Having had skin cancer twice — once on her arm as a teenager and another on her back, four decades later — Lavinia Newlands was understandably nervous when, two years ago, she developed a raised brown patch just above her lip.
There was also a smaller rough patch under her right eye (which she could feel but was difficult to see in the mirror). They’d slowly emerged over months.
Neither looked like the skin cancers she’d had before: these had been basal cell carcinomas (BCC), which typically form red, scaly patches that can ulcerate and scab. But Lavinia, 62, was concerned, and feared more bad news — not least because she’d often had sunburn as a child.
‘I grew up in a generation who didn’t know about sunscreens,’ she says. ‘I spent summers on British bucket-and-spade holidays, running around all day outside without any form of sun protection. I remember peeling off my swimming costume and howling as my skin was so sore from sunburn.’
Having treatment: Lavinia Newlands, from Amberley, West Sussex, is one of thousands to have dangerous sun damage – but a single treatment of Daylight PDT could be the answer
When she asked her GP about the suspect patches, ‘he was quite dismissive and said these weren’t going to kill me’, says Lavinia, a private cook and mother of two, from Amberley, West Sussex. ‘So I just kept moisturising the rough patch above my lip, and monitored the other one.’
Then, last year, both patches began to grow. Lavinia went to see a different GP, who referred her to a dermatologist privately.
The news was far from reassuring; both patches were what are known as actinic keratosis, which Lavinia was warned could become a type of skin cancer called squamous cell carcinoma (which can be seen in the first image on the right, showing Lavinia’s sun damaged skin).
Unlike BCC, if left untreated, these can spread to other areas of the body, and in some cases can be fatal.
Actinic keratoses are innocuous-looking rough patches or raised brown growths — sometimes referred to as sun or liver spots — that occur on sun-exposed parts of the body, such as the face, backs of the hands, ears and the scalps of balding men.
They are incredibly common, with one in four of all northern Europeans over the age of 60 having at least one, according to Dr Bav Shergill, a consultant dermatologist in Sussex and spokesperson for the British Association of Dermatologists.
At risk: Lavinia was warned her sun damage could become a type of skin cancer called squamous cell carcinoma, which can be fatal if not treated
Actinic keratoses are a sign that you have underlying sun damage (what dermatologists call ‘field change’) — but there may be other pre-cancerous changes in the area that are not visible to the naked eye.
Millions of Britons could be affected. But the good news is that there is a cream now available on the NHS that can undo the vast majority of this damage — so reducing the risks of cancer even occurring — with minimal side-effects.
However, many who could benefit from it are missing out.
WHY IT’S SO SIMPLE TO USE
Actinic keratoses are formed of abnormal keratinocytes, the most abundant cells in the skin; these produce keratin, a waxy protein that provides a protective barrier.
But after years of sun exposure, the DNA in these cells can be damaged and grow abnormally, forming rough patches that can become raised and discoloured.
‘If you were to take biopsies of the surrounding area, they would show significant skin damage and these areas can develop into non-melanoma skin cancer — basal cell or squamous cell carcinoma,’ adds Dr Anthony Bewley, a consultant dermatologist at Barts Health NHS Trust. ‘However, many of the changes are at a subclinical stage, so you can’t see them.’
Sunburn as a child is a high risk factor for malignant melanoma, the most serious form of skin cancer. But accumulative sun exposure — not just sunburn — can also be a risk factor for BCC and squamous cell carcinoma. There are creams that can undo most, if not all, of this damage. However, some need to be applied daily for weeks and lead to unpleasant side-effects.
The newer, light-activated cream is applied once, and you then sit in the sun for two hours. It’s so simple that some people have used it themselves at home.
It could benefit hundreds of thousands of patients, and the NHS, too, explains Dr Justine Hextall, who sits on the skin cancer committee at the British Association of Dermatologists.
She believes there is a case for using it, and other treatments, for background sun damage more widely. ‘As clinicians we underutilise the treatments for field change — signs of widespread sun damage — such as little red marks, areas of more pigmentation, age spots and little warty growths.’
‘I grew up in a generation who didn’t know about sunscreens,’ she says. ‘I spent summers running around all day outside without any form of sun protection. I remember peeling off my swimming costume and howling as my skin was so sore from sunburn.’
A 2014 study in the European Academy of Dermatology and Venereology suggested that 63 per cent of cases of squamous cell carcinoma cancers arose from a flat, early actinic keratosis.
‘These are the ones that we tend not to treat — we generally only suggest treating the raised ones,’ says Dr Hextall. ‘But this study suggests we should be treating even these early ones.’
‘We could save the NHS a lot of time and money if we stepped in sooner, especially in the case of frequent flyers — people who turn up with a couple of lesions but also widespread sun damage,’ adds Dr Hextall, who practises at the Tarrant Street Clinic in Arundel, West Sussex.
YOU COULD AVOID FACIAL SCARS
She adds: ‘These are often people in their late 60s or 70s who will go on to present with new skin cancers repeatedly, often requiring complex, and unfortunately sometimes disfiguring, surgical treatment, as so many non-melanoma skin cancers and so much sun damage is on the face.’
Treatments that act on field damage and pre-cancerous lesions could help significantly reduce the number of skin cancers that are diagnosed every year.
Figures from a new skin cancer database published in the journal Jama Dermatology last November found that there were 45,000 cases of squamous cell carcinoma alone diagnosed each year in England, 350 per cent more than previously estimated.
The chance of an actinic keratosis turning into a squamous cell carcinoma is around 5 per cent, which means treating the pre-cancerous condition could spare thousands developing cancer every year.
So what is this new cream and why is it not used more widely?
It is based on a principle known as daylight photodynamic therapy (daylight PDT). It contains aminolevulinic acid (ALA), which harnesses the body’s immune system to kill the pre-cancerous cells, and is activated by sunlight. ‘ALA gets absorbed preferentially by the sun‑damaged cells you want to target — and does no harm to healthy skin,’ says Dr Hextall.
And it doesn’t just clear squamous cell carcinoma, it clears BCCs, too.
To activate the ALA, the patient must sit in daylight within 30 minutes of the cream being applied, and stay there for two hours, even if it’s overcast, but the sun is only strong enough from April until October in the UK.
There may be tingling for a few days and some crusting, which peaks within a week and clears within a fortnight.
Sunburn as a child is a high risk factor for malignant melanoma, the most serious form of skin cancer, but accumulative sun exposure — not just sunburn — can also be a risk factor
IT’S NOT JUST CHANGING MOLES YOU NEED TO WATCH…
If you have moles with any of these signs (below), or all of them, see your GP and ask to be referred to a dermatologist.
A — Asymmetrical shape
B — Border is irregular
C — Colour isn’t uniform (i.e., two or more colours)
D — Diameter more than 6mm
E — Evolving in size, shape or colour
‘People should also be keeping an eye out for red, scaly areas or lumps, such as actinic keratosis, that could potentially spell trouble because of the risk of squamous cell carcinoma,’ adds consultant dermatologist Dr Anthony Bewley.
‘People often ignore bits of skin that become scaly or red or sore but this should be seen to, especially if it appears on highly sun-exposed areas such as the bridge of the nose, forehead, the shoulders in men or the lower legs in women.
‘Bald men tend to be very bad about checking their scalp — but this is such an important area to monitor. It’s not so easy without a partner to keep an eye on your scalp, so I recommend people use their smartphone and take pictures.
A recent study in the Journal of the European Academy of Dermatology and Venereology, involving 50 patients with actinic keratoses who were given daylight PDT to use at home, discovered that 98 per cent found it easy to use, and after three months 62 per cent were clear of all visible lesions. ‘Daylight PDT clears about 70 per cent or more of pre-cancerous cells, and if it was cheaper it would be used more widely,’ says Dr Shergill. And therein lies the rub. A tube of the cream costs around £150 and each treatment requires one or two tubes.
The current treatments for actinic keratosis usually start with liquid nitrogen to freeze them off, or scraping them off — which are cheaper.
However, daylight PDT also tackles ‘invisible’ background damage; those treatments don’t.
Daylight PDT is normally a one‑off treatment (occasionally a second treatment is needed) and aftercare tends to be minimal, while recurrences and clearance rate from scraping or freezing can mean more follow-ups.
A study in Jama Dermatology in 2014 found that after three months, the clearance rate with PDT (the forerunner to daylight PDT) was 14 per cent better than freezing.
Although daylight PDT is available on the NHS, it’s typically used only for those who have multiple acitinic keratoses that have not responded to other multiple treatments.
OTHER CREAMS THAT CAN HELP
It’s not the only product available for treating actinic keratosis and field change.
GPs may offer a nonsteroidal anti-inflammatory cream called Solaraze that has to be used twice a day for 90 days, although it is not as effective at treating background damage. ‘Also, 90 days is a long time, and sometimes people give up,’ says Dr Hextall.
Another prescription cream, imiquimod, stimulates the immune system to attack the abnormal skin cells. This causes inflammation that ultimately destroys the actinic keratosis. It has to be used five days on, two days off, usually for four weeks.
How many times do you need to be told? Many people don’t realise they need to use sunscreen in the UK, assuming our weather means they won’t get much sun damage
SUNSCREEN WON’T AFFECT YOUR VITAMIN D LEVELS
Many people worry that using sunscreen will reduce their levels of vitamin D, which our bodies produce in response to sunlight.
In fact, these fears are unfounded, according to a major review of 75 studies, published recently in the British Journal of Dermatology.
‘This isn’t the first time that a study has shown this — you actually don’t need that much sun exposure in order to synthesise vitamin D,’ says dermatologist Dr Justine Hextall. ‘I’m really glad this study has been published as fear about a lack of vitamin D is the main argument I hear from patients against using sunscreen. Personally, I use factor 50 on my face every single day.’
Many people don’t realise they need to use sunscreen in the UK, assuming our weather means they won’t get much sun damage.
‘Often it’s young people who are the worst,’ says dermatologist Dr Bav Shergill. ‘There is a window of teenage independence when they do what they want — and get burned. Sun exposure before the age of 20 is the highest risk factor for all skin cancers.’
While effective for some, it can lead to weeping, cracked skin that lasts weeks, which can make people nervous of continuing with it. It costs around £55 per tube.
A further alternative, Efudix, contains fluorouracil, a type of chemotherapy. This is used once or twice a day for four to six weeks. Cheaper than daylight PDT (it costs around £65 for four to six weeks’ treatment), it attacks abnormal skin cells and can be used on lesions and areas of sun-damaged skin.
This can also cause crusting and inflammation, which may last weeks — meaning, again, that not everyone continues with it.
A trial last year, published in Dermatologic Therapy, comparing Efudix to daylight PDT found that Efudix was slightly more effective, clearing 93 per cent of lesions compared to 80 per cent with daylight PDT. However, the daylight PDT caused fewer adverse effects and patients preferred it.
But these are all game-changing treatments and experts believe that they’re not being offered widely enough.
WHEN YOU NEED TO SEEK ADVICE
Dr Bewley says pre-cancerous growths generally are not taken seriously enough by doctors or the public. ‘There is some awareness about the need to watch out for possible malignant melanomas [often in the form of brown, mole-like marks],’ he says. ‘But when it comes to actinic keratosis, doctors often say just keep an eye on it — which is sometimes the right advice, but it is always important to watch for any changes.’
Currently, doctors advise keeping an eye on ‘early’ actinic keratosis, when it is small, flat and alone. Some may clear on their own. If it becomes painful or inflamed, this can be a sign it is transforming into a squamous cell carcinoma.
But Dr Hextall says: ‘GPs and hospitals are overwhelmed. So if someone comes in with an actinic keratosis, they often freeze it off there and then. We miss the chance to treat the field changes and pick up the small squamous or basal cell carcinomas that may be there.’
After Lavinia was diagnosed with actinic keratoses, the dermatologist tried to freeze them off. But ‘the one under my eye didn’t really respond at all and the one on my lip returned after a few months’, she says.
She then went to see another dermatologist privately who suggested daylight PDT. It not only got rid of the actinic keratosis it also treated some wider underlying sun damage on her face, reducing her risk of more skin cancers.
‘I was quite surprised at how much crusting appeared afterwards — a sign of just how much sun damage I had that had just not been apparent,’ Lavinia says. ‘The treatment was pain-free. If I hadn’t had it done I might have been at risk of further skin cancer. I had a lucky escape, and I hope more people can benefit.’
WHAT IS MELANOMA AND HOW CAN YOU PREVENT IT?
Melanoma is the most dangerous form of skin cancer. It happens after the DNA in skin cells is damaged (typically due to harmful UV rays) and then not repaired so it triggers mutations that can form malignant tumors.
The American Cancer Society estimates that more than 91,000 people will be diagnosed with melanoma in the US in 2018 and more than 9,000 are expected to die from it.
Around 15,900 new cases occur every year in the UK, with 2,285 Britons dying from the disease in 2016, according to Cancer Research UK statistics.
- Sun exposure: UV and UVB rays from the sun and tanning beds are harmful to the skin
- Moles: The more moles you have, the greater the risk for getting melanoma
- Skin type: Fairer skin has a higher risk for getting melanoma
- Hair color: Red heads are more at risk than others
- Personal history: If you’ve had melanoma once, then you are more likely to get it again
- Family history: If previous relatives have been diagnosed, then that increases your risk
This can be done by removing the entire section of the tumor or by the surgeon removing the skin layer by layer. When a surgeon removes it layer by layer, this helps them figure out exactly where the cancer stops so they don’t have to remove more skin than is necessary.
The patient can decide to use a skin graft if the surgery has left behind discoloration or an indent.
- Immunotherapy, radiation treatment or chemotherapy:
This is needed if the cancer reaches stage III or IV. That means that the cancerous cells have spread to the lymph nodes or other organs in the body.
- Use sunscreen and do not burn
- Avoid tanning outside and in beds
- Apply sunscreen 30 minutes before going outside
- Keep newborns out of the sun
- Examine your skin every month
- See your physician every year for a skin exam
Source: Skin Cancer Foundation and American Cancer Society