Western Skin Institute Skin Blog is a platform to keep you, the patient updated on latest news about the skin and useful information on looking after your skin. All information are written by dermatologists for the lay public. We hope you’ll find the information useful and that you will share it with all your friends and family.
Skin blog 10 – March 2018: Do I need a face-to-face full skin check or a Molemap®/Molescan/ some “other Scan” technology?
*Actual Dermoscopy image obtained from a face-to-face consultation with Dr. Tan* Image: Courtesy of Western Skin Institute.
Teledermatology or the practice of Dermatology with the use of digital images, has come a long way since its inception in the early 1990’s. Initial studies were limited by poor quality images and slow internet speeds. The role of teledermatology is ever increasing now with advancements in technology.
Recent studies have shown that when provided with dermoscopic images (Dermoscopy is the use of a Dermatoscope, a polarising microscope), Dermatologists were able to diagnose skin lesions with the same accuracy as a face-to-face consultation.1-4 In fact, the author has published one of the pioneering articles on this topic.4
However, there are several points to consider when deciding between a face-to-face examination versus a “scan”:
- Who is viewing the images? – Published studies have compared the accuracy of teledermatology when the images are read by Dermatologists. We have insufficient evidence for images that are interpreted by other specialties. MoleMap® is a system of digital dermoscopy where the images are viewed by Dermatologists. Before engaging in a “scan”, it is important to enquire who is visualising the image? Is it a Dermatologist or is it some other practitioner?
- Who is taking the image? – Is it a doctor or a technician?
- Which lesion will be imaged? – Most digital photography systems image the lesion that you are concerned about, or the lesion that they spot. However, you could potentially have a suspicious lesion that neither you nor the person imaging the lesion have noted.
In summary, it is always appropriate to have a first face-to-face skin check with a Dermatologist. A skin check is not just a check of your moles. It is a full examination of your skin including non-pigmented lesions and will also involve the use of a dermatosope – a similar tool to what is involved in teledermatology above. It is not uncommon that Dermatologists pick up spots that you are not aware of. A skin check also involves risk stratification, skin care and sun protection advice. Your Dermatologist may then recommend a follow up face-to-face examination or a teledermatology follow up. This decision is dependent on your skin type, the number of lesions you have and the risk of skin cancer.
- Blum A, Luedtke H, Ellwanger U, Schwabe R, Rassner G, Garbe C. Digital image analysis for diagnosis of cutaneous melanoma. Development of a highly effective computer algorithm based on analysis of 837 melanocytic lesions. Br J Dermatol.2004 Nov;151(5):1029-38.
- Fabbrocini G, Balato A, Rescigno O, Mariano M, Scalvenzi M, Brunetti B. Telediagnosis and face-to-face diagnosis reliability for melanocytic and non-melanocytic ‘pink’ lesions. J Eur Acad Dermatol Venereol.2008 Feb;22(2):229-34. doi: 10.1111/j.1468-3083.2007.02400.x.
- Piccolo D, Smolle J, Wolf IH, Peris K, Hofmann-Wellenhof R, Dell’Eva G, Burroni M, Chimenti S, Kerl H, Soyer HP. Face-to-facediagnosis vs telediagnosis of pigmented skin tumors: a teledermoscopic study. Arch Dermatol. 1999 Dec;135(12):1467-71.
- Tan E, Yung A, Jameson M, Oakley A, Rademaker M. Successfultriage of patients referred to a skin lesion clinic using teledermoscopy (IMAGE IT trial). Br J Dermatol. 2010 Apr;162(4):803-11. doi: 10.1111/j.1365-2133.2010.09673.x. Epub 2010 Mar 5.
Skin blog 9 – January 2018 Skin checks – Who, What, When & How?
*Big thanks to Hamish for increasing awareness on having regular skin checks! http://www.hamishandandy.com/
Australia and NZ have the highest rate of skin cancers in the world. 2 out of 3 Australians will be diagnosed with a skin cancer by the age of 70.
Am I at risk of having a skin cancer? If you are very fair, always burns and never tan you are at high risk of having a skin cancer. This risk is higher if you already have a family member with a skin cancer. Those at medium risk are individuals who mildly burn and tan with some difficulty. Those at low risk are those who have olive skin, rarely burns and < 25 years old.
What is involved in a skin check? A skin check is more than just looking. It involves a full history of skin cancer risk, skin care advice, addressing spots of concern and a systematic exam of all body parts with particular attention to sun-exposed sites. Your dermatologist may elect to use dermatoscopy which is a skin surface microscopy to further enhance diagnostic accuracy. If there is suspicion of a skin cancer, a biopsy (removal of a tiny piece of skin) may be performed and sent to the laboratory for further analysis.
It is recommended that individuals with high risk have a skin check at least every 12 months with a doctor and perform 3-monthly self examination. Those at medium risk should be checked every 2-5 years with 3-6 monthly self checks and low risk individuals can have a one-off skin check with a doctor in conjunction with annual self-skin checks.
Can you be cool like Hamish and get regular skin checks?
Skin blog 8 – December 2017: Omalizumab – a new subsidised treatment for Urticaria
Those who suffer from chronic urticaria know how itchy this condition is. Also known as hives, the most common cause of chronic urticaria in adults is unknown. This can be a frustrating condition for patients.
What is Omalizumab?
Omalizumab (Xolair®) is a monoclonal antibody directed against IgE. It was first TGA (Therapeutic Goods Australia) registered on 13 June 2002 for the management of adults and adolescent patients with moderate allergic asthma. Recently, it has become approved for treatment of chronic urticaria.
This medication is only subsidised for severe urticaria and there are criteria which need to be fulfilled before this medication can be used.
The PBS (Pharmaceutical Benefit Scheme) criteria are:
- Severe urticaria without any known cause after investigation
- Severe urticaria that persists on a daily basis for at least 6 weeks in spite of H1 antihistamine treatment.
- Failed treatment for at least 2 weeks of:
- H1 antihistamine
- H2 antihistamine
- High itch and urticaria score
How is Omalizumab administered?
Omalizumab is administered as a subcutaneous injection of 150 or 300mg every 4 weeks.
What are the side effects?
Omalizumab is generally well tolerated and side effects are rare. These include anaphylaxis and local injection site skin reactions.
Skin blog 7 – June 2017 : Is acne related to food?
This question has been raised for decades. Studies as early as the 1970’s have found little or no association. Recent evidence however, points otherwise.
A large study involving 47,355 women in the Nurses’ Health Study that used retrospective data collection to determine diet during high school found an association between acne and intake of milk. This was supported by several other case-control studies.
It is proposed that the natural hormonal components of milk or other bioactive molecule in milk exacerbates acne. Milk consumption was also related to increased levels of serum IGF (insulin-like growth factor).
IGF is also increased by high sugar foods particularly those with a high glycemic index.
- Moderate-severe acne is associated with high consumption of milk, in particular skim milk, cheese/yogurt, sweets/cakes, chocolate, and a low consumption of fish, and limited intake of fruits/vegetables.
- Foods with high glycemic index can worsen acne.
- Cordain L et al. Acne vulgaris: a disease of Western civilization. Arch Dermatol. 2002;138(12):1584.
- Grossi E et al The constellation of dietary factors in adolescent acne: a semantic connectivity map approach. J Eur Acad Dermatol Venereol. 2016;30(1):96. Epub 2014 Dec 2.
Skin blog 6 – January 2017 – How safe are sunscreens? (and a note on how to spot fake news!)
We are yet facing another wave of Facebook posts of fake news where sunscreens are considered “unsafe” or “cancer causing due to nanoparticles”. This blog hopes to bust the misinformation and present the evidence. For busting myths of “spray-on sunscreens” see earlier blog (below this article).
What are nanoparticles?
Nanoparticles are fine particles in the range of 100 and 2500 nanometers. Nanoparticles are in between the size of bulk molecules (such as a red blood cell) and the size of an atom.
Source: Chemical Communications: Chem. Commun., 2006, 941-949
Nanoparticles are not new. They have been used since the 9th century in Mesopotamia when artisans used these to generate a glittering effect on the surface of pots. This lustre is due to the film containing silver and copper nanoparticles in the glassy matrix of the ceramic glaze.
Why are nanoparticles used in sunscreens?
Bulk forms of zinc oxide and titanium dioxide have been used for decades. Their main disadvantage is that they are visible on the skin as an opaque layer and hence the comment, “pale as a ghost”. This has been the main criticism of the older generation sunscreens. This undesirable visual effect has been addressed by reducing them to the size of nanoparticles. When used in this form, these oxides cannot be seen on the skin, but they still retain their UV-blocking properties.
Source: Antaria Nanotechnologies http://www.antaria.com/irm/content/nanotechnology.aspx
Why the hype about nanoparticles?
Similar to the hype on Facebook about spray-on sunscreens, there has been concern that nanoparticles in sunscreens can be absorbed into the circulation causing cancer.
How safe are sunscreens?
The available evidence suggests that sunscreens have an excellent safety profile and are without significant absorption. This website by the Australian Government Therapeutic Goods Administration (TGA) concluded that titanium dioxide and zinc oxide nanoparticles do not penetrate the underlying layers of skin, with penetration limited to the stratum corneum (outermost layer of the skin), and neither of them is likely to cause harm when used in sunscreens. I highly encourage a read:
Are there any downsides to sunscreen?
Yes. Some individuals are allergic to sunscreen This ranges from mild to severe. Most of the UV filters known to be contact sensitizers such as para-aminobenzoic acid (PABA), amyl-dimethyl-PABA, or benzophenone-10 are now rarely used in sunscreen manufacture. Oxybenzone (benzophenone-3), is the most frequent cause of sunscreen-induced photoallergic contact dermatitis. However, the estimated rate of contact sensitization to oxybenzone-containing products is <0.1 percent to 1.0 percent.
Some UV filters (eg, octinoxate, oxybenzone) have been found to have estrogenic effects in animal models. In one study, oral oxybenzone induced an uterotrophic effect in immature rats. However, when studied in humans, there is no evidence that sunscreens alter the sex hormones in humans.
How to spot fake news?
Whilst I have done my best to present scientific data, this fake news of “sunscreens causing cancer” will be one of a million other fake news yet to come. A while ago when news was delivered in print, authors had to think long and hard before publishing news as print was expensive.
Here are some tips on spotting fake news:
1. Check the source: Someone’s personal opinion on Facebook, a personal video on Facebook, The Onion, The Daily Mail, The Sun, these are not considered scientific evidence.
2. Look for concomitant headlines from the source: If you see a subsequent headline from the same author citing that “Elvis is alive” or that a “cure for cancer has been found”, it would give you an indication of the source’s integrity.
3. Check the credentials of the author: Are they an expert in the field? What are their educational qualifications?
4. Check references from the article: If there are none, question why that is. If there are, which reputable journal are they published?
5. Check the quality of the written article and domain name: Articles loaded with obvious spelling errors, grammatical error or domain sites ending in “.ru or .co” is a red flag.
Skin blog 5 – November 2016 – The low-down on Sunscreens, open water swimming and being Sun-Smart
Did you know that ultraviolet radiation is a Class I carcinogen (cancer causing agent)? This means that it is in the same category as a nuclear bomb explosion, arsenic and asbestos. Yes, the sun that creates all life on planet earth, is also the biggest cancer causing agent. So what can one do to prevent skin cancer? You simply have to be sun-smart. Felt like you’ve heard this before? Read on:
The low-down on sunscreens
Sunscreens are really the key to prevention of skin cancer and sun damage. However, studies have shown that the compliance to sunscreen advice is about 4.4%. This means that out of one hundred people that I provide sunscreen advice, only four would use it properly.
A sunscreen’s SPF (Sun protection Factor) measures the ability of the sunscreen to protect against sunburn. For example, an SPF 15 means that 1/15th of the burning radiation will reach the skin, assuming an application of 2 milligrams per square centimetre (mg/cm2).
This is what 2mg/cm2 looks like:
It is the equivalent of ¼ teaspoon to cover the area of your face. Any amount less than this will reduce the effectiveness of the sunscreen.
Unfortunately, there has been recent trends for overzealous marketing towards higher digit SPFs to promote the sale of the sunscreen. Merely applying sunscreen is not a guarantee against skin cancer. Application amount (as above), application technique, water resistance and type of sunscreen are all important.
The water resistance of sunscreen is always measured under artificial, experimental conditions. This means that human skin (with sunscreen) has been submerged in a temperature regulated water tank and subject to various water agitation and then having its SPF re-measured.
For open water swimmers, the practical application of this artificial simulation is limited. We swim at varying water temperatures, against current, our skin moves as we perform each stroke; hence the actual/real-life water resistance of sunscreen is much less.
The average user of sunscreen applies sunscreen so thinly; it achieves only 20-50% of its effectiveness. In addition to applying the right amount as detailed above, application technique is also important as areas that are commonly missed are ears, back of hands, neck, feet and legs. In addition, sunscreens are often applied non-uniformly, resulting in some sites achieving little or no protection.
Sunscreen should be applied 15-20 minutes before going out and then re-applied 15-20mins after sun exposure begins and then every 2-3 hours thereafter. The best sunscreen is only as good as the user.
Choosing the right sunscreen
A good sunscreen will have protection against both Ultraviolet B and Ultraviolet A rays so do not be fixated on just the SPF. Sunscreens are divided into two categories: physical blocks (eg. Zinc oxide, Titianium oxide) and chemical blocks (Eg. Parsol MCX, Oxybenzone). Most sunscreens have a combination of both. However, some individuals may be allergic to chemical blocks and therefore have to use only physical block sunscreens.
Spray-on vs cream
Spray-on sunscreen works equally as well as hand-applied creams. The choice between the two comes down to individual preference. It is advisable not to use spray on sunscreens on the face as the constituents of the sunscreen could enter the eye and sting. Spray-on sunscreen are more convenient, but the most common problem is not spraying enough on. Remember, a sunscreen is only as good as the person that is applying it.
The sunscreen paradox
Sunscreen use has paradoxically been associated with increasing incidence of skin cancer.
Why? Sunscreen use failure. There is a sense of immortality when using sunscreens. Studies have shown that using sunscreens with high SPF has been associated with longer duration of sun exposure than sunscreens with a lower SPF.
Application of sunscreen is just one measure for controlling sun exposure. Seeking shade around mid-day, wearing clothes and wide-brimmed hats are also important.
1. Apply sunscreen 15-30 minutes before going out in the sun.
2. Re-apply sunscreen 15-30mins after sun exposure begins.
3. Further re-application of sunscreen is necessary (at 2-3 hour intervals).
4. Seek shade at mid-day and cover up.
5. Regular skin checks by a dermatologist can help detect skin cancers early and address any issues you may have about your skin.
Dr. Eugene Tan is an open water swimmer, Ironman triathlete and Dermatologist/ Mohs micrographic surgeon. He swims all year round with the Bay Open Water swimmers and the Williamstown Mussels. He has a passion for open water swimming and will be completing the RIP swim and the Alcatraz swim in April 2017.
Skin blog 4 – November 2015 Can a Vitamin prevent skin cancer?
Non-melanoma skin cancers, such as basal-cell carcinoma and squamous-cell carcinoma, are common cancers that are caused principally by ultraviolet (UV) radiation.
In a recent study, published in the New England Journal of Medicine, Nicotinamide (vitamin B3*) has been shown to have protective effects against damage caused by UV radiation and to reduce the rate of actinic keratosis (sun damage).
*Vitamin B3 is present in most multi-vitamin supplements but its concentration is too low to have any real effect.
The investigators studied 386 participants who had had at least two non-melanoma skin cancers in the previous 5 years. They were randomly allocated to receive 500 mg of nicotinamide (Vitamin B3) twice daily or placebo for 12 months. Participants were evaluated by dermatologists at 3-month intervals for 18 months.
At 12 months, the rate of new non-melanoma skin cancers was lower by 23% along with a reduction in 11% of actinic keratosis (sun damage).
What does this mean for me?
The results from the study are promising. It must be borne in mind that this is one of the first study of its kind, follow up is relatively short (18 months) and only 386 participants was studied. In spite of these limitations, this study is exciting.
Whilst a definite cure or prevention of 100% of skin cancer is not yet available, there is promise that for something as simple as taking Vitamin B3 at doses recommended by the study (500mg – 1000mg) may be useful.
Andrew C. Chen, M.B., B.S., Andrew J. Martin, Ph.D., Bonita Choy, M.Med., Pablo Fernández-Peñas, Ph.D., Robyn A. Dalziell, Ph.D., Catriona A. McKenzie, M.B., B.S., Richard A. Scolyer, M.D., Haryana M. Dhillon, Ph.D., Janette L. Vardy, M.D., Anne Kricker, Ph.D., Gayathri St. George, M.Sc.Med., Niranthari Chinniah, M.B., B.S., Gary M. Halliday, D.Sc., and Diona L. Damian, Ph.D. A Phase 3 Randomized Trial of Nicotinamide for Skin-Cancer Chemoprevention N Engl J Med 2015; 373:1618-1626
Skin Blog 3 – October 2015
The PBS funds new revolutionary drug for psoriasis. Am I eligible?
As of 1st October 2015, the PBS (Pharmaceutical Benefits Schedule) now funds a new medication Cosentyx (Secukinumab) for the treatment of psoriasis.
The most common question that dermatologists gets asked is, “Can I be on the drug?”.
Psoriasis is a common skin problem that affects up to 6.6% (or 1.6 million) Australians. Of those individuals, 1% will have psoriasis that is severe enough that treatment is needed as it affects quality of life.
Treatment for psoriasis is chosen based on severity, patient preference, effectiveness and assessment of response. As a dermatologist, the safety of any medication is paramount and must be balanced by risks of under-treatment.
The four broad categories of treatment (chosen in order of severity and side effects) are:
1. Topical therapy – Creams
2. Ultraviolet therapy – Narrowband phototherapy (given under supervision of a Dermatologist)
3. Systemic therapy (tablets) – Methotrexate, Acitretin or Cyclosporin
4. Biologic therapy (Injections) – Etanercept (Enbrel®), Adalimumab (Humira®), Ustekinumab (Stelara®) and Secukinumab (Cosentyx®)
The PBS imposes criteria for eligibility of biologic therapy. These are:
1. Severe chronic plaque psoriasis of the whole body where lesion have been present for at least 6 months from the time of initial diagnosis where PASI score is greater than 15 (http://www.dermnetnz.org/scaly/pasi.html) or Severe chronic plaque psoriasis of the face, palm or soles of foot for at least 6 months where at least 2 of the 3 PASI symptoms scores are rated as severe or very severe or the skin is 30 percent or more of the face, palm of hand or sole of foot.
1. Has failed to achieve adequate response as indicated by PASI for a minimum of 6 weeks treatment to at least 3 out of 4 of the following:
- Phototherapy > 200 treatments
- Methotrexate at dose of at least 10mg once weekly
- Cyclosporin at dose of at least 2mg per kg per day
- Acitretin at dose of at least 0.4mg per kg per day
Cosentyx® is a human IgG1 monoclonal antibody that selectively binds to the interleukin-17A (IL-17A) cytokine (protein that is secreted by cells that carry signals to neighbouring cells) and inhibits its interaction with the IL-17 receptor. IL-17A is a naturally occurring cytokine involved in normal inflammatory and immune responses. Cosentyx® inhibits the release of proinflammatory cytokines and chemokines that are important in the development of psoriasis.
Cosentyx® along with other biologics, carry risks/ side effects. Cosentyx® may increase the risk of infections. A higher rate of infections was observed with secukinumab treatment in clinical trials, and these may be life-threatening.
It is administered by injection (subcutaneously), 300 mg once weekly at weeks 0, 1, 2, 3, and 4 followed by 300 mg every 4 weeks. Some patients may only require 150 mg per dose.
Your dermatologist would be the best person to discuss psoriasis treatment with you. Whilst, the appeal of a new drug is apparent, patients must fulfil PBS criteria to be eligible for funding of this medication. No medication is without side effects. If you think you may be eligible for Cosentyx®, discuss this with your General Practitioner and a referral to a Dermatologist may be warranted.
Skin Blog 2 – August 2015
Winter and Your Skin
The words “winter and dry skin” are often considered synonymous. Did you know that dryness of the skin has almost nothing to do with the amount of water you drink?
Dryness of the skin (xerosis) is actually related to changes in the protein and lipid content of the stratum corneum (uppermost layer of the skin). This change in the stratum corneum alters the scattering and reflection of light leading to a dull, rough appearance to the skin. Skin dryness can be triggered by changes in the environment or due to factors related to your overall health. In winter, the most common cause is a change in the humidity of the environment.
Winter brings about three common problems in the skin: dry skin, worsening of eczema and skin cancer. The stratum corneum plays an important role in the barrier function of the skin and when skin becomes dry, its barrier function is affected and this can exacerbate eczema. A good moisturizer is an important part of winter-skin-care and those that contain glycolic acid will improve the skin’s appearance and texture.
Skin cancer does not respect seasons. Research has shown that melanomas are thicker and diagnosed at a later stage in winter than in summer. This is most likely due to an increased awareness of skin cancer in summer when compared to winter. Hence winter is not a time to be complacent. Your dermatologist is the best person to discuss skin checks and skin care.
Blog 1 July/2015
Keytruda® (Pembrolizumab) – New treatment for Melanoma.
What does this mean and how does it apply to me?
Last week, the Australian Government approved funding of Keytruda® to treat melanoma:
Malignant melanoma is a serious type of skin cancer due to uncontrolled growth of pigment cells (melanocytes). Australia and New Zealand have the highest incidence of melanoma in the world. Despite sun protection messages over the last 30 years, melanoma incidence has increased more rapidly than for any other cancer.
In most cases, melanoma arises from otherwise normal appearing skin (75% of cases) but a melanoma can also occur in a precursor lesion such as a normal mole (benign melanocytic naevus) , afunny-looking mole (atypical naevus) or a birthmark (congenital melanocytic naevus).
Melanoma is staged depending on how thick it is and whether or not it has spread from its original site. The thicker the melanoma, the more advanced the stage and the poorer the survival.
Keytruda® is also known by its drug name, Pembrolizumab. When a malignant melanoma develops, it can express certain proteins on its surface such as PDL-1 which helps it evade or hide from the immune system. This means the melanoma will remain undetected from the immune system. PDL-1 on the melanoma binds to specific proteins (PD-1 and B7.1) on T-cells (an important cell in our immune system) and disrupts their ability to detect the melanoma.
Pembrolizumab is an antibody against PD-1. By blocking this protein on the T-cell, it returns the T-cell to its active state allowing it to detect the melanoma and destroy it. Therapy with Keytruda® improves overall survival in patients with advanced melanoma (6-month progression-free-survival rates of 47.3% for pembrolizumab every 2 weeks, 46.4% for pembrolizumab every 3 weeks, and 26.5% for ipilimumab and 12-month survival rates were 74.1%, 68.4%, and 58.2%, respectively). The drug is given by intravenous infusion every 3 weeks for as long as it is working.
How does this affect me? Keytruda® is licensed for use in advanced, metastatic melanoma. This is also known as Stage IV disease or melanoma that has spread beyond its initial site at the skin to the rest of the body. Keytruda® is not for use in healthy individuals for prevention of melanoma, nor is it licensed for use in earlier stages of melanoma. If you have advanced, metastatic melanoma you may want to discuss your case with your cancer specialist, Oncologist on whether or not Keytruda® may be of benefit to you.
For most cases of melanoma, diagnosis is made at an early stage and surgical excision is curative. A skin check by a dermatologist can greatly assist in detecting melanoma at an early stage.
Blogs Written by: Dr. Eugene Tan Dermatologist and Fellowship-trained Micrographic Surgeon MBChB, FACD, FRACP, FNZDS, FACMS