Hoffman S.; Yohn J.; Robinson W.; Norris D.
Colorado University Sch. of Medicine,Denver, CO United States
Hospital Practice (United States) 1994, 29/6 (37-40+43-44+47-48+50)

The disease is perhaps the clearest instance of a cancer for which early treatment is crucial. Increasing knowledge of risk factors (including brief, intense sun exposure and sunburn damage early in life) aids the identification of persons at highest risk-one reason for physicians not to be pessimistic about the value of urging patients to limit their sun exposure.

Becker B.; Jospe N.; Goldsmith L.A.
University of Rochester, Box 697, 601 Elmwood Avenue,Rochester, NY 14642 United States
Pediatric Dermatology (United States) 1994, 11/2 (120-124)

One morphologic feature of Turner syndrome is increased numbers of melanocytic nevi; however, little attention has been given to their characterization. The development of a melanoma in one of our patients with Turner syndrome prompted this study. We prospectively examined 10 patients with the disease, confirmed by karyotype. All patients underwent full body skin examination noting the number, size, distribution, and degree of clinical atypia of melanocytic nevi. Representative and unusual lesions were photographed. An average of 115 nevi were seen, with the majority measuring 1 to 5 mm. Most were located on the back and extremities. Clinical atypia was uncommon. Our patients had larger numbers of benign-appearing nevi than the general population. Large numbers of melanocytic nevi is a risk factor for melanoma , suggesting that these patients have an increase in one risk factor. Longitudinal studies are indicated to clarify this issue; nevertheless, we recommend periodic skin examinations and the regular use of sunscreens for individuals with Turner syndrome.

Setlow R.B.; Woodhead A.D.
Biology Department, Brookhaven National Laboratory,Upton, NY 11973 United States
Mutation Research - Fundamental and Molecular Mechanisms of Mutagenesis (Netherlands) 1994, 307/1 (365-374)

The incidence of malignant cutaneous melanoma has been increasing for more than 50 years, and is now rising more rapidly than that of any other cancer. This increase is not explicable by changes in the physical environment, particularly by any observed increase in UVB radiation (290-320 nm). The distribution of melanomas on the body differs from the site distribution of nonmelanoma skin cancer (relatively many more melanomas occur on areas of the body not chronically exposed to sunlight, such as the back of the trunk in males, and the legs in females). This localization of melanoma , together with its epidemiology, suggest that a change in lifestyle has contributed to the fast-rising incidence in many countries. There is no convenient mammalian animal model for malignant melanoma . However, certain inter- and intra-specific hybrids of fish of the genus Xiphophorus are very sensitive to light-induced melanomas; we have used them to determine the wavelengths effective in melanoma induction. The action spectrum has a relatively very large component in the UVA region (320-400 nm) compared to human erythema. Hence, if the human and fish spectra were similar, the use of sunscreens that minimize erythema would have little effect in preventing the induction of melanoma , and if people using sunscreens expose themselves to sunlight for longer periods, they will be increasing dramatically their exposure to these melanoma -inducing wavelengths. Such considerations are sufficient to explain the rising incidence of malignant melanoma and its distribution on the body.

Halpern A.C.; Schuchter L.M.; Elder D.E.; Guerry IV D.; Elenitsas R.; Trock B.; Matozzo I.
Department of Dermatology, 3600 Spruce St,Philadelphia, PA 19104 United States
Journal of Clinical Oncology (United States) 1994, 12/5 (1028-1035)

Purpose: As potential precursors of melanoma and markers of increased melanoma risk, dysplastic nevi are suitable targets of strategies for melanoma chemoprevention. We report the results of a pilot study of topical retinoic acid in patients with dysplastic nevi.

Patients and Methods: Five male patients with dysplastic nevi applied tretinoin to half of the back for 6 months. Baseline photographs of dysplastic nevi were compared with posttreatment photographs and assessed for morphologic change. At study completion, each subject had four nevi excised from the treated side and four from the untreated side of the back. Biopsies were histologically evaluated for the presence of dysplasia.

Results: All patients developed signs of irritation as a result of treatment. One patient was not compliant with treatment due to skin irritation. The four compliant patients showed significant decreases in the clinical atypia of treated lesions, with concomitant fading and even disappearance of many treated nevi. Histologically, only four of 16 treated nevi met histologic criteria for dysplasia, in comparison to 13 of 16 untreated nevi.

Conclusion: These results suggest that there is concomitant clinical and histologic improvement in a significant percentage of dysplastic nevi treated with topical tretinoin. However, the utility of topical tretinoin for chemoprevention of melanoma is limited by difficulty of application and associated inflammation. While new strategies in chemoprevention of melanoma are explored, sun protection and assiduous avoidance of sunburn must remain the mainstay of melanoma prevention.

Urbach F.
Temple Medical Practices,Fort Washington, PA 19034 United States
Aktuelle Dermatologie (Germany) 1993, 19/12 (368-371)

Direct evidence for induction of non-melanoma skin cancer by UV irradiation is derived from animal experiments in mice and rats. A multitude of epidemiological data confirm this relationship also for human skin. Tumours are confined to skin sites with high cumulative sun exposure. Patients well-protected by constitutively dark skin pigmentation have a very low incidence of skin cancer. If natural defensive mechanisms are disturbed as in albinism or xeroderma pigmentosum, the risk of skin cancer is extremely high. In some countries a direct relationship between latitude and skin cancer with rising incidence in areas with high sun exposure has been described. Immunosuppression enhances tumourigenesis. A reduction of the stratospheric ozone layer by 1% may result in a 3% increase of squamous cell carcinoma incidence. Efforts to reduce air pollution in the troposphere increase UV irradiance at the earth's surface. Patients at risk should be encouraged to protect their skin by suitable clothing, use of sunscreens, and change of life styles, especially sun exposure habits during leisure time.

Grob J.J.; Guglielmina C.; Gouvernet J.; Zarour H.; Noe C.; Bonerandi J.J.
Service de Dermatologie, Hopital Ste-Marguerite, 270 Boulevard Ste-Marguerite,F-13274 Marseille Cedex 9 France
Dermatology (Switzerland) 1993, 186/2 (94-98)

Excessive sun exposure in the first 15 years of life has been shown to be a deter rninant risk factor for melanoma . This study was conducted on a randomly selected sample of 200 adolescents (13-14 years old) and 150 children (3 years old) in Marseille (South of France). Children and adolescents were examined and interviewed (mothers answered for young children). Our results show that a large number of highly sensitive children were not identified as such by their parents and most adolescents do not realize or at least admit being highly sun sensitive. Adequate sun protection measures were used in only 63% of 3-year-olds and 38% of adolescents. With reference to their constitutional skin sensitivity and taking into account their possible use of effective sun protection measures, 33% of the children and 62% of the adolescents were highly overexposed. Only good sun protection habits of the mother were predictive of acceptable sun exposure in children. In the adolescents the predictive variables were sun protection habits of the father and sunbathing only to obtain a tan. The main reason why adolescents sunbathed was embellishment. Conversely, most mothers said that they exposed their young children to the sun for health. Many adolescents and mothers were reasonably well informed but considered the risk of sun exposure to be exaggerated by the media. These results may be important to determine the targets of future melanoma prevention campaigns.

Webb G.
Div of Workplace Health and Safety, PO Box 6665,Cairns, QLD 4870 Australia
Journal of Occupational Health and Safety - Australia and New Zealand (Australia) 1992, 8/6 (479-485)

Ultraviolet radiation in sunlight presents a potential risk to health for outdoor workers. The paper examines the issues of health effects of solar radiation, including skin cancer, identification of high-risk groups for skin cancer, legal implications for employers in the context of occupational health and safety legislation, and measures for prevention or minimisation of solar radiation exposure of outdoor workers. The issue of worker compliance with protective measures is explored, using the Health Belief Model as a framework.

Calhoun K.H.; Wagner R.F.
Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX 77550 United States
Texas Medicine (United States) 1991, 87/12 (64-69)

Skin cancer incidence is increasing rapidly. We outline the indications for and advantages of diagnostic techniques and treatments, including curettage and electrodesiccation, surgical excision, Mohs' micrographic surgery, cryosurgery, radiation therapy, interferon injection, and photodynamic therapy. We describe our interdisciplinary treatment protocol for skin cancer treatment and emphasize avoidance of the sun and early treatment of photodamaged skin. This treatment includes oral retinoids, topical tretinoin (Retin-A), 5 fluorouracil, and chemical peels performed with trichloroacetic acid or phenol.

Bolognia J.L.; Berwick M.; Fine J.A.; Simpson P.; Jasmin M.
Department of Dermatology, Yale University, School of Medicine, 333 Cedar St,New Haven, CT 06510 United States
American Journal of Diseases of Children (United States) 1991, 145/10 (1125-1129)

We investigated the effect of education on the sun exposure of newborns. Mothers of healthy newborns (n = 275) were enrolled in the spring of 1989 and interviewed by telephone in the fall of 1989. The mothers were divided into a control group, a low-level intervention group, and a high-level intervention group. Both the low-level and high-level interventions succeeded in reducing the amount of time the newborns were allowed to spend in direct sunlight. Both types of intervention also resulted in reduced sun exposure time for the mothers. Although the number of mothers who used sunscreen was approximately the same in all three groups, when sunscreen use was controlled for, the intervention groups spent significantly less unprotected time in the sun than the control group. The mothers and newborns in both intervention groups simply spent less time outdoors.

Beitner H.; Norell S.E.; Ringborg U.; Wennersten G.; Mattson B.
Department of Dermatology, Karolinska Hospital,S-104 01 Stockholm Sweden
British Journal of Dermatology (United Kingdom) 1990, 122/1 (43-51)

A case-control study of cutaneous malignant melanoma (CMM) was based on 523 incident cases and 505 age- and sex-matched controls selected from the general population. The purpose was to investigate the relative risk of developing CMM associated with different sun habits and indicators of pigmentation, such as skin type, eye colour and hair colour. Compared to people with black hair, blonde subjects had a relative risk of 74.4 (95% confidence interval, 45.8-120.8). Associations with skin type and eye colour were considerably weaker. Relative risks of about 1.5-2.5 were found for certain sun habits. The results suggest that in a population of Caucasian origin with a predominantly fair complexion, pigmentary status characterized by hair colour is a far more important aetiological factor than sun habits.

Pathak M.A.
Dept. Dermatol., Harvard Med. Sch., Massachusetts Gen. Hosp., Boston, MA 02114 United States
Journal of the American Academy of Dermatology (United States) 1982, 7/3 (285-314)

This review deals with topical and systemic approaches for protection of human skin against the harmful effects of solar radiation. Two concerns about the deleterious effects of sun exposure involve: (1) acute effects (e.g., sunburn and drug-induced phototoxicity) and (2) potential long-term risks of repeated sun exposures leading to development of solar elastosis, keratoses, induction of both nonmelanoma and melanoma skin cancer, and alteration of immune responses and functions. Action spectra of normal and abnormal reactions of human skin to acute and chronic effects of solar radiation are presented with a view to helping the physician prescribe the appropriate sunscreens. Factors that influence acute effects of sunburn are reviewed. Various artificial methods effective in minimizing or preventing harmful effects of solar radiation, both in normal individuals and in patients with photosensitivity-related problems, are discussed. Emphasis is placed on the commercially available chemical sunscreens and their properties. Sun protection factor (SPF) values of several brand-name formulations determined with a solar simulator under indoor conditions (laboratory) and with solar radiation under natural, field conditions are prevented. Factors responsible for variations of SPF values observed under indoor and outdoor conditions are reviewed. Systemic photoprotective agents and their limitations are outlined. The photobiology of melanin pigmentation (the tanning reaction) is briefly discussed, with emphasis on the dangers of using quick-tanning lotions for stimulation of the tanning reaction.

Chen W; Barthelman M; Martinez J; Alberts D; Gensler HL
Department of Radiation Oncology, College of Medicine, University of Arizona, Tucson 85724, USA.
Nutr Cancer (United States) 1997, 29 (3) p205-11

Mutations or alterations in the p53 gene have been observed in 50-100% of ultraviolet light (UV)-induced squamous cell carcinoma in humans and animals. Most of the mutations occurred at dipyrimidine sequences, suggesting that pyrimidine dimers in the p53 gene play a role in the pathogenesis of cutaneous squamous cell carcinoma. We previously showed that topical alpha-tocopherol prevents UV-induced skin carcinogenesis in the mouse. In the present study we asked whether topical alpha-tocopherol reduces the level of UV-induced cyclobutane pyrimidine dimers in the murine epidermal p53 gene. Mice received six dorsal applications of 25 mg each of alpha-tocopherol, on alternate days, before exposure to 500 J/m2 of UV-B irradiation. Mice were killed at selected times after irradiation. The level of dimers in the epidermal p53 gene was measured using the T4 endonuclease V assay with quantitative Southern hybridization. Topical alpha-tocopherol caused a 55% reduction in the formation of cyclobutane pyrimidine dimers in the epidermal p53 gene. The rate of reduction of pyrimidine dimers between 1 and 10 hours after irradiation was similar in UV-irradiated mice, regardless of alpha-tocopherol treatment. Therefore, the lower level of cyclobutane pyrimidine dimers in UV-irradiated mice treated with alpha-tocopherol than in control UV-irradiated mice resulted from the prevention of formation of the dimers, and not from enhanced repair of these lesions. Our results indicate that alpha-tocopherol acts as an effective sunscreen in vivo, preventing the formation of premutagenic DNA lesions in a gene known to be important in skin carcinogenesis.

Bestak R; Halliday GM
Department of Medicine (Dermatology), University of Sydney, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
Photochem Photobiol (United States) Jul 1996, 64 (1) p188-93

Previously we reported that the broad-spectrum sunscreen microfine titanium dioxide (MTD) could completely protect C3H/HeJ mice from UV radiation-induced immunosuppression to a contact sensitizer. In contrast, 2-ethylhexyl p-methoxycinnamate (2-EHMC), a UVB-absorbing sunscreen , only partially protected the skin immune system. In this study we investigated further this differential protection of the skin immune system by comparing the ability of 2-EHMC and MTD to protect these mice from the promotion phase of tumorigenesis. The mice were initiated using a single subcarcinogenic dose of 7,12-dimethylbenz(alpha)anthracene (DMBA) followed by promotion with chronic low-dose solar-simulated UV radiation for 32 weeks. We used doses of UV insufficient to cause edema in order to simulate daily human exposure to solar UV radiation. Mice were observed for the appearance of squamous cell carcinomas for 48 weeks. The DMBA-initiation alone and DMBA-initiated, sunscreen -treated groups did not develop tumors. Ultra-violet alone induced the appearance of tumors in 46% of mice at week 48 and therefore some tumors were initiated by UV. Initiation with DMBA prior to UV irradiation enhanced tumorigenesis such that 87% of mice at week 48 had tumors. Both 2-EHMC and MTD completely protected these mice from UV-induced promotion as well as from complete carcinogenesis despite the different UV-absorption spectra of the sunscreens and their differential abilities to protect from UV-induced immuno-suppression. Furthermore, we have shown that, if UV exposure is not increased to compensate for tolerance to edema, protection from tumorigenesis is afforded by sunscreens.

Robert C; Muel B; Benoit A; Dubertret L; Sarasin A; Stary A
Laboratory of Molecular Genetics, Institut de Recherches sur le Cancer, Villejuif, France.
J Invest Dermatol (United States) Apr 1996, 106 (4) p721-8

Although it is known that sunlight is carcinogenic,few molecular data are available concerning the mutagenic effects of ultraviolet (UV) B (290-320 nm) and UVA (320-400 nm) radiation in human cells. To analyze the biologic effects of UVA and UVB, we irradiated the 293 human cell line, derived from adenovirus-transformed human embryonic kidney cells, in which we had stably introduced a shuttle vector harboring the lacZ' bacterial gene as the mutagenesis target. Identical cell survival occurred after UVA doses 700-fold higher than UVB. This comparable to the UVA/UVB ratio that reaches the basal cell layer of the skin after sunlight exposure with UVB sunscreen . The frequency of UVA- and UVB- induced mutations increased with the UV dose as cell survival decreased. At cell survival levels greater than 10%, UVA and UVB induced similar frequencies of mutations in the episomal lacZ gene, whereas for cell survival lower than 10%, UVA induced twice as many mutations as UVB. Sequence analysis of 81 independent lacZ mutants (36 UVA- and 45 UVB-induced) revealed specific characteristics for some UV-induced-mutations, particularly for UVB. Mutations at A/T base pairs were induced more frequently by UVA than by UVB. The UVA-induced mutation spectrum that we have observed in human cells may help help to elucidate the mechanism of skin carcinogenesis.

Harth Y; Ulman Y; Peled I; Friedman-Birnbaum R
Department of Dermatology, Rambam Medical Center, Haifa, Israel.
Photodermatol Photoimmunol Photomed (Denmark) Aug 1995, 11 (4) p140-2

Sixty-three patients (mean age 54 +/- 9 years) who were treated for a basal cell carcinoma (BCC) and 54 control subjects (mean age 51 +/- 11 years) filled out detailed questionnaires on their sun exposure and sun protection habits. Patients were given the questionnaires at least 1 year after their skin tumors had been excised. Differences between patients and controls in mean age, gender, Fitzpatrick's skin type and eye and hair color were statistically nonsignificant. The level of education was high in both patients and controls (mean of 13.4 +/- 3.1 school years). Differences in education were statistically nonsignificant. We found that both patients and controls were knowledgeable about the role of sunscreens in preventing skin tumors (79% and 83% respectively) and in preventing sun-induced aging (90% and 85% respectively). Significantly more patients used sunscreens regularly (64%) compared with controls (36%). Nevertheless, our data show no statistically significant differences between the sun exposure habits of the patients previously treated for BCC and controls. Moreover, we found that, although 82% of the patients declared that they tried to avoid sun, only 49% regularly wore hats or shirts with long sleeves in the summer (19%). Sixty-two percent of the patients used two or fewer bottles of sunscreens per year, which is inadequate for effective year-round sun protection. In addition, we found that many patients, as well as the controls, applied sunscreens only once a day (57% and 46% respectively), did not reapply after swimming (58%, 74% respectively), and did not use sunscreens in the winter (49%, 61%). Our data show that, although patients after BCC removal have a significantly higher sunscreen use compared with controls, the amount and methods of application are less than adequate. Moreover, other simpler methods to prevent photodamage, such as simple sun avoidance or the use of protective clothing, are often neglected.

Grodstein F; Speizer FE; Hunter DJ
Channing Laboratory, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
J Natl Cancer Inst (United States) Jul 19 1995, 87 (14) p1061-6

BACKGROUND: Few epidemiologic studies are available that quantify the magnitude of the risk of squamous cell carcinoma (SCC) of the skin associated with sun exposure and related factors such as skin type. In addition, several studies have found an association between cigarette smoking and SCC.

PURPOSE: We prospectively examined the risk of developing SCC in relation to phenotype and the effects of sun exposure, as well as to cigarette smoking and other factors, during 8 years of follow-up in a cohort of 107,900 predominantly white women aged 30-55 years at base line in 1976.

METHODS: Questionnaires regarding medical history and health-related variables were sent to Nurses' Health Study participants every 2 years, beginning in 1976. Information on constitutional factors (natural hair color, childhood and adolescent tendency to sunburn and tan, and lifetime number of severe sunburns), lifestyle factors (regular time spent outdoors in the summer and sunscreen use), the state lived in at birth and at ages 15 and 30 years, and cigarette smoking habits were ascertained by questionnaire. A total of 197 women with first-incident, histologically confirmed, invasive SCCs that were diagnosed from 1982 to 1990 were included in this analysis. Multivariate analysis using proportional hazards models was used to calculate the relative risks (RRs) and corresponding 95% confidence intervals (CIs), with adjustment for confounders.

RESULTS: The risk of SCC was increased in women living in California (RR = 1.8; 95% CI = 1.3-2.6) and Florida (RR = 2.1; 95% CI = 1.1-3.9) at base line, compared with those living in the northeastern states. This risk was higher for women living in those states at birth and at 15 years of age (RR = 2.5; 95% CI = 1.4-4.4 for California and RR = 3.0; 95% CI = 0.7-1.2 for Florida). Red (RR = 2.0; 95% CI = 1.1-3.7) and light brown (RR = 1.7; 95% CI = 1.2-2.4) hair colors were associated with an increased risk of SCC, compared with dark brown hair. After adjusting for the number of sunburns, women who tended to burn after 2 or more hours of sun exposure as children had a slightly higher risk of SCC than those who never burned (RR = 1.5; 95% CI = 0.9-2.5 for burn and RR = 1.1; 95% CI = 0.6-2.0 for painful burn), although the actual number of severe burns appeared to be a more important factor (RR = 2.4; 95% CI = 1.5-4.0 for six or more burns). Finally, current cigarette smokers showed a 50% increase in the risk of SCC compared with never smokers (RR = 1.5; 95% CI = 1.1-2.1).

CONCLUSION: Exposure to the sun leading to sunburn, particularly at early ages, should be avoided to decrease the risk of incident SCC.

Naylor MF; Boyd A; Smith DW; Cameron GS; Hubbard D; Neldner KH
Department of Dermatology, University of Oklahoma Health Sciences Center, Oklahoma City.
Arch Dermatol (United States) Feb 1995, 131 (2) p170-5

BACKGROUND AND DESIGN: A controlled trial was undertaken from December 1987 to December 1990 to test the hypothesis that a strong sunscreen can reduce the number of cancerous and precancerous skin lesions. Candidates were selected from a high-risk population attending either a university- or Veterans Affairs-based dermatology practice in Lubbock, Tex, for a prospective, double-blind, controlled trial of daily application of sunscreen vs placebo over a 2-year period. Participants were asked to volunteer if they had demonstrated premalignant changes (actinic keratoses) or nonmelanoma skin cancer (basal cell carcinoma or squamous cell carcinoma), had continuing sun exposure, and were not using sunscreen on a regular basis. Fifty-three volunteers were initially enrolled in the study, and 37 came for the final 24-month visit.

RESULTS: The rate of appearance of new precancerous skin lesions was less for the treatment group than for control subjects. People with darker skin had fewer actinic keratoses, women had fewer lesions than men, and people with fewer lesions at enrollment had fewer lesions during the study. The numbers of new nonmelanoma skin cancers appearing during the study period were too small for statistical analysis.

CONCLUSIONS: The regular use of sunscreens can significantly reduce cutaneous neoplasia, as indicated by its suppression of precancerous lesions. A longer and/or larger study would be necessary to demonstrate an effect on malignant lesions.

Green A; Battistutta D; Hart V; Leslie D; Marks G; Williams G; Gaffney P; Parsons P; Hirst L; Frost C; et al
Queensland Institute of Medical Research, Brisbane, Australia.
Control Clin Trials (United States) Dec 1994, 15 (6) p512-22

The Nambour Skin Cancer and Actinic Eye Disease Prevention Trial (the Nambour Trial) is a field trial conducted in an unselected adult population in Australia. Using a randomized 2 x 2 factorial design, the principal aim is to evaluate whether regular use of high-protection sunscreen and/or dietary supplementation with beta-carotene (30 mg daily) can alter the incidence rates of basal cell carcinomas and squamous cell carcinomas of the skin over a minimum follow-up time of 4.5 years. Changes in the incidence of solar keratoses and actinic eye disease and the rate of photoaging after intervention will also be investigated. In 1992, 1626 participants between the ages of 25 and 75 years were enrolled, all of whom had been randomly selected from residents of the southeastern Queensland township of Nambour for an earlier skin cancer prevalence survey. This paper describes the background to the trial and its design, with respect to evaluation of effects on actinic skin disease, and documents the baseline characteristics of participants recruited into the Nambour Trial.

Guercio-Hauer C; Macfarlane DF; Deleo VA
State University of New York Health Science Center at Brooklyn.
Am Fam Physician (United States) Aug 1994, 50 (2) p327-32, 334

Overexposure to ultraviolet and visible radiation causes sunburn. Aspirin and other nonsteroidal anti-inflammatory drugs, cool baths and topical steroids offer only mild relief. Long-term sun exposure causes chronic inflammatory skin changes. Photodamage, rather than the normal aging process, may account for 90 percent of age-associated cosmetic skin problems. Physicians should stress to their patients that all ultraviolet exposure (including sun beds and tanning salons) causes skin damage. Regular sunscreen use during childhood and adolescence may result in an 80 percent reduction in the lifetime incidence of ultraviolet-induced skin damage, including nonmelanoma skin cancers. (17 Refs.)

Thompson SC; Jolley D; Marks R
Anti-Cancer Council of Victoria, Carlton, Australia.
N Engl J Med (United States) Oct 14 1993, 329 (16) p1147-51

BACKGROUND. The incidence of and mortality from skin cancer are increasing in many countries. In view of the added concern about ozone depletion, many organizations are promoting the regular use of sunscreens to prevent skin cancer, despite the absence of evidence that these products have this effect. Solar (actinic) keratosis is a precursor of squamous - cell carcinoma of the skin.

METHODS. We conducted a randomized, controlled trial of the effect on solar keratoses of daily use of a broad-spectrum sunscreen cream with a sun-protection factor of 17 in 588 people 40 years of age or older in Australia during one summer (September 1991 to March 1992). The subjects applied either a sunscreen cream or the base cream minus the active ingredients of the sunscreen to the head, neck, forearms, and hands.

RESULTS. The mean number of solar keratoses increased by 1.0 per subject in the base-cream group and decreased by 0.6 in the sunscreen group (difference, 1.53; 95 percent confidence interval, 0.81 to 2.25). The sunscreen group had fewer new lesions (rate ratio, 0.62; 95 percent confidence interval, 0.54 to 0.71) and more remissions (odds ratio, 1.53; 95 percent confidence interval, 1.29 to 1.80) than the base-cream group. There was a dose-response relation: the amount of sunscreen cream used was related to both the development of new lesions and the remission of existing ones.

CONCLUSIONS. Regular use of sunscreens prevents the development of solar keratoses and, by implication, possibly reduces the risk of skin cancer in the long-term.

van Praag MC; Tseng LN; Mommaas AM; Boom BW; Vermeer BJ
Department of Dermatology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands.
Drug Saf (New Zealand) May 1993, 8 (5) p340-9

Psoralen photochemotherapy (PUVA) is a combination of orally administered psoralen and long wave ultraviolet-A radiation (UVA), and is one of the most effective forms of therapy for psoriasis. The unwanted effects of PUVA therapy can be divided into short and long term adverse effects. The short term adverse effects include erythema, pruritus, nausea and headache. While short term adverse effects are limited and reversible after discontinuation of treatment, potential long term adverse effects such as chronic actinic skin damage, dyskeratotic and precancerous skin conditions, nonmelanoma skin cancer, immunological alterations and cataract formation are of greater concern. Long term risks associated with PUVA therapy can be minimised by several measures. Careful patient selection is mandatory; for example, patients with chronic actinic damage and a history of skin cancer may bear a higher risk for the development of new cancers, and previous arsenic intake and ionising radiation also increase the risk of nonmelanoma skin cancers. Certain drug combinations make it possible to lower the UVA dose, which is important because of the dose-dependent increase in the incidence of squamous cell carcinomas in patients treated with PUVA. It has been demonstrated that 200 treatments or a total UVA dose of 1200 J/cm2 seems to be the threshold for development of nonmelanoma skin cancer. Shielding male genitalia during PUVA treatment is essential because of the increased risk of genital squamous cell carcinomas. Yearly dermatological examination to detect skin cancer at an early stage is highly advisable. Sunscreen use, protective clothing and avoidance of sun exposure reduce the uncontrolled dose of solar UV radiation. Other psoralens with a less carcinogenic potential can be used. UVA-opaque sunglasses during the entire period of increased photosensitivity after psoralen ingestion help avoid cataract formation. Assignment to PUVA ought to be based on the risk-benefit ratio for the individual patient and should be limited to those who can be monitored and controlled by informed, competent and conscientious physicians. (56 Refs.)

Reeve VE; Greenoak GE; Gallagher CH; Canfield PJ; Wilkinson FJ
Aust J Exp Biol Med Sci (Australia) Dec 1985, 63 (Pt 6) p655-65

The effect of two immunosuppressive agents, azathioprine and cyclophosphamide, with and without UVB sunscreen protection on UV-induced skin carcinogenesis was studied in the albino hairless mouse. In a daily treatment regime spanning 9 weeks, groups of mice were immunosuppressed with either drug, and were exposed to minimally erythemal doses of a light source simulating the UV portion of the solar spectrum. The accumulated UV exposure alone induced skin tumours in 77% of mice. Azathioprine, but not cyclophosphamide, significantly enhanced the incidence of UV tumorigenesis. Photoprotection by topical application of one of two commonly used UVB sunscreens, 2-ethyl-hexyl-p-methoxycinnamate (2-EHMC) or octyl-N-dimethyl-p -aminobenzoate (o-PABA), reduced the UV tumour incidence to zero in immunologically normal mice and to 8-15% in immunosuppressed mice. Unexpressed latent tumour initiations were revealed in all sunscreen -protected groups by the subsequent application of a tumour promoter, croton oil. In immunologically normal mice 2-EHMC had allowed initiations in 39% of UV-irradiated mice, and o-PABA in 16.5%. However, in UV-irradiated mice immunosuppressed with azathioprine there had been initiations in 78% of mice protected with 2-EHMC and 65% of mice protected with o-PABA. Photoprotected mice immunosuppressed with cyclophosphamide did not show the same increase in UV-initiations (22% with 2-EHMC, 23% with o-PABA). These results provide evidence that azathioprine increases the susceptibility of the skin to UV carcinogenesis. However, UVB sunscreens afford effective protection from overt tumour expression in the absence of a tumour promoter.

Lundeen RC; Langlais RP; Terezhalmy GT
J Am Dent Assoc (United States) Oct 1985, 111 (4) p617-21

It has been stated that the key to prevention of oral cancer is to avoid the "five Ss: smoking, spirits, spices, sepsis, and syphilis." There is certainly enough evidence to add another "S"--sunlight. Although there is a paucity of information in the dental literature on the use of sunscreens, the following dermatologic recommendation is noteworthy: "Persons with Skin Types I and II should never sunbathe and should adopt a program of daily application of effective sunscreens (SPF 15) as a habit and from an early age--in much the same manner as daily brushing of the teeth is adopted to prevent dental caries." The dentist should advise patients at high risk for squamous cell carcinoma and those with recurrent herpes labialis to use a sunscreen for the lips of at least SPF 15. The best sunscreen formulation at the present time is a combination of either PABA or an ester of PABA along with a benzophenone. A frequent combination seen on product labels is Padimate O and oxybenzone. Sunscreens should be used year-round on the lips with two applications 1 hour before sun exposure, and hourly reapplication while in the sun. If the convenience of a "lipstick" product is not important to the patient, then a skin product of the liquid or gel type should be used. If the appearance is not important, a white opaque cream containing titanium dioxide, talc, or zinc oxide may be used as a physical barrier. Women may use an opaque lipstick, but should first apply a chemical sunscreen of at least SPF 15.(ABSTRACT TRUNCATED AT 250 WORDS)

Cartwright LE; Walter JF
J Am Acad Dermatol (United States) Jun 1983, 8 (6) p830-6

Sunscreens containing 5-methoxypsoralen (5-MOP) are currently being marketed to promote tanning by inducing psoralen-mediated ultraviolet (UV) A (320-400 nm) melanogenesis. The rationale is that this may prevent UVB (290-320 nm) radiation-induced skin damage. However, mouse studies have shown that 5-MOP has the same cutaneous photocarcinogenic potential as 8-methoxypsoralen. In addition, the 5-MOP--containing sunscreen Sun System III (SS III), when combined with UVA, induces epidermal ornithine decarboxylase activity, an enzyme associated with tumor promotion. Therefore, we investigated whether SS III had sufficient psoralen concentration to be tumorigenic in hairless mice exposed to chronic, intermittent UVA radiation. SS III was applied to hairless mice 5 days per week for 20 weeks. After each application the mice were exposed to 2.5 to 10 joules/cm2 UVA radiation. All test groups developed atypical squamous papillomas in direct proportion to the dosage of UVA radiation received. A shorter latency period for tumor development was seen with larger UVA doses. Test animals followed up to 1 year developed invasive squamous cell tumors. Control groups (SS III without UVA and UVA without SS III) remained free of tumors. Animals receiving SS III plus UVA developed persistent skin thickening and increased dermal cyst formation similar to that reported with chronic exposure to UVB, a known carcinogenic wavelength. Over-the-counter sunscreens containing 5-MOP do contain sufficient psoralen concentrations to cause cutaneous phototoxicity and photocarcinogenicity in mice, and their use in humans should be discouraged in the interest of preventing further UV-induced skin damage and skin cancer.

Wulf HC; Poulsen T; Brodthagen H; Hou-Jensen K
J Am Acad Dermatol (United States) Aug 1982, 7 (2) p194-202

Sunscreens with different sun protection factors (SPFs) have been tested for their capability of delaying or preventing actinic damage and skin cancer development in groups of hairless, pigmented mice exposed to artificial ultraviolet (UV) light of increasing intensity. The dose delivered was less than or equal to 1 minimal erythema dose (MED) in the group of untreated mice, so that the mice to which sunscreens were applied never obtained a sunburn after UV exposure. The quality of UV light was similar to bright midday sun at a latitude of 56 degrees (city of Copenhagen). Tumorigenesis was demonstrated to be delayed corresponding to the SPF claimed by the manufacturer, but almost all of the UV-irradiated mice developed skin tumors. Histologic examination revealed actinic degeneration and tumors of squamous cell type with marked variation in differentiation. Metastases to lymph nodes and lungs were found in only 10%. Toxic reactions, such as eczematous-like skin reactions, dark coloring, and amyloidosis, were observed predominantly in the group treated with the sunscreen of highest SPF value. Long-term investigations seem to be necessary to unveil these problems--in particular, the specific SPF value, in sunscreens, that should be recommended to the public for prevention or delay of actinic damage and/or cancer development.

Soparkar C.N.S.; Patrinely J.R.
Dr. C.N.S. Soparkar, Plastic Eye Surgery Associates, PLLC, 6500 Fannin Street, Houston, TX 77030 United States
Current Opinion in Ophthalmology (United States) 1998, 9/5 (49-53)

Eyelid cancers, like most malignancies, are on the rise, creating an ever-enlarging population of patients with these diseases. Trends in eyelid cancer diagnosis, prognostic evaluation, prevention, and management are reviewed. Special emphasis is placed upon understanding perineural invasion by squamous cell carcinoma, the role of genetic mutations in eyelid cancer development and prognosis, and new techniques for total upper eyelid reconstruction.

English III J.C.; Canchola D.R.; Finley E.M.
Dr. J.C. English III, 1940 Avalon Ct., Colorado Springs, CO 80919 United States
American Family Physician (United States) 15 APR 1998 , 57/8 (1860-1864)

Basal cell carcinoma is the most common skin malignancy. While this lesion most often occurs in sun-exposed areas of the skin, it can also develop in sites that are not usually exposed to sunlight or artificial ultraviolet radiation, such as the breast, palm or groin. A periodic complete examination of the skin should be performed to ensure that atypical presentations of basal cell carcinoma are not overlooked or misdiagnosed. Treatment options include curettage and desiccation, cryosurgery, surgical excision, radiotherapy and Mohs micrographic surgery.

Burpen R.; Scaletta C.; Frenk E.; Panizzon R.G.; Applegate L.A.
L.A. Applegate, Department of Dermatology, Laboratory of Photobiology, University Hospital, CH-1011 Lausanne Switzerland
Lee.Laurent-Applegate@chuv.hospvd.ch
International Journal of Cancer (United States) 13 APR 1998, 76/2 (201-206)

DNA damage by UV radiation plays an essential role in skin cancer induction. We report that even sub-erythemal doses of solar simulating radiation, are capable of inducing substantial nuclear damage, namely pyrimidine dimers and p33 induction in human skin in situ. The quantity and distribution of p53 induced in human skin by UV radiation depended highly on the waveband and dose of UV used. Solar simulating radiation induced very high levels of p53 throughout all layers in epidermal keratinocytes 24 hr following an erythemal dose (230 +/- 15.9/1000 cells), and the induction followed a dose response. Following UVA I + II and UVA I radiations, p53 expression was approximately half of that seen with equivalent biological doses of solar simulating radiation (63.5 +/- 28.5 and 103 +/- 15.9, respectively). Expression of p53 was seen in basal cell keratinocytes at lower doses of UVA, but all layers of the epidermis were affected at higher doses. Pyrimidine dimer induction, however, was seen to be the same for equivalent biological doses of UVA I, UVA I + II and solar simulating radiations, which coincides with previous findings that pyrimidine dimers initiate the erythemal response and are implicated in skin carcinogenesis. When equivalent biological doses of pure UVA are used with no UVB contamination, significant nuclear alterations occur in human skin in situ, which can approach those seen with UVB radiation. Our results suggest that DNA damage assessed in vivo by immunohistochemistry could provide a very sensitive endpoint for determining the efficacy of protective measures, such as sunscreens or protective clothing, against both UVB- and UVA-induced damage in human skin.

Witheiler D.D.; Lawrence N.; Cox S.E.; Cruz C.; Cockerell C.J.; Freemen R.G.; Brody H.J.
Dr. D.D. Witheiler, 221 W. Colorado Blvd., Dallas, TX 75208 United States
Dermatologic Surgery (United States) 1997, 23/3 (191-196)

BACKGROUND. Few studies have examined the long-term efficacy of fluorouracil (FU) or chemical peels for the treatment of actinic keratoses (AK). Our earlier work examined the efficacy and safety of a medium-depth chemical peel compared with the standard regimen of topical FU in the treatment of widespread facial AK through 12 months.

OBJECTIVES. To determine long-term efficacy of both treatments by extending our observations through 32 months.

METHODS. Fifteen patients with severe facial actinic damage were treated on the left side with a single application of Jessner's solution and 35% trichloroacetic acid and on the right side with twice daily applications of 5% FU cream for 3 weeks. Parameters evaluated at 1, 6, 12, and 32 months included counts of visible AK, random skin biopsies from both treatment areas, development of intercurrent neoplasms, and surveys assessing sun exposure.

RESULTS. Eight patients were available for reevaluation at 32 months. Both treatment sides showed a reduction in mean number of AK at 12 months followed by an increase in mean AK number between 12 and 32 months. Improvements in biopsies of clinically actinically damaged skin were seen in keratinocytic atypia, hyperkeratosis, parakeratosis, and inflammation at all treatment times during the study with both treatments. Three squamous cell carcinomas developed in the patients after initial treatment; one developed on the side treated with the peel, and two developed on the side treated with fluorouracil. Surveys failed to demonstrate an association between sun exposure and clinical response.

CONCLUSION. Based on these findings, patients with widespread actinic keratoses treated with medium-depth chemical peel or with 5% FU should be reevaluated yearly or every 1.5 years for reappearance of AK and retreatment.

Kibarian M.A.; Hruza G.J.
One Barnes Hospital Plaza,St Louis, MO 63110 United States
Postgraduate Medicine (United States) 1995, 98/6 (39-40+45-46+48+55-56+58)

The incidence of nonmelanoma skin cancer is rapidly increasing. With early diagnosis and treatment, almost all basal cell and squamous cell carcinomas can be cured. Premalignant actinic keratoses are treated with cryosurgery; the COinf 2 laser is the treatment of choice for actinic cheilitis. Generally; nonmelanoma skin cancer can be effectively treated with excision, electrodesiccation and curettage, cryosurgery, or radiation therapy; 5-year cure rates are over 90%. Large, locally recurrent, and aggressive lesions, as well as lesions located in the central face, are best managed with Mohs' surgery; 5-year cure rates as high as 99% have been reported. Patient education about the dangers of sun exposure and tanning salons can potentially reduce the incidence of nonmelanoma skin cancer. The use of sunscreens starting early in life should be stressed.

Hacker S.M.; Browder J.F.; Ramos-Caro F.A.
Dermatology/Cutaneous Surgery Div., Department of Medicine, Florida University Coll. of Medicine, PO Box 100277,Gainesville, FL 32610-0277 United States
Postgraduate Medicine (United States) 1993, 93/8 (101-111)

Basal cell carcinoma is the most common type of malignant tumor in the United States. The five types of basal cell carcinoma (noduloulcerative, pigmented, morpheaform, and superficial basal cell carcinoma, and premalignant fibroepithelioma) vary in clinical presentation and behavior. Diagnosis is made by skin biopsy. The size, type, and site of a lesion and the age and sex of the patient affect the choice of treatment. Electrodesiccation and curettage, cryosurgery, surgical excision, Mohs' surgery, and radiation therapy are available. Knowledge of these therapies and of when they should and should not be used is important in proper management of basal cell carcinoma.

Shelley E.D.; Shelley W.B.
Department of Medicine, Medical College of Ohio, PO Box 10008,Toledo, OH 43699-0008 United States
Cutis (United States) 1992, 50/3 (217-220)

Most of what we learn comes from reading, not from listening. Thus, for us, the poster presentation is ideal. It allows us to escape from the confinement of the lecture hall and from the constraint of having to listen to the obvious, the repetitious, the uninteresting, and the irrelevant. Come with us and scan those posters that caught our roving clinical eye as we viewed a thousand poster 'lectures.'

Prawer S.E.
Assoc. Skin Care Specialists, 7205 University Ave NE,Fridley, MN 55432-3133 United States
Postgraduate Medicine (United States) 1991, 89/8 (51-54+59-61+64-66)

Severe photoaging of the skin, which may be caused by exposure to both natural and artificial ultraviolet light, ultimately results in actinic keratoses and cancer. Cancers are common on the head, neck, arms, and hands. Because of the potential for metastasis, squamous cell carcinomas generally require surgical excision and histologic examination. Although metastasis is rare with basal cell carcinoma, neglected lesions around the eyes, nose, or ears can invade bone, nerves, and cartilage and may cause death. Avoidance of sun, physical protection, and regular use of sunscreens are recommended.

Flindt-Hansen H.; Thune P.; Nielsen C.J.
Department of Dermatology, Ullevaal Hospital, N-0407 Oslo 4 Norway
Photodermatology (Denmark) 1989, 6/6 (263-267)

A solution of para-aminobenzoic acid (PABA) was exposed to ultraviolet (UV) radiation emitted from a Philips TL 40 W/12 sunlamp and the degree of photodegradation following an exposure of 27 J/cmsup 2 was estimated to be approximately 40%. The formation of the photoproducts was confirmed by mass spectroscopy and UV spectroscopy. The solution was painted on the backs of hairless light-pigmented mice prior to daily UV irradiation by the above sunlamp, and this procedure was continued for 30 weeks. The preirradiated solution of PABA significantly retarded the tumor induction time and reduced significantly the number of squamous cell carcinomas compared with non-protected controls. This tumor-retarding ability did not differ significantly from the effect achieved then using nonirradiated PABA.

Kozarev J
Med Pregl (Yugoslavia) Nov-Dec 1998, 51 (11-12) p555-8

OBJECTIVE: There is evidence that in spite of worldwide campaigns against excessive sun exposure, children as well as adults still spend long periods in the sun. The purpose of this study was to evaluate sun exposure in a group of doctors of different specialties and to compare their knowledge about sun protection methods with regular use of sun protection products.

METHODS: 51 doctors of different specialties, volunteers, mean age 40.78, filled out questionnaires with 21 multiple choice questions about their skin type, sun exposure habits, sun protection habits and questions about meaning of the Sun Protection Factor.

RESULTS: Thirty-three percent of our study participants spent more than two peak ultraviolet hours outdoors every day, and additional 33.33% are sun exposed for longer than 5 hours, regularly. Only 39% of them utilized sunscreens. Majority of sunscreen users utilized less than 100 ml of commercial sunscreen products which is an inadequate amount for full body protection per year. Majority of study participants did not believe that sunscreens could prevent skin cancer, but 57% of them believed that these compounds can slow the process of skin aging . Meaning of the term Sun Protection Factor is not familiar to 84.3% study participants. The two most common reasons for not using sunscreens are time consuming application and high cost.

CONCLUSION: Results of the presented study confirm our statement that there is bad understanding of a need for sun protection which is in correlation with deficient application of sun protective measures. It should be stressed out that our study participants lack well formed sun protection habits.

Gasparro FP; Mitchnick M; Nash JF
Department of Dermatology & Cutaneous Biology, Thomas Jefferson University, Philadelphia, PA 19107, USA
francis.gasparro@mail.tju.edu
Photochem Photobiol (United States) Sep 1998, 68 (3) p243-56

The use of sunscreen products has been advocated by many health care practitioners as a means to reduce skin damage produced by ultraviolet radiation (UVR) from sunlight. There is a need to better understand the efficacy and safety of sunscreen products given this ongoing campaign encouraging their use. The approach used to establish sunscreen efficacy, sun protection factor (SPF), is a useful assessment of primarily UVB (290-320 nm) filters. The SPF test, however, does not adequately assess the complete photoprotective profile of sunscreens specifically against long wavelength UVAI (340-400 nm). Moreover, to date, there is no singular, agreed upon method for evaluating UVA efficacy despite the immediate and seemingly urgent consumer need to develop sunscreen products that provide broad-spectrum UVB and UVA photoprotection. With regard to the safety of UVB and UVA filters, the current list of commonly used organic and inorganic sunscreens has favorable toxicological profiles based on acute, subchronic and chronic animal or human studies. Further, in most studies, sunscreens have been shown to prevent the damaging effects of UVR exposure. Thus, based on this review of currently available data, it is concluded that sunscreen ingredients or products do not pose a human health concern. Further, the regular use of appropriate broad-spectrum sunscreen products could have a significant and favorable impact on public health as part of an overall strategy to reduce UVR exposure. (147 Refs.)

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