It is obvious that people with darker skin (for example African-Americans and Asians) have a lower risk of skin cancer than fair skinned people (for examples those of European lineage).  That is because they incur less ultraviolet-induced DNA damage for the same amount of sun exposure.  So, people assume that having a tan will also protect them against sun damage.  This is a common rationale people give me for going to a tanning salon to obtain a “base tan”.  I have always argued that more of a bad thing does not make a good thing, and that a dark tan only has an SPF of 4.  At that level you can blister off your base tan in one morning by the pool if you don’t wear sunscreen, so I recommend wearing sunscreen from the get go (SPF of 30 or higher) and just tan slowly.

Now there is even better evidence against getting a “base tan”.  In a recent study published in Pigment Cell Melanoma Research by Miyamura et al, the investigators looked at the protection from a tan caused by tanning beds (UVA) and the tan caused by the wavelength that dominates natural sunlight (UVB), and compared that to untanned skin.  First they tanned people with either UVA or UVB, then then they exposed the tanned skin to a combination of UVA and UVB in a ratio that mimics natural sunlight.  The people who had a tan from UVA suffered just as much DNA damage as people whose skin had no “base tan”.  The people who had a tan from UVB were modestly protected, but to obtain their tan they already had extensive DNA damage.

Summary:  Do not go to tanning beds.  Do not use natural sunlight to tan.  If you want a tan for cosmetic reasons, use a self-tanner.  When outside, wear sunscreen and hope for the best!

In case you missed it, July 2009 marked a significant change in attitudes about tanning bed use. Until then, ultraviolet light was considered a probable carcinogen, or cancer causing agent. But after a review of the facts, the World Health Organization toughened its stance.

In June, scientists from nine countries met at the International Agency for Research on Cancer to study data associating tanning beds with the risk of skin cancer. Their conclusion: the use of tanning beds and sunlamps before age 18 increases the risk of melanoma skin cancer by 75%. That’s a lot! They also concluded that tanning beds increase the risk of melanoma of the eye.

These are serious issues that have received surprisingly little press. Melanomas are potentially fatal tumors. The overall incidence of melanoma has already increased from 1:1500 in the 1950’s to 1:50 today. Among Caucasian women age 15-39 the incidence of melanoma increased by 50% between 1980 and 2004. Even for the earliest detected invasive melanomas, disease-free survival 5 years after surgery is about 5%; that means up to 1 in 20 people will be dead or struggling with a recurrence within 5 years. And for melanomas in the eye survival is even bleaker, with the best outcome being alive with one eye surgically removed.

It is unthinkable that something that is placed in the highest risk group for causing cancer, a group that includes x-rays and genital warts, should be so lightly regulated.

The American Cancer Society agrees. According to Dr. Ken Lichtenfeld of the ACS, “The report firmly establishes ultraviolet radiation as a human carcinogen”. He goes on to say, “Young women in particular are the heaviest users of tanning beds, and are at the greatest risk of causing harm to themselves. This report also puts to rest the argument that tanning with UVA light is safe”.

The first priority of the World Health Organization is to restrict the use of tanning beds by those under 18.

Now, there is another dark side to tanning bed use. Not only does ultraviolet light cause cancer, it is also the cause of some of the most obvious signs of aging. A young woman with smooth, evenly toned, wrinkle-free skin who goes to a tanning bed is signing up for age spots, crows feet and other wrinkles, large prominent pores that become blackheads, and lax skin that sags below the bony eye orbit and jawline. Nice!

Just because you are over 18 doesn’t mean you can tan safely. Cancer risk from ultraviolet light is cumulative; that means that the risk goes up the more you are exposed. “Pre-tanning” before a vacation, or “only tanning before the prom”, or “I don’t burn myself in the tanning bed, so it’s OK” are all just justifications for increasing your total exposure to a known carcinogen. Just say no!

Physician do no harm.  This simple statement is the crux of medical therapy, but it can be complicated to weigh the risk/benefit ratio of many treatments.  Too much aspirin causes tinnitus (ringing ears) and bleeding stomach ulcers, yet low dose aspirin is a nearly ubiquitous recommendation as a way to reduce the risk of heart attacks and stroke.  More problematic is when a drug is shown to cause unexpected side effects.  This was the case with Raptiva, or efalizumab, a medication used to treat psoriasis.  Raptiva was pulled from the market June 8 after 3 cases of a deadly brain infection called progressive multifocal leukoencelphalopaty (PML) occured in 1,900 patients who had received the drug for more then 3 years.  I was sad to see Raptive go, because it was a life-changing drug for many of my patients who were using it, but there was no way I would have continued prescribing it anyway; we had already contacted our patients on the drug and begun transitioning them to something new before the drug was pulled.  Genentech, the maker of Raptive, pulled the drug from the market voluntarily, and had maintained a running dialogue as the problem unfolded, so they were in no way the evil corporation out for profit above safety.  What this does show, however, is the difficulty in finding rare side effects that occur only after prolonged use.  Certainly we should all look at any new drug askance while experience with it accumulates, but when the disease is severe and options are limited, sometimes the benefits outweigh the unknown risks.

On a different note, recently Botox received a dreaded “black box” warning label from the FDA.  Black box warnings are given to drugs with potentially fatal side effects, but this is another example of the FDA using a broad brush to deal with an unlikely problem.  Botox is based on a protein, botulinum toxin type A, produced by a bacteria called Clostridium botulinum.  The protein prevents muscles from contracting.  A person who eats a damaged can of food that has been contaminated with Clostridium botulinum will lose muscle control and be unable to breath.  When using this protein as Botox, the dose that will be fatal to 50% of adults is about 3,000 units.  When I inject Botox, however, the maximum dose needed is 100 units and most people receive between 25 and 50 units.  That is a broad margin of safety, equal to or greater then most drugs including aspirin.  So what is the problem?  Botox is also used to relieve the painful muscle spasms of children with cerebral palsy, and the dose used is much larger.  In that group there have been problems with generalized muscle weakness.  To date, I have never read of a documented serious side effect from Botox used for cosmetic purposes, and I have never had one in my practice.  This then is an example of the FDA lumping instead of splitting; the black box warning should have been limited to the medical use of Botox and reflected the risk from using large doses.

Separately, there is a competitor to Botox finally approved by the FDA for use in the United States:  Dysport.  I am glad Botox finally has some competition, which should slow down price increases on this already very expensive drug.  Dysport and Botox have been used in Europe for 17 years, however, and yet Botox has 90% of the market share overseas.  The reason is the difference in the protein itself; botulinum toxin type A is a biologic drug, produced in factories by culturing Clostridium botulinum, and the two drugs use different strains.  Accordingly the two drugs are different in potency and effect; Dysport is more likely to spread further from the point of injection, which is not good for the small areas we treat on the face.  I don’t intend to use Dysport anytime soon, except for the armpits where I use it to treat excessive sweating (hyperhidrosis) and the increased spread of the medication would be a good thing.  Still, I  hope Dysport achieves enough market share to keep the makers of Botox honest about pricing.

Methicillin-resistant Staphylococcus aureus (MRSA) is not a new bacterial problem.  Despite the recent media attention to extremely bad infections, we have had to deal with antibiotic resistant Staphylococcus (staph) since the 1950’s, soon after the introduction of penicillin.  So what makes MRSA so scary?  Let’s separate the facts from the media hyperbole.

After staph became resistant to penicillin, methicillin was created.  This antibiotic was the fallback drug, yet before long methicillin-resistance was encountered.  Initially this occurred in hospitalized patients, but a different genetic type of methicillin-resistant staph then developed in the general community.  Methicillin-resistance became the marker for multiple-drug resistant staph, and in the last few years it has become more common.  However, community acquired MRSA (CA-MRSA) is resistant to fewer antibiotics and is generally less aggressive then hospital acquired MRSA.  CA-MRSA creates the same general problems as non-resistant staph:  boils, infected hair follicles, surgical wound infections, and impetigo are common types of staph infections.   There are still commonly used antibiotics that will treat community-acquired MRSA (CA-MRSA) well. 

So why the hysteria over CA-MRSA?  Well, it tends to infect young, healthy people like athletes, military personnel, and others who are in close contact with other people.  That would be the same group that is infected with any type of staph.  Rarely, the bacteria will cause a more serious infection, like pneumonia, infected heart valves, or a deep skin infection.  That too is the same as regular staph.  CA-MRSA is also mercifully rare.  In one study the incidence of CA-MRSA in an outpatient clinic was 7.5% of infections over 6 years.

Clearly any bacterial infection can be serious.  Jim Henson, the creator of the Muppets, died of streptococcal pneumonia in 1990.  Streptococcus generally causes a sore throat.  Mariana Bridi, a 20 year-old Brazilian model recently died of a Pseudomonas infection, a bacteria that generally causes urinary tract infections.  Similarly, staph and CA-MRSA occasionally cause overwhelming infections. 

Luckily, CA-MRSA and other bacteria are easily removed by daily bathing and, important point here, hand washing.  If you or someone you know develops CA-MRSA or regular staph, there is no need to panic, but pay attention to things like a fever, increasing pain and redness in a skin infection, or signs of other organ systems becoming infected.  There is no need to close schools or businesses, but good hygiene is important.

A recent article in Journal of Drugs in Dermatology (December 2008, Volume 7, Issue 12, page 1153-1157) compared two common medications used in atopic dermatitis:  Protopic and Elidel.  These are both nonsteroidal, topical calcineurin inhibitors used for mild to severe atopic dermatitis.  They are useful as steroid-sparing agents, but have their own risk profile.  Despite that, they are generally considered safer then long-term, medium strength topical steroids.  The problem has been to decide which is better.  Since Protopic has an official indication for moderate to severe atopic dermatitis, but Elidel’s indication has been for mild to moderate atopic dermatitis, I have assumed that Protopic is more effective.  Well, it has been proven true.  In this randomized, comparative 6 week study of 98 patients, patients treated with Protopic achieved a 59% improvement in the signs and symptoms of atopic dermatitis, versus a 43% improvement in patients treated with Elidel.  The patients treated with Protopic also cleared faster.  Notice that both groups of patients improved, and within the study some Elidel patients probably improved more then some Protopic patients.  That is what I notice in my practice, and which makes some patients swear Protopic is ineffective. This study, however, demonstrates the importance of a real trial with an adequate number of participants; overall Protopic is a better treatment.  I will use this study to guide my therapeutic choices.

Looking older is not completely inevitable.  With proper care, you can avoid wrinkles, age spots and coarse, leathery skin changes.

As you know, skin-ageing changes are the result of the inability of your skin cells to repair itself.   Damage can occur to cell membranes, dermal collagen fibers, melanocytes and DNA.  For example, ultraviolet light damages your skin cell membranes so your skin gets rough and coarse.  It also damages dermal collagen, resulting in a sallow skin tone, inelastic and wrinkled skin, and a cobbled skin texture.  Damage to melanocytes causes abnormal pigment production, or brown age spots.  Damaged DNA, among other things, can cause skin cancer.  

Our cells have many mechanisms to correct different types of cellular damage.  Unfortunately, the mechanisms cannot be 100% effective, and they can be overwhelmed by intense or cumulative damage.  Damaged DNA is particularly problematic, since it is the translation of DNA into normal proteins that both allows other cellular components to be repaired, and allows a normal daughter cell to be produced before the skin cell dies. Ultraviolet damage is like a 1950’s commie plot, causing the system to break down due to attack from within.

Now, broad-spectrum sunscreens absorb a tremendous amount of ultraviolet, assuming you put it on, put it on heavily enough, and replace it often enough throughout the day.  In the best of situations, however, some cellular damage will inevitably occur.  While ultraviolet will directly damage your skin cells, a lot of its damaging effect is mediated by free-radicals.  These are oxidative molecules that steal electrons from other molecules and thus damage the structure that was attacked (like your DNA or those cell membranes).

After considering the various anti-oxidants available, I have chosen Revale for sale at our office.  Revale contains the most potent anti-oxidant available topically, derived from coffee berries.  It neutralizes free radical formation and protects your skin from oxidative damage.  If you use this regularly, with frequent application of a good sunblock, you should age more slowly and look younger when others will look old.

Not as sexy a benefit, but your risk of skin cancer should also be lower.

The day-cream contains a good sunblock, suitable for a day in the office.  The night-cream contains a higher level of coffee berry extract, and the cleanser prepares your skin well for absorption of the products.  It works very well with a Clarisonic cleanser, which increases penetration even more.

When sun damage has already occurred, we have several other product lines for more active rejuvenation.  See our web site for details.

Vitamin D is an important chemical that has been found to do far more then maintain healthy bones.  Dermatologists have used a derivative of Vitamin D, calcipotriene, for decades as a treatment for psoriasis.  It is now known that Vitamin D also prevents several types of internal malignancies, cardiovascular disease and some neurologic diseases.  The controversy has been how to obtain Vitamin D.  Natural sunlight generates Vitamin D in the skin, so some have advocated unprotected sun exposure as a means of increasing Vitamin D levels.   Please, read the following excerpt from the American Academy of Dermatology; it is based on scientific facts, not suppositions.  Bottom line:  get your Vitamin D through a healthy diet and don’t unnecessarily increase your risk of skin cancer. 

The American Academy of Dermatology recommends that an adequate amount of vitamin D 

should be obtained from a healthy diet that includes foods naturally rich in vitamin D, 

foods/beverages fortified with vitamin D, and/or vitamin D supplements; it should not be 

obtained from unprotected exposure to ultraviolet (UV) radiation.   

 Unprotected UV exposure to the sun or indoor tanning devices is a known risk factor for 

the development of skin cancer.1  Studies have shown that UV radiation from both the 

sun and tanning devices can cause oncogenic mutations in skin cells.2,3  Use of sunbeds 

have also been associated with increased risk for melanoma and squamous cell 

carcinoma.4 

 To minimize the risk of UV-induced skin cancers, a comprehensive photoprotective 

regimen, including the regular use and proper use of a broad-spectrum sunscreen , is 

recommended.5  This is especially important for those with fair skin, as the amount of UV 

exposure required to maximize vitamin D synthesis in the skin is far less than the 

sunburn dose.6,7  

The Academy also recommends that physicians should discuss options for obtaining sufficient 

dietary or supplementary sources of vitamin D with their patients. 

 Many epidemiological studies suggest an association between low serum vitamin D 

levels and increased risk of certain types of cancers, neurologic disease, autoimmune 

disease and cardiovascular disease.8-16  Further research is needed to determine the 

appropriate serum concentration of vitamin D required for overall good health.17 

 The National Academy of Sciences Institute of Medicine guidelines for vitamin D are a 

standard reference for advising patients on proper minimal intake levels (see Table 

below).18  A higher dose of vitamin D supplementation for individuals with known risk 

factors for vitamin D deficiency (dark skin, elderly, photosensitive patients) should be 

considered.6,19 

It should be noted, however, that the currently recommended adequate intake levels established 

by the Institute of Medicine may be revised upward due to evolving research on the increasing 

clinical benefit of vitamin D.   

Well, as Joe Jackson said in a song, “Everything gives you cancer…”.  A recent study on mice found that their risk of skin cancer went up when they were exposed to both twice-weekly, moderate dose UVB ultraviolet exposure and to several moisturizers.  The presumed culprits were the ingredients sodium lauryl sulfate and mineral oil.  Yikes.  While studies on humans or even other mammals need to be done to test the relevance of this problem, it raises questions.  Clearly manufacturers of moisturizers, and also the cream vehicles used to mix topical medications into, need to prove their products are safe. If moisturizers do cause cancer, this unexpected finding suggests that more ingredients need to be tested for their interaction with ultraviolet light and their possible connection to skin cancer.  More to follow…