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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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Children with smartphones more likely to get head lice

British children who have smartphones or tablets are significantly more likely to get head lice than those who don’t, according to a study being presented at the British Association of Dermatologists' Annual Conference in Liverpool. Despite past theories that selfies increase the transmission of lice, no conclusive evidence of this was discovered by the study.

The study, which was primarily researching the incidence of head lice amongst children in the UK, also found that previous estimates of the prevalence of head lice in British children may be conservative, although this could also reflect the longer period covered by the study. Previously it’s been thought that between two and eight per cent of school-aged children have head lice, however, this study found that 45 per cent of children had had headlice in the last five years, with girls with siblings who are aged 6–9 years most commonly affected.

Data was gathered on 202 children which found that 104 (51.5%) owned a smartphone or tablet; 82 (40.5%) were using a device for ‘selfies’. Taking regular selfies did increase risk, compared with not taking selfies, but not enough to draw conclusions. The study did not differentiate between individual and group selfies. Of the 98 children who did not own or use a smartphone or tablet, 29 (29.5%) experienced head lice compared to 65 of the 104 (62.5%) who did own or use a smartphone or tablet.

Matthew Gass of the British Association of Dermatologists said:

“Head lice are a pain to deal with, both for children and their parents. Speaking from experience, they are intractable misery bugs that take far more time and effort to remove than is reasonable. Not to mention the obligatory quarantine period that they necessitate. That’s why a better understanding of how these pests are transmitted is useful. Prevention is always better than a cure, particularly if the cure means wrenching your poor daughter’s hair with a fine-toothed nit comb, or relying on over-the-counter remedies that head lice are increasingly resistant to.

“We’re not saying that smartphones are causing children to get head lice, but that there is a link, so if there’s an outbreak at home or at school, consider how electronic devices might cause children to congregate, allowing head lice to spread.”

Dr Tess McPherson of Oxford University Hospitals NHS Foundation Trust, one of the researchers, said:

“Compared to previous estimates of head lice incidence, our figures were much higher, showing that almost half of children have had them in the last five years, which may not come as a surprise to parents. We also noted that children with smartphones or tablets were more likely to get head lice, which is interesting but we can only guess that this is due to the way that young people gather around them, though there could be other reasons.

“Selfie culture gets its fair share of negative press so it’s worth noting that despite previous speculation it seems that selfies can’t specifically be blamed for helping the spread of head lice at this stage.”

-Ends-
Notes to editors:

For more information on head lice and treatments please see the BAD’s patient information leaflet.

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. 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 

PA14 How common are head lice? Are smartphone/tablet devices to blame?

N. Hitchen, T. McPherson and D. Warnapala Oxford University Hospitals NHS Foundation Trust, Oxford, U.K.

There is limited scientific data on current prevalence of head lice in the U.K., but it has been previously cited at between 2% and 8% in school-aged children. There has been evidence that links lower socioeconomic status, long hair and low frequency of washing to head lice infestation (Moosazadeh M, Afshari M, Keianian H et al. Prevalence of head lice infestation and its associated factors among primary school students in Iran: a systematic review and meta-analysis. Osong Public Health Res Perspect 2015; 6: 346–56; Falagas ME, Matthaious DK, Rafailidis PI et al. Worldwide prevalence of head lice. Emerg Infect Dis 2008; 14: 1493–4). It has been suggested that head lice prevalence is increasing worldwide. Additionally there is a theory that increasing use of portable devices such as smartphones and tablets has led to increased transmission of head lice. This study aims to investigate the current prevalence of head lice and identify possible factors associated with transmission. Questionnaires were given to all parents/guardians attending the paediatric outpatient department at the John Radcliffe Hospital in Oxford, over a 1-month period. Completion required information on all children in the household. Questions included information on sex, hair length, socioeconomic status, and smartphone or tablet ownership. Ninety two questionnaires were completed, which included data on 202 children. Of these, 91 (45%) had experienced head lice within the last 5 years, and girls with siblings aged 6–9 years were most commonly affected. Of the 202 children, 104 (51.5%) owned a smartphone or tablet; 82 (40.5%) were using a device for ‘selfies’, and 45 (54.8%) of those performing selfies experienced head lice. Of the 98 children who did not own or use a smartphone or tablet, 29 (29.5%) experienced head lice. Use of a smartphone significantly increased risk of head lice [risk ratio (RR) = 3.97, v2 = 12.02; P < 0.001]. Taking regular selfies did increase risk (RR = 1.76), compared with not taking selfies, but did not reach significance. The cohort we studied shows that head lice are common in this population and the prevalence is higher than that reported by other U.K. studies, which may reflect the longer time period. Those with a history of head lice were most commonly female and of younger age, although all ages were affected. Notably, over half the children owned a smartphone or tablet and this significantly increased their risk of having had head lice, which raises interesting questions about transmission.
 

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Doctor’s warn of the dangers of so-called “herbal creams”

Doctors at the British Association of Dermatologists’ Annual Conference in Liverpool have issued a warning about the dangers of using unlabelled herbal treatments, after potent steroids were detected in samples of several such products.

Doctors are also urging people not to use herbal preparations for the treatment of skin cancer, following a series of cases in which this has occurred, leaving patients in need of reconstructive surgery.

Herbal remedies are particularly popular for treating skin conditions, with researchers estimating that approximately 33 per cent of all herbal treatments are used to target wounds or skin diseases, this compares with only one to three per cent of Western medicines.

Herbal products with few or no ingredients listed, and often claiming to be ‘miracle creams’, were obtained from 11 patients, and tested by Researchers from the Birmingham Skin Centre, based at City Hospital, using a liquid chromatography–mass spectrometry–(time of flight) analyser, a highly sensitive and specific technology used to detect drugs and other chemicals to a high degree of accuracy. Super-potent topical steroids such as clobetasol propionate were found in seven of the 11 samples, which were largely being used to treat chronic skin conditions, such as eczema or psoriasis particularly in children.

In the UK, all cosmetic products are subject to European Union safety regulations and must comply with detailed compositional and labelling requirements. The failure of the products tested to provide a detailed ingredients list is a breach of these regulations.

Dr Sue Ann Chan, one of the researchers from the Birmingham Skin Centre, which is run by Sandwell and West Birmingham Hospitals NHS Trust, said:

“It is very concerning that unregulated topical herbal remedies continue to be accessible to patients with chronic skin disorders. The people selling these products in the UK are doing so illegally, and are putting peoples’ health in jeopardy. A common reason why people resort to these products is fear of potential long-term side effects of prescribed Western medicines, however, they end up inadvertently using potent drugs that should be used under instruction from a doctor.”

Dr Donna Thompson, Consultant Dermatologist and Head of Department at the Birmingham Skin Centre, who was also one of the researchers, said:

“The results of our tests were quite shocking, a number of these so-called herbal ‘miracle creams’ in fact contained super-potent steroids, which could have significant adverse health implications for users, particularly if they are being used on a regular basis. People have the right to know what ingredients are present in the treatments they are using and public awareness should be raised regarding this matter. If you notice that a cream you are using does not list ingredients, then I would strongly urge you not to use it on yourself or on your children.”

Another study at the BAD Annual Conference involved four cases in which patients had been self-medicating with herbal remedies that they believed were capable of treating skin cancers. All patients delayed seeing a doctor and undergoing surgical intervention due to their faith in the efficacy of their herbal treatments, this delay resulted in larger surgical defects in all cases, according to the doctors from St James’ Hospital, Dublin.

One 51-year-old man with a basal cell carcinoma (BCC, the most common type of skin cancer) on his nose had been diagnosed a year before by a dermatologist but instead of surgical removal decided to apply an alternative treatment* on a daily basis for several months. This delay resulted in a large crater-like tumour, which required two stages of surgery to remove resulting in the complete loss of the tip of his nose and necessitating a reconstructive procedure called a paramedian forehead flap, where skin from the forehead above the eyebrow is used to replace missing tissue from the nose.

In other cases a 70-year-old man presented with a nonhealing lesion over the right cheek, which turned out to be a squamous cell carcinoma (SCC, the second most common type of skin cancer). He had been applying an alternative topical therapy (pawpaw ointment), which was sent to him by his daughter living in Australia. A 46-year-old woman was referred with a BCC on her nose, which she was treating with an alternative treatment and a supplement, convinced that these would result in a nonsurgical cure of the BCC. Finally, a 58-year-old woman who 10 years previously had had a BCC excised from the left temple presented with a recurrence of the cancer, the patient had been using topical zinc chloride paste over the site as a means of treatment.

Dr Rupert Barry, Consultant Dermatologist and Dermatological surgeon, one of the researchers from St. James’s Hospital, Dublin, said:

“We feel that it’s really important to highlight the increasing trend of patients who seek alternative topical therapies for skin cancers, even for high-risk facial tumours. Interestingly, all of these patients were utterly convinced by the online claims made by either the manufacturers or in forums of the efficacy of such therapies, despite a lack of clinical evidence to suggest this.”


Dr Michael Lavery, another researcher from St. James’s Hospital, Dublin, said:

“Surgical removal of skin cancer is a highly effective treatment; the earlier it is done the better. Scarring for small non-melanoma skin cancers can be relatively minor, but if left the cancer has time to grow and scarring can be significant in some cases. It is understandable that people are hesitant about surgery, and want a non-surgical option, but it’s important that people understand that it really is the best option.”

Matthew Gass of the British Association of Dermatologists said:

“We’ve been concerned about the popularity of herbal creams for the treatment of skin disease for a long time. The increasing availability of some bogus treatments online has made them easier than ever to buy. The dangers of these products are two-fold, firstly that it is claimed that they treat a disease which they don’t, leaving it unchecked, and secondly that they are poorly labelled, and often contain ingredients that should only be used on advice from a doctor.

“Big online marketplaces need to make a concerted effort to root out these unprincipled sellers and remove them from their websites. More efforts need to be made to educate people, who are often scared and desperate, on the dangers of these products. It’s also important for people to remember that when you recommend untested herbal treatments to friends, family members, or co-workers with a cancer you are potentially risking their life – please encourage them to see a doctor instead.”

-Ends-
Notes to editors:

* The names of all products can be found in the study abstract provided below please note that in most cases it is members of the public, or third-party sellers making claims about these products’ abilities to treat different conditions, not the manufacturers.

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

P100 Unravelling the mystery of the miracle cream: a retrospective regional review

S.A. Chan and D.A. Thompson Birmingham Skin Centre, Birmingham, U.K.

Approximately one-third of all herbal medicines are used to treat wounds or skin diseases, compared with only 1–3% of Western medicines, with their uses based mainly on historical and anecdotal evidence. Two reports have demonstrated evidence of topical corticosteroids in some herbal preparations. However, dermatologists continue to find patients using these preparations with little or no ingredients labelling. In the U.K., all cosmetic products are subject to wide European Union safety regulations and must comply with detailed compositional and labelling requirements. We conducted a 5-year retrospective review (2011–2015) to examine recent trends in the usage of topical herbal preparations for skin conditions. Samples sent to a regional toxicology unit for analysis were identified from 11 patients, all of Asian ethnicity (Indian, Pakistani and other), with an age range of 2–39 years. All patients had atopic dermatitis and reported obtaining preparations from the following sources: ‘herbalists’ (unclear source) (n = 6), Birmingham herbalists (n = 2), India (n = 2) and Pakistan (n = 1). All samples were inappropriately labelled with little or no ingredients listed. Samples were analysed using a liquid chromatography–mass spectrometry–time of flight analyser, a highly sensitive and specific technology used to detect drugs and other analytes to a high degree of accuracy. Gross appearances of the samples included light orange-pink cream (n = 4; three of the four creams with this appearance were labelled as ‘miracle cream’), clear paraffin consistency (n = 2), light green fragrant paraffin consistency (n = 2), clear fragrant brown oil (n = 1) and perfumed white cream (n = 1, labelled as ‘hydrogel cream’ and found to contain clotrimazole). Superpotent topical steroids/clobetasol propionate were found in seven of the eleven samples, including orange-pink cream (n = 4), light brown oil (n = 1), clear paraffin consistency (n = 1) and another with no clear description. Three other samples were free of drugs/corticosteroids, one of which was labelled ‘95% graphite’ cream. Unregulated topical herbal remedies continue to be accessible to patients with chronic skin disorders, particularly to those of Asian ethnicity, who often resort to these alternative preparations fearing potential long-term side effects of prescribed Western medicines. The majority of the products marketed as herbal preparations may contain potent topical steroids not mentioned on the labels, and dermatologists need to highlight the potential harms of these herbal remedies to their patients.

DS51 ‘Natural’ topical therapies don’t lead to healthy surgical defects

M.J. Lavery, J. Boggs, D. Wall, P. Ormond and R.B.M. Barry St James’ Hospital, Dublin, Ireland

Basal cell carcinomas (BCCs) are the most common cutaneous neoplasm. Treatment is predominantly surgical; however, the use of herbal medicines is becoming more common. We present a case series of four patients who self-medicated with alternative medicine topical therapies. The delayed presentation to a dermatologist resulted in larger, more extensive surgical defects. A 51-year-old man was seen as a tertiary referral for a biopsy-proven infiltrative BCC on the nasal tip. He had been diagnosed 1 year previously by the referring dermatologist but elected to pursue alternative topical treatment (‘Curaderm Bec 5’ on a daily basis for several months). One year later, the tumour was now a large crateriform scar-like BCC that now extended into multiple nasal cosmetic subunits. He underwent Mohs micrographic surgery (MMS) of the tumour, which was cleared after two stages, resulting in a deep large nasal defect (27 9 26 mm) requiring a paramedian forehead flap. A 70-year-old man presented with a nonhealing eroded plaque over the right zygomatic cheek. He had been applying an alternative topical therapy (Lucas’ Pawpaw ointment) acquired from Australia. A diagnostic biopsy showed a moderately differentiated invasive squamous cell carcinoma. This was excised after one stage of MMS and repaired with superficial muscular aponeurotic system plication sutures, which enabled primary closure. A 46-year-old woman was referred with a biopsy-proven BCC on the right nasal sidewall. She had been using topical ‘Curaderm Bec 5’ and a Juiceplus supplement, convinced that these would result in a nonsurgical cure of the BCC. She ultimately underwent MMS and required a full-thickness skin graft to repair a 16 9 14-mm defect. A 58- year-old woman with a past history of a BCC excised from the left temple 10 years previously presented with a recurrence at the inferior margin of the scar. The patient had been using topical zinc chloride paste over the site as a means of treatment. The patient underwent MMS excision and was repaired with a primary layered closure with a W-plasty at the lateral canthus. We highlight the increasing trend of some patients who seek alternative topical therapies for nonmelanoma skin cancers, even for high-risk facial tumours. Interestingly, all of these patients were utterly convinced by the online claims of efficacy of such therapies. In fact, all patients delayed appropriate surgical excision of their facial tumours, leading to larger surgical defects.
 

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