What is happening to your skin when you tan?

The following is a link to an article authored by Prof Peter Soyer of The University of Queensland regarding the changes in your skin that lead to a tan. Prof Soyer is a dermatologist well known for his skin-related research. It is worth a read.

The access the article
click here.

Routine daily sunscreen advised

We have long recommended the routine application of daily facial sunscreen as an important strategy against sun-induced skin ageing and skin cancer. Now it's official…

The peak bodies responsible for sun safety advice in NZ and Australia have adopted a new policy recommending people apply sunscreen daily as part of their morning routine - just like brushing our teeth. The policy change follows an Australasian Sunscreen Summit in Brisbane last year. Prior to this, sunscreen was only recommended prior to anticipated outdoor exposure. It is now officially recognised that we get a lot of incidental sun exposure from everyday activities such as walking to public transport or to/from our car, walking to lunch, putting out the washing, having work breaks outside etc.

The new recommendation sticks with the traditional threshold of applying sunscreen when the UV index is 3 or greater. It is worth noting however; recent NZ study evidence suggests relying on the UV index may still lead to over-exposure.
Click here for more information.

Important warning about the flammability of moisturisers

It has been known for some time that moisturisers containing paraffin are flammable and can pose a significant risk of fire and injury if ignited. The most common scernario is for a spark from a fire or cigarette to ignite clothing/pyjamas of a child that are oily after application of moisturiser. Severe burns and deaths have been reported.

A recent warning published by the UK Medicines and Healthcare Products Regulatory Agency has extended the issue to moisturisers containing less than 50% paraffin and to non-paraffin containing products.

Patients who use these products should not smoke, go near naked flames, and be warned of the easy ignition of clothing, bedding, dressings and other fabric that have dried residue of an emollient product on them.

More evidence for the role of topical silicon in wound healing

The role of silicon in wound healing and scar treatment is well established. The initial discovery that scar tissue more readily loses water than normal skin was made incidentally during research for eczema. Silicon sheeting was designed which was found to help improve scar tissue symptoms and appearance. Later, silicon gel was designed to provide the same benefits but in a much more user-friendly form.

Dr Gunson has used these products for many years for new surgical and traumatic wounds, superficial wounds, and scarring. Most silicon products are not licensed for open wounds, or application to broken skin. Swiss manufacturers, Stratpharma however offer a range of silicon gel products, including one licensed for use on broken skin and open wounds.

Further evidence for the benefits of topical silicon in open wounds has just been published in the Clinical and Experimental Dermatology Journal (2018 43:718-37). The authors presented three patients who had undergone skin tumour excision on the scalp and extremities where the decision was made to allow the wounds to heal on their own, without sutures (termed second intention healing). The first case involved a scalp where the bone and it's covering periosteum was exposed. Usual wound care was applied but at day 15, the wound healing was not progressing well with non-viable tissue and a persistence of uncovered periosteum. Stratamed (Stratpharma) gel was then applied regularly to the wound and within 3 days, healthy granulation tissue (new vascular healing tissue) appeared, and complete healing progressed quickly thereafter. Two other cases were reported when the same gel was applied from day one and total healing time was reduced from the time usually expected (around 7 weeks for scalp wounds with exposed periosteum). The authors did not disclose any industry involvement, sponsorship, or other conflict of interest.

More information regarding silicon gel can be found
here.

The much anticipated Dermapen 4 MD has arrived

After an extended delay, we are pleased to have taken delivery of the brand new Dermapen 4 MD. This is a significant upgrade on our previous Dermapen 3 MD dermal microneedling device. There are 12 new features marketed on the new device. From our point-of-view, the most important are:

1. A new "scar treatment" setting which extends the depth of microneedling to 3 mm for stubborn scarring. Depth is digitally programmable in 0.1 mm increments for precision.

2. A 33% increase in microneedle density. The number of needles per disposable treatment head is increased from 12 to 16, creating more rejuvenating channels and more efficacy.

3. Oscillation speed is also increased up to 120 revolutions per second. This translates to a 1920 holes per second; 47.9% more than its Dermapen 3 predecessor.

4. Battery powered operation. This allows much improved convenience, manoeuvrability, and speed.

5. Improved treatment head design to automatically calibrate for precise reproducible needle depth, minimise drag and fluid build-up, as well as prevent any possibility of fluid cross-contamination.

The dermal microneedling process is now a well-established effective and safe skin procedure. Our most common indications are
scarring (old, new, acne, surgical, stretch-marks) and rejuvenation of age and sun-related skin damage (fine lines, wrinkles, dullness, and pigmentation).

For more information
click here.

Merkel cell carcinoma

There are numerous types of skin cancer. The three most common types are basal cell carcinoma, squamous cell carcinoma, and melanoma in order of incidence. These account for the vast majority of skin cancers.

Merkel cell carcinoma is one of the more rare types. It is about 30 times less common than melanoma in the US. However, diagnosis rates have been increasing recently. The reasons for this are unclear but it may in part be due to increased awareness of the signs and symptoms. Merkel cell carcinoma is an aggressive skin cancer and its prognosis is far better if it is picked up an a very early stage.

Some of the issues making Merkel cell carcinoma so dangerous are its rapid growth, tendency to spread (metastasise) early, and its relatively non-specific clinical features. We have the well-established
ABCDE criteria to help us all identify melanoma but knowledge of Merkel cell carcinoma is poor. An easily remembered acronym to help identify Merkel cell carcinoma was devised by a group who reported their findings in the Journal of the American Academy of Dermatology in 2008. Their AEIOU acronym is as follows:

A: Asymptomatic (generally not sore, bleeding, itchy etc)
E: Expanding rapidly (will grow quickly over weeks to a month or two)
I: Immunocompromised (people with HIV, chronic lymphocytic leukaemia, medication suppressing the immune system, organ transplant recipients are at much higher risk). However, 90% of patients do not have these issues
O: Older than 50 years (the incidence gets higher with every decade)
U: Ultraviolet-exposed fair skin

Almost 90% of Merkel cell carcinoma patients have 3 or more of these criteria. However, there are a number of other diagnoses that can share some of these features so not every skin bump with these signs is a Merkel cell carcinoma. An benign inflamed cyst or lipoma (fatty growth) or another skin cancer could present in a similar fashion.

However, if you or a family member has a bump that rapidly expanding like this, it is prudent to have it reviewed promptly and biopsy considered. Photos and further information about Merkel cell carcinoma can be found at:
https://www.dermnetnz.org/topics/merkel-cell-carcinoma

Sun protection advice based on UV index may not be correct

International health agencies recommend that no sun protection is necessary when the UV index is under 3. However, new data from a New Zealand NIWA research group published last month (www.nature.com/scientific reports) raised significant questions about the validity of this advice.

The issue is that the UV index value of 3 was chosen as the level of UV intensity which will lead a fair skin person to burn after one hour of exposure. This assumes no one spends more than one hour at a time outside, which is clearly flawed. Their data suggests that similar skin damage can be done from a long exposure at low UV dose, as is seen in short exposure at a higher UV dose.

This sits somewhat contrary to data about the body's ability to adapt to low dose sun exposure reported in this blog on 4 February 2017 below. The current study quotes recent evidence that there is a measurable increase in DNA damage from small increases in UV exposure even at low level. The February report however looked at a reduction in DNA damage with time, suggesting the body can adapt over a period of weeks if the exposure levels are low. The beauties and controversies of medical science!

They do raise another interesting observation. In winter, UV exposure to the face and neck is higher than the UV index would suggest. This is a result of the sun sitting lower in the sky, and therefore more dose hits these vertical surfaces than it does the horizontal surface that is used to measure the UV index.

What people want in the treatment of skin cancer

A recent study published in the medical journal, Dermatologic Surgery investigated patient preference in the treatment of the most common type of skin cancer, basal cell carcinoma. They reviewed six studies on the subject.

In four of the six studies, recurrence of the tumour was rated the most important attribute. Cosmetic appearance of the area after treatment was rated most important in one study, and the second most important in three studies.

This information is not surprising but highlights the utility of Mohs micrographic surgery for appropriately selected skin cancer lesions. Mohs surgery offers the lowest recurrence rates for these cancers and because it also specifically allows for the sparing of normal surrounding tissue, the defect size and subsequent reconstruction/scar can be minimised for the best cosmetic result. Additionally, recurrent tumours will require further surgery at a later date resulting in a larger defect and reconstruction. Also, recurrent tumours are more difficult to clear, have lower cure rates, and are more technically difficult to reconstruct.

Therefore, the first chance to treat is always the best chance to minimise the recurrence rate, and maximise the cosmetic outcome.

Stimulate your skin to rejuvenate itself

You may have read in the media this week that a number of people, including celebrities, are requesting removal of cosmetic implants and fillers. It is a reminder of the sense behind stimulating your skin to rejuvenate itself with its own natural collagen and elastin, rather than injecting or implanting foreign substances in order to simulate a younger look.

Sure, the injectables produce a faster and more pronounced result. However, if you are willing to wait for your skin to produce its own collagen and elastin after stimulation by dermal needling, you get a very natural and lasting result. You will also never be faced with wanting to remove a foreign substance at a later date because it is causing unwanted effects, or hasn't produced the natural look you are after.

Tell your skin to produce more of the natural components it had when it was younger. More information on dermal microneedling is available
here

Using heat to detect skin cancer

With skin cancer being such a major health issue in New Zealand it is always pleasant to read people are working on ways to improve challenges in the diagnosis of this disease.

In a recently published paper in the journal Skin Research and Technology, Magalhaes and colleagues reviewed the literature to date on the use of infrared thermal imaging for the diagnosis of skin cancer. This picks up subtle differences in temperature between benign and malignant skin lesions, presumably based on increased blood flow in the malignant lesions.

This non-invasive technology may be a promising tool for the identification of early skin cancer, hopefully in the not-too-distant future.

Reflected UV not as big as we thought

We have always been led to believe the UV radiation reflected off the water and sand when at the beach, or out on the water is part of the reason we are more prone to sunburn when undertaking these activities.

Interestingly, a recent study in the medical journal Photodermatology Photoimmunology Photomedicine (March 2018) concluded that in fact the vast majority of the sun's UV radiation passes into the water, and very little is reflected especially when the sun is high in the sky (the time when the UV level peaks). We certainly notice the reflected light with our eyes, but the reflected UV does not appear to have a major bearing on our skin.

The corollary of this fact is of course that we are still exposed to almost the same UV when we are swimming under the water as when sitting on the beach. The UV index was only reduced to half by a depth of two meters under the surface.

Adequate shade and protection from the sun above remains the priority when enjoying the beach or water sports.

The 'ugly-duckling' sign in melanoma

Self skin examination is very useful for detecting melanoma. In 1985, the ABCD acronym was introduced to help people identify suspicious moles themselves.

A = Asymmetry
B = Border irregularity
C = Colour irregularity
D = Diameter > 6mm

The E was a later but very important addition.

E = Evolving (changing)

Since that time, many of us have changed the D from diameter to DIFFERENT (i.e an 'ugly-duckling' mole that looks different for any of your other moles).

A late 2017 study reported in the Journal of the American Academy of Dermatology tested the utility of just the Ugly Duckling sign versus the ABCD acronym for simulated moles in 101 adult volunteers. The ugly duckling sign demonstrated superior accuracy of melanoma recognition, and better specificity than the ABCD group.

This is a simulated study in a relatively small number of participants, but it underlines the usefulness of a very simple tool that may increase the pick-up of melanoma by all of us. We tend to teach the whole ABCDE (with D as different) but given this data, possibly using just the D on its own is easier and more effective.

Does a higher SPF sunscreen provide better protection?

A lot has been written lately about sunscreens in the medical literature and the press. One comment you will read frequently is that there is very little benefit to an SPF (Sun protection factor) higher than SPF30. The basis behind this advice is scientifically sound.

Approximate UVB ray blockade:

SPF15 sunscreens block 93%
SPF30 sunscreens block 97%
SPF50 sunscreens block 98%

Looking at these figures, it would certainly seem reasonable to conclude, increasing SPF above 30 provides very little additional benefit.

However, standard SPF laboratory testing that dictates a sunscreens SPF rating is very different from how sunscreens are used in real life. Multiple studies have confirmed the fact that we do not apply our sunscreen anywhere near as thick as in the standardised SPF testing protocol (2 mg/cm2). When we apply our sunscreen at the beach, we are likely to be getting considerably less protection than the product provided in the laboratory setting. Therefore, using a higher SPF rated product will help cover the difference between testing and real-life usage.

This has now been proven in a December 2017 study published in the Journal of the American Academy of Dermatology. Nearly 200 people were randomised to apply a SPF50 sunscreen to one side of their face, and a SPF100 sunscreen to the opposite side of their face without knowing which was which. No advice was given as to the amount, or how to apply the sunscreen, so the experiment was closer to representing real-life usage. Independent and the subjects' own assessment of sunburn scores following sun exposure both showed significantly higher sunburn on the SPF50 side of the face compared to the SPF100 side.

There is also a second reason why a higher SPF sunscreen is likely to be more desirable. Broad-spectrum sunscreens (which are universally recommended as the best) can only be labelled 'broad-spectrum' when their UVA protection is at least 30% of the UVB protection (the SPF rating is based on UVB testing alone). UVA is a longer wavelength radiation present in the sun which has been implicated in both skin cancer and sun-damage to the skin. A higher SPF sunscreen therefore offers a higher UVA protection and therefore better broad-spectrum protection.

Sunscreens are only filters and do not block all of the sun's harmful radiation. They should be used in conjunction with other sun-protection behaviours such as seeking shade, using clothing and sunglasses, and keeping out of the sun in the middle of the day when the UV levels are at their highest. However, it seems higher SPF rated sunscreens do indeed offer increased protection when used in real life.

What is a Physician and does this differ from a Specialist?

The terminology used to refer to medical practitioners is becoming increasingly confusing. The word Specialist is often used to mean a variety of qualifications or special interests of a doctor. Physician is another term that is easily misunderstood.

What is a Physician?


In Australasia, a physician is a medical specialist who has completed at least six years of additional training in a medical specialisation after their medical degree and internship. In some countries (such as the United States of America) the term Physician is interchangeable with medical practitioner. This is not the case in New Zealand and Australia.

Specialist versus Physician?

All Physicians are Specialists, but not all Specialists are Physicians. Physicians training and accreditation is under the
Royal Australasian College of Physicians (RACP). The term "Skin Specialist" is sometimes used by those without Dermatology Specialist training.

So what is a Dermatologist?

Every Dermatologist trained in New Zealand is a RACP specialist Physician. They are also all Fellows of the New Zealand Dermatological Society (FNZDS). Further information is available at the website of the
New Zealand Dermatological Society Incorporated.
Pasted Graphic

Why is the risk of skin cancer so high in New Zealand?

If you talk to those who travel, it is widely noted that the intensity of the sun in New Zealand is significantly higher than that in North America or Europe. In fact, a NIWA study has shown that our UV index is approximately 40% higher than similar latitudes in the northern hemisphere.

It is interesting to note in the recent publication of the NZ Health Promotion Agency (New Zealand Skin Cancer Primary Prevention and Early Detection Strategy 2017 to 2022) the following three reasons are listed as the main causes of the difference in UV index intensity:

1. Our clearer, unpolluted skies (a 20% effect)
2. Our lower ozone levels (a 7-10% effect)
3. The reduced distance between us and the sun during our summer compared to a northern hemisphere summer due to the elliptical orbit of the earth around the sun (a 7% effect)

The full document can be read at
www.sunsmart.org.nz

How exercise may lower cancer risk

The New York Times reported on an interesting study into how exercise may protect us from the development of cancer. The study was published in the journal Cell Metabolism and involved laboratory mice with melanoma. The mice that were provided with running wheels developed far less melanoma and metastases than those mice that remained sedentary.

They found higher levels of adrenaline, interleukin-6 (IL-6), and natural killer (NK) cells in the exercising mice. NK cells are immune cells with a known cancer-fighting ability. It seemed from their study that the increased blood levels of adrenaline in the exercising mice, primed their IL-6 producing cells to activate the NK cells. More data is needed to prove the same mechanism occurs in humans, but other studies have shown adrenaline and NK cells are both increased by moderate exercise in humans.

Exercise is good for our body and mind in so many ways. This interesting study provides further evidence of its benefits.

The full article is available
here.

Merry Christmas and a Happy New Year

Wishing all our valued patients a happy Christmas, relaxing holidays, and a prosperous 2018.

Dermal microneedling in the journals again

The Dermatologic Surgery journal has just published a literature review of microneedling including all references to skin scarring and rejuvenation. The article conclusion was "Microneedling is a safe, minimally invasive, and effective aesthetic treatment for several different dermatologic conditions including acne and other scars, rhytids, and striae. Given its expedient post-treatment recovery, limited side-effect profile, and significant clinical results, microneedling is a valuable alternative to more invasive procedures such as laser skin resurfacing and deep chemical peeling."

They refer to the studies that hypothesise the mode of action is that the creation of numerous microchannels physically breaks up compact scar tissue in the superficial dermis, while spontaneously inducing the production of new collagen and elastin underneath. The same production of new but native components of the dermis works to elevate existing furrows and wrinkles, and tighten and rejuvenate the skin. The microchannels represent tiny wounds which also stimulate the release of various growth factors such as platelet-derived growth factor, fibroblast growth factor, and transforming growth factor (TGF) alpha and beta. Perhaps most exciting is that the data shows up-regulation of TGF-B3 over TGF-B2. TGF-B2 is associated with fibrotic scarring in most wounds, but TGF-B3 promotes regeneration without scarring (scarless healing). A direct demonstration of this phenomenon is seen in foetal wounds that heal without scarring because of the predominance of TGF-B3 over TGF-B2 in the foetus.

While there is nothing particularly new in this article, it summarises well the advantages of this minimally invasive but effective treatment. We have been consistently very pleased with the results in our own patients. It is worth noting that the collagen induction and skin improvement is not immediate and the beneficial effects of each treatment can continue to work for up to 12 months. Treatment intervals are usually between two to four week to allow time for the cumulative effect to take place. There are a myriad of products and procedures advertised to treat scarring and skin rejuvenation. The benefits of skin microneedling are that it is promoting your own skin to rejuvenate itself with your body's own growth factors and dermal components rather than applying these or injecting them. The effects are therefore likely to last much longer and are much safer.

The authors indicated they had no significant interest with commercial supporters.

Reference: Microneedling: A review and practical guide. Alster TS, Graham PM. Dermatol Surg 2017;0:1-8.

Good topical acne treatment reduces scarring

A recent small study published in The Journal of the European Academy of Dermatology and Venereology confirms what we know of the benefits of good treatment early in acne using topical retinoids (vitamin A analogues). 31 adults with moderate acne and atrophic (sunken) facial acne scars were treated on one side of the face with a combination cream (adapalene and benzoyl peroxide) and the other side treated with a placebo cream. The duration of the study was six months.

Scarring increased over the study period on the placebo side, but did not on the active side. There was also a significant reduction in the severity of existing scarring on the treatment side, but not on the placebo side.

Dermatologists have long understood the value of early topical retinoid use in acne for improving control without contributing to antibiotic resistance. Prevention of acne scarring is far preferable to treatment. Topical retinoids also have a significant role in improving existing scarring.

Daily facial sunscreen improves photoaging

A recent prospective study of 32 participants over a one-year period has demonstrated that applying a broad-spectrum SPF30 daily facial sunscreen improves all the studied signs of photo-aging. The signs that improved were: overall photo damage, overall skin tone, crow's feet, fine lines, mottled pigmentation, discrete pigmentation, evenness of skin tone, clarity, and texture. Some of the improvements were also noted as earlier as 12 weeks into the study. Not only did the investigator scores improve, but the participants themselves agreed with the improvement. The most profound improvement was in skin surface and tone.

This study helps confirm dermatologist's long-standing belief of the benefit of a daily application of facial sunscreen (preferably in a pleasant moisturiser base) to not only protect against skin cancer, but also improve cosmetic appearance. Of course, this is not a ground-breaking new concept and there is a risk that people tire of the suggestion, but sunscreen is one of the most important factors in any anti-aging regimen. Remember, we believe 80% of the appearance of ageing skin originates from sun-damage rather than age itself. Just compare the look of the skin on your forearm to that the skin on the inside of your upper arm.

Source: Randhawa M, et al. Dermatol Surg 2016

Dr Gunson is a nib Health insurance First Choice provider

Dr Gunson is a First Choice provider to nib Health insurance. This means for those nib customers affected by the nib First Choice network, they will have 100% of eligible costs covered (in line with their policy) when they see Dr Gunson.

NIB first choice provider

Caution regarding melanoma following laser treatment of pigmented skin lesions

It is of critical importance to have a confident diagnosis of a coloured skin lesion prior to laser being performed. A study published recently in The Journal of Dermatology reported 11 patients with a melanoma diagnosed in a region previously treated with laser therapy. In 9 cases, no biopsy was taken prior to laser. In the other two, pre-laser biopsy had shown a benign lesion. Four of the 11 patients progressed to stage IV disease and at least one died of melanoma.

This emphasises the very real difficulty in the diagnosis and treatment of pigmented skin lesions. It is imperative that a reliable diagnosis is established prior to any laser treatment. Each case is different, but a biopsy should be considered. As demonstrated with this series however, a partial biopsy of a pigmented lesion is not always representative of the lesion as a whole.

A high level of suspicion and caution should be exercised before making the decision to have a brown mark lasered off. We see cases, not infrequently, where the laser has removed the pigment but not the melanoma cells themselves. This can delay the subsequent diagnosis and treatment of the melanoma - with potentially fatal consequences. Pigmented skin lesions are not necessarily a mere cosmetic issue, and must be treated with the respect they deserve.

Dr Gunson's research findings incorporated into the WHO global guidelines for the prevention of surgical site infection

Dr Gunson's research group is honoured to have been referenced in the 2016 World Health Organization (WHO) Global Guidelines For The Prevention Of Surgical Site Infection. The document provides detailed, evidence-based, peer-reviewed consensus recommendations regarding pre-, intra-, and postoperative interventions aimed at reducing the risk of infection related to surgical procedures.

Section 4.2 Decolonization with mupirocin ointment with or without chlorhexidine gluconate body wash for the prevention of Staphylococcus aureus infection in nasal carriers undergoing surgery, makes the recommendation that treatment be considered in patients with known nasal carriage of S. aureus undergoing other types of surgery with perioperative intranasal application of mupirocin 2% ointment with or without a combination of CHG body wash.

This recommendation references Dr Gunson's 2013 study using this approach in the prevention of surgical site infection in Mohs micrographic surgery. Austral J Dermatol. 2013;54(2):109-14.

The full WHO guidelines are available for download at:
http://www.who.int/gpsc/ssi-prevention-guidelines/en/

Coffee consumption may reduce the risk of basal cell carcinoma

You read statements like this all the time. Often, you end up reading a contradictory article on the same topic not long after. You then choose to believe the one that suits best!

Here's a meta-analysis study (a study looking at all the previous smaller studies on the topic) published in the European Journal of Cancer Prevention. If you like your coffee, the news is all good. It states that there is a statistically significant reduction in the risk of basal cell carcinoma (our most common skin cancer) which increases with the more coffee you drink. The relative risk at one cup per day was 0.96 (a 4% reduction in risk) and this increased steadily to 0.81 (a 19% reduction in risk) for more than three cups of coffee per day.

Go and grab yourself a coffee - you've got the justification, if you need it!

Steroid phobia for kids with eczema needs to stop

Our Australasian College of Dermatologists (ACD) has today made public is study and resulting position statement, patient fact sheet, and Q&A.

This is a significant issue due mostly to people with good intents but simply based on misinformation. This study is a positive step for children with eczema and their families. This disease can caused huge morbidity and appropriate, effective management is very important.

Links:

ACD Media release

Topical corticosteroids and eczema position statement

Patient fact sheet

Patient Q&A

Adding some clarity to the vitamin D debate: all things in moderation

The debate regarding the benefits of sun-exposure with respect to vitamin D production, versus the risk of skin cancer has been prolonged and confusing. An increasing list of the virtues of a healthy vitamin D level to our bodies is evolving. Against this; the production of vitamin D relies on the exposure of our skin to ultraviolet light (UV) which is well known as a human carcinogen. Mixed messages are sent, leaving the public unsure and distrusting of the advice received. One minute we are told to cover-up. The next report tells us there is a vitamin D deficiency epidemic and we must all get more sun-exposure to help our bones, our immune system, and prevent cancer. While media reports favour dramatic and sweeping statements, it is difficult to give general advice when each person's genetic and environmental make-up is so varied. Dark-skinned people living in areas of low UV-exposure are far more at risk of vitamin D deficiency than skin cancer. The opposite is true for fair-skinned people living in a high UV environment.

A 2014 study in fair-skinned Danish people proved that exposure to high UV levels while on holiday in the Canary Islands unfortunately not only led to an increase in vitamin D levels, but also to a significant increase in known biological markers of skin cell DNA damage. So what do we do? We need sun-exposure to make vitamin D, but as soon as we try to get it, we induce skin cancer??

As with most debates, a degree of moderation often ends up the best conclusion. With this in mind, a recent study performed by Felton et al. was reported in the British Journal of Dermatology. Our natural skin pigmentation level is measured by the Fitzpatrick Skin Type Scale. Fitzpatrick skin type I through to type VI document extremely fair skin that always burns and never tans (pale peach, blond or red hair, blue eyes, freckles) through to very dark skin that never burns, and always tans.

In the latest study, Felton et al. compared the results of people of Type V skin (dark brown) to Type II skin (fair) to simulated UK-latitude sun-exposure. The UV-exposure was equivalent to 13-17 minutes of exposure to the UK June midday sun, six times per week for a six-week period. They confirmed what we know: Type II skin demonstrated more DNA damage, and Type V skin less serum vitamin D production following sun-exposure.

However, interestingly they also found that mechanisms within our skin are present to respond to gentle sun-exposure by repairing sun-damaged DNA, and therefore reducing the risk of UVB-induced skin cancer. 24-hours after the six-week exposure period, the urine levels of CPD (a surrogate marker of skin DNA damage) and another DNA-damage marker (8-oxo-dG) were undetectable in both groups. This strongly suggests that fair skin can adapt to gentle sun-exposure, protecting itself against damage while allowing the production of vitamin D.

Moderation

The important difference between the Danish study results and Felton's study is the level of UV exposure. The Danish study involved high-intensity UV levels. Felton's study involved longer, lower level exposures. Clearly, the summer-time UV levels in New Zealand and Australia are intense, and 13-17 minutes in the midday sun is likely to yield very different and detrimental results. However, gentle low-level exposure (e.g early mornings and late evenings, non-summertime etc) may mean we can get the best of both worlds. This also sits nicely with advice to use sunscreen during times of high exposure. Sunscreen filters out a proportion of UV radiation (rather than completely blocking it) reducing the dose reaching your skin and therefore should help achieve the effect seen in Felton's study rather than that seen in the Danish study. A number of studies have shown that the use of sunscreen does not reduce vitamin D levels in subjects exposed to the sun. Again, generalised advice is difficult. We need to take into consideration our skin type, our individual risk-factors for skin cancer (past exposure, family history etc), and our geographic location to strike a balance that will work well for our own situation.

We have known from previous studies that the high-intensity UV-exposure is not needed for efficient vitamin D production. In fact, vitamin D begins to be degraded at high UV exposure levels. While the relationship between increasing UV exposure and DNA damage is linear, the relationship between UV exposure and vitamin D production is non-linear. Maximum vitamin D production is seen at around 1/3 of the UV dose that induces a slight sunburn. Clearly, the advice never to allow yourself to get sun-burnt stands strong. The body's homeostatic and protective mechanisms are incredible, but can be overcome but extreme exposure (common during Australasian summertime sunlight exposure). However, we don't need to completely avoid all sun-exposure and risk vitamin D deficiency either. The benefits of sunlight (independent of vitamin D) as well as regular outdoor physical activity are well known. This study helps us to understand that with moderation, the clever machine that is our body, may well be able to manage the balance between optimal vitamin D level and skin cancer risk.

A word of caution however, Felton's study was performed on subjects aged 23-59 years old. Whether the same results would be found in older subjects is unknown. Prior studies demonstrate older skin lacks the same ability to repair skin DNA damage due to reduced IGF-1 production by the skins fibroblasts. Interestingly, anti-ageing resurfacing procedures such as micro-needling, dermabrasion, and lasers appear not only to improve the skin's appearance, but to rejuvenate the dermal fibroblasts protective IGF-1 production. Studies on this topic are ongoing to determine if skin resurfacing procedures do indeed produce a lasting preventative effect against skin cancer - rejuvenating not only the skin's appearance, but it's function as well.

Vitamin B3 (nicotinamide) role in preventing skin cancer

Nicotinamide (Vitamin B3) has been shown by Professor Diona Damian's research group (The University of Sydney) to have a role in the prevention of non-melanoma skin cancer and the common pre-cancerous skin lesions, actinic keratoses. Their landmark study (ONTRAC) published in the New England Journal of Medicine late last year demonstrated a 23% reduction in new non-melanoma skin cancers in high-risk patients taking nicotinamide when compared with the placebo group. There was no significant difference in side-effects in the nicotinamide group versus the placebo group.

The exciting aspect of this research is that the treatment potentially offers an inexpensive and safe way to reduce non-melanoma skin cancer which is extremely common in New Zealand. Nicotinamide appears to work by enhancing DNA repair in sun-damaged skin, and by reducing the immunosuppression in the skin causing by UV light.


Do sunscreens prevent you getting necessary vitamin D?

No. Only a small amount of vitamin D is received directly from diet. The majority of our bodies vitamin D comes from conversion in our skin due to sunlight exposure. We know vitamin D is critical for healthy bones but it may have other major health benefits in many areas of our body.

So, if we protect ourselves against skin cancer with sunscreen - are we risking getting low on vitamin D? Fortunately, a number of studies demonstrate that sunscreen, in normal use, does not cause vitamin D deficiency. There are a number of explanations for this. Firstly, sunscreen is only a screen, not a total block. Some UV still gets through to the skin. Secondly, the data tells us, we only need a very small amount of UV to generate vitamin D. Depending on your skin type, exposing just 10% of your skin to 3-7 mins of sun in the New Zealand summer is enough to provide adequate vitamin D without sunburn. In fact, after a certain point of exposure, vitamin D begins to get degraded by further UV exposure. Finally, when sunscreen is applied in real-world situations, it not applied as thickly, as completely, or as frequently as it should be to provide maximum protection.

Sources: Research Review Educational Series. An update on sunscreen IV. 2015 and Sunscreen Myths Busted. 
Medscape. Jul 19, 2016.

Do sunscreens actually prevent skin cancer and pre-cancerous skin lesions?

Yes. The most regarded randomised controlled trial on the subject is the Nambour study out of Queensland, Australia. The study followed 1600+ people from 1992 to 2006. The reduction of squamous cell carcinoma (the second most common type of skin cancer) in the group that applied daily sunscreen was profound. Invasive melanomas were substantially reduced in the sunscreen group while the thinnest melanomas (melanoma in-situ) showed a trend towards reducing. No clear reduction in basal cell carcinoma was seen in this study. A possible explanation of this finding is that the time from sun exposure to basal cell carcinoma development is very long, and so it is very difficult to capture this effect in a study spanning even 5-8 years. This study and three other randomised controlled trials confirm that the regular use of sunscreen reduces actinic keratoses (precancerous skin lesions that may progress to squamous cell carcinoma with time). Source: Research Review Educational Series. An update on sunscreen IV. 2015

New UV index app

A new mobile app called uv2Day has been released that gives real-time updates on the current UV index specific to your location around New Zealand. Data is supplied by NIWA. You can download it for free from the Apple App Store, or Google Play.

Dermal microneedling compared with laser for acne scarring: same effect, less side-effects

A long-awaited randomised clinical trial comparing the effect of fractional erbium laser with microneedling for the treatment of acne scarring, was published in the February 2016 issue of the Dermatologic Surgery journal.

46 patients with facial acne scars were randomised to receive either laser or microneedling for three, monthly sessions. Two blinded dermatologists assessed the results at two and six months after treatment. Both groups showed significant improvement, and there was no statistically significant difference between the results of both therapies. The redness after each session was longer in the laser group, and 13.6% of subjects experienced post-inflammatory hyperpigmentation. No post-inflammatory hyperpigmentation was observed in the microneedling group.

The study concluded both treatments are comparable and effective in the treatment of acne scarring. Microneedling however was better tolerated, with fewer side-effects, and a shorter down-time.

Men, two ways to reduce your chances of premature greying

A cross-sectional study of more than 6000 men published in the Journal of the American Academy of Dermatology journal identified three risk-factors associated with premature hair greying:

1. Family history of premature greying (especially on father's side)
2. Obesity
3. Smoking (more than a 5 packet-year history)

You can't change your family, but quitting smoking, and maintaining a healthy body weight can reduce the chance of turning grey early. Do it in 2016.

A superior application technique for sunscreen

A recent article published in the Photodermatology, Photoimmunology & Photomedicine medical journal describes a new technique of applying sunscreen which dramatically improves the coverage compared with how most people apply sunscreen. One known issue is the quantity of sunscreen we routinely apply is insufficient. This article suggests appropriate quantities for each body area measured in teaspoons. The second issue is the application technique which will spread the sunscreen evenly minimising the chance of gaps. The principle is to apply evenly spaced spots of sunscreen to the area, then rub them in a circular motion appropriate to the area of the body. UV analysis with photographs were used to compare the new method with the standard method. The new method was superior in the following parameters: evenness of spread, amount applied, and body surface area covered.

The article is available free at:
http://onlinelibrary.wiley.com/doi/10.1111/phpp.12138/epdf

You don't need to read all the detail but the table at the top of the third page is most important, as it explains the technique in pictures.

Modified-Mohs surgery optimal for the management of melanoma in-situ

A new study published in the November 2015 edition of the British Journal of Dermatology, adds further confirmation as to the optimal treatment for melanoma in-situ (the earliest/thinnest and most common form of melanoma).

This has been Dr Gunson's treatment of choice for this form of melanoma for many years. The technique is a modification of the standard Mohs Micrographic surgery method. It is often very difficult to accurately interpret melanoma cells on the frozen section used during standard Mohs surgery for other skin cancers. Utilising a paraffin-based tissue sectioning for melanoma provides increased accuracy. Unfortunately, paraffin-sectioning takes longer and requires sending the specimen to an off-site laboratory. With this comes delay and logistical issues. However, as this new study has again demonstrated, the superior results make the additional time and hassle well worthwhile, leading to significant improvements in cure rates, compared with tradition surgical excision.

The fundamental difference is that Mohs-type analysis seeks to examine 100% of the peripheral margin of the excision. Standard paraffin-sectioning relies on a small number of cross-sections cut as you would when slicing a loaf of bread. The biology of this type of melanoma is renown for extensive sub-clinical spread (melanoma cells extending well past that seen on the surface of skin). Random cross-sectional analysis examines a very small proportion of the total peripheral margin of the excision, increasing the chances of melanoma cells being left behind following a "complete" standard excision.

The Modified Mohs technique takes place in a staged-fashion with the highly accurate pathology analysis occurring overnight. The wound is dressed and the patient is able to return home. The results are available the following day. Further targeted excision of any residual melanoma can then taken if necessary, and sent for the same rigorous examination. Once no further melanoma cells are seen, the wound is reconstructed in the usual manner. The patient and doctor can then share confidence that the tumour has been removed with the highest chance that it will not recur at a later date.

Acne and diet

It turns out, Grandma was right… Chocolate gives you pimples.

In the 1930-60's it was widely believed that too much chocolate was responsible for acne. Two relatively weak studies in the late 1960's/early 70's however showed no link, and from then through to around 2012, it was all considered a myth.

However, there are now numerous, robust scientific studies that show that the consumption of high glycemic index food is associated with acne. The glycemic index (GI) refers to the effect different carbohydrate-containing foods have on blood sugar levels, and hence the body's insulin levels. A high GI food leads to a rapid rise in insulin secretion. The insulin, and associated insulin-like growth factor (IGF-1) both lead to changes in the skin and oil glands that cause acne. In addition, they result in increased androgens (male hormones known to stimulate acne).

Milk also stimulates insulin, and therefore has the same effects on acne. In addition, cows milk contains IGF-1 (identical to human IGF-1), and a number of dihydrotestosterone precursors (androgens). The evidence for the role of milk in acne is based on less robust data, but there are numerous observational studies that support it. The studies suggest skim-milk to be particularly acne-stimulating, likely because of a higher whey protein concentration.

Finally, whey protein containing supplements (e.g. body-building) are highly likely to cause acne based on their ability to stimulate insulin. Whey protein is the soluble milk product left over after the coagulation process in cheese-making.

So, chocolate
can give you pimples after all…

Further information regarding the GI index, including an extensive searchable database of foods is available at
glycemicindex.com

Congratulations to the All Blacks!

Is not officially skin news, but huge congratulations to the ALL BLACKS!! A great game, and a very well deserved win. World champions again!

Dermapen® dermal needling

Dermapen® is one of our most useful and safe tools for a variety of skin disorders. Thousands of micro needle channels are created in the skin at a fully controllable depth. Established research shows that these channels stimulate the body's healing response, and the creation of new collagen and elastin fibres within the dermis. For this reason, it is also known as Collagen Induction Therapy (CIT) or Percutaneous Collagen Induction (PCI).

One of the key effects of PCI is it's induction of Transforming Growth Factor Beta-3 (TGF-
3) within the skin. Studies have shown elevated levels of TGF-3 for up to two weeks following PCI treatment. As a result, the healing response is directed to lay down normal collagen, rather than scar-type collagen.

Secondly, the needling process develops micro channels without using heat. This means less inflammation, and a large reduction in risk of scar-type collagen and post-treatment pigmentation, even in darker skin types.

Thirdly, Dermapen can be used to increase the absorption of other active ingredients that would otherwise struggle to reach the desired level within the skin, in an adequate concentration.

Finally, Dermapen has a very minimal associated post-treatment downtime. For most treatments, the skin is red and perhaps slightly swollen in the affected area for 12-48 hours. It is common to experience some very superficial dryness and/or peeling of the skin from day 3-10.

Dermapen is used to treat:

Scarring (acne, surgical, hypertrophic, keloidal)
Ageing skin (wrinkles, laxity, lack-lustre surface, pigmentation)
Stretch marks
Dilated pores

Click for more information

Clinical Excellence Award Winner

Dr Gunson’s research group is very pleased to be the recipient of a Clinical Excellence Award from the Australian Government’s National Lead Clinicians Group.  The theme of the 2014 awards was Excellence in Innovative Implementation of Clinical Practice, and the research was judged in the antimicrobial resistance category.  A pdf poster summarising the award-winning research can be viewed here: clinical excellence award 2014.pdf.  Further information regarding the National Lead Clinicians Group awards can be found here.  Summaries of Dr Gunson’s international journal article publications can be found here.

Top 10 international dermatology journal article winner for 2014

Dr Gunson’s research paper regarding the prophylactic use of antibiotics in cutaneous surgery made the prestigious list of the top 10 most important research papers in the field of dermatology as decided by the New England Journal of Medicine.  You can view the list here, and a summary of the article here.

Archive

Sunscreen Controversies

A recent Researchreview.co.nz publication “An update on sunscreens III” made the following useful points regarding some of the current controversies and mis-information regarding sunscreens:

Vitamin D deficiency:

Reviews of the published literature indicate that the topical use of sunscreen protects against skin cancer but does not cause sub-normal vitamin D levels.  A randomised double-blind study by Marks and colleagues demonstrated that daily use of a broad-spectrum SPF17 sunscreen over the summer season was not associated with sub-normal vitamin D levels in Australian adults.  New Zealand researchers have demonstrated that exposure of the hands, face, and neck (10% of skin surface area) for about 3 minutes per day in the Auckland summer (through to about 60 minutes per day in the Invercargill winter) is sufficient to maintain normal vitamin D levels.

Sunscreen toxicity:
A number of studies conclude systemic toxicity of sunscreen in humans has not be demonstrated.  Regarding consumer concerns that nanoparticles in sunscreen might be absorbed into the bloodstream, the Australian Therapeutic Goods Administration states that nanoparticles are not a risk to health.

Sun damage is mainly obtained at the beach:
A prevalent perception is that sunburn occurs mainly during water-based activities, such as at the beach.  However, there is data showing that most people actually get sunburnt during home-based activities such as gardening or other activity around the home.



Vit B3 appears to prevent non-melanoma skin cancer in high risk adults


An Australian study presented at the American Society of Clinical Oncology Annual Meeting in Chicago, suggests the rate of non-melanoma skin cancer is reduced in high-risk patients (more than 2 skin cancers in the past 5 years) by taking oral nicotinamide (vitamin B3).  In this placebo-controlled trial, 500mg twice daily dosing was given for 12 months.  There was a significant reduction in new non-melanoma skin cancers (1.77 vs 2.42 over 12 months).  The treatment is inexpensive and appeared to be as safe and well-tolerated as the placebo in this study.  Reported elsewhere, nicotinamide can cause gastrointestinal upset.  Caution is always necessary basing recommendations on a single study but the findings are very encouraging.
Martin AJ et al.  Oral nicotinamide to reduce actinic cancer: A phase 3 double-blind randomized controlled trial. American Society of Clinical Oncology Annual Meeting, Chicago, May 2015. Abstract 9000.



Confusion regarding conflicting SPF testing on New Zealand sunscreens


A recent Consumer magazine article has reported concerns regarding the reproducibility of sun protection factor (SPF) testing.  Read the online article here.  In general terms, stick with reputable brands, observe the storage instructions and expiry date, shake the product well prior to application, and apply plenty of sunscreen, at least 15 minutes prior to exposure.  Seeking physical protection via shade and clothing is also very important.  Any sunscreen is only a ‘screen’ to reduce, but not block all UV radiation.



Atopic dermatitis (Eczema) news:

Vitamin D for winter eczema
A study of 107 children, aged 2 to 17 years-old has shown a clinical and statistically significant improvement in winter eczema with oral vitamin D supplementation daily for one month.  The study took place in Mongolia - a place where winter vitamin D deficiency is likely, and so the relevance to New Zealand is unclear.  We do routinely see eczema worsens in the winter months when the relative humidity is lower.  As always, the frequent application of moisturisers is critical to the good control of eczema. 


Moisturisers prevent eczema in at-risk babies
Two separate studies involving 242 newborns at risk of developing atopic dermatitis, show that applying simple moisturisers from the first 1-3 weeks of life dramatically reduces the likelihood of the infant developing atopic dermatitis at 6 and 8 months of age.  The risk was halved in the study involving 124 newborns.  Moisturisers used in the study were petroleum jelly, sunflower oil, and a commercial cream or ointment.  This approach appears safe and inexpensive, with the potential for a dramatic reduction in the risk of a disease which causes a significant burden on children, and their families.

The above three articles were published in the October 2014 issue of the Journal of Allergy and Clinical Immunology.




The biology of addiction to the sun

An article published in the medical journal Cell in June sheds light of why humans enjoy the feeling of sunlight on our skin.  It turns out, that when the cells in our epidermis are exposed to UV radiation, DNA damage leads to the polypeptide POMC (proopiomelanocortin) being broken down into various peptides.  One of these peptides stimulates melanocytes (pigment cells) to produce a tan.  Another peptide is beta-endorphin - a feel-good chemical that travels from the skin to the blood stream.  Endorphins are ‘morphine-like’ chemicals which can reduce the transmission of pain signals, and also provide a feeling of euphoria.
From this and other research, sun-exposure appears to have a clear biological potential for addiction; similar to smoking and alcohol.  It is not yet known what effect sunscreen has on UV-induced endorphins.  A subconscious aversion to sunscreen could theoretically occur if sunscreen indeed does block the desired opioid effect.
Skin β-Endorphin Mediates Addiction to UV Light. Fell GL, Robinson KC, Mao J, Woolf CJ, Fisher DE. Cell. 2014 Jun 19;157(7):1527-34.




Auckland UV levels at least as high as Australia

Australia is commonly referred to internationally as one of the highest-risk environments for skin cancer.  New Zealand seldom gets a mention - presumably because of its much smaller size from an international perspective.  However,  even within Australasia, many people falsely assume, the risk and rates of skin cancer are much higher in Australia than New Zealand.  Presumably this is based on assumptions of higher ambient temperatures, and/or sunshine hours.  Interestingly, the environment in New Zealand is at least as dangerous as it is in Australia based on UV indices.  A cooler ambient temperature, and potentially more cloud-cover may in fact, increase the risk of prolonged outdoor exposure and hence skin cancer.  The two tables below demonstrate the maximum UV index levels in Australian cities versus those in NZ.  Interestingly, Auckland equates fairly closely to that of Perth.



Oz UV



Source:  wiki.cancer.org.au/skincancerstats/vitamin_d


NZ UV

Source: wwwi.cancernz.org.nz/reducing-your-cancer-risk/sunsmart/the-ultraviolet-index/the-ultraviolet-index/



Elevated melanoma risk in pilots and cabin crew

According to a recent study published in the journal JAMA Dermatology, pilots have a 2.22 fold increase risk of melanoma, and cabin crew 2.09 fold increase, compared to the general population.  It is known that airline staff are exposed to higher levels of cosmic and UV radiation, but the study does not demonstrate the mechanism of this increased risk.  Further study is needed to investigate this confirmation of what we see clinically in our patients who are pilots. 
Sanlorenzo M et al. JAMA dermatol, published online 3 Sept 2014.



Educating teenagers about sun-protection

As with all public health messages, it is important to convey the desired message in such a way that is likely to achieve a maximal beneficial response.  A recent study in the Journal of the American Academy of Dermatology confirmed what we suspected with regard to educating young people about sun-protection.  50 adolescents (average age 17-years-old) were divided into two groups - one group was shown a video regarding the dangers of melanoma and non-melanoma skin cancer; the second group was shown a video demonstrating changes in appearance caused by sun-exposure (wrinkles, sun-spots etc).  While both groups showed an increase in understanding of the dangers of UV exposure, only the adolescents in the appearance video group actually changed their sun-protection behaviour by increasing their use of sunscreen.
Tuong W, Armstrong AW.  Effect of appearance-based education compared with health-based education on sunscreen use and the knowledge: a randomized controlled trial.  JAAD 2014;70(4):665



How long does the sun-protection message last after a melanoma diagnosis?

A recent Danish study used UV-watches to measure sun-exposure in a group of 21 melanoma patients, and 21 non-melanoma subjects over a three-year period.  Over the three years, the control subjects had stable sun exposure.  In contrast, the melanoma patients gradually increased their sun exposure, and after the second year following their melanoma diagnosis, they were exposing themselves to more UV than the control subjects. 
Idorn LW, Datta P, Heydenreich J, Philipsen PA, Wulf HC. A 3-year follow-up of sun behavior in patients with cutaneous malignant melanoma. JAMA Dermatol 2014Feb;150(2):163-168



Sun protect you, not just your moles

A recent European study regarding the use of sunscreen made the interesting discovery that nearly 5% of those surveyed were applying sunscreen only to their moles.  The intention was to allow a tan without risking the moles turning into melanoma.  The authors remind us that this practice has no scientific basis, and that the application of sunscreen and other sun-protection measures should be on the entire body.  Melanoma and non-melanoma skin cancers often arise in normal skin and therefore sun-protection needs to include all exposed skin to be effective.
Suppa M1, Argenziano G, Moscarella E, et al. Selective sunscreen application on nevi: frequency and determinants of a wrong sun-protective behaviour. J Eur Acad Dermatol Venereol 2014 Mar ;28(3):348-354.



Ongoing need for surveillance following first melanoma diagnosis even with the earliest melanomas (melanoma in situ)

A new study out of Queensland examined the risk of developing a subsequent invasive melanoma after diagnosis of the first.  The relative risk (risk compared with the age-matched normal population) of developing a further invasive melanoma was calculated from data of over 62000 cases. Persons with a first primary invasive melanoma had a risk of 5.4 times normal.  Persons with a first primary in situ melanoma had a risk of 4.6 times normal.  The second melanoma was more likely to occur at the same body site.  This emphasises the need for ongoing surveillance of the skin in any melanoma survivor, even if their first melanoma was of the lowest severity.  The study has been published in the JAMA Dermatology journal and a summary can be found on NZ Melnet.



Daylight-activated Photodynamic therapy

This new technology is based on years of successful experience with traditional red-light photodynamic therapy for superficial skin cancers.  It is a highly effective treatment for precancerous actinic keratoses.  The procedure involves preparation of the skin and application of medication by Dr Gunson, followed by activation of the medication by spending two hours in the daylight.  The treatment is rapid, convenient, and almost painless.  It offers an excellent addition to the available options for treatment of this very common precancerous condition.



Young non-melanoma skin cancer survivors more likely to get other cancers

PHILADELPHIA — People who had non-melanoma skin cancer (NMSC) were at increased risk for subsequently developing melanoma and 29 other cancer types, and this association was much higher for those under 25 years of age, according to a study published in Cancer Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research.

“Our study shows that NMSC susceptibility is an important indicator of susceptibility to malignant tumors and that the risk is especially high among people who develop NMSC at a young age,” said Rodney Sinclair, M.B.B.S., M.D., director of dermatology at the Epworth Hospital and professor of medicine at the University of Melbourne in Australia. “The risk increases for a large group of seemingly unrelated cancers; however, the greatest risk relates to other cancers induced by sunlight, such as melanoma.”

Compared with people who did not have NMSC, those who did were 1.36 times more likely to subsequently develop any cancer, including melanoma and salivary gland, bone, and upper gastrointestinal cancers. Survivors younger than 25 years of age, however, were 23 times more likely to develop any cancer other than NMSC. In particular, they were 94 and 93 times more likely to get melanoma and salivary gland cancer, respectively.

“Early detection of cancers through screening of asymptomatic people works best when screening can be targeted at those at greatest risk,” said Sinclair. “Our study identifies people who receive a diagnosis of NMSC at a young age as being at increased risk for cancer and, therefore, as a group who could benefit from screening for internal malignancy.”

Sinclair and colleagues hypothesized that people who develop skin cancers later in life do so as a result of accumulated sun exposure, while those who develop skin cancer at a younger age may do so as a result of an increased susceptibility to cancer in general. To investigate this, they stratified the risk ratios by age and discovered that young people with NMSC are more cancer-prone.  The researchers used data from the All England Record-linked Hospital and Mortality data set collected between 1999 and 2011, and constructed two cohorts: a cohort of 502,490 people with a history of NMSC, and a cohort of 8,787,513 people who served as controls. They followed up with the participants electronically for five to six years, and 67,148 from the NMSC cohort and 863,441 from the control cohort subsequently developed cancers.  They found that for those who had NMSC, the relative risk for developing cancers of the bladder, brain, breast, colon, liver, lung, pancreas, prostate, and stomach remained consistently elevated for the entire period of the study, and the risk for cancers of the brain, colon, and prostate increased with time.

The researchers also found that those who had NMSC before 25 years of age were 53 times more likely to get bone cancer, 26 times more likely to get blood cancers, 20 times more likely to get brain cancer, and 14 times more likely to get any cancer excluding those of the skin.   The risk for developing any cancer subsequent to NMSC decreased with increasing age: 23 times higher risk for those under 25 years of age, 3.52 for those 25-44 years of age, 1.74 for those 45-59 years of age, and 1.32 for those older than 60 years. Thus, although the risk decreased with increasing age, it remained higher compared with individuals who never had NMSC.

This study was funded by the English National Institute for Health Research. Sinclair has no conflicts of interest to declare.

Comment:  Non-melanoma skin cancer presenting in patients under 25 years-old fortunately remains uncommon.  This study however points to the importance of more aggressive health screening is those who do develop skin cancer at a young age.



New vaccine to reduce the occurrence and severity of shingles

The Zostavax vaccine has just been registered in New Zealand.  It is suggested for people over the age of 50 years to prevent shingles, prevent post-herpetic neuralgia (the potentially severe long-lasting pain following the resolution of the shingles rash), and reduce the severity of the acute and chronic pain associated with a shingles episode.  Studies have shown a 70% reduction in shingles attacks in vaccinated people aged 50-59 years, and a 67% and 61% reduction in post-herpetic neuralgia and acute and chronic shingles pain in patients aged over 60 years respectively. 

Shingles (herpes zoster) is the reactivation of the dormant chickenpox virus which 97% of New Zealand adults carry.  One third of people experience shingles in their life-time but the risk increases sharply after the age of 50 years.  Pain is a major feature of the condition and often precedes the skin rash (small blisters on one area and side of the body).  Sometimes that pain persists for many months or years after the rash has resolved and this phenomena is known as post-herpetic neuralgia.

If you are over 50 years old, ask your GP if Zostavax is right for you.   See www.shingles.co.nz for more information.



2014 brings a new option for the topical treatment of precancerous sun damage

For many years we have had very successful results with 5-fluorouracil cream (Efudix).  For the first time in New Zealand, a new product became available in January 2014.  Ingeninol mebutate (Picato) is an Australian product based an extract from the milk-weed plant.  Early study results promise similar results to what we are used to with 5-fluorouracil, but with an application time of just three days compared to 2-3 weeks.  Like Efudix, Picato causes skin inflammation in the area treated but this peaks at day 7-8 and resolves by day 14-15 on average.  We are enthusiastic about this new product for the treatment of actinic keratoses, and anticipate it will provide improved convenience for patients.



A wealth of sun, skin cancer, and sun-protection advice specifically for New Zealanders
Check it out at Sunsmart New Zealand’s website.


sunsmart icon




How much sunscreen should you apply?

Ever wondered what quantity of sunscreen you should be applying to get the intended level of sun protection?  The Australian Sunsmart group have developed an online calculator to estimate this based on your height, weight, and type of clothing.  Check it out here.

Results from the latest New Zealand Sun Exposure Survey

The Health Promotion Agency (HPA) undertakes the Sun Exposure Survey (SES) every three years. The purpose of this ongoing research is to collect consistent information on attitudes and behaviours towards sun exposure, to facilitate comparison with historical survey data, and to inform future decision making in the sun safety and skin cancer prevention sector.
The SES was formerly known as the Triennial Sun Protection Survey (TSPS), which had been conducted in 1994, 1997, 2000, 2003 and 2006. Following a review of the TSPS in 2009 the SES was developed, with a focus on the same measures to allow the continued identification of trends over time, and the inclusion of some new questions. The SES is conducted with adults between the ages of 18 and 54 years and teens between the ages of 13 and 17 years.
This report provides an overview of findings for the adult sample (18-54 years) of the 2013 SES. Three types of result are presented in this report: (1) time series results with age adjusted data from the 2010 SES and the first five waves of the TSPS, (2) results comparing questions asked in 2010 and 2013 only, and (3) results for questions that were asked for the first time in 2013. In this report these results are grouped into five key thematic sections: skin type, sun sensitivity and sunburn; outdoor activity; sun protection behaviour; sun protection knowledge; and tanning.

View the report here.



Painful nodule or lump on the ear

It is not uncommon for people to develop a small area on or near the rim of the ear which causes considerable pain when pressure is applied.  This is an important condition to have evaluated by a dermatologist promptly for two reasons.  The two most common causes of this problem are chondrodermatitis nodularis helicus (a pressure-induced inflammation of the skin and underlying cartilage) and squamous cell carcinoma (a potentially aggressive type of skin cancer).  Prompt diagnosis and treatment is especially critical for skin cancer.  With the correct approach, the condition can often be diagnosed and chondrodermatitis cured in one small surgical procedure.  Non-surgical treatments of chondrodermatitis may also be appropriate after assessment, as a first-line strategy.  Relief of pain is important for this condition as well as correcting the underlying cartilage abnormality.  Sleeping on the opposite side is helpful, but it is often not possible to achieve reliably.  The condition starts with chronic inflammation of the skin and cartilage and if left can lead to progressive breakdown of the cartilage.  Dr Gunson utilises a number of surgical and non-surgical modalities for this condition depending on the specific situation.



Excessive underarm sweating (Hyperhidrosis)

Sweating is a natural and necessary body response to provide cooling in hot conditions.  However, when underarm sweating is excessive or experienced at times when it is unnecessary, it can be embarrassing, stressful, and uncomfortable.  It can be a particular problem in both work and social situations, and is often precipitated in times when high performance is required.    Sufferers tend to avoid these situations, and be confined to dark clothing in an attempt to better hide the wet areas.
Fortunately there are effective therapies available to reduce the excessive sweating and get you back into life.  Discuss the situation with your dermatologist.  There are medical treatments and devices which can be effective.  Injectable botulium toxin (eg BOTOX) has been used for over 15 years in New Zealand and Australia for a wide variety of medical indications.  It is often highly successful at managing underarm hyperhidrosis, with the effects of the first treatment lasting an average of seven months.  Dr Gunson offers this treatment and would be happy to discuss the options with you.




Self Skin Examination Guide now available online

A pictorial guide to the easy and very important Self Skin Examination technique is now available. Click here, or on “Self Skin examination” in the navigation bar above.




Advice on sun-protection

Ultraviolet radiation from the sun is well established as the leading cause of skin cancer.  Protecting ourselves from the sun then follows as a critical strategy in the prevention of this highly prevalent disease.  A combination of physical barriers (shade and clothing) and sunscreen is recommended when the UV index is 3 or greater.  In Auckland, the UV index typically only dips below 3 between May and August.  In addition, the UV index is strongly weighed towards UVB radiation, and therefore tends to underestimate UVA radiation which shows much less variation with respect to time-of-day, and time-of-year than UVB.  UVA is the predominant wavelength of sunlight that is thought to cause skin ageing and is also implicated in causing skin cancer.  “I therefore recommend broad-spectrum sunscreen on the face all year round given these factors, and the generally more aggressive and cosmetically sensitive nature of facial skin cancers” says dermatologist, Dr Gunson.

“Based on what we know from treating skin cancers, there are some skin sites that consistently produce high numbers of skin cancers and precancerous sun-damage”.  The top of the nose, the nostrils, the temples, the rims of the ears, the scalp (especially in balding males), the upper cheeks, shoulders, and the back of the hands are all very common sites for basal and squamous cell carcinomas.  Dr Gunson says these upward-facing sites receive a high dose of UV radiation and require special attention when it comes to sun-protection.  He also notes a small number of areas on the head and neck where people are most often surprised a skin cancer has developed.  “The inner corners of the eyes/bridge of the nose, the lower eyelid margin, and the front and back surface of the ears are all places where people are often very surprised they have grown a cancer”.  It may be that we are not as good at protecting these areas because they are not considered as high risk.  Finally, the lower lip is a common site for extensive sun damage (known as actinic cheilitis) and can lead to the development of squamous cell carcinoma which may act very aggressively in this location.

In conclusion, Dr Gunson suggests adding the following to your “slip, slop, slap” routine to maximise your chances of preventing skin cancer and premature skin-aging:

  • 1.Protect your face daily all year-round with an SPF30 sunscreen.

  • 2.Wear sun-glasses to protect your eyes themselves, as well as the surrounding delicate skin.

  • 3.Wear an SPF-containing lip balm and reapply very frequently when outside, as it wears off quickly.

  • 4.Do not neglect to apply your sunscreen to the temples, front and back of your ears, and your whole nose - including the sides of the bridge and nostrils.  Take it right up to the hairline, including the eyebrows.   Reapply sunscreen to the backs of your hands after washing them. 

  • 5.Research consistently tells us, people apply insufficient quantities of sunscreen.  Do not skimp on it, or you will be limiting its protection of your skin.

  • 6.Sunscreen is effective but it is only a filter - not complete protection.  You should therefore wear protective clothing such as long-sleeve shirts, collars, broad-brimmed hats, “rash-shirts”, and sunglasses.

  • 7.If you have a new or changing spot or bump on your skin, get it checked early.

The New Zealand Cancer Society also has useful SunSmart information sheets on their website.



A highly effective treatment for warts


Warts are a very common viral infection of the skin, but are often extremely difficult to cure.  In most cases, the body eventually recognises the Human Papillomavirus (HPV) infection, and the immune system is then able to eradicate the warts.  This may take many years however, and many people are distressed about the appearance and/or discomfort of the warts.  There are a huge number of wart remedies, and the number unfortunately reflects the lack of one or two treatments that work well in most or all cases.  Many treatments are painful or require a large commitment and perseverance on the part of the patient, and still may not offer an effective solution.  Cantharidine however is a physician -applied topical treatment which is painless at application (a significant benefit particularly for children) and highly effective at removing warts with excellent cosmetic results.  It is derived from the blister beetle Cantharis vesicatoria and has in-fact been used for various indications for thousands of years.  Interestingly, one such historic use was as an aphrodisiac, and it is because of this, it has been listed as a restricted drug in New Zealand.  This means it’s importation is controlled by customs and it is a lengthy and expensive process to obtain.  All of this is worthwhile however, as it provides a very effective and safe topical treatment for warts.  It can be used for thin facial warts (where one treatment is often sufficient) through to thick and extensive verrucae on the soles of the feet (where multiple treatments are usually required).  Dr Gunson has used this treatment very successfully for many years.  If you or your children suffer from problematic warts, consider asking if this treatment is a good option.



Mohs surgery represents the most cost-effective treatment for skin cancer


This was the conclusion of a study recently published in the medical journal “Dermatological Surgery”.  The research was led by Dr Larisa Ravitskiy from Ohio State University in Columbus, and involved 406 tumours treated with Mohs micrographic surgery (MMS).  The costs were compared with those of subsequent re-excision and reconstruction of tumours that were recurrent following treatment with other modalities.  The author notes “The common misperception of MMS as an expensive option has its roots in the poorly understood bundled reimbursement of the procedure, which includes costs of surgical excision, histology preparation, and pathology”.
Dermatol Surg 2012;38: 585-94



Under the sun


While a sunny day does a huge amount for our physical and psychological well-being, we know exposure of our skin to too much sun can have major detrimental effects.  The UV radiation emitted by the sun is the major cause of aging of the skin, and DNA damage of the cells making them prone to the development of skin cancer, often years later. 
In addition, UV radiation suppresses the local immune system of the skin.  Our immune system not only protects our bodies from infections, it also patrols the skin for DNA damage and destroys badly damaged cells prior to their progression to skin cancer.  This means the sun we get today may allow the sun-damaged cells we have from years previous, to finally progress into cancerous growth.  This is one reason we tend to see more people presenting with skin cancers during the summer months. 
Enjoy sunny days, but first protect your skin from the damaging UV rays by use of shade, clothing, hats, sunscreen and sunglasses.



Tomatoes and the skin


Lycopene is the red pigment responsible for the colour of tomatoes.  This chemical has powerful antioxidant effects and has been shown to reduce the damage UV radiation does on the skin.  There is also preliminary research showing it may help reduce the risk of some human cancers.  It is not available in raw tomatoes but is released on cooking and is therefore found in high concentration in tomato paste.  It has not been shown to reverse photo-aging but may help prevent it.  A good excuse for another slice of pizza?