“Be Proactive, Perform Regular Skin Self‐Exams and Protect Yourself”: Producing the Skin‐Aware Biocitizen in the Context of the United States

Optimal time to provide skin cancer and photoprotection education to pediatric solid organ transplant recipients

This scoping review aims to summarize available research literature on previous skin cancer educational programs among hair professionals or cosmetology students to inform the creation of an effective cosmetology school curriculum that will promote early detection of melanoma on the scalp and neck. Cutaneous melanoma on the scalp and neck is a significant cause of morbidity and mortality in the United States, and the number of new cases continues to rise. Hair professionals can detect this cancer by regularly inspecting the skin under these hair-bearing areas. Providing skin cancer education to cosmetology students can potentially affect significant changes in screening and referral practices, improving the stage at which this cancer is treated. All articles in this study involved hair professionals or cosmetology students in the context of hair salons, barbershops, or cosmetology schools. These articles included a focus on skin cancer or melanoma education. A systematic search of electronic databases (CINAHL, MEDLINE, Science Direct, and Google Scholar) for full-length, peer-reviewed journal articles written in English in the last 20 years was performed in August 2022 and January 2023. Articles were initially screened by title, abstract, and keywords, followed by full-length review and reference scanning. Data were systematically extracted from included articles, summarized, and presented in narrative and table form. Search terms included “hairdressers, barbers, cosmetology students, salons, barbershops, cosmetology schools, education, curriculum, intervention, knowledge, skin cancer, and melanoma.” Thirteen sources of evidence were included in the review, all of which were empirical research studies. Nine studies evaluated the effectiveness of a skin cancer educational intervention for hair professionals or cosmetology students, and 4 assessed skin cancer knowledge, attitudes, or beliefs in this population. All interventions improved knowledge, confidence, screening behaviors, or referral practices in hair professionals or cosmetology students. No specific educational modality was more effective than another, no apparent difference was seen with different intervention lengths, and the type of information included within each educational modality was rarely discussed. Most hair professionals believe they lack adequate training or confidence in skin cancer detection and are interested in becoming educated on this subject. Short videos or live lectures were the preferred skin cancer educational modalities among hair professionals and cosmetology students. Brief skin cancer educational programs improve cosmetology students and hair professionals’ knowledge about melanoma and screening practices. This population has a perceived and measured need for skin cancer education. Including this type of program in the cosmetology school curriculum can effectively disseminate information to these individuals, leading to earlier diagnosis of melanomas on the scalp and neck, thus decreasing the mortality rate of this disease. Further research, including larger, diverse samples and more rigorous study designs, is needed to bolster the results of the review findings.

As the minority population increases in the United States, the incidence of skin cancer has important public health consequences, including poor skin cancer outcomes, in part because of late-stage diagnosis. Therefore, it is important to identify obstacles in skin cancer prevention in these communities. To characterize skin cancer prevention and education needs in uninsured, minority, and immigrant communities in South Florida. At a large free medical clinic in Florida, a convenience sample of people completed a 23-question survey in English, Spanish, or Haitian Creole assessing their skin cancer risk perception, knowledge, sun protective behaviors and barriers, and desirable outreach methods. All participants were uninsured and living at least 200% below the federal poverty level. Participants were adults recruited from the general waiting room who understood 1 of the 3 languages and were not present for a scheduled dermatology visit. The survey used Likert-type scales, true or false, and yes or no questions. Data were analyzed with SPSS IBM statistical software (version 22) using 1-way analysis of variance, χ2 tests, and Pearson correlations. Among the 219 people invited, 206 participants (mean [SD] age, 43 [13.2] years) completed the survey; 75% of respondents were women who usually worked indoors. Almost a quarter (49 [24.5%) had never heard of skin cancer or melanoma. Nearly half (89 [44.3%]) had never conducted a self-skin examination. One in 5 (41 [20.7%]) believed that people with dark skin cannot get skin cancer. Three quarters (156 [75.7%]) of respondents fell into the "low/inconsistent" sun protective behavior category. Barriers to sun-protective behaviors were "using sun protection is too hot" (75 participants [39.3%]) and "I forget." (72 [37.7%]). More than 85% (175 [87.9%]) wanted to learn more about how to prevent skin cancer. Watching a video (37.3%) and text messaging (30.8%) were identified as the most popular outreach methods. Important barriers to skin cancer prevention were lack of knowledge, the belief that dark skin was protective, and using sun protection made them feel too hot. Skin cancer education and intervention efforts in uninsured, minority, immigrant populations may be provided by videos and text messaging.

Skin cancer screening after solid organ transplantation: Survey of practices in Canada.

It is important to develop an understanding of what the public knows about skin cancer and what sun safety precautions they are taking. Research on the evaluation of skin cancer education targeting adults is minimal. To assess the knowledge and behavior related to skin cancer and sun exposure, and to determine if an informal interaction between dermatologists and the public could promote skin cancer awareness and precautions. In May 2000, a dermatologist-staffed educational booth was set up at an Indianapolis Indians baseball game. Attendees were educated through discussions and handouts. Attendees completed a self-administered questionnaire prior to this interaction and a mailed follow-up questionnaire in August 2000. One hundred and thirty-six attendees participated in May, and 60 completed the second questionnaire in August. The May results revealed that 92% believed that sun exposure caused skin cancer; 37% used sunscreens "sometimes" and 29%"never." There was a significant decrease in the number of hours spent outdoors per week during the summer of 2000 compared to 1999. Frequent and unprotected sun exposure occurs despite awareness of the adverse effects. Although the number of subjects in our study was small, informal education at public events has the potential to influence behavior.

Hardly a week goes by when the attention of the scientific press and the general public is not focused on a new report about the health effects of sunshine. Most studies of the effects of strong or prolonged ultraviolet radiation (UVR) exposure on the skin have emphasized the importance of sun avoidance and protection against sun exposure to reduce skin cancer risk. In recent years, though, these reports have competed for attention with studies about the health benefits and protective effects of vitamin D, and the potentially serious health risks caused by vitamin D insufficiency and deficiency. Because most vitamin D is produced in the skin by sun exposure, and specifically by DNA-damaging and carcinogenic UVB wavelengths, the development of tension within the medical community over the costs and benefits of sun exposure was inevitable. Important data bearing on this dilemma come from the study of Lindqvist and colleagues in this issue. The authors report the results of a longitudinal cohort study designed to assess how all-cause mortality risk may be influenced by avoidance of active sun exposure. The population studied by Lindqvist et al. consisted of women had been recruited for a prospective 20-year follow-up of the Melanoma in Southern Sweden (MISS) cohort. Equal numbers of women aged 25–64 years with no history of cancer were invited into the study in 1990; 29,518 (74%) formally entered the study. The survey questions about sun exposure explored the frequency of activities that involved exposure of large surface areas of the body under strong sunlight or simulated sunlight; these activities included summertime sunbathing, vacation sunbathing and the use of tanning beds. Along with standard anthropometrics, hereditary disposition to malignant melanoma (MM) was assessed, smoking habits at the inception of the study were recorded, and level of exercise was categorized. Cases of MM and fatalities due to MM were dichotomized by Breslow thickness. At the inception of the study in 1990, the investigators almost certainly did not anticipate that avoidance of sun exposure would be associated with an increase in all-cause mortality, but that is exactly what they discovered. Data available at that time indicated a strong causal relationship between sun exposure and MM, but no relationship between avoidance of sun exposure and increased mortality. In fact, in 1990, avoiding sun exposure was considered one of the healthiest things one could do because data on increased prevalence of skin cancers – especially amongst light-skinned people of European ancestry living in or even vacationing in sunny places – presented a dramatic picture of the risks of unprotected sun exposure. At that time, relatively few details were known about the relationship between sun exposure and the cutaneous production of vitamin D or other bioactive compounds, and there was no intimation that avoidance of sun exposure might pose a significant health risk. The primary finding of Lindqvist et al. was that the mortality rate amongst sun avoiders in their cohort was approximately twice that of the most active sun exposers, yielding an excess mortality with a population attributable risk of 3%. This is a small effect, but very significant due to sample size and power. The authors are guarded in their discussion of the reasons why sun avoidance is associated with increased mortality. In previous studies, they speculated that this was due to insufficient vitamin D levels amongst sun avoiders, but cautioned that their results could not indicate a causal relationship. They are even more restrained here. They go to great lengths to point out that vitamin D is just one of several bioactive compounds produced by strong UVR solar ultraviolet exposure that may have an effect on morbidity and mortality. The ‘dose-dependent’ inverse relationship between sun exposure and all-cause mortality seen in their models is intriguing and supports the argument that some unidentified factor correlated with sun exposure is protective. Vitamin D is a strong candidate because of its myriad immune system boosting functions 1, but it probably cannot account entirely for the effects observed in the study. Cutaneous vitamin D production is strictly the product of UVB exposure, and southern Sweden boasts a highly seasonal UVB regime and a long UVB-free winter. Studies show at the autumnal equinox (September 22), Boston, Massachusetts, at 42.5°N still receives ample UVB to catalyse vitamin D formation in the skin, but Malmö, Sweden, at 55.5°N does not (Fig. 1) 2. One of the most interesting implications of the Lindqvist et al. data is that the most active sun exposers with the lowest mortality rates in the study were almost certainly experiencing high UVA loads because of their winter sun and tanning bed exposures. Thus, the mortality-reducing effects observed amongst the most active exposers probably were due to many factors including a suite of bioactive compounds produced by both UVB and UVA exposure: vitamin D and nitrous oxide, respectively. The skin is now recognized as harbouring a reservoir of nitric oxide (NO) metabolites, which are activated by UVA and which appear to exert a benign effect of cardiovascular homeostasis 3. Sun avoiders thus lose out on both photosynthesized vitamin D and photoactivated NO. Detailed data on the nature and duration of sun and tanning bed exposures of the MISS cohort would have helped significantly to illuminate the origin of the protective effects experienced by the active sun exposers in the Lindqvist et al. study. The ratio of UVB to UVA in sunlight varies according to latitude, season, time of day, levels of air pollution and other factors which were not possible to consider in the study 4. Although UVA is present in sunlight throughout the year, UVB becomes more seasonal and attenuated with increasing latitude, resulting in significantly reduced potential for cutaneous biosynthesis of vitamin D 5. Successful adaptations to high-latitude environments such as southern Sweden have been both biological and cultural, involving increasing amounts of vitamin D-rich foods in the diet to supplement seasonally photosynthesized vitamin D 6. Throughout history and in most places, however, human vitamin D is derived primarily from sun exposure and not from food 7. The biggest questions to emerge from the Lindqvist et al. study surround the nature and activity of the compounds produced by sun exposure and what happens in sun avoiders when these compounds are absent or present only at low levels. If this is primarily a vitamin D effect, then remedial measures such as additional food fortification or recommendations for vitamin supplementation can be implemented relatively easily, with no risk of additional skin cancers. Vitamin D deficiency is associated with increased susceptibility to infectious diseases such as tuberculosis and complex chronic diseases such as type 2 diabetes 8, 9, and it is widely accepted that that the high prevalence of vitamin D deficiency requires some kind of intervention. What is a modern human supposed to do? If sun exposure is to be recommended, it should be of the wavelengths and energies to which a person's skin is adapted. Our ancestors spent most of their time outdoors, but did not sunbathe or subject themselves to intense prolonged solar irradiation on foreign holidays. With skin as the major interface with our physical environment, we faced changing solar conditions, outside, day by day. Only in the last few thousand years have large numbers of us spent significant amounts of time indoors, and only in the last century have large numbers of people engaged in the kinds of episodic sun exposure on weekends and foreign vacations – often leading to sunburns – that we consider normal today. In today's highly urbanized world, most people pursue indoor lifestyles whilst wearing concealing clothing. And, because of migration, many of us live under vastly different solar conditions than those of our ancestors. Understanding these changes will allow us to compensate for modernity through bespoke prescriptions for sun exposure and diet that are appropriate to our ancestry, location and lifestyle. The results of the Lindqvist et al. study indicate that we need to think about these things sooner rather than later. The author is a member of the Scientific Advisory Board of L'Oréal.

Renal transplant recipients (RTRs) are at an increased risk of skin cancer (SC), especially squamous cell carcinoma (SCC). As the number of successful transplant recipients increases, pressure on dermatology services increases. The focus has shifted from simply screening RTRs for SC to implementing preventive measures, including SP education programmes. Sun exposure is a modifiable risk, yet RTRs are known to adopt sun-protective (SP) behaviour only partially. There is a dearth of research on why this is. We performed an in-depth qualitative study using inductive thematic analysis of 14 semistructured interviews of seven male RTRs to assess the impact of the current SP education and explore their current SP behaviour. Participants included those with SC, premalignant skin disease and no SC. Two themes were constructed. Each theme had two subthemes. The first theme was ‘Timing it Right—Skin cancer information’, with the subthemes of ‘A time of great emotion’ and ‘Providing knowledge—learning needs differ’. Choosing a suitable time to impart information on SC is important. Immediately prior to and on receiving a kidney transplant was not felt by patients to be the most appropriate time. Most felt unable to consider perceived future risks to their health during this critical period. When delivered, recipients expressed preference for an ‘in-person’ approach with supplementary information available (online and written). The second theme was ‘The person within the patient’, with the subthemes of ‘What matters to the patient’ and ‘Authentic engagement’. It is important to see the person within the patient. Each brought with them different worries and requirements, sometimes feeling guilty when expressing them as they had received a new ‘gift of life’. Participants knew what constituted a good health education experience for them. The healthcare professional who was compassionate and listened was valued and more likely to influence behaviour. Interviewees spoke about the strong bond they form with their renal teams and how they trust them. Misconceptions were also uncovered such as the belief that the Irish sun differed from that experienced abroad and that SP was just for ‘sunny days’. An overriding concern for developing melanoma rather than cutaneous SCC was evident, as was the lack of confidence in ability to self-monitor skin. SC prevention programmes are becoming increasingly well established; our study identified gaps in the knowledge of RTRs and highlighted some key areas and approaches to improve the impact of educational interventions. To maximize the impact, it is important to consider patient perspectives, cultural context and the key role our renal colleagues play in patients’ lives. Funding: support was received from The City of Dublin Skin and Cancer Hospital Charity (registered Charity Number: 20004620).

To determine factors related to the observation of suspicious lesions on the scalp, neck, and face of customers by hair professionals (cosmetologists and barbers). Survey of hair professionals in January 2010. Single hair professional educational conference. Hair professionals from a chain of 17 salons in the greater Houston, Texas, area. Frequency with which hair professionals looked for lesions on their customers' scalp, neck, and face during the previous month. Of 304 surveys distributed to hair professionals, 203 were completed (66.8% response rate). Few hair professionals had received formal skin cancer education (28.1%). Forty-nine percent of hair professionals were "very" or "extremely" interested in participating in a skin cancer education program. Of responding participants, 37.1% looked at more than 50% of their customers' scalps, 28.8% looked at more than 50% of their customers' necks, and 15.3% looked at more than 50% of their customers' faces for suspicious lesions during the preceding month. Frequency of observation of customers' lesions was associated with hair professionals' self-reported health communication practices (P < .001) and personal skin protection practices (P = .05) but was not associated with hair professionals' skin cancer knowledge (P = .48). This study suggests that hair professionals are looking for suspicious lesions on customers' scalp, neck, and face and are acting as lay skin cancer educators. These results provide evidence that hair professionals would be receptive to skin cancer education and that further investigation into the role of hair professionals in skin cancer prevention and detection campaigns is needed.

BackgroundHead-and-neck skin cancers have a worse prognosis than those that develop elsewhere on the body. Self-screening this area for suspicious skin changes can be difficult. Hairdressers and barbers observe this area closely during hair appointments and could bring their customers’ attention to suspicious skin changes earlier.ObjectivesTo investigate a sample of UK hairdressers’ and barbers’ skin cancer education, customer screening practices and influences on screening, and to compare hairdressers’ and barbers’ screening practices.MethodsStratified random sampling was utilized to select hairdressers and barbers working in a UK city. Participants were invited to complete a survey.ResultsThirty-seven participants completed the survey. Five per cent reported having had skin cancer awareness training and 24% were screening customers. Thirty-five per cent had advised a customer of a suspicious mole or skin lesion; of these participants, 39% had had customers diagnosed with skin cancer. ‘Not having received training’ was reported by 65% of participants as a deterrent to screening. Knowing someone who had experienced skin cancer was significantly associated with screening and advising customers of suspicious skin changes. Most participants (92%) indicated they would like, or maybe like, skin cancer awareness training.ConclusionsIn this UK city study, perceived knowledge of the signs and symptoms of skin cancer appeared to arise from knowing someone who had experienced skin cancer rather than formal training. Lack of skin cancer education was a deterrent to screening, but most participants would like training. Trained hairdressers and barbers could potentially provide regular head-and-neck skin screening for customers.

Predictors of Basal Cell Carcinoma in High-Risk Patients in the VATTC (VA Topical Tretinoin Chemoprevention) Trial

Skin examinations and skin cancer prevention counseling by US physicians: A long way to go

In the past 20 years, long-term survival for solid-organ transplant recipients has improved dramatically; about 223,000 patients are alive in the United States with organ transplants today. As survival rates improve, however, the morbidity and mortality associated with lifelong immunosuppressive therapy is increasing in significance. Skin cancer is common among recipients of all major organ transplants, including the kidney, liver, heart, lung, and pancreas. Although skin cancer is the most common cancer in transplant recipients, many cases can be prevented by sun protection, skin self-examinations, and physician examinations. Because transplant recipients visit the transplant clinic frequently, clinicians have ample opportunities to teach patients about the importance of prevention and detection of skin cancer. At a routine visit, the clinician should inquire about sun protection practices, especially for tanned, light-skinned, or freckled patients or patients who are planning a warm-weather vacation or time in the sun during the summer. Skin cancer education should be integrated into the care of transplant patients as part of their numerous visits to the transplant clinic. Although some transplant recipients may resist adopting new behaviors at first, use of the ample clinic opportunities for patient education can dramatically reduce their risk of skin cancer.

BackgroundRising healthcare expenditures places the potential for substitution of hospital care towards primary care high on the political agenda. As low-risk basal cell carcinoma (BCC) care is one of the potential targets for substitution of hospital care towards primary care the objective of this study is to gain insight in the views of healthcare professionals regarding substitution of skin cancer care, and to identify perceived barriers and potential strategies to facilitate substitution.MethodsA qualitative study was conducted consisting of 40 interviews with dermatologists and GPs and three focus groups with 18 selected GPs with noted willingness regarding substitution of skin cancer care. The interviews and focus groups focused on general views, perceived barriers and potential strategies to facilitate substitution of skin cancer care, using predefined topic lists. All sessions were audio-taped, transcribed verbatim and analyzed using the program AtlasTi.ResultsGPs were generally positive regarding substitution of skin care whereas dermatologists expressed more concerns. Lack of trust in GPs to adequately perform skin cancer care and a preference of patients for dermatologists are reported as barriers by dermatologists. The main barriers reported by GPs were a lack of confidence in own skills to perform skin cancer care, a lack of trust from both patients and dermatologists and limited time and financial compensation. Facilitating strategies suggested by both groups mainly focused on improving GPs’ education and improving the collaboration between primary and secondary care. GPs additionally suggested efforts from dermatologists to increase their own and patients’ trust in GPs, and time and financial compensation. The selected group of GPs suggested practical solutions to facilitate substitution focusing on changes in organizational structure including horizontal referring, outreach models and practice size reduction.ConclusionsGPs and, to lesser extent, dermatologists are positive regarding substitution of low-risk BCC care, though report substantial barriers that need to be addressed before substitution can be further implemented. Aside from essential strategies such as improving GPs’ skin cancer education and time and financial compensation, rearranging the organizational structure in primary care and between primary and secondary care may facilitate effective and safe substitution of low-risk BCC care.

Massage therapists encounter skin on a daily basis and have a unique opportunity to recognize potential skin cancers. The purpose of this study was to describe the skin cancer education provided to massage therapists and to assess their comfort regarding identification and communication of suspicious lesions. An observational retrospective survey study was conducted at the 2010 American Massage Therapy Association Meeting. Sixty percent reported receiving skin cancer education during and 25% reported receiving skin cancer education after training. Massage therapists who examine their own skin are more likely to be comfortable with recognizing a suspicious lesion and are more likely to examine their client's skin. Greater number of clients treated per year and greater frequency of client skin examinations were predictors of increased comfort level with recognizing a suspicious lesion. Massage therapists are more comfortable discussing than identifying a potential skin cancer. Massage therapists may be able to serve an important role in the early detection of skin cancer.

The COVID‐19 pandemic has required new ways of working in dermatology.1 Men aged > 50 years are at higher risk of mortality from malignant melanoma (MM) potentially due to poorer engagement with awareness and prevention campaigns, and to delayed presentation.2 Skin cancer clinical nurse specialists (SCCNSs) provide an essential role in education, guidance and support at all stages of skin cancer care.3 Prior to the pandemic, our SCCNSs provided skin cancer education to older men by attending ‘Men's Shed’ meetings. Men's Sheds are community‐based projects where men come together to learn, share skills and make friendships, and to promote social inclusion. Following the Irish national lockdown on 12 March 2020, all Men's Sheds were closed to reduce the transmission of SARS‐CoV‐2, with reopening scheduled for September 2021. Our skin cancer education sessions were converted to online sessions. We aimed to assess participant feedback from the Men's Sheds group for planning of future education.