12 Min In Clinical
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Record learning outcomes
Learning objectives
After reading this feature you should be able to:
- Describe the measures your patients should take to stay safe in the sun
- Help customers select the right sunscreen
- Identify the signs and symptoms of potential skin cancer that warrant further investigation.
Skin cancer is the leading type of cancer in the UK, with melanoma skin cancer the fifth most common cancer type. New figures from Cancer Research show that, over the past decade, melanomas — the most serious form — have increased by 31 per cent.1,2
Dr Bav Shergill, chair of the British Association of Dermatologists (BAD) skin cancer prevention group, said: “We want to get the message out that it is not just the summer months that people need to stay on top of their sun protection. The window is actually from April to September.”
Melanoma skin cancer rates are projected to continue rising by just under 10 per cent a year. Every day in the UK, around 46 new cases are diagnosed and at least six people die from the disease.2 However, the stark reality is that up to 90 per cent of melanomas could be prevented – simply by enjoying the sun safely.1,2
Cancer Research UK advocates a trio of measures – shade, clothing and sunscreen – as the key to staying safe in the sun.
Shade can be provided by trees, umbrellas or canopies/awnings, or created individually by wearing a wide-brimmed hat that covers the face, ears and neck. When relying on structures for shade, it is important to check their robustness – for example, a damaged or weathered parasol is unlikely to provide sufficient protection. Similarly, a tree may let through dappled sunlight and therefore ultraviolet (UV) rays via gaps in the branches.
UV rays can penetrate certain types of fabric and may reflect off the ground, walls or other surfaces. Up to 85 per cent of UV radiation is reflected back from snow, 15 per cent from sand and 10 per cent from water. Patches of shade will also change position as the sun moves across the sky during the course of the day. These are all important points to bear in mind – especially when seeking shady positions for babies or young children.
In terms of clothing, the best protection is afforded by loose-fitting, close-weave fabrics that are darker in colour. Hats should be wide-brimmed and sunglasses should be as large as possible, or wraparound in style, for maximum protection. Pharmacy teams should encourage customers to look for sunglasses carrying the CE Mark or British Standard, offering at least UV 400 and 10 per cent UV protection.
“Up to 90 per cent of melanomas could be prevented – simply by enjoying the sun safely”
Sunscreens in focus
Shade and clothing are both better at protecting the skin from harmful UV rays than sunscreen. However, customers on holiday may be understandably reluctant to cover up or eschew the warming rays of the sun. So use of plentiful quantities of good quality sunscreen is essential.
Customers should be encouraged to choose a sunscreen with a minimum UVB sun protection factor (SPF) of 15 and a 4 or 5 star rating for UVA protection. This should be smoothed generously onto all areas of skin that are not covered by clothing and should be reapplied regularly, especially after swimming.
In terms of the actual chemical ingredients in sunscreen products, it is important to be aware of what each of these offers in terms of clinical activity and sun protective properties. The active ingredients in sunscreen products include both organic and inorganic UV filters.
Organic UV filters (also known as chemical filters) are carbon-based synthetic molecules with a conjugated structure that absorb UV light; typically they protect from either UVB or UVA rays. UVB is the major cause of sun-induced skin cancer and also causes sunburn. UVA also plays a role in the development of skin cancer and is the major cause of premature skin ageing including wrinkles and age spots.
Organic UVB filters can be identified by looking for the INCI (International Nomenclature of Cosmetic Ingredients): benzophenone-3, ethylhexyl methoxycinnamate and ethylhexyl salicylate. Organic UVA filters are less common; the most widely used is butyl methoxydibenzoylmethane.
In recent years, there have been some organic UV filter developments that have been designed to be ‘broad spectrum’ (i.e. they can protect against both UVB and UVA rays). INCI names to look out for are bis-ethylhexyloxyphenol methoxyphenyl triazine, diethylamino hydroxybenzoyl hexyl benzoate and methylene bis-benzotriazolyl tetramethylbutylphenol.
Problematic
When it comes to helping customers navigate the vast array of sunscreen products now on the market, Helene Hine, global marketing manager for photoprotection at Croda Personal Care, provides some important tips and advice.
“Innovation in formulation formats is evolving fast in sun care – as well as sprays we now see powders, foam mousses and serums”, says Helen, who cautions that “these novel formats can be problematic as they require an even application of a continuous film on the skin at a dose of 2mg/cm2 to give the labelled SPF”.
On the issue of application of sunscreen in sufficient quantities, Helene says that, even with traditional creams and lotions, users typically apply half the required amount or less.
“The application dose should be equivalent to two strips of sunscreen squeezed out onto the index and middle fingers and applied to each area of the body. As it is much easier to measure out and evenly apply a traditional lotion or cream, these tend to be a safe bet for sunscreen products.
“Having said that, my motto is always ‘the best sunscreen is the one you will actually use’, so if someone prefers a different format, then they should go for it, making sure they apply it liberally and evenly, and re-apply it regularly.”
Sensitive skin or sun-induced allergies
For customers with sensitive skin or sun-induced allergies, choosing a sun protection product can prove particularly problematic.
Reactions to sunscreens are rare, but benzophenones, cinnamates and dibenzoylmethanes are known to induce photoallergic reactions or photocontact dermatitis, says Helene Hine of Croda Personal Care.
“Zinc oxide and titanium dioxide have not been reported to cause contact allergy so are an excellent choice for people who have experienced sunscreen photoallergy,” confirms Hine. “For sensitive skin I would recommend avoiding products containing alcohol, which can dry out the skin. Also, a fragrance-free formula is a good choice as fragrances are one of the most common allergens in topical products.”
Child proof
As the school summer holidays approach, Helene also has some important advice when it comes to choosing sun protection products for children. “The first thing to bear in mind is that children tend to have more sensitive skin, so a product made with mineral UV filters is a safe bet.
“Secondly, children are much more active in the sun compared to adults, so advise using a waterproof formula. The film formers used in these formulas not only reduce the amount of sunscreen that is washed off in the water but also help it to stay on the skin longer while doing other activities like playing in the sand.
“Lastly, kids tend to not like standing still long enough to apply sunscreen, so a pumpable or sprayable lotion, even a roll-on, can make application easier. For the same reasons, it is also a good idea to choose the highest SPF possible, ideally an SPF 50+. If a parent cannot get the full amount on the child, the higher SPF should help to compensate for that.”
Weather or not
Even for those not travelling abroad this year, sun safe advice and recommendations for effective sunscreen product choices remain important. Many people are caught out by the fact that sunburn can happen even on cold, overcast or foggy days at home. In fact, over 80 per cent of the sun’s harmful UV radiation is able to penetrate through cloud and mist, so the same sun protection practices should be followed irrespective of the weather.
In the UK, mid-March to mid-October, between 11am and 3pm, is the time period when the sun’s UV rays become strong enough to inflict potential damage. The UV index, which often features on radio and TV weather forecasts (and is supplied daily by the Met Office) provides an indicator of the sun’s strength on a particular day. A value of three or above indicates a potential risk of sunburn.
When the UV index reaches six or above (high or very high exposure to UV rays), almost all skin tones require protection. Another handy tip suggested by Cancer Research UK (CRUK), and one which works anywhere in the world, is the so-called shadow rule. If the shadow cast by your body is shorter than your actual height, then this means the sun’s UV rays are strong, the risk of sunburn is high, and skin protection is warranted.
People at greatest risk of sunburn are those with light coloured skin, hair or eyes; a large number of moles or freckles; and/or a personal or family history of skin cancer. Individuals will likely be aware of their own sunburn history and how prone their skin is to burning, and should take action accordingly.
In addition to exposing customers to valuable sun-safe messages, pharmacy teams should also be alert for signs and symptoms of potential skin cancer that warrant further investigation. The NHS advice on moles recommends that customers see their GP for any mole that:
- Changes shape, size or colour
- Is painful or itchy
- Becomes inflamed, crusty or bleeds.
Individuals with any new or unusual marks on their skin that fail to heal or resolve within a few weeks, or dark areas under a nail that are not a result of an injury, should also be encouraged to seek medical attention.
Even simple everyday activities that expose the skin to the sun’s rays, such as gardening, working outside, jogging or even just sitting in the park, carry a risk of skin cancer and, in turn, require sensible sun-safe practices. As CRUK starkly points out: just one case of sunburn every two years can triple a person’s risk of developing melanoma skin cancer.2
References
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In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.