Melanoma

ORLANDO – Despite a paucity of recently approved treatments for squamous cell carcinoma, you can use study findings from the past few years to refine your clinical approach, Dr. Suzanne Olbricht said.

"It would be nice if I had some new treatments to discuss, but I don't. So let's go through some recent studies," Dr. Olbricht said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Photodynamic Therapy

Investigators, for example, found methyl aminolevulinate photodynamic therapy (MAL-PDT) superior to 5-fluorouracil and cryosurgery for squamous cell carcinoma in situ. In addition, ophthalmologists might start using more imiquimod to treat periorbital skin cancers based on outcomes of a recent case series, Dr. Olbricht said. Other findings support promise for the oral medications cetuximab and capecitabine.

The prospective, randomized study that bolsters use of MAL-PDT included 225 patients with biopsy-confirmed squamous cell carcinoma in situ (Arch. Dermatol. 2006;142:729-35). Researchers found an 80% complete response rate in the MAL-PDT–treated patients at 12 months, compared with a 69% rate with 5-fluorouracil and a 67% rate in patients treated with cryotherapy.

"MAL-PDT was judged [to have the] most acceptable cosmetic outcome," Dr. Olbricht said. She added that 5-fluorouracil is "still a good therapy if some patients prefer to do things at home."

This is a "large study that is worth thinking about," said Dr. Olbricht, chair of the department of dermatology at the Lahey Clinic in Burlington, Mass., and a member of the dermatology faculty at Harvard Medical School, Boston.

Photodynamic therapy (PDT) was associated with a 72% complete response in a smaller study of 30 patients with recurrent tumors of the head and neck (J. Drugs Dermatol. 2010;9:122-6).

These investigators described PDT as effective, tolerable, and associated with good cosmetic results for recurrent squamous cell carcinoma or basal cell carcinoma. One concern, Dr. Olbricht said, is "they did not describe how they did the PDT."

Imiquimod Therapy

Another noteworthy study supports imiquimod for periorbital skin lesions (Orbit 2010;29:83-7). Two patients in this case series had basal cell carcinoma of the eyelid, one had actinic keratosis, and another had intraepidermal squamous cell carcinoma (Bowen’s disease). A fifth patient presented with concomitant squamous cell carcinoma and intraepidermal squamous cell carcinoma. All tumors regressed with a clinical cure at 6-9 months.

"It’s a short follow-up, but your ophthalmologic colleagues will be using imiquimod," Dr. Olbricht said.

Cetuximab and Capecitabine

Oral cetuximab (Erbitux, Imclone) was associated with a complete clinical response for a patient with organ metastases from cutaneous squamous cell carcinoma (Dermatol. Surg. 2010;36:2069-74). Keep two caveats in mind with a cetuximab treatment strategy, Dr. Olbricht said. First, it's expensive – costing approximately $30,000 for an 8-week series of infusions. Second, cetuximab is effective only for skin cancer patients who do not have a KRAS mutation.

Another treatment showing promise is capecitabine (Xeloda, Hoffmann La Roche), an oral 5-fluorouracil precursor. New lesion development was halted within 6 months for three patients with a history of more than one new squamous cell carcinoma occurrence per month for more than 3 years (Dermatol. Surg. 2009;35:1657-72). Dr. Olbricht noted that hand and foot erythema occurred, which "is supposedly well known with this oral medication."

A meeting attendee asked how Dr. Olbricht manages patients with chronic, multiple squamous cell carcinomas. "I probably have six or seven people for years who come in at least once a month for skin cancer," she replied. "I try to take care of what they have at that moment."

For example, she recently treated a man whose biggest clinical concern is skin cancer 7 years post kidney transplant. "We sent 12 specimens to pathology. We did two Mohs procedures on his face, two excisions on his legs, and the rest were probably electrodesiccation and curettage on his trunk."

"I know I would make more money if I treated each lesion at individual sessions ... but I think this is best approach to this kind of patient," Dr. Olbricht said.

Dr. Olbricht said she had no relevant disclosures.

ORLANDO – Despite a paucity of recently approved treatments for squamous cell carcinoma, you can use study findings from the past few years to refine your clinical approach, Dr. Suzanne Olbricht said.

"It would be nice if I had some new treatments to discuss, but I don't. So let's go through some recent studies," Dr. Olbricht said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Photodynamic Therapy

Investigators, for example, found methyl aminolevulinate photodynamic therapy (MAL-PDT) superior to 5-fluorouracil and cryosurgery for squamous cell carcinoma in situ. In addition, ophthalmologists might start using more imiquimod to treat periorbital skin cancers based on outcomes of a recent case series, Dr. Olbricht said. Other findings support promise for the oral medications cetuximab and capecitabine.

The prospective, randomized study that bolsters use of MAL-PDT included 225 patients with biopsy-confirmed squamous cell carcinoma in situ (Arch. Dermatol. 2006;142:729-35). Researchers found an 80% complete response rate in the MAL-PDT–treated patients at 12 months, compared with a 69% rate with 5-fluorouracil and a 67% rate in patients treated with cryotherapy.

"MAL-PDT was judged [to have the] most acceptable cosmetic outcome," Dr. Olbricht said. She added that 5-fluorouracil is "still a good therapy if some patients prefer to do things at home."

This is a "large study that is worth thinking about," said Dr. Olbricht, chair of the department of dermatology at the Lahey Clinic in Burlington, Mass., and a member of the dermatology faculty at Harvard Medical School, Boston.

Photodynamic therapy (PDT) was associated with a 72% complete response in a smaller study of 30 patients with recurrent tumors of the head and neck (J. Drugs Dermatol. 2010;9:122-6).

These investigators described PDT as effective, tolerable, and associated with good cosmetic results for recurrent squamous cell carcinoma or basal cell carcinoma. One concern, Dr. Olbricht said, is "they did not describe how they did the PDT."

Imiquimod Therapy

Another noteworthy study supports imiquimod for periorbital skin lesions (Orbit 2010;29:83-7). Two patients in this case series had basal cell carcinoma of the eyelid, one had actinic keratosis, and another had intraepidermal squamous cell carcinoma (Bowen’s disease). A fifth patient presented with concomitant squamous cell carcinoma and intraepidermal squamous cell carcinoma. All tumors regressed with a clinical cure at 6-9 months.

"It’s a short follow-up, but your ophthalmologic colleagues will be using imiquimod," Dr. Olbricht said.

Cetuximab and Capecitabine

Oral cetuximab (Erbitux, Imclone) was associated with a complete clinical response for a patient with organ metastases from cutaneous squamous cell carcinoma (Dermatol. Surg. 2010;36:2069-74). Keep two caveats in mind with a cetuximab treatment strategy, Dr. Olbricht said. First, it's expensive – costing approximately $30,000 for an 8-week series of infusions. Second, cetuximab is effective only for skin cancer patients who do not have a KRAS mutation.

Another treatment showing promise is capecitabine (Xeloda, Hoffmann La Roche), an oral 5-fluorouracil precursor. New lesion development was halted within 6 months for three patients with a history of more than one new squamous cell carcinoma occurrence per month for more than 3 years (Dermatol. Surg. 2009;35:1657-72). Dr. Olbricht noted that hand and foot erythema occurred, which "is supposedly well known with this oral medication."

A meeting attendee asked how Dr. Olbricht manages patients with chronic, multiple squamous cell carcinomas. "I probably have six or seven people for years who come in at least once a month for skin cancer," she replied. "I try to take care of what they have at that moment."

For example, she recently treated a man whose biggest clinical concern is skin cancer 7 years post kidney transplant. "We sent 12 specimens to pathology. We did two Mohs procedures on his face, two excisions on his legs, and the rest were probably electrodesiccation and curettage on his trunk."

"I know I would make more money if I treated each lesion at individual sessions ... but I think this is best approach to this kind of patient," Dr. Olbricht said.

Dr. Olbricht said she had no relevant disclosures.

ORLANDO – Despite a paucity of recently approved treatments for squamous cell carcinoma, you can use study findings from the past few years to refine your clinical approach, Dr. Suzanne Olbricht said.

"It would be nice if I had some new treatments to discuss, but I don't. So let's go through some recent studies," Dr. Olbricht said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Photodynamic Therapy

Investigators, for example, found methyl aminolevulinate photodynamic therapy (MAL-PDT) superior to 5-fluorouracil and cryosurgery for squamous cell carcinoma in situ. In addition, ophthalmologists might start using more imiquimod to treat periorbital skin cancers based on outcomes of a recent case series, Dr. Olbricht said. Other findings support promise for the oral medications cetuximab and capecitabine.

The prospective, randomized study that bolsters use of MAL-PDT included 225 patients with biopsy-confirmed squamous cell carcinoma in situ (Arch. Dermatol. 2006;142:729-35). Researchers found an 80% complete response rate in the MAL-PDT–treated patients at 12 months, compared with a 69% rate with 5-fluorouracil and a 67% rate in patients treated with cryotherapy.

"MAL-PDT was judged [to have the] most acceptable cosmetic outcome," Dr. Olbricht said. She added that 5-fluorouracil is "still a good therapy if some patients prefer to do things at home."

This is a "large study that is worth thinking about," said Dr. Olbricht, chair of the department of dermatology at the Lahey Clinic in Burlington, Mass., and a member of the dermatology faculty at Harvard Medical School, Boston.

Photodynamic therapy (PDT) was associated with a 72% complete response in a smaller study of 30 patients with recurrent tumors of the head and neck (J. Drugs Dermatol. 2010;9:122-6).

These investigators described PDT as effective, tolerable, and associated with good cosmetic results for recurrent squamous cell carcinoma or basal cell carcinoma. One concern, Dr. Olbricht said, is "they did not describe how they did the PDT."

Imiquimod Therapy

Another noteworthy study supports imiquimod for periorbital skin lesions (Orbit 2010;29:83-7). Two patients in this case series had basal cell carcinoma of the eyelid, one had actinic keratosis, and another had intraepidermal squamous cell carcinoma (Bowen’s disease). A fifth patient presented with concomitant squamous cell carcinoma and intraepidermal squamous cell carcinoma. All tumors regressed with a clinical cure at 6-9 months.

"It’s a short follow-up, but your ophthalmologic colleagues will be using imiquimod," Dr. Olbricht said.

Cetuximab and Capecitabine

Oral cetuximab (Erbitux, Imclone) was associated with a complete clinical response for a patient with organ metastases from cutaneous squamous cell carcinoma (Dermatol. Surg. 2010;36:2069-74). Keep two caveats in mind with a cetuximab treatment strategy, Dr. Olbricht said. First, it's expensive – costing approximately $30,000 for an 8-week series of infusions. Second, cetuximab is effective only for skin cancer patients who do not have a KRAS mutation.

Another treatment showing promise is capecitabine (Xeloda, Hoffmann La Roche), an oral 5-fluorouracil precursor. New lesion development was halted within 6 months for three patients with a history of more than one new squamous cell carcinoma occurrence per month for more than 3 years (Dermatol. Surg. 2009;35:1657-72). Dr. Olbricht noted that hand and foot erythema occurred, which "is supposedly well known with this oral medication."

A meeting attendee asked how Dr. Olbricht manages patients with chronic, multiple squamous cell carcinomas. "I probably have six or seven people for years who come in at least once a month for skin cancer," she replied. "I try to take care of what they have at that moment."

For example, she recently treated a man whose biggest clinical concern is skin cancer 7 years post kidney transplant. "We sent 12 specimens to pathology. We did two Mohs procedures on his face, two excisions on his legs, and the rest were probably electrodesiccation and curettage on his trunk."

"I know I would make more money if I treated each lesion at individual sessions ... but I think this is best approach to this kind of patient," Dr. Olbricht said.

Dr. Olbricht said she had no relevant disclosures.

SAN DIEGO – Aggressive skin cancers can recur, spread, and kill – and these lesions deserve special consideration after even an apparently successful Mohs procedure.

"Mohs is especially well suited to identify the rare patient who has a high-risk profile for local recurrence or metastasis," Dr. David Hodgens said at a meeting sponsored by the American Society for Mohs Surgery. "We can work together to develop radiotherapy techniques that treat both the primary site and the nodal basins to minimize toxicity and give the patient a better chance of a cure."

The Mohs surgeon is unlikely to see many patients who will need postoperative radiotherapy, said Dr. Hodgens, director of radiation oncology at Scripps Memorial Hospital, La Jolla, Calif. "Keep in mind the vast majority of patients will not need this – but be on the lookout for those who might."

Any skin cancer – squamous or basal cell carcinoma, Merkel cell tumor, melanoma or angiosarcoma – can be increasingly dangerous if certain risk factors are present, Dr. Hodgens said. Risk factors for local recurrence or metastatic spread include a lesion size greater than 2 cm; depth greater then 4 mm or a Clark level IV-V; location on the ear or lip, or within a scar; or perineural or periosteal invasion. Immunosuppressed patients are at particularly high risk, as are those with an already recurrent lesion. "A lesion that has recurred after prior treatment is one of the greatest risks of further recurrence or metastatic spread," he stressed.

Electron beam radiation is the best treatment for high-risk skin cancers. "Electrons are essential in treating the postoperative Mohs patient. If your radiation oncologist is not using electrons, find one who is," he said.

High-energy x-rays are also used, but mostly to cover a nodal basin where spread is suspected. But electrons have a unique property that allows a narrow beam to deliver 90% of its energy to a prespecified depth and then very rapidly decrease that energy as the beam goes deeper into the tissue. "Electrons provide penetration to a desired depth without the through transmission of x-rays," Dr. Hodgens said.

Post-Mohs radiation calls for a large treatment field that encompasses the entire surgical field and generous margins. "We try to get at least 2 cm around the surgical bed," he said. Patients typically receive daily treatments for 5-7 weeks, with 1.8-2 Gy/day to the primary site. The total radiation dose is usually around 50-60 Gy.

"We treat them as seriously as we do any of our patients with breast, lung, or brain tumors," Dr. Hodgens said. "They have the potential to die of their skin cancer. This is a long aggressive course of treatment designed to give the best chance of cure."

X-rays can be added to treat the associated nodal basin, if nodal spread is a concern. "The toxicity of adding nodal radiation is minimal," Dr. Hodgens said. "It’s very well tolerated, with mostly just mild erythema. It’s really an easy thing to do and very worthwhile."

There are few studies published on postoperative radiation for strict indications after well-performed Mohs surgery. Most recently, a Greek study of 315 patients found that post-Mohs radiation was associated with a 92% reduced risk of recurrence (Eur. J. Cancer 2010;46:1563-72).

Last year, an Australian study of 118 patients with cutaneous head or neck cancers found that surgery plus radiotherapy improved survival rates, even among those with perineural involvement – a very poor prognostic factor. The 5-year local control rates were 90% for those with histologically proven perineural involvement and 57% for those with symptoms of perineural involvement (Head Neck 2009;31:604-10)

Dr. Hodgens had no financial disclosures.

SAN DIEGO – Aggressive skin cancers can recur, spread, and kill – and these lesions deserve special consideration after even an apparently successful Mohs procedure.

"Mohs is especially well suited to identify the rare patient who has a high-risk profile for local recurrence or metastasis," Dr. David Hodgens said at a meeting sponsored by the American Society for Mohs Surgery. "We can work together to develop radiotherapy techniques that treat both the primary site and the nodal basins to minimize toxicity and give the patient a better chance of a cure."

The Mohs surgeon is unlikely to see many patients who will need postoperative radiotherapy, said Dr. Hodgens, director of radiation oncology at Scripps Memorial Hospital, La Jolla, Calif. "Keep in mind the vast majority of patients will not need this – but be on the lookout for those who might."

Any skin cancer – squamous or basal cell carcinoma, Merkel cell tumor, melanoma or angiosarcoma – can be increasingly dangerous if certain risk factors are present, Dr. Hodgens said. Risk factors for local recurrence or metastatic spread include a lesion size greater than 2 cm; depth greater then 4 mm or a Clark level IV-V; location on the ear or lip, or within a scar; or perineural or periosteal invasion. Immunosuppressed patients are at particularly high risk, as are those with an already recurrent lesion. "A lesion that has recurred after prior treatment is one of the greatest risks of further recurrence or metastatic spread," he stressed.

Electron beam radiation is the best treatment for high-risk skin cancers. "Electrons are essential in treating the postoperative Mohs patient. If your radiation oncologist is not using electrons, find one who is," he said.

High-energy x-rays are also used, but mostly to cover a nodal basin where spread is suspected. But electrons have a unique property that allows a narrow beam to deliver 90% of its energy to a prespecified depth and then very rapidly decrease that energy as the beam goes deeper into the tissue. "Electrons provide penetration to a desired depth without the through transmission of x-rays," Dr. Hodgens said.

Post-Mohs radiation calls for a large treatment field that encompasses the entire surgical field and generous margins. "We try to get at least 2 cm around the surgical bed," he said. Patients typically receive daily treatments for 5-7 weeks, with 1.8-2 Gy/day to the primary site. The total radiation dose is usually around 50-60 Gy.

"We treat them as seriously as we do any of our patients with breast, lung, or brain tumors," Dr. Hodgens said. "They have the potential to die of their skin cancer. This is a long aggressive course of treatment designed to give the best chance of cure."

X-rays can be added to treat the associated nodal basin, if nodal spread is a concern. "The toxicity of adding nodal radiation is minimal," Dr. Hodgens said. "It’s very well tolerated, with mostly just mild erythema. It’s really an easy thing to do and very worthwhile."

There are few studies published on postoperative radiation for strict indications after well-performed Mohs surgery. Most recently, a Greek study of 315 patients found that post-Mohs radiation was associated with a 92% reduced risk of recurrence (Eur. J. Cancer 2010;46:1563-72).

Last year, an Australian study of 118 patients with cutaneous head or neck cancers found that surgery plus radiotherapy improved survival rates, even among those with perineural involvement – a very poor prognostic factor. The 5-year local control rates were 90% for those with histologically proven perineural involvement and 57% for those with symptoms of perineural involvement (Head Neck 2009;31:604-10)

Dr. Hodgens had no financial disclosures.

SAN DIEGO – Aggressive skin cancers can recur, spread, and kill – and these lesions deserve special consideration after even an apparently successful Mohs procedure.

"Mohs is especially well suited to identify the rare patient who has a high-risk profile for local recurrence or metastasis," Dr. David Hodgens said at a meeting sponsored by the American Society for Mohs Surgery. "We can work together to develop radiotherapy techniques that treat both the primary site and the nodal basins to minimize toxicity and give the patient a better chance of a cure."

The Mohs surgeon is unlikely to see many patients who will need postoperative radiotherapy, said Dr. Hodgens, director of radiation oncology at Scripps Memorial Hospital, La Jolla, Calif. "Keep in mind the vast majority of patients will not need this – but be on the lookout for those who might."

Any skin cancer – squamous or basal cell carcinoma, Merkel cell tumor, melanoma or angiosarcoma – can be increasingly dangerous if certain risk factors are present, Dr. Hodgens said. Risk factors for local recurrence or metastatic spread include a lesion size greater than 2 cm; depth greater then 4 mm or a Clark level IV-V; location on the ear or lip, or within a scar; or perineural or periosteal invasion. Immunosuppressed patients are at particularly high risk, as are those with an already recurrent lesion. "A lesion that has recurred after prior treatment is one of the greatest risks of further recurrence or metastatic spread," he stressed.

Electron beam radiation is the best treatment for high-risk skin cancers. "Electrons are essential in treating the postoperative Mohs patient. If your radiation oncologist is not using electrons, find one who is," he said.

High-energy x-rays are also used, but mostly to cover a nodal basin where spread is suspected. But electrons have a unique property that allows a narrow beam to deliver 90% of its energy to a prespecified depth and then very rapidly decrease that energy as the beam goes deeper into the tissue. "Electrons provide penetration to a desired depth without the through transmission of x-rays," Dr. Hodgens said.

Post-Mohs radiation calls for a large treatment field that encompasses the entire surgical field and generous margins. "We try to get at least 2 cm around the surgical bed," he said. Patients typically receive daily treatments for 5-7 weeks, with 1.8-2 Gy/day to the primary site. The total radiation dose is usually around 50-60 Gy.

"We treat them as seriously as we do any of our patients with breast, lung, or brain tumors," Dr. Hodgens said. "They have the potential to die of their skin cancer. This is a long aggressive course of treatment designed to give the best chance of cure."

X-rays can be added to treat the associated nodal basin, if nodal spread is a concern. "The toxicity of adding nodal radiation is minimal," Dr. Hodgens said. "It’s very well tolerated, with mostly just mild erythema. It’s really an easy thing to do and very worthwhile."

There are few studies published on postoperative radiation for strict indications after well-performed Mohs surgery. Most recently, a Greek study of 315 patients found that post-Mohs radiation was associated with a 92% reduced risk of recurrence (Eur. J. Cancer 2010;46:1563-72).

Last year, an Australian study of 118 patients with cutaneous head or neck cancers found that surgery plus radiotherapy improved survival rates, even among those with perineural involvement – a very poor prognostic factor. The 5-year local control rates were 90% for those with histologically proven perineural involvement and 57% for those with symptoms of perineural involvement (Head Neck 2009;31:604-10)

Dr. Hodgens had no financial disclosures.

ORLANDO – Mohs surgery is an appropriate choice for lentigo maligna patients because advances in immunostaining allow easier and more efficient identification of melanocytes on frozen sections, said Dr. Basil S. Cherpelis.

Recent literature shows the recommended 5-mm margin for melanoma is often inadequate, Dr. Cherpelis said at the Orlando Dermatology Aesthetic and Clinical conference.

The margins needed for successful treatment of lentigo maligna vary – 5 mm is enough for some melanomas, while others might need a 1-cm margin.

"It makes sense to use a method of intraoperative margin control," said Dr. Cherpelis, of the Moffitt Cancer Center at the University of South Florida in Tampa. "That’s what gives you the flexibility to adjust your margins based on the melanoma that you happen to be treating."

One option for intraoperative margin control is traditional frozen sections, Dr. Cherpelis said. But frozen sections offer a limited view of the margin, and they pose the problem of freeze artifacts, which can make the distinction between melanocytes and keratinocytes difficult. A second option is the square or perimeter method, but this method involves a 1-2 week wait for complete results, which is inconvenient for doctors and patients.

A third option is Mohs surgery. Literature shows that Mohs is effective for melanoma, with the benefits of entire visualization and same-day reconstruction, but it is not widely used, Dr. Cherpelis said. One reason: Melanomas on permanent sections have halos around them, making identification easy, but frozen sections have similar halos around keratinocytes and melanocytes.

Using immunostaining as part of Mohs surgery can solve the identification problem, but until recently immunostain protocols could take at least an hour.

Dr. Cherpelis and his colleagues have streamlined the process.

"We have been able to shorten our protocols down to 19 minutes for MART-1 [melanoma-associated antigen recognized by T cells] and 35 minutes for MITF [microphthalmia-associated transcription factor]," Dr. Cherpelis said (Derm. Surg. 2009;35:207-13; Am. J. Dermatopath. 2010; 32:319-25, respectively). The protocols make Mohs surgery easier because the immunostain helps clinicians easily identify melanocytes.

MART-1 (a cytoplasmic stain) is the most common immunostain, but some data suggest it can falsely label keratinocytes in inflamed skin or in pigmented actinic keratoses, Dr. Cherpelis said. It also can cause pseudo-confluence (the appearance of touching melanocytes). By contrast, MITF is a nuclear stain, so it does not have the problem of pseudo-confluence.

Dr. Cherpelis said he had no relevant financial disclosures.

ORLANDO – Mohs surgery is an appropriate choice for lentigo maligna patients because advances in immunostaining allow easier and more efficient identification of melanocytes on frozen sections, said Dr. Basil S. Cherpelis.

Recent literature shows the recommended 5-mm margin for melanoma is often inadequate, Dr. Cherpelis said at the Orlando Dermatology Aesthetic and Clinical conference.

The margins needed for successful treatment of lentigo maligna vary – 5 mm is enough for some melanomas, while others might need a 1-cm margin.

"It makes sense to use a method of intraoperative margin control," said Dr. Cherpelis, of the Moffitt Cancer Center at the University of South Florida in Tampa. "That’s what gives you the flexibility to adjust your margins based on the melanoma that you happen to be treating."

One option for intraoperative margin control is traditional frozen sections, Dr. Cherpelis said. But frozen sections offer a limited view of the margin, and they pose the problem of freeze artifacts, which can make the distinction between melanocytes and keratinocytes difficult. A second option is the square or perimeter method, but this method involves a 1-2 week wait for complete results, which is inconvenient for doctors and patients.

A third option is Mohs surgery. Literature shows that Mohs is effective for melanoma, with the benefits of entire visualization and same-day reconstruction, but it is not widely used, Dr. Cherpelis said. One reason: Melanomas on permanent sections have halos around them, making identification easy, but frozen sections have similar halos around keratinocytes and melanocytes.

Using immunostaining as part of Mohs surgery can solve the identification problem, but until recently immunostain protocols could take at least an hour.

Dr. Cherpelis and his colleagues have streamlined the process.

"We have been able to shorten our protocols down to 19 minutes for MART-1 [melanoma-associated antigen recognized by T cells] and 35 minutes for MITF [microphthalmia-associated transcription factor]," Dr. Cherpelis said (Derm. Surg. 2009;35:207-13; Am. J. Dermatopath. 2010; 32:319-25, respectively). The protocols make Mohs surgery easier because the immunostain helps clinicians easily identify melanocytes.

MART-1 (a cytoplasmic stain) is the most common immunostain, but some data suggest it can falsely label keratinocytes in inflamed skin or in pigmented actinic keratoses, Dr. Cherpelis said. It also can cause pseudo-confluence (the appearance of touching melanocytes). By contrast, MITF is a nuclear stain, so it does not have the problem of pseudo-confluence.

Dr. Cherpelis said he had no relevant financial disclosures.

ORLANDO – Mohs surgery is an appropriate choice for lentigo maligna patients because advances in immunostaining allow easier and more efficient identification of melanocytes on frozen sections, said Dr. Basil S. Cherpelis.

Recent literature shows the recommended 5-mm margin for melanoma is often inadequate, Dr. Cherpelis said at the Orlando Dermatology Aesthetic and Clinical conference.

The margins needed for successful treatment of lentigo maligna vary – 5 mm is enough for some melanomas, while others might need a 1-cm margin.

"It makes sense to use a method of intraoperative margin control," said Dr. Cherpelis, of the Moffitt Cancer Center at the University of South Florida in Tampa. "That’s what gives you the flexibility to adjust your margins based on the melanoma that you happen to be treating."

One option for intraoperative margin control is traditional frozen sections, Dr. Cherpelis said. But frozen sections offer a limited view of the margin, and they pose the problem of freeze artifacts, which can make the distinction between melanocytes and keratinocytes difficult. A second option is the square or perimeter method, but this method involves a 1-2 week wait for complete results, which is inconvenient for doctors and patients.

A third option is Mohs surgery. Literature shows that Mohs is effective for melanoma, with the benefits of entire visualization and same-day reconstruction, but it is not widely used, Dr. Cherpelis said. One reason: Melanomas on permanent sections have halos around them, making identification easy, but frozen sections have similar halos around keratinocytes and melanocytes.

Using immunostaining as part of Mohs surgery can solve the identification problem, but until recently immunostain protocols could take at least an hour.

Dr. Cherpelis and his colleagues have streamlined the process.

"We have been able to shorten our protocols down to 19 minutes for MART-1 [melanoma-associated antigen recognized by T cells] and 35 minutes for MITF [microphthalmia-associated transcription factor]," Dr. Cherpelis said (Derm. Surg. 2009;35:207-13; Am. J. Dermatopath. 2010; 32:319-25, respectively). The protocols make Mohs surgery easier because the immunostain helps clinicians easily identify melanocytes.

MART-1 (a cytoplasmic stain) is the most common immunostain, but some data suggest it can falsely label keratinocytes in inflamed skin or in pigmented actinic keratoses, Dr. Cherpelis said. It also can cause pseudo-confluence (the appearance of touching melanocytes). By contrast, MITF is a nuclear stain, so it does not have the problem of pseudo-confluence.

Dr. Cherpelis said he had no relevant financial disclosures.

The Food and Drug Administration has awarded orphan drug designation to BioSante Pharmaceuticals' melanoma cancer vaccine.

The vaccine will be used to treat stage IIb-IV melanoma, says the company, in a statement. The Lincolnshire, Ill.–based BioSante estimates that 68,000 people were diagnosed with melanoma in 2010, and that 8,700 died. The FDA grants orphan status for products intended to treat fewer than 200,000 patients in the United States. According to the agency, makers of orphan products are eligible for tax credits and marketing incentives, but they still have to submit the same efficacy and safety data required of other products. Orphan status does not change the timetable for approval.

The BioSante vaccine is in early development at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center. It is a "GVAX" vaccine. According to a BioSante statement, it uses cell lines that are genetically modified to secrete granulocyte-macrophage colony–stimulating factor (GM-CSF). The cells are then irradiated to prevent further cell division. The GVAX model is also being used in BioSante products in development for pancreatic cancer, acute myeloid leukemia, and chronic myeloid leukemia.

The Food and Drug Administration has awarded orphan drug designation to BioSante Pharmaceuticals' melanoma cancer vaccine.

The vaccine will be used to treat stage IIb-IV melanoma, says the company, in a statement. The Lincolnshire, Ill.–based BioSante estimates that 68,000 people were diagnosed with melanoma in 2010, and that 8,700 died. The FDA grants orphan status for products intended to treat fewer than 200,000 patients in the United States. According to the agency, makers of orphan products are eligible for tax credits and marketing incentives, but they still have to submit the same efficacy and safety data required of other products. Orphan status does not change the timetable for approval.

The BioSante vaccine is in early development at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center. It is a "GVAX" vaccine. According to a BioSante statement, it uses cell lines that are genetically modified to secrete granulocyte-macrophage colony–stimulating factor (GM-CSF). The cells are then irradiated to prevent further cell division. The GVAX model is also being used in BioSante products in development for pancreatic cancer, acute myeloid leukemia, and chronic myeloid leukemia.

The Food and Drug Administration has awarded orphan drug designation to BioSante Pharmaceuticals' melanoma cancer vaccine.

The vaccine will be used to treat stage IIb-IV melanoma, says the company, in a statement. The Lincolnshire, Ill.–based BioSante estimates that 68,000 people were diagnosed with melanoma in 2010, and that 8,700 died. The FDA grants orphan status for products intended to treat fewer than 200,000 patients in the United States. According to the agency, makers of orphan products are eligible for tax credits and marketing incentives, but they still have to submit the same efficacy and safety data required of other products. Orphan status does not change the timetable for approval.

The BioSante vaccine is in early development at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center. It is a "GVAX" vaccine. According to a BioSante statement, it uses cell lines that are genetically modified to secrete granulocyte-macrophage colony–stimulating factor (GM-CSF). The cells are then irradiated to prevent further cell division. The GVAX model is also being used in BioSante products in development for pancreatic cancer, acute myeloid leukemia, and chronic myeloid leukemia.

Coloring the skin with dihydroxyacetone to create an artificial tan was discovered serendipitously in the 1950s by Eva Wittgenstein, whose patients were taking DHA orally. She observed that when patients regurgitated the DHA, pigmented spots remained on the skin (Science 1960;132:894-5).

The change in pigmentation results from the interaction of DHA with amino acids in the stratum corneum (Br. J. Dermatol. 2003;149:332-40).

Although the first product brought to market to exploit this new knowledge in 1959 met with initial success, it fell into disuse because of the poor cosmetic results (J. Am. Acad. Dermatol. 2003;49:1096-106; South. Med. J. 2005;98:1192-5).

Public awareness of sunless tanning has grown in recent years, however, and has been met with formulations that afford a much improved cosmetic performance, with DHA remaining as the main active ingredient in sunless-tanning agents (South. Med. J. 2005;98:1192-5; Am. J. Clin. Dermatol. 2002;3:317-8).

This column will briefly review the role of sunless-tanning lotions and sprays in dermatology, and will try to place recommendations to patients about sunless tanners in the context of sunscreens and tanning attitudes.

Sunless tanners have been used, with varying degrees of popularity, for 50 years; recent evidence suggests that the use of these products has increased in recent years. A long track record of usage and research indicates that sunless-tanning compounds are safe (J. Environ. Pathol. Toxicol. Oncol. 1984;5:349-51; Am. J. Clin. Dermatol. 2002;3:317-8; South. Med. J. 2005;98:1192-5; J. Am. Acad. Dermatol. 2007;56:387-90.) However, there is some debate as to whether the use of these products renders users more inclined to stay in the sun longer. Also, ongoing research has raised some safety issues regarding DHA.

Chemical Protection

In 2004, Petersen et al. investigated the effects of DHA on cell survival and proliferation of a human keratinocyte cell line, HaCaT. Significant genotoxic activity was identified in these cultured cells, as researchers noted dose- and time-dependent morphologic alterations as well as cytoplasmic budding and cell detachment in DHA-treated cells, and apoptosis and marked declines in proliferation 1 day after DHA exposure. Interestingly, the development of DNA strand breaks was prevented via preincubation with antioxidants. The authors suggested that their findings raised concerns about the long-term use of treating the skin with DHA-containing formulations (Mutat. Res. 2004;560:173-86).

A small study by Faurschou et al. showed that DHA provided human skin with modest UVB protection, with a 5% DHA cream applied three times or a 20% DHA cream applied once yielding an effect similar to an SPF 1.6. They acknowledged that most commercial DHA products contain 3%-5% DHA and offer scant protection. A potential advantage of sunless tanners, if they offer protection, suggested the authors, would be that no spots would be left unattended since such gaps would be conspicuous for lack of browning (Arch. Dermatol. 2004;140:886-7).

Howe, Reed, and Dellavalle contended that DHA in self-tanning agents provided enough UVA protection to warrant use as an adjunct to daily sunscreen use for broad-band protection (J. Am. Acad. Dermatol. 2008;58:894). The researchers referenced a 1975 study in which 3% DHA augmented sunlight tolerance among five patients with UVA-sensitive dermatoses (Dermatologica 1975;150:346-51; J. Am. Acad. Dermatol. 2008;58:894).

In 2009, Choquenet et al. assessed the sun protection potency of self-tanners and foundations using an in vitro method to identify indicators such as sun protection factor (SPF), UVA protection factor (PF-UVA), and UVB/UVA ratio. Using seven amino acids in the corneal cells of the epidermis, the investigators identified SPFs virtually equivalent to zero (approximately SPF 2). Conversely, they found foundations to exhibit satisfactory photostability and a non-negligible SPF, noting that such products are safe given their typically once-daily application (J. Dermatol. 2009;36:587-91).

Attitudes and Behavior

Users of sunless-tanning products were found, in a survey of 2,005 randomly selected South Australian adults published in 2001, to be more likely to use sunscreen but less likely to wear a hat or other sun-protective clothing. Sunburns were also linked to the use of sunless tanners in this study (Med. J. Aust. 2001;174:75-8; J. Am. Acad. Dermatol. 2007;56:387-90).

In 2005, Mahler et al. conducted a randomized, controlled trial with 1-month follow-up of 146 Southern California college students to study the impact of UV photoaging photographs and data on the sun protection plans and behaviors of young adults, and whether sunless-tanning lotion might play a role in sun-protective behavior. Of the 146 volunteers, 91.1% completed the "surprise" 1-month follow-up. The intervention consisted of volunteers being shown a UV facial photo and short video illustrating the etiology and results of photoaging. The investigators found that the UV photographic intervention was successful insofar as significantly better sun protection strategies and behaviors were employed by the test group, compared with controls. In addition, they noted that those who used sunless-tanning lotion were more likely to exhibit extensive sun-protective behavior, compared with individuals who received the intervention alone. The authors suggested that such interventions represented a cost-effective approach that might yield behaviors with long-term health benefits in the form of a lower incidence of skin cancer (Arch. Dermatol. 2005;141:373-80).

Later that year, Sheehan and Lesher reported on their anonymous survey of 121 adults (107 women and 14 men) who received spray-on sunless-tanning treatments between February and May 2004. Most reported that sunless tanning had not or would not affect their use of sunscreen or time spent outdoors. Interestingly, though, 73% of the respondents who had used tanning beds indicated that they had reduced or would reduce their use of indoor tanning. The researchers concluded that practitioners should recommend sunless tanning to their patients who use conventional tanning beds as a way to lower their solar exposure and risk of skin cancer (South. Med. J. 2005;98:1192-5).

In 2006, Brooks et al. reported on their July 2004, greater Boston, cross-sectional survey of 448 nonrandomly selected people aged 18-30 years on the subjects of artificial tanning products, recent history of sunburns, and tanning-bed use. During the preceding year, 22% of respondents had used sunless-tanning products and the same percentage hadn’t but would consider using them in the next year. Users of these lotions were more likely to have been severe burners and, after controlling for skin type, the investigators found that previous and potential users were more likely to have experienced sunburns during the summer and to have used tanning beds than were respondents who had neither used nor planned to use sunless tanners. The researchers concluded that the option of sunless tanning did not seem to lower the incidence of sunburn or the use of tanning beds. Further, they urged caution in offering broad support for artificial tanning products, even though looking for alternatives to UV exposure is to be encouraged (J. Am. Acad. Dermatol. 2006;54:1060-6).

A 2007 study using data from 5,491 completed interviews as part of the National Cancer Institute’s HINTS (Health Information National Trends Survey) 2005 set out to determine the prevalence of sunless-tanning formulation use and to understand the relationship between sunless tanning, indoor tanning, and sun-protective behavior. In so doing, the investigators found that the use of sunless-tanning products was relatively rare, with an estimated 11% of U.S. adults claiming to have used such products in the previous year. Of this group, 13% used sunless tanners more than 25 times; 12% used them 11-24 times; 35% used them 3-10 times; and 40% used them just once or twice. Users and exclusive users were more likely to be women, well educated, and living in the West (J. Am. Acad. Dermatol. 2007;56:387-90).

Recent Cause for Pause

In 2008, Jung et al. used the electron spin resonance spectroscopy–based radical sun protection factor, which measures free-radical reactions in skin biopsies during UV exposure and can determine the protective effect of UV filters and sunscreens, to analyze three different self-tanning agents, including DHA. Noting that the reaction of the reducing sugars in such products and amino acids (Maillard reaction) in the skin layer engendered Amadori products that created free radicals during UV irradiation, the investigators reported that in DHA-treated skin, more than 180% additional radicals were produced during sun exposure, compared with untreated skin. They concluded that the use of self-tanners necessitated reducing solar exposure duration (Spectrochim. Acta A. Mol. Biomol Spectrosc. 2008;69:1423-8). Consequently, DHA users would be well advised to wait at least 24 hours before solar exposure following application of sunless lotion or spray (Dermatol. Clin. 2009;27:149-54).

Conclusion

In addition to the need to continually persuade patients to engage in skin-protective behavior – namely, limiting sun exposure, avoiding peak-time exposures, wearing wide-brimmed hats and clothing with SPF value, and using sunscreens (preferably those containing avobenzone, Mexoryl, zinc oxide, or titanium dioxide) every day – it is incumbent upon dermatologists to disabuse our patients of the idea that untanned skin is less attractive or, conversely, that tans should be equated with attractive skin. Although healthy messages (that there is no such thing as a healthy tan, and that a tan indicates skin damage) are slowly spreading, sunless tanners appear to be a medically and cosmetically acceptable intermediary step, far surpassing the patently detrimental effects of indoor tanning. That said, patients should be advised to refrain from solar exposure for a full 24 hours after applying sunless tanners. Furthermore, much more research is necessary to truly establish that DHA delivers even modest protection from UVA or UVB. Accordingly, patients should be counseled that sunless tanners do not suffice as a base, nor do they justify extended solar exposure, and that sunscreens should also be applied.

Coloring the skin with dihydroxyacetone to create an artificial tan was discovered serendipitously in the 1950s by Eva Wittgenstein, whose patients were taking DHA orally. She observed that when patients regurgitated the DHA, pigmented spots remained on the skin (Science 1960;132:894-5).

The change in pigmentation results from the interaction of DHA with amino acids in the stratum corneum (Br. J. Dermatol. 2003;149:332-40).

Although the first product brought to market to exploit this new knowledge in 1959 met with initial success, it fell into disuse because of the poor cosmetic results (J. Am. Acad. Dermatol. 2003;49:1096-106; South. Med. J. 2005;98:1192-5).

Public awareness of sunless tanning has grown in recent years, however, and has been met with formulations that afford a much improved cosmetic performance, with DHA remaining as the main active ingredient in sunless-tanning agents (South. Med. J. 2005;98:1192-5; Am. J. Clin. Dermatol. 2002;3:317-8).

This column will briefly review the role of sunless-tanning lotions and sprays in dermatology, and will try to place recommendations to patients about sunless tanners in the context of sunscreens and tanning attitudes.

Sunless tanners have been used, with varying degrees of popularity, for 50 years; recent evidence suggests that the use of these products has increased in recent years. A long track record of usage and research indicates that sunless-tanning compounds are safe (J. Environ. Pathol. Toxicol. Oncol. 1984;5:349-51; Am. J. Clin. Dermatol. 2002;3:317-8; South. Med. J. 2005;98:1192-5; J. Am. Acad. Dermatol. 2007;56:387-90.) However, there is some debate as to whether the use of these products renders users more inclined to stay in the sun longer. Also, ongoing research has raised some safety issues regarding DHA.

Chemical Protection

In 2004, Petersen et al. investigated the effects of DHA on cell survival and proliferation of a human keratinocyte cell line, HaCaT. Significant genotoxic activity was identified in these cultured cells, as researchers noted dose- and time-dependent morphologic alterations as well as cytoplasmic budding and cell detachment in DHA-treated cells, and apoptosis and marked declines in proliferation 1 day after DHA exposure. Interestingly, the development of DNA strand breaks was prevented via preincubation with antioxidants. The authors suggested that their findings raised concerns about the long-term use of treating the skin with DHA-containing formulations (Mutat. Res. 2004;560:173-86).

A small study by Faurschou et al. showed that DHA provided human skin with modest UVB protection, with a 5% DHA cream applied three times or a 20% DHA cream applied once yielding an effect similar to an SPF 1.6. They acknowledged that most commercial DHA products contain 3%-5% DHA and offer scant protection. A potential advantage of sunless tanners, if they offer protection, suggested the authors, would be that no spots would be left unattended since such gaps would be conspicuous for lack of browning (Arch. Dermatol. 2004;140:886-7).

Howe, Reed, and Dellavalle contended that DHA in self-tanning agents provided enough UVA protection to warrant use as an adjunct to daily sunscreen use for broad-band protection (J. Am. Acad. Dermatol. 2008;58:894). The researchers referenced a 1975 study in which 3% DHA augmented sunlight tolerance among five patients with UVA-sensitive dermatoses (Dermatologica 1975;150:346-51; J. Am. Acad. Dermatol. 2008;58:894).

In 2009, Choquenet et al. assessed the sun protection potency of self-tanners and foundations using an in vitro method to identify indicators such as sun protection factor (SPF), UVA protection factor (PF-UVA), and UVB/UVA ratio. Using seven amino acids in the corneal cells of the epidermis, the investigators identified SPFs virtually equivalent to zero (approximately SPF 2). Conversely, they found foundations to exhibit satisfactory photostability and a non-negligible SPF, noting that such products are safe given their typically once-daily application (J. Dermatol. 2009;36:587-91).

Attitudes and Behavior

Users of sunless-tanning products were found, in a survey of 2,005 randomly selected South Australian adults published in 2001, to be more likely to use sunscreen but less likely to wear a hat or other sun-protective clothing. Sunburns were also linked to the use of sunless tanners in this study (Med. J. Aust. 2001;174:75-8; J. Am. Acad. Dermatol. 2007;56:387-90).

In 2005, Mahler et al. conducted a randomized, controlled trial with 1-month follow-up of 146 Southern California college students to study the impact of UV photoaging photographs and data on the sun protection plans and behaviors of young adults, and whether sunless-tanning lotion might play a role in sun-protective behavior. Of the 146 volunteers, 91.1% completed the "surprise" 1-month follow-up. The intervention consisted of volunteers being shown a UV facial photo and short video illustrating the etiology and results of photoaging. The investigators found that the UV photographic intervention was successful insofar as significantly better sun protection strategies and behaviors were employed by the test group, compared with controls. In addition, they noted that those who used sunless-tanning lotion were more likely to exhibit extensive sun-protective behavior, compared with individuals who received the intervention alone. The authors suggested that such interventions represented a cost-effective approach that might yield behaviors with long-term health benefits in the form of a lower incidence of skin cancer (Arch. Dermatol. 2005;141:373-80).

Later that year, Sheehan and Lesher reported on their anonymous survey of 121 adults (107 women and 14 men) who received spray-on sunless-tanning treatments between February and May 2004. Most reported that sunless tanning had not or would not affect their use of sunscreen or time spent outdoors. Interestingly, though, 73% of the respondents who had used tanning beds indicated that they had reduced or would reduce their use of indoor tanning. The researchers concluded that practitioners should recommend sunless tanning to their patients who use conventional tanning beds as a way to lower their solar exposure and risk of skin cancer (South. Med. J. 2005;98:1192-5).

In 2006, Brooks et al. reported on their July 2004, greater Boston, cross-sectional survey of 448 nonrandomly selected people aged 18-30 years on the subjects of artificial tanning products, recent history of sunburns, and tanning-bed use. During the preceding year, 22% of respondents had used sunless-tanning products and the same percentage hadn’t but would consider using them in the next year. Users of these lotions were more likely to have been severe burners and, after controlling for skin type, the investigators found that previous and potential users were more likely to have experienced sunburns during the summer and to have used tanning beds than were respondents who had neither used nor planned to use sunless tanners. The researchers concluded that the option of sunless tanning did not seem to lower the incidence of sunburn or the use of tanning beds. Further, they urged caution in offering broad support for artificial tanning products, even though looking for alternatives to UV exposure is to be encouraged (J. Am. Acad. Dermatol. 2006;54:1060-6).

A 2007 study using data from 5,491 completed interviews as part of the National Cancer Institute’s HINTS (Health Information National Trends Survey) 2005 set out to determine the prevalence of sunless-tanning formulation use and to understand the relationship between sunless tanning, indoor tanning, and sun-protective behavior. In so doing, the investigators found that the use of sunless-tanning products was relatively rare, with an estimated 11% of U.S. adults claiming to have used such products in the previous year. Of this group, 13% used sunless tanners more than 25 times; 12% used them 11-24 times; 35% used them 3-10 times; and 40% used them just once or twice. Users and exclusive users were more likely to be women, well educated, and living in the West (J. Am. Acad. Dermatol. 2007;56:387-90).

Recent Cause for Pause

In 2008, Jung et al. used the electron spin resonance spectroscopy–based radical sun protection factor, which measures free-radical reactions in skin biopsies during UV exposure and can determine the protective effect of UV filters and sunscreens, to analyze three different self-tanning agents, including DHA. Noting that the reaction of the reducing sugars in such products and amino acids (Maillard reaction) in the skin layer engendered Amadori products that created free radicals during UV irradiation, the investigators reported that in DHA-treated skin, more than 180% additional radicals were produced during sun exposure, compared with untreated skin. They concluded that the use of self-tanners necessitated reducing solar exposure duration (Spectrochim. Acta A. Mol. Biomol Spectrosc. 2008;69:1423-8). Consequently, DHA users would be well advised to wait at least 24 hours before solar exposure following application of sunless lotion or spray (Dermatol. Clin. 2009;27:149-54).

Conclusion

In addition to the need to continually persuade patients to engage in skin-protective behavior – namely, limiting sun exposure, avoiding peak-time exposures, wearing wide-brimmed hats and clothing with SPF value, and using sunscreens (preferably those containing avobenzone, Mexoryl, zinc oxide, or titanium dioxide) every day – it is incumbent upon dermatologists to disabuse our patients of the idea that untanned skin is less attractive or, conversely, that tans should be equated with attractive skin. Although healthy messages (that there is no such thing as a healthy tan, and that a tan indicates skin damage) are slowly spreading, sunless tanners appear to be a medically and cosmetically acceptable intermediary step, far surpassing the patently detrimental effects of indoor tanning. That said, patients should be advised to refrain from solar exposure for a full 24 hours after applying sunless tanners. Furthermore, much more research is necessary to truly establish that DHA delivers even modest protection from UVA or UVB. Accordingly, patients should be counseled that sunless tanners do not suffice as a base, nor do they justify extended solar exposure, and that sunscreens should also be applied.

Coloring the skin with dihydroxyacetone to create an artificial tan was discovered serendipitously in the 1950s by Eva Wittgenstein, whose patients were taking DHA orally. She observed that when patients regurgitated the DHA, pigmented spots remained on the skin (Science 1960;132:894-5).

The change in pigmentation results from the interaction of DHA with amino acids in the stratum corneum (Br. J. Dermatol. 2003;149:332-40).

Although the first product brought to market to exploit this new knowledge in 1959 met with initial success, it fell into disuse because of the poor cosmetic results (J. Am. Acad. Dermatol. 2003;49:1096-106; South. Med. J. 2005;98:1192-5).

Public awareness of sunless tanning has grown in recent years, however, and has been met with formulations that afford a much improved cosmetic performance, with DHA remaining as the main active ingredient in sunless-tanning agents (South. Med. J. 2005;98:1192-5; Am. J. Clin. Dermatol. 2002;3:317-8).

This column will briefly review the role of sunless-tanning lotions and sprays in dermatology, and will try to place recommendations to patients about sunless tanners in the context of sunscreens and tanning attitudes.

Sunless tanners have been used, with varying degrees of popularity, for 50 years; recent evidence suggests that the use of these products has increased in recent years. A long track record of usage and research indicates that sunless-tanning compounds are safe (J. Environ. Pathol. Toxicol. Oncol. 1984;5:349-51; Am. J. Clin. Dermatol. 2002;3:317-8; South. Med. J. 2005;98:1192-5; J. Am. Acad. Dermatol. 2007;56:387-90.) However, there is some debate as to whether the use of these products renders users more inclined to stay in the sun longer. Also, ongoing research has raised some safety issues regarding DHA.

Chemical Protection

In 2004, Petersen et al. investigated the effects of DHA on cell survival and proliferation of a human keratinocyte cell line, HaCaT. Significant genotoxic activity was identified in these cultured cells, as researchers noted dose- and time-dependent morphologic alterations as well as cytoplasmic budding and cell detachment in DHA-treated cells, and apoptosis and marked declines in proliferation 1 day after DHA exposure. Interestingly, the development of DNA strand breaks was prevented via preincubation with antioxidants. The authors suggested that their findings raised concerns about the long-term use of treating the skin with DHA-containing formulations (Mutat. Res. 2004;560:173-86).

A small study by Faurschou et al. showed that DHA provided human skin with modest UVB protection, with a 5% DHA cream applied three times or a 20% DHA cream applied once yielding an effect similar to an SPF 1.6. They acknowledged that most commercial DHA products contain 3%-5% DHA and offer scant protection. A potential advantage of sunless tanners, if they offer protection, suggested the authors, would be that no spots would be left unattended since such gaps would be conspicuous for lack of browning (Arch. Dermatol. 2004;140:886-7).

Howe, Reed, and Dellavalle contended that DHA in self-tanning agents provided enough UVA protection to warrant use as an adjunct to daily sunscreen use for broad-band protection (J. Am. Acad. Dermatol. 2008;58:894). The researchers referenced a 1975 study in which 3% DHA augmented sunlight tolerance among five patients with UVA-sensitive dermatoses (Dermatologica 1975;150:346-51; J. Am. Acad. Dermatol. 2008;58:894).

In 2009, Choquenet et al. assessed the sun protection potency of self-tanners and foundations using an in vitro method to identify indicators such as sun protection factor (SPF), UVA protection factor (PF-UVA), and UVB/UVA ratio. Using seven amino acids in the corneal cells of the epidermis, the investigators identified SPFs virtually equivalent to zero (approximately SPF 2). Conversely, they found foundations to exhibit satisfactory photostability and a non-negligible SPF, noting that such products are safe given their typically once-daily application (J. Dermatol. 2009;36:587-91).

Attitudes and Behavior

Users of sunless-tanning products were found, in a survey of 2,005 randomly selected South Australian adults published in 2001, to be more likely to use sunscreen but less likely to wear a hat or other sun-protective clothing. Sunburns were also linked to the use of sunless tanners in this study (Med. J. Aust. 2001;174:75-8; J. Am. Acad. Dermatol. 2007;56:387-90).

In 2005, Mahler et al. conducted a randomized, controlled trial with 1-month follow-up of 146 Southern California college students to study the impact of UV photoaging photographs and data on the sun protection plans and behaviors of young adults, and whether sunless-tanning lotion might play a role in sun-protective behavior. Of the 146 volunteers, 91.1% completed the "surprise" 1-month follow-up. The intervention consisted of volunteers being shown a UV facial photo and short video illustrating the etiology and results of photoaging. The investigators found that the UV photographic intervention was successful insofar as significantly better sun protection strategies and behaviors were employed by the test group, compared with controls. In addition, they noted that those who used sunless-tanning lotion were more likely to exhibit extensive sun-protective behavior, compared with individuals who received the intervention alone. The authors suggested that such interventions represented a cost-effective approach that might yield behaviors with long-term health benefits in the form of a lower incidence of skin cancer (Arch. Dermatol. 2005;141:373-80).

Later that year, Sheehan and Lesher reported on their anonymous survey of 121 adults (107 women and 14 men) who received spray-on sunless-tanning treatments between February and May 2004. Most reported that sunless tanning had not or would not affect their use of sunscreen or time spent outdoors. Interestingly, though, 73% of the respondents who had used tanning beds indicated that they had reduced or would reduce their use of indoor tanning. The researchers concluded that practitioners should recommend sunless tanning to their patients who use conventional tanning beds as a way to lower their solar exposure and risk of skin cancer (South. Med. J. 2005;98:1192-5).

In 2006, Brooks et al. reported on their July 2004, greater Boston, cross-sectional survey of 448 nonrandomly selected people aged 18-30 years on the subjects of artificial tanning products, recent history of sunburns, and tanning-bed use. During the preceding year, 22% of respondents had used sunless-tanning products and the same percentage hadn’t but would consider using them in the next year. Users of these lotions were more likely to have been severe burners and, after controlling for skin type, the investigators found that previous and potential users were more likely to have experienced sunburns during the summer and to have used tanning beds than were respondents who had neither used nor planned to use sunless tanners. The researchers concluded that the option of sunless tanning did not seem to lower the incidence of sunburn or the use of tanning beds. Further, they urged caution in offering broad support for artificial tanning products, even though looking for alternatives to UV exposure is to be encouraged (J. Am. Acad. Dermatol. 2006;54:1060-6).

A 2007 study using data from 5,491 completed interviews as part of the National Cancer Institute’s HINTS (Health Information National Trends Survey) 2005 set out to determine the prevalence of sunless-tanning formulation use and to understand the relationship between sunless tanning, indoor tanning, and sun-protective behavior. In so doing, the investigators found that the use of sunless-tanning products was relatively rare, with an estimated 11% of U.S. adults claiming to have used such products in the previous year. Of this group, 13% used sunless tanners more than 25 times; 12% used them 11-24 times; 35% used them 3-10 times; and 40% used them just once or twice. Users and exclusive users were more likely to be women, well educated, and living in the West (J. Am. Acad. Dermatol. 2007;56:387-90).

Recent Cause for Pause

In 2008, Jung et al. used the electron spin resonance spectroscopy–based radical sun protection factor, which measures free-radical reactions in skin biopsies during UV exposure and can determine the protective effect of UV filters and sunscreens, to analyze three different self-tanning agents, including DHA. Noting that the reaction of the reducing sugars in such products and amino acids (Maillard reaction) in the skin layer engendered Amadori products that created free radicals during UV irradiation, the investigators reported that in DHA-treated skin, more than 180% additional radicals were produced during sun exposure, compared with untreated skin. They concluded that the use of self-tanners necessitated reducing solar exposure duration (Spectrochim. Acta A. Mol. Biomol Spectrosc. 2008;69:1423-8). Consequently, DHA users would be well advised to wait at least 24 hours before solar exposure following application of sunless lotion or spray (Dermatol. Clin. 2009;27:149-54).

Conclusion

In addition to the need to continually persuade patients to engage in skin-protective behavior – namely, limiting sun exposure, avoiding peak-time exposures, wearing wide-brimmed hats and clothing with SPF value, and using sunscreens (preferably those containing avobenzone, Mexoryl, zinc oxide, or titanium dioxide) every day – it is incumbent upon dermatologists to disabuse our patients of the idea that untanned skin is less attractive or, conversely, that tans should be equated with attractive skin. Although healthy messages (that there is no such thing as a healthy tan, and that a tan indicates skin damage) are slowly spreading, sunless tanners appear to be a medically and cosmetically acceptable intermediary step, far surpassing the patently detrimental effects of indoor tanning. That said, patients should be advised to refrain from solar exposure for a full 24 hours after applying sunless tanners. Furthermore, much more research is necessary to truly establish that DHA delivers even modest protection from UVA or UVB. Accordingly, patients should be counseled that sunless tanners do not suffice as a base, nor do they justify extended solar exposure, and that sunscreens should also be applied.

Review

Michelle I. Rhiner RN, MSN, ACHPN

^,

and Charles F. von Gunten MD, PhD   [Author vitae]

Referred to by:		The Challenges of Treating Patients with Cancer Pain The Journal of Supportive Oncology, Volume 8, Issue 6, November-December 2010, Pages 239-240, Sloan Beth Karver, Jessalyn H. Berger PDF (90 K)   |
Referred to by:		A Conceptual Solution to Improve the Management of Cancer-Related Breakthrough Pain The Journal of Supportive Oncology, Volume 8, Issue 6, November-December 2010, Page 241, Wendy Ledesma, Toby C. Campbell PDF (73 K)   |

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11 American Pain Foundation, Breakthrough Cancer Pain Survey Fact Sheet http://www.painfoundation.org/learn/programs/spotlight-on-cancer-pain/breakthrough-pain/btcp-fact-sheet.pdf 2009.

12 National Cancer Institute, Pain (PDQ®) Health Professional Version 2010 http://www.cancer.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional Accessed January 29, 2010.

13 J. Abrahm, A Physician's Guide to Pain and Symptom Management in Cancer Patients (2nd ed.), Johns Hopkins University Press, Baltimore (2005).

14 S.M. Colleau, The significance of breakthrough pain in cancer, Cancer Pain Release (1999), p. 12.

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16 S.J. Farr and B.A. Otulana, Pulmonary delivery of opioids as pain therapeutics, Adv Drug Deliv Rev 58 (2006), pp. 1076–1088. Article |

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17 C.M. Terpening and W.M. Johnson, Methadone as an analgesic: a review of the risks and benefits, W V Med J 103 (2007), pp. 14–18. View Record in Scopus | Cited By in Scopus (10)

18 G. Zeppetella, Opioids for cancer breakthrough pain: a pilot study reporting patient assessment of time to meaningful pain relief, J Pain Symptom Manage 35 (2008), pp. 563–567. Article |

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19 National Cancer Institute, Pain (PDR®) Health Professional Version 2009 http://www.cancer.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional Accessed December 1, 2009.

20 National Comprehensive Cancer Network (NCCN), National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology, Adult Cancer Pain http://www.nccn.org/professionals/physician_gls/f_guidelines.asp Accessed May 10, 2010.

21 , Actiq (oral transmucosal fentanyl citrate lozenge) prescribing information Cepahlon, Inc.: Salt Lake City, UT http://www.actiq.com/pdf/actiq_package_insert_4_5_07.pdf Accessed May 21, 2010.

22 , Fentora (fentanyl buccal tablet) prescribing information Cephalon, Inc.: Frazer, PA http://www.fentora.com/pdfs/pdf100_prescribing_info.pdf Accessed May 21, 2010.

23 , Onsolis (fentanyl buccal soluble film) prescribing information Meda Pharmaceuticals, Inc.: Somerset, NJ http://onsolisfocus.com/pdf/pi.pdf Accessed May 21, 2010.

24 F. Brennan, D.B. Carr and M. Cousins, Pain management: a fundamental human right, Anesth Analg 105 (2007), pp. 205–221. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (109)

25 T.E. Elliott and B.A. Elliott, Physician attitudes and beliefs about use of morphine for cancer pain, J Pain Symptom Manage 7 (1992), pp. 141–148. Abstract |

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26 B.A. Rich, An ethical analysis of the barriers to effective pain management, Camb Q Healthc Ethics 9 (2000), pp. 54–70. View Record in Scopus | Cited By in Scopus (27)

27 K.L. Sees and H.W. Clark, Opioid use in the treatment of chronic pain: assessment of addiction, J Pain Symptom Manage 8 (1993), pp. 257–264. Article |

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28 J.E. Mortimer and N.L. Bartlett, Assessment of knowledge about cancer pain management by physicians in training, J Pain Symptom Manage 14 (1997), pp. 21–28. Abstract |

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29 R. Gallagher, P. Hawley and W. Yeomans, A survey of cancer pain management knowledge and attitudes of British Columbian physicians, Pain Res Manag 9 (2004), pp. 188–194. View Record in Scopus | Cited By in Scopus (17)

30 B.G. Jenkins, P.H. Tuffin, C.L. Choo and S.A. Schug, Opioid prescribing: an assessment using quality statements, J Clin Pharm Ther 30 (2005), pp. 597–602. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (7)

31 C.M. Reid, R. Gooberman-Hill and G.W. Hanks, Opioid analgesics for cancer pain: symptom control for the living or comfort for the dying?: A qualitative study to investigate the factors influencing the decision to accept morphine for pain caused by cancer, Ann Oncol 19 (2008), pp. 44–48. View Record in Scopus | Cited By in Scopus (18)

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33 R. Benyamin, A.M. Trescot and S. Datta et al., Opioid complications and side effects, Pain Physician 11 (2008), pp. S105–S120. View Record in Scopus | Cited By in Scopus (86)

34 K. Bell and A. Salmon, Pain, physical dependence and pseudoaddiction: redefining addiction for “nice” people?, Int J Drug Policy 20 (2009), pp. 170–178. Article |

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36 American Pain Society, Definitions Related to the Use of Opioids for the Treatment of Pain http://www.ampainsoc.org/advocacy/opioids2.htm Accessed March 23, 2010.

37 J. Hojsted and P. Sjogren, Addiction to opioids in chronic pain patients: a literature review, Eur J Pain 11 (2007), pp. 490–518. Article |

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38 O.H. Wilder-Smith, Opioid use in the elderly, Eur J Pain 9 (2005), pp. 137–140. Article |

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39 D. Jourdan, S. Boghossian and A. Alloui et al., Age-related changes in nociception and effect of morphine in the Lou rat, Eur J Pain 4 (2000), pp. 291–300. Abstract |

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40 E. Kramer and R.J. Bodnar, Age-related decrements in morphine analgesia: a parametric analysis, Neurobiol Aging 7 (1986), pp. 185–191. Abstract |

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41 M.A. Smith and J.D. Gray, Age-related differences in sensitivity to the antinociceptive effects of opioids in male rats: Influence of nociceptive intensity and intrinsic efficacy at the mu receptor, Psychopharmacology (Berl) 156 (2001), pp. 445–453. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (26)

42 F.M. Gloth 3rd, Pain management in older adults: prevention and treatment, J Am Geriatr Soc 49 (2001), pp. 188–199. Full Text via CrossRef

43 S.M. Weinstein, L.F. Laux and J.I. Thornby et al., Physicians' attitudes toward pain and the use of opioid analgesics: results of a survey from the Texas Cancer Pain Initiative, South Med J 93 (2000), pp. 479–487. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (94)

44 B. Collett, S. O'Mahoney, P. Schofield, S.J. Closs and J. Potter, The assessment of pain in older people, Clin Med 7 (2007), pp. 496–500. View Record in Scopus | Cited By in Scopus (2)

45 R.A. Morrison, Update on sickle cell disease: incidence of addiction and choice of opioid in pain management, Pediatr Nurs 17 (1991), p. 503. View Record in Scopus | Cited By in Scopus (6)

46 C.H. Pegelow, Survey of pain management therapy provided for children with sickle cell disease, Clin Pediatr (Phila) 31 (1992), pp. 211–214. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (46)

47 C. Wright, S. Schnoll and D. Bernstein, Risk evaluation and mitigation strategies for drugs with abuse liability: public interest, special interest, conflicts of interest, and the industry perspective, Ann N Y Acad Sci 1141 (2008), pp. 284–303. View Record in Scopus | Cited By in Scopus (0)

48 M. Zenz, T. Zenz, M. Tryba and M. Strumpf, Severe undertreatment of cancer pain: a 3-year survey of the German situation, J Pain Symptom Manage 10 (1995), pp. 187–191. Abstract |

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49 C. Wright, S. Schnoll and D. Bernstein, Risk evaluation and mitigation strategies for drug with abuse liability: public interest, special interest, conflicts of interest and industry perspective, Ann N Y Acad Sci 1141 (2008), pp. 284–303. View Record in Scopus | Cited By in Scopus (6)

50 D. Nemecek, Improving access to buprenorphine: A managed care company overcomes several obstacles to make this treatment more available, Behav Healthc 27 (2007), pp. 40–42. View Record in Scopus | Cited By in Scopus (1)

51 C.C. Corizzo, M.C. Baker and G.C. Henkelmann, Assessment of patient satisfaction with pain management in small community inpatient and outpatient settings, Oncol Nurs Forum 27 (2000), pp. 1279–1286. View Record in Scopus | Cited By in Scopus (10)

52 R. Sapir, R. Catane and B. Kaufman et al., Cancer patient expectations of and communication with oncologists and oncology nurses: the experience of an integrated oncology and palliative care service, Support Care Cancer 8 (2000), pp. 458–463. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (37)

53 K. Forbes, Opioids: beliefs and myths, J Pain Palliat Care Pharmacother 20 (2006), pp. 33–35. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (8)

54 P.E. Berry and S.E. Ward, Barriers to pain management in hospice: a study of family caregivers, Hosp J 10 (1995), pp. 19–33. View Record in Scopus | Cited By in Scopus (45)

55 H. Breivik, N. Cherny and B. Collett et al., Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes, Ann Oncol 20 (2009), pp. 1420–1433. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (36)

56 S.H. Neo, E.C. Loh and W.H. Koo, An audit of morphine prescribing in a hospice, Singapore Med J 42 (2001), pp. 417–419. View Record in Scopus | Cited By in Scopus (8)

57 M. Weber and C. Huber, Documentation of severe pain, opioid doses, and opioid-related side effects in outpatients with cancer: a retrospective study, J Pain Symptom Manage 17 (1999), pp. 49–54. Article |

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58 F. De Conno, A. Caraceni and A. Gamba et al., Pain measurement in cancer patients: a comparison of six methods, Pain 57 (1994), pp. 161–166. Abstract |

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59 G.D. Hakonsen, S. Hudson and T. Loennechen, Design and validation of a medication assessment tool for cancer pain management, Pharm World Sci 28 (2006), pp. 342–351. View Record in Scopus | Cited By in Scopus (5)

60 A. Caraceni, N. Cherny and R. Fainsinger et al., Pain measurement tools and methods in clinical research in palliative care: recommendations of an Expert Working Group of the European Association of Palliative Care, J Pain Symptom Manage 23 (2002), pp. 239–255. Article |

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61 J.C. Holen, M.J. Hjermstad and J.H. Loge et al., Pain assessment tools: is the content appropriate for use in palliative care?, J Pain Symptom Manage 32 (2006), pp. 567–580. Article |

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62 P.A. Sloan, M.B. Donnelly, B. Vanderveer, M. Delomas, R.W. Schwartz and D.A. Sloan, Cancer pain education among family physicians, J Pain Symptom Manage 14 (1997), pp. 74–81. Abstract |

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63 P.A. Sloan, B.L. Vanderveer, J.S. Snapp, M. Johnson and D.A. Sloan, Cancer pain assessment and management recommendations by hospice nurses: University of Kentucky, Lexington, Kentucky, J Pain Symptom Manage 18 (1999), pp. 103–110. Article |

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64 C.T. Furstenberg, T.A. Ahles and M.B. Whedon et al., Knowledge and attitudes of health-care providers toward cancer pain management: a comparison of physicians, nurses, and pharmacists in the state of New Hampshire, J Pain Symptom Manage 15 (1998), pp. 335–349. Article |

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Conflicts of interest: M. I. R. has served on the speaker's bureau and nurse advisory boards of Cephalon, Inc., and Meda Pharmaceuticals, Inc. She was also a clinical trial subinvestigator for Cephalon's Actiq and Fentora clinical trials and Meda/BDSI's Onsolis clinical trial. C. F. v. G. received an honorarium from Meda Pharmaceuticals, Inc., for describing the features of their buccal fentanyl product.

Correspondence to: Michelle Rhiner, RN-BC, MSN, GNP-BC, CCM, Pallgesia Associates, PO Box 8127, Alta Loma, CA 91737; telephone: (909) 319-1603; fax: (909) 945-2923

Review

Michelle I. Rhiner RN, MSN, ACHPN

^,

and Charles F. von Gunten MD, PhD   [Author vitae]

Referred to by:		The Challenges of Treating Patients with Cancer Pain The Journal of Supportive Oncology, Volume 8, Issue 6, November-December 2010, Pages 239-240, Sloan Beth Karver, Jessalyn H. Berger PDF (90 K)   |
Referred to by:		A Conceptual Solution to Improve the Management of Cancer-Related Breakthrough Pain The Journal of Supportive Oncology, Volume 8, Issue 6, November-December 2010, Page 241, Wendy Ledesma, Toby C. Campbell PDF (73 K)   |

Conflicts of interest: M. I. R. has served on the speaker's bureau and nurse advisory boards of Cephalon, Inc., and Meda Pharmaceuticals, Inc. She was also a clinical trial subinvestigator for Cephalon's Actiq and Fentora clinical trials and Meda/BDSI's Onsolis clinical trial. C. F. v. G. received an honorarium from Meda Pharmaceuticals, Inc., for describing the features of their buccal fentanyl product.

Correspondence to: Michelle Rhiner, RN-BC, MSN, GNP-BC, CCM, Pallgesia Associates, PO Box 8127, Alta Loma, CA 91737; telephone: (909) 319-1603; fax: (909) 945-2923

Review

Michelle I. Rhiner RN, MSN, ACHPN

^,

and Charles F. von Gunten MD, PhD   [Author vitae]

Referred to by:		The Challenges of Treating Patients with Cancer Pain The Journal of Supportive Oncology, Volume 8, Issue 6, November-December 2010, Pages 239-240, Sloan Beth Karver, Jessalyn H. Berger PDF (90 K)   |
Referred to by:		A Conceptual Solution to Improve the Management of Cancer-Related Breakthrough Pain The Journal of Supportive Oncology, Volume 8, Issue 6, November-December 2010, Page 241, Wendy Ledesma, Toby C. Campbell PDF (73 K)   |

Conflicts of interest: M. I. R. has served on the speaker's bureau and nurse advisory boards of Cephalon, Inc., and Meda Pharmaceuticals, Inc. She was also a clinical trial subinvestigator for Cephalon's Actiq and Fentora clinical trials and Meda/BDSI's Onsolis clinical trial. C. F. v. G. received an honorarium from Meda Pharmaceuticals, Inc., for describing the features of their buccal fentanyl product.

Correspondence to: Michelle Rhiner, RN-BC, MSN, GNP-BC, CCM, Pallgesia Associates, PO Box 8127, Alta Loma, CA 91737; telephone: (909) 319-1603; fax: (909) 945-2923

The American Academy of Dermatology still recommends vitamin D come from a healthy diet and supplements, not from unprotected skin exposure to ultraviolet radiation, according to their newly updated position statement.

The update comes in response to the Institute of Medicine's (IOM) recent review of existing data on possible roles for vitamin D status in certain types of cancers, and neurologic, infectious, autoimmune, and cardiovascular diseases. In the report, the IOM called existing evidence "inconsistent, inconclusive as to causality, and insufficient to inform nutritional requirement." However, the organization found that the evidence does support a role for vitamin D in bone health.

"The IOM's review of the scientific evidence about vitamin D supports the Academy's long-standing recommendation on safe ways to get this important vitamin – through a healthy diet which incorporates foods naturally rich in vitamin D, vitamin D–fortified foods and beverages, and vitamin D supplements," AAD president Dr. William D. James noted in a statement.

In particular, the statement reinforces the idea that unprotected UV exposure to the sun or indoor tanning devices is a known risk factor for the development of skin cancer. There is no scientifically validated, safe threshold level of UV exposure from the sun or indoor tanning devices that allows for maximal vitamin D synthesis without increasing skin cancer risk.

The Academy recommends a comprehensive photoprotective regimen, including the regular and proper use of a broad-spectrum sunscreen to protect against skin cancer.

The statement also includes new IOM Recommended Dietary Allowances (RDA) for calcium and vitamin D intake. Of note, these age-based values were derived assuming minimal or no sun exposure, given inconsistent contributions of sunlight to vitamin D in the population and also because of the risk of cancer associated with sun exposure.

Adequate vitamin D was defined by the IOM as blood levels of at least 20 ng/mL as measured in the United States (50 nmol/L as measured in Canada).

Physicians should discuss options for obtaining sufficient dietary or supplementary sources of vitamin D with patients having concerned about their vitamin D levels.

The American Academy of Dermatology still recommends vitamin D come from a healthy diet and supplements, not from unprotected skin exposure to ultraviolet radiation, according to their newly updated position statement.

The update comes in response to the Institute of Medicine's (IOM) recent review of existing data on possible roles for vitamin D status in certain types of cancers, and neurologic, infectious, autoimmune, and cardiovascular diseases. In the report, the IOM called existing evidence "inconsistent, inconclusive as to causality, and insufficient to inform nutritional requirement." However, the organization found that the evidence does support a role for vitamin D in bone health.

"The IOM's review of the scientific evidence about vitamin D supports the Academy's long-standing recommendation on safe ways to get this important vitamin – through a healthy diet which incorporates foods naturally rich in vitamin D, vitamin D–fortified foods and beverages, and vitamin D supplements," AAD president Dr. William D. James noted in a statement.

In particular, the statement reinforces the idea that unprotected UV exposure to the sun or indoor tanning devices is a known risk factor for the development of skin cancer. There is no scientifically validated, safe threshold level of UV exposure from the sun or indoor tanning devices that allows for maximal vitamin D synthesis without increasing skin cancer risk.

The Academy recommends a comprehensive photoprotective regimen, including the regular and proper use of a broad-spectrum sunscreen to protect against skin cancer.

The statement also includes new IOM Recommended Dietary Allowances (RDA) for calcium and vitamin D intake. Of note, these age-based values were derived assuming minimal or no sun exposure, given inconsistent contributions of sunlight to vitamin D in the population and also because of the risk of cancer associated with sun exposure.

Adequate vitamin D was defined by the IOM as blood levels of at least 20 ng/mL as measured in the United States (50 nmol/L as measured in Canada).

Physicians should discuss options for obtaining sufficient dietary or supplementary sources of vitamin D with patients having concerned about their vitamin D levels.

The American Academy of Dermatology still recommends vitamin D come from a healthy diet and supplements, not from unprotected skin exposure to ultraviolet radiation, according to their newly updated position statement.

The update comes in response to the Institute of Medicine's (IOM) recent review of existing data on possible roles for vitamin D status in certain types of cancers, and neurologic, infectious, autoimmune, and cardiovascular diseases. In the report, the IOM called existing evidence "inconsistent, inconclusive as to causality, and insufficient to inform nutritional requirement." However, the organization found that the evidence does support a role for vitamin D in bone health.

"The IOM's review of the scientific evidence about vitamin D supports the Academy's long-standing recommendation on safe ways to get this important vitamin – through a healthy diet which incorporates foods naturally rich in vitamin D, vitamin D–fortified foods and beverages, and vitamin D supplements," AAD president Dr. William D. James noted in a statement.

In particular, the statement reinforces the idea that unprotected UV exposure to the sun or indoor tanning devices is a known risk factor for the development of skin cancer. There is no scientifically validated, safe threshold level of UV exposure from the sun or indoor tanning devices that allows for maximal vitamin D synthesis without increasing skin cancer risk.

The Academy recommends a comprehensive photoprotective regimen, including the regular and proper use of a broad-spectrum sunscreen to protect against skin cancer.

The statement also includes new IOM Recommended Dietary Allowances (RDA) for calcium and vitamin D intake. Of note, these age-based values were derived assuming minimal or no sun exposure, given inconsistent contributions of sunlight to vitamin D in the population and also because of the risk of cancer associated with sun exposure.

Adequate vitamin D was defined by the IOM as blood levels of at least 20 ng/mL as measured in the United States (50 nmol/L as measured in Canada).

Physicians should discuss options for obtaining sufficient dietary or supplementary sources of vitamin D with patients having concerned about their vitamin D levels.

A majority of dermatologists, internists, and family physicians routinely perform full-body examinations for skin cancer – but time constraints and patient reluctance are common barriers to better exam rates, according to a report in the January issue of the Archives of Dermatology.

A total of 81% of dermatologists, 56% of internists, and 60% of family physicians in a nationally representative sample reported that they routinely perform the skin cancer examinations.

All three groups of physicians also identified barriers to performing skin examinations more often, but the barriers varied by specialty, said Susan A. Oliveria, Sc.D., of Memorial Sloan-Kettering Cancer Center’s dermatology service, New York, and her associates (Arch. Dermatol. 2011;147:39-44).

The investigators assessed skin cancer screening practices because little is known about the subject, and a better understanding both of the obstacles and of the facilitating factors could help improve primary and secondary screening.

To examine the issue, the researchers used data from a survey to which 1,669 physicians in group or solo private practice responded. The respondents included 679 dermatologists, 431 internists, and 559 family physicians. Most reported that they saw 200-600 patients per month, and most were aged 41-60 years.

Approximately 54% of internists and family physicians reported that time constraints prevented them from doing full-body skin exams more frequently, compared with only 31% of dermatologists. Half of the internists and family physicians also said that "competing comorbidities" often took priority over skin exams, compared with only 16% of dermatologists.

In contrast, significantly more dermatologists (44%) identified patient embarrassment or reluctance as a barrier to performing full-body skin exams, compared with internists (33%) or family physicians (31%). That is likely because most patients see a dermatologist for an isolated skin condition such as a wart or rash, the investigators noted, and do not expect to undress for a full-body exam.

In contrast, patients expect to undress for an internist or family physician, because disrobing for pelvic or rectal exams often is part of their annual physical examinations. Moreover, primary care physicians "have years to build up relationships with their patients," the study authors explained, while dermatologists typically do not.

To overcome that barrier, "dermatologists could educate their patients about the role of a full-body skin examination in a routine visit by providing them with written material to read and establishing a comforting physician-patient relationship," Dr. Oliveria and her colleagues said.

All the physicians reported that they were more likely to screen for skin cancer in patients who had one or more risk factors for the disease. Even so, only 87% of dermatologists, 65% of internists, and 70% of family physicians reported that they performed full-body exams in most of their high-risk patients.

Another common reason for performing a full-body skin cancer screen was the same for all three specialties: having a patient ask to have such an exam or to have a suspicious mole checked. That shows that it is important to maintain public education programs encouraging patients to request skin exams or mole checks, the researchers said.

Fewer internists (56%) and family physicians (54%) than dermatologists (78%) reported that their skill and expertise at performing skin exams and diagnosing skin cancer facilitated their screening practices. That finding suggests that enhanced dermatologic training during medical school and continuing medical education programs would be beneficial, the investigators added.

The National Cancer Institute supported the study. No financial conflicts of interest were reported.

A majority of dermatologists, internists, and family physicians routinely perform full-body examinations for skin cancer – but time constraints and patient reluctance are common barriers to better exam rates, according to a report in the January issue of the Archives of Dermatology.

A total of 81% of dermatologists, 56% of internists, and 60% of family physicians in a nationally representative sample reported that they routinely perform the skin cancer examinations.

All three groups of physicians also identified barriers to performing skin examinations more often, but the barriers varied by specialty, said Susan A. Oliveria, Sc.D., of Memorial Sloan-Kettering Cancer Center’s dermatology service, New York, and her associates (Arch. Dermatol. 2011;147:39-44).

The investigators assessed skin cancer screening practices because little is known about the subject, and a better understanding both of the obstacles and of the facilitating factors could help improve primary and secondary screening.

To examine the issue, the researchers used data from a survey to which 1,669 physicians in group or solo private practice responded. The respondents included 679 dermatologists, 431 internists, and 559 family physicians. Most reported that they saw 200-600 patients per month, and most were aged 41-60 years.

Approximately 54% of internists and family physicians reported that time constraints prevented them from doing full-body skin exams more frequently, compared with only 31% of dermatologists. Half of the internists and family physicians also said that "competing comorbidities" often took priority over skin exams, compared with only 16% of dermatologists.

In contrast, significantly more dermatologists (44%) identified patient embarrassment or reluctance as a barrier to performing full-body skin exams, compared with internists (33%) or family physicians (31%). That is likely because most patients see a dermatologist for an isolated skin condition such as a wart or rash, the investigators noted, and do not expect to undress for a full-body exam.

In contrast, patients expect to undress for an internist or family physician, because disrobing for pelvic or rectal exams often is part of their annual physical examinations. Moreover, primary care physicians "have years to build up relationships with their patients," the study authors explained, while dermatologists typically do not.

To overcome that barrier, "dermatologists could educate their patients about the role of a full-body skin examination in a routine visit by providing them with written material to read and establishing a comforting physician-patient relationship," Dr. Oliveria and her colleagues said.

All the physicians reported that they were more likely to screen for skin cancer in patients who had one or more risk factors for the disease. Even so, only 87% of dermatologists, 65% of internists, and 70% of family physicians reported that they performed full-body exams in most of their high-risk patients.

Another common reason for performing a full-body skin cancer screen was the same for all three specialties: having a patient ask to have such an exam or to have a suspicious mole checked. That shows that it is important to maintain public education programs encouraging patients to request skin exams or mole checks, the researchers said.

Fewer internists (56%) and family physicians (54%) than dermatologists (78%) reported that their skill and expertise at performing skin exams and diagnosing skin cancer facilitated their screening practices. That finding suggests that enhanced dermatologic training during medical school and continuing medical education programs would be beneficial, the investigators added.

The National Cancer Institute supported the study. No financial conflicts of interest were reported.

A majority of dermatologists, internists, and family physicians routinely perform full-body examinations for skin cancer – but time constraints and patient reluctance are common barriers to better exam rates, according to a report in the January issue of the Archives of Dermatology.

A total of 81% of dermatologists, 56% of internists, and 60% of family physicians in a nationally representative sample reported that they routinely perform the skin cancer examinations.

All three groups of physicians also identified barriers to performing skin examinations more often, but the barriers varied by specialty, said Susan A. Oliveria, Sc.D., of Memorial Sloan-Kettering Cancer Center’s dermatology service, New York, and her associates (Arch. Dermatol. 2011;147:39-44).

The investigators assessed skin cancer screening practices because little is known about the subject, and a better understanding both of the obstacles and of the facilitating factors could help improve primary and secondary screening.

To examine the issue, the researchers used data from a survey to which 1,669 physicians in group or solo private practice responded. The respondents included 679 dermatologists, 431 internists, and 559 family physicians. Most reported that they saw 200-600 patients per month, and most were aged 41-60 years.

Approximately 54% of internists and family physicians reported that time constraints prevented them from doing full-body skin exams more frequently, compared with only 31% of dermatologists. Half of the internists and family physicians also said that "competing comorbidities" often took priority over skin exams, compared with only 16% of dermatologists.

In contrast, significantly more dermatologists (44%) identified patient embarrassment or reluctance as a barrier to performing full-body skin exams, compared with internists (33%) or family physicians (31%). That is likely because most patients see a dermatologist for an isolated skin condition such as a wart or rash, the investigators noted, and do not expect to undress for a full-body exam.

In contrast, patients expect to undress for an internist or family physician, because disrobing for pelvic or rectal exams often is part of their annual physical examinations. Moreover, primary care physicians "have years to build up relationships with their patients," the study authors explained, while dermatologists typically do not.

To overcome that barrier, "dermatologists could educate their patients about the role of a full-body skin examination in a routine visit by providing them with written material to read and establishing a comforting physician-patient relationship," Dr. Oliveria and her colleagues said.

All the physicians reported that they were more likely to screen for skin cancer in patients who had one or more risk factors for the disease. Even so, only 87% of dermatologists, 65% of internists, and 70% of family physicians reported that they performed full-body exams in most of their high-risk patients.

Another common reason for performing a full-body skin cancer screen was the same for all three specialties: having a patient ask to have such an exam or to have a suspicious mole checked. That shows that it is important to maintain public education programs encouraging patients to request skin exams or mole checks, the researchers said.

Fewer internists (56%) and family physicians (54%) than dermatologists (78%) reported that their skill and expertise at performing skin exams and diagnosing skin cancer facilitated their screening practices. That finding suggests that enhanced dermatologic training during medical school and continuing medical education programs would be beneficial, the investigators added.

The National Cancer Institute supported the study. No financial conflicts of interest were reported.

ORLANDO - Standard surgical margins often are inadequate for lentigo maligna; instead, perimeter excision techniques or Mohs surgery is preferable because these approaches consistently provide high cure rates, according to Dr. Basil S. Cherpelis.

Photo (c)2010 Clinics in Plastic Surgery published by Elsevier

Lentigo maligna is a subtype of melanoma in situ, characterized as an overgrowth of atypical melanocytes with the potential to become lentigo maligna melanoma. "I think of it as the problem child of the melanoma family," Dr. Cherpelis said at the annual meeting of the Florida Society of Dermatologic Surgeons.

"What margin should I use, and if I am going to do Mohs, how can I see margins on frozen sections?" Intraoperative margin control is recommended, but recent literature suggests that standard 5-mm margins are frequently inadequate (Clin. Plast. Surg. 2010;37:35-46; Int. J. Dermatol. 2010;49:482-91).

In general, traditional frozen sections permit only 1% of margins to be assessed. For that reason, Dr. Cherpelis said he prefers permanent processing or Mohs surgery for these patients. With permanent processing, a surgeon leaves a central island of tissue and removes peripheral strips. Excised samples sent to a lab for evaluation typically take several days for results.

"Permanent processing has excellent cure rates. But on the downside, a patient has to wait for pathology results, which can be inconvenient," said Dr. Cherpelis, a cutaneous oncologist at Moffitt Cancer Center at the University of South Florida in Tampa.

In contrast, Mohs micrographic excision and repair are performed on the same day. Because the entire margin is visualized, cure rates are "excellent," Dr. Cherpelis said.

As to why Mohs isn’t more widely used, one possible reason is that it can be difficult to distinguish melanocytes from keratinocytes on frozen section, he said.

Immunohistostains to the rescue: Melanoma antigen recognized by T cells (MART-1) and microphthalmia-associated transcription factor (MITF) staining each has a role.

"MART-1 is a valuable immunostain for melanoma in situ on photodamaged skin," said Dr. L. Frank Glass, a dermatopathologist at Moffitt Cancer Center. MART-1 on frozen sections can provide the same data as permanent processing. "But MART-1 is not a magic bullet," he added. "There can be false positives."

In addition, expertise and teamwork are required with immunohistostains, Dr. Glass said. "The right MART-1 staining takes a technical staff to do it right."

MITF works in frozen sections and produces results similar to permanent sections. Clinicians can use this nuclear immunostain to quantify melanocytes and assess other parameters that distinguish melanoma in situ from solar lentigines or skin with chronic sun damage, for example.

"MITF is particularly useful in combination with MART-1," Dr. Glass said.

Instead of dendritic processes that overlap and look like confluence, MITF reveals discreet melanocytic cells, Dr. Glass said. "You can feel more comfortable calling a case negative with MITF – if it shows no abnormal cytology – in the same patient where the MART-1 shows clumping."

"The bottom line is we are looking for 100% specificity for melanoma," Dr. Glass said. He and his colleagues also are developing cutoff values, based on melanocyte diameter and density, to distinguish melanoma in situ from solar lentigo or sun-damaged skin.

Dr. Cherpelis and Dr. Glass said they had no relevant financial disclosures.

ORLANDO - Standard surgical margins often are inadequate for lentigo maligna; instead, perimeter excision techniques or Mohs surgery is preferable because these approaches consistently provide high cure rates, according to Dr. Basil S. Cherpelis.

Photo (c)2010 Clinics in Plastic Surgery published by Elsevier

Lentigo maligna is a subtype of melanoma in situ, characterized as an overgrowth of atypical melanocytes with the potential to become lentigo maligna melanoma. "I think of it as the problem child of the melanoma family," Dr. Cherpelis said at the annual meeting of the Florida Society of Dermatologic Surgeons.

"What margin should I use, and if I am going to do Mohs, how can I see margins on frozen sections?" Intraoperative margin control is recommended, but recent literature suggests that standard 5-mm margins are frequently inadequate (Clin. Plast. Surg. 2010;37:35-46; Int. J. Dermatol. 2010;49:482-91).

In general, traditional frozen sections permit only 1% of margins to be assessed. For that reason, Dr. Cherpelis said he prefers permanent processing or Mohs surgery for these patients. With permanent processing, a surgeon leaves a central island of tissue and removes peripheral strips. Excised samples sent to a lab for evaluation typically take several days for results.

"Permanent processing has excellent cure rates. But on the downside, a patient has to wait for pathology results, which can be inconvenient," said Dr. Cherpelis, a cutaneous oncologist at Moffitt Cancer Center at the University of South Florida in Tampa.

In contrast, Mohs micrographic excision and repair are performed on the same day. Because the entire margin is visualized, cure rates are "excellent," Dr. Cherpelis said.

As to why Mohs isn’t more widely used, one possible reason is that it can be difficult to distinguish melanocytes from keratinocytes on frozen section, he said.

Immunohistostains to the rescue: Melanoma antigen recognized by T cells (MART-1) and microphthalmia-associated transcription factor (MITF) staining each has a role.

"MART-1 is a valuable immunostain for melanoma in situ on photodamaged skin," said Dr. L. Frank Glass, a dermatopathologist at Moffitt Cancer Center. MART-1 on frozen sections can provide the same data as permanent processing. "But MART-1 is not a magic bullet," he added. "There can be false positives."

In addition, expertise and teamwork are required with immunohistostains, Dr. Glass said. "The right MART-1 staining takes a technical staff to do it right."

MITF works in frozen sections and produces results similar to permanent sections. Clinicians can use this nuclear immunostain to quantify melanocytes and assess other parameters that distinguish melanoma in situ from solar lentigines or skin with chronic sun damage, for example.

"MITF is particularly useful in combination with MART-1," Dr. Glass said.

Instead of dendritic processes that overlap and look like confluence, MITF reveals discreet melanocytic cells, Dr. Glass said. "You can feel more comfortable calling a case negative with MITF – if it shows no abnormal cytology – in the same patient where the MART-1 shows clumping."

"The bottom line is we are looking for 100% specificity for melanoma," Dr. Glass said. He and his colleagues also are developing cutoff values, based on melanocyte diameter and density, to distinguish melanoma in situ from solar lentigo or sun-damaged skin.

Dr. Cherpelis and Dr. Glass said they had no relevant financial disclosures.

ORLANDO - Standard surgical margins often are inadequate for lentigo maligna; instead, perimeter excision techniques or Mohs surgery is preferable because these approaches consistently provide high cure rates, according to Dr. Basil S. Cherpelis.

Photo (c)2010 Clinics in Plastic Surgery published by Elsevier

Lentigo maligna is a subtype of melanoma in situ, characterized as an overgrowth of atypical melanocytes with the potential to become lentigo maligna melanoma. "I think of it as the problem child of the melanoma family," Dr. Cherpelis said at the annual meeting of the Florida Society of Dermatologic Surgeons.

"What margin should I use, and if I am going to do Mohs, how can I see margins on frozen sections?" Intraoperative margin control is recommended, but recent literature suggests that standard 5-mm margins are frequently inadequate (Clin. Plast. Surg. 2010;37:35-46; Int. J. Dermatol. 2010;49:482-91).

In general, traditional frozen sections permit only 1% of margins to be assessed. For that reason, Dr. Cherpelis said he prefers permanent processing or Mohs surgery for these patients. With permanent processing, a surgeon leaves a central island of tissue and removes peripheral strips. Excised samples sent to a lab for evaluation typically take several days for results.

"Permanent processing has excellent cure rates. But on the downside, a patient has to wait for pathology results, which can be inconvenient," said Dr. Cherpelis, a cutaneous oncologist at Moffitt Cancer Center at the University of South Florida in Tampa.

In contrast, Mohs micrographic excision and repair are performed on the same day. Because the entire margin is visualized, cure rates are "excellent," Dr. Cherpelis said.

As to why Mohs isn’t more widely used, one possible reason is that it can be difficult to distinguish melanocytes from keratinocytes on frozen section, he said.

Immunohistostains to the rescue: Melanoma antigen recognized by T cells (MART-1) and microphthalmia-associated transcription factor (MITF) staining each has a role.

"MART-1 is a valuable immunostain for melanoma in situ on photodamaged skin," said Dr. L. Frank Glass, a dermatopathologist at Moffitt Cancer Center. MART-1 on frozen sections can provide the same data as permanent processing. "But MART-1 is not a magic bullet," he added. "There can be false positives."

In addition, expertise and teamwork are required with immunohistostains, Dr. Glass said. "The right MART-1 staining takes a technical staff to do it right."

MITF works in frozen sections and produces results similar to permanent sections. Clinicians can use this nuclear immunostain to quantify melanocytes and assess other parameters that distinguish melanoma in situ from solar lentigines or skin with chronic sun damage, for example.

"MITF is particularly useful in combination with MART-1," Dr. Glass said.

Instead of dendritic processes that overlap and look like confluence, MITF reveals discreet melanocytic cells, Dr. Glass said. "You can feel more comfortable calling a case negative with MITF – if it shows no abnormal cytology – in the same patient where the MART-1 shows clumping."

"The bottom line is we are looking for 100% specificity for melanoma," Dr. Glass said. He and his colleagues also are developing cutoff values, based on melanocyte diameter and density, to distinguish melanoma in situ from solar lentigo or sun-damaged skin.

Dr. Cherpelis and Dr. Glass said they had no relevant financial disclosures.