<h2>Practice points</h2>Nicotinamide 500 mg twice daily reduces NMSC formation by 23% in high-risk patients.5 It can be used as an adjunct to other skin-protective measures for chemoprevention. Nicotinamide appears to have a good safety profile with minimal side effects5,6<ul><li> <ul><li> <h2>Description</h2> </li><li><ul><li>Skin cancer is divided into two major groups, melanoma skin cancer and non-melanoma skin cancer (NMSC)1</li><li>NMSC includes:</li><li><ul><li>Basal cell carcinomas (BCCs), make up 75% of cases. BCCs arise from basal cells found in the outer layer of the epidermis and specialised structures (hair follicles, sweat ducts).1 A BCC appears as a red papule or plaque and may have a pearly edge. The edge becomes more obvious when skin is stretched under good light. Spread is local2</li><li>Squamous cell carcinomas (SCCs), make up 20% of cases. SCCs originate from scaly cells on the surface of the skin.1 A SCC grows locally but can spread to regional nodes and beyond. High risk locations are the lips, ears and scalp2</li><li>Rare skin cancers such as Merkel cell lesions, Kaposi sarcoma and cutaneous lymphoma1,3</li></ul></li><li>Actinic keratoses (AKs) are pre-cancerous lesions that develop on sun-exposed areas of the skin. They appear as rough dry patches. With preventative measures such as sun exposure avoidance and use of sunscreen, these keratoses can sometimes disappear. Most persist and can develop into the invasive skin cancer SCC4</li><li> NMSC is the most common cancer diagnosed in Australia with an estimated 400,000 new cases per year. Approximately two-thirds of Australians will experience at least one NMSC before the age of 70 years3</li><li>NMSC risk factors:</li><li><ul><li>Ultraviolet (UV) radiation (i.e. excess sun exposure), particularly during childhood and adolescence3</li><li>Personal or family history of NMSC or melanoma4</li><li>Presence of a large numbers of freckles or moles4</li><li>Fair complexion3</li><li>Skin types that are prone to burn rather than tan when exposed to the sun3</li><li>Immunosuppression due to organ transplant3</li></ul></li></ul></li></ul> </li></ul>

<h2>Management principles</h2><ul><li>Adopt preventative measures - avoid UV light exposure and protect the skin from excessive exposure, keep the skin healthy by moisturising dry skin, and improve general nutrition</li><li> Advise to check the skin regularly through self- examination and yearly clinical skin examinations</li><li>Recommend nicotinamide for those with a history of NMSC. Always advise to continue sunscreen use and undergo regular skin checks</li></ul>

Management

<h2>Primary recommendations</h2><h2>NICOTINAMIDE</h2>Nicotinamide is an amide form of vitamin B36Mechanism of action<ul><li> A range of photoprotective effects are shown in vitro and in vivo. It enhances DNA repair, reduces UV radiation- induced suppression of skin immune responses, modulates inflammatory cytokine production and skin barrier function, and restores cellular energy levels after UV exposure8</li></ul>Dosage<ul><li>Adults: 500 mg nicotinamide twice daily.5,6 Effects are noted as early as at 3 months.5,6</li></ul>Adverse effects<ul><li>Nicotinamide is well tolerated.6</li><li>Important - use the nicotinamide form of vitamin B3 not the nicotinic acid (niacin) form, which can cause vasodilatory side effects like headaches, hypotension and flushing. These side effects have not been found with nicotinamide.6 </li><li>Key interactions</li><li> Refer to the Complementary medicine interactions guide: </li><li><a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">https://www.blackmoresinstitute.org/interactions</a></li><li> </li></ul>

Primary

<h2>Diet and lifestyle</h2><ul><li> Improve general nutrition particularly where individuals may have low levels of iron, antioxidants, vitamin D, vitamin C, zinc, vitamin B6 or low protein intake.2</li><li>Reduce total fat intake as a low-fat diet may have a beneficial effect in the prevention of both NMSC and melanoma skin cancers.1</li><li>Encourage foods rich in omega-3s to help keep the skin healthy as omega-3s help maintain the stratum corneum, inhibit pro-inflammatory eicosanoids and cytokines, elevate sunburn threshold, and promote apoptosis in malignant cells.1</li><li>Drink green tea as green tea is rich in polyphenol antioxidants. These have protective effects due to inhibition of free radicals, inhibition of lipid peroxidation, inhibition of UV light-induced and chemical-induced tumour growth, reduction of inflammation associated with UV exposure, DNA repair and inhibition of oncogenic expression.1</li><li>Turmeric with its active constituent curcumin shows potential to repair photo-damaged skin, as a means of preventing degeneration into solar-induced skin cancers.1</li><li>Protect your skin and use the advice from the Cancer Council.7</li><li><ul><li>Slip on some sun-protective clothing.</li><li>Slop on broad spectrum, water resistant SPF30+ sunscreen. Put it on 20 minutes before you go outdoors and every two hours afterwards. Sunscreen should never be used to extend the time you spend in the sun.</li><li>Seek shade.</li><li>Slide on some sunglasses – that meet Australian standards.</li></ul></li><li>Encourage yearly clinical skin examinations and well as regular self-examination.1</li><li>Keep the skin healthy and dry skin needs to be managed as it leaves the skin more vulnerable to disease. Use moisturisers and emollients as they soften and condition the skin. Drink an adequate amount of water to keep the skin well-hydrated.2</li></ul>

Diet & lifestyle

<h2>References</h2>1. Rakel D. Integrative Medicine. Third edition. Elsevier Saunders. 726-731.
 2. Phelps K et al. General Practice - The Integrative Approach. Australia, Churchill Livingstone, Elsevier, 618-622.
 3. Australian Institute of Health and Welfare and Cancer Australia. Non-melanoma skin cancer. General practice consultations, hospitalisation and mortality. Australian Institute of Health and Welfare Canberra. September 2008.
 4. Australian College of Dermatologists. Actinic keratosis. https://www.dermcoll.edu.au/atoz/actinic-keratoses/ Downloaded 2 January 2019.
 5. Chen A et al. A phase 3 randomised trial of nicotinamide for skin-cancer chemoprevention. N Engl J Med 2015;373:1618-26.
 6. Barton M, Nicotinamide found to reduce the rate of nonmelanoma skin cancers in high risk patients. CA: A Cancer Journal for Clinicians. 2016 Mar-Apr; (2):91-2.
 7. Cancer Council Australia. Understanding Skin Cancer - A guide for people with cancer, their families and friends 2021. https://www.cancer.org.au/assets/pdf/understanding-skin-cancer-booklet Accessed 27 September 2023.
 8. Damian D. Nicotinamide for skin cancer chemoprevention. Australas J Dermatol. 2017 Aug;58(3):174-180.

Non-melanoma skin cancer

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