A national survey of sun safety activities at U.S. zoos

Skin cancer incidence in the United States has increased. Exposure to ultraviolet radiation (UVR) is a major risk factor for skin cancer. Every year, millions of children with their families visit outdoor leisure facilities such as zoos where overexposure to UVR may occur. This study was conducted to assess the proportion of U.S. zoos that provided sun safety activities during the summer of 1998 and their willingness to incorporate skin cancer prevention strategies at their facility in the future. A 56 item self-administered questionnaire was mailed to 140 zoos accredited by the American Zoo and Aquarium Association. A follow-up telephone survey was also conducted with 33 mail non-respondents. The response rate was 97% (N = 136). Results revealed that in the summer of 1998, only 5% of zoos provided sun safety recommendations to visitors and 25% of zoos provided recommendations to their employees. The recommendations made most often to visitors and employees were to use sunscreen and wear protective clothing. Eighty-five percent of zoos indicated interest in providing sun safety activities at their facilities in the future. The next step will be to design environmentally appropriate sun safety programs for zoos and to encourage zoos to implement these programs.

Predictors of the use of sunscreen in dermatological patients in Central Europe

BACKGROUND

There is mounting evidence that sun exposure is a cause of skin cancer. Therefore, the focus of skin cancer prevention is on sun protection. The present study investigated the use of sunscreens in a sample from the adult Central European population.

METHODS

As part of a case-control study of cutaneous melanoma, a total of 498 controls with classical dermatological disorders were selected from hospitals in Central Europe. All people underwent whole-body skin examinations and were interviewed using a standardized questionnaire.

RESULTS

Overall, 40.8% of the people never used sunscreen and of the 281 persons who used sunscreen, 41.5% applied it only once per sun bath. Persons who did not use sunscreen tended to be older (P<0.0001) and of male gender (P = 0.0004). Young people, women, and people who expressed a positive attitude to the sun spent more time in the sun and were more likely to apply sunscreens. People who worked almost always outdoors had a six times increased odds ratio of not using sunscreens (P<0.0001) compared to people who worked always indoors.

CONCLUSIONS

Men, older people, and outdoor workers should be targeted in health education campaigns. On the other hand, people who apply sunscreen as a means of sun protection should be advised about adequate usage.

High incidence and regression rates of solar keratoses in a queensland community

The presence of solar keratoses on the skin is one of the major risk factors for basal cell and squamous cell carcinomas, which constitute a growing public health problem in today's white populations. In spite of this, little is known of the natural history of solar keratoses. We conducted follow-up studies to monitor the incidence, regression, and recurrence rates of solar keratoses in a random sample (N = 96) of the Nambour community in Queensland. At baseline, 43 participants (46%) were diagnosed with at least one solar keratosis [26 men (55%), 17 women (37%)] with a total count of 494 prevalent solar keratoses. The distribution of lesions per person was highly skewed, with 11 individuals (12%) having 65% of the total number of solar keratoses. During 12 mo of follow-up, 614 incident solar keratoses were diagnosed (549 in men and 65 in women); 526 solar keratoses regressed and 53 prevalent solar keratoses recurred, giving a net 45% increase in solar keratosis numbers in men (from 354 to 512 solar keratoses) and a net 44% reduction in women (from 114 to 64). Regression rates were higher in prevalent (74%) than incident (29%) solar keratoses. Solar keratosis prevalence increased with age in both sexes, and individuals with solar keratoses at baseline were over seven times more likely to develop additional solar keratoses in the next 12 mo than those without prevalent solar keratoses at baseline. These results show that the natural history of solar keratoses in the community is one of high turnover and that a small percentage of susceptible individuals carry the major burden of solar keratoses in the community.

Drug-induced solar urticaria due to tetracycline

Solar urticaria is an uncommon disorder characterized by pruritus, erythema and whealing commencing within minutes of exposure to ultraviolet (UV) and visible light, and generally resolves in a few hours. We describe a 28-year-old woman who developed pruritus and erythema 5 min after sun exposure while on tetracycline for treatment of perioral dermatitis. Phototesting elicited urticarial reactions in the UVA, UVB and visible spectra. Repeat phototesting after cessation of tetracycline was negative. This report documents the first case of solar urticaria induced by tetracycline.

Lupus erythematosus tumidus--a neglected subset of cutaneous Lupus erythematosus: report of 40 cases

BACKGROUND

Lupus erythematosus tumidus (LET) is characterized clinically by erythematous, succulent, edematous, nonscarring plaques in sun-exposed areas. Results of histological examination show perivascular and periadnexal lymphocytic infiltration and interstitial mucin deposition. The main differential diagnoses are polymorphous light eruption, Jessner's lymphocytic infiltration of the skin, reticular erythematous mucinosis, and pseudolymphoma. Since its first description in 1930, LET has been documented rarely in the literature, and its clinical importance has not been fully appreciated.

OBSERVATIONS

We characterized 40 patients with clinical and histological features of LET observed at our department from 1984 through 1998. The onset of the disease clustered in summer because of sun exposure, and 28 (70%) of the patients showed a remarkable photosensitivity confirmed by results of provocative phototesting. A complete resolution of the skin lesions was seen after systemic therapy with antimalarials and, in some cases, with local corticosteroids or spontaneously without any treatment. In 4 (10%) of the patients, antinuclear antibodies were detected; however, there was no evidence of underlying systemic involvement in any of the patients.

CONCLUSIONS

Our data constitute the largest number of patients with LET collected until now. The clinical picture, extreme photosensitivity, histological findings, and effective treatment with antimalarials are so characteristic that LET should be considered as a separate entity and differentiated from other variants of cutaneous LE. Arch Dermatol. 2000;136:1033-1041

[Xeroderma pigmentosum]

Xeroderma pigmentosum(XP) is an autosomal recessive disease that is characterized by hypersensitivity to sunlight with high incidence of skin cancer and that exhibit variable neurological abnormalities in some groups. There are eight different complementation groups in XP; groups A through G and a variant(XP-V). XP-A through XP-G have a defect in nucleotide excision repair(NER), while XP-V has a defect in translesion DNA synthesis. Almost all of genes for XP have been cloned and their functions in the NER mechanism have been progressively unveiled. In this review, the present knowledge of the pathological features and genetic defects in XP has been discussed.

A comparison of 3 lasers and liquid nitrogen in the treatment of solar lentigines: a randomized, controlled, comparative trial

OBJECTIVE

To determine if laser therapy is superior to liquid nitrogen for the treatment of solar lentigines and if so, to determine if one laser is superior to the other lasers that were tested.

DESIGN

Randomized, controlled, comparative study with blinded observers.

SETTING

University-based dermatology clinic.

PARTICIPANTS

Twenty-seven patients with multiple solar lentigines on the backs of both hands.

INTERVENTIONS

Liquid nitrogen cryotherapy, the Medlite II frequency-doubled Q-switched Nd:YAG laser (Continuum Biomedical, Livermore, Calif), the HGM K1 krypton laser (HGM Medical Laser Systems Inc, Salt Lake City, Utah), and the DioLite 532-nm diode-pumped vanadate laser (Iridex Corp, Mountain View, Calif).

MAIN OUTCOME MEASURES

Photographs of the hands were taken prior to and 6 and 12 weeks following treatment. Blinded observers and patients evaluated each treatment on its ability to lighten pigmented lesions without causing unwanted adverse effects.

RESULTS

Many new laser systems claim an advantage for treating pigmented lesions by selectively destroying melanin. In this study, the frequency-doubled Q-switched Nd:YAG laser was most likely to provide significant lightening (P<.05), followed by the HGM K1 krypton laser, the 532-nm diode-pumped vanadate laser, and liquid nitrogen. The frequency-doubled Q-switched Nd:YAG laser also had the fewest adverse effects (P<.05), while the HGM K1 krypton laser had the most (P<.05). Of the 27 patients, 25 preferred laser therapy to cryotherapy, with the frequency-doubled Q-switched Nd:YAG laser being the most popular.

CONCLUSIONS

Laser therapy is superior to liquid nitrogen for the treatment of solar lentigines. Of the laser systems tested in this study, the frequency-doubled Q-switched Nd:YAG laser is the most effective.

Radiation therapy for extensive actinic keratosis

Actinic keratosis in the most common premalignant keratotic tumour of sun-exposed skin. A 66-year-old man developed a large actinic keratosis on his scalp, which did not respond to conventional treatment. Fractionated radiotherapy with a cumulative dose of 28 Gy resulted in complete remission without relapse during a 14-month follow-up. In older subjects in whom conventional treatment fails, low-dose fractionated radiation therapy is an effective alternative method.

A graded work site intervention program to improve sun protection and skin cancer awareness in outdoor workers in Israel

OBJECTIVES

A graded worksite intervention program to improve sun protection and skin cancer awareness of outdoor workers was implemented and evaluated longitudinally over a period of 20 months.

METHODS

Outdoor male workers (144/213 recruits) from geographically separated units of the Israel National Water Company were allocated to complete (n = 37), partial (n = 72) or minimal (n = 35) intervention groups. Subsequent to the assignment and training of local safety officers, an educational and medical screening package was provided to the corresponding groups either once, or repeatedly a year later. Personal sun protective gear was provided upon repeated intervention. Outcome measures were evaluated through self-response questionnaires administered prior to the first intervention pulse, and 8 months after the first and second interventions.

RESULTS

A 15-61% improvement in sun-protection habits was noted in the entire study population 8 months after initialization, compared to no sunscreen use, 20% sun-exposed skin area and highest mean occupational exposure dose of 1.68 MED/day at pre-test. An even greater use of sunscreen was evident 1 year later in the complete and partial intervention groups, + 80% and + 52%, respectively. The baseline rate of self-examination of the skin in the same two groups (49%) increased significantly at post-test (+ 71% and + 53%, respectively).

CONCLUSIONS

This integrated intervention program led to significantly improved sun protection and skin cancer awareness. Repeated intervention combined with the supply of sun-protective gear contributed to an even greater impact.

Gene-environment interaction in melanoma

Gene-environment interaction can be defined as a different effect of an environmental exposure in people with different genotypes, or a different effect of a genotype in people with different histories of environmental exposure. Interaction applies when one stratum (high risk) responds differently to an exposure (sun) than another stratum (low risk). Genetic predisposition would appear to be a very important modifier of risk. This paper discusses the concept of gene-environment interaction applied to cutaneous melanoma through discussion of highly penetrant genes and their interaction with sun exposure, through discussion of low penetrant genes and their interaction with sun exposure, and by suggesting a new model for investigation of gene-environment interaction in melanoma. It is stressed that this area of investigation is extremely early in its development.

An unusual case of purpuric erythropoietic protoporphyria

Erythropoietic protoporphyria (EPP) is the most common of the erythropoietic porphyrias. Recent advances in diagnostic laboratory tests have led to the discovery of a number of previously undiagnosed cases. We describe a case of EPP presenting late with a purpuric eruption and discuss the pathogenesis and significance of purpura in EPP.

Molecular genetic alterations and viral presence in ophthalmic pterygium

Pterygium is a lesion of the corneoscleral limbus which tends to grow in size, often recurs after surgical excision and is associated with exposure to solar light. Additionally, a family history is frequently reported. Loss of heterozygosity (LOH), increased P53 expression and the presence of oncogenic viruses, such as human papilloma virus (HPV) and herpes simplex virus (HSV), have been detected in pterygia, supporting the possible neoplastic nature of the lesion. Co-infection by HSV and HPV as well as LOH at some loci have also been correlated with clinical features, such as postoperative recurrence and history of conjunctivitis. A possible model of pterygium formation is proposed, in which genetic predisposition, environmental factors and viral infection(s) participate in a multi-step process. Future research may lead to new ways of pterygium treatment such as anti-viral or gene therapy.

[Histopathology of sun prurigo]

BACKGROUND

Solar or actinic prurigo (PS) is one of the most common skin diseases observed in our country, particularly in the pediatric age; in our institution it is on the 14 place with a frequency of 1.34%. It represents an abnormal reaction to solar light and in its pathogenesis diverse factors participate, mainly immunogenetical and environmental. Although their clinical characteristics are already specified, the histopathological features are still not well documented.

MATERIAL AND METHODS

We carried out a retrospective and observational study in order to analyze the histopathologic changes in 20 samples of skin coming from 20 pediatric patients with PS; in all of them diagnosis was well established on clinical criteria.

RESULTS

Twenty children with PS of more than one year of evolution, ten of each sex, all mestizos or indigenous inhabitants of Mexico City and vicinity; we identified recent and late lesions, with epidermal and dermal changes, the more conspicuous were: spongiotic papules usually with psoriasiform epidermal hyperplasia, in association with perivascular, superficial and mild lymphocytic infiltrates, usually with few eosinophils, exocytosis of lymphocytes into the epidermis, pigment incontinence and extravasation of erythrocytes.

CONCLUSIONS

The PS is an inflammatory cutaneous disease for which histopathological diagnosis is feasible of being established on skin biopsies of recent or late lesions.

Papular elastosis

I report two typical cases of a cutaneous disorder caused by sunlight, which is common in Phoenix, Arizona, "The Valley of the Sun." It currently masquerades under the misnomer, adult colloid milium. It generally presents clinically as asymptomatic, shiny, smooth, firm papules, 1 to 10 mm in diameter, involving chronically sun-damaged skin of adults. The papules are generally multiple, but may be solitary, with various colorations. Microscopically, the papules all show severe elastosis involving most of the papillary cutis. It is most important to biopsy these lesions because clinically they may mimic a variety of skin lesions, some of which would require further investigations and therapy. This is a distinct clinical form of severe solar elastosis, which I propose to term papular elastosis.

Sunlight associated hyperthermia as a consistent and rapidly developing clinical sign in sheep intoxicated by St John's wort (Hypericum perforatum)

OBJECTIVE

To assess the usefulness of rectal temperature responses in Australian bred Merino sheep, following the oral administration of Hypericum perforatum (St John's wort), as an early indicator of Hypericum intolerance.

DESIGN

Thirty-three Merino ewes were divided into three groups of 11. Each group was dosed with finely ground, dried, flowering growth stage H perforatum plant material at either 5.7, 4.0, or 2.85 g dry plant per kg live weight. This corresponded to 5.3, 3.7 and 2.65 mg hypericin per kg live weight, respectively.

PROCEDURE

The sheep were dosed with a plant slurry by stomach tube and then exposed to bright sunlight for up to 5 h per day over successive days. Their clinical responses were observed and rectal temperature measured.

RESULTS

Ingestion of H perforatum followed by exposure to bright sunlight frequently resulted in clinical signs attributable to skin irritation and central nervous effects, including an inappropriate increase in body temperature. A decrease in H perforatum ingestion from 5.7 to 2.85 g dry plant per kg live weight and a corresponding decrease in hypericin ingestion from 5.3 to 2.65 mg per kg live weight, was associated with a decrease in the severity of the clinical signs, including the severity of the hyperthermia.

CONCLUSIONS

The rectal temperature rise in affected sheep is a reliable indicator of the early development of an adverse clinical effect. There appears to be an absolute requirement for exposure to bright sunlight before any effects of H perforatum will develop. A single dose of H perforatum remains potentially effective for up to 4 days. In the small group of Merino sheep tested a tolerance level for H perforatum, eaten at the flowering stage, of < 1% (plant wet weight) of body weight and a tolerance level for hypericin of < 2.65 mg per kg live weight, were demonstrated.

Outdoor work and the risk of pterygia: a case-control study

AIM

To investigate the relationship between outdoor work and pterygium formation in a hospital-based case-control study in Singapore.

METHOD

Sixty-one patients with pterygium (49 males, mean age 54.2 years) and 125 controls (41 males, mean age 50.2 years), excluding patients with cataract and age-related macular degeneration presenting at outpatient clinics of the Singapore National Eye Centre were interviewed face-to-face with a standard questionnaire. Demographic data and information on outdoor work and eye protection, were collected.

RESULTS

Thirty-eight subjects (20.4%) were outdoor workers and 148 (79.6%) were indoor workers. Outdoor workers were more likely to be male smokers and alcohol drinkers with lower family income and higher sunlight exposure than indoor workers. The crude odds ratio for pterygium in outdoor workers was 7.0 (95% confidence interval 3.2, 15.3). The adjusted odds ratio was 4.2 (95% confidence interval 1.7, 10.1).

CONCLUSION

There is a statistically significant association between outdoor work and pterygium formation, which may be related to the higher exposure to sunlight and dust in outdoor workers. Efforts may be made to educate outdoor workers to wear proper equipment to protect their eyes against excessive sunlight.

[Sunbathing habits and risk of melanoma]

The increasing frequency of malignant melanoma (MM) is believed mainly to be due to the habit of sunbathing, which has an impact on the skin due to ultraviolet radiation, especially if intermittent and causing sunburn. Frequent use of tanning booths possibly increases the risk of MM but the question has not been settled. Use of sunscreens has a certain prophylactic effect on actinic keratoses, but no documented effect on MM. This does not imply that sunscreens are not advisable, but stresses the importance of correct use of sunscreens together with other sun protective measures. Primary prevention of MM is mainly a question of minimizing the impact of ultraviolet radiation (including tanning booths) on the skin: limit time in the sun, cover up with clothing, and use a sunscreen with a protection factor of at least 15.

Basal and squamous cell carcinoma

Nonmelanotic skin cancer, primarily basal and squamous cell carcinoma, represents a major health concern in both the United States and the world. Primary care physicians must be able to recognize these cancers and perform the appropriate diagnostic tests to confirm their clinical suspicion. Several biopsy techniques are available for the physician to use in their office, and once diagnosis is confirmed, a variety of treatment modalities exist that provide excellent cure rates. Nevertheless, primary prevention with the use of sunscreen, protective clothing, and wide-brimmed hats is necessary to reduce the incidence of this costly disease.