Melanoma Disparities among US Hispanics: Use of the Social Ecological Model to Contextualize Reasons for Inequitable Outcomes and Frame a Research Agenda

Review article: Emerging issues in pediatric skin of color, part 1

Dermatology for the pediatric skin of color population is the application of dermatology to the genetically diverse and distinctive segment of the pediatric population that includes children of non-White racial and ethnic groups with increased pigmentation including individuals of Asian, LatinX, African, Native American, Pacific Island descent, Indigenous Peoples, among others, with overlap in particular individuals, and mixtures thereof. Treating children of color is a unique skill set within the field of pediatric dermatology, requiring knowledge and sensitivity. The discipline of pediatric skin of color can be challenging. Difficulty in diagnosis of common conditions stems from underlying pigmentation, variations in common hairstyling practices, and differences in demographics of cutaneous disease, whereas some conditions are more common in children of color, other conditions have nuances in clinical appearance and/or therapeutics with regard to skin color. This article is the first in a series of two articles looking at recently published skin-related issues of high concern in children of color. Conditions reviewed in Part 1 include (1) hairstyling hair-related concerns (traction alopecia, central centrifugal cicatricial alopecia, endocrine disruption), (2) autoimmune concerns (cutaneous lupus, vitiligo), and (3) infections (tinea capitis, progressive macular hypomelanosis).

Understanding individual and socio-cultural factors associated with hispanic parents' provision of sugar-sweetened beverages to young children

Sugar-sweetened beverages (SSBs) contribute to childhood obesity, long-term risks for diet-related diseases, and health disparities affecting communities of color. Hispanic children are disproportionately affected by obesity, but research is needed to better understand culturally specific reasons for providing SSBs to Hispanic children. This exploratory study utilized the Social Ecological Model framework to evaluate Hispanic parents' perceptions of SSBs and serving them to young children. A cross-sectional survey (in English and Spanish) used a national US online panel to recruit a convenience sample of Hispanic parents (N = 350) with young children (aged 1-5 years). Participants reported types of drinks and SSB brands that they served their child in the past month and rated drink healthfulness. Attitude questions assessed individual, community-level, and socio-cultural factors, including normative beliefs, about serving SSBs to young children. Nearly all parents (98%) reported serving their child SSBs in the past month, averaging 6.7 different SSB types. For all categories of SSBs except fruit-flavored drinks, parents who served that type of SSB rated it as significantly healthier than parents who did not serve them. A linear regression model examined associations between individual and socio-cultural factors and number of SSB types served to their child. In the model, higher average rating of SSB healthfulness, child's age, normative beliefs that others serve SSBs to children, being born in the US/Puerto Rico, and parent and child enjoyment of SSBs were positively associated with serving more SSB types, while concerns about SSBs for their own health was negatively related. Language-related acculturation and community-level factors assessed were not significant. Public health initiatives should focus on healthfulness misperceptions of some SSB categories and address normative beliefs to help reduce serving SSBs to Hispanic children.

Sunscreen application technique amongst patients with a history of skin cancer

BACKGROUND

Data on how patients with a history of skin cancer apply sunscreen are lacking.

OBJECTIVE

To characterize (1) gender differences in sunscreen application technique (quantity used, anatomic site coverage, and time allocated) and (2) differences in sunscreen application to unaffected skin versus previous skin cancer sites.

METHODS

Subjects with a history of skin cancer were asked to apply sunscreen to their head as they normally would. The amount of sunscreen used and application time were recorded. Before and after photos were taken. Using Wood's lamp lighting, an anatomic site coverage score was rated on an ordinal scale (1 = 0-25%, 2 = 26-50%, 3 = 51-75%, 4 = 76-100% coverage).

RESULTS

Males used 530 mg more sunscreen (p < 0.001) and applied approximately 5 mg/cm² of sunscreen versus women, who applied 2 mg/cm². The average coverage score was 3.27. Males were 7.61 times more likely to adequately apply sunscreen to the ears (p = 0.001). No differences were noted in application times. Coverage scores were similar for unaffected skin and previous skin cancer sites.

LIMITATIONS

Observations in a controlled setting may not reflect usual sunscreen application practices.

CONCLUSIONS

Overall, skin cancer survivors of both genders effectively applied sunscreen in line with recommended quantity guidelines, but men were significantly better at protecting their ears.

Trends in emergency department visits due to sunburn and factors associated with severe sunburns in the United States

Little is known regarding the burden of sunburns leading to emergency department (ED) visits in the United States (US). The objectives of this research were to characterize the burden of sunburn ED visits, investigate predictors of severe sunburns, and evaluate risk factors for increased cost of care in patients presenting to the ED for sunburn. In this nationally representative cross-sectional study of the National Emergency Department Sample (NEDS, 2013-2015), multivariable models were created to evaluate adjusted odds for sunburn ED visits, seasonal/regional variation in sunburn ED visits, adjusted odds for second and third degree sunburns, and risk factors for increased ED expenditure. 82,048 sunburn ED visits were included in this study. On average, the cost of care for a sunburn ED visit was $1132.25 (± $28.69). The prevalence and cost of ED visits due to sunburn increased during the summer months. Controlling for sociodemographic factors, comorbidities, and hospital characteristics, patients presenting to the ED for all sunburns (and for severe sunburns) were most likely to be lower income young adult men. Older, higher income patients in metropolitan hospitals had more expensive ED visits. This research provides nationally representative estimates of visits to the ED due to sunburn in the US, as well as evaluates determinants for severe sunburns and more expensive sunburn ED visits. Ultimately, characterizing the national burden of ED visits due to sunburn is critical in the development of interventions to reduce the impact of sunburn ED visits on the US healthcare system.

Video Education to Promote Skin Cancer Awareness and Identification in Spanish-speaking Patients

Objective: We sought to evaluate the efficacy of a Spanish-language educational video in teaching primary Spanish speaking patients to recognize benign and malignant lesions and to increase their awareness about skin cancer. Materials and Methods: Thirty-seven subjects were enrolled in study. An instructional video was developed to increase knowledge of benign and malignant lesions, skin cancer awareness, and prevention among Spanish-speaking patients. Two examples each of six common skin lesions (e.g., malignant melanoma, cherry angioma, seborrheic keratosis, benign melanocytic nevus, basal cell carcinoma, and squamous cell carcinoma) were presented as high-quality images to the participants before and after watching the two-minute educational video. A pre- and postvideo survey was used to assess competency. Results: The prevideo baseline median score was six points (interquartile range [IQR]: 5-6 points); postviewing median score improved to 11 points (IQR: 11-12 points), which was statistically significant (Median=5 points, IQR: 4-6 points; p<.001). The ability of the participants to identify nonmelanoma skin cancers improved from 74 percent to 98 percent and from 35 percent to 99 percent for squamous cell carcinoma and basal cell carcinoma. Initially, only 30 percent of participants could identify melanoma prior to viewing the video. Afterwards, 97 percent of participants could identify this malignancy. However, the video format preferences were not statistically significant: 67.6 percent of the participants preferred the video format. Conclusion: These results suggest that this educational video is an effective and valuable method to enhance knowledge about skin health and improve identification of skin cancer among Spanish-speaking patients.

Clinical Presentations of Melanoma in African Americans, Hispanics, and Asians

BACKGROUND

Skin cancer has traditionally been studied in Caucasian skin. Although it does occur with increased relative frequency in Caucasians, patients with skin of color suffer from elevated morbidity and mortality when diagnosed with skin cancer.

OBJECTIVE

To detail the unique demographic, clinical, and genetic features of melanoma in patients with skin of color, including Hispanic, African American, and Asian patients.

MATERIALS AND METHODS

A PubMed search was conducted spanning dates 1947 to June 2017. A total of 246 articles were screened, from which 69 were included in this review.

RESULTS

Relative to Caucasians, melanoma has unique demographic, clinical, and genetic features in African Americans, Hispanics, and Asians that include gender and subtype predominance.

CONCLUSION

Familiarization with these unique presentations of skin cancer in skin of color is imperative to accurate identification and treatment of cutaneous malignancies in these populations and ultimately to improved disease-related outcomes.

MC1R Variation in a New Mexico Population

BACKGROUND

The Melanocortin 1 Receptor (MC1R) contributes to pigmentation, an important risk factor for developing melanoma. Evaluating SNPs in MC1R and association with race/ethnicity, skin type, and perceived cancer risk in a New Mexico (NM) population will elucidate the role of MC1R in a multicultural population.

METHODS

We genotyped MC1R in 191 NMs attending a primary care clinic in Albuquerque. We obtained individuals' self-identified race/ethnicity, skin type, and perceived cancer risk. We defined genetic risk as carriage of any one or more of the nine most common SNPs in MC1R.

RESULTS

We found that one MC1R SNP, R163Q (rs885479), was identified in 47.6% of self-identified Hispanics and 12.9% of non-Hispanic whites (NHW), making Hispanics at higher "genetic risk" (as defined by carrying one of the MC1R common variants). When we deleted R163Q from analyses, Hispanics were no longer at higher genetic risk (33.3%) compared with NHW (48.3%), consistent with melanoma rates, tanning ability, and lower perceived risk. Hispanics had a perceived risk significantly lower than NHW and a nonsignificant better tanning ability than NHW.

CONCLUSIONS

The R163Q variant in MC1R may not be a risk factor for melanoma among NM Hispanics. This suggestion points to the need to carefully interpret genetic risk factors among specific populations.

IMPACT

Genetic risk cannot be extrapolated from Northern European populations directly to non-European populations.

Predictors of Sun Protective Behaviors among Latino Day Laborers

Objectives

Despite the substantial solar ultraviolet radiation experienced by Latino day laborers, little attention has been given to factors that are associated with sun protective behaviors. The purpose of this study was to examine psychological and nonpsychological predictors of sun protective behaviors among Latino day laborers.

Methods

This cross-sectional study included a nonrandom sample of 137 Latino day laborers recruited from Mississippi and Illinois. Participants completed a self-report survey instrument, available in English and Spanish, on sun protective behaviors.

Results

Multivariate regression results showed that sun protective behaviors were significantly greater among Latino day laborers: (a) who had greater perceptions that their supervisor also engaged in sun protective behaviors (β = 0.25, p ≤ 0.01); (b) who reported higher levels of health literacy (β = 0.23, p ≤ 0.001); (c) who have greater knowledge of skin cancer risk factors (β = 0.21, p ≤ 0.01); and (d) who have skin tone that was self-perceived to be more prone to sunburns (β = 0.19, p ≤ 0.01).

Conclusions

Latino day laborers possess marginal levels of skin cancer knowledge and engage minimally in sun protective behaviors. Skin cancer prevention interventions are warranted for this high-risk group, particularly in the locations in which Latino day laborers work.