7/5/2011 Sun Safety Ultraviolet radiation primer Sun protection strategies Sunscreens Vitamin D Brent Spencer, MD, FAAD Skin Cancer Basal cell carcinoma Squamous cell carcinoma www.dermntx.com Melanoma 972.712.5100 Treatments Board-certified Dermatologist 4 years of training post-medical school Denison 1 year in general medicine 3 years in dermatology Fellowship-trained Mohs Surgeon Additional year of intense training in Mohs and reconstructive surgery Ultraviolet radiation is the primary cause of skin cancer Three types of UV Radiation UVA UVB UVC Each type can contribute to skin cancer and aging Ultraviolet radiation gets more intense the closer you are to the equator 1 7/5/2011 UVC UVA 100-280 nm UVA1 – 340-400 nm UVA2 – 320-340 nm Blocked by the ozone layer Causes tanning Used commonly to help sterilize objects Tanning beds emit high levels of UVA UVB Penetrates deeper into the skin 280-320 nm Causes photoaging of the skin Blocked by glass Has smaller role in causing skin cancer Primary cause of sunburn At sea level, UVA accounts for 95% of UV radiation reaching earth’s surface. (UVB 5%) Primary component of UV radiation responsible for skin cancer Avoidance UV Protective Clothing Avoid outdoor exposure between the hours of Ultraviolet Protection Factor (UPF) Scale 10AM and 4PM when UV intensity is highest Does not equate to SPF Seek shade when outdoors Measures blockage of both UVA and UVB Sunscreens White cotton t-shirt = UPF 7 Darker and thicker fabrics have a higher UPF UV Protective Clothing UPF Protection Category % UV Radiation Coolibar Rating Blocked Solartex UPF 15-24 Good 93.3 - 95.9 Some Nike, Adidas, & Under Armour shirts UPF 25-39 Very Good 96.0 - 97.4 UPF 40-49 Excellent 97.5 or more UPF 50 + Considered the ultimate in UV sun protection 2 7/5/2011 UV Protective Clothing Sunscreens only work if used properly Sun Guard Apply 15 minutes before going outdoors Contains Tinsorb FD One ounce of sunscreen is required to cover the Increases UPF of clothing entire body Manufacture claims UPF of 30 Lasts 20 washes Shot glass of sunscreen $1.99 per box If you are using one tube of sunscreen each http://sunguardsunprotection.com summer, you are not using enough Reapply every 2 hours More frequently if in water or sweating Which sunscreen do I buy? Physical Sunscreens Vehicle Sunscreen Max Range of Protection Provided Lotion, Cream, Gel, Spray Concentration protection Brand Zinc Oxide 25 % 290-400 nm UVB, UVA2, UVA1 Titanium Dioxide 25 % 290-350 nm UVB, UVA2 Cost Reflect and scatter UV radiation The best sunscreen is one that you use regularly Can produce whitish tint American Academy of Dermatology Newer nanotechnology prevents recommends a SPF of at least 30 the old fashioned white nose look Chemical Sunscreen Max Range of Peak Absorption Protection Concentration protection Provided PABA (rare) 15 % 260-313 nm 238 nm UVB Chemical Sunscreens Padimate O 8 % 290-315 nm 311 nm UVB Octinoxate 7.5 % 280-310 nm 311 nm UVB Act by absorbing UV photons Cinoxate 3 % 270-328 nm 290 nm UVB Tend to be more elegant cosmetically Octisalate 5 % 260-310 nm 307 nm UVB Less greasy Homosalate 15 % 290-315 nm 306 nm UVB Less tinting Trolamine salicylate 12 % 269-320 nm 260-355 nm UVB Carry a risk of contact sensitization Octylocrylene 10 % 287-323 nm 303 nm UVB Ensulizole 4 % 290-340 nm 310 nm UVB Some people develop a poison ivy type rash to these sunscreens Oxybenzone 6 % 270-350 nm 290, 325 nm UVB, UVA2 This is why some do not recommend their use in young Sulisobenzone 10 % 250-380 nm 366 nm UVB, UVA2 children Dioxybenzone 3 % 206-380 nm 352 nm UVB, UVA2 Meradimate 5 % 200-380 nm 336 nm UVA2 Avobenzone 3 % 310-400 nm 360 nm UVA1, UVA2 Ecamsule 10 % 295-359 nm 345 nm UVA1, UVA2 3 7/5/2011 Sun Protection Factor (SPF) Measurement of UVA blockage Measures amount of UV radiation necessary to No uniformly accepted measure produce erythema compared to unprotected skin In vivo (PPD) and in vitro methods exist Primarily measures UVB blockage 2007 – FDA proposed 4 star system Does not measure UVA blockage directly Based on in vivo and in vitro methods SPF of 30 blocks 97% of UVB light Star UVA Protection Level As some sunscreens increase UVA protection, SPF Rating incidentally goes up. None Low Rating system dropped AAD recommends sunscreens of at least SPF 30 In final 2011 FDA ruling Medium High Highest New FDA Guidelines New FDA Guidelines Published June 14, 2011 SPF 2-14 Take effect Summer 2012 “Skin Cancer/Skin Aging Alert: Spending time in the sun increases your risk of skin cancer and early skin aging. “Broad Spectrum” This product has been shown only to help prevent Must cover UVA and UVB using standardized FDA test sunburn, not skin cancer or early skin aging.” Replaces 4 star system Water Resistance Must have a critical wavelength of 370 nm or greater No longer can use terms “waterproof” or “sweatproof” Only Broad Spectrum sunscreens with an SPF value of 15 Labels must list amount of time user can expect to get or higher can claim to reduce the risk of skin cancer and declared SPF level while swimming or sweating early skin aging Two times permitted: 40 or 80 minutes New FDA Guidelines My recommendations Restricted product claims Now: SPF of 50 or higher “Sunblock” is no longer allowed 2012: Broad Spectrum SPF 50 or higher Cannot claim instant protection or protection lasting Adults longer than 2 hours Neutrogena Aveeno Proposed: No SPFs >50; only to be labeled as “SPF 50+” Helioplex Active photobarrier complex Further study of sunscreen sprays La Roche Posay Mexoryl 4 7/5/2011 My recommendations What about sprays? Children or Sensitive Skin Ok to use, but be sure to use enough Zinc oxide based sunscreen Spray to hand, then apply to face Neutrogena Sensitive Skin Men tend to prefer, as they are less greasy Blue Lizard New Neutrogena spray can go on wet skin Coppertone Waterbabies Future Directions Low Vitamin D Adding antioxidants Poor bone health Verdict not out yet May influence development of certain cancers, Helioplex 360 neurologic disease, infectious disease, autoimmune European Sunscreens disease, and cardiovascular disease Not yet FDA approved “A recent review of this topic by the National Mexoryl XL (drometriazole trisiloxane) Academy of Sciences Institute of Medicine (IOM) Tinosorb S (bemotrizinol) concluded that the evidence for associating vitamin Tinosorb M (bisoctrizole) D status with outcomes not related to bone health UVAsorb HEB (diethylhexyl butamido triazone) was inconsistent, inconclusive as to causality, and Neo Heliopan AP (bisdisulizole disodium) insufficient to inform nutritional requirement.” Uvinul A Plus Recommended Daily Allowance Incidental sun exposure in Texas should be more Age 1-70: 600 I.U. than adequate to produce adequate vitamin D Age >70: 800 I.U. levels American Academy of Dermatology Terushkin, et al. J Am Acad recommends Dermatol. June 2010 Vitamin D be obtained through dietary sources Compared vitamin D and/or supplements production in Boston and Vitamin D should not be obtained through Miami at varying times of exposure to UV radiation the years in Fitzpatrick skin types I, III, and V. 5 7/5/2011 Boston, MA at 12 PM Latitudes Month 400 I.U. 1000 I.U. Fitz I Fitz III Fitz V Fitz I Fitz II Fitz V Boston, MA: 42.36° N January 16 23 48 40 62 -- Miami, FL: 25.78° N April 3 4 7 6 9 17 Frisco, TX: 33.14° N July 2 3 5 4 7 13 October 5 8 15 13 19 38 Using this data, depending on the time of year, 5-20 minutes of sun will provide you with nearly Miami, FL at 12 PM 1000 IU of vitamin D. Month 400 I.U. 1000 I.U. Fitz I Fitz III Fitz V Fitz I Fitz II Fitz V There is no role for intentional sun exposure to January 4 6 12 10 15 29 increase vitamin D levels in Texas. April 2 3 5 5 7 13 July 2 3 5 4 6 12 October 3 4 8 7 10 18 Rates of skin cancer are now higher than ever 2006 – 3,507,693 Nonmelanoma skin cancers in US 76.9% increase in Medicare cases from 1992 to 2006 1 in 5 seventy-year-olds have had a NMSC Prevalence of a NMSC cancer history 5 times higher than that of breast or prostate cancer Greater than the 31-year prevalence of all other cancers combined Annual US Health Care Cost estimated at $2.6 Billion Melanoma rates also increasing Most common malignancy in Caucasians 68,130 Americans estimated to be diagnosed in Intermittent intense sun (UVB) exposure 2010 2/3 occur in sun exposed skin 8,700 deaths estimated in 2010 1.93% of the population will develop melanoma in Increasing incidence: younger patients their lifetime Clinical variants: nodular, pigmented, superficial Incidence of melanoma increasing yearly and morpheaform Locally destructive Very rare metastasis 6 7/5/2011 What to look for? Non-healing lesions Pimples that won’t go away Spots that bleed easily Where to look? Sun-exposed areas Second most common skin malignancy Most arise in sun exposed skin Chronic, long-term sun exposure Fair skinned, tan poorly, freckled 200,000 cases/year in U.S. 2500 deaths/ year SCC metastasizes more frequently than BCC About 3 BCCs for every 1 SCC What to look for? Non-healing lesions Pimples that won’t go away Spots that bleed easily Where to look? Sun-exposed areas 7 7/5/2011 Lesion is scraped with dermal curette Locally destructive methods Area is lightly electrodessicated Electrodessication & Curretage Cryotherapy Repeated 2-3 times Surgical methods Wide excision Mohs Micrographic Surgery Radiation Topical agents Imiquimod and 5-Fluorouracil – only superficial BCC Cure rates of 85-92% Otherwise known as cutting it out Indicated for nodular or superficial BCC and 3-5 mm margin is drawn around visible