Proper Use of Sunscreen Important to Prevent Skin Cancer

"Trust me, I'm a doctor!" (Dr. Noorali Bharwani)
"Trust me, I'm a doctor!" (Dr. Noorali Bharwani)

Skin cancer is the most common cancer in North America. The benefits of sunscreen outweigh the inconvenience of using it.

First step in the prevention against skin cancer is to avoid sun exposure between 10 a.m. and 2 p.m. whatever the season. These are prime hours for exposure to skin-damaging ultraviolet (UV) radiation from the sun, even on overcast days.

Second step is to wear protective clothing. This includes pants, shirts with long sleeves, sunglasses and a wide-brimmed hat.

Third step is to use sunscreen. Apply sunscreen generously and reapply regularly, says a dermatologist at Mayo Clinic.

There are two types of UV light that can harm your skin – UVA and UVB. A broad-spectrum sunscreen protects you from both.

UVA rays can prematurely age your skin, causing wrinkles. UVB rays can burn your skin. Too much exposure to UVA or UVB rays can cause skin cancer. The best sunscreen offers protection from all UV light.

SPF stands for sun protection factor, a measure of how well sunscreen protects against UVB rays. UVA protection isn’t rated. Manufacturers calculate SPF based on how long it takes to sunburn skin that’s been treated with the sunscreen as compared to skin with no sunscreen.

When applied correctly, a sunscreen with an SPF of 30 will provide slightly more protection from UVB rays than does a sunscreen with an SPF of 15. But the SPF 30 product isn’t twice as protective as the SPF 15 product. Sunscreens with SPFs greater than 50 provide only a small increase in UV protection.

Often sunscreen is not applied thoroughly or thickly enough, and it can be washed off during swimming or sweating. As a result, even the best sunscreen might be less effective than the SPF number suggests.

Rather than looking at a sunscreen’s SPF, choose a broad-spectrum sunscreen. A water-resistant sunscreen means the SPF is maintained for up to 40 minutes while swimming or sweating. Very water resistant means the SPF is maintained for 80 minutes.

Is one sunscreen better than others?

Experts at Consumer Report (May 2017) tested 62 lotions, sprays, sticks, and lip balms. Out of these, 23 tested at less than half their labeled SPF number. That doesn’t mean the products aren’t protective, but you may not be getting the degree of protection you think you are.

To compare the full list of sunscreens you will have to go to the Consumer Report. Here are the top five brands mentioned in the Report:

  1. Equate Sport Lotion SPF 50 (Walmart)
  2. Pure Sun Defense Lotion SPF 50
  3. Equate Ultra Protection Lotion SPF 50 (Walmart)
  4. Trader Joes Spray SPF 50+
  5. Equate Sport Continuous Spray SPF 30 (Walmart)

If you cannot find one of the above sunscreens, then choose a chemical sunscreen with an SPF of 40 or higher that will give you a better chance of getting at least SPF 30.

How to use the sunscreen?

  1. Shake it well.
  2. Apply 15 to 30 minutes before going out.
  3. Use at least a teaspoon on each body part.
  4. Reapply every two hours.
  5. Use spray sunscreens carefully so you don’t inhale it, they can also be flammable. Avoid using sprays on children.

Be safe and enjoy the summer.

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Smart Sunscreen Strategy Needed to Prevent Skin Cancer

Sunset in Hawaii. (Dr. Noorali Bharwani)
Sunset in Hawaii. (Dr. Noorali Bharwani)

There are three types of skin cancers. Basal cell cancer (BCC) and Squamous cell cancer (SCC) are not lethal but can leave you with scars and deformities on your face and other parts of the body. Then there is melanoma. If not detected early and treated melanoma can be lethal.

When exposed to sunrays, some people burn easily and others slowly. Those who burn easily have a higher risk of skin cancer than others. But everybody is at some risk of getting skin cancer. So be smart and prevent skin cancer. Here are some guidelines.

Minimize sun exposure. Avoid the sun or stay in the shade when the sun is the strongest (10 a.m. to 4 p.m.), and dress right for the occasion. Wear a hat and clothing that’s made from tightly woven fabric.

Use appropriate sunscreen. The American Academy of Dermatology (AAD) guidelines recommend people use sunscreens with three important qualities:

  1. Use broad-spectrum sunscreen to protect against ultraviolet A rays and B rays. Ultraviolet A rays make up 95 percent of the UV spectrum and are most associated with wrinkling. Ultraviolet B rays, cause sunburn and are stronger at midday and in the summer. Both types of rays can cause skin cancer.
  2. Use water resistant sunscreen – no sunscreen is “water proof” but water resistant means you can go up to 80 minutes in the water before you need to reapply.
  3. Use sunscreen with SPF of at least 30.

To understand what sunscreens people actually use compared to what they need to prevent burning, the researchers looked at the most popular sunscreens on Amazon – the top one per cent, or 65 products.

The researchers found 40 percent – 26 of 65 – of the products did not meet AAD requirements. Most products that failed to meet the standards, 72 percent, did so because they were not water resistant.

A Consumer Reports study (May 2016) found only the following five met the AAD criteria:

  1. Hawaiian Tropic Sunscreen Silk Hydration SPF 30
  2. Neutrogena Age Shield Face Lotion Sunscreen SPF 110
  3. EltaMD UV Physical SPF 41
  4. Neutrogena Ultra Sheer Dry – Touch Sunscreen SPF 55
  5. Neutrogena Sunscreen Ultra Sheer Stick SPF 7

Make sure you use enough sunscreen. Apply sunscreen 15 to 30 minutes before you go outside. For lotions, a good rule of thumb is a teaspoon per body part or area.

For sprays, apply as much as can be rubbed in, then repeat. Regardless of which kind you use, reapply every two hours and after swimming or sweating. Use spray sunscreens carefully. Sprays are flammable; so let it dry before going near an open flame.

Consumer Reports article concludes by saying, “Tests over the past four years indicate that choosing a chemical sunscreen with an SPF of 40 or higher will give you a better chance of getting at least an SPF 30. Using any sunscreen is better than using none, but it’s just one part of a smart sun protection strategy.”

Take care and enjoy the summer.

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Making a Mountain out of a Molehill to Prevent Skin Cancer

A boat sailing on River Nile in Aswan, Egypt. (Dr. Noorali Bharwani)
A boat sailing on River Nile in Aswan, Egypt. (Dr. Noorali Bharwani)

The other day a gentleman asked me, “Doctor B, I have a mole. Do you think I have melanoma?” I didn’t think he had a mole. I thought it was a skin tag. He said, “OK doc, tell me what does a mole look like and when should I worry about it.”

Defining a mole is not easy. People use the word very loosely to describe any blemish on the skin as a mole.

The majority of moles appear during the first two decades of a person’s life, with about one in every 100 babies being born with moles. Acquired moles are a form of benign new growths, while congenital moles, or congenital nevi, are considered a minor malformation and may be at a higher risk for melanoma. Moles are also known as nevi. Most of them have no malignant potential. But real moles and sunburns have a potential to become cancerous.

Real moles are skin growths that are usually brown or black. During sun exposure, teenage years and pregnancy, these cells multiply and become darker. They can be anywhere on the skin, alone or in clusters. Most moles appear in early childhood and by the age of 20, one can have anywhere between 10 to 50 or more moles. Some moles may appear later in life.

Most moles are benign. The only moles that are of medical concern are those that look different than other existing moles or those that first appear after age 20. If you notice changes in a mole’s colour, height, size or shape, you should have these moles checked. If the moles bleed, ooze, itch, appear scaly or become tender or painful then it is time to have them removed and checked for cancer.

The following ABCDEs are important signs of moles that could be cancerous:

  • Asymmetry – one half of the mole does not match the other half.
  • Border – the border or edges of the mole are ragged, blurred or irregular.
  • Colour – the colour of the mole is not the same throughout or has shades of tan, brown, black, blue, white or red.
  • Diameter – the diameter of a mole is six millimetres or larger.
  • Evolution – are the moles changing over time?

Melanoma is one of the three common skin cancers. The other two are basal cell carcinoma and squamous cell carcinoma. Melanoma is the most serious form of skin cancer. If diagnosed and removed early then the cure rate can be excellent. Once the cancer advances and spreads to other parts of the body, it is hard to treat.

Does melanoma occur in children? Yes, approximately two per cent of melanomas occur in patients under the age of 20 years and about 0.4 per cent of melanomas occur in pre-pubertal children.

We can reduce the risk of skin cancer by protecting against sun exposure and sunburn. Natural protection (shade) is considered the best protection. And sunscreen (SPF 15 or higher) should be adjunct to natural protection. Wear sun protective clothing. Wear wide brim hats. And use eyeglasses that block both UVA and UVB light.

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Indoor Tanning Beds are Not Safer than Natural Sunlight

A woman lying in a tanning bed. (Stockbyte/Thinkstock)
A woman lying in a tanning bed. (Stockbyte/Thinkstock)

Many snowbirds are getting ready to move down south for winter. Some are also booking holidays to get away for a couple weeks to warmer places. The idea is to get away from cooler temperatures, spend time on a beach and soak in the natural sunlight. Before they go away, some travellers visit indoor tanning salons to get a mild tan thinking that this would protect them from sunburn and skin cancer.

There are people who like to look tanned year round and visit indoor tanning salons on a regular basis ignoring the fact that indoor tanning is as bad as basking in the natural sunlight. Some parents encourage their children to visit indoor tanning salons. Studies have shown indoor tanning bed use and childhood sunburns increase skin cancer in young adults.

There is no doubt, exposure to ultraviolet (UV) radiation damages your skin, whether the exposure comes from tanning beds or natural sunlight. The damage eventually leads to premature aging of the skin and skin cancer.

A recent Mayo Clinic study, published in the April 2012 issue of Mayo Clinic Proceedings, found dramatic rise in skin cancer in young adults, especially among people under 40. Researchers speculate indoor tanning bed use and childhood sunburns are key culprits. The study found the incidence of melanoma has escalated, and young women are the hardest hit.

“We anticipated we’d find rising rates, as other studies are suggesting, but we found an even higher incidence than the National Cancer Institute had reported using the Surveillance, Epidemiology and End Result database, and in particular, a dramatic rise in women in their 20s and 30s,” says lead investigator Jerry Brewer, M.D., a Mayo Clinic dermatologist, who was quoted in one of the reports.

The study found the incidence of melanoma increased eightfold among young women and fourfold among young men. The lifetime risk of melanoma is higher in males than females, but the opposite is true in young adults and adolescents. The good news is mortality rates from the disease have improved over the years, likely due to early detection of skin cancer and prompt medical care.

If you are a frequent user of indoor tanning beds then you are 74 per cent more likely to develop melanoma. Young women frequent indoor tanning salons more often than young men even though many of them know indoor tanning has carcinogenic effects that increase the risk of melanoma.

A study from New Brunswick showed that by Grade 12, one-third of girls were using tanning salons, and one-third of them were going with their mothers, says a report in the Medical Post. It is unacceptable that mothers should encourage their daughters to expose themselves to well recognized carcinogens. There are seven other studies involving nearly 7,400 cases showing that first exposure to sunbeds before age 35 increase melanoma risk by 75 per cent.

The message is clear, exposure to ultraviolet rays ultimately lead to premature aging of the skin and skin cancer. So, understand the risk and take care of yourself. There are many ways to enjoy winter months. Be safe and have fun.

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Bob Marley and Importance of Melanoma in Darker-Pigmented Population

A reggae hat. (iStockphoto/Thinkstock)
A reggae hat. (iStockphoto/Thinkstock)

A case of recurrent melanoma in a Caucasian male – temple area.

I enjoy Bob Marley music. I listen to his songs quite often. As most of you know, Bob Marley was a Jamaican singer-songwriter and musician. In May 1981, he died at a very young age of 36 from melanoma. This was tragic. If he would have listened to his doctors then, who knows, he would still be around entertaining us with live performances.

In 1977, Marley was found to have malignant melanoma under the nail of one of his toes. Marley turned down doctors’ advice to have his toe amputated, citing his religious beliefs. He followed the Rastafari tradition. The spread of melanoma to his lungs and brain caused his death. Before his death, he is reported to have said, “Money can’t buy life”.

Bob Marley’s case is interesting from a medical point of view. First, melanoma is not that common in black population and secondly, melanoma under the nail (subungual) is not common either. It is an accepted fact that malignant melanoma in black population and other minority ethnic populations represents an aggressive disease highly associated with invasive lesions. They present with more advanced stage of disease at diagnosis, and consequently with a decreased survival compared with Caucasians.

Melanoma is the sixth most common cancer in North America and the single most common one among young adults 25-29 years old. Lifetime risk of developing melanoma in whites is currently estimated at 1 in 50, compared to 1 in 1000 in African-Americans.

Darker-pigmented populations are consistently reported to have lower risk for melanoma, possibly related to protection from ultraviolet radiation (UVR) provided by melanin.

Melanin is the primary determinant of skin color. It is also found in hair, the pigmented tissue underlying the iris of the eye, and other pigmented areas of the body and brain. The melanin in the skin is produced by cells called melanocytes. Some individuals have very little or no melanin in their bodies, a condition known as albinism.

Production of melanin is stimulated by DNA damage induced by UVB-radiation, and it leads to a delayed development of a tan. It is an excellent photoprotectant. This is because it efficiently absorbs harmful UV-radiation (ultraviolet) and transforms the energy into harmless heat. This prevents the indirect DNA damage that is responsible for the formation of malignant melanoma and other skin cancers.

Caucasians have a predilection to develop lesions on sun-exposed surfaces, including face and neck. Blacks have lesions predominantly located on sun-protected mucosal and acral sites.

Acral sites are the palms, soles, under the nails and in the mouth. It occurs on non hair-bearing surfaces of the body which may or may not be exposed to sunlight. Unlike other forms of melanoma, acral lentiginous melanoma (ALM) does not appear to be linked to sun exposure.

Lentiginous means small, flat, pigmented spot on the skin or under the nail. The reason these lesions have poor prognosis is because they are quite often clinically misdiagnosed.

In fact, an estimated one-third to one-half of all cases of ALM are incorrectly diagnosed at initial presentation as the more commonly appearing benign skin lesions including warts, infections, ulcers, callus, traumatic wounds, and blood clots. Some melanomas have no pigment and these are hard to diagnose early unless you notice some change.

The moral of today’s story is: be vigilant, protect against UV rays, and report to your doctor if there is any change in a mole. If you have a pigmented lesion under a nail, palm of your hands, or sole of your feet which does not go away (a blood clot will slowly disappear) then get a biopsy done. And listen to your doctor. Melanoma can be cured if picked up early.

Long live Bob Marley and his music.

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Melanoma treated in early stages has good prognosis.

Now that the summer is fast approaching, we should revisit the topic of skin cancer. Today, we will discuss melanoma, next week we will visit non-melanoma skin cancers and in the third week we will discuss appropriate use of sunscreen.

In early stages, surgical removal of melanoma is usually successful. Once the melanoma has spread then the prognosis is grim. Recently, FDA has approved certain drugs to be used in late stage melanoma. But these drugs do not cure the cancer and the side-effects are many. The current prognosis for survival in metastatic melanoma is nine months or less, with 9,000 people dying in the U.S. each year.

For Canadian males, the rate for melanoma has tripled since the late 1960s. For Canadian females, the rates have varied over the years but still show a gradual increase. The death rate from melanoma continues to rise about two percent annually. Approximately, two per cent of melanomas occur in patients under the age of 20 years, and about 0.4 per cent of melanomas occur in pre-pubertal children.

Melanoma arises from cells called melanocytes. These cells contain melanin (melas = black) – a principal pigment responsible for the color of human skin, hair, and eyes. Melanin also acts as a filter to decrease the harmful effects of ultraviolet rays to the dermis.

When the skin is exposed to ultraviolet radiation, there is immediate increase in the number of melanocytes and production of melanin pigment. This results in tanning. The amount of melanin produced is genetically determined. That is why some people burn easily without tanning.

The risk of skin cancer is increased in individuals who spend too much time outdoors; children who have had episodic sunburn, and if there is a family or personal history of skin cancer (especially melanoma). Males are affected more than females.

Melanoma is usually found on the backs or chest in men and lower legs in women. These areas are most exposed to sunlight. Melanoma can also occur in eyes, mouth or internal organs although these areas are not directly exposed to sun.

Examples of melanoma on the abdominal wall skin:
Abdominal wall skin melanoma.
Abdominal wall skin melanoma.

There are four different types of melanomas:
-superficial spreading melanoma: most common, looks like a spreading mole
-nodular melanoma: 10 per cent of cases, looks like a dome rising from a mole
-lentigo maligna: less common, looks like an irregular stain in older Caucasians, not related to moles
-acral lentiginous melanoma: found in all skin types in the sole of the feet, palms of the hands, undersides of the fingers or finger nails or toe nails

Prevention is better than cure. We should avoid sunburn and generally reduce exposure to ultraviolet radiation by staying out of the midday sun, wearing protective clothing, and seeking shade and applying sunscreen.

Now, that cannot be too difficult!

Example of recurrent melanoma:
Example of recurrent melanoma.

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