Skin in the game

three girls on beach, only one has hat

Pharmacists have a key role in promoting skin health, especially reinforcing the importance of sun protection given research indicates many people still seek a tan

Key points

  • One in every two Australians has been sunburnt in the past year.
  • Many people don’t realise cloudy days can also cause harmful UV levels and forget to apply sunscreen.
  • There are many myths about sunscreen failure, and pharmacists have a role in refuting these.
  • Sunscreen must be applied liberally and regularly to be effective.

Poor skin health has a significant impact on quality of life, but this is often not recognised, according to recent research.

It can affect everything from our social to our working lives to our sexual activities, relations with partners, close friends and relatives, and well as mental health and wellbeing. Yet many people do little to care for their skin.

Indeed, a recent YouGov Galaxy study found that fewer than one-in-10 people prioritise a dermatologist health check for moles or skin cancer over other routine health checks and only four-in-10 say it is in their top three most important routine health checks.

The biggest barriers are cost; not knowing how to access one; believing they are too young or thinking it is unnecessary to see a dermatologist given they don’t have fair skin.

A burning issue

The survey reported that one-in-two have been sunburnt in the past year, while a staggering 3.4 million Australians admitted to having been sunburnt three or more times in the past year alone.

Despite this, three in 10—the equivalent of 5.6 million people—say they intend to spend time in the sun this summer to deliberately get a tan.

Similarly, results from the Skin Health Australia Report Card (SHARC), conducted by the Skin Health Institute, found that almost 70% of people had unexpected sunburns.

And even though skin cancer was the skin condition of highest concern among participants (44%), a surprising 47% said they had no concerns at all about cancer or sun spots.

The report found that the top three skin concerns are signs of ageing, dry skin and signs of sun damage—with 45% of participants reporting that they have a current skin condition.

According to the report authors, these concerns “need to be leveraged into action and awareness”.

“Many Australians do not understand UV risk and believe that sunburn mostly happens on hot, sunny summer days during the hottest time of the day, dismissing the risk of sunburn happening on cloudy, cool days.”

In addition, the report authors said they were concerned that too few Australians checked their skin for signs of disease and it was also “worrying that less than 40% are not confident that they could identify a possible skin cancer”.

They called for more public health messages to raise awareness of the need to protect against skin disease, given that unhealthy skin and many common skin issues such as itchy skin can be a signpost to other health conditions such as asthma or allergies.

“Unhealthy skin and common skin problems may be signs of other, more significant health problems… And while 20% of respondents with a current skin problem say they have itchy skin, which can be sign of asthma or allergies, 9% don’t seek any treatment or say they work out their own treatment (6%) rather than see a healthcare professional.”

Overall, the report found that despite many people having a troublesome skin condition that is affecting their quality of life, a large proportion do not seek professional help or dismiss the issue as merely a cosmetic problem. Just over half see a GP, 31% see a pharmacist or dermatologist, 23% say they work out their own treatment and 18% seek no treatment.

“Thinking that skin problems are only cosmetic issues means that they are often overlooked. For example, inflammatory skin disease comes in various forms from rashes, itchy skin and redness in relation to chronic conditions like psoriasis, rosacea and eczema. Inflammatory skin conditions can often disguise other underlying health factors that need professional medical opinion and diagnosis,” the report warned.

Associate Professor Rosemary Nixon, president of the Skin Health Institute, said the findings underlined that skin conditions have a significant impact on quality of life, but people may not know where to get help.

“We know that skin conditions have a significant effect on quality of life. Acne is a good example, and yet people often spend thousands (literally) before getting to a dermatologist. Pharmacists have a role to encourage people to get professional advice, rather than following something they might read on social media,” she said.

She said she gets quite “despairing” about misinformation coming from social influencers that is resulting in skin issues.

“In the past couple of months, I’ve seen half a dozen people using multiple products on their skin from serums to toners to oils to moisturisers to day creams to night creams to masks to exfoliators and they still don’t have a sunscreen in their regimen. People are following this so-called advice and getting acne—and not using sunscreen—and it’s costing them a fortune,” she said.

woman drinking water

Not getting the message

The SHARC report found that people worry about different skin issues at different times in their lives—for example, acne was more likely to be a concern to younger people. But dry skin or scaly hands or legs was the most common specific skin problem among all report respondents.

“How to deal with dry skin is something that pharmacy can promote. In Melbourne we see a lot of patients with very dry skin who have scratched at it and they end up with eczema so we are constantly reinforcing the importance of moisturising the skin in winter time—and using a lotion in the summer—that’s an important public health message for pharmacists to promote,” Prof Nixon told the AJP.

“But one of the most important things to take out of the report is that that people are not sun protecting themselves in the sun appropriately.

Part of the problem comes from confusion about UV and the temperature, she said.

“We see this a lot in Melbourne—you do get high UV when the temperature is high in December and January but people don’t realise that UV can be very high on cloudy cooler days too. So, if it is 30°C people will remember their sunscreen but if it is 20°C they won’t remember their sunscreen… so there is this huge misunderstanding by the population that the UV is related to heat.

“I think it would be useful to have a sign in the pharmacy with the daily UV index indicating when you should be protecting your skin (which can be changed weekly like the old petrol price signs).”

Another key message is that people should be reminded that changes to their skin was something to look out for, she said

Prof Nixon added that pharmacists can reinforce sun smart and skin smart messages while promoting awareness of the Cancer Council’s SunSmart app.

“It tells you when the sun is safe so that people can get their vitamin D. And I maintain it is much better to get your vitamin D from the sun rather than a tablet—as there is some evidence to support this.”

According to Professor Saxon Smith, from the Dermatology and Skin Cancer Centre, one way to push the message home about sun safety, could be to focus on the ageing effect of the sun.

“Several Australian studies over recent years have shown again and again that there is still a tanning behaviour in Australia. This is despite the 30 years of public health campaigns around sun safety.

In fact, around 30% of 18–30 years still actively suntan. Therefore, it is important for pharmacists as with all healthcare professionals to enhance and encourage the correct sun protection behaviours. It is sometimes useful to remind people that 70% of ageing in Australia is sun damage, and that using sunscreen regularly will help people to have skin that looks better for longer,” he said.

“Pharmacists can play a critical role in filling the gaps in the community’s understanding and use of sunscreen include: the need to store sunscreen below 25–30°C otherwise it will become heat affected and lose its efficacy; checking for expiry dates on your current sunscreen; and ensuring that people use appropriate amounts of sunscreen. These three knowledge gaps lead to decreased efficacy of the sunscreen people apply.”

sun sunshine heatwave vitamin d

Combating the myths

Dermatologist Dr Melissa Manahan (who also holds a pharmacy degree) said pharmacists should be aware of some of the myths that have popped up about sunscreen ‘failures’.

“There’s a lot of variables that could be the cause of the so-called failure and why someone might get burnt. The failure could be a result of it being applied incorrectly, or not as frequently as needed. Or it could be that it wasn’t stored correctly—for example, in a hot car whereby the ingredients actually broke down and were no longer effective. Or they might have had an allergy to one of the preservatives in the sunscreen and it has caused a reaction.

Alternatively, it could be that the individual actually has a condition that is exacerbated by the sun. This could be a polymorphic light eruption rash or lupus, or they might have a photosensitive drug reaction to another medication they are on and sunscreen alone without appropriate protective clothing and sun avoidance was not enough to avoid the reaction,” she said.

Pharmacists need to remind people that reliance on sunscreen alone is not going to provide the protection they need, Dr Manahan added.

“Indeed, there is a lot of complacency in that people think applying sunscreen is all they have to do but it does not give them as much physical protection as a wearing a long-sleeved shirt and hat. On top of that, people don’t apply enough sunscreen to get the benefits, even when they apply SPF 50+. Also, people need to consider the sunscreen delivery too. For example, if the sunscreen is a spray this isn’t going to give thorough coverage so they should spray it into their hands first and apply it that way to ensure coverage is sufficient.”

Picking the right product

Pharmacists can offer advice about basic skin care within their scope of practice, Dr Manahan said.

“This includes the use of soap-free washes, moisturisers and sunscreens. Pharmacists need to be able to explain how and when to apply them and use them. How to use topical steroids is also particularly important as historically there has been often been contradictory advice given between the pharmacist and the prescribing practitioners.”

Pharmacists also have a critical role in helping people understand what labels and ingredients used in many skin products mean, she said.

“People sometimes assume that when a label says ‘dermatology approved’, ‘natural’ or ‘hypoallergenic’ it means it is fine for everyone to use. But there is no regulation that describes what is natural, hypoallergenic or dermatology-approved as they are marketing terms.

“Or they may get people with concerns that are actually not based on fact but on rumour and what people see online. For example, there’s a big concern in the community about the use of products containing parabens and the risk of endocrine-based cancers“.

The concentrations used in topical products are considered safe, she said.

“In fact, it is very rare to be allergic to a paraben, but people have become very concerned about them and may opt for something else that they think is better.

For example, many shampoos and conditioners contain methylchloroisothiazolinone that’s been found to be quite allergenic. So, it is important to remember that just because something is paraben-free it does not mean it is going to be better or safer,” she said.

Optimising advice

John Bell, community pharmacist and academic at UTS graduate school of pharmacy, says it is “critically” important that pharmacists reinforce the advice that sunscreen needs to be applied frequently and liberally to be effective.

“If you play sport, or you are at the beach or in the water, you need to be applying it often. Put it on thickly, ideally on cool skin before you go out in the sun—all this information needs to be reinforced every single time you sell sunscreen to someone,” Bell said.

“Giving sun protection advice is paramount all year round but there are other skin care issues that we tend to see more of in summer such as mosquito bites, rashes and stings. For example, ticks are prevalent right down the east coast of Australia into Victoria, whereas in the past we only use to see them in Queensland.

They can cause a significant problem and people need to be aware of this. Dealing with the issue of stings and bites is also a good time to remind people of the importance of ensuring that they have a good first aid kit containing appropriate dressings and so on.”

And with everything we sell it is important to optimise it with personalised advice, where possible, he said.

“As I have been involved with the PSA’s Self Care program I always think it is really important to give patients some written information to take away. So, it could be a Self-Care Fact Card, a CMI, or company product information, and if possible, personalise it for the patient and underline any relevant aspects or features that are relevant.

“In addition, it is really important to follow up with the patient to find out if a treatment has worked. We say to our pharmacy students—and this apples to other conditions and not just dermatology—they should ask patients to return in a week’s time or give the pharmacist a call. In my pharmacy group we take the patient’s details so that we can ring them to find out how they are doing.

It is amazing what that does for the patient and the goodwill of the pharmacy”.

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