by Ross M. Levy, MD, and C. William Hanke, MD, MPH
The numbers are indisputable: Skin cancer is rising at an alarming rate. In 2007 more than 1,000,000 individuals were diagnosed with non-melanoma skin cancer and approximately 60,000 were diagnosed with melanoma. It is estimated that 1 in 5 Americans will develop some form of skin cancer in their lifetimes. Currently, non-melanoma skin cancer (NMSC), which includes basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is the most common form of cancer in the United States. With these rising rates, it is imperative that the public learns how to prevent the development of and recognize lesions suspicious for skin cancer.
Patients commonly ask “What do I look for?” but they should also be asking “Where do I look for it?” There are certain high-risk areas, such as the nose, where skin cancer is more common and aggressive. Recognizing that these areas are more prone to develop cancer and ensuring that they are protected from the sun is the first step in preventing the development of malignant skin lesions.
In a recent study of 194 BCCs of the head and neck region, the nose was the most common location for skin cancer, comprising one third of all cases. Another investigation found that 40 percent of BCCs on the head and neck were on or adjacent to the nose. To better assess the particular areas on the nose where skin cancer is most prevalent, we prospectively evaluated 111 patients with nasal skin cancer in our practice. The specific type of cancer, the exact location on the nose and the gender of the patient were documented.
Our study population consisted of 99 people with BCCs and 12 with SCCs. There were 46 males and 65 females included in the study. Figure 1 exhibits the normal anatomy of the nose and figure 2 shows the distribution of skin cancers in our study. The most common location for skin cancers on the nose was the alae (n=42) — the outer flaring walls atop the nostrils — followed by the tip (n=35). There were no significant differences between gender and type of skin cancer or location. Our results are similar to previously published distributions of skin cancer on the nose. For example, in a recent study of BCCs in China, 52 percent were located on the alae, 22 percent on the dorsum (the nose’s external ridge), 16 percent on the tip and 10 percent in other locations.
Risk factors for skin cancer include age, gender, and race, but the most important risk factor is sun exposure. Ultraviolet (UV) light exposure at the earth’s surface is primarily in the form of long-wave UVA and shorter-wave UVB rays. While UVB has been traditionally thought of as the most damaging form of UV light, current evidence implicates UVA as an increasingly important contributor to UV-induced skin damage. The areas on the body most susceptible to skin cancer are those that are least protected from the sun, such as the nose, ears, cheeks, and forehead.
In particular, the alar and tip regions of the nose, the most outwardly protruding areas on the face, are most vulnerable. It is not surprising that the majority of skin cancers on the nose (approximately 75 percent) in our study were on the alar and tip regions, likely owing to their prominent exposure to UV light.
Prevention of Nasal Skin Cancers
Skin cancers on the nose are often difficult to treat due to the complex anatomy of this region. Once the cancer has been removed, reconstruction can be challenging since the nose is a rigid structure that relies on important and complex anatomic landmarks for its aesthetic appearance. Preventing skin cancer is the best way to avoid surgery. So, what is the best way to protect your nose from the hazards of sunlight and potential skin cancer? The answer is simple: Make sure you keep your nose out of the sun or protected in the sun.
Frequent application of a broad spectrum sunscreen with an SPF of at least 15 is one of the best ways to protect your nose from sun exposure. It is important to note that not all sunscreens are created equal. The most effective formulations are ones that contain both UVA and UVB protection. For the best protection your sunscreen should contain one or more of the following ingredients: titanium dioxide, zinc oxide, avobenzone or ecamsule (MexorylTM SX). Currently there are many new elegant and inconspicuous sunscreen formations available, so protecting your nose doesn’t mean sacrificing your looks.
In addition to using the right sunscreen, it is crucial to apply sunscreen correctly. Unfortunately, most people put on too little sunscreen, too infrequently. Approximately one ounce (two tablespoons) will cover the entire body surface. Frequent reapplication (every two hours) is necessary for complete protection throughout the day. Re- application is especially important immediately after going into the water or sweating, even if the sunscreen claims to be waterproof: No sunscreen is completely waterproof.
In addition to sunscreen, physical blockers can be very useful for protect- ing yourself from the sun; wide-brimmed hats and clothing designed specifically to block UV light are excellent additional methods of sun protection.
The nose is extremely important from both a functional and cosmetic standpoint. As skin cancer rates rise at an alarming rate, it is vital to recognize areas such as the nose that are prone to developing cancer. Protecting yourself from the sun is the most important way to prevent skin cancer. It’s OK to be nosy; just be sure to put on sunscreen.
Dr. Hanke, Director of the Laser and Skin Surgery Center of Indiana in Carmel, is a nationally and internationally recognized expert in the treatment of skin cancer, dermatologic surgery, laser and cosmetic surgery. He founded the Mohs Micrographic Surgery Unit at Indiana University School of Medicine. Past Editor-in-Chief of the Journal of Dermatologic Surgery and Oncology, he has authored or coauthored more than 240 medical articles and books. Dr. Hanke is a Senior Vice President of The Skin Cancer Foundation and President of the American Academy of Dermatology.
Dr. Levy is currently a Mohs Micrographic Surgery and Procedural Dermatology Fellow at the Laser and Skin Surgery Center of Indiana in Carmel.