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Brent Spencer, MD, FAAD

www.dermntx.com

972.712.5100

Sun SafetyUltraviolet radiation primer

Sun protection strategies

Sunscreens

Vitamin D

Skin CancerBasal cell carcinoma

Squamous cell carcinoma

Melanoma

Treatments

Board-certified Dermatologist4 years of training post-medical school

1 year in general medicine

3 years in dermatology

Fellowship-trained Mohs SurgeonAdditional year of intense training in Mohs and reconstructive surgery

Denison

Ultraviolet radiation is the primary cause of skin cancer

Three types of UV RadiationUVA

UVB

UVC

Each type can contribute to skin cancer and aging

Ultraviolet radiation gets more intense the closer you are to the equator

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UVC100-280 nm

Blocked by the ozone layer

Used commonly to help sterilize objects

UVB280-320 nm

Blocked by glass

Primary cause of sunburn

Primary component of UV radiation responsible for skin cancer

UVAUVA1 – 340-400 nm UVA2 – 320-340 nm

Causes tanningTanning beds emit high levels of UVA

Penetrates deeper into the skin

Causes photoaging of the skin

Has smaller role in causing skin cancer

At sea level, UVA accounts for 95% of UV radiation reaching earth’s surface. (UVB 5%)

AvoidanceAvoid outdoor exposure between the hours of 10AM and 4PM when UV intensity is highest

Seek shade when outdoors

Sunscreens

UV Protective ClothingCoolibar

Solartex

Some Nike, Adidas, & Under Armour shirts

UV Protective ClothingUltraviolet Protection Factor (UPF) Scale

Does not equate to SPF

Measures blockage of both UVA and UVB

White cotton t-shirt = UPF 7

Darker and thicker fabrics have a higher UPF

UPF Rating

Protection Category % UV Radiation Blocked

UPF 15-24 Good 93.3 - 95.9

UPF 25-39 Very Good 96.0 - 97.4

UPF 40-49 Excellent 97.5 or more

UPF 50 + Considered the ultimate in UV sun protection

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UV Protective ClothingSun Guard

Contains Tinsorb FD

Increases UPF of clothing

Manufacture claims UPF of 30

Lasts 20 washes

$1.99 per box

http://sunguardsunprotection.com

Sunscreens only work if used properly

Apply 15 minutes before going outdoors

One ounce of sunscreen is required to cover the entire body

Shot glass of sunscreen

If you are using one tube of sunscreen each summer, you are not using enough

Reapply every 2 hours More frequently if in water or sweating

Which sunscreen do I buy?Vehicle

Lotion, Cream, Gel, Spray

Brand

Cost

The best sunscreen is one that you use regularly

American Academy of Dermatology recommends a SPF of at least 30

Physical Sunscreens

Reflect and scatter UV radiation

Can produce whitish tint

Newer nanotechnology prevents

the old fashioned white nose

look

Sunscreen Max Concentration

Range of protection

Protection Provided

Zinc Oxide 25 % 290-400 nm UVB, UVA2, UVA1

Titanium Dioxide 25 % 290-350 nm UVB, UVA2

Chemical SunscreensAct by absorbing UV photons

Tend to be more elegant cosmeticallyLess greasy

Less tinting

Carry a risk of contact sensitizationSome people develop a poison ivy type rash to these sunscreens

This is why some do not recommend their use in young children

Chemical Sunscreen Max Concentration

Range of protection

Peak Absorption Protection Provided

PABA (rare) 15 % 260-313 nm 238 nm UVB

Padimate O 8 % 290-315 nm 311 nm UVB

Octinoxate 7.5 % 280-310 nm 311 nm UVB

Cinoxate 3 % 270-328 nm 290 nm UVB

Octisalate 5 % 260-310 nm 307 nm UVB

Homosalate 15 % 290-315 nm 306 nm UVB

Trolamine salicylate 12 % 269-320 nm 260-355 nm UVB

Octylocrylene 10 % 287-323 nm 303 nm UVB

Ensulizole 4 % 290-340 nm 310 nm UVB

Oxybenzone 6 % 270-350 nm 290, 325 nm UVB, UVA2

Sulisobenzone 10 % 250-380 nm 366 nm UVB, UVA2

Dioxybenzone 3 % 206-380 nm 352 nm UVB, UVA2

Meradimate 5 % 200-380 nm 336 nm UVA2

Avobenzone 3 % 310-400 nm 360 nm UVA1, UVA2

Ecamsule 10 % 295-359 nm 345 nm UVA1, UVA2

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Sun Protection Factor (SPF)Measures amount of UV radiation necessary to produce erythema compared to unprotected skin

Primarily measures UVB blockage

Does not measure UVA blockage directly

SPF of 30 blocks 97% of UVB light

As some sunscreens increase UVA protection, SPF incidentally goes up.

AAD recommends sunscreens of at least SPF 30

Measurement of UVA blockageNo uniformly accepted measure

In vivo (PPD) and in vitro methods exist

2007 – FDA proposed 4 star systemBased on in vivo and in vitro methods

Star Rating

UVA Protection Level

None

Low

Medium

High

Highest

Rating system droppedIn final 2011 FDA ruling

New FDA GuidelinesPublished June 14, 2011

Take effect Summer 2012

“Broad Spectrum”Must cover UVA and UVB using standardized FDA test

Replaces 4 star system

Must have a critical wavelength of 370 nm or greater

Only Broad Spectrum sunscreens with an SPF value of 15 or higher can claim to reduce the risk of skin cancer and early skin aging

New FDA Guidelines SPF 2-14

“Skin Cancer/Skin Aging Alert: Spending time in the sun increases your risk of skin cancer and early skin aging. This product has been shown only to help prevent sunburn, not skin cancer or early skin aging.”

Water ResistanceNo longer can use terms “waterproof” or “sweatproof”

Labels must list amount of time user can expect to get declared SPF level while swimming or sweating

Two times permitted: 40 or 80 minutes

New FDA GuidelinesRestricted product claims

“Sunblock” is no longer allowed

Cannot claim instant protection or protection lasting longer than 2 hours

Proposed: No SPFs >50; only to be labeled as “SPF 50+”

Further study of sunscreen sprays

My recommendationsNow: SPF of 50 or higher

2012: Broad Spectrum SPF 50 or higher

AdultsNeutrogena Aveeno

Helioplex Active photobarrier complex

La Roche Posay

Mexoryl

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My recommendationsChildren or Sensitive Skin

Zinc oxide based sunscreen

Neutrogena Sensitive Skin

Blue Lizard

Coppertone Waterbabies

What about sprays?Ok to use, but be sure to use enough

Spray to hand, then apply to face

Men tend to prefer, as they are less greasy

New Neutrogena spray can go on wet skin

Future DirectionsAdding antioxidants

Verdict not out yet

Helioplex 360

European SunscreensNot yet FDA approved

Mexoryl XL (drometriazole trisiloxane)

Tinosorb S (bemotrizinol)

Tinosorb M (bisoctrizole)

UVAsorb HEB (diethylhexyl butamido triazone)

Neo Heliopan AP (bisdisulizole disodium)

Uvinul A Plus

Low Vitamin DPoor bone health

May influence development of certain cancers, neurologic disease, infectious disease, autoimmune disease, and cardiovascular disease

“A recent review of this topic by the National Academy of Sciences Institute of Medicine (IOM) concluded that the evidence for associating vitamin D status with outcomes not related to bone health was inconsistent, inconclusive as to causality, and insufficient to inform nutritional requirement.”

Recommended Daily AllowanceAge 1-70: 600 I.U.

Age >70: 800 I.U.

American Academy of Dermatology recommends

Vitamin D be obtained through dietary sources and/or supplements

Vitamin D should not be obtained through exposure to UV radiation

Incidental sun exposure in Texas should be more than adequate to produce adequate vitamin D levels

Terushkin, et al. J Am AcadDermatol. June 2010

Compared vitamin D production in Boston and Miami at varying times of the years in Fitzpatrick skin types I, III, and V.

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Boston, MA at 12 PMMonth 400 I.U. 1000 I.U.

Fitz I Fitz III Fitz V Fitz I Fitz II Fitz V

January 16 23 48 40 62 --

April 3 4 7 6 9 17

July 2 3 5 4 7 13

October 5 8 15 13 19 38

Miami, FL at 12 PMMonth 400 I.U. 1000 I.U.

Fitz I Fitz III Fitz V Fitz I Fitz II Fitz V

January 4 6 12 10 15 29

April 2 3 5 5 7 13

July 2 3 5 4 6 12

October 3 4 8 7 10 18

LatitudesBoston, MA: 42.36° N

Miami, FL: 25.78° N

Frisco, TX: 33.14° N

Using this data, depending on the time of year, 5-20 minutes of sun will provide you with nearly 1000 IU of vitamin D.

There is no role for intentional sun exposure to increase vitamin D levels in Texas.

Rates of skin cancer are now higher than ever2006 – 3,507,693 Nonmelanoma skin cancers in US

76.9% increase in Medicare cases from 1992 to 2006

1 in 5 seventy-year-olds have had a NMSC

Prevalence of a NMSC cancer history 5 times higher than that of breast or prostate cancer

Greater than the 31-year prevalence of all other cancers combined

Annual US Health Care Cost estimated at $2.6 Billion

Melanoma rates also increasing68,130 Americans estimated to be diagnosed in 2010

8,700 deaths estimated in 2010

1.93% of the population will develop melanoma in their lifetime

Incidence of melanoma increasing yearly

Most common malignancy in Caucasians

Intermittent intense sun (UVB) exposure

2/3 occur in sun exposed skin

Increasing incidence: younger patients

Clinical variants: nodular, pigmented, superficial and morpheaform

Locally destructive

Very rare metastasis

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What to look for?Non-healing lesions

Pimples that won’t go away

Spots that bleed easily

Where to look?Sun-exposed areas

Second most common skin malignancy

Most arise in sun exposed skinChronic, long-term sun exposure

Fair skinned, tan poorly, freckled

200,000 cases/year in U.S.

2500 deaths/ yearSCC metastasizes more frequently than BCC

About 3 BCCs for every 1 SCC

What to look for?Non-healing lesions

Pimples that won’t go away

Spots that bleed easily

Where to look?Sun-exposed areas

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Locally destructive methodsElectrodessication & Curretage

Cryotherapy

Surgical methodsWide excision

Mohs Micrographic Surgery

Radiation

Topical agentsImiquimod and 5-Fluorouracil – only superficial BCC

Lesion is scraped with dermal curette

Area is lightly electrodessicated

Repeated 2-3 times

Cure rates of 85-92%

Indicated for nodular or superficial BCC and well-differentiated SCC

Leaves a flat, white scarLooks like a cigarette burn on the skin

Good for areas where cosmesis is not of high concern

Trunk, Extremities

Otherwise known as cutting it out

3-5 mm margin is drawn around visible tumor

Scalpel excises down to the fat

Resulting defect closed with stitches

Cure rates of 88-94%

Lower rates of success with aggressive tumors, recurrent tumors

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After specimen is excised, it is sent for pathologic examination

Specimen is “bread loafed”

Only about 10% of margin is evaluated

Named after Frederic Mohs

Developed procedure at the University of Wisconsin in the 1940s and 50s

Currently used frozen-tissue method done since the 1970s

Offers the highest cure rates for skin cancersBCC – over 99%

SCC – 96-98%

ProcessTumor is excised using special beveled technique

Map is made to orient tissue

Tissue conformed and frozen so that entire margin (peripheral and deep) resides in one plane

100% of margin is examined

Frozen sections made and reviewed

If tumor is present, it is marked on map and re-excision is performed at involved area

Wound reconstructed

Why not use Mohs for every skin cancer?External factors

Government, Insurance companies

Specific indicationsLocation

Tumor in high risk location

Head, neck, hands, feet, pretibial, genitalia

Tumor Features

Large tumors, poorly defined clinical borders, rapid growth, recurrent tumor, perineural invasion

Tumor with positive margin on previous excision

Immunosuppressed patient

Young patients

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The Mohs College DifferenceMember of Mohs College (ACMS) have completed a rigorous 1 year fellowship in Mohs surgery and reconstructive surgery

At least 500 cases must be supervised and completed

Most fellowships complete 1000s of cases

This training is in addition to dermatology residency

Make sure that your Mohs surgeon is a member of the Mohs College

Do I need a plastic surgeon?Fellowship-trained Mohs surgeons are extensively trained in reconstruction

Training requirements

Fellowship-trained Mohs surgeon – 1000s of cases

Plastic surgeon – 15 skin cancer cases

For larger cases or cases where general anesthesia is needed, care can be coordinated with a plastic surgeon.

One of the deadliest forms of skin cancer

Even a small lesion can be deadly

Primarily affects sun exposed areas:Back – most common site

Posterior legs also very common

Can occur anywhere there are melanocytesSkin, Eye, Nails, Genitalia

DetectionRemember your ABCDEs

A = Asymmetry

B = Border

C = Color

D = Diameter

E = Evolving

Perform monthly self skin examinations

When in doubt, see a dermatologist

Asymmetry Border IrregularityColor - Multiple

Diameter > 6 mm

TreatmentEarly, thin lesion (< 1 mm thick)

Surgical Excision

Thicker lesions (> 1 mm thick)Surgical Excision +/- Sentinel Lymph Node Biopsy

Lymph node removal

Chemotherapy

The key is to detect these lesions earlyTumor prognosis directly related to depth of invasion

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Thank you for your time

Questions or comments?

www.dermntx.com

972.712.5100

FDA Sunscreen Rules:http://www.gpo.gov/fdsys/pkg/FR-2011-06-17/pdf/2011-14766.pdf

Vitamin DAAD Position StatementEstimated equivalency of vitamin D production from natural sun exposure versus oral vitamin D supplementation across seasons at two US latitudes VitalyTerushkin, Anna Bender, Estee L. Psaty, Ola Engelsen, Steven Q. Wang, Allan C. Halpern Journal of the American Academy of Dermatology 1 June 2010 (volume 62 issue 6 Pages 929.e1-929.e9 DOI: 10.1016/j.jaad.2009.07.028)

SunscreensSunscreens: An overview and update. Divya R. Sambandan, Desiree Ratner. Journal of the American Academy of Dermatology 1 April 2011 (volume 64 issue 4 Pages 748-758 DOI: 10.1016/j.jaad.2010.01.005)

Photoprotection. Prisana Kullavanijaya, Henry W. Lim. Journal of the American Academy of Dermatology 1 June 2005 (volume 52 issue 6 Pages 937-958 DOI: 10.1016/j.jaad.2004.07.063)

Skin CancerIncidence estimate of nonmelanoma skin cancer in the United States, 2006.Rogers HW, Weinstock MA, Harris AR, Hinckley MR, Feldman SR, Fleischer AB, Coldiron BM. Arch Dermatol. 2010 Mar;146(3):283-7.

Prevalence of a history of skin cancer in 2007: results of an incidence-based model. Stern RS. Arch Dermatol. 2010 Mar;146(3):279-82.