1

Sun Protection in Pediatric PatientsBasic Dermatology Curriculum

Content for this module was developed

by The Society for Pediatric DermatologyLast updated March 1, 2015

Goals and Objectives

Upon completion of this module, the learner will be able to:

Explain the short and long-term risks of sun exposure Screen for risky sun-seeking behaviors in adolescents Counsel patients on effective sun safety and protection Identify patients with photosensitivity disorders that may

require referral to dermatology

Case #1: Sunburn

• A 6 year old male presents to urgent care with a sunburn on his face and trunk, one day after spending an afternoon at the beach

• Upon examination you discover small bullae on his shoulders

• Which of the following is true regarding this patient?

Case #1: Sunburn

A. His lifetime risk of melanoma is now likely higher than that of other children who have never sunburned

B. Topical lidocaine is indicated to soothe the discomfort

C. Use of SPF 30 sunscreen would have prevented the burn by blocking 70% of the sun’s radiation

D. UVA radiation in sunlight is what caused the sunburn

Case #1: Answer

A. His lifetime risk of melanoma is now likely higher than that of other children who have never sunburned

– Meta-analyses suggest that any sunburn is associated with increased melanoma risk. This risk increases with the number of sunburns.

– Lidocaine can be irritating to burned skin– SPF 30 sunscreen blocks 97% of the sun’s UVB

radiation– UVB radiation plays a bigger role in sunburn than

UVA

Ultraviolet radiation: brief review

• Sunlight emits a wide range of radiation energy including visible light and ultraviolet (UV) light

• UVA and UVB light are most dangerous to skin– UVB has a wavelength of 290-320 nm

• Absorbed in the epidermis

– UVA has a wavelength of 320-400 nm• Reaches the dermis

– Visible light is 400-800 nm

• UV exposure increases by 4% for every 1,000 foot elevation above sea level

Risks of sun exposure

There are many risks of sun exposure• Short term risks include:

– Sunburn– UV-associated dermatoses

• Long term risks include:– Photoaging (wrinkles and discoloration)– Photocarcinogenesis (skin cancer)

Short term risk: Sunburn

• The skin becomes red and tender in the hours after sun exposure

• Keratinocyte damage predominantly from UVB light– Cell cycle arrest followed by repair of injured DNA– Apoptosis (programmed cell death)– “B” is for burning

• Langerhans cell depletion resulting in local immunosuppression

• Epidermal thickening • Inflammatory cytokine stimulation

My patient has a sunburn. Now what?

DO:– Soothe hot, burning skin by applying a cool compress or water– Apply moisturizer frequently, especially right after bathing

• Choose a hypoallergenic, fragrance-free cream which is less occlusive than an ointment

– Consider using systemic analgesic/anti-inflammatory medications such as NSAIDS

– Consider mild topical corticosteroids which may bring some relief

DON’T:– Use potentially irritating treatments such as topical lidocaine or

benzocaine preparations

Short term risk: UV-associated dermatoses

• Photosensitivity disorders– Affected persons will develop a rash after sun

exposure.

• Photosensitizing medications– Certain medications make healthy individuals

more sensitive to the sun and more likely to sunburn.

These will be discussed later in the presentation

Long-term risk: Photoaging

• Skin changes secondary to long-term exposure to sunlight– Wrinkling, skin texture changes, freckles, discoloration

• UVA light is thought to be the biggest

offender, due to deeper penetration into the dermis– UVA is able to penetrate window glass– A is for “Aging”

• UVB light also contributes to photoaging – Higher energy photons cause DNA damage

Long-term risk:Photocarcinogenesis

• Sun exposure and sunburns increase the risk of several types of skin cancer, including:– Basal cell carcinoma

• The most common type of skin cancer, but is rarely seen in children

– Squamous cell carcinoma• Rare in children

– Melanoma• The most deadly form of skin cancer• 1-3% of cases occur in the pediatric population (<20yo)

Long term risk: Photocarcinogenesis

• 2008 meta-analysis published in the Annals of Epidemiology:– Sunburns increased the lifetime risk of melanoma, and age at time of

sunburn matters• ANY sunburn before the age of 13 years = 1.9x more likely to

develop melanoma • ANY sunburn between 13-19 years= 1.6x more likely to develop

melanoma • ANY sunburn after 19 years of age = 1.4x more likely to develop

melanoma– More sunburns meant higher risk of melanoma, suggesting a dose-

response relationshipDennis, L.K, et al. Sunburns and risk of cutaneous melanoma, does age matter: a comprehensive meta-analysis. Ann Epidemiol. (2008); 18 (8): 614-627

Case #2: Tanning Beds

• A 17 year old Caucasian female presents for a health maintenance visit with her mother.

• You ask about the use of tanning beds. Your patient admits to occasional tanning.

• She explains that she has been tanning to improve her health, since her vitamin D was recently discovered to be low. She also wants to decrease her risk of sunburn on her upcoming family vacation to Florida.

• Her mother asks your opinion about indoor tanning; what is the next best step in the care of this patient?

Case #2: Tanning Beds

A. Agree that she can continue tanning in the short-term to prevent sunburn during her upcoming trip

B. Reassure the patient’s mother that the benefits of increased Vitamin D synthesis outweigh the risks of tanning bed use

C. Recommend that she only continue indoor tanning if she wears sunscreen to minimize the risks.

D. Strongly recommend discontinuation of indoor tanning because it is not an effective way to prevent sunburn or to synthesize Vitamin D

Case #2: Answer

D. Strongly recommend discontinuation of indoor tanning as it is not an effective way to prevent sunburn or to synthesize Vitamin D

– A suntan provides protection that is equivalent to an SPF of 4 or less. This is not sufficient to prevent sunburn.

– Tanning beds emit mostly UVA radiation. Vitamin D synthesis occurs in the UVB range (peaks at ~300nm) so tanning beds are not very effective for Vitamin D synthesis

• Increased dietary intake of Vitamin D is the safest way to improve Vitamin D levels

– The use of sunscreen does not eliminate risks of tanning beds

Risky sun-seeking behavior:Sunbathing/tanning

• Adolescents, especially females, may view sunbathing or “tanning” as a positive activity

• Suntanner’s goal is to get a “healthy glow”– But tanning is actually the skin’s response to

photodamage– Melanocytes transfer melanin to keratinocytes

in an effort to “shield” the DNA from harmful radiation

Risky sun-seeking behavior:Indoor tanning

• Since 2009, tanning beds are classified as “carcinogenic to humans” by the International Agency for Research of Cancer (IARC)– Considered a Group I carcinogen, similar to cigarettes

• At least 41 states and the District of Columbia have some tanning regulations in place, including a ban on tanning in minors in some states

• Nearly 20% of high school students have been to an indoor tanning facility in the previous year– Approximately 50% of these teens are tanning at least 10x yearly– Caucasian girls are the greatest users of indoor tanning facilities – Up to 35% of teens have tried a tanning bed at least once

Risks of tanning beds

• Incidence of melanoma has doubled in the US over the last 20 years in young women– This parallels the increased rate of indoor tanning

• For young men, the incidence of melanoma has reached a plateau or begun to decline– Young men are less likely to use tanning beds

• 2007 meta-analysis by WHO’s IARC Working Group:– First exposure to indoor tanning beds before age 35 increases risk of

developing melanoma by 75% (RR 1.75, CI 1.35-2.26)– Ever-use of indoor tanning equipment increases risk of developing

melanoma by 15% (RR 1.15, CI 1.00-1.31)

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.

Case #3: Photoprotection

• You are seeing a 4 month old female for her routine visit.

• The patient’s mother notes that the family is going to Disneyworld for vacation.

• She asks what sunscreen you recommend she use on the baby.

Case #3: Photoprotection

A. Reassure that no sun protection is needed as long as she is not outdoors for more than an hour at a time

B. Recommend a sunscreen labeled as a “baby product” with SPF 70

C. Recommend protecting the infant with clothing and shade and using a physical blocking sunscreen only on exposed skin

D. Recommend the trip be delayed until the child is at least 6 months of age since sunscreen products are not approved for use in infants younger than this

Case #3: Answer

C. Recommend protecting the infant with clothing and shade and using a physical blocking sunscreen only on exposed skin

– The AAP recommends sunscreen use in young infants only if adequate clothing and shade are not available

– Infants are at risk of systemic absorption of chemical sunscreens with widespread use, so physical sunscreens are preferred

– Careful education of parents regarding these concerns and emphasis on other forms of protection should allow families to safely bring infants to sunny environments

Sunscreen

• Sunscreens are topically applied agents designed to protect the skin from the effects of UV light

• Appropriate sunscreen use has been shown to reduce the incidence of sun-induced skin cancers (basal cell carcinoma, squamous cell carcinoma, melanoma)

Sunscreen basics: What are the types of sunscreen?

Sunscreen type PHYSICAL BLOCKERS CHEMICAL SUNSCREENS

Mechanism of action Blocks and scatters UV and visible light

Absorbs light and re-emits energy as insignificant quantities of heat

Active ingredients zinc oxidetitanium dioxide

benzophenoneavobenzoneoxybenzonePABA others

Advantages Less irritating to sensitive skin, immediately effective

Not as messy, easier to apply, less apparent white sheen

Sunscreen basics: What is SPF?

• SPF = sun protection factor• It is calculated using the following equation:The amount of time it takes to produce erythema on sun-protected skin

÷

The time it takes to produce the same erythema without sunscreen

• Theoretically, someone who normally burns after 10 minutes can stay outside for 2.5 hours before burning (15 times longer) if wearing SPF 15

How to choose and apply sunscreen

• SPF only measures protection against sunburn from UVB; doesn’t measure effects from UVA – “broad spectrum” sunscreens are best

• SPF 30 or greater is recommended– SPF 30 blocks 97% of the sun’s rays, so higher SPF

products do not have much additional benefit

• All sunscreens need to be reapplied every few hours • Sunscreen must be applied in an adequate amount to

obtain the expected protection. – The average adult should use 1 ounce (a shot glass

size) per full body application

Sun protection and infants

• The sun puts young infants at risk for overheating and sunburn

• The preferred method of sun protection for young infants is sun avoidance (including shade) and protective clothing

• Physical blocker-type sunscreens are a better choice than chemical sunscreens– Less irritating to the sensitive skin of infants– Less likely to be absorbed

Other ways to protect from the sun

• Avoid sun exposure during peak hours – Sun’s rays are strongest between 10 am and 4 pm– Seek shade when your shadow is shorter than you

are

• Use photoprotective clothing and hats– Measured by the ultraviolet protective factor (UPF)

• Good: UPF 15-24• Very good: UPF 25-39• Excellent: UPF 40-50

Case #4: Photosensitivity

• You are seeing a 14 year old female for a rash that developed 10 days ago, 2 days after arriving in Mexico for a spring break vacation

• She states she had a similar rash last spring while on vacation in Florida, and then again early last summer

• The rash consisted of itchy pink bumps on her face and forearms and now it seems to be getting better

• She admits that she only remembered to wear sunscreen a few times and used a zinc-oxide formula

• She is otherwise feeling well with a negative review of systems and takes no medications

• What is the appropriate next step?

Case #4: Photosensitivity

A. Advise her to avoid salt water because she is prone to Seabather’s eruption

B. Counsel that she is likely allergic to the sunscreen that she was using

C. Refer her to dermatology to evaluate for xeroderma pigmentosum or porphyria

D. Tell her that this seems most consistent with polymorphous light eruption

Case #4: Answer

D. Tell her that this seems most consistent with polymorphous light eruption

– Polymorphous light eruption (PMLE) will be discussed in detail later

– Allergy to zinc oxide is rare and would be expected to involve all areas of application

– Seabather’s eruption is a reaction to larva in seawater and tends to involve skin covered by swimming garments

– Xeroderma pigmentosa and porphyria tend to present with severe sunburns early in life

Screening for photosensitivity

• Most people will develop a sunburn if exposed to the sun for long enough without adequate protection

• A person’s hair color, eye color and tendency to burn defines his/her skin type– Skin types are classified from type I (lightest)

to type VI (darkest)

Identifying patients with photosensitivity: Skin type

Skin Type Response to sun exposure Phenotype

I Burn easily and severely Tan little or not at all

Red or blond hairBlue or brown eyes

II Usually burn easilyTan minimally or lightly

Red, blond or brown hairBlue, hazel, or brown eyes

III Burn moderatelyTan gradually and uniformly

Average Caucasian skin

IV Burn minimallyTan easily

Dark brown hairDark eyesWhite or light brown skin

V Rarely burnTan well and easily

Brown-skinned (Middle Eastern and Hispanic)

VI Almost never burnTan profusely

Black skin

Incr

easi

ng r

isk

of p

hoto

sens

itivi

ty

When should I suspect abnormal photosensitivity?

• If your patient develops a sunburn reaction, swelling, or intense itching after limited exposure to sunlight

• If your patient develops a rash or scarring predominantly in sun-exposed areas

If you suspect your patient has abnormal photosensitivity, you should refer to dermatology

Photodermatoses (UV-induced rashes)

• These are rashes that occur in otherwise healthy people after even limited exposure to sunlight– They are idiopathic, but probably

immunologically based

Photodermatoses seen in childhood

Polymorphous Light Eruption* *most common

Actinic Prurigo

Hydroa Vacciniforme

Solar Urticaria

Polymorphous light eruption

• Affects 10-15% of US population• Most commonly affects females in 2nd and 3rd decades of life• Polymorphic lesions that occur 1-2 days after sudden intense sun

exposure; often appears on vacation• Most common on sun-exposed areas of face, neck, upper limbs• Lesions range from papules to wheals to vesicles to plaques; may

appear eczematous and be severely itchy• Self-resolves in 1-2 weeks• May appear in the spring and improve

as skin “hardens” from routine UV

exposure

Solar urticaria

• Type I, IgE-mediated hypersensitivity• Occurs during, or within 30 minutes, of sunlight exposure• Characterized by erythema and sensation of itching/

burning, followed almost immediately by urticaria on exposed skin

• Treatment ranges from oral antihistamines to oral corticosteroids to IVIG to avoidance of daytime sun

• Sun tolerance can sometimes be established with carefully metered exposures to sunlight or use of PUVA phototherapy

Photodermatoses seen in childhood

PMLE Solar urticaria Actinic prurigo Hydroa vacciniforme

Appears within hours to days of exposure

Appears within minutes of exposure

May appear even in UV-protected areas

Appears within hours or days of exposure

Lasts for days Lasts for hours May last for months

Vesicles / bullae dry up after 3-4 d

Idiopathic Type I IGE-mediated hypersensitivity

Idiopathic, Latino population

Result of chronic EBV infection

Photosensitizing medications

Antibiotics: doxycyline, sulfonamides, nalidixic acid, fluoroquinolones

Antifungals: griseofulvin, voriconazole

Non-steroidal anti-inflammatory preparations (NSAIDS)

Other: chlorpromazine, sulfonylurea hypoglycemic agents, anovulatory drugs, lamotragine, phenothiazine antihistamines, furosemide, amiodarone, quinine, isoniazid, thiazide diuretics

• Certain medications make healthy persons more sensitive to the sun and more likely to sunburn.

Conditions characterized by photosensitivity

There are several conditions that have photosensitivity as a

prominent or presenting feature

Xeroderma pigmentosum

Porphyrias

Other genetic syndromes: Cockayne syndrome, Trichothiodystrophy, Bloom syndrome, Rothmund-Thompson syndrome, Kindler syndrome

Pellagra (niacin deficiency)

Severe sunburn early in life should prompt consideration of these entities

Conditions characterized by photosensitivity

There are also certain medical conditions that are exacerbated or triggered by sun exposure

Lupus erythematosus

Dermatomyositis

Herpes simplex infection

Acne

other rare conditions

Perform a thorough history and physical and consider referral if you suspect one of these diagnoses

TAKE-HOME POINTS

• RISKS of sun exposure include sunburns, wrinkles and an aged appearance, precipitation of certain dermatoses, and skin cancer

• ASK your adolescent patients if they use tanning beds; many of them do!

• EXPLAIN the risk of childhood sunburns for future melanoma

• TEACH your patients safe sun habits• KNOW which patients are at highest risk for

photosensitivity

Acknowledgements

This module was developed by the Society for Pediatric Dermatology Education Committee for the American Academy of Dermatology Basic Dermatology Curriculum

Primary authors: Jessica Sempler MD, Sarah Stein MD, Ingrid Polcari MD

Peer reviewers: Erin Mathes, Sheilagh Maguiness Revisions and editing: Rebecca Chasnovitz Last revised February 2015

43

References

• American Academy of Dermatology (2014). Sun Protection. Retrieved from http://www.aad.org/dermatology-a-to-z/health-and-beauty/general-skin-care/sun-protection/sunscreen-labels/how-to-select-a-sunscreen

• American Academy of Dermatology (2014). Treating Sunburn. Retrieved from http://www.aad.org/dermatology-a-to-z/for-kids/about-skin/skin-cancer/treating-sunburn

• Dennis, L.K., et al. Sunburns and risk of cutaneous melanoma, does age matter: a comprehensive meta-analysis. Ann Epidemiol. (2008); 18(8): 614-627.

• Gosis B., Sampson, B.P., Seidenbery, A.B., Balk, S.J., Gottlieb, M., and Geller, A.C. Comprehensive Evaluation of Indoor Tanning Regulations: A 50-state Analysis, 2012. Journal of Investigative Dermatology (2014); 134: 620-627.

• Paller, A.S. and Mancini, A.J. Hurwitz Clinical Pediatric Dermatology: A textbook of skin disorders of childhood and adolescence. 4th Edition. China: Elsevier Sounders, 2011.

• Woo, D.K. and Eide, M.J. Tanning beds, skin cancer, and vitamin D: an examination of the scientific evidence and public health implications. Dermatologic Therapy (2010); 23: 61-71.