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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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