FROM THE AMERICAN ACADEMY OF PEDIATRICS

Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children Technical Report—Ultraviolet Radiation: A Hazard to Children and Adolescents

Sophie J. Balk, MD, and the COUNCIL ON ENVIRONMENTAL HEALTH and SECTION ON DERMATOLOGY abstract KEY WORDS Sunlight sustains life on earth. Sunlight is essential for vitamin D syn- sun, ultraviolet radiation, children, skin cancer, skin-cancer prevention, melanoma, vitamin D, prevention, sun protection, thesis in the skin. The sun’s ultraviolet rays can be hazardous, however, sunscreen, tanning, artificial tanning because excessive exposure causes skin cancer and other adverse ABBREVIATIONS health effects. Skin cancer is a major public health problem; more than UVR—ultraviolet radiation 2 million new cases are diagnosed in the United States each year. NMSC—nonmelanoma skin cancer Ultraviolet radiation (UVR) causes the 3 major forms of skin cancer: PABA—para amino benzoic acid SPF—sun-protection factor basal cell carcinoma; squamous cell carcinoma; and cutaneous malig- BCC—basal cell carcinoma nant melanoma. Exposure to UVR from sunlight and artificial sources SCC—squamous cell carcinoma early in life elevates the risk of developing skin cancer. Approximately IARC—International Agency for Research on Cancer FDA—Food and Drug Administration 25% of sun exposure occurs before 18 years of age. The risk of skin UPF—ultraviolet protection factor cancer is increased when people overexpose themselves to sun and NHANES—National Health and Nutrition Examination Survey intentionally expose themselves to artificial sources of UVR. Public AAP—American Academy of Pediatrics 25(OH)D—25-hydroxyvitamin D awareness of the risk is not optimal, compliance with sun protection is This document is copyrighted and is property of the American inconsistent, and skin-cancer rates continue to rise in all age groups Academy of Pediatrics and its Board of Directors. All authors have including the younger population. People continue to sunburn, and filed conflict of interest statements with the American Academy of teenagers and adults are frequent visitors to tanning parlors. Sun Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of exposure and vitamin D status are intertwined. Adequate vitamin D is Pediatrics has neither solicited nor accepted any commercial needed for bone health in children and adults. In addition, there is involvement in the development of the content of this publication. accumulating information suggesting a beneficial influence of vitamin The guidance in this report does not indicate an exclusive course of D on various health conditions. Cutaneous vitamin D production re- treatment or serve as a standard of medical care. Variations, taking quires sunlight, and many factors complicate the efficiency of vitamin into account individual circumstances, may be appropriate. D production that results from sunlight exposure. Ensuring vitamin D adequacy while promoting sun-protection strategies, therefore, re- quires renewed attention to evaluating the adequacy of dietary and supplemental vitamin D. Daily intake of 400 IU of vitamin D will prevent vitamin D deficiency rickets in infants. The vitamin D supplementation amounts necessary to support optimal health in older children and adolescents are less clear. This report updates information on the relationship of sun exposure to skin cancer and other adverse health effects, the relationship of exposure to artificial sources of UVR and www.pediatrics.org/cgi/doi/10.1542/peds.2010-3502 skin cancer, sun-protection methods, vitamin D, community skin- cancer–prevention efforts, and the pediatrician’s role in preventing doi:10.1542/peds.2010-3502 skin cancer. In addition to pediatricians’ efforts, a sustained public All technical report from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, health effort is needed to change attitudes and behaviors regarding revised, or retired at or before that time. UVR exposure. Pediatrics 2011;127:e791–e817 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2011 by the American Academy of Pediatrics BACKGROUND Sunlight sustains life on earth. The sun provides warmth, is needed for photosynthesis, drives biorhythms, and promotes feelings of well-being, and sunlight is essential for vitamin D synthesis in skin.

PEDIATRICS Volume 127, Number 3, March 2011 e791 Downloaded from www.aappublications.org/news by guest on September 26, 2021 The sun emits electromagnetic ra- in winter, at midday than in morning or TABLE 1 Classification of Sun-Reactive Skin diation that ranges from short- late afternoon, in places closer to the Types5 wavelength, high-energy x-rays to long- equator, and at higher altitudes. Sand, Skin History of Sunburning or Tanning Type wavelength, lower-energy radio waves. snow, concrete, and water can reflect I Always burns easily, never tans Ultraviolet (“above-violet”) radiation up to 85% of sunlight, thus intensifying II Always burns easily, tans minimally (UVR) waves range from 200 to 400 nm. exposure.3 Water is not a good photo- III Burns moderately, tans gradually and UVR waves are longer than x-rays and protectant, because UVR can pene- uniformly (light brown) IV Burns minimally, always tans well shorter than visible light (400–700 trate to a depth of 60 cm, which results (moderate brown) nm) and infrared (“below-red” or in a significant exposure. In contrast to V Rarely burns, tans profusely (dark brown) “heat”) radiation (Ͼ700 nm). UVR is the variability of UVB radiation, UVA ra- VI Never burns, deeply pigmented (black) subdivided into UVC (200–290 nm), diation is relatively constant through- UVB (290–320 nm), and UVA (320–400 out the day and the year. nm, further subdivided into UVA2 UVR can be produced by man-made expressed as the erythema “action [320–340 nm]) and UVA1[340–400 lamps (eg, sunlamps) and tools (eg, spectrum” (the rate of a physiologic nm]). UVC rays possess the highest welding tools), but the sun is the pri- activity plotted against wavelength of energy but do not penetrate the at- mary source of UVR for most people.4 light showing which wavelength of mosphere. Thus, middle-wavelength UVR has been used for decades to treat light is most effectively used in a spe- (UVB) and long-wavelength (UVA) skin diseases, especially psoriasis.1 cific chemical reaction). The action UVR, visible light, and infrared radia- spectrum for erythema and sunburn is tion have the greatest biological UVR EFFECTS ON THE SKIN mainly in the UVB range.6 significance. The skin is the organ most exposed to Tanning Solar radiation that reaches the environmental UVR and to associated earth’s surface constitutes approxi- sequelae. Exposure to UVR may result Tanning is a protective response to 7 mately 95% UVA and 5% UVB.1 Most UVB in erythema and sunburn, tanning, sun exposure. Immediate tanning (or radiation is absorbed by stratospheric skin aging, photosensitivity, and carci- immediate pigment-darkening) re- ozone, but ozone absorbs little or no nogenesis (nonmelanoma skin cancer sults from oxidation of existing mela- UVA or visible light. The ozone layer [NMSC] and cutaneous malignant nin after exposure to visible light and does not have uniform thickness; melanoma). UVA. Immediate pigment-darkening be- ozone concentration tends to increase comes visible within several minutes toward the poles but is thinning in Erythema and Sunburn and usually fades within 1 to 2 hours. Delayed tanning occurs when new mel- some areas.2 Ozone depletion has a Erythema and sunburn are acute reac- significant effect on the amount of UVB anin is formed after UVB exposure. De- tions to excessive amounts of UVR. Ex- layed tanning becomes apparent 2 to 3 that reaches the earth.2 Chlorofluoro- posure to solar radiation causes vaso- carbons used as aerosol propellants days after exposure, peaks at 7 to 10 dilatation and increases the volume of days, and may persist for weeks or and in refrigeration and air condition- blood in the dermis, which results in ing can destroy ozone. months. According to recent evidence, erythema. The minimal erythema (or the tanning response means that DNA UVR that passes through the strato- erythemal) dose (the amount of UVR damage has occurred in skin.8 sphere (10–50 km above sea level) is exposure that will cause minimal ery- scattered by molecules such as oxygen thema or slight pinkness of the skin) Skin-Aging (Photoaging) and nitrogen. It then passes through the depends on factors such as (1) skin Chronic unprotected exposure to UVR troposphere (0–10 km above sea level), type, (2) skin thickness, (3) the amount weakens the skin’s elasticity and re- where it is absorbed and scattered by of melanin in the epidermis, (4) mela- sults in sagging cheeks, deeper facial pollutants, such as soot, and attenuated nin production after sun exposure, and wrinkles, and skin discoloration. Pho- by clouds. Clouds reduce the intensity of (5) the intensity of the radiation. A clas- toaged skin is characterized by alter- UVR but not to the same extent that infra- sification system of 6 skin types rang- ations of cellular components and of red intensity is reduced; the sensation of ing from light to dark (Table 1) takes the extracellular matrix. There is accu- heat is diminished, which results in the into account a person’s expected sun- mulation of disorganized elastin and of 5 potential for overexposure. burn and suntan tendency. fibrillin (its microfibrillar component The intensity of UVB radiation varies; it The ability of UVR to produce erythema in the deep dermis) and a severe loss has greater intensity in summer than depends on the radiation wavelength of interstitial collagens, the major

e792 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS structural proteins of the dermal con- factor (SPF) when some light expo- than 50 years, and the incidence in this nective tissue. These changes result sure is inevitable.12 age group is increasing rapidly.16–18 primarily from exposure to UVR- Plants that contain furocoumarins People with immune suppression, in- generated reactive oxygen species may lead to phototoxic reactions or cluding organ transplant recipients, that deplete and damage the skin’s en- phytophotodermatitis. These com- also are at higher risk. Genetically zymatic and nonenzymatic antioxidant monly encountered plants include an- based conditions, such as basal cell defense systems.9,10 ise, diseased celery, dill, fennel, fig, nevus syndrome, xeroderma pigmen- lemon, lime, mustard, parsnip, pars- tosum (a condition in which there is a Photosensitivity ley, and chrysanthemums. Phytophoto- genetically determined defect in the 19 Chemical photosensitivity refers to an dermatitis can occur through inges- repair of DNA damaged by UVR), and adverse cutaneous reaction that re- tion of plants or, more commonly, albinism, are risk factors for the accel- erated development of NMSC. Treat- sults when certain chemicals or drugs through topical contact.13 are applied topically or taken systemi- ment with UVR for psoriasis also in- Up to 80% of patients with lupus ery- creases risk.19 NMSC is extremely rare cally at the same time that a person is thematosus have photosensitivity. The exposed to UVR or visible radiation. in children in the absence of predis- threshold UVR dose that triggers cuta- posing conditions.20 Phototoxicity is a form of chemical neous or systemic reactions is much The incidence of NMSC is increasing in photosensitivity that does not depend lower than that for sunburn. Many pa- young adults. Researchers examined on an immunologic response; the reac- tients are not aware of the association the gender- and age-specific incidence tion can occur on first exposure to an of flares with UVR exposure, because of BCC and SCC in a young (Ͻ40-year- agent. Most phototoxic agents are ac- the latency period between exposure old), primarily white and middle-class tivated in the range of 320 to 400 nm and skin eruptions can range from population within Olmsted County, (the UVA range). Drugs associated with several days to 3 weeks.14 phototoxic reactions include those Minnesota, by using comprehensive medical records available through commonly used by adolescents, such Carcinogenesis as nonsteroidal anti-inflammatory the Rochester (MN) Epidemiology 21 agents; tetracyclines and tretinoin; Nonmelanoma Skin Cancer Project. Over the period of other medications such as phenothia- NMSC includes basal cell carcinoma 1976–2003, the incidence of BCC in- zines, psoralens, sulfonamides, and (BCC) and squamous cell carcinoma creased significantly among young thiazides; and para amino benzoic acid (SCC). In the US adult population, NMSC women, and the incidence of SCC in- (PABA) esters.11 Photoallergy is an ac- is the most common malignant neo- creased significantly among both men quired altered reactivity of the skin, plasm, with more than 2 million cases and women. usually triggered by exposure to UVA, diagnosed each year. Most of these are A trend toward a greater number of that depends on antigen-antibody or BCC, SCC occurs less often.15 The rate BCC cases occurring on the torso in cell-mediated hypersensitivity. Pho- of NMSC has been increasing in the younger patients has been report- toallergic reactions involve an immu- United States, but the exact number is ed.21–23 This change in location sup- nologic response to a chemical or drug not precisely known, because physi- ports the possibility that excessive out- that is altered by UVR. PABA-containing cians are not required to report NMSC door tanning, use of tanning booths, or sunscreens, fragrances, sulfonamides, to cancer registries. NMSC is rarely fa- both give rise to BCC. Tanning-bed use and phenothiazines are associated tal; nevertheless, it is estimated that has been shown to be a risk factor for 24 with photoallergic reactions.11 The each year, approximately 2000 people NMSC in young women. consequences of exposure to a pho- die of NMSC.15 Sun exposure is the main environmen- tosensitizing agent can be uncom- In general, NMSC occurs in maximally tal cause of NMSC. Cumulative expo- fortable, serious, or life-threatening. sun-exposed areas of fair-skinned peo- sure over long periods, which results People who take medications or use ple. NMSC is uncommon in black peo- in photodamage, is considered impor- topical agents known to be sensitiz- ple and people with increased natural tant in the pathogenesis of SCC. ing should do their best to limit sun pigmentation. The head and neck re- exposure and avoid UVA from artifi- gion is the most common site for BCC Melanoma cial sources. They should wear fully and SCC; 80% to 90% of cases occur in Melanoma is primarily a disease of the protective clothing and apply sun- this area in the general population. skin. Primary extracutaneous sites in- screen with a high sun-protection NMSC is more common in people older clude the eye, mucous membranes,

PEDIATRICS Volume 127, Number 3, March 2011 e793 Downloaded from www.aappublications.org/news by guest on September 26, 2021 gastrointestinal tract, genitourinary young women aged 15 to 39 years.31 EVIDENCE THAT UVR CAUSES SKIN tract, leptomeninges, and lymph People at highest risk have light skin CANCER nodes. Ninety-five percent of melano- and eyes and sunburn easily. Risk of In 1992, the International Agency for mas occur in the skin.25 If detected developing melanoma is increased at Research on Cancer (IARC) reviewed when the tumor is thin and small, cu- older ages, in people who have already the evidence for the carcinogenicity of taneous malignant melanoma has an had melanoma, or in people who have solar radiation. They concluded that excellent prognosis. However, meta- had a first-degree relative with mela- “[t]here is sufficient evidence in hu- static melanoma has no successful noma. Melanomas frequently are mans for the carcinogenicity of solar treatment options. Prevention and found in people with xeroderma pig- radiation. Solar radiation causes cuta- early detection, therefore, are crucial mentosum and related disorders. In a neous malignant melanoma and non- in this disease. large case-control study from the melanocytic skin cancer.1” Since that Many authorities have stated that the Netherlands, the risk of developing time, evidence has strengthened the incidence of cutaneous malignant mel- melanoma was increased in women link between sunlight exposure and anoma (hereafter referred to as “mel- who had used estrogens (either as skin cancer. anoma”) has reached epidemic pro- oral contraceptives or hormone- portions. Possible factors contributing replacement therapy) for more than Cellular Studies to the increased incidence of mela- half a year.32 UVB is absorbed by and can directly noma include the decrease in the Melanoma is rare in children, but it damage DNA, which ultimately leads to earth’s protective ozone layer, chang- 38 does occur. Studies have documented the development of skin cancer. The ing patterns of dress that favor more genotoxic effects of solar UVB radia- an increase in the incidence in chil- skin exposure, more opportunities tion are mainly mediated by direct ab- dren and adolescents, even in the ab- for leisure activities in sunny areas, sorption in the epidermis of photons sence of predisposing conditions such and increased exposure to artificial by DNA, which results primarily in cy- as xeroderma pigmentosum. From sources of UVR for tanning purposes. clobutane pyrimidine dimers (formed 1973 to 2001, the incidence of mela- In the United States, melanoma is the between adjacent pyrimidine bases lo- noma in US children younger than 20 fifth most common cancer in men and cated on the same DNA strand) and py- years increased 2.9% annually.33 An in- the sixth most common in women.26 rimidine (6-4) pyrimidone photoprod- crease in incidence was noted in Swe- The incidence of melanoma is increas- ucts.7 Incorrect repair of these lesions den during 1973–1992,34 but incidence ing rapidly in the United States.27 In results in the formation of mutations 35 36 1935, the lifetime risk for a person in then decreased. Ferrari et al re- in epidermal cells, which causes the the United States developing invasive viewed a 25-year experience with 33 development of cancer.7,39 Italian children with melanoma who melanoma was 1 in 1500. In 2007, this UVA penetrates more deeply into the were 14 years or younger at presenta- risk was 1 in 63 for invasive melano- skin than does UVB, including reaching mas and 1 in 33 when in situ melano- tion. The children’s lesions were not the basal layer of the epidermis and mas were included. Worldwide, mela- typical of melanoma lesions in adults. dermal fibroblasts.38 UVA causes oxi- noma is increasing faster than any Melanoma lesions in adults gener- dative damage to DNA that is poten- other malignancy.28 Melanoma repre- ally follow the “ABCDEs”: they are tially mutagenic.7 sents fewer than 5% of all skin cancers asymmetric (A), have irregular bor- but is the cause of almost all skin- ders (B), variegated color (C), and Biological Evidence cancer deaths. The American Cancer diameter (D) larger than 6 mm (the Biological evidence suggests that sun- Society predicted that approximately size of a pencil eraser), and change light exposure is important in the 68 130 new melanoma cases would be or evolve (E).37 In the Ferrari et al36 pathogenesis of melanoma. Results of diagnosed in 2010, with 8700 deaths.29 series, however, many lesions in chil- studies in opossums suggest that por- Melanoma is more likely to occur in dren were amelanotic (pink, pink- tions of the UVA spectrum may play a males and at older ages but also oc- white, or red) and tended to be role in the pathogenesis of melanoma40 curs in teenagers and young adults. It raised and to have regular borders. and that portions of the UVA and UVB is the second most common cancer of The key to diagnosis for these chil- spectrums promote development of women in their 20s and the third most dren was the recognition that the carcinomas in mice.41 Melanoma can common cancer of men in their 20s.30 melanoma lesions were unlike any be induced by UVB and UVA radiation in Melanoma incidence is increasing in other lesions on the child. certain fish.42 Research ethics make it

e794 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS impossible to determine directly variation in human skin appearance. History of Sun Exposure which wavelengths result in skin can- Melanin that is genetically determined The pattern of sun exposure is impor- cer in humans. is termed “constitutive” melanin pig- tant in the etiology of BCC, SCC, and Melanoma has been induced in human mentation. When this basic pigmenta- melanoma skin cancers. Personal sun newborn foreskins grafted onto immu- tion is increased by exposure to UVR, it exposure is usually characterized by nologically tolerant animals exposed is termed “inducible” or “facultative” (1) total sun exposure, (2) occupa- to UVR.43 Melanomas and NMSC are of- melanin pigmentation. Melanin is tional exposure (which signifies a ten found in people with xeroderma thought to have evolved as an optical more chronic exposure), and (3) non- pigmentosum and related disorders.44 and chemical photoprotective filter occupational or recreational exposure that functions as a natural “sun- (which signifies intermittent expo- Epidemiologic Evidence screen” to regulate UVR penetration sure).46 SCC is significantly associated Latitude or Estimated Ambient into skin. In early human evolution, the with estimated total sun exposure and Solar UVR more highly melanized skins of people with occupational exposure. Chronic The rates of BCC and SCC increase with indigenous to the tropics afforded bet- exposure to UVB is now considered the increasing ambient solar UVR. There is ter protection against the deleterious main environmental cause of SCC. SCC a direct relationship between the inci- effects of UVR. A dark epidermis pro- seems to be most straightforwardly dence of NMSC and latitude; higher tected sweat glands from UVR-induced related to the total sun exposure: these rates are found closer to the equator injury and ensured the integrity of so- tumors occur on skin areas that are (where the amount of sunlight is matic thermoregulation. Highly mela- most regularly exposed (face, neck, greater).28 The relationship of mela- nized skin also protected against and hands), and the risk rises with the 47 noma with latitude is not as clear as UVR-induced photolysis of folate, a me- lifelong accumulated dose of UVR. that for NMSC.28 tabolite essential for normal develop- BCC and melanoma are significantly associated with intermittent sun expo- ment of the embryonic neural tube.45 Race and Pigmentation sure (ie, sunburning or “brutal” expo- As people migrated outside the trop- BCC and SCC occur primarily in white sure), whereas SCC does not show ics to northern areas, a lighter skin people.15 Incidence and mortality rates this relationship. Melanoma is more color was needed as an adaptation to of melanoma are highest in white peo- strongly associated with intermittent promote maintenance of UVR- ple (Table 2).27 There is, in general, an sun exposures than is BCC.46 induced synthesis of vitamin D in ar- inverse relationship between skin- 3 45 cancer incidence and the skin pigmen- eas of lower UVR exposure. As the Childhood Sun Exposure pace of human migrations quickened tation of people in various countries in Childhood and adolescence are often in recent centuries, however, popu- the world. Superficial epidermal mela- considered to contain “critical periods lations have found themselves in nin decreases the transmission of of vulnerability” when people are espe- UVR, which may protect the deeper UVR-irradiation patterns to which cially susceptible to effects of toxic ex- basal layer melanocytes and several they are poorly adapted. Cultural posures. Approximately 25% of lifetime layers of keratinocytes from sunlight- practices, such as sunbathing and sun exposure occurs before 18 years induced changes that lead to their ma- covering up for religious reasons, ex- of age.48 Sun exposure and blistering lignant transformation.7 acerbate or mitigate the mismatch in sunburns during youth may be more Melanin, a dark pigment produced by degree of melanin protection to UVR intense than later in life because of melanocytes, accounts for most of the exposures.45 youths’ behavior. Exposure may result in alteration of melanocyte DNA and an increase in the risk of malignant de- TABLE 2 Melanoma Incidence and Mortality Rates According to Race/Ethnicity27 generation in nevi as children age. Race/Ethnicity Men, Rate per Women, Rate per Sunlight exposure during childhood 100 000 Men 100 000 Women and adolescence is generally consid- Incidence Mortality Incidence Mortality ered to confer increased risk of mela- White 28.9 4.4 18.7 2.0 noma compared with exposure at Black 1.1 0.5 1.0 0.4 Asian/Pacific Islander 1.6 0.5 1.3 0.3 older ages. This issue was reviewed in American Indian/Alaska Native 3.9 1.6 2.8 0.9 an analysis of epidemiologic studies Hispanic 4.6 0.9 4.7 0.6 categorized into 2 groups.49 The first

PEDIATRICS Volume 127, Number 3, March 2011 e795 Downloaded from www.aappublications.org/news by guest on September 26, 2021 group contained 20 ecologic studies whether sunburn occurred during during the period of peak melanocytic (ie, studies in which the unit of obser- childhood or adulthood. The summary activity. Populations exposed to high vation is the population or community) odds ratios associated with sunburn sunlight levels in childhood will have relating the risk of melanoma to during childhood and adulthood were more people with more initiated mela- places of residence. These studies 1.8 (95% confidence interval: 1.6–2.2) nocytes than populations of those who were conducted on the basis of the fact and 1.5 (95% confidence interval: 1.3– experienced lower sunlight levels. This that ambient solar radiation increases 1.8), respectively, although there was “melanoma potential” is retained with proximity to the equator and in- significant heterogeneity among the when people move to a different cluded studies of migrants to locations studies for the estimates of childhood environment.49 with markedly different levels of sun- sunburn. The authors underscored the light. The second group consisted of lack of reliability of recalling personal Nevi case-control studies in which mea- sun exposure as a reason for the in- Acute sun exposure is implicated in the sures of sun exposure between people consistencies between the migrant development of nevi (moles) in chil- with melanoma and those without and case-control studies and consid- dren. The number of nevi increases were compared. ered the evidence from the migrant with age52; nevi occur with more fre- In the first group, most studies re- studies to be of higher quality.49 In a quency on sun-exposed areas, and the vealed that people who migrated from large multicenter case-control study, number of nevi on exposed areas in- “low” to “high” areas of ambient solar the authors concluded that excessive creases with the total cumulative sun radiation had decreasing melanoma UVR exposure later in life may be as exposure during childhood and ado- risk with arrival at older ages, important a risk for melanoma as UVR lescence.53 Children with light skin who whereas those who arrived in child- exposure earlier in life.50 There was a tend to burn rather than tan have hood (younger than 10 years) or ado- similar upward gradient of melanoma more nevi at all ages, and children who lescence (younger than 15 years) had risk related to sunburns during have more severe sunburns have more similar risks as people who were childhood (defined as age Յ 15 years) nevi.52 native-born. The 1 study that investi- and adulthood (defined as age Ͼ 15 There is a relationship between the gated age-specific “high-to-low” migra- years). More than 5 sunburns doubled number and type of melanocytic nevi tion demonstrated higher risk in peo- the melanoma risk irrespective of and the development of melanoma. ple born in a sunny area or having had whether those sunburns occurred in The presence of congenital melano- more than 1 year living in a sunny area childhood or adulthood.50 cytic nevi (CMN) (pigment cell malfor- before 10 years of age.49 The results of There is biological plausibility to sup- mations formed during gestation and most studies of the age of migration, port the heightened susceptibility of visible at or shortly after birth) in- therefore, supported the “critical- young melanocytes. Peak melanocytic creases melanoma risk. In a review of period” hypothesis. activity occurs in early life as demon- 14 studies—case series with adequate Ten case-control studies that exam- strated by the steady acquisition of follow-up periods—investigators found ined melanoma risks associated with nevi during childhood and adoles- an overall risk of melanoma arising in personal sun exposure during 2 or cence. Freckling is also prominent at CMN of 0.7%, which was lower than ex- more age periods were evaluated in these ages; freckles in children often pected. Melanoma risk strongly de- the second group. Findings of these appear abruptly after high-dose sun pended on the size of the CMN and was studies differed widely without consis- exposure and are thought to represent highest in nevi designated as garment tent associations with childhood sun clones of mutated melanocytes. The nevi (defined as nevi situated on the exposure. Three studies reported sig- presence of freckles is associated with trunk that measure Ͼ40 cm in largest nificantly increased risks of mela- an increased risk of melanoma.7 Young diameter or expected to reach this noma associated specifically with melanocytes may be especially vulner- size in adulthood). The mean age at episodes of sunburns during child- able to the adverse effects of solar ra- melanoma diagnosis (15.5 years) hood, whereas 1 Swedish study found diation. Sunlight may have both early and median age of diagnosis (7 no effect of childhood sunburn but re- and late effects on the development of years) underscored the maximum ported significantly higher risks asso- melanoma (akin to cancer “initiation,” risk in childhood and adolescence.54 ciated with adulthood sunburns. The “promotion,” and “progression”51), Dysplastic melanocytic nevi typically remaining 5 studies reported similar and the biological effectiveness of sun- are 5 mm or larger in diameter; usu- risks of melanoma regardless of light in initiating melanoma is greatest ally have fuzzy, irregular borders; and

e796 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS have variegated color. Dysplastic nevi traocular malignant neoplasm in of white recipients in Western coun- are considered precursor lesions that adults, is associated with light skin tries and 70% to 80% of those in Aus- increase melanoma risk.55 The familial color, blond hair, and blue eyes. There tralia will have developed at least 1 dysplastic nevus syndrome is a disor- is contradictory evidence regarding NMSC (mostly SCC).66 People who have der with the following features: (1) a the role of UVR in causing uveal had renal transplants also have an in- distinctive appearance of abnormal melanoma.63,64 creased incidence of melanoma.67 Be- melanocytic nevi; (2) unique histologic cause ongoing immunosurveillance features of the nevi; (3) autosomal UVR EFFECTS ON THE IMMUNE has been lacking, skin cancers in peo- dominant pattern of inheritance; and SYSTEM ple who have received organ trans- (4) hypermutability of fibroblasts and Exposure to UVR contributes to immu- plants are likely to behave aggres- lymphoblasts. Fibroblasts and lympho- nosuppression, which is increasingly sively with a higher rate of local blasts from patients with this syn- recognized as important in the devel- recurrence and a greater tendency to drome are abnormally sensitive to UV opment of skin cancer. UVR exposure be invasive and metastatic.66 damage, and people with this syn- is thought to have 2 effects: skin- drome are at markedly higher risk cancer induction and immune sup- ARTIFICIAL SOURCES OF UVR of developing melanoma.56 Certain pression.65 Experiments in mice chron- People may be exposed to artificial families with germ-line mutations in ically exposed to UVR have shown that sources of UVR in several ways, includ- CDKN2A, CDK4, and other genes are at tumors induced by UVR are highly an- ing as treatment for medical condi- increased risk of developing dysplas- tigenic and are recognized and re- tions (such as psoriasis), in occupa- tic nevi and melanoma.57 jected by animals with normal immune tional settings (such as welding), and History of Exposure to Artificial UVR systems. The tumors grow progres- for cosmetic purposes. Sunlamps and Exposure to tanning beds and sun- sively, however, when transplanted tanning beds are the main sources of lamps, which produce primarily UVA, is into mice with immune systems that artificial UVR used for deliberate pur- 65 68 associated with increased risk of de- are compromised. UVR exposure in- poses. Artificial tanning is a relatively veloping BCC, SCC, and melanoma. duces “systemic” immune suppres- new phenomenon that results in po- sion so that exposure on 1 body site tentially large exposures to UVA and UVR EFFECTS ON THE EYE suppresses the immune response UVB. The “tanning industry” has grown In adults, more than 99% of UVR is ab- when the antigen is introduced at a quickly; it takes in $5 billion in annual sorbed by the anterior structure of the distant site that was not irradiated. revenue, up from $1 billion in 1992.69 eye, although some of it reaches the Soluble factors implicated in sys- Each day, more than 1 million people retina.58 Acute exposure to UVR can re- temic immune suppression include tan in one of 50 000 tanning facilities in sult in photokeratitis.59 Gazing directly platelet-activating factor (PAF), pros- the United States.69 Indoor tanning also into the sun (as can occur during an taglandin E2 (PGE2), cis-urocanic is popular in northern Europe and is eclipse) can cause focal burns to the acid, histamine, interleukin 4, interleu- gaining popularity in Australia.68 retina (solar retinopathy).60 kin 10, and ␣-melanocyte-stimulating Artificial tanning is a common practice 65 Exposure to solar UVB radiation is as- hormone. among teenagers. In a national sample sociated with an increased risk of cat- Skin cancers are common in people ex- of non-Hispanic white teenagers 13 to aracts.61 UVR can contribute to the posed to immunosuppressive agents, 19 years of age in the United States, development of pterygium, corneal de- which further illustrates the role of the 24% of respondents—representing generative changes, and cancer of the immune system. In people who have 2.9 million teenagers—reported using skin around the eye.58 There is evi- had renal transplants, lifelong immu- a tanning facility at least once in their dence for a probable relationship be- nosuppressive treatment needed for lives.70 In another national survey, 10% tween UVR exposure and squamous adequate graft function leads to a re- of youth 11 to 18 years of age reported intraepithelial neoplasms of the con- duction of immunosurveillance and an using indoor tanning beds or sun- junctiva or cornea, but there is insuffi- increased risk of various cancers. With lamps in the previous year.71 Women cient evidence to determine if there is increased duration of transplantation, and girls represent the majority of a relationship between UVR exposure skin cancer is now one of the common- people who artificially tan. Of the 1 mil- and the development of macular de- est causes of death in renal transplant lion people daily who are tanning- generation.62 Melanoma of the uveal recipients. Twenty years after trans- salon customers, 70% are females 16 tract, the most common primary in- plantation, approximately 40% to 50% to 49 years of age.69 Twenty-eight per-

PEDIATRICS Volume 127, Number 3, March 2011 e797 Downloaded from www.aappublications.org/news by guest on September 26, 2021 cent of white US teenaged girls inter- tured that ultraviolet light exposure re- nature and is a new phenomenon in viewed in 1996 had used tanning sa- sults in induction of cutaneous endor- people.78 lons 3 or more times during their phins; thus, endorphin release may Artificial UVR exposure has been lives.70 Tanning-bed use increases with play a role in driving UVR-exposure be- shown repeatedly to induce erythema age, from 7% among 14-year-old girls havior. If cutaneous endorphins are in- and sunburn. Erythema or burning ef- to 16% among 15-year-old girls and to duced, an endorphin blockade would fects were reported by 18% to 55% of 35% among 17-year-old girls.72 be expected to block the effect.76 A re- users of indoor tanning equipment in Tanning-bed use by adolescent girls is cent study assessed the prevalence of Europe and North America.68 Although often associated with other unhealthy addiction to indoor tanning among col- UVB is much more potent than UVA in behaviors. In 1 study, frequent tanning- lege students and its association with causing sunburn, high fluxes of UVA bed use was associated with smok- substance use and symptoms of anxi- can cause erythema in people who are ing cigarettes, binge-drinking, being ety and depression. Two written sensitive to sunlight. In people who tan highly concerned about weight, and measures, the CAGE (cut down, an- easily, exposure to tanning appliances other risk behaviors.73 noyed, guilty, eye-opener) Question- will lead first to immediate pigment- naire, used to screen for alcoholism, darkening. A more permanent tan will Evidence That Tanning and the Diagnostic and Statistical occur with accumulated exposure, de- May Be Addictive Manual of Mental Disorders, Fourth pending on individual tanning ability Exposure to UVR from sunlight or tan- Edition, Text Revision (DSM-IV-TR) crite- and the amount of UVB present in the ning parlors may be addictive. Beach- ria for substance-related disorders light spectrum of the tanning lamps. goers aged 18 years and older in were modified to evaluate study partic- Immediate pigment-darkening has no Galveston, Texas, were interviewed us- ipants for addiction to indoor tanning. photoprotective effect against UVR- ing questions to evaluate dependence Self-report measures of anxiety, de- induced erythema or sunburn. In addi- on tanning. Subjects completed sur- pression, and substance use were ad- tion, the permanent tan induced by UVA and UVA-induced skin-thickening veys that included a tanning-specific ministered. Among the 229 study par- provides little photoprotection. modification of a screening instru- ticipants who had tanned indoors, 70 ment for alcoholism and questions to (30.6%) met CAGE criteria and 90 Other frequently reported effects of ar- evaluate criteria for tanning-specific (39.3%) met DSM-IV-TR criteria for ad- tificial tanning include skin dryness, substance-related disorder. Of 145 diction to indoor tanning. Indoor tan- pruritus, nausea, photodrug reac- subjects, 26 (18%) screened positive ners reported significantly greater tions, disease exacerbation (eg, sys- on both measures, and 63 (43%) symptoms of anxiety and greater use temic lupus erythematosus), and dis- screened positive on 1 measure. The of alcohol, marijuana, and other sub- ease induction (eg, polymorphous authors concluded that those who stances than those who did not meet light eruption). Long-term health ef- chronically and repeatedly expose these criteria. Depressive symptoms fects include skin-aging, effects on the themselves to UVR to tan may have did not significantly vary according to eye (eg, cataract formation), and a type of UVR substance-related indoor-tanning-addiction status.77 carcinogenesis. disorder.74 In a study of 14 adults, tan- In 1992, the IARC1 classified the “use ners overwhelmingly preferred UVR- Effects of Artificial UVR on Human of sunlamps and sunbeds” as “prob- emitting beds when asked to choose Skin ably carcinogenic to humans.” In blindly between UVR-emitting and Tanning beds primarily emit UVA radi- 2000, the National Institutes of Health non–UVR-emitting tanning beds. A ation, although a small amount (Ͻ5%) stated that “exposure to sunlamps or more relaxed and less tense mood was is in the UVB range.68 In terms of bio- sunbeds is known to be a human car- reported after UVR exposure com- logical activity, the intensity of UVA ra- cinogen, based on sufficient evi- pared with after non-UVR exposure.75 diation produced by large, powerful dence of carcinogenicity from stud- In another study, the opioid antagonist tanning units may be 10 to 15 times ies in humans, which indicate a naloxone was given to 8 frequent salon higher than that of the midday sun. causal relationship between expo- tanners and 8 people who were infre- Frequent indoor tanners may receive sure to sunlamps or sunbeds and hu- quent tanners. Withdrawal-like symp- 1.2 to 4.7 times the annual dose of UVA man cancer.”79 toms were induced in 4 of 8 frequent than is received from the sun, in addi- A case-control study demonstrated a salon tanners; no symptoms occurred tion to doses from sun exposure.68 This significant association between using in the 8 infrequent tanners. It is conjec- intensity of exposure is not found in any tanning device and the incidence

e798 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS of SCC and BCC.80 A prospective cohort artificial tanning. The Indoor Tanning province of New Brunswick, Canada.87 study of 106 379 women in Scandinavia Association, an industry group founded Currently (as of February 2011), more examined melanoma risk in females in 1999, promotes “a responsible mes- than 60% of US states regulate tanning who reported having used a sunbed or sage about moderate tanning and sun- facilities for minors.88 Some states sunlamp. A 55% increase in melanoma burn prevention.”82 Their mission is to completely ban salon access to chil- risk was found in women who reported “protect the freedom of individuals to dren younger than 14 years, whereas having used a tanning device at least acquire a suntan, via natural or artifi- other states ban access to adolescents once per month in at least 1 of the 3 cial light.”83 The Indoor Tanning Associ- 15 or 16 years of age. Some states re- decades between 10 and 39 years of ation claims that “controlled” salon quire written parental consent or writ- age, compared with those who had tanning is safer than “uncontrolled” ten consent with the parent present at never or rarely used a tanning device beach tanning; this concept is not sup- the facility or a doctor’s prescription. during those 3 decades.81 ported by laboratory, behavioral, or In California, where tanning-salon use is In 2006, the IARC published an updated epidemiologic data.78 Another com- banned for children younger than 14 analysis of studies of the carcinogenic- monly held misconception is that getting years, recent legislation made annual ity of artificial UVR with regard to mel- a “prevacation tan”—when people visit signed parental consent required for anoma, SCC, and BCC.68 On the basis of tanning salons to prepare skin for a tanning-facility use by adolescents 14 to 89 19 studies, any previous use of sun- sunny vacation—will protect against 17 years of age. During the 2010 legis- beds was positively associated with subsequent skin damage during the va- lative session, 20 states introduced melanoma (summary relative risk: cation. This practice actually leads to ex- bills to regulate tanning facilities for 88, 1.15 [95% confidence interval: 1.00– tra radiation exposure not only before minors. * 1.31]), although there was no consis- the vacation but also afterward, because The Indoor Tanning Association has tent evidence of a dose-response re- people use fewer sun-protection precau- fought against legislative initiatives lationship. First exposure to sunbeds tions during the vacation because of a and stated that legislation will harm before 35 years of age significantly in- mistaken belief that the tan will protect business90 and that tanning is an issue creased the risk of melanoma on the them.69 A prevacation tan results in min- of parental rights: “When it involves a basis of 7 studies (summary relative imal protection (an SPF of 3),78 which suntan, the State has no business in- risk: 1.75 [95% confidence interval: provides virtually no protection against serting itself between child and par- 1.35–2.26]). The summary relative risk sun-induced DNA damage.68 ent. This notion that government knows of 3 studies of SCC showed an in- more about child rearing than parents is creased risk. Studies did not support Antitanning Legislation and preposterous.”89 Pediatric health advo- an association for BCC. The evidence Recommendations cates have countered this argument by did not support a protective effect of Because of mounting evidence about the stating that laws to limit minors’ access the use of sunbeds against damage carcinogenicity of artificial UVR, support to tanning parlors should be thought of to the skin from subsequent sun for regulations to limit teenagers’ ac- in the same way as laws that limit youth 87,89 exposure. cess to tanning facilities has been wide- access to tobacco. All states prohibit the purchase of tobacco products by Biological evidence supports the epi- spread. The World Health Organization,84 those younger than 18 years; some pro- demiologic studies. The skin of volun- the American Medical Association,85 and hibit tobacco sales to those younger teers exposed to UVA lamps used in the American Academy of Dermatology86 than 19 years.87 Tanning legislation is of- tanning appliances showed DNA dam- all support legislation to ban the use of ten not enforced.91 age.68 The IARC concluded that young artificial tanning devices by people adults should be discouraged from us- younger than 18 years. The IARC review Artificial Tanners (Spray Tans and ing indoor tanning equipment and that concluded that young adults should be Sunless Tanning Lotions) restricted access to sunbeds by mi- discouraged from using indoor tanning Several organizations have suggested nors should be strongly considered. equipment and that restricted access to that people who wish to obtain the look sunbeds by minors should be strongly of a tanned skin use artificial (or “sun- Tanning-Industry Response considered.68 less”) tanning products to substitute The tanning industry has fought vigor- France has banned indoor tanning for ously to allow teenagers access to tan- people younger than 18 years since *For more information on current state laws that restrict the use of tanning beds by children and ning salons and promotes the pur- 1997; indoor tanning for those younger teenagers, please contact the AAP Division of State ported health benefits and safety of than 18 years also is prohibited in the Government Affairs.

PEDIATRICS Volume 127, Number 3, March 2011 e799 Downloaded from www.aappublications.org/news by guest on September 26, 2021 for tanning obtained by going outside ucts that contain added sunscreen 3. Seek shade. or at tanning salons. Sunless tanners provide UVR protection only during the 4. Use extra caution near water, snow, contain dihydroxyacetone, a chemical first few hours after application and and sand. that reacts with amino acids in the that additional sun protection must be 5. Apply sunscreen. stratum corneum to form brown-black used during the duration of the artifi- compounds—melanoidins—that de- cial tan. 6. Wear sunglasses. posit in skin. Dihydroxyacetone is a Clothing and Hats mutagen that induces DNA strand PREVENTION Clothing can be an excellent UVR bar- breaks in certain strains of bacteria; it The incidence of skin cancer continues rier, because it offers a simple and has not been shown to be carcinogenic to rise despite public health efforts practical means of sun protection. In in animal studies.92 to increase awareness of sun-safety contrast to sunscreens, the photopro- measures. Children and teenagers Dihydroxyacetone is the only color ad- tection afforded by clothing does not continue to sunburn: in 1 large study of ditive approved by the US Food and diminish throughout the day unless more than 10 000 white teenagers 12 Drug Administration (FDA) for use as the clothing becomes wet. Infants and 93 to 18 years of age, most respondents a tanning agent. Dihydroxyacetone- children may be dressed in cool, com- (83% [n ϭ 8355]) reported sunburning containing tanning preparations may fortable clothing and wear hats with at least once, and 36% of children re- be applied to the consumer’s bare skin brims. One study revealed that wear- ported 3 or more burns during the pre- by misters at sunless tanning booths. ing clothing decreases the develop- vious summer.72 Only one-third of re- Bronzers are water-soluble dyes that ment of nevi.103 Protective factors in spondents reported routine use of temporarily stain the skin. Bronzers clothing include fabric type, thickness, sunscreen during the past summer. are easily removed with soap and color, and chemical enhancement.2 Sunburning during the summer was water. Wool and synthetic materials such as reported in a nationwide survey of The prevalence of sunless tanner use polyester are more protective, whereas youth, although many reported using in Australia has ranged from 9% to cotton, linen, acetate, and rayon are less sunscreen before their most serious 22%94; 28% of women between 18 and protective. A tighter weave lets in less sunburn.96 Among adolescents 16 to 18 24 years of age reported using sunless sunlight than a looser weave. Darker col- years of age, the prevalence of sun- tanners.95 A survey of young adults 18 ors are more protective than lighter burn and the average number of days to 24 years of age in the United States ones. Clothes that cover more of the spent at the beach increased be- revealed that 22% had used sunless body provide more protection; sun- tween surveys conducted in 1998 and tanners in the previous 12 months, and protective styles cover to the neck, el- 2004.97 another 22% who had not used these bows, and knees. Treating fabrics with products would consider doing so in It has been estimated that sun avoid- chemical absorbers or washing them the next 12 months.94 Sunless-tanning- ance could reduce the number of life- with optical brighteners increases UVR product users were more likely to be time NMSC cases by almost 80%.98 protectiveness. Although other risk factors (eg, pre- female, to be younger, and to report In 1996, Australia and New Zealand es- cursor lesions, older age, race, previ- having sunburned during the previous tablished standards for the UVR pro- ous melanoma, and family history) are summer than potential users or tectiveness of clothing. The United more closely associated with mela- nonusers. States developed standards in 2001. noma than sunburns, exposure to UVR Dihydroxyacetone-induced tans be- The ultraviolet protection factor (UPF) is the only risk factor that is avoidable. come apparent within 1 hour; maximal measures a fabric’s ability to block Leading organizations (the American darkening occurs within 8 to 24 hours. UVR from passing through the fabric Cancer Society,99 Centers for Disease Most users report that color disap- and reaching the skin. The UPF is clas- Control and Prevention,100 Healthy Peo- pears over 5 to 7 days. Because neither sified from 15 to Ն50 as follows: 15 to ple,101 National Council on Skin Cancer dihydroxyacetone nor melanoidins af- 24 is rated as “good”; 25 to 39 is rated Prevention102) have recommended ford any significant UV protection, con- as “very good”; and 40 to Ն50 is rated sun-safe behaviors. UVR-protective sumers must be advised that sunburn as “excellent.” Although garments with messages include: and sun damage may occur unless a UPF above 50 may be labeled “UPF they use sunscreen and other sun- 1. Do not burn; avoid suntanning and 50ϩ,” these garments may not offer protection methods. Consumers must tanning beds. substantially more protection than also be warned that any sunless prod- 2. Wear protective clothing and hats. those with a UPF of 50. Any garment

e800 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS

with a UPF lower than 15 should not be TABLE 3 FDA-Approved Sunscreens110,115 labeled as “sun protective” or “UV pro- Sunscreen Range of Comments tective.”104 Denim provides a UPF of protection 1700.2 Typical summer cotton T-shirts Organic PABA derivatives UVB — provide a UPF of 5 to 9. The UPF of fab- PABAa rics can be increased by shrinking and Padimate O (octyl dimethyl PABA) decreased by stretching. If cotton fab- Cinnamates UVB — Octinoxate (octyl rics get wet, the UPF decreases. The methoxycinnamate) US Federal Trade Commission moni- Cinoxate tors advertising claims about sun- Salicylates UVB — protective clothing.105 Octisalate (octyl salicylate) Homosalate Hats provide variable sun protection Trolamine salicylatea for the head and neck, depending on Benzophenones UVB, UVA2 Penetrates skin; estrogenicity in animal Oxybenzone (benzophenone 3) studies the brim width, material, and weave. A Sulisobenzone (benzophenone 4) wide-brimmed (3-in) hat provides an Dioxybenzone (benzophenone 8)a SPF of 7 for the nose, 3 for the cheek, 5 Others Octocrylene UVB In combination with other sunscreen agents, for the neck, and 2 for the chin. improves product photostability Medium-brimmed (1- to 3-in) hats pro- Ensulizole (phenylbenzimidazole UVB — vide an SPF of 3 for nose, 2 for the sulfonic acid) Avobenzone (butyl methoxybenzoyl UVA1, UVA2 Photolabile; efficacy decreases by ϳ60% cheek and neck, and none for the chin. methane, Parsol 1789) after 60 min of exposure A narrow-brimmed hat provides an Ecamsule (terephthalylidene UVB, UVA2 Photostable; particularly effective for UVA2; SPF of 1.5 for the nose but little protec- dicamphor sulfonic acid) approved by the FDA in 2007 tion for the chin and neck.2 Meradimate (menthyl UVA2 — anthranilate)a Inorganic Shade Titanium dioxide UVB, UVA2/UVA1 — Zinc oxide UVB, UVA2/UVA1 — Infants younger than 6 months should Note that other agents are approved for use in the European Union. be kept out of direct sunlight. When- a These agents are rarely used in sunscreen formulations. ever possible, children’s outdoor activ- ities should be planned to minimize peak-intensity midday sun (10 AM to 4 sunburn. Most FDA-approved sun- tection from full-spectrum UVR.3 Table PM). Seeking shade is somewhat useful, screen agents are organic chemicals 3 lists the FDA-approved sunscreen but people can still sunburn, because that absorb various wavelengths of agents. light is scattered and reflected. A fair- UVR, primarily in the UVB range; others SPF is a grading system developed to skinned person sitting under a tree are effective in the UVA range.110 Some quantify the degree of protection from can burn in less than an hour. Shade agents are not photostable in the UVA erythema provided by using a sun- provides relief from heat and possibly range and degrade with sun exposure. screen; the higher the SPF, the greater provides a false sense of security Combinations of chemicals are needed the protection. For example, a person about UVR protection. Clouds decrease to provide broad-spectrum protection who would normally experience sun- UVR intensity but not to the same ex- and increase photostability.110 burn in 10 minutes can be protected tent that they decrease heat intensity The 2 FDA-approved inorganic physical up to approximately 150 minutes (10 ϫ and, thus, may promote a mispercep- sunscreens are zinc oxide and tita- 15) with an SPF-15 sunscreen. SPF per- tion of protection.6 nium dioxide, which prevent penetra- tains only to UVB. The SPF is deter- tion of skin by UVB, UVA1, and UVA2. mined indoors according to a stan- Sunscreen Physical sunscreens are usually white dard protocol that uses artificial light Sunscreen is the main form of protec- or tinted after application; some sources and application of a defined tion used by the population, including newer formulations are less visible on amount of sunscreen (2 mg/cm2). An parents who use sunscreen to protect the skin but may be less effective.110 SPF-2 sunscreen applied at this thick- children.106–109 Sunscreens reduce the Physical sunscreens are useful for ness blocks approximately 50% of UVB intensity of UVR affecting the epider- people with photosensitivity disorders radiation; an SPF-10 blocks 90%; an mis, thus preventing erythema and and other conditions that require pro- SPF-15 blocks 94%; and an SPF-30

PEDIATRICS Volume 127, Number 3, March 2011 e801 Downloaded from www.aappublications.org/news by guest on September 26, 2021 blocks 97%. However, sunscreens system that would rate product pro- mended by the American Academy of 123 block the pre-D3 effective radiation tection from “low” (1 star) to “highest” Dermatology and many other orga- more effectively than the erythemally (4 stars).114 The FDA also proposed nizations as part of a total program of effective radiation.111 that the “sun-protection factor” be sun protection. In actual use, the SPF often is substan- changed to “UVB sunburn-protection Sunscreens may be systemically ab- tially lower than expected, because the factor.”115 The proposed grading sys- sorbed. In 1 study, sunscreen products amount applied to the skin is less than tem would divide sunscreens into 4 were studied in vitro to assess the ex- half the recommended amount (2 mg/ protection categories: low (SPF-2–SPF- tent of absorption after application to cm2).112 To adequately cover all sun- 15); medium (SPF-15 to lower than SPF- excised human skin. Half of the prod- exposed areas of an average adult 30); high (SPF-30–SPF-50); and highest ucts were marketed specifically for wearing a bathing suit, 1 oz (30 mL) of (higher than SPF-50). Manufacturers children. Of the 5 chemical sunscreen sunscreen would be needed. It is rec- would be unable to label their prod- ingredients present in the products, ommended that sunscreen with an SPF ucts with specific SPF values higher only oxybenzone (benzophenone 3) of at least 15 be applied liberally 15 to than 50, because the FDA believes that penetrated skin.124 In another report, 30 minutes before sun exposure to al- there are no data showing accuracy researchers from the Centers for Dis- low for absorption into the skin and to and reproducibility of SPF determina- ease Control and Prevention examined decrease the likelihood that the sun- tions higher than 50.115 The proposed more than 2500 urine samples col- screen will be washed off. Further- FDA rule had not been finalized as of lected during 2003–2004 for oxyben- more, it is recommended that sun- February 2011. zone. The samples selected were rep- screens be reapplied every 2 hours The regular use of a broad-spectrum resentative of the US population aged 6 and after swimming, sweating, or dry- sunscreen preparation can prevent years and older as part of the National ing off with a towel.110 Sunscreen prod- solar (actinic) keratoses, which are Health and Nutrition Examination Sur- ucts with a greater SPF provide some- precursor lesions of SCC.116,117 One ran- vey (NHANES), an ongoing survey that what greater protection. Products domized clinical trial revealed that assesses the health and nutritional with a higher SPF have been recom- sunscreen also decreases the risk of status of the US civilian population. The mended for some people, including developing SCC.118 The role of sun- analysis found oxybenzone in 97% of those who have had skin cancer.113 For screen in preventing BCC and mela- the samples,125 which suggests wide- most users, however, proper applica- noma has not been fully elucidated. No spread exposure to the population. Fe- tion and reapplication are more im- studies have demonstrated that sun- males and non-Hispanic white people portant factors than using a product screen use prevents melanoma or had the highest concentrations re- with a higher SPF. BCC. Some research has revealed that gardless of age. Data are not available The formulating, testing, and labeling sunscreen users have a higher risk of for children younger than 6 years. of sunscreen products is regulated by melanoma and BCC and more nevi.103 Results of animal studies have shown the FDA. The FDA has approved 17 sun- These observations have led to con- alterations in liver, kidney, and repro- screen chemicals for use in the United cern that people who use sunscreens ductive organs in rats given oral or States. Several more are available in also spend more time in the sun be- transepidermal doses of oxyben- the European Union. Four chemicals ef- cause they do not sunburn.119 The zone.126 A study of 6 commonly used fective in the UVA range have been ap- American College of Preventive Medi- UVB and UVA sunscreens was con- proved for use in the United States, al- cine found “insufficient evidence to ducted to determine estrogenicity in though others are available in the recommend for or against sunscreen vivo and in vitro. Five of the 6 sun- European Union. In May 1999, the FDA use. Nonmelanoma skin cancers may screen ingredients (benzophenone published its final rule for over-the- be reduced with regular, daily sun- 3, homosalate, 4-methyl-benzylidene counter sunscreen products that pro- screen use. There is insufficient evi- camphor [4-MBC], octyl methoxycin- tect against UVB. Regulations concern- dence that chemical sunscreens pro- namate [OMC] and octyl-dimethyl- ing UVA were delayed until reliable tect against malignant melanoma and PABA) increased cell proliferation testing methods could be developed. In they may, in fact, increase risk.”120 Two in breast cancer cells, and the August 2007, the FDA proposed new reviews, however, did not support the sixth sunscreen ingredient, butyl- sunscreen regulations that focused on association between sunscreen use methoxydibenzoylmethane (avoben- manufacturing, testing, and labeling of and an increased risk of melanoma.121,122 zone), was inactive. In the in vivo UVA sunscreens using a 4-star rating Sunscreen continues to be recom- analysis, rats fed the sunscreen ingre-

e802 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS dients OMC, 4-MBC, and benzophenone these chemicals have endocrine activ- effects of alcohol, boric acid (in diaper 3 showed dose-dependent increases in ity in animals, the authors suggested powder), hexachlorophene (in antisep- uterine weight. Epidermal application that exposure could be lessened if tic cleansers), and mercuric chloride of 1 of the products (4-MBC) also in- mothers abstained from using these (in diaper rinses).133 Risks from cuta- creased uterine weight.127 Research- products during their children’s sensi- neous exposure to environmental toxi- ers investigating human prenatal ex- tive life stages.130 cants and chemicals may be height- posures to phthalate and phenol Sunscreens are lipophilic and can bioac- ened in children compared with adults metabolites and their relationship to cumulate in the environment. Sunscreen for reasons that include differing be- birth weight found that higher mater- ingredients have been identified in havior patterns; anatomic and physio- nal concentrations of benzophenone 3 fish.127 Because of recent data on bioac- logic differences in absorption, metab- were associated with a decrease in cumulation in humans and wildlife, re- olism, distribution, and excretion; and birth weight in girls but a greater birth searchers have called for an in-depth developmental differences of vital or- 128 weight in boys. A study in young men analysis of the systemic toxicology of gans that may result in different end and postmenopausal women given sunscreen ingredients.127 Sunscreen in- organ effects.133 Infants have a greater generous daily applications of benzo- gredients are not listed as known or sus- ratio of surface area to body weight phenone 3, OMC, and 4-MBC revealed pected human carcinogens.131 compared with older children and detectable levels of these chemicals in Sunscreen products that contain zinc adults, which allows infants to per- plasma and urine.129 There were no ef- and titanium oxides are increasingly cutaneously absorb proportionately fects on serum concentrations of re- manufactured by using nanotechnology— greater quantities of topical medica- productive hormones related to sun- the design and manipulation of mate- tions or other preparations.134 screen exposure in men or women. The rials on atomic and molecular scales. The development of barrier function of authors concluded that although the infant skin has been investigated. The data showed skin penetration of Nanoscale particles are measured in skin barrier limits water loss, protects these sunscreen chemicals, there did nanometers, or billionths of a meter. the body from entry by toxic sub- not seem to be an effect on the Using nanoscale particles renders hypothalamic-pituitary-gonadal axis. products that contain zinc and tita- stances, and resists mechanical trau- 135 Caution, however, was suggested for nium oxides nearly transparent and in- ma. Vernix caseosum provides a children. Researchers in Europe inves- creases cosmetic acceptability. Con- barrier during fetal life. Once the ver- tigated analyzed samples of human cerns have been raised, however, nix is removed after birth, the stratum milk for the presence of sunscreens about the dearth of safety information corneum of the epidermis provides and other chemicals with possible en- available about nanoscale ingredients, protection. It was previously thought docrine activity. Mothers were asked including the effect on skin that is dam- that the stratum corneum assumed 132 about their use of sunscreens and cos- aged by sunburn. There are no data adult function in the first few weeks of metics that contained sunscreen in- available about the effects of these life. Accumulating research suggests, gredients (benzophenone 2, benzophe- products on infants and children. Ad- however, that the stratum corneum none 3, 3-benzylidene camphor, 4-MBC, vocacy groups have called on the FDA continues to develop through the early OMC, homosalate, octocrylene, and to require more testing and increased years of life. One study136 assessed the octyl-dimethyl PABA). Responding to regulatory oversight. dynamic transport and distribution of questionnaires, 78.8% of the women To our knowledge, toxicity in infants water in the stratum corneum in in- reported using products that con- and children from absorption of sun- fants (3–12 months of age) and adults tained sunscreens; 76.5% of human screen ingredients has not been re- (14–73 years of age) by measuring milk samples contained these chemi- ported. Permeability of skin to topi- transepidermal water loss (TEWL) (“in- cals. There was a high correlation re- cally applied products is, however, of sensible water loss,” a measure of the ported between mothers’ use of these concern for infants and young chil- amount of water that passively dif- chemicals and their concentrations in dren, especially preterm infants, in fuses through the epidermis), capaci- human milk. The authors concluded whom the stratum corneum of the epi- tance (a measure of skin hydration), that except for lipsticks (the ingestion dermis is thinner and a less effective rates of absorption and desorption, of which is probably important), their barrier than that of term newborn in- and concentration of water and natu- results agree with studies in animals fants and adults. Well-known toxicity ral moisturizing factor (NMF) in the and humans showing dermal absorp- from percutaneous absorption in in- skin. Infants’ skin had greater hydra- tion of sunscreens. Given that some of fants and children include the adverse tion, greater TEWL, greater water ab-

PEDIATRICS Volume 127, Number 3, March 2011 e803 Downloaded from www.aappublications.org/news by guest on September 26, 2021 sorption and desorption, and lower an insect repellent such as DEET are perience exacerbations of their dis- concentration of NMF. NMFs normally available. Using individual DEET and ease while riding in a car.143 Most take up water; lower levels may con- sunscreen products at the same time states do not allow plastic films with tribute to faster water desorption, is an acceptable practice, but the use less than 35% visible light transmit- which possibly affects barrier func- of combination products is not rec- tance. The minimum allowable visi- tion. The authors concluded that the ommended. A sunscreen should be ble light transmission levels for side unique properties of infant skin con- reapplied after swimming or sweat- and rear windows are determined tinue to persist at least through the ing, whereas insect repellent gener- by each state143 and are available first 12 months of life. In an Italian ally does not need to be reapplied.141 from the International Window Film study,137 TEWL, capacitance, and pH Furthermore, concerns have been Association.144 were measured in 70 infants (8–24 raised about potential toxicity of per- It has been hypothesized that the in- months of age) without skin disease cutaneously absorbed repellents in crease in melanoma in indoor workers and 30 healthy adult women (25–35 children, especially with repeated (but not outdoor workers) during the years of age). TEWL measurements did application.142 last century may be a result of their not differ between the infants and exposure to UVA passing through win- adults. Capacitance values and pH Window Glass dows.145 These researchers agree that were higher in infants. The authors Standard clear window glass absorbs overexposure to UVB initiates mela- concluded that, despite the similari- wavelengths below 320 nm (UVB). UVA, noma but that increased UVA expo- ties in TEWL, differences found in ca- visible light, and infrared radiation are sures (which can cause mutations and pacitance and pH indicated functional transmitted through standard clear break down cutaneous vitamin D ) and immaturity, possibly resulting in in- 3 window glass. Large window areas are low vitamin D concentrations in the creased permeability. 3 now commonly part of residential skin promote melanoma. Infrequently, topical sunscreen agents and commercial architectural design. can have adverse effects, including Modern windows increasingly incor- Sunglasses erythema, itching, burning, or stinging. porate energy-efficient glazes that de- Allergic contact dermatitis and pho- crease heat gain and loss through win- Sunglasses protect against sun glare toallergic and phototoxic reactions oc- dows. Many of these energy-efficient and harmful radiation. The first sun- cur rarely.110 glazes provide some UVR protection, glass standard was published in Aus- tralia in 1971; standards were subse- It is generally recommended that in- but only a few provide full UVR quently adopted in Europe and the fants younger than 6 months be kept protection.143 United States. The latest US sunglass out of direct sunlight. The Australasian Transmission of UVR through automo- standard was published in 2001 by the College of Dermatologists recom- bile glass depends on the type and the American National Standards Institute. mends the use of a sunscreen for in- tint of the glass. Because of safety rea- This standard is voluntary and is not fants when exposure to the sun cannot sons, all windshields are made of lam- followed by all manufacturers.143 be prevented by other avoidance mea- inated glass, a product made stronger sures: “Shade, clothing and broad through bonding with a tough, clear Major US visual health organizations rimmed hats are the best sun protec- plastic. Laminated glass filters out recommend that sunglasses that ab- tion measures for infants. Sunscreens most UVA. Side and rear windows, sorb 97% to 100%146 or 99% to 100%59 should be applied to areas of the skin however, are usually made from non- of the full UV spectrum (up to 400 nm) not protected by clothing.”138 The laminated glass, which allows signifi- should be worn. Expensive sunglasses American Academy of Pediatrics (AAP) cant UVA exposure, especially UVA1. do not necessarily provide better UVR has stated that sunscreen may be used Tinted glass removes more UVA than protection. Purchasing sunglasses on infants younger than 6 months on does clear glass; it is possible for au- that meet standards for a safe level of small areas of skin if adequate cloth- tomobile owners to add tinted window UVR should be the goal. Wearing a hat ing and shade are not available.139 films to side and rear windows to re- with a brim can greatly reduce the UVR Sunscreens may increase absorption duce transmission of light, UVR, and exposure to the eyes and surrounding of the insect repellent DEET (N,N- heat.143 The parts of a driver’s or pas- skin. It is recommended that people dimethyl-metatoluamide), especially senger’s body closest to a window re- wear sunglasses outdoors when work- when DEET is applied first.140 Products ceive the most radiation. Individuals ing, driving, participating in sports, that combine a sunscreen agent with with photosensitivity disorders can ex- taking a walk, or running errands.147

e804 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Sunglasses for infants and children in the liver to 25-hydroxyvitamin D 1,25-dihydroxyvitamin D from circulat- are available. (25[OH]D), which is used to determine ing vitamin D.157 1,25-Dihydroxyvitamin a patient’s vitamin D status; 25(OH)D is D controls more than 200 genes, in- The UV Index metabolized in the kidneys to its active cluding those responsible for regulat- The UV index was developed in 1994 by form, 1,25-dihydroxyvitamin D, also ing cellular proliferation, differentia- the National Weather Service in consul- known as calcitriol. tion, apoptosis, and angiogenesis.150 tation with the US Environmental Pro- Vitamin D synthesis in skin depends on These cell-regulation actions are found tection Agency and the Centers for Dis- skin type. A person with skin type I who at 25(OH)D concentrations higher than ease Control and Prevention. The UV burns easily after a first moderate UVR 75 nmol/L.152 index predicts the intensity of UV light exposure will rapidly achieve maximal Relationships between 25(OH)D status for the following day on the basis of the vitamin D synthesis. In contrast, a per- and markers of functional outcomes in sun’s position, cloud movements, alti- son with skin type VI will have relatively children and adolescents vary accord- 148 tude, ozone data, and other factors. limited vitamin D synthesis, because ing to age, race, environment, and ge- It is conservatively calculated on the UVR will be absorbed by melanin netic predisposition.153,158,159 A study of basis of effects on skin types that burn rather than other cellular targets.149 bone health in Australian adolescent easily. Higher numbers predict more Because excess previtamin D or vita- boys identified a 25(OH)D concentra- intense UV light during midday of the 3 min D is destroyed by sunlight, expo- tion of at least 43 to 55 nmol/L as opti- following day: 0 to 2, minimal; 3 to 4, 3 sure to sunlight does not cause mal.160 Several studies reviewed by low; 5 to 6, moderate; 7 to 9, high; and vitamin D intoxication.150 The action Wagner et al156 noted associations of 10 or higher, very high. Sun-protection spectrum that induces cutaneous vita- low 25(OH)D concentration with in- strategies should be applied at even min D synthesis is in the UVB range.151 creased parathyroid hormone and re- minimal levels of the UV index, and in- 3 duced bone metabolism. Hypovitamin- creasing stringency should be used as Vitamin D Health Effects osis D may reduce maximum peak the UV index increases (eg, avoiding out- Vitamin D is essential for normal bone mass in pubertal girls.161 A sub- door exposures from 10 AM to 4 PM if the 152 sequent study supported these associ- UV index is 7 or higher). The index is avail- growth and skeletal development. At ations for girls,162 but another study re- able online for thousands of cities at a 25(OH)D concentration lower than 50 Ͻ ported a larger gain in bone area and www.weather.com. It is printed in the nmol/L ( 20 ng/mL), children are at 153 bone mineral content for children with weather section of many daily newspa- increased risk of developing rickets ; lower 25(OH)D concentration.163 In a pers and reported through weather re- concentrations below this amount are randomized controlled trial, vitamin D ports of local radio, television, and considered to be deficient. In adults, a supplementation in girls 10 to 17 years weather stations. The UV index can be 25(OH)D concentration of 80 nmol/L of age was associated with higher lean used to plan outdoor activities. (32 ng/mL) is generally recognized as the threshold of an optimal level, and a mass and higher bone mineral con- VITAMIN D concentration of 50 to 79 nmol/L is con- tent.164 Authors of a study of girls 11 to 150,154,155 Sun exposure and vitamin D concen- sidered “insufficient.” The AAP 15 years of age reported calcium ab- trations are intricately intertwined. recommends that pregnant women sorption to be unrelated to 25(OH)D Thus, effects of limiting sun exposure maintain a 25(OH)D concentration of status and to vary according to race; 156 on vitamin D status must be under- 80 nmol/L or higher. relationships between 25(OH)D status stood and addressed. The benefits of vitamin D in adults are and parathyroid hormone were also 165 many and include improved bone found to vary according to race. Metabolism health, prevention of fractures, better In observational studies (ie, studies in Humans get vitamin D from exposure muscle health, and reduced risk of fall- which people are observed or certain to sun, dietary sources (such as forti- ing in older people.150 The actions of outcomes are measured), higher in- fied milk and oily fish), and vitamin vitamin D that extend beyond bone takes of vitamin D via food in preg- supplements. After sunlight exposure, mineral metabolism are increasingly nancy and supplementation in infancy 7-dehydrocholesterol in the skin is being understood. Many human tis- were associated with a lower risk of type 1 diabetes in children.166,167 converted to previtamin D3; previtamin sues, including brain, prostate, breast, D3 is then converted to vitamin D3 and colon, as well as immune cells, Ecologic studies have revealed a lower (cholecalciferol). Vitamin D from the have vitamin D receptors, and some incidence of breast, colon, and pros- skin and diet is metabolized primarily have enzymes capable of producing tate cancers in areas of higher sun ex-

PEDIATRICS Volume 127, Number 3, March 2011 e805 Downloaded from www.aappublications.org/news by guest on September 26, 2021 posure.150,168–170 A recent meta-analysis 90% 25-OH vitamin D of observational studies provided evi- <50 nmol/L 80% <75 nmol/L 76% dence of a decreased risk of colorectal 73% 73% 73% cancer and colorectal adenoma asso- 68% 70% 66% ciated with higher serum 25(OH)D con- centrations.171 The analysis also found 60% 56% nonsignificant reduced risk of breast 50% 50% cancer and no evidence for associa- tion of vitamin D and prostate cancer. 40% 35% Two double-blind placebo-controlled 32% 29% 30% randomized trials with vitamin D sup- 24% plementation at 400 IU (10 ␮g)/day 20% 16% failed to demonstrate effects on colo- 13% 8% rectal172 or breast cancer173 incidence, 10% 8% which suggests that ecologic studies 0% may not adequately control for con- 1–5 y 6–11 y 12–19 y 20–49 y 1–5 y 6–11 y 12–19 y 20–49 y 171 founding variables or that vitamin D Males selameF supplementation needs to be substan- tially higher to achieve a protective ef- FIGURE 1 fect.168,171 Low vitamin D status also is Prevalence of serum 25(OH)D concentrations below selected thresholds according to age and gender: NHANES 2000–2004.183 directly associated with increased all- cause mortality; reasons for this asso- ciation merit further examination.171 ship to cancer prevention171 and son, and higher BMI.181 25(OH)D defi- other outcomes. ciency is common in populations such Ecologic studies have revealed a lower as infants born to mothers at high risk risk of multiple sclerosis in areas of Prevalence of Hypovitaminosis D of hypovitaminosis D; breastfed in- high sun exposures174; dietary vitamin Hypovitaminosis D is common among fants; children with sickle cell disease, D lowers risk of multiple sclerosis,175 US children.181,182 Data from the 2000– possibly through regulating genetic type 1 diabetes, malabsorption, or obe- 2004 NHANES indicate that approxi- susceptibility.176 People with low vita- sity; and those who take medications mately 30% of US teenagers and young min D concentrations are at higher such as anticonvulsants or glucocorti- adults have 25(OH)D deficiency (ie, coids. In US non-Hispanic white adults, risk of insulin resistance and the met- 25[OH]D Ͻ 50 nmol/L), as do approxi- 177 25(OH)D concentrations were 5 to 9 abolic syndrome, future abnormal mately 15% of children 6 to 11 years of 178 nmol/L higher in 1988–1994 compared glucose regulation, periodontal dis- age and 8% of children 1 to 5 years of 179 180 with 2000–2004; increasing BMI, de- ease, diminished heart health, and age (Fig 1).183 Because NHANES data other conditions. To date, however, the creased milk intake, and increased are collected in the South in winter use of sun-protection methods be- relationships between vitamin D sup- months and the North in the summer, tween study periods seemed to be fac- plementation and cancer risks have these national data may underesti- tors accounting for approximately 20% not been evaluated by randomized con- mate seasonal variations in 25(OH)D of the difference.183 trolled trials providing vitamin D at concentrations. The prevalence of hy- doses that would be high enough to povitaminosis D is high among sam- Sun-Exposure Considerations achieve 25(OH)D concentrations similar ples of women in many areas including to those thought to provide protective ef- Australia,184 Bangladesh, and Hong Many factors influence the efficiency of fects. Until such data are available, ques- Kong, where cutaneous vitamin D syn- vitamin D production resulting from tions will remain about the influence of thesis can take place year-round.185,186 sunlight exposures. The amount of skin confounding factors (eg, diet, latitude, exposed to the sun results in differ- skin melanin) on previously reported Risk Factors for Vitamin D ences in vitamin D synthesis. In a 1985 cancer-related outcomes. New random- Deficiency study of young infants in Cincinnati, ized controlled trials are needed to guide Risk factors for hypovitaminosis D in Ohio, who were fully clothed (without the development of guidelines for vi- US youth include increasing age, low hats) and exclusively breastfed, it was tamin D supplementation in relation- vitamin D intake, dark skin, winter sea- determined that 2 hours of sun expo-

e806 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS sure weekly were needed to maintain skinned person living in New York, New stitute of Medicine recommended an 25(OH)D concentrations higher than York, or Boston, Massachusetts. Al- adequate intake level for vitamin D of 27.5 nmol/L, compared with infants though leaders in skin-cancer preven- 200 IU/day.196 An updated report on vi- who were wearing only a diaper, for tion agree that vitamin D is important tamin D from the Institute of Medicine whom only 30 minutes/week of sun ex- for good health, they oppose inten- was released in November 2010.197 posure were required.187 tional sun exposure to induce vitamin However, because 200 IU/day of vita- It has been stated that at least 20% of D production, because UVR is a known min D is insufficient to maintain a 151,190 the body surface needs to be exposed human carcinogen. There are no 25(OH)D concentration higher than 50 to UVB for vitamin D concentrations to studies of children suggesting a level nmol/L, the AAP and others currently recommend that exclusively and par- increase.152 Dark-skinned people re- of sun exposure that would negate the quire exposures approximately 5 to 10 need to comply with dietary vitamin D tially breastfed infants receive supple- ments of 400 IU/day of vitamin D times as long as do light-skinned peo- recommendations. Thus, use of delib- shortly after birth and continue to re- ple to achieve similar levels of cutane- erate sun exposure to maintain vita- ceive these supplements until they are ous vitamin D production.188 At lati- min D sufficiency is not recommended. weaned and consume 1000 mL/day or tudes above 35°N (eg, north of Given the high prevalence of hypovita- more of vitamin D–fortified formula or Memphis, TN; Kyoto, Japan; and minosis D, however, it seems clear that vitamin D–fortified milk.152,156 This level Cyprus) and below 35°S (eg, south of renewed attention must be paid to of supplementation in a breastfed in- Adelaide, South Australia; and Montev- evaluating the adequacy of dietary and fant will generally achieve a 25(OH)D ideo, Uruguay), UVB photons do not supplemental vitamin D intake and concentration of more than 70 nmol/L penetrate to the earth’s surface in win- how much, if any, unprotected sun ex- and prevent vitamin D deficiency rick- ter months, which makes cutaneous vi- posure is beneficial. It is important to ets.151 All nonbreastfed infants who in- tamin D production negligible in those keep in mind that infants younger than gest less than 1000 mL/day of vitamin months. Because of the scatter of UVB, 6 months should be kept out of direct D–fortified formula should receive a vi- sun exposure outside the peak sun sunlight as much as possible. tamin D supplement of 400 IU/day. For- hours of 10 AM to 3 PM in the spring, mulas for term infants sold in the summer, and fall has limited impact on Dietary and Supplemental Vitamin D Recommendations United States generally provide ap- cutaneous vitamin D synthesis.188 It has proximately 400 IU of vitamin D per L, been stated that brief exposures to Many children get less than 400 IU (10 and the majority of vitamin D–only and high overhead sunlight have maximum ␮g) of vitamin D daily from their diets. multivitamin liquid supplements pro- vitamin D benefit with most limited Approximately 22% of US children 1 to vide 400 IU per dose. The AAP also rec- erythema risk.111 8 years of age, 50% of girls 9 to 18 ommends that older children and ado- years of age, and 35% of boys 9 to 18 One author has recommended that lescents who do not obtain 400 IU/day years of age get less than 200 IU (5 ␮g) children and healthy adults practice through vitamin D–fortified milk and of vitamin D daily from food or supple- “sensible sun exposure” (ie, exposure foods should take a 400-IU vitamin D ments.191 No primary care–based of arms and legs for 5–30 minutes, de- supplement daily. The effect of such studies have examined the sensitivity pending on the time of day, season, lat- routine supplementation on 25(OH)D of evaluations of dietary vitamin D itude, and skin pigmentation, between status in children and adolescents has intake or sunlight-exposure assess- 10 AM and 3 PM twice weekly) as a way to not yet been evaluated. The extent to ments to determine vitamin D ade- maintain vitamin D concentrations and which 25(OH)D increases with supple- quacy in children. avoid deficiency.150 This same author mentation will vary depending on the recommended that, after such expo- The main source of vitamin D is expo- amount of vitamin D synthesized over sure, a sunscreen with an SPF-15 or sure to sunlight,192–195 which makes it the summer months and the dosage greater can be applied if the person difficult to establish a dietary require- and duration of use.198 Children at high wishes to remain outdoors.189 In con- ment that has broad generalizability, risk of vitamin D deficiency, such as trast, the American Academy of Der- especially because of the many vari- those with chronic fat malabsorption matology has stated that maximum ables (eg, skin pigmentation, body and those who chronically take antisei- production of vitamin D occurs after mass, season, outdoor exposure, zure medications, may need vitamin D only brief exposure to UVR; this clothing, sunscreen use, etc) associ- doses higher than 400 IU/day,156 and amount of time is 2 to 5 minutes of ated with differences in vitamin D con- studies that have tested supplementa- midday summer exposure for a light- centrations.156 In a 1997 report, the In- tion in special populations have used

PEDIATRICS Volume 127, Number 3, March 2011 e807 Downloaded from www.aappublications.org/news by guest on September 26, 2021 much larger doses safely.199,200 Treat- 2000–2004 NHANES, compared with comes include the possibility that vita- ment of hypovitaminosis D in infants similar subjects in the 1988–1994 min D deficiency results from sun- and toddlers is safely done with 2000 NHANES.183 Other studies of adults screen use; according to the USPSTF, a IU of vitamin D daily for 6 weeks.201 found expected relationships between randomized controlled trial in people reported levels of sun exposure and older than 40 years found that sun- Influence of Vitamin D 25(OH)D concentration but no associa- screen use over the summer had no Supplementation tion between reported sunscreen use effect on 25(OH)D concentrations.207 Several studies have evaluated the in- and 25(OH)D concentration.204,205 Au- There are concerns that sun avoidance fluence of the amount of vitamin D sup- thors of a small, controlled trial that may result in reduced physical ac- plementation on 25(OH)D levels. In involved 24 elderly adult sunscreen us- tivity levels among children and nega- adults, daily supplementation with 400 ers and 19 controls over 2 years re- tive effects on mental health; there IU of vitamin D increases 25(OH)D con- ported that lower 25(OH)D concentra- have been no studies regarding the ef- centration by 7.0 nmol/L.202 Supple- tion in sunscreen users did not result fects of protection behaviors on these mentation of a pregnant woman with in increases in parathyroid hormone outcomes.207 400 IU of vitamin D, as in prenatal vita- or increases in bone biological mark- In a survey of children’s caregivers at- 206 mins, has little effect on her 25(OH)D ers. Sunscreen users generally ap- tending a university-based clinic in concentration.160 For adult men at lati- ply insufficient amounts to meet the ex- Florida, only 30% of caregivers re- tude 41°N, the amount of supplemental pected SPF level. Sunscreen efficacy ported having been counseled by their vitamin D (in addition to dietary vita- also depends on uniform application physician about sun protection. Care- min D) needed to maintain baseline to exposed body parts, the sunscreen’s givers who were counseled had 25(OH)D concentration over the winter durability and substantivity (a mea- greater sun-protection knowledge, was 500 IU/day.202 In a sample of young, sure of the sunscreen’s ability to be were more likely to report regular use healthy adults living at Ն51° latitude, adsorbed by or adhered to the skin of sun protection for their child, and the vitamin D supplemental require- while swimming, bathing, or perspir- were more likely to report teaching ment (in addition to dietary vitamin D) ing), and reapplication. Thus, evalua- their child about sun protection.208 In for 97.5% of the sample to maintain tion of sunscreen use without also surveys of Massachusetts and Texas a 25(OH)D concentration higher than considering other sun-protection mea- pediatricians, approximately three- 25 nmol/L was 348 IU of vitamin D sures may not accurately indicate risk quarters of them indicated that they per day; the supplemental dose of vita- of low 25(OH)D status. recommended safe sun practices or min D required to maintain a 25(OH)D sunscreen use to a majority of their concentration higher than 50 nmol/L PEDIATRICIAN COUNSELING patients. However, the messages they for 97.5% of the sample was 1120 IU Pediatricians can play important roles presented included a limited number of vitamin D per day and was 1644 IU in counseling about sun protection. In of the available sun-protection strate- of vitamin D per day to maintain a a 2003 report, the US Preventive Ser- 209,210 25(OH)D concentration higher than vices Task Force (USPSTF) determined gies. Counseling regarding sun protection is prioritized lower than 80 nmol/L.203 The Institute of Medi- that clinician counseling may have an 209,211 cine report released in November effect on parents’ use of sunscreen for counseling on other safety issues. 2010 provided an extensive review their children but not for using other Time constraints are often mentioned of the effects of vitamin D sun-protection measures such as as a main barrier to providing counsel- 211 supplementation.197 wearing protective clothing, reducing ing. A “teachable moment” may arise excessive sun exposure, avoiding sun- when the child or adolescent presents Influence of Sun Protection lamps/tanning beds, or practicing skin with a sunburn. on 25(OH)D self-examination. The USPSTF noted A few studies of adults, but none of that only limited data exist about EARLY DETECTION children, have examined associations potential harm of counseling or of The US Preventive Services Task Force with sun protection or sunscreen use specific skin-protection behaviors.207 concluded that evidence is insufficient to and 25(OH)D concentrations. Higher Harm could include the possibility that recommend for or against routine use of sun protection was associated focusing on sunscreen use may result screening for skin cancer in adults by with statistically significantly lower in a false sense of security and more using a total-body skin examination for 25(OH)D concentrations in non- time spent in the sun because users do the early detection of cutaneous mela- Hispanic white adult subjects in the not sunburn.119 Other harmful out- noma, BCC, or SCC in people without a

e808 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS history of skin cancer or otherwise at and middle schools (and their caregiv- tices.225 A randomized trial of an high risk.212 However, because early de- ers) how to protect themselves from educational intervention to reduce sun- tection increases survival rates,213,214 it overexposure to the sun. The SunWise burn rates and improve sun-protection has been recommended that complete program has been shown to promote im- behavior in schoolchildren showed no cutaneous examinations be performed provement in knowledge, intentions to difference in sunburn episodes between by physicians and other health care pro- play in the shade and to use sunscreen, the study and control groups.226 viders, coupled with periodic self- and attitudes regarding healthiness of a examination of the skin by the individual tan.217 A recent study of the SunWise pro- PUBLIC HEALTH CAMPAIGNS person.214 Skin lesions with malignant gram demonstrated that every federal Australia, the country with the highest features noted in physical examinations dollar invested in it generates $2 to $4 in incidence of skin cancer in the world, should be biopsied. There are no recom- public health benefits.218 has been in the forefront of the public mendations on skin-cancer screening in health response to this disease. children. Because melanoma occurs in COMMUNITY-BASED PROGRAMS SunSmart, a population-based skin- teenagers and is a common cancer Multicomponent community-wide ap- cancer–prevention program run by the among young adults, it seems prudent to proaches have been recommended by Australian state of Victoria since 1988, recommend that clinicians caring for health education experts219 and can be incorporates substantial public educa- thesegroupsincludeaskinexaminationas effective. Several community-directed tion efforts as well as structural and en- part of a complete physical examination. campaigns have addressed sun protec- vironmental change strategies in tion in younger children. A randomized schools, workplaces, local government PREVENTION IN SCHOOLS controlled trial of the SunSafe project, an settings, and pools. Paid television ad- The Centers for Disease Control and intervention in New England, involved vertising has been part of a strategy of Prevention has published guidelines to schools, child care settings, primary public education. The authors of a recent protect schoolchildren from excessive care offices, and beach settings. The assessment of the SunSmart program sun exposure in schools. Recommen- SunSafe program was effective in chang- concluded that sun-protection methods dations include reducing skin-cancer ing sun-protection practices observed at and rates of sunburn showed substan- risks through policies; creation of community beaches for children 2 to 10 tial general improvement over time but physical, social, and organizational en- years of age.220,221 stalled in recent years. Most initial gains vironments that facilitate protection Use of sun-protection practices begins were sustained over 15 years of assess- from UVR; education of young people; to decline in early adolescence222 as me- ments, but there was no further progress professional development of staff; in- dia and peer influences on teen attitudes with regard to sunburn, sunscreen use, volvement of families; work by nurses and behaviors increase and parental in- body exposure, and attitudes.227 and other school health services staff; fluences decrease.223 A randomized con- In a 2008 editorial, Martin Weinstock, and program evaluation.100 Authors of a trolled trial of the SunSafe program was MD, an internationally known derma- systematic review published in 2004 conducted in 5 intervention and 5 control tologist and researcher, concluded (search updated to June 2000) con- communities to assess the impact of a that data suggest that public health ef- cluded that efforts to teach children how sun education program in the middle forts at skin-cancer prevention are in- to protect themselves from UVR were ef- school years. The SunSafe in the Middle adequate.228 Four challenges to effec- fective when implemented in primary School Years program augmented the tive skin-cancer prevention campaigns schools and in recreational settings. original program by involving sports were identified. First, sun-protection There was insufficient evidence, how- teams and peer-led activities. After 2 messages to avoid or limit time during ever, about the effectiveness of imple- years of intervention, adolescents in in- peak sun hours may conflict with mentation in other settings.215 tervention communities had less of the health-promotion messages regarding Schools have a role in determining chil- expected deterioration in sun-safety physical activity. This potential conflict dren’s attitudes and behaviors. The Sun- practices compared with adolescents in may be resolved by following the “slip, Wise Program, developed by the Environ- control communities.224 slop, slap” motto of the Australians to mental Protection Agency, is a brief, Other interventions were not effective. slip on a shirt, slop on sunscreen, and standardized sun-protection education Australian adults who received solar UV slap on a hat—a message consistent program.216 It is the first environmental forecasts and supporting communica- with conducting outdoor physical ac- education program for sun safety de- tions did not implement markedly en- tivity in a sun-protective manner. Next, signed to teach children in elementary hanced personal sun-protection prac- there is controversy about how much

PEDIATRICS Volume 127, Number 3, March 2011 e809 Downloaded from www.aappublications.org/news by guest on September 26, 2021 sun exposure is needed for vitamin D Morbidity and deaths from skin cancer supplements, and incidental sun expo- synthesis, which possibly results in ex- are preventable. Pediatricians may play sure. Because current intake levels of cessive exposure to sun and deliberate an important role in providing education vitamin D by children and adolescents exposure to artificial UVR. Third, it has about skin-cancer prevention to patients may not prevent vitamin D deficiency, it been reported that skin-cancer risk and their parents, yet many do not take is recommended that all infants, chil- behaviors cluster with other risky be- opportunities to do so. Pediatricians are dren, and adolescents receive 400 IU of haviors, such as smoking and risky urged to provide advice on hundreds of vitamin D per day. Additional vitamin D drinking. A greater understanding of topics,229 so it may be impractical to ex- supplementation and laboratory eval- these behaviors may help with inter- pect pediatricians to discuss skin- uations of vitamin D status may be ventions. Fourth, the increasingly prof- cancer prevention and sun protection needed for some children in some ar- itable tanning industry benefits from during every health-maintenance visit. It eas. Overexposure to UVR from sun- unrestrained selling of UVR. These is, however, reasonable to expect that light and exposure to UVR from artifi- challenges suggest that it is uncertain skin-cancer prevention be discussed on cial sources raise the risk of skin whether primary prevention efforts to at least a few visits during the course of a cancer, photoaging, and other adverse effects and should be avoided. reduce skin cancer through UVR pro- pediatrician’s long-term relationship tection will be successful. with a child and his or her family. Be- cause parents’ comprehensive sun- LEAD AUTHOR RESEARCH NEEDS Sophie J. Balk, MD–Former Chairperson, AAP protection practices for children start Outstanding research questions exist in Committee on Environmental Health to decline when children are very many areas, including relationships of 230 COUNCIL ON ENVIRONMENTAL HEALTH, sunscreen use to melanoma and BCC; young, it is important to begin dis- cussions early in the child’s life. Dis- 2010–2011 safety of absorbed ingredients in sun- Helen J. Binns, MD, MPH, Chairperson screens; effects of long-term use of sun- cussions are especially important for Heather L. Brumberg, MD, MPH screen, especially when this practice be- children at high risk of developing skin Joel A. Forman, MD cancer—children with light skin, Catherine J. Karr, MD, PhD gins early in life; the role of vitamin D in Kevin C. Osterhoudt, MD, MSCE preventing cancer and other health con- those with nevi and/or freckling, and Jerome A. Paulson, MD ditions; the relationship of 25(OH)D to those with a family history of mela- Megan T. Sandel, MD noma. Melanoma is rare in children, James M. Seltzer, MD functional outcomes for children; devel- Robert O. Wright, MD, MPH oping and assessing strategies for esti- but moles are not rare. Education can mating vitamin D status during a clinical include a discussion of moles and the LIAISONS encounter; determining how much sun need to be aware of changes in them. As Mary Mortensen, MD, MS – Centers for children approach puberty, it is impor- Disease Control and Prevention/National exposure and vitamin D supplementa- Center for Environmental Health tion is “enough” depending on a person’s tant to include information about the Sharon Savage, MD – National Cancer Institute age and gender, his or her geographic dangers of artificial tanning. Pediatri- Walter J. Rogan, MD – National Institute of location, the season of the year, and cians also have an important role as ad- Environmental Health Sciences other factors; effects of long-term use of vocates in helping to support legislation STAFF vitamin D supplementation at various to ban minors’ access to tanning salons. Paul Spire [email protected] levels; and utility of routine counsel- Lifelong sun protection is recommended ing on sun-avoidance strategies in beginning at an early age. Although sun- SECTION ON DERMATOLOGY, clinical encounters. screen is the most commonly used 2010–2011 CONCLUSIONS method of sun protection, patients Michael L. Smith, MD, Chairperson Richard Antaya, MD should be counseled to not overly rely on UVR is a known human carcinogen and Bernard A. Cohen, MD sunscreen. A complete program of sun has numerous other adverse health ef- Sheila Fallon Friedlander, MD protection includes wearing clothing Fred E. Ghali, MD fects. Skin-cancer rates have reached Albert C. Yan, MD epidemic proportions, and skin cancers and hats, timing activities to minimize occur in young people and sometimes peak hours of the sun, and wearing sun- FORMER EXECUTIVE COMMITTEE result in death. Excessive exposure to glasses. Advice should be framed in the CHAIRPERSON Daniel P. Krowchuk, MD UVR during childhood and adolescence context of promoting regular outdoor play and other physical activity. is thought to confer an increased STAFF risk of developing skin cancer. Vitamin D is available through foods, Lynn Colegrove, MBA

e810 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS

REFERENCES

1. International Agency for Research on Can- skin cancers? Available at: www.cancer.org/ the skin. Available at: www.seer.cancer. cer. IARC Monographs on the Evaluation of cancer/skincancer-basalandsquamouscell/ gov/statfacts/html/melan.html. Accessed Carcinogenic Risks to Humans. Volume 55: detailedguide/skin-cancer-basal-and- February 8, 2011 Solar and Ultraviolet Radiation. Summary squamous-cell-key-statistics. Accessed Feb- 28. Rigel DS. Cutaneous ultraviolet exposure of Data Reported and Evaluation. Geneva, ruary 8, 2011 and its relationship to the development of Switzerland: World Health Organization; 16. Gallagher RP, Ma B, McLean DI, et al. skin cancer. J Am Acad Dermatol. 2008; 1997. Available at: http://monographs. Trends in basal cell carcinoma, squamous 58(5 suppl 2):S129–S132 iarc.fr/ENG/Monographs/vol55/volume55. cell carcinoma, and melanoma of the skin 29. American Cancer Society. How many people pdf. Accessed February 8, 2011 from 1973 through 1987. J Am Acad Der- get melanoma? Available at: www.cancer. 2. Kullavanijaya P, Lim HW. Photoprotection. matol. 1990;23(3 pt 1):413–421 org/Cancer/Skincancer-Melanoma/Detailed J Am Acad Dermatol. 2005;52(6):937–958 17. Harris RB, Griffith K, Moon TE. Trends in the guide/melanoma-skin-cancer-key-statistics. 3. Gilchrest BA. Actinic injury. Annu Rev Med. incidence of nonmelanoma skin cancers Accessed February 8, 2011 1990;41:199–210 in southeastern Arizona, 1985–1996. JAm 30. Wu X, Groves FD, McLaughlin CC, Jemal A, 4. World Metereological Organization. WMO Acad Dermatol. 2001;45(4):528–536 Martin J, Chen VS. Cancer incidence pat- UV radiation site. What is UV? Available at: 18. Karagas MR, Greenberg ER, Spencer SK, terns among adolescents and young http://uv.colorado.edu/what.html. Ac- Stukel TA, Mott LA. Increase in incidence adults in the United States. Cancer Causes cessed February 8, 2011 rates of basal cell and squamous cell skin Control. 2005;16(3):309–320 5. Fitzpatrick TB. The validity and practicality cancer in New Hampshire, USA. New 31. Purdue MP, Beane Freeman LE, Anderson of sun-reactive skin types I through VI. Hampshire Skin Cancer Study Group. Int J WF, Tucker MA. Recent trends in incidence Arch Dermatol. 1988;124(6):869–871 Cancer. 1999;81(4):555–559 of cutaneous melanoma among US Cauca- 6. Diffey BL. Ultraviolet radiation and human 19. American Cancer Society. What causes sian young adults. J Invest Dermatol. 2008; health. Clin Dermatol. 1998;16(1):83–89 basal and squamous cell skin cancer? 128(12):2905–2908 7. Gilchrest BA, Eller MS, Geller AC, Yaar M. Available at: www.cancer.org/Cancer/ 32. Koomen ER, Joosse A, Herings RMC, Caspa- The pathogenesis of melanoma induced by SkinCancer-BasalandSquamousCell/ rie MK, Guchelaar J, Nijsten T. Estrogens, ultraviolet radiation. N Engl J Med. 1999; OverviewGuide/skin-cancer-basal-and- oral contraceptives and hormone replace- 340(17):1341–1348 squamous-cell-overview-what-causes. ment therapy increase the incidence of cu- taneous melanoma: a population-based 8. Woo DK, Eide MJ. Tanning beds, skin can- Accessed February 8, 2011 case-control study. Ann Oncol. 2009;20(2): cer, and vitamin D: an examination of the 20. Sasson M, Mallory SB. Malignant primary 358–364 scientific evidence and public health impli- skin tumors in children. Curr Opin Pediatr. 33. Strouse JJ, Fears TR, Tucher MA, Wayne AS. cations. Dermatol Ther. 2010;23(1):61–71 1996;8(4):372–377 Pediatric melanoma: risk factor and sur- 21. Christenson LJ, Borrowman TA, Vachon 9. Pillai S, Oresejo P, Hayward J. Ultraviolet vival analysis of the surveillance, epidemi- CM, et al. Incidence of basal cell and squa- radiation and skin aging: roles of reactive ology and end results database. J Clin On- mous cell carcinomas in a population oxygen species, inflammation and pro- col. 2005;23(21):4735–4741 tease activation, and strategies for pre- younger than 40 years. JAMA. 2005;294(6): 34. Karlsson P, Boeryd B, Sander B, Wester- vention of inflammation-induced matrix 681–690 mark P, Rosdahl I. Increasing incidence of degradation: a review. Int J Cosmet Sci. 22. Emmett AJ. Surgical analysis and biologi- cutaneous malignant melanoma in chil- 2005;27(1):17–34 cal behaviour of 2277 basal cell carcino- dren and adolescents 12–19 years of age mas. AustNZJSurg. 1990;60(11):855–863 10. Wlaschek M, Tantcheva-Poór I, Naderi L, et in Sweden 1973–92. Acta Derm Venereol. al. Solar UV irradiation and dermal photo- 23. Scrivener Y, Grosshans E, Cribier B. Varia- 1998;78(4):289–292 aging. J Photochem Photobiol B. 2001; tions of basal cell carcinomas according 35. Karlsson PM, Fredrikson M. Cutaneous 63(1–3):41–51 to gender, age, location and histopatho- malignant melanoma in children and ado- logical subtype. Br J Dermatol. 2002; 11. Weston WL, Lane AT, Morelli JG. Drug erup- lescents in Sweden, 1993–2002: the in- tions. InColor Textbook of Pediatric Der- 147(1):41–47 creasing trend is broken. Int J Cancer. matology. St Louis, MO; Mosby; 2002: 24. Boyd AS, Shyr Y, King LE Jr. Basal cell car- 2007;121(2):323–328 287–297 cinoma in young women: an evaluation of 36. Ferrari A, Bono A, Baldi M, et al. Does mel- 12. Lankerani L, Baron ED. Photosensitivity to the association of tanning bed use and anoma behave differently in younger chil- exogenous agents. J Cutan Med Surg. smoking. J Am Acad Dermatol. 2002;46(5): dren than in adults? A retrospective study 2004;8(6):424–431 706–709 of 33 cases of childhood melanoma from a 13. eMedicine from WebMD. Plant poisoning, 25. Markovic SN, Erickson LA, Rao RD, et al. single institution. Pediatrics. 2005;115(3): phytophototoxins. Available at: www. Malignant melanoma in the 21st century, 649–654 emedicine.com/emerg/byname/plant- part 1: epidemiology, risk factors, screen- 37. American Academy of Dermatology. ABC- poisoning-phytophototoxins.htm. Ac- ing, prevention, and diagnosis. Mayo Clin DEs of melanoma detection. Available at: cessed February 8, 2011 Proc. 2007;82(3):364–380 www.aad.org/public/exams/abcde.html. 14. Obermoser G, Zelger B. Triple need for 26. Jemal A, Siegel R, Ward E, et al. Cancer Accessed February 8, 2011 photoprotection in lupus erythematosis. statistics, 2009. CA Cancer J Clin. 2009; 38. Marrot L, Meunier J. Skin DNA photodam- Lupus. 2008;17(6):525–527 59(4):225–249 age and its biological consequences. JAm 15. American Cancer Society. What are the key 27. Surveillance Epidemiology and End Re- Acad Dermatol. 2008;58(5 suppl 2): statistics about basal and squamous cell sults. SEER stat fact sheets: melanoma of S139–S148

PEDIATRICS Volume 127, Number 3, March 2011 e811 Downloaded from www.aappublications.org/news by guest on September 26, 2021 39. Mitchell DL, Nairn RS. The biology of the ily history as risk factors for cutaneous a systematic review [published correction (6-4) photoproduct. Photochem Photobiol. malignant melanoma. J Natl Cancer Inst. appears in Int J Cancer. 2007;120(11): 1989;49(6):805–819 1984;72(2):257–266 2526]. Int J Cancer. 2007;120(5): 40. Ley RD. Ultraviolet radiation A-induced pre- 54. Krengel S, Hauschild A, Schafer T. Mela- 1116–1122 cursors of cutaneous melanoma in Mono- noma risk in congenital melanocytic naevi: 69. Levine JA, Sorace M, Spencer J, Siegel D. delphis domestica. Cancer Res. 1997; a systematic review. Br J Dermatol. 2006; The indoor UV tanning industry: a review of 57(17):3682–3684 155(1):1–8 skin cancer risk, health benefit claims. J 41. de Gruijl FR, Sterenborg HJ, Forbes PD, Da- 55. Naeyaert JM, Brochez L. Dysplastic nevi. N Am Acad Dermatol. 2005;53(6):1038–1044 vies RE, Cole C, Kelfkens G. Wavelength de- Engl J Med. 2003;349(23):2233–2240 70. Demko CA, Borawski EA, Debanne SM, Coo- pendence of skin cancer induction by ul- 56. Clark WH Jr. The dysplastic nevus syn- per KD, Stange KC. Use of indoor tanning traviolet irradiation of albino hairless drome. Arch Dermatol. 1988;124(8): facilities by white adolescents in the mice. Cancer Res. 1993;53(1):53–60 1207–1210 United States. Arch Pediatr Adolesc Med. 42. Bennett DC. Ultraviolet wavebands and 57. Tucker MA, Fraser MC, Goldstein AM, et al. 2003;157(9):854–860 melanoma initiation. Pigment Cell Mela- A natural history of melanomas and dys- 71. Cokkinides VE, Weinstock MA, O’Connell noma Res. 2008;21(5):520–524 plastic nevi: an atlas of lesions in MC, Thun MJ. Use of indoor tanning sun- 43. Atillasoy ES, Seykora JT, Soballe PW, et al. melanoma-prone families. Cancer. 2002; lamps by US youth, ages 11–18 years, and UVB induces atypical melanocytic lesions 94(12):3192–3209 by their parent or guardian caregivers: and melanoma in human skin. Am J Pathol. 58. American Optometric Association. State- prevalence and correlates. Pediatrics. 1998;152(5):1179–1186 ment on Ocular Ultraviolet Radiation Haz- 2002;109(6):1124–1130 44. Taylor AM, McConville CM, Byrd PJ. Cancer ards in Sunlight. St Louis, MO: American 72. Geller AC, Colditz G, Oliveria S, et al. Use of and DNA processing disorders. Br Med Optometric Association; 1993 sunscreen, sunburning rates, and tanning Bull. 1994;50(3):708–717 59. American Optometric Association. UV pro- bed use among more than 10 000 US chil- 45. Jablonski NG, Chaplin G. The evolution of tection. Available at: www.aoa.org/uv- dren and adolescents. Pediatrics. 2002; human skin coloration. J Hum Evol. 2000; protection.xml. Accessed February 8, 2011 109(6):1009–1014 39(1):57–106 60. Wong SC, Eke T, Ziakas NG. Eclipse burns: a 73. O’Riordan DL, Field AE, Geller AC, et al. Fre- 46. Armstrong BK, Kricker A. The epidemiology prospective study of solar retinopathy fol- quent tanning bed use, weight concerns, of UV induced skin cancer. J Photochem lowing the 1999 solar eclipse. Lancet. and other health risk behaviors in adoles- Photobiol B. 2001;63(1–3):8–18 2001;357(9251):199–200 cent females (United States). Cancer 47. de Gruijl FR, van Kranen HJ, Mullenders LH. 61. American Academy of Ophthalmology. Causes Control. 2006;17(5):679–686 UV-induced DNA damage, repair, muta- What are cataracts? Available at: www. 74. Warthan MM, Uchida T, Wagner RF. UV light tions and oncogenic pathways in skin can- aao.org/eyesmart/know/cataracts.cfm. tanning as a type of substance-related dis- cer. J Photochem Photobiol B. 2001; Accessed February 8, 2011 order. Arch Dermatol. 2005;141(8): 63(1–3):19–27 62. Gallagher RP, Lee TK. Adverse effects of ul- 963–966 48. Godar DE, Wengraitis SP, Shreffler J, Sliney traviolet radiation: a brief review. Prog 75. Feldman SR, Liguori A, Kucenic M, et al. DH. UV doses of Americans. Photochem Biophys Mol Biol. 2006;92(1):119–131 Ultraviolet exposure is a reinforcing stim- Photobiol. 2001;73(6):621–629 63. Shah CP, Weis E, Lajous M, Shields JA, ulus in frequent indoor tanners. J Am Acad 49. Whiteman DC, Whiteman CA, Green AC. Shields CL. Intermittent and chronic ultra- Dermatol. 2004;51(1):45–51 Childhood sun exposure as a risk factor violet light exposure and uveal melanoma: 76. Kaur M, Liguori A, Lang W, Rapp SR, Fleis- for melanoma: a systematic review of epi- a meta-analysis. Ophthalmology. 2005; cher AB Jr, Feldman SR. Induction of demiologic studies. Cancer Causes Con- 112(9):1599–1607 withdrawal-like symptoms in a small ran- trol. 2001;12(1):69–82 64. Singh AD, Rennie IG, Seregard S, Giblin M, domized, controlled trial of opioid block- 50. Pfahlberg A, Kolmel KF, Gefeller O. Timing McKenzie J. Sunlight exposure and patho- ade in frequent tanners. J Am Acad Derma- of excessive ultraviolet radiation and genesis of uveal melanoma. Surv Ophthal- tol. 2006;54(4):709–711 melanoma: epidemiology does not sup- mol. 2004;49(4):419–428 77. Mosher CE, Danoff-Burg S. Addiction to in- port the existence of a critical period of 65. Ullrich SE. Sunlight and skin cancer: les- door tanning: relation to anxiety, depres- high susceptibility to solar ultraviolet sons from the immune system. Mol Car- sion, and substance use. Arch Dermatol. radiation-induced melanoma. Br J Derma- cinog. 2007;46(8):629–633 2010;146(4):412–417 tol. 2001;144(3):471–475 66. Ho WL, Murphy GM. Update on the patho- 78. Autier P. Perspectives in melanoma pre- 51. Vincent TL, Gatenby RA. An evolutionary genesis of post-transplant skin cancer in vention: the case of sunbeds. Eur J Cancer. model for initiation, promotion, and pro- renal transplant recipients. Br J Dermatol. 2004;40(16):2367–2376 gression in carcinogenesis. Int J Oncol. 2008;158(2):217–224 79. US Department of Health and Human Ser- 2008;32(4):729–737 67. Hollenbeak CS, Todd MM, Billingsley EM, vices, Public Health Service, National Toxi- 52. Gallagher RP, McLean DI, Yang CP, et al. Harper G, Dyer A, Lengerick EJ. Increased cology Program. Eleventh report on Suntan, sunburn, and pigmentation fac- incidence of melanoma in renal transplant carcinogens: exposure to sunbeds or sun- tors and the frequency of acquired mela- patients. Cancer. 2005;104(9):1962–1967 lamps. Available at: http://ntp.niehs.nih. nocytic nevi in children: similarities to 68. International Agency for Research on Can- gov/ntp/roc/eleventh/profiles/s183uvrr. melanoma—the Vancouver Mole Study. cer Working Group on Artificial Ultraviolet pdf. Accessed February 8, 2011 Arch Dermatol. 1990;126(6):770–776 (UV) Light and Skin Cancer. The associa- 80. Karagas M, Stannard VA, Mott LA, Slattery 53. Holman CD, Armstrong BK. Pigmentary tion of use of sunbeds with cutaneous ma- MJ, Spencer SK, Weinstock MA. Use of tan- traits, ethnic origin, benign nevi, and fam- lignant melanoma and other skin cancers: ning devices and risk of basal cell and

e812 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS

squamous cell skin cancers. J Natl Cancer ning. J Am Acad Dermatol. 2004;50(5): sumer alert: sun-protective clothing— Inst. 2002;94(3):224–226 706–713 wear it well. Available at: www.ftc.gov/bcp/ 81. Veierød MB, Weiderpass E, Thorn M, et al. A 94. Brooks K, Brooks D, Dajani Z, et al. Use of edu/pubs/consumer/alerts/alt094.shtm. prospective study of pigmentation, sun ex- artificial tanning products among young Accessed February 8, 2011 posure and risk of cutaneous malignant adults. J Am Acad Dermatol. 2006;54(6): 106. Hall HI, Jorgensen CM, McDavid K, Kraft JM, melanoma in women. J Natl Cancer Inst. 1060–1066 Breslow R. Protection from sun exposure 2003;95(20):1530–1538 95. Beckmann KR, Kirke BA, McCaul KA, Roder in US white children ages 6 months to 11 82. Indoor Tanning Association. Promoting re- DM. Use of fake tanning lotions in the years. Public Health Rep. 2001;116(4): sponsible sun care and sun burn preven- South Australian population. Med J Aust. 353–361 tion. Available at: www.theita.com. Ac- 2001;174(2):75–78 107. Johnson K, Davy L, Boyett T, Weathers L, cessed February 8, 2011 96. Davis KJ, Cokkinides VE, Weinstock MA, Roetzheim RG. Sun protection practices for children: knowledge, attitudes, and 83. Indoor Tanning Association. Mission state- O’Connell MC, Wingo PA. Summer sunburn parent behaviors. Arch Pediatr Adolesc ment. Available at: www.theita.com/ and sun exposure among US youths ages Med. 2001;155(8):891–896 ?pageϭMission_Statement. Accessed 11 to 18: national prevalence and associ- February 8, 2011 ated factors. Pediatrics. 2002;110(1 pt 1): 108. Robinson JK, Rigel DS, Amonette RA. 27–35 Trends in sun exposure knowledge, atti- 84. World Health Organization. Sunbeds, tan- tudes, and behaviors: 1986 to 1996. JAm ning and UV exposure. Available at: www. 97. Cokkinides V, Weinstock M, Glanz K, Albano Acad Dermatol. 1997;37(2 pt 1):179–186 who.int/mediacentre/factsheets/fs287/ J, Ward E, Thun M. Trends in sunburns, sun en. Accessed February 8, 2011 protection practices, and attitudes toward 109. Robinson JK, Rigel DS, Amonette RA. Sum- sun exposure protection and tanning mertime sun protection used by adults for 85. American Medical Association. Policy among US adolescents, 1998–2004. Pedi- their children. J Am Acad Dermatol. 2000; D-440.960. Protect children from skin can- atrics. 2006;118(3):853–856 42(5 pt 1):746–753 cer. Available at: www.ama-assn.org/ad- 110. A new sunscreen agent [published correc- com/polfind/Directives.pdf. Accessed Feb- 98. Stern RS, Weinstein MC, Baker SG. Risk re- tion appears in Med Lett Drugs Ther. 2007; ruary 8, 2011 duction for nonmelanoma skin cancer with childhood sunscreen use. Arch Der- 49(1271):84]. Med Lett Drugs Ther. 2007; 86. American Academy of Dermatology; AAD matol. 1986;122(5):537–545 49(1261):41–43 Association. Indoor tanning. Available at: 111. Sayre RM, Dowdy JC. Darkness at noon: www.aad.org/members/media/_doc/ 99. American Cancer Society. Skin cancer pre- sunscreens and vitamin D . Photochem Indoor%20Tanning%202007%20-%20FINAL. vention and early detection. Available at: 3 Photobiol. 2007;83(2):459–463 doc. Accessed February 8, 2011 www.cancer.org/docroot/PED/content/ ped_7_1_Skin_Cancer_Detection_What_ 112. Prevention and treatment of sunburn. 87. Dellavalle RP, Parker ER, Cersonsky N, et al. You_Can_Do.asp?siteareaϭ&levelϭ. Ac- Med Lett Drugs Ther. 2004;46(1184):45–46 Youth access laws: in the dark at the tan- cessed February 8, 2011 113. Skin Cancer Foundation. Sunscreens ex- ning parlor? Arch Dermatol. 2003;139(4): 100. Glanz K, Saraiya M, Wechsler H; Centers for plained. Available at: www.skincancer. 443–448 Disease Control and Prevention. Guide- org/sunscreens-explained.html. Accessed 88. National Conference of State Legislatures. Tan- lines for school programs to prevent skin February 8, 2011 ning restrictions for minors: a state-by-state cancer. MMWR Recomm Rep. 2002;51(RR- 114. US Food and Drug Administration, Center comparison. Available at: www.ncsl.org/ 4):1–16. Available at: www.cdc.gov/mmwr/ for Drug Evaluation and Research. FDA programs/health/tanningrestrictions.htm. Ac- preview/mmwrhtml/rr5104a1.htm. Ac- aims to update sunscreen labeling. Avail- cessed February 8, 2011 cessed February 8, 2011 able at: www.fda.gov/ForConsumers/ 89. Balk SJ, Geller AC. Teenagers and artificial 101. US Department of Health and Human Ser- ConsumerUpdates/ucm049091.htm. Ac- tanning. Pediatrics. 2008;121(5): vices. Healthy People 2010. Available at: cessed February 8, 2011 1040–1042 www.healthypeople.gov/Document/pdf/ 115. Sunscreens: an update. Med Lett Drugs 90. Indoor Tanning Association. Help defeat Volume1/03Cancer.pdf. Accessed Febru- Ther. 2008;50(1294):70–72 the Ohio under 18 ban. Available at: www. ary 8, 2011 116. Thompson SC, Jolley D, Marks R. Reduction ϭ theita.com/?page Press_Releases. Ac- 102. National Council on Skin Cancer Preven- of solar keratoses by regular sunscreen cessed February 8, 2011 tion. Skin cancer prevention tips. Available use. N Engl J Med. 1993;329(16):1147–1151 91. Mayer JA, Hoerster KD, Pichon LC, Rubio at: www.skincancerprevention.org/skin- 117. Naylor MF, Boyd A, Smith DW, Cameron GS, DA, Woodruff SI, Forster JL. Enforcement of cancer/prevention-tips. Accessed Febru- Hubbard D, Nelder KH. High sun protection state indoor tanning laws in the United ary 8, 2011 factor sunscreens in the suppression of States. Prev Chronic Dis. 2008;5(4):. Avail- 103. Autier P, Dore JF, Cattaruzza MS, et al. Sun- actinic neoplasia. Arch Dermatol. 1995; able at: www.cdc.gov/pcd/issues/2008/ screen use, wearing clothes, and number 131(2):170–175 oct/07_0194.htm. Accessed February 8, of nevi in 6- and 7-year old European chil- 118. Green A, Williams G, Neale R, et al. Daily 2011 dren. J Natl Cancer Inst. 1998;90(24): sunscreen application and betacarotene 92. National Toxicology Program. Executive 1873–1880 supplementation in prevention of basal- summary dihydroxyacetone (96-26-4). 104. US Federal Trade Commission. Facts for cell and squamous-cell carcinomas of the Available at: http://ntp.niehs.nih.gov/ consumers: sunscreens and sun- skin: a randomised controlled trial [pub- index.cfm?objectidϭ6F5E9EA5-F1F6-975E- protective clothing. Available at: www.ftc. lished correction appears in Lancet. 1999; 767789EB9C7FA03C. Accessed February 8, gov/bcp/edu/pubs/consumer/health/ 354(9183):1038]. Lancet. 1999;354(9180): 2011 hea14.shtm. Accessed February 8, 2011 723–729 93. Fu JM, Duxza SW, Halpern AH. Sunless tan- 105. US Federal Trade Commission. FTC con- 119. Autier P, Dore JF, Negrier, et al. Sunscreen

PEDIATRICS Volume 127, Number 3, March 2011 e813 Downloaded from www.aappublications.org/news by guest on September 26, 2021 use and duration of sun exposures: a productive hormone levels in humans. J content/full/e200399. Accessed February double-blind randomized trial. J Natl Can- Invest Dermatol. 2004;123(1):57–61 8, 2011 cer Inst. 1999;91(15):1304–1309 130. Schlumpf M, Kypkec K, Vöktd CC, et al. En- 143. Tuchinda C, Srivannaboon S, Lim HW. Pho- 120. American College of Preventive Medicine. docrine active UV filters: developmental toprotection by window glass, automobile Skin protection from ultraviolet light toxicity and exposure through breast milk. glass, and sunglasses. J Am Acad Derma- exposure: American College of Preventive Chimia (Aarau). 2008;62:345–351 tol. 2006;54(5):845–854 Medicine practice policy statement. Avail- 131. National Toxicology Program. 11th Report 144. International Window Film Association. able at: www.acpm.org/skinprot.htm. Ac- on Carcinogens (RoC). Available at: http:// State window tinting rules & laws cessed February 8, 2011 ntp.niehs.nih.gov/?objectidϭ035E5806- chart. Available at: www.iwfa.com/ 121. Huncharek M, Kupelnick B. Use of topical F735-FE81-FF769DFE5509AF0A. Accessed PreProduction_copy(1)/consumer_info/ sunscreens and the risk of malignant February 8, 2011 auto_statelaws.html. Accessed February melanoma: a meta-analysis of 9067 pa- 132. Baier-Anderson C. Burning questions: are 8, 2011 tients from 11 case-control studies. Am J sunscreens containing nanomaterials 145. Godar DE, Landry RJ, Lucas AD. Increased Public Health. 2002;92(7):1173–1177 safe? Available at: http://environmental UVA exposures and decreased cutaneous 122. Dennis LK, Beane Freeman LE, VanBeek MJ. defenseblogs.org/nanotechnology/2008/07/ vitamin D3 levels may be responsible for Sunscreen use and the risk for melanoma: 16/burning-questions-are-sunscreens- the increasing incidence of melanoma. a quantitative review. Ann Intern Med. containing-nanomaterials-safe. Accessed Feb- Med Hypotheses. 2009;72(4):434–443 2003;139(12):966–978 ruary 8, 2011 146. American Academy of Ophthalmology. This 123. American Academy of Dermatology. 133. Mancini AJ. Skin. Pediatrics. 2004;113(4 summer keep an eye on UV safety. Avail- Sunscreens/sunblocks. Available at: www. suppl):1114–1119 able at: www.aao.org/newsroom/release/ 20070629.cfm. Accessed February 8, 2011 aad.org/public/publications/pamphlets/ 134. West DP, Worobec S, Solomon LM. Pharma- sun_sunscreens.html. Accessed February cology and toxicology of infant skin. J In- 147. American Optometric Association. Shop- 8, 2011 vest Dermatol. 1981;76(3):147–150 ping guide for sunglasses. Available at: http://aoa.org/documents/SunglassShopping 124. Jiang R, Roberts MS, Collins DM, Benson 135. Harpin VA, Rutter N. Barrier properties of Guide0810.pdf. Accessed February 8, 2011 HAE. Absorption of sunscreens across hu- the newborn infant skin. J Pediatr. 1983; 148. National Weather Service Climate Pre- man skin: an evaluation of commercial 102(3):419–425 products for children and adults. Br J Clin diction Center. UV index: information. 136. Nikolovski J, Stamatas G, Kollias N, Wie- Pharmacol. 1999;48(4):635–637 Available at: www.cpc.ncep.noaa.gov/ gand B. Barrier function and water- 125. Calafat AM, Wong LY, Ye X, Reidy JA, Need- products/stratosphere/uv_index/uv_ holding and transport properties of infant ham JL. Concentrations of the sunscreen what.shtml. Accessed February 8, 2011 stratum corneum are different from adult agent benzophenone-3 in residents of the 149. Gilchrest BA. Sun protection and vitamin D: and continue to develop through the first United States: National Health and Nutri- three dimensions of obfuscation. J Steroid year of life. J Invest Dermatol. 2008;128(7): tion Examination Survey 2003–2004. Envi- Biochem Mol Biol. 2007;103(3–5):655–663 1728–1736 ron Health Perspect. 2008;116(7):893–897 150. Holick MF. Vitamin D deficiency. N Engl J 137. Giusti F, Martella A, Bertoni L, Seidenari S. 126. National Toxicology Program. NTP Techni- Med. 2007;357(3):266–281 Skin barrier, hydration, Ph of skin of in- cal Report on Toxicity Studies of 2-Hydroxy- 151. Lim HW, Carucci JA, Spencer JM, Rigel DS. fants under two years of age. Pediatr Der- 4-methoxybenzophenone (CAS Number: Commentary: a responsible approach to matol. 2001;18(2):93–96 131-57-7) Administered Topically and in maintaining adequate serum vitamin D Dosed Feed to F344/N Rats and B6C3F1 138. Australasian College of Dermatologists. levels. J Am Acad Dermatol. 2007;57(4): Mice. Research Triangle Park, NC: National A-Z of skin: baby & toddler protection. 594–595 Available at: www.dermcoll.asn.au/public/ Toxicology Program, National Institute of 152. Misra M, Pacaud D, Petryk A, Paulo Collett- a-z_of_skin-baby_toddler_protection.asp. Environmental Health Sciences, US Depart- Solberg F, Kappy M; Drug and Therapeutics Accessed February 8, 2011 ment of Health and Human Services; 1992. Committee of the Lawson Wilkins Pediatric Available at: http://ntp.niehs.nih.gov/ntp/ 139. American Academy of Pediatrics. Pediatric Endocrine Society. Vitamin D deficiency in htdocs/ST_rpts/tox021.pdf. Accessed Feb- Environmental Health. Etzel RA, Balk SJ, children and its management: review of ruary 8, 2011 eds. 2nd ed. Elk Grove Village, IL: American current knowledge and recommenda- 127. Schlumpf M, Cotton B, Conscience M, Academy of Pediatrics; 2003 tions. Pediatrics. 2008;122(2):398–417 Haller V, Steinmann B, Lichtensteiger W. In 140. Wang T, Gu X. In vitro percutaneous perme- 153. Greer FR. 25-Hydroxyvitamin D: functional vitro and in vivo estrogenicity of UV ation of the repellant DEET and the sun- outcomes in infants and young children. screens. Environ Health Perspect. 2001; screen oxybenzone across human skin. J Am J Clin Nutr. 2008;88(2):529S–533S 109(3):239–244 Pharm Pharm Sci. 2007;10(1):17–25 154. Bischoff-Ferrari HA, Giovannucci E, Willett 128. Wolff MS, Engel SM, Berkowitz GS, et al. 141. Roberts Jr, Weil WB Jr, Shannon MW. DEET WC, Dietrich R, Dawson-HushesB. Estima- Prenatal phenol and phthalate exposures alternatives considered to be effective tion of optimal serum concentration of 25- and birth outcomes. Environ Health Per- mosquito repellents. AAP News. June 6, hydroxyvitamin D for multiple health out- spect. 2008;116(8):1092–1097 2005;26:15 comes [published corrections appear in 129. Janjua NR, Mogensen B, Andersson A, et al. 142. American Academy of Pediatrics, Commit- Am J Clin Nutr. 2006;84(5):1253 and Am J Systemic absorption of the sunscreens tee on Environmental Health. Follow safety Clin Nutr. 2007;86(3):809]. Am J Clin Nutr. benzophenone-3, octyl-methoxycinnamate, precautions when using DEET on children. 2006;84(1):18–28 and 3-(4-methyl-benzylidene) camphor af- AAP News. May 2003. Available at: http:// 155. Dawson-Hughes B, Heaney RP, Holick MF, ter whole-body topical application and re- aapnews.aappublications.org/cgi/ Lips P, Meunier PJ, Vieth R. Estimates of

e814 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS

optimal vitamin D status. Osteoporos Int. Vitamin D and prevention of colorectal hydroxy-vitamin D3 and periodontal dis- 2005;16(7):713–716 cancer. J Steroid Biochem Mol Biol. 2005; ease in the US population. Am J Clin Nutr. 156. Wagner CL, Greer FR; American Academy of 97(1–2):179–194 2004;80(1):108–113 Pediatrics, Section on Breastfeeding and 169. John EM, Schwartz GG, Dreon DM, Koo J. 180. Pilz S, März W, Wellnitz B, et al. Association Committee on Nutrition. Prevention of rick- Vitamin D and breast cancer risk: the of vitamin D deficiency with heart failure ets and vitamin D deficiency in infants, chil- NHANES (National Health and Nutrition Ex- and sudden cardiac death in a large cross- dren, and adolescents [published correc- amination Survey) I epidemiologic sectional study of patients referred for tion appears in Pediatrics. 2009;123(1): follow-up study, 1971–1975 to 1992. Can- coronary angiography. J Clin Endocrinol 197]. Pediatrics. 2008;122(5):1142–1152 cer Epidemiol Biomarkers Prev. 1999;8(5): Metab. 2008;93(10):3927–3935 157. Bikle D. Nonclassic actions of Vitamin D. J 399–406 181. Rovner AJ, O’Brien KO. Hypovitaminosis D Clin Endocrinol Metab. 2009;94(1):26–34 170. Robsahm TE, Tretli S, Dahlback A, Moan J. among healthy children in the United 158. Baroncelli GI, Bereket A, El Kholy M, et al. Vitamin D3 from sunlight may improve the States: a review of the current evidence. Rickets in the Middle East: role of environ- prognosis of breast, colon and prostate Arch Pediatr Adolesc Med. 2008;162(6): ment and genetic predisposition. J Clin En- cancer (Norway). Cancer Causes Control. 513–519 docrinol Metab. 2008;93(5):1743–1750 2004;15(2):149–158 182. Huh SY, Gordon CM. Vitamin D deficiency in 159. Prentice A, Goldberg GR, Schoenmakers I. 171. World Health Organization, International children and adolescents: epidemiology, Vitamin D across the lifecycle: physiology Agency for Research on Cancer Working impact and treatment. Rev Endocr Metab and biomarkers. Am J Clin Nutr. 2008; Group on Vitamin D. Vitamin D and Cancer. Disord. 2008;9(2):161–167 A Report of the IARC Working Group on 88(2):500S–506S 183. Looker AC, Pfeiffer CM, Lacher DA, Schlei- Vitamin D. Reports Vol 5. Geneva, 160. Jones G, Dwyer T, Hynes KL, Parameswa- cher RL, Picciano MF, Yetley EA. Serum Switzerland: International Agency for ran V, Greenaway TM. Vitamin D insuffi- 25-hydroxyvitamin D status of the US Research on Cancer, World Health ciency in adolescent males in southern population: 1988–1994 compared with Organization; 2008. Available at: www.iarc. Tasmania: prevalence, determinants, and 2000–2004. Am J Clin Nutr. 2008;88(6): fr/en/publications/pdfs-online/wrk/wrk5/ relationship to bone turnover markers. Os- 1519–1527 teoporos Int. 2005;16(6):636–634 Report_VitD.pdf. Accessed February 8, 2011 184. van der Mei IAF, Ponsonby AL, Engelsen O, 161. Lehtonen-Veromaa MKM, Möttönen TT, et al. The high prevalence of vitamin D in- 172. Wactawski-Wende J, Kotchen JM, Ander- Nuotio IO, Irjala KMA, Leino AE, Viikari J. sufficiency across Australian populations son GL, et al. Calcium plus vitamin D sup- Vitamin D and attainment of peak bone is only partly explained by season and lat- plementation and the risk of colorectal mass among peripubertal Finnish girls: a itude. Environ Health Perspect. 2007; 3-y prospective study. Am J Clin Nutr. 2002; cancer. N Engl J Med. 2006;354(7): 115(8):1132–1139 76(6):1446–1453 684–696 185. Islam MZ, Shamim AA, Kemi V, et al. Vitamin 162. Cashman KD, Hill TR, Cotter AA, et al. Low 173. Chlebowski RT, Johnson KC, Kooperberg C, D deficiency and low bone status in adult vitamin D status adversely affects bone et al. Calcium plus vitamin D supplementa- female garment workers in Bangladesh. health parameters in adolescents. Am J tion and the risk of breast cancer. J Natl Br J Nutr. 2008;99(6):1322–1329 Clin Nutr. 2008;87(4):1039–1044 Cancer Inst. 2008;100(22):1581–1591 186. Woo J, Lam DWK, Leung J, et al. Very high 163. Tylavsky FA, Ryder KM, Li R, et al. Prelimi- 174. Ebers GC. Environmental factors and mul- rates of vitamin D insufficiency in women nary findings: 25(OH)D levels and PTH are tiple sclerosis. Lancet Neurol. 2008;7(3): of child-bearing age living in Beijing and indicators of rapid bone accrual in puber- 268–277 Hong Kong. Br J Nutr. 2008;99(6): tal children. J Am Coll Nutrition. 2007; 175. Munger KL, Zhang SM, O’Reilly E, et al. Vita- 1330–1334 26(5):462–470 min D intake and incidence of multiple 164. El-Hajj Fuleihan G, Nabulsi M, et al. Effect of sclerosis. Neurology. 2004;62(1):60–65 187. Specker BL, Valanis B, Hertzberg V, Ed- wards N, Tsang RC. Sunshine exposure and vitamin D replacement on musculoskeletal 176. Ramagopalan SV, Maugeri NJ, Handunnet- serum 25-hydroxyvitamin D concentra- parameters in school children: a random- thi L, et al. Expression of the multiple tions in exclusively breast-fed infants. J Pe- ized controlled trial. J Clin Endocrinol sclerosis-associated MHC class II allele Metab. 2006;91(2):405–412 HLA-DRBI*1501 is regulated by vitamin D. diatr. 1985;107(3):372–376 165. Weaver CM, McCabe LD, McCabe GP, et al. PLoS Genet. 2009;5(2):e1000369 188. Holick MF. Sunlight and vitamin D for bone Vitamin D status and calcium metabolism 177. Chiu KC, Chu A, Go VL, Saad MF. Hypovita- health and prevention of autoimmune dis- in adolescent black and white girls on a minosis D is associated with insulin resis- eases, cancers, and cardiovascular dis- range of controlled calcium intakes. J Clin tance and beta cell dysfunction. Am J Clin ease. Am J Clin Nutr. 2004;80(6 suppl): Endocrinol Metab. 2008;93(10):3907–3914 Nutr. 2004;79(5):820–825 1678S–1688S 166. Fronczak CM, Barón AE, Chase HP, et al. In 178. Forouhi NG, Luan J, Cooper A, Boucher BJ, 189. Holick MF. Vitamin D: a millenium perspec- utero dietary exposures and risk of islet Wareham NJ. Baseline serum 25-hydroxy tive. J Cell Biochem. 2003;88(2):296–307 autoimmunity in children. Diabetes Care. vitamin D is predictive of future glycemic 190. American Academy of Dermatology; AAD 2003;26(12):3237–3242 status and insulin resistance: the Medical Association. Vitamin D and UV exposure. 167. Zipitis CS, Akobeng AK. Vitamin D supple- Research Council Ely Prospective Study Available at: www.aad.org/members/ mentation in early childhood and risk of 1990–2000. Diabetes. 2008;57(10): media/_doc/Vitamin%20D%20and%20UV% type 1 diabetes: a systematic review and 2619–2625 20Exposure%202007%20-%20FINAL.doc. meta-analysis. Arch Dis Child. 2008;93(6): 179. Dietrich T, Joshipura KJ, Dawson-Hughes Accessed February 8, 2011 512–517 B, Bischoff-Ferrari HA. Association be- 191. Moore CE, Murphy MM, Holick MF. Vitamin 168. Gorham ED, Garland CF, Garland FC, et al. tween serum concentrations of 25- D intakes by children and adults in the

PEDIATRICS Volume 127, Number 3, March 2011 e815 Downloaded from www.aappublications.org/news by guest on September 26, 2021 United States differ among ethnic groups. tended oral dosing with cholecalciferol. malignant.html. Accessed February 8, J Nutr. 2005;135(10):2478–2485 Am J Clin Nutr. 2003;77(1):204–210 2011 192. Dawodu A, Wagner CL. Mother-child vita- 203. Cashman KD, Hill TR, Lucey AJ, et al. Estima- 214. Rigel DS, Carucci JA. Malignant melanoma: min D deficiency: an international perspec- tion of the dietary requirement for vitamin prevention, early detection, and treatment tive. Arch Dis Child. 2007;92(9):737–740 D in healthy adults. Am J Clin Nutr. 2008; in the 21st century. CA Cancer J Clin. 2000; 193. Lehtonen-Veromaa M, Möttönen T, Irjala K, 88(6):1535–1542 50(4):215–236 et al. Vitamin D intake is low and hypovita- 204. Burgaz A, Akesson A, Oster A, Michaelsson 215. Saraiya M, Glanz K, Briss PA, et al. Interventions minosis D common in healthy 9- to 15-year- K, Wolk A. Associations of diet, supplement to prevent skin cancer by reducing exposure to old Finnish girls. Eur J Clin Nutr. 1999; use, and ultraviolet B radiation exposure ultraviolet radiation: a systematic review. Am J 53(9):746–751 with vitamin D status in Swedish women Prev Med. 2004;27(5):422–466 194. Lehtonen-Veromaa M, Möttönen T, Nuotio I, during winter. Am J Clin Nutr. 2007;86(5): 216. US Environmental Protection Agency. Sun- Irjala K, Viikari J. The effect of conventional 1399–1404 Wise program summary. Available at: vitamin D(2) supplementation on serum 205. Kimlin M, Harrison S, Nowak M, Moore M, www.epa.gov/sunwise/summary.html. Ac- 25(OH)D concentration is weak among Brodie A, Lang C. Does a high UV environ- cessed February 8, 2011 peripubertal Finnish girls: a 3-y prospec- ment ensure adequate vitamin D status? J 217. Geller AC, Rutsch L, Kenausis K, Slezer P, tive study. Eur J Clin Nutr. 2002;56(5): Photochem Photobiol B. 2007;89(2–3): Zhang Z. Can an hour or two of sun protec- 431–437 139–147 tion education keep the sunburn away? 195. Schoenmakers I, Goldberg GR, Prentice A. 206. Farrerons J, Barnadas M, Rodríguez J, et Evaluation of the Environmental Protection Abundant sunshine and vitamin D defi- al. Clinically prescribed sunscreen (sun Agency’s Sunwise school program. Envi- ciency. Br J Nutr. 2008;99(6):1171–1173 protection factor 15) does not decrease ron Health. 2003;2(1):. Available at: www. ehjournal.net/content/2/1/13. Accessed 196. Institute of Medicine, Food and Nutrition serum vitamin D concentration sufficiently February 8, 2011 Board. Dietary Reference Intakes: Calcium, either to induce changes in parathyroid Phosphorus, Magnesium, Vitamin D, and function or in metabolic markers. Br J Der- 218. Kyle JW, Hammitt JK, Lim HW, et al. Eco- nomic evaluation of the US Environmental Fluoride. Washington, DC: National Acade- matol. 1998;139(3):422–427 Protection Agency’s SunWise program: mies Press; 1997 207. US Preventive Services Task Force. Coun- sun protection education for young chil- seling to Prevent Skin Cancer: Recommen- 197. Institute of Medicine. Dietary Reference In- dren. Pediatrics. 2008;121(5). Available at: dations and Rationale. Rockville, MD: takes for Calcium and Vitamin D. Washing- www.pediatrics.org/cgi/content/full/121/ Agency for Healthcare Research and ton, DC: Institute of Medicine; November 5/e1074 30, 2010. Available at: http://iom.edu/ Quality; 2003. Available at: www.ahrq.gov/ 219. Buller DB, Borland R. Skin cancer preven- Reports/2010/Dietary-Reference-Intakes- clinic/3rduspstf/skcacoun/skcarr.htm. tion for children: a critical review. Health for-Calcium-and-Vitamin-D.aspx. Accessed February 8, 2011 Educ Behav. 1999;26(3):317–343 Accessed February 8, 2011 208. Davy L, Boyett T, Weathers L, Campbell RJ, 220. Dietrich AJ, Olson AL, Sox CH, et al. A 198. Tylavsky FA, Cheng S, Lyytikainen A, Vilja- Roetzheim RG. Sun protection counseling community-based randomized trial en- kainen H, Lamberg-Allardt C. Strategies to by pediatricians. Ambul Pediatr. 2002;2(3): couraging sun protection for children. Pe- improve vitamin D status in northern Euro- 207–211 diatrics. 1998;102(6). Available at: www.pe- pean children: exploring the merits of vita- 209. Geller AC, Robinson J, Silverman S, Wyatt diatrics.org/cgi/content/full/102/ min D fortification and supplementation. J SA, Shifrin D, Koh HK. Do pediatricians 6/e64 Nutr. 2006;136(4):1130–1134 counsel families about sun protection? A 221. Dietrich AJ, Olson AL, Sox CH, Tosteson T, Massachusetts survey. Arch Pediatr Ado- 199. Arpadi SM, McMahon D, Abrams EJ, et al. Grant-Peterson J. Persistent increase in lesc Med. 1998;152(4):372–376 Effect of bimonthly supplementation children’s sun protection in a randomized with oral cholecalciferol on serum 25- 210. Gritz ER, Tripp MK, de Moor CA, Eicher SA, controlled community trial. Prev Med. hydroxyvitamin D concentrations in HIV- Mueller NH, Spedale JH. Skin cancer pre- 2000;31(5):569–574 infected children and adolescents [pub- vention counseling and clinical practices 222. Coogan PF, Geller A, Adams M, Benjes LS, lished correction appears in Pediatrics. of pediatricians. Pediatr Dermatol. 2003; Koh HK. Sun protection practices in pread- 2009;123(5):1437]. Pediatrics. 2009; 20(1):16–24 olescents and adolescents: a school-based 123(1). Available at: www.pediatrics. 211. Balk SJ, O’Connor KG, Saraiya M. Counsel- survey of almost 25,000 Connecticut org/cgi/content/full/123/1/e121 ing parents and children on sun schoolchildren. J Am Acad Dermatol. 2001; 200. Green D, Carson K, Leonard A, et al. Current protection: a national survey of pediatri- 44(3):512–519 treatment recommendations for correct- cians. Pediatrics. 2004;114(4):1056–1064 223. Cokkinides VE, Johnston-Davis K, Wein- ing vitamin D deficiency in pediatric pa- 212. US Preventive Services Task Force. Screen- stock M, et al. Sun exposure and sun- tients with cystic fibrosis are inadequate. ing for Skin Cancer: Recommendations protection behaviors and attitudes among J Pediatr. 2008;153(4):554–559 Statement—Screening for Skin Cancer. U.S. youth, 11 to 18 years of age. Prev Med. 201. Gordon CM, Williams AL, Feldman HA, et al. Rockville, MD: US Preventive Services Task 2001;33(3):141–151 Treatment of hypovitaminosis D in infants Force; 2009. Available at: www.ahrq.gov/ 224. Olson AL, Gaffney C, Starr P, Gibson JJ, Cole and toddlers. J Clin Endocrinol Metab. clinic/uspstf09/skincancer/skincanrs. BF, Dietrich AJ. SunSafe in the middle school 2008;93(7):2716–2721 htm. Accessed February 8, 2011 years: a community-wide intervention to 202. Heaney RP, Davies KM, Chen TC, Holick MF, 213. American Academy of Dermatology. Malig- change early-adolescent sun protection. Barger-Lux MJ. Human serum 25- nant melanoma. Available at: www.aad. Pediatrics. 2007;119(1). Available at: www. hydroxycholecalciferol response to ex- org/public/publications/pamphlets/sun_ pediatrics.org/cgi/content/full/119/1/e247

e816 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS

225. Dixon HG, Hill DJ, Karoly DJ, Jolley DJ, Aden schools. the “SoleSi SoleNo-GISED” Project. J 229. Belamarich PF, Gandica R, Stein REK, SM. Solar UV forecasts: a randomized trial Invest Dermatol. 2007;127(8):1871–1877 Racine AD. Drowning in a sea of advice: assessing their impact on adults’ sun- 227. Dobbinson SJ, Wakefield MA, Jamsen SM, pediatricians and American Academy of protection behavior. Health Educ Behav. et al. Weekend sun protection and sun- Pediatrics policy statements. Pediatrics. 2007;34(3):486–502 burn in Australia trends (1987–2002) 2006;118(4). Available at: www.pediatrics. 226. Naldi L, Chatenoud L, Bertuccio P, et al; Oncol- and association with SunSmart televi- org/cgi/content/full/118/4/e964 ogy Cooperative Group of the Italian Group sion advertising. Am J Prev Med. 2008; 230. Benjes LS, Brooks DR, Zhang Z, et al. Chang- for Epidemiologic Research in Dermatology 34(2):94–101 ing patterns of sun protection between the (GISED). Improving sun-protection behavior 228. Weinstock MA. The struggle for primary first and second summers in very young among children: results of a cluster- prevention of skin cancer. Am J Prev Med. children. Arch Dermatol. 2004;140(8): randomized trial in Italian elementary 2008;34(2):171–172 925–930

PEDIATRICS Volume 127, Number 3, March 2011 e817 Downloaded from www.aappublications.org/news by guest on September 26, 2021 Ultraviolet Radiation: A Hazard to Children and Adolescents Sophie J. Balk, the Council on Environmental Health and Section on Dermatology Pediatrics 2011;127;e791 DOI: 10.1542/peds.2010-3502 originally published online February 28, 2011;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/127/3/e791 References This article cites 175 articles, 33 of which you can access for free at: http://pediatrics.aappublications.org/content/127/3/e791#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Current Policy http://www.aappublications.org/cgi/collection/current_policy Council on Environmental Health http://www.aappublications.org/cgi/collection/council_on_environme ntal_health Dermatology http://www.aappublications.org/cgi/collection/dermatology_sub Section on Dermatology http://www.aappublications.org/cgi/collection/section_on_dermatolo gy Environmental Health http://www.aappublications.org/cgi/collection/environmental_health_ sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 26, 2021 Ultraviolet Radiation: A Hazard to Children and Adolescents Sophie J. Balk, the Council on Environmental Health and Section on Dermatology Pediatrics 2011;127;e791 DOI: 10.1542/peds.2010-3502 originally published online February 28, 2011;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/127/3/e791

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2011 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on September 26, 2021