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There is little doubt that the sight of the sun shining lifts the spirits, particularly after a long, grey winter – but there can also be some downsides...

 

One of the major of sun exposure is skin cancer. In 2010, nearly 100,000 cases of non-melanoma skin cancers (NMSC) were recorded in the UK – the actual figure is probably considerably higher due to under-reporting – and there were nearly 13,000 new cases of malignant skin melanoma (see panel to understand the differences between these two conditions). Put into context, that’s more than twice the number of women who were diagnosed with breast cancer during the same year.

Pharmacy has an important role to play when it comes to advising people who are worried that they may have skin cancer. Anyone who has noticed changes to their skin, such as a lump or discoloured patch that doesn’t heal within a few weeks, or a mole that is new or has changed in appearance, should see their GP. If the doctor is concerned that it may be cancerous, the patient is likely to be referred to a dermatologist for further tests, which will usually involve a biopsy.

What happens next depends on the type of cancer it is. NMSCs are usually surgically removed, along with some of the surrounding skin in case the cancer has spread. A skin graft may be performed if significant scarring is likely. Radiotherapy may be undertaken if the cancer covers a large area or after surgical excision to prevent a recurrence.

Melanomas are also usually surgically removed, although advanced tumours may need to be shrunk using radiotherapy or chemotherapy beforehand. Additional tests will be carried out to see if any other areas of the body are affected, and will dictate further treatment.

It is worth remembering that – as is often the case – men may be reluctant to go to their GP to report a skin change, and dismiss it as a minor problem. However, malignant melanoma is one of the diseases for which there is a significant disparity in survival rates between the sexes, with five-year survival rates standing at 92 per cent for women but just 84 per cent for men.

The reasons for this are not entirely clear, and may be to do with different tumour thicknesses between men and women, but attitudes towards health certainly play a part and need tackling. Reminding men – and concerned partners – that melanoma treatment is much more effective if done early on rather than being left for a period of time, may be all the encouragement that is needed.

Prevention

As with many things in life, prevention is better than cure. Minimising skin exposure to the sun is probably the most important measure individuals can take, including:

• Choosing to spend time in the shade rather than the sun, particularly between 11am and 3pm when ultraviolet rays are at their strongest
• Covering the skin, at the minimum with a t-shirt made from a close-weave fabric such as cotton jersey rather than a thinner material such as cheesecloth, and wearing a wide brimmed hat and good quality wraparound sunglasses
• Using sunscreen of factor 15 or higher that has either a four or five-star UVA rating and has been open for no more than 18 months
• Applying sun protection products generously and regularly, including before going out into the sun and after showering, swimming or changing clothes, even if the product claims to be a once-daily or waterproof formula
• Making sure other skin products such as moisturiser, insect repellent or make-up are applied after sunscreen, although emollients and steroids for eczema should be put on around 30 minutes before using sun protection products
• Setting a good example to children by ensuring they adhere to the basics of sun safety and understand why it is important
• Keeping babies under six months of age out of the sun altogether.

Such advice is particularly pertinent for those at increased risk of developing skin cancer. This includes people with fair skin, red or fair hair, lots of moles or freckles, light coloured eyes, a history of sunburn, or a personal or family history of skin cancer.

People with dark skin are less likely to develop skin cancer because the extra melanin in their skin offers additional protection against UV damage, but they should still take care in the sun. This group should be advised to keep an eye on areas of the body that are less exposed to the sun, such as the soles of the feet, as this is where skin cancer tends to occur in darker-skinned individuals.

There is some research pointing towards certain medical conditions increasing the risk of melanoma, particularly Parkinson’s disease, women who have had chemotherapy for breast cancer, inflammatory bowel disease (Crohn’s disease and ulcerative colitis) and individuals with lowered immunity due to immunosuppressive drug treatment or conditions such as HIV.

For other conditions, such as endometriosis and atopic eczema, some studies suggest there is an increased risk whereas other papers have found no link. Similarly, although there has been some work intimating that melanoma risk increases with alcohol intake, the evidence does not seem terribly robust.

Other problems

While skin cancer may grab the headlines in terms of sun safety, other conditions can also result from exposure to the sun.

Sunburn

Too much exposure to the sun causes the skin to become red, hot and painful to touch, with peeling or blistering common a few hours later.

The symptoms may not be immediately apparent, so someone who spends the day at the beach may think that they are fine when they first get home but discover upon showering in the evening that their skin hasn’t coped as well as they originally thought. While UV exposure is most definitely the cause of sunburn, other weather plays a part; for example a breeze that cools the skin can mask the damage that is being wreaked.

The main aim of treatment is to cool the skin, which is best accomplished by applying cool towels or taking a lukewarm shower or bath. Analgesics may be taken to relieve pain if needed. Keeping the skin well moisturised is a must to ease the itching and damage that can result from peeling and blistering. Drinking plenty of fluids staves off dehydration.

Very severe sunburn may require treatment at a GP surgery or A&E department. While often considered minor, the condition is, after all, a type of burn, and serious cases need treating as such.

Heat exhaustion

Heat exhaustion is a condition caused by dehydration due to prolonged heat exposure (e.g. during a heatwave). The resulting drop in blood volume and blood pressure cause extreme tiredness, dizziness, nausea, sweating, tachycardia, and can lead to the individual becoming confused or faint. The groups of people who are more likely to suffer the complications of dehydration – babies and infants, the elderly, those with renal or cardiac problems, insulin-dependent diabetics – are more at risk of developing heat exhaustion, but it also often affects those who do very strenuous jobs, such as athletes, firefighters and military personnel.

The treatment for heat exhaustion is straightforward: move the individual to somewhere cool (shade is good, air conditioning even better), remove any excess clothing, cool the skin as is done in cases of sunburn, and encourage the sufferer to drink plenty of water or rehydration fluids. For those who are otherwise healthy, the recovery should be swift and straightforward. Individuals who are at risk of dehydration should be checked over by a medical professional.

Heat stroke

Heat stroke is a very different condition to heat exhaustion, although the two are often confused. In heat stroke, the body is unable to cool itself and starts to overheat. The skin, which was formerly drenched in sweat, becomes dry suddenly, the body temperature goes up to 40°C or even higher, heart and breathing rates rise, and the individual may experience muscle cramps. With the nervous system affected, other symptoms may include confusion, loss of co-ordination, seizures, headache, anxiety, problems understanding or speaking to others, hallucinations and loss of consciousness.

Heat stroke is a medical emergency because, if left untreated, it can lead to organ failure and brain damage. While waiting for medical help to arrive, the sufferer should be moved to a cool place and fanned, their skin may be cooled using towels or sheets soaked in water, and they should be given water to sip if they are conscious. Once in hospital, the aim of treatment is to lower the body temperature as rapidly as possible, usually by placing the person in an ice bath or spritzing them with cool water while warm air is fanned across the body to encourage rapid heat loss via evaporation.

The importance of regularly applying sufficient quantities of sun screen can’t be emphasised enough

Vitamin D

One aspect of sun exposure that can seem slightly at odds with the sun safety message is the issue of vitamin D. Unlike many other nutrients, most vitamin D is not obtained from the diet but comes from exposure to sunlight. The vitamin has been prominent in the news headlines over the past couple of years, with many claims being made regarding its health benefits, and warnings that many living in the UK are likely to be deficient.

The truth is, unsurprisingly, not as clear cut as the tabloids make out. A serum level of 25-hydroxy vitamin D (25OHD) over 50nmol/L is considered fine, whereas a level below 30nmol/L points towards a deficiency. In between the two, it isn’t really known what the implications are for health.

As for the benefits of supplementation, a recent BMJ paper concluded that for many outcomes – covering a wide spectrum of skeletal, malignant, cardiovascular, autoimmune, infectious, metabolic and other diseases – there was no convincing evidence of a clear role for vitamin D.

In heat stroke, the body is unable to cool itself and starts to overheat

So, in order to get enough vitamin D to have healthy bones, the best approach is to get a bit of sun exposure on a regular basis. The amount of time needed in the sun to make enough vitamin D to fulfil the body’s requirements varies according to several personal, environmental and physical factors, but is generally accepted as being less than the amount of time needed for the skin to burn. Little and often is best, so a short walk in the sunshine without first putting on sunscreen a couple of times a week will do the trick.

It is sensible to bear in mind those who may be at risk of vitamin D deficiency because they don’t get much sun exposure, such as individuals who are housebound, people with darker skin (because it takes the skin longer to produce as much vitamin D as someone with paler skin) and those who cover their skin, such as Muslim women who wear a burqa (a robe that covers the whole body from the top of the head to the ground) or a niqab (a veil that covers the entire face apart from the eyes). These groups, plus pregnant and breastfeeding women, older people aged 65 years and over, and infants aged between six months and five years, may all benefit from vitamin D supplements.

Skin cancer - the facts

Skin cancers fall into two categories: non-melanomas and melanomas.

• Non-melanoma skin cancers (NMSC) are common, but cause relatively few deaths. Nearly three-quarters of NMSC cases are basal cell carcinomas (BCCs), and most of the remaining proportion are squamous cell carcinomas (SCCs). Both are commoner in men than women, are eminently treatable and have very high survival rates, although, if left untreated, they can become more destructive. A small number of NMSCs are neither BCCs or SCCs, and tend to not have such a good prognosis
• Malignant melanomas are considerably less common than NMSCs, and affect more women than men. In men, the commonest site for the condition to develop is on the chest or back, whereas in women the legs are most commonly affected. Survival rates are good if the disease is caught early, but it is more difficult to treat if the melanoma is ulcerated, thicker than usual, or has spread to the lymph nodes or other areas of the body. According to the charity Cancer Research UK, sun exposure is the main cause of melanoma and non-melanoma skin cancers. 

 

Resources

• Cancer Research UK’s SunSmart publications include leaflets to help people reduce their risk of skin cancer and identify changes in their skin, posters on skin cancer identification and the need to keep kids covered up in the sun, and postcards on sun safety
• The British Association of Dermatologists has a range of literature on sun awareness including a pack of leaflets and posters, a mole check guide, a fact sheet on sunscreen and skin cancer, and information on vitamin D and the sun
• The NHS Choices website has information on sun safety including a slide show on mole changes and a video on how to apply sunscreen
• Macmillan Cancer Support has information on telling the difference between a normal mole and melanoma, plus a video on the symptoms of melanoma 
• Factsheets are available from Public Health England’s Skin Cancer Hub 
• The National Osteoporosis Society has information and posters to support its Sunlight campaign
• Read this feature in conjunction with our essential guide to travel health.