June 24, 2024 • 18 mins
In this third episode of the Rash Decisions melanoma series, Dr George Moncrieff and Dr Roger Henderson guide you through "The Art of Melanoma Spotting" in primary care. They’ll upskill you on the essential techniques for early melanoma detection, emphasising the key role of dermatoscopy and mole mapping. Our experts also share their thoughts on UVA and UVB exposure whilst exploring the complexities of sunblock usage, debunking common myths and providing practical advice for you to pass on to your patients.
Tune in to gain the expertise needed to spot early melanomas confidently and improve patient outcomes in your practice.
Thank you to our kind sponsor AproDerm, who provide a comprehensive range of quality emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
To simplify the process of finding the most suitable emollient for each patient, they have developed a remarkable solution: the AproDerm Emollient Starter Pack. This pack conveniently combines all four of their emollients in a single prescription, enabling patients to identify their ideal emollient more efficiently, aiding both compliance and adherence.
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Is there a dermatology topic you’d like us to explore? Email us at info@aproderm.com, and we’ll do our best to cover it.
The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
Episode Resources:
Reduced Melanoma After Regular Sunscreen Use: Randomized Trial Follow-Up: https://ascopubs.org/doi/10.1200/JCO.2010.28.7078
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:08):
Hello and welcome to this Rash Decisionspodcast where we look at skin-related
issues, conditions and treatments inan interesting and informative way.
I'm Dr Roger Henderson, I'ma GP with a long-standing
interest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I was a Chair of
(00:29):
the Dermatology Council for England.
So today, George and I are going to betalking about the recognition of melanomas
in primary care and how we can improveour sensitivity in diagnosing these,
as well as looking at the benefits, orotherwise, of sunscreens and sunblocks.
Now, this is the third of threepodcasts about this type of skin cancer.
(00:51):
So, if you were with us for the first two,well, firstly, many thanks for listening.
We both really do appreciate it.
And secondly, we do hope you foundthem helpful in your practice.
So, to kick off this week's podcast,George, let's look, I suppose, at how
(01:13):
we should all aim to be improving ourconfidence, in picking up malignant
melanomas, and we touched on this inour second podcast, but we really do
have to start with one word here, andthat word is 'dermatoscopy', isn't it?
I couldn't agree more.
As I said last time, I couldn'tbegin to imagine trying to give
an opinion nowadays on a lesion,particularly a pigmented lesion,
(01:36):
without what the dermatoscopy shows.
I would feel totally insecure.
But, we do need to improve our abilityto recognise melanoma early, and
I honestly think picking up earlymelanomas can only be done effectively
by using a dermatoscope in primary care.
(01:56):
I think we should also be thinkingabout, some targeted mole mapping, in
high risk individuals, not necessarilydone from general practice, but a
patient, for example, who's had oneor two melanomas before, or bad family
history, or they've got multiple molesin particular, they're the sort of people
who I think should have their molesmapped, and ideally mapped also with
dermatoscopy images, so that [if] theydevelop a new lesion, it can be compared
(02:22):
with previous images, and it can becompared with their other moles as well.
And I think we probably ought to be urgingfor some kind of public health campaign,
to encourage the early presentationof new lesions in people over 30.
I don't think the public are necessarilyaware that if they've got a new
melanocytic naevus over the age of 30,it needs to be looked at carefully.
(02:46):
The trouble is, as you get over30, you start getting other
pigmented lesions on your skin.
Yes.
And so it's a matter ofmaking a careful call there.
And I think we need to help secondarycare, by avoiding the unnecessary
referral of obviously benign lesions,but to do that, I couldn't do that
(03:07):
without the additional informationI get from my dermatoscope.
It really is a life changingexperience, using a dermatoscope.
However, it does needconsiderable training.
It's not something youcan just buy and then use.
You need to know what you're seeing.
And, you do need to go on acourse, to recognise the features
(03:29):
that are associated with benignlesions and ones with malignant.
And I think we ought to be thinkingabout sensible UV exposure.
There are clearly advantages to beingout in the sun, but we need to do
it sensibly, and we need to be usinga quality sunblock, appropriately.
Of course, no sunlight exposurein children if we can help it.
We keep all children, underthe age of 11, out of the sun.
(03:52):
Yeah, you mentioned sunblock there,and this is a tricky question.
You walk into any supermarket,any pharmacy, there's an enormous
choice of sunblocks, sunscreens,available to people who might, quite
justifiably, feel somewhat confusedabout what's on offer, and I think
we should sort of touch on that.
But before we do, let's just remind ourlisteners about the difference between
(04:15):
UVA and UVB, because that's reallyimportant, as well as other factors
that impact upon their effects upon us.
So, let's go with the ultravioletlight first, and then we'll come
on to sunscreens and sunblocks.
Well, there are extraordinarydifferences between UVA and UVB.
(04:35):
The first thing I need to say is thatUVB is a hundred times more burning than
UVA, but UVA penetrates much more deeply.
So, it penetrates into the skinand can cause the ageing changes.
So, A for aging, B for burning.
It causes the solar elastosis andthe wrinkling, and the other features
(04:57):
that we see, caused by sunlight.
Because UVA is much more penetrative,it goes through glass, it goes through
cloud, just like visible light.
If you can see the colours of therainbow, when you're indoors, you're
also seeing UVA, 80% goes through glass.
And the intensity of visible lightbarely changes between dawn and
(05:22):
noon and dusk, and it barely changesbetween the summer and the winter.
Similarly, the intensity ofUVA barely changes from dawn
to noon to dusk or season.
So, in other words, the UVA thatyou're seeing at dusk in December in
the Northern Hemisphere, isn't thatdifferent to the UVA that you're
(05:44):
getting exposed to at noon in June.
Right.
UVB however changes dramatically.
There's virtually no UVB gettingthrough, at dawn or at dusk and very
little UVB in the, winter months.
And it's UVB that most people are worriedabout, but I get more worried about UVA.
(06:05):
Interestingly, actually,whilst UVB produces vitamin D,
UVA destroys vitamin D.
But UVA does other useful things as well.
So, when you're thinking about yoursunlight exposure and what you need to do,
you've got so many things to factor into,besides your personal vulnerability, your
family history, your skin type, and so on.
The latitude matters enormously.
(06:26):
The altitude, matters enormously.
For example, the UVB increasesby 4% every 300 metres you go up.
So, if you're going skiing and upto 2000 metres or whatever, you're
getting a huge amount more UVBup there than you are lower down.
Ozone holes make a big difference.
(06:46):
Ozone absorbs a huge amountof these ultraviolet waves.
I've already talked about glass andcloud and season and time of year,
but, UVB and UVA reflect off the groundand much more so from sand, about 15%
reflect straight back up from the sand.
And with snow, it's 80%reflects back from the snow.
(07:09):
So you're getting a lot more there.
Pollution has an interestingimpact as well, haze and, pollution
along with broken cloud effect.
If you've got cumulus, that cancause a scattering of the light,
which actually increases theintensity of the UVB by up to 20%.
So even in the shade, whenyou've got broken cloud, the
(07:33):
UVB is actually more powerful.
So there are lots of these factorsthat we need to take into account.
I think the other thing in factis, I touched on in an earlier
podcast, the benefit of a good tan.
When you produce a tan, you'restimulating the melanocytes to produce
loads of melanosomes, which go downtheir long dendritic processes.
(07:54):
And each of those arms of the melanocytesare communicating with the epidermocytes,
which phagocytose those melanosomes,release the melanin into the cytoplasm.
And this is the clever bit.
The epidermocytes somehow know thatthey need to put that melanin as an
umbrella on the outer surface of thenucleus, protecting the nucleus from
(08:16):
further UV radiation damage, butleaving the cytoplasm, which is where
you make the nitric oxide, which lowersyour blood pressure and the vitamin D
and the endorphins to be exposed toultraviolet light and do their job.
So, a good suntan, I think, isa fairly perfect combination.
(08:37):
You've protected your nuclei and you'vegot cells that can now still do their job.
When you put sunblock on, you'restopping any sunlight getting into
the skin, if you use it properly.
So, you're losing the benefitsof sunlight as far as lower
blood pressure and vitamin D.
And of course then differentwavelengths have different impacts
(08:58):
on how permanent that sun tan is.
So for example, UVA doesn'thave a very high PPD, factor.
It's persistent pigmentary darkening.
UVA causes release of thesemelanosomes, but doesn't stimulate
the production of more melanosomes.
Whereas UVB does producea nice permanent pigment.
So we've talked about differencesbetween permanent and temporary
(09:21):
tanning, and the UVA and UVBdo have different impacts there.
So I hope I haven't confused everybody.
There's a lot of factors totake into account before you
start thinking about sunblock.
Yeah, and, that is really helpfuland it can be seen as a panacea
to all skin problems when inmany ways it usually isn't.
(09:44):
I don't tend to use sunblockmyself, but who should be using it?
I mean, it has its uses but perhaps notas much as many people think it does.
I probably would say, you know,if I see a child under the age of
11 on a beach, they should have,you know, be covered in sunblock.
Yes.
(10:05):
Well, because sunlighthas other advantages.
I didn't mention those.
We use ultraviolet light therapy,very carefully, for treating
psoriasis and eczema and mycosisfungoides and the list goes on.
So, there are useful effects ofsunlight, but who should be using it?
Yeah, definitely children under 11.
They should have sun vests to protectthem, hats, wide brimmed hats, and they
(10:28):
should be using high factor sunblocks.
If you've got a photoaggravated skincondition, like lupus, or even rosacea
or melasma, for example, as well asthings like xeroderma pigmentosum.
These individuals clearly need to beprotecting that skin, the affected skin,
from the effects of ultraviolet light.
People who are on photosensitisingmedications, whether that's
(10:50):
isotretinoin for acne, or doxycycline,or amiodarone, the list is huge.
If you're on medication that makesyour skin more sensitive to sunlight,
clearly you need to be more careful.
And I suppose if you've had a historyof a keratotic skin cancer, or even a
melanoma, then that's somebody I wouldsay should be protecting their skin.
(11:11):
Maybe more important than protecting theirskin, I think, is protecting their eyes.
I think we should be wearing UVprotecting sunglasses because
UV light causes cataracts.
And so I think when we're talkingabout sunblock, we shouldn't be
forgetting about the sunglasses as well.
But sort of going back a bit, theproblems with sunblocks is that
(11:32):
they're not really used and used wellenough and used properly, you need
one that's not sticky, it shouldn'tbe expensive, because most of the time
we expect our patients to buy them.
We're told to use them at twomilligrams per square centimetre.
That's a vast amount, I don'tthink anybody puts their
sunblock on that thickly.
And in the studies where they gettheir factoring, they suggested they
(11:53):
should be put on every couple of hours.
Again, I don't think peopleare doing that either.
Are you familiar with the two finger rule?
If you, if you squeeze out the sunblockfrom the tip of your index finger to the
palm, not into the palm, but just to thepalm, and the same with the middle finger,
that two finger rule should be enough forthe face, but actually that's far more
(12:16):
than most people would put on the face.
I think they'd use half that.
Yeah.
Not all sunblock is UV stable, and so,you go out in the direct sunlight, it's
going to lose its potency, and so youneed to be using a quality sunblock.
And of course, if you go swimming,and it's not a water resistant one,
or when you towel off vigorously,or you're doing a lot of running and
(12:36):
sweating, you may need to remember toput sunblock on straight away after that.
So particularly in those groups,you need to be using sunblock
and using it effectively.
Well asking a slightly dull question Isuppose, George, if such a thing exists.
Do sunblocks actually protectus from skin cancer, I guess?
That's a really interesting question.
Just because a sunblock protectsagainst erythema and photoaging
(13:00):
doesn't necessarily mean itreduces the risk, of melanoma.
There was one trial, which everyonequotes, is the Nambour Trial in 2011.
And this did demonstrate thatsunblock resulted in fewer total
melanomas, in fact, roughly half, andsignificantly fewer invasive melanomas.
(13:25):
However, they did acknowledgethat the benefits of sunblock
for melanoma are controversial.
And a meta-analysis of observationalcross-control studies in 2009 demonstrated
no association between sunscreen use andthe development of malignant melanoma.
So it's a really tricky subject, butthey protect you from sunburn, they
(13:49):
protect you from photoaging, almostcertainly I think they will protect you
from the keratotic cancers, but how muchwill they protect you from melanoma?
It's a very much more complicatedmessage than it appears at first glance.
And of course, I don't know thatin those studies, whether they
distinguish the different strengths.
We talk about sun protection factor,whether it's 15, 30, 50, or 100 even.
(14:14):
What you're saying there, with afactor 30, is that you can stay
out in ultraviolet light for 30times longer for the same amount of
erythema caused by ultraviolet light.
So factor 30 offersabout 97% UVB protection.
Right.
Go up to factor 50, you're onlyincreasing that by 1% to 98%.
(14:36):
And go up to factor 100,you're going up to 99%.
So the differences aren't that huge.
And when you get onto the higherfactor sunblocks, they've often got
heavy metals in them, like titaniumand zinc, which cause the light to
reflect, and they make it much morevisible that you're using a sunblock
(15:00):
and are less cosmetically acceptable.
So I personally think that if I'mgoing to use sunblock, apart from in
children, I'd probably use a factor30, but I'd also want a high UVA
star rating, like a four star rating.
And I would consider using a high starrating sunblock in the winter months,
(15:22):
when the UVA is just as strong as it isin the summer, or pretty well just as
strong, and is destroying my vitamin D.
But it gets even more complicated atthat point because it's UVA that causes
the release of nitric oxide, which isthe thing I really want, because that's
what keeps my blood pressure low.
So it's, it's a fascinating topicand we could argue these things round
(15:43):
and round in circles all day long.
But I don't know about you, butI tend to use my sunblock more in
the winter than the summer months.
Yes, I do too.
And in the summer, I'mvery careful about the sun.
I don't want to burn.
And so if I'm concerned I'm going toburn, I'll use sunblock and a hat.
Actually, I don't think the top ofmy head needs any more sun exposure.
It's had more than enough for a lifetime.
(16:03):
But other parts of my body, I'm lessconcerned of the keratotic cancer
risk there because it hasn't hadso much cumulative light exposure.
And I am keen to get that outand build up my natural tan.
That's really, really helpful.
And I suppose as part of this overallpicture, we really can't close off
without mentioning vitamin D, can we?
(16:25):
I mean, we do forget about it from timeto time, but it is so in the mix here.
Yeah.
Vitamin D, I hope you're takingindustrial doses of vitamin D, Roger.
Are you?
I forgot to take mine this morning.
I must rush off and take it now, I think.
Yeah.
But I do take it every day, yes.
(16:47):
Yeah.
My wife and I take industrialdoses, and I mean industrial.
I'm always intrigued.
I learnt at medical school about themilk-alkali syndrome and precautions
with vitamin D and things like that.
But, I think, unless you've got ahistory of hyperparathyroidism or
renal stones or some other cause ofhypercalcemia, I would say you're very
hard pressed to overdose on vitamin D.
(17:10):
And I'm personally nottaking it for my bones.
I'm taking it for my immune systemand low levels of vitamin D are
associated with an increased riskof cancers and multiple sclerosis.
So, there's a lot of benefits to vitaminD, which doesn't hugely surprise me.
If you look at the molecule, it's basedon the original steroid base molecule.
It's just been opened up andgot a long hydrocarbon chain.
(17:32):
So, it's very similar to steroids, whichalso come from that cholesterol base.
And vitamin D goes around thebody and it has a huge impact on
almost every cell in the body.
I don't think just take vitaminD in the winter months, I
think take it all year round.
And, NICE, they say much the same now.
Yes, I must toddle off and takemine I forgot this morning, but
(17:54):
that's a good reminder to bringthis particular episode to a close.
We do hope that you found this thirdpodcast on melanomas interesting
and helpful and especially on apractical basis, when you're in
your surgeries, the next time you'relooking at someone and wondering
whether they may have a melanoma.
(18:14):
And Roger and I hope you'll joinus again next time when we'll be
discussing more skin-related conditions.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Rash Decisions podcasts together.
We couldn't have done it without them.
So until the next time,it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
Hello and welcome to this Rash Decisionspodcast where we look at skin-related
issues, conditions and treatments inan interesting and informative way.
I'm Dr Roger Henderson, I'ma GP with a long-standing
interest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I was a Chair of
(00:29):
the Dermatology Council for England.
So today, George and I are going to betalking about the recognition of melanomas
in primary care and how we can improveour sensitivity in diagnosing these,
as well as looking at the benefits, orotherwise, of sunscreens and sunblocks.
Now, this is the third of threepodcasts about this type of skin cancer.
(00:51):
So, if you were with us for the first two,well, firstly, many thanks for listening.
We both really do appreciate it.
And secondly, we do hope you foundthem helpful in your practice.
So, to kick off this week's podcast,George, let's look, I suppose, at how
(01:13):
we should all aim to be improving ourconfidence, in picking up malignant
melanomas, and we touched on this inour second podcast, but we really do
have to start with one word here, andthat word is 'dermatoscopy', isn't it?
I couldn't agree more.
As I said last time, I couldn'tbegin to imagine trying to give
an opinion nowadays on a lesion,particularly a pigmented lesion,
(01:36):
without what the dermatoscopy shows.
I would feel totally insecure.
But, we do need to improve our abilityto recognise melanoma early, and
I honestly think picking up earlymelanomas can only be done effectively
by using a dermatoscope in primary care.
(01:56):
I think we should also be thinkingabout, some targeted mole mapping, in
high risk individuals, not necessarilydone from general practice, but a
patient, for example, who's had oneor two melanomas before, or bad family
history, or they've got multiple molesin particular, they're the sort of people
who I think should have their molesmapped, and ideally mapped also with
dermatoscopy images, so that [if] theydevelop a new lesion, it can be compared
(02:22):
with previous images, and it can becompared with their other moles as well.
And I think we probably ought to be urgingfor some kind of public health campaign,
to encourage the early presentationof new lesions in people over 30.
I don't think the public are necessarilyaware that if they've got a new
melanocytic naevus over the age of 30,it needs to be looked at carefully.
(02:46):
The trouble is, as you get over30, you start getting other
pigmented lesions on your skin.
Yes.
And so it's a matter ofmaking a careful call there.
And I think we need to help secondarycare, by avoiding the unnecessary
referral of obviously benign lesions,but to do that, I couldn't do that
(03:07):
without the additional informationI get from my dermatoscope.
It really is a life changingexperience, using a dermatoscope.
However, it does needconsiderable training.
It's not something youcan just buy and then use.
You need to know what you're seeing.
And, you do need to go on acourse, to recognise the features
(03:29):
that are associated with benignlesions and ones with malignant.
And I think we ought to be thinkingabout sensible UV exposure.
There are clearly advantages to beingout in the sun, but we need to do
it sensibly, and we need to be usinga quality sunblock, appropriately.
Of course, no sunlight exposurein children if we can help it.
We keep all children, underthe age of 11, out of the sun.
(03:52):
Yeah, you mentioned sunblock there,and this is a tricky question.
You walk into any supermarket,any pharmacy, there's an enormous
choice of sunblocks, sunscreens,available to people who might, quite
justifiably, feel somewhat confusedabout what's on offer, and I think
we should sort of touch on that.
But before we do, let's just remind ourlisteners about the difference between
(04:15):
UVA and UVB, because that's reallyimportant, as well as other factors
that impact upon their effects upon us.
So, let's go with the ultravioletlight first, and then we'll come
on to sunscreens and sunblocks.
Well, there are extraordinarydifferences between UVA and UVB.
(04:35):
The first thing I need to say is thatUVB is a hundred times more burning than
UVA, but UVA penetrates much more deeply.
So, it penetrates into the skinand can cause the ageing changes.
So, A for aging, B for burning.
It causes the solar elastosis andthe wrinkling, and the other features
(04:57):
that we see, caused by sunlight.
Because UVA is much more penetrative,it goes through glass, it goes through
cloud, just like visible light.
If you can see the colours of therainbow, when you're indoors, you're
also seeing UVA, 80% goes through glass.
And the intensity of visible lightbarely changes between dawn and
(05:22):
noon and dusk, and it barely changesbetween the summer and the winter.
Similarly, the intensity ofUVA barely changes from dawn
to noon to dusk or season.
So, in other words, the UVA thatyou're seeing at dusk in December in
the Northern Hemisphere, isn't thatdifferent to the UVA that you're
(05:44):
getting exposed to at noon in June.
Right.
UVB however changes dramatically.
There's virtually no UVB gettingthrough, at dawn or at dusk and very
little UVB in the, winter months.
And it's UVB that most people are worriedabout, but I get more worried about UVA.
(06:05):
Interestingly, actually,whilst UVB produces vitamin D,
UVA destroys vitamin D.
But UVA does other useful things as well.
So, when you're thinking about yoursunlight exposure and what you need to do,
you've got so many things to factor into,besides your personal vulnerability, your
family history, your skin type, and so on.
The latitude matters enormously.
(06:26):
The altitude, matters enormously.
For example, the UVB increasesby 4% every 300 metres you go up.
So, if you're going skiing and upto 2000 metres or whatever, you're
getting a huge amount more UVBup there than you are lower down.
Ozone holes make a big difference.
(06:46):
Ozone absorbs a huge amountof these ultraviolet waves.
I've already talked about glass andcloud and season and time of year,
but, UVB and UVA reflect off the groundand much more so from sand, about 15%
reflect straight back up from the sand.
And with snow, it's 80%reflects back from the snow.
(07:09):
So you're getting a lot more there.
Pollution has an interestingimpact as well, haze and, pollution
along with broken cloud effect.
If you've got cumulus, that cancause a scattering of the light,
which actually increases theintensity of the UVB by up to 20%.
So even in the shade, whenyou've got broken cloud, the
(07:33):
UVB is actually more powerful.
So there are lots of these factorsthat we need to take into account.
I think the other thing in factis, I touched on in an earlier
podcast, the benefit of a good tan.
When you produce a tan, you'restimulating the melanocytes to produce
loads of melanosomes, which go downtheir long dendritic processes.
(07:54):
And each of those arms of the melanocytesare communicating with the epidermocytes,
which phagocytose those melanosomes,release the melanin into the cytoplasm.
And this is the clever bit.
The epidermocytes somehow know thatthey need to put that melanin as an
umbrella on the outer surface of thenucleus, protecting the nucleus from
(08:16):
further UV radiation damage, butleaving the cytoplasm, which is where
you make the nitric oxide, which lowersyour blood pressure and the vitamin D
and the endorphins to be exposed toultraviolet light and do their job.
So, a good suntan, I think, isa fairly perfect combination.
(08:37):
You've protected your nuclei and you'vegot cells that can now still do their job.
When you put sunblock on, you'restopping any sunlight getting into
the skin, if you use it properly.
So, you're losing the benefitsof sunlight as far as lower
blood pressure and vitamin D.
And of course then differentwavelengths have different impacts
(08:58):
on how permanent that sun tan is.
So for example, UVA doesn'thave a very high PPD, factor.
It's persistent pigmentary darkening.
UVA causes release of thesemelanosomes, but doesn't stimulate
the production of more melanosomes.
Whereas UVB does producea nice permanent pigment.
So we've talked about differencesbetween permanent and temporary
(09:21):
tanning, and the UVA and UVBdo have different impacts there.
So I hope I haven't confused everybody.
There's a lot of factors totake into account before you
start thinking about sunblock.
Yeah, and, that is really helpfuland it can be seen as a panacea
to all skin problems when inmany ways it usually isn't.
(09:44):
I don't tend to use sunblockmyself, but who should be using it?
I mean, it has its uses but perhaps notas much as many people think it does.
I probably would say, you know,if I see a child under the age of
11 on a beach, they should have,you know, be covered in sunblock.
Yes.
(10:05):
Well, because sunlighthas other advantages.
I didn't mention those.
We use ultraviolet light therapy,very carefully, for treating
psoriasis and eczema and mycosisfungoides and the list goes on.
So, there are useful effects ofsunlight, but who should be using it?
Yeah, definitely children under 11.
They should have sun vests to protectthem, hats, wide brimmed hats, and they
(10:28):
should be using high factor sunblocks.
If you've got a photoaggravated skincondition, like lupus, or even rosacea
or melasma, for example, as well asthings like xeroderma pigmentosum.
These individuals clearly need to beprotecting that skin, the affected skin,
from the effects of ultraviolet light.
People who are on photosensitisingmedications, whether that's
(10:50):
isotretinoin for acne, or doxycycline,or amiodarone, the list is huge.
If you're on medication that makesyour skin more sensitive to sunlight,
clearly you need to be more careful.
And I suppose if you've had a historyof a keratotic skin cancer, or even a
melanoma, then that's somebody I wouldsay should be protecting their skin.
(11:11):
Maybe more important than protecting theirskin, I think, is protecting their eyes.
I think we should be wearing UVprotecting sunglasses because
UV light causes cataracts.
And so I think when we're talkingabout sunblock, we shouldn't be
forgetting about the sunglasses as well.
But sort of going back a bit, theproblems with sunblocks is that
(11:32):
they're not really used and used wellenough and used properly, you need
one that's not sticky, it shouldn'tbe expensive, because most of the time
we expect our patients to buy them.
We're told to use them at twomilligrams per square centimetre.
That's a vast amount, I don'tthink anybody puts their
sunblock on that thickly.
And in the studies where they gettheir factoring, they suggested they
(11:53):
should be put on every couple of hours.
Again, I don't think peopleare doing that either.
Are you familiar with the two finger rule?
If you, if you squeeze out the sunblockfrom the tip of your index finger to the
palm, not into the palm, but just to thepalm, and the same with the middle finger,
that two finger rule should be enough forthe face, but actually that's far more
(12:16):
than most people would put on the face.
I think they'd use half that.
Yeah.
Not all sunblock is UV stable, and so,you go out in the direct sunlight, it's
going to lose its potency, and so youneed to be using a quality sunblock.
And of course, if you go swimming,and it's not a water resistant one,
or when you towel off vigorously,or you're doing a lot of running and
(12:36):
sweating, you may need to remember toput sunblock on straight away after that.
So particularly in those groups,you need to be using sunblock
and using it effectively.
Well asking a slightly dull question Isuppose, George, if such a thing exists.
Do sunblocks actually protectus from skin cancer, I guess?
That's a really interesting question.
Just because a sunblock protectsagainst erythema and photoaging
(13:00):
doesn't necessarily mean itreduces the risk, of melanoma.
There was one trial, which everyonequotes, is the Nambour Trial in 2011.
And this did demonstrate thatsunblock resulted in fewer total
melanomas, in fact, roughly half, andsignificantly fewer invasive melanomas.
(13:25):
However, they did acknowledgethat the benefits of sunblock
for melanoma are controversial.
And a meta-analysis of observationalcross-control studies in 2009 demonstrated
no association between sunscreen use andthe development of malignant melanoma.
So it's a really tricky subject, butthey protect you from sunburn, they
(13:49):
protect you from photoaging, almostcertainly I think they will protect you
from the keratotic cancers, but how muchwill they protect you from melanoma?
It's a very much more complicatedmessage than it appears at first glance.
And of course, I don't know thatin those studies, whether they
distinguish the different strengths.
We talk about sun protection factor,whether it's 15, 30, 50, or 100 even.
(14:14):
What you're saying there, with afactor 30, is that you can stay
out in ultraviolet light for 30times longer for the same amount of
erythema caused by ultraviolet light.
So factor 30 offersabout 97% UVB protection.
Right.
Go up to factor 50, you're onlyincreasing that by 1% to 98%.
(14:36):
And go up to factor 100,you're going up to 99%.
So the differences aren't that huge.
And when you get onto the higherfactor sunblocks, they've often got
heavy metals in them, like titaniumand zinc, which cause the light to
reflect, and they make it much morevisible that you're using a sunblock
(15:00):
and are less cosmetically acceptable.
So I personally think that if I'mgoing to use sunblock, apart from in
children, I'd probably use a factor30, but I'd also want a high UVA
star rating, like a four star rating.
And I would consider using a high starrating sunblock in the winter months,
(15:22):
when the UVA is just as strong as it isin the summer, or pretty well just as
strong, and is destroying my vitamin D.
But it gets even more complicated atthat point because it's UVA that causes
the release of nitric oxide, which isthe thing I really want, because that's
what keeps my blood pressure low.
So it's, it's a fascinating topicand we could argue these things round
(15:43):
and round in circles all day long.
But I don't know about you, butI tend to use my sunblock more in
the winter than the summer months.
Yes, I do too.
And in the summer, I'mvery careful about the sun.
I don't want to burn.
And so if I'm concerned I'm going toburn, I'll use sunblock and a hat.
Actually, I don't think the top ofmy head needs any more sun exposure.
It's had more than enough for a lifetime.
(16:03):
But other parts of my body, I'm lessconcerned of the keratotic cancer
risk there because it hasn't hadso much cumulative light exposure.
And I am keen to get that outand build up my natural tan.
That's really, really helpful.
And I suppose as part of this overallpicture, we really can't close off
without mentioning vitamin D, can we?
(16:25):
I mean, we do forget about it from timeto time, but it is so in the mix here.
Yeah.
Vitamin D, I hope you're takingindustrial doses of vitamin D, Roger.
Are you?
I forgot to take mine this morning.
I must rush off and take it now, I think.
Yeah.
But I do take it every day, yes.
(16:47):
Yeah.
My wife and I take industrialdoses, and I mean industrial.
I'm always intrigued.
I learnt at medical school about themilk-alkali syndrome and precautions
with vitamin D and things like that.
But, I think, unless you've got ahistory of hyperparathyroidism or
renal stones or some other cause ofhypercalcemia, I would say you're very
hard pressed to overdose on vitamin D.
(17:10):
And I'm personally nottaking it for my bones.
I'm taking it for my immune systemand low levels of vitamin D are
associated with an increased riskof cancers and multiple sclerosis.
So, there's a lot of benefits to vitaminD, which doesn't hugely surprise me.
If you look at the molecule, it's basedon the original steroid base molecule.
It's just been opened up andgot a long hydrocarbon chain.
(17:32):
So, it's very similar to steroids, whichalso come from that cholesterol base.
And vitamin D goes around thebody and it has a huge impact on
almost every cell in the body.
I don't think just take vitaminD in the winter months, I
think take it all year round.
And, NICE, they say much the same now.
Yes, I must toddle off and takemine I forgot this morning, but
(17:54):
that's a good reminder to bringthis particular episode to a close.
We do hope that you found this thirdpodcast on melanomas interesting
and helpful and especially on apractical basis, when you're in
your surgeries, the next time you'relooking at someone and wondering
whether they may have a melanoma.
(18:14):
And Roger and I hope you'll joinus again next time when we'll be
discussing more skin-related conditions.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Rash Decisions podcasts together.
We couldn't have done it without them.
So until the next time,it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
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