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Summertime fun and dangers
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Summer is officially here, children are out of school, and summertime outdoor fun is beginning. Unfortunately, potential dangers are beginning as well because the sun’s radiation as well as biting insects can cause acute and long-term problems in children. The application of sunscreen and insect-repellent products can minimize or prevent these associated medical problems, such as sunburn and increased risk for skin cancer, or transmission of vector-borne diseases.
Skin cancer remains the most common type of cancer in the United States, and its major cause is exposure to ultraviolet (UV) radiation (sunlight). Squamous cell and basal carcinoma are the most prevalent skin cancers. Although melanoma represents far fewer skin cancers, it has a significantly higher morbidity (80% of all skin cancer deaths). The use of sunscreens and other behavioral modifications can significantly reduce a child or adolescent’s risk for sunburn and long-term risk for developing skin cancer. However, having children, parents, and adolescents institute these behaviors can be challenging.
USPSTF on behavioral counseling to prevent skin cancer
This year, the U.S. Preventive Services Task Force (USPSTF) published recommendations on behavioral counseling for the primary prevention of skin cancer. This publication updated previous recommendations from 2012. The USPSTF recommends counseling children (and their parents), adolescents and young adults with fair skin, aged 6 months to 24 years, on minimizing exposure to UV radiation to reduce their risk for skin cancer. This recommendation is assessed as a “B” evidence quality — “The USPSTF recommends the service. There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial.” Fair skin is described as ivory or pale skin, light hair and eye color, freckles, or those who sunburn easily because these characteristics increase risk for skin cancer. Other risk factors include use of tanning beds, persons with a history of sunburns or skin cancer, increased number of nevi, and immunosuppressive comorbidities. Most studies of sun protection behaviors have included only participants with fair skin types. Sunlight is a well-known carcinogen, and published evidence demonstrates that the relationship between sunlight exposure and skin cancer is strongest during childhood and adolescence. Thus, pediatric health care providers have an important role to play in reducing this long-term risk for our patients.
The USPSTF recommendations are based upon a review of the published literature. Six trials were identified that evaluated the effect of interventions on sun protection behaviors in children and adolescents. Most of these trials demonstrated a statistically significant improvement in sun protection behaviors compared with control groups. These trials employed a variety of methods to increase sun protection behavior, including one-on-one counseling, distribution of informative print materials, provision of free samples (sunscreen, hats), mailed materials, and follow-up telephone counseling, in addition to other methods. The USPSTF guide additionally targets the use of indoor tanning beds as a risk factor for skin cancer, with several published studies documenting the increasing use of indoor tanning as a risk factor for the development of melanoma, squamous cell, and basal cell carcinoma. Indoor tanning use prior to age 35 years, 10 or more indoor tanning sessions over a lifetime, and indoor tanning use for longer than 1 year have all been associated with increased skin cancer risk.
In an interesting editorial accompanying the USPSTF report, Robinson and Jablonski disagree with use of the term “fair skin type” because this phrase may exclude others who sunburn but do not have fair skin. These authors prefer use of “sun-sensitive skin” to include those who may not be described as having “fair skin” but nonetheless can still sunburn and have risk factors for skin cancer. Other risk factors include: personal or family history of skin cancer, immunosuppressive comorbidities, use of indoor tanning, having at least 50 nevi, or use of photosensitizing medications (for a comprehensive list see: www.dhs.wisconsin.gov/radiation/medications.htm).
Sunscreens
The USPSTF report includes summaries of published studies of sunscreen use and their benefits. These studies demonstrate that sunscreen use decreases the risk for squamous cell carcinoma and melanoma compared with control groups (no sunscreen use). In 2012, the FDA revised its sunscreen product regulations and product labeling definitions. Health care professionals should recommend use of “broad-spectrum” sunscreen products — those that provide protection against UVA and UVB radiation. UVA radiation penetrates deep into skin layers and results in skin aging and other damage. UVB primarily results in sunburn. Sunscreen SPF (sun protection factor) commonly found on product packaging describes the products’ ability to protect against UVB radiation only. SPF describes the increase in time before sunburn development relative to use of no sunscreen (eg, 30 minutes in the sun causes sunburn to a child without sunscreen; use of a sunscreen with SPF 30 would allow 15 hours in the sun to produce a similar sunburn, when properly applied). A sunscreen SPF 15 product properly applied blocks 93% of UVB rays; SPF 30 blocks 97%; SPF 40 blocks 97.5%. Thus, use of higher SPF sunscreen products may not be as increasingly effective as one assumes. Published studies have shown consumers’ overreliance on the SPF rating and their poor knowledge of an adequate amount of sunscreen to apply. The AAP recommends use of SPF 15 or higher sunscreen products, and the American Academy of Dermatology recommends use of SFP 30 or higher sunscreen products.
Equally important, however, is use of a proper dose (ie, a proper amount of sunscreen applied). The proper amount of sunscreen for a child is 1 oz of sunscreen for the body (skin exposed to the sun), or enough to fill a child’s cupped palm, including 1 tsp to each arm, leg, face/ears/neck, chest torso, and back. The proper amount of sunscreen for an adolescent or adult is 2 oz (about a full shot glass, or 10 tsp), including 1 tsp to each arm, face/ears/neck, and 2 tsp to each leg, chest torso, and back.
It is common for a subtherapeutic dose of sunscreen to be applied. Several published studies have documented that the application of an inadequate amount of sunscreen results in a reduction of SPF protection (ie, application of 50% of a proper amount of a SPF 15 product results in protection equivalent to using a SPF 7.5 product). Additionally, sunscreens should be reapplied every 2 hours while the person is in the sun, and after swimming. If these reapplications do not occur, the potential for inadequate sun protection from sunscreens increases substantially. Sunscreen products best used are products labeled as “broad spectrum” (providing protection for UVA and UVB radiation), “water-resistant” (if swimming), and at least SPF 15 to 30.
Sprays, although easy to use, may not allow enough sunscreen to be applied. If spray products are used, it is best to spray enough of the product onto one’s hand to equate to 1 to 2 oz as described above, or if sprayed directly onto skin, the skin should glisten after application of an appropriate amount. Lotion products are preferred, as they are more likely to be applied in an appropriate amount. The July 2018 issue of Consumer Reports magazine tested and rated sunscreen products and recommended several: Equate (Walmart) Sport Lotion SPF 50, BullFrog Land Sport Quick Gel SPF 50, Coppertone WaterBablies SPF 50, or Equte (Walmart) Ultra Protection Lotion SPF 50. Other products can also be used and are described in the full Consumer Reports article.
Vector-borne diseases and insect-repellent products
The CDC recently published data indicating that the number of vector-borne disease cases has increased approximately 300% in recent years (2004-2016) in the U.S. and U.S. territories. In the U.S., the most common vector-borne pathogens are transmitted by ticks and mosquitos, resulting in Lyme disease, Rocky Mountain spotted fever, West Nile, dengue and Zika virus diseases. Tick-borne diseases have increased more than 200% during this time period and comprised 77% of all vector-borne disease cases. The pace of the emergence of new vector-borne pathogens is increasing as well. From 2004 to 2016, nine vector-borne human diseases were reported for the first time from the U.S. and U.S. territories.
Protection against biting insects and the prevention of vector-borne diseases includes the use of protective clothing when outside (long pants and sleeves, shoes, socks, hat) and checking the skin after returning from the outdoors, among other actions. Additionally, applying insect repellents can be helpful. Insect-repellent products contain a variety of ingredients, yet only several agents are recommended by professional medical organizations for application directly to skin: DEET, picaridin, oil of lemon eucalyptus, IR3535, and 2-undecanone. DEET is the preferred agent because it possesses many years of proven safety and effectiveness when used for all ages, and it has the longest duration of action when a sufficient dose is applied (ie, if a product contains a high enough percentage of the ingredient). DEET-based products are available in concentrations of up to 100%. As concentrations of DEET increase, the duration of action also increases. This increase is believed to plateau at approximately 50% DEET, providing a duration of action of about 8 hours. DEET is labeled for use for all ages, and has no age restriction limitations (ie, it can be applied to infants when necessary). Products containing oil of lemon eucalyptus may be preferred by parents requesting a “natural” product. Products containing 30% oil of lemon eucalyptus have a duration of action of 4 to 6 hours. Oil of lemon eucalyptus, however, is not labeled for use on children aged younger than 3 years. Examples of insect-repellent products recently evaluated and recommended by Consumer Reports include Total Home (CVS Pharmacy brand) Woodland Scent Insect Repellent (DEET 30%), Off Deep Woods Insect Repellent VIII Dry (DEET 25%), Repel Plant-Based Lemon Eucalyptus Insect Repellent2 (oil of lemon eucalyptus 30%), or Sawyer Premium Insect Repellent 20% Picaridin (picaridin 20%).
Summary
The use of sunscreen and insect-repellent products is a relatively easy means to minimize or prevent sunburn, long-term effects of UV radiation (skin cancer), and transmission of several vector-borne infectious diseases. It is challenging, however, to convince our patients and caregivers to adopt and use these preventive behaviors. When recommending a sunscreen product, it is most important to consider the use of a broad-spectrum product that is at least SPF 15 to 30, and to apply a sufficient amount every 2 hours. Insect-repellent products containing DEET are preferred because they provide the longest duration of action, although several other safe and effective ingredients are available in many different products.
- References:
- Consumer Reports. Shop Smarter for Sunscreen. https://www.consumerreports.org/sunscreens/shop-smarter-for-sunscreen/. Accessed June 25, 2018.
- Grossman DC, et al. JAMA. 2018;doi:10.1001/jama.2018.1623.
- Henrikson NB, et al. JAMA. 2018;doi:10.1001/jama.2017.21630.
- Robinson JK, et al. JAMA. 2018;doi:10.1001/jama.2018.0163.
- Rosenberg R, et al. MMWR Morb Mortal Wkly Rep. 2018;doi:10.15585/mmwr.mm6717e1.
- For more information:
- Edward A. Bell, PharmD, BCPS, is a professor of pharmacy practice at Drake University College of Pharmacy and Health Sciences and Blank Children’s Hospital and Clinics, Des Moines, Iowa. He also is a member of the Infectious Diseases in Children Editorial Board. Bell can be reached at ed.bell@drake.edu.
Disclosure: Bell reports no relevant financial disclosures.