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We had the Beast from the East, then a mini heatwave, then storms and a spell of unseasonably cold weather – now it’s rather pleasant and the BBQs are out. Yet such variable weather could mean pharmacy customers drop their guard and think sun protection in the UK isn’t necessary. You need to put them right.

Skin cancer is now the commonest cancer in the UK and the number of people affected is growing all the time. The British Skin Foundation estimates that over 100,000 new cases are diagnosed each year, with the disease killing 2,500 people annually.¹

Cancer Research UK, which tracks instances of melanoma (the malignant form of skin cancer), ranks it as the fifth commonest cancer in the country,² with around 13,000 new cases each year. In 86 per cent of instances this type of cancer is preventable.

While melanoma is higher among the male population (thought to be because a greater number of men work outdoors), experts are keen to point out that the current ratio of 51:49 per cent is actually fairly negligible.² Instead, they point to instances of skin cancer in younger people from their teens upwards as a far more worrying trend because it is bucking the more established pattern of skin cancer as a result of longevity.

According to skin cancer charity Skcin, just one blistering sunburn episode in childhood or adolescence more than doubles a person’s chances of developing melanoma later in life.³ However, it adds that even in the short-term, melanoma is now one of the commonest cancers in 15 to 34-year-olds.³

Sophia Lowes, health information officer at Cancer Research UK, agrees that it is a big problem. “Fake tans are popular in the winter months, but by summer it is clear that many younger people are still looking to the sun,” she says.

“We’ve launched a nationwide campaign specifically for 16 to 24-year-olds to try and encourage greater awareness of protecting particular skin types called ‘#Own your tone’. It is our hope that this will go some way to helping [young] people understand their own limits.”

Understanding skin cancer

There are two types of skin cancer:
• Non-melanoma skin cancer – which includes basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)
• Malignant melanoma.

BCC is the commonest form of skin cancer, which grows slowly over months and years, and may damage nearby tissues and organs if left untreated.

SCC is less common but grows faster than BCC. It may spread to other parts of the body and can be deadly if left untreated.

Malignant melanoma is a less common but more serious type of skin cancer that can spread to other parts of the body to form a new cancer.

While anyone can develop skin cancer at any time, people are thought to be more prone if they have:³
• Skin that burns easily
• Light or fair-coloured skin, hair or eyes
• A lot of moles or freckles
• A history of sunburn
• A personal or family history of skin cancer.

Blame it on the weather

While she would refrain from calling skin cancer a crisis, Sophia Lowes insists the message from the statistics is loud and clear: sunshine is something we are all exposed to, which means we are all at risk of developing skin cancer.

“People are no longer in the dark when it comes to sun safety, with the UV index now included in the weather forecast or via the Met Office,” she says. “That means sun protection can easily be incorporated into a person’s routine. We say that for UV levels above 3, people should be thinking about protecting their skin.”

Yet, in spite of all the data available, people can’t seem to help overdoing it in the sun. “One of the main issues for people in the UK is that we tend to be a bit blasé when it comes to sun protection,” Lowes says, “but in actual fact the sun is strong enough to burn the skin from April to September, with the potential for damage from UV rays even on cloudy days.”

Boots pharmacist Vikram Pandya agrees. “Because we live in a climate that is best described as irregular, most Brits will normally take any opportunity to get a tan. There is also a common misconception that using a higher SPF will hinder their ability to do that, so we often see people opting for lower ratings in response.”

This propensity to underestimate the sun’s power is backed by a recent study by Boots Soltan,⁴ which found that over half (51 per cent) of parents choose a sun cream based only on its SPF rating to prevent sunburn, without understanding the star rating that indicates protection against long-term damage caused by UVA rays.

A poll of 1,000 parents of children aged 14 years and under discovered that, while 87 per cent understand that it is possible to get permanent skin damage from the sun, 40 per cent believe that the effects are short-term and last no longer than a week. More than half (55 per cent) admitted they did not even know what a UVA rating was.

The research also found that just 14 per cent of parents consciously choose a sun cream based on its UVA rating, with 39 per cent of parents with primary school-aged children not considering the UVA rating at all.

Even in the face of such research, Vikram Pandya believes that people are becoming more aware of the need for sun protection. “Skin-related issues and skin cancers are gaining notice and that is definitely having a knock-on effect,” he says. “Within pharmacy, we would expect to have a conversation about skin cancer quite regularly, especially if any family members have experienced it.”

Protection measures

Both Vikram Pandya and Sophia Lowes emphasise that a sun protection product shouldn’t be the first or only line of defence but should be used to complement other measures – such as seeking shade and wearing suitable clothing. “For us, its primary use should be to protect the parts you can’t cover,” says Lowes.

Skcin, which is working to promote cultural and behavioural changes regarding sun safety in the UK, advocates the ‘five Ss’ approach:⁵
• Slip on a sun t-shirt
• Slop on SPF 30+ broad spectrum UVA sunscreen
• Slap on a broad-brimmed hat
• Slide on quality sunglasses
• Shade from the sun whenever possible.

Material matters

When it comes to clothing, Cancer Research UK says:⁶
• Clothes should be loose-fitting and deeper in colour
• Customers should look for materials with a close weave and hold the material up to check they can’t see through the fabric
• Hats with wider brims should be chosen for better shade and protection from the sun
• Make sure sunglasses protect the side of the eye by choosing a wrap-around style and have a ‘CE Mark’ and ‘British Standard’, ‘UV 400’ or ‘100% UV protection’ written on the label or sticker.

Buying products

The vast array of different brands and types of sun care products can make sun protection confusing for customers, says Vikram Pandya, particularly in terms of labelling or how they are displayed.

“There is also a vast difference in terms of price and it certainly doesn’t follow that the most expensive products will offer the best protection,” he says. “Generally, with any sun care product, we would recommend going with a minimum SPF 30 with a 4 or 5-star rating. However, one of the key messages that we are really keen to push is re-application and this is a habit we are trying to instill in our patients.”

Despite there being one-application products on the market, experts agree that any sun protection should be re-applied approximately every two hours and certainly after swimming in water, towel-drying, sweating and any other rubbing off.

As a guide, two layers should be applied 20 minutes or so before heading outside. An average-sized adult should apply at least a teaspoon of sunscreen to each arm, leg, and the front and back of the body, and at least half a teaspoon to the face (including the ears and neck). This equates to 35ml of sunscreen for one full body application.⁷

In reality, however, experts estimate that consumers apply only about one-third of the recommended amount,⁸ hence the need for layering and re-application.

First-line support

Community pharmacies are superbly placed to offer advice and support – both in terms of reminding their customers to check their bodies and helping them to understand what to look for, says Claire Dale, campaign manager at Skcin. “Older people, in particular, may find it difficult to identify any worrying growths on their skin, especially if they live alone or have no one who can check their skin.

“With this in mind, what we would really like to see is pharmacies spreading the message about skin cancer all year round and not just reminding people about sun safety during peak holiday periods.”

Skcin has developed a new educational programme for the hair, health and beauty industries, which is also open to pharmacists. This free resource entitled Melanoma And Skin Cancer Early Detection (MASCED) can be accessed at masced.uk.

“The thinking behind this accreditation is that individuals working in the hair, health and beauty industries have direct access to skin and so are well placed to raise awareness of the issue of skin cancer,” says Dale. “The aim is not to attempt any diagnosis, but to highlight anything they have noticed, with a view to recommending a follow-up with a health professional.

“Pharmacists who sign up will automatically be sent a sun safety booklet and MASCED guide, as well as a mole ruler – which can be used as a guide for any suspicious marks. These materials have been compiled by dermatologists, so we are in no doubt that if this training is applied on a regular basis, MASCED will help save lives in the future.”

Vikram Pandya agrees that the pharmacy team is able to play a key role in highlighting the issue of skin cancer and helping customers identify any problems. “At Boots, we offer mole screening and I know other providers do, too. We’ve seen good take-up of this service and we know that it has already had the effect of picking up some melanomas at a very early stage.”

Skin cancer can manifest itself on a patch of skin or nail, so customers should be advised to see a doctor if they notice any unusual changes,⁶ including:
• Any new growth or sore that won’t heal
• A spot, mole or sore that itches or hurts
• Any mole or growth that bleeds, oozes, crusts or scabs.

Sophia Lowes also recommends using the established ABCDE of mole checking:
A: Asymmetry: the two halves don’t match
B: Border: might be irregular, blurred or jagged
C: Colour: may be uneven, with different colours
D: Diameter: might be the width of a pencil (6mm)
E: Evolving: anything that changes over time.

Vitamin D – striking a balance

As understanding about the risks of sun exposure has increased, achieving adequate levels of vitamin D has become a new challenge – with fears about sun exposure prompting some people to avoid the sun altogether.

Vitamin D helps regulate the amount of calcium and phosphate in the body and is required for healthy bones, teeth and muscles. In general, it is thought that 15-20 minutes in the sun each day is enough to top up levels. The NHS states that children from the age of one year and certain adults (including pregnant and breastfeeding women, and people at risk of vitamin D deficiency), need 10mcg of vitamin D a day. Babies require 8.5-10mcg.¹⁰

The question of whether sun protection will hinder vitamin D production has also been a source of debate,¹¹ although Sophia Lowes says this is not the case. Just being out and about in summer usually gives a person enough vitamin D, she says, and is something that shouldn’t stop them wearing sunscreen. However, additional supplements are generally recommended for babies and small children, pregnant and breastfeeding women, or those with lower immunity or mobility issues.

“As we live in quite a cool climate, most people, particularly those with mobility issues or the elderly, might find it beneficial to take vitamin D as a general supplement anyway,” says Vikram Pandya, “but that shouldn’t be seen as an alternative to getting out and about and absorbing our natural quota too.

“In supplement form, vitamin D is often blended with calcium to aid absorption. If a customer does have any concerns about their vitamin D levels, we recommend a visit to their GP for a routine blood test. If it is low, a doctor will typically prescribe a top-up supplement with an ongoing maintenance dose. In the case of children, vitamin D is widely recommended from infancy onwards and is freely available in a range of OTC products.”

Vitamin D can also be found in various foods,¹¹ including:
• Oily fish (e.g. salmon, sardines, herring, mackerel and fresh tuna)
• Red meat
• Liver
• Egg yolks
• Fortified foods such as most fat spreads and some breakfast cereals.

Conversely, a recent study¹² suggested that higher vitamin D levels in the blood could mean lower cancer risk in Asian populations, but overall the evidence for a possible link has been mixed – with Sophia Lowes pointing out that it is not clear whether being deficient in vitamin D has a direct impact on cancer risk or just reflects poor health in general.

<sup>Reference sources
1. Britishskinfoundation.org.uk/SkinInformation/SkinCancer.aspx
2. Cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/skin-cancer
3. Skcin.org/skinCancerInformation/sunburnTheFacts.htm
4. Boots Soltan press release; Research conducted by Mortar Research between 8th
and 12th March 2018
5. Skcin.org/sunSafetyAndPrevention/theFiveSsOfSunSafety.htm
6. Skin Cancer Awareness/Pharmacy Staff Support Briefing/Cancer Research UK/2018
7. Skcin.org/sunSafetyAndPrevention/sunscreenKnowYourFacts.htm
8. Nice.org.uk/guidance/ng34/evidence/expert-paper-4-achieving-adequate-sun-protection-with-adequate-vitamin-d-status-pdf-2311152880
9. Cancerresearchuk.org/about-cancer/causes-of-cancer/sun-uv-and-cancer/am-i-at-risk-of-sunburn
10. Nhs.uk/conditions/vitamins-and-minerals/vitamin-d/#how-much-vitamin-d-do-i-need
11. Dailymail.co.uk/health/article-2335478/Worried-suncream-blocks-vitamin-D-Heres-good-news.html
12. Theguardian.com/science/2018/mar/07/vitamin-d-may-offer-protection-against-cancers-study-says</sup>