[Characterization of sun protection performance: Quo vadis?]

Die Aufgabe der ersten Sonnenschutzmittel war es, die Entstehung von Sonnenbrand zu verhindern und, dem Zeitgeist der 1950/60er-Jahre folgend, die Bräunung der Haut nicht zu beeinträchtigen. Schnell entstand die Notwendigkeit, die Schutzleistung zu quantifizieren. Ursprünglich unter Zuhilfenahme des natürlichen – heute eines künstlichen – Sonnenlichts wurde eine Methode zur Bestimmung eines Sonnenschutzfaktor (SPF) entwickelt. Dieser ist heute formal als das Verhältnis zwischen minimaler erythemwirksamer UV-Dosis auf mit Sonnenschutzmittel geschützter und minimaler erythemwirksamer UV-Dosis auf ungeschützter Haut definiert (ISO 24444:2019). Drei Beobachtungen stellen die Eignung der Methode infrage: 1) Zwischen-Labor-Variabilität: Trotz strenger Normierung sind Resultate von SPF-Bestimmungen aus verschiedenen Labors und Regionen sehr großen Schwankungen unterworfen. 2) Natürliches vs. künstliches Sonnenlicht: Das Strahlungsspektrum des künstlichen Sonnenlichts unterscheidet sich von dem des natürlichen Sonnenlichts. Die mit künstlichem Sonnenlicht bestimmten SPFs (wie auf allen derzeit im Handel befindlichen Sonnenschutzmitteln abgebildet) sind im Vergleich zur SPF-Bestimmung mit natürlichem Sonnenlicht deutlich zu hoch. 3) Erythembelastung: Bei der Bestimmung des SPF werden die Probanden potenziell schädlicher Strahlung ausgesetzt. Vor diesem Hintergrund werden alternative Methoden – In-vitro-SPF, hybride diffuse Reflexionsspektroskopie (HDRS) und In-silico-Berechnungen – vorgestellt. Diese haben das Potenzial, die heutige mit erheblichen Einschränkungen verbundene Methode abzulösen. Als Sofortmaßnahme wird die Rückbesinnung auf die für alle verständliche Beschreibung niedriger, mittlerer, hoher und sehr hoher Schutz empfohlen, in Zukunft unter Berücksichtigung des Spektrums des natürlichen Sonnenlichtes.

Percutaneous Absorption of Sunscreen Filters: Review of Issues and Challenges

Although skin is a vital barrier to the outside world, it is permeable to certain substances used in topical pharmacotherapy. It is therefore not surprising that other xenobiotics intentionally or accidentally coming in contact with skin can cross the skin barrier. Long before the turn of the millennium, it became clear that sunscreen filters from sunscreen products can be systemically absorbed and detected in urine and plasma. Against this background, we review issues and challenges with safety assessments related to the possible percutaneous absorption of the sunscreen filters. A reference is made to the Regulation (EC) No. 1223/2009 of the European Parliament and of the Council of 30 November 2009 on cosmetic products (version 1 August 2018) and the concepts of the Maximal Usage Trial (MUsT) and Generally Recognized As Safe and Effective (GRASE), currently discussed in the United States.

Challenges in Sun Protection

Since time immemorial, people protected themselves from solar radiation. Limiting time in the sun by seeking shade or wearing clothing was a matter of course. In the early 20th century, tanned skin - a result of exposure to sunlight - was associated with good health. At the same time, however, one also had to protect oneself against the potential of excessive exposure to avoid sunburns. Around 1945, the first sunscreen products for protection against solar radiation became available. In the years to follow and up to the recent past, a vast number of different sunscreen filters were developed and incorporated into a wide variety of product formats. Frameworks regulating filter substances and preparations and methods to characterize sunscreen products' performance parameters were developed. Over the past 50-70 years, the perception regarding the tasks of sunscreen products changed several times. It was initially promoted as a lifestyle product and had the task of preventing sun-related erythema (tan without burn). Later, the prevention of skin cancer was added. Only in recent times, sunscreen products have been increasingly advertised and perceived as beauty and lifestyle products again. Also, the use of sunscreen products for antiaging purposes is now commonplace. The different intended purposes (averting harm and prevention) and the widespread use of topical sunscreen products have promoted many investigations and generated a vast and ongoing need for consumer and patient information and education. In the following review, we analyze and discuss current topics from conflicting areas, such as sun protection products (e.g., ideal sun protection products, sun protection metrics), product safety (e.g., nanoparticulate sunscreen filters, regulatory issues), application in everyday life (e.g., wish to tan, vulnerable cohorts), as well as controversies and future challenges (e.g., risks and benefits of UV radiation).

Past, Present, and Future of Sun Protection Metrics

Since the beginning of the development of sunscreen products, efforts have been made to measure and quantify the protection performance of such products. Early on an in vivo method was established that allowed statements on the sun protection performance in humans. Later, by establishing defined basic and experimental conditions, the method became internationally standardized delivering the well-known sun protection factor (SPF). The method was widely used and is nowadays regarded as a gold-standard method. Further standardized methods were added shortly thereafter. However, shortcomings such as the confined radiation spectra used by the methods, the invasiveness, the complexity in their application, as well as their time- and cost-intensity promoted the development of alternative methods. The shortcomings were recently followed by another, namely, the large interlaboratory variances of the sun protection metrics SPFISO 24444. This all together shows that there is a justifiable need to explore the potential of alternative methods, to complement the existing methods, to serve as equivalents, or even to replace it in the future. Based on the work of Uhlig and coworkers, the authors propose to test the suitability of the alternative methods and their possible equivalency to the reference methods in a broad-based investigation, taking into account possible interlaboratory variances. A research program - developed by a consortium - is in public planning where stakeholders from research, industry, authorities, and the public can come together to facilitate and further advance standardization of the measurement of the sun protection performance. The authors give an insight into historical, technical--conceptual, and future developments of methods for -determining the protective performance of sun protection products.

Size Matters! Issues and Challenges with Nanoparticulate UV Filters

Preparations containing pigments have been used since ancient times to protect against negative effects of solar radiation. Since the 1950s, sunscreen products containing micronized TiO2 and ZnO have been marketed. These products were soon regarded as cosmetically unattrac-tive due to their property of remaining as a white paste on the skin, a result of particle sizes. In order to eliminate these unfavourable properties, particle size distribution was lowered into a range below 100 nm, a size threshold for decreasing the particle's optical property to reflect visible light. After 2000, new nanoparticulate organic filters were developed. Effects of both the inorganic and organic nanoparticulate substances - alone or in combination - with non-particulate UV filters were well documented and had shown great effectiveness. At the time, nanotechnology fuelled great hope in the progress of science and technology, including the health sector and cosmetics industry. Instead, influenced by images from the science fiction literature of self-replicating nanorobots destroying all living matter or health and environmental disasters caused by asbestos, fear of this new unknown amongst the general population has hindered acceptance and progress of nano-enabled products. Consumers have started to suspect that the particles permeate through skin, are absorbed by the blood and are distributed throughout the body, causing disease. Not least because of public pressure, cosmetics - which include sunscreen products - became the first product segment in which appropriately manufactured substances were subject to stringent rules. Despite advanced regulation and rigorous approval procedures for nanoparticulate UV filters, widespread reservations remain. Possible reasons could be a lack of knowledge of current legislation and unclear ideas about nature and behaviour of nanoparticles. Against this background, we discuss the nature and behaviour of nanoparticulate UV filters within finished products, on the skin and potentially in the skin, and the regulatory framework that ensures that nanoparticulate UV filters and the sunscreen products containing them are safe to use.

The effect of a basic skin care product on the structural strength of the dermo-epidermal junction: An exploratory, randomised, controlled split-body trial

Skin ageing is associated with various structural alterations including a decreased strength of the dermo‐epidermal adhesion increasing the risk for shear type injuries (skin tears). Topical applications of basic skin care products seem to reduce skin tear incidence. The suction blister method leads to the artificial and controlled separation of dermis and epidermis. Therefore, time to blister formation may be used as outcome measuring the strength of dermo‐epidermal adhesion. We conducted an exploratory, randomised, controlled trial with a split‐body design on forearms in healthy female subjects (n = 12; mean age 70.3 [SD 2.1] years). Forearms assigned to the intervention were treated twice daily with petrolatum for 8 weeks. Suction blisters were induced on forearms after 4 and 8 weeks and time to blister formation was measured. Stratum corneum and epidermal hydration were measured and epidermal thickness was assessed via optical coherence tomography. Time to blistering was longer and stratum corneum as well as epidermal hydration was consistently higher in intervention skin areas. We conclude that topical application of basic skin care products may improve mechanical adhesion of the dermo‐epidermal junction and that the parameter “time to blistering” is a suitable outcome to measure dermo‐epidermal adhesion strength in clinical research.

Skin care interventions in infants for preventing eczema and food allergy

BACKGROUND

Eczema and food allergy are common health conditions that usually begin in early childhood and often occur together in the same people. They can be associated with an impaired skin barrier in early infancy. It is unclear whether trying to prevent or reverse an impaired skin barrier soon after birth is effective in preventing eczema or food allergy.

OBJECTIVES

Primary objective To assess effects of skin care interventions, such as emollients, for primary prevention of eczema and food allergy in infants Secondary objective To identify features of study populations such as age, hereditary risk, and adherence to interventions that are associated with the greatest treatment benefit or harm for both eczema and food allergy.

SEARCH METHODS

We searched the following databases up to July 2020: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We searched two trials registers and checked reference lists of included studies and relevant systematic reviews for further references to relevant randomised controlled trials (RCTs). We contacted field experts to identify planned trials and to seek information about unpublished or incomplete trials.

SELECTION CRITERIA

RCTs of skin care interventions that could potentially enhance skin barrier function, reduce dryness, or reduce subclinical inflammation in healthy term (> 37 weeks) infants (0 to 12 months) without pre-existing diagnosis of eczema, food allergy, or other skin condition were included. Comparison was standard care in the locality or no treatment. Types of skin care interventions included moisturisers/emollients; bathing products; advice regarding reducing soap exposure and bathing frequency; and use of water softeners. No minimum follow-up was required.

DATA COLLECTION AND ANALYSIS

This is a prospective individual participant data (IPD) meta-analysis. We used standard Cochrane methodological procedures, and primary analyses used the IPD dataset. Primary outcomes were cumulative incidence of eczema and cumulative incidence of immunoglobulin (Ig)E-mediated food allergy by one to three years, both measured by the closest available time point to two years. Secondary outcomes included adverse events during the intervention period; eczema severity (clinician-assessed); parent report of eczema severity; time to onset of eczema; parent report of immediate food allergy; and allergic sensitisation to food or inhalant allergen.

MAIN RESULTS

This review identified 33 RCTs, comprising 25,827 participants. A total of 17 studies, randomising 5823 participants, reported information on one or more outcomes specified in this review. Eleven studies randomising 5217 participants, with 10 of these studies providing IPD, were included in one or more meta-analysis (range 2 to 9 studies per individual meta-analysis). Most studies were conducted at children's hospitals. All interventions were compared against no skin care intervention or local standard care. Of the 17 studies that reported our outcomes, 13 assessed emollients. Twenty-five studies, including all those contributing data to meta-analyses, randomised newborns up to age three weeks to receive a skin care intervention or standard infant skin care. Eight of the 11 studies contributing to meta-analyses recruited infants at high risk of developing eczema or food allergy, although definition of high risk varied between studies. Durations of intervention and follow-up ranged from 24 hours to two years. We assessed most of this review's evidence as low certainty or had some concerns of risk of bias. A rating of some concerns was most often due to lack of blinding of outcome assessors or significant missing data, which could have impacted outcome measurement but was judged unlikely to have done so. Evidence for the primary food allergy outcome was rated as high risk of bias due to inclusion of only one trial where findings varied when different assumptions were made about missing data. Skin care interventions during infancy probably do not change risk of eczema by one to two years of age (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.81 to 1.31; moderate-certainty evidence; 3075 participants, 7 trials) nor time to onset of eczema (hazard ratio 0.86, 95% CI 0.65 to 1.14; moderate-certainty evidence; 3349 participants, 9 trials). It is unclear whether skin care interventions during infancy change risk of IgE-mediated food allergy by one to two years of age (RR 2.53, 95% CI 0.99 to 6.47; 996 participants, 1 trial) or allergic sensitisation to a food allergen at age one to two years (RR 0.86, 95% CI 0.28 to 2.69; 1055 participants, 2 trials) due to very low-certainty evidence for these outcomes. Skin care interventions during infancy may slightly increase risk of parent report of immediate reaction to a common food allergen at two years (RR 1.27, 95% CI 1.00 to 1.61; low-certainty evidence; 1171 participants, 1 trial). However, this was only seen for cow's milk, and may be unreliable due to significant over-reporting of cow's milk allergy in infants. Skin care interventions during infancy probably increase risk of skin infection over the intervention period (RR 1.34, 95% CI 1.02 to 1.77; moderate-certainty evidence; 2728 participants, 6 trials) and may increase risk of infant slippage over the intervention period (RR 1.42, 95% CI 0.67 to 2.99; low-certainty evidence; 2538 participants, 4 trials) or stinging/allergic reactions to moisturisers (RR 2.24, 95% 0.67 to 7.43; low-certainty evidence; 343 participants, 4 trials), although confidence intervals for slippages and stinging/allergic reactions are wide and include the possibility of no effect or reduced risk. Preplanned subgroup analyses show that effects of interventions were not influenced by age, duration of intervention, hereditary risk, FLG mutation,  or classification of intervention type for risk of developing eczema. We could not evaluate these effects on risk of food allergy. Evidence was insufficient to show whether adherence to interventions influenced the relationship between skin care interventions and risk of developing eczema or food allergy.

AUTHORS' CONCLUSIONS

Skin care interventions such as emollients during the first year of life in healthy infants are probably not effective for preventing eczema, and probably increase risk of skin infection. Effects of skin care interventions on risk of food allergy are uncertain. Further work is needed to understand whether different approaches to infant skin care might promote or prevent eczema and to evaluate effects on food allergy based on robust outcome assessments.

Topical corticosteroid vehicle composition and implications for clinical practice

This narrative review highlights the therapeutic significance of topical corticosteroid (TCS) vehicles and provides subsequent guidance to improve clinical and research outcomes. A greater understanding of the relationship between the topical vehicle, corticosteroid and skin is needed to ensure safer, more effective treatment for patients. Topical vehicles are not inert and can affect TCS bioavailability, due to the ability of their composition to positively or negatively influence skin status and change the physiochemical characteristics of an inherent corticosteroid. However, this principle is not commonly understood, and has contributed to inconsistencies in potency classification systems. This review provides an insight into the research methods and standardization needed to determine TCS product bioavailability. It identifies formulation components responsible for vehicle composition that underpin the quality, stability, compounding and functionalities of vehicle ingredients. This helps to contextualize how topical vehicles can be responsible for clinically significant effects, and how their composition gives products unique properties. In turn, this facilitates a more in-depth understanding of which resources offer information to inform the best selection of TCS products and why products should be prescribed by brand or manufacturer. This review will better equip clinicians and formulary teams to appraise products. It will also inform prescribing of Specials and why products should not be manipulated. The recommendations, accompanied by patient perspectives on using TCS products, assist clinical decision-making. They also identify the need for research into concomitant application of TCS products with other topical therapies.

Buffered lidocaine 1%/epinephrine 1:100,000 with sodium bicarbonate (sodium hydrogen carbonate) in a 3:1 ratio is less painful than a 9:1 ratio: A double-blind, randomized, placebo-controlled, crossover trial

BACKGROUND

Neutralizing (buffering) lidocaine 1%/epinephrine 1:100,000 solution (Lido/Epi) with sodium hydrogen carbonate (NaHCO₃) (also called sodium bicarbonate) is widely used to reduce burning sensations during infiltration of Lido/Epi. Optimal mixing ratios have not been systematically investigated.

OBJECTIVES

To determine whether a Lido/Epi:NaHCO₃ mixing ratio of 3:1 (investigational medicinal product 1) causes less pain during infiltration than a mixing ratio of 9:1 (IMP2) or unbuffered Lido/Epi (IMP3).

METHODS

Double-blind, randomized, placebo-controlled, crossover trial (n = 2 × 24) with 4 investigational medicinal products (IMP1-4).

RESULTS

The 3:1 mixing ratio was significantly less painful than the 9:1 ratio (P = .044). Unbuffered Lido/Epi was more painful than the buffered Lido/Epi (P = .001 vs IMP1; P = .033 vs IMP2). IMP4 (NaCl 0.9% [placebo]) was more painful than any of the anesthetic solutions (P = .001 vs IMP1; P = .001 vs IMP2; P = .016 vs IMP3). In all cases, the anesthesia was effective for at least 3 hours.

LIMITATIONS

Results of this trial cannot be generalized to other local anesthetics such as prilocaine, bupivacaine, or ropivacaine, which precipitate with NaHCO₃ admixtures.

CONCLUSIONS

Lido/Epi-NaHCO₃ mixtures effectively reduce burning pain during infiltration. The 3:1 mixing ratio is significantly less painful than the 9:1 ratio. Reported findings are of high practical relevance, given the extensive use of local anesthesia today.

Influence of Topical Formulations: Lipid Lamella Organization and Lipid Composition of Stratum Corneum as a Surrogate Marker for Barrier Integrity

Skin barrier repair therapies often involve the use of medicated and non-medicated topical preparations. To measure the effect of topical preparations, clinical (scoring systems, for example, Score of Atopic Dermatitis, Dermatology Quality of Life Index) and biophysical procedures (e.g., trans-epidermal water loss, skin hydration) are widely used. However, the results of these procedures describe the condition of the barrier indirectly. A direct assessment of skin barrier integrity is primarily possible by electron-microscopic examination, visualization and morphometric analysis of the lipid lamellae in the intercellular space of the stratum corneum (SC) and by quantitatively characterizing the composition of key SC lipids. Recently, the combination of a non-invasive lipid barrier visualization (Lipbarvis®) technique (SC sampling and morphometric analysis) and SC lipid composition analysis (chromatographic analysis) has been proposed to directly characterize the skin barrier integrity. Initial experience demonstrates that morphometric analysis of the lipid lamellae organization in the intercellular space of the SC as well as the characterization of the composition of key SC lipids may serve as surrogate marker to study the influence of topical non-medicated preparations including pH-lowered preparations.

Metamorphosis of Vehicles: Mechanisms and Opportunities

The visibility of a skin condition or dermatosis led to the reasonable assumption that the direct application of a therapeutic remedy to the target tissue holds many advantages. Through centuries, the nomenclature of topical preparations has proliferated and finally been moulded into the compulsory nomenclature of official compendia. In everyday life, many terms have been added and have complicated understanding and communication among and between healthcare professionals and laypersons. A large proportion of marketed topical preparations contain significant amounts of volatile vehicle ingredients that evaporate once they are applied onto the skin, that is, the vehicle format as well as the sum of vehicle ingredients in the primary container are different from the vehicle format and the sum of vehicle ingredients on the skin. This phenomenon and the potential consequences have so far been often ignored by many healthcare professionals and laypersons. To gain a better understanding, this phenomenon has been coined as the metamorphosis of the vehicle. The metamorphosis of the vehicle describes the vehicle (a) in the primary container (primary formulation), (b) during and immediately after application onto the skin (secondary formulation) and (c) after all volatile vehicle ingredients have evaporated from the vehicle on top of the skin (tertiary or residual formulation). The secondary and tertiary formulations may offer increased delivery of cosmetic or pharmaceutical actives. This is achieved by (a) an intended post-application creation of supersaturation of actives in the secondary and tertiary formulations or by (b) physico-chemical triggers such as pH.

Skin Care Products for Healthy and Diseased Skin

The industry offers a vast armamentarium of skin care products (SCP) to cleanse the skin; to reduce/eliminate unpleasant skin symptoms; to restore, reinforce, fortify and protect undamaged, vulnerable or damaged skin; and to provide a pleasant skin and body feel. Skin care products are readily available and their promotions with a variety of tall claims are omnipresent. This text discusses the various interpretations of skin care, the diversity of its comprehensions and the various groups of receivers and their needs for skin care. Skin care is part of our daily routines, the information on the effects of SCP is omnipresent and the purchase of SCP seems straightforward. However, the true essence of SCP remains concealed to many. This is mainly due to that fact that the "physico-chemical anatomy," the nomenclature and the regulatory classification of SCP as well as the role and the significance of active and inactive ingredients within these products are not well understood. This text addresses the different views, interpretations and comprehensions. The final part highlights the current challenges with SCP and gives an outlook on how to improve our mutual understanding of SCP.

The Acid Mantle: A Myth or an Essential Part of Skin Health?

Ninety years ago - in 1928, the term acid mantle was coined by the physicians Heinrich Schade and Alfred Marchionini in Kiel, Germany. A decade later Marchionini and several coworkers published 5 scientific communications in the Klinische Wochenschrift on "Der Säuremantel der Haut und Bakterienabwehr" (acid mantle and defense against bacteria). They described experimental detail, documented age- and body site as well as skin disease-dependent skin pH shifts, and discussed the significance of the pH and bacterial growth on the skin. In their fourth and fifth communication, they made the first connection between the altered quantitative and qualitative bacterial growth in pathologically modified skin and the shifted skin pH and attributed it partly to the gap in the acid mantle (pathologische Lücke des Säuremantels). They also investigated the pH of several topical dermatologic preparations and concluded that their benefit can at least partly be attributed to their acid character and recommended the systematic investigation of acid treatments in dermatology. At that time, the physiologic role of the acid skin surface was thought to be a protective mechanism against invading organisms. Hence, it seemed reasonable to allocate protection to an easy and conceivable term such as "mantle." Today, "acid mantle" as a term is still a very suitable metaphor to illustrate the protective quality of the "acid" in the skin and the term has become part of colloquial speech. In the meantime, our understanding of the skin pH has broadened, and we know that the acid character and its gradual change within the skin also help to orchestrate epidermal differentiation and corneocyte shedding. For many more biochemical processes within the skin, the compartmental pH is crucial, for example, in pigmentation, ion homeostasis, epidermal (stem) cell behavior, and so on. The often existing difference between the H+ concentration of extra- and intracellular as well as subcellular compartments establishes an ionic, electric, and/or osmotic driving force; hence, H+ concentration per se acts as an extra-, intra,- and subcellular signaling modality affecting and controlling many cellular functions. One may even consider pH a universal signal and effector. It is therefore also no surprise that skin pH shifts have been observed in various skin pathologies. More recently, in carefully controlled trials (acne, atopic dermatitis, incontinence-associated dermatitis, aged skin), the benefits of targeted skin acidification have become evident and the use of topical preparations with reduced pH may be recommended. The currently prevailing formulation concepts for direct acidification are based on a reduced pH of the hydrophilic product phase in combination with a buffer with a sufficiently high buffering capacity within the vehicle.

Commentary on the "Evidence- and Consensus-Based (S3) Guidelines for the Treatment of Actinic Keratosis" Published by the International League of Dermatological Societies in Cooperation with the European Dermatology Forum

In 2015, the International League of Dermatological Societies and the European Dermatology Forum published a guideline for the treatment of actinic keratosis, which is classified as an evidence- and consensus-based S3 guideline. From the point of view of the GD Task Force "Licht.Hautkrebs.Prävention," an interdisciplinary expert panel of the Society for Dermopharmacy for the prevention and treatment of skin cancer, this guideline reveals strengths and weaknesses but, in summary, does not meet the claim for an evidence- and consensus-based S3 guideline.

YouTube as a source of health information: Analysis of sun protection and skin cancer prevention related issues

Although social media ubiquitously supplementstraditional information sources such as newspapers,magazines, radio, and television, investigation of onlinehealth information related to sun protection and skincancer prevention has been scarce and largely limitedto English language sources. Using the search terms"sun protection," "sunscreen," "skin cancer prevention,""tanning bed" and "vitamin D," we investigated 281YouTube videos presented in 6 languages: English,German, French, Spanish, Swedish, and Danish. Foreach video, we used a four-sectioned checklist toassess general information, popularity, expert drivenmeasures, and heuristic driven measures. Differencesbetween languages were detected: English languagevideos were most frequently viewed (median numberof views: 5488 compared to 248 -1591 in otherlanguages). Approximately 60% of videos revealednegative effects of solar ultraviolet (UV)-exposure.The majority of videos (75%) targeted adults. Videoson tanning beds and sunscreen contained false ormisleading information 40% and 20% of the time,respectively. We confirm observations made withrespect to other medical disciplines that the generalquality of YouTube contributions is often inferiorand does not deliver sustainable information. Othersources of information should be included whensearching for health information online.

Skin Surface Topography and Texture Analysis of Sun-Exposed Body Sites in View of Sunscreen Application

BACKGROUND/AIMS

To determine the roughness of the surface of human skin at highly sun-exposed anatomical sites in a wide age range in order to derive consequences for sunscreen application.

METHODS

The forehead, cheek, nose, shoulder, and dorsal hand of 4 age groups (0-9, 20-39, 40-59, and >60 years) were investigated by replica formation, and areal topography was determined by confocal chromatic imaging. The arithmetic mean height as a roughness parameter and the void volume of the surface profile were calculated.

RESULTS

Age and site had a significant effect on roughness. Both the dorsal hand and nose exhibited the greatest roughness over the age of 40, and the forehead of the youngest age group exhibited the smallest roughness. Differentiation between sites progressed with age, whereas roughness increased significantly with age for the dorsal hand and nose but not for the other sites. The void volume was smaller than the volume corresponding to the typically recommended amount of sunscreen application except for the cases of largest roughness.

CONCLUSIONS

Different site-age combinations show significant variation of skin surface roughness. The application of sunscreen may in some instances need to be adjusted to take into account the increased roughness of highly sun-exposed anatomical sites.

Topical corticosteroid concerns from the clinicians' perspective

PURPOSE

Topical corticosteroids concerns (TCC) are common in dermatology patients, possibly leading to non-adherence to topical corticosteroids (TCS) and poor disease control. Clinicians play a key role in that context, as they can reduce or reinforce these concerns. It is unknown, if clinicians have accurate knowledge of TCC to appropriately address this issue and whether they have concerns themselves to use TCS. This questionnaire-based study aimed to assess these two aspects.

MATERIALS AND METHODS

Accuracy of knowledge was defined by how close the clinicians' estimates were to reference values of our previous study, in which we had examined TCC in dermatology outpatients. Moreover, clinicians indicated whether they have concerns themselves to use TCS.

RESULTS

Totally 202 clinicians participated. They underestimated both the prevalence of TCC and the resulting non-adherence. Whereas most clinicians correctly estimated characteristics of patients with TCC and the impact of patient information, only 31% of clinicians knew that skin atrophy was the leading concern, and only 30% correctly ranked the reasons for TCC. 74% of the clinicians had at least minor concerns themselves.

CONCLUSION

The majority of clinicians may have inaccurate knowledge of certain aspects of TCC and own concerns to use TCS.

Principles of skin care in the elderly

With aging, skin undergoes progressive structural and functional degeneration that leaves it prone to a wide variety of bothersome and even serious conditions and diseases. As skin conditions and diseases may affect all ages from cradle to grave, a disproportionate burden will clearly fall on the elderly and may significantly impact on quality of life (QoL). With a reduced ability of the skin to regenerate, the elderly are at an increased risk of skin breakdowns from even the simplest insults. It is therefore vital that skin care in the late adulthood is seen as a priority among both clinicians and caregivers. The scientific literature on diagnosing and assessing age-related skin conditions and diseases is vast; however, when it comes to preventive care and treatment, the scientific data available is less profound, and the recommendations are often based on personal experience, opinions or at best on consensus documents rather than on scientific data retrieved from controlled clinical trials. In addition to the absence of the scientific data, the imprecise terminology to describe the topical products, as well as the lack of understanding the essence of the vehicle, contributes to vague and often unhelpfully product recommendations. This paper aims to elucidate some basic principles of skincare, the choice of skincare products and their regulatory status. The paper discusses adherence to topical therapies, percutaneous absorption in the elderly, and skin surface pH and skin care. Lastly, it also discusses skin care principles in selected age related skin conditions and diseases.

Skin Cancer Prevention, Tanning and Vitamin D: A Content Analysis of Print Media in Germany and Switzerland

BACKGROUND

Print media are a major source of health information.

OBJECTIVES

To analyse press coverage related to skin cancer prevention.

METHODS

We conducted a content analysis of print media articles pertaining to skin cancer prevention, solaria and vitamin D published in Germany and Switzerland over a 1-year period between 2012 and 2013.

RESULTS

Overall, 2,103 articles were analysed. Applying sunscreen was by far the most common sun protection recommendation. A considerable number of articles on solaria and vitamin D advocated exposure to ultraviolet radiation to enhance physical appearance and vitamin D photosynthesis, often without mentioning any precaution measures. In total, 26.8% of the articles contained misleading or erroneous statements mostly related to sunscreen use and vitamin D issues.

CONCLUSIONS

Print media can serve as powerful education tools to foster skin cancer prevention. However, misleading or erroneous reports may negatively impact sun-safe behaviour.

Nonsteroidal anti-inflammatory drugs and the risk of nonmelanoma skin cancer

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been assigned a promising role in the chemoprevention of various malignancies. However, epidemiological data on the association between NSAID use and nonmelanoma skin cancer (NMSC) are limited. To explore whether patients regularly exposed to systemic NSAIDs are at a reduced risk of basal cell carcinoma (BCC) or squamous cell carcinoma (SCC), we conducted a population-based case-control analysis using the Clinical Practice Research Datalink, a United Kingdom primary care database. We identified 65,398 patients with incident BCC and 7,864 patients with incident SCC diagnosed between 1995 and 2013 and matched 1 and 4 NMSC-free controls to each BCC and SCC case, respectively, on age, sex, general practice, calendar time and years of history in the database. We compared prior NSAID exposure between cases and controls using multivariate conditional logistic regression analyses controlling for several potential confounders. Overall, we found no association between NSAID use and BCC, but when looking exclusively at users of single NSAID substances there was a suggestion of a reduced BCC risk in regular users of aspirin and ibuprofen (adjusted odds ratio [adj. OR]: 0.92, 95% confidence interval [CI]: 0.85-0.99 and adj. OR: 0.61, 95% CI: 0.48-0.78, respectively). The risk of SCC was slightly decreased in regular users of any NSAIDs (adj. OR: 0.89, 95% CI: 0.82-0.97), with the strongest risk reduction observed in current users of coxibs (adj. OR: 0.77, 95% CI: 0.62-0.95). These findings provide evidence that patients predisposed to NMSC might benefit from chemoprevention with NSAIDs.

Prevention of palmar-plantar erythrodysesthesia with an antiperspirant in breast cancer patients treated with pegylated liposomal doxorubicin (SAKK 92/08)

BACKGROUND

Elevated concentrations of doxorubicin are found in eccrine sweat glands of the palms and soles. We therefore evaluated an antiperspirant as preventive treatment for palmar-plantar erythrodysesthesia (hand-foot syndrome) in patients with metastatic breast cancer treated with pegylated liposomal doxorubicin.

PATIENTS AND METHODS

An antiperspirant containing aluminum chlorohydrate or placebo cream was applied to the left or right hand and foot in a double-blinded manner (intra-patient randomization). The primary endpoint was the rate of grade 2 or 3 palmar-plantar erythrodysesthesia. A secondary endpoint was the patient-reported symptom burden (tingling, numbness, pain, or skin problems). Using McNemar's matched pairs design, 53 patients were needed to detect a 20% difference between the treatment and placebo sides with a significance level of 5% and power of 90%.

RESULTS

Grade 2 or 3 PPE occurred in 30 (58%) of 52 evaluable patients; in six patients adverse effects occurred on the placebo side but not on the treatment side, whereas one patient developed palmar-plantar erythrodysesthesia on the treatment side only (P = 0.07). Four patients developed grade 2 or 3 palmar-plantar erythrodysesthesia on their foot on the placebo side but not on the treatment side (P = 0.05). In the cohort with grade 2 or 3 palmar-plantar erythrodysesthesia there was a trend towards fewer dermatologic symptomatologies with the active treatment (P = 0.05), and no difference for other adverse events.

CONCLUSION

Using topical aluminum chlorohydrate as an antiperspirant appears to reduce the incidence of grade 2 or 3 palmar-plantar erythrodysesthesia following pegylated liposomal doxorubicin chemotherapy for metastatic breast cancer.

Antidepressants relevant to oral and maxillofacial surgical practice

Background:

Depression is commonly associated with a high-carbohydrate diet, lack of interest in proper oral hygiene and xerostomia connected to the use of antidepressants. Patients often consult their dentists as a result of changes affecting the hard dental substance and the soft-tissues.

Aim:

The aim of this study was to identify adverse drug interactions between the antidepressants and medications commonly administered in dentistry in order to give practicing dentists an overview of the scientific literature.

Objective:

The objective is to identify the adverse drug interactions between antidepressants and medication commonly administered in dentistry.

Study Design:

The literature search was performed using PubMed, Cochrane and the specific search items. The review (1984-2009) focused on medicines used in dental practice (vasoconstrictors, non-opioid analgesics, non-steroidal anti-inflammatory drugs, antibiotics, antifungals and benzodiazepines).

Results:

There are various drug interactions between antidepressants and medicines used in dentistry. When two or more drugs are co-administered, a drug interaction must always be anticipated though many of the interactions are potential problems, but do not seem to be real clinical issues.

Conclusion:

The probability of a drug interaction can be minimized by careful history-taking, skillful dose adjustment and safe administration of the therapeutic agent.

Howard I. Maibach: Extraordinary Leadership in Integrating Key Concepts Underpinning Our Understanding of Percutaneous Absorption and Occupational Dermatology

The purpose of the present article is to briefly highlight some contributions of Prof. Howard I. Maibach to the field of dermatology. After a few introducing remarks regarding Howard's personal career, the article specifically reviews contributions to the understanding of percutaneous absorption and to occupational dermatology. He and his companions/coworkers established and introduced experimental prerequisites to better study and understand percutaneous absorption - both in vitro and in vivo. Not less influential was his contribution to occupational dermatology acting as a founding member of the International Contact Dermatitis Research Group and coinaugurating the North American Contact Dermatitis Group. These groups have been very active ever since. As an academic teacher, he inspired young colleagues to perform original research work and to establish their own working groups. He has done this most successfully with many fellows who worked with him over the years, and who are now leading departments or companies dedicated to dermatological research all over the world. Probably this is his most important and lasting achievement.