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SKIN CARE

S pringtime brings the promise of warm sunny weather along with participation in outdoor

sports and recreation — not to mention summer holidays. The first hints of fine weather and lighter evenings often encourage people to pack away their winter clothes and begin thinking about their summer wardrobe, and, it is at this time of year, that many people become more aware of their skin and its exposure to the sun.

The UK is often referred to as a nation of ‘sun-seekers’ and people do spend a great deal of their leisure time pursuing outdoor activities or going on holidays abroad. It is also commonly accepted that exposure to sunshine generates feelings of physical, psychological and social

Dealing with the effects of seasonal changes on the skin

Polly Buchanan

wellbeing (Kampfer and Mutz, 2013). However, from a healthcare point of view, this statement could be regarded as counter-productive in light of warnings about sun exposure and skin cancer prevention. Nevertheless, it is unrealistic to expect people to stay out of the sun entirely, despite a body of evidence identifying its harmful effects on the skin (Lucas et al, 2006).

Community nurses in particular may need to give advice to patients regarding seasonal changes and common skin conditions. This advice may be related to seasonal dermatoses, skin cancer prevention and/or seasonal phenomena.

Table 1 identifies common skin conditions that are relieved or aggravated by sunshine and seasonal changes, which should form part of the advice provided by community nurses in travel clinics, school clinics and health centres.

SKIN CANCER

BackgroundUltraviolet radiation (UVR) both natural and artificial, is the single most important factor in the aetiology of skin cancer. Both malignant

melanoma and non-melanoma skin cancers — basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) — are linked with long-term excessive sun exposure (Motley et al, 2002; Telfer et al, 2008) (Figure 1).

Non-melanoma skin cancers are the commonest form of all skin cancers with BCC the largest of this group (Level et al, 2013). They are extremely common but rarely life-threatening and skin cancer registries do not collect all the figures for non-melanoma skin cancers. However, Information Services Division (ISD) Scotland did register 10,872 non-melanoma skin cancers in 2012 (ISD Scotland, 2014). On the other hand, malignant melanoma is the fifth commonest cancer in men and the seventh in women, although five-year survival is reported at over 80% (ISD Scotland, 2014).

Malignant melanoma Malignant melanoma is a cancer of the pigment-producing cells of the skin (melanocytes), which lie at the dermo-epidermal junction. Melanocytes release granules of melanin (natural pigment) in response to UVR, which appears as tanning of the skin. This is a protective mechanism to prevent the skin burning and ageing prematurely. Non-pigmented lesions do not contain melanin pigment (Gilcrest and Eller, 1990).

A collection of normal melanocytes will appear on the skin as a mole or nevus. Malignant melanoma develops on the skin as lesions that change their pigmentation and appear different to other moles. It also has the potential to spread via the blood and lymphatic system to other sites in the body (National Radiological Protection Board [NRPB], 2002; Buchanan and

Polly Buchanan, lead nurse, research and development, NHS Fife; chair, Scottish Dermatology Nursing Society

Skin reactions and insect bites associated with the spring and summer months are commonly seen in community settings. In this article, the author provides an overview of the most common skin reactions, including skin cancers, that can occur through increased exposure to the sun, as well as highlighting management techniques for community nurses faced with patients who have seasonal-associated skin complaints. With prevention being key, particularly where melanoma are concerned, this article provides a useful source of information for community nurses dealing with skin problems at this time of year.

KEYWORDS:Dermatology Skin cancer Insect bites Skin care guidance

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For those patients with dry skin conditions such as eczema, The British Association of Dermatologists guidelines advise that the use of soap or detergent based products can exacerbate their symptoms. They recommend the use of soap substitutes.1

Doublebase Bath, Wash and Shower provide an effective alternative to the harshness of soap. They all contain a non-foaming soap substitute, which gently cleanses the skin, and a humectant which attracts water to moisturise the skin. The high oil content softens the skin and protects against dryness.

Doublebase™ Emollient Shower GelDoublebase™ Emollient Wash GelIsopropyl myristate 15% w/w, liquid paraffin 15% w/w.Uses: Highly moisturising and protective hydrating gels for dry skin conditions. Directions: Adults, children and the elderly: Use regularly, as required, as soap substitutes.Doublebase™ Emollient Bath AdditiveLiquid paraffin 65% w/w. Uses: For the relief of dry skin conditions. Directions: Adults, children and the elderly: Add to a bath of warm water. Soak and pat dry.

Contra-indications, warnings, side effects etc: Please refer to SPC for full details before prescribing. Do not use if sensitive to any of the ingredients. In the rare event of a reaction stop treatment. Take care not to slip in the bath or shower. Package quantities, NHS prices and MA numbers: Doublebase Shower: 200g shower pack £5.21, PL00173/0196. Doublebase Wash: 200g pump dispenser £5.21, PL00173/0402. Doublebase Bath: 500ml bottle £5.45, PL00173/0200. Legal categories: Doublebase Shower & Doublebase Wash P . Doublebase Bath GSL. MA holder: Dermal Laboratories, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR. Date of preparation: January 2014. ‘Doublebase’ is a trademark.

Reference: 1. http://www.bad.org.uk/site/796/default.aspx

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Dermal.

DoublebaseTM Bath, DoublebaseTM Wash, DoublebaseTM ShowerIsopropyl myristate 15% w/w, liquid paraffin 15% w/w.Liquid paraffin 65% w/w.

BECAUSE DRY SKIN NEEDS A SOAP SUBSTITUTE

10mm

www.dermal.co.uk

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Courtenay, 2006; National Institute for Health and Care Excellence [NICE], 2011).

Malignant melanoma can appear anywhere on the body, although it is more common on sun-exposed sites. Malignant melanomas are usually larger and darker than benign (normal) moles, being irregular in size, shape and colour.

Asymmetry, irregular borders, darker colours, larger diameter and erythema are all particularly sinister signs. Malignant melanomas are usually asymptomatic, although itching and bleeding are later signs (British Association of Dermatologists [BAD], 2014a).

Non-melanoma skin cancers (NMSC)Like malignant melanoma, non-melanoma skin cancers usually develop on sun-exposed sites but involve the basal cells (BCC) and squamous cells (SCC) of the epidermis. These skin cancers are slower growing and can spread directly to neighbouring tissue and local lymph glands (SCC in particular) (NRPB, 2002; Buchanan and Courtenay, 2006; NICE, 2011).

BCCs and SCCs often present on sun-damaged skin and are frequently not-pigmented. Solar damage to the skin is slow and insidious, developing over many years. Low intensity, long-term exposure to UVR causes a weakening

SCC usually presents as isolated scaly lumps or nodules, with surface scale/keratoses and underlying ulcer and erythema (BAD, 2014c).

PreventionNational public awareness programmes are now commonplace as a prevention strategy (BAD, 2014d), and the key message for community nurses is that people should enjoy the benefits of fine weather but always avoid sunburn.

Where possible, people should be advised to stay in the shade and wear protective clothing, sunglasses and apply sunscreens, which should be broad spectrum (filtering both UVA and UVB) with a sun protection factor (SPF) of at least 15+ and ideally 50+ (Cancer Research UK, 2014).

Protection of children is especially important, as cumulative exposure to UVR increases skin cancer risk in adult life. Children aged under one-year should be kept out of strong sunshine altogether (Cancer Research UK, 2014). Skin cancer screening programmes are recommended for at-risk people, e.g. those with a personal or family history of skin cancer and atypical mole syndrome. Aytpical mole syndrome is a genetically determined condition where people are predisposed to developing large numbers of skin moles (over 50) of varying size, shape and colour.

These lesions are usually benign in nature, although histologically

of the dermal infrastructure (elastin fibres/collagen) and a thickening of the epidermis. The skin gradually appears wrinkled, creased and mottled in colour as well as becoming thicker (NRPB, 2010).

BCC rarely metastasises or causes death, but can erode tissue, especially on the head and neck. SCC affects the cells that produce keratin, a wax-like substance that helps to form the protective outer layer of the skin. SCC can metastasise and cause death.

BCC presents on the skin as silvery, pink or red lesions, which may have a ‘pearly’ outer edge, ulcerated centres, nodules, plaque-like appearance and telangietasia (visible capillaries). Some BCCs are superficial, scaly and numerous (BAD, 2014b).

Table 1: Common skin conditions that can be relieved or aggravated by sunshine and seasonal change

Common skin conditions improved by sun exposure

Common skin conditions adversely affected/caused by sun exposure

Eczema (can also worsen)PsoriasisAcneFungal/yeast infection

Polymorphic light eruption (PLE)Photosensitive skin reactionsPhototoxic skin reactionsJuvenile spring eruption (JSE)Freckling/solar lentigoPigment changes (tanning, vitiligo, pityriasis versicolor)Hyperpigmentation*Basal cell papilloma*Solar erythema (sunburn)Actinic keratosis*Bowen’s Disease*Non-melanoma skin cancers (BCC; SCC)*Malignant melanoma*

* with long-term cumulative sun exposure

Figure 1.Example of skin damaged by sunburn.

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More than just a bath oil

Washing shouldn’t have to be bad for eczema

NICE guidance is clear that emollients should be used for washing and bathing, as well as moisturising, because soaps and detergents can damage the skin barrier and exacerbate symptoms.1 All children require an essential package of emollient therapy including a topical emollient and a wash product.1

Not only do Oilatum wash products provide an active emollient bene� t, rehydrating the stratum corneum and helping to restore the skin barrier, they also cleanse skin effectively, avoiding the need for soap.

To help your patients receive an active emollient bene� t even

when washing, prescribe a fragrance-free product from the No. 1 prescribed emollient wash range2 – Oilatum.

Prescribing Information

Oilatum® Junior (light liquid paraf� n 63.4%) Bath Additive

Indications Contact dermatitis, atopic eczema, senile pruritus, ichthyosis and related dry skin conditions. Dosage and administration Use as often as necessary. Apply to wet skin or add to water. Adult bath: 1-3 capfuls in an 8 inch bath of water, soak for 10-20 minutes, pat dry. Infant bath: ½-2 capfuls in a basin of water, apply gently over entire body with a sponge, pat dry. Precautions Hypersensitivity to any ingredient. Stop use if rash or irritation develops. Side effects See SPC for full details. Application site reactions including irritation, erythema, rash, pruritus, dermatitis. Legal category GSL. Presentation and NHS cost 150 ml £2.82, 250 ml £3.25, 300 ml £5.10, 600 ml £5.89. PL 00079/0708. PL holder Stiefel, 980 Great West Road, Brentford, Middlesex, TW8 9GS. Date of revision February 2014.

Oilatum® Shower Gel Fragrance-Free (light liquid paraf� n 70%)

Indications Contact dermatitis, atopic dermatitis, senile pruritus, ichthyosis and related dry skin conditions. Dosage and administration All ages: Apply to wet skin, normally as a shower gel. Use as frequently as necessary. Precautions Hypersensitivity to any ingredient. Not for use on greasy skin. Side effects See SPC for full details. Application site reactions including irritation, erythema, rash, pruritus, dermatitis. Legal category GSL. Presentation and NHS cost 150 g £5.15. PL 00079/0704. PL holder Stiefel, 980 Great West Road, Brentford, Middlesex, TW8 9GS. Date of revision March 2014.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.

Adverse events should also be reported to Stiefel, on 0800 917 9511.

References: 1. NICE Clinical Guideline 57. Atopic eczema in children. Management of atopic eczema in children from birth up to the age of 12 years. December 2007. Available at http://guidance.nice.org.uk/CG57. Accessed 02/05/14. 2. IMS unit performance data, MAT to March 2014.

Date of preparation: May 2014. CHGBI/CHOIL/0016/14j.

OILATUM is a registered trade mark of the GSK group of companies.

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high-risk — some may develop dysplasia (precancerous melanocyte changes) and neoplasia (cancerous melanocyte changes) (BAD, 2014e).

The main role of community nurses is to provide skin cancer prevention advice and teach self-examination techniques to patients and families. Self-examination techniques include: Systematically scanning the

skin for any changes in moles or development of new lesions — commencing at the face and neck, the individual should observe and touch his or her skin to check for new moles, moving down the body, arms, trunk, legs and feet (the back and scalp can be examined using a mirror)

Photographs can be taken to record any unusual changes or lesions using a mobile phone

Measurement (diameter) of lesions can be undertaken using a small ruler.

Self-examination should be carried out annually at least, and more often in at-risk individuals or families. This depends on the level of risk, with high-risk families requiring

3–6 monthly screens (Marsden et al, 2010; BAD, 2014e; BAD, 2014f).

The ABCDE of skin cancer can be used as an aide-memoire when assessing pigmented lesions (or moles) (De Giorgi et al, 2013): Asymmetry: the two halves of the

lesion may differ in shape Border: the lesion edges may be

notched, irregular or blurred Colour: there may be pigment

variation in the lesion — black, brown, blue, silver and pink may be seen

Diameter: most melanomas are at least 6mm in diameter — seek medical advice if there is a change in size, shape or diameter

Expert: if in any doubt, refer to a consultant dermatologist. The key word for nurses to bear

in mind is ‘change’, as any irregularity in the size, shape and/or colour of a pigmented skin lesion is the cardinal sign of malignancy. For example, nodular melanoma (an invasive form of skin cancer that proliferates downwards through the skin) may present as a symmetrical lesion, but there will usually have been a period of growth and change in colour (over a number of weeks as opposed to months).

The concern is that the lack of asymmetry seen in nodular melanoma means it can be missed when using the ABCDE method of assessment. Recent changes in size, and colour, including erythema, are most sinister signs for poorer prognosis nodular melanoma. If community nurses see any suspicious changes in any pigmented lesion, they should encourage patients to seek medical advice immediately. Malignant melanoma and suspicious skin lesions require urgent surgical excision by an appropriate trained practitioner. Early diagnosis and prompt excision improve the prognosis of malignant melanoma.

Managing non-melanoma skin cancersNon-melanoma skin cancers can be numerous and appear as firm, dry, scaly, flesh-coloured, and/or ulcerated lesions with evidence of underlying erythema (Motley et al, 2002). Pre-cancerous lesions (a biologically benign lesion that has the potential to develop dysplasic and neoplasic

changes over time) include actinic keratosis (scaly skin patches that develop after years of exposure to the sun) and Bowen’s disease (red scaly patches on the skin), and these are managed according to national guidelines (de Berker et al, 2007; Morton et al, 2014). For example, common treatments for actinic keratoses include (Ashton and Leppard, 2005): Observation Cryosurgery: application of

extreme cold to destroy diseased tissue

Curette and cautery Photodynamic therapy: non-toxic

light-sensitive compounds that are exposed selectively to light, becoming toxic to malignant cells

Immiquimod: an immune response modifier

Topical diclofenac sodium: a non-steroidal anti-inflammatory.

Bowen’s disease can be treated with (Ashton and Leppard, 2005): Cryotherapy: freezing of tissues 5-Fluorouracil: a chemotherapy drug Photodynamic therapy Excision surgery Immiquimod depending on site,

size and patient preference.

Seborrhoeic keratoses (basal cell papillomas; seborrhoeic warts) are benign genetic skin lesions that can mimic skin cancers. They can cause patients concern as they appear unsightly, can be numerous, increase in number each year and can be aggravated by sunshine. Common sites are the face and trunk and while treatment is not usually required, cryosurgery (application of extreme cold to destroy abnormal or diseased tissue), curettage (the ‘scraping’ away of tissue) and cautery (burning away of tissue) may all be considered (Primary Care Dermatology Society [PCDS], 2014a).

PHOTODERMATOSES

Photodermatosis is the term used to describe skin conditions that are triggered by UVR (PCDS, 2013a). Generally, this group of conditions are categorised into two main groups: Pre-existing conditions aggravated

by exposure to sunlight, e.g.

Answer the following questions about this topic, either to test the

new knowledge you have gained or to form part of your ongoing practice

development portfolio.

1 – What are the main different types of skin cancer?

2 – Name the most common cause of skin cancers?

3 – Can you list the different symptoms of skin cancers?

4 – List the main treatments/preventive techniques for skin cancers?

5 – What are some of the other skin problems associated with seasonal change?

Five-minute test

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Herpes simplex, rosacea, lupus erythematosus, Darier’s disease

Other conditions that develop are due to a photosensitive reaction to UVR (usually UVA) alongside a chemically mediated response (drug-induced), an immunological response or a genetic DNA repair abnormality.

Common photosensitive dermatoses include: Polymorphic light eruption (PLE):

a skin rash that occurs with exposure to the sun (including juvenile spring eruption [JSE], a variant of PLE, which only affects the ears)

Solar urticaria: a UV-induced hypersensitivity reaction that causes ‘wheals’ on the skin (raised pale fleshed-coloured or red welts)

Drug-induced photosensitivity Chronic actinic dermatitis: where

the skin becomes inflamed, in areas that have been exposed to sunlight

Photo-contact allergic reactions: interaction between UVR and products such as sun cream or perfume, for example

Phytophoto reactions: a mixture of plant contact and UVR, resulting from exposure to the photosensitising compounds in some plants.

PLE and solar urticaria are commonly seen in community settings.

Polymorphic light eruptionPLE and variant JSE are photosensitive reactions to natural and artificial UVR (sunbeds, for instance), usually involving the UVA component of the spectrum. They can occur at any age, but are more common in younger people. JSE is a localised reaction, which specifically affects the upper and lateral aspects of the ear rim and generally affects boys aged between five and 14 years of age (PCDS, 2014b).

The skin reaction caused by PLE and JSE presents as a diffuse pink/red papular rash on sun-exposed skin, which usually arises within 24 hours. Blistering (vesicles) may occur and the rash can be very uncomfortable with an accompanying itch or burning sensation.

natural phenomena such as insects and other organisms, which can adversely affect the skin’s health.

Stinging and biting insectsThe increased heat of summer often sees a rise in the population of biting and stinging insects, as well as an increase in exposed human skin. Insect stings and bites are extremely common and can occur as single or multiple lesions. Lesions and reactions to stings and bites range from mild to life-threatening (anaphylaxis) in severity.

However, most incidences involve mild localised reactions and appear as small itchy inflamed papules or nodules with or without a visible puncture site. Oedema, wheal and flare, blisters, and pain may occur.

If patients avoid UVR, the PLE/JSE usually resolves within a few days. Therefore, management of an acute PLE reaction is usually uncomplicated, including UV avoidance and the provision of relevant information and advice.

Symptomatic relief can be achieved with emollient therapy and a soothing topical agent such as calamine lotion (PCDS, 2014b). If sleep is being affected during an acute flare, a sedating antihistamine can be considered (PCDS, 2014b).

Longer term management includes gentle and gradual exposure to sunlight each spring. Systemic prednisone (a corticosteroid) may be required for moderately severe cases (Ashton and Leppard, 2005).

Referral to dermatology services for advice will be required in severe cases where phototesting and phototherapy (a programme of desensitisation), can be performed.

Solar urticariaSolar urticaria is a reaction to UVR or visible light and presents as raised pale lesions with surrounding erythema (wheal and flare reaction).

Solar urticaria can resemble a nettle rash or hives and is an immunological type-1 hypersensitivity reaction, i.e. an immediate hypersensitivity reaction as opposed to a delayed hypersensitivity reaction such as contact dermatitis (Krishna et al, 2001).

The rash arises within minutes of exposure, is widespread over sun-exposed skin, can be profoundly itchy and resolves rapidly when protected from UVR. Similar to other photodermatoses, solar urticaria is managed with UV avoidance, relevant advice and antihistamines. Severe cases can be referred to dermatology specialists for phototesting, phototherapy and immunosuppressive therapy (PCDS, 2013b).

SEASONAL PHENOMENA AND SKIN REACTIONS

Spring and summer bring many

KEY POINTS Seasonal ultraviolet radiation

(UVR) is an important factor in the aetiology of certain skin conditions.

It is unrealistic to expect people to stay out of the sun entirely, despite a body of evidence identifying the harmful effects of sunshine on the skin.

Community nurses in particular may need to give advice to patients regarding seasonal changes and common skin conditions.

Advice may be related to seasonal dermatoses, skin cancer prevention and/or seasonal phenomena.

Skin rashes are most prevalent in the spring and summer, mainly due to the increase in UVR intensity.

Spring and summer see a rise in the population of biting and stinging insects, as well as an increase in exposed human skin.

Photodermatoses is the term used to describe skin conditions that are triggered by UVR.

UVR, both natural and artificial, is the single most important factor in the aetiology of skin cancer.

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Biting and stinging insects include wasps, bees, hornets, midges, mosquitoes, gnats, horseflies, black fly (Blandford fly, in particular), ladybirds and bedbugs. Black fly bites can cause a particularly uncomfortable skin reaction as well as painful swelling, pyrexia and joint pain (NHS Choices, 2012).

Arachnids such as spiders and ticks can also bite to produce a localised and/or systemic reaction. Community nurses should remind people to be particularly aware of ticks, which can host the Borrelia genus of bacteria and which is the causative organism of Lyme disease in humans (NHS Choices, 2013a). Following removal of the tick, observation of the bite site is required for at least two weeks.

It is vital to know that a ring-shaped pink/red rash developing a few days or weeks after the original bite is one of the first clinical signs of Lyme disease and antibiotic therapy will be required to prevent further systemic affects (headaches, muscle and joint pain) (Ashton and Leppard, 2005; Wormser et al, 2006).

Most insect bites are mild, transient and easily managed with a topical combination of anti-inflammatory/anti-pruritic/sting-neutralising agents (British Medical Association [BMA]Royal Pharmaceutical Society [RPS], 2014a). Short courses of oral sedating antihistamines can also be considered (BMA/RPS, 2014b).

Secondary infection — where an infection occurs in a pre-existing skin condition, i.e. infection in the excoriated skin of insect bites and eczema — can occur and in this case topical or systemic antibiotics will be necessary. Excoriated skin is a portal of entry for pathogenic organisms already colonising the skin and oral antibiotic therapy is usually required (Bridgett et al, 1996).

In the most severe cases of insect venom reaction, the anaphylactic reaction can be life-threatening — the onset of signs and symptoms may be sudden and alarming, including (BMA/RPS, 2014a):

Angioedema (swelling of the deeper layers of the skin)

Wheal and flare Wheezing Difficulty breathing Dysphagia Tachycardia Dizziness Collapse Agitation Confusion.

In the worst case scenario, symptoms can lead to death. Intramuscular injection of adrenaline, emergency services and life support will be required in extreme cases.

progress to the gut to complete its life-cycle (DermNet NZ, 2014).

Fortunately, humans are not a natural host for hookworm larvae and the skin basement membrane (situated between epidermis and dermis) cannot be penetrated. The larvae are unable to survive in the epidermis, therefore, the rash is self-limiting and resolves within 4–8 weeks. Usually no specific treatment is necessary from community nurses, other than offering reassurance and advice (DermNet NZ, 2014).

EXISTING SKIN CONDITIONS AND SEASONAL CHANGE

Skin rashes are more visible in the spring and summer, mainly due to the increase in UVR intensity. Some existing skin conditions such as vitiligo (depigmentation of parts of the skin) and pityriasis vesicolor (a yeast infection, which is asymptomatic and produces a fine scale on the skin) can appear more obvious in the summer as the natural pigmentation in the skin surrounding the lesions increases through tanning (NHS Choices, 2013b). In black and Asian people, the lesions appear hypopigmented (loss of skin color).

Conversely, acne lesions, inflammatory papules and pustules usually respond well to sunshine and can resolve during the summer months only to reappear during the autumn and winter.

Psoriasis can also respond well to sunshine and often improves during the summer months. However, people with rosacea frequently report a worsening of their facial skin rash when exposed to sunlight. Skin responses to sunshine vary for people with eczema, with reports of deterioration and improvement when exposed to UVR.

CONCLUSION

Clearly, seasonal UVR is an important factor in the aetiology of certain skin conditions. In general, any advice regarding UV exposure that community nurses provide should follow national guidelines

'... any advice regarding UV exposure that community nurses provide should follow national guidelines and always advocate good skin protection, especially of children'

Cutaneous larva migransWith the advent of global travel people increasingly visit tropical and sub-tropical regions for work and/or holidays. Larva migrans is a parasitic skin infestation associated with hookworm larvae, which is picked up from warm sandy soil that has been contaminated with animal faeces and can invade human skin directly, or via fissures and cracks in the skin or hair follicles. Commonly infected sites include the feet (especially the webs between the toes), hands, knees and buttocks.

Although rare, occasionally people will return from a trip to a tropical or sub-tropical country and discover on their return that they have developed a localised skin rash, which initially appears as a palpable serpiginous (snake-like) track on the skin and can be red, pink or flesh-coloured.

Cutaneous larva migrans often only manifests itself after the individual has returned from a trip because the larvae remains dormant for a few weeks before migrating through the skin in an attempt to reach the vascular dermis and

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and always advocate good skin protection, especially of children (Cancer Research UK, 2014).

Protection includes reducing exposure by using shade, clothes, sun glasses and sunscreen. Babies should remain out of strong sunshine altogether. Sunscreens should be broad spectrum (UVA and UVB) with a SPF of 15+ and ideally 50+. This is especially important for people at risk of skin cancer or photodermatoses.

It is important that community nurses remind people to be careful about UVR exposure during spring and summer. Similarly, helping to spread awareness of the dangers of UVR will enhance people’s ability to look after their own skin health. JCN

REFERENCES

Ashton R, Leppard B (2005) Differential Diagnosis in Dermatology. 3rd edn. Radcliffe Publishing, Oxford

BAD (2014a) BAD Guidelines. Available at: www.bad.org.uk/healthcare-professionals/clinical-standards/clinical-guidelines (accessed 19 May, 2014)

BAD (2014b) Basal Cell Carcinoma. BAD Guidelines. Available at: http://www.bad.org.uk/healthcare-professionals/clinical-standards/clinical-guidelines (accessed 19 May, 2014)

BAD (2014c) Squamous Cell Carcinoma. BAD Guidelines. Available at: http://www.bad.org.uk/healthcare-professionals/clinical-standards/clinical-guidelines (accessed 19 May, 2014)

BAD (2014d) Sun Awareness Week. Available at: www.bad.org.uk/for-the-public/sun-awareness-campagin/sun-awareness-week (accessed 21 May, 2014)

BAD (2014e) Atypical Mole Syndrome: Patient information Leaflet. BAD, London

BAD (2014f) Stage II Melanoma Patient Information Leaflet. BAD, London

BMA/RSP (2014a) British National Formulary. Chapter 13, section 13.3. BMA/RSP, London

BMA/RSP (2014b) British National Formulary. Antihistamines 3.4.1. BMA/RSP, London

Bridgett C, Noren P, Staughton R (1996) Complications during conventional treatment. In: Bridgett C, Noren P, Staughton R (eds). Atopic Skin Disease: a manual for practitioners. Wrightson Biomedical Publishing, Petersfield: 36-41

Buchanan P, Courtenay M (2006) Skin cancer. In: Buchanan P, Courtenay M (eds). Prescribing in Dermatology. Cambridge University Press, Cambridge: 109–23

Cancer Research UK (2014) Sunsmart Campaign. Available at: www.sunsmart.org.uk (accessed 11 May, 2014)

de Berker D, McGregor JM, Hughes BR (2007) Guidelines for the management of actinic keratoses. Br J Dermatol 56: 222–30

De Giorgi V, Papi F, Giorgi L, Savarese L, Verdelli A, Scarfì F, Gandini S (2013) Skin self-examination and the ABCDE rule in the early diagnosis of melanoma: is the game over? Br J Dermatol 168(6): 1370–71

DermNet NZ (2014) Cutaneous Larva Migrans. Available at: www.dermnetnz.org/arthropods/larva-migrans.html (last accessed 11 May, 2014)

Gilcrest BA, Eller MS (1990) DNA photodamage stimulates melanogenesis and other photoprotective responses. J Invest Dermatol Symp Proct 4(1): 35–40

ISD Scotland (2014) Cancer Incidence Report. ISD Scotland

Kampfer S, Mutz M (2013) On the sunny side of life: sunshine effects on life satisfaction. Social Indicators Research 110(2): 579–95

Krishna MT, Mavroleon G, Holgate S (2001) Essentials of Allergy. Taylor and Francis, Abingdon

Lucas R, McMichael T, Smith W, Armstrong B (2006) Solar Ultraviolet Radiation: global burden of disease from solar ultraviolet radiation. Environmental Burden of Disease Series, No. 13. World Health Organization (WHO), Geneva

Level NJ, Igali L, Wright KA, Greenburg DC (2013) Basal cell carcinoma epidemiology in the UK: the elephant in the room. Clin Exp Dermatol 38(4): 367–69

Marsden G, Newton Bishop J, Burrows L, et al (2010) BAD guidelines: the revised guidelines for the management of malignant melanoma. Br J Dermatol 163: 238–56

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