Sunburnt to death

GPs and paediatricians are in many cases the first line of defence against skin cancer, but many are failing in their duty to protect Caucasians living in the Middle East against the dangers of this disease. Callan Emery spoke to Dr Ikramullah Al Nasir, a specialist dermatologist, about the issue.

Fair-skinned Caucasians living in the Middle East are at high risk of getting skin cancer from accumulative sunburn, yet many remain unaware of the dangers posed by living in this hot, sunny climate.

What may surprise many people is that skin cancer can be fatal. In the United States, where good statistics are available, it is estimated that more 10,000 people die each year from skin cancer.

The World Health Organisation (WHO) estimates that more than 60,000 people a year die from ‘getting too much sun’ and that most of these deaths are from skin cancer.

Dr Ikramullah Al Nasir, a specialist dermatologist and medical director of the Dermacare Skin Centre in Dubai, United Arab Emirates, is a vocal and proactive campaigner for raising awareness about the dangers of skin cancer. And he doesn’t mince his words when he says that General Practitioners and paediatricians could and should be doing much more than they are to diagnose skin cancer early and educate their patients about the disease.

“The skin is the body’s largest organ, yet it is often overlooked in routine medical check-ups,” Dr Al Nasir said sternly. “This needs to change.” “From my observations, I’ve noticed very few general practitioners, family physicians or paediatricians make a routine examination of the skin.”

He pointed out that in many cases if skin cancer is diagnosed early it can be treated and cured. According to the American Academy of Dermatology both basal cell carcinoma and squamous cell carcinoma have a better than 95% five-year cure rate if detected and treated early.

Types of skin cancer

Skin cancers are divided into one of two classes – nonmelanoma skin cancers and melanoma. Three types of skin cancer account for nearly 100% of all diagnosed cases. These are Basal cell carcinoma, Squamous cell carcinoma and Melanoma. Each of these three cancers begins in a different type of cell within the skin, and each cancer is named for the type of cell in which it begins.

Basal cell carcinoma (BCC) is the most common cancer in humans. It develops in more than one million people every year in the United States alone. BCC develops in the basal cells – skin cells located in the lowest layer of the epidermis and accounts for about 80% of all skin cancers.

Squamous cell carcinoma (SCC) accounts for about 16% of diagnosed skin cancers. This cancer begins in the squamous cells, which are found in the upper layer of the epidermis.

Melanoma accounts for about 4% of all diagnosed skin cancers. Melanoma begins in the melanocytes, cells within the epidermis that give skin its colour. It is the most lethal form of skin cancer because it can rapidly spread to the lymph system and internal organs. Other nonmelanoma skin cancers account for less than 1% of diagnosed cases.

These include Merkel cell carcinoma, dermatofibromasarcoma protuberans, Paget’s disease and cutaneous T-cell lymphoma.

According to the WHO the incidence of both non- melanoma and melanoma skin cancers has been increasing over the past decades, due in large part to the growth in the fashionable habit of sun tanning.

Currently, between two million and three million non-melanoma skin cancers and 132,000 melanoma skin cancers occur globally each year. The WHO warns that with climate change and the depletion of the atmosphere’s ozone, the incidence of skin cancer will increase as the atmosphere progressively loses its ability to filter out the harmful ultraviolet rays from the sun that are ultimately responsible for causing skin cancer. The WHO estimates that a 10% decrease in ozone levels will result in an additional 300,000 non-melanoma and 4,500 melanoma skin cancer cases.

Dr Al Nasir said skin cancer statistics for the Middle East are not readily available, but adds “through my observations with the Caucasian population in the region the incidence of skin cancer has doubled in the past five to seven years”.

He says that following current migration trends the Caucasian population is expected to increase significantly in the region and forecasts that the incidence of skin cancer is likely to double again in the next five to 10 years. “We will have a lot of fairskinned Caucasian people in this region. And the climate here is not skinfriendly for these people.

They don’t understand the dangers of this climate,” he warned.

GPs & paediatricians

Dr Al Nasir said the responsibility for educating people at risk of skin cancer lay, in large part, with the General Practitioners and paediatricians. He also said that many of these physicians do not check the skin of their patients regularly, which “will go a long way to ensuring early diagnosis and treatment.

“Paediatricians and GPs also have an important role to play in preventing skin cancer,” he said. They are, in most cases, the first person a patient will visit for advice when they have a medical problem, he explained, adding that for many Caucasians the GP is like the family physician.

He said that “it is quite common nowadays for people to visit their GP for an annual medical check-up whether they have a medical complaint or not. “Yet they very rarely make a comment on the skin during a routine examination].

And even if they see something wrong with the skin, it is often ignored,” he said. “How can you declare a person free of health problems when the largest organ of the body has not been checked?” he asked.

“Paediatricians and GPs are not giving enough attention to their patient’s skin.

“They should make it part of their practice to check skin. They should make a point of educating children and their parents about the dangers of sunburn. They need to do more to emphasise the dangers of climate and skin cancer.”

Dr Al Nasir said: “Although skin cancer is not common in children, it is at this young age when the protective measures against sunburn should start because it is the accumulative sun damage to the skin which results in the development of skin cancer.”

He said there were several probable reasons why GPs and paediatricians failed to check the skin of their patients, particularly if they had no complaint regarding their skin.

“One is that they had poor clinical orientation about skin diagnosis. They are not experienced in this field of medicine.” He added however, that this knowledge is readily available in medical literature and it would require only a little effort to brush up on this important skill. “Secondly, there are cultural influences on their practice. If they are trained in Asia, for example, their exposure to certain risk factors, such as fair skin, is limited. This is unfortunate.”

Dr Al Nasir explained that when checking the skin, doctors should look specifically at the moles, as this is often where skin cancer develops – either in existing moles or in new ones. “The mole check should be part of a routine examination,” he stressed.

“There is a simple rule for checking moles - it’s called the ‘A, B, C, D of moles’.” A. asymmetry – change in shape, the two halves of the mole do not look the same B. border irregularity – the edges of the mole are irregular, blurred or jagged C. colour change – the colour of the mole is uneven D. diameter – the mole is wider than 6mm in diameter “These are the basic parameters for any mole examination,” Dr Al Nasir said.

“Further to this there are a few other factors that can be looked at. Is it a new growth that won’t heal? Is the surface texture scaly or scabby? Is it itchy or is there a burning sensation?

“The family history related to skin cancer and melanoma should also be explored,” Dr Al Nasir recommended.

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