Sunscreen Story: Interpreting Current Guidelines for Your Patients …img.medscape.com/images/826/855/826855-Web-Reprint.pdf · Target Audience This activity is intended for dermatologists,

View this activity online at:http://www.medscape.org/viewarticle/826855

Sunscreen Story: Interpreting Current Guidelines for Your Patients CME/CE

Joshua A. Zeichner, MDKavita Mariwalla, MDSherrill J. Rudy, RN, MSN, CRNP

Supported by an independent educational grant from Johnson & Johnson Consumer Companies, Inc.

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This article is a CME/CE-certified activity.To earn credit for this activity visit:

http://www.medscape.org/viewarticle/826855

CME/CE Released: 07/01/2014; Valid for credit through 07/01/2015

Target AudienceThis activity is intended for dermatologists, primary care physicians, pediatricians, nurses, nurse practitioners, and pharmacists.

GoalThe goal of this activity is to promote clinician understanding of current FDA-required sunscreen labeling requirements and to provide expert perspective aimed at furthering clinician ability to make appropriate sun protection recommendations to patients.

Learning ObjectivesUpon completion of this activity, participants will be able to:1. Discuss the impact of new FDA labeling requirements for sun protection products on patient care

2. Review current guidelines on sun protection products in order to tailor recommendations to individual patient needs

3. Describe effective patient communication strategies to reinforce the importance of sun protection

Credits AvailablePhysicians - maximum of 0.75 AMA PRA Category 1 Credit(s)™

Nurses - 0.50 ANCC Contact Hour(s) (0.50 contact hours are in the area of pharmacology)

Pharmacists -0.50 Knowledge-based ACPE (0.05 CEUs)

All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.

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The Icahn School of Medicine at Mount Sinai designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Faculty and DisclosuresIt is the policy of the Icahn School of Medicine at Mount Sinai to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material.

A. Zeichner, MDAssistant Professor, Mount Sinai Medical School; Director of Cosmetic and Clinical Research, Dermatology Department, Mount Sinai Hospital, New York, NY

Disclosure: Joshua A. Zeichner, MD, has disclosed the following relevant financial relationships: Served as an advisor or consultant for: Galderma Laboratories, L.P.; Bayer HealthCare Pharmaceuticals; Valeant Pharmaceuticals International; Onset Dermatologics; L’Oréal Group; Procter & Gamble; Promius Pharma Served as a speaker or a member of a speakers bureau for: Allergan, Inc.

Received grants for clinical research from: Medicis Pharmaceutical Corporation; Valeant Pharmaceuticals International Dr Zeichner does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States. Dr Zeichner does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Kavita Mariwalla, MDAssistant Clinical Professor, Columbia University, New York, New York; Assistant Professor, State University of New York, Stony Brook, New York

Disclosure: Kavita Mariwalla, MD, has disclosed no relevant financial relationships. Dr Mariwalla does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the US Food and Drug Administration (FDA) for use in the United States. Dr Mariwalla does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Sherrill J. Rudy, RN, MSN, CRNPAdjunct Professor of Nursing, Robert Morris University, Pittsburgh, Pennsylvania

Disclosure: Sherrill J. Rudy, RN, MSN, CRNP, has disclosed the following relevant financial relationships: Served as an advisor or consultant for: Johnson & Johnson Pharmaceutical Research & Development, L.L.C. Ms Rudy does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States. Ms Rudy does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.


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EditorGina KaeuperScientific Director, Medscape, LLC

Disclosure: Gina Kaeuper has disclosed no relevant financial relationships.

CE Reviewer/Nurse PlannerAmy Bernard, MS, BSN, RN-BCLead Nurse Planner, Medscape, LLC

Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.

Peer ReviewerGary Goldenberg, MDAssistant Professor Dermatology, Assistant Professor Pathology, Icahn School of Medicine at Mount Sinai

Disclosure: Gary Goldenberg, MD, has disclosed no relevant financial relationships.

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Joshua A. Zeichner, MD: Hello. My name is Josh Zeichner. I am director of Cosmetic and Clinical Research in the Dermatology Department at Mount Sinai Medical Center in New York City. I want to welcome you to this program on sunscreens. We will have a discussion today on the new sunscreen labels, with the goal of helping clinicians to better advise their patients on the importance of sun protection and ways to properly select sunscreen products. It is my pleasure to have a great panel with me today. First, I have Kavita Mariwalla.

Kavita Mariwalla, MD: Thanks, Josh. My name is Kavita Mariwalla and I’m a private practicing dermatologist and Mohs surgeon on the South Shore of Long Island, New York.

Dr Zeichner: Great, and we also have Sherrill Rudy.

Sherrill J. Rudy, MSN, RN, CRNP: Hi, Josh. My name is Sherrill Rudy. I’m a pediatric dermatology nurse practitioner and an adjunct professor at Robert Morris University in Pittsburgh, Pennsylvania.


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Dr Zeichner: Great. Thank you both for being here.

Before we talk about sunscreen and sun-protective behavior, I think it’s important to mention ultraviolet (UV) light. There are primarily 2 types of UV rays that penetrate to the earth’s surface: ultraviolet A (UVA) and ultraviolet B (UVB). There are also ultraviolet C (UVC) rays, but those are mostly filtered out by the ozone layer and don’t reach the earth’s surface.

Now, in light of understanding UV rays, let’s talk about sunscreen labeling. Sherrill, as we know, there have been changes to what we see on the sunscreen bottle. Tell us about those new labels.

Ms Rudy: This is really a hot topic right now. In 2011, the Food and Drug Administration (FDA) came out with new sunscreen labeling guidelines in response to consumer confusion about product benefits as they try to decide what type of sunscreen product to buy.[3]

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One of the most significant changes from the FDA monograph is that in order for a product to be labeled as “broad spectrum,” it needs to cover that whole spectrum of UVA and UVB rays that you mentioned. If a product meets that criteria and also has an SPF ≥15, it may list a benefit claim that its use may protect against skin cancer and early skin aging.[3]

Dr Zeichner: In order to receive the label “broad spectrum,” products must pass a laboratory test known as the critical wavelength test. It’s important for consumers and physicians to understand this requirement. In order to pass this test, a sunscreen product must have 90% of its UV absorption at a critical wavelength ≥370 nm.[3] This critical wavelength test measures the breadth of coverage, meaning that it covers both UVB and UVA rays. Different sunscreen products may have different ways of passing this test, and not all sunscreens are created equal. While the critical wavelength test measures that breadth of coverage, it does not measure the height -- or quality -- of protection. I encourage consumers to speak to the sunscreen producers and to ask them about the quality of protection that they’re getting from the product that they’re buying.

There are several other changes that we see on the bottle. Kavita, tell us more about the label changes.


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Dr Mariwalla: I think the goal of the FDA monograph really is to protect the consumer. As you pointed out, a good example of this is clarifying the term “broad spectrum.” We used to think that UVA rays caused the aging and UVB rays caused the burn. Now we know that actually both types of rays cause skin cancer. The FDA monograph has helped clinicians back that up by putting that information right on the label. Now all sunscreens with SPF <15 are labeled that this level of protection will not protect from skin cancer or skin aging.[3] That’s very helpful, because there’s been some controversy that wearing sunscreen can actually be bad for your health. This label information supports physicians’ ability to really tell patients that that’s not true. You need to wear a product that is SPF ≥15.

The other important label change was to prohibit the use of words like “waterproof” and “sweatproof” because there’s really no such thing. Now, bottles may be labeled as “water resistant” for either 40 minutes or 80 minutes.[3]

Dr Zeichner: So, based on what we know how do you think these label changes are really going to influence the way providers recommend sunscreens and the way that consumers perceive them? Sherrill, what do you think?

Ms Rudy: Well, the real goal is to help clear up confusion so that consumers understand what protection they are actually getting -- they are getting broad-spectrum protection when the bottle says broad spectrum on it. And, also they can better predict how long that water resistance will last and when they need to reapply. I think both of those things really help clarify some of the confusion.

Dr Mariwalla: My patients used to say, “Oh, I use an SPF 100 and it’s a big number.” They thought the higher the number -- well, then it must be good. But then they were not reapplying it; they didn’t really understand that regardless of the SPF number, all sunscreen lasts for only a certain period of time. So, I think that removing those higher SPF numbers allows people to really see that it’s as important to reapply as it is to have a good broad-spectrum protection.

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Dr Zeichner: Let’s switch gears a little bit and talk about ways that we can educate our patients on using sunscreens. I tell all of my patients, regardless of their skin tone, that they need to wear sunscreen every day, really incorporating it into their everyday regimen just like they would brush their teeth and floss. Skin cancer is the most common cancer, and it’s partially preventable. Even low levels of UV light exposure have been shown to have a significant impact on the skin over time.

Dr Mariwalla: You know, it’s interesting that you say that, because there was actually a study done about sun exposure.[4] Many people think, “Oh, I’m not out in the sun that much,” but they will take that 2-week vacation to some sunny place. In the study, they did an examination of patients who did that and showed that intermittent intense sun is almost as bad as prolonged low-level sun. So, I couldn’t agree with you more that you have to tell patients, “no matter what, just like you brush your teeth, you should apply your sunscreen.”

Dr Zeichner: I have many patients who come in and say to me, “I don’t go out in the sun.” I say to them, “Well, how’d you get here?” Very few of them probably walk around with a parasol, so I would assume they are all getting some sun.

Dr Mariwalla: And there’s always the old standard that it depends on which side of the road you drive, right? In the United States, people get more skin cancer on their left sides than in England, where it’s more common on the right because that’s the side that faces out the window when they’re driving.

Dr Zeichner: When we make recommendations to our patients, they are primarily based on guidelines from 3 main sources: the Skin Cancer Foundation (SCF), the American Academy of Dermatology (AAD), and the American Academy of Pediatrics (AAP). Sherrill, take us through some of the other things that we can tell our patients, such as other types of sun-protective behaviors.


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Ms Rudy: I think it is really important to talk about sun-protective behaviors with children. People get 25% of their lifetime sun exposure before age 18 years, so we can’t rely just on sunscreen.[5] We also need to seek shade, particularly during those high-intensity times between 10 AM to 2 PM. We need to encourage children to play in the shade and also to use clothing as protection. You can actually get clothing that has an SPF on it that will provide coverage instead of using sunscreen. Also, use hats and sunglasses to protect the eyes. And a major recommendation, particularly with teenagers, is to avoid tanning beds and other artificial exposure to UV light. And even children should be getting regular skin checks.

Dr Zeichner: And, what about those baseball caps? Do you think that those are enough?

Ms Rudy: Well, no, because they’re leaving the ears and the back of the neck exposed. Instead, we need to use a hat with a wide brim and clothing with sleeves. There are many bathing suits coming out now that have leg extensions and arm coverage and provide great coverage when children are playing in the sun all day.

Dr Zeichner: I have many patients who come in and have poikiloderma. For the viewers out there who aren’t familiar with this term, we’re talking about a skin condition with redness, atrophy, and light and dark spots on the sides of the neck. The patients don’t understand how this condition occurred. Many times the shaded area right under their chin is clear.

Dr Mariwalla: Right. Their chin shadow.

Dr Zeichner: Baseball caps cannot help prevent poikiloderma.

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Dr Mariwalla: I think another important issue is that there is a great deal of misconception about how much sunscreen to apply. Depending on the type of patient, you can make it relatable to them. I tell my patients you need to use 1 oz. So, what does that mean? It’s the size of a golf ball or a ping-pong ball or a shot glass, for the entire body.

It turns out that most people don’t use enough sunscreen to actually equate to the SPF that’s on the bottle.[6] Most consumers, as you know, apply 25% to 50% less sunscreen than they should.[6] So, when using a product with SPF 50, the way most people apply it means they are getting only about half as much on as needed to reach that SPF. And so, I tend to tell people to select the higher number SPF. If patients are not using the right amount of product, they really need to use a higher SPF product to help ensure adequate protection.

Dr Zeichner: Sure. I’d do the same thing. I tend to err on the side of recommending a product with a higher SPF because, although the patient may not realize it, I know that they are not getting the SPF value labeled on the bottle.

Dr Mariwalla: That’s right. I tell people 30 is the new 15.

Ms Rudy: Right. And, it’s really important to make sure that people are applying these sunscreens 15 to 30 minutes before actually going out in the sun and not be sitting on the beach and putting on the sunscreen, because they really need to give time for the sunscreen to connect with the skin. And, I like to tell them to think about spreading it on the skin rather than rubbing it in, just spread it like they would spread the icing on a cake and to make sure to get all the areas covered well.

Dr Zeichner: What about the water resistance? We know that the bottle will say 40 or 80 minutes, but what does that really translate to? What do they have to do?

Dr Mariwalla: People will apply sunscreen and then go into the ocean, go into the pool, and then come out and wait a couple of hours, and then reapply it. As soon as someone goes into water, sunscreen becomes essentially ineffective when you come out. This applies not only to water, but also to high-intensity sports. If you’re running, biking, or doing something where you sweat a great deal, you need to reapply immediately afterwards. Many of my patients will say that if they apply sunscreen while doing something active, like running or biking, it gets into their eyes. I tell them that there are many formulations out there that won’t do that.


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Dr Zeichner: So, you see many different types of patients, as do all of us. What specific recommendations do you make for different skin types?

Dr Mariwalla: I think it’s really important to tailor the product to the patient. Let’s face it. Putting sunscreen on is a chore even for you and me, right? You have to apply it every 2 or 3 hours. Sometimes the consistency isn’t pleasant. If you have kids, it’s like trying to herd cats. You’re trying to get enough cream on them before they’re out there and getting burnt.

So, I talk to my patients about their lifestyle. If they’re men, sometimes they’re not into hats, and so I tell them that there are sprays that are available that you can use on the thinning areas of your scalp that won’t feel like hairspray and won’t look all gelled up. For women, they often tell me, “Oh, don’t worry, Dr Mariwalla. I used the sunscreen that’s in my foundation.” It’s critical to remind patients that that’s not enough. I tell them to wear sunscreen. Some very elegant sunscreens are now available that can be substituted for moisturizers. So, I tell them to wear the sunscreen and then wear their makeup on top of that. If they’re using anti-aging products, I tell them to layer starting with their serums, then the sunscreen, and then the foundation.

I try to also consider year-round activities. For skiers, there’s a great deal of UV reflecting off those slopes, and there are products that are sort of like anti-freeze that help protect the skin. And, in general, I try to give my patients little tips to remember. For example, with golfers, a good rule of thumb is to reapply every 9 holes.

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Dr Zeichner: What about with sensitive skin?

Dr Mariwalla: I actually tell them to use the baby stuff.

Ms Rudy: That’s right. The baby products probably cause the fewest sensitivity reactions. They tend not to sting the eyes and burn, and they also tend not to penetrate the skin as much. So, I think those are really safer for patients with sensitive skin.

Dr Zeichner: I treat many acne patients, and for those patients I’m really looking for oil-free formulations or products that are labeled as non-comedogenic or non-acnegenic. Acne patients really have a misconception that they can’t or shouldn’t be using sunscreens. In fact, sunscreen use is almost more important in those patients.

Dr Mariwalla: Right, because of the medications they’re on.

Dr Zeichner: So, you mentioned spray sunscreen earlier. One controversy has to do with asthmatic patients. What are your thoughts on that?


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Dr Mariwalla: In fairness, the FDA monograph doesn’t quite cover the sprays, the towelettes, and those other types of vehicles, but as busy people and in response to patient’s lifestyles, you must talk about sprays. The primary thing that patients should remember when using spray sunscreen is to not make a plume. You’re not in the department store where they’re spraying perfume.

You really want to spray close to the skin to the point where it’s glistening -- that means that you have enough on. For patients who are asthmatic, you need to be careful that the product is not being inhaled. There are some sunscreens that spray on as lotions, so you have the convenience of the spray form, but in a lotion consistency.

Dr Mariwalla: Sherrill, what do you think about sprays for children?

Ms Rudy: Sprays and sticks are really popular means of applying sunscreen on children. It makes the application much easier. I also instruct patients to apply it until it glistens, and that they may need to take their hand and spread it to make sure there’s an even coverage. I caution families about applying it in the wind because much of it can be just blown away and not actually attach to the skin. And I also then caution about the use of sprays around open flames. There are cases where fires and injuries have resulted, so be very careful.

Dr Mariwalla: So, barbecue and spray is not the best combination.

Ms Rudy: That’s right, definitely.

With sticks, it’s important for patients to understand that you have to apply it properly to get adequate coverage. The general guideline right now is that you need to make 4 passes on the skin with the stick in order to get the SPF factor that the stick is stating that it has. So, making sure that it is applied well is really important.

Dr Mariwalla: And, speaking of sticks, I think people often overlook the lips. It is very important to use lip balms with an SPF.

Ms Rudy: That’s right.

Dr Zeichner: Especially the lower lip.

Dr Mariwalla: Yes. Many young patients have freckles all along the lip line. We do know now that those labial melanotic macules or those lip freckles or moles can actually progress to something much worse.

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Dr Zeichner: Yes. You know, we talked about the sprays and the sticks, and as you mentioned before, the FDA is looking more into certain formulations. But the general rule on testing of sunscreens is based on a certain density of that sunscreen ingredient on the skin -- 2 mg/cm2. The whole idea of spraying the skin until it glistens or applying 4 passes of a stick is really based on the idea of getting that same type of density of sunscreen on your skin when you go out.

Dr Mariwalla: That’s right, and I think that’s why they’re still looking into towelettes. It’s hard to know exactly how many passes you need.

Dr Zeichner: With my son, I tell him 4 passes is the count. It makes it a little bit more challenging when he’s screaming, but you get him protected.

So, Kavita, I think the idea of vitamin D is really controversial. I have all these patients saying to me, “Dr Zeichner, how am I going get my vitamin D if I’m all covered up and protected?” What do you tell your patients?

Dr Mariwalla: I tell my patients to start with their primary care doctor or pediatrician to make sure that they have adequate vitamin D levels. The thing to keep in mind is that the sun is not the only source of vitamin D. They did studies on Hawaiian surfers -- nobody gets more sun than a Hawaiian surfer -- and they turned out to have low vitamin D levels.[8] So, I tell patients that the vitamin D story is a controversial one. If a patient’s levels are low, they should supplement with vitamins, and if their levels are not low, they’re fine. We do know that sun exposure can cause skin cancer. So, you want to go with what you know. Wear a sunscreen to prevent it, and supplement with vitamin D if you need it.


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Dr Zeichner: What about patients with darker skin types?

Dr Mariwalla: So, in patients with darker skin types, the myth is that, “Oh, I tan. There should be no issue. I’m not going to get skin cancer.” When I was practicing Mohs micrographic surgery in Manhattan, 25% of my patient population had my skin tone or darker. So, I always tell them that although they may be at lower risk for skin cancer than lighter-skinned people, darker skin color only imparts an SPF of about 4. Sunscreen use will at least prevent hyperpigmentation or discoloration, but it will certainly also protect against skin cancer.

Dr Zeichner: I have many patients with darker skin and they’re really concerned about the way that the sunscreen looks on the skin, making them look white or purple or ashy. There are several melt-in formulations of sunscreens, milks, and other types of lotions that are cosmetically elegant enough for dark skin types.

Dr Mariwalla: Absolutely, and it’s really the zinc and the titanium that can give that chalky white appearance. There are plenty of formulations without those ingredients, but even in products that have them, some have a tint that can be pretty universal, so it’s nice.

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Dr Zeichner: The other big question that I get has to do with our youngest patients. Sherrill, take us through the recommendations that you make for infants and children.

Ms Rudy: Our new understanding about how infant skin differs from adult skin really applies here. We know that the stratum corneum and the epidermis are actually thinner and more hydrated in children.[9,10] The hair follicle density is greater.[10[ In infants age <1 year, their melanocyte function is immature, and they also have a much larger body surface area ratio compared with their body weight.[9,10] All of these factors affect how much sunscreen to use and how much will be absorbed. So, what I like to advise is to use a physical sunblock only in the areas where the skin is exposed, and to primarily focus on sun avoidance and using clothing, hats, and sunglasses to protect, particularly in children age <6 months. That’s a vulnerable time. In any premature infant, you would not want to have any sun exposure.

In children age >6 months, it’s much more safe to use a sunblock across more areas of the body. But we should also continue to focus on seeking shade and other forms of sun protection in our youngest infants.


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Dr Zeichner: You said something really interesting that I want to readdress. Even in our youngest patients, in patients age <6 months, you said it is okay to treat exposed areas of skin with sunscreen.

Ms Rudy: It is. The AAP does recommend that, because they feel that it’s important to cover those exposed areas of skin because of the risk of future skin cancer.[11] But the primary tactic for young patients should be sun avoidance.

Dr Mariwalla: I think a time where it’s tricky and it can sneak up on you is when you have the baby in the stroller.

Ms Rudy: Yes.

Dr Mariwalla: You think with the baby in the carriage, with the hood up, that they’re not getting much sun. But there are areas that are exposed. I tell my patients to look for clothing or blankets that have a tight cotton weave. If they can hold it up to the light and see through it easily, that’s something to avoid. If it blocks a bit of the light you can use those items to help with sun protection.

Ms Rudy: That’s right. Definitely, and any darker colored clothing, that will help as well.

We really don’t have much data on toxicity in infants and that’s why we tend to go with the physical blockers in most of the baby products. They contain primarily zinc oxide and titanium dioxide. We really look for children to use an SPF ≥30. That’s the recommendation from the AAD.[13] And, in infants you really have to be aware of any kind of irritation to the eyes, because if they are rubbing their hands in their eyes you don’t want to have something that’s going to sting and burn. And, also, with the physical blockers the sensitivity risk is much less.

Dr Mariwalla: One tip that I tell my patients when they’re applying sunscreen on the face -- and this applies to children as well -- is to only apply up to the orbital rim, because the action of blinking will actually wick it into the areas it needs to without it getting into the eye itself.

Dr Zeichner: That’s a good tip.

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You know, when I see teenagers, I always make a point of educating them. I tell them hindsight is 20/20, but what we need is foresight. I tell them pale is the new tan. I use all of these tips to try to get through to these patients, but I know that the teenage group of patients is really a difficult age.

Ms Rudy: It’s a tough age because you see pretty good sunscreen use in the younger age group, but when it comes to teens and it becomes more their responsibility to apply the sunscreen, you see use decline.[9] And, interestingly, there’s a recent study that was conducted with teenagers showing them videos on some of the issues around premature aging and skin cancer.[14] The teens who saw the videos on premature aging actually significantly increased their use of sunscreen compared with the teens that saw information only related to skin cancer. So, I guess that means that we just play to their vanity when we talk to them and really focus on skin aging and show them pictures. Visual things are always good to show wrinkles and sunspots, and all of those things that can happen later on.

Dr Zeichner: You know, as far as I’m concerned, it doesn’t really make a difference what gets them to put the sunscreen on. Obviously, I wish that they’d be more concerned about health risks like skin cancers, but if you have to tell them that they’re going to get wrinkles if they don’t do it, and that’s what motivates them, then that’s fine with me.


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Dr Mariwalla: And let’s talk about the elephant in the room with teenagers -- those tanning beds. They love to go any time of the year, especially before prom -- they cannot possibly be pale in their prom dress. One of the things that I tell them is that every time you use a tanning bed, you’re actually doing more harm than you are gaining the benefit of supposedly looking better. Some people tell me, “Oh, I’m going on vacation and I don’t want to get burned so I have to go to the tanning bed.” The truth is that pre-tanning doesn’t help at all. It only offers an SPF of about 3, and a UV bed does not help thicken the skin, which is what prevents burning from happening. So, it’s actually a myth.

I also try to tell patients that every time you go into a tanning bed, it actually increases your risk of melanoma -- not just basal cell or squamous cell cancers, but deadly melanoma -- 6 times the risk you would otherwise be if you’re age <35 years.[16]

Dr Zeichner: Yes, and according to World Health Organization (WHO), tanning beds are considered a Group 1 carcinogen.[17] That’s in the same category as plutonium. I think that’s a strong message that even teenagers who don’t quite know what plutonium is, still kind of get it. They know it’s bad.

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So, what other conversations do you guys have with your patients to try to get the message across?

Dr Mariwalla: In my practice, we sort of hit patients over the head with the messaging. We have sun-sensing bracelets that we give out at the end of every total body skin exam. I tell patients that those turn purple when exposed to UV light, and it’s a gentle reminder, or maybe not so gentle, to wear sunscreen.

The other thing I do is every time I have an aesthetic patient, whenever we’re massaging anything in, or even after every sort of facial that we do in my practice, we actually use sunscreen as the moisturizer. It gives us time to be able to educate them about sunscreen habits. At the end of the day, anti-aging starts with sun protection.

Dr Zeichner: And, Sherrill, what about you?

Ms Rudy: The AAP has just come out with new guidelines on how pediatricians and pediatric healthcare practitioners should approach this issue.[5] They say that teaching parents about sun protection needs to be addressed at well visits, particularly at touch points whenever people are going to be spending much more time outdoors, and also before vacations to sunny locations or up to the ski slopes. Studies have shown that it’s not been a subject that’s been addressed as much and needs to be increased.

Dr Zeichner: Yes, and I really think it’s our responsibility as care providers, whether we’re pediatricians, nurses, dermatologists, or primary care doctors, to tell our patients that sun protection is as important as brushing your teeth and heart health. It’s important to take care of the outside of your body as well as the inside of your body.

Dr Mariwalla: Right. It is your largest organ, and unfortunately you won’t see what you’ve done wrong until it’s much later on in life. I think that’s the hard part about it, and I think that with the tips that we’re providing, hopefully our viewers will be able to help their patients pick good products.


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Dr Zeichner: I want to thank you both so much for having this conversation with me.

Dr Mariwalla: Thank you.

Ms Rudy: Thank you.

Dr Zeichner: I would also like to thank everyone out there for participating in this activity. Click on the Earn CME/CE Credit link to revisit the question presented at the beginning of the activity and see what you’ve learned. The CME/CE posttest and evaluation will follow.

This transcript has been edited for style and clarity.

This article is a CME/CE certified activity. To earn credit for this activity visit:http://www.medscape.org/viewarticle/826855

ABBREVIATIONSAAD = American Academy of Dermatology

AAP = American Academy of Pediatrics

FDA = Food and Drug Administration

IARC = International Agency for Research on Cancer

SCF = Skin Cancer Foundation

SPF = sun protection factor

UV = ultraviolet

UVA = ultraviolet A

UVB = ultraviolet B

UVC = ultraviolet C

WHO = World Health Organization

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REFERENCES1. Fourtanier A, Moyal D, Seite S. UVA filters in sun-protection products: regulatory and biological aspects. Photochem Photobiol Sci. 2012;11:81-89. 2. Young AR, Boles J, Herzog B, Osterwalder U, Baschong W. A sunscreen’s labeled sun protection factor may overestimate protection at temperate latitudes: a human in vivo study. J Invest Dermatol. 2010;130:2457-2462. 3. Food and Drug Administration, HHS. Labeling and effectiveness testing; sunscreen drug products for over-the-counter human use. Final rule. Fed Regist. 2011;76:35620-35665. 4. Zanetti R, Rosso S, Martinez C, et al. Comparison of risk patterns in carcinoma and melanoma of the skin in men: a multi- centre case-case- control study. Br J Cancer. 2006;94:743-751. 5. Council on Environmental Health, Section on Dermatology, Balk SJ. Ultraviolet radiation: a hazard to children and adolescents. Pediatrics. 2011;127:588-597. 6. Teramura T, Mizuno M, Asano H, Naito N, Arakane K, Miyachi Y. Relation ship between sun- protection factor and application thickness in high- performance sunscreen: double application of sunscreen is recommended. Clin Exp Dermatol. 2012;37:904-908. 7. Food and Drug Administration, HHS. Sunscreen drug products for over- the-counter human use; request for data and information regarding dosage forms. Fed Regist. 2011;76:56682-56683.8. Hollis BW, Wagner CL, Drezner MK, Binkley NC. Circulating vitamin D3 and 25-hydroxyvitamin D in humans: an important tool to define adequate nutritional vitamin D status. J Steroid Biochem Mol Biol. 2007; 103:631-634. 9. Paller AS, Hawk JL, Honig P, et al. New insights about infant and toddler skin: implications for sun protection. Pediatrics. 2011;128:92-102. 10. Stamatas GN, Nikolovski J, Luedtke MA, Kollias N, Wiegand BC. Infant skin microstructure assessed in vivo differs from adult skin in organization and at the cellular level. Pediatr Dermatol. 2010;27:125-131. 11. American Academy of Pediatrics. Sun safety: information for parents about sunburn % sunscreen. June 5, 2014. Available at: http://www.healthychildren.org/English/safety-prevention/at-play/Pages/ Sun-Safety.aspx. Accessed June 10, 2014.12. Skin Cancer Foundation. Sun safety tips for infants, babies and toddlers. 2014. http://www.skincancer.org/prevention/sun- protection/children/ sun-safety-tips-for-infants-babies-and-toddlers. Accessed June 10, 2014.13. American Academy of Dermatology. Sunscreen FAQs. 2014. Available at: http://www.aad.org/media-resources/stats-and- facts/ prevention-and-care/sunscreens. Accessed June 10, 2014.14. Tuong W. Armstrong AW. Effect of appearance-based education compared with health-based education on sunscreen use and knowledge: a randomized controlled trial. J Am Acad Dermatol. 2014;70:665-669. 15. World Health Organization. Sunbeds, tanning and UV exposure. Fact sheet number 287. Interim revision April 2010. Available at: http://www.who.int/ mediacentre/factsheets/fs287/en/. Accessed June 10, 2014.16. International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review. Int J Cancer. 2007;120:1116-1122. 17. El Ghissassi F, Baan R, Straif K, et al; WHO International Agency for Research on Cancer Monograph Working Group. A review of human carcinogens -- part D: radiation. Lancet Oncol. 2009;10:751-752.

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Sunscreen Story: Interpreting Current Guidelines for Your Patients …img.medscape.com/images/826/855/826855-Web-Reprint.pdf · Target Audience This activity is intended for dermatologists,