Skin Cancer

What is the skin?

The skin is the largest and most visible organ of the body and has many purposes. The major function of skin is to protect the body from injury and infection and to regulate the temperature of the body.

The skin is divided into 2 main layers they are as follows:

• Epidermis – this is the outside layer of your skin and also the thinnest, it is made up of many cells. The 3 main types of cells, which are affected by skin cancer are found in the epidermis, they are called basal cells, squamous cells and melanocytes.
• Dermis – this is the layer underneath the epidermis, the dermis is the thickest part of the skin and contains nerve endings, blood vessels, hair follicles and oil and sweat glands.

What is skin cancer?

Skin cancer is the most common form of cancer in the U.K. There are 3 main types of skin cancer and they are as follows:

1. Basal cell carcinoma, sometimes called a rodent ulcer, is the most common type of skin cancer in the U.K. This cancer begins in the basal cells, it is slow growing and it does not spread to other parts of the body. The majority of people with this cancer are completely cured.
2. Squamous cell carcinoma is the second most commonest type of skin cancer in the U.K. This type of cancer begins in the squamous cells and may spread to other parts of the body. However, like basal cell carcinoma, the majority of people with this type of cancer will be completely cured.
3. Malignant melanoma is still fortunately quite rare in the U.K. Cells in the skin, called melanocytes protect us against the suns damaging rays. Melanocytes produce a protective pigment called melanin, which is what causes our skin to tan and change colour. Collections of melanocytes appear on the skin surface as a mole or beauty spot. Malignant melanoma affects melanocytes cells and often appears as a new mole or a changed mole. If caught late, this type of skin cancer is more difficult to treat and can rapidly spread to other parts of the body.

Basal and squamous cell carcinomas are known as non-melanoma skin cancer. They are more common and less dangerous than malignant melanoma. Early treatment is still recommended for non-melanoma types of cancer as if left they will grow and cause disfiguration.

What causes skin cancer?

The main cause of skin cancer is exposure to sunlight. Sunlight contains ultraviolet (U.V.) rays that can cause damage to the skin. The number of people with skin cancer is increasing as more people are taking holidays in hot countries and more people are regularly using sunlamps (beds) to obtain a tan. Sunlamps give off artificial U.V. radiation. There are different factors, which can affect the intensity of U.V. rays, such as latitude (the closer to the equator you are, the stronger the rays) and altitude ( the intensity of U.V. rays increases, the higher you are). Continued damage to the ozone layer may also play a role in the increase of people with skin cancer, as more U.V. rays reach the Earth.

Non-melanoma cancer (basal and squamous) is caused by long-term exposure to sunlight, which is why they occur mainly in the elderly. However, malignant melanoma is associated with frequent sun exposure e.g. sun sensitive people who spend most of the year indoors and then take a 2 week holiday in the sun.

Am I at risk of getting skin cancer?

You are more at risk of getting skin cancer if you are fair skinned and tend to go red or freckle when exposed to sunlight. You will also have an increased risk if you have a large number of moles (50-100) or if there is a history of skin cancer in your family. The risk of skin cancer also increases if you burn. Sunburn is skin damage and though on the surface the burnt skin peels away, deep down the damage remains.

Black or brown skinned people are less likely to develop skin cancer as their bodies produce more of the pigment melanin, which protects the skin.

What are the symptoms of skin cancer?

Squamous and basal cell carcinomas can appear in many different forms, they are most likely to appear on skin which is regularly exposed to the sun e.g. face and neck, but they can be found on other areas of the body. Symptoms to look for include:

• A small lump on your skin, which is smooth in appearance, it may bleed or develop a crust.
• Flat red spot, which is crusty and scaly.
• An open sore or ulcer that bleeds or crusts over but does not heal.
• Firm red painless lump.

Most malignant melanomas start as small black or brown marks on the skin, they are hard to distinguish from normal moles and may develop from existing moles. Malignant melanomas may affect most parts of the body, but the most common areas they can be found are on the back and chest in men and on the arms and legs in women (areas of the body that are regularly exposed to the sun). The symptoms of malignant melanoma include:

• A new mole.
• A mole that changes in size or shape. Most melanomas have an irregular shape and if you were to draw a line down the middle, one half would not match the other.
• A mole that changes colour, it may become darker. Most melanomas are not one colour.
• If a mole becomes inflamed or has a reddish edge.
• A mole that itches or bleeds.
• A blood blister under a nail, which is not as a result of injury.

You should remember that when detected early, skin cancer has a 99% cure rate, so if you notice anything unusual on your skin, which does not go away after a month, you should ask your doctor for advice. Please remember that many other skin conditions could show these symptoms.

How can I prevent getting skin cancer?

To prevent all types of skin cancers you should avoid being burnt by the sun and keep in the shade when possible. Wear protective clothing and a wide brimmed hat when out-doors and avoid the sun between the hours 11am till 3pm. Most importantly, always apply sunscreen of at least S.P.F. (Sun Protection Factor) 15, 30 minutes before exposure to the sun and then re-apply every 2-3 hours, more often if you are in and out of the water. The majority of us do not apply enough sunscreen and do not apply it evenly, exposing areas of the skin to sunburn. Pay particular attention to areas of the body which are not used to sun exposure.

Many people believe that the sun in the UK is not strong enough to harm their skin. You should remember that the sun in the UK, especially in the summer months has the same burning power as that of a European holiday resort at the same time of year.

Avoid using sun beds, if you don’t tan in the sunlight you will not tan under a sun bed either.
You should always make sure that children are well protected when playing outdoors, they are unlikely to remember to cover up themselves or notice when they get burned. Encourage your child to wear a hat and sunglasses when outside and dress them in long sleeve t-shirts and long shorts or skirts. There is a great amount of evidence that says children who are exposed to sunburn at an early age are at a much greater risk of developing skin cancer when they get older.

If you still want a golden tan why not consider using one of the many fake tans available on the market. I personally like and use Boots Soltan™ self tanning mousse, St Tropez (which is available in large department stores and is the one many celebrities use) and Clarins™ after sun with self tanning cream. The majority of fake tans contain an ingredient called DHA (Dihydroxyacetone).

How is skin cancer diagnosed?

Your doctor will usually be able to tell from a simple examination if your skin problem is caused by cancer, though he/she will not be able to tell which type. To diagnose which cancer you have, a biopsy will almost certainly have to be done. This is a simple procedure, which involves the doctor removing part, or the entire lump/mole, which is causing concern, it will then be sent away for analysis.

Once the type of cancer has been determined you may then have an X-ray or scan to see if the cancer has spread.

How is skin cancer treated?

As mentioned earlier, the majority of skin cancers are curable. The type of treatment you receive will depend on the type and size of the tumour. A small non-melanoma (basal) skin cancer can be treated with minor surgery carried out by a specially trained GP, in their surgery.

Excisional biopsy will involve your GP removing the affected area of skin and a small amount of healthy tissue surrounding it, to ensure all the cancer is removed. The removed tissue will then be sent off to a pathologist to examine.  The pathologist will report back confirming the type of cancer and whether any further treatment will be necessary.

Cryosurgery uses liquid nitrogen to freeze the cancer.  The GP will spray the affected area with the liquid nitrogen, and over the following weeks a scab will form which will then drop off, taking the cancerous cells with it.

A less common treatment is curettage and electrocautery. This involves anaesthetising the cancer tissue and surrounding area then removing the cancer and small amount of adjacent tissue using a curette (round blade).  An electric needle is then used to kill any cancerous cells that maybe left behind in the surrounding area.

A GP carrying out the above types of treatments will have received specialist training.

Larger skin cancers will require hospital treatment as you may need a general anaesthetic.  Depending on the area removed, stitches or a skin graft or skin flap maybe required to repair the treated area.

Occasionally, you may require radiotherapy to ensure all cancer cells have been killed and to prevent it re-occurring. Radiotherapy kills cancer cells using high-energy waves, similar to x-rays. Radiotherapy can be used to treat both basal cell and squamous cell cancers where the cancer covers a large area, is in an area difficult to operate on, or after surgery.  It may also be used when a person does not want surgery, is assessed as not suitable for receiving general anaesthetic or if the cancer has spread elsewhere in the body i.e. lymph nodes or lungs.

Other therapies used to treat skin cancer are Photodynamic Therapy, Chemotherapy and imiquimod cream.

Imiquimod cream is used to treat superficial basal cell skin cancers measuring up to 2cm across which are found on the chest, back, neck, arms and legs.  The cream stimulates the body to produce a protein called interferon which destroys the skin cancer cells. Imiquimod cream is applied to the affected area 5 days a week for 6 weeks.

Photodynamic Therapy (PDT) uses a special light with a drug that contains a photosensitising agent. This procedure can be used to treat non-melanoma skin cancers that cover a large area, or several areas which would otherwise require a lot of surgery. Treatment involves the drug being injected into your blood stream or placed on the skin as a cream.  The special light is then shone on the area to be treated, killing any cells that have absorbed the drug. If the cancer is thick, a further treatment maybe required 4 weeks later once the area has healed from the previous treatment. This type of treatment will continue make a person’s skin sensitive to sunlight and bright light for a time after treatment. Your doctor will advise you on how best to protect yourself.

Chemotherapy uses drugs to destroy cancer cells or interfere with the way they work.   Chemotherapy drugs can be administered as a cream directly onto the skin cancer or through a drip into the vein. The cream used is called Efudix and is used to treat cancers affecting the top layer of skin.  You will be shown how to apply the cream and instructed to apply it twice a day for several weeks.

Chemotherapy into the vein is used to treat squamous cell cancer that has spread to other parts of the body.  The treatment may involve one or a combination of drugs, administered in a cycle of several weeks then a week of no treatment. Your doctor will advise on the number of cycles of treatment needed.

If Malignant melanoma is caught at an early stage it is usually curable, but once it has spread to other parts of the body treatment becomes more difficult and can quite often be fatal.  Although this is the rarest form of skin cancer it is responsible for the most deaths.