Pediatric Dermatoiogy Vol. 9 No. 4 351-352
Current Issues in Photosusceptibility and Protection Lawrence A. Schachner, M.D. Division of Pediatric Dermatology, University of Miami School of Medicine Epidemiologic studies in the United States, Australia, and Scotland suggested that children and adolescents are particularly vulnerable to long-term sequelae of ultraviolet radiation (U VR) skin damage from the sun. There is significant reason to suspect that age-related structural and/or immunologic differences heighten pediatric UVR vulnerability. Numerous intrinsic and extrinsic factors have been suggested for this increased photosusceptibility. Pediatric photoprotection by appropriate clothing, sunscreen, and avoidance of peak sun hours (10:00 A.M.-3:00 P.M.) will significantly help protect children and must be advocated by pediatric health care providers. Furthermore, the potential dam^es from artificial tanning, be it in tanning parlors or by use of home devices, must be made clear. A 15-year survey from the National Cancer Institute clearly shows that melanoma is number one in terms of increasing frequency among all cancers. Over the past 40 years, it has increased from 1 in 1500 to about 1 in 100, and will soon be 1 in 90. A recent study of primary care physicians revealed an 11 % increase in total outpatient visits and a 50% increase in visits pertaining to potential skin cancers. These statistics lead one to conclude that the estimated number of 600,000 new cases of nonmelanoma skin cancer per year in the United States is probably modest, as is the estimated frequency of 30,000 new melanomas per year. Melanoma does occur in young people. It is the number one cancer in women 25 to 29 and number two in women 30 to 34 years of age. Twenty-five percent of all melanomas occur in people under 40 years of age. Tanning parlors may contribute to this disturbing trend, since the leading consumers are adolescent females who are at risk for developing this form of skin cancer early in adulthood. As it is difficult to affect the behavior of adolescents, we must intensify our efforts with the pediatric age
group, who may need sun protection the most but cannot necessarily ask for it or practice it without adult assistance. FACTORS AFFECTING PHOTOSUSCEPTIBILITY
Several intrinsic factors affect the photosusceptibility of young people: skin type (I-^VI); tendency to bum or to tan; light eye and hair color; ethnicity; tendency to freckle; number of acquired nevi; and age at exposure. Inherited disorders, such as albinism and xeroderma pigmentosum, and acquired disorders, such as lupus erythematosus, further affect photosusceptibility. The decrease in ozone is an extrinsic factor affecting UVR vulnerability. It has been calculated that an increase in UVB of about 2% occurs on earth for every 1% reduction in the stratospheric ozone layer. Appropriate sun-protective clothing and use of sunscreens are additional extrinsic factors that can affect photosusceptibility. Furthermore, parents have to be aware that certain medications such as oral antibiotics, immunosuppressives, and nonsteroidal antiinflammatory drugs (NSAIDs) may increase vulnerability to sun exposure. Children should be properly dressed in sunprotective clothing, especially in southern and tropical climates. Cotton clothing is recommended since it has a tighter weave than synthetic fabrics and allows less UVR to pass through. Also, the clothing is of lighter weight so the children will be more likely to tolerate longer sleeves and pants. The Frogskin Company (Tucson, AZ) produces clothing that is sun-protective wet or dry. Whenever possible, children should also wear caps or wide-brimmed hats. To appear in vogue, they often wear their caps backward. We must encourage them to tum their hats around so the visors protect their faces. A well-
351
352 Pediatric Dermatology Vol. 9 No. 4 December 1992
placed cap will protect about 70% of the face. This change in behavior could reduce the risk and slow the occurrence rate of not only facial nonmelanoma and melanoma, but cataracts. Efforts should be made to minimize children's sun exposure between 10 A.M. and 3 P.M., when the sun is directly overhead and UVB is most intense. Finally, parents must be advised to use broadspectrum sunscreens containing chemicals that absorb UVB and UVA rays. Tanning salons are used by a million people a day in the United States. Only recently many states have created adequate legislation regarding tanning parlors, such as who administers the treatments, supervises the use of eyewear, and monitors clients with photosensitivity due to certain medications. In Florida a bill is now being proposed that stipulates an individual must be at least 14 years old to receive tanning treatments. It also requires parental signatures, a list of medications be checked, and licensed operators. Warning signs must be posted, of significant size, regarding the tanning devices. This is the type of legislation dermatologists should promote to help educate the public. EDUCATION An impiortant step that has been taken in education is the Joel Mole program. Joel Mole is an American Academy of Dennatology educational figure created for school programs to teach the ABCs of sun
protection. Children are rewarded with stickers when they correctly respond to questions about protecting their skin from UVR. Joel Mole Etlso encourages the children to speak out to family and friends about the ABCs of sun protection. When confronting adolescents, the emphasis is on photo-aging. Close-up photography of young adults with crow's feet and fine wrinkling draws gasps from adolescents, strongly focused on their appearance. Suddenly, a tan is not all that "cool." When dealing with an adolescent, I like to use a grape and raisin to demonstrate the before and after of UVR damage to skin. Sun protection messages have also been introduced by industry at United States shopping malls. They are effective in that they provide an opportunity to deliver skin care information to whole families. On the beaches, there are surfside dispensers of sunscreen at a minimal cost for those who forgot to bring one along. An excellent future goal, suggested at a National Institutes of Health conference, is to identify an animal model for pediatric photobiology research. Another goal would be to identify role models for our youth from sports and entertainment industries to serve as spokespersons with respect to safe sun practices for children and adolescents. The risks associated with sun exposure are high and getting higher. With appropriate use of sunscreens, proper clothing, and behavior modifications, the frequency of skin cancer could be reduced by over 50%.
Current Issues in Photosusceptibility and Protection Lawrence A. Schachner, M.D. Division of Pediatric Dermatology, University of Miami School of Medicine Epidemiologic studies in the United States, Australia, and Scotland suggested that children and adolescents are particularly vulnerable to long-term sequelae of ultraviolet radiation (U VR) skin damage from the sun. There is significant reason to suspect that age-related structural and/or immunologic differences heighten pediatric UVR vulnerability. Numerous intrinsic and extrinsic factors have been suggested for this increased photosusceptibility. Pediatric photoprotection by appropriate clothing, sunscreen, and avoidance of peak sun hours (10:00 A.M.-3:00 P.M.) will significantly help protect children and must be advocated by pediatric health care providers. Furthermore, the potential dam^es from artificial tanning, be it in tanning parlors or by use of home devices, must be made clear. A 15-year survey from the National Cancer Institute clearly shows that melanoma is number one in terms of increasing frequency among all cancers. Over the past 40 years, it has increased from 1 in 1500 to about 1 in 100, and will soon be 1 in 90. A recent study of primary care physicians revealed an 11 % increase in total outpatient visits and a 50% increase in visits pertaining to potential skin cancers. These statistics lead one to conclude that the estimated number of 600,000 new cases of nonmelanoma skin cancer per year in the United States is probably modest, as is the estimated frequency of 30,000 new melanomas per year. Melanoma does occur in young people. It is the number one cancer in women 25 to 29 and number two in women 30 to 34 years of age. Twenty-five percent of all melanomas occur in people under 40 years of age. Tanning parlors may contribute to this disturbing trend, since the leading consumers are adolescent females who are at risk for developing this form of skin cancer early in adulthood. As it is difficult to affect the behavior of adolescents, we must intensify our efforts with the pediatric age
group, who may need sun protection the most but cannot necessarily ask for it or practice it without adult assistance. FACTORS AFFECTING PHOTOSUSCEPTIBILITY
Several intrinsic factors affect the photosusceptibility of young people: skin type (I-^VI); tendency to bum or to tan; light eye and hair color; ethnicity; tendency to freckle; number of acquired nevi; and age at exposure. Inherited disorders, such as albinism and xeroderma pigmentosum, and acquired disorders, such as lupus erythematosus, further affect photosusceptibility. The decrease in ozone is an extrinsic factor affecting UVR vulnerability. It has been calculated that an increase in UVB of about 2% occurs on earth for every 1% reduction in the stratospheric ozone layer. Appropriate sun-protective clothing and use of sunscreens are additional extrinsic factors that can affect photosusceptibility. Furthermore, parents have to be aware that certain medications such as oral antibiotics, immunosuppressives, and nonsteroidal antiinflammatory drugs (NSAIDs) may increase vulnerability to sun exposure. Children should be properly dressed in sunprotective clothing, especially in southern and tropical climates. Cotton clothing is recommended since it has a tighter weave than synthetic fabrics and allows less UVR to pass through. Also, the clothing is of lighter weight so the children will be more likely to tolerate longer sleeves and pants. The Frogskin Company (Tucson, AZ) produces clothing that is sun-protective wet or dry. Whenever possible, children should also wear caps or wide-brimmed hats. To appear in vogue, they often wear their caps backward. We must encourage them to tum their hats around so the visors protect their faces. A well-
351
352 Pediatric Dermatology Vol. 9 No. 4 December 1992
placed cap will protect about 70% of the face. This change in behavior could reduce the risk and slow the occurrence rate of not only facial nonmelanoma and melanoma, but cataracts. Efforts should be made to minimize children's sun exposure between 10 A.M. and 3 P.M., when the sun is directly overhead and UVB is most intense. Finally, parents must be advised to use broadspectrum sunscreens containing chemicals that absorb UVB and UVA rays. Tanning salons are used by a million people a day in the United States. Only recently many states have created adequate legislation regarding tanning parlors, such as who administers the treatments, supervises the use of eyewear, and monitors clients with photosensitivity due to certain medications. In Florida a bill is now being proposed that stipulates an individual must be at least 14 years old to receive tanning treatments. It also requires parental signatures, a list of medications be checked, and licensed operators. Warning signs must be posted, of significant size, regarding the tanning devices. This is the type of legislation dermatologists should promote to help educate the public. EDUCATION An impiortant step that has been taken in education is the Joel Mole program. Joel Mole is an American Academy of Dennatology educational figure created for school programs to teach the ABCs of sun
protection. Children are rewarded with stickers when they correctly respond to questions about protecting their skin from UVR. Joel Mole Etlso encourages the children to speak out to family and friends about the ABCs of sun protection. When confronting adolescents, the emphasis is on photo-aging. Close-up photography of young adults with crow's feet and fine wrinkling draws gasps from adolescents, strongly focused on their appearance. Suddenly, a tan is not all that "cool." When dealing with an adolescent, I like to use a grape and raisin to demonstrate the before and after of UVR damage to skin. Sun protection messages have also been introduced by industry at United States shopping malls. They are effective in that they provide an opportunity to deliver skin care information to whole families. On the beaches, there are surfside dispensers of sunscreen at a minimal cost for those who forgot to bring one along. An excellent future goal, suggested at a National Institutes of Health conference, is to identify an animal model for pediatric photobiology research. Another goal would be to identify role models for our youth from sports and entertainment industries to serve as spokespersons with respect to safe sun practices for children and adolescents. The risks associated with sun exposure are high and getting higher. With appropriate use of sunscreens, proper clothing, and behavior modifications, the frequency of skin cancer could be reduced by over 50%.
