INTRODUCTION
Skin cancer is the neoplasm with the highest incidence both in Brazil and in the world1. Much attention is directed to melanomas, but non-melanomas such as basal cell carcinoma
(BCC) and squamous cell carcinoma (SCC) also profoundly impact public health.
The main risk factor for the onset of skin cancer, in general, is exposure to solar
ultraviolet radiation2. Some studies have documented a strong relationship between BCC and melanoma with
intermittent intense sun exposure, especially before 20 years of age, while SCC occurs
due to the cumulative effect of ultraviolet radiation throughout life, appearing in
photodamaged areas3. Other risk factors have also been identified for skin cancer, such as red hair,
clear eyes and skin, dysplastic nevi, smoking, alcohol consumption, arsenic exposure,
ionizing radiation, chronic skin irritation processes, burn scars, use of immunosuppressants
and papillomavirus infection. Genetic alterations may also predispose to early-manifestation
skin cancer, as in the case of xeroderma pigmentosum and basocellular nevus syndrome4,5.
The most common skin cancer is BCC, accounting for approximately 80% of diagnosed
cases. SCC is the second most common, and its incidence is increasing progressively.
Malignant melanoma accounts for only about 5% of skin cancers worldwide but is responsible
for more than 77% of cancer-related deaths.
Often skin neoplasms, when they are diagnosed, show no symptoms. In most cases, the
primary lesion is perceived by the patient or some family member6. Even if it is not a specialist physician who is the first to evaluate this lesion,
a well-trained eye may have good accuracy to differentiate benign lesions from malignant
lesions( 7).
The head and neck are sites very susceptible to skin neoplasms development because
they are generally more exposed to the sun. However, in these regions, the lesions
may be barely visible by the person himself or hidden in the hair, causing a delay
in his diagnosis and treatment, contributing to the prognosis’s worsening.
Hairdressers and beauty professionals are professionals still little explored in their
potential for early detection of these lesions8. Skin neoplasms, especially melanomas, can be easily screened through well-established
criteria9.
Considering these factors and the current reality, where knowledge is available on
an ever-increasing scale through digital platforms, the “Projeto Pele Alerta” (PPA) (Alert Skin Project) was conceived to bring accurate information to professionals
who work directly with the beauty and personal care market.
METHODS
The research ethics committee approved this project of UNIFESP with the number 3415290116/2016.
It was defended as a thesis in the professional master’s degree in science, technology,
and management applied to tissue regeneration.
Firstly, the target audience was defined, consisting of all beauty or related professionals
who work in direct contact with the population’s skin, such as hairdressers, manicurists,
tattoo artists, makeup artists, massage therapists, among others.
A completely online and free project was developed, in which these professionals can
have access to educational videos, accompanied by material illustrated in PDF format
on the project’s website (www.projetopelealerta.com).
The name “Project Alert Skin” was defined in a way to directly present its purpose:
to create an alert in these professionals, so that, knowing what skin cancer is, its
possible presentations and causes, they can detect suspicious lesions and refer to
medical care.
RESULTS
The initial program of the “Projeto Pele Alerta” has four chapters, with possible
future expansions:
Ultraviolet ray and skin. Nodes about ultraviolet rays and how they affect the skin;
Skin cancer: our feared enemy. Brings the types of skin cancer with some features
and photos to illustrate;
Sun protection: enjoying the sun in the right way. Views on photoprotection and prevention
of skin cancer.
Where to suspect any injury? Tips to professionals who watch the content about where
to pay special attention during their daily work.
The website of “Projeto Pele Alerta” (www.projetopelealerta.com) centralizes the campaign’s
subject and serves as a starting point for professionals who wish to access its contents.
The site’s slogan, “Beauty allied to prevention,” aims to make the professional who
works with beauty feel familiar with the content. It also carries the message: “Take
care of your clients in an even more special way” because knowledge adds value to
their everyday work, with a role in the prevention and early detection of skin cancer
(Figure 1).
Figure 1 - “Home” page of the “Projeto Pele Alerta”.
Figure 1 - “Home” page of the “Projeto Pele Alerta”.
In the “Downloads” section, participants have access to the list of topics covered
and a link to download the support material in PDF (Figures 2, 3 and 4).
Figure 2 - “Downloads” page of the “ Projeto Pele Alerta “.
Figure 2 - “Downloads” page of the “ Projeto Pele Alerta “.
Figure 3 - Covers of PDF files.
Figure 3 - Covers of PDF files.
Figure 4 - Mosaic with pages of material in PDF.
Figure 4 - Mosaic with pages of material in PDF.
In the “Videos” section, there is a thumbnail for each video of the “Projeto Pele
Alerta.” Participants can choose to watch them from their website or migrate to YouTube
and watch there (Figures 5 and 6).
Figure 5 - “Videos” page of the “ Projeto Pele Alerta “.
Figure 5 - “Videos” page of the “ Projeto Pele Alerta “.
Figure 6 - Print video of the “Projeto Pele Alerta”.
Figure 6 - Print video of the “Projeto Pele Alerta”.
In the “Contact” section, there is a possibility of contact with the project organizers,
creating a bilateral communication that allows feedback, in addition to the possible
comments on the videos.
DISCUSSION
The current panorama of Brazil, increasingly online, mainly due to the broad access
to the internet and smartphones, fosters a range not previously possible for preventive
campaigns. An online project manages to reach many wilderness locations in this heterogeneous
country. In places where access by route can be difficult, this content has potential
reach if there is an internet connection.
The format of the material prioritized videos representing the easiest way of consuming
information today, being passive and representing less effort, requiring only that
the person is watching and understanding. However, the material was created in PDF
to facilitate a quick visualization of the subjects covered. The creation of a project
website was conceived to centralize all these forms of communication in one unit,
allowing that when accessing this website, the participant can, in addition to accessing
the materials, have a form of contact with the team is behind its creation.
Early detection of skin cancer is the strategy that is believed to be the most cost-effective.
Most of them are directed at melanomas due to their greater morbidity and mortality,
but non-melanomas, due to their greater incidence, may represent even greater costs
to the health system10.
Early detection allows thinner lesions to be treated with a better prognosis in the
case of melanomas and allows for less extensive scarring with better aesthetic results11,12.
Many people have misconceptions about ultraviolet radiation, photoprotection, how
skin cancer arises, its types and characteristics13. This project then proves essential by bringing correct information to the lay population,
combating possible myths and wrong ideas.
Since the 1980s, with the “Sun Smart” campaign, Australia has been a pioneer country
in skin cancer prevention programs because it has the highest incidence of the disease
worldwide, representing a high health cost. An efficient strategy in this country
was to act locally, knowing the reality of the affected population. However, in today’s
connected world, an online project can reach a large portion of the population. Partnerships
between diverse sectors of the population, such as government, industry and medical
services, were also a key to Australian success. Consistency is also important, as
engagement and protective behaviors can fluctuate according to the intensity of exposure
to the campaign and the arrival of information to participants14,15. The online content is dynamic and can be changed in content and format to seek the
attention of a greater number of interlocutors to the subject. In the “Euromelanoma”
campaign, this has been one of the biggest challenges: maintaining the motivation
of professionals over time and reaching the high-risk population16,17.
Skin cancer screening outs the health system. The assistance of professionals alerted
after the PPA can be fundamental to reach high-risk people who do not usually go to
the doctor or who would not participate in a campaign. This exchange of information
is very positive. An American hairdresser who pioneered this role has been looking
for more than 20 years to look for suspicious injuries to her clients. She encourages
colleagues to take on this “double journey” that adds more value to their work and
offers broader care. Ironically, it was she who had a malignant injury detected by
one of her clients(.)
Lachiewicz et al., in 200819, raised in the literature the possibility of acquiring knowledge about skin cancer
by hairdressers because melanomas of the head and neck are the ones with the highest
mortality. As these professionals have intimate and frequent contact with these regions’
skin and attachment, they have a valuable opportunity for detection. This is the logic
of the PPA. Later other authors8 deepened this issue from the suspicion of skin lesions by hairdressers. They focused
on head and neck melanomas due to their mortality, but this concept can be extrapolated
to other lesions. There are standardized criteria that allow the suspicion of a malignant
skin lesion, even if the person is not a specialized doctor. Besides, they pointed
out other positive experiences in these professionals’ performance in health promotion
related to diseases, such as breast and prostate cancer. Beauty professionals are
an option that is still little used and has great potential for action. There is a
range of professionals who have frequent and prolonged access to the skin of the population.
However, to avoid any ethical dilemma, it is very important to emphasize to these
professionals that they help detect potential malignant lesions but that the effective
diagnosis, positive or negative, remains a medical responsibility.
Doran et al., in 201620, carried out a cost-effectiveness analysis of three Australian media campaigns in
New South Wales, concluding that they are a good investment due to their potential
to reduce the morbidity, mortality and economic burden caused for skin cancer. In
this analysis, there was a 3.85 dollars return for each dollar invested, which becomes
even more positive in a low-cost project like the PPA.
Beauty is very important in today’s society, especially in Brazil. According to SEBRAE
(Brazilian Service of Support to Micro and Small Enterprises), in 2014 there were
345,977 individual microentrepreneurs in Brazil in the field of “hairdressers, manicures
and pedicures.” This creates a very large social importance of these professionals,
who in certain places have a greater reach than the health services themselves, with
regularity, trust and proximity, which overcomes possible cultural gaps21.
Another point addressed by the PPA is the importance in media and society of the desire
to be tanned. According to Perez et al., in 201522, this desire is greater among young people, especially among women, very influenced
by fashion. The PPA highlights the sensitivity to ultraviolet radiation, the differences
between skin color tones and points out that the healthiest skin color is the one
we were born with, to mitigate erroneous beliefs that a white skin (pejoratively described
as “pale” ) is a sign of a less healthy person than the one who sustains a tan, at
the expense of exposure to skin cancer risks.
As perspectives for the future of this project, the establishment of partnerships
should be fundamental for the expansion and feeding of the project content and dissemination.
Volunteering is not something very present in Brazilians’ routine, so the real interest
of beauty professionals in acquiring this knowledge that does not bring an immediate
financial return is not yet known.
However, even with suspicion of malignant injury by a lay professional, this patient’s
gateway through the health system will be through family doctors in basic health units.
They, therefore, require more consistent training on skin cancer, which does not receive
much attention in the usual residency programs in family medicine23.
CONCLUSION
The “Projeto Pele Alerta” is an educational project in prevention and early detection
of skin cancer, aimed at professionals in the beauty and personal care market, which
is on the internet ready for use and to be disseminated throughout the Brazilian territory.
REFERENCES
1. Sociedade Brasileira de Dermatologia (SBD). Análise de dados das campanhas de prevenção
ao câncer da pele promovidas pela Sociedade Brasileira de Dermatologia de 1999 a 2005.
An Bras Dermatol. 2006;81(6):533-9.
2. Markuza AG, Book SE. Basal cell carcinoma: pathogenesis, epidemiology, clinical features,
diagnosis, histopathology, and management. Yale J Biol Med. 2015 Jun;88(2):167-79.
3. Gallagher RP, Lee TK. Adverse effects of ultraviolet radiation: a brief review. Prog
Biophys Mol Biol. 2006 Set;92(1):119-31.
4. Rigual NR, Popat SR, Jayprakash V, Jaggernauth W, Wong M. Cutaneous head and neck
melanoma: the old and the new. Expert Rev Anticancer Ther. 2008 Jul/Ago;8(3):403-12.
5. Gandhi SA, Kampp J. Skin cancer epidemiology, detection, and management. Med Clin
North Am. 2015 Nov;99(6):1323-35.
6. Hamidi R, Peng D, Cockburn M. Efficacy of skin self-examination for the early detection
of melanoma. Int J Dermatol. 2010 Fev;49(2):126-34.
7. Rat C, Quereux G, Riviere C, Clouet S, Senand R, Volteau C, et al. Targeted melanoma
prevention intervention: a cluster randomized controlled trial. Ann Fam Med. 2014
Jan;12(1):21-8.
8. Roosta N, Wong MK, Woodley DT. Utilizing hairdressers for early detection of head
and neck melanoma: an untapped resource. J Am Acad Dermatol. 2012;66(4):687-8.
9. Kienstra AM, Padhya TA. Head and neck melanomas. Cancer Control. 2005;12(4):242-7.
10. Hoorens I, Vossaert K, Pil L, Boone B, Schepper S, Ongenae K, et al. Total-body examination
vs lesion-directed skin cancer screening. JAMA Dermatol. 2016 Jan;152(1): 27-34.
11. Berwick M, Begg CB, Fine JA, Roush GC, Barnhill RL. Screening for cutaneous melanoma
by skin self-examination. J Natl Cancer Inst. 1996 Jan;88(1):17-23.
12. Bariani RL, Nahas FX, Barbosa MVJ, Farah AB, Ferreira LM. Carcinoma basocelular: perfil
epidemiológico e terapêutico de uma população urbana. Acta Cir Bras. 2006;21(2):66-73.
13. Barber K, Searles GE, Vender R, Teoh H, Ashkenas J; Canadian Non-melanoma Skin Cancer
Guidelines Committee. Non-melanoma skin cancer in Canada chapter 2: primary prevention
of non-melanoma skin cancer. J Cutan Med Surg. 2015 Mai/Jun;19(3):216-26.
14. Oyebanjo E, Bushell F. A critical evaluation of the UK SunSmart campaign and its relevance
to black and minority ethnic communities. Perspect Public Health. 2014 Mai;134(3):144-9.
15. Sinclair C, Foley P. Skin cancer prevention in Australia. Br J Dermatol. 2009;161(Supl
3):116-23.
16. Stratigos AJ, Forsea AM, Van Der Leest RJT, Vries E, Nagore E, Bulliard JL, et al.
Euromelanoma: a dermatology-led european campaign against nonmelanoma skin cancer
and cutaneous melanoma. Past, present and future. Br J Dermatol. 2012;167(Supl 2):
99-104.
17. Conejo-Mir J, Bravo J, Díaz-Pérez JL, Fernández-Herrera J, Guillén C, Martí R, et
al. Euromelanoma day. Results of the 2000, 2001 and 2002 campaigns in Spain. Actas
Dermosifiliogr. 2005;96(4):217-21.
18. Campos L. Hairdresser on double-duty. USF health communications [Internet]. 2007;
[acesso em 2016 Nov 20]. Disponível em: https://hscweb3.hsc.usf.edu/health/now/hairdresser-on-double-duty/index.html
19. Lachiewicz AM, Berwick M, Wiggins CL, Thomas NE. Survival differences between patients
with scalp or neck melanoma and those with melanoma of other sites in the Surveillance,
Epidemiology, and End Results (SEER) program. Arch Dermatol. 2008 Abr;144(4):515-21.
20. Doran CM, Ling R, Byrnes J, Crane M, Shakeshaft AP, Searles A, et al. Benefit cost
analysis of three skin cancer public education mass-media campaigns implemented in
New South Wales, Australia. PLoS One. 2016;11(1):e0147665.
21. Wilson TE, Fraser-White M, Feldman J, Homel P, Wright S, King G, et al. Hair salon
stylists as breast cancer prevention lay health advisors for African American and
Afro-Caribbean women. J Health Care Poor Underserved. 2008 Fev;19(1):216-26.
22. Perez D, Kite J, Dunlop SM, Cust AE, Goumas C, Cotter T, et al. Exposure to the "dark
side of the tan" skin cancer prevention mass media campaign and its association with
tanning attitudes in New South Wales, Australia. Health Educ Res. 2015;30(2):336-46.
23. Eide MJ, Asgari MM, Fletcher SW, Geller AC, Halpern AC, Shaikh WR, et al. Effects
on skills and practice from a web-based skin cancer course for primary care providers.
J Am Board Fam Med. 2013 Nov/Dez;26(6):648-57.
1. Universidade Federal de São Paulo, Discipline of Plastic Surgery, São Paulo, SP,
Brazil.
Corresponding author: Caroline Kroeff Machado Rua Botucatu , 740, 2º Andar, Vila Clementino, São Paulo, SP, Brazil Zip Code: 04023-062
E-mail: ck@ckplastica.com.br
Article received: February 02, 2020.
Article accepted: July 15, 2020.
Conflicts of interest: none
COLLABORATIONS
CKM Conception and design study, Methodology, Visualization, Writing - Original Draft
Preparation, Writing - Review & Editing
AH Conception and design study, Conceptualization, Final manuscript approval, Supervision,
Visualization
IDAOS onception and design study, Conceptualization, Final manuscript approval
LMF inal manuscript approval, Methodology, Supervision
