Skin Cancer, S Sunscreen, a and T Tips for Su Success i in M - - PowerPoint PPT Presentation

Skin Cancer, S Sunscreen, a and T Tips for Su Success i in M Managing Com

• mmon Ra

Rashes i in Y

• ur Clinic

Brittney Schultz, M D Assistant Professor of Dermatology University of M innesota August 18, 2019

Objec ectives es

• Identify common skin cancers and choose appropriate biopsy

techniques for diagnosis

• Discuss proper use of sunscreen and evaluate recent sunscreen

controversies in the media

• Diagnose common rashes in clinic and determine appropriate

treatment

Discl closures

• No financial disclosures
• No off-label use of medications

Skin C Cancer: r: It’s a a problem!

Basal cell carcinoma Squamous cell carcinoma M elanoma

Image source: VisualDx.com

Skin C Cancer r in M Minnesota

Source: M innesota Department of Health

Skin C Cancer r in M Minnesota

Source: M innesota Department of Health

Clues t to Skin C Cancer

Size M atter! S ymptoms

Clues t to Skin C Cancer: r: B Basal cell c carcinoma

• Painful
• Growing
• Bleeding
• Shiny
• Ulcerated
• Prominent vessels
• Scaly red patches
• Scar-like
• Can have pigment!

Image source: VisualDx.com

Clues es to Skin Cancer er: S Squamous c cel ell carcinoma

• Painful
• Growing
• Bleeding
• Pink bumps
• Red patches
• Scaly
• Can develop quickly

Image source: VisualDx.com

Clues t to Skin C Cancer: r: M Melanoma

• Painful
• Growing
• Bleeding
• Changing
• “ Ugly ducking”
• ABCDEs
• Can be amelanotic

Image source: VisualDx.com

Mimick ckers o s of S Ski kin Cance ancer

Dermal nevus Eczema Seborrheic keratosis

Image source: VisualDx.com

He Heigh ghten en S Suspicion

• n
• Transplant patient
• Immunosuppressed
• Azathioprine
• Voriconazole
• HIV patient
• Tanning bed use
• Family history of melanoma
• History of

radiation/ burns/chronic inflammation

https:/ /commons.wikimedia.org/ w/ index.php?curid=34547559

Diagnosis of Skin Cancer

Biopsy!

When t to Punch, When t to Shave…

Ho How you

• u wou
• uld biop
• psy t

this l lesion

• n?

Image source: VisualDx.com

Ho How you

• u wou
• uld biop
• psy t

this l lesion

• n?

Image source: VisualDx.com

Ho How you

• u wou
• uld biop
• psy t

this l lesion

• n?

Image source: VisualDx.com

Biopsy: B Basal and Squamous Cell C Carcinoma

• Shave most commonly

employed

• Quicker
• Less expensive
• No suture closure
• Can result in surrounding

erythema that creates an indistinct border and may result in larger than necessary excision/ treatment

• Portion is adequate but ensure

adequate depth

• Punch from center of lesion may

also have advantages

• M ay better define the growth

pattern

• E.g. micronodular, morpheaform, or

infiltrative features may only be present in deeper portions

• Could change treatment

J Am Acad Dermatol. 2016 Jan;74(1):1-16; quiz 17-8.

Biopsy: M Melanoma

• Complete excision

recommended

• Can be performed via

saucerization for macular lesions using 0.5-2 mm margins

• Partial biopsy associated with

inaccurate diagnosis and staging

• Concern for tumor colonization
• f a deep punch biopsy but no

evidence this worsens prognosis

J Am Acad Dermatol. 2016 Jan;74(1):1-16; quiz 17-8.

Biopsy: Le Lenti tigo Malig ligna

• Size of lesion may preclude

complete excision

• Broad thin shave biopsy or

multiple small shave biopsies recommended

Image source: VisualDx.com J Am Acad Dermatol. 2016 Jan;74(1):1-16; quiz 17-8.

Sunscreen

Sunscreen B Basics

• Sun gives off UVA and UVB (and UVC)
• UVA

aging, passes through windows

• UVB

sunburn, does not pass through windows

• SPF = Sun Protection Factor

No sunscreen 5 min 5 min x SPF 30 = 150 min SPF 30 SPF = M inimal erythema dose (protected) M inimal erythema dose (unprotected)

Sunscreen B Basics

• Physical blockers (inorganic)
• Titanium dioxide
• Zinc oxide
• Chemical blockers (organic)
• Oxybenzone
• Avobenzone
• Octisalate
• Ensulizole
• Octocrylene
• Octinoxate

Scatter/ deflect UVA/ UVB Absorb UVA + UVB photochemical reaction to render ineffective

UVA/ UVB UVA/ UVB Not all protect against both UVA/ UVB

Sunscreen B Basics

• Use broad-spectrum (UVA and

UVB)

• SPF 30 or higher
• Waterproof
• Apply 15 minutes before going
• utside
• Re-apply every 2 hours or after

sweating/swimming

• M ost adults need 1 ounce to

cover entire body

• Better yet…
• Sun protective clothing
• Avoid peak hours of sun (10 am to

2 pm)

• Caution with water, snow, sand

Daylight = sunlight!

“Does sunscreen even work rk?”

“Does sunscreen even work rk?”

• Reduce UV exposure/sunburn? Y

es.

• Reduce skin cancer? A little more complicated.
• UV exposure definitively associated with skin cancer
• Some studies demonstrate reduction of skin cancer with sunscreen use and some do

not, but overall quality of evidence has been poor

• Bottom line: Probably yes but challenging to definitively prove

“I n need to get a a base t tan”

“I n need to get a a base t tan”

• Not true – every UV exposure is damaging your skin
• “ Base tan” provides SPF 3
• Reduces sun protection measures on vacation
• Bottom line: No you don’t

J Am Acad Dermatol. 2005 Dec;53(6):1038-44.

No sunscreen 5 min 5 min x 3= 15 min

“My vi vitamin D D is already low”

“My vi vitamin D D is already low”

• Sources of vitamin D: diet and sun exposure (UVB)
• “ Exposure of 5% of uncovered body surface 2x/ week in summer may be

equivalent to intake of 430 IU of vitamin D daily; however, for a given surface area, a plateau is reached after 20 minutes”

• 8 oz glass of milk: 100 IU
• 3.5 oz salmon: 360 IU
• Vitamin D supplements do not carry risk of skin cancer and

photoaging

• Bottom line: Supplement J

J Am Acad Dermatol. 2005 M ay;52(5):868-76.

“Su “Sunsc screens s are d e damagin ing c cor

• ral r

l ree eefs”

“Su “Sunsc screens s are d e damagin ing c cor

• ral r

l ree eefs”

• Organic (chemical) UV filters have been identified in water worldwide
• Oxybenzone #1
• Highest percutaneous absorption and identified in human urine, serum, and breast milk
• Others: octocrylene, octinoxate, 4-methylbenzylidene camphor (4-M BC)
• Also found in cosmetics, shampoos, fragrances, flavors
• Difficult to remove from water supply
• Hormonal effects have been reported, including antiandrogen and

both proestrogen and antiestrogen effects, but significance in humans unclear

J Am Acad Dermatol. 2019 Jan;80(1):266-271.

“Su “Sunsc screens s are d e damagin ing c cor

• ral r

l ree eefs”

• In vitro, a species of green algae was exposed to varying levels of
• xybenzone
• Lowest levels ~similar to environment (0.01-0.1 parts per billion)
• Highest up to 5000 parts per billion
• Higher concentrations of oxybenzone

decrease chlorophyll content and growth

• High concentrations of oxybenzone in fish species

decreased egg production and fewer hatchings

• High concentrations of zinc oxide nanoparticles in vitro

bleaching (not seen with titanium dioxide)

J Am Acad Dermatol. 2019 Jan;80(1):266-271. Sci Total Environ. 2018 Oct 1;637-638:1279-1285.

Oxybenzone Octinoxate

Bottom line:

• There is concerning data regarding chemical sunscreens and

nanoparticles, however, these were in vitro studies with much higher

concentrations that currently found in the water supply

• Additional studies are needed
• In meantime – safest thing to do is use physical sunscreens without

nanoparticles and continue using sun-protective clothing, seeking shade, etc.

“Su “Sunsc screens s are d e damagin ing c cor

• ral r

l ree eefs”

“Sunscreen een gets in you

• ur blood
• odstrea

eam”

“Sunscreen een gets in you

• ur blood
• odstrea

eam”

J AM A. 2019 M ay 6. Epub ahead of print.

“Sunscreen een gets in you

• ur blood
• odstrea

eam”

• 24 participants
• Randomized to 1 of 4 sunscreens: spray 1, spray 2, lotion, and cream
• 2 mg of sunscreen per 1 cm2 was applied to 75% BSA 4 times daily for 4 days
• 30 blood samples collected over 7 days
• Not exposed to direct sunlight during this time period
• Primary outcome = maximum plasma concentration of avobenzone
• Secondary outcomes = maximum plasma concentrations of
• xybenzone, octocrylene, and ecamsule
• Particularly interested in 0.5 ng/ mL threshold (established by FDA for

potentially waiving nonclinical toxicology studies for sunscreens)

J AM A. 2019 M ay 6. Epub ahead of print.

J AM A. 2019 M ay 6. Epub ahead of print.

J AM A. 2019 M ay 6. Epub ahead of print.

“Sunscreen een gets in you

• ur blood
• odstrea

eam”

• Y

es but…

• What does it mean?
• What are the health effects of this?
• Were this realistic conditions?

J AM A. 2019 M ay 6. Epub ahead of print.

“Sunscreen een gets in you

• ur blood
• odstrea

eam”

• FDA has proposed rule to update regulatory requirements for

sunscreen products in the US

• Proposed classification of sunscreen ingredients
• GRASE = generally recognized as safe and effective, does not need FDA

approval

• Titanium dioxide, zinc oxide
• Not GRASE (also not in US)
• P

ABA, tolamine salicylate

• Calling for more safety data on 12 ingredients before determining GRASE/ not

GRASE including oxybenzone, octinoxate, avobenzone, etc.

• If not GRASE, needs FDA approval

“ Sunscreen FAQS.” J Am Acad Dermatol.

“Sunscreen een gets in you

• ur blood
• odstrea

eam”

Bottom line:

• We don’t know what the significance of bloodstream absorption
• means. The study did not prove these products are unsafe but they

do deserve additional investigation.

• The FDA is investigating which sunscreens should be considered

GRASE and not GRASE. Any not GRASE products will need FDA

• approval. Final decision TBD ~November 2019.
• In meantime, if concerned, can use physical sunscreens and continue

using sun-protective clothing, seeking shade, etc.

Future Directions

• Additional studies investigating harms to coral reefs
• Significance of bloodstream absorption and health effects
• Some sunscreens may need FDA approval in future
• In meantime, please keep protecting your skin!

Tips for r Success i in Managing C Common Rashes in Y

• ur

r Clinic

Tip #1: Different a acne diff fferent t tre reatment

• Comedonal acne
• Retinoid, retinoid, retinoid
• Tretinoin 0.025% cream
• Adapalene 0.1% cream
• Adapalene 0.1% gel (OTC) = Differin

Image source: VisualDx.com

Tip #1: Different a acne diff fferent t tre reatment

• Inflammatory acne
• Clindamycin 0.1% lotion
• Benzoyl peroxide 5% wash
• Retinoid
• If deep-seated, may need short

course of antibiotic (max 3-6 mo)

• Doxycycline 100 mg BID for up to 3

months, then taper

• Low threshold to refer for

isotretinoin

M ust use together, never topical abx alone resistance Image source: VisualDx.com

Tip #1: Different a acne diff fferent t tre reatment

• Hormonal acne
• Jawline predominance, especially

women > 25 years old, flare with menses

• OCP – anti-androgen progestin e.g.

drospirenone

• FDA approved = Ortho Tri-Cyclen,

Estrostep, Y az, Loryna, and Beyaz

• Spironolactone
• Consider screening for PCOS

Image source: VisualDx.com

Tip #1: Different a acne diff fferent t tre reatment

Image source: VisualDx.com

Comedonal

• Retinoid

Inflammatory

• Retinoid
• Topical antibiotic + BP wash
• M ay need oral antibiotic for

short courses

• Low threshold to refer for

isotretinoin

Hormonal

• OCP
• Spironolactone

Tip #2: Different r rosacea differ eren ent tre reatment

• Erythematotelangiectatic rosacea
• Flushing
• No papules/ pustules
• M etronidazole does not usually

help

• Rx:
• Photoprotection, gentle skin care
• Avoid triggers
• Alpha-agonists: brimonidine and
• xymetazoline
• PDL

Image source: VisualDx.com

Tip #2: Different r rosacea differ eren ent tre reatment

• Papulopustular rosacea
• M etronidazole does help
• Sometimes need oral antibiotics,

usually less than acne doses

• Doxycycline 100 mg BID for 2

months, then taper to minimum dose

• Role for demodex? Ivermectin

has been used

Image source: VisualDx.com

Tip #2: Different r rosacea differ eren ent tre reatment

• Rhinophymatous rosacea
• Overgrowth of sebaceous glands
• Retinoids – topical or oral
• Surgical debulking
• If ocular component, usually

need cyclosporine drops or oral antibiotics (low doses)

Image source: VisualDx.com

Tip #3: When it’s not lupus, it’s probably seborrh rrheic d derm rmatitis o

• r rosacea

Systemic lupus erythematosus Acute “ butterfly rash” Nasolabial fold sparing Seborrheic dermatitis Loves the nasolabial folds – also check scalp, ears, beard Greasy scale common

• Rx. Ketoconazole cream or shampoo

Image source: VisualDx.com

Tip #3: When it’s not lupus, it’s probably seborrh rrheic d derm rmatitis o

• r rosacea

Systemic lupus erythematosus Acute “ butterfly rash” Nasolabial fold sparing Rosacea M ay see papules/ pustules Can be difficult – history most helpful

Image source: VisualDx.com

Tip #4: Is it scabies?

• Worried about scabies?
• First…

put on gloves

• Then check:
• Volar wrists
• Finger webs
• Umbilicus
• Genitalia
• Breasts
• Skin folds
• If no rash there, probably not

scabies

Image source: VisualDx.com

Tip #5: Atopic derm rmatitis u usually not influen enced ed by f food

• od a

aller ergi gies es

• Food allergies common in

patients with atopic dermatitis but rarely are they a cause/ trigger for atopic dermatitis

• Clues to food allergy:
• Urticaria
• Angioedema
• Worsening in atopic dermatitis

following exposure to allergen

• Keep eating!
• Pediatrics. 2014 Dec;134(6):e1735-44.

Image source: VisualDx.com

Tip #6: We usually don’t find a cause f for r urticari ria

• Urticaria
• Acute: <6 weeks
• Chronic: > 6 weeks
• Associations
• If chronic, possible increased risks of

thyroid disease, T1D, SLE, and RA

• Rarely associated with periodic fever

syndromes

• Eval
• Careful ROS

consider CBC, CM P , TSH, ESR

• Biopsy usually not helpful
• Treatment
• Antihistamines, antihistamines,

antihistamines

• Avoid triggers (NSAIDs)

Image source: VisualDx.com J Am Acad Dermatol. 2018 Oct;79(4):599-614. Cetirizine 10-20 mg BID plus Fexofenadine 180 mg BID

• Allergy. 2018 Jul;73(7):1393-1414.

Tip #7: Know y your s r steroids (or r at least know

• ne

e steroi

• id from
• m stron
• ng, mod
• der

erate, weak)

• Ointment > cream > lotion
• “Ointment is greasy but works better”
• “ I’d rather give you use something you will actually use”
• OTC hydrocortisone is like water, I’m not surprised when it doesn’t

work

• Should have a good trial of twice daily for 2-3 weeks before someone “ fails”

something

• If lesions are thick, they need more potent topical corticosteroids but

location needs to guide you

Tip #7: Know y your s r steroids (or r at least know

• ne

e steroi

• id from
• m stron
• ng, mod
• der

erate, weak)

• Potencies simplified (disclaimer – over-simplified!)
• Face and/or groin
• Desonide 0.05% ointment
• Hydrocortisone valerate 0.2% ointment
• Trunk and extremities
• Triamcinolone 0.1% ointment – our workhorse
• Hands/ feet and thick lesions on trunk and extremities
• Fluocinonide 0.05% ointment (Lidex)
• Clobetasol 0.05% ointment (the strongest)

Ti Tip #8: Pois

• ison ivy n

nee eeds s 3 week eeks s of

• f or
• ral

l ster eroid ids s (if i it need eeds or

• ral s

ster eroid ids a s at all)

• If mild involvement

potent topical steroid

• If more diffuse
• ral steroids

reasonable

• Need to continue for 3 weeks to

prevent rebound

• 40 mg x 5 days
• 30 mg x 5 days
• 20 mg x 5 days
• 10 mg x 5 days

Image source: VisualDx.com

Tip #9: Don’t use c combination antifungal and topical steroid

If unsure, start with topical antifungal BID x 2 weeks Switch to steroid if not improved

Tip p #10: #10: VisualDx Dx.com is your ur friend nd

Take e Hom

• me P

Poin

• ints
• When on the hunt for skin cancer, symptoms matter.
• Never punch a melanoma!
• Don’t stop using sunscreen. M ore studies needed on recently raised

concerns on environmental impact and blood absorption.

• When in doubt, use physical sunscreens and other photoprotective

measures.

• Acne and rosacea have differing subtypes, with differing treatments.
• Don’t use topical steroid + topical antifungal.
• It’s never lupus.

Thank Y Y

• u!

u!

bschultz@umn.edu

Refer eren ences es

• Antia et al. Urticaria: A comprehensive review: Epidemiology, diagnosis, and work-up. J Am Acad Dermatol. 2018 Oct;79(4):599-

614.

• Corinaldesi et al. Impact of inorganic UV filters contained in sunscreen products on tropical stony corals (Acropora spp.). Sci Total
• Environ. 2018 Oct 1;637-638:1279-1285.
• Green et al. Reduced melanoma after regular sunscreen use: randomized trial follow-up. J Clin Oncol. 2011 Jan 20;29(3):257-63.
• Elston DM , EJ Stratman, and SJ M iller. Skin biopsy: Biopsy issues in specific diseases. J Am Acad Dermatol. 2016 Jan;74(1):1-16; quiz

17-8.

• Levine et al. The indoor UV tanning industry: a review of skin cancer risk, health benefit claims, and regulation. J Am Acad
• Dermatol. 2005 Dec;53(6):1038-44.
• Lim et al. Sunlight, tanning booths, and vitamin D. J Am Acad Dermatol. 2005 M ay;52(5):868-76.
• Riegel DS. Cutaneous ultraviolet exposure and its relationship to the development of skin cancer. J Am Acad Dermatol. 2008

M ay;58(5 Suppl 2):S129-32.

• Sanchez et al. Sun protection for preventing basal cell and squamous cell skin cancers. Cochrane Database S

yst Rev. 2016 Jul 25;7:CD011161.

• Schneider SL and HW Lim. Review of environmental effects of oxybenzone and other sunscreen active ingredients. J Am Acad
• Dermatol. 2019 Jan;80(1):266-271.
• Sunscreen FAQs. American Academy of Dermatology. https:/ / www.aad.org/ media/stats/ prevention-and-care/sunscreen-faqs
• Tollefson M M and AL Bruckner; Section on Dermatology. Atopic dermatitis: skin-directed management. Pediatrics. 2014

Dec;134(6):e1735-44.

• Watts et al. Sunscreen Use and M elanoma Risk Among Y
• ung Australian Adults. JAM A Dermatol. 2018 Sep 1;154(9):1001-1009.
• Zuberbier et al. The EAACI/ GA²LEN/ EDF/ WAO guideline for the definition, classification, diagnosis and management of urticaria.
• Allergy. 2018 Jul;73(7):1393-1414.