Communications About Family Members' Risk of Melanoma

Archives Of Dermatology

As many as 5% to 12% of patients with melanoma have a family history of the disease, and patients with a positive family history of melanoma should be observed closely because of their elevated risk. When the initial diagnosis of melanoma is made, dermatologists play a crucial role in communicating risk assessment to their patients and recommending that family members be screened.

Feet Home To More Than 100 Types of Fungus

From: Dermatology Daily

The Los Angeles Times (5/23, Netburn) reports, "At least 80 types of fungi reside on a typical person's heel, along with 60 between the toes and 40 on the toenail." In fact, "the feet are home to more than 100 types of fungus, more than any other area of the human body, according to a study published Wednesday by the journal Nature."
On it's "All Things Considered" program and on its "Shots" blog, NPR (5/22, Stein) reports that the "census of the fungi that inhabit different places on our skin" is "part of a big scientific push to better understand the microbes that live in and on our bodies. 'This is the first study of fungi, which are yeast and other molds that live on the human body,' says Julie Segre, of the National Human Genome Research Institute, who led the survey."
The NBC News (5/23, Fox) "The Body Odd" blog reports that "one family" of fungus called Malassezia "covers most of our bodies." HealthDay (5/23, Norton) reports, "The new study...took advantage of DNA-sequencing technology to analyze the fungi on 10 healthy volunteers' skin." Also covering the story are BBC News (5/23, Briggs) and Medscape (5/23, Laidman).

SELF Magazine Awards Glytone "Best Night Cream"

From: Practical Dermatology June 2013

Glytone won one of SELF Magazine's 14th annual Healthy Beauty Awards, landing the distinction of "Best Night Cream" 2013 for Glytone Anti-aging Night Cream. The publications surveyed more than 1,600 US readers on their favorite beauty products-based on products that deliver on their promise-in five different categories: Hair, Makeup, Face, Body, and Sun.

Skin Cancer Myths-And Facts

From: Skin Cancer Foundation Journal

Myth: Eighty percent of a person's lifelong sun exposure is acquired before age 18.
Fact: Actually, only about 23 percent of lifetime exposure occurs by age 18. You can-and should-protect yourself from the sun at every age.

Myth: Tanning at a salon is safer than tanning outdoors-it's a controlled does of radiation.
Fact: When compared to people who have never tanned indoors, indoor tanners have a higher risk of all skin cancers. A "controlled" dose of tanning lamp radiation provides as much as 12 times the annual ultraviolet A (UVA) dose tanners receive from sun exposure. Just one indoor tanning session increases users' chances of developing melanoma by 20 percent.

Myth: Ingredients in sunscreen can cause cancer.
Fact: Research shows that when used as directed, sunscreens are safe and effective.

Myth: The sun is the best way to obtain vitamin D.
Fact: Our bodies can produce some vitamin D following sun exposure. However, within as little as a few minutes, vitamin D manufacture reaches its maximum. Meanwhile, the sun is damaging your skin and immune system. Diet and supplements are the safest way to obtain vitamin D.

Myth: You can't sustain sun damage on a cloudy day.
Fact: Believe it or not, up to 80 percent of the sun's harmful UV rays can penetrate clouds and fog.

Myth: A "base tan" protects your skin from sunburn.
Fact: A tan is a sign of skin damage. Skin tans in response to UV damage to the skin's DNA; a tan is the skin's attempt to repair damage and prevent further injury. But imperfect repairs can eventually lead to skin cancer.

Myth: A high SPF is all that you need in a sunscreen.
Fact: A sunscreen's SPF (sun protection factor) indicates protection from UVB rays, but UVA protection is necessary, too. Apply a UVA- and UVB- screening/broad-spectrum sunscreen with an SPF of 15+ (or 30+ for extended outdoor activity).

Myth: People of color don't get skin cancer.
Fact: People of color are less likely to develop skin cancer than Caucasians, but they have a higher risk of dying from it. The dangerous and fast-spreading skin cancer acral lentiginous melanoma is more common among darker-skinned people. Whatever your skin color, protect yourself.

Myth: Windows protect us from the sun's ultraviolet rays.
Fact: While glass blocks most UVB rays, UVA radiation can get through. However, UVA-screening window film is also available.

Cat Allergy vaccine effects persist at 2 years

From: SKNews April 2013

San Antonio-A short course of treatment with an investigational synthetic cat-peptide-antigen desensitizing vaccine, or Cat-PAD, results in a substantial and persistent reduction in cat allergy symptom scores, according to 2-year findings from a randomized controlled study involving 202 adults patients.
Participants in the phase II trial were initially randomized to receive eight 3-nmol intradermal doses at 2-week intervals, four 6-nmol doses at 4-week intervals, or placebo. At 1-year follow-up, the improvement in Total Rhinoconjunctivitis Symptom Score (TRSS) was significantly greater in the patients who received four doses of Circassia's Cat-PAD (ToleroMune Cat) than in patients who received the placebo (-7.1 points vs. -2.99 points), investigators reported online in the journal of Allergy and Clinical Immunology (2013;131:AB147[doi: 10.1016/j.jaci.2012.12.1185]).
Data from a 2-year follow-up study were reported by Rod P. Hafner, Pd.D., and his colleagues in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
Of 89 patients enrolled into the follow-up study, 50 returned at 2 years after the start of treatment, having received no additional treatment, for an environmental exposure chamber (EEC) challenge. The magnitude of difference from baseline in TRSS seen at 1 year in those who received four doses and those who received placebo was maintained at 2 years (-5.87 vs. -2.02 points) among those who initially received the four-dose regimen.
"Cat-PAD is the first in a new class of synthetic peptide immune-regulatory epitopes. The results from this study provide the first evidence that four doses of 6 nmol Cat-PAD over a 12-week period have a disease-modifying effect, with subjects showing sustained improvement at 2 years," the investigators wrote.
Study participants were aged 18-65 years with cat allergy who underwent a baseline EEC challenges at 18-22 weeks and at 100-104 weeks.
"Cat allergen was dispersed into the EEC to achieve a consistent mean level of approximately 50 ng Fel d1/m3, using a validated method," they explained, noting that TRSS was calculated at each EEC challenge based on self-scoring of four nasal symptoms (running nose, sneezing, blocked nose, itchy nose), and four ocular symptoms (itchy eyes, watery eyes, red eyes, sore eyes) on a scale of 0 to 3, every 30 minutes during the challenge.
Cat-PAD is a "potentially exciting new approach to cat allergy immunotherapy," the investigators said, noting that improvements in the TRSS seen in the initial phase II study and follow-up study represent a substantial improvement over numerous therapies investigated in the past, in symptom reduction.
In late 2012 the investigators began enrolling participants for a phase III study.
This study was funded by Circassia. Dr. Hafner is employed by Circassia.

VZV Vaccination for the Prevention of Shingles

From: Practical Dermatology March 2013

Increasingly, there is interest in developing a vaccine that would prevent additional outbreaks of HSV among individuals who are already positive for HSV. The vaccine would presumably boost the patient's immunity to prevent subsequent outbreaks.

VZV Vaccine
The shingles vaccine is actually a concentrated form of the vaccine given to children for the prevention of chicken pox. In the original trials for the vaccine, all subjects were age 60 or older. Subjects received either active vaccine or placebo. There was a 51 percent reduction overall in the incidence of shingles among those in their 60's.
These findings would seem to support vaccination in younger elderly patients. For one, the risk of developing shingles increases with age. Furthermore, the vaccine seems to be potentially more effective in younger patients. Overall, there was a 2/3 reduction in the incidence of post-herpetic neuralgia among those subjects who received the vaccination but nonetheless developed shingles.
A subsequent study enrolled patients in their 50s and determined that the efficacy rate of the vaccine was about 70 percent. The vaccine (Zostavax, Merck and Co.) received FDA approval for use in individuals 50 or older.

When To Vaccinate
The average age of patients presenting in Dr. Trying's office with shingles is 51. This suggests that patients who receive the vaccination upon turning 50 may significantly reduce their risk for developing shingles. Increased age is a known risk factor for developing shingles. Although stress has frequently been identified as a risk factor, it appears that only significant, acute stress, such as the loss of a loved one, may be associated with shingles outbreak. Most recently, family history of shingles has emerged as a significant risk factor for developing shingles. Having a first-degree relative with shingles may double an individual's risk for developing shingles.
Vaccination is not recommended for an individual who has recently has shingles. However, individuals who had shingles some time in the past (approximately a decade or so), vaccination may prevent re-emergence of shingles.
Finally, patient recollection of a personal history of chicken pox is rarely reliable. Many individuals simply do not recall having chicken pox as children. Furthermore, many sero-positive patients say that their parents never acknowledged that the patient had chicken pox. Importantly, patients do not require an antibody test prior to receiving the VZV vaccine. Cost of the vaccine, which may not be covered by third-party payors, can remain a limiting factor.

UV Protection from the Patient's Perspective

From: Practical Dermatology March 2013

In a recent survey of American consumers, 86 percent of respondents said they know that sunscreen helps prevent skin cancer when used with other protection measures, yet the majority do not use sunscreen on a regular basis. Reasons consumers gave for not using sunscreen include not thinking about doing it (40 percent), believing that they do not stay out long enough in the sun to burn (44 percent), and having an aversion to sunscreen texture (51 percent).

Memorial Sloan Kettering's Steven Q. Wang, MD, Director of Dermatologic Surgery and Dermatology at Basking Ridge Dermatology, addressed consumer behaviors and strategies to increase UV avoidance. He, along with Stephen Dusza, PhD, conducted the study described above and has written extensively on sunscreen formulations and science. Ahead, he answers questions about UV avoidance and sunscreen formulation and use.

Q. You found that 86 percent of Americans understand the importance of sun protection, yet most don't use sunscreens or use them properly. Why do you think this is and how can this change?
"The public understands the need to use sunscreens and to limit UV exposure, but there is a gap," observes Dr.Wand. "The gap is in how they translate knowledge into motivation and motivation into behavior." He likens adoption of UV avoidance behavior to weight loss or smoking cessation. "People understand this is important, but they just cannot change their behaviors."
There are ways to support patients and facilitate change. "I encourage dermatologists to emphasize comprehensive photoprotective strategies," Dr. Wang says. He argues that the current emphasis on sunscreens, "puts the hierarchy of sun protection strategies in reverse." Over-dependence on sunscreens gives patients a false sense of security.
It is more important, he says, for patients to understand when and how they are exposed to UV radiation and how they can limit exposure through sun avoidance and physical protection strategies: staying out of the sun as much as possible, especially during midday hours, wearing protective hats and clothing, etc. When patients adopt these crucial strategies, then sunscreen becomes a secondary mode of defense to protect minimal exposure rather a first line of defense.
When patients adopt adequate UV avoidance strategies, then use of a daily sunscreen SPF 30 is probably sufficient for day-to-day use. Remind patients that windows block out UVB, Dr. Wang suggests.
Dermatologists should also, "Focus on the need for adequate application of sunscreens," Dr. Wang says. "Most people use about one-third the desired amount of sunscreen, which translates to about one-half or one-third the stated level of protection."

Q. Your research and other surveys have found that patients are concerned about the safety of sunscreen ingredients and the cosmetic elegance of formulations. What should dermatologists know about these topics?
"There have been some overblown concerns regarding sunscreen ingredients," Dr. Wang acknowledges. "Many people voice concern about oxybenzone," he says, noting that the degree of exposure needed to realize theoretical oxybenzone affects on human hormone levels are far above those achieved with normal sunscreen use. In fact, he says, it would take more than 270 years of consistent application to achieve problematic levels.
Additionally, fear of nanotechnology is also "not valid" according to Dr. Wang. Micronized or nanosized TiO and ZnO are important for cosmetic elegance of sunscreen formulations; compared to older, larger particle size formulations that tended to leave white residues on the skin. "Studies to date suggest that micronized and nanosized UV filters do not penetrate beyond the stratum corneum," he explains, meaning little to no risk of systemic exposure. Even if nanosized particles are deposited within the stratum corneum, constant shedding of the SC does not permit accumulation of material.
Furthermore, there are concerns that nanoparticle filters, upon exposure to UV, can generate damaging free radicals in the skin. Free radicals are associated with photoaging, immunosuppression, and photocarcinogenesis. It is shown that excess UVA irradiation and exposure to pollutants are themselves drivers of ROS-generation in human skin.
While in vitro studies using cell culture models did suggest a high level of ROS generation when non-organic nanosized filters were exposed to UV irradiation, subsequent in vitro studies have not borne out these findings. However, Dr. Wang says, most nanosized filters are coated to reduce reactivity and thus limit free-radical formation. Furthermore, the skin's natural antioxidant capacity can readily neutralize any ROS generated through enzymes and nonenzymatic molecules.
As an additional measure of protection, many sunscreen formulations now incorporate topical antioxidants, which may have the potential to diminish the ROS generated from exposure to UVA radiation. This antioxidant capacity may be especially important, given that most sunscreens tend to provide greater protection against UVB than UVA. Dr. Wang and colleagues recently have published on the use and benefits of topical antioxidants within sunscreen formulations, but he cautions that much depends on the quality of the finished product. Failure to provide sufficient concentrations of antioxidants or stable formulations will negate the benefit of the antioxidants.

Q. What are your recommendations for effectively educating patients about UV avoidance? How can this be achieved quickly in the average clinic visit?
"What I find helpful and what I encourage dermatologists to do is to give specific recommendations," Dr. Wang says. "Most people only want to hear what sunscreen and what SPF they should be using."
Dr. Wang also strongly encourages dermatology practices to develop a handout that lays out a specific, appropriate, comprehensive UV avoidance strategy "It is very important to have a sheet of instructions ready."
Specific product recommendations can be made on  this handout. Of course, Dr. Wang says, give a few options across various price points, and encourage patients to seek out a product they like.
"Overall, I think US sunscreen manufactures have done a good job creating products for the American consumer," Dr. Wang says. But patients still have preferences. Common consumer complaints about sunscreen tend to focus on texture, which may be perceived as greasy to some. Formulations intended to be water resistant may have a sticky feel.

Q. What are remaining questions in the area of sunscreens?
The FDA is still trying to determine whether formulations should indicate a level of UVA protection and how to best accomplish this. There also remain questions about certain dosage forms, such as sprays. Under the current FDA proposed ruling, Dr. Wang notes,"wipes, powders, and washes cannot claim SPFs because they were deemed to not provide sufficient protection."
Sprays are popular due to their convenience, ease of application at certain anatomic sites, and the ease of use in children, who may not like creams or lotions. The challenge is in achieving adequate and consistent coverage, Dr. Wang says. Even if a spray is applied imperfectly, "it's better than nothing," he says.
There are methods to optimize use of sprays. One is to spray the product into the hand and then apply to the desired area, though this somewhat defeats the purpose of the spray, Dr. Wang admits. Alternatively, consumers should move the can slowly over the target area to ensure a good amount of coverage. The product should still be rubbed in by hand once on the skin.