KIDS
April 11, 2011

Here Comes the Sun

Sun exposure in childhood and adolescence than can set the stage for skin cancers and problems later.

The American Academy of Pediatrics recently published a report entitled, "Ultraviolent Radiation: A Hazard to Children and Adolescents." The bottom line is clear — sun exposure is a real health threat and you and your children may not always be as well-protected as you may think. As we age we become more aware and protective of our skin. But it is exposure in childhood and adolescence than can set the stage for skin cancers and problems later on.

Avoid The Sun Now; Reduce Cancer Risk Later

Because body tissues are in a state of rapid growth and development, childhood and adolescence are often considered to contain "critical periods of vulnerability" when newly developing cells and tissues are especially susceptible to effects of toxic exposures, including the sun. Typically, because of aged-related behavior and lifestyle including more opportunities for outside time and more risk taking behaviors, approximately 25% of lifetime sun exposure occurs before 18 years of age.

The Risk to Eyes and Skin
The sun's rays cause cancer. This was recognized in 1992 by the International Agency for Research on Cancer, and ongoing research since then has provided an increased understanding of the details and extent of the problem. The sun’s rays are 95% ultraviolet A (UVA) and 5% UVB. UVA rays are constant during the day and during the year, while UVB rays are stronger in the summer, at midday, closer to the equator, and at high altitudes. Overexposure to both kinds of rays is considered dangerous for skin and for eyes.

It is exposure in childhood and adolescence than can set the stage for skin cancers and problems later on.

Yes, children's eyes are also at risk for extreme sun exposure. The child or adolescent who is out without sunglasses and a hat with a reasonable (4") brim at the pool, ballpark or beach can experience photokeratitis, or corneal burns. Chronic exposure increases the risk of developing cataracts.

Carcinomas
Basal cell and squamous cell carcinomas make up about 95% of skin cancers. They occur primarily in the sun-exposed areas of fair skinned people. While they used to be most common in the older generation, the incidence in under-40-year-olds has been increasing dramatically.

Basal cell carcinomas are not fatal, but if they aren’t removed, they can cause extensive damage to the skin, tissue, and bone surrounding them. They tend to recur in the same place and once you’ve had one, your chance of another is increased. On the face, ears and neck, basal cell carcinomas can look like a pearly white or waxy bump that may bleed, crust, or form a depressed center and may have visible blood vessels. On the back and chest, they may look like flat, scaly, brown, or flesh colored patches and may grow as large as six inches. The location of basal cell carcinomas on the body has extended from primarily the head and neck to the torso which likely reflects both outdoor tanning and artificial tanning device use.

While carcinomas used to be most common in the older generation, the incidence in under-40-year-olds has been increasing dramatically.

Squamous cell cancers usually grow slowly. When treated early, they cause no problems, but rarely, if left untreated, they can destroy healthy tissue nearby and spread to other organs. Squamous cell cancers may appear as firm, red nodules or flat scaly crusted lesions on the face, lip, ears, neck, hands or arms or as an ulcer or flat white patch inside your mouth, anus, or genitals.

Basal cell and squamous cell carcinomas are treated with freezing, surgery, cauterization, laser, or radiation, depending on their size and location.

Melanomas
Melanoma, while comprising less than 5% of skin cancers is treatable if detected when small, but usually fatal once it has metastasized. Risk for melanoma is increased in people with light skin and eyes who sunburn easily; those who have a first degree relative with a history of melanoma or a personal history of melanoma; and people who freckle easily or have a many moles. Melanoma can occur in young adults and teenagers. Worldwide, melanoma is increasing faster than any other malignancy.

The ABC’s of moles are frequently cited as red flags for concern: A is for asymmetrical shape, B is for irregular border, C is for changes in color throughout the mole…

Melanomas most commonly develop in areas that have exposure to the sun. However, they can also develop in "hidden" areas such as the soles of the feet, palms of hands, scalp, genitals, and fingernail beds. Hidden melanomas can also develop in the mouth, digestive tract, urinary tract and eye. Skin melanoma often presents as a change in an existing mole or the development of a new unusual skin growth.

The ABC’s of moles are frequently cited as red flags for concern: A is for asymmetrical shape, B is for irregular border, C is for changes in color throughout the mole, D is for diameter greater than ¼ inch, E is for evolving and changing in shape, size, or starting to bleed or get irritated or itchy.

Early treatment of meloma is surgical removal. Once they have metastasized, melanomas may be treated with surgery, chemotherapy, radiation, and immunotherapy. However, there is currently no cure for metastatic melanoma.

The pattern of one’s sun exposure strongly influences the type of skin cancer for which the risk is greatest. Chronic occupational exposure to ultraviolet radiation is considered the main environmental cause of squamous cell cancer (SCC). These squamous cell cancers typically occur on skin areas that are most regularly exposed such as face, neck, and hand and the risk is directly proportional to the lifelong cumulative dose of sun. In contrast, basal cell carcinomas (BCC) and melanoma are significantly associated with intermittent sun exposure (sun burning); melanoma even more so than BCC.

How to Judge UV Exposure Accurately

Temperature and sun exposure are not always in sync. Just because we feel cool doesn’t mean we are adequately protected from the sun’s harmful rays. Kids and adults can be fooled into thinking they are not at risk for sun exposure and sunburn because they aren't hot or the day isn't sunny.

Even though clouds decrease the intensity of the heat experienced from the direct sun, they do not diminish the UV exposure to the same extent. It is entirely possible to get sunburned on a cloudy day.

Sunlight is scattered and reflected by water, concrete, sand and snow, so one must be careful, even while sitting in the shade, of excessive sun exposure. And even though clouds decrease the intensity of the heat experienced from the direct sun, they do not diminish the UV exposure to the same extent. It is entirely possible to get sunburned on a cloudy day.

Swimming can be similarly deceiving. The sun’s harmful rays can penetrate up to 60 cm (about two feet) in water, so it is easy to be burned floating in the pool. Swimming also reduces the effectiveness of even waterproof sunblock, so it's important to teach children to be aware of the need to re-apply sunblock after swimming.

A Tan is Not Protection; A Tan is Not Healthy

To many of us, bronzed skin is a sign of health, but unfortunately, this isn't the case. Tanning is a protective response to sun exposure but that doesn’t mean it is a healthy one. The tanning reaction decreases the elasticity of the skin and causes wrinkles, sagging skin, and discoloration, as we age. According to recent evidence, the tanning response means that DNA damage has occurred in skin.

Tanning booths are mainly UVA rays and can be 10-15 times more intense than the midday sun. Artificial tanning before a vacation may give one a mild tan but its protective benefit is only the equivalent of an SP3 sunscreen.

As tan skin became a beauty status symbol and form of cosmetic skin "care", tanning salons became popular. In 2000, the National Institutes of Health stated that "exposure to sunlamps or sunbeds is known to be a human carcinogen, based on sufficient evidence of carcinogenicity from studies in humans, which indicate a causal relationship between exposure to sunlamps or sunbeds and human cancer."

Tanning booths are mainly UVA rays and can be 10-15 times more intense than the midday sun. Artificial tanning before a vacation may give one a mild tan but its protective benefit is only the equivalent of an SP3 sunscreen. Tanning beds have all the risks of excess sun exposure including skin cancers, skin aging, and eye problems.

Studies have shown that use of tanning beds increases the incidence of both melanoma and non melanoma skin cancers. In addition, exposure to UVR from sunlight or tanning parlors may be addictive because of the feelings of well being (endorphins) that some tanners experience.

The World Health Organization, the American Medical Association, and the American Academy of Dermatology have all called for laws to ban the use of artificial tanning devices by people younger than 18 years and many states have regulations governing their use. If your child is determined to be tan, help him or her learn to use one of the many cosmetic bronzers that are now available. But be aware that unless these bronzers and sunless tanning sprays have sunscreen added, the "tan" appearance they produce is not protective against sun damage. And as with plain sunscreen, in order to maintain the UV protection, the combination tan/sunscreen products must be reapplied every few hours as well as following water exposure or excessive sweating, even though the tan appearance persists.

Sun Protection

Protective Clothing
Clothing can be a major part of sun protection. The ultraviolet protection factor (UPF) measures a fabric's ability to block ultraviolet rays from passing through the fabric and reaching the skin. Most clothing, particularly warm weather wear, is not especially sun protective. While denim provides a UPF of 1700, typical summer cotton T-shirts provide a UPF of only 5 to 9, and this decreases when it gets wet.

There are specialized sun protective garments available. The UPF of different protective fabrics ranges from 15 to 50 with 15 to 24 is rated as "good;" 25 to 39 is rated as "very good;" and 40 to 50 rated as "excellent." Any garment with a UPF lower than 15 should not be labeled as "sun protective" or "UV protective."

Sunscreen Is Not The Whole Answer
When used regularly sunscreen can prevent solar (actinic) keratoses. These are often brown or tan crusty patches of skin and stem from premalignant changes which can precede squamous cell carcinomas. So far no studies have shown that sunscreen prevents either melanomas or basal cell carcinomas.

People assume they are safe when using sunscreen and actually spend more time exposing themselves to sunlight. Unfortunately, some studies have in fact shown an increase in the risk of melanoma and BCC in sunscreen users.

Sunscreens work by either absorbing the ultraviolet rays (oxybenzone, PABA), or by providing a barrier between rays and the skin so they can’t penetrate (zinc oxide, titanium dioxide). The SPF rating system tells you how long, when using the sunscreen, it would take to experience a sunburn.

If you normally burn after 10 minutes of sun exposure, and you use an SPF 15 sunscreen, it will take 15 times as long or 150 minutes before you burn. But sunscreens must be used properly; applied 15-30 minutes before exposure, applied in the proper quantify, and reapplied regularly during the period of exposure. If you use a sunscreen spray, be sure you have the bottle close to the body part you are spraying. If you spray from too far away, you may not cover all skin that the sun’s rays will touch.

People – teens and adults – assume they are safe when using sunscreen and actually spend more time exposing themselves to sunlight. Unfortunately, some studies have in fact shown an increase in the risk of melanoma and BCC in sunscreen users.

Babies under age six months should not be covered with sunblock; they should be covered up and kept out of the sun.

Professional medical organizations, such as the American Academy of Dermatology, continue to recommend regular sunscreen use along with other sun protective measure, but these recommendations should not be mistaken as a license to spend hours in the sun. It is important to impress upon your children – and remember yourself – that your skin needs plenty of time out of the sun.

Babies under age six months should not be covered with sunblock; they should be covered up and kept out of the sun. The American Academy of Pediatrics, because of concerns about absorption of the sunscreen chemicals, recommends its use for only those small areas of skin that can’t be protected by hats, clothes or shade.

Acne and Other Sun-Sensitizing Medications

There are some chemicals or drugs that when applied directly to the skin or taken orally increase the skin’s sensitivity to sunlight and increase the risk of burning and skin damage even in people who don’t usually burn easily. These include some drugs commonly used by adolescents and young adults, such as non-steroidal anti-inflammatory agents (Advil, Motrin, ibuprofen) and acne medications such as tetracyclines and tretinoin.

The consequences of exposure to a photosensitizing agent can range from an uncomfortable to a life threatening skin reaction. Limiting exposure to sun and artificial UV light is critical when using sun-sensitizing medications or topical agents.

The bottom line remains clear. Awareness of the health threats posed by the sun’s rays is a critical component of enjoying outdoor activities safely.

Sun safe practices include;

  1. Avoid burning and tanning, both naturally and artificially
  2. Wear protective clothing, hats and sunglasses
  3. Seek shade
  4. Use caution near water, snow, and sand
  5. Use sunscreen liberally and re-apply it often
  6. Limit outdoor time during maximal sun exposure hours: from 11 am to 3 pm

Online Resources
http://www.cdc.gov/cancer/skin/basic_info/prevention.htm
http://www.familydoctor.org/online/famdocen/home/common/cancer/risk/159.html
http://www.kidsskinhealth.org/grownups/skin_habits_sun.html
http://www.aad.org/skin-conditions/dermatology-a-to-z/skin-cancer/signs-symptoms

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