EXPOSURE TO EXPOSURE TO ULTRAVIOLET (UV) LIGHT ULTRAVIOLET (UV) LIGHT Sophie J. Balk, M.D. Sophie J. Balk, M.D. Professor of Clinical Pediatrics Professor of Clinical Pediatrics Albert Einstein College of Albert Einstein College of Medicine Medicine NEETF NEETF Children’s Environmental Children’s Environmental Health Health Faculty Champions Faculty Champions Initiative Initiative
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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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EXPOSURE TO EXPOSURE TO ULTRAVIOLET (UV) LIGHTULTRAVIOLET (UV) LIGHT
Sophie J. Balk, M.D.Sophie J. Balk, M.D.
Professor of Clinical PediatricsProfessor of Clinical PediatricsAlbert Einstein College of Medicine Albert Einstein College of Medicine
NEETFNEETFChildren’s Environmental HealthChildren’s Environmental Health
Faculty Champions InitiativeFaculty Champions Initiative
www.charlie.org
GOALS: TO DISCUSS..GOALS: TO DISCUSS.. Background on UV radiation Background on UV radiation
(UVR)(UVR) Health effectsHealth effects
•Focus on skin cancerFocus on skin cancer Prevention messagesPrevention messages What to ask in the historyWhat to ask in the history ResourcesResources
SUNLIGHTSUNLIGHT
UVR MODIFIED BY PASSAGE UVR MODIFIED BY PASSAGE THROUGH ATMOSPHERE….THROUGH ATMOSPHERE….
Stratosphere (10 - 50 Km above Stratosphere (10 - 50 Km above sea level)sea level)• Absorption by ozoneAbsorption by ozone• Scattering by moleculesScattering by molecules
Troposphere (0 -10 Km above sea Troposphere (0 -10 Km above sea level)level)• Absorption by pollutantsAbsorption by pollutants• Scattering by particulatesScattering by particulates• CloudsClouds
At middayAt midday In summerIn summer Closer to the equatorCloser to the equator At higher altitudesAt higher altitudes Reflected from ground Reflected from ground
surfaces, sand, snow, watersurfaces, sand, snow, water
HEALTH EFFECTS OF UVRHEALTH EFFECTS OF UVR
SkinSkin EyesEyes Immune systemImmune system
AAP Pediatric Environmental Health, November 2003.
EFFECTS ON THE SKINEFFECTS ON THE SKIN Vitamin D ProductionVitamin D Production Erythema and sunburnErythema and sunburn TanningTanning Skin agingSkin aging PhotosensitivityPhotosensitivity Non-melanoma skin cancerNon-melanoma skin cancer
AAP Pediatric Environmental Health, November 2003.
American Cancer Society 2006 ( www.cancer.org)
Gilchrest et al. NEJM April 1999.
ERYTHEMA & SUNBURNERYTHEMA & SUNBURN
Minimal erythemal dose Minimal erythemal dose (MED) depends on (MED) depends on •Skin type and thicknessSkin type and thickness•Amount of melanin and ability Amount of melanin and ability
to produce melanin after to produce melanin after exposureexposure
• Intensity of the radiationIntensity of the radiation Six sun-reactive skin typesSix sun-reactive skin types
SKIN TYPES
TANNINGTANNING Protective response to sun Protective response to sun
by UV-A, no new melaninby UV-A, no new melanin Delayed tanningDelayed tanning: Induced by : Induced by
UV-B, begins at 2-3 days, UV-B, begins at 2-3 days, peaks at 7-10 days, new peaks at 7-10 days, new melanin formedmelanin formed
NON-MELANOMA NON-MELANOMA SKIN CANCER (NMSC)SKIN CANCER (NMSC)
Basal cell carcinoma (BCC) and Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)squamous cell carcinoma (SCC)
Most common malignancies in Most common malignancies in adults: > 1,000,000/year adults: > 1,000,000/year
Found on maximally-exposed areas Found on maximally-exposed areas Usually not fatal unless untreatedUsually not fatal unless untreated Related to Related to cumulativecumulative sun exposure sun exposure
American Cancer Society 2006 ( www.cancer.org). Accessed 6-28-06.
MELANOMAMELANOMA
Most common Most common fatalfatal skin cancer skin cancer 2006: 62,190 new cases with 2006: 62,190 new cases with
7,910 deaths7,910 deaths11
Occurs in teens, young adultsOccurs in teens, young adults Metastatic melanoma has a Metastatic melanoma has a
grave prognosisgrave prognosis Prevention, early detection are Prevention, early detection are
keykey1 – American Cancer Society 2006 (www.cancer.org). Accessed 6-28-06.
MELANOMA IN YOUNG ADULTSMELANOMA IN YOUNG ADULTSAND CHILDRENAND CHILDREN
A common malignancy in whitesA common malignancy in whites11 • 22ndnd most common, women 20 – 29 most common, women 20 – 29• 33rdrd most common, men 20 - 29 most common, men 20 - 29
Melanoma in childrenMelanoma in children22
• Incidence risingIncidence rising• 33 patients 33 patients << 14; 25 yr experience 14; 25 yr experience
Presentation often atypical: most Presentation often atypical: most lesions raised, well-defined borders lesions raised, well-defined borders
Lesions unlike any other on childLesions unlike any other on child
1 - Wu et al. Cancer Causes and Control 2005; 2 - Ferrari et al, Pediatrics 2005
Lifetime riskLifetime risk• 1930: 1 in 15001930: 1 in 1500• 1987: 1 in 1201987: 1 in 120• 2002: 1 in 682002: 1 in 6811
• 2010: 1 in 502010: 1 in 5011
1- Rigel DS. Dermatol Clin 2002; 20
WHY IS THE INCIDENCE OF WHY IS THE INCIDENCE OF MELANOMA RISING?MELANOMA RISING?
Thought to be related to sun Thought to be related to sun exposureexposure• 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
SUNLIGHT AND MELANOMASUNLIGHT AND MELANOMA
Epidemiologic and biological Epidemiologic and biological evidence implicate sunlight evidence implicate sunlight in the pathogenesis of in the pathogenesis of melanomamelanoma
Pediatric Environmental Health. AAP 2003
SUNLIGHT AND MELANOMASUNLIGHT AND MELANOMA
LatitudeLatitude Race and pigmentation Race and pigmentation Childhood exposureChildhood exposure NeviNevi
Pediatric Environmental Health. AAP 2003
CHILDHOOD EXPOSURECHILDHOOD EXPOSURE
~25% of lifetime sun exposure ~25% of lifetime sun exposure occurs during childhood and occurs during childhood and adolescenceadolescence11
Episodic high exposures Episodic high exposures sufficient to cause sunburn, sufficient to cause sunburn, particularly in childhood and particularly in childhood and adolescence, increase the risk of adolescence, increase the risk of melanomamelanoma22
1- Godar et al. Photochem Photobiol 2003 2 -Elwood, Jopson. Int J Cancer 1997;73
CHILDHOOD EXPOSURECHILDHOOD EXPOSURE
Migration studies: High sun Migration studies: High sun exposure during childhood is exposure during childhood is important in the pathogenesis of important in the pathogenesis of melanomamelanoma11
1 - Khlat et al. Am J Epidemiol. 1992;135
NEVINEVI
Acute sun exposure is implicated Acute sun exposure is implicated in the development of nevi in in the development of nevi in childrenchildren11
There is a relationship between There is a relationship between the number and type of nevi and the number and type of nevi and the development of melanomathe development of melanoma11
Dysplastic nevi: precursor Dysplastic nevi: precursor lesions that increase risklesions that increase risk22
Do not burn; avoid sun tanning and Do not burn; avoid sun tanning and tanning beds tanning beds
Generously apply sunscreen Generously apply sunscreen Wear protective clothing Wear protective clothing Seek shadeSeek shade Use extra caution near water, snow Use extra caution near water, snow
and sandand sand www.skincancerprevention.org/Tips/tabid/www.skincancerprevention.org/Tips/tabid/
54/ Default.aspx54/ Default.aspx
DO NOT BURN; AVOID SUN DO NOT BURN; AVOID SUN TANNING AND TANNING BEDSTANNING AND TANNING BEDS
Burning raises melanoma riskBurning raises melanoma risk Avoid/limit exposure during Avoid/limit exposure during
Sunscreen is the sun protection Sunscreen is the sun protection method most commonly usedmethod most commonly used11
Apply to all exposed skin using Apply to all exposed skin using SPF SPF >> 15 15
Broad protection (UVA & UVB) Broad protection (UVA & UVB) Reapply often Reapply often
1 - Olson et al. Pediatrics 1997;99
WEAR PROTECTIVE CLOTHING WEAR PROTECTIVE CLOTHING
Simple, practical protectionSimple, practical protection The structure (weave) of the The structure (weave) of the
fabric is most importantfabric is most important Light-weight long pants and Light-weight long pants and
sleeves suggested sleeves suggested Hats with a bill or brimHats with a bill or brim SunglassesSunglasses
SEEK SHADESEEK SHADE
Shade is useful but…Shade is useful but… Shade offers insufficient Shade offers insufficient
protection because UV light protection because UV light is scattered and reflectedis scattered and reflected•A fair-skinned person sitting A fair-skinned person sitting
under a tree can burn in an under a tree can burn in an hourhour
SUNSCREENSSUNSCREENS
Came into use in 1950’sCame into use in 1950’s Promoted tanning without Promoted tanning without
burningburning First true sunscreen (PABA) First true sunscreen (PABA)
became available in 1970’sbecame available in 1970’s High-intensity sunscreens within High-intensity sunscreens within
last 15 yearslast 15 years
Rigel DS. Dermatol Clin 2002; 20.
OPAQUE SUNSCREENSOPAQUE SUNSCREENS
Scatter, reflect, block UV lightScatter, reflect, block UV light Zinc oxide, titanium dioxide, red Zinc oxide, titanium dioxide, red
vetenary petrolatum, talcvetenary petrolatum, talc Effective for diseases related to Effective for diseases related to
light exposure (SLE, XP, solar light exposure (SLE, XP, solar urticaria)urticaria)
Useful for those spending Useful for those spending extensive periods outsideextensive periods outside
SUN PROTECTION FACTOR - SUN PROTECTION FACTOR - SPF SPF
Ratio of amount of time to sunburn Ratio of amount of time to sunburn with with sunscreen compared to time to sunscreen compared to time to sunburn sunburn withoutwithout sunscreen sunscreen
LIMITATIONS OF SPF SYSTEMLIMITATIONS OF SPF SYSTEM
Applies to UVB protection onlyApplies to UVB protection only Measured under ideal conditionsMeasured under ideal conditions Concerns about: Concerns about:
• Using adequate amountsUsing adequate amounts• Applying before neededApplying before needed• Need for frequent reapplicationNeed for frequent reapplication
• Can prevent SCCCan prevent SCC22 No conclusive data in humans to No conclusive data in humans to
demonstrate that sunscreen demonstrate that sunscreen prevents melanoma or BCCprevents melanoma or BCC
1 - Thompson, Jolley, Marks. NEJM 1993; 3292 – Green et al. Lancet 1999; 354
IS SUNSCREEN USE A RISK IS SUNSCREEN USE A RISK FACTOR FOR MELANOMA?FACTOR FOR MELANOMA?
Swedish case-control study Swedish case-control study found increased riskfound increased risk11
Several studies found increased Several studies found increased risk with sunscreen use; some risk with sunscreen use; some studies found decreased risk; studies found decreased risk; others found no changeothers found no change22
1 – Westerdal et al. Melanoma Res 1995; 5:59-65. 2 - Cooper, Lim. J Amer Acad Dermatol 1999; 40.
IS SUNSCREEN USE A RISK IS SUNSCREEN USE A RISK FACTOR FOR MELANOMA?FACTOR FOR MELANOMA?
No studies demonstrate that No studies demonstrate that sunscreens are carcinogenicsunscreens are carcinogenic11
Sunscreen users may extend Sunscreen users may extend their time out in the suntheir time out in the sun22
There may be greater exposure There may be greater exposure to UVAto UVA11
1-Cooper, Lim. J Amer Acad Dermatol 1999; 402-Autier et al. J Natl Cancer Inst. 1999;91:1304-1309
April 2006: 9 suits involving April 2006: 9 suits involving popular brands charged that popular brands charged that manufacturers inflated claims manufacturers inflated claims about sunscreens’ protection about sunscreens’ protection
Sunscreen called the “snake oil Sunscreen called the “snake oil of the 21st century“of the 21st century“
Focus on labels claiming equal Focus on labels claiming equal UVA/UVB protection; “all day”; UVA/UVB protection; “all day”; “waterproof”; “waterproof”;
Sunscreen is one part of a sun Sunscreen is one part of a sun protection programprotection program
Sunscreen should not be used to Sunscreen should not be used to extend time spent in the sunextend time spent in the sun
SUNSCREEN AND VITAMIN D SUNSCREEN AND VITAMIN D METABOLISMMETABOLISM
Vitamin D produced in the skin Vitamin D produced in the skin by action of UVBby action of UVB
Inadequate sunlight is an Inadequate sunlight is an important risk factor for ricketsimportant risk factor for rickets
Concerns that sunscreen use Concerns that sunscreen use may affect levels of Vitamin Dmay affect levels of Vitamin D
SUNSCREEN AND VITAMIN D SUNSCREEN AND VITAMIN D METABOLISMMETABOLISM
AAP policy - April 2003AAP policy - April 2003 Infants need 200 IU Vit D/dayInfants need 200 IU Vit D/day Human milk: Human milk: << 25 IU/L Vit D 25 IU/L Vit D Infant formula: 400 IU/L Vit DInfant formula: 400 IU/L Vit D Supplementation: all breast-fed Supplementation: all breast-fed
infants, formula-fed infants infants, formula-fed infants taking <500 ml/day, children taking <500 ml/day, children with inadequate intake/sunwith inadequate intake/sun
AAP Section on Breastfeeding and Committee on Nutrition. Pediatrics 2003; 111.
VITAMIN D VITAMIN D AND CANCER PREVENTIONAND CANCER PREVENTION
Recent studies suggest a role for Recent studies suggest a role for vitamin D in cancer preventionvitamin D in cancer prevention• Colon, breast, prostate, lung Colon, breast, prostate, lung
High prevalence of vitamin D High prevalence of vitamin D deficiency/insufficiency deficiency/insufficiency
Insufficient evidence to make Insufficient evidence to make recommendations about sun recommendations about sun exposure exposure
Salon use in <25 year oldsSalon use in <25 year olds• 1996 - 8%; 2003 - 26%1996 - 8%; 2003 - 26%
College students: 32% – 55% College students: 32% – 55% usage ratesusage rates
High school studentsHigh school students• Males 6 - 44% Males 6 - 44% • Females 20 – 70%Females 20 – 70%
2001: Indoor tanning industry 2001: Indoor tanning industry generated $4 billion in revenuesgenerated $4 billion in revenues
1 - Scientific and regulatory issues related to indoor tanning. JAAD 2004.
INDOOR TANNING AND INDOOR TANNING AND MELANOMAMELANOMA
Epidemiologic evidence suggests Epidemiologic evidence suggests that indoor tanning causes that indoor tanning causes melanoma and SCC; perhaps melanoma and SCC; perhaps BCCBCC11
NIEHS recommends that UV light NIEHS recommends that UV light from artificial sources such as from artificial sources such as tanning booths and tanning beds tanning booths and tanning beds be listed as a known human be listed as a known human carcinogencarcinogen22
1 - Scientific and regulatory issues related to indoor tanning. JAAD 20042 - http://www.nih.gov/news/pr/oct97/niehs-30.htm. Accessed 7-04-06
ARE SUN PROTECTION ARE SUN PROTECTION MESSAGES EFFECTIVE?MESSAGES EFFECTIVE?
Melanoma rates rising quicklyMelanoma rates rising quickly Geller et al: Nationwide survey Geller et al: Nationwide survey
of > 10,000 teens 12 - 18of > 10,000 teens 12 - 18• 83%: 83%: >>1 sunburns in previous 1 sunburns in previous
summersummer• 36%: 36%: >>3 sunburns3 sunburns• Sunscreen use in 34%Sunscreen use in 34%• ~ 10% reported tanning bed use in ~ 10% reported tanning bed use in
previous yearprevious year
Geller et al. Pediatrics 2002.
UV LIGHT - HISTORYUV LIGHT - HISTORY
Family history of melanoma?Family history of melanoma? Are you (your child) protected Are you (your child) protected
from excess sun exposure?from excess sun exposure? Do you visit tanning parlors? Do you visit tanning parlors? Target children at high riskTarget children at high risk
• Family history of melanomaFamily history of melanoma• Skin Types I & IISkin Types I & II• Nevi, frecklingNevi, freckling• Sunburns Sunburns
Do not burn; avoid sun tanning and Do not burn; avoid sun tanning and tanning beds tanning beds
Generously apply sunscreen Generously apply sunscreen Wear protective clothing Wear protective clothing Seek shadeSeek shade Use extra caution near water, snow Use extra caution near water, snow
and sandand sand Early detection is also recommendedEarly detection is also recommended
National Council on Skin Cancer National Council on Skin Cancer Prevention: Prevention: www.skincancerprevention.orgwww.skincancerprevention.org
Pediatric EnvironmentalHealth, November 2003
RESOURCES
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