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Table of Contents


book Rising trends in melanoma . An hypothesis concerning sunscreen effectiveness
book Changes in sun-related attitudes and behaviours, and reduced sunburn prevalence in a population at high risk of melanoma.
book Melanoma and skin cancer: evaluation of a health education programme for secondary schools.
book Beneficial effects of sun exposure on cancer mortality.
book Melanoma prevention: behavioral and nonbehavioral factors in sunburn among an Australian urban population.
book Adolescence and sun protection.
book Sun exposure and sunscreen use following a community skin cancer screening.
book Case-control study of melanoma and dietary vitamin D: implications for advocacy of sun protection and sunscreen use.
book Sun protection in childhood
book Sunscreen: one weapon against melanoma.
book Dysplastic nevi and malignant melanoma.
book Analysis of the effect of a sunscreen agent on the suppression of natural killer cell activity induced in human subjects by radiation from solarium lamps.
book Harmful effects of ultraviolet radiation. Council on Scientific Affairs.
book The association of solar ultraviolet and skin melanoma incidence among caucasians in the United States.
book Risk reduction for nonmelanoma skin cancer with childhood sunscreen use.
book Efficacy of topical sunscreen preparations on the human skin: combined indoor-outdoor study.
book Predictors of sunbathing and sunscreen use in college undergraduates
book Protecting skin and preventing melanoma
book Photoprotection: An active shield against exposure to sunlight health information for the public
book Relevance of in vitro melanocytic cell studies to the understanding of melanoma
book Prevention and control of melanoma: The public health approach
book News in photoprotection
book Sun-induced skin damage
book Chronic sunlight exposure-induced skin damage and skin cancer: Cutaneous manifestations, prevention, and treatment
book Sunscreens: The ounce of prevention
book Prevention and early detection strategies for melanoma and skin cancer: Current status
book Preventive strategies and research for ultraviolet-associated cancer
book Overview of ultraviolet radiation and cancer: What is the link? How are we doing?
book Genotoxicity, mutagenicity, and carcinogenicity of UVA and UVB
book Environmental skin injuries in children
book Cancer of the skin in the next century
book Predictors of sunscreen use in childhood
book Self screening for risk of melanoma: Validity of self mole counting by patients in a single general practice
book Xeroderma pigmentosum
book Children and photoprotection
book Daily sun protection


Rising trends in melanoma . An hypothesis concerning sunscreen effectiveness

Garland CF; Garland FC; Gorham ED
Department of Community and Family Medicine, University of California at San Diego, La Jolla 92138-0631.
Ann Epidemiol (United States) Jan 1993, 3 (1) p103-10

Incidence rates of melanoma have risen especially steeply since the mid-1970s. The two principal strategies for reduction of risk of melanoma and other skin cancers are sun avoidance and use of chemical sunscreens. Rising trends in the incidence of and mortality from melanoma have continued since the 1970s and 1980s, when sunscreens with high sun protection factors became widely used. Commonly used chemical sunscreens block ultraviolet B (UVB) but are virtually transparent to ultraviolet A (UVA), which makes up 90 to 95% of ultraviolet energy in the solar spectrum. Because sunscreens prevent erythema and sunburn, and inhibit accommodation of the skin to sunlight, their use may permit excessive exposure of the skin to portions of the solar spectrum other than UVB. If melanoma and basal cell carcinoma are initiated or promoted by solar radiation other than UVB, as laboratory data suggest, then UVB sunscreens might not be effective in preventing these cancers, and sunscreen use might increase the risk of their occurrence. Alternative explanations for the rapid rise in the incidence and mortality rates of melanoma , such as changes in patterns of recreational sun exposure, are discussed. Traditional means of limiting overexposure to the sun, such as wearing of hats and adequate clothing and avoidance of prolonged sunbathing, may be more prudent than reliance on chemical sunscreens. (94 Refs.)

Changes in sun-related attitudes and behaviours, and reduced sunburn prevalence in a population at high risk of melanoma.

Hill D; White V; Marks R; Borland R
Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, Carlton South, Australia.
Eur J Cancer Prev (England) Nov 1993, 2 (6) p447-56

This study aimed to determine trends in exposure to sunlight in the context of a melanoma prevention programme by monitoring the prevalence of sunburn and sun-related attitudes and behaviours. Telephone interviews were conducted in a baseline summer (December 1987 to February 1988) and two subsequent summers after the introduction of the SunSmart health promotion campaign. Interviewing a sample of 4,428 adult residents of the Australian city of Melbourne took place throughout summer on Monday evenings. Behavioural and sunburn data were reported for the previous weekend and relevant attitudinal data were collected. After adjusting for ambient ultraviolet radiation levels and temperature, survey month, age, sex and skin type, a significant reduction in sunburn was found. The crude proportion of sunburnt dropped from 11% to 10% to 7% over 3 years and the adjusted odds ratios (and 95% confidence intervals) were as follows: Year 1/Year 2; 0.75 (CI 0.57-0.99) and Year 1/Year 3; 0.59 (CI 0.43-0.81). Substantial attitudinal shifts occurred over the 3 years. Hat wearing increased significantly each year (19%, 26%, 29%), as did sunscreen use (12%, 18%, 21%). However, the trends in mean proportion of body surface area covered by clothing were less clear cut (0.67, 0.64, 0.71). It is concluded that melanoma risk factor exposure of populations can change fairly rapidly and that well-conducted health promotion campaigns can play a part in producing such change.

Melanoma and skin cancer: evaluation of a health education programme for secondary schools.

Hughes BR; Altman DG; Newton JA
Department of Dermatology, Royal London Hospital, U.K.
Br J Dermatol (England) Apr 1993, 128 (4) p412-7

The effectiveness of an education package for secondary schools about the sun and skin cancer was assessed using questionnaires. A variety of teaching methods was used, including pamphlets, workbooks, and a video. The effect of this material was assessed by asking pupils to complete questionnaires immediately after receiving the package (July), and after the summer holiday (September). Five-hundred and forty-three children from seven schools were recruited into the study. Results of the questionnaire demonstrated a significant difference in knowledge (P < 0.001) and reported attitude (P < 0.001) compared with a control group. There was no significant difference in behaviour of the taught groups compared with the control group. The only significant activity associated with increased knowledge was wearing a sunscreen (P < 0.005). In contrast, in terms of attitude, those who covered up in the sun (P < 0.0001), wore a sunscreen (P < 0.004), and sat in the shade (P < 0.02), had significantly better attitudes than those who did not behave in this way. This project is a first attempt to assess health education in schools, and reports changes in knowledge, attitudes, and some aspects of behaviour. Adolescents are a group who are difficult to influence, but our study has produced some useful information about how these children respond to such teaching measures.

Beneficial effects of sun exposure on cancer mortality.

Ainsleigh HG
Prev Med (United States) Jan 1993, 22 (1) p132-40

For more than 50 years, there has been documentation in the medical literature suggesting that regular sun exposure is associated with substantial decreases in death rates from certain cancers and a decrease in overall cancer death rates. Recent research suggests that this is a causal relationship that acts through the body's vitamin D metabolic pathways. The studies reviewed here show that (a) sunlight activation is our most effective source of vitamin D; (b) regular sunlight/vitamin D "intake" inhibits growth of breast and colon cancer cells and is associated with substantial decreases in death rates from these cancers; (c) metabolites of vitamin D have induced leukemia and lymphoma cells to differentiate, prolonged survival of leukemic mice, and produced complete and partial clinical responses in lymphoma patients having high vitamin D metabolite receptor levels in tumor tissue; (d) sunlight has a paradoxical relationship with melanoma , in that severe sunburning initiates melanoma whereas long-term regular sun exposure inhibits melanoma ; (e) frequent regular sun exposure acts to cause cancers that have a 0.3% death rate with 2,000 U.S. fatalities per year and acts to prevent cancers that have death rates from 20-65% with 138,000 U.S. fatalities per year; (f) there is support in the medical literature to suggest that the 17% increase in breast cancer incidence during the 1991-1992 year may be the result of the past decade of pervasive anti-sun advisories from respected authorities, coinciding with effective sunscreen availability; and (g) trends in the epidemiological literature suggest that approximately 30,000 U.S. cancer deaths yearly would be averted by the widespread public adoption of regular, moderate sunning.(ABSTRACT TRUNCATED AT 250 WORDS) (43 Refs.)

Melanoma prevention: behavioral and nonbehavioral factors in sunburn among an Australian urban population.

Hill D; White V; Marks R; Theobald T; Borland R; Roy C
Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, Carlton South, Australia.
Prev Med (United States) Sep 1992, 21 (5) p654-69

BACKGROUND. To determine the independent contribution of behavioral factors to the occurrence of sunburn, sun protection behavior was assessed over 13 successive summer weekends in a total of 1,655 adults in Melbourne, Australia.

METHODS. Telephone survey respondents provided detailed accounts of activities engaged in, time spent outside, and hat, clothing, and sunscreen coverage in the 4 hr around the solar midday on both weekend days, as well as skin type, sociodemographic descriptors, and degree of sunburn experienced. Independent measures of atmospheric temperature and ambient ultraviolet radiation (UVR) were added to individual records.

RESULTS. The (mostly recreational) weekend sunburn in this urban sample was strongly associated with UVR, as expected. Temperature at 3 PM, sensitive skin type, youthfulness, and being male were also independently associated with sunburn. After all other predictors were controlled for, the body exposure index (which took into account time outside and hat, clothing, and sunscreen coverage) made a strong independent contribution to the explanation of sunburn (P < 0.001).

CONCLUSION. It was concluded that behavior change strategies to prevent malignant melanoma of the skin are warranted.

Adolescence and sun protection.

McGee R; Williams S
Hugh Adam Cancer Epidemiology Unit, University of Otago Medical School, Dunedin.
N Z Med J (New Zealand) Oct 14 1992, 105 (943) p401-3

AIM: to examine adolescents' sun behaviours and use of sun protection measures, attitudes to tanning, and awareness of melanoma , in the light of the Cancer Society's Sun-smart campaign in the summer of 1990-1.

METHODS: a sample of 345 fourth formers from schools in Auckland, Wellington and Christchurch was surveyed regarding their experiences and beliefs about tanning, and their use of sun protection measures including sunblock lotions, hats and clothing; their knowledge of melanoma and risks for melanoma ; and their exposure to the educational campaign and its message.

RESULTS: despite relatively high awareness of melanoma as a dangerous form of cancer, a significant proportion of the sample showed high positive attitudes towards tanning and high levels of sun exposure without adequate sun protection. On the positive side, reports of exposure to sources of information about melanoma were correlated with melanoma awareness, which in turn predicted use of sun protection measures.

CONCLUSION: the findings suggest that campaigns such as those of the Cancer Society have an important role to play in reducing high levels of sun exposure among adolescents. Continued efforts need to be directed at adolescents to increase the acceptability and use of sun protection measures.

Sun exposure and sunscreen use following a community skin cancer screening.

Berwick M; Fine JA; Bolognia JL
Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut 06510.
Prev Med (United States) May 1992, 21 (3) p302-10

BACKGROUND. In May 1988, a community skin cancer screening was held, and of the 251 individuals who attended, 214 (85%) completed a follow-up questionnaire. The objective of this study was to examine the associations among attitudes, knowledge, and behavior in those who had attended the screening.

RESULTS. Analysis showed that females were twice as likely to have false positive screening diagnoses as males (odds ratio 2.2; P = 0.06). Attitudes toward tanning were not correlated with knowledge about the harmful effects of excess sun exposure (rp = -0.02; P = 0.67) or with behaviors such as reported sun exposure (for positive attitude versus "poor" attitude, linear trend P less than 0.11) and sunscreen use (linear trend P = 0.70). Behavior, defined as reported sunscreen use, was highly correlated with knowledge, both of the harmful effects of the sun and of the definition of SPF (linear trend P less than 0.001). Sunscreen use was also associated with the younger age group (those less than 59, P less than 0.05), female sex (P less than 0.001), higher education (P less than 0.05), and perceived risk for melanoma (P less than 0.05).

CONCLUSIONS. We conclude that more targeted education in the domain of knowledge would benefit males and those over the age of 59.

Case-control study of melanoma and dietary vitamin D: implications for advocacy of sun protection and sunscreen use.

Weinstock MA; Stampfer MJ; Lew RA; Willett WC; Sober AJ
Dermatoepidemiology Unit, VA Medical Center, Providence, RI 02908.
J Invest Dermatol (United States) May 1992, 98 (5) p809-11

The rapid increase in melanoma incidence and mortality has given rise to nationwide and international campaigns that encourage the public to protect themselves from solar radiation with clothing, sunscreens, and other measures. The basis of these campaigns has been challenged by proponents of the theory that vitamin D, which is generated in the skin by ultraviolet B radiation, inhibits the development of melanoma . The present investigation tests this theory by examining the relation between dietary vitamin D and melanoma risk in a case-control study. Vitamin D intake was assessed by a food-frequency questionnaire in 165 melanoma patients and 209 controls. After controlling for age, hair color, and family history of melanoma , there was no association of melanoma risk with total vitamin D intake, calorie-adjusted vitamin D intake, vitamin D intake from foods, or consumption of milk or vitamin D supplements. We find no evidence to suggest that vitamin D protects against melanoma , and therefore continue to support the ongoing public health campaigns aimed at reducing sun exposure for the prevention of melanoma .

Sun protection in childhood

Truhan AP
Department of Dermatology, Harvard Medical School, Massachusetts General Hospital, Boston 02114.
Clin Pediatr (Phila) (United States) Dec 1991, 30 (12) p676-81
[corrected and republished article originally printed in Clin Pediatr (Phila) 1991 Jul;30(7):412-21]

There is compelling evidence that childhood is a particularly vulnerable time for the photocarcinogenic effects of sun exposure on the skin. Studies indicate that excessive sun exposure during the first 10-20 years of life greatly increases the risk of skin cancer. Nonmelanoma skin cancer (basal cell and squamous cell carcinoma) has been associated with cumulative sun exposure, whereas melanoma has been associated with short, intense sun exposure or blistering sunburn. Under normal circumstances, children receive three times the annual sun exposure of adults; most of one's lifetime sun exposure occurs in childhood. Depletion of the earth's protective ozone layer adds to the photodamage problem. It is clear that sun protection is most vital in the early years. Those with fair skin are at highest risk. Photoprotective measures including sunscreen , clothing, and sun avoidance in childhood may significantly reduce the occurrence of melanoma and other skin cancer in later life. Regular use of sunscreen with a sun protection factor of 15 during the first 18 years of life could reduce the lifetime incidence of nonmelanoma skin cancer by 78%. Pediatricians can play a major role in educating parents and children. (27 Refs.)

Sunscreen: one weapon against melanoma.

O'Donoghue MN
Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois.
Dermatol Clin (United States) Oct 1991, 9 (4) p789-93

It is hoped that this review has given some information to direct the clinician in his approach to his patients. Certainly, we would desire that the incidence of malignant melanoma as well as other skin cancers would start to decrease. (46 Refs.)

Dysplastic nevi and malignant melanoma.

Crutcher WA; Cohen PJ
Children's Hospital of San Franscisco, California.
Am Fam Physician (United States) Aug 1990, 42 (2) p372-85

The incidence of melanoma has been steadily increasing, with a trend for this tumor to develop at younger ages. The only satisfactory treatment for melanoma is early intervention; therefore, routine screening for melanoma and dysplastic nevi during the general physical examination is important. The prevalence of dysplastic nevi is estimated to be 2 to 5 percent. Patients with dysplastic nevi appear to have at least a 6 percent lifetime risk of melanoma . In the most severely affected patients (those with a family history of dysplastic nevi and more than one melanoma), the lifetime risk may exceed 50 percent. Patients with dysplastic nevi merit periodic follow-up. Since these nevi tend to be familial, close relatives of affected patients may also benefit from a screening examination. Individuals at increased risk for melanoma may display one or more of the following risk factors: dysplastic nevi, freckling, tendency to sunburn and numerous common nevi. Such individuals may benefit most from education in sunburn avoidance, sunscreen use and self-examination for changing nevi. A better informed public and heightened physician awareness are the most effective means of reducing mortality from this virulent malignancy. (35 Refs.)

Analysis of the effect of a sunscreen agent on the suppression of natural killer cell activity induced in human subjects by radiation from solarium lamps.

Hersey P; MacDonald M; Burns C; Schibeci S; Matthews H; Wilkinson FJ
J Invest Dermatol (United States) Mar 1987, 88 (3) p271-6

Previous studies in rodents have shown that ultraviolet radiation (UVR) may have direct effects on the immune system in the skin and at higher doses may induce systemic suppression of immune responses. We have previously shown that UVR from sun or solarium beds may induce systemic effects in human subjects. The purpose of the present study was to examine whether these systemic effects in human subjects could be prevented by use of commercially available sunscreen agents. Groups of 12 normal subjects were exposed to radiation from solarium lamps after application of a sunscreen agent or the base used in its preparation. Twelve half-hourly exposures induced a depression of natural killer (NK) cell activity against a melanoma and the K562 target cell which was not prevented by use of the sunscreen agent. Changes in functional activity were accompanied by a reduction in NK cell numbers assessed by Leu-11 monoclonal antibodies against the labile Fc receptor. Application of the sunscreen agent also did not protect against effects of solarium exposure on recall antigen skin tests and immunoglobulin production in vitro in pokeweed mitogen-stimulated cultures of B and T cells. These results suggest that further evaluation of the wave-length spectrum of UVR and the effectiveness of sunscreen agents in prevention of UVR-induced effects on the immune system is needed.

Harmful effects of ultraviolet radiation. Council on Scientific Affairs.

JAMA (United States) Jul 21 1989, 262 (3) p380-4

Tanning for cosmetic purposes by sunbathing or by using artificial tanning devices is widespread. The hazards associated with exposure to ultraviolet radiation are of concern to the medical profession. Depending on the amount and form of the radiation, as well as on the skin type of the individual exposed, ultraviolet radiation causes erythema, sunburn, photodamage (photoaging), photocarcinogenesis, damage to the eyes, alteration of the immune system of the skin, and chemical hypersensitivity. Skin cancers most commonly produced by ultraviolet radiation are basal and squamous cell carcinomas. There also is much circumstantial evidence that the increase in the incidence of cutaneous malignant melanoma during the past half century is related to increased sun exposure, but this has not been proved. Effective and cosmetically acceptable sunscreen preparations have been developed that can do much to prevent or reduce most harmful effects to ultraviolet radiation if they are applied properly and consistently. Other safety measures include (1) minimizing exposure to ultraviolet radiation, (2) being aware of reflective surfaces while in the sun, (3) wearing protective clothing, (4) avoiding use of artificial tanning devices, and (5) protecting infants and children. (30 Refs.)

The association of solar ultraviolet and skin melanoma incidence among caucasians in the United States.

Scotto J; Fears TR
Biostatistics Branch, National Cancer Institute, Bethesda, Maryland 20892.
Cancer Invest (United States) 1987, 5 (4) p275-83

Using recent data from cancer incidence surveys and measures of UVB exposure levels at seven geographic locations within the United States, we estimate the dose-response relation between UVB and skin melanoma incidence. Mathematical models used information from general population interview studies conducted in these locations to adjust for potentially confounding factors such as age, skin color, ancestry, eye color, hair color, sunburn sensitivity, prevalence of moles, freckles, and hours spent outdoors, use of sunscreen /lotion, and other variables. The effect of geographic UVB exposure on incidence was found to be statistically significant (p less than 0.01) after adjusting for each variable and certain combinations of these variables. We found that incidence rates for those skin melanomas arising in the face, head, neck, or upper extremities (i.e, the most exposed sites) were more sensitive to UVB increases than the incidence rates for those lesions occurring in the ordinarily less exposed sites of the trunk and lower extremities.

Risk reduction for nonmelanoma skin cancer with childhood sunscreen use.

Stern RS; Weinstein MC; Baker SG
Arch Dermatol (United States) May 1986, 122 (5) p537-45

Exposure to ultraviolet radiation is the principle cause of basal and squamous cell carcinomas of the skin, which are the most frequent tumors occurring in white residents of the United States. Using a mathematical model based on epidemiologic data, we quantified the potential benefits of using a sunscreen with a sun protective factor of 15 and estimate that regular use of such a sunscreen during the first 18 years of life would reduce the lifetime incidence of these tumors by 78%. Additional benefits of sunscreen use during childhood include reduced risk of sunburn, retarding the pace of skin aging, and possible reduction in melanoma risk. We recommend that pediatricians encourage sunscreen use and sun avoidance as a regular part of pediatric preventive health care.

Efficacy of topical sunscreen preparations on the human skin: combined indoor-outdoor study.

Azizi E; Kushelevsky AP; Schewach-Millet M
Isr J Med Sci (Israel) Jul 1984, 20 (7) p569-77

The sun protection factors (SPF) of 35 commercially available sunscreen preparations were tested on human skin under various conditions. Five distinct groups of products, ranging from minimal (SPF 2 to less than 4) to ultra sun protection (SPF 15 to greater than 19) were evaluated. Claimed SPF values were not always consistent with those obtained in our tests. Substantivity studies of a randomly selected group of sunscreen preparations during the hot, highly humid Israeli summer showed mean SPF reductions of 47 and 60%, respectively, following exercise-induced sweating or a 20-min swim. Judicious selection and use of an appropriate sunscreen preparation according to individual skin type or life-style, as well as the introduction of strict testing and labeling regulations, are essential measures for reducing the risk of sun-induced skin cancer and malignant melanoma in Israel.

Predictors of sunbathing and sunscreen use in college undergraduates

Hillhouse J.J.; Stair III A.W.; Adler C.M.
J.J. Hillhouse, Department of Psychology, East Tennessee State University, Box 70,649, Johnson City, TN 37614 United States
Journal of Behavioral Medicine (United States) 1996, 19/6 (543-561)

Sunbathing and sunscreen use, as well as related intentions, attitudes, beliefs, and knowledge, were assessed in 90 Southern Appalachian undergraduates. A large majority (75%) reported sunbathing; with more than half reporting sun lamp use. A slight majority (56.7%) reported some use of sunscreen . Subjects reporting an intention to tan spent more time sunbathing, both outside and under a sun lamp. Individuals reporting a sun protection intention had lighter tans and spent less time sunbathing. Sunbathing was predicted by perceptions of sunbathing as relaxing, while sun lamp use was predicted by more positive views of suntans. Sunscreen use was predicted by more positive sun protection attitudes and less negative sunscreen attitudes.

Protecting skin and preventing melanoma

Woodruff J.
Manufacturing Chemist (United Kingdom) 1996, 67/10 (79-81)

Skin cancer is increasing in frequency, and using sun protection products has never been more important. John Woodruff looks at efficacy improving suncare formulation developments.

Photoprotection: An active shield against exposure to sunlight health information for the public

Richard M.A.; Grob J.J.
Service de Dermatologie, Hopital Sainte Marguerite, 270 Bd de Sainte Marguerite,F-13277 Marseille Cedex 9 France
Aktuelle Dermatologie (Germany) 1996, 22/Suppl. 2 (93-96)

Photoprotection is an important prophylaxis against sun burn, photodermatoses, light-induced, premature aging of the skin, and especially against the increasing numbers of skin neoplasms. Aside from the individual constitution and other 'environmental' factors, the role of solar radiation in the etiology of skin tumors is undisputed. According to epidemiological studies, frequent and excessive exposure to sunlight, such as for example, sunburn with the formation of blisters influences the risk of melanoma whereas the cumulative solar radiation received during life appears to be responsible for the formation of carcinoma. According to estimates, about 25% of the total exposure to solar radiation occurs during childhood and adolescence. It is thus important to provide prophylactic information adapted to the respective target group (children, adolescents, adults). The major objective of such information should be to emphasize the risks of excessive and cumulated exposure to sunlight, to adjust exposure to the individual tolerance for sunlight, and to encourage changes in behavior and clothing instead of the use of an insufficient suntan cream. This information should be distributed by general practitioners and the news media in nation-wide campaigns.

Relevance of in vitro melanocytic cell studies to the understanding of melanoma

Linge C.
RAFT Institute of Plastic Surgery, Mount Vernon Hospital,Northwood, Middlesex HA6 2RN United Kingdom
Cancer Surveys (United States) 1995, 26/- (71-88)

The constitutional pigmentation characteristics of black skin provide a strong sunscreen , filtering out the vast majority of UV radiation that reaches the melanocytes. In addition, at a cellular level, the high melanin content and enhanced free radical modulating systems seen in the melanocytes of black skin provide further protection from UV radiation induced damage and presumably mutagenesis. By contrast, the low melanin content of both non-tanned white skin and their melanocytes provides little if any sunscreen protection. Instead, the variation in susceptibility to melanoma among white skinned people may depend on other factors, which include the ratio of photoprotective eumelanin to potentially phototoxic phaeomelanin, the status of the anti-oxidant systems, the level of photosensitizer molecules and the efficacy of DNA repair and associated mechanisms.

Prevention and control of melanoma: The public health approach

Marks R.
Department of Medicine (Dermatology), University of Melbourne, St. Vincent's Hospital,Fitzroy, Vic. Australia
Ca-A Cancer Journal for Clinicians (United States) 1996, 46/4 (199-216)

Incidence and mortality rates for melanoma have been rising steadily during the 20th century. Primary prevention and early detection are the two major public health approaches now being considered or undertaken to decrease mortality. This article reviews both approaches, outlining the data and assumptions on which the approaches are based and giving examples of program development, delivery, and measurement of outcome.

News in photoprotection

Amblard P.
Hopital La Tronche, Service de Dermatologie,38043 Grenoble Cedex France
Nouvelles Dermatologiques (France) 1996, 15/5 (349-353)

External photoprotection is still a topical subject, and the controversy surrounding sunscreens is not yet resolved. The essential question remains: do sunscreens prevent or on the contrary put the user at risk of developing skin cancer? A recent epidemiological Swedish study concludes that sunscreens do not protect from malignant melanoma . On the other hand, it has been said that the persons who spend the longest time in the sun are the same who frequently use sunscreens. This is contradicted by a Danish study which asserts that sunscreen use does not prolong sun exposure. On the contrary, one study in animals and another in man tend to prove that the use of large spectrum sunscreens prevents the appearance of contact photoimmunosuppression which seems to be an important factor in photocarcinogenesis as well as in photoaging. This shows the importance of UVA in the genesis of sun induced skin lesions. A recent Lavker study shows the importance of UVA1 (340-400 nm). A Harth study confirms the bad utilisation of sunscreens whereas Bohm puts the light on the possible ill effects of titan dioxide. On the other hand, a number of recent substances applied on the skin have been shown to have a sunscreen effect: DHA (Moyal), N-acetyl-cysteine (Van Den Broeke), green tea polyphenols (Katiyar), selenium and thiol compound association (Emonet). Three studies concern tocopherol. The Bisset research team showed that tocopherols sorbate was more active that alpha tocopherol. The de Vries research team showed that tocopherol's acetate was a pro drug which transforms itself very slowly in active tocopherol and that is why Gers-Barlag suggested to add to it fural glucitol whose photoprotective action is very fast (1/2 hour) but ephemeral (12 hours). Internal photoprotection is becoming a topical subject because it is not anymore only indicated in photodermatosis. Black confirmed the fact that a diet poor in fat lowers the incidence of solar keratosis and of carcinomas and Rhodes showed the protective effect of fish oil at very high doses. On the other hand, the Gilchrest research team did not find any protective action on sunburn cells neither from beta-carotene nor from tocopherol. This question whether oral intake of free radical scavengers to prevent photoaging and skin cancer is of interest. Although one can certainly propose a cocktail of these agents, further investigations are needed in order to confirm their utility.

Sun-induced skin damage

Raab W.
Walfischgasse 3,A-1010 Wien 1 Austria
Aktuelle Dermatologie (Germany) 1996, 22/Suppl. 1 (2-6)

Ultraviolet-induced skin lesions may be provoked via different mechanisms. Most frequently, an overload of the natural sun defense is encountered, resulting in sunburn - seen immediately - or in chronic sun damage emerging only after decades. With the increasing life expectancy, the symptoms of such a chronic sun damage are more and more often noticed by the dermatologist (skin dryness, premature skin ageing, pigmented spots, actinic keratoses, non-melanoma skin cancer). Other sun-induced skin lesions include specific dermatoses caused by ultraviolet rays ('sun-Kobner'), the consequences of immunosuppression (Herpes simplex 'solaris', LE, melanoma) and photodynamic reactions due to, for example, various drugs. True photodermatoses are only rarely seen, possibly due to the fact that their diagnosis is rather complicated and mild cases are misdiagnosed. - Sun protection in general and even more in the ever - increasing cases of pathological sun reactions is one of the most important tasks of the dermatologist. Problems of pigmentation, physical and chemical sun protection, strength of the sun protection 'factor' (effective only up to 60% of the erythema threshold dose!) must be discussed with the patient exhibiting sun-induced skin lesions or just asking for advice.

Chronic sunlight exposure-induced skin damage and skin cancer: Cutaneous manifestations, prevention, and treatment

Buchner S.A.
Dermatologische Universitatsklinik, Kantonsspital, Petersgraben 4,CH-4031 Basel Switzerland
Aktuelle Dermatologie (Germany) 1996, 22/Suppl. 1 (7-12)

Clinical, epidemiologic, and experimental evidence strongly supports the relationship between chronic sunlight exposure, UV-induced damage of the skin and nonmelanocytic skin cancers. Although UVB is the major causative action spectrum for sunlight-induced skin damage and nonmelanoma skin cancers, UVA is also implicated being shown to induce DNA damage. Cumulative sun exposure is thought to reduce the cell capacity to repair DNA damaged by UV radiation. Absent or deficient DNA repair may lead to different point mutations which are responsible for the majority of actinic changes, malignant cell clone formation, and appear to be most relevant in the development of UV-induced nonmelanoma skin tumors. The clinical spectrum of actinic damage due to the cumulative sunlight exposure includes wrinkling, furrowing, actinic elastosis, irregular pigmentation, and teleangiectasia. On the sunlight-damaged skin frequently occur precancerous skin lesions, basal cell carcinomas, squamous cell carcinomas, and lentigo maligna-melanoma . Early detection of precursors to skin cancer as well as primary prevention programs educating all age groups of the population about the risks of excessive sun exposure, and the regular use of sunscreens are needed in order to reduce the incidence of skin cancer.

Sunscreens: The ounce of prevention

Wentzell J.M.
Billings Clinic, 2825 8th Ave. N.,Billings, MT 59107-5100 United States
American Family Physician (United States) 1996, 53/5 (1713-1719)

Sun exposure is linked to visible signs of skin aging, skin cancer, photodermatoses, exacerbation of systemic disease and photoallergic, as well as phototoxic, drug eruptions. Sunscreens very considerably in their ability to protect patients from exposure to ultraviolet light and its effects. Inappropriate choice and use of sunscreen products can lead to worse problems than using no sunscreen at all. Controversies about sunscreen include adequate level of sun protection factor, appropriate age of users, and whether use of sunscreen products can prevent skin cancer. Instructing patients in how to select end use sunscreen can help prevent or mitigate a variety of cutaneous end systemic diseases.

Prevention and early detection strategies for melanoma and skin cancer: Current status

Koh H.K.; Geller A.C.; Miller D.R.; Grossbart T.A.; Lew R.A.
Boston University School of Medicine, 80 E Concord St,Boston, MA 02118 United States
Archives of Dermatology (United States) 1996, 132/4 (436-442)

Skin cancer represents an increasingly urgent worldwide public health problem. Estimates project almost a million (or more) new cases each year in the United States; this number is roughly equal to that of all other cancers combined. The incidence of cutaneous melanoma , which is mounting faster than that of any other cancer in white persons, nearly doubled from 1973 to 1990; in addition, the rise in melanoma mortality rates in white persons ranks second only to lung cancer. While the overall 5-year melanoma survival rates in the United States rose from 49% (in the early 1950s) to 82% (in the early 1990s), death rates more than doubled during the same time; these rates were driven up by the rising incidence. This year in the United States, melanoma will strike 34 000 persons and kill 7200-part of an estimated 90 000 cases diagnosed worldwide. Despite exciting advances in innovative treatment approaches (eg, immunotherapy and gene therapy), metastatic melanoma remains largely incurable. Decades of research have not only crystallized an understanding of the epidemiology, risk factors, and natural history of skin cancer but also have begun to stimulate international efforts to promote its prevention and control. In theory, the public health burden of melanoma and skin cancer could be lowered through some combination of effective primary and secondary prevention measures. Reduction of excessive sun exposure (primary prevention) could theoretically reduce the incidence, since experts hypothesize that 90% of the cases of nonmelanoma skin cancer (NMSC) and two thirds of the cases of melanoma may be attributed to excessive sunlight exposure. Primary prevention strategies can include personal behavior changes for individuals (eg, minimizing UV exposure and using sunscreen), as well as policy and environmental interventions for populations (eg, provision of shady areas and preservation of the ozone layer). Early detection (secondary prevention) should increase melanoma cure rates, since long-term survival figures of 92% for localized melanoma decline sharply to lower than 5% for metastatic disease. Furthermore, these external, visible cancers have identifiable risk factors, should be readily recognizable by the public and health professionals alike, and are easily treated in the early stages. We summarize the current state of melanoma and skin cancer control around the world.

Preventive strategies and research for ultraviolet-associated cancer

Koh H.K.
Cancer Prevention and Control Center, Boston University School of Medicine, 80 E. Concord Street C-324,Boston, MA 02118 United States
Environmental Health Perspectives (United States) 1995, 103/Suppl. 8 (255-257)

Ultraviolet (UV)-associated cancer is the most common cancer in the United States. Approximately 90% of nonmelanoma skin cancer and 65% of melanoma are attributable to UV exposure and theoretically could be eliminated by primary prevention measures. Safe sun strategy includes use of sunscreens, use of protective clothing, minimization of exposure from 10 A.M. to 3 P.M., and avoidance of tanning parlors. Although more definitive data in human populations on the effectiveness of sunscreens to prevent melanoma and skin cancer are needed, sunscreens are thought to reduce risk. Safe sun prevention must start in childhood and adolescence when people receive most of their UV exposure. Secondary prevention through professional and public education and early detection may further reduce melanoma mortality.

Overview of ultraviolet radiation and cancer: What is the link? How are we doing?

Weinstock M.A.
Dermatoepidemiology Unit, VA Medical Center 111D, 830 Chalkstone Avenue,Providence, RI 02908-4799 United States
Environmental Health Perspectives (United States) 1995, 103/Suppl. 8 (251-254)

Sun exposure has now been established as the most important avoidable cause of nonmelanoma skin cancer (NMSC) and melanoma . With specific reference to melanoma , there are several key issues that remain to be resolved. These include definition of the action spectrum, the importance of systemic effects of sun exposure, whether a tan is protective, the risk of tanning booth exposures, and the efficacy of sunscreens. Also the role, if any, of sun exposure in noncutaneous malignancies remains to be established. Melanoma incidence and mortality have increased dramatically over the past several decades, but these increases have now slowed, and for mortality among those 15 to 45 years of age, decreasing rates are now observed. Improving the coverage of the Surveillance, Epidemiology, and End Results (SEER) registries by requiring pathology laboratories in non-SEER areas to report cancers among SEER area residents will allow correct interpretation of these trends in the future at minimal cost. The available data on trends in NMSC incidence and mortality are suboptimal but suggest a pattern of declining mortality despite increasing incidence. Trends in NMSC morbidity have not been defined. Establishing NMSC registries in a few diverse sentinel areas would allow more reliable inference and monitoring. Techniques are being developed for reducing sun exposures and increasing early detection of skin cancers in the general population, but improved monitoring of incidence, mortality, and morbidity is required to monitor the effects of current and future ozone depletion and to evaluate prevention and early detection measures.

Genotoxicity, mutagenicity, and carcinogenicity of UVA and UVB

Runger T.M.
Hautklinik und Poliklinik, Georg-August Universitat, Abteilung Dermatologie-Venerologie, von-Siebold Strasse 3,37075 Gottingen Germany
H+G Zeitschrift fur Hautkrankheiten (Germany) 1995, 70/12 (877-881)

Mutations following UV-induced DNA damage represent the genetic cause of UV-induced malignant tumors of the skin. Different wavelengths of ultraviolet radiation possess different biological effects. UVA, as well as UVB, is capable to induce malignant epithelial tumors. However, UVA might be more important in the induction of malignant melanoma . UVA and UVB generate different kinds of DNA damage. UVB is able to exite the DNA molecule directly, whereby it generates pyrimidine dimers. Longerwave UV candamage the DNA molecule only indirectly. In that case another molecule, a so-called photosensitizer is exited and then transfers its energy or electrons onto the DNA. Many of these reactions are mediated by reactive oxygen species, mainly singlet oxygen. Predominantly purine base modifications entail. Directly and indirectly UV-induced DNA damage is processed differently by cellular DNA repair systems, generating different mutations. Oxidative, photosensitizer-mediated DNA damage by UVA offers a molecular explanation for the observations of genotoxic, mutagenic, and carcinogenic effects of UVA. In order to prevent malignant tumors of the skin, especially malignant melanoma , a protection against UVA should be included.

Environmental skin injuries in children

Duarte A.M.
Miami University School of Medicine, PO Box 016250,Miami, FL 33101 United States
Current Opinion in Pediatrics (United States) 1995, 7/4 (423-430)

Recently interest in the potential impact of the environment on our general health has heightened. Particular focus has been directed toward environmental skin injuries because the integument, the only organ of the body that is constantly exposed to the surrounding environment, directly demonstrates the damaging effects of the environment and thereby allows for direct visual recognition by both physicians and laypersons. The characteristic cutaneous features, physiologic responses, therapeutic approaches to promote healing, and preventive measures that may be taken to avoid future environmental injury are discussed. The scope of environmental injuries to the skin is extremely vast; therefore, the focus of this review is limited to cutaneous injuries that may result as a consequence of ultraviolet irradiation, marine life, and electrical forces.

Cancer of the skin in the next century

Marks R.; Kopf A.W.
Department of Medicine, University of Melbourne, St. Vincent's Hospital,Fitzroy, Vic. 3065 Australia
International Journal of Dermatology (Canada) 1995 , 34/7 (445-447)

One can confidently predict that the 21st century will be a span of intense activity in unraveling the precise molecular and biochemical events that lead to the various forms of cutaneous cancers. These discoveries will lead to new approaches in our therapeutic armamentarium that currently do not exist. Eventually, the incidence rates and mortality rates from cancers of the skin will markedly decline-the finite goal of all the combined endeavors of the scientific and practicing medical community.

Predictors of sunscreen use in childhood

Zinman R.; Schwartz S.; Gordon K.; Fitzpatrick E.; Camfield C.
Izaak Walton Killam Children's Hosp., 5850 University Ave,Halifax, NS B3J 3G9 Canada
Archives of Pediatrics and Adolescent Medicine (United States) 1995, 149/7 (804-807)

Objective: To identify risk factors predictive of sunscreen use in children.

Design: Cross-sectional review of convenience sample.

Setting: Emergency department of a regional referral pediatric hospital. Subjects: Nine hundred twenty-five parents of children presenting to the emergency department in August 1993.

Main Outcome Measures: Parental risk factors assessed were use of sunscreen , tanning behaviors, previous blistering sunburn, knowledge of cancer risk related to sunburn and sun protection factor definition, education level, and other health-promoting behaviors. The parents were asked about perceived risk for their child's being sunburned in the next month or development of skin cancer in their lifetime, as well as an estimation of safe sun exposure time for their child. Child risk factors included a history of previous painful sunburn and parental assessment of their child's skin type based on susceptibility to sunburn.

Results: Eighty- four percent of parents reported that their children had used sunscreen at least once in the previous 2 months. The use of sunscreen in children younger than 1 year was 54%, from 1 to 12 years of age was 91%, and older than 12 years was 68%. Factors associated with increased likelihood of sunscreen use were age of 1 to 12 years, parental use of sunscreen , estimation of safe sun exposure of less than 30 minutes, description of child skin type as burns 'sometimes,' 'easily,' or 'always,' and correct definition of sun protection factor. Application of a multivariate model yielded a sensitivity of 96%, specificity of 36%, and positive predictive value of sunscreen use of 89%.

Conclusions: Sunscreen use in parents is predictive of use in their children and relates more to experience with sunburn than with concerns about future skin cancer risk.

Self screening for risk of melanoma: Validity of self mole counting by patients in a single general practice

Little P.; Keefe M.; White J.; Keeley D.
Dept. of Primary Care, Fac. Medicine, University of Southampton, Aldermoor Health Centre,Southampton SO16 5ST United Kingdom
British Medical Journal (United Kingdom) 1995, 310/6984 (912-916)

Objective - To validate self screening by patients of high mole counts, assess the within family association of sun protection behaviour and mole counts, and estimate prevalence of risk factors for melanoma .

Setting and subjects - Systematic sample of families from a single affluent general practice population in Wessex.

Design - Subjects completed a questionnaire about risk factors for melanoma and counted their moles. Subsequently a mole count was done by a general practitioner trained at dermatology clinics.

Main outcome measures - Validation of self counts by observer's count. Within family association of sun protection behaviour and mole counts; self reported risk factors.

Results - 199/237 subjects (84%) returned the questionnaire; 212/237 (89%) were examined. High counts by patients on the front of the trunk (> 7 moles of >= 2 mm) were reasonably sensitive (79%), predictive (75%), and specific (97%) of the observer's mole counts (kappa = 0.74), unlike arm or total body counts. Sun protection behaviour correlated between individuals and other family members (Spearman's coefficient r = 0.50, P < 0.01). in the past three months 15/114 adults (13.2%, 95% confidence interval 7.0% to 19.4%) reported any change in a mole and 6/114 (5.3%, 2.0% to 11.1%) 'major' changes; 6/109 adults (5.3%, 2.6% to 11.1%) had both high mole counts and freckling.

Conclusions - Asking patients to count trunk moles could be a feasible way of identifying patients at high risk of melanoma . Concentrating on reported major changes in moles should avoid considerable workload in general practice. The generalisability of these findings and the adverse effects, net benefit in earlier diagnosis and prevention, and workload implications of such self screening need further research.

Xeroderma pigmentosum

Lambert W.C.; Kuo H.-R.; Lambert M.W.
Medical Science Building, UMD-New Jersey Medical School, 185 South Orange Avenue,Newark, NJ 07103-2714 United States
Dermatologic Clinics (United States) 1995, 13/1 (169-209)

Xeroderma pigmentosum is a rare, recessively transmitted disease associated with increased sensitivity to ultraviolet radiation in wavelengths found in sunlight, development of cancers in sun-exposed areas of the body in much larger numbers and much earlier in life than in normal individuals, and in some patients, neurologic deficiencies unrelated to sun exposure. Extensive cellular, biochemical, and molecular genetic studies in numerous laboratories have revealed that cells derived from patients with this disease have defective repair of ultraviolet-light-induced damage in cellular DNA, and that extensive genetic heterogeneity and numerous distinct genes are involved in the genetics of this disease and the etiopathogenesis of its changes. A number of these genes and gene products are now being, or have been, cloned, and their gene products characterized.

Children and photoprotection

Jeanmougin M.
Unite de Photodermatologie, Hopital Saint Louis,75010 Paris France
Nouvelles Dermatologiques (France) 1994, 13/6 (415-422)

The photoprotection of children is an extremely acute public health concern. The prevention of cutaneous cancers necessarily requires a reduction of sun exposures and the promotion of photoprotection since infancy. Facts are that children are much more exposed to sun than adults, that the majority of cutaneous carcinomas are photo-induced, and that intense and intermittent sun exposures increase the risk of a melanoma . For these reasons, it is absolutely necessary to protect children, especially children with a light phototype who are likely to be exposed to intense sunlight and/or who display multiple melanocytary nevi. Appropriate covering clothes, a sensible use of sun products, and family education are the basis of an efficient photoprotection. External photoprotectors should ensure a lasting protection against UVB, of course, but also against UVA and possibly against infrared rays. Because of the possible occurrence of allergies or contact photoallergies caused by sunscreens in children, photoprotectors exclusively made up of ultra thin mineral screens should be prescribed. These sunscreens also have another advantage: they are biologically inert, photo-stable, and their action is strictly a surface one. Sunscreens are not made to increase the number of hours one can spend under the sun, but to protect those cutaneous areas which cannot be covered with regular clothes. Family education and preventive information should be given by the mass media on the one hand and by physicians, pharmacists and educators on the other hand.

Daily sun protection

Schmitt G.J.
Korperpflegemittelbereich, Procter and Gamble Europa, Sulzbacher Str. 40,D-65824 Schwalbach/Taunus Germany
Dermatosen in Beruf und Umwelt (Germany) 1994, 42/3 (107-110)

There is increasing scientific knowledge concerning the risks for skin associated with chronic cumulative UV-irradiation extending from photoaging to non-melanoma carcinoma. Therefore, it is an important task for dermatologists to increase the public awareness for the necessity of adequate light protection preventing the harmful effects of UV irradiation at appropriate times throughout the year. Understanding the importance to protect against about 90% of the biologically relevant UV-B/UV-A irradation has to be promoted, especially among people with light sensitive skin. Such light portection effects are typically provided by products with a protection factor of then (DIN) or above. A balanced UV-B and UV-A screening is required.

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