Practice Gaps—Failure to Scrutinize Actual UV-A

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Despite these limitations, our study shows that many day creams do not offer long-wave UV-A protection. Best-selling products 29 with SPF >15 Until sunscreen labeling clearly defines the degree of UV-A protection, dermatologists should educate their patients and the public to select products with ingredi- UV-A/UV-B 23 Broad- 6 UV-B /UV-A2 ents that contain the appropriate concentrations of spectrum UV-A /UV-B only∗ Coverage? avobenzone, octocrylene, and ecamsule and/or zinc oxide. Active UV-A 14 2 Avobenzone 7 Zinc ingredient? Avobenzone + ecamsule† oxide‡ Steven Q. Wang, MD Jacqueline M. Goulart, BA Henry W. Lim, MD 1 Stable 2 Stable Avobenzone 13 (octocrylene (octocrylene Unstable formulation? ≥3.6%) § ≥3.6%) Accepted for Publication: November 1, 2010. Published Online: January 17, 2011. doi:10.1001

7 1 Octinoxate + /archdermatol.2010.406 5 Octocrylene octocrylene Octoinoxate|| Author Affiliations: Memorial Sloan-Kettering Cancer <3.6%¶ <3.6%# Center, New York, New York (Dr Wang and Ms Gou- lart); and Henry Ford Hospital, Detroit, Michigan (Dr Lim). Correspondence: Dr Wang, Dermatology Service, Me- Figure. Flow diagram of sunscreens included in study according to UV-protective ingredients. *Products 3, 6, 10, 13, 18, and 20; †products 1 morial Sloan-Kettering Cancer Center, 136 Mountain and 7; ‡products 9, 12, 14, 15, 19, 24, and 29; §product 2; ࿣products 8, 11, View Blvd, Basking Ridge, NJ 07920 (wangs@mskcc 22, 26, and 28; ¶products 5, 16, 17, 21, 23, 25, and 27; #product 4. .org). Author Contributions: All authors had full access to all of the data in the study and take responsibility for the Our review shows that few products contain the ad- integrity of the data and the accuracy of the data analy- equate concentrations and optimal combinations of UV sis. Study concept and design: Wang. Analysis and inter- filters necessary to provide the reliable UV-A1 protec- pretation of data: Wang, Goulart, and Lim. Drafting of the tion. Six products (20%) had no UV-A1 filters (avoben- manuscript: Wang, Goulart, and Lim. Critical revision of zone, ecamsule, or zinc oxide) in the formulation. Al- the manuscript for important intellectual content: Wang, though 16 products contained avobenzone, an effective Goulart, and Lim. Administrative, technical, and material UV-A1 filter, the molecule is inherently unstable and is support: Goulart. Study supervision: Wang and Lim. Con- degraded after 1 hour of UV exposure. High concentra- tent expert: Lim. tions of octocrylene or other active ingredients are Financial Disclosure: None reported. needed to prevent the breakdown. Despite this well- known fact, only 3 products (10%) contained avoben- 1. Wang SQ, Stanfield JW, Osterwalder U. In vitro assessments of UVA protec- zone in photostable formulations (defined by the pres- tion by popular sunscreens available in the United States. J Am Acad Dermatol. Ͼ 2008;59(6):934-942. ence of octocrylene, 3.6%). Seven products with 2. Cole CA, Volhardt J, Mendrok C. Formulation and stability of sunscreen avobenzone only had a minute amount of octocrylene products. In: Lim HW, Draelos ZD, eds. Clinical Guide to Sunscreens and Pho- toprotection. New York, NY: Informa; 2009:39-51. (average, 1.7%). Also, 6 products with avobenzone con- 3. Tuchinda C, Srivannaboon S, Lim HW. Photoprotection by window glass, au- tained octinoxate; it is known that avobenzone in a tomobile glass, and sunglasses. J Am Acad Dermatol. 2006;54(5):845-854. photoexcited state not only spontaneously photode- grades but also degrades octinoxate.2 Zinc oxide is an inorganic UV filter with coverage ex- tending into the UV-A1 range. Seven products con- PRACTICE GAPS tained zinc oxide, but only 3 products had concentrations above 5%, while the remainder had a mean concentration of 2.7%, which is too low to provide adequate UV-A1 protection. Failure to Scrutinize Actual UV-A Protection Our study has a number of limitations. We assessed When Recommending Sunscreen-Containing the degree of UV-A protection based solely on the com- Moisturizing Creams bination and presence of UV filters; the presence of non-UV filter stabilizers was not taken into account. Since he deleterious effects of UV-A radiation (UV-A) octocrylene is the most widely used photostable UV fil- are important in many areas of dermatology, inter to photostabilize avobenzone, the presence of octo- cluding cutaneous oncology, photoaging, and Ͼ T crylene ( 3.6%) was used as the criterion for avoben- connective tissue disorders. Because a fundamental ob- zone photostabilization; the possible synergistic effect of jective in caring for patients is educating them about mea- other less commonly used photostabilizing UV filters (eg, sures that may reduce the burden of their disease, der- homosalate, oxybenzone) was not taken into account. matologists strive to ensure that their patient education Clearly, future studies using either in vitro or persistent is as accurate as possible. For years, dermatologists have pigment-darkening assays are needed to accurately de- been educating the public about the importance of look- termine the degree of UV-A protection offered by these ing beyond the UV-B–specific sun protection factor. We day creams. instruct patients to select only those sunscreens and fa-

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©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 cial moisturizers that specifically state “UV-A protec- Author Affiliations: Department of Dermatology, Marsh- tion” on the label. However, Wang et al note that prod- field Clinic, Marshfield, Wisconsin ucts containing UV-A sunscreens do not necessarily contain Correspondence: Dr Unwala, Department of Dermatol- adequate proportions or adequate coingredients to actu- ogy, Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI ally block UV-A when applied. The analysis of 29 daily 54449 ([email protected]) facial moisturizers that claim to have “broad-spectrum” Financial Disclosure: None reported. UV coverage identified only 10 with adequate UV-A1 protection, based on established principles of photobiology 1. Stege H, Budde MA, Grether-Beck S, Krutmann J. Evaluation of the capacity of sunscreens to photoprotect lupus erythematosus patients by employing the and photochemistry. The use of sunscreens that lack ef- photoprovocation test. Photodermatol Photoimmunol Photomed. 2000;16(6): fective UV-A protection could result in exacerbated pho- 256-259. toaging and increased skin cancer risk, and the use of sun- 2. Safeer RS, Keenan J. Health literacy: the gap between physicians and patients. screens with different UV-A blocking capabilities provides, Am Fam Physician. 2005;72(3):463-468. at best, inconsistent protection for patients with cutaneous lupus erythematosus.1 Patients rely on their dermatologists to distill the vast body of scientific knowledge and transmit the informa- VIGNETTES tion necessary to optimize patient health in a manner that people of all health literacy levels understand.2 Many dermatology encounters include patient education about proper sun-protection measures. Wang et al identify a Severe Livedoid Vasculopathy Associated practice gap in translating basic scientific knowledge into With Antiphosphatidylserine-Prothrombin a message that will allow patients to critically evaluate Complex Antibody Successfully Treated a manufacturer’s claim. Not all UV-A sunscreen– With Warfarin containing products sufficiently block UV-A. Our message to patients about qualifying products should be- ivedoid vasculopathy (LV) is a chronic recurrent come more specific. skin disease associated with various coagulopa- L thies, clinically characterized by livedo reticu- Practice Gaps poll available at laris, atrophie blanche, and painful ulcerations predomi- nantly localized on the lower extremities. We herein report http://www.archdermatol.com dramatic effects of warfarin therapy against rapidly pro- The major barrier to bridging the gap between under- gressive digital gangrene and foot ulcers in a patient with standing the optimal chemical formulation of a sunscreen LV and antiphosphatidylserine-prothrombin complex an- with adequate UV protection and teaching the patient how tibody (aPS/PT). to identify an appropriate sunscreen to meet their health needs is the complexity of the message. With many de- Report of a Case. A 66-year-old Japanese woman pre- mands on a dermatologist’s time, it is difficult to spend more sented with a 40-year history of recurrent painful ulcer- time explaining this issue in the patient examination room. ations on her lower extremities. Two weeks earlier, an To narrow this practice gap, dermatologists should ulceration involving her right dorsal foot and gangrene critically review their patient education materials to en- of the right toes emerged. Physical examination re- sure that they instruct on the latest information in a simple vealed gangrene of the right fourth and fifth toes and ul- manner. We should ensure that we are not inadver- cerations on the right ankle and dorsal surfaces of both tently undermining our message by dispensing poorly cho- feet, and atrophie blanche (Figure 1A-C). A skin bi- sen samples and cosmeceuticals or by offering mixed mes- opsy specimen showed nonspecific findings typically sages in our patient-education materials (eg, pamphlets, seen in chronic leg ulcers (Figure 2). While prothrom- reading material in the waiting room, and posters from bin time, activated partial thromboplastin time, and lev- multiple sources with different sun-protection mes- els of proteins C and S, antinuclear antibody, antineu- sages). As specialists, dermatologists should continue to trophil cytoplasmic antibody, lupus anticoagulant, IgG ␤ advocate for patients by working with industry to insist and IgM anticardiolipin antibodies (aCLs), and 2 gly- on ingredient concentrations that appropriately block coprotein I–dependent anticardiolipin antibody were UV-A in product formulations. within normal ranges, IgM aPS/PT findings were Ͻ The study by Wang et al is a fresh approach to “bench strongly positive (60 U/mL; normal, 12 U/mL). Find- to bedside” research that examines what patients are ac- ings for IgG aPS/PT were also slightly positive (13 U/ml; Ͻ tually doing (eg, shopping on Amazon.com) and what normal, 12 U/mL). we, as dermatologists, can do to positively influence this The patient was diagnosed as having LV. Despite 3 behavior. Future research may provide valuable guid- weeks of wound care with administration of intrave- ance to patients who become lost in the vast market- nous alprostadil, argatroban, and oral beraprost, digital place of over-the-counter skin care products. This study gangrene progressed rapidly (Figure 1D). Considering also reminds us to critically evaluate our own educa- positive results from an aPS/PT test, we started warfarin tional materials to ensure they always reflect the latest therapy with concurrent use of heparin for an initial 2 basic scientific knowledge. weeks, maintaining the international normalized ratio between 1.5 and 2.5. Within 1 month of the initiation of Rashmi Unwala, MD warfarin therapy, the progression of gangrene was ar-

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