Faculty Bibliography

Importance: Sun-protective behavior affects skin cancer prevention. Shade works by physically shielding skin from direct harmful UV rays; however, skin may still remain exposed to reflected and indirect UV rays. There is no current standard metric to evaluate shade for its effectiveness in sun protection, and there is insufficient clinical evidence that a beach umbrella alone can provide adequate sun protection. Objective: To directly measure sunburn protection offered by a standard beach umbrella compared with that provided by sunscreen with a high sun protection factor under actual use conditions. Design, Setting, and Participants: A single-center, evaluator-blinded, randomized clinical study was conducted from August 13 to 15, 2014, in Lake Lewisville, Texas (elevation, 159 m above sea level), among 81 participants with Fitzpatrick skin types I (n = 1), II (n = 42), and III (n = 38). Participants were randomly assigned to 2 groups: 1 using only a beach umbrella, and the other using only sunscreen with a sun protection factor of 100. All participants remained at a sunny beach for 3(1/2) hours at midday. Clinical sunburn evaluation of each individual for all exposed body sites was conducted 22 to 24 hours after sun exposure. Interventions: The shade provided by a beach umbrella or protection provided by sunscreen with a sun protection factor of 100. Main Outcomes and Measures: Sunburn on all exposed body sites 22 to 24 hours after sun exposure. Results: Among the 81 participants (25 male and 56 female; mean [SD] age, 41 [16] years) for all body sites evaluated (face, back of neck, upper chest, arms, and legs), the umbrella group showed a statistically significant increase in clinical sunburn scores compared with baseline and had higher postexposure global scores than the sunscreen group (0.75 vs 0.05; P < .001). There was a total of 142 sunburn incidences in the umbrella group vs 17 in the sunscreen group. Thirty-two of the 41 participants (78%) in the umbrella group showed erythema in 1 or more sites vs 10 of the 40 participants (25%) in the sunscreen group (P < .001). Neither umbrella nor sunscreen alone completely prevented sunburn. Conclusions and Relevance: A beach umbrella alone may not provide sufficient protection for extended UV exposure. It is important to educate the public that combining multiple sun protection measures may be needed to achieve optimal protection. Trial Registration: isrctn.org Identifier: ISRCTN19177299.

OBJECTIVE:To correlate Multi-spectral Digital Skin Lesion Analysis classifier scores with histopathological severity of pigmented lesions and clinical features of melanoma. DESIGN/METHODS:Classifier scores were computed for 1,632 skin lesions. Dermatologists evaluated the same lesions for Asymmetry, Border Irregularity, Color variegation, Diameter >6mm, Evolution, Patient's Concern, Regression, and/or "Ugly Duckling" sign. Classifier scores were correlated to the number of clinical risk features and for six histopathological severity levels of pigmented lesions. MEASUREMENTS/METHODS:Average classifier score, Welch's t-test, and chi-square analysis. RESULTS:Melanomas had higher mean classifier scores (3.5) than high-grade dysplastic nevi (2.7, p=0.002), low-grade dysplastic nevi (1.7, p<0.0001), non-dysplastic nevi (1.6, p<0.0001), and benign non-melanocytic lesions (2.0, p<0.0001). Classifier score and the number of clinical risk characteristics directly correlated (Pearson coefficient 0.32, p<0.0001). CONCLUSION/CONCLUSIONS:Correlation of classifier scores to clinical and histological melanoma features supports the effectiveness of Multi-spectral Digital Skin Lesion Analysis in assessing the risk of pigmented lesions requiring biopsy. Optimizing outcomes of dermatologist decisions to biopsy suspicious pigmented lesions may be enhanced utilizing Multi-spectral Digital Skin Lesion Analysis.

The American Academy of Dermatology and dermatologists' themselves, have recommended public education and patient counseling regarding sunscreen. The purpose of this study was to determine US dermatologists' actual sunscreen perceptions as well as their recommendations and personal usage. 540 practicing US dermatologists responded to an online survey that assessed each physician's perception of safety and efficacy of sunscreen, recommendation factors, and personal usage. Dermatologists have an overall positive view of sunscreen. 99% of dermatologists agree that regular sunscreen use helps lower skin cancer risk, reduces subsequent photoaging, and recommend their family/friends use sunscreen. Most dermatologists believe that oxybenzone and retinyl palmitate are safe in sunscreen (86% and 85%, respectively). Dermatologists used multiple sunscreen recommendation criteria including Sun Protection Factor (SPF) level, broad spectrum protection, cosmetic elegance/feel, and photostability (96%, 98%, 85%, and 68%, respectively). The use of sunscreen remains a critical part of sun protection. Therefore, it is important to assess and understand the perspective and patient recommendations provided by dermatologists.

J Drugs Dermatol 2016;15(9):1121-1123.

Spectators at baseball games may receive a considerable amount of exposure to solar UV radiation (UVR). The purpose of this study was to evaluate if public education about sun protection over the last 10 years has impacted the use of hats at Major League Baseball (MLB) games. Photographs of seating sections during a 3-game series in New York, New York, were obtained and analyzed to evaluate the percentage of spectators wearing hats. Different seating sections were evaluated (sunny, shaded, bleachers) and assessed as well as compared to similar data reported 10 years prior. Given the limited change in hat use over the last decade, a knowledge and behavioral gap exists that may be exploitable to achieve better skin cancer prevention.

BACKGROUND: Guidelines exist for the management of cutaneous malignant melanoma, but their adoption, prevalence, and impact have not yet been determined. OBJECTIVE: To determine current melanoma clinical management practices of US dermatologists and the variance from guidelines that might exist. METHODS: A cross-sectional e-mail survey study assessing preferred biopsy methods for lesions suspicious for melanoma, margins used for excision, and recommended follow-up intervals were sent to 6177 US dermatologists (540 responding). The representative nature of the responding subset was verified by comparing their demographics to that from the American Academy of Dermatology (AAD) membership. RESULTS: Management varied from published guidelines. Shave biopsy (35%) was the most commonly used method followed by narrow excisional biopsy (31%), saucerization/scoop shave (12%), punch (11%), and wide excision (3%). Excisional margins narrower than recommended were noted and follow-up intervals varied. There were significant management differences noted for dermatologists by practice setting and by years in practice. LIMITATIONS: The impact of patient history, lesion anatomic site, and size of lesion were not assessed. Recall and nonresponder sampling bias may exist. CONCLUSION: Variations in dermatologists' approaches to melanoma management and variance from current guidelines suggest that a knowledge gap may exist representing an educational opportunity. However, emerging data may also justify deviations from existing guidelines, suggesting a reassessment of the guidelines may be indicated.

BACKGROUND: Early detection and subsequent management of melanoma are critical for patient survival. New technologies have been developed to augment clinician analysis of suspicious pigmented skin lesions. OBJECTIVE: To determine how information provided by a multispectral digital skin lesion analysis device affects the biopsy decisions of international dermatologists following clinical and dermoscopic pigmented skin lesion evaluation. METHODS: Participants at a dermoscopy conference in Vienna, Austria, were shown 12 clinical and dermoscopic images of pigmented skin lesions (2 melanomas in situ, 3 invasive melanomas, and 7 low-grade dysplastic nevi) previously analyzed by multispectral digital skin lesion analysis. Participants were asked if they would biopsy the lesion based on clinical images, again after observing high-resolution dermoscopy images, and again when subsequently shown multispectral digital skin lesion analysis information. RESULTS: Data were analyzed from a total of 70 international dermatologists. Overall, sensitivity was 58 percent after clinical evaluation (C) and 59 percent post-dermoscopy (D), but 74 percent after multispectral digital skin lesion analysis. Participant specificity was 56 percent (C) decreasing to 51 percent (D), but increasing to 61 percent with multispectral digital skin lesion analysis. Diagnostic accuracy was 57 percent (C) decreasing to 54 percent (D), but increasing to 67 percent for dermatologists after integrating the multispectral digital skin lesion analysis data into the biopsy decision. The overall number of lesions biopsied increased from 50 percent (C) to 53 percent (D), rising to 54 percent after multispectral digital skin lesion analysis. CONCLUSION: Decisions to biopsy melanocytic lesions were more sensitive and specific when multispectral digital skin lesion analysis information was provided with no significant increase in the number of biopsies recommended. Providing multispectral digital skin lesion analysis data may lead to additional improvement in biopsy accuracy with a concomitant decrease in the number of nonessential biopsies for pigmented skin lesions even after dermoscopic evaluation.

Background: The American Academy of Dermatology and FDA recommend reapplying sunscreen at two hour intervals. Additionally, the sun protection factor (SPF) of sunscreens is tested using a thickness of 2 mg/cm². However, studies show that sunscreen under real-life conditions is neither applied sufficiently and often not reapplied. Recently developed sunscreen products claim to offer improved water resistance and photostability. This study investigated the durability of two current sunscreens with different SPF protection over an eight hour period. Methods: Participants (n = 50) were randomized into two study groups utilizing either 2 mg/cm² (FDA testing concentration) or 1 mg/cm² (real-life application levels) amounts of sunscreen. Two current SPF 15 and 70 sunscreens were applied to test spots on each participant's back. In vivo SPF values were obtained at baseline, 3.5, and 8 hours post initial application during which subjects completed 30 minutes of moderate exercise followed by 80 minutes of water exposure. All participants and evaluators were blinded of their study group or product used. Results: Participants in both dose study groups revealed only a 15-20% overall decrease in their SPF protection 8 hours after application. The study group that received half the FDA test concentration of sunscreen also achieved approximately half or less the labeled SPF. At 8 hours, the test sites that received SPF 70 maintained an average SPF greater than 60 (2 mg/cm² application) and 20 (1 mg/cm² application). Similarly, the SPF 15 product test sites revealed an in vivo protection of 12 (2 mg/cm²) and 6 (1 mg/cm²). Conclusions: This study demonstrates that current sunscreens may be durable on skin even following significant exercise and water exposure suggesting that reapplication intervals may be longer than currently recommended. In addition, the higher SPF sunscreen maintained a skin-cancer protective level of SPF following extended use. High SPF sunscreen may provide an additional margin of safety especially for people who do not reapply frequently. Advances in sunscreen technology should continue to involve higher SPF products that can offer durable real-use protection