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Citation: Ocarina L, Khachemoune A, Chawkat L. The dark side of the sun: Affected demographics of skin
cancers.Jr.med.res.2021; 4(2):11-13. Ocarina et al© All rights are reserved. https://doi.org/10.32512/jmr.4.2.2021/11.13
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Mini Review
The dark side of the Sun: Affected demographics of skin cancers.
Ocarina Lin
1*
, Khachemoune Amor
1
, Chawkat Leila
1
.
1: Premier Dermatology, Bentonville
Arkansas, USA
* Corresponding author
Correspondence to:
Ocarinalin1@gmail.com
Publication data:
Submitted: May 24 ,2021
Accepted: September 22 ,2021
Online: November 30, 2021
This article was subject to full peer-review.
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Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are the most
common skin malignancies. BCC and SCC are affecting the corresponding cells in
the epidermis where tumorogenesis starts. The onset of these diseases is caused
by sun exposure and ultraviolet radiation (UVR). However, it seems that there are
more vulnerable groups within the population. Several other leading factors have
been described in the literature. Elderly, male and fair-skinned individuals may have
significantly increased skin cancer risk. Understanding the characteristics of these
cancers epidemiology may allow their early detection and ensure better medical and
surgical management.
Keywords:
Skin cancer risk; Ultraviolet radiation; Sun exposure; Sun protection; Review.
Summary
Skin cancer is the most common carcinoma affecting millions worldwide. BCC is affecting
approximately 3.6 million people in the United States, while SCC is targeting 1.8 million
Americans every year [1,2]. Chronic sun exposure and ultraviolet radiation (UVR) are
directly involved in tumorogenesis initiation and progression [3]. The photodamage is
cumulative and dose-dependent [4]. Ultraviolet A with its wavelength of 315 to 400 nm
is more associated with keratosis and photocarcinogenesis [5]. BCC and SCC clinical
presentations are variable. Lesions frequently present as shiny translucent skin-colored
or pigmented bump generally in the head and neck areas [6].
The aim of this review was to provide a comprehensive study of skin cancers risk factors
to highlight the most important prognostic indicators for this disease.
Skin types are classified according to the Fitzpatrick scale which assess the response of
different types of skin to UV light. It classifies the skin colors into six phototypes from
the light pale white to dark brown [7]. Photodamage following chronic sun exposure
seems to be more important and less reversible for skin type with less epidermal melanin
level [8]. Colored skin epidermal barrier filter twice as much UVR as in white skin [9].
However, the correlation between photoprotection and melanin pigmentation involves
more complex mechanisms, and no skin type is immune to cancer [10]. Moreover, some
other recent reports confirmed that the risk to develop BCC in highly UV-exposed skin
was doubled independently of histological subtype, tumor localization and Fitzpatrick
phototype and [11]. Non melanoma skin cancers are significantly more frequent for
phototype II and III in old female patients [12].
The dark side of the sun: Affected demographics of skin cancers
Citation: Ocarina L, Khachemoune A, Chawkat L. The dark side of the sun: Affected demographics of skin
cancers.Jr.med.res.2021; 4(2):11-13. Ocarina et al© All rights are reserved.
Submit your manuscript: www.jmedicalresearch.com
There are specific dermoscopic characteristics in skin of color
for benign neoplasms. However, there is a lack of data about
specific features for skin cancers. Further descriptive studies
are needed to better characterize specific predisposing
factors in this skin phototype [13].
Actinic keratosis (AK) is a severe grade of skin damage. It is
considered as precancerous condition and represents a
reliable marker of chronic photodamage as well as skin
microbiome modifications which may start immediately with
UVR exposure [14]. Photodamage is a progressive
phenomenon. Severe alteration of the skin texture may be
observed within 30 years of UVR exposure [15]. There are
several epidemiological and molecular data suggesting that
skin cancer is predominantly a disease of the elderly. More
than half of skin cancer-related deaths are observed in
patients of more than 65 years old [16]. Intrinsic skin aging
process implies random mutations-related cell damages.
Excessive free radicals production during metabolic processes
may accelerate the implementation of precancerous
cutaneous lesions [17]. Predominance of male sex in skin
cancer patients has been widely cited in the literature.
However, confrontation of this evidence with the geographic,
ethnic, and sociocultural factors should be considered [18].
Several studies demonstrated that dermoscopic, histologic
and hormonal characteristics enhance photodamage repair in
female. This may decelerate the photodamage-precancerous
lesions-skin cancer filiation sequence in female patients
[19,20]. However, molecular and genetic comparative studies
are to be conducted to rule out clearly the involvement of
gender in skin tumorogenesis. A recent south African
comparative study found that the incidence of Cutaneous
melanoma in Black Africans is about 10% of that in Whites.
There was no difference in age and sex distribution.
Independent risk factors list included sun exposure, skin
trauma, human immunodeficiency virus infection, albinism,
and genetic predisposition [21].
Some groups of patients are genetically predisposed to
skin cancer. The most common syndromes associated
with BCC are: Gorlin-Goltz syndrome, Rombo syndrome,
and Bazex-Dupré-Christol syndrome. Multiple SCC is usually
associated to xeroderma pigmentosum, Rothmund-Thomson
syndrome and Bloom syndrome. Malignant melanoma can be
inherited, as in familial atypical multiple mole melanoma
syndrome [22,23]. Chronic UVR exposure seems to be higher
in male workers in sunny countries. In these same conditions
we could note the lack of social coverage and health
insurance which make the access to specialized health
facilities more difficult. The skin cancer diagnosis is always
delayed which is significantly interfering with the prognosis.
Demographics and other epidemiologic factors should be
studied in correlation with patients individual characteristics and
social specificities as well.
In our experience according to short cohort observational study
results, we noted that fair-skinned patients (Fitzpatrick I and II)
were more likely at risk than the other phototypes. Age >65
and male gender were the other significant skin cancer risk
factors in our study.
The data heterogeneity related to skin cancer risk assessment
explain partially the absence of prevention strategy guidelines
[24,25]. Based on the evidence that skin cancer is an
environmental cancer rising on photo-damaged skins due to
UVR exposure, all the prevention efforts were focused on
sunscreens industry over the last decade [26]. Sunscreens are
objectively a considerable part of the prevention strategy. In
addition to its role in UVR filtration, sunscreen may reduce the
p53 oncogene mutation [27]. Sunscreen’s clinical effectiveness
is related to its ability to reduce DNA damage, immune system
modulation and free radical generation. However, there are still
several gaps in research and knowledge regarding safety,
efficacy, and overall public benefit perception. In the United
States the Food and Drug Administration (FDA) is only
approving zinc oxide and titanium dioxide for UVA filtration.
Other non-mineral sunscreens may be more efficient but less
stable [28-30].
This raises the concern about the ideal molecule needed and if
ever the progress of the sunscreen industry is really based on
clinical evidence. The establishment of screening strategy may
allow early cancers diagnosis and enhance the prognosis. The
primary prevention should be focused on high-risk groups. The
risk assessment must consider all personal and environmental
factors to elaborate a personalized protection plan.
Key takeaways
▪ Skin cancers are of the most common malignancies.
The incidence may be still underestimated due to the
absence of effective screening strategy and the limited
access to dermatology specialized consultation for a
considerable part of high-risk population.
▪ The chronic sun exposure and photodamage caused by
UVR significantly increase the risk of skin cancer.
However, several personal predisposing conditions
must be considered for an objective risk assessment.
▪ Melanin is an UVR filter. This may explain the
vulnerability of fair skin to UVR induced damages. The
incidence of cancer in skin of color might be higher in
male sun-exposed workers and in southern African
countries.
▪ Prevention of this entity is almost totally based on
sunscreens dermo-protection. More efforts could be
done in the sensibilization and primary prevention of
people at risk.
12
The dark side of the sun: Affected demographics of skin cancers
Citation: Ocarina L, Khachemoune A, Chawkat L. The dark side of the sun: Affected demographics of skin
cancers.Jr.med.res.2021; 4(2):11-13. Ocarina et al© All rights are reserved.
Submit your manuscript: www.jmedicalresearch.com
[1] Leiter U, Keim U, Garbe C. Epidemiology of Skin Cancer: Update 2019. Adv Exp Med
Biol. 2020;1268:123-39.
[2] Liu MA, Nguyen J. Employing geriatric principles in the management of nonmelanoma
skin cancers. J Am Acad Dermatol. 2021;84:e65
[3] Raimondi S, Suppa M, Gandini S. Melanoma epidemiology and sun exposure. Acta
Derm Venereol. 2020;100: adv00136.
[4] Fontanillas P, Alipanahi B, Furlotte NA, Johnson M, Wilson CH; 23andMe Research
Team, et al. Disease risk scores for skin cancers. Nat Commun. 2021; 12:160.
[5] Weimann ETS, BrandÃo CM, Terzian LR, Paschoal FM, Filho CDSM, Criado PR.
Correlation between demographic and tumor characteristics in non-melanoma skin
cancers submitted to Mohs micrographic surgery. In Vivo. 2020; 34:2107-11.
[6] Byrne N, Markham T. Knowledge, attitudes and behaviours in relation to skin
cancer prevention. Ir J Med Sci. 2020;189:197-202.
[7] Wright CY, du Preez DJ, Millar DA, Norval M. The epidemiology of skin cancer
and public health strategies for its prevention in southern Africa. Int J Environ Res
Public Health. 2020; 17:1017.
[8] Kim YJ, Jung CJ, Park GH, Won CH, Chang SE, Choi JH, et al. Twenty-eight-year
incidence and characteristics of post-transplant skin cancers: Comparative analysis of past
and recent 10-year experience. J Dermatol. 2020;47:1131-40.
[9] Jung SK, Lim J, Yang SW, Jee D, Won YJ. Nationwide trends in the incidence and
survival of eyelid skin cancers in Korea. Ophthalmic Epidemiol. 2020; 27:438-48.
[10] Durmishi A, Fida M, Hoxha S, Naqo X, Bardhi B, Xhelili M, et al. Are military personnel
at a more risk for skin cancers? Dermatol Ther. 2020;33:e14340.
[11] Akdeniz M, Hahnel E, Ulrich C, Blume-Peytavi U, Kottner J. Prevalence and associated
factors of skin cancer in aged nursing home residents: A multicenter prevalence study.
PLoS One. 2019;14: e0215379.Erratum in: PLoS One. 2019;14: e0220488.
[12] Gupta AK, Bharadwaj M, Mehrotra R. Skin Cancer Concerns in People of Color: Risk
factors and prevention. Asian Pac J Cancer Prev. 2016;17:5257-64.
[13] Lopes FCPS, Sleiman MG, Sebastian K, Bogucka R, Jacobs EA, Adamson AS. UV
Exposure and the Risk of Cutaneous Melanoma in Skin of Color: A Systematic Review.
JAMA Dermatol. 2021;157:213-219.
[14] Syrigos KN, Tzannou I, Katirtzoglou N, Georgiou E. Skin cancer in the elderly. In Vivo.
2005 ;19:643-52.
[15] Vora NB, Connolly KL, Dusza S, Rossi AM, Nehal KS, Lee EH. Functional status and
survival in patients ≥85 years of age who have keratinocyte carcinoma: A retrospective
cohort study. J Am Acad Dermatol. 2020 ;83:463-68.
[16] Chattopadhyay S, Zheng G, Hemminki A, Försti A, Sundquist K, Sundquist J,et al.
Influence of family history on risk of second primary cancers and survival in patients with
squamous cell skin cancer. Br J Dermatol. 2020; 183:488-94.
[17] Hahnel E, Blume-Peytavi U, Trojahn C, Dobos G, Jahnke I, et al. Prevalence and
associated factors of skin diseases in aged nursing home residents: a multicentre
prevalence study. BMJ Open. 2017 ;7: e018283.
[18] Dakup PP, Porter KI, Little AA, Zhang H, Gaddameedhi S. Sex differences in the
association between tumor growth and T cell response in a melanoma mouse model.
Cancer Immunol Immunother. 2020;69:2157-62.
[19] Liu-Smith F, Farhat AM, Arce A, Ziogas A, Taylor T, Wang Z, et al. Sex differences in
the association of cutaneous melanoma incidence rates and geographic ultraviolet light
exposure. J Am Acad Dermatol. 2017; 76:499-505.
[20] Latini A, Alei L, Magri F, Eibenschutz L, Cota C, Dona' MG, et al. Nonmelanoma skin
cancer and melanoma in HIV-1-infected patients. AIDS. 2020;34:1570-72.
[21] Wright CY, du Preez DJ, Millar DA, Norval M. The Epidemiology of Skin Cancer and
Public Health Strategies for Its Prevention in Southern Africa. Int J Environ Res Public
Health. 2020;17:1017.
[22] Schierbeck J, Vestergaard T, Bygum A. Skin Cancer Associated Genodermatoses: A
literature review. Acta Derm Venereol. 2019;99:360-69.
[23] Heibel HD, Hooey L, Cockerell CJ. A review of Non-invasive techniques for skin cancer
detection in dermatology. Am J Clin Dermatol. 2020;21:513-24.
[24] Fenini G, Karakaya T, Hennig P, Di Filippo M, Beer HD. The NLRP1 inflammasome in
human skin and beyond. Int J Mol Sci. 2020;21:4788.
[25] Ventéjou S, Bagny K, Waldmeyer J, Cartault F, Machet L, Osdoit S. Skin cancers in
patients of skin phototype V or VI with xeroderma pigmentosum type C (XP-C): A
retrospective study. Ann Dermatol Venereol. 2019;146:192-203.
[26] Saka B, Akakpo SA, Teclessou JN, Gnossike P, Adam S, Mahamadou G, et al. Skin
cancers in people with albinism in Togo in 2019: results of two rounds of national mobile
skin care clinics. BMC Cancer. 2021;21:26.
[27] Lopes FCPS, Sleiman MG, Sebastian K, Bogucka R, Jacobs EA, Adamson AS. UV
Exposure and the Risk of Cutaneous Melanoma in Skin of Color: A Systematic Review.
JAMA Dermatol. 2021;157:213-19
References
Conflict of interest: none
[28] Bauer A, Haufe E, Heinrich L, Seidler A, Schulze HJ, Elsner P, et al. Basal cell
carcinoma risk and solar UV exposure in occupationally relevant anatomic sites: do
histological subtype, tumor localization and Fitzpatrick phototype play a role? A
population-based case-control study. J Occup Med Toxicol. 2020;15:28.
[29] Paul SP. Ensuring the Safety of Sunscreens, and Their Efficacy in Preventing
Skin Cancers: Challenges and Controversies for Clinicians, Formulators, and
Regulators. Front Med (Lausanne). 2019;6:195.
[30] Sander M, Sander M, Burbidge T, Beecker J. The efficacy and safety of
sunscreen use for the prevention of skin cancer. CMAJ. 2020; 192: E1802-08.
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