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EXPOSURE TO ULTRAVIOLET (UV) LIGHT EXPOSURE TO ULTRAVIOLET (UV) LIGHT Sophie J. Balk, M.D. Professor of Clinical Pediatrics Albert Einstein College of.

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Presentation on theme: "EXPOSURE TO ULTRAVIOLET (UV) LIGHT EXPOSURE TO ULTRAVIOLET (UV) LIGHT Sophie J. Balk, M.D. Professor of Clinical Pediatrics Albert Einstein College of."— Presentation transcript:

1 EXPOSURE TO ULTRAVIOLET (UV) LIGHT 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

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3 GOALS: TO DISCUSS.. Background on UV radiation (UVR) Background on UV radiation (UVR) Health effects Health effects Focus on skin cancerFocus on skin cancer Prevention messages Prevention messages What to ask in the history What to ask in the history Resources Resources

4 SUNLIGHT

5 UVR MODIFIED BY PASSAGE THROUGH ATMOSPHERE…. Stratosphere ( Km above sea level) Stratosphere ( Km above sea level) Absorption by ozoneAbsorption by ozone Scattering by moleculesScattering by molecules Troposphere (0 -10 Km above sea level) Troposphere (0 -10 Km above sea level) Absorption by pollutantsAbsorption by pollutants Scattering by particulatesScattering by particulates CloudsClouds

6 INCREASED UV INTENSITY... At midday At midday In summer In summer Closer to the equator Closer to the equator At higher altitudes At higher altitudes Reflected from ground surfaces, sand, snow, water Reflected from ground surfaces, sand, snow, water

7 HEALTH EFFECTS OF UVR Skin Skin Eyes Eyes Immune system Immune system AAP Pediatric Environmental Health, November 2003.

8 EFFECTS ON THE SKIN Vitamin D Production Vitamin D Production Erythema and sunburn Erythema and sunburn Tanning Tanning Skin aging Skin aging Photosensitivity Photosensitivity Non-melanoma skin cancer Non-melanoma skin cancer Basal cell carcinomaBasal cell carcinoma Squamous cell carcinomaSquamous cell carcinoma Melanoma Melanoma AAP Pediatric Environmental Health, November 2003.

9 American Cancer Society 2006 (

10 Gilchrest et al. NEJM April 1999.

11 ERYTHEMA & SUNBURN Minimal erythemal dose (MED) depends on Minimal erythemal dose (MED) depends on Skin type and thicknessSkin type and thickness Amount of melanin and ability to produce melanin after exposureAmount of melanin and ability to produce melanin after exposure Intensity of the radiationIntensity of the radiation Six sun-reactive skin types Six sun-reactive skin types

12 SKIN TYPES

13 TANNING Protective response to sun exposure Protective response to sun exposure Immediate tanning: Induced by UV-A, no new melanin 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 Delayed tanning: Induced by UV-B, begins at 2-3 days, peaks at 7-10 days, new melanin formed

14 NON-MELANOMA SKIN CANCER (NMSC) Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) Most common malignancies in adults: > 1,000,000/year Most common malignancies in adults: > 1,000,000/year Found on maximally-exposed areas Found on maximally-exposed areas Usually not fatal unless untreated Usually not fatal unless untreated Related to cumulative sun exposure Related to cumulative sun exposure American Cancer Society 2006 ( Accessed www.cancer.org

15 MELANOMA Most common fatal skin cancer Most common fatal skin cancer 2006: 62,190 new cases with 7,910 deaths : 62,190 new cases with 7,910 deaths 1 Occurs in teens, young adults Occurs in teens, young adults Metastatic melanoma has a grave prognosis Metastatic melanoma has a grave prognosis Prevention, early detection are key Prevention, early detection are key 1 – American Cancer Society 2006 (www.cancer.org). Accessed www.cancer.org

16 MELANOMA IN YOUNG ADULTS AND CHILDREN A common malignancy in whites 1 A common malignancy in whites 1 2 nd most common, women 20 – 292 nd most common, women 20 – 29 3 rd most common, men rd most common, men Melanoma in children 2 Melanoma in children 2 Incidence risingIncidence rising 33 patients < 14; 25 yr experience33 patients < 14; 25 yr experience Presentation often atypical: most lesions raised, well-defined borders Presentation often atypical: most lesions raised, well-defined borders Lesions unlike any other on child Lesions unlike any other on child 1 - Wu et al. Cancer Causes and Control 2005; 2 - Ferrari et al, Pediatrics 2005

17 MELANOMA A - Asymmetry B - Border C - Color D - Diameter E - Evolving

18 MELANOMA Lifetime risk Lifetime risk 1930: 1 in : 1 in : 1 in : 1 in : 1 in : 1 in : 1 in : 1 in Rigel DS. Dermatol Clin 2002; 20

19 WHY IS THE INCIDENCE OF MELANOMA RISING? Thought to be related to sun exposure Thought to be related to sun exposure Depletion of the ozone layerDepletion of the ozone layer Changing patterns of dressChanging patterns of dress More leisure timeMore leisure time “Sun culture”“Sun culture” Pediatric Environmental Health. AAP 2003

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23 SUNLIGHT AND MELANOMA Epidemiologic and biological evidence implicate sunlight in the pathogenesis of melanoma Epidemiologic and biological evidence implicate sunlight in the pathogenesis of melanoma Pediatric Environmental Health. AAP 2003

24 SUNLIGHT AND MELANOMA Latitude Latitude Race and pigmentation Race and pigmentation Childhood exposure Childhood exposure Nevi Nevi Pediatric Environmental Health. AAP 2003

25 CHILDHOOD EXPOSURE ~25% of lifetime sun exposure occurs during childhood and adolescence 1 ~25% of lifetime sun exposure occurs during childhood and adolescence 1 Episodic high exposures sufficient to cause sunburn, particularly in childhood and adolescence, increase the risk of melanoma 2 Episodic high exposures sufficient to cause sunburn, particularly in childhood and adolescence, increase the risk of melanoma 2 1- Godar et al. Photochem Photobiol Elwood, Jopson. Int J Cancer 1997;73

26 CHILDHOOD EXPOSURE Migration studies: High sun exposure during childhood is important in the pathogenesis of melanoma 1 Migration studies: High sun exposure during childhood is important in the pathogenesis of melanoma Khlat et al. Am J Epidemiol. 1992;135

27 NEVI Acute sun exposure is implicated in the development of nevi in children 1 Acute sun exposure is implicated in the development of nevi in children 1 There is a relationship between the number and type of nevi and the development of melanoma 1 There is a relationship between the number and type of nevi and the development of melanoma 1 Dysplastic nevi: precursor lesions that increase risk 2 Dysplastic nevi: precursor lesions that increase risk 2 1 – Gallagher et al. Arch Dermatol. 1990; Clark. Arch Dermatol. 1988;124

28 BIOLOGIC EVIDENCE UVB exposure  DNA lesions (pyrimidine dimers) whose incomplete repair leads to mutations 1 UVB exposure  DNA lesions (pyrimidine dimers) whose incomplete repair leads to mutations 1 UVA causes oxidative damage to DNA  mutations 1 UVA causes oxidative damage to DNA  mutations 1 UVR contributes to immune suppression 2 UVR contributes to immune suppression Gilchrest et al. N Engl J Med. 1999;340 2 – Strickland, Kripke. Clin Plast Surg. 1997;24

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

30 SUN PROTECTION Sun protection is recommended to prevent skin cancer, including melanoma Sun protection is recommended to prevent skin cancer, including melanoma Sun protection is recommended beginning early in life Sun protection is recommended beginning early in life Pediatric clinicians may play an important role in delivering messages Pediatric clinicians may play an important role in delivering messages Pediatric Environmental Health. AAP 2003

31 PREVENTION AT ALL DEVELOPMENTAL STAGES Infants Infants Lack mobilityLack mobility Skin has less melanin than at any other timeSkin has less melanin than at any other time Children Children New patterns of exposureNew patterns of exposure Adolescents Adolescents Susceptible to society’s ideas about beauty and healthSusceptible to society’s ideas about beauty and health

32 UV LIGHT – PREVENTION MESSAGES Do not burn; avoid sun tanning and tanning beds Do not burn; avoid sun tanning and tanning beds Generously apply sunscreen Generously apply sunscreen Wear protective clothing Wear protective clothing Seek shade Seek shade Use extra caution near water, snow and sand Use extra caution near water, snow and sand tabid/54/ Default.aspx tabid/54/ Default.aspx tabid/54/ Default.aspx tabid/54/ Default.aspx

33 DO NOT BURN; AVOID SUN TANNING AND TANNING BEDS Burning raises melanoma risk Burning raises melanoma risk Avoid/limit exposure during peak hours (10AM – 4PM) Avoid/limit exposure during peak hours (10AM – 4PM) Avoid intentional tanning Avoid intentional tanning

34 GENEROUSLY APPLY SUNSCREEN Sunscreen is the sun protection method most commonly used 1 Sunscreen is the sun protection method most commonly used 1 Apply to all exposed skin using SPF > 15 Apply to all exposed skin using SPF > 15 Broad protection (UVA & UVB) Broad protection (UVA & UVB) Reapply often Reapply often 1 - Olson et al. Pediatrics 1997;99

35 WEAR PROTECTIVE CLOTHING Simple, practical protection Simple, practical protection The structure (weave) of the fabric is most important The structure (weave) of the fabric is most important Light-weight long pants and sleeves suggested Light-weight long pants and sleeves suggested Hats with a bill or brim Hats with a bill or brim Sunglasses Sunglasses

36 SEEK SHADE Shade is useful but… Shade is useful but… Shade offers insufficient protection because UV light is scattered and reflected Shade offers insufficient protection because UV light is scattered and reflected A fair-skinned person sitting under a tree can burn in an hourA fair-skinned person sitting under a tree can burn in an hour

37 SUNSCREENS Came into use in 1950’s Came into use in 1950’s Promoted tanning without burning Promoted tanning without burning First true sunscreen (PABA) became available in 1970’s First true sunscreen (PABA) became available in 1970’s High-intensity sunscreens within last 15 years High-intensity sunscreens within last 15 years Rigel DS. Dermatol Clin 2002; 20.

38 OPAQUE SUNSCREENS Scatter, reflect, block UV light Scatter, reflect, block UV light Zinc oxide, titanium dioxide, red vetenary petrolatum, talc Zinc oxide, titanium dioxide, red vetenary petrolatum, talc Effective for diseases related to light exposure (SLE, XP, solar urticaria) Effective for diseases related to light exposure (SLE, XP, solar urticaria) Useful for those spending extensive periods outside Useful for those spending extensive periods outside Rigel DS. Dermatol Clin 2002; 20.

39 CHEMICAL SUNSCREENS Protection Range PABA 260 – 313 Octyl methoxy- cinnamate 280 – 310 Oxybenzone 270 – 350 Parsol 310 – 400 Rigel DS. Dermatol Clin 2002; 20. UVB: 290 – 320 nm UVA: 320 – 400 nm

40 SUN PROTECTION FACTOR - SPF Ratio of amount of time to sunburn with sunscreen compared to time to sunburn without sunscreen 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 1970’s: SPF’s 2 – 4: 50 – 75% protection High-potency sunscreens: SPF’s 15 – 50, 93 – 98% protection High-potency sunscreens: SPF’s 15 – 50, 93 – 98% protection Rigel DS. Dermatol Clin 2002; 20.

41 LIMITATIONS OF SPF SYSTEM Applies to UVB protection only Applies to UVB protection only Measured under ideal conditions Measured under ideal conditions Concerns about: Concerns about: Using adequate amountsUsing adequate amounts Applying before neededApplying before needed Need for frequent reapplicationNeed for frequent reapplication

42 SUNSCREEN AND MELANOMA Sunscreen Sunscreen Reduces sunburnReduces sunburn Can prevent actinic keratoses 1Can prevent actinic keratoses 1 Can prevent SCC 2Can prevent SCC 2 No conclusive data in humans to demonstrate that sunscreen prevents melanoma or BCC No conclusive data in humans to demonstrate that sunscreen prevents melanoma or BCC 1 - Thompson, Jolley, Marks. NEJM 1993; – Green et al. Lancet 1999; 354

43 IS SUNSCREEN USE A RISK FACTOR FOR MELANOMA? Swedish case-control study found increased risk 1 Swedish case-control study found increased risk 1 Several studies found increased risk with sunscreen use; some studies found decreased risk; others found no change 2 Several studies found increased risk with sunscreen use; some studies found decreased risk; others found no change 2 1 – Westerdal et al. Melanoma Res 1995; 5: Cooper, Lim. J Amer Acad Dermatol 1999; 40.

44 IS SUNSCREEN USE A RISK FACTOR FOR MELANOMA? No studies demonstrate that sunscreens are carcinogenic 1 No studies demonstrate that sunscreens are carcinogenic 1 Sunscreen users may extend their time out in the sun 2 Sunscreen users may extend their time out in the sun 2 There may be greater exposure to UVA 1 There may be greater exposure to UVA 1 1-Cooper, Lim. J Amer Acad Dermatol 1999; 40 2-Autier et al. J Natl Cancer Inst. 1999;91:

45 SUNSCREEN MAKERS SUED FOR MISLEADING CLAIMS April 2006: 9 suits involving popular brands charged that manufacturers inflated claims about sunscreens’ protection April 2006: 9 suits involving popular brands charged that manufacturers inflated claims about sunscreens’ protection Sunscreen called the “snake oil of the 21st century“ Sunscreen called the “snake oil of the 21st century“ Focus on labels claiming equal UVA/UVB protection; “all day”; “waterproof”; Focus on labels claiming equal UVA/UVB protection; “all day”; “waterproof”; Accessed

46 RECOMMENDATIONS RECOMMENDATIONS AAP, ACS, AAD, EPA, CDC, others recommend multi-component message AAP, ACS, AAD, EPA, CDC, others recommend multi-component message Sunscreen is one part of a sun protection program Sunscreen is one part of a sun protection program Sunscreen should not be used to extend time spent in the sun Sunscreen should not be used to extend time spent in the sun

47 SUNSCREEN AND VITAMIN D METABOLISM Vitamin D produced in the skin by action of UVB Vitamin D produced in the skin by action of UVB Inadequate sunlight is an important risk factor for rickets Inadequate sunlight is an important risk factor for rickets Concerns that sunscreen use may affect levels of Vitamin D Concerns that sunscreen use may affect levels of Vitamin D

48 SUNSCREEN AND VITAMIN D METABOLISM AAP policy - April 2003 AAP policy - April 2003 Infants need 200 IU Vit D/day Infants need 200 IU Vit D/day Human milk: < 25 IU/L Vit D Human milk: < 25 IU/L Vit D Infant formula: 400 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 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.

49 VITAMIN D AND CANCER PREVENTION Recent studies suggest a role for vitamin D in cancer prevention Recent studies suggest a role for vitamin D in cancer prevention Colon, breast, prostate, lungColon, breast, prostate, lung High prevalence of vitamin D deficiency/insufficiency High prevalence of vitamin D deficiency/insufficiency Insufficient evidence to make recommendations about sun exposure Insufficient evidence to make recommendations about sun exposure Accessed

50 People Magazine May 05

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52 INDOOR TANNING 1 Salon use in <25 year olds Salon use in <25 year olds %; % %; % College students: 32% – 55% usage rates College students: 32% – 55% usage rates High school students High school students Males %Males % Females 20 – 70%Females 20 – 70% 2001: Indoor tanning industry generated $4 billion in revenues 2001: Indoor tanning industry generated $4 billion in revenues 1 - Scientific and regulatory issues related to indoor tanning. JAAD 2004.

53 INDOOR TANNING AND MELANOMA Epidemiologic evidence suggests that indoor tanning causes melanoma and SCC; perhaps BCC 1 Epidemiologic evidence suggests that indoor tanning causes melanoma and SCC; perhaps BCC 1 NIEHS recommends that UV light from artificial sources such as tanning booths and tanning beds be listed as a known human carcinogen 2 NIEHS recommends that UV light from artificial sources such as tanning booths and tanning beds be listed as a known human carcinogen Scientific and regulatory issues related to indoor tanning. JAAD Accessed http://www.nih.gov/news/pr/oct97/niehs-30.htm

54 INDOOR TANNING LEGISLATION Federal regulation of manufacturers Federal regulation of manufacturers States regulate operation of equipment States regulate operation of equipment 26 states regulate salon operators 26 states regulate salon operators Legislation variesLegislation varies Limited enforcementLimited enforcement

55 ARE SUN PROTECTION MESSAGES EFFECTIVE? Melanoma rates rising quickly Melanoma rates rising quickly Geller et al: Nationwide survey of > 10,000 teens Geller et al: Nationwide survey of > 10,000 teens %: >1 sunburns in previous summer83%: >1 sunburns in previous summer 36%: >3 sunburns36%: >3 sunburns Sunscreen use in 34%Sunscreen use in 34% ~ 10% reported tanning bed use in previous year~ 10% reported tanning bed use in previous year Geller et al. Pediatrics 2002.

56 UV LIGHT - HISTORY Family history of melanoma? Family history of melanoma? Are you (your child) protected from excess sun exposure? Are you (your child) protected from excess sun exposure? Do you visit tanning parlors? Do you visit tanning parlors? Target children at high risk Target children at high risk Family history of melanomaFamily history of melanoma Skin Types I & IISkin Types I & II Nevi, frecklingNevi, freckling SunburnsSunburns

57 UV LIGHT – PREVENTION MESSAGES Do not burn; avoid sun tanning and tanning beds Do not burn; avoid sun tanning and tanning beds Generously apply sunscreen Generously apply sunscreen Wear protective clothing Wear protective clothing Seek shade Seek shade Use extra caution near water, snow and sand Use extra caution near water, snow and sand Early detection is also recommended Early detection is also recommended Default.aspx Default.aspx

58 RESOURCES Ultraviolet Index Ultraviolet Index EPA SunWise Program: EPA SunWise Program: CDC “Choose Your Cover” campaign: CDC “Choose Your Cover” campaign: National Council on Skin Cancer Prevention: National Council on Skin Cancer Prevention:

59 Pediatric Environmental Health, November 2003 RESOURCES

60 THANK YOU!

61 Contact Information Leyla Erk McCurdy Senior Director, Health & Environment National Environmental Education & Training Foundation (NEETF) Phone: NEETF is tracking pediatric environmental health education activities for health care providers and requests your feedback


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