An Added Benefit of Masks During the COVID-19 Pandemic: Ultraviolet Protection

The widespread use of masks during the COVID-19 pandemic presents a new avenue for protecting the lower half of the face from the harms of sun exposure. The increased social acceptability of masks, which may persist post-pandemic, has the potential to impact prevention of photosensitive disorders, photoaging, and skin cancer. The authors sought to review clinically relevant information on the ultraviolet (UV) shielding properties of masks. This synthesis of current research will help physicians counsel patients on optimal mask choices, from both dermatological and public health viewpoints. The variables impacting the UV protection of masks were reviewed, including fabric type, construction, porosity, and color. Other factors related to wear and use such as moisture, stretch, laundering, and sanitization are discussed in the context of the pandemic. Black, tightly woven, triple-layered polyester cloth masks were determined to be optimal for UV protection. The most protective choice against both SARS-CoV-2 and UV radiation is a medical mask worn underneath the aforementioned cloth mask. In order to preserve the filtration capacity of the fabric, masks should be changed once they have become moist. Washing cotton masks before first use in laundry detergents containing brightening agents increases their UV protection. Overall, cloth masks for the public that are safest against SARS-CoV-2 are generally also the most protective against UV damage. People should be encouraged to procure a high-quality mask to simultaneously help reduce the spread of SARS-CoV-2 and shield against sun exposure. Further investigation is needed on the UV-protective properties of medical masks.

Protective effects of liquiritin on UVB-induced skin damage in SD rats

Overexposure to ultraviolet B (UVB) rays can cause damage to the skin. Liquiritin has a variety of pharmacological effects, such as anti-inflammatory and antioxidant. In the present study, the effect of liquiritin on UVB irradiated rat skin was investigated. Results showed that UVB irradiation caused erythema and wrinkles on the skin surface, as well as thickening and loss of elasticity of the epidermis and a significant increase in the level of ROS in the skin tissue. At the same time, western blot detected an increase in nuclear factor kappa-B (NF-κB) and matrix metalloproteinases (MMPs) and Elisa also detected an increase in pro-inflammatory factors. Therefore, we hypothesized that UVB irradiation-induced damage is associated with inflammation. Interestingly, application of liquiritin to exposed skin of rats reduced the increase in ROS, pro-inflammatory factors, and MMPs caused by UVB irradiation and increased the levels of Sirtuin3 (SIRT3) and Collagen α1. In addition, after intraperitoneal injection of the SIRT3 inhibitor 3-TYP in rats, the protective effect of liquiritin against UVB damage was found to be diminished. These results suggested that promotion of SIRT3 with liquiritin inhibits UVB-induced production of pro-inflammatory mediators, possibly acting through the SIRT3/ROS/NF-κB pathway. In conclusion, this study suggests that liquiritin is an effective drug candidate for the prevention of UVB damage.

'More extraordinary than mundane … ' A phenomenological analysis of the experiences of individuals living with CLE and their taking care in the sun

Introduction

CLE is a chronic inflammatory autoimmune condition of which photosensitivity is a major symptom. Individuals living with CLE are advised to practice photoprotection. Despite the benefits for disease control, many individuals living with CLE do not practice optimal photoprotection. The aim of this study was to gain a deep insight into the lived experiences of individuals with CLE and their photoprotective practices.

Methods

A qualitative study approach was conducted, using Hermeneutic phenomenology. Individuals living with CLE were recruited and interviewed. Rich pictures were used to enrich the interviews. Interviews were transcribed and analysed using Template Analysis.

Results

Analysis revealed four themes: ‘Much more than just a photosensitive skin condition’, ‘The impact of sun on CLE and social dynamics’, ‘Drifting to the sun: personal transitions and social norms’ and ‘Taking care in the sun: easier said than done’.

Discussion and conclusion

This study provides a nuanced insight into the lived experiences of individuals with CLE and their photoprotective practices. Taking care in the sun is not a simplistic process. Beyond the biomedical model of illness, the social impact that CLE has on individuals has a dominant influence on their photoprotective behaviours. Such insights could help healthcare professionals tailor photoprotective advice.

Prevention of photosensitivity with action spectrum adjusted protection for erythropoietic protoporphyria

Erythropoietic protoporphyria is a genetic disease characterized by sensitivity to sunlight caused by the accumulation of protoporphyrin IX. Photoprotection against ultraviolet A and visible light is necessary for erythropoietic porphyria patients because the absorption spectrum of protoporphyrin IX lies in both ultraviolet A and visible light region. We developed a novel index, in vitro porphyrin protection factor, based on the protoporphyrin IX absorbance spectrum. We also selected appropriate photoprotective products designed according to protoporphyrin IX absorbance. The porphyrin protection factors of a combination of make-up base with a powder as well as with a liquid foundation were significantly higher than those of a conventional sunscreen product, even at a small application dose. An in-use test carried out for 6 months showed that the efficacy of these products was 78.3%, and no adverse reactions were observed. Male subjects preferred liquid foundation, whereas all female subjects used powder foundation. The preference of the subjects could lead to the long-term use of the tested products. In conclusion, this study provided a new approach to improve photoprotection in erythropoietic protoporphyria patients.

Research gaps in the management and prevention of cutaneous squamous cell carcinoma in organ transplant recipients

Although tremendous progress has been made in recent years in skin cancer care for organ transplant recipients, significant gaps remain in data-driven clinical guidelines, particularly for the treatment and prevention of cutaneous squamous cell carcinoma (cSCC), the most common malignancy among this population. In this review, we aim to summarize current knowledge around the management of cSCC and highlight the most significant gaps in knowledge that continue to pose challenges in the delivery of skin cancer care for organ transplant recipients. We suggest future directions for research that will bridge existing gaps and establish evidence-driven guidelines for primary prevention, screening and treatment of cSCC in this high-risk patient population.

Evaluation of benefit to educational material for photoprotection in those with cutaneous lupus erythematosus

BACKGROUND

Photosensitivity (PS) in cutaneous lupus erythematosus (CLE) contributes to decreased quality of life (QoL).

AIMS

We aimed to assess baseline knowledge about sun protection in persons with CLE and identify knowledge differences by race. Additionally, we aimed to determine the impact of a verbal educational intervention on photoprotection and CLE.

METHODS

31 adults with CLE were recruited from an academic-based dermatology clinic and completed a 17-item questionnaire about CLE and sun protection at three time points: pre- intervention (PR-I), post-intervention (PO-I), and 3-month phone follow up (3MF). An educational intervention using American Academy of Dermatology CLE and sun protection education materials was delivered between PR-I and PO-I.

RESULTS

31 subjects participated at PR-I and PO-I, and 25 subjects (81%) at 3MF. Baseline CLE-related PS and photoprotection knowledge differed significantly by race, with non-Caucasians demonstrating less knowledge (P= 0.049). Knowledge about sun exposure being linked to lupus increased from 81% to 97% (P=0.25) between PR-I and PO-I. At PR-I, 19% agreed that smoking was linked to lupus compared to 90% PO-I (P<0.001). There was increased knowledge of lupus risk for non-Caucasians, UV exposure indoors, and photo-avoidance during peak daytime (P<0.001).

CONCLUSION

There is a baseline disparity in knowledge related to PS and photo protection in CLE by race. A short educational intervention successfully improved immediate lupus-related PS and sun exposure knowledge, but knowledge was not retained long-term. It appears educational materials must be improved.

[Pharmaceutical chemistry of drug-initiated photosensitivity]

The photosensitivity originated from drugs is a common problem in medical and pharmaceutical practice. It is of prominent importance in drug development and in regulatory issues. The photosensitizer effect of drug substances is determined by their chemical structures, and it mainly originates from aromatic chromophore systems and photo-dissociable bonds forming free radicals. The photodegradation may happen in many different types of chemical reaction pathways. Our aim is to demonstrate in this review the interrelations between structure and photodegradation. We show examples for the different reaction types, with drugs from different pharmacologic therapeutic classes. The in vivo chemical reactivity of photodegradates of pharmaceutical substances, the in vitro methods of investigation for testing photoreactivity and phototoxicity, and briefly the clinical tests for photosensitivity disorders are also discussed.

Sunscreens in the management of photodermatoses

Key to the management of photodermatoses is photoprotection, which includes seeking shade; wearing photoprotective clothing, wide brimmed hats, and sunglasses; and applying sunscreens. The process of selecting the most effective sunscreen depends on identification of the wavelengths of photons that are responsible for inducing the sensitivity reaction, which can be determined through assessment of patient history or by phototesting. Sunscreens with sun protection factor (SPF) >30 that incorporate photostable or photostabilized ultraviolet A (UVA) filters (labeled as 'broad spectrum' in the US) are usually the appropriate choice for adequate photoprotection.

[Avene-50 and Ebastine in treatment and prevention of photodermatosis]

The clinical efficacy of antihistaminic preparation "Kestine" (Ebastine) in combined treatment of 50 patients suffering from photo-allergic dermatosis (15 - solar urticaria, 20 - solar erythema and 15 - solar eczema) are evaluated. Kestine in dosage of 10 mg a day was prescribed in duration of 10 days. Itch disappearance was observed in 87% of patients, reduction of itching - in 10% and in 3% of patients an itch was remain. Photo protector Avene-50 as sunburn preparation, assigned for different type of skins, has been used. This preparation fit for different demands (including prevention of both beginnings and exacerbation of photo allergic reactions) of patients. Water- and sweat-resistance of Avene-50 formula has been taken in account. Treatment caused increasing of some indices of non specific reactions (Kavetski skin test) that confirms recovery of conjunctive tissue elements' activity. Efficacy and safety of this combined method of photodermatosis treatment allow us to use it widely in dermatologic clinic.

Chloasma--the mask of pregnancy

Chloasma is a required hypermelanosis of sun-exposed areas occurred during pregnancy and it can affect 50-70% of pregnant women. It presents as symmetric hyperpigmented macules, which can confluent or punctuate. The most common locations are the cheeks, the upper lip, the chin and the forehead. The exact mechanism by which pregnancy affects the process of melanogenesis is unknown. Estrogen, progesterone, and melanocyte-stimulating hormone (MSH) levels are normally increased during the third trimester of pregnancy. However, nulliparous patients with chloasma have no increased levels of estrogen or MSH. In addition, the occurrence of melasma with estrogen- and progesterone-containing oral contraceptive pills has been reported. The observation that postmenopausal woman who are given progesterone develop melasma, while those who are given only estrogen do not, implicates progesterone as playing a critical role in the development of melasma. UV-B, UV-A, and visible light are all capable of stimulating melanogenesis. The condition is self-limited; however spontaneous resolution is time-consuming and may take months to resolve normal pigmentation. Therefore, it is worthwhile to prevent the onset of chloasma, by strict photoprotection. Prudent measures to avoid sun exposure include hats and other forms of shade combined with the application of a broad-spectrum sunscreen at least daily. Sunscreens containing physical blockers, such as titanium dioxide and zinc oxide, are preferred over chemical blockers because of their broader protection. Chloasma can be difficult to treat. Quick fixes with destructive modalities (eg, cryotherapy, medium-depth chemical peels, lasers) yield unpredictable results and are associated with a number of potential adverse effects. The mainstay of treatment remains topical depigmenting agents. Hydroquinone (HQ) is most commonly used.

Update on sunscreens

Sunscreens have been around for more than 70 years. Designed originally to protect against sunburn, recognition of the various harmful effects of ultraviolet (UV) radiation has broadened the use of sunscreens. The addition of effective UVA sunscreen agents has enabled claims beyond protection against sunburn to include prevention of idiopathic photodermatosis, actinic keratoses, skin cancer, and photoaging. This article will review some of the recent advances in photoprotection, including the development of sunscreen formulations offering higher and broader protection against solar radiation.

Photoprotection

Sun exposure is the main cause of photocarcinogenesis, photoageing, and photosensitivity; thus, photoprotection is an important issue. In a skin cancer prevention strategy, behavioural measures--eg, wearing sun protective clothes and a hat and reducing sun exposure to a minimum--should be preferred to sunscreens. Often this solution is deemed to be unacceptable in our global, outdoor society, and sunscreens could become the predominant mode of sun protection for various societal reasons (eg, healthiness of a tan, relaxation in the sun). The application of a liberal quantity of sunscreen has been shown to be by far the most important factor for effectiveness of the sunscreen, followed by the uniformity of application and the specific absorption spectrum of the agent used. The sunscreen market--crowded by numerous products--shows various differences worldwide. Nevertheless, sunscreens should not be abused in an attempt to increase time in the sun to a maximum. Controversies about safety of sunscreens and clinical recommendations are discussed.

Reliability of the histopathologic diagnosis of keratinocyte carcinomas

OBJECTIVE

We sought to determine the interobserver reliability of the histopathologic diagnosis of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) (keratinocyte carcinomas) in the setting of a Department of Veteran Affairs multicenter chemoprevention study.

METHODS

Interobserver concordance was assessed by blinded review of histopathologic slides by study dermatopathologists.

RESULTS

Overall interobserver agreement between the two dermatopathogists was kappa = 0.69 (95% confidence interval [CI] 0.67-0.69). The dermatopathologists' interobserver agreement was highest for basal cell carcinoma at kappa = 0.88 (95% CI 0.84-0.91) and for a diagnostic category in the SCC-actinic keratosis spectrum at kappa = 0.80 (95% CI 0.73-0.86). The largest disagreements between the two reference dermatopathologists were regarding the categories of invasive SCC at kappa = 0.62 (95% CI 0.52-0.72), SCC in situ at kappa = 0.42 (95% CI 0.29-0.56), and actinic keratosis at kappa = 0.51 (95% CI 0.40-0.62). Agreement between the local pathologists and central reference dermatopathologists were similar to the agreement between the central dermatopathologists. The morphea subtype of basal cell carcinoma was the only reliably diagnosed subtype (kappa = 0.79, 95% CI 0.51-1.00), and tumor depth was reliably measured.

LIMITATIONS

A limitation of this study was the use of only two reference dermatopathologists.

CONCLUSION

Because of the impact on physician decision making and patient care, researchers and clinicians need to be aware of reliability of histopathology results, particularly pertaining to the SCC and actinic keratosis spectrum.

Managing cutaneous vasculitis in a patient with lupus erythematosus

Lesions and rashes are the most common dermatologic manifestation in patients who have lupus erythematosus and are directly related to inflammation of the small and medium-size vessels of the skin. Inflammation of these vessels is known as cutaneous vasculitis and is often an indicator that a more severe, life-threatening inflammatory process could be occurring in the major organs of the body.

Oxidative stress in the pathogenesis of skin disease

Skin is the largest body organ that serves as an important environmental interface providing a protective envelope that is crucial for homeostasis. On the other hand, the skin is a major target for toxic insult by a broad spectrum of physical (i.e. UV radiation) and chemical (xenobiotic) agents that are capable of altering its structure and function. Many environmental pollutants are either themselves oxidants or catalyze the production of reactive oxygen species (ROS) directly or indirectly. ROS are believed to activate proliferative and cell survival signaling that can alter apoptotic pathways that may be involved in the pathogenesis of a number of skin disorders including photosensitivity diseases and some types of cutaneous malignancy. ROS act largely by driving several important molecular pathways that play important roles in diverse pathologic processes including ischemia-reperfusion injury, atherosclerosis, and inflammatory responses. The skin possesses an array of defense mechanisms that interact with toxicants to obviate their deleterious effect. These include non-enzymatic and enzymatic molecules that function as potent antioxidants or oxidant-degrading systems. Unfortunately, these homeostatic defenses, although highly effective, have limited capacity and can be overwhelmed thereby leading to increased ROS in the skin that can foster the development of dermatological diseases. One approach to preventing or treating these ROS-mediated disorders is based on the administration of various antioxidants in an effort to restore homeostasis. Although many antioxidants have shown substantive efficacy in cell culture systems and in animal models of oxidant injury, unequivocal confirmation of their beneficial effects in human populations has proven elusive.

Hereditäre Photodermatosen

Hereditary photodermatoses are characterized by an increased photosensitivity caused by an inherited single gene defect. With few exceptions, they manifest in early childhood, reveal heterogeneous clinical symptoms, and are difficult to treat. Although these diseases are rare, it is very important to make an accurate diagnosis on the basis of clinical symptoms, specific diagnostic tests, and direct DNA analysis. We review the spectrum of inherited photodermatoses, including porphyria cutanea tarda, erythropoietic protoporphyria, actinic prurigo, Kindler syndrome, and disorders associated with a defect in DNA repair, including xeroderma pigmentosum, trichothiodystrophy, Cockayne syndrome, and Bloom syndrome. Early diagnosis may prevent complications associated with prolonged unprotected exposure to sunlight and makes it possible to offer genetic counseling and, when indicated, prenatal diagnosis to families at risk for these rare heritable disorders.

UV-Schutzgesetz

The article reports on a petition to the German Bundestag in the field of UV protection for persons under the age of 18 against the dangers of artificial sunbed tanning for cosmetic purposes. On 16 March 2006 the Parliament agreed to adopt the proposal of the author, after the Ministry of Environment announced it is working on a UV Protection Law for Germany. Furthermore the committee recommended the petition to the government and the parliamentary parties. The UV Protection Law is still in progress, and no draft has yet been published. Therefore, the author explains the difficulties in creating such law from a legal and a public health perspective, pointing out that the split of competence between the federation and the states poses difficulties. He concludes that the German Constitution would allow a sunbed prohibition for minors in public studios and explains why a complete prohibition for the adult population would be disproportionate and unconstitutional.

Nichthereditäre Photodermatosen im Kindesalter

Non-hereditary photodermatoses with well-known trigger factors and idiopathic light eruptions occur quite frequently during childhood and are at least temporarily associated with a marked impairment of quality of life in affected patients and their parents. Thus, it is crucial that the involved specialties are familiar with acquired UV-associated disorders in order to guarantee a quick diagnosis and effective therapy. Additionally, the recurrence of photodermatoses associated with potentially severe long-term complications has to be prevented. This requires a stringent prophylaxis that can only succeed after age-adapted instruction of the patient and parents.

Medication and supplement use by athletes

Athletes are affected in various ways by medications and supplements. Physicians caring for athletes need to be aware of medicines that athletes are taking and how they may interact with performance, exercise, environment, and other medicines. Athletes may attempt to gain a performance advantage with the use of a variety of dietary supplements and performance enhancers. Physicians must be knowledgeable of these so that athletes are properly educated about potential benefits and risks and physical effects. This article first reviews common medicines that athletes use and their potential efficacy and interactions with exercise and environment, then reviews dietary supplements and the data on their efficacy for performance enhancement. Finally, current and future doping issues are discussed.

Sunscreen use in photodermatoses

Photodermatoses are relatively uncommon, but most dermatologists will have to diagnose and treat them at some point. This article highlights several photodermatoses, their common symptoms and possible. Unfortunately, sunscreens marketed in the United States do not presently contain agents that are effective against longer wavelengths. There are agents available in other countries that offer better protection. It is hypothesized that these products will soon be available in the United States. Until such time, clinicians should recommend agents with avobenzones, benzophenones, and the physical blockers titanium oxides. Two other agents, dihydroxyacetone and iron oxide, may also offer benefit in some of these patients.

An overview of ultraviolet radiation, sunscreens, and photo-induced dermatoses

The incidence of sunlight-induced skin aging and skin cancers, particularly melanoma skin cancer, has been increasing in many parts of the world. Authorities are recommending primary prevention programs to reduce cutaneous photodamage and skin carcinogenesis. An integral component of these programs is the use of protective clothing and effective sunscreens. Most modern sunscreens have highly efficient absorption or reflecting capabilities throughout ultraviolet B, partly ultraviolet A, and in some instances infrared wavelengths. Over the last several years, more efficient sunscreening ingredients have been developed for improved skin protection. More recently, direct evidence has demonstrated the effectiveness of sunscreens in their ability to reduce the incidence of solar keratoses. This article reviews the protectiveness of sunscreens and assays that predict their levels of protection.

Scientific problems of photosensitivity

Photosensitive skin reactions occur when human skin reacts to ultraviolet radiation or visible light abnormally. The forms of photosensitivity are phototoxicity and photoallergy. Phototoxic disorders have a high incidence, whereas photoallergic reactions are much less frequent in human population. Several hundred substances, chemicals, or drugs may invoke phototoxic and photoallergic reactions. In order to avoid photosensitive reactions it is essential to determine the photosensitizing properties of such substances before drugs are introduced in therapy or products made available on the market. The article reviews the mechanisms of photosensitization, explains the most important differences between phototoxic and photoallergic reactions, summarizes the most common photosensitizers, and presents the clinical features and diagnostic procedures of phototoxic and photoallergic reactions.

Novel Emerging Sunscreen Technologies

Because of increases in the number of skin cancers diagnosed annually, adverse effects of ultraviolet (UV) rays are being recognized, and major public education programs have been undertaken concerning photoprotection, including the use of sunscreen. In daily life, UV exposure is unavoidable; therefore sunscreen should be used regularly. Development in sunscreen manufacturing has grown tremendously in the last decade. Sunscreen active ingredients now are incorporated into cosmetics products to minimize photoaging changes. With the advances in technologies, many new UV filters have been developed recently. These have improved efficacy and safety. This article reviews these new filters, along with regulatory issues in the United States.

Nonsteroidal anti-inflammatory drugs and the risk of actinic keratoses and squamous cell cancers of the skin

BACKGROUND

Although animal studies suggest that nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, may protect against cutaneous squamous cell carcinoma (SCC) and actinic keratoses (AKs), possible effects on keratinocytic cancers in humans are unknown.

OBJECTIVE

We sought to examine the relationship between ingestion of NSAIDs and the risk of SCC and AKs in humans.

METHODS

We conducted a case-control study nested within a community-based cohort of 1621 people in southern Queensland, Australia. Eighty-six persons with SCC were compared with 187 age- and sex-matched control subjects randomly selected from within the cohort. NSAID use was captured through face-to-face interviews with study participants, supplemented by color photographs of product packaging. We defined regular use of NSAIDs as consumption of at least two tablets per week (low frequency) or at least 8 tablets per week (high frequency) for at least 1 year. AKs were counted on the face, ears, right hand, and right forearm by a single physician.

RESULTS

Patients with SCC were significantly less likely than control subjects to have used any NSAIDs 8 or more times per week for more than 1 year (multivariate odds ratio [OR] 0.07, 95% confidence interval [CI] 0.01-0.71) and to have used full-dose NSAIDs 2 or more times per week for more than 5 years (OR, 0.20; 95% CI, 0.04-0. 96). Among participants without SCC, current regular users of NSAIDs (> or =2 times per week) had significantly lower counts of AKs than nonusers (rate ratio [RR], 0.52; 95% CI, 0.30-0.91).

LIMITATIONS

Estimates of NSAID use were based on self-reported data. Statistical power to detect associations was limited by the number of cases with SCC.

CONCLUSION

Regular users of NSAIDs appear to have lower risks of SCC and lower counts of AKs than nonusers.

Lichtschutz: Moglichkeiten und Grenzen. Sunprotection: Possibilities and limitations

Protection against ultraviolet (UV) irradiation prevents from the development of acute skin damage such as erythema formation and chronic skin changes such as premature skin ageing. Especially those sunscreens with higher sun protection factors do not only protect against solar dermatitis but also inhibit UV-induced immunosuppression by blocking the release of immunosuppressive mediators from UV-exposed epidermis. In particular, the protection against UV-induced immunosuppression by sunscreens is supposed to reduce the development of UV-induced skin cancer. Besides immunosuppression UV-irradiation is also able to induce "UV signature" mutations within UV-exposed DNA. Topical application of DNA repair enzymes induces nucleotide excision repair and corrections of DNA damages. Thereby, the risk to develop UV-induced skin malignancies is markedly reduced. Accordingly, future perspectives in the development of sunscreens include DNA repair enzymes or factors, which can induce the endogenous cellular DNA repair system. Until these developments come to practice reasonable sun protection according to the skin complexion is of primary importance.

Normalized ultraviolet (UV) induction of Langerhans cell depletion and neutrophil infiltrates after artificial UVB hardening of patients with polymorphic light eruption

BACKGROUND

Ultraviolet (UV) B hardening has been widely used as a prophylactic treatment in patients with polymorphic light eruption (PLE). Recent investigations have shown that in patients with PLE Langerhans cells (LCs) and neutrophils display less migration from and to the epidermis after an intense UVB irradiation compared with controls.

OBJECTIVES

To investigate the effect of UVB hardening of patients with PLE on their cell migratory responses after intense UVB exposure.

METHODS

Thirteen patients with PLE were recruited and UVB provocation testing was performed before entering the study. Among these patients, seven developed PLE rash upon UVB provocation ('UVB-P') and the other six did not respond ('UVB-NP'). Eleven age/sex-matched controls were included. Buttock skin of all included individuals was exposed to 6 minimal erythema doses (MED) of UVB (TL-12 lamps). Biopsies were taken after 24 h and 48 h, together with one control biopsy of unirradiated skin. Patients received total-body UVB hardening therapy consisting of 12 irradiations, on average rising from 10% to 140% of the initial MED in 6 weeks. Subsequently, MEDs were reassessed and biopsies were taken from newly irradiated (6 MED UVB) and unirradiated buttock skin. Skin sections were stained for the presence of LCs, macrophages and neutrophils. The cross-sectional area (in percentage) of positively stained cells within the epidermis was assessed from patients before and after hardening and compared with controls.

RESULTS

Before therapy, epidermal LC depletion and neutrophil influx at 48 h after 6 MED were most significantly reduced in 'UVB-P' patients (P = 0.025 and P =0.006, respectively) when compared with controls. 'UVB-NP' patients did not differ significantly from controls. After therapy, there were no longer any significant differences in the cell numbers among these three groups.

CONCLUSIONS

UVB hardening significantly improves UV-induced cell migratory responses in patients with PLE. UVB provokability of PLE appears to be most strongly linked to reduced UVB-induced trafficking of LCs and neutrophils, and 'UVB-P' patients show normalization of these responses after UVB hardening.

Welder’s maculopathy?

OBJECTIVE

The aim of this study was to verify or to disprove whether the term 'Welder's maculopathy' or 'Welding arc maculopathy' has to be considered being a justifiable occupational hazard and is to be annexed to the list of occupational diseases.

METHODS

Multifocal electroretinography (MERG) and thorough ophthalmologic examinations were performed in a group of 89 welders. The matched control group comprised 81 subjects who had never been exposed to welding. All participants of this study were examined by a specialist of occupational medicine prior to the MERG.

RESULTS

Multifocal electroretinography as well as ophthalmological tests did not reveal a significant morphological or functional differences between the welders and the control group. On an average, the welders' visual acuity appeared to be better than that of the control group. This phenomenon could be attributed to the so-called healthy worker effect.

CONCLUSION

Welding arc maculopathy seems to be rather a sequel of occupational accidents and negligence of safety regulations. The results of this study indicate that the usual protective measures in professional welding appears to be sufficient in order to prevent an occupational risk of welding arc maculopathy.

Chronic actinic dermatitis treated with mycophenolate mofetil

Chronic actinic dermatitis (CAD) is a persistent photodermatosis that usually affects elderly men. We report two male patients, aged 55 years (patient A) and 49 years (patient B), who presented with an eczematous eruption on sun-exposed skin. Phototesting revealed a markedly reduced 24-h minimal erythema dose (MED). Both patients had refractory disease and developed significant side-effects to conventional therapies, including topical steroids, prednisolone, psoralen with ultraviolet A, azathioprine and ciclosporin. They had each received at least 6 years of treatment prior to commencing mycophenolate mofetil (MMF). Each noted a significant improvement in symptoms within 6 weeks and subsequent clearing of the eczematous lesions. Patient A still requires continuous treatment with MMF 500 mg twice daily to prevent relapses. Patient B maintains remission by using MMF 1 g twice daily only during the spring and summer months. Both patients have tolerated the treatment well with no abnormalities in blood cell counts or liver biochemistry. Since commencing MMF, their quality of life has significantly improved. These observations suggests that MMF should be considered as an alternative treatment to conventional therapies for refractory CAD.

Prevention of murine erythropoietic protoporphyria-associated skin photosensitivity and liver disease by dermal and hepatic ferrochelatase

Erythropoietic protoporphyria (EPP) is caused by a defect in ferrochelatase, leading to the accumulation of protoporphyrin predominantly in erythrocytes and hepatocytes, and resulting in skin photosensitivity upon leaching of blood protoporphyrin into the skin. Some patients also develop severe liver damage. Because the respective contributions of hepatic and erythrocytic protoporphyrin to the pathophysiology of EPP remain unclear, we investigated this question using the murine model of EPP. Transplantation of bone marrow from EPP mice to normal recipients resulted in elevated erythrocyte and plasma protoporphyrin levels. However, quantification of serum liver enzymes and bilirubin together with histopathologic examination of liver sections of mice up to 16 months post-transplantation showed no evidence of liver damage. Moreover, despite massive elevation of serum protoporphyrin, transplanted mice showed minimal evidence of skin photosensitivity. Photosensitivity could also be prevented locally by implanting skin grafts from normal mice onto the backs of EPP recipients. These data validate the hypothesis that the main source of toxic protoporphyrin originates from the erythrocytes. However, we unexpectedly observed that normal ferrochelatase activity in hepatic and dermal cells of wild-type mice is sufficient to prevent liver disease and significant skin photosensitivity. These findings may provide new strategies for the treatment of EPP.

Awareness, knowledge and attitudes to non-melanoma skin cancer and actinic keratosis among the general public

BACKGROUND

The incidence of nonmelanoma skin cancer (NMSC) has dramatically increased worldwide. In areas of high incidence this will place a significant burden on the health system. Objectives To establish the awareness, knowledge and attitudes of the general public to NMSC and provide an overview on their level of understanding and knowledge of preventative measures.

METHODS

Two thousand and one hundred Caucasian and Hispanic individuals, aged 40-75 years, from the UK, Italy, Germany, Spain, France, the USA and Australia were randomly selected to participate in this market research survey. In a structured telephone interview lasting approximately 10 min, respondents answered questions on NMSC, specifically actinic keratosis (AK) and basal cell carcinoma (BCC).

RESULTS

Overall, 6% of respondents had been diagnosed with NMSC, of which the incidence was highest in Australia and the USA. The frequency of skin cancer detection examinations was also greater within these populations. Countries with a high incidence of NSMC had greater awareness of the condition, with more awareness of BCC than AK. The majority of respondents believed there was a correlation between skin cancer and sun exposure, however, a minority of respondents associated skin cancer with 'moderate' tanning. Overall, 86% of respondents claimed that they always took precautions against ultraviolet exposure when in the sun, but only 26% applied sunscreen most or all of the time when they were exposed to the sun for more than 1 h. In most of the countries, outside workers reported lower sunscreen use than other respondents.

CONCLUSION

Nonmelanoma skin cancer awareness and prevention behaviors varied significantly among the countries studied. Improved population-specific documentation of skin cancer knowledge and prevention behaviors will facilitate the development and assessment of public health campaigns.

Implication for photosensitive patients of ultraviolet A exposure in vehicles

BACKGROUND

Photosensitive patients sometimes report disease flares during journeys by car. Window glass blocks all UVB but not all UVA. All car windscreens are made from laminated glass. Side and rear windows are usually made of nonlaminated glass.

OBJECTIVES

To determine which types of glass provide most protection from UVA with particular reference to the implications for patients with polymorphic light eruption (PLE).

METHODS

The percentage transmission of UVA was determined for a selection of glass, both laminated and nonlaminated, and with differing colour tints.

RESULTS

Laminated glass transmits less UVA than nonlaminated glass. Tinted glass transmits less UVA than clear glass. Nonlaminated clear glass transmitted the highest percentage of UVA (62.8%) and grey laminated glass the lowest (0.9%). A dose of 5 J cm(-2) UVA, enough to trigger PLE in some patients, could be transmitted through clear nonlaminated glass in 30 min but would take 50 h through grey laminated glass.

CONCLUSION

Patients with severe UVA-induced PLE and other photosensitivity disorders may have disease flares from solar UVA transmission through side-window glass. Protective measures such as wearing long-sleeved clothing, keeping the arm beneath the bottom of the window aperture, or choosing tinted and laminated car windows may be helpful.

Ergocalciferol promotes in vivo differentiation of keratinocytes and reduces photodamage caused by ultraviolet irradiation in hairless mice

BACKGROUND

Ergocalciferol (VD(2)) is usually administered orally and it is metabolized to produce its biologically active metabolites in the liver and kidney. Active vitamin D is a well-known potent regulator of cell growth and differentiation.

PURPOSE

Active vitamin D such as 1,25-dihydroxyvitamin D(3) (1alpha,25(OH)(2)D(3)) prevents photodamage, including wrinkles and morphologic alterations. However, its clinical and cosmetic use is limited because of its potent, associated effect on calcium metabolism. We examined the efficacy of vitamin D analogues with few adverse effects for preventing skin photodamage.

METHOD

Topical application of VD(2) to hairless mouse dorsal skin, and exposure to solar-simulating ultraviolet (UV) radiation at a dose of 10.8 J/cm(2) (UVA) were performed for 15 weeks, five times a week on weekdays. At the end of the final irradiation, histological and analytical studies were performed.

RESULTS

Topical application of VD(2) significantly prevented wrinkle formation and abnormal accumulation of extracellular matrix components. In addition, VD(2) suppressed excessive secretion of IL-6 induced by UV irradiation in cultured human normal keratinocytes, in a dose-dependent manner.

CONCLUSION

VD(2) promoted keratinocytes differentiation in the epidermis and showed diverse physiological effects, the same as the active form of VD(3). The results suggested that the suppression of skin photodamage involved the promotion of keratinocytes differentiation and suppression of IL-6 secretion induced by exposure to UV. Topical application of VD(2) may become an effective means to suppress solar UV-induced human skin damage.

Sunlight and the 10-Year Incidence of Age-Related Maculopathy

OBJECTIVE

To examine the association of sunlight exposure and indicators of sun sensitivity with the 10-year incidence of age-related maculopathy (ARM).

DESIGN

Population-based cohort study.

PARTICIPANTS

We included persons aged 43 to 86 years at the baseline examination from 1988 to 1990, living in Beaver Dam, Wis, of whom 3684 persons underwent 5-year follow-up and 2764 underwent 10-year follow-up.

METHODS

Data on sun exposure and indicators of sun sensitivity were obtained from a standardized questionnaire administered at baseline and/or follow-up. We determined ARM status by grading stereoscopic color fundus photographs using the Wisconsin Age-Related Maculopathy Grading System.

MAIN OUTCOME MEASURES

Incidence and progression of ARM.

RESULTS

While controlling for age and sex, we found that participants exposed to the summer sun for more than 5 hours a day during their teens, in their 30s, and at the baseline examination were at a higher risk of developing increased retinal pigment (risk ratio [RR], 2.99; 95% confidence interval [CI], 1.18-7.60; P =.02) and early ARM (RR, 2.20; 95% CI, 1.02-4.73; P =.04) [corrected] by 10 years than those exposed less than 2 hours per day during the same periods. In participants reporting the highest summer sun exposure levels in their teens and 30s, the use of hats and sunglasses at least half the time during the same periods was associated with a decreased risk of developing soft indistinct drusen (RR, 0.55; 95% CI, 0.33-0.90; P =.02) and retinal pigment epithelial depigmentation (RR, 0.51; 95% CI, 0.29-0.91; P =.02). Participants who experienced more than 10 severe sunburns during their youth were more likely than those who experienced 1 or no burn to develop drusen with a 250-microm diameter or larger (RR, 2.52; 95% CI, 1.29-4.94 [corrected] P =.01) by the 10-year examination. No relationships were found between UV-B exposure, winter leisure time spent outdoors, skin sun sensitivity, or number of bad sunburns experienced by the time of the baseline examination and the 10-year incidence and progression of ARM or its associated lesions.

CONCLUSIONS

Few significant relationships between environmental exposure to light and the 10-year incidence and progression of ARM were found in the Beaver Dam Eye Study. Consistent with results from the baseline and 5-year follow-up examinations, significant associations were found between extended exposure to the summer sun and the 10-year incidence of early ARM and increased retinal pigment. A protective effect of hat and sunglasses use by participants while in their teens and 30s against the 10-year incidence of soft indistinct drusen and retinal pigment epithelial depigmentation was also found, but only in those who reported the highest amount of sun exposure during the same periods.

A comparison of six and 12 PUVA treatments in the prophylaxis of polymorphic light eruption

Polymorphic light eruption (PLE) is a common condition for which the most effective treatment is prophylactic phototherapy. This is traditionally given in courses of approximately 12-15 exposures. We compared the effect of six and 12 treatments of psoralen-UVA (PUVA) therapy, in the prophylaxis of PLE, in a side-to-side within-patient comparison pilot study. In six out of eight patients, six treatments provided as much protection as 12 treatments. Five of these six patients had reported relatively mild disease in the previous year, in comparison to the other two patients. In view of the inconvenience and increased incidence of adverse effects associated with long treatment courses, we recommend the use of short courses, particularly in patients who are relatively mildly affected.