EXPOSURE TO ULTRAVIOLET UV LIGHT

Slide 1: EXPOSURE TO ULTRAVIOLET (UV) LIGHT

Sophie J. Balk, M.D. Professor of Clinical Pediatrics Albert Einstein College of Medicine NEETF Children’s Environmental Health Faculty Champions Initiative Good morning. This morning I’m going to talk to you about UV radiation. The sun is responsible for life on earth – it provides warmth, is needed for photosynthesis, drives biorhythms, promotes feelings of well-being. It is also needed for vitamin D production in the absence of supplementation. As we’ll review, however, exposure to Ultraviolet Light – from the sun and also from artificial sources – tanning parlors, lamps – is hazardous AND it is clearly an issue for pediatricians. Good morning. This morning I’m going to talk to you about UV radiation. The sun is responsible for life on earth – it provides warmth, is needed for photosynthesis, drives biorhythms, promotes feelings of well-being. It is also needed for vitamin D production in the absence of supplementation. As we’ll review, however, exposure to Ultraviolet Light – from the sun and also from artificial sources – tanning parlors, lamps – is hazardous AND it is clearly an issue for pediatricians.

Slide 2:Before I start the rest of this talk, I’d like to give a reason that it is personal for me. I have known several people with melanoma. One of my doctors – someone I’d known for 30 years – died of melanoma 3 years ago. And last year while I was attending a meeting of the National Council on Skin Cancer Prevention, I met Valerie Guild. This is her daughter, Charlie Guild, who died of melanoma at the age of 26. She’d had 4 pediatricians, 2 in NY and 2 in California and no one had ever spoken to her or her mother about being at risk for melanoma. Valerie says that had Charlie known she was at risk, she would have taken precautions to avoid the sun. So after she died her mother founded the Charlie Guild Skin Cancer Foundation. Valerie has dedicated her work to the prevention and early detection of this terrible disease. Before I start the rest of this talk, I’d like to give a reason that it is personal for me. I have known several people with melanoma. One of my doctors – someone I’d known for 30 years – died of melanoma 3 years ago. And last year while I was attending a meeting of the National Council on Skin Cancer Prevention, I met Valerie Guild. This is her daughter, Charlie Guild, who died of melanoma at the age of 26. She’d had 4 pediatricians, 2 in NY and 2 in California and no one had ever spoken to her or her mother about being at risk for melanoma. Valerie says that had Charlie known she was at risk, she would have taken precautions to avoid the sun. So after she died her mother founded the Charlie Guild Skin Cancer Foundation. Valerie has dedicated her work to the prevention and early detection of this terrible disease.

Slide 3:GOALS: TO DISCUSS..

Background on UV radiation (UVR) Health effects Focus on skin cancer Prevention messages What to ask in the history Resources I’ll review some of the basic information on UV radiation Then discuss the health effects with a focus on skin cancer Prevention messages – new unified messages put forward by the National Council on Skin Cancer Prevention that can be used in the office. There are also community-based efforts to address this problem but we are not going to discuss these today because of time considerations.I’ll review some of the basic information on UV radiation Then discuss the health effects with a focus on skin cancer Prevention messages – new unified messages put forward by the National Council on Skin Cancer Prevention that can be used in the office. There are also community-based efforts to address this problem but we are not going to discuss these today because of time considerations.

Slide 4:Here you see the spectrum. Visible: 400 – 700 nm, Infrared (also called heat): >700 nm, Ultraviolet (UV): <400 nm UV-A: 320 – 400 nm, UV-B: 290 – 320 nm, UV-C: <290 nm A nanometer is 10-9 meter, or a billionth of a meter. Long wave rays have less energy than short wave rays.Here you see the spectrum. Visible: 400 – 700 nm, Infrared (also called heat): >700 nm, Ultraviolet (UV): <400 nm UV-A: 320 – 400 nm, UV-B: 290 – 320 nm, UV-C: <290 nm A nanometer is 10-9 meter, or a billionth of a meter. Long wave rays have less energy than short wave rays.

Slide 5:UVR MODIFIED BY PASSAGE THROUGH ATMOSPHERE….

Stratosphere (10 - 50 Km above sea level) Absorption by ozone Scattering by molecules Troposphere (0 -10 Km above sea level) Absorption by pollutants Scattering by particulates Clouds Point 1: The ozone in the stratosphere is not the air pollutant found closer to earth. UVR is scattered by molecules such as nitrogen and oxygen Point 2: absorption and scattering by pollutants (soot) are the main attenuating processes. Clouds reduce UV intensity but not to the same extent as infrared intensity is reduced, so heat sensation is diminished, resulting in the potential for overexposure. Point 1: The ozone in the stratosphere is not the air pollutant found closer to earth. UVR is scattered by molecules such as nitrogen and oxygen Point 2: absorption and scattering by pollutants (soot) are the main attenuating processes. Clouds reduce UV intensity but not to the same extent as infrared intensity is reduced, so heat sensation is diminished, resulting in the potential for overexposure.

Slide 6:INCREASED UV INTENSITY...

At midday In summer Closer to the equator At higher altitudes Reflected from ground surfaces, sand, snow, water Point 2: The closer we are to summer (June 21 or so), the greater is the UV intensity – so the sun is more intense in May than in August. Point 4: UV intensity increases 2% for each 1000 foot elevation. Point 5: Up to 80% is reflected by snow; sand 15%; water 10%. This results in greater exposure.Point 2: The closer we are to summer (June 21 or so), the greater is the UV intensity – so the sun is more intense in May than in August. Point 4: UV intensity increases 2% for each 1000 foot elevation. Point 5: Up to 80% is reflected by snow; sand 15%; water 10%. This results in greater exposure.

Slide 7:HEALTH EFFECTS OF UVR

Skin Eyes Immune system AAP Pediatric Environmental Health, November 2003. We’re not going to focus on the immune system today but immune suppression is increasingly recognized as important in the development of skin cancer. We know that cells containing damaged DNA that has not been repaired can be kept from proliferating by the immune system. We’re not going to focus on the immune system today but immune suppression is increasingly recognized as important in the development of skin cancer. We know that cells containing damaged DNA that has not been repaired can be kept from proliferating by the immune system.

Slide 8:EFFECTS ON THE SKIN

Vitamin D Production Erythema and sunburn Tanning Skin aging Photosensitivity Non-melanoma skin cancer Basal cell carcinoma Squamous cell carcinoma Melanoma AAP Pediatric Environmental Health, November 2003. Point 2: erythema and sunburn are injuriesPoint 2: erythema and sunburn are injuries

Slide 9:Here is a familiar picture of the skin. See epidermis, dermis, subcutaneous tissue. Here is the epidermis where you see the top layer of squamous cells, and a layer of basal cells – and melanocyte interspersed between the basal cells. Melanocytes synthesize melanin, a brown-black pigment. Melanin has a photoprotective function in the skin and it directly absorbs UV photons as well as reactive oxygen species. We know that melanin is protective because skin that is poorly melanized is much more vulnerable than melanized skin to acute and chronic injury caused by UVR. Here is a familiar picture of the skin. See epidermis, dermis, subcutaneous tissue. Here is the epidermis where you see the top layer of squamous cells, and a layer of basal cells – and melanocyte interspersed between the basal cells. Melanocytes synthesize melanin, a brown-black pigment. Melanin has a photoprotective function in the skin and it directly absorbs UV photons as well as reactive oxygen species. We know that melanin is protective because skin that is poorly melanized is much more vulnerable than melanized skin to acute and chronic injury caused by UVR.

Slide 10:This slide illustrates the photoprotective effect of epidermal melanin. This is a woman with vitiligo who was exposed to midday summer sun for approximately one hour three days before this photograph was taken. Her normal skin has begun to tan and is asymptomatic. In contrast, the depigmented areas affected by vitiligo and hence lacking melanocytes are severely sunburned, with erythema and the beginning of desquamation, and are painful even to light touch. This slide illustrates the photoprotective effect of epidermal melanin. This is a woman with vitiligo who was exposed to midday summer sun for approximately one hour three days before this photograph was taken. Her normal skin has begun to tan and is asymptomatic. In contrast, the depigmented areas affected by vitiligo and hence lacking melanocytes are severely sunburned, with erythema and the beginning of desquamation, and are painful even to light touch.

Slide 11:ERYTHEMA & SUNBURN

Minimal erythemal dose (MED) depends on Skin type and thickness Amount of melanin and ability to produce melanin after exposure Intensity of the radiation Six sun-reactive skin types What factors determine if a person will sunburn? Point 1b: Melanin is protective as you saw in the last slide. After “Intensity” point: The ability of UVR to produce erythema also depends on the radiation wavelength. For erythema and sunburn, the action spectrum is mainly in the UVB range. Six sun-reactive skin classifications have been developed to help classify a person’s reaction to sun exposure.What factors determine if a person will sunburn? Point 1b: Melanin is protective as you saw in the last slide. After “Intensity” point: The ability of UVR to produce erythema also depends on the radiation wavelength. For erythema and sunburn, the action spectrum is mainly in the UVB range. Six sun-reactive skin classifications have been developed to help classify a person’s reaction to sun exposure.

Slide 12:I – Always burns easily, never tans 2 – Always burns easily, tans minimally 3 – Burns moderately, tans gradually and uniformly (light brown) 4 – burns minimally, always tans well (moderate brown) 5 – Rarely burns, tans profusely (dark brown) 6 – never burns, deeply pigmented (black)I – Always burns easily, never tans 2 – Always burns easily, tans minimally 3 – Burns moderately, tans gradually and uniformly (light brown) 4 – burns minimally, always tans well (moderate brown) 5 – Rarely burns, tans profusely (dark brown) 6 – never burns, deeply pigmented (black)

Slide 13:TANNING

Protective response to sun exposure Immediate tanning: Induced by UV-A, no new melanin Delayed tanning: Induced by UV-B, begins at 2-3 days, peaks at 7-10 days, new melanin formed Tanning is a protective response to the injurious effects of UV radiation Immediate tanning results from oxidation of existing melanin after exposure Delayed tanning…may last for days or monthsTanning is a protective response to the injurious effects of UV radiation Immediate tanning results from oxidation of existing melanin after exposure Delayed tanning…may last for days or months

Slide 14:NON-MELANOMA SKIN CANCER (NMSC)

Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) Most common malignancies in adults: > 1,000,000/year Found on maximally-exposed areas Usually not fatal unless untreated Related to cumulative sun exposure American Cancer Society 2006 ( www.cancer.org). Accessed 6-28-06. Point 1 and 2: Most of the cancers are basal cell – about 800,000 to 900,000. Squamous cell cancer occurs less often – perhaps about 200,000 to 300,000. The exact number is not precisely known because physicians are not required to report these cancers to cancer registries. Point 4: People do not often die of these cancers: about 1,000 - 2,000 people die of NMSC each year in this country. Most are older and have not received treatment for their cancers soon enough. Other people likely to die of skin cancer are those whose immune systems are suppressed – mostly those who have received organ transplants Point 5: Related to cumulative exposure and in general, NNSC occurs in people who are occupationally exposed – such as farmers and fishermen.Point 1 and 2: Most of the cancers are basal cell – about 800,000 to 900,000. Squamous cell cancer occurs less often – perhaps about 200,000 to 300,000. The exact number is not precisely known because physicians are not required to report these cancers to cancer registries. Point 4: People do not often die of these cancers: about 1,000 - 2,000 people die of NMSC each year in this country. Most are older and have not received treatment for their cancers soon enough. Other people likely to die of skin cancer are those whose immune systems are suppressed – mostly those who have received organ transplants Point 5: Related to cumulative exposure and in general, NNSC occurs in people who are occupationally exposed – such as farmers and fishermen.

Slide 15: MELANOMA

Most common fatal skin cancer 2006: 62,190 new cases with 7,910 deaths1 Occurs in teens, young adults Metastatic melanoma has a grave prognosis Prevention, early detection are key 1 – American Cancer Society 2006 (www.cancer.org). Accessed 6-28-06. The number of melanoma cases and deaths is an estimate from the American Cancer Society. Point 3: Melanoma is most commonly seen in older adult white males – but it is also seen in teens and young adults. Point 4: When detected early, there is an excellent prognosis but…The number of melanoma cases and deaths is an estimate from the American Cancer Society. Point 3: Melanoma is most commonly seen in older adult white males – but it is also seen in teens and young adults. Point 4: When detected early, there is an excellent prognosis but…

Slide 16:MELANOMA IN YOUNG ADULTS AND CHILDREN

A common malignancy in whites1 2nd most common, women 20 – 29 3rd most common, men 20 - 29 Melanoma in children2 Incidence rising 33 patients < 14; 25 yr experience Presentation often atypical: most lesions raised, well-defined borders Lesions unlike any other on child 1 - Wu et al. Cancer Causes and Control 2005; 2 - Ferrari et al, Pediatrics 2005 Point 1: Melanoma is predominantly seen in white, particularly older people. It is also seen in young people. Although cancer is uncommon in young people, melanoma is a common cancer in the young. The most common malignancy in young white women is thyroid cancer; in young men, testicular cancer and Hodgkin’s lymphoma are more common. Point 2a: Although still exceedingly rare, the incidence is rising in Sweden and Australia: 1/1 million ages 1 – 4; 30/1 million in ages 10 – 14. So now early detection is now an issue for pediatric clinicians – this is new since (when I trained) we were taught that melanoma NEVER occurs (in the absence of predisposing conditions).Point 1: Melanoma is predominantly seen in white, particularly older people. It is also seen in young people. Although cancer is uncommon in young people, melanoma is a common cancer in the young. The most common malignancy in young white women is thyroid cancer; in young men, testicular cancer and Hodgkin’s lymphoma are more common. Point 2a: Although still exceedingly rare, the incidence is rising in Sweden and Australia: 1/1 million ages 1 – 4; 30/1 million in ages 10 – 14. So now early detection is now an issue for pediatric clinicians – this is new since (when I trained) we were taught that melanoma NEVER occurs (in the absence of predisposing conditions).

Slide 17:Melanoma characteristicsMelanoma characteristics

Slide 18:MELANOMA

Lifetime risk 1930: 1 in 1500 1987: 1 in 120 2002: 1 in 681 2010: 1 in 501 1- Rigel DS. Dermatol Clin 2002; 20 Incidence was 8.7/100,000 in 1975; 17.7/100,000 in 2000. Incidence was 8.7/100,000 in 1975; 17.7/100,000 in 2000.

Slide 19:WHY IS THE INCIDENCE OF MELANOMA RISING?

Thought to be related to sun exposure Depletion of the ozone layer Changing patterns of dress More leisure time “Sun culture” Pediatric Environmental Health. AAP 2003 Point 1 – referring to stratospheric ozone Point 3 – Seen in people recreationally exposed – white collar workers on sunny vacations who get a “blast” of sun. This is thought to be a result of people’s relatively recent abilities to travel to distant sports for vacations.Point 1 – referring to stratospheric ozone Point 3 – Seen in people recreationally exposed – white collar workers on sunny vacations who get a “blast” of sun. This is thought to be a result of people’s relatively recent abilities to travel to distant sports for vacations.

Slide 20:What is sun culture? This picture shows what we wore at the beach at the turn of the last centuryWhat is sun culture? This picture shows what we wore at the beach at the turn of the last century

Slide 21:Here is what we do now Here is what we do now

Slide 22:This poster from the American Cancer Society illustrates the point that our culture worships the sun with potentially disastrous consequences later on.This poster from the American Cancer Society illustrates the point that our culture worships the sun with potentially disastrous consequences later on.

Slide 23:SUNLIGHT AND MELANOMA

Epidemiologic and biological evidence implicate sunlight in the pathogenesis of melanoma Pediatric Environmental Health. AAP 2003 What causes melanoma?What causes melanoma?

Slide 24:SUNLIGHT AND MELANOMA

Latitude Race and pigmentation Childhood exposure Nevi Pediatric Environmental Health. AAP 2003 There are different lines of evidence. Re latitude: In whites, there is an inverse relationship between latitude and the incidence and mortality rates of melanoma Higher rates near the equator Sun more directly overhead Less ozone Highest rates in Australia – a subtropical nation with a largely Celtic population Re race and pigmentation: Melanoma occurs predominantly in whites Incidence in whites 20x higher than in blacks Risk highest in blonds and redheads (skin types I and II) There are different lines of evidence. Re latitude: In whites, there is an inverse relationship between latitude and the incidence and mortality rates of melanoma Higher rates near the equator Sun more directly overhead Less ozone Highest rates in Australia – a subtropical nation with a largely Celtic population Re race and pigmentation: Melanoma occurs predominantly in whites Incidence in whites 20x higher than in blacks Risk highest in blonds and redheads (skin types I and II)

Slide 25:CHILDHOOD EXPOSURE

~25% of lifetime sun exposure occurs during childhood and adolescence1 Episodic high exposures sufficient to cause sunburn, particularly in childhood and adolescence, increase the risk of melanoma2 1- Godar et al. Photochem Photobiol 2003 2 -Elwood, Jopson. Int J Cancer 1997;73 Until recently, we used to think that 80% of sun exposure came during childhood and adolescence. Diane Godar studied this using records of minute-by-minute activities and then calculating personal exposures. Now we know that only ¼ of sun exposure is incurred at this time of life. Still, it is a crucial time.. 5 or more sunburns double risk of developing melanoma. So childhood exposure is important – adult exposure is also important but childhood exposure is especially important.Until recently, we used to think that 80% of sun exposure came during childhood and adolescence. Diane Godar studied this using records of minute-by-minute activities and then calculating personal exposures. Now we know that only ¼ of sun exposure is incurred at this time of life. Still, it is a crucial time.. 5 or more sunburns double risk of developing melanoma. So childhood exposure is important – adult exposure is also important but childhood exposure is especially important.

Slide 26:CHILDHOOD EXPOSURE

Migration studies: High sun exposure during childhood is important in the pathogenesis of melanoma1 1 - Khlat et al. Am J Epidemiol. 1992;135 E.g. those spending 1st few years of life in sunny environments (Australia), then moving to the sun (Great Britain), will show rates of melanoma similar to that of Australia; and vice versa. E.g. those spending 1st few years of life in sunny environments (Australia), then moving to the sun (Great Britain), will show rates of melanoma similar to that of Australia; and vice versa.

Slide 27:NEVI

Acute sun exposure is implicated in the development of nevi in children1 There is a relationship between the number and type of nevi and the development of melanoma1 Dysplastic nevi: precursor lesions that increase risk2 1 – Gallagher et al. Arch Dermatol. 1990; 126 2 - Clark. Arch Dermatol. 1988;124 Childhood is the most important time for developing nevi (moles). Sun exposure is thought to increase melanoma risk by increasing the number of nevi. Childhood is the most important time for developing nevi (moles). Sun exposure is thought to increase melanoma risk by increasing the number of nevi.

Slide 28:BIOLOGIC EVIDENCE

UVB exposure ? DNA lesions (pyrimidine dimers) whose incomplete repair leads to mutations1 UVA causes oxidative damage to DNA ? mutations1 UVR contributes to immune suppression2 1 - Gilchrest et al. N Engl J Med. 1999;340 2 – Strickland, Kripke. Clin Plast Surg. 1997;24 Point 2: We know that cells containing damaged DNA that has not been repaired can be kept from proliferating by the immune system BUT: 3rd point Point 2: We know that cells containing damaged DNA that has not been repaired can be kept from proliferating by the immune system BUT: 3rd point

Slide 29:BIOLOGIC EVIDENCE: XP

Xeroderma pigmentosum (XP): Grossly deficient repair of DNA damaged by UVR1 SCC, BCC and melanoma seen beginning at young ages1 1 - Photosensitivity. In Behrman, Kliegman, Jenson, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, PA: WB Saunders Co; 2000:1998-2001

Slide 30:SUN PROTECTION

Sun protection is recommended to prevent skin cancer, including melanoma Sun protection is recommended beginning early in life Pediatric clinicians may play an important role in delivering messages Pediatric Environmental Health. AAP 2003 So the evidence is strong linking UV exposure to melanoma development. There are other risk factors – age, family history – but these can’t be avoided and the sun is avoidable SO..read all and after last point: Not everyone sunburns but anyone can developing skin aging, damage to the eyes and damage to the immune system. So the evidence is strong linking UV exposure to melanoma development. There are other risk factors – age, family history – but these can’t be avoided and the sun is avoidable SO..read all and after last point: Not everyone sunburns but anyone can developing skin aging, damage to the eyes and damage to the immune system.

Slide 31:PREVENTION AT ALL DEVELOPMENTAL STAGES

Infants Lack mobility Skin has less melanin than at any other time Children New patterns of exposure Adolescents Susceptible to society’s ideas about beauty and health Point 1: Infants lack mobility and depend on adults to keep them out of the sun Point 2: Children start attending day care and schoolsPoint 1: Infants lack mobility and depend on adults to keep them out of the sun Point 2: Children start attending day care and schools

Slide 32:UV LIGHT – PREVENTION MESSAGES

Do not burn; avoid sun tanning and tanning beds Generously apply sunscreen Wear protective clothing Seek shade Use extra caution near water, snow and sand www.skincancerprevention.org/Tips/tabid/54/ Default.aspx These messages, in this order, were developed by the National Council on Skin Cancer Prevention and are designed to be promote a unified message among many organizations, including the AAP, interested in skin cancer prevention. READ LIST. Message 5: Water, snow and sand reflect the damaging rays of the sun which can increase your chance of sunburn. These messages, in this order, were developed by the National Council on Skin Cancer Prevention and are designed to be promote a unified message among many organizations, including the AAP, interested in skin cancer prevention. READ LIST. Message 5: Water, snow and sand reflect the damaging rays of the sun which can increase your chance of sunburn.

Slide 33:DO NOT BURN; AVOID SUN TANNING AND TANNING BEDS

Burning raises melanoma risk Avoid/limit exposure during peak hours (10AM – 4PM) Avoid intentional tanning Message 1: We strongly discourage sunburning. Message 2: We strongly discourage intentional tanning - if teens want to look like they have been in the sun, they can consider using a sunless self-tanning product, but should continue to use sunscreen with it. Message 1: We strongly discourage sunburning. Message 2: We strongly discourage intentional tanning - if teens want to look like they have been in the sun, they can consider using a sunless self-tanning product, but should continue to use sunscreen with it.

Slide 34:GENEROUSLY APPLY SUNSCREEN

Sunscreen is the sun protection method most commonly used1 Apply to all exposed skin using SPF > 15 Broad protection (UVA & UVB) Reapply often 1 - Olson et al. Pediatrics 1997;99 Message 2: Apply sunscreen to all exposed skin using a Sun Protection Factor (SPF) of at least 15 which provides broad-spectrum protection from both ultraviolet A (UVA) and ultraviolet B (UVB) radiation. Re-apply every two hours, even on cloudy days, and after swimming or sweating. Message 2: Apply sunscreen to all exposed skin using a Sun Protection Factor (SPF) of at least 15 which provides broad-spectrum protection from both ultraviolet A (UVA) and ultraviolet B (UVB) radiation. Re-apply every two hours, even on cloudy days, and after swimming or sweating.

Slide 35:WEAR PROTECTIVE CLOTHING 

Simple, practical protection The structure (weave) of the fabric is most important Light-weight long pants and sleeves suggested Hats with a bill or brim Sunglasses Point 2: A tight weave is most protective. If the fabric lets in little light when held up to the sun, it has a tight weave. There is a relatively new UPF (Ultraviolet Protective Factor) rating for clothing. Point 4: Hats should have a 3” brim to shade the face, cheeks and nose. Sunglasses should be rated to block 99-100% of UVA and UVB. Sunglasses are coated with a UV-protective chemical - the darkness of the sunglass has nothing to do with the UV protection afforded. Point 2: A tight weave is most protective. If the fabric lets in little light when held up to the sun, it has a tight weave. There is a relatively new UPF (Ultraviolet Protective Factor) rating for clothing. Point 4: Hats should have a 3” brim to shade the face, cheeks and nose. Sunglasses should be rated to block 99-100% of UVA and UVB. Sunglasses are coated with a UV-protective chemical - the darkness of the sunglass has nothing to do with the UV protection afforded.

Slide 36:SEEK SHADE

Shade is useful but… Shade offers insufficient protection because UV light is scattered and reflected A fair-skinned person sitting under a tree can burn in an hour Point 2: Shade also provides relief from heat, making people feel protectedPoint 2: Shade also provides relief from heat, making people feel protected

Slide 37:SUNSCREENS

Came into use in 1950’s Promoted tanning without burning First true sunscreen (PABA) became available in 1970’s High-intensity sunscreens within last 15 years Rigel DS. Dermatol Clin 2002; 20. Point 2: The first sunscreens were marketed as “suntan lotions” (remember Coppertone’s “Tan don’t burn” campaign)Point 2: The first sunscreens were marketed as “suntan lotions” (remember Coppertone’s “Tan don’t burn” campaign)

Slide 38:OPAQUE SUNSCREENS

Scatter, reflect, block UV light Zinc oxide, titanium dioxide, red vetenary petrolatum, talc Effective for diseases related to light exposure (SLE, XP, solar urticaria) Useful for those spending extensive periods outside Rigel DS. Dermatol Clin 2002; 20. There are 2 types of sunscreens, opaque and chemical Point 3: Because people with these disorders need to be shielded from all UVR.There are 2 types of sunscreens, opaque and chemical Point 3: Because people with these disorders need to be shielded from all UVR.

Slide 39:CHEMICAL SUNSCREENS

Rigel DS. Dermatol Clin 2002; 20. UVB: 290 – 320 nm UVA: 320 – 400 nm These absorb UV rays. Note that none of these protect through all of UVA and UVB so they must be combined. Here are some examples of 1 - PABA esters 2 - Cinnamates 3 - Benzophenones 4 - Dibenzoylmethanes (eg parsol) These absorb UV rays. Note that none of these protect through all of UVA and UVB so they must be combined. Here are some examples of 1 - PABA esters 2 - Cinnamates 3 - Benzophenones 4 - Dibenzoylmethanes (eg parsol)

Slide 40:SUN PROTECTION FACTOR - SPF

Ratio of amount of time to sunburn with sunscreen compared to time to sunburn without sunscreen 1970’s: SPF’s 2 – 4: 50 – 75% protection High-potency sunscreens: SPF’s 15 – 50, 93 – 98% protection Rigel DS. Dermatol Clin 2002; 20. Point 1 – For example, for SPF 15, if a person develops erythema after 10 minutes in the sun, he can stay in the sun for 10 X 15 minutes before experiencing erythema. Point 1 – For example, for SPF 15, if a person develops erythema after 10 minutes in the sun, he can stay in the sun for 10 X 15 minutes before experiencing erythema.

Slide 41:LIMITATIONS OF SPF SYSTEM

Applies to UVB protection only Measured under ideal conditions Concerns about: Using adequate amounts Applying before needed Need for frequent reapplication Point 3A – 1 ounce per application is considered an adequate amount for an adult. The bottom line is that because of these factors, the amount of protection afforded by a sunscreen is often less than expected as advertised on the label. Point 3A – 1 ounce per application is considered an adequate amount for an adult. The bottom line is that because of these factors, the amount of protection afforded by a sunscreen is often less than expected as advertised on the label.

Slide 42:SUNSCREEN AND MELANOMA

Sunscreen Reduces sunburn Can prevent actinic keratoses1 Can prevent SCC2 No conclusive data in humans to demonstrate that sunscreen prevents melanoma or BCC 1 - Thompson, Jolley, Marks. NEJM 1993; 329 2 – Green et al. Lancet 1999; 354 Point 2 – In fact, there’s been discussion over the last few years about whether sunscreen use is a RISK FACTOR for melanomaPoint 2 – In fact, there’s been discussion over the last few years about whether sunscreen use is a RISK FACTOR for melanoma

Slide 43:IS SUNSCREEN USE A RISK FACTOR FOR MELANOMA?

Swedish case-control study found increased risk1 Several studies found increased risk with sunscreen use; some studies found decreased risk; others found no change2 1 – Westerdal et al. Melanoma Res 1995; 5:59-65. 2 - Cooper, Lim. J Amer Acad Dermatol 1999; 40. A Swedish case-control study found increased risk for “almost always” versus “never” using sunscreen with an odds ration of 1.8. They didn’t address the details of use, just “when you are out in the sun, do you use sunscreen?”. So this line of questioning reflected current use. A Swedish case-control study found increased risk for “almost always” versus “never” using sunscreen with an odds ration of 1.8. They didn’t address the details of use, just “when you are out in the sun, do you use sunscreen?”. So this line of questioning reflected current use.

Slide 44:IS SUNSCREEN USE A RISK FACTOR FOR MELANOMA?

No studies demonstrate that sunscreens are carcinogenic1 Sunscreen users may extend their time out in the sun2 There may be greater exposure to UVA1 1-Cooper, Lim. J Amer Acad Dermatol 1999; 40 2-Autier et al. J Natl Cancer Inst. 1999;91:1304-1309 In fact, a melanoma researcher, Phillippe Autier, conducted a double blind randomized controlled trial of sunscreen use of 2 groups of young people on sunny vacations. He gave each group tubes of sunscreen that were identical except for SPF. He asked all subjects to keep diaries of sun exposure and showed that those using the higher SPF sunscreen spent more time in the sun. Because sunscreen may provide better UVB protection and people burn less, they may spend more time in the sun. In fact, a melanoma researcher, Phillippe Autier, conducted a double blind randomized controlled trial of sunscreen use of 2 groups of young people on sunny vacations. He gave each group tubes of sunscreen that were identical except for SPF. He asked all subjects to keep diaries of sun exposure and showed that those using the higher SPF sunscreen spent more time in the sun. Because sunscreen may provide better UVB protection and people burn less, they may spend more time in the sun.

Slide 45:SUNSCREEN MAKERS SUED FOR MISLEADING CLAIMS

April 2006: 9 suits involving popular brands charged that manufacturers inflated claims about sunscreens’ protection Sunscreen called the “snake oil of the 21st century“ Focus on labels claiming equal UVA/UVB protection; “all day”; “waterproof”; www.consumeraffairs.com/news04/2006/03/sunscreen.html. Accessed 7-29-06 Point 1: Brands included Coppertone, Banana Boat, Hawaiian Tropic, Bullfrog and Neutrogena. Lawsuit charged that they lulled consumers into believing they are safe from the dangers of prolonged sun exposure. Point 3: They allege that consumers have purchased sun protection products under the false impression that they are receiving protection from all of the sun’s harmful ultraviolet rays. The suits also allege that parents have been misled into believing their children are protected as a result of claims in labels for products aimed specifically at children, such as Coppertone Water Babies. Point 1: Brands included Coppertone, Banana Boat, Hawaiian Tropic, Bullfrog and Neutrogena. Lawsuit charged that they lulled consumers into believing they are safe from the dangers of prolonged sun exposure. Point 3: They allege that consumers have purchased sun protection products under the false impression that they are receiving protection from all of the sun’s harmful ultraviolet rays. The suits also allege that parents have been misled into believing their children are protected as a result of claims in labels for products aimed specifically at children, such as Coppertone Water Babies.

Slide 46: RECOMMENDATIONS

AAP, ACS, AAD, EPA, CDC, others recommend multi-component message Sunscreen is one part of a sun protection program Sunscreen should not be used to extend time spent in the sun Even though there remain uncertainties about sunscreen, there is a consistent message. Sunscreen prevents sunburn and should be used for that purpose and to possibly prevent other adverse effects. The American Academy of Pediatrics, American Cancer Society, American Academy of Dermatology, Environmental Protection Agency and Centers for Disease Control all recommend sunscreen as part of a multicomponent program. Even though there remain uncertainties about sunscreen, there is a consistent message. Sunscreen prevents sunburn and should be used for that purpose and to possibly prevent other adverse effects. The American Academy of Pediatrics, American Cancer Society, American Academy of Dermatology, Environmental Protection Agency and Centers for Disease Control all recommend sunscreen as part of a multicomponent program.

Slide 47:SUNSCREEN AND VITAMIN D METABOLISM

Vitamin D produced in the skin by action of UVB Inadequate sunlight is an important risk factor for rickets Concerns that sunscreen use may affect levels of Vitamin D On the other side of things are emerging concerns about not getting enough sunlight. Point 2: There have been reports of rickets especially in breast fed babies. On the other side of things are emerging concerns about not getting enough sunlight. Point 2: There have been reports of rickets especially in breast fed babies.

Slide 48:SUNSCREEN AND VITAMIN D METABOLISM

AAP policy - April 2003 Infants need 200 IU Vit D/day Human milk: < 25 IU/L Vit D Infant formula: 400 IU/L Vit D Supplementation: all breast-fed infants, formula-fed infants taking <500 ml/day, children with inadequate intake/sun AAP Section on Breastfeeding and Committee on Nutrition. Pediatrics 2003; 111. Because of concerns about staying out of the sun and using sunscreen could result in rickets, the AAP came out with this policy a few years ago. Because of concerns about staying out of the sun and using sunscreen could result in rickets, the AAP came out with this policy a few years ago.

Slide 49:VITAMIN D AND CANCER PREVENTION

Recent studies suggest a role for vitamin D in cancer prevention Colon, breast, prostate, lung High prevalence of vitamin D deficiency/insufficiency Insufficient evidence to make recommendations about sun exposure http://msnbc.msn.com/id/7875140/print/1/displaymode/1098. Accessed 7-04-06 The evidence for the role of vitamin D in cancer prevention is particularly strong for colorectal cancer. There was a recent (March 2006) conference in Toronto titled “UV, Vitamin D and Health”. Key recommendations for additional research were: 1 - the optimum level of blood concentration and daily intake of vitamin D needed to maintain health; 2 - the amount of UVB exposure needed to synthesize optimum vitamin D in the skin; in particular, the appropriate recommendation given skin pigmentation, age and latitude.  It appears that recommendations must be individualized based on age, skin pigmentation, geographic location and other factors;  3 - the long-term risks, if any, of lifetime ingestion of large quantities of vitamin D; and 4 - the level of vitamin D sufficiency that is clinically relevant, decreasing the risk of health problems, such as cancer.The evidence for the role of vitamin D in cancer prevention is particularly strong for colorectal cancer. There was a recent (March 2006) conference in Toronto titled “UV, Vitamin D and Health”. Key recommendations for additional research were: 1 - the optimum level of blood concentration and daily intake of vitamin D needed to maintain health; 2 - the amount of UVB exposure needed to synthesize optimum vitamin D in the skin; in particular, the appropriate recommendation given skin pigmentation, age and latitude.  It appears that recommendations must be individualized based on age, skin pigmentation, geographic location and other factors;  3 - the long-term risks, if any, of lifetime ingestion of large quantities of vitamin D; and 4 - the level of vitamin D sufficiency that is clinically relevant, decreasing the risk of health problems, such as cancer.

Slide 50:This article from a May 2005 People Magazine talks about the risks of indoor tanningThis article from a May 2005 People Magazine talks about the risks of indoor tanning

Slide 51:Here is a tanning bed. These emit primarily UVA - 20 minutes of sunbed exposure represents a UVA dose equivalent to 2-3 hours of sun exposure in the midday summer sun Here is a tanning bed. These emit primarily UVA - 20 minutes of sunbed exposure represents a UVA dose equivalent to 2-3 hours of sun exposure in the midday summer sun

Slide 52:INDOOR TANNING1

Salon use in <25 year olds 1996 - 8%; 2003 - 26% College students: 32% – 55% usage rates High school students Males 6 - 44% Females 20 – 70% 2001: Indoor tanning industry generated $4 billion in revenues 1 - Scientific and regulatory issues related to indoor tanning. JAAD 2004. These are data from a 2004 symposium organized by the FDA, the American Academy of Dermatology and the American Society for Photobiology. Tanning salon use by those ages 25 and under has increased dramatically. These are data from a 2004 symposium organized by the FDA, the American Academy of Dermatology and the American Society for Photobiology. Tanning salon use by those ages 25 and under has increased dramatically.

Slide 53:INDOOR TANNING AND MELANOMA

Epidemiologic evidence suggests that indoor tanning causes melanoma and SCC; perhaps BCC1 NIEHS recommends that UV light from artificial sources such as tanning booths and tanning beds be listed as a known human carcinogen2 1 - Scientific and regulatory issues related to indoor tanning. JAAD 2004 2 - http://www.nih.gov/news/pr/oct97/niehs-30.htm. Accessed 7-04-06 Epidemiologic evidence of the relationship of tanning to skin cancer was also reviewed. Epidemiologic evidence of the relationship of tanning to skin cancer was also reviewed.

Slide 54:INDOOR TANNING LEGISLATION

Federal regulation of manufacturers States regulate operation of equipment 26 states regulate salon operators Legislation varies Limited enforcement http://news.findlaw.com/prnewswire/20050317/17mar2005164738.html Point 2: Once manufacturers sell the equipment, it is up to the states.. Point 3:Although 26 states (as of early July 2006) regulate salon operators, legislation varies (some states prohibit access of minors to tanning booths without parental consent; while others require warning signs in a visible location. Regarding enforcement, it is not clear who is responsible. Many have made the point that we protect kids from alcohol and smoking – but not from tanning. The AAD recently issued an endorsement of a WHO recommendation that no person under the age of 18 use a tanning bed. They cited the link between UV light and skin cancer. And they said that indoor tanning was particularly troubling because “it is so unnecessary” - not associated with playing sports but is purely cosmetic and results in people putting their health at risk. Point 2: Once manufacturers sell the equipment, it is up to the states.. Point 3:Although 26 states (as of early July 2006) regulate salon operators, legislation varies (some states prohibit access of minors to tanning booths without parental consent; while others require warning signs in a visible location. Regarding enforcement, it is not clear who is responsible. Many have made the point that we protect kids from alcohol and smoking – but not from tanning. The AAD recently issued an endorsement of a WHO recommendation that no person under the age of 18 use a tanning bed. They cited the link between UV light and skin cancer. And they said that indoor tanning was particularly troubling because “it is so unnecessary” - not associated with playing sports but is purely cosmetic and results in people putting their health at risk.

Slide 55:ARE SUN PROTECTION MESSAGES EFFECTIVE?

Melanoma rates rising quickly Geller et al: Nationwide survey of > 10,000 teens 12 - 18 83%: >1 sunburns in previous summer 36%: >3 sunburns Sunscreen use in 34% ~ 10% reported tanning bed use in previous year Geller et al. Pediatrics 2002. We have a long way to goWe have a long way to go

Slide 56:UV LIGHT - HISTORY

Family history of melanoma? Are you (your child) protected from excess sun exposure? Do you visit tanning parlors? Target children at high risk Family history of melanoma Skin Types I & II Nevi, freckling Sunburns Whom to target? When to deliver messages? Summertime and at other times of expected high sun exposure – such as ski vacations are important. It’s recommended to discuss sun/UV protection with everyone – not everyone sunburns but anyone can get damage to the eye and immune suppression. If this is not feasible because of time constraints and other factors… at least target children and adolescents who are at high risk – skin types I and II Whom to target? When to deliver messages? Summertime and at other times of expected high sun exposure – such as ski vacations are important. It’s recommended to discuss sun/UV protection with everyone – not everyone sunburns but anyone can get damage to the eye and immune suppression. If this is not feasible because of time constraints and other factors… at least target children and adolescents who are at high risk – skin types I and II

Slide 57:UV LIGHT – PREVENTION MESSAGES

Do not burn; avoid sun tanning and tanning beds Generously apply sunscreen Wear protective clothing Seek shade Use extra caution near water, snow and sand Early detection is also recommended www.skincancerprevention.org/Tips/tabid/54/ Default.aspx WE HAVE MUCH WORK TO DO! To recap prevention messages for the office and other settings…WE HAVE MUCH WORK TO DO! To recap prevention messages for the office and other settings…

Slide 58:RESOURCES

Ultraviolet Index EPA SunWise Program: www.epa.gov/sunwise CDC “Choose Your Cover” campaign: www.cdc.gov/ChooseYourCover National Council on Skin Cancer Prevention: www.skincancerprevention.org

Slide 59:The AAP Handbook of Pediatric Environmental Health has a chapter on UV Light and in the chapter on Taking an Environmental History suggests that questions about sun/UV exposure be basic to the environmental history.The AAP Handbook of Pediatric Environmental Health has a chapter on UV Light and in the chapter on Taking an Environmental History suggests that questions about sun/UV exposure be basic to the environmental history.

Slide 61:Contact Information

Leyla Erk McCurdy Senior Director, Health & Environment National Environmental Education & Training Foundation (NEETF) Email: mccurdy@neetf.org Phone: 202.261.6488 NEETF is tracking pediatric environmental health education activities for health care providers and requests your feedback http://www.neetf.org/health