Doctor Urges Greater Skin Protection For Summer

With school ending and pools opening, summer is just around the corner. That means more time outside, and under the sun.

Dr. Alan Thomay is an associate professor of surgery at the West Virginia University Department of Surgery specializing in surgical oncology. He spoke with reporter Chris Schulz about increasing skin cancer rates, and how to stay safe.

This interview has been edited for length and clarity.

Schulz: Can you tell me just a little bit about the prevalence of skin cancer in the United States these days?

Thomay: Skin cancer has been markedly increasing for the last several decades. We see basal cell carcinoma, which makes up about 80% of all skin cancers, very frequently now. Squamous cell carcinoma, which makes up about 15% of all skin cancers. That we’re seeing pretty regularly as well. 

But what has increased significantly and is of much higher clinical concern is melanoma, and we’ve seen a 50% increase in melanoma over the last probably 10 years or so, and they expect another 50% increase by 2040. When we look at melanoma, when we look at how it has evolved, I think in the 1970s there was about seven cases per 100,000 of population, and that’s how most epidemiologists, that’s the number system that they use for these. So 1970s it was seven melanomas per 100,000 in the United States. Today, I think it’s 30 per 100,000 and it’s estimated to go up to about 40 to 45 over the next 10 to 15 years. So we’re really seeing a huge increase in melanoma, and that has profound implications for cancer deaths, because melanoma makes up the majority of patients who die of skin cancer.

Schulz: Is West Virginia more or less in line with the national statistics?

Thomay: We’re just about average. So melanoma as a state is 30th in the nation for the incidence of melanoma, with about 530 new diagnoses each year.

Schulz: Do we have any concept of what is leading to this increase?

Thomay: We know that the biggest risk factor for any type of skin cancer, for sure, is exposure to ultraviolet radiation. What we are seeing with global warming, we’re just seeing a higher overall incidence of UV radiation reaching people’s skin. We’re also seeing more outdoor activities. We’re seeing fewer long sleeve or protective clothing being worn, and overall, the use of sunscreen or other protective agents has just diminished, interestingly, specifically in our state. What we also see is that elevation leads to increased rates of skin cancers, and West Virginia is the highest average elevation of any state east of the Mississippi River. This elevation leads to less atmospheric filtering of UV radiation, thereby increasing UV exposure at higher altitudes, seeing increased risk of skin cancers. So we’re seeing it just a lot here. And what’s interesting is, we talked about West Virginia is right around the middle, 30th in the nation, so right around the average. However, West Virginia has the second highest mortality rate for melanoma in the nation. So even though our incidence is about the national average, we’re having more patients die than typical.

Schulz: Let’s talk briefly about prevention. You mentioned a couple different things there, long sleeve garments, sunscreen. What are some basic steps that people should keep in mind as we enter the summer season here?

Thomay: One of the ways that I try to explain this to my patients is, if you were to go out with some friends of yours from high school, you might have a couple of drinks, you might have a cocktail, you might have a glass of wine with dinner. But you’re going to kind of stop that right around dessert and have coffee, and then you’re going to have some water and chat with your friends before you start to drive home. It’s okay to have a drink, but we talk a lot as a society about drinking responsibly. I think the same comparison can be used for skin health and UV radiation protection, which is, we should enjoy our planet. We only have this one life to live, and so I want people to go out and enjoy the outdoors, but we should do so responsibly. 

So what that means is that we should try to minimize UV radiation and direct UV radiation to our skin. Enjoying the sun during the early morning hours or the late evening hours is much better for your skin than trying to mow your lawn or do gardening between the hours of 10 a.m. and 4 p.m., where the sun is directly overhead and the overall direct exposure to your skin is highest. In addition, long sleeve clothing, especially long sleeve clothing that has UV protection built into it. You can find these at big box stores like Cabela’s or Bass Pro Shops, etc, and they will be labeled with a UPF rating. Much like sunscreen has an SPF rating, clothing will have a UPF rating that will signify how much it is protecting you from the sun’s rays. Remembering to use a wide-brim hat to protect your neck and your ears and your nose. 

And then sunscreens can be incredibly effective and we know this is true. I know there’s been some concern about sunscreens recently. For instance, there are two main types of sunscreens. Chemical sunscreens: they absorb UV rays, converting them to heat, which is then released. These can be lightweight. They blend into the skin a little bit easier, but some ingredients can be irritating or allergic. And then the other substance is a physical sunscreen. We know that these are actually better in protecting. However, they tend to leave kind of more of a white, chalky look, which a lot of people don’t like but these can be much better, because they actually physically block the UV radiation from hitting the skin. All of them can be effective, but they need to be applied properly. So the biggest thing I see from my patients is that sunscreen is not applied properly. If you want to protect your skin, you need to apply sunscreen every two hours or more frequently when you’re in the pool or sweating a lot.

Schulz: The release from the university also mentioned the utilization or exposure to tanning beds, which is obviously going to be a much more intentional and direct exposure to UV radiations. Is there any safe use of those devices?

Thomay: No. So we know that one sunburn throughout your lifetime will double your risk for melanoma. So one sunburn that’s bad enough to blister or peel, which just about everybody has had, will double your risk for melanoma. Just one hour in a tanning bed will do the exact same thing, and that’s over your entire lifetime. 50 hours or more within a tanning bed increases your risk for melanoma somewhere between four and five times the general population. We have a lot of young women, especially around WVU, that are using tanning beds an hour a week, and they’ll get 50 hours within a year. And so their risk for melanoma or other skin cancers just becomes astronomical. One of the phrases I use with my patients sometimes is that we pay for the sins of our youth, and so we really need to be careful about protecting our skin, especially at younger ages. Some of the genetic changes that initiate the progression towards cancer can happen when people are children, when they didn’t even know about these things or think about these types of things. So we have to be really careful about our younger generations coming up and making sure that they protect their skin, because these rates are only going to increase if we don’t.

Schulz: What should people be looking for as far as abnormalities on their skin? And how often should people be checking for those types of things?

Thomay: They have a scale called the Fitzpatrick skin classification scale, something that people can Google and look up. And essentially it outlines the basic appearance, if you will, of skin types. The skin type that would be most susceptible to the sun’s UV radiation would be the Fitzpatrick skin classification number one, which tends to be Irish, English and Scottish ethnicity, typically with freckles, red or blonde hair, with light and blue eyes. They’re going to be at substantial risk. Whereas a skin type of a six would be African American, typically, black hair, brown eyes. They typically do not burn, because their skin will protect them from that UV radiation for a much longer period of time. They can burn, it just takes quite a long period of time. Knowing where you are on that skin classification scale will help you understand your personal risk of sun exposure. Really, anybody with kind of lighter skin tone, and so most Caucasians would fit into this. 

Routine dermatologic screening would be the number one thing that they can do. So to answer your question in a more succinct way, I would say anybody with light skin and a history of either sun burns or sun exposure should have routine dermatologic surveillance at least annually, if not more frequently, looking for new lesions that might need to be biopsied. We know that catching a skin cancer early is the best thing that we can do for treatment. So surveillance is really, really, really important. (Patients) should be looking at their body, and this should be for everything we talk about, the importance of people looking and taking ownership of their own health. We routinely recommend that women do self breast examinations, looking for masses or risk for breast cancers. Skin examinations, the same thing. Whenever you’re getting out of the shower, look at yourself in the mirror and focus on the spots on your skin that look different. If you have a mole, you’ve had a mole your whole life, but if it starts changing or doing other things, that’s what you should be looking for. For melanoma specifically, we talk to patients about the ABCDEs, and what that stands for is: 

• A stands for asymmetry. So when you look at the mole, both sides should be even. They should not be asymmetrical in any way. 
• B The borders should be nice and regular and smooth. If there are irregular, ragged, notched or blurred. That is a concerning feature. 
• C The color of most moles is a light or darker brown if they start to change colors, especially when they become darker, like black, purple, dark blue, red, those are concerning signs for melanoma. 
• D When the diameter changes, that means a larger a mole or a lesion becomes the more concerning or riskier it is. 
• E stands for evolution, which means if it changes in any way, size, shape, color, overall form, if it becomes more raised, those are all signs that a malignancy could be evolving and we need to evaluate it further. 

Those are signs, the ABCDEs of when you should seek clinical care for a mole or other lesion on your skin.

Schulz: This maybe is part of the contribution to that concern about sunscreen, is that it doesn’t allow for the synthesis of vitamin D, and that there has been some evidence that the dietary vitamin D is not sufficient to supplement the vitamin D that your body produces from sun exposure. Is that anything that you’re aware of or that you have been looking at, and how concerned should people be about their vitamin D levels?

Thomay: I think overall, very low. I do think that the majority of Americans are probably on the lower end of vitamin D, just because most people have an inside day job. But I would tell you that in general, you would have to use sunscreen perfectly to have such a decreased amount of sun exposure to decrease your need for vitamin D. So I think that overall would be very, very, very low, just, I think, 15 to 20 minutes of sun exposure throughout a day. I remember reading that at one point, although that’s not my area of expertise, but I don’t think it’s, it’s a significant concern.

Schulz: There’s also this discussion, especially as more people become aware of cosmetics from other countries, is the use of other chemicals in other countries. Do you have any awareness of or opinions about the FDA rigors and requirements for sunscreen in the United States, and whether or not it would be beneficial to see a widening of the available sunscreens on the market?

Thomay: I would tell you the specific makeup and chemical structures of sunscreens is not my area of expertise. What I do know is that some of the products in other countries, Europe in particular, have been proven to be safe and incredibly effective by those countries and the European Union. Our FDA is certainly looking at it. And I looked at this not too long ago, and I think the expectation was that those would be products that could come on the market in the United States, probably somewhere in the range of 18 to 24 months, as the FDA is looking at it. And I would urge the public to remember that the FDA’s job is trying not to just make sure that something is effective, but trying as best as it can to ensure that any product that they endorse is safe. And that takes time. So looking at incidences for cancers or other things, takes a considerable amount of time to make sure that they’re not missing anything. So that process, it does have its downsides, and that it is a lengthy delay, but it’s that for a reason, so that they can be as sure as they can be at that time point that is both effective and safe.

Schulz: Just one last one here, because this is one that I’ve heard before, and maybe it’s an old wives tale, but the efficacy or the safety of early exposure and often to create what people refer to as a base tan or a base layer. I guess thinking that once you get tan, you gain some of that melanin protection that you alluded to earlier.

Thomay: Interestingly we talked earlier about how that one burn bad enough to blister or peel will double your risk for melanoma. The same is true for chronic sun exposure. That type of base tan every summer for a decade or more, that is chronic exposure, and your risk for melanoma will double at the very minimum. So that chronic sun exposure does the exact same thing as just one bad burn.

Schulz: Is there anything that you’d like to highlight, or anything that we haven’t given you a chance to talk about please do so now.

Thomay: When I talk to patients about sunscreen use, I have a lot of patients with questions about what sunscreen is the best? What brand do I recommend? What SPF factor should I use? Should I use mineral or chemical? Ultimately, for the prevention of skin cancer, the best sunscreen is the one that a patient will apply liberally and often, so it should look and feel good on their skin to make that possible. So we know that mineral sunscreens protect better. We know that creams are more universally applied and therefore protect the overall skin surface better, but we also know that some people don’t like how that looks or feels, and therefore they won’t use it. So I just want the population to understand that when you’re picking a sunscreen, pick one that you like, because you’re more likely to actually use it, and that’s way more important than having, quote, unquote, the best sunscreen if you never use it.

The sooner we catch a skin cancer, the more likely we are to be able to cure it, and the minimal operative cost it will have to the patient. So smaller and earlier lesions lead to smaller operations. Overall, just making sure that we’re catching things early and seeking treatment in West Virginia. One of the reasons that our mortality rate for melanoma is higher is because of a lack of care, or patients not getting care for whatever reason. So making sure that these are screened, making sure patients see a dermatologist. Sometimes, if a dermatologist is not available in your part of the state, your primary care doctor can perform these types of skin exams, so making sure that patients are seeking care is important.