Prolonged Prevention of Squamous Cell Carcinoma of the Skin by Regular Sunscreen Use

The association of sun sensitivity, sun protective behaviors and depression in both genders: a study based on the U.S. population

Objective

The purpose of this study was to analyze the association between sun sensitivity, common sun protective behaviors (stay in shade, wear long sleeves, use sunscreen) and depression, respectively, in both genders, after adjusted for each other as confounders.

Materials and methods

Data from the National Health and Nutrition Examination Survey 2017-2018 cycle were aggregated. Sun sensitivity and sun protective behaviors were assessed through the dermatology questionnaire. Depression was assessed through the 9-item Patient Health Questionnaire, with a score > 4 as the cutoff point. Gender specific logistic regressions were carried out to analyze the association between sun sensitivity, sun protective behaviors and depression.

Results

A sample of 2,605 participants (mean age 39.99 ± 11.57 years) was analyzed, including 1,227 (47.1%) males and 1,378 (52.9%) females. No association between sun sensitivity and depression was observed. In the sample, stay in shade (OR = 1.27, 95% CI: 1.03-1.57) was positively associated with depression, use sunscreen (OR = 0.69, 95% CI: 0.53-0.90) was negatively associated with depression. Gender specific regressions showed no associations between sun protective behaviors and depression in males; both wear long sleeves (OR = 0.65, 95% CI: 0.42-0.99) and use sunscreen (OR = 0.71, 95% CI: 0.52-0.97) were negatively associated with depression in females.

Conclusion

No association between sun sensitivity and depression. Stay in shade was positively associated with depression, while use sunscreen was negatively associated. Gender differences were observed: no association between sun protective behaviors and depression in males; wear long sleeves and use sunscreen may be negatively associated with depression in females.

Sunscreens part 1: Mechanisms and efficacy

As our knowledge of the harmful effects of ultraviolet radiation continues to evolve, sunscreen remains an integral part of a comprehensive photoprotection strategy against multiple endpoints of ultraviolet radiation-mediated damage. Part 1 of this review covers sunscreen active and additive ingredient properties, mechanisms of action and gaps in coverage. Following an overview of sunscreen's efficacy in protecting against sunburn, photocarcinogenesis, photoaging, pigmentary disorders, and idiopathic photodermatoses, we highlight considerations for product use and selection in children and individuals with skin of color.

Photocarcinogenesis of the skin: Current status and future trends

Solar radiation is essential for life on Earth but is also a major contributor to skin carcinogenesis. Solar radiation, particularly ultraviolet (UV) B (280-320 nm) and UVA (320-400 nm), induces photocarcinogenesis via various pathways. UV light can directly cause DNA damage, resulting in genetic mutations if not repaired correctly. UV light can also induce photocarcinogenesis by generating reactive oxygen species, inducing immunosuppression and inflammation. Recently, visible light (400-760 nm) has been shown to contribute to photocarcinogenesis by activating oxidative pathways. In addition to the irradiation dose (fluence, J/m2), UVB irradiance (W/m2) is also considered a factor influencing photocarcinogenesis. In this review, we summarize the mechanisms of photocarcinogenesis and provide strategies to prevent skin cancer.

A review of sunscreen in the prevention of skin cancer

ObjectiveDespite the reported benefits of sunscreen use in preventing skin cancer, the overall protection from melanoma and non-melanoma skin cancers putatively reflects the frequency of use and sunscreen type. Herein, we review the current knowledge regarding sunscreen's effectiveness at averting the development of skin cancers.Data sourcesWe conducted an extensive PubMed search comprising several review articles on the topic of sunscreen use and prevention of skin cancer, with specific terms that included sunscreen and usage, skin cancer, and sunscreen side effects.Data summarySeveral observational, cohort studies and randomized controlled trials have underscored the benefits of sunscreen in forestalling skin cancers. In particular, the incidence of melanoma and squamous-cell carcinoma is reduced, although the effect of sunscreen on basal-cell carcinoma is relatively less pronounced.ConclusionsThe implications from this study indicate that sunscreen reduces the incidence of melanoma and non-melanoma skin cancers although deriving the intended effect is contingent upon the type of sunscreen and adherence to the recommended guidelines. The primary side effects from sunscreen include dermal irritation and rash; and since there is some indication that UV filter-based sunscreens may harbor carcinogenic properties, clinicians should advise their patients on the type of sunscreen, not to mention the frequency of use.

Distance-based integration method for human skin type identification

Although identifying human skin types is essential in dermatology, cosmetology, and facial recognition, the classification of human skin types is challenging due to the complex nature, varied characteristics, and the influence of external factors. Traditional methods for skin type identification often rely on subjective assessments, leading to inconsistent and inaccurate results. Therefore, this paper proposes a novel method named a distance-based integration method to identify skin types based on the Fitzpatrick skin scale, also known as the Fitzpatrick skin type. This study focuses on the objective distance measurement, integrated with the Fuzzy Analytic Hierarchy Process (AHP). The objective distance was utilized to determine the distance between each HEX color code for a clinical image and each target skin type. The Fuzzy AHP algorithm was employed to calculate the total score for each target class to identify human skin type. For this study, 1,022 images of human skin were used in the experiment. The results indicated that the proposed method achieved a high average accuracy of 93 %, precision of 80 %, and specificity of 96 %.

Cost-effectiveness analysis and return on investment of SunSmart Western Australia to prevent skin cancer

Each year, malignant melanoma accounts for 57 000 deaths globally. If current rates continue, there will be an estimated 510 000 new cases annually and 96 000 deaths by 2040. Melanoma and keratinocyte cancers (KCs) incur a large societal burden. Using a mathematical population model, we performed an economic evaluation of the SunSmart program in the state of Western Australia (WA), a primary prevention program to reduce the incidence of skin cancer, versus no program. A societal perspective was taken combining costs to the health system, patients and lost productivity. The model combined data from pragmatic trial evidence of sun protection, epidemiological studies and national cost reports. The main outcomes modelled were societal and government costs, skin cancer counts, melanoma deaths, life years and quality-adjusted life years. Over the next 20 years, the model predicted that implementing the WA SunSmart program would prevent 13 728 KCs, 636 melanomas and 46 melanoma deaths per 100 000 population. Furthermore, 251 life years would be saved, 358 quality-adjusted life years gained and AU$2.95 million in cost savings to society per 100 000 population would be achieved. Key drivers of the model were the rate reduction of benign lesions from sunscreen use, the costs of purchasing sunscreen and the effectiveness of reducing KCs in sunscreen users. The likelihood of WA SunSmart being cost-effective was 90.1%. For the WA Government, the estimated return on investment was $8.70 gained for every $1 invested. Primary prevention of skin cancer is a cost-effective strategy for preventing skin cancers.

Skin Cancer Risk Is Increased by Somatic Mutations Detected Noninvasively in Healthy-Appearing Sun-Exposed Skin

Skin cancer risk is increased by exposure to ultraviolet radiation (UVR). Because UVR exposure accumulates over time and lighter skin is more susceptible to UVR, age and skin tone are risk factors for skin cancer. However, measurements of somatic mutations in healthy-appearing skin have not been used to calculate skin cancer risk. In this study, we developed a noninvasive test that quantifies somatic mutations in healthy-appearing sun-exposed skin and applied it to a 1038-subject cohort. Somatic mutations were combined with other known skin cancer risk factors to train a model to calculate risk. The final model (DNA-Skin Cancer Assessment of Risk) was trained to predict personal history of skin cancer from age, family history, skin tone, and mutation count. The addition of mutation count significantly improved model performance (OR = 1.3, 95% confidence interval = 1.14-1.48; P = 5.3 × 10-6) and made a more significant contribution than skin tone. Calculations of skin cancer risk matched the known United States population prevalence, indicating that DNA-Skin Cancer Assessment of Risk was well-calibrated. In conclusion, somatic mutations in healthy-appearing sun-exposed skin increase skin cancer risk, and mutations capture risk information that is not accounted for by other risk factors. Clinical utility is supported by the noninvasive nature of skin sample collection through adhesive patches.

Possible Explanations for Rising Melanoma Rates Despite Increased Sunscreen Use over the Past Several Decades

The incidence of cutaneous melanoma continues to rise despite the increased use of sunscreens within the last several decades. Some research even suggests that the use of sunscreen is associated with increased rates of melanoma. Given the aggressive, and often deadly, nature of cutaneous melanoma, the aim of this communication is to better elucidate the relationship between sunscreen use and melanoma development and if there are other preventative measures to be aware of. A search was performed to identify the studies that have investigated melanoma development in individuals who used sunscreen and those who did not. Study limitations and possible confounding variables were identified, which guided a subsequent search to determine what data were available to support that these limitations and confounding variables may explain the perplexing association between sunscreen use and melanoma development. Five hypotheses were generated, which were related to increased awareness and reporting, the relationship between sunscreen use and the duration of sun exposure, the importance of broad-spectrum protection, and the effect of sunscreen on reactive oxygen species formation. The main conclusion is that more recent studies that control for confounding variables are required to determine the true effect of adequate broad-spectrum sunscreen use today on the development of melanoma.

European consensus-based interdisciplinary guideline for invasive cutaneous squamous cell carcinoma. Part 1: Diagnostics and prevention-Update 2023

Invasive cutaneous squamous cell carcinoma (cSCC) is one of the most common cancers in white populations, accounting for 20% of all cutaneous malignancies. Overall, cSCC mostly has very good prognosis after treatment, with 5-year cure rates greater than 90%. Despite the overall favourable prognosis and the proportionally rare deaths, cSCC is associated with a high total number of deaths due to its high incidence. A collaboration of multidisciplinary experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), the European Society for Radiotherapy and Oncology (ESTRO), the European Union of Medical Specialists (UEMS), the European Academy of Dermatology and Venereology (EADV) and the European Organization of Research and Treatment of Cancer (EORTC), was formed to update recommendations on cSCC, based on current literature and expert consensus. Part 1 of the guidelines addresses the updates on classification, epidemiology, diagnosis, risk stratification, staging and prevention in immunocompetent as well as immunosuppressed patients.

Inorganic nanoparticles in dermopharmaceutical and cosmetic products: Properties, formulation development, toxicity, and regulatory issues

The use of nanotechnology strategies is a current hot topic, and research in this field has been growing significantly in the cosmetics industry. Inorganic nanoparticles stand out in this context for their distinctive physicochemical properties, leading in particular to an increased refractive index and absorption capacity giving them a broad potential for cutaneous applications and making them of special interest in research for dermopharmaceutical and cosmetic purposes. This performance is responsible for its heavy inclusion in the manufacture of skin health products such as sunscreens, lotions, beauty creams, skin ointments, makeup, and others. In particular, their suitable bandgap energy characteristics allow them to be used as photocatalytic semiconductors. They provide excellent UV absorption, commonly known as UV filters, and are responsible for their wide worldwide use in sunscreen formulations without the undesirable white residue after consumer application. In addition, cosmetics based on inorganic nanoparticles have several additional characteristics relevant to formulation development, such as being less expensive compared to other nanomaterials, having greater stability, and ensuring less irritation, itching, and propensity for skin allergies. This review will address in detail the main inorganic nanoparticles used in dermopharmaceutical and cosmetic products, such as titanium dioxide, zinc oxide, silicon dioxide, silver, gold, copper, and aluminum nanoparticles, nanocrystals, and quantum dots, reporting their physicochemical characteristics, but also their additional intrinsic properties that contribute to their use in this type of formulations. Safety issues regarding inorganic nanoparticles, based on toxicity studies, both to humans and the environment, as well as regulatory affairs associated with their use in dermopharmaceuticals and cosmetics, will be addressed.

Comparison between endocrine activity assessed using ToxCast/Tox21 database and human plasma concentration of sunscreen active ingredients/UV filters

Sunscreen products are composed of ultraviolet (UV) filters and formulated to reduce exposure to sunlight thereby lessening skin damage. Concerns have been raised regarding the toxicity and potential endocrine disrupting (ED) effects of UV filters. The ToxCast/Tox21 program, that is, CompTox, is a high-throughput in vitro screening database of chemicals that identify adverse outcome pathways, key events, and ED potential of chemicals. Using the ToxCast/Tox21 database, octisalate, homosalate, octocrylene, oxybenzone, octinoxate, and avobenzone, 6 commonly used organic UV filters, were found to have been evaluated. These UV filters showed low potency in these bioassays with most activity detected above the range of the cytotoxic burst. The pathways that were most affected were the cell cycle and the nuclear receptor pathways. Most activity was observed in liver and kidney-based bioassays. These organic filters and their metabolites showed relatively weak ED activity when tested in bioassays measuring estrogen receptor (ER), androgen receptor (AR), thyroid receptor, and steroidogenesis activity. Except for oxybenzone, all activity in the endocrine assays occurred at concentrations greater than the cytotoxic burst. Moreover, except for oxybenzone, plasma concentrations (Cmax) measured in humans were at least 100× lower than bioactive (AC50/ACC) concentrations that produced a response in ToxCast/Tox21 assays. These data are consistent with in vivo animal/human studies showing weak or negligible endocrine activity. In sum, when considered as part of a weight-of-evidence assessment and compared with measured plasma concentrations, the results show these organic UV filters have low intrinsic biological activity and risk of toxicity including endocrine disruption in humans.

The adverse consequences of not using sunscreens

The adverse effects of solar ultraviolet radiation (UVR) on normal skin are well established, especially in those with poorly melanized skin. Clinically, these effects may be classified as acute, such as erythema or chronic such as keratinocyte and melanocyte skin cancers. Apart from skin type genetics, clinical responses to solar UVR are dependent on geophysical (e.g., solar intensity) and behavioural factors. The latter are especially important because they may result in 'solar overload' with unwanted clinical consequences and ever greater burdens to healthcare systems. Correctly used, sunscreens can mitigate the acute and chronic effects of solar UVR exposure. Laboratory studies also show that sunscreens can inhibit the initial molecular and cellular events that are responsible for clinical outcomes. Despite public health campaigns, global trends continue to show increasing incidence of all types of skin cancer. Large-scale epidemiological studies have shown the benefits of sunscreen use in preventing skin cancer, though it is likely that sunscreen use has not been optimal in such studies. It is evident that without substantial changes in sun-seeking behaviour, sunscreen use is a very important part of the defence against the acute and chronic effects of solar exposure. Ideally, sunscreens should be able to provide the level of protection that reduces the risk of skin cancer in susceptible skin types to that observed in heavily melanized skin.

Contribution of skin cancer to overall healthcare costs of lung transplantation in Queensland, Australia

BACKGROUND

Skin cancers are a major source of morbidity in lung transplant recipients, but the relative costs associated with their treatment are unknown.

METHODS

We prospectively followed 90 lung transplant recipients from enrollment in the Skin Tumors in Allograft Recipients study in 2013-2015, until mid-2016. We undertook a cost analysis to quantify the health system costs relating to the index transplant episode and ongoing costs for 4 years. Linked data from surveys, Australian Medicare claims, and hospital accounting systems were used, and generalized linear models were employed.

RESULTS

Median initial hospitalization costs of lung transplantation were AU$115,831 (interquartile range (IQR) $87,428-$177,395). In total, 57 of 90 (63%) participants were treated for skin cancers during follow-up at a total cost of AU$44,038. Among these 57, total government costs per person (mostly of pharmaceuticals) over 4 years were median AU$68,489 (IQR $44,682-$113,055) vs AU$59,088 (IQR $38,190-$94,906) among those without skin cancer, with the difference predominantly driven by more doctors' visits, and higher pathology and procedural costs. Healthcare costs overall were also significantly higher in those treated for skin cancers (cost ratio 1.50, 95%CI: 1.09, 2.06) after adjusting for underlying lung disease, age on enrollment, years of immunosuppression, and the number of treated comorbidities.

CONCLUSIONS

Skin cancer care is a small component of overall costs. While all lung transplant recipients with comorbidities have substantial healthcare costs, those affected by skin cancer incur even greater healthcare costs than those without, highlighting the importance of skin cancer control.

A multicenter case-control study comparing sun exposure habits and use of photoprotection measures in patients diagnosed with different types of skin cancer

BACKGROUND

While skin cancer awareness programs have significantly furthered public understanding about the harmful effects of the sun, there is a disparity between photoprotection knowledge and protection practices.

OBJECTIVE

To compare sun exposure habits and photoprotection measures in patients diagnosed with basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma versus controls.

METHODS

Multicentre case-control observational study carried out by 13 Spanish dermatologists between April 2020 and August 2022. Patients diagnosed with BCC, SCC, or melanoma were considered cases. The control group consisted of individuals with no history of skin cancer.

RESULTS

Of the 254 cases (56.2% female; mean age, 62.67 ± 15.65), 119 (31.2%) had BCC, 62 (16.27%) SCC, and 73 (19.1%) melanoma. The control group consisted of 127 (33.33%) individuals. Avoiding sun exposure between 12:00 and 16:00 was the most commonly used photoprotection measure (habitually/always: 63.1%), followed by the use of sunscreen (habitually/always: 58.9%). Patients with melanoma were less likely to use clothing and shade to avoid sun exposure (p < .05), whereas those with BCC and SCC reported greater use of head coverings (p = .01). BCC and SCC groups reported greater sun exposure 15 years prior, whereas controls reported greater use of sunscreen. However, at the time of this study all groups reported using SPF ≥ 21, and the majority SPF > 50. No differences were observed in photoprotection measures between people with and without a previous history of skin cancer.

CONCLUSIONS

We describe differences in photoprotection measures and sun exposure patterns among patients diagnosed with different skin tumor types. Whether these differences may influence the type of tumor each developed will require further investigation.

Patient Perception of Skin Cancer Reduction by Nicotinamide Correlates With Use

Introduction Nicotinamide (Vitamin B3) has been shown to reduce the rate of non-melanoma skin cancers by 23%, yet most patients do not know that this supplement reduces skin cancer. Understanding patient beliefs about skin cancer reduction attributed to nicotinamide is important to appropriately counsel patients on oral supplement use and ultimately to prevent non-melanoma skin cancers. Objective The objective of this study was to determine the association between nicotinamide use and perceived efficacy in skin cancer reduction. Methods Patients who underwent Mohs surgery in 2019 were sent an online survey assessing nicotinamide use, efficacy compared to sunscreen, and perceived skin cancer risk reduction. Results Data from 50 surveys revealed a perceived risk reduction attributed to nicotinamide of 31.2% for basal cell carcinoma (BCC), 30.2% for squamous cell carcinoma (SCC), and 24.3% for melanoma. In the subset of respondents taking nicotinamide, the perceived risk reduction was significantly higher at 41.2% for BCC and 38.3% for SCC (p<0.05) and positively correlated with reported nicotinamide use (p<0.05). The perceived risk reduction of melanoma was not significantly increased in patients taking nicotinamide (31.6%); however, the perceived risk reduction was correlated with nicotinamide use (p<0.05). In addition, 15.6% of respondents believed that nicotinamide was more effective than sunscreen at preventing skin cancer. Conclusion A larger perceived reduction of non-melanoma skin cancers attributed to nicotinamide is associated with increased oral nicotinamide use. Better patient education regarding the reduction of skin cancers with oral nicotinamide will need to be implemented to change patients' perceptions of the value of nicotinamide.

Sunscreens: Misconceptions and Misinformation

Over the past 70 years, sunscreens have evolved from beach products designed to prevent sunburn to more cosmetically elegant skincare products intended to protect against multiple long-term adverse consequences of characteristically low-intensity daily UV and visible light exposure. Sunscreen testing and labeling intended to quantify such protection are unfortunately often misunderstood by users and have also led to illegal misleading and potentially dangerous industry practices. Changes in regulatory requirements, better policing, and more informative sunscreen labeling would benefit users and their physician advisors.

Impact of UV Modifying Factors on the Incidence of Keratinocyte Carcinomas in Solid Organ Transplant Recipients: A Systematic Review

INTRODUCTION

Solid organ transplant recipients (SOTR) are at an increased risk for developing keratinocyte carcinomas (KC). Four ultraviolet (UV) modifying factors have been identified that impact the incidence of KC: Fitzpatrick Skin Type (FST), race, sun exposure, and sun-protective factors.

OBJECTIVES

We conducted a systematic review to summarize the association between UV modifying factors and the incidence of KC in SOTR.

METHODS

We systematically searched PubMed, Scopus, and Web of Science databases, and after screening for inclusion and exclusion criteria, we included 13 studies with 6,910 solid organ transplant recipients in our analysis.

RESULTS

Our review found that lower FST (I-II), white and Latinx populations, lack of regulated sunscreen application, and occupational and residential sun exposure are individual risk factors among solid organ transplant recipients for KC incidence. Although previous studies showed an in-creased SCC:BCC ratio, some studies found a contradictory increased BCC:SCC ratio. Limitations include few research studies that analyze these UV modifying factors and a lack of incorporating both varying immunosuppressant factors and transplantation follow-up times.

CONCLUSIONS

These findings support the need for dermatological advice in increased risk patient demographic populations, lower FST and white and Latinx populations, and subsequently moderating sun exposure and protective factors.

The Impact of Flavonoid-Loaded Nanoparticles in the UV Protection and Safety Profile of Topical Sunscreens

Excessive UV radiation exposure is harmful to skin cells since sunburn is accompanied by oxidative burst, leading to a rapid increase in skin cancer. However, the insufficient UV photoprotection of approved sunscreens and the negative impact of their compositions on ecosystems and human health makes the utility of sunscreen a questionable recommendation. Therefore, discovering UV filters with significant antioxidant activity and improved topical performance and photostability is an urgent need. Recently, the use of nanosized natural molecules incorporated in sunscreens has been a scientific hot topic, as it has been suggested that they provide a synergistic effect with synthetic UV filters, improving overall SPF and antioxidant activity, higher retention on the epidermis, and less toxicity. The aim of this review was to verify the usefulness of sunscreens incorporating flavonoid-loaded nanoparticles. A literature review was performed, where original and review articles published in the last 6 years were analyzed. Formulations containing nanosized flavonoids with improved UVA photoprotection and safer toxicological profiles, associated or not with synthetic filters, are promising sunscreens and more clinical investigation must be performed to validate these findings.

Nicotinamide for Skin-Cancer Chemoprevention in Transplant Recipients

BACKGROUND

Immunosuppressed organ-transplant recipients have an increased incidence of, and mortality from, skin cancer. Nicotinamide (vitamin B3) enhances the repair of ultraviolet (UV) radiation-induced DNA damage, reduces the cutaneous immunosuppressive effects of UV radiation, and reduces the incidence of keratinocyte cancers (including squamous-cell and basal-cell carcinomas) and actinic keratoses among high-risk immunocompetent patients. Whether oral nicotinamide is useful for skin-cancer chemoprevention in organ-transplant recipients is unclear.

METHODS

In this phase 3 trial, we randomly assigned, in a 1:1 ratio, organ-transplant recipients who had had at least two keratinocyte cancers in the past 5 years to receive 500 mg of nicotinamide or placebo twice daily for 12 months. Participants were examined for skin lesions by dermatologists at 3-month intervals for 12 months. The primary end point was the number of new keratinocyte cancers during the 12-month intervention period. Secondary end points included the numbers of squamous-cell and basal-cell carcinomas during the 12-month intervention period, the number of actinic keratoses until 6 months after randomization, safety, and quality of life.

RESULTS

A total of 158 participants were enrolled, with 79 assigned to the nicotinamide group and 79 to the placebo group. The trial was stopped early owing to poor recruitment. At 12 months, there were 207 new keratinocyte cancers in the nicotinamide group and 210 in the placebo group (rate ratio, 1.0; 95% confidence interval, 0.8 to 1.3; P = 0.96). No significant between-group differences in squamous-cell and basal-cell carcinoma counts, actinic keratosis counts, or quality-of-life scores were observed. Adverse events and changes in blood or urine laboratory variables were similar in the two groups.

CONCLUSIONS

In this 12-month, placebo-controlled trial, oral nicotinamide therapy did not lead to lower numbers of keratinocyte cancers or actinic keratoses in immunosuppressed solid-organ transplant recipients. (Funded by the National Health and Medical Research Council; ONTRANS Australian New Zealand Clinical Trials Registry number, ACTRN12617000599370.).

Interventions for preventing keratinocytic cancer in patients with a history of a previous keratinocytic carcinoma: A systematic review

Keratinocyte cancer (KC) is the most common cancer worldwide. It is important to analyze the actual interventions that are available for the prevention of patients with a previous history of a KC. We aim to review the existent literature to assess the efficacy and safety of interventions to prevent KC in patients with a history of previous KC. We searched clinical trials in which the main outcome was the prevention of KC in patients with a previous history of KC using the strategy published in the International Prospective Register of Systematic Reviews (PROSPERO registry), CRD42016045981. We analyzed 18 clinical trials from which eight reported a benefit with their respective intervention but had methodological flaws and a variable risk of bias. Two clinical trials (regarding celecoxib and oral supplementation with nicotinamide) seemed to have the most beneficial results reducing the incidence of KC in treated groups. However, all of the studies are highly heterogeneous, which does not allow a meta-analysis to be performed. New studies with greater epidemiological value should be conducted.

Topical treatment of actinic keratoses in organ transplant recipients: a feasibility study for SPOT (Squamous cell carcinoma Prevention in Organ transplant recipients using Topical treatments)

BACKGROUND

The risk of cutaneous squamous cell carcinoma (cSCC) is significantly increased in organ transplant recipients (OTRs). Clearance of actinic keratoses (AKs) is generally regarded as a surrogate biomarker for cSCC prevention. OTR-cSCC chemoprevention with topical AK treatments has not been investigated in randomized controlled trials (RCTs), although there is evidence that 5% 5-fluorouracil (5-FU) may be chemoprotective in immunocompetent patients.

OBJECTIVES

To assess the feasibility, activity and evaluation outcomes relevant to the design of a future phase III RCT of topical cSCC chemoprevention in OTRs.

METHODS

OTRs with 10 or more AKs in predefined areas were randomized 1 : 1 : 1 to topical 5-FU, 5% imiquimod (IMIQ) or sunscreen (sun-protective factor 30+) in a phase II, open-label RCT over 15 months. Feasibility outcomes included proportions of eligible OTRs randomized, completing treatment and willing to be re-treated. AK activity [AK clearance, new AK development, patient-centred outcomes (toxicity, health-related quality of life, HRQoL)] and evaluation methodology (clinical vs. photographic) were assessed.

RESULTS

Forty OTRs with 903 AKs were randomized. All feasibility outcomes were met (56% of eligible OTRs were randomized; 89% completed treatment; 81% were willing to be re-treated). AK activity analyses found 5-FU and IMIQ were superior to sunscreen for AK clearance and prevention of new AKs. 5-FU was more effective than IMIQ in AK clearance and prevention in exploratory analyses. Although toxicity was greater with 5-FU, HRQoL outcomes were similar.

CONCLUSIONS

Trials of topical AK treatments in OTRs for cSCC chemoprevention are feasible and AK activity results support further investigation of 5-FU-based treatments in future phase III trials. What is already known about this topic? Cutaneous squamous cell carcinoma (cSCC) is significantly more common in immunocompromised individuals including organ transplant recipients (OTRs) compared with immunocompetent populations. cSCC chemoprevention activity of sunscreen and 5-fluorouracil-based (5-FU) actinic keratosis (AK) treatments has been demonstrated in randomized controlled trials (RCTs) in immunocompetent populations but not in OTRs. AKs are cSCC precursors and their clearance and prevention are generally regarded as surrogate endpoint biomarkers for potential cSCC chemoprevention activity. What does this study add? SPOT (SCC Prevention in OTRs using Topical treatments) has confirmed that RCTs of OTR-cSCC chemoprevention with topical AK treatments are feasible. It also suggests that topical 5-FU may be superior to 5% imiquimod and sunscreen in AK clearance and prevention. Together with recent evidence from several RCTs in the general population, these data provide a compelling rationale for further studies of intervention with 5-FU-based topical chemoprevention approaches in OTR-cSCC prevention.

An Exploration of the Use and Impact of Preventive Measures on Skin Cancer

Background: Skin cancer is the most common form of cancer, and both clinical and epidemiological data link cumulative solar dosages and the number of sunburns to skin cancer. Each year, more than 5.4 million new cases of skin cancer are diagnosed, incurring a significant health and financial burden. Recommended preventive measures for skin cancer include the use of sunscreen, sun avoidance, and protective clothing. This study used a national database to examine the association of preventive measures with the prevalence of skin cancer, specifically analyzing the preventive measures of sunscreen use, staying in the shade, and wearing long-sleeved shirts. The second aim was to determine which characteristics, if any, correlated with using prevention measures. Methods: This study analyzed data from the National Health and Nutritional Examination Survey 2015−2016 cycle to examine the association of three preventive measures (using sunscreen, staying in the shade, and wearing long-sleeved shirts) with skin cancer. Logistic regression and chi-square tests were utilized to examine the relationship between skin cancer and these prevention methods. Results: Sunscreen use (OR = 3.752; p < 0.05) was statistically associated with a lower prevalence of skin cancer, while wearing long-sleeved shirts (OR = 6.911; p = 0.064) and staying in the shade (OR = 0.646; p = 0.481) did not emerge as factors significantly associated with a lower prevalence after controlling for gender, race/ethnicity, marital status, income, health insurance, and general health. Additionally, men and individuals of color were less likely to use sunscreen. Conclusion: Sunscreen use was associated with a lower prevalence of skin cancer, while wearing long-sleeved shirts and staying in the shade was not significantly linked to lower rates of skin cancer, suggesting that these measures may not be as effective as sunscreen for preventing skin cancer. Men and individuals of color were significantly less likely to use sunscreen. These findings can help guide future education efforts and research regarding skin cancer prevention and suggest the need to develop male-oriented programs to mitigate the gender disparity in employing sun-protection measures.

[Sunscreens of the future: challenges and opportunities]

Sunscreens provide excellent protection against erythema and against chronic damage such as photoaging and skin cancer. Today's challenges concern safety of the products and improved methods for standardizing the evaluation of their efficacy. Other important topics are the further development of sunscreen products, as well as personalization of use. Personalized sun protection based on the phenotype, the genetic profiles and moreover the skin's microbiome - all linked to the identification of certain consumer susceptibility factors - is an exciting new area of research. In particular, the expansion with innovative topical agents such as DNA repair liposomes in improved galenic formulations with UV filters tailored to the skin phototype and new topical antioxidants could in future provide even more comprehensive sun protection. New antioxidants and other agents such as nicotinamide could increase systemic photoprevention. Sustainability will also be an important aspect to protect consumers, but also the environment (i.e. especially marine wildlife) from toxic effects of sunscreens.

Environmental Fate and Toxicity of Sunscreen-Derived Inorganic Ultraviolet Filters in Aquatic Environments: A Review

An increasing number of inorganic ultraviolet filters (UVFs), such as nanosized zinc oxide (nZnO) and titanium dioxide (nTiO2), are formulated in sunscreens because of their broad UV spectrum sunlight protection and because they limit skin damage. However, sunscreen-derived inorganic UVFs are considered to be emerging contaminants; in particular, nZnO and nTiO2 UVFs have been shown to undergo absorption and bioaccumulation, release metal ions, and generate reactive oxygen species, which cause negative effects on aquatic organisms. We comprehensively reviewed the current study status of the environmental sources, occurrences, behaviors, and impacts of sunscreen-derived inorganic UVFs in aquatic environments. We find that the associated primary nanoparticle characteristics and coating materials significantly affect the environmental behavior and fate of inorganic UVFs. The consequential ecotoxicological risks and underlying mechanisms are discussed at the individual and trophic transfer levels. Due to their persistence and bioaccumulation, more attention and efforts should be redirected to investigating the sources, fate, and trophic transfer of inorganic UVFs in ecosystems.

Topical Pharmacotherapy for Actinic Keratoses in Older Adults

Actinic keratosis is caused by excessive lifetime sun exposure. It must be treated, regardless of thickness, because it is the biologic precursor of invasive squamous cell carcinoma, a potentially deadly malignancy. Physical ablative techniques such as cryotherapy, lasers, and curettage are the most used treatments for isolated lesions. Multiple lesions are treated with topical drugs, chemical peelings, and physical techniques. Drug preparations containing diclofenac plus hyaluronate, aminolevulinic acid, and methyl aminolevulinate and different concentrations of imiquimod and 5-fluorouracil are approved for this clinical indication. All treatments have a good profile of efficacy and tolerability although there are relevant differences in the clearance rate, tolerability, and type and frequency of adverse effects. In addition, they have very different mechanisms of action and treatment protocols. No differences in the efficacy and tolerability were found in older patients compared with younger patients, therefore no dose adjustments are needed. That said, older patients often need to be motivated to treat actinic keratoses and a careful attention to expectations, needs, and preferences should be used to obtain the maximal adherence and prevent treatment failure. This goal can be achieved with a careful evaluation not only of published efficacy, toxicity, and tolerability data but also of practical topics such as the frequency of daily applications, the overall duration of therapy, and the need for a caregiver. Finally, particular attention must be paid in the case of frail patients and immunosuppressed patients.

Slip versus Slop: A Head-to-Head Comparison of UV-Protective Clothing to Sunscreen

Simple Summary

Photoprotection reduces invasive melanoma incidence and mortality, but not all sun protection modalities are created equal. Dermatologists have long debated the pros and cons of photoprotective clothing and sunscreen, but few studies compare the effectiveness of these two modalities head-to-head. This study uses both in vitro and in vivo techniques to compare the ultraviolet radiation (UVR) protective capacity of four modern textiles and two commercially available, broad-spectrum sunscreens.

Abstract

Ultraviolet radiation (UVR) exposure is the most important modifiable risk factor for skin cancer development. Although sunscreen and sun-protective clothing are essential tools to minimize UVR exposure, few studies have compared the two modalities head-to-head. This study evaluates the UV-protective capacity of four modern, sun-protective textiles and two broad-spectrum, organic sunscreens (SPF 30 and 50). Sun Protection Factor (SPF), Ultraviolet Protection Factor (UPF), Critical Wavelength (CW), and % UVA- and % UVB-blocking were measured for each fabric. UPF, CW, % UVA- and % UVB-blocking were measured for each sunscreen at 2 mg/cm² (recommended areal density) and 1 mg/cm² (simulating real-world consumer application). The four textiles provided superior UVR protection when compared to the two sunscreens tested. All fabrics blocked erythemogenic UVR better than the sunscreens, as measured by SPF, UPF, and % UVB-blocking. Each fabric was superior to the sunscreens in blocking full-spectrum UVR, as measured by CW and % UVA-blocking. Our data demonstrate the limitations of sunscreen and UV-protective clothing labeling and suggest the combination of SPF or UPF with % UVA-blocking may provide more suitable measures for broad-spectrum protection. While sunscreen remains an important photoprotective modality (especially for sites where clothing is impractical), these data suggest that clothing should be considered the cornerstone of UV protection.

Sunscreens With High Versus Low Sun Protection Factor and Cutaneous Squamous Cell Carcinoma Risk: A Population-Based Cohort Study

Evidence on sunscreen use and cutaneous squamous cell carcinoma (cSCC) risk is limited. Most studies have not taken sun protection factor (SPF) into consideration and used nonusers of sunscreen as the reference group. Nonusers are likely a priori at lower cSCC risk than users. No study has investigated the effect of high- versus low-SPF sunscreens on cSCC, appropriately adjusting for time-varying confounding. Using data from the Norwegian Women and Cancer Study (1991–2016), we investigated whether use of SPF ≥15 versus SPF <15 sunscreens reduces cSCC risk. We used a marginal structural Cox proportional hazards model with inverse probability of treatment and censoring weights to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). During follow-up of 148,781 women (mean follow-up, 14.3 years), 653 women were diagnosed with cSCC. The effect on cSCC risk of sunscreens with SPF ≥15 versus SPF <15 was close to the null when used at any latitudes (HR = 1.02, 95% CI: 0.82, 1.27) and when used in lower-latitude settings (HR = 1.05, 95% CI: 0.84, 1.32). In conclusion, we found no indication that sunscreens with SPF ≥15 reduced Norwegian women’s cSCC risk more than sunscreens with SPF <15, suggesting that either there is no difference in their effects long-term or the difference is diluted by incorrect application.

Mechanistic photophysics and photochemistry of unnatural bases and sunscreen molecules: insights from electronic structure calculations

Photophysics and photochemistry are basic subjects in the study of light-matter interactions and are ubiquitous in diverse fields such as biology, energy, materials, and environment. A full understanding of mechanistic photophysics and photochemistry underpins many recent advances and applications. This contribution first provides a short discussion on the theoretical calculation methods we have used in relevant studies, then we introduce our latest progress on the mechanistic photophysics and photochemistry of two classes of molecular systems, namely unnatural bases and sunscreens. For unnatural bases, we disclose the intrinsic driving forces for the ultrafast population to reactive triplet states, impacts of the position and degree of chalcogen substitutions, and the effects of complex environments. For sunscreen molecules, we reveal the photoprotection mechanisms that dissipate excess photon energy to the surroundings by ultrafast internal conversion to the ground state. Finally, relevant theoretical challenges and outlooks are discussed.

Evaluating the Sun Protection Factor of Cosmetic Formulations Containing Afzelin

Exposure to UV radiation damages the skin and increases the risk of skin cancer. Sunscreen is used to protect the skin from the harmful effects of UV radiation. However, the chemical UV filters used in sunscreen can show toxicity and cause allergic reactions. A safe sunscreen that includes a lower content of chemical UV filters and exerts an excellent effect on UV protection needs to be developed. The objective of this study was to investigate whether the addition of afzelin to sunscreen could improve the sun protection factor (SPF). A synergistic effect between afzelin and organic sunscreen agents including padimate O and oxybenzone was confirmed. Interestingly, 100% in vitro SPF-boosting was observed when afzelin (0.05%) was applied with a standard SPF formulation containing organic sunscreens while afzelin alone had no contribution to the SPF. In vivo SPF analysis of the standard SPF formulation showed an SPF value of 13.3 that increased to 20.1 when supplemented with afzelin (0.05%). Additionally, afzelin showed no skin irritation in a human trial. These results suggest that afzelin is useful as a natural additive in sunscreen formulations and provides an SPF-boosting effect. Afzelin supplementation to the formulation showed the potential to reduce the use of synthetic photoprotectors, which could minimize the risk of synthetic agent toxicity.

Phenylene Bis-Diphenyltriazine (TriAsorB), a new sunfilter protecting the skin against both UVB + UVA and blue light radiations

Sunlight induces actinic keratosis, skin cancers and photoaging. Photoprotection is thus a major issue in public health to prevent the harmful effects of solar ultraviolet (UV) radiations. Recent data have shown that the visible (VIS) and infrared (IR) radiations can lead to skin damage by oxidative stress, suggesting that a balanced protection across the entire spectrum of sunlight is necessary to prevent cutaneous alterations. In this context, we developed a new generation of sunfilter called Phenylene Bis-Diphenyltriazine or TriAsorB (CAS N°55514-22-2). The aim of the present study was to assess the photoprotective efficacy of TriAsorB from UV to IR light. Spectrophotometric assays were performed to measure absorption and reflectance of TriAsorB in the different spectral ranges of sunlight: UV, VIS including blue light or high energy visible (HEV) and IR. DNA damage was evaluated using reconstructed human epidermis (RHE): 8-hydroxy-2'-deoxyguanosine (8OHdG) in response to HEV exposure, pyrimidine dimers (CPDs) and (6-4) photoproducts following solar-simulated radiation (SSR). TriAsorB is a broad spectrum UVB + UVA filter including long UVA. Interestingly, it also absorbs VIS radiations, especially in the HEV region. These radiations are also reflected. Protection in the IR spectral range is weak. Furthermore, the sunfilter specifically protects the skin against the oxidative lesions 8OHdG induced by HEV and prevents SSR-induced DNA damage. Thus, TriAsorB is an innovative sunfilter that might be used in sun care products for skin photoprotection from UV to VIS radiations. Finally, it prevents sunlight genotoxicity and protected the skin against solar radiations, especially blue light.

The Use of Calcium Phosphates in Cosmetics, State of the Art and Future Perspectives

Calcium phosphates (CaPs) belong to a class of biomimetic materials widely employed for medical applications thanks to their excellent properties, such as biodegradability, biocompatibility and osteoinductivity. The recent trend in the cosmetics field of substituting potentially hazardous materials with natural, safe, and sustainable ingredients for the health of consumers and for the environment, as well as the progress in the materials science of academics and chemical industries, has opened new perspectives in the use of CaPs in this field. While several reviews have been focused on the applications of CaP-based materials in medicine, this is the first attempt to catalogue the properties and use of CaPs in cosmetics. In this review a brief introduction on the chemical and physical characteristics of the main CaP phases is given, followed by an up-to-date report of their use in cosmetics through a large literature survey of research papers and patents. The application of CaPs as agents in oral care, skin care, hair care, and odor control has been selected and extensively discussed, highlighting the correlation between the chemical, physical and toxicological properties of the materials with their final applications. Finally, perspectives on the main challenges that should be addressed by the scientific community and cosmetics companies to widen the application of CaPs in cosmetics are given.

Interventions to Increase Sunscreen Use in Adults: A Review of the Literature

Skin cancers are the most common malignancy in Australia. Regular sunscreen use can reduce the incidence of cutaneous squamous cell carcinomas and actinic keratoses and has been associated with reducing the incidence of basal cell carcinomas and melanomas. However, sunscreen effectiveness is limited by the failure of the population to use it routinely. Interventions that promote the daily application of sunscreen may reduce the morbidity, mortality, and economic burden associated with skin malignancies. We reviewed the literature that examines the effectiveness of interventions to increase routine sunscreen use and found that no one strategy has been shown to be clearly effective in adults and that relatively few studies have aimed to increase routine use in groups at extreme skin cancer risk. Future research should consider how interventions can be best designed and how sunscreen use is measured so that cost-effective, feasible strategies that result in improved sunscreen use in adults can be established.

Evaluation of the acceptance and efficacy of a bespoke sun protection package for persons with oculocutaneous albinism living in Malawi

INTRODUCTION

Skin cancer is the main cause of death in persons with albinism (PWA) in Africa. Education would minimize sun damage.

OBJECTIVE

To evaluate the efficacy and acceptance of a photoprotection educative and sunscreen (Umozi Max) package designed for PWA in reducing sunburns and skin cancer.

PATIENTS AND METHODS

A multicenter, noncontrolled, before-and-after, interventional study was conducted in PWA > 12 years of age, from February to May, 2019, in Malawi. During the baseline and the follow-up visits (at 8 and 15 weeks), subjects received an educational program designed to PWA and use of Umozi Max. At every visit, photoprotection behavior and knowledge were checked and cutaneous lesions were recorded. Univariate and bivariate analysis were performed.

RESULTS

A total of 210 PWA were analyzed, 50% males, with a mean age of 24.5 (SD 11.29) years. The percentage of people using sun protective clothing increased from 80% to 100% and sunscreen from 81.9% to 99.5%. People avoiding the midday sun increased by 38.9% (P < 0.05). Participants that erroneously applied the sunscreen at night diminished from 40% to 4% (P < 0.001). Absent erythema on the face increased from 40% to 90% (P < 0.05). The percentage of patients with actinic keratoses (AK) on all locations significantly decreased during the study. All the participants preferred Umozi Max to previously used sunscreens. The satisfaction with the program was unanimous.

CONCLUSION

The educational program enhanced the use of all photoprotection measures, improved behaviors, and decreased the incidence of solar erythema and contributed to decreasing the incidence of new AKs.

The Sunscreen for Kindergarteners (SKIN) Study trial protocol

BACKGROUND

Exposure to ultraviolet radiation (UVR) is the major modifiable risk factor for skin cancers. The majority of lifetime UVR exposure occurs before age 20, underscoring an important window for risk reduction. Incorporation of skills-based sunscreen education into school health curricula may foster the development of consistent and effective use of sunscreen among children and youth. We describe the study protocol for a first-of-its-kind study that examined the feasibility of bringing skills-based sunscreen education into kindergarten classrooms.

METHODS

Participants were 96 kindergarten students across four classrooms in a single elementary school. A single-blind open-label trial design was used to evaluate the feasibility of incorporating a song-based, video-guided intervention for independent application of sunscreen into the kindergarten curriculum. Students first completed a 10-day no-intervention baseline period, followed by a 10-day intervention period, and then a 10-day randomized follow-up period where students were randomly assigned to continue with the intervention or to revert to the no-intervention condition.

OUTCOMES

Feasibility metrics associated with study process, resources, management, scientific outcomes and safety were gathered. The primary outcome was pre-to-post intervention changes in student engagement in the sunscreen task. The secondary outcome was pre-to-post intervention changes in the proportion of exposed skin to which a student applies sunscreen. Teacher and student perceptions of intervention value and utility were also evaluated.

DISCUSSION

This is the study protocol for a clinical trial designed to determine the feasibility of implementing a skills-based sunscreen curriculum in kindergarten classrooms. Next steps include evaluation of the intervention for efficacy and effectiveness.

CLINICAL TRIAL REGISTRATION

NCT03752736.

Extra-anogenital giant cutaneous squamous cell carcinomas require multidisciplinary management

Cutaneous squamous cell carcinoma (cSCC) is a highly prevalent cancer and the majority of cSCC have a good prognosis. However, a subset of cSCC can progress to advanced disease. We present the first reported case of a giant cSCC located on the breast. In addition, a systematic literature search on extra-anogenital giant (EAG) cSCC was performed using Pubmed and MEDLINE databases. Thirty-one articles could be retained which were relevant for this review. A total of 42 well-described cases were identified. Median age at presentation was 70 years (range 9-100 years). Twenty-four (57%) patients were male, eighteen were female (43%). The estimated median delay of treatment was 12 months (range 1 to >240 months). In 27 patients (64%) the giant cSCC was localized on the neck, face or scalp, 6 on the thoracic wall or back (14%), 4 on the lower limb (10%), 2 on the hip or buttock (5%), 2 on the upper limb (5%), one (2%) on the breast. Tumor stage at presentation was T2, T3 and T4 in respectively 26 (62%), 11 (26%) and 5 (12%) cases. Lymph node metastases were identified in 1 patient (2%) and distant metastases in another patient (2%). In 34 out of 42 cases (81%) primary radical surgical excision was performed, 3 received radiotherapy, 2 chemotherapy and 3 palliative care. In the cases with reported follow-up, four patients (4/30: 13%) died of disease. The treatment of EAG cSCC poses many problems, making a multidisciplinary approach of paramount importance.

Assessing Sunscreen Protection Using UV Photography: Descriptive Study

BACKGROUND

Photography using a UV transmitting filter allows UV light to pass and can be used to illuminate UV blocking lotions such as sunscreens.

OBJECTIVE

The aim of this study is to compare currently available UV photography cameras and assess whether these devices can be used as visualization tools for adequate coverage of sun protection lotions.

METHODS

This study was conducted in 3 parts: in phase 1, 3 different UV cameras were tested; in phase 2, we explored whether UV photography could work on a range of sun protection products; and in phase 3, a UV webcam was developed and was field-tested in a beach setting. In phase 1, volunteers were recruited, and researchers applied 3 sun protection products (ranging from sun protection factor [SPF] 15 to 50+) to the participants' faces and arms. UV photography was performed using 3 UV cameras, and the subsequent images were compared. In phase 2, volunteers were recruited and asked to apply their own SPF products to their faces in their usual manner. UV photographs were collected in the morning and afternoon to assess whether the coverage remained over time. Qualitative interviews were conducted to assess the participants' level of satisfaction with the UV image. In phase 3, a small portable UV webcam was designed using a plug-and-play approach to enable the viewing of UV images on a larger screen. The developed webcam was deployed at a public beach setting for use by the public for 7 days.

RESULTS

The 3 UV camera systems tested during phase 1 identified the application of a range of sun protection lotions of SPF 15 to 50+. The sensitivity of the UV camera devices was shown to be adequate, with SPF-containing products applied at concentrations of 2 and 1 mg/cm2 clearly visible and SPF-containing products applied at a concentration of 0.4 mg/cm2 having lower levels of coverage. Participants in phase 2 reported high satisfaction with the UV photography images, with 83% (29/35) of participants likely to use UV photography in the future. During phase 2, it was noted that many participants used tinted SPF-containing cosmetics, and several tinted products were further tested. However, it was observed that UV photography could not identify the areas missed for all tinted products. During phase 3, the electrical components of the UV webcam remained operational, and the camera was used 233 times by the public during field-testing.

CONCLUSIONS

In this study, we found that UV photography could identify the areas missed by sun protection lotions with chemical filters, and participants were engaged with personalized feedback.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12619000975190; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377089 ; Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12619000145101; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376672.

Skin Cancers and Lung Transplant

It is well known that solid-organ transplant recipients (SOTRs) have a 65- to 100-fold increase in the risk of developing skin cancer, namely, nonmelanoma skin cancers (NMSCs) such as cutaneous squamous cell carcinoma (cSCC) and basal cell carcinoma (BCC). In addition, these patients are also at increased risk for development of melanoma as well as other less common cutaneous malignancies (Merkel's cell carcinoma, Kaposi's sarcoma). SOTRs with NMSC (namely cSCC) are also at significantly increased risk of poor clinical outcomes including local recurrence, nodal and distant metastasis, and disease-specific death relative to patients who are not immunosuppressed. Increased surveillance and monitoring in patients at risk of aggressive disease and poor outcomes who are on immunosuppression is essential in patients with lung transplants given the high degree of immunosuppression. Increased awareness of risks, treatments, and management allows for improved outcomes in these patients. This article will provide an overview of the risk factors for the development of cutaneous malignancies in organ transplant recipients as well as a detailed discussion of various immunosuppressant and prophylactic medications used in this patient population that contribute to the risk of developing cutaneous malignancies, with an emphasis on NMSC (cSCC and BCC) in lung transplant recipients. Finally, this article includes a discussion on the clinical and dermatologic management of this high-risk immunosuppressed population including a review of topical and systemic agents for field therapy of actinic damage and chemoprevention of keratinocyte carcinomas. In addition, indications for additional treatment and preventive measures such as adjuvant radiation treatment after surgical management of cutaneous malignancies and potential modification of immunosuppressive medication regimens are discussed.

Photoprotection according to skin phototype and dermatoses: practical recommendations from an expert panel

Increasing evidence on the impact of the different wavelengths of sunlight on the skin demonstrates the need for tailored recommendations of sunscreen according to skin phototype and dermatoses, which is now possible due to advances in the filters and formulations of sunscreens. A selective literature search was performed by an international expert panel, focusing on the type of sunscreen to recommend for photoaging, skin cancers, photodermatoses, pigmentary disorders and skin inflammatory disorders. Protection against ultraviolet (UV)B is especially important for light skin as there is a high risk of sunburn, DNA damage and skin cancers. Darker skin may be naturally better protected against UVB but is more prone to hyperpigmentation induced by visible light (VL) and UVA. Protection against UVA, VL and infrared A can be helpful for all skin phototypes as they penetrate deeply and cause photoaging. Long‐wave UVA1 plays a critical role in pigmentation, photoaging, skin cancer, DNA damage and photodermatoses. Adapting the formulation and texture of the sunscreen to the type of skin and dermatoses is also essential. Practical recommendations on the type of sunscreen to prescribe are provided to support the clinician in daily practice.

Epidemiology and Prevention of Cutaneous Cancer

Cutaneous malignancy is becoming an increasing public health burden in terms of morbidity and cost, associated with changing environmental exposures and increased longevity of the general and the immunosuppressed population. Yet the understanding of the scope of this problem is hindered by lack of robust registries for nonmelanoma skin cancer. The risk factor responsible for most of these cancers, exposure to ultraviolet radiation, can be mitigated. However, greater consensus is necessary to enact effective prevention and screening programs. New developments, including identification of biomarkers and use of artificial intelligence, show promise for targeting screening efforts.

Sun Exposure during Water Sports: Do Elite Athletes Adequately Protect Their Skin against Skin Cancer?

Excessive sun exposure is the main avoidable cause of skin cancer. Outdoor sports performed without adequate photoprotection are risky practices in this respect. This study examines whether elite athletes in water sports (specifically surfing, windsurfing, and sailing) take appropriate measures to protect their skin from the sun, and whether there are differences in this respect according to age, gender, or sports discipline. This study is based on a questionnaire-based health survey. World championship competitors completed a self-administered questionnaire on their sun protection and exposure habits, as well as sunburns during the last sports season. In total, 246 participants, with an age range of 16–30 years, completed the questionnaire. Of these, 49.6% used inadequate sun protection. Those who protected their skin appropriately tended to be older than those who did not (average age = 23.28 and 20.69 years, respectively; p = 0.000). There were no significant differences in sun protection habits between male and female athletes. The rate of sunburn was very high (76.7%). A high proportion (22.5%) of participants never used sunscreen. Elite athletes in water sports are at real risk of skin lesions from overexposure to the sun, associated with inadequate photoprotection practices. Campaigns to raise awareness and to promote the early detection of skin cancer should target these risk groups.

Sunscreens: UV filters to protect us: Part 1: Changing regulations and choices for optimal sun protection

Sunscreens are topical preparations containing any number of ultraviolet filters (UVFs). The first part of the review will focus on the recent Food and Drug Administration (FDA) regulations of 2019 and general use of these agents. While sunscreen products are becoming more regulated in the United States, we still lag behind other countries in our options for UVFs. Sun protection to prevent skin cancer and aging changes should be a combination of sun avoidance, protective structures, and clothing as well as use of sunscreen products. Newer and safer products are needed to help supplement and replace older agents as well as improve their cosmetic acceptability. This will be a review of ingredients, local toxicities (i.e. contact dermatitis, photocontact dermatitis), special considerations for children, and cosmesis of sunscreen preparations. Part 2 will focus on the environmental, ecological and human toxicities that have been increasingly related to UVFs.

Actinic Keratoses: Reconciling the Biology of Field Cancerization with Treatment Paradigms

This Perspective briefly reviews the relationship between UV-induced mutations in habitually sun-exposed human skin and subsequent development of actinic keratoses (AKs) and skin cancers. It argues that field therapy rather than AK-selective therapy is the more logical approach to cancer prevention and hypothesizes that treatment early in the process of field cancerization, even prior to the appearance of AKs, may be more effective in preventing cancer as well as more beneficial for and better tolerated by at-risk individuals. Finally, the Perspective encourages use of rapidly advancing DNA analysis techniques to quantify mutational burden in sun-damaged skin and its reduction by various therapies.

Sun Safe Partners Online: Pilot Randomized Controlled Clinical Trial

Background

Harnessing supportive influences in close relationships is an innovative and potentially effective strategy to improve sun protection behaviors.

Objective

This pilot randomized controlled clinical trial evaluates the feasibility and impact of Sun Safe Partners Online, a web-based, couples-focused intervention to improve sun protection behavior.

Methods

A total of 75 couples reporting suboptimal levels of sun protection recruited from Facebook advertisements were randomized to receive a web-based intervention called Sun Safe Partners Online or a Generic Online Sun Safety Information intervention. Sun Safe Partners Online had 4 individual-focused modules and 4 couples-focused modules. Feasibility was assessed by study enrollment, engagement, follow-up survey completion, and intervention evaluation. Participants completed baseline and a 1-month postintervention survey assessing sun protection and exposure, along with individual and relationship attitudes about the importance of sun protection.

Results

Using Facebook as a recruitment strategy resulted in rapid enrollment and higher acceptance than for the prior telephone and print trial. The follow-up survey completion was higher in the Generic Online condition (100%) than in the Sun Safe Partners Online condition (87.2%). Engagement in Sun Safe Partners Online was high, with more than two-thirds of participants completing all modules. Evaluations of Sun Safe Partners Online content and features as well as ease of navigation were excellent. Sun Safe Partners Online showed small effects on sun protection behaviors and sun exposure on weekends compared with the Generic Online intervention and moderate effect size increases in the Sun Safe Partners Online condition.

Conclusions

This study uses a novel approach to facilitate engagement in sun protection by harnessing the influence of relationships among spouses and cohabiting partners. A couples-focused intervention may hold promise as a means to improve sun protection behaviors beyond interventions focused solely on individuals by leveraging the concern, collaboration, and support among intimate partners and addressing relationship-based barriers to sun protection.

Trial Registration

ClinicalTrials.gov NCT04549675; https://clinicaltrials.gov/ct2/show/NCT04549675