Behavioral factors associated with the development of skin cancer in patients of arsenicosis

The study was conducted to evaluate the behavioral factors associated with the development of skin cancer in arsenicosis patients. Arsenicosis patients without skin cancer were taken as control. In the sun-exposed area of the body, 57.2% of skin carcinoma was Bowen’s disease. In the covered area of the body, 56.0% was Bowen’s disease, 36% was squamous cell carcinoma and 8% was basal cell carcinoma. Again, 53.1% of case and 59.4% of control never used fertilizer and pesticide. The majorities were non-smoker (case 53.1%, control 59.3%). Mean cumulative sun exposure was more in the case group (5853.9 ± 2219.7 hours) than in the control group (2219 ± 392.4 hours) and the rate of sun exposure was also higher in the case group. In conclusion, sun exposure was significantly higher in carcinoma patients and since most of the lesions were in the covered areas of the body, it can be said that these carcinomas were due to arsenicosis and not due to sun exposure and smoking status, use of fertilizer and pesticides were not associated with the development of skin carcinoma.


Introduction
Arsenic is a naturally occurring metalloid.2][3][4][5] Skin cancer in arsenicosis patients has been well documented over the past several decades.Most common forms of skin cancer found in these patients are Bowen's disease, squamous cell carcinoma and basal cell carcinoma. 6, 7The body response to arsenic exposure varies among individuals.Other factors such as sun exposure, smoking, fertilizer use etc. might also contribute to the development of skin lesion in arsenicosis. 8-14So, the identification of environmental factors that enhance the development of skin cancer and by modifying them might lessen the carcinoma burden.

Materials and Methods
This study was conducted from April 2015 to August 2016.Consecutive type of sampling technique was applied to collect the sample from the study population.Arsenicosis patients who fulfilled the inclusion and exclusion criteria were selected as case and without skin cancer were taken as control.Inclusion criteria were age >20 years and both sexes, patients with skin lesions fulfilling WHO diagnostic criteria of a clinically confirmed case of arsenicosis were taken as control.Arsenicosis patient with skin cancer histopathologically confirmed was taken as case and participants who had willingly given written consent were included.Exclusion criteria were skin conditions mimicking arsenicosis, subjects having carcinoma other than skin carcinoma and skin carcinoma secondary to other skin diseases.

Study procedure
An informed consent was taken from each patient who met the inclusion criteria.For data collection, structured questionnaire and consent form were used when interviewing each respondent.At the baseline visit, the questionnaire was used to collect data on the background of the respondents, socio-demographic factors, family history, community status, personal history, occupational history, disease type and its duration.Arsenicosis patients were diagnosed by the history and clinical examination with the help of an arsenic expert.Cutaneous manifestations of arsenicosis include melanosis, raindrop pigmentation, leucomelanosis of the trunk and extremities; and focal or diffuse thickening of the palms and soles.Skin cancer diagnosed clinically by the presence of erythematous scaling or crusted patches and plaques; non-healing

Abstract
The study was conducted to evaluate the behavioral factors associated with the development of skin cancer in arsenicosis patients.Arsenicosis patients without skin cancer were taken as control.In the sun-exposed area of the body, 57.2% of skin carcinoma was Bowen's disease.In the covered area of the body, 56.0% was Bowen's disease, 36% was squamous cell carcinoma and 8% was basal cell carcinoma.Again, 53.1% of case and 59.4% of control never used fertilizer and pesticide.The majorities were non-smoker (case 53.1%, control 59.3%).Mean cumulative sun exposure was more in the case group (5853.9± 2219.7 hours) than in the control group (2219 ± 392.4 hours) and the rate of sun exposure was also higher in the case group.In conclusion, sun exposure was significantly higher in carcinoma patients and since most of the lesions were in the covered areas of the body, it can be said that these carcinomas were due to arsenicosis and not due to sun exposure and smoking status, use of fertilizer and pesticides were not associated with the development of skin carcinoma.

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Cite this arti le:
Noo T, Sikde MS, Kho dke L, Bhui a MSI, Rah a T. Beha io al fa to s asso iated ith the de elop e t of ski a e i patie ts of a se i osis.Ba gaa dhu Sheikh Muji Med U i J. ; : -.

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The op ight of this a ti le is etai ed the autho s [At i utio CC-B .] A aila le at: .a glajol.ifo Cumulative lifetime sun exposure in both summer and winter during 9:00 am to 3:00 pm was calculated by summing weekday and weekend day exposures across different age intervals.The rate of sun exposure i.e. the average number of hours spent outdoors per year was estimated to observe the effect of current age, e.g., total hours spent in outdoor for older than for the younger participants.

Severity of arsenical skin lesions
Arsenic-induced skin lesion served as a biological marker of exposure.Melanosis is the early and common manifestation of arsenicosis.Keratosis appears in more advanced stages of arsenicosis.A sudden increase in the size of keratotic lesion or crack or bleeding of lesion suggests malignant transformation.

Results
Table I shows that in sun-exposed area, 57.2% of skin carcinoma was Bowen's disease, 28.6% was squamous cell carcinoma and 14.3% was basal cell carcinoma.In the covered area, 56% was Bowen's disease, 36% was squamous cell carcinoma and 8% was basal cell carcinoma.Chi-square test (χ²) was performed and found not significant (p=0.852).
Table II shows the distribution of study subjects by use of fertilizer and pesticide.About 53.1% of case and 59.4% of control had never used fertilizer and pesticide.About 46.9% of case and 40.6% of control were fertilizer and pesticide user.Chi-square test (χ²) was not significant (p=0.614).

Discussion
Arsenic-associated squamous cell carcinoma is distinguished from the ultraviolet-induced squamous cell carcinomas by their tendency to occur on the palms, soles and trunk rather than solely on sun -exposed areas such as the head and neck. 2 In this study, most of skin cancers were found both in the exposed and covered areas and the lesions in the covered areas outnumbered the sun-exposed areas.Arsenical basal cell carcinomas most often arise from the normal tissue, frequently occur on the trunk. 2 In this study, among the 3 basal cell carcinoma, 2 were found on the trunk and one in the palm.
As there is negligible amount of arsenic absorbed through the skin, the mechanisms through which exposure to fertilizers and pesticides lead to increased risk of arsenic-induced skin lesions remain unknown.Fertilizers and pesticides usually cause irritant contact dermatitis which may aggravate or modify the arsenic-induced skin lesions.Studies conducted by Melkonian et al. (2010) and Chen et al. (2003) found that users of fertilizers and pesti-cides were more prone to arsenic-induced skin lesions. 8, 15In this study, no association was found regarding exposure to fertilizer and pesticide with severity of arsenical skin lesions and the effect of these agents were comparable in both groups.
A cross-sectional study in Chile found that methylation capacity of arsenic was poor among the smokers, as indicated by a higher ratio of urinary monomethylarsonate to dimethylarsinate in smokers. 16In two different studies conducted in Araihazar, Bangladesh by  15 In this study, the smoking status was observed between the two groups and no association was found in the development of skin cancer with the smoking status.
In an experimental study conducted by Burns et al.  (2004) showed that skin tumors occurring in mice given ultraviolet radiation along with arsenite appeared earlier and more invasive than in mice given ultraviolet radiation alone. 17Chen et al. (2006)  suggest that the risk of skin lesions associated with any given level of arsenic exposure was greater with excessive sun exposure. 15This finding corelates with the current study as greater cumulative sun exposure and the rate of sun exposure were observed in carcinoma group than in non-carcinoma group and found statistically significant.

Conclusion
Smoking status, use of fertilizer and pesticides were not associated with the progression of arsenical skin lesions to skin carcinomas.Sun exposure was significantly higher in carcinoma patients but as most of the lesions were in covered areas of the body, it can be said that these carcinomas were due to arsenicosis and not due to sun exposure.
t e t of De atolog a d Ve eeolog , Fa ult of Medi i e, Ba gaa dhu Sheikh Muji Medi al U i e sit , Shah ag, Dhaka, Ba gladesh Key ords: A se i ; Basal ell a i oa; Bo e 's disease; Ski a e ; S ua ous ell a i o a; Su e posu e

Shahidullah Sikder, Lubna Khondker, Mohammed Saiful Islam Bhuiyan and Tanvir Rahman
and obese (>25.0 kg/m²).Sun exposure was measured by cumulative sun exposure and rate of sun exposure.The climate of our country is mostly hot and summer season mostly extends from March to October.During winter season people intentionally expose to sunlight for warming body.
A Jou al of Ba ga a dhu Sheikh Muji Medi al U i e sit , Dhaka, Ba gladesh Behavioral factors associated with the development of skin cancer in patients of arsenicosis Towhida Noor, Md.Body mass index was evaluated by measuring weight in kg divided by height in meter square and the patients were divided into the following categories: Underweight (<18.5 kg/m²), normal weight (18.5-23.0kg/m²), overweight (23.0-25.0kg/m²)

Table III Rate of sun exposure in different age group
Melkonian et al. (2010) and Chen et al. (2006) have found increased skin lesions among the smokers. 8,