Care that is more than skin deep

The Jewish Chronicle - - NEWS - BY MAL­COLM RUSTIN

THE SKIN is the largest or­gan in our body. In an av­er­age 70kg in­di­vid­ual, it weighs over 5kg and cov­ers a sur­face area ap­proach­ing 2 sq me­tres.

It acts as a bar­rier keep­ing the out­side world out but also func­tions as a sen­sory, en­docrine and im­muno­log­i­cal or­gan, and helps to con­trol body tem­per­a­ture.

Skin fail­ure in­creases the risk of in­fec­tions lead­ing to mor­bid­ity and dis­abil­ity.

Age­ing of the skin has an in­trin­sic com­po­nent, due to ad­vanc­ing years, and an ex­trin­sic com­po­nent which is caused by ex­po­sure to ul­tra­vi­o­let (UV) ir­ra­di­a­tion.

The com­bi­na­tion re­sults in im­paired bar­rier func­tion be­cause of a thin­ning of the up­per layer of the skin ( the epi­der­mis) and dam­age to the sup­port­ing col­la­gen and elastin in the lower layer (the der­mis).

This pro­duces a con­di­tion known as der­mato­poro­sis char­ac­terised by a thin skin which eas­ily bruises, bleeds and tears after mi­nor trauma.

Un­for­tu­nately at present we can­not re­verse this process but bet­ter ed­u­ca­tion about pro­tec­tion against UV rays can min­imise the im­pact.

There is a dilemma about sun ex­po­sure. On the one hand the sun is needed for the pro­duc­tion of vi­ta­min D by the skin. UV ir­ra­di­a­tion also in­creases the pro­duc­tion of ni­tric ox­ide which opens up blood ves­sels, re­duces blood pres­sure and pos­si­bly pro­tects against coro­nary artery spasm.

On the other hand, dam­ag­ing ef­fects of UV ir­ra­di­a­tion causes der­mato­poro­sis and ab­sorp­tion of UV ra­di­a­tion in­duces mu­ta­tions within skin cells.

These mu­ta­tions may cre­ate pre­ma­lig­nant con­di­tions such as ac­tinic ker­atoses and Bowen’s dis­ease and even­tu­ally cause a va­ri­ety of skin can­cers.

Although sun­light will in­crease vi­ta­min D pro­duc­tion, it is not pos­si­ble to pre­dict how much sun ex­po­sure is re­quired.

Pub­lic Health Eng­land rec­om­mends that adults and chil­dren over the age of one should con­sider tak­ing a daily sup­ple­ment con­tain­ing 10mcg of vi­ta­min D, par­tic­u­larly dur­ing au­tumn and win­ter if they are not of­ten out­doors,

Ac­cord­ing to re­cent find­ings, the de­vel­op­ment of skin can­cers as a re­sult of UV ex­po­sure ( known as pho­to­car­cino­gen­e­sis) in­volves a cas­cade of pro­cesses caus­ing var­i­ous cel­lu­lar, bio­chem­i­cal, and molec­u­lar changes closely re­lated to each other

Ex­po­sure of the DNA within the skin cells to UV ir­ra­di­a­tion cause changes that al­ter the way DNA is sub­se­quently pro­cessed.

It has also been shown to trig­ger im­muno­sup­pres­sion which plays an im­por­tant role in pho­to­car­cino­gen­e­sis.

The re­sult is that after a vary­ing time of sun ex­po­sure, hard crusted le­sions (ac­tinic ker­atoses) may ap­pear, or more ex­ten­sive red crusted ar­eas (Bowen’s dis­ease) may de­velop.

These are pre-ma­lig­nant and although some may spon­ta­neously regress, oth­ers can de­velop into more se­ri­ous squa­mous cell car­ci­no­mas.

Treat­ment of the pre-ma­lig­nant le­sions can be un­der­taken us­ing cryother­apy (freez­ing with liq­uid ni­tro­gen) or by the ap­pli­ca­tion of creams such as 5-Flu­o­rouracil, Imiquimod or Ingenol.

All these treat­ments kill off the ab­nor­mal cells al­low­ing new healthy skin to grow back.

Mu­ta­tions in other genes are in­volved in the de­vel­op­ment of ma­lig­nant basal cell car­ci­no­mas and melanomas.

Basal cell car­ci­no­mas are the most com­mon and the least se­ri­ous of skin can­cers as they only very rarely spread to other parts of the body (metas­ta­size).

This is in con­trast to squa­mous cell car­ci­no­mas that do have the po­ten­tial to metas­ta­size.

The lat­est 2014 statis­tics re­veal that in that year there were more than 130,000 basal cell car­ci­no­mas and squa­mous cell car­ci­no­mas di­ag­nosed in the UK, but this is con­sid­ered a se­ri­ous un­der­re­port­ing as it is not manda­tory to record basal cell car­ci­no­mas.

Although very early basal cell car­ci­no­mas can be treated in the same way Dif­fer­ent lay­ers of the skin re­act in a va­ri­ety of ways to UV ir­ra­di­a­tion

as pre-ma­lig­nant le­sions, most of these tu­mours and squa­mous cell car­ci­no­mas are ex­cised or, less com­monly, treated with ra­dio­ther­apy.

For these rea­sons we should be on the look­out for any le­sion that is itchy, chang­ing in shape, size or colour, or bleeds. If you are con­cerned, con­sult your GP.

Cases of ma­lig­nant melanoma — when a tu­mour arises from the pig­ment-pro­duc­ing melanocytes within the skin — have risen by 360 per cent since the late 1970s and this wor­ry­ing trend con­tin­ues. The mor­tal­ity rates have in­creased by 156 per cent since the early ’70s and the life­time risk of de­vel­op­ing a melanoma is one in 52 for men and one in 54 for women.

As the only chance of cur­ing a melanoma is for it to be ex­cised at an early stage, it is cru­cial that self-as­sess­ment of one’s skin should be un­der­taken and if there are changes in the shape, out­line, size or colour, or if the le­sion should be itchy, sore or bleeds then it would be ap­pro­pri­ate to seek pro­fes­sional ad­vice.

There has been great ex­cite­ment over the avail­abil­ity of new treat­ments for melanoma that has metas­ta­sized, but our aim should be to de­tect such tu­mours early and cure the pa­tient by prompt ex­ci­sion.

Age­ing skin be­comes pro­gres­sively drier which is due to changes in the molec­u­lar com­po­si­tion of the epi­der­mal cells, most prom­i­nent of which is the re­duc­tion in the pro­tein fi­lag­grin.

Fil­la­grin acts as a nat­u­ral mois­tur­is­ing fac­tor, al­low­ing hy­dra­tion of the skin. The com­bi­na­tion of this de­fi­ciency, to­gether with the de­greas­ing ef­fect of soap and a cen­trally heated en­vi­ron­ment, may en­cour­age the de­vel­op­ment of eczema.

This can be treated with the ap­pli­ca­tion of emol­lients and top­i­cal steroids.

An un­com­mon dis­ease oc­cur­ring in more ma­ture Ashke­nazi in­di­vid­u­als is bul­lous pem­phigoid. This can present ini­tially with an eczema be­fore evolv­ing into blis­ters. If any itchy rash or eczema is not set­tling with sim­ple treat­ments a pro­fes­sional opin­ion is re­quired.

Other fea­tures of age­ing skin are the ap­pear­ance of brown warty growths known as se­b­or­rheic ker­atoses, and dot­ted, raised, red le­sions which rep­re­sent col­lec­tions of blood ves­sels known as cherry an­giomata. Both of these le­sions are en­tirely harm­less but if they get big­ger or bleed it would be sen­si­ble to seek an ex­pert opin­ion.

This ar­ti­cle is an edited ver­sion of a talk given in the Jewish Care Health In­sights se­ries. Pro­fes­sor Mal­colm Rustin is a con­sul­tant der­ma­tol­o­gist at the Royal Free Hospi­tal

Sun can be both an enemy and a friend to the skin


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