Sun damaged skin?

A few questions anwered.

Note that I am a patient and not qualified in medical matters in any way. Therefore don't believe what I've written and see a doctor if you have skin worries.

I've done a lot of outdoor activity. Walking, jogging, gardening, DIY, travelling to the tropics and any excuse to be in the sun mainly with inadequate protection for my head. I'd add that to make matters worse I went bold around 30 so had no protection on top. Fortunately I was almost always fully dressed so my body, arms and legs aren't effected. At the age of 50 I had quite a few keratosis on top of my head. At 57 I got a BCC and the keratosis became worse. I later found that I'd been carrying a Bowens Disease 'patch'. At 58 I found my forehead developing a few keratosis and at 59 my face is showing some signs but they're not easily visible.

When you get to 50 sun damaged skin is fairly common in white skinned people. Just how damaged and whether you are more susceptible to cancerous lesions is what you need to think about. There area a lot of different types of damage and most of it, even cancer, isn't as serious as many people think. Most skin cancers are successfully removed, from what I've read over 95%. Ignoring them is the worst thing you can do as they will damage you badly if you give them time and we're all different.

I live in the UK and find that Americans have the best references on this matter and are more effected, along with Australians, due to their climate. My dermotologist says he's seen far worse than mine and in 25 years hasn't lost anyone with my condition. I'm not at all complacent about it though and wear high factor sun screens, hats, dense shirts, long sleeves and long trousers when I'm outside during daylight. A bit of a drag really although not too bad in the British climate, 54 degrees north, closer to the arctic circle than the tropics.

Types of Skin Cancer

1. Pre-cancer: Actinic or Solar Keratosis (AK), Bowens Disease.

2. Basal Cell Carcinoma (BCC)

3. Squamous Cell Carcinoma (SCC)

4. Malignant Melanoma - not discussed on this site.

There might be more as I hadn't heard of Bowens Disease till I had it. Some doctors class pre-cancers as cancers, some say that is unnecessarily scarey for patients.

How worrying are they?

Actinic Keratosis need treating but I found my doctor seems quite relaxed about mine. He says it is only a small percentage that change into full cancers, type SCC, so if you have a lot or for a long time the probability increases. Mine are restricted to my scalp with a few developing now on my forehead and face. My body, arms and legs have none. Mine are either a sort of a rounded small bit of raised skin, a rough hard, sandpapery, raised bit of skin or a scabbish bit with perhaps a bit of red underneath. They can take a lot of forms. On my face there is a very small slightly raised area that tingles if I go out in the sun and my doctor froze it off. He says AK start on the scalp (if you've no hair or maybe on the parting) and then spread down the face, depends how you have been exposed to the sun.

Bowens: at one point my Bowens was thought to be an SCC. My doctor said it was only a thin layer and it is if they change and get deeper that they become urgent. Bowens can look very innocuous though. A red patch, clearly demarcated, of roughish skin, ulcerated, then crusted maybe. Mine went through some changes. They can take several forms.

BCC, my doctor didn't treat this with any urgency. If I'd known more at the time though I would have sought faster treatment. In my case it was more a cosmetic issue as it was growing wider but not deeper. I was told they only grow deeper if they are ignored for too long and that is when they become urgent.

SCC, my doctor said it is when they get deeper that they become dangerous. They look like bad keratosis but can take many forms. They should be treated as soon as possible.

If you look at photographs of each type they can look very similar and the opposite they can look very different but be the same thing. They say doctors can tell which they are but I can't think that they can be sure in many cases. You can torment yourself looking at photos and reading descriptions. A good doctor gives the best advice.

What do you do about it?

An obvious answer is that from now use sun-cream, protective clothing, stay out of the sun within 2-3 hours of its peak height depending where you are. Noting that peak height isn't always midday, for example in the UK in summer it is around 1pm.

Another obvious answer is visit your doctor immediately you suspect something on your skin isn't healing as it should, changes, bleeds or there is a red or rough patch.

In the UK I'd ask how long you expect to wait to see the dermotologist. My GP usually says something like I'll try to get you in quickly, but I know he won't when he's said its nothing much. If you get in fast it might not need a graft as the dermotologist might sort it. Then again if it needs a biopsy this can take over 2 months and it can be a long way from treatment depending what it is.

The other thing is maybe its best to get a check of all your skin while you are at it, be ready to take off your clothes.

If you've had one of these conditions, never be caught out unprotected in the sun and don't believe it's gone away. Depends how risk averse you are though.

Pre-cancer: Actinic or Solar Keratosis (AK). See your GP and, in the UK, you'll be referred to a dermatologist. He might; immediately freeze off large ones. Might use curettage to cut it out but this is a minor op and enables a sample to go to the lab if needed. Give you cream for more widespread areas. I've had them all. I was given Efudix cream but I've read about one called Carac. These are serious creams and contain chemotherapy compounds. Some people get reactions. I was OK with it though and did a small area trial before doing a larger area. I'm not sure but I think cutting them out is the only permanent solution. For large areas cutting out isn't a practical solution.

Pre-cancer: Bowens Disease: mine was biopsied, the doctor meant to cut it out as a large keratosis but then suspected SCC. I was hoping to use Photo-Dynamic Therapy (PDT) or Efudix cream but he said the most permanent solution is excision. As I thought it looked worse than the Bowens photo's I'd seen on the internet I thought it was best to go for safety even though I already had a graft and wasn't happy about the cosmetic effect. So I had a skin graft about an inch diameter. It's not too painful to have done and is only an hour at the hospital. I know I'l l never look or feel the same even though my second graft is well done.

BCC: my first experience was with a BCC. Saw my GP who said it was nothing much and referred me slow time to a dermotologist who said it was a keratosis and froze it. It came back bigger and he said it looked like a BCC. I was biopsied in slow time so that it became too big for a dermatologist to treat and needed a graft. What do you do about it? I'd say don't let them put you on slow time. Make sure it's cut out properly with a margin as soon as possible.

SCC: As I said above I did think I'd got an SCC for a while. Bowens and keratosis are considered SCC by some doctors and a Bowens is medically an SCC-in situ or sort of constrained to the upper skin. In general my dermotologist said an SCC that is shallow and not large is not life threatening and has high probability of complete removal by excision. If you ignore them they get deeper and more threatening. Even so my doctor said you need to ignore it a lot for this to happen.

What are the treatments like?

Cryotherapy - liquid nitrogen

AK and small lesions are often treated by the dermatologists favourite tool. His liquid nitrogen gun, cryotherapy. Just sit still. Hissssssss. 5 seconds for an easy one, 10 for more difficult and more for larger, deeper, harder ones. At about 7 seconds it becomes painful, over 10 seconds and more than one and its eye-watering. Pain doesn't last long though and in 3 to 4 weeks its healed and hopefully gone. It's good to see that AK on top of a blister. It can leave a small indent and loss of colour. A simple and fast treatment.

Curettage

Large AK and small lesions may also be curetted and it's a more permanent fix. So you have a small anaesthetic injection while sitting still and wait a few minutes for it to work. Then he asks the nurse for a curette and you might feel it or not. He'll then cauterise it with an electric probe to stop the bleeding. This goes beep as the current is turned on and there is a crackling sound. You only feel the injection. Can take 3 to 8 weeks to heal depending on how big and deep.

Topical Cream

Widespread AK and Bowens Disease (in the UK ony - I think) may be treated by topical creams. I had Efudix, also known as Efudex, although I've read about Carac which seems to be a more advanced type enabling lesser doses. You rub a thin layer of cream onto the area to be treated. It only effects cells that are growing abnormally. So you might have some hidden ones that it finds. On the other hand there might be cells it doesn't find, that's why excision is more permanent.

There are mixed reactions. Mine was a bit unusual in that my hospital only recommends one application a day for 4 weeks. Most are 2 applications for 14 days. My reaction was slow, it took 10 days to go red and only smallish blotches came up. They were a bit sore but not too bad. If you do 2 a day it works faster and the effect can be more extreme but from what I've seen after 30 days it can be almost healed whereas with mine I'll still be rubbing in cream. See the CancerCompass website forum below, it has a forum with over 500 e-mails on Efudix / Carac.

Another cream I was prescribed at my first plastic surgeon consultation is called Solaraze. The second dermatologist I saw said that Solaraze is quite weak compared to Efudix. My experience was that it did work although the Bowens remained. The AK came back quite quickly though.

Photo-Dynamic Therapy

Widespread AK and Bowens Disease (in the UK I think) may be treated with Photo-Dynamic Therapy (PDT). I havn't had this but it appears to use a cream like Efudix except it takes 4 hours to treat using a laser to activate the cream and then its straight into healing. There is a slideshow of PDT on the British Association of Dermotologists website below. They say this is a good treatment and improvements in creams and lasers are making it better but my doctor says you can't beat excision for a permanent solution.

Excision

Excision: If your lesion is small and in an area with plenty of skin they can pull it together after cutting it out. I didn't have this. Local anaesthetic. Takes about 30 minutes for a small one. A young woman had one just before I had my graft, she was worried about it leaving a raised eyebrow, but when I saw her walk out the bandage was very small and her eyebrow looked normal. They always take a margin of clear skin so it'll be bigger than the lesion.

Excision and Graft

Excision and Graft. I had two of these 5 months apart, full thickness grafts about an inch diameter including a 4mm margin of unaffected skin that was removed. The scalp has no spare skin to stretch so a graft is needed. They were able to do it within an hour and then I was off home. It's a full operation dressed in a hospital gown and laid on an operating table. I expect at a certain size you'd stay in hospital also the scalp is apparently a good grafting site whereas a leg is not, particularly around the ankle.

Basically, in an operating theatre they give you a local anaesthetic in both the area to be grafted and the donor site which is where the leg meets the body, although the second one was a bit higher. They then trace out the size of graft needed and cut it out from the donor site. They then stitch up the donor site and cut out the lesion. There is cauterising of the lesion area to stop bleeding using an electric probe. Lots of crackling, perhaps a bit of a smell of burning flesh and a few pricks of pain.

Then they start stitching in the graft. Press it down hard with a heavy and well attached dressing. You don't feel much and the staff are chatting and have a radio on.

I was told that for 5 days it needs care and this is the critical time but you don't touch it or wash it or anything. On the 7th day the dressing is removed and it doesn't look too good but its clean, neat and the stitching is clear. Then up to week 4 it doesn't really feel like it's attached and might throb if you bend over or do anything vigorous. Around weeks 4-6 I found it a bit yellowish and some bits of scab started to look a bit like they might not be right. After that it becomes more part of you and the scab and stitches are mainly gone by week 10.

The donor area doesn't cause any problems but you can't put stress on it for a few weeks and it leaves a scar and will bruise to some degree.

The graft is numb and white and that might take ages to change. They tell you to massage the scar with moisturising cream and it can take 18 months to heal fully. It is indented a bit. My first graft is very indented, you don't realise how thick your skin is. The second one is hardly indented, don't know why. Was it the size or the surgeon? Apparently they scrape the fat off the graft to make it heal better but it makes the skin thinner there. Probably there is great skill in cutting the fat off to the right level and keeping it smooth.

Is there any other help?

I found a lot of websites with information. However there are a couple of things to watch out for. It can appear that in black and white the above conditions read worse than they possibly are. Also some websites appear to have an axe to grind for commercial reasons. Another source is the library although I read a book by a GP that was quite simple and good but it seemed that he'd mis-interpreted some of the information he'd got from interviews with dermotologists, in my humble opinion.

My experience is that your own doctor is the best source and if you ask he'll clarify what you've read.

Also your local Dermatology Department might have a Patient Support Group and possibly an Expert Patients Group. If not you could start one.

One of the best websites I've found is CancerCompass but its search engine isn't that clever. The link below is to a discussion board on using Efudix (Efudex) or Carac cream. It also has an excellent slide show by a contributor called 'aceaceace' who photographed his Efudex (US spelling) treatment every day. Don't know how normal his reaction was as it was severe but he was very plucky and tongue in cheek about it. The result is good though.

http://www.cancercompass.com/message-board/message/all,4537,55.htm

Below is a link to 'aceaceace' slideshow for days 1 to 14 - applying Efudex. From here there is a link to days 15 to 35 - healing. Please come back to this site.

http://www.slide.com/r/UOS38iRG0z_1PeL2Uf6edu7M91i06eJ3?previous_view=mscd_embedded_url&view=original

Another website I read is emedicine but I did find my doctor needed to soften it after reading some stuff.

http://www.emedicine.com/derm/

Another source in the UK is the British Association of Dermatologists. This has patient leaflets and is written in an easy style. There are also some slideshows of treatments.

http://www.bad.org.uk/patients/leaflets/

Summary of BCC treatment - Sept 06 to Sept 07.

This is a personal account of my treatment for Basal Cell Carcinoma by the NHS. Although the skills were there, the slicing of work into multiple short appointments enabled my treatment to last 12 months. This transformed a smallish blemish into a large blemish needing what appears to me to be quite a disfiguringly large graft.

After the GP, there were 4 visits to a Dermatologist followed by 2 with a Plastic Surgeon. In total about 80 minutes contact with doctors in the 12 months, including the 45 minute operation.

The original mark that I saw my GP with was about 3-4mm diameter but by the time it was treated it was about 20mm wide and needed a full thickness skin graft about 30mm diameter on my head.

While not doubting the skills applied, the process is much too slow. I've read in a charity website that BCC is treated as non-urgent so a 3 month wait to see a specialist is normal. Can't say I agree. In this case the timescales were;

GP to first specialist appointment = 3.5 months.
GP to biopsy result = 8 months.
GP to surgery = 12 months.

I'm told that in 2008 the NHS targets mean you will be treated faster.

Summary of other treatment - Oct 07 onwards

Visit to GP in Oct 07 to view a mark on my cheek. He suggests I visit a doctor privately as he can't see anything particular and with my history.

October - private doctor gives me a thorough check over and says he'd recommend I have the Actinic Keratosis removed from my head using curettage on the NHS. Also looks at a couple of moles and applies cryotherapy to a mark on my face and a wart.

December - NHS hospital, doctor says there are signs of Squamous Cell Carcinoma in one large Keratosis and he's sending it to the lab. However he believes the curettage should have removed it. Quite a large hole in my scalp and 9 small holes.

2008

January 08, doctor rang to advise biopsy result and said its Bowens Disease which is classed in some texts as pre-cancer and in others as squamous cell carcinoma. Officially 'SCC in-situ'. He says he'll treat it - or at least that was my interpretation.

January 31st - the lesion is healing to look exactly as it was, doctor says excision is the best and only almost guaranteed permanent solution so I agree to see plastic surgeon. A bit disappointed as he gave me the impression he'd treat it and I didn't want a second graft.

As a note, there seem to be 2 NHS process problems here;

1 - The Dermatologist told me it wasn't urgent yet a week later plastic surgeons are ringing saying it is urgent.

2 - You can get an NHS fast consultation classed urgent but they won't guarantee your op will be urgent - this means you can't risk taking the NHS assessment. Apparently there are tracks to cancer treatment lasting 31 or 62 days depending on urgency, however you can't find out which track you are on until assessment and then no-one actually mentions these tracks. It does seem that the tracks do work to some extent but it's a bit 'smoke and mirrors' in that it seems out of your control and you are unaware of it.

7th Feb - appointment at private hospital to see plastic surgeon and he says 'excise and graft'. NHS ring on 6th with appointment for 14th saying all lesions are assessed urgently, the Dermo consultant is trying to make a point that the NHS isn't as slow as I think. However they can't guarantee the surgery date so I continue the private route.

27th Feb - 4pm, private appointment for surgery. Not clear how much time I saved, if any, over NHS - I'd estimate 1 to 4 weeks but at least I have known the dates since 8th Feb. Had the surgery in the evening.

5th March - Dressing removal. Although the graft is fairly large it is smoother than the previous one and looks like it could heal very well. The donor area has only a very small bruise and is stitched very finely compared to the large bruise and stitching on my previous op. Photo of new graft freshly unbandaged with old graft top right just visible. Call me Patch.

freshly unbandaged graft.

3rd April - private appointment to look at graft progress. Says looks good and all effected cells have been removed. Says biopsy shows severe sun damage to that area. If I use Efudix keep it away from the graft it doesn't need any challenges at this stage.

Use of Efudix / Efudex (in US) - 1 application a day for 4-6 weeks. (Most hospitals say twice daily for 14 days).

14th April - appointment at NHS dermatology. Doctor freezes off 3 AK that are close to the graft. Says its OK to use Efudix on my forehead but keep it away from the frozen area and although graft probably OK by now keep it away from graft.

20th April - have used Efudix on small area for 5 days with little apparent effect, so there is no adverse reaction. Decide to start on whole of forehead.

27th April - some small blemishes on forehead.

1st May - decide to do an area of AK above my forehead.

5th May - day 20. A few red and slightly sore blotches on forehead as photo below. No widespread deep redness like I've seen on other peoples photos. Want to do more so make earlier appointment with doctor for go-ahead. Want to do twice a day as well to shorten treatment.

forehead after 20 days of Efudix

BCC treatment by excision and graft - photos
Photo No.1) FEBRUARY 2006 one small scab. Didn't see GP until Sept 06. It was a bit bigger then.	Photo 2, JULY 2007 scab has moved from right arrow to the left arrow, area in-between is pinkish indented and will need to be removed, so diameter about 15-20mm. Unfortunately it grew more by September. Not a very clear photo, I know.
Photo 3, SEPTEMBER 2007 stapled down dressing over graft. Quite neat. Graft is about the same size as the dressing. Graft is circular, 30mm diameter, which is probably a margin of 5 to 7mm.	Photo 4, 1 week after op, bandage removed. Looks better in photo than from other certain angles. Neat job though.
Photo 5, 3 weeks after op, beginning to heal, area at back slightly bruised after sharp stitch caused slight bleed.	Photo 6, 4 weeks after op. Healing better, the bruised bit is clearing.
Photo7, 5 weeks after op. Healing slowly. New eruptions still occur but the overall trend is getting better.	Photo 8, 6 weeks after op. Feels more robust now. Stitches in middle still there, don't know what they're attached to.
Photo 9, 7 weeks after op. Able to rub cream on it easily and it is clearing up the scabs. Looks better but a different colour and indented. From the front it looks very indented.	Photo 10, 11 weeks after op. Looking better although in certain lights it stands out. Told colour will get better and scar improve.
May 2008. The graft hasn't changed much from the last photo. It does seem more indented that I'd expected.