Risk factors of squamous cell carcinoma of the skin. A case-control study in the Montreal region

Toxic Interaction Between Solar Radiation and Cigarette Smoke on Primary Human Keratinocytes

Solar radiation and cigarette smoke are two environmental risk factors known to affect skin integrity. Although the toxic effects of these factors on skin have been widely studied separately, few studies have focused on their interaction. The objective of this study was to evaluate and understand the synergistic harmful effects of cigarette smoke and solar rays on human primary keratinocytes. The keratinocytes were exposed to cigarette smoke extract (CSE) and then irradiated with a solar simulator light (SSL). The viability, as determined by measuring metabolic activity of skin cells, and the levels of global reactive oxygen species (ROS) were evaluated after exposure to CSE and SSL. The combination of 3% CSE with 29 kJ m-2 UVA caused a decrease of 81% in cell viability, while with 10% to 20% CSE, the cell viability was null. This phototoxicity was accompanied by an increase in singlet oxygen but a decrease in type I ROS when CSE and SSL were combined in vitro. Surprisingly, an increase in the CSE's total antioxidant capacity was also observed. These results suggest a synergy between the two environmental factors in their effect on skin cells, and more precisely a phototoxicity causing a drastic decrease in cell viability.

UVR Exposure and Prevention of Street Construction Workers in Colombia and Germany

(1) Solar ultraviolet radiation (UVR) poses a major risk factor for developing skin cancer after years of chronic exposure. The irradiation is strongly dependent upon the activity or occupation carried out, but also on the climate conditions at the workplace. Knowledge of both has been tested within the occupational group of road construction workers in Colombia and Germany. (2) The GENESIS-UV measurement system has been used at both locations for consistency. A number of workers in both countries wore an electronic data logging dosimeter for several months to deliver detailed information on UVR exposure. (3) It was found that in a tropical climate, UVR exposure remains constant throughout the year, while in a temperate climate seasonal effects are visible, superimposed by behavioural aspects e.g., in springtime. The daily distribution of the radiation shows a distinct dip, especially in the Colombian data. Derived data show the high fraction of working days exceeding a threshold set by the skin type. (4) Road construction work involves high UVR exposure. In both countries, preventive measures are required to reduce the personal exposure to a minimum. Exceedance of the minimal erythema dose (MED) suggests a possible enhancing effect, especially in fair skinned people. Intercomparison of UVR exposure at workplaces is possible between countries and climate zones, emphasizing efforts for global action against skin cancer.

Exposome and Skin. Part 2. The Influential Role of the Exposome, Beyond UVR, in Actinic Keratosis, Bowen's Disease and Squamous Cell Carcinoma: A Proposal

Actinic keratosis (AK) is the main risk factor for the development of cutaneous invasive squamous cell carcinoma (SCC). It represents the first sign of severe chronic ultraviolet radiation exposure, which has a clear significant effect. Nevertheless, the skin is exposed to many other exposome factors which should be thoroughly considered. Our aim was to assess the impact of exposome factors other than ultraviolet radiation (UVR) on the etiopathology of AK and Bowen's disease (BD) and progression of AK to SCC and to design tailored prevention strategies. We performed an exhaustive literature search in September 2021 through PubMed on the impact of exposome factors other than UVR on AK, BD and SCC. We conducted several parallel searches combining terms of the following topics: AK, BD, SCC and microbiome, hormones, nutrition, alcohol, tobacco, viral infections, chemical contaminants and air pollution. Notably, skin microbiome studies have shown how Staphylococcus aureus infections are associated with AK and AK-to-SCC progression by the production of chronic inflammation. Nutritional studies have demonstrated how a caloric restriction in fat intake, oral nicotinamide and moderate consumption of wine significantly reduce the number of premalignant keratoses and SCC. Regarding lifestyle factors, both alcohol and smoking are associated with the development of SCC in a dose-dependent manner. Relevant environmental factors are viral infections and chemical contaminants. Human papillomavirus infections induce deregulation of cellular proliferation and are associated with AK, BD and SCC. In addition to outdoor jobs, occupations such as industrial processing and farming also increase the risk of developing keratoses and SCC. The exposome of AK will undoubtedly help the understanding of its etiopathology and possible progression to SCC and will serve as a basis to design tailored prevention strategies.

Epidemiology of nonmelanoma skin cancer in Japan: Occupational type, lifestyle, and family history of cancer

Skin cancer is the most frequently diagnosed cancer in the fair-skinned population. In recent years, the incidence of nonmelanoma skin cancer (NMSC) has been increasing worldwide. However, there is no epidemiological study on skin cancer in the Asian population. A prospective cohort study including 140 420 participants was initiated in 1990 for cohort Ⅰ and 1993 for cohort Ⅱ at baseline survey from 11 public health center (PHC) areas. Of these participants, 284 NMSC cases were diagnosed during the follow-up period (through 2012 in the Osaka PHC area and 2013 in the other PHC areas). The Cox proportional hazards model was used to estimate hazard ratios and 95% confidence intervals (CI) for NMSC incidence according to occupational type, lifestyle factors (alcohol consumption, coffee consumption, smoking status, physical activity, and body mass index), and family history of cancer. Among men, compared with indoor workers, outdoor workers were associated with 2.18 (95% CI, 1.17-4.04) higher risk of squamous cell carcinoma (SCC) but not of basal cell carcinoma (BCC). Furthermore, men who have a family history of cancer had 1.99 (95% CI, 1.10-3.62) higher SCC risk. In women, we did not observe any association between occupational type and the risk of SCC (1.26; 95% CI, 0.68-2.32) or BCC (0.74; 95% CI, 0.42-1.28). In conclusion, men who are outdoor workers or have a family history of cancer had an increased risk of SCC.

Global evidence on occupational sun exposure and keratinocyte cancers: a systematic review

Individual studies have suggested that the association between occupational exposure to solar ultraviolet radiation (UVR) and the development of keratinocyte cancers (KCs) may only be valid in populations of European ancestry living in certain geographical regions. Comparative global data are scarce and so this review aimed to summarize current evidence on the association between occupational exposure to solar UVR and the development of KCs, with a specific focus on geographical location and skin colour. Ovid MEDLINE, PubMed, Embase and Web of Science were searched for potentially relevant records. Extracted data were summarized by study, country and region. We included one prospective cohort study and 18 case-control studies (n = 15 233) from 12 countries in regions where the majority of the population is white skinned (Americas, Europe and Oceania). Eighteen of the 19 studies reported effect estimates suggesting an increased risk of basal cell carcinoma (BCC) and/or squamous cell carcinoma (SCC) among outdoor workers. Only 11 studies found a significantly increased risk and many had imprecise estimates. There was a significantly increased risk of BCC and SCC in individual studies in North America, Latin America and the Caribbean, Western Europe and Southern Europe, but not across regions or countries. Overall, 95% of studies reported higher risks among outdoor workers, although the increases in risk were statistically significant in just over half of the studies. Well-designed and sufficiently powered occupational case-control and cohort studies with adequate adjustment for confounding factors and other risk factors are required to provide more accurate risk estimates for occupational KC.

Predicting keratinocyte carcinoma in patients with actinic keratosis: development and internal validation of a multivariable risk-prediction model

BACKGROUND

Patients with actinic keratosis (AK) are at increased risk for developing keratinocyte carcinoma (KC) but predictive factors and their risk rates are unknown.

OBJECTIVES

To develop and internally validate a prediction model to calculate the absolute risk of a first KC in patients with AK.

METHODS

The risk-prediction model was based on the prospective population-based Rotterdam Study cohort. We hereto analysed the data of participants with at least one AK lesion at cohort baseline using a multivariable Cox proportional hazards model and included 13 a priori defined candidate predictor variables considering phenotypic, genetic and lifestyle risk factors. KCs were identified by linkage of the data with the Dutch Pathology Registry.

RESULTS

Of the 1169 AK participants at baseline, 176 (15·1%) developed a KC after a median follow-up of 1·8 years. The final model with significant predictors was obtained after backward stepwise selection and comprised the presence of four to nine AKs [hazard ratio (HR) 1·68, 95% confidence interval (CI) 1·17-2·42], 10 or more AKs (HR 2·44, 95% CI 1·65-3·61), AK localization on the upper extremities (HR 0·75, 95% CI 0·52-1·08) or elsewhere except the head (HR 1·40, 95% CI 0·98-2·01) and coffee consumption (HR 0·92, 95% CI 0·84-1·01). Evaluation of the discriminative ability of the model showed a bootstrap validated concordance index (c-index) of 0·60.

CONCLUSIONS

We showed that the risk of KC in patients with AK can be calculated with the use of four easily assessable predictor variables. Given the c-index, extension of the model with additional, currently unknown predictor variables is desirable. Linked Comment: Kim et al. Br J Dermatol 2020; 183:415-416.

Diffusion Reflection Measurements of Antibodies Conjugated to Gold Nanoparticles as a Method to Identify Cutaneous Squamous Cell Carcinoma Borders

Diffusion reflectance spectroscopy measurements targeted with gold nanoparticles (GNPs) can identify residual cutaneous squamous cell carcinoma (SCC) in excision borders. Human SCC specimens were stained with hematoxylin and eosin to identify tumor borders, and reflected onto an unstained deparaffinized section. Diffusion reflection of three sites (normal and SCC) were measured before and after GNPs targeting. Hyperspectral imaging showed a mean of 2.5 sites with tumor per specimen and 1.2 tumor-free (p < 0.05, t-test). GNPs were detected in 25/30 tumor sites (sensitivity 83.3%, false-negative rate 16.6%) and 12/30 non-tumor sites (specificity 60%, false-positive rate 40%). This study verifies the use of nanotechnology in identifying SCC tumor margins. Diffusion reflection scanning has high sensitivity for detecting the residual tumor.

Human health in relation to exposure to solar ultraviolet radiation under changing stratospheric ozone and climate

The Montreal Protocol has limited increases in the UV-B (280-315 nm) radiation reaching the Earth's surface as a result of depletion of stratospheric ozone. Nevertheless, the incidence of skin cancers continues to increase in most light-skinned populations, probably due mainly to risky sun exposure behaviour. In locations with strong sun protection programs of long duration, incidence is now reducing in younger age groups. Changes in the epidemiology of UV-induced eye diseases are less clear, due to a lack of data. Exposure to UV radiation plays a role in the development of cataracts, pterygium and possibly age-related macular degeneration; these are major causes of visual impairment world-wide. Photodermatoses and phototoxic reactions to drugs are not uncommon; management of the latter includes recognition of the risks by the prescribing physician. Exposure to UV radiation has benefits for health through the production of vitamin D in the skin and modulation of immune function. The latter has benefits for skin diseases such as psoriasis and possibly for systemic autoimmune diseases such as multiple sclerosis. The health risks of sun exposure can be mitigated through appropriate sun protection, such as clothing with both good UV-blocking characteristics and adequate skin coverage, sunglasses, shade, and sunscreen. New sunscreen preparations provide protection against a broader spectrum of solar radiation, but it is not clear that this has benefits for health. Gaps in knowledge make it difficult to derive evidence-based sun protection advice that balances the risks and benefits of sun exposure.

A common cancer in an uncommon location: A case report of squamous cell carcinoma of the nipple

•

Squamous cell cancer of the nipple is rare but should be included in the differential diagnoses of pathologies of the nipple.

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Patients with former history of skin cancer may present with skin cancers in unusual locations.

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Thorough clinical and diagnostic evaluations are mandatory to rule out pathologiesand direct management decisions.

Introduction

Cutaneous squamous cell carcinoma (SCC) is common however SCC is rarely seen on the nipple, with only ten cases of SCC of the nipple in literature (American Cancer Society, 2015; Scotto et al., 1983; Pendse and O’Connor, 2015; Loveland-Jones et al., 2010; Brookes et al., 2005; Sofos et al., 2013; King and Kremer, 2012; Venkataseshan et al., 1994; Hosaka et al., 2011) [1–9].

Case

An 80 year old female presenting with a chief complaint of an abnormal lesion on the medial portion of her right nipple areola complex. A biopsy showed well-differentiated squamous cell carcinoma. She had an extensive history of prolonged sun exposure predisposing her to cutaneous SCC however none to the breast region. Her mammogram was negative for any invasive disease so a wide local excision was performed with no complications.

Discussion

Due to the rarity of SCC of the breast or nipple, a biopsy is necessary to rule out other more common types of malignancies on the nipple that present with a similar physical appearance. We then examined the many different risk factors for SCC and the different methods for treating SCC whether it is cutaneous or of the nipple or breast. We also discussed the treatment of Paget’s disease of the breast (PDB) as SCC of the nipple or breast can be mistaken for PDB.

Conclusion

The cases of SCC of the Nipple demonstrate the importance of recognizing changes of the skin even in locations not typically associated with SCC (American Cancer Society, 2015; Scotto et al., 1983; Pendse and O’Connor, 2015; Loveland-Jones et al., 2010; Brookes et al., 2005; Sofos et al., 2013; King and Kremer, 2012; Venkataseshan et al., 1994; Hosaka et al., 2011) [1–9]. We concluded with a future suggestion of investigating possible risk factors specific to SCC of the breast or nipple.

Cutaneous squamous cell carcinoma: an epidemiological review

Cutaneous squamous cell carcinoma (SCC) is a common cancer in white populations and its disease burden is often substantially underestimated. SCC occurs more often in men than women and increases dramatically with age; those affected often develop multiple primaries over time, which increases the burden. The main external cause is solar ultraviolet radiation (UVR), with immunosuppression being the other established risk factor, shown by the high SCC rates in organ transplant recipients. Sunbed use and certain genetic disorders and medical conditions are also associated with SCC, while associations with human papillomavirus infection and high bodyweight are not established. The presence of actinic keratoses (AKs) on sun-damaged skin is one of the strongest predictors of SCC in unaffected people and a very small proportion of AKs are SCC precursors, although the true rate of malignant transformation of AKs is unknown. The mainstay of SCC prevention is protection of the skin from undue sun exposure by use of clothing cover and sunscreen during summer or in sunny places. Educational, behavioural and multicomponent interventions directed at individuals ranging from parents of newborns, to school children and adolescents, to outdoor workers, have repeatedly been shown to be effective in improving sun-protective behaviours. Health policies can facilitate SCC prevention by setting standards for relevant behaviours to reduce UVR exposure, for example, by legislated restriction of the tanning industry. Skin cancer prevention initiatives are generally highly cost-effective and public investment should be encouraged to control the growing public health problems caused by SCC.

Clinical Characteristics of Non-Melanoma Skin Cancers Recurring within 5 years after Mohs Micrographic Surgery: Single Institution Retrospective Chart Review

Background

Mohs micrographic surgery (MMS) is used to treat certain high-risk non-melanoma skin cancers (NMSC) due to its high cure rate. However, clinical recurrences do occur in a small number of cases.

Objective

We examined specific clinical characteristics associated with NMSC recurrences following MMS.

Methods

We employed a retrospective chart review of the 1467 cases of NMSC that underwent MMS at UC San Diego from January 1, 2008 through December 31, 2009. A total of 356 cases were excluded due to lack of follow-up.

Results

Five (0.45%) of 1111 cases developed recurrences of NMSC at the site of MMS. There were 741 cases of basal cell carcinomas (BCC); 3 were recurrences (0.40%). There were 366 cases of squamous cell carcinomas (SCC); 2 were recurrences (0.55%). Review of MMS histopathology of these recurrent tumors showed that there were no errors or difficulty with the processing or interpretation of the slides.

Conclusion

Five-year recurrence rate of NMSC following MMS at our institution is below the reported average. Our retrospective chart review identified specific clinical characteristics associated with NMSC recurrence including a history of smoking, anatomical location on the cheeks, ears or nose, and a history of immunosuppression for SCCs.

Cutaneous Effects of Smoking

Background:

Cigarette smoking is the single biggest preventable cause of death and disability in developed countries and is a significant public health concern. While known to be strongly associated with a number of cardiovascular and pulmonary diseases and cancers, smoking also leads to a variety of cutaneous manifestations.

Objective:

This article reviews the effects of cigarette smoking on the skin and its appendages.

Methods:

A literature review was based on a MEDLINE search (1966–2004) for English-language articles using the MeSH terms cutaneous, dermatology, tobacco, skin, and smoking. An additional search was subsequently undertaken for articles related to smoking and associated mucocutanous diseases, with the focus on pathogenesis and epidemiologic data. Articles presenting the highest level of evidence and latest reports were preferentially selected.

Results:

Smoking is strongly associated with numerous dermatologic conditions including poor wound healing, wrinkling and premature skin aging, squamous cell carcinoma, psoriasis, hidradenitis suppurativa, hair loss, oral cancers, and other oral conditions. In addition, it has an impact on the skin lesions observed in diabetes, lupus, and AIDS. The evidence linking smoking and melanoma, eczema, and acne is inconclusive. Anecdotal data exist on the possible protective effects of smoking in oral/genital aphthosis of Behçet's disease, herpes labialis, pyoderma gangrenosum, acral melanoma, and Kaposi's sarcoma in AIDS patients.

Conclusions:

An appreciation of the adverse cutaneous consequences of smoking is important. Dermatologists can play an integral role in promoting smoking cessation by providing expert opinion and educating the public on the deleterious effects of smoking on the skin.

Keratinocyte Carcinoma as a Marker of a High Cancer-Risk Phenotype

Keratinocyte carcinoma (KC) (also referred to as nonmelanoma skin cancer) is by far the most common form of human cancer. A personal history of KC is well established to be associated with increased risk of recurrent KC and malignant melanoma, a less common yet more fatal form of skin cancer. More surprising is that a substantial body of epidemiologic evidence now indicates that a personal history of KC is significantly associated with an overall elevated risk of noncutaneous malignancies. This association is not limited to one or a few types of cancer but applies across many different types of malignancy. This association has been consistently observed in prospective studies across genders for both major histologic types of KC, basal cell carcinoma and squamous cell carcinoma. The risk of other cancers has been even stronger in those with younger compared with older age of onset of KC. A robust body of evidence lends support to the notion that KC may be a marker of a high cancer-risk phenotype. The underlying mechanisms for this association remain to be elucidated, but the cross-cutting nature of this association across numerous malignancies suggests that research to uncover these mechanisms is a promising line of inquiry that could potentially yield valuable insight into human carcinogenesis.

Trends in Non-Melanoma Skin Cancer (Basal Cell Carcinoma and Squamous Cell Carcinoma) in Canada

Background:

Despite its increased incidence and status as the most prevalent cancer in Canada, there is a paucity of epidemiological data on non-melanoma skin cancer (NMSC).

Objective:

To assess trends of keratinocyte carcinomas (KC) in Canada over 5 decades.

Methods:

Articles published from 1960 to 2015 on NMSC in Canada were identified through MEDLINE. Six articles met our search criteria.

Results:

Overall, KC has increased. However, the rate of increase in the past decade has slowed down and decreased in younger age cohorts. Men had higher incidences of KC. In both sexes, the basal cell carcinoma and squamous cell carcinoma ratio was ≥2.5:1. Keratinocyte carcinomas were most commonly located on the head and neck, and increasing rates are occurring on the trunk.

Limitations:

The methods of registering skin cancer cases vary among different provinces.

Conclusion:

Keratinocyte carcinomas incidence is overall increasing; however, there may be evidence that the incidence is leveling off and decreasing in younger age cohorts.

Non-melanoma skin cancer: occupational risk from UV light and arsenic exposure

Non-melanoma skin cancer (NMSC) has a significant impact on public health and health care costs as a result of high morbidity and disfigurement due to the destruction of surrounding tissues. Although the mortality rates of these tumors are low, the high incidence rates determine a considerable number of deaths. NMSC is the most common type of skin cancer, representing about 1/3 of all malignancies diagnosed worldwide each year. The most common NMSC are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Studies on humans and experimental animals indicate that ultraviolet (UV) light and arsenic play important roles in the development of these skin malignancies. Several epidemiological studies have investigated the risk of developing NMSC and the potential link between exposure to sunlight and arsenic in the agricultural and industrial occupational settings. To date, the published literature suggests that there is no apparent skin cancer risk as regards workplace exposure to artificial UV light or arsenic. Concerning UV light from sun exposure at the workplace, most published studies indicated an elevated risk for SCC, but are less conclusive for BCC. Many of these studies are limited by the methodology used in the evaluation of occupational exposure and the lack of adjustment for major confounders. Therefore, further epidemiological studies are required to focus on exposure assessment at the individual level as well as potential interactions with other occupational and non-occupational exposures and individual susceptibility. In doing so, we can better quantify the true risk of skin cancer in exposed workers and inform effective public health prevention programs.

Predictors of squamous cell carcinoma in high-risk patients in the VATTC trial

Invasive squamous cell carcinoma (SCC) of the skin is one of the most common cancers in the United States, with no proven means for prevention other than systemic retinoids, which have significant toxicity, and sunscreen. We sought to determine the risk factors for invasive SCC on the face or ears in a high-risk population comprising 1,131 veterans in the Veterans Affairs Topical Tretinoin Chemoprevention (VATTC) Trial. Participants were required to have been diagnosed with at least two keratinocyte carcinomas (KCs) in the 5 years prior to enrollment. The median duration of follow-up was 3.7 years. Twenty-three percent of the participants developed a new invasive SCC, and the cumulative risk of invasive SCC was 30% at 5 years. The following factors independently predicted for new invasive SCCs: number of invasive SCCs and number of in situ SCCs in the 5 years prior to enrollment, actinic keratoses count at enrollment, a history of ever use of topical 5-fluorouracil, and total occupational time spent outdoors. In contrast, the use of angiotensin-convering enzyme inhibitors or angiotensin receptor blockers during the study and a history of warts anywhere on the body were found to protect against new invasive SCCs. These independent predictors remained the same for all SCCs (invasive and in situ combined). The number of basal cell carcinomas in the 5 years prior to enrollment, sunburns, sun sensitivity, and recreational sun exposure were not associated with new SCCs. These findings identify key risk factors for additional SCCs in patients with multiple prior KCs, and suggest that a history of warts may be associated with reduced SCC risk.

Smoking and risk of skin cancer: a prospective analysis and a meta-analysis

BACKGROUND

The association between smoking and the risk of skin cancer has not been well established.

METHODS

In two large cohorts in the USA, we prospectively examined the risks of melanoma, basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) among participants grouped according to smoking variables.

RESULTS

Among men, compared with never smokers, ever smokers had a significantly lower risk of melanoma [relative risk (RR) = 0.72; 95% confidence interval (CI): 0.58-0.86]; those who smoked for ≥30 years had an RR of 0.65 (95% CI: 0.48-0.89) (P(trend) = 0.003); those who smoked ≥15 cigarettes per day had an RR of 0.32 (95% CI: 0.13-0.78) (P(trend) = 0.006) and those who smoked for > 45 pack years had an RR of 0.66 (95% CI: 0.45-0.97) (P(trend) = 0.03). Ever smokers also had a slightly lower risk of BCC (RR = 0.94; 95% CI: 0.90-0.98). There was no significant association for SCC (RR = 0.99; 95% CI: 0.89-1.12). In women, no significant association was found for melanoma (RR = 0.96; 95% CI: 0.83-1.10). Compared with never smokers, ever smokers had a slightly higher risk of BCC (RR = 1.06; 95% CI: 1.03-1.08) and a higher risk of SCC (RR = 1.19; 95% CI: 1.08-1.31). A significant inverse association between smoking and melanoma was limited to the head and neck (RR = 0.65; 95% CI: 0.42-0.89).

CONCLUSIONS

Smoking was inversely associated with melanoma risk, especially on the head and neck. Further studies are warranted to investigate the underlying mechanism(s).

Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis

OBJECTIVE

To synthesise the literature on indoor tanning and non-melanoma skin cancer.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed (1966 to present), Embase (1974 to present), and Web of Science (1898 to present).

STUDY SELECTION

All articles that reported an original effect statistic for indoor tanning and non-melanoma skin cancer were included. Articles that presented no data, such as review articles and editorials, were excluded, as were articles in languages other than English.

DATA EXTRACTION

Two investigators independently extracted data. Random effects meta-analysis was used to summarise the relative risk of ever use versus never use of indoor tanning. Dose-response effects and exposure to indoor tanning during early life were also examined. The population attributable risk fraction for the United States population was calculated.

RESULTS

12 studies with 9328 cases of non-melanoma skin cancer were included. Among people who reported ever using indoor tanning compared with those who never used indoor tanning, the summary relative risk for squamous cell carcinoma was 1.67 (95% confidence interval 1.29 to 2.17) and that for basal cell carcinoma was 1.29 (1.08 to 1.53). No significant heterogeneity existed between studies. The population attributable risk fraction for the United States was estimated to be 8.2% for squamous cell carcinoma and 3.7% for basal cell carcinoma. This corresponds to more than 170 000 cases of non-melanoma skin cancer each year attributable to indoor tanning. On the basis of data from three studies, use of indoor tanning before age 25 was more strongly associated with both squamous cell carcinoma (relative risk 2.02, 0.70 to 5.86) and basal cell carcinoma (1.40, 1.29 to 1.52).

CONCLUSIONS

Indoor tanning is associated with a significantly increased risk of both basal and squamous cell skin cancer. The risk is higher with use in early life (<25 years). This modifiable risk factor may account for hundreds of thousands of cases of non-melanoma skin cancer each year in the United States alone and many more worldwide. These findings contribute to the growing body of evidence on the harms of indoor tanning and support public health campaigns and regulation to reduce exposure to this carcinogen.

Patterns and timing of sunlight exposure and risk of basal cell and squamous cell carcinomas of the skin--a case-control study

BACKGROUND

Non-melanoma skin cancer (NMSC), comprised of basal (BCC) and squamous (SCC) cell carcinomas, is the most common cancer in Caucasians. Ultraviolet radiation (UVR) exposure is the most important environmental risk factor for NMSC. However, the precise relationship between UVR and the risk of NMSC is complex, and the relationship may differ by skin cancer type.

METHODS

A case-control study was conducted among Florida residents to investigate measures of patterns (intermittent vs. continuous) and timing (childhood vs. adulthood) of sunlight exposure in BCC and SCC. Participants included 218 BCC and 169 SCC cases recruited from a university dermatology clinic and 316 controls with no history of skin or other cancers.

RESULTS

A history of blistering sunburn (a measure of intermittent sunlight exposure) was associated with both BCC (OR = 1.96, 95% CI = 1.27-3.03) and SCC (OR = 2.02, 95% CI = 1.22-3.33). Additionally, having a job in the sun for ≥ 3 months for 10 years or longer (a measure of continuous sunlight exposure) was also associated with both BCC and SCC in our study population. With the exception of younger age at first blistering sunburn, measures of younger age at sunlight exposure tended to be associated with SCC, but not BCC risk.

CONCLUSIONS

Results from the current study suggest that sunlight exposure is associated with both BCC and SCC risk regardless of the pattern in which the exposure was received (i.e. intermittent vs. continuous). The data also suggest that sunlight exposure at a younger age may be more important for SCC but not BCC, however additional studies are needed to further characterize sunlight exposure-response relationships in different types of NMSC.

Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis

OBJECTIVE

To estimate the burden of melanoma resulting from sunbed use in western Europe.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, ISI Web of Science (Science Citation Index Expanded), Embase, Pascal, Cochrane Library, LILACS, and MedCarib, along with published surveys reporting prevalence of sunbed use at national level in Europe.

STUDY SELECTION

Observational studies reporting a measure of risk for skin cancer (cutaneous melanoma, squamous cell carcinoma, basal cell carcinoma) associated with ever use of sunbeds.

RESULTS

Based on 27 studies ever use of sunbeds was associated with a summary relative risk of 1.20 (95% confidence interval 1.08 to 1.34). Publication bias was not evident. Restricting the analysis to cohorts and population based studies, the summary relative risk was 1.25 (1.09 to 1.43). Calculations for dose-response showed a 1.8% (95% confidence interval 0% to 3.8%) increase in risk of melanoma for each additional session of sunbed use per year. Based on 13 informative studies, first use of sunbeds before age 35 years was associated with a summary relative risk of 1.87 (1.41 to 2.48), with no indication of heterogeneity between studies. By using prevalence data from surveys and data from GLOBOCAN 2008, in 2008 in the 15 original member countries of the European Community plus three countries that were members of the European Free Trade Association, an estimated 3438 cases of melanoma could be attributable to sunbed use, most (n=2341) occurring among women.

CONCLUSIONS

Sunbed use is associated with a significant increase in risk of melanoma. This risk increases with number of sunbed sessions and with initial usage at a young age (<35 years). The cancerous damage associated with sunbed use is substantial and could be avoided by strict regulations.

Epidemiology of basal cell carcinoma

Basal cell carcinoma is the most common malignant neoplasm in humans and its incidence has increased over the last decades. Its high frequency significantly burdens the health system, making the disease a public health issue. Despite the low mortality rates and the rare occurrence of metastases, the tumor may be locally invasive and relapse after treatment, causing significant morbidity. Exposure to ultraviolet radiation is the main environmental risk factor associated with its cause. However, other elements of risk are described, such as light skin phototypes, advanced age, family history of skin carcinoma, light eyes and blond hair, freckles in childhood and immunosuppression. Behavioral aspects such as occupational sun exposure, rural labor and sunburns at a young age also play a role. Between 30% and 75% of the sporadic cases are associated with patched hedgehog gene mutation, but other genetic changes are also described. The tumor is commonly found in concomitance with skin lesions related to chronic sun exposure, such as actinic keratoses, solar lentigines and facial telangiectasia. The prevention of basal cell carcinoma is based on the knowledge of risk factors, early diagnosis and treatment, as well as on the adoption of specific measures, particularly in susceptible populations. The authors present a review of the epidemiology of basal cell carcinoma.

Case-control study of smoking and non-melanoma skin cancer

OBJECTIVE

To investigate the association between cigarette smoking and basal and squamous cell carcinomas (BCC and SCC) of the skin, a clinic-based case-control study was conducted in Tampa, FL.

METHODS

Patients with histologically confirmed BCC/SCC were recruited from a university dermatology clinic (n = 215 BCC, 165 SCC). Controls were comprised of individuals with no history of skin cancer who screened negative for skin cancer upon physical examination at the affiliated cancer screening or primary care clinics (n = 315). Information on smoking and other risk factors was obtained from self-administered questionnaires.

RESULTS

After adjustment for age, sex, and other skin cancer-risk factors, ever smoking was not associated with BCC (odds ratio (OR) = 1.26, 95% confidence interval (CI) = 0.83-1.92), but was statistically significantly associated with SCC (OR = 1.97, 95% CI = 1.19-3.26), with significant trends observed for SCC associated with increasing cigarettes per day (p = 0.01) and pack-years smoked (p = 0.01). Among men, smoking ≥20 pack-years was associated with non-significant increased risks of BCC (OR = 1.90, 95% CI = 0.88-4.12) and SCC (OR = 1.97, 95% CI = 0.84-4.66), whereas among women, no association was observed with BCC (OR = 0.98, 95% CI = 0.39-2.46) while a statistically significant three-fold risk was observed with SCC (OR = 3.00, 95% CI = 1.02-8.80).

CONCLUSION

Cigarette smoking is more strongly associated with SCC than BCC, particularly among women.

Tobacco smoking and cutaneous squamous cell carcinoma: a 16-year longitudinal population-based study

BACKGROUND

Although tobacco smoking is commonly cited as a risk factor for cutaneous squamous cell carcinoma (SCC), the evidence from previous clinical and case-control studies is conflicting. We therefore aimed to prospectively examine the role of tobacco smoking in the development of SCC of the skin in a population-based study.

METHODS

Study participants were 1,287 adults aged 25 to 75 years in 1992, randomly selected from the Nambour community, with no previous history of SCC. Standard skin pigment and sun-sensitivity profiles were obtained at baseline. Detailed prospective information on sun exposure, smoking, and skin cancer occurrence (histologically confirmed) was collected over a 16-year period, 1992 to 2007.

RESULTS

Of 1,287 participants, 43% were male and average age was 48 years. A total of 188 first cutaneous SCCs were identified during the study period. After adjustment for other known risk factors, neither former nor current smokers were at raised risk of SCC: relative risk (RR) = 1.1, 95% CI: 0.8-1.5 and RR = 1.1, 95% CI: 0.7-1.5, respectively, compared with lifelong nonsmokers, nor were there any dose-response relationships with amount smoked or duration of smoking and risk of SCC.

CONCLUSIONS

In this Australian follow-up study, tobacco smoking did not increase the risk of SCC of the skin.

IMPACT

These prospective adjusted data provide strong evidence which suggests that cutaneous SCC should not be on the list of tobacco-related cancers.

The combined influence of oral contraceptives and human papillomavirus virus on cutaneous squamous cell carcinoma

The vast majority of cutaneous squamous cell carcinoma (CSCC) will occur in those with fair complexion, tendency to burn, and high ultraviolet radiation (UVR) exposure. Organ transplant recipients also are an important population at great risk for CSCC. An association has been reported between oral contraceptive (OC) use, human papillomavirus virus (HPV) and cervical cancer, and there could be a similar association for CSCC. The cutaneous HPV β-E6 protein, a close cousin of the transformative E6 protein underlying anogenital cancers, has been shown to inhibit apoptosis in response to UVR damage and stimulate morphologic transformation in rodent fibroblast cell lines. Furthermore, OC use has been shown to enhance HPV transcription and may contribute to CSCC risk through this pathway.

Tobacco and the skin

Smoking negatively impacts the health of the skin as it does every organ system. This contribution reviews the effect of cigarette smoking on wound healing, wrinkling, and aging of the skin, skin cancer, psoriasis, and other inflammatory skin diseases, hidradenitis suppurativa, acne, alopecia, lupus erythematosus, polymorphous light eruption, and tobacco-associated oral lesions. Dermatologists need to encourage their patients to discontinue this deleterious habit.

UVR exposure sensitizes keratinocytes to DNA adduct formation

UV radiation (UVR) and exposure to tobacco smoke, a source of polycyclic aromatic hydrocarbons (PAH), have been linked to skin carcinogenesis. UVR-mediated activation of the aryl hydrocarbon receptor (AhR) stimulates the transcription of CYP1A1 and CYP1B1, which encode proteins that convert PAH to genotoxic metabolites. We determined whether UVR exposure sensitized human keratinocytes to PAH-induced DNA adduct formation. UVR exposure induced CYP1A1 and CYP1B1 in HaCaT cells, an effect that was mimicked by photooxidized tryptophan (aTRP) and FICZ, a component of aTRP. UVR exposure or pretreatment with aTRP or FICZ also sensitized cells to benzo(a)pyrene (B[a]P)-induced DNA adduct formation. alphaNF, an AhR antagonist, suppressed UVR-, aTRP-, and FICZ-mediated induction of CYP1A1 and CYP1B1 and inhibited B[a]P-induced DNA adduct formation. Treatment with 17-AAG, an Hsp90 inhibitor, caused a marked decrease in levels of AhR; inhibited UVR-, aTRP-, and FICZ-mediated induction of CYP1A1 and CYP1B1; and blocked the sensitization of HaCaT cells to B[a]P-induced DNA adduct formation. FICZ has been suggested to be a physiologic ligand of the AhR that may have systemic effects. Hence, studies of FICZ were also carried out in MSK-Leuk1 cells, a model of oral leukoplakia. Pretreatment with alpha-naphthoflavone or 17-AAG blocked FICZ-mediated induction of CYP1A1 and CYP1B1, and suppressed the increased B[a]P-induced DNA adduct formation. Collectively, these results suggest that sunlight may activate AhR signaling and thereby sensitize cells to PAH-mediated DNA adduct formation. Antagonists of AhR signaling may have a role in the chemoprevention of photocarcinogenesis.

Synergistic damage by UVA radiation and pollutants

Not only is skin cancer by far the most common human cancer but also the incidence of skin cancer has been increasing at an alarming rate in recent decades. Fortunately, most people now realize that sun exposure causes unattractive photoaging and skin cancer, so they do apply sunscreens conscientiously. However, until recently, most sunscreens did not adequately protect against ultraviolet A (UVA) radiation. Although UVA is indeed less erythrogenic and less carcinogenic than UVB, UVA directly causes photoaging and enhances UVB-induced skin cancer. Furthermore, recent research demonstrates that UVA combined with environmental pollutants (including cigarette smoke) significantly increases the risk of skin cancer. Similarly, previous research demonstrated another synergy between environmental pollutants and UV: When ozone exposure precedes UV exposure, there is enhancement of UV-induced depletion of protective vitamin E from the skin's stratum corneum. This article reviews experimental evidence that environmental pollutants (such as benzo[a]pyrene (BaP), a commonly used index of environmental pollution) are photosensitizers that generate reactive oxygen species (ROS) when exposed to UVA radiation. This in turn causes oxidative and genetic damage, leading to unattractive photodamage and carcinogenesis.

Effects of tobacco smoking on cancer and cardiovascular disease in urban black South Africans

Demographic and lifestyle information from 9690 black patients diagnosed with cancer or cardiovascular disease was collected in an ongoing case–control study in Johannesburg, South Africa. Compared to never smokers, the odds ratio (OR) for lung cancer among current smokers was 16.3 (95% confidence interval (CI), 9.6–27.6) for men and 6.4 (95% CI, 4.0–10.4) for women. The corresponding OR for other smoking-related cancers was 4.6 (95% CI, 3.7–5.7) among men and 1.9 (95% CI, 1.6–2.2) among women, and for cardiovascular disease, 3.4 (95% CI, 2.1–5.4) among men and 1.5 (95% CI, 1.1–2.1) among women. Risks were higher among smokers than former smokers, and all risk estimates increased with increasing levels of smoking duration and intensity. Non-electric domestic fuel was associated with approximately 60% increase in the risk of smoking-related cancer, but not cardiovascular disease. Risks for cancers of cervix, oesophagus, oral cavity/pharynx, stomach, larynx, pancreas and anogenital region, as well as squamous cell carcinoma of skin were all significantly higher among current than never-smokers, with ORs ranging from 1.5 for cervix (95% CI, 1.2–1.8) to 14.7 for larynx (95% CI, 7.2–30). The risks of tobacco-related disease reported here are similar to that currently observed in Western countries, even though cigarette consumption is relatively low in this population.

Daily coffee consumption and prevalence of nonmelanoma skin cancer in Caucasian women

The purpose of this study was to assess the relationship between daily coffee consumption and nonmelanoma skin cancer. This study was a cross-sectional analysis of women enrolled in the Women's Health Initiative Observational Study (n=93 676). As nearly all cases of self-reported nonmelanoma skin cancer occurred among Caucasian women (97.8%), we focused our analyses on this group. Compared with nondrinkers, women drinking only caffeinated coffee on a daily basis had a 10.8% lower prevalence of nonmelanoma skin cancer. Consumption of six or more cups of caffeinated coffee per day was associated with a 36% reduction in nonmelanoma skin cancer. After adjusting for various demographic and life style variables, daily consumption of six or more cups was associated with a 30% reduced prevalence of nonmelanoma skin cancer. In contrast to caffeinated coffee, daily consumption of decaffeinated coffee was not associated with a significant change in self-reported nonmelanoma skin cancer for Caucasian women. Daily caffeinated coffee consumption was associated with a dose-related decreased prevalence of nonmelanoma skin cancer in Caucasian women.

Healthy and safe school environment, Part I: Results from the School Health Policies and Programs Study 2006

BACKGROUND

Policies set at the state, district, and school levels can support and enhance a healthy and safe school environment.

METHODS

The Centers for Disease Control and Prevention conducts the School Health Policies and Programs Study every 6 years. In 2006, computer-assisted telephone interviews or self-administered mail questionnaires were completed by state education agency personnel in all 50 states plus the District of Columbia and among a nationally representative sample of school districts (n=461). Computer-assisted personal interviews were conducted with personnel in a nationally representative sample of elementary, middle, and high schools (n=1025).

RESULTS

Most districts had adopted a policy on the inspection and maintenance of school facilities and equipment, and most schools had inspected and provided appropriate maintenance for each type of school facility and equipment during the 12 months preceding the study. Nearly all districts and schools had a comprehensive crisis preparedness, response, and recovery plan. Nearly all districts and schools prohibited tobacco, alcohol, and illegal drug use; fighting; weapons use; and weapon possession; but when students broke rules related to those behaviors, punitive measures were taken more often than provision of supportive services. Most schools did not reschedule outdoor activities to avoid times when the sun was at peak intensity, nor did they encourage the use of sunscreen before going outside.

CONCLUSIONS

To provide students with a truly healthy and safe school environment in which learning can take place, more schools need to promote a positive school climate and reduce violence, injuries, and the use of tobacco, alcohol, and other substances. States and districts need to continue to provide policy and technical assistance in support of school efforts.

Occupation and skin cancer: the results of the HELIOS-I multicenter case-control study

Background

Non-melanoma skin cancer (NMSC) is the most frequent tumour among Caucasian populations worldwide. Among the risk factors associated with this tumour, there are host-related factors and several environmental agents. A greater likelihood of high exposure to physical agents (with the exception of solar radiation) and chemical agents depends on the work setting. Our objective is to evaluate the role of occupational exposures in NMSC, with special emphasis on risk factors other than solar radiation and skin type.

Methods

We analysed 1585 cases (1333 basal cell carcinoma (BCC) and 183 squamous cell carcinoma (SCC)) and 1507 controls drawn from the Helios-I multicenter study. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression mixed models.

Results

For NMSC as a whole (both histological types), miners and quarrymen, secondary education teachers, and masons registered excess risk, regardless of exposure to solar radiation and skin type (OR 7.04, 95% CI 2.44–20.31; OR 1.75, 95% CI 1.05–2.89 and OR 1.54, 95% CI 1.04–2.27, respectively). Frequency of BCC proved higher among railway engine drivers and firemen (OR 4.55; 95% CI 0.96–21.57), specialised farmers (OR 1.65; 95% CI 1.05–2.59) and salesmen (OR 3.02; 95% CI 1.05–2.86), in addition to miners and quarrymen and secondary education teachers (OR 7.96; 95% CI 2.72–23.23 and OR 1.76; 95% CI 1.05–2.94 respectively). The occupations that registered a higher risk of SCC (though not of BCC) were those involving direct contact with livestock, construction workers not elsewhere classified (OR 2.95, 95% CI 1.12–7.74), stationary engine and related equipment operators not elsewhere classified (OR 5.31, 95% CI 1.13–21.04) and masons (OR 2.55, 95% CI 1.36–4.78).

Conclusion

Exposure to hazardous air pollutants, arsenic, ionizing radiations and burns may explain a good part of the associations observed in this study. The Helios study affords an excellent opportunity for further in-depth study of physical and chemical agents and NMSC based on matrices of occupational exposure.

Ultraviolet Carcinogenesis in Nonmelanoma Skin Cancer Part II: Review and Update on Epidemiologic Correlations

The relationship between ultraviolet radiation and nonmelanoma skin cancer (NMSC) is further elucidated by a review of case-control studies relating type of exposure to the development of NMSC. Intermittent sun exposure is important in the pathogenesis of basal cell carcinoma, whereas cumulative exposure is important for both basal cell carcinoma and squamous cell carcinoma. The regional distribution of NMSC is also in areas of sun exposure. Furthermore, there are inherent risk factors for the development of NMSC that include hair and eye colors. Once an individual develops NMSC, he/she has increased risk of developing basal cell carcinoma, squamous cell carcinoma, or melanoma.

Epidemiology of nonmelanoma skin cancer (NMSC) in Europe: accurate and comparable data are needed for effective public health monitoring and interventions

Nonmelanoma skin cancer (NMSC) is the most common malignancy occurring in white populations. It is currently becoming an important challenge in terms of public health management as the increasing incidence rates will probably have a tremendous impact on healthcare costs. Possible factors driving this rise in NMSC numbers are increases in both acute and prolonged UV exposure together with increasing numbers of older people in the population. A better understanding of NMSC epidemiology in Europe is essential if an evidence-based European-wide public health policy is to be developed. It is obvious this can only be achieved by recording and analysing comparative epidemiological data. Finally, by improving the skin examination training for physicians, developing guidelines and exchanging best practices, a high level of healthcare could be provided for NMSC.

The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systematic review

Exposure to solar ultraviolet (UV) radiation is a known cause of skin cancer. Sunbed use represents an increasingly frequent source of artificial UV exposure in light-skinned populations. To assess the available evidence of the association between sunbed use and cutaneous malignant melanoma (melanoma) and other skin cancers, a systematic review of the literature till March 2006 on epidemiological and biological studies on sunbed use was performed in Pubmed, ISI Web of Science, Embase, Pascal, Cochrane library, Lilacs and Medcarib. Search for keywords in the title and in the abstract was done systematically and supplemented by manual searches. Only case-control, cohort or cross-sectional studies were selected. Data were abstracted by means of a standardized data-collection protocol. Based on 19 informative studies, ever-use of sunbeds was positively associated with melanoma (summary relative risk, 1.15; 95% CI, 1.00-1.31), although there was no consistent evidence of a dose-response relationship. First exposure to sunbeds before 35 years of age significantly increased the risk of melanoma, based on 7 informative studies (summary relative risk, 1.75; 95% CI, 1.35-2.26). The summary relative risk of 3 studies of squamous cell carcinoma showed an increased risk. For basal cell carcinoma, the studies did not support an association. The evidence does not support a protective effect of the use of sunbeds against damage to the skin from subsequent sun exposure. Young adults should be discouraged from using indoor tanning equipment and restricted access to sunbeds by minors should be strongly considered.

Occupational exposure to ultraviolet radiation: the duality dilemma

Human exposure to ultraviolet (UV) radiation is a component of everyday life and a significant hazard for outdoor workers. In addition, a large range of artificial sources also has the potential to provide extreme occupational UV exposure. Even though the human health risks of overexposure to UV are well documented, to date relatively little is known quantitatively about UV exposure. For example, the evidence indicates that workers who are exposed to particular sources (for example, welding arcs) are exposed to extreme UV exposures, despite the use of current control measures. In contrast, increasing evidence points to significant health impacts resulting from underexposure to UV, particularly with the production (or more correctly lack of production) of vitamin D in the skin. The latter poses a serious issue for the work-force, with specific risks for workers lacking adequate sun exposure-underground miners, long-haul flight crews, shift workers, and perhaps indoor workers. Using a risk-management approach, this paper provides a comprehensive review of occupational UV sources, health impact of occupational UV exposure, occupational exposure standards, and levels of exposure in various settings, and discusses the appropriate control measures. In addition, the duality aspect of health impacts from overexposure and underexposure to UV and the associated occupational health implications are specifically explored.

Modification of risk of arsenic-induced skin lesions by sunlight exposure, smoking, and occupational exposures in Bangladesh

BACKGROUND

The risk of skin lesions associated with arsenic exposure from drinking water in Bangladesh is considerably greater in men than in women.

METHODS

Using baseline data from 11,062 cohort members in the Health Effects of Arsenic Longitudinal Study in Araihazar, Bangladesh, we performed a cross-sectional analysis to evaluate whether the association between arsenic exposure from drinking water and the risk of skin lesions is modified by tobacco smoking, excessive sunlight, the use of fertilizer, and the use of pesticides. A time-weighted well arsenic concentration was estimated for each participant by incorporating history of well use. Relative excess risk for interaction (RERI) and its 95% confidence intervals (CIs) were estimated using adjusted prevalence odds ratios.

RESULTS

We observed a synergistic effect between the highest level of arsenic exposure (> 113 microg/L) and tobacco smoking on risk of skin lesions in men (RERI = 1.5 [95% CI = 0.3 to 2.7] overall and 1.7 [0.2 to 3.4] for the subpopulation with longer-term arsenic exposure). We also observed suggestive synergistic effects between higher levels (28.1-113.0 microg/L and 113.1-864.0 microg/L) of arsenic exposure and fertilizer use in men (RERI = 1.0 [-0.2 to 2.2] and 1.3 [-0.2 to 2.9] respectively). Furthermore, the risk of skin lesions associated with any given level of arsenic exposure was greater in men with excessive sun exposure. The patterns of effect estimates in women indicate similar-but-weaker interaction effects of arsenic exposure with tobacco smoking and fertilizer use.

CONCLUSIONS

These findings help explain why the risk of arsenic-related skin lesions was much greater in men than in women in Bangladesh. Because most arsenic-induced skin cancers arise from these skin lesions, treatment and remediation plans should take into consideration these etiologic cofactors.

The epidemiology of sunburn in the US population in 2003

BACKGROUND

Sunburn is a major preventable risk factor for skin cancer.

OBJECTIVE

We investigated risk factors for sunburn in the United States based on the 2003 Behavioral Risk Factor Surveillance System.

DESIGN AND METHODS

A random sample of 207,776 respondents provided data for the population-based survey. The main outcome measure was any report of sunburn within the previous 12 months.

RESULTS

Overall, 39% of respondents had at least one sunburn. The strongest factors associated with sunburn were age and socioeconomic factors. Sunburn prevalence was greatest in respondents 18 to 24 years old (61%). This group was more likely to have a sunburn than respondents 45 to 54 years of age (odds ratio [OR] = 2.76). Higher income and higher levels of education were positively associated with sunburn (OR 1.67 and 1.63, respectively). Individuals reporting recent binge drinking had a higher prevalence of sunburn (OR = 1.33).

LIMITATIONS

The Behavioral Risk Factor Surveillance System does not include data on skin type or sun protection behavior; therefore the impact of these factors was not assessed.

CONCLUSION

Sunburn occurs at a very high rate in the United States.