Photoprotection in specific populations: Children and people of color

Photoprotection in specific populations: Children and people of color Tania Cestari, MD, PhD,a and Kesha Buster, MDb,c Porto Alegre, Brazil; Tulsa, Oklahoma; and Birmingham, Alabama Improved education on appropriate photoprotection in children is vital. Photoprotection for these individuals should include seeking shade, the use of physical agents (clothing, hat, sunglasses), and application of sunscreens on exposed areas. Avoidance of the use of tanning beds is an important component of education for teenagers. Ultraviolet radiation exposure induces DNA damage and photoaging in all skin types, including people of color. The extent of such damage is inversely related to constitutive skin pigmentation. Therefore, personalized photoprotection recommendations concerning skin cancer risk factors, desired treatment outcomes, health needs (eg, vitamin D), and photoaging based on the needs and preferences of the patient are essential. It is clear that additional research is needed on optimal levels of protection against ultraviolet radiation for people of color. ( J Am Acad Dermatol http:// dx.doi.org/10.1016/j.jaad.2016.09.039.) Key words: children; people of color; photoprotection; tanning beds.

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uidelines for photoprotection and sun exposure recommend that everyone protects their skin from solar ultraviolet (UV) radiation (UVR) exposure by seeking shade, wearing sun-protective clothing, and using a sunscreen with a sun-protection factor (SPF) of at least 30. However, because the understanding of risk from UVR exposure is not consistent among all individuals, and there is a belief by some dark-skinned individuals that photoprotection is not essential, it is clear that more specific guidance and education about photoprotection are needed. Two of these special populations are children (aged #18 years)1 and people of color (POC). For the latter, data on the effects of UVR exposure are limited. The purpose of this article is to highlight the distinctive aspects of photoprotection practice and education in children and in POC.

CHILDREN Solar radiation has more pronounced biologic effects on the skin of children compared with adults.

From Department of Dermatology, Federal University of Rio Grande do Sul, School of Medicine, Hospital de Clınicas de Porto Alegrea; Buster Dermatology, Tulsab; and University of Alabama at Birmingham.c Publication of this supplement is supported by Laboratoires Dermatologiques Avene. Disclosure: Dr Cestari received grants and research funding from AbbVie, Janssen-Cilag, La Roche-Posay/L’Oreal, and Novartis, and honoraria from Pierre Fabre Dermo-Cosmetique/Avene. Dr Buster received honorarium from Pierre Fabre DermoCosm etique/Av ene.

Abbreviations used: 25(OH)D: AAD: ACD: CPD: MED: POC: PP: SPF: UV: UVR:

25-hydroxyvitamin D American Academy of Dermatology Australasian College of Dermatologists cyclobutane pyrimidine dimer minimal erythemal dose people of color pyrimidine-pyrimidine photoproducts sun-protection factor ultraviolet ultraviolet radiation

Children’s skin, particularly up to age 3 years, has a lower concentration of protective melanin and a thinner stratum corneum.2,3 This allows UVR to penetrate deeper, resulting in photodamage. Because the epidermis of very young children is thin, UVR can easily reach dermal papillae and the dermal capillaries, which may promote photoimmunosuppression. In addition, the basal cell layer is relatively rich in stem cells, which are susceptible to

Accepted for publication September 24, 2016. Reprint requests: Tania Cestari, MD, PhD, R Santo Inacio 500 Ap 1002, Porto Alegre RS 90570-150, Brazil. E-mail: tcestari@terra. com.br. Published online December 23, 2016. 0190-9622/$36.00 Ó 2016 Published by Elsevier on behalf of the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2016.09.039

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UVR-induced mutagenesis. Despite these properties, preceding 12 months.19 According to a review of 29 however, the minimal erythemal dose (MED) to UVB studies from Australia, Europe, Japan, Mexico, the in children has been shown to be similar to that of United Kingdom, and the United States, children and adults.4 adolescents spend a mean of 1.5 to 5.1 hours outdoors daily.20 It has been estimated that by 18 to In contrast, infants’ skin develops sunburn more easily than that of adults because the skin of infants is 20 years of age, everyone will have received 40% to thinner and has an increased rate of percutaneous 50% of their cumulative UVR exposure up to age absorption and transepider60 years.21 Thus, preventing 5 mal water loss. In newerythema and sunburn in CAPSULE SUMMARY childhood should help to borns, the ability to develop minimize the development pigmentation (tanning) after Photoprotection in children includes of photodamage and photoUVR exposure has seeking shade, the use of physical carcinogenesis later in life. been demonstrated to occur agents, application of sunscreens on within the first months (30exposed areas, and avoidance of the use 45 days) of life.6 The Photoprotection of tanning beds. Education of peers and increased vulnerability of The most important stratparents are essential. the skin of children to the egy for photoprotection for Although more research is needed, effects of UVR exposure inchildren is behavioral modiphotoprotection for people of color dicates that children and fications related to sun expowould ideally involve personalized their parents need to be sure. Approaches based on recommendations taking into account properly educated on photophysical protection, such as the preferences of the patient and the protection. It should be shade, clothing, hats, and risk factors for photocarcinogenesis and noted that photodamage sunglasses, represent the photoaging. can occur in children of all best and least expensive skin types. photoprotection strategies.22 UVR exposure during A strong body of evidence childhood is a critical period for the increase in indicates that in adults, the use of sunscreens reduces skin cancer risk later in life.7-9 A meta-analysis of 51 the incidence of premalignant lesions (actinic kerastudies concluded that ‘‘ever’’ having a sunburn toses), malignant lesions (squamous cell carciduring childhood almost doubles the risk for the nomas), photoaging (solar elastosis), and even viral development of cutaneous melanoma in adultinfections (herpes labialis) (see Young et al, this hood.10 Studies in immigrants to Australia showed supplement). A number of studies in children have that moving within the first 10 years of life to regions shown that use of sunscreens can prevent the with more intense UVR results in an elevated risk of development of melanocytic nevi, which is strongly developing melanoma and nonmelanoma skin canassociated with the development of cutaneous cer to levels similar to those in inhabitants born in melanoma.23-27 It is important to note that the use Australia; in contrast, moving later in life is associated of sunscreens is intended to minimize UV-induced with a lower risk compared with those born in damage to the skin; it should not be regarded as a Australia.3,11,12 Among indoor tanning bed users, means of increasing the duration of sun exposure. higher risk for the development of basal cell carciFor children aged 6 months and older, current noma was observed in those who started using guidelines recommend a broad-spectrum, watertanning beds in high school or college, compared resistant sunscreen with an SPF 30 or higher, ideally with those who started at 25 to 35 years of age.13 It with a predominance of inorganic (ie, physical) has been calculated that regular use of sunscreen filters (zinc oxide or titanium dioxide, which cause with an SPF of 15 during the first 18 years of life less irritation to sensitive skin).28-30 Ideal sunscreen would reduce the lifetime incidence of basal and products for children should have broad-spectrum squamous cell carcinomas of the skin by 78%.14 Even UVR coverage and good photostability, dispersibilrepeated suberythemal doses of UVR are capable of ity, and aesthetics. They should be water resistant, producing long-term effects that are preventable and have low potential for irritation to the skin and with use of medium SPF sunscreen.15 eyes. Sunscreen should be applied in adequate Among US children, the incidence of sunburn is amounts (2 mg/cm2) covering all exposed skin high: 29% to 83% over the entire summer season, and surfaces, paying special attention to areas such as 7% to 13% over any summer weekend.16-18 In 2010, the ears, neck, and the backs of the hands. It should approximately one third of US teens aged 14 to be applied 20 minutes before sun exposure, and 17 years reported having had a sunburn during the reapplied approximately every 2 hours when d

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Table I. American Academy of Pediatrics sun-protection recommendations for infants and children Infants aged \6 mo

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Infants aged $6 mo Infants and children

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Keep out of direct sunlight. Cover with appropriate protective clothing and hats. Apply sunscreen on small exposed areas only when sun avoidance impossible. Protect skin by dressing in cool, comfortable clothing that covers the body. Use a hat. Limit sun exposure between 10 AM and 4 PM. Use child-sized sunglasses with UV protection. Use broad-spectrum sunscreen with SPF $15, apply 15-30 min before going outside and reapply every 2 h and after swimming, sweating, or drying off with a towel. For sensitive areas of the body (nose, cheeks, tops of ears, shoulders), use a sunscreen containing zinc oxide or titanium oxide. Supplementation with vitamin D 400 IU daily.

SPF, Sun-protection factor; UV, ultraviolet. Adapted from American Academy of Pediatrics Sun Safety information.29

outdoors. Sunscreens in cream and lotion form are better for an even application. When spray is used, it should be sprayed onto the palm of the parent/ guardian, and then applied to the skin of the child. When using spray, care should be taken to avoid inhalation. Sunscreen sticks should be used for the lips. Sunscreen should be incorporated into the daily routine of children in the same way as adults. For infants younger than 6 months, most organizations, including the American Academy of Pediatrics (Table I),29,30 the American Academy of Dermatology (AAD),28 and the US Food and Drug Administration,31 recommend keeping them out of direct sunlight as the most appropriate photoprotection measure. Application of sunscreens should be minimized for several reasons. The skin of infants is less mature and therefore prone to a greater degree of percutaneous absorption. Furthermore, infants have a higher surface area to bodyweight ratio compared with older children and adults. In practice, if exposure to sunlight is unavoidable, a small amount of sunscreen with SPF of at least 15 can be applied to the exposed areas such as the cheeks and back of the hands.28,31 Sunscreens should be washed off once the infant is no longer sun-exposed. The Australasian College of Dermatologists (ACD) and Cancer Council Australia advise against exposing infants younger than 12 months to direct sun when UVR index levels reach 3 or higher.32 Children and photoprotection Despite public health campaigns to encourage sun-protection behavior, the use of sunscreens in children and adolescents is still suboptimal, even among those with a family history of skin cancer.33,34 In the United States, national surveys of children aged 12 years or younger reported that only 61.8% had ‘‘ever used’’ suncreens.35 In another survey of

children aged 5 to 10 years, only 62% were found to use sunscreen regularly.36 A study evaluating data on sunscreen use between 1999 and 2009 found that 62% to 65% of high school students reported never or rarely wearing sunscreen on a sunny day.37 A survey of a nationally representative sample of high school students found a decline in the use of sunscreen between 2001 (67.7%) and 2011 (56.1%).38 Even when sunscreen is applied, administration is known to be inadequate. In the Children and Sunscreen Study, children were found to apply sunscreen at a median thickness of 0.48 mg/cm2, less than one quarter of the quantity of sunscreen used during SPF testing (2 mg/cm2), indicating that the in-use SPF was less than one fourth of the SPF on the label.39 A number of reasons have been documented as to why many adolescents worldwide are not interested in sun protection. A major reason is the positive attitude toward tanning.40 In a survey done in Brazil of adolescents aged 12 to 19 years, 72% said they felt more attractive with a tan.41 Tanning was also associated with the perception of a better body image among US high school students.42 Many adolescents who avoid sunscreen use are unaware of the skin cancer risks associated with sun exposure, especially outside the United States.43-45 Even among those who are aware of the harmful effects of the sun on the skin, many still favor tanning.46 Adolescents are more likely to use sunscreen if their parents/ guardians expect them to wear it or if they always bring some with them when they are planning to be out in the sun.46,47 Nonetheless, sun-protection practices among adolescents appear to be declining.48-50 Infants, toddlers, and younger children are more dependent on parent/caregiver beliefs and attitudes about sun protection.51,52 Conversely, a parental positive attitude toward tanning is inversely

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associated with protective measures taken for the children.53 Sunscreen use in parents is predictive of use in their children.54,55 Although some improvement has been reported, parents of adolescents in the United States continue to report low compliance with recommended sun-protection behavior. Although sunscreen is applied to children frequently, it is not always applied appropriately.56 Education on photoprotection The US Preventive Services Task Force recommends skin cancer counseling on sun-protection behavior for children, adolescents, and young adults aged 10 to 24 years with fair skin,57 based on limited evidence from clinical trials showing a small beneficial effect.58 Despite this recommendation, which is supported by many medical organizations, only a small percentage of physicians appear to be implementing it into their practice. According to a national survey, children and adolescents were the least likely to be recommended sunscreen (0.07% of physician visits) compared with all other age groups.59 Because children are influenced by parental sunprotection behavior, it is clear that parents should be counseled along with their children. Raising awareness about the deleterious effects of sun exposure and changing attitudes toward the importance of photoprotection is the most effective strategy for educating children and their parents/ guardians on photoprotection.60 Although education strategies for photoprotection have been widely effective in increasing public knowledge, they have yet to achieve meaningful changes in behavior.61 Public health campaigns that educate children and their parents/caregivers, such as SunSmart (Victorian Health Promotion Foundation and Cancer Council Victoria, Australia), the best known and longestrunning of the campaigns,62 achieved some results in changing sun-protection behavior, although the level of improvement in some behaviors appears to have plateaued.63 School programs are key to improving sunexposure behaviors; they can organize activities involving families to encourage sun-safe behaviors at home.64,65 In the national SunSmart schools program, schools with a written sun-protection policy saw a significant link to practice of sun-protection behavior among pupils.66 The US SunWise School Program (National Environmental Education Foundation), which provided a brief period of sunprotection education to schools,67 was associated with improvements in children’s knowledge of photoprotection, and modification in their perception of the healthiness of a tan and their intentions to seek shade when outdoors.68 SunWise was

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estimated to have prevented more than 50 premature deaths and nearly 11,000 skin cancer cases, along with $2 to $4 in medical care costs and productivity losses for every $1 invested in the program.69 Regional programs targeting children, such as SunSafe in New Hampshire (National Cancer Institute) and SolSano in Arag on, Spain, also produced improvements in sun-protection practices and a reduction in the number of children who experienced a sunburn during the summer.70-72 The most efficient programs targeting children, according to the World Health Organization, involve training sessions that are long, repeated, or both, with active individual participation.73 Programs based on the deleterious consequences of sun exposure on physical appearance seem to produce better results in terms of changes in attitude and behavior. Programs for children should be ageappropriate. Education through drama and art that allows active participation is particularly suitable for children who have not yet achieved high levels of reading and writing skills. Strategies to educate older children and adolescents may be incorporated into the regular curriculum, making use of the Internet (World Wide Web sites, blogs, social media, messaging), which children perceive as ‘‘not boring.’’ Conferences should involve specialists trained in youth language, using medical students and very young professionals with whom children can identify and use as role models more easily than older teachers. A clear message should be communicated that being attractive and healthy do not mean being tan, and aesthetic alternatives should be presented.74 Education on the side effects of indoor tanning should be done, and restriction of indoor tanning by minors should be enforced.75 It should be noted that minors aged younger than 18 years are banned from tanning salons in a number of European countries, including France, Germany, and the United Kingdom.76 In the United States, a number of states have passed laws preventing the use of indoor tanning devices by minors. Tanning salons are banned altogether in Australia77 and Brazil.76 General practitioners and pediatricians are in an excellent position to promote sun protection because they see children and families on a regular basis. Dermatologic societies should ensure that the message about sun protection is consistent and understandable by the target audience.

PEOPLE OF COLOR POC constitute a broad range of racial and ethnic groups and vary widely in skin tone. Accounting for about 28% of the US population,78 POC are

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commonly skin types IV to VI by the Fitzpatrick classification, but can includes lighter skin tones based on the racial/ethnic heritage with which the person identifies.79,80* Originally developed for categorizing white skin according to UVR sensitivity, the Fitzpatrick classification has been identified as less useful in POC, particularly people of African descent,81,82 Asians,83,84 Arabs/Mid-Easterners,85 and lighter-skinned Hispanics.82 Other, more objective systems have been created to measure constitutive skin pigmentation that could serve as more accurate and consistent criteria for defining skin color. These include direct measures such as spectrometry and colorimetry,86-89 and visual inspection measures such as skin color identification charts that can be used without specialized training.90,91 Photocarcinogenesis Skin cancers, including melanoma, are less prevalent in POC but associated with a poorer prognosis compared with Caucasians.92 Melanoma in American blacks and non-white Hispanics tends to be given a diagnosis at a more advanced stage with lower 5-year survival than in whites.93,94 UVR exposure is a risk factor for skin cancer in POC, including African Americans, Asians, and Hispanics92,95-101 although the risk is lower in darker skin compared with lighter skin types.93 This is attributable to the higher content of melanin of darker skin102,103 that directly correlates with decreased UVR sensitivity and UVR-induced DNA damage compared with lighter skin.104 Despite the protective mechanisms of melanin, however, epidemiologic studies have shown that sunburn occurs even in darkly pigmented POC105-107 and UVR-induced skin damage has been documented in all skin phototypes, from very light to very dark tone.89 Cyclobutane pyrimidine dimers (CPDs), the major photoproduct when DNA damage is generated by UVR exposure, have been shown to form in all epidermal layers in light skin, whereas they only form in the suprabasal layers in brown and darkbrown skin.91 A study in people representing 6 different racial/ethnic groups using a light source emitting both UVB and UVA found that although DNA damage was most pronounced in light-toned, UVR-sensitive skin types, the darkest, UVR-resistant skin incurred significant DNA damage at levels of 1 or less MED.108 However, levels of DNA damage were approximately 7- to 8-fold lower in black skin *This review follows American Medical Association style guidance in using race/ethnicity terminology as defined by the original investigators in the literature cited (http://www.amamanualofstyle. com).

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compared with white skin (other racial/ethnic skin types gave consistently intermediate values). DNA damage peaked immediately after irradiation in all subjects and was gradually reduced toward the background level over time, but there was no correlation between melanin content or racial/ethnic group and rate of DNA damage removal/repair. A follow-up study in fair, intermediate, and dark skin types showed that immediately after 1 MED UVR exposure, levels of 6-4 pyrimidine-pyrimidine photoproducts (PP) were 3.9-fold lower (P \.05) in dark skin compared with fair skin.109 DNA damage in intermediate and dark skin was significantly lower in the lower epidermis than in the upper epidermis immediately after UVR exposure (1.4-fold, P \ .05 and 2.5-fold, P\.01, respectively). This was not seen in fair skin, suggesting that the upper epidermis protects against UVR-induced 6-4PP, particularly in darker skin. No significant differences were found in 6-4PP levels at 1 and 7 days after UVR exposure among dark, intermediate, and fair skin, indicating that the repair of 6-4PP is rapid across skin types. CPD formation after UVR exposure did not differ significantly between the lower and upper epidermis of fair skin after UVR exposure, but in dark skin it was 2.1-fold or greater (P \ .01) less in the lower epidermis compared with the upper epidermis, even though dark skin required 2-fold more UVR to reach 1 MED. This indicated that UVR reaches deeper in lighter skin and that the repair of CPD after 1 MED UVR exposure is decreased in fair skin compared with dark skin. Melanin content correlated inversely with 6-4PP and CPD formation in the upper and lower epidermis, showing that less DNA damage occurs in the lower epidermis in dark skin whereas DNA damage in the upper epidermis is similar among racial/ethnic groups after exposure to UVR. Although the skin in the studies noted above suffered injury with 1 MED, even at suberythemal doses light, intermediate, and dark skin types incur DNA damage.108,110 There is an inverse relationship between constitutive skin pigmentation and DNA damage,89,108,109,111-113 so that darker skin acquires less and light skin more DNA damage after UVR exposure. In black skin, melanin provides SPF approximately equivalent to 13.4, compared with 3.4 in white skin.92,99 Therefore, the intrinsic SPF in black skin is similar in value to the SPF of sunscreen (SPF 15) used in a 4-year Australian study with an 8year follow-up, which demonstrated that regular use of sunscreen reduced the development of actinic keratoses, squamous cell carcinoma, and melanoma, and to a lesser extent, basal cell carcinoma.114 Given the varied level of intrinsic photoprotection, the level of external photoprotection needed for prevention

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of DNA damage in skin with different amounts of pigmentation may vary. Photoaging As with photocarcinogenesis, constitutive pigmentation exhibits an inverse relationship with photoaging. Compared with Caucasians, people with darker skin manifest photoaging much later in life, in approximately the fifth and sixth decade.115 Visual assessment of photoaging shows more severe fine lines, wrinkles, laxity, and overall photodamage in white skin, whereas African American skin shows more hyperpigmentation and uneven skin tone.116 Dermatosis papulosa nigra, idiopathic guttate hypomelanosis, and other forms of dyspigmentation are also seen in darker-skinned patients.117 Pigmentary disorders such as melasma and postinflammatory hyperpigmentation disproportionally affect POC and UVR can worsen hyperpigmentation and reverse the progress made with therapy.112 Asian populations also show pigmentary changes and increase in wrinkling.118,119 Few data are available on photoaging in Hispanic populations, but 1 study reported that at least fine wrinkles are present120 and other photoaging changes might be expected in these populations. Solar (actinic) elastosis, the dermal histologic hallmark of photoaging, is seen in Asian and Hispanic skin along with Caucasian skin.120,121 A 1991 study found no solar elastosis in black skin regardless of patient age,122 although a later study reported high-grade solar elastosis in 10% of African American subjects.123 DNA damage is seen in fibroblasts in the papillary dermis of light, intermediate, and tan-colored skin, but not in brown or dark skin.89 Avoidance of sun exposure and use of sunscreen are widely accepted photoprotective practices against photoaging as they limit or eliminate UVRinduced DNA and collagen damage.124 Although sunscreens are the most widely used photoprotective measure in the United States, United Kingdom, and Europe, in other parts of the world cover-up clothing and parasols are widely used. There are few data on appropriate levels of photoprotection to slow photoaging in POC. Kim et al125 showed that sunscreen was effective at the stated SPF in Asian skin when the recommended amount of 2 mg/cm2 was used, but that SPF values were decreased when lower doses were applied. Photoprotection behavior A number of studies have demonstrated that POC are less likely to practice sun-protective behaviors. Of African Americans surveyed in New York, 74% (n = 50) never used sunscreen,126 whereas a larger

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study (n = 2187) of African Americans living in California found that 62.7% never used sunscreen and 39.1% never wore a wide-brimmed hat.127 Only 31% reported always using 1 or more sun-protective behavior (ie, sunglasses, hat, and/or sunscreen). Analysis of data from the 2003 to 2006 National Health and Nutrition Examination Survey (n = 6549) indicated that non-Hispanic blacks were more than 7 times less likely to use sunscreen than were nonHispanic whites.128 Although this study reported that Hispanics were only about 1.5 times less likely to use sunscreen than non-Hispanic whites, other studies in Hispanics have reported higher rates of failure to apply sun protection. A survey of 149 Hispanic workers in the United States reported that 69% never or rarely used sunscreen while working outdoors in the sun.129 Another study found that almost half (47.1%) of 1676 Hispanic adults surveyed in the United States never or rarely used sunscreen and 60.3% never or rarely wore sun-protective clothing.130 In an analysis of data from a national survey in Puerto Rico,131 where 88% of the population identifies as Hispanic (75.8% white, 12.4% black) and skin cancer incidence has quadrupled in recent decades,132 approximately half of the 639 respondents reported they never applied sunscreen or wore a hat when outside on a hot sunny day.131 In a study examining photodamage in Koreans, none of the 407 subjects used sunscreen.119 Pengpid and Peltzer133 examined sun-protection behavior in 25 countries (n = 18,687, Fitzpatrick skin types II-V) and confirmed that lighter skin color is associated with more frequent use of sun protection. Analysis of a US health survey indicates that blacks are aware of their lower risk of skin cancer,134 but they, like Hispanics, did not have accurate perceptions regarding other skin cancer risk factors (eg, lifestyle) or symptoms.134,135 Awareness of decreased skin cancer risk may help explain why some POC are less likely to use sun protection.134,135 Other reasons cited by whites, Asian/Pacific Islanders, and Hispanics for not using sunscreen include ‘‘I often forget’’ and ‘‘It is too greasy.’’136 The third most cited reason by Hispanics for failing to use sunscreen was ‘‘I am dark skinned.’’136 POC may also be less likely to be prescribed a sunscreen by their physician.59,135 The National Ambulatory Medical Care Survey of patient visits to nonfederal outpatient physician offices at US ambulatory care practices between January 1989 and December 2010 found that sunscreen was recommended in 237 visits annually for every 100,000 visits by white patients compared with 26 visits annually for every 100,000 visits by black patients.59 Compared with black patients, white patients were

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Table II. American Academy of Dermatology recommendations for photoprotection and early detection of skin cancer in people of color d d d

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Seek shade whenever possible. Wear sun-protective clothing. Wear a wide-brimmed hat to shade the face and neck, and shoes that cover the entire foot. Wear sunglasses with UVR-absorbing lenses. Apply broad-spectrum sunscreen with SPF $30. Sunscreens without inorganic filters (titanium dioxide and zinc oxide) are generally better accepted by people of color because of their better cosmesis on dark skin. Apply sunscreen to dry skin 15-30 min before going outdoors. When outdoors, reapply every 2 h to all exposed skin, and after perspiring or swimming. Avoid exposure to indoor tanning beds/lamps. Take vitamin-D supplement: 400 IU daily for infants age #1 y, 600 IU daily age 1-70 y, and 800 IU daily age [70 y. Perform monthly self-skin examinations, paying close attention to subungual skin, palms, soles, mucous membranes, groin, and perianal area.

SPF, Sun-protection factor; UVR, ultraviolet radiation. Reprinted with permission from Agbai et al.148

9 times more likely to be recommended sunscreen. Physicians are also less likely to prescribe sunscreen for treatment of dyschromias in POC than whites, as demonstrated by an analysis of more than 5 million patient visits for the sole diagnosis of dyschromia.137 Sunscreen use was prescribed for 32% of whites compared with 17% of blacks and 7% of Asians. A goal of Healthy People 2020 is to increase by 10% the proportion of adults across racial and ethnic groups who follow protective measures that may reduce skin cancer risk.138 Photoprotection recommendations The amount of sun protection needed by POC is difficult to define, because it is necessary to balance between minimizing the risk of sunburn, skin cancer, and photoaging, with the need for adequate levels of vitamin D, which is produced endogenously when UVB from sunlight strikes the skin and triggers vitamin-D synthesis. Low levels of serum 25hydroxyvitamin D [25(OH)D] have been linked to cardiovascular disease; all-cause mortality; breast, colorectal, and prostate cancer; and impaired bone health in a number of studies, but a recent Agency for Healthcare Research and Quality report concluded that the findings were inconsistent and that no firm conclusions could be drawn.139 POC, including African Americans and, to a lesser extent, Hispanics have consistently been shown to have lower serum 25(OH)D levels compared with whites.140 However, several studies have indicated that optimal levels of

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25(OH)D in African Americans may be lower than in Caucasians (approximately 20 vs 30 ng/mL, respectively)141,142 This has been supported by the identification of 3 genetic markers for serum 25(OH)D in African Americans but not in Caucasians.143 Beyond vitamin-D synthesis, continued research may reveal additional benefits of UVR. Recent observational evidence suggests that extensive sun avoidance in Swedish women (n = 29,518) is associated with increased mortality,144 and increased solar UVR exposure with decreased cardiovascular and overall death.145 It is not known whether these outcomes are associated with vitamin-D levels. Of note, Sweden is a country of increased latitude and thus lower UVB irradiance and UV index compared with the United States. However, studies in the United States have also identified an inverse association between UVB irradiance and cancer in Caucasians along with POC including African Americans, Asians, and other minorities.146,147 Guidelines on skin cancer and photoprotection in POC for health care providers and patients in the United States were issued by the AAD in 2014.148 Although the authors acknowledged the lack of sufficient data to support specific SPF requirements based on skin type, these recommendations cover prevention of skin cancer and reduction in photoaging and UV-induced dyspigmentation. The AAD recommendations for photoprotection and early detection of skin cancer in POC are shown in Table II. Other guidelines that provide recommendations for POC include those of the ACD. In conjunction with other medical organizations in Australia and New Zealand, the ACD issued a position statement on skin cancer prevention and vitamin D in 2007 cautioning that naturally dark-skinned people (Fitzpatrick skin type V and VI) are at higher risk of vitamin-D deficiency.149 The statement advises that because people with dark skin are relatively protected from skin cancer by skin pigmentation, they may safely increase exposure to the sun to increase vitamin-D levels. However, a more recent version of the position statement (2016) takes a more personalized approach and advises that very dark-skinned people and others at risk for vitamin-D deficiency discuss their vitamin-D needs with their medical practitioner to determine whether sun exposure or dietary supplementation is suitable.150 A consensus statement issued in 2010 by the British Association of Dermatologists states that people with darker skin will require longer UV exposures to produce the same amount of vitamin D as people with lighter skin, but recommends that people at risk for vitamin-D deficiency such as those with darker skin take a 10-g supplement of vitamin

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D daily.151 The statement asserts that with ‘‘sun exposure, little and often is best, and the more skin that is exposed, the greater the chance of making sufficient vitamin D before burning.’’ Given the various elements to consider in determining ideal photoprotection in POC, it is likely that personalized recommendations based on constitutive pigmentation and UV index will be key in balancing risks and benefits of UVR exposure. This may be based on personalized technology such as telephone apps that can advise on the need for UV protection based on location and skin type (eg, World UV [http://www.bad.org.uk/for-the-public/ sun-awareness-campaign/world-uv-app]). Such recommendations may eventually be optimized by considering the needs and preferences of the patient, skin cancer risk factors (eg, history, immunosuppression), desired treatment outcomes (eg, correction of dyspigmentation), health needs (eg, vitamin D), aesthetic concerns (photoaging), and exposure (eg, time, skin, activity). To achieve this, additional research is needed on optimal levels of UVR protection for POC. Greater awareness in POC of the risks of UVR exposure can be achieved through increased education and public health campaigns using television, social media, the Internet, newspapers, and public billboards specifically tailored to the various racial and ethnic groups that comprise POC.

SUMMARY Children and POC are 2 special populations for whom a more focused photoprotection education is needed. For children, the education message should be age-appropriate, and engagement of parents/ guardians is essential. In POC, photoprotection education and recommendations based on constitutive pigmentation and UV index is likely necessary to balance the risks and benefits of UVR, but more research is needed. REFERENCES 1. Balk SJ. Council on Environmental Health and Section on Dermatology, American Academy of Pediatrics. Technical reporteultraviolet radiation: a hazard to children and adolescents. Pediatrics. 2011;127:e791-e871. 2. Stamatas GN, Nikolovski J, Luedtke MA, Kollias N, Wiegand BC. Infant skin microstructure assessed in vivo differs from adult skin in organization and at the cellular level. Pediatr Dermatol. 2010;27:125-131. 3. Volkmer B, Greinert R. UV and children’s skin. Prog Biophys Mol Biol. 2011;107:386-388. 4. Cox NH, Diffey BL, Farr PM. The relationship between chronological age and the erythemal response to ultraviolet B radiation. Br J Dermatol. 1992;126:315-319. 5. Hoeger PH, Enzmann CC. Skin physiology of the neonate and young infant: a prospective study of functional skin parameters during early infancy. Pediatr Dermatol. 2002;19:256-262.

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