Recommendation: Daily sun protection in the prevention of chronic UV-induced skin damage

Charting the landscape of the environmental exposome

The exposome depicts the total exposures in the lifetime of an organism. Human exposome comprises exposures from environmental and humanistic sources. Biological, chemical, and physical environmental exposures pose potential health threats, especially to susceptible populations. Although still in its nascent stage, we are beginning to recognize the vast and dynamic nature of the exposome. In this review, we systematically summarize the biological and chemical environmental exposomes in three broad environmental matrices-air, soil, and water; each contains several distinct subcategories, along with a brief introduction to the physical exposome. Disease-related environmental exposures are highlighted, and humans are also a major source of disease-related biological exposures. We further discuss the interactions between biological, chemical, and physical exposomes. Finally, we propose a list of outstanding challenges under the exposome research framework that need to be addressed to move the field forward. Taken together, we present a detailed landscape of environmental exposome to prime researchers to join this exciting new field.

The Role of the Global Solar UV Index for Sun Protection of Children in German Kindergartens

More than twenty-five years ago, the Global Solar UV index (UVI) was introduced as a simple means of visualizing the intensity of ultraviolet radiation and to alert people to the need for sun protection. In our survey, among directors of 436 kindergartens in southern Germany we investigated the level of awareness and knowledge about the UVI as well as the practical consequences for sun protection in kindergartens. Less than half of the directors (n = 208, 47.7%) had ever heard of the UVI, and only a small minority of them (n = 34, 8.7%) used the daily UVI information to adapt sun protective measures in their kindergartens. Detailed knowledge about the UVI was a rarity among the respondents. The proportion of respondents with self-perceived detailed UVI knowledge was five times higher than the actual knowledge assessed by an in-depth structured interview using open-ended questions about the UVI (14.2% vs. 2.8%). No clear relationship between UVI awareness, knowledge, and use and directors' age and gender was found. The UVI-related variables also showed no association with directors' knowledge of risk factors for skin cancer and their attitudes towards tanned skin. Overall, the results paint a sobering picture regarding the penetration of the UVI into sun protection policies of German kindergartens. Future public health campaigns should aim to increase the awareness and understanding of the UVI as well as its relevance for sun protection of children.

Sun-health behaviours and attitudes towards sun safety amongst Australian teenagers: a qualitative update

OBJECTIVE

This study aimed to explore current attitudes towards sun protection, and sun-seeking behaviour among young Australian adolescents. It was done as part of a larger project aiming to develop a digital resource to support young people in making informed sun-health decisions.

RESULTS

Ten (4 male, 6 female) adolescents (12-13 years of age) living in Perth (Western Australia) were recruited through a social media-based strategy. Each participant engaged in a semi-structured telephone interview which explored their sun-health decision-making, with interview transcripts assessed qualitatively using NVivo. Three major themes (and eight sub-themes) were identified: (1) 'personal sun health considerations'; (2) 'attitudes towards sun protection'; and (3) 'recommendations'. The importance of sun protection was appreciated by participants. However, females were more diligent in the use of sun protection while males were indifferent. Behaviours were influenced by parental input, the school environment and engagement in sport. Adolescents had limited knowledge of the UV Index and its implications for sun protection, and the health importance of sun-derived vitamin D. Overall, the importance of sun protection was acknowledged but did not consistently translate into sun protective behaviours.

Secondary prevention of UV-induced skin cancer: development and pilot testing of an educational patient counseling approach for individual sun protection as standard procedure of patient care

Objective

To outline the development and pilot testing of a patient counseling approach for individual sun protection for patients in outdoor professions diagnosed with squamous cell carcinoma or multiple actinic keratosis due to solar UV radiation. This is a secondary prevention measure as part of the standard procedure of patient care by the respective statutory accident insurance.

Methods

Results of guideline-based qualitative interviews with seven outdoor workers and a search of literature formed the basis for the counseling approach, which was compiled in a manual. Interdisciplinary experts (dermatologists and educators) reviewed and consented the final manual. The pilot testing was conducted in consecutive steps (N₁ = 36 patients and N₁ = 2 counselors; N₄ = 12 patients and N₄ = 6 counselors). The first two stages of the revised guideline ‘Criteria for Reporting the Development and Evaluation of Complex Interventions in healthcare (CReDECI 2)’ serve as background and structure for presenting the results.

Results

The ‘counseling approach for individual sun protection (ILB: Individuelle Lichtschutz-Beratung)’ consists of seven general and eight add-on modules. These can be combined and tailored according to the patient’s individual needs. Interactive, educational components (e.g. haptic experiments) are crucial elements of the counseling approach.

Conclusions

The special requirements of outdoor workers are hardly taken into consideration in Germany, even though the interest for an improved sun protection behavior of some occupational groups is high. The advantage of the presented approach is that the heterogeneous needs of patients can be specifically addressed with its various modules.

[Occupational skin cancer : Prevention and recommendations for UV protection as part of the treatment approved by the public statutory employers' liability insurance]

In Germany, approximately 2 to 3 million employees work in outdoor professions. They are exceptionally exposed to solar ultraviolet (UV) radiation for a large part of their daily working time. Cumulative UV exposure is associated with a significantly increased risk of skin cancer for outdoor workers from various occupational groups (e. g. landscape and horticulture, agriculture and forestry, fisheries and seafaring, construction and trade, as well as sports teachers, lifeguards and mountain guides). Since 1 January 2015, squamous cell carcinoma and multiple actinic keratosis due to natural UV radiation can be recognised as occupational disease No. 5103 by the German statutory social accident insurance. Reducing cumulative UV exposure is the main prevention aspect of this type of skin damage. Therefore, technical, organisational and personal UV protection measures should be implemented in the professional and private environment. Moreover, they have to be regularly used in an appropriate way. In addition to guideline-oriented therapy, training and counselling of patients with already existing actinic skin damage or a recognised occupational disease No. 5103 is therefore of particular importance. The focus should be on improving the individual UV protection behaviour. This article gives an overview of current recommendations for UV protection in the professional environment. It outlines possible solutions for patient counselling in terms of UV protection in everyday practice.

Photosensitivity and photoprotection in patients with lupus erythematosus

Lupus erythematosus (LE) represents a spectrum of inflammatory autoimmune disease comprising varying clinical entities ranging from primary cutaneous to systemic disease. There is a clear relationship between ultraviolet irradiation (UVR) and the clinical manifestations of LE in both adult and pediatric populations. Although it has been established that UVR exacerbates pre-existing LE, it remains unclear whether UVR induces the development of the disease. This review serves to discuss effective photoprotective measures in LE and describe the pathogenic relationship of UVR and LE.

Age-Associated Skin Conditions and Diseases: Current Perspectives and Future Options

The International League of Dermatological Societies (ILDS), a global, not-for-profit organization representing 157 dermatological societies worldwide, has identified the consequences of skin aging as one of the most important grand challenges in global skin health. Reduced functional capacity and increased susceptibility of the skin with development of dermatoses such as dry skin, itching, ulcers, dyspigmentation, wrinkles, fungal infections, as well as benign and malignant tumors are the most common skin conditions in aged populations worldwide. Environmental (e.g., pollution) and lifestyle factors (e.g., smoking, sunbed use) negatively affect skin health. In turn altered appearance, dry skin, chronic wounds, and other conditions decrease general health and reduce the likelihood for healthy and active aging. Preventive skin care includes primary, secondary, and tertiary interventions. Continuous sun protection from early childhood onward is most important, to avoid extrinsic skin damage and skin cancer. Exposure to irritants, allergens, or other molecules damaging the skin must be avoided or reduced to a minimum. Public health approaches are needed to implement preventive and basic skin care worldwide to reach high numbers of dermatological patients and care receivers. Education of primary caregivers and implementation of community dermatology are successful strategies in resource-poor countries. Besides specialist physicians, nurses and other health care professionals play important roles in preventing and managing age-related skin conditions in developing as well as in developed countries. Healthy skin across the life course leads to better mental and emotional health, positive impact on social engagement, and healthier, more active, and productive lives.

Apoptosis induction is involved in UVA-induced autolysis in sea cucumber Stichopus japonicus

Autolysis easily happens to sea cucumber (Stichopus japonicus, S. japonicus) for external stimulus like UV exposure causing heavy economic losses. Therefore, it is meaningful to reveal the mechanism of S. japonicas autolysis. In the present study, to examine the involvement of apoptosis induction in UVA-induced autolysis of S. japonicas, we investigated the biochemical events including the DNA fragmentation, caspase-3 activation, mitogen-activated protein kinases (MAPKs) phosphorylation and free radical formation. Substantial morphological changes such as intestine vomiting and dermatolysis were observed in S. japonicus during the incubation after 1-h UVA irradiation (10W/m(2)). The degradation of the structural proteins and enhancement of cathepsin L activity were also detected, suggesting the profound impact of proteolysis caused by the UVA irradiation even for 1h. Furthermore, the DNA fragmentation and specific activity of caspase-3 was increased up to 12h after UVA irradiation. The levels of phosphorylated p38 mitogen activated protein kinase (MAPK) and phosphorylated c-Jun.-N-terminal kinase (JNK) were significantly increased by the UVA irradiation for 1h. An electron spin resonance (ESR) analysis revealed that UVA enhanced the free radical formation in S. japonicas, even through we could not identify the attributed species. These results suggest that UVA-induced autolysis in S. japonicas at least partially involves the oxidative stress-sensitive apoptosis induction pathway. These data present a novel insight into the mechanisms of sea cucumber autolysis induced by external stress.

Coexistence effect of UVA absorbers to increase their solubility and stability of supersaturation

OBJECTIVE

Sunscreens containing UVA absorbers in high concentrations are expected to be developed, since recent studies have suggested the possibility of involvement of UVA ray in skin cancer and early skin aging. Solubility and stability of supersaturation of UVA absorbers in UVB absorber were determined in the absence and the presence of cosmetic oil. Coexistence effect of UVA absorbers was analyzed to dissolve them in high concentrations.

METHODS

Two UVA absorbers, diethylamino hydroxybenzoyl hexyl benzoate (DHHB) and butyl methoxydibenzoylmethane (BMDM), a UVB absorber, 2-ethylhexyl methoxycinnamate (EHMC), and a cosmetic oil, 2-ethylhexyl ester of oligomer of hydroxystearic acid (EH-O-HSA), were used. Their solutions were prepared at 80°C and cooled to 5°C. The solid DHHB and/or BMDM were added to it, and the time evolution of concentrations of the UVA absorbers in the solution phase was monitored.

RESULTS

At the saturation in the absence of EH-O-HSA at 5°C, weight ratio of DHHB and BMDM to EHMC was 0.39/1.00 and 0.22/1.00, respectively. Addition of EH-O-HSA slightly changed the solubility of DHHB and BMDM. When the weight ratio of EH-O-HSA to EHMC was 0.20/1.00, weight ratio of DHHB and BMDM to EHMC was 0.35/1.00 and 0.25/1.00, respectively at the saturation at 5°C. In the presence of EH-O-HSA, a strong coexistence effect of DHHB and BMDM was found on their solubility. A thermodynamically stable saturated solution at 5°C having the composition that DHHB: BMDM: EHMC: EH-O-HSA = 0.47: 0.46: 1.00: 0.20 was obtained by the simultaneous addition of solid DHHB and BMDM into the initial solution.

CONCLUSION

The solution type composite having the highest concentrations of DHHB and BMDM prepared in this study exhibited critical wavelength at 368 nm that was just below the border for sunscreens being qualified as 'Broad Spectrum' protection under the new rule launched by US FDA.

Apigenin, a bioactive flavonoid from Lycopodium clavatum, stimulates nucleotide excision repair genes to protect skin keratinocytes from ultraviolet B-induced reactive oxygen species and DNA damage

In this study, we examined the antioxidative and the DNA protective potentials of apigenin, a flavonoid polyphenol isolated from Lycopodium clavatum, in both in-vitro (HaCaT skin keratinocytes) and in-vivo (mice) models against UV-B radiation. We used DAPI staining in UV-B-irradiated HaCaT skin keratinocytes pre-treated with and without apigenin to assess DNA damage. We also used a flow-cytometric analysis in mice exposed to UV-B radiation with or without topical application of apigenin to assess, through a comet assay, chromosomal aberrations and quanta from reactive oxygen species (ROS) generation. Data from the stability curves for the Gibb's free energy determined from a melting-temperature profile study indicated that apigenin increased the stability of calf thymus DNA. Immunofluorescence studies revealed that apigenin caused a reduction in the number of cyclobutane pyrimidine dimers (CPDs) after 24 h, the time at which the nucleotide excision repair (NER) genes were activated. Thus, apigenin accelerated reversal of UV-B-induced CPDs through up-regulation of NER genes, removal of cyclobutane rings, inhibition of ROS generation, and down-regulation of NF-κB and MAPK, thereby revealing the precise mechanism of DNA repair.

UV-induced occupational skin cancer: possibilities of secondary individual prevention in the "Dermatologist's Procedure"

Invasive squamous cell carcinoma (SCC) as a "quasi occupational disease" according to §9 Section 2 of the German Social Code Book (SGB) VII typically develops on chronically UV-damaged skin from actinic keratoses. After the Medical Scientific Committee of the Federal Ministry of Labor and Social Affairs has confirmed the legal criteria for acknowledging UV-induced SCC as an occupational disease, it is expected that the condition will be added to the official list of occupational diseases issued by the Federal Government in the near future. The Social Accident Insurance is required by law (§3 Occupational Disease Regulation) to prevent these tumors by "all appropriate means". There are excellent therapeutic and preventive measures for the management of actinic keratoses to avoid the development of SCC. The "Dermatologist's Procedure" according to §§ 41-43 of the agreement between the Social Accident Insurance and the Federal Medical Association was established in Germany in 1972 to take preventive measures in insured persons with skin lesions possibly developing into an occupational disease, or worsening it, or leading to a recurrence of it This procedure proved to be very successful in the prevention of severe and/or recurring skin diseases forcing a worker to leave his job. On the basis of this agreement, the Social Accident Insurance has the instruments to independently provide preventive measures for the new occupational skin disease SCC induced by natural UV light according to §9 Section 2 of the German Social Code Book (SGB) VII.

Antagonizing effects and mechanisms of afzelin against UVB-induced cell damage

Ultraviolet (UV) radiation induces DNA damage, oxidative stress, and inflammatory processes in human keratinocytes, resulting in skin inflammation, photoaging, and photocarcinogenesis. Adequate protection of skin against the harmful effects of UV irradiation is essential. Therefore, in this study, we investigated the protective effects of afzelin, one of the flavonoids, against UV irradiation in human keratinocytes and epidermal equivalent models. Spectrophotometric measurements revealed that the afzelin extinction maxima were in the UVB and UVA range, and UV transmission below 376 nm was <10%, indicating UV-absorbing activity of afzelin. In the phototoxicity assay using the 3T3 NRU phototoxicity test (3T3-NRU-PT), afzelin presented a tendency to no phototoxic potential. In addition, in order to investigate cellular functions of afzelin itself, cells were treated with afzelin after UVB irradiation. In human keratinocyte, afzelin effectively inhibited the UVB-mediated increase in lipid peroxidation and the formation of cyclobutane pyrimidine dimers. Afzelin also inhibited UVB-induced cell death in human keratinocytes by inhibiting intrinsic apoptotic signaling. Furthermore, afzelin showed inhibitory effects on UVB-induced release of pro-inflammatory mediators such as interleukin-6, tumor necrosis factor-α, and prostaglandin-E2 in human keratinocytes by interfering with the p38 kinase pathway. Using an epidermal equivalent model exposed to UVB radiation, anti-apoptotic activity of afzelin was also confirmed together with a photoprotective effect at the morphological level. Taken together, our results suggest that afzelin has several cellular activities such as DNA-protective, antioxidant, and anti-inflammatory as well as UV-absorbing activity and may protect human skin from UVB-induced damage by a combination of UV-absorbing and cellular activities.

The relationship between occupational sun exposure and non-melanoma skin cancer: clinical basics, epidemiology, occupational disease evaluation, and prevention

BACKGROUND

The cumulative effect of solar ultraviolet (UV) radiation is responsible for the worldwide increase in non-melanoma skin cancer, a category that includes squamous cell carcinoma and its precursors (the actinic keratoses) as well as basal-cell carcinoma. Non-melanoma skin cancer is the most common type of cancer in areas of the world with a light-skinned population. The occupational exposure to UV radiation is high in many outdoor occupations; recent studies suggest that persons working in such occupations are more likely to develop non-melanoma skin cancer.

METHODS

On the basis of a selective review of the literature, we present the current state of knowledge about occupational and non-occupational UV exposure and the findings of meta-analyses on the association of outdoor activity with non-melanoma skin cancer. We also give an overview of the current recommendations for prevention and for medicolegal assessment.

RESULTS

Recent meta-analyses have consistently documented a significantly higher risk of squamous cell carcinoma of the skin among persons who work outdoors (odds ratio [OR] 1.77, 95% confidence interval [CI] 1.40-2.22, p<0.001). There is also evidence for an elevated risk of basal-cell carcinoma (OR 1.43, 95% CI 1.23-1.66, p = 0.0001), but the effect is of lesser magnitude and the study findings are not as uniform.

CONCLUSION

The association of occupational exposure to solar UV radiation with squamous cell carcinoma, including actinic keratosis, has been conclusively demonstrated. It follows that, in Germany, suspected non-melanoma skin cancer in persons with high occupational exposure to UV radiation should be reported as an occupational disease under § 9, paragraph 2 of the Seventh Book of the German Social Code (Sozialgesetzbuch, SGB VII). Preventive measures are urgently needed for persons with high occupational exposure to UV radiation.

UVB-induced DNA damage, generation of reactive oxygen species, and inflammation are effectively attenuated by the flavonoid luteolin in vitro and in vivo

Ultraviolet (UV) radiation induces DNA damage, oxidative stress, and inflammatory processes in human keratinocytes resulting in skin inflammation, photoaging, and photocarcinogenesis. The flavonoid luteolin is one of the most potent antioxidative plant polyphenols. We investigated the UV protective and antioxidant properties of luteolin in human keratinocytes in vitro, ex vivo, and in vivo. Spectrophotometric measurements revealed extinction maxima of luteolin in the UVB and UVA range. UV transmission below 370 nm was <10%. In human skin, luteolin effectively reduced the formation of UVB-induced cyclobutane pyrimidine dimers. The free radical scavenging activity of luteolin was assessed in various cell-free and cell-based assays. In the cell-free DPPH assay the half-maximal effective concentration (EC₅₀) of luteolin (12 μg/ml) was comparable to those of Trolox (25 μg/ml) and N-acetylcysteine (32 μg/ml). In contrast, in the H₂DCFDA assay performed with UVB-irradiated keratinocytes, luteolin (EC₅₀ 3 μg/ml) was much more effective compared to Trolox (EC₅₀ 12 μg/ml) and N-acetylcysteine (EC₅₀ 847 μg/ml). Luteolin also inhibited both UVB-induced skin erythema and the upregulation of cyclooxygenase-2 and prostaglandin E₂ production in human skin via interference with the MAPK pathway. These data suggest that luteolin may protect human skin from UVB-induced damage by a combination of UV-absorbing, DNA-protective, antioxidant, and anti-inflammatory properties.

UV-induced skin cancer at workplace and evidence-based prevention

PURPOSE

The present review is aimed at providing an overview of skin cancer with particular focus on occupational concern and giving evidence-based recommendation for effective prevention at workplace.

METHODS

We performed a systematic search of literature using PubMed and the Cochrane Library.

RESULTS

Outcome of preventive strategies depends either on efficacy of the strategy itself but also on acceptance and implementation of protective means among the persons at possible risk for hazardous health effects. Epidemiological studies have reported significantly more non-melanoma skin cancer in men than in women. Life-style choices and difference in immunosuppression play a major role in this gender disparity. Tumor biology of skin cancer is diverging: severe blistering sunburns corresponding to intermittent intense UV exposures are associated with an increased risk for both melanoma and basal cell carcinoma (BCC); whereas the risk of squamous cell carcinoma (SCC) and actinic keratoses (AK) is strongly associated with chronic UV exposure. Several clinical trials give evidence that long-term use of sunscreen prevents the appearance of non-melanotic skin cancer such as AK and SCC, but not of BCC. All technical and organizing measures aimed at reducing UV exposure at workplace belong to first-line prevention; however, there is much room for improvement. The efficacy of personal protection means (second-line strategy) strongly depends on the workers' compliance which is quite low at workplace.

CONCLUSION

Evidence-based data confirming the benefit of sun protective strategies are scarce, general recommendations are mainly based on the avoidance of UV radiation being identified as potential risk factor for non-melanoma skin cancer in epidemiological studies. Occupational screenings should include regular interventions aimed at enhancing a clear understanding of risk factors for individuals and finally improving the acceptance and maintenance for UV-protective means at workplace.

Rationale Behandlung von Patienten mit Verbrennungen 1. Grades

First-degree burns are the most common type of burn, but are often inadequately treated. The methods of treatment and the course of healing are poorly documented owing to the fact that first-degree burns are generally not considered to be a serious injury. First-degree burns can be caused by thermal injury or UV irradiation (sunburn). The pathophysiology and the therapeutic approach are similar, although the damage follows a different time course for each injury--immediate damage after contact with hot objects, liquids or fire, delayed damage after sun exposure. After initial cooling with water, aqueous emulsions with small amounts of well-tolerated lipids (O/W emulsions) are best suited for treating first-degree burns or sunburn. Water evaporates producing cooling and reducing inflammation; the lipids accelerate the repair of the damaged skin barrier and reduce drying. Foam sprays and lotions are ideal because they are easy and painless to apply. The use of topical corticosteroids is not recommended, as superiority to the vehicle has not been shown.