Sunburn

It is now well recognised that excessive or prolonged exposure to the sun’s rays and inadequate skin protection can result in skin cancers, particularly squamous cell carcinoma, basal cell carcinoma and malignant melanoma. Malignant melanoma is associated with acute, intense, and intermittent blistering sunburns. Pharmacists therefore have a major role to play in promoting sun safety messages, and making appropriate referrals with regard to suspicious lesions. For example, the number of malignant melanoma cases is increasing (currently about 1,000 new cases each year) and is associated with the highest mortality rate of any skin cancer, but is curable if detected and treated early.

Sunburn is the body’s immediate protective reaction to over exposure to sunlight and is an acute inflammatory response that causes capillary vasodilation (seen as the redness) and release of chemical mediators (producing pain and swelling). Over time, melanocytes produce melanin causing the skin to darken (the suntan) but by which time skin damage (sunburn) has already happened.

Preventing sunburn

The most effective way to prevent sunburn (and ultimately reduce the chance of developing melanoma) is to avoid direct exposure to UV light. Cancer research UK has promoted a Sun Smart cancer prevention programme, which highlights the key sun avoidance measures that should be promoted to the public:

S – Spend time in the shade between 11 am and 3 pm
M – Make sure you never burn
A – Aim to cover up with a t-shirt, hat and sunglasses
R – Remember to take extra care with children
T – Then use sunscreen with sun protection factor (SPF) of 15+

Probably of greatest significance in promoting SMART is the use of a high factor sunscreen. Pharmacy staff must ensure that people understand the need to use a high factor sunscreen and must not promote matching skin type to SPF as has been previously advocated. All sunscreens should be applied 20 minutes before exposure to the sun, and reapplied every two to four hours and after swimming to ensure maximum protection.

Sunburn can be managed with a combination of topical cooling preparations, such as calamine, and systemic analgesia. In addition, there is currently an application to reclassify ibuprofen lotion (under the name Ibusol) to P status to reduce pain associated with mild to moderate sunburn. If approved it will be licensed for children over the age of 12 years and applied when needed up to a maximum of eight times a day.

Referring suspicious lesions

The first sign of melanoma is often a change in the size, shape or colour of a mole, although melanoma can also appear on the body as a new mole. Early identification of their progression is essential. UK Guidelines (Prodigy) use a seven point checklist produced by the British Association of Dermatologists. The weighted checklist consists of three major (each scoring two points) and four minor points (each scoring one point). Major points are:

1. Change in shape
2. Change in size
3. Change in colour.

And minor points are:
4. Largest diameter 7mm or more
5. Inflammation
6. Oozing
7. Change in sensation (eg itch or irritation)

Lesions should be considered suspicious if any major feature is present, or the total score is three or more.

References:
1. Sheikh A, Panesar SS, Dhami S. Seasonal Allergic Rhinitis. British Medical Journal Clinical Evidence 2006. www.clinicalevidence.com.
2. Mann RD, Pearce GL, Dunn N et al. Sedation with ‘nonsedating’ antihistamines: four prescription-event monitoring studies in general practice. BMJ 2000; 320: 1184-6
3. Lee TA, Pickard AS. Meta-analysis of azelastine nasal spray for the treatment of allergic rhinitis. Pharmacotherapy 2007; 27(6): 852-9
4. Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, et al. The diagnosis and management of rhinitis: an updated practice parameter. The Journal of Allergy and Clinical Immunology 2008; 122(2S): 1-84
5. Lindsay-Miller ACM. Group comparative trial of 2% sodium cromoglicate (Opticrom) with placebo in treatment of seasonal allergic conjunctivitis. Clinical Allergy 1979; 9: 271-275

Dr Paul Rutter is principal lecturer in pharmacy practice at the University of Wolverhampton