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There's No Such Thing as a Safe Tan

Michael Rushbrook

Do you hear it calling? Summer is sing-songing its old sweet tune, coaxing people all over the northern hemisphere to come out to play. The season’s everlasting days beckon folks into the yard, into the garden, onto the lake and onto the beach. Its voice is mesmerizing. Its lure is irresistible, intoxicating. Finally, there’s plenty of fresh air and sunshine to go around.

Unfortunately, as most people now know, the sun’s ultraviolet (UV) rays, as good as their warmth makes us feel, aren’t benign mood boosters. UVB rays cause skin to burn. UVA rays, the worst culprits, damage collagen and cause aging of the skin. The long wavelengths of UVA rays can pass through window glass, such as that of a car, making people vulnerable even when behind the wheel. The invisible beams have the power to damage skin cells’ DNA, which can result in gene mutations.  Gene mutations underlie cancers of the skin.

Although the layperson tends to consider skin cancer as a single threatening entity, there are three general types. Basal cell carcinoma is by far the most common in the U.S. “Basal cell skin cancer won’t metastasize,” says Sanders Callaway, M.D., of Dermatology Specialists of Augusta. Loretta S. Davis, M.D., professor and chief of dermatology at the Medical College of Georgia at Georgia Regents University, concurs. She adds, “It doesn’t shorten life, but it can cause disfigurement,” therefore it should never be ignored.

A common assumption is that older adults with liver spots and
overgrown moles are the primary victims of melanoma...
it is not a disease confined to the old.

Squamous cell carcinoma is not as common as basal cell and, unlike basal cell carcinoma, if not treated for a very long time, it can metastasize.  Dr. Calloway estimates that about 25 percent of skin cancer deaths result from squamous cell carcinoma. Similar to basal cell cancer, even if it does not metastasize it can result in disfigurement.

Both squamous cell and basal cell carcinoma are related to long-term sun exposure over a lifetime and occur on areas of the body not routinely covered by clothing. For example, Dr. Davis notes that squamous cell skin cancer “likes” forearms and the tops of hands, but any area consistently subject to UV rays risks developing basal or squamous cell carcinoma. These two types of skin cancer are most common in people with occupations or hobbies that take them outdoors for hours each day over many years. Moles and other skin blemishes that persistently itch, bleed, scab over and resist healing indicate the possible presence of either cancer type.

The third and most deadly category of skin cancer is melanoma. It results from genetic mutation of melanocytes, which are the cells that give skin its color or pigment. Whereas basal cell and squamous cell carcinomas usually grow relatively slowly, melanoma grows swiftly and metastasizes rapidly. “Even a very small melanoma has the potential to metastasize,” says Dr. Callaway. Melanomas can occur anywhere on the body, but frequently present on women’s lower legs and on men’s backs. Parts of the body that rarely or never see the sun are also susceptible. “You can get them where the sun doesn’t shine in all skin types,” adds Dr. Davis.

Dr. Davis advises, “People who have lots of moles and who have a family history of melanoma are at high risk.” Other risk factors include having had one or more bad sunburns as a child, intermittent sunburns (acute, intense sun exposure as opposed to chronic daily sun exposure), fair skin and a tendency to freckle. In addition, a suppressed immune system may contribute to development of melanoma.

Those with dark complexions are not completely in the clear, either. For example, melanoma in African-Americans commonly shows up on the palms of their hands and soles of their feet. Melanomas are frequently identified in moles displaying uneven pigment (more than one shade of brown) and increasing diameter. Over time, a mole affected with melanoma becomes less symmetrical with a ragged border.
A common assumption is that older adults with liver spots and overgrown moles are the primary victims of melanoma. False. Melanoma is not a disease confined to the old. “It does not respect age,” says Dr. Davis. The young are not spared from its devastating effects. In fact, according to Dr. Callaway, “Melanoma is the most common malignancy for women 20 to 30 years old and second most common after breast cancer for women 30 to 40 years old.”

Spotting a potential skin cancer of any type depends on cultivating the habit of examining one’s skin routinely. A monthly self-check introduces the lay person to his freckles, moles, liver spots and other discolorations and blemishes of the skin. Familiarity with how your skin looks will prime you to notice when something looks different.

When checking your skin, use the ABCDES method. Check moles and other skin pigmentations for “Asymmetry.” If you could fold it in half, would the edges NOT match up? Next examine “Borders.” Are edges jagged or scalloped rather than smooth? Inspect “Color.” Is there more than one shade of brown within a single mole? Does a particular spot of interest seem to be turning red or blue or white? Is there inflammation associated with the change in color? Visually measure the “Diameter.” Is a mole expanding in size? Is a mole larger than the diameter of a pencil eraser? “Evolution” or change is a critical indicator. Is something different about a particular place on the skin from the last self-examination? Finally, note “Symptoms.” Is it tender, painful or bleeding? “Nothing substitutes for a good skin exam,” says Dr. Davis. A yes answer to any one of these questions should prompt an appointment with a dermatologist.

Researchers estimate a 2,000 percent rise in the incidence of melanoma since 1930. The rise may be related to several factors, including longer lifespan and improved public education and awareness. But methods for diagnosis and staging are improving as well. Thus, patients are diagnosed sooner making cure (by excision) rates better.

Though dermatologists still rely on their expert eye 95 percent of the time, says Dr. Davis, most also keep a dermatoscope, a handheld polarized light, within reach for improved examination of suspicious lesions. Using dermoscopy, which came into favor in the early 2000s, physicians can more effectively distinguish between lesions that should be biopsied and those that should not. Another diagnosis device, the MelaFind, which aids in detection of melanoma at its earliest stages, has recently gained FDA approval and is being used by a handful of doctors across the U.S. Other non-invasive diagnosis methods, such as an analysis of skin cells removed from a suspected lesion via application of a specialized tape, also show promise in the lab and are just over the horizon. Nonetheless, says Dr. Callaway, “The gold standard is still skin examination and biopsy.”

Beginning this year, only sunscreens that have passed the prescribed broad spectrum (they block both UVA and UVB rays) test can be labeled as broad spectrum. The terms “waterproof,” “sweatproof” and “sunblock” are disallowed.

The most critical puzzle piece in treating melanoma is catching it as early as possible. “Melanoma is tricky in its staging,” says Brent Limbaugh, M.D., an oncologist with Augusta Oncology Associates. Dermatologists and oncologists are challenged to determine just how far it has spread. Fortunately, breakthroughs in the staging of melanoma have been achieved in the last five years. The standard pathologist’s report on the biopsy of a suspected melanoma includes information about how deep it is, whether it is nodular or spreading and whether it’s ulcerated. Now pathologists also include the melanoma’s mitotic rate, which indicates how rapidly the melanoma cells are dividing.

A second important advance in the staging of melanoma is the use of sentinel lymph node biopsy. In this procedure, the melanoma plus additional surrounding tissue is excised. Then physicians determine if the lymph node closest to the tumor shows evidence of invasion. If not, doctors are relatively confident that they have removed the entire melanoma.

For metastasized melanomas, “There’s no extremely effective treatment that exists,” explains Limbaugh. Current therapies only extend life for a few months up to about two years. Therefore, early detection and, more importantly, prevention remain the best courses of action. 

The FDA has taken steps to ensure that over-the-counter sunscreen labeling accurately represents to the consumer a product’s effectiveness. As of June 2012, new testing and labeling requirements went into effect and all sunscreen manufacturers were required to comply as of December 2012. Beginning this year, only sunscreens that have passed the prescribed broad spectrum (meaning they block both UVA and UVB rays) test can be labeled with the words “broad spectrum.” Any sunscreen on the shelves this summer that is not specifically labeled “broad spectrum” or that has an SPF value ranging from 2 to 14 (even if labeled ”broad spectrum”) is considered to only protect against sunburn and must display the following warning: “Skin Cancer/Skin Aging Alert:  Spending time in the sun increases your risk of skin cancer and early skin aging. This product has been shown only to help prevent sunburn, not skin cancer or early skin aging.”

Furthermore, claims of “waterproof” or “sweatproof” on labeling are disallowed, as is the term “sunblock.” Sunscreen products may only claim to be “water resistant” and must inform the user of how long protection will be effective while swimming or sweating.

Throw out sunscreen from last summer and purchase the new broad spectrum products. Apply sunscreen liberally (about the amount that would fill a shot glass is recommended) before going outside and re-apply at least every two hours. Wear protective clothing like wide-brimmed hats and long sleeves. Stay inside or in the shade between the hours of 9 a.m. and 3 p.m.  Teach children that there’s no such thing as a safe tan.

The lazy days of summer are here, but don’t be lazy about caring for your skin. There are so many sweet summertimes ahead to enjoy. 

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