin cancer screening alongside their transplant follow up appointments.  It would be good to see this model developed elsewhere.”

Dr John Lear Consultant Dermatologist at Manchester Royal Infirmary and one of the study’s authors, said: “In September 2006 we established a one stop transplant-dermatology surveillance clinic as a joint collaboration between the regional transplant unit and dermatology services. In a weekly nurse led clinic, the Transplant Advanced Nurse Practitioner (ANP) was supported by a consultant dermatologist, whose clinic would run simultaneously in an adjacent clinic room in dermatology outpatients. To avoid extra hospital visits, patients' annual skin surveillance appointments were arranged to coincide with a transplant follow-up appointment whenever possible.

“The joint transplant dermatology surveillance clinic has been effective in reducing delays in detection and treatment of transplant associated malignancies and premalignant skin lesions. The one-stop clinic offers a quality service as waiting times have been eliminated and the pathways for review and treatment have reduced.”

-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 Scottish Exhibition & Conference Centre, Glasgow from July 7th to 10th 2009, and is attended by UK and worldwide dermatologists and dermatology nurses.

Conference 2009 study: “The role of a transplant-dermatology surveillance clinic in the management of renal transplant recipients”
Venura Samarasinghe1, Vishal Madan1, Jibu Varghese1, Sheila Russell2, John T Lear1
1The Dermatology Centre, Salford Royal Hospital Foundation Trust and Central Manchester Dermatology Centre, Manchester Royal Infirmary, Manchester, United Kingdom, 2Renal Transplant Unit, Manchester Royal Infirmary, Manchester, United Kingdom

* British Journal of Dermatology, estimated publication date October 2008, “Skin cancer surveillance in renal transplant recipients: re-evaluation of UK practice and comparison with Australian experience.” S.Garg, R.P. Carroll*, R.G.Walker*, H.M. Ramsay and P.N. Harden¹; Dept of Dermatology, Royal Hallamshire Hospital, Sheffield, UK; *Department of Nephrology, Royal Melbourne Hospital, Australia; ¹Oxford Kidney Unit, Churchill Hospital, Oxford, UK; DOI: 10.1111/j.1365-2133.2008.08837.x
Articles in the BJD can be viewed online: http://www.blackwell-synergy.com/loi/BJD

Skin cancer is a major cause of morbidity and mortality in transplantation medicine. Skin cancer risk increases with time post transplant, age of patient and sun exposure. In 2006, within the National Institute of Clinical Excellence (NICE) document 'Improving outcomes for people with skin tumours including melanoma', recommendations were made for improving patient care pathways between the general practitioner, transplant unit and dermatologists for transplant recipients. This included the establishment of a transplant skin clinic at each transplant centre, early referral of precancerous lesions to a dermatologist, six monthly follow-up for high risk patients, primary prevention education and use of systemic retinoids in recurrent skin cancer.

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High Levels of Skin Cancer Revealed in the South West

A Sun Awareness Campaign mole check has highlighted the worryingly high levels of skin cancer amongst beachgoers in the South West, a report due to be released at the British Association of Dermatologists’ annual conference next week will reveal.

Members of the public enjoying the sun at Sandbanks beach, Dorset, were offered free screening for skin cancer and advice on protecting their skin in the sun by a team of dermatologists from Poole and Bournemouth, in conjunction with the British Association of Dermatologists. The pick-up rate for dermatological conditions at the screening was much higher than expected.

Screening Results
Alarmingly, just under one fifth (18.6%) of those screened had a significant dermatological condition either requiring treatment from their GP or a referral to a dermatologist. This included skin cancer, abnormal moles or pre-cancerous sun damage.

Of particular concern, six percent of those screened were suspected of having either a malignant melanoma or a basal cell carcinoma – types of skin cancer - and were advised to seek medical attention.

Survey
Those screened on the beach were also asked to fill in a survey that examined their attitudes and behaviour towards the sun.

Just under a third (28%) of those who took part in the survey admitted to using sunbeds. Worryingly only 39 percent used a sunscreen of SPF 20 or more. The British Association of Dermatologists recommends using a high protection sunscreen of at least SPF 30.

Rebecca Freeman, who runs the British Association of Dermatologists’ Sun Awareness campaign, said: “The screening on Sandbanks beach has exemplified extremely worrying levels of skin cancer in the South West of England.

“Had this event not been held, these cancers could have gone undetected, as most people had not seen their doctor about their skin before.

“In areas such as Dorset where the beach is one of the main attractions, it is vital that those spending long periods of time in the sun protect their skin sufficiently. If spending all day on the beach, holiday makers should seek shade during the hottest period of the day between 11am and 3pm and make sure that they cover up as much as possible with loose clothing. Using a sunscreen of SPF 30 or above is very important but people must remember that it is not the only way to protect the skin.

“People spending long periods of time in the sea, such as surfers, should also ensure that they are wearing protective clothing and water resistant sunscreen with a high SPF. UV rays reflect off the water onto your skin therefore it is particularly important to protect areas such as the face and hands which may be exposed not only to the sun for long periods of time, but also to the UV rays reflecting off the water.

“The alarmingly high number of skin cancer cases that were picked up at this screening reflects the wider picture in the UK. Over 100,000 people a year in the UK are developing skin cancer. Our understanding about the risks of skin cancer is in fact improving, however our behaviour isn’t. Many people think they are protecting their skin by applying sunscreen, but then choose a product with a low protection, use it as an excuse to stay out in the sun, or don’t reapply it often enough.”

Caroline Morgan, Consultant Dermatologist and Lead for skin cancer at Poole hospital, said: “We hope that we have helped to raise awareness about skin cancer through this event. If you are concerned about a mole or changes to your skin it is very important to go and see your GP so that they can refer you on to a dermatologist if necessary. Melanoma death rates in the UK are now higher than those in Australia, and early detection is crucial to successful treatment of skin cancer, which is why this event was so important.”

Skin cancer rates in Dorset, Devon and Cornwall are the highest in the UK and a very high 65 per cent of all new GP referrals to the dermatology department at Poole Hospital are for skin cancer.

The results from this screening seem to reflect the high numbers of patients with skin cancer that Poole and the surrounding areas are now seeing in their hospitals.

Summary of results
• 18.6% of those screened had a significant dermatological condition
• 6% of those screened had either a malignant melanoma or a basal cell carcinoma (types of skin cancer) detected
• 28% of those who filled in the survey admitted to using sunbeds.
• Only 39% used a sunscreen of SPF 20 or more.
• 65% of all new GP referrals to the Dermatology Unit of Poole Hospital are for suspected skin cancer


-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 Scottish Exhibition & Conference Centre, Glasgow from July 7th to 10th 2009, and is attended by UK and worldwide dermatologists and dermatology nurses.

“The Incidence of Skin Cancer Detected at a Sun Awareness Beach Campaign” Caroline Morgan, Sarita Jain, Abhiney Jain and Catherine Stephens. Poole Hospital NHS Foundation Trust, Poole, United Kingdom
Based on results found at a Poole Hospital NHS Foundation Trust Mole check event held in conjunction with British Association of Dermatologists, July 2008.

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. 

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