Download Sun Protection - American Academy of Dermatology

Sun Protection
Basic Dermatology Curriculum
Content for this module was developed
by the Society for Pediatric Dermatology
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Goals and Objectives
Upon completion of this module, the learner
should be able to:
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Explain the short and long-term risks of sun exposure
Screen for risky sun-seeking behaviors in adolescents
Counsel patients on effective sun safety and protection
Identify patients with photosensitivity disorders that may
require referral to dermatology
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Case #1: Sunburn
• A 6 year old male presents to urgent care
with a sunburn on his face and trunk, one
day after spending an afternoon at the
beach
• Upon examination you discover small
bullae on his shoulders
• Which of the following is true regarding
this patient?
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Case #1: Sunburn
A. His lifetime risk of melanoma is now likely higher
than that of other children who have never
sunburned
B. Topical lidocaine is indicated to soothe the
discomfort
C. Use of SPF 30 sunscreen would have prevented
the burn by blocking 70% of the sun’s radiation
D. UVA radiation in sunlight is what caused the
sunburn
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Case #1: Answer
A. His lifetime risk of melanoma is now likely
higher than that of other children who have never
sunburned
– Meta-analyses suggest that any sunburn is
associated with increased melanoma risk. This risk
increases with the number of sunburns.
– Lidocaine can be irritating to burned skin
– SPF 30 sunscreen blocks 97% of the sun’s UVB
radiation
– UVB radiation plays a bigger role in sunburn than
UVA
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Ultraviolet radiation: brief review
• Sunlight emits a wide range of radiation energy
including visible light and ultraviolet (UV) light
• UVA and UVB light are most dangerous to skin
– UVB has a wavelength of 290-320 nm
• Absorbed in the epidermis
– UVA has a wavelength of 320-400 nm
• Reaches the dermis
– Visible light is 400-800 nm
• UV exposure increases by 4% for every 1,000
foot elevation above sea level
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Risks of sun exposure
There are many risks of sun exposure
• Short term risks include:
– Sunburn
– UV-associated dermatoses
• Long term risks include:
– Photoaging (wrinkles and discoloration)
– Photocarcinogenesis (skin cancer)
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Short term risk: Sunburn
• The skin becomes red and tender in the hours after sun
exposure
• Keratinocyte damage predominantly from UVB light
– Cell cycle arrest followed by repair of injured DNA
– Apoptosis (programmed cell death)
– “B” is for burning
• Langerhans cell depletion resulting in local
immunosuppression
• Epidermal thickening
• Inflammatory cytokine stimulation
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My patient has a sunburn.
Now what?
• DO:
– Soothe hot, burning skin by applying a cool compress or water
– Apply moisturizer frequently, especially right after bathing
• Choose a hypoallergenic, fragrance-free cream which is less
occlusive than an ointment
– Consider using systemic analgesic/anti-inflammatory medications
such as NSAIDS
– Consider mild topical corticosteroids which may bring some relief
• DON’T:
– Use potentially irritating treatments such as topical lidocaine or
benzocaine preparations
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Short term risk: UV-associated
dermatoses
• Photosensitivity disorders
– Affected persons will develop a rash after sun
exposure.
• Photosensitizing medications
– Certain medications make healthy individuals
more sensitive to the sun and more likely to
sunburn.
These will be discussed later in the presentation
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Long-term risk: Photoaging
• Skin changes secondary to long-term exposure to
sunlight
– Wrinkling, skin texture changes, freckles, discoloration
• UVA light is thought to be the biggest
offender, due to deeper penetration into the dermis
– UVA is able to penetrate window glass
– A is for “Aging”
• UVB light also contributes to photoaging
– Higher energy photons cause DNA damage
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Long-term risk:
Photocarcinogenesis
Sun exposure and sunburns increase the risk of
several types of skin cancer, including:
– Basal cell carcinoma
• The most common type of skin cancer, but is rarely seen in
children
– Squamous cell carcinoma
• Rare in children
– Melanoma
• The most deadly form of skin cancer
• 1-3% of cases occur in the pediatric population (<20yo)
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Long term risk: Photocarcinogenesis
2008 meta-analysis published in the Annals of Epidemiology:
– Sunburns increased the lifetime risk of melanoma, and age at time
of sunburn matters
• ANY sunburn before the age of 13 years = 1.9x more likely to
develop melanoma
• ANY sunburn between 13-19 years= 1.6x more likely to
develop melanoma
• ANY sunburn after 19 years of age = 1.4x more likely to
develop melanoma
– More sunburns meant higher risk of melanoma, suggesting a
dose-response relationship
Dennis, L.K, et al. Sunburns and risk of cutaneous melanoma, does age matter: a comprehensive meta-analysis.
Ann Epidemiol. (2008); 18 (8): 614-627
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Case #2: Tanning Beds
• A 17 year old Caucasian female presents for a health
maintenance visit with her mother.
• You ask about the use of tanning beds. Your patient
admits to occasional tanning.
• She explains that she has been tanning to improve her
health, since her vitamin D was recently discovered to
be low. She also wants to decrease her risk of sunburn
on her upcoming family vacation to Florida.
• Her mother asks your opinion about indoor tanning; what
is the next best step in the care of this patient?
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Case #2: Tanning Beds
A. Agree that she can continue tanning in the short-term to
prevent sunburn during her upcoming trip
B. Reassure the patient’s mother that the benefits of
increased Vitamin D synthesis outweigh the risks of
tanning bed use
C. Recommend that she only continue indoor tanning if
she wears sunscreen to minimize the risks.
D. Strongly recommend discontinuation of indoor tanning
because it is not an effective way to prevent sunburn or
to synthesize Vitamin D
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Case #2: Answer
D. Strongly recommend discontinuation of indoor
tanning as it is not an effective way to prevent
sunburn or to synthesize Vitamin D
– A suntan provides protection that is equivalent to an SPF of
4 or less. This is not sufficient to prevent sunburn.
– Tanning beds emit mostly UVA radiation. Vitamin D
synthesis occurs in the UVB range (peaks at ~300nm) so
tanning beds are not very effective for Vitamin D synthesis
• Increased dietary intake of Vitamin D is the safest way to improve
Vitamin D levels
– The use of sunscreen does not eliminate risks of tanning
beds
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Risky sun-seeking behavior:
Sunbathing/tanning
• Adolescents, especially females, may view
sunbathing or “tanning” as a positive
activity
• Suntanner’s goal is to get a “healthy glow”
– But tanning is actually the skin’s response to
photodamage
– Melanocytes transfer melanin to keratinocytes
in an effort to “shield” the DNA from harmful
radiation
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Risky sun-seeking behavior:
Indoor tanning
• Since 2009, tanning beds are classified as “carcinogenic to
humans” by the International Agency for Research of Cancer
(IARC)
– Considered a Group I carcinogen, similar to cigarettes
• At least 41 states and the District of Columbia have some tanning
regulations in place, including a ban on tanning in minors in some
states
• Nearly 20% of high school students have been to an indoor tanning
facility in the previous year
– Approximately 50% of these teens are tanning at least 10x
yearly
– Caucasian girls are the greatest users of indoor tanning
facilities
– Up to 35% of teens have tried a tanning bed at least once
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Risks of tanning beds
• Incidence of melanoma has doubled in the US over the last 20
years in young women
– This parallels the increased rate of indoor tanning
• For young men, the incidence of melanoma has reached a plateau
or begun to decline
– Young men are less likely to use tanning beds
• 2007 meta-analysis by WHO’s IARC Working Group:
– First exposure to indoor tanning beds before age 35 increases risk
of developing melanoma by 75% (RR 1.75, CI 1.35-2.26)
– Ever-use of indoor tanning equipment increases risk of developing
melanoma by 15% (RR 1.15, CI 1.00-1.31)
International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer. The
association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systematic review.
Int J Cancer. 2007;120:1116–1122.
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Case #3: Photoprotection
• You are seeing a 4 month old female for
her routine visit.
• The patient’s mother notes that the family
is going to Disneyworld for vacation.
• She asks what sunscreen you recommend
she use on the baby.
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Case #3: Photoprotection
A. Reassure that no sun protection is needed as long as
she is not outdoors for more than an hour at a time
B. Recommend a sunscreen labeled as a “baby product”
with SPF 70
C. Recommend protecting the infant with clothing and
shade and using a physical blocking sunscreen only on
exposed skin
D. Recommend the trip be delayed until the child is at least
6 months of age since sunscreen products are not
approved for use in infants younger than this
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Case #3: Answer
C. Recommend protecting the infant with clothing
and shade and using a physical blocking sunscreen
only on exposed skin
– The AAP recommends sunscreen use in young infants only if
adequate clothing and shade are not available
– Infants are at risk of systemic absorption of chemical sunscreens
with widespread use, so physical sunscreens are preferred
– Careful education of parents regarding these concerns and
emphasis on other forms of protection should allow families to
safely bring infants to sunny environments
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Sunscreen
• Sunscreens are topically applied agents designed
to protect the skin from the effects of UV light
• Appropriate sunscreen use has been shown to
reduce the incidence of sun-induced skin cancers
(basal cell carcinoma, squamous cell carcinoma,
melanoma)
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Sunscreen basics: What are the types of
sunscreen?
Sunscreen type
PHYSICAL BLOCKERS
CHEMICAL SUNSCREENS
Mechanism of action
Blocks and scatters UV and
visible light
Absorbs light and re-emits
energy as insignificant
quantities of heat
Active ingredients
zinc oxide
titanium dioxide
benzophenone
avobenzone
oxybenzone
PABA
others
Advantages
Less irritating to sensitive
skin, immediately effective
Not as messy, easier to
apply, less apparent white
sheen
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Sunscreen basics: What is SPF?
• SPF = sun protection factor
• It is calculated using the following equation:
The amount of time it takes to produce erythema on sun-protected skin
÷
The time it takes to produce the same erythema without sunscreen
• Theoretically, someone who normally burns after
10 minutes can stay outside for 2.5 hours before
burning (15 times longer) if wearing SPF 15
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How to choose and apply sunscreen
• SPF only measures protection against sunburn
from UVB; doesn’t measure effects from UVA
– “broad spectrum” sunscreens are best
• SPF 30 or greater is recommended
– SPF 30 blocks 97% of the sun’s rays, so higher SPF
products do not have much additional benefit
• All sunscreens need to be reapplied every few
hours
• Sunscreen must be applied in an adequate amount
to obtain the expected protection.
– The average adult should use 1 ounce (a shot glass
size) per full body application
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What to look for in sunscreen
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Sun protection and infants
• The sun puts young infants at risk for
overheating and sunburn
• The preferred method of sun protection for
young infants is sun avoidance (including
shade) and protective clothing
• Physical blocker-type sunscreens are a
better choice than chemical sunscreens
– Less irritating to the sensitive skin of infants
– Less likely to be absorbed
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Other ways to protect from the sun
• Avoid sun exposure during peak hours
– Sun’s rays are strongest between 10 am and 4 pm
– Seek shade when your shadow is shorter than you
are
• Use photoprotective clothing and hats
– Measured by the ultraviolet protective factor (UPF)
• Good: UPF 15-24
• Very good: UPF 25-39
• Excellent: UPF 40-50
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Case #4: Photosensitivity
• You are seeing a 14 year old female for a rash that developed
10 days ago, 2 days after arriving in Mexico for a spring break
vacation
• She states she had a similar rash last spring while on
vacation in Florida, and then again early last summer
• The rash consisted of itchy pink bumps on her face and
forearms and now it seems to be getting better
• She admits that she only remembered to wear sunscreen a
few times and used a zinc-oxide formula
• She is otherwise feeling well with a negative review of
systems and takes no medications
• What is the appropriate next step?
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Case #4: Photosensitivity
A. Advise her to avoid salt water because
she is prone to Seabather’s eruption
B. Counsel that she is likely allergic to the
sunscreen that she was using
C. Refer her to dermatology to evaluate for
xeroderma pigmentosum or porphyria
D. Tell her that this seems most consistent
with polymorphous light eruption
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Case #4: Answer
D. Tell her that this seems most consistent
with polymorphous light eruption
– Polymorphous light eruption (PMLE) will be discussed in
detail later
– Allergy to zinc oxide is rare and would be expected to
involve all areas of application
– Seabather’s eruption is a reaction to larva in seawater and
tends to involve skin covered by swimming garments
– Xeroderma pigmentosa and porphyria tend to present with
severe sunburns early in life
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Screening for photosensitivity
• Most people will develop a sunburn if
exposed to the sun for long enough
without adequate protection
• A person’s hair color, eye color and
tendency to burn defines his/her skin type
– Skin types are classified from type I (lightest)
to type VI (darkest)
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Increasing risk of photosensitivity
Identifying patients with photosensitivity:
Skin type
Skin Type
Response to sun exposure
Phenotype
I
Burn easily and severely
Tan little or not at all
Red or blond hair
Blue or brown eyes
II
Usually burn easily
Tan minimally or lightly
Red, blond or brown hair
Blue, hazel, or brown eyes
III
Burn moderately
Tan gradually and uniformly
Average Caucasian skin
IV
Burn minimally
Tan easily
Dark brown hair
Dark eyes
White or light brown skin
V
Rarely burn
Tan well and easily
Brown-skinned (Middle
Eastern and Hispanic)
VI
Almost never burn
Tan profusely
Black skin
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When should I suspect abnormal
photosensitivity?
• If your patient develops a sunburn
reaction, swelling, or intense itching after
limited exposure to sunlight
• If your patient develops a rash or scarring
predominantly in sun-exposed areas
If you suspect your patient has abnormal photosensitivity, you
should refer to dermatology
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Photodermatoses (UV-induced rashes)
• These are rashes that occur in otherwise
healthy people after even limited exposure
to sunlight
– They are idiopathic, but probably
immunologically based
Photodermatoses seen in childhood
Polymorphous Light Eruption*
*most common
Actinic Prurigo
Hydroa Vacciniforme
Solar Urticaria
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Polymorphous light eruption
•
•
•
•
•
•
•
Affects 10-15% of US population
Most commonly affects females in 2nd and 3rd decades of life
Polymorphic lesions that occur 1-2 days after sudden intense sun
exposure; often appears on vacation
Most common on sun-exposed areas of face, neck, upper limbs
Lesions range from papules to wheals to vesicles to plaques; may
appear eczematous and be severely itchy
Self-resolves in 1-2 weeks
May appear in the spring and improve
as skin “hardens” from routine UV
exposure
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Solar urticaria
• Type I, IgE-mediated hypersensitivity
• Occurs during, or within 30 minutes, of sunlight exposure
• Characterized by erythema and sensation of itching/
burning, followed almost immediately by urticaria on
exposed skin
• Treatment ranges from oral antihistamines to oral
corticosteroids to IVIG to avoidance of daytime sun
• Sun tolerance can sometimes be established with
carefully metered exposures to sunlight or use of PUVA
phototherapy
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Photodermatoses seen in childhood
PMLE
Solar urticaria
Actinic prurigo
Hydroa
vacciniforme
Appears within
hours to days of
exposure
Appears within
minutes of
exposure
May appear even in Appears within
UV-protected areas hours or days of
exposure
Lasts for days
Lasts for hours
May last for months Vesicles / bullae dry
up after 3-4 d
Idiopathic
Type I IGE-mediated Idiopathic, Latino
hypersensitivity
population
Result of chronic
EBV infection
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Photosensitizing medications
Certain medications make healthy persons more
sensitive to the sun and more likely to sunburn.
Antibiotics: doxycyline, sulfonamides, nalidixic acid, fluoroquinolones
Antifungals: griseofulvin, voriconazole
Non-steroidal anti-inflammatory preparations (NSAIDS)
Other: chlorpromazine, sulfonylurea hypoglycemic agents, anovulatory drugs,
lamotragine, phenothiazine antihistamines, furosemide, amiodarone, quinine,
isoniazid, thiazide diuretics
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Conditions characterized by
photosensitivity
There are several conditions that have
photosensitivity as a
prominent or presenting feature
Xeroderma pigmentosum
Porphyrias
Other genetic syndromes: Cockayne syndrome,
Trichothiodystrophy, Bloom syndrome, Rothmund-Thompson
syndrome, Kindler syndrome
Pellagra (niacin deficiency)
Severe sunburn early in life should prompt consideration of these entities
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Conditions characterized by
photosensitivity
There are also certain medical conditions that
are exacerbated or triggered by sun exposure
Lupus erythematosus
Dermatomyositis
Herpes simplex infection
Acne
other rare conditions
Perform a thorough history and physical and consider referral if
you suspect one of these diagnoses
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Take-Home Points
• RISKS of sun exposure include sunburns, wrinkles and
an aged appearance, precipitation of certain
dermatoses, and skin cancer
• ASK your adolescent patients if they use tanning beds;
many of them do!
• EXPLAIN the risk of childhood sunburns for future
melanoma
• TEACH your patients safe sun habits
• KNOW which patients are at highest risk for
photosensitivity
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Acknowledgements
 This module was developed by the Society for
Pediatric Dermatology Education Committee for the
American Academy of Dermatology Basic
Dermatology Curriculum
 Primary authors: Jessica Sempler MD, Sarah Stein
MD, Ingrid Polcari MD
 Peer reviewers: Erin Mathes, Sheilagh Maguiness
 Revisions and editing: Rebecca Chasnovitz
 Last revised January 2016
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References
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American Academy of Dermatology (2014). Sun Protection. Retrieved from
http://www.aad.org/dermatology-a-to-z/health-and-beauty/general-skin-care/sunprotection/sunscreen-labels/how-to-select-a-sunscreen
American Academy of Dermatology (2014). Treating Sunburn. Retrieved from
http://www.aad.org/dermatology-a-to-z/for-kids/about-skin/skin-cancer/treatingsunburn
Dennis, L.K., et al. Sunburns and risk of cutaneous melanoma, does age matter:
a comprehensive meta-analysis. Ann Epidemiol. (2008); 18(8): 614-627.
Gosis B., Sampson, B.P., Seidenbery, A.B., Balk, S.J., Gottlieb, M., and Geller,
A.C. Comprehensive Evaluation of Indoor Tanning Regulations: A 50-state
Analysis, 2012. Journal of Investigative Dermatology (2014); 134: 620-627.
Paller, A.S. and Mancini, A.J. Hurwitz Clinical Pediatric Dermatology: A textbook
of skin disorders of childhood and adolescence. 4th Edition. China: Elsevier
Sounders, 2011.
Woo, D.K. and Eide, M.J. Tanning beds, skin cancer, and vitamin D: an
examination of the scientific evidence and public health implications.
Dermatologic Therapy (2010); 23: 61-71.
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To take the quiz, click on the following link:
https://www.aad.org/quiz/sun-protectionlearners
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