Treatment of sun induced disorders

No sun-induced skin disorder is particularly easy to treat and it is far better to prevent its development in the first place if possible.

SUNBURN

There is little that can be done to treat the immediate symptoms of this effectively, and nothing at all to stop any associated long-term damage afterwards; however, if you do overdo things somewhat, the following may help a little until natural healing takes place:
• Drink plenty of non-alcoholic fluids and apply soothing preparations, such as calamine lotion or aqueous cream, to the affected areas; you can buy both over the counter at pharmacies.

• Take aspirin (except in children), paracetamol or non-steroidal anti-inflammatory tablets such as ibuprofen in normal doses as soon as possible after exposure, to help ease soreness until the skin has healed. Ibuprofen gel or similar, although not made specifically for sunburn, and local anaesthetic preparations may also help. Ask the advice of your pharmacist.

• Stay out of the sun for two to three days, until the redness and soreness have fully subsided.

• If your sunburn is severe or widespread – for example, if your skin has blistered significantly or you have symptoms such as shivering, headaches or nausea – you should probably consult a doctor, or in particularly serious cases go to a hospital accident and emergency department. The complications of very severe widespread sunburn can include skin infection and scarring, as well as generalised dehydration, collapse and rarely even death. Severe over-exposure to the sun can be very dangerous!

PHOTOAGEING

If your skin is already affected by photoageing, you may be able to improve its appearance to some extent by using simple moisturising creams regularly to help relieve the associated dryness and smooth out any wrinkles, but you will need to use them constantly. In addition, there is some evidence that the daily use of creams containing vitamin A derivatives (so-called retinoids), and in particular Retin-A or Retinova, both of which contain tretinoin and are available on prescription, may slowly reduce irregular pigmentation and smooth out fine wrinkles to a minor extent if used regularly.
Cosmetic or plastic surgery by an appropriate surgeon can also help in a more invasive, expensive and perhaps risky fashion, in many cases satisfactorily smoothing out wrinkled, sagging areas of skin. Relatively mild, often effective treatments for brown blotchiness and thread veins include cryo­therapy and cold point cautery, generally available from specialist dermatologists. If these are not helpful, however, other more aggressive treatments for the same problem are chemical peels and laser therapy, the latter being particularly effective for wrinkles and thread veins. However, this treatment for wrinkles leaves treated areas extremely red and raw initially for days to weeks, and you will need to take into account the high cost and the slight risk of permanent scarring or skin discoloration before deciding to go ahead. Discuss it carefully with a dermatologist or surgeon first.

SKIN CANCER

The treatment of skin cancer depends on its precise type and location on the body. Regardless of which treatment you are offered, you will always be strongly advised to cut down considerably on future sun exposure. In other words, the fact that you have had a skin cancer already means that the sun-exposed skin on other parts of your body is also likely to have been significantly damaged, and you are therefore at high risk of developing another cancer if you continue your exposure to sunlight.

Solar (or actinic) keratoses

There is a degree of debate among doctors as to whether the treatment of solar keratoses offers enough benefit in terms of reducing future skin cancer risk to be worth doing, as so many older people have them and only a few progress to cancer. However, some certainly do, especially if the person concerned does not reduce his or her sun exposure from then on, or happens to be on drugs that tend to suppress the immune system, such as ciclosporin or azathioprine (mostly prescribed after organ transplan­tations but occasionally also for other reasons). Most people also find the lesions unsightly, sore or itchy, so it is now generally agreed that they should be treated and you should consult your doctor if you have any possible lesions. Treatment is most commonly by cryotherapy, which is almost always effective. Cancer cell-killing cream available on prescription (5-fluorouracil) may also be recom­mended on occasion, and this must be applied regularly over several weeks, during which it kills off the abnormal but not the normal skin. It does, however, usually make the treated area unpleasantly red and sore during the treatment periods. More recently, a further preparation (three per cent diclofenac in a one per cent hyaluronidase gel) has appeared to be effective for mild lesions, with irritation as the only likely side effect, although some centres also use so-called photodynamic therapy (PDT) (see page 56) to treat lesions of cosmetically important sites without the occasional scarring of cryotherapy. Staying out of the sun appears to help prevent the development of new lesions and resolution of old ones.

Basal cell cancers

Small basal cell cancers can be treated with cryotherapy, but cutting them out surgically or their destruction by radiotherapy is much more reliable for larger ones. Sometimes, they can come back after any treatment, and a similar, but more careful, surgical approach is then generally used to provide a final cure. Basal cell cancers never spread to other parts of the body, and the only real trouble with them is the way they look and their tendency to enlarge very slowly into nearby tissue.

Squamous cell cancers

Squamous cell cancers are most often treated by surgery, except sometimes in difficult-to-reach skin sites or in people who are frail, when radiotherapy may be used instead; it is relatively unusual for the condition to recur. However, a few lesions may rarely reappear or, very much less often, spread to other parts of the body, such as nearby lymph glands in the neck or armpit, for example, or very occasionally to the lungs, bones or brain. If this should happen by chance, further surgery or chemotherapy will then be used to discourage further growth. It is generally only cancers left over very long periods to become large that cause such problems, although lesions of the lip or ear, or those in individuals whose immune system is suppressed by certain illnesses or medications such as azathioprine or ciclosporin, are also relatively likely to spread if not dealt with early. If you have a growth that you think might be this form of cancer, you should see your doctor soon, so the problem can be dealt with effectively before any chance of spread.

Melanoma

Melanomas are virtually always treated by surgery. They are generally cut out under local anaesthetic and fully and permanently cured. The usual procedure is that any suspicious mole is removed first with a narrow margin of normal skin for careful examination under the microscope. If a melanoma is confirmed, however, a larger area is often removed at a separate visit to ensure that no tumour remains. Occasionally, this may require skin grafting but more often you will be left with just a line scar.
If you have a melanoma, you should discuss the matter in detail at your dermatological or surgical consultation. The vast majority of such tumours are, however, very thin and non-invasive, do not recur and give no further trouble. Nevertheless, occasional deeper ones do have a risk of recurrence or spread to other areas of the body through the lymph vessels or bloodstream, and it is certainly advisable to discuss the matter again with your doctor after your surgery. You will then have had time to think about things and make a list of questions that you might want to ask.
For example, you might want to be told about your own specific risk of recurrence or spread, or whether the event might affect any future decision to have children, or whether you might conceivably develop another tumour. If necessary, see also ‘Useful addresses’ for contact details of the Macmillan Nurses, who specialise in the care of people with difficult melanomas.
After treatment, anyone who has had a melanoma will normally have regular check-ups in the clinic by the dermatologist or surgeon about every six months for five years, or sometimes longer. At these visits, the scar and local lymph nodes will usually be examined for any sign of possible recurrence; usually there isn’t any. A cancer that does reappear in the same place is often treated with further surgery, which is frequently successful. If, on the other hand, the condition has spread to the local lymph glands, these can often also be removed effectively at surgery, although chemotherapy may be given at this stage to help further to prevent dispersal, the drugs used in this technique destroying cancer cells anywhere in the body.
Although rare, melanoma is potentially the most lethal skin cancer; however, early diagnosis and prompt removal are almost always curative.

PROCEDURES USED FOR DIAGNOSING AND TREATING SKIN CANCERS

Surgery – the skin biopsy for diagnosis and treatment

You will probably need a special procedure called a skin biopsy to establish the precise diagnosis of your condition. This is a simple technique that removes part or all of a tumour for microscopic examination to determine what cancer it is and what, if any, further treatment is best to dispose of it. Usually, the abnormality is completely removed during the biopsy, and the tissue is just examined to check the diagnosis. If the margins of the lesion impinge on the removed skin edges, however, your doctor may need to excise more tissue to get
rid of the lesion completely. If it is large to begin with or awkward to remove completely because of where it is, only a small biopsy may be done at first just for microscopic examination and a further procedure undertaken later.
The skin biopsy procedure itself is relatively simple and normally requires no special preparation on your part; you can eat and drink normally beforehand, and also as soon afterwards as you wish. Furthermore, it usually takes only 10 to 30 minutes to perform and the local anaesthetic usually leaves no unpleasant after-effects. As long as you feel comfortable, therefore, there is no real reason not to drive home or go back to work later if you wish. However, you may prefer to take the day off just in case the event is a strain or any minor sore­ness afterwards is disruptive; you may therefore also arrange for someone to drive you home.

You should tell your doctor beforehand if you are on any medication, such as steroids, aspirin, non-steroidal anti-inflam­matory drugs or warfarin, all of which can conceivably interfere with healing or cause increased bleeding during the procedure. You should also say if you have ever had an adverse reaction to any anaesthetic, although this is rare, or if you are allergic to any other relevant substances, such as sticking plaster. Finally, you should mention if you have had any heart valve abnormalities or replacements, because you may then require a short course of antibiotics at the time of the biopsy.

The local anaesthetic used is a generally a liquid gently injected through a fine needle into and around the area to be removed. You can usually briefly feel the sharpness of the needle, some skin areas being more sensitive than others, and often also a little stinging as the anaesthetic goes in, but this rapidly passes and there should then be no further discomfort. As the effect gradually wears off over an hour or so, you may again experience a little soreness, aching or tenderness at the biopsy site, but this is usually mild and can be eased if neces­sary by taking mild pain relief medication.
After the event, the removal site will usually be closed with stitches and covered with a dressing. All you then need to do is keep the affected skin carefully clean and dry, before returning to your doctor four to fourteen, or occasionally more, days later to have the stitches removed. However, if the wound oozes or bleeds more than a little after the operation, you may need to see your doctor again sooner, and may perhaps need a pressure pad or further stitch for the wound. If you develop pain or swelling at the site over the next few days, you should again consult your doctor because the area may have become infected, which interferes with healing. If this does happen, antibiotics usually solve the problem, or the stitches may need to be removed early.

Radiotherapy

Although most skin cancers can be cured surgically, occasionally this approach may not be the best, particularly if a lesion is large, in a place making removal awkward, or affecting a very old or frail person. In these circumstances, therefore, radiotherapy may be better; this generally involves the use of superficial X-rays over a short course of treatment to destroy the abnormal cells. In addition, some normal tissue may be damaged in such a way that skin whiteness, superficial scarring or thread veins may develop; however there are generally no other important side effects.

Photodynamic therapy

In rare instances, so-called photo-dynamic therapy (PDT) may be used to treat your solar keratosis or skin cancer; this is still used relatively infrequently, however, and your doctor will explain the procedure fully beforehand if it is being considered. The technique involves the use of a photosensitising chemical called a porphyrin precursor, which is either injected into or applied to the skin, after which it is taken up just by the cancer cells because they are the most metabolically active. When visible light is then applied to the affected area over a course of treatment, it is absorbed by the chemical and destroys the cancer, generally causing an accompanying soreness or burning sensation, but no other problems. However, some people who have this treatment may be advised to avoid daylight exposure for some hours after­wards, as the skin may remain very sensitive to light-induced burning for a length of time after administration of the drug.

Cryotherapy

For most solar keratoses and some small or superficial basal cell cancers, the preferred treatment is usually cryotherapy, sometimes after biopsy to confirm the diag­nosis. This technique is relatively simple and involves freezing of the lesion for a few seconds on one or several occasions a few weeks apart with a localised spray of liquid nitrogen. A severe cold injury of around –40°C is inflicted on the cancer or pre-cancer cells which kills them. During treatment the skin goes white for a few seconds because of the cold and a moderate­to-marked burning occurs, which persists for seconds to minutes, after which the skin will be red for another few minutes to hours, before sometimes blistering or breaking down over a day or so to form a scab. Thereafter, usually over about a further two weeks, healthy skin grows back into the treated site; this is usually reddish to begin with, but later totally normal.
Occasionally, the area may become temporarily tanned for a few weeks or else very rarely permanently pale, especially if a larger lesion needs to be treated aggressively.

Cryotherapy is generally convenient and effective, being quick, involving relatively modest discomfort and virtually never leaving scars, but still killing any cancer or pre-cancer cells effectively. It does not, however, pene­trate very deeply and, any lesion that is large, of uncertain diagnosis or suspected of being aggressive must be excised or, less commonly, treated with radiotherapy, usually after a biopsy, to ensure success.