Sun smarts: The essentials of sun protection

S

un exposure can be a problem. Excessive sun exposure causes a change in the skin’s blood flow, cell kinetics, and pigment products. Damages (occurring primarily from ultraviolet B radiation) include erythema, pigmentary or texture changes, and potential carcinogenesis. Ultraviolet radiation from the sun can also damage the lens and retina of the eye, causing cataracts and other conditions harmful to vision later in life. Initial injury from sun exposure begins as quickly as 30 minutes after exposure, peaks at 24 hours, and may last for 72 hours. Medications (especially griseofulvin, nonsteroidal anti-inflammatory drugs, oral contraceptives, tetracycline, topical diphenhydramine, and tretinoin) and certain illnesses are other factors that contribute to sun sensitivity. Children are at increased risk for sunburn and its sequelae because of the amount of time they spend in the sun. Most people receive 80% of their lifetime exposure to sun by the time they are 18 to 21 years of age (Kim, Ghali, & Tunnessen, 1997; Weston, Lane, & Morelli, 1996). Blistering sunburns before 20 years of age more than double the chance of skin cancer. Factors contributing to the degree of burn include the coloring of skin and hair (see Box 1) and the amount of previous sun exposure. Bums are less common in children with darker hair and skin because of their increased amount of melanin. Other factors affecting skin sensitivity are timing of sun exposure, altitude, and latitude, because ultraviolet rays are strongest between 10 AM and 2 PM, at higher alti-

136

tudes, and nearer the equator. Sunburn can occur on cloudy days, and reflection from sand, water, snow, and concrete increase the risk of bum. Photoaging effects of the sun include telangiectasia and actinic keratosis, cataracts, retinal damage, heat stroke, and a change in immune response (Kim et al., 1997). Cases of skin cancer (basal cell carcinoma, squamous cell carcinoma, and malignant melanoma) and resultant deaths are increasing rapidly, with 1 million cases diagnosed annually. Two percent of these cases occur in children (Kim et al., 1997; Orlow, 1995). Risk factors for skin cancer include skin types 1 and 2, history of multiple blistering sunburns, presence of multiple atypical moles, development of new nevi, and a family history of melanoma. Basal and squamous cell carcinomas are slowspreading cancers that are directly linked with long-term exposure to ultraviolet light. Basal cell carcinomas appear in varied forms, as nodular, pearly pigmented lesions often located on the hand, neck, or head. Squamous cell carcinomas appear as quickly growing firm indurated nodules with or without ulceration on sun-exposed areas, especially the rim of the ear, face, lips, and mouth. Malignant melanomas account for 5% of skin cancers but 75% of deaths (Kim et al., 1997).

Melanomas appear as new lesions or as changes in existing moles. Melanomas have a link to multiple severe, blistering sunburn, but family history is a more important factor. The majority of melanomas are found in sun-exposed areas in White adolescents (Orlow, 1995). Any change in a mole, especially with rapid asymmetric growth, crusting, ulceration, or color variation, calls for immediate evaluation.

MINIMIZING ADVERSE EFFECTS OF SUN EXPOSURE Education is a key component in minimizing injury from sun exposure. Initially, ensuring that every child and parent knows his or her skin type and sun protection needs is essential (see Box 1). Continual reinforcement that a tan is not a sign of good health but of skin injury also is important. This strategy includes modeling sun-smart behavior and working to enforce the idea that there is no such thing as a healthy tan. Programs have been developed that teach sun protection; for example, the American Academy of Dermatology and Coppertone sponsor a program called “Block the Sun, Not the Fun.” This program includes curricula, family support materials, and posters to educate elementary-aged children about decreasing sun exposure and

Reprint requests: Nancy Barber Starr, MS, CPNP, Aurora Pediatric Associates, Aurora, CO 80012. J Pediatr Health Care. (1999). Copyright

+0

Ave, #l 10,

13, 136-I 38.

0 1999 by the National Association

0891~5245/99/$8.00

13650 E Mississippi

of Pediatric Nurse Associates

& Practitioners.

25/S/97905

May/June

1999

El

PATIENT MANAGEMENT EXCHANGE

BOX II Skin types and protection needs l l l l

l

l

Fair (Celtic, Irish)-always burns, never tans; SPF 15+ Fair (Caucasian)-easily burns, minimally tans; SPF 15 Lightly pigmented (dark Caucasian)-sometimes burns, gradually tans; SPF 8-10 Pigmented (Mediterranean, Asian, Hispanic)-minimally burns, always tans; SPF 6-8 Moderately pigmented (American Indian, Hispanic, Mid-Eastern)-rarely burns, profusely tans; SPF 4 Heavily pigmented (American and African Black)-never or rarely burns, deep tan; no or low SPF needed

BOX 2 Resources Block the Sun, Not the Fun American Academy of Dermatology 930 N Meacham Rd, PO Box 4014 Shaumberg, IL 60168 telephone: (800) 462-DERM or (312) 8X-8888 Web site: www,aad.org or. www.coppertone.com Skin cancer atlas and other dermatologic information Loyola University Dermatology Medical Education Web Site www.meddean.luc.edu/lumen/ MedEd/medicine/dermatology/ mel-ton/title.htm/

Shadesby Biobottoms PO Box 1607 Secaucus, NJ 07094-3613 telephone: (800) 766-7254

increasing protective behavior (see Box 2). Sun-smart behaviors include using appropriate protective and avoidance behaviors. protection from the sun can be achieved with sunscreens, sunblocks, sunglasses, hats, and clothing. Sunscreens block the rays of the sun to help prevent sunburn. Sun protection factor (SPF) is the length of time a person can be exposed to the sun without burning if sunscreen is used appropriately The substarttivity of a sunscreen describes its adherence. Sweat resistant (effective for up to 30 minutes of heavy continuous perspiration), water resistant (effective for up ‘to 40 minutes of swimming) and waterproof (effective for up to 80 minutes of immersion) are different types of substantivity. Sunscreens are available in various chemical combinations (eg,

JOURNAL OF PEDIATRIC HEALTH CARE

Skin Cancer Foundation PO Box 561 New York, NY 10156 OR 245 5th Ave #2402 New York, NY 10016 telephone (212) 725-5176

So/umbra by Sun Precautions 2815 Wetmore Ave Everett, WA 98201 telephone: (800) 882-7860 Stingray Bay Sun Protection telephone: (800) 969-4SUN Web site: www.stingrayby.com

SunSkinsby After the Stork PO Box 4432 1 Rio Rancho, NM 87174-4321 telephone: (BOO) 441-4775 or (800) 61 O-0094

para-aminobenzoic acid [PABA], PABA esters, cinnamates, benzophenes, salicylates, octocrylene, and dibenzoyl-methane) and vehicles (eg, emollient for dry skin, gel or lotion for oily skin, and noncomedogenic for acne-prone skin). If a child is sensitive to one sunscreen, try another with different ingredients. A PABA-free sunscreen is recommended for children. Dibenzoyl-methane provides the most protection from ultraviolet A radiation. Sunblocksscatter and reflect light. Zinc oxide, titanium oxide, or a combination product such as Sportz Bloc are useful for especially sensitive areas such as the nose, lips, or previously burned areas (see Box 3 for specific recommendations about the use of sunscreens and sunblocks). Sunglasses should be used beginning in infancy whenever a child is in

Barber Starr

the sun long enough to get a burn or tan. Neither dark lenses, mirror lenses, nor polarized lenses offer the protection needed; protection comes from a chemical that is added to the lens. One of the following labels indicates adequate ultraviolet radiation protection: “blocks 99% of UV rays,” “UV absorption to 400 run,” “special purpose,” and “meets ANSI UV requirement.” Sunglasses that have large framed, wraparound lenses with side shields provide the best protection. The lens and frame should be nonbreakable plastic. Wearing a hat with a wide (3 inch) brim and neck drape for full protection is also recommended in addition to sunglasses. Tight weave, long-sleeved, longpant clothing with sunscreen applied to skin underneath provides maximum protection. Color, weight, stretch, wetness, and quality of material all affect the amount of protection offered. Solumbra and SunSkins are clothing lines that provide 30+ SPF and block 97% of ultraviolet rays. Shadesis another line with clothing that provides 81% ultraviolet protection. Stingray Bay Sun Protection offers swimwear that blocks 99% of the sun’s rays (see Box 2 for information). Good rules for avoiding damaging sun exposure include staying out of the sun between 10 AM and 2 PM, rninimizing the length of time in the sun, and learning the “shadow rule” (seek shade if your shadow is shorter than you are tall). Remember to be cautious when at higher altitudes, at a latitude near the equator, on cloudy days, or near reflection from sand, water, snow, or concrete. Many newspapers print the predicted index of ultraviolet exposure (1 to 10) as prepared by the National Weather Service. Additional sun-smart behaviors include avoiding tanning devices or parlors and staying out of the sun while taking the medications listed in the first paragraph.

DEALING WITH THE RESULTS OF SUN INJURY Sunburn is the most common sun injury seen by NPs. Cool water or saline solution compresses and ice packs at least 4 times a day ease pain and reduce swelling. Baking soda or cornstarch baths help cool skin, and white vinegar or milk compresses initiate healing. Extra fluid intake is important to prevent dehydration and restore natural moisture

May/June 1999

13 7

PATIENT MANAGEMENT

EXCHANGE

BOX 3 Sunscreen recommendations

Barber Starr

BOX 4

Use a sunscreen with at least a 15 SPF, nonalcohol base, without lanolin, parabens, or fragrance. Use a waterproof product when in water but reapply every 80 minutes with continuous water exposure. l Apply at least 30 minutes before exposure to sun; reapply at least every 2 hours while in the sun, and after swimming, toweling, or heavy perspiration. l Apply liberally (1 oz for an adult) and, for better coverage, use cream instead of lotion. l Pay special attention to the eyelids, nose, cheeks, ears, neck, scalp, shoulders, hands, and feet. Use a lip balm with a SPF of 15 or sunblock. l Do not use sunscreen on infants less than 6 months of age, but keep the baby out of the sun completely, using shade, a widebrimmed hat, and protective clothing. . Use sunscreen daily in summer or in warm climates. Use even on overcast or cloudy days. . Extra protection is needed with increasing altitude, closer location to the equator, and near sand, snow, concrete, or water reflection. l Set an example by using sunscreen yourself.

l

Monthly

skin examination

The ABCDE’s of skin examination l Asymmetry . Border irregularity or notching l Color variation, especially if multicolored l Diameter greater than 6 mm l Elevation, especially if asymmetric Note any new growths, itchy patches, nonhealing sores, changes in size, irritability, or different sensation in any moles.

balance. Skin emollients such as aloe Vera or moisturizer provide comfort if the skin is dry. Jojoba oil and vitamin E creams are sometimes helpful. Avoid use of petrolatum, butter, or any occlusive ointment, which only intensifies the burn. Prostaglandin inhibitors such as ibuprofen (5 to 10 mg/kg per dose given as soon as possible and every 6 to 8 hours for the next 2 to 3 days) or acetaminophen offer fever and pain relief. Low-dose cortisone creams (0.5% or 1%) 2 to 3 times a day reduce inflammation and pain but must be used with caution because of increased absorption by damaged skin. Local anesthetic sprays or first-aid creams with benzoCaine are contraindicated because of the risk of sensitization. If bhsters break, dead skin should be trimmed and an antibiotic ointment applied. NPs should be involved in screening for skin cancer. All school-age children,

The process of skin examination Use a full-length mirror, a hand mirror, and a brightly lit room. Examine the following areas: l Front and back and right and left sides with arms raised l Elbows (bend them), forearms, and back of arms and palms l Back of legs and feet, toes and soles l Back of neck and scalp l Back and buttocks

adolescents, and any child with risk factors (listed previously) should be taught to do a monthly skin evaluation (see Box 4). Any child with suspicious lesions should be referred for further evaluation. Treatment consists of surgical removal and histologic evaluation. Being a sun-smart provider requires modeling appropriate behaviors, sharing important information, and maintaining an appropriate alertness in caring for children of all ages. These attitudes lead to a safe “fun-in-the-sun” approach for all families enjoying time outdoors.

REFERENCES Kim, H. J., Ghali, F. E., & Tmessen, W. W. (1997). Here comes the sun. Contemporary Pediatrics, 14, 41-69. Orlow, S. J. (1995). Melanomas in children. Pediatrics in Review, X,365-369. Weston, W. L., Lane, A. T., & Morelli, J. G. (1996). Color textbook ofpediatric dermatology (2nd ed.). St. Louis, MO: Mosby.

WANTED: CHILDREN’S DRAWINGS The Journal is interested in publishing children’s drawings of their responses to illness, treatment, or encounters with the health care system or personnel. Please send the drawings, along with the child’s age, gender, any pertinent information regarding the child’s condition, and written parental permission to print the drawing, to Bobbie Crew Nelms, PhD, RN, CPNP 3133 Barbara St San Pedro, CA 90731 I

13 8

Volume 13 Number 3 Part 1

I

JOURNAL OF PEDIATRIC HEALTH CARE