When skin therapist Angie Micallef noticed a tiny bump on her right eye’s lower lash line six years ago, she scratched it off and thought little more about it.

Now – after having to undergo an eyelid reconstruction to cut out three malignant growths that grew over the years – Angie is speaking up to encourage people to protect their face and skin from the sun.

The 36-year-old is also urging people not to ignore skin abnormalities and to seek a second opinion when it comes to such delicate health matters.

Figures from the National Cancer Registry show that the number of skin cancer cases has doubled over the last decade, increasing from almost 650 in 2010 to nearly 1,170 cases in 2020. 

That data includes cases of the three most common forms of skin cancer. 

Stephen Brincat, Director of Oncology at Saint James Hospital, said “the most worrying trend” is the marked increase in melanoma, which is the most aggressive and deadliest form of skin cancer.

Data shows that 40 cases of melanoma were found early in 2010, with the figure increasing to 72 in 2020. In 10 years, the number of deaths also doubled from six to 12.

Cutaneous invasive malignant melanoma increased from 54 in 2010 to 88 in 2020.

Most of the cases of skin cancer recorded, however, were non-melanoma skin cancer, which is more common, highly treatable and usually much less serious than melanoma.

Cases of basal cell carcinoma – the most common form of skin cancer and typically not a threat to life – increased from 451 in 2010 to 877 in 2020. Squamous cell carcinoma – another non-melanoma skin cancer with a high cure rate – increased from 143 in 2010 to 200 in 2020.

Brincat said the increase in incidence can be attributed to increased sunlight exposure, environmental changes increasing the amount of radiation coming from the sun, increased awareness leading to increased diagnosis, and an increase in population.

A little bump grows in importance

For Angie, the first signs began when she turned 30 and had just had her third child. She noticed a tiny, itchy, skin-coloured bump on the lower lash line of her right eye. After she scratched it off it healed as a little bump.

A few months later, her eyelashes in the area started growing inwards and scratching her eye. She went to get it checked and was told it was “nothing” and was possibly an eyelash condition.

“Four years down the line, one bump became two, then three, more lashes grew into my eyes and I plucked them out, as the doctor had recommended. The bumps were skin colour, not dark like a mole… I am a qualified skin therapist. I have studied the skin, it’s my field. I would never have imagined that those bumps in my eye were skin cancer,” she said.

As time passed and Angie became more uncomfortable, she made an appointment with ophthalmologist Maria Agius, who specialises in eyelid surgery, at Saint James Hospital. The ophthalmologist recommended a biopsy.

“The biopsy was carried out in May. A week later I received the results by post. I opened it and I saw the words ‘basal cell carcinoma’. I went into panic mode,” she recalled.

Basal cell carcinoma is a type of non-melanoma skin cancer and the most common type of cancer worldwide. More than 50 per cent of eyelid BCCs start in the lower lid.

However, they rarely spread to other parts of the body and are almost never life-threatening, according to Agius, a consultant ophthalmologist with a special interest in oculoplastic.

“We can cure basal cell carcinoma in almost every case. The most common treatment is surgical excision. The treatment will be much easier if we detect the basal cell carcinoma early. Basal cell carcinomas can vary in their appearance, but it is advisable to see a specialist if you have any concern.

“Any suspicious-looking lumps, especially if they are itchy or bleed, loss of eyelashes or misdirected eyelashes should be pro­perly examined and the area biopsied as deemed necessary," he said. 

What are the risk factors for skin cancer?

The main cause of skin cancer is ultraviolet (UV) radiation from the sun or tanning beds. Prolonged and repeated exposure to UV radiation can damage the DNA in skin cells, leading to the development of cancer. Sunbathing, working outdoors or spending long hours exposed to the sun can greatly increase your chances of getting skin cancer.

Other risk factors include fair skin, a history of sunburns, a weakened immune system, a family history of skin cancer, and certain genetic factors.

Brincat said it was particularly important to avoid sunburn in childhood.

“People with a fair complexion are more susceptible and tend to get skin cancer earlier and in greater numbers. Apart from an inherited complexion there are other less common hereditary conditions that predispose to skin cancer.

“Smoking also doubles the risk of developing one particular type of skin cancer – squamous cell carcinoma,” he said.

'Get a second opinion'

Last July, Angie had a full eyelid reconstruction using the Tenzel flap method – a procedure through which the bumps and the area surrounding them was cut out to create a U-shaped indent under the eyelid. A slit was then cut on the side of the eye to be able to pull the skin to stitch closed the open U-shaped area.

Angie had to remain in bed for four days. “It was the week of that insane heatwave. The week of the power cuts. I didn’t have one. God was with me,” she says.

Two days after the surgery she removed the eye patch, as recommended. Her eye was swollen and stitches still very visible. “When my children saw it, they said: ‘ouch mummy’.”

Now, just over a month later, Angie is on the road to recovery.

“I miss looking in the mirror and seeing myself. I have to wait and be patient. Looking back, I blame my sun exposure for what happened. When I was a child, I’d spend hours in the sun without any sunblock. Our generation did not have enough of that drilling. Then, in my 20s, I started wearing sunblock and sunglasses to protect my skin.

“Today the awareness is there. We need to protect ourselves and our children. It’s not only about sunblock. We must protect their eyes too with good sunglasses or caps.

“Also, one thing I recommend to everyone after all this is: get a second opinion,” she said.

How can I prevent skin cancer?

Other than regular skin checks, you can prevent skin cancer in other ways such as:

• Seek shade. Especially during peak sunlight hours (11am to 3pm) when UV rays are the strongest. 
• Wear protective clothing.
• Use sunblock. You should apply a broad-spectrum sunscreen with a minimum SPF of 30 on all exposed skin areas (including often forgotten areas such as the ears and neck), and re-apply every two hours, especially after swimming or sweating. UV rays can penetrate clouds so SPF is recommended every day, even in the winter or when it isn’t particularly sunny.
• Avoid tanning beds.