Intense Sun Exposure Research Articles

Survenue d’un carcinome spinocellulaire chez un patient traité par sorafenib

Sorafenib is a multikinase inhibitor approved for the treatment of renal cell carcinoma and hepatocellular carcinoma. Associated short-term cutaneous adverse events are well known. Regarding long-term adverse events, keratoacanthoma has been reported more recently and, more rarely, invasive squamous cell carcinoma. A 56-year-old man was treated with sorafenib in December 2008 for renal cell carcinoma with cutaneous metastases. The patient had a skin phototype IV and no history of intense sun exposure. Within five months of starting sorafenib, he developed deeply invasive well-differentiated retroauricular squamous cell carcinoma. Sorafenib modifies the immunostimulatory capacity of dendritic cells by reducing cytokine secretion and CD1a expression. Blockade of autocrine vascular endothelial growth factor (VEGF) signalling in keratinocytes can also select tumoural clones with increased oncogenic Ras mutation, increased activation of phospholipase D and modulation of the Ras/Raf/MAP kinase signalling pathway involved in cutaneous squamous cell carcinogenesis. Cases of keratoacanthomas and deeply invasive squamous cell carcinomas reported in patients on sorafenib emphasise the need for multidisciplinary follow-up of this population and the important role of dermatologists in managing the short and long-term adverse effects of multitarget tyrosine inhibitors.

Relationship between sun exposure and melanoma risk for tumours in different body sites in a large case-control study in a temperate climate

Aim A melanoma case-control study was conducted to elucidate the complex relationship between sun exposure and risk. Methods Nine hundred and sixty population-ascertained cases, 513 population and 174 sibling controls recruited in England provided detailed sun exposure and phenotype data; a subset provided serum 25-hydroxyvitamin D 2 + D 3 levels. Results Phenotypes associated with a tendency to sunburn and reported sunburn at ⩾20 years of age were associated with increased melanoma risk (odds ratio (OR) 1.56, 95% confidence intervals (CI) 1.23–1.99). Holiday sun exposure was not associated with an increased melanoma risk although this may be in part because reported sun exposure overall was much lower in those with a sun-sensitive phenotype, particularly among controls. Head and neck melanoma was associated with less sun exposure on holidays at low latitudes (OR 0.39, 95% CI (0.23–0.68) for >13 h/year compared to <3.1). Overall the clearest relationship between reported sun exposure and risk was for average weekend sun exposure in warmer months, which was protective (OR 0.67, 95% CI 0.50–0.89 for highest versus lowest tertile of exposure). Serum vitamin D levels were strongly associated with increased weekend and holiday sun exposure. Conclusions Sun-sensitive phenotypes and reported sunburn were associated with an increased risk of melanoma. Although no evidence was seen of a causal relationship between holiday sun exposure and increased risk, this is consistent with the view that intense sun exposure is causal for melanoma in those prone to sunburn. A protective effect of regular weekend sun exposure was seen, particularly for limb tumours, which could be mediated by photoadaptation or higher vitamin D levels.

Revised UK guidelines for the management of cutaneous melanoma 2010

These guidelines for the management of cutaneous melanoma present an evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiology, diagnosis, investigation, and follow-up.

FC30 An epidemiologic study of prevalent risk factors of basal cell carcinoma in the Greek population

Introduction The risk for BCC development results from the interplay of both constitutional and environmental factors, with ultraviolet radiation (UVR) being the primary established risk factor in the development of BCC [1,2]. The epidemiologic risk factors of BCC in Mediterranean populations remain unclear. Aim To investigate the risk associations of BCC in the Greek population. Methods We conducted a hospital-based case-control study. We studied 199 patients with histologically confirmed BCC and 200 cancer-free controls. The following data were collected by the use of a standardized questionnaire: pigmentary traits (tanning ability, ease of sunburning), patterns of sun exposure (continuous versus intermittent), timing of sun exposure, history of severe sunburns, use of sunscreens, exposure to artificial sources of UVR, personal or family history of skin cancer, and lifestyle-related factors (smoking). A clinical examination was performed with respect to pigmentary traits (skin/hair/eye color), number of melanocytic nevi, actinic keratoses, lentigines, and the presence of elastosis. Results In our multivariate analysis of BCC, several factors were found to be significantly associated with BCC (P<0.05), including female sex, light skin color, number of years of occupational sun exposure, number of sunburns during adulthood, no use of sunscreen, and presence of nevi and lentigines. A trend for a ‘dose-response’ effect was noted for patients who had 5 years or more, of occupational sun exposure. No association was found with skin type, exposure to non-solar UVR exposure, and lifestyle-related factors (smoking, alcohol consumption). Statistically significant risk factors for early BCC (age at diagnosis <50 years) included female sex, number of weeks per year spent at the beach before the age of 20, and the number of sunburns during childhood. Conclusion BCC risk was associated with light skin color, occupational sun exposure, and the presence of nevi and lentigines. The association of early onset BCC with recreational sun exposure and sunburns during childhood and adolescence suggests that intense intermittent sun exposure during the early years of life may be a key risk factor for development of BCC at an early age.

Hepatoerythropoietic Porphyria Misdiagnosed as Child Abuse

Hepatoerythropoietic porphyria (HEP) is a rare autosomal recessive disorder resulting from the markedly deficient, but not absent, activity of the heme biosynthetic enzyme uroporphyrinogen decarboxylase (UROD). The disorder typically manifests during infancy or early childhood with extreme photosensitivity, skin fragility in sun-exposed areas, hypertrichosis, erythrodontia, and pink urine. Three siblings, offspring of parents of Puerto Rican and Dominican descent, had with excessive scarring on the face and dorsal aspect of the forearms, which initially led to the erroneous suspicion of child abuse. Although these lesions were photodistributed, overt photosensitivity had not been observed, with the exception of a single episode of blistering and onycholysis after intense sun exposure in 1 affected child. Mild facial hypertrichosis, chronic anemia, polyarticular arthritis, and developmental delay represented additional findings. Biochemical studies of urine, plasma, and erythrocyte porphyrins from the affected siblings established the diagnosis of HEP. Sequencing of the UROD gene revealed compound heterozygosity for a novel missense mutation, V166A, and a complex deletion/insertion, 645del1053ins10. Our report expands the phenotypic and genotypic spectrum of HEP, highlighting mild cutaneous presentations that can occur without obvious photosensitivity and masquerade as child abuse.

Smoking, sun exposure, number of nevi and previous neoplasias are risk factors for melanoma in older patients (60 years and over)

Malignant melanoma risk factors have been studied in different geographical area populations. However, no study has focused on risk factors which are more frequently associated to the over 60's age group. A case-control study was performed that included 160 patients age > or = 60 years diagnosed of cutaneous melanoma and 318 controls matched for age and sex. Both groups were assessed, by personal interview and physical examination, for different phenotype characteristics (hair and eye color, phototype), the presence of other cutaneous lesions (solar lentigines, actinic keratoses and nevi), degree and type of solar exposure and personal and family past history of cutaneous or non-cutaneous cancer. Differences were evaluated by contingency tables and univariate and multivariate logistic regression. Of 17 factors, those risk factors with a strong effect on the development of melanoma in the elderly were: fair eyes, severe sunburns, years of occupational sun exposure, smoking, > 50 melanocytic nevi and personal history of NMSC and other non-cutaneous neoplasias. Tobacco smoking is an independent risk factor for cutaneous melanoma in the elderly. Intense (both acute and chronic) sun exposure and constitutional features, such as tumor susceptibility (NMSC, non-cutaneous neoplasias, and multiple nevi) are also associated with melanoma risk. All these factors should help to better design educational campaigns in older people.

Reticular variant of mid-dermal elastolysis after insertion of a pacemaker

Summary Mid-dermal elastolysis is an unusual process characterized by the absence of the elastic fibres within the mid-dermis. The disappearance of these fibres causes fine wrinkles (type 1) or perifollicular protrusions (type 2) affecting the trunk, neck and arms. There is a female predilection, and most patients have a history of intense sun exposure. Recently, some cases of mid-dermal elastolysis presenting as reticular erythema have been reported. We report a case of reticular erythema with mid-dermal elastolysis that occurred in a 70-year-old man after insertion of a pacemaker.

Life course sun exposure and risk of prostate cancer: Population‐based nested case‐control study and meta‐analysis

There is currently no means of primary prevention for prostate cancer. Increased exposure to ultraviolet-radiation may be protective, but the literature is inconclusive. We investigated associations of life course exposure to sunlight with prostate cancer. The study design was a UK-wide nested case-control study, based on 1,020 prostate specific antigen-detected cases and 5,044 matched population controls and a systematic review with meta-analysis. Men with olive/brown skin (OR = 1.47; 95% CI: 1.00 to 2.17), men who burnt rarely/never (OR = 1.11; 0.95 to 1.29) and men with the lowest levels of intense sun exposure in the 2 years prior to diagnosis (OR = 1.24; 1.03 to 1.50) had an increased prostate cancer risk. However, amongst men with prostate cancer, spending less time outside was associated with a reduced risk of advanced cancer (OR = 0.49; 0.27 to 0.89) and high Gleason grade (OR = 0.62; 0.43 to 0.91), and men who burnt rarely/never had a reduced risk of advanced cancer (OR = 0.71; 0.47 to 1.08). The meta-analysis provided weak evidence that men with the lowest (versus highest) sunlight exposure had an increased prostate cancer risk (4 studies, random-effects pooled relative risk = 1.13; 0.98 to 1.29) and higher advanced or fatal prostate cancer risk (6 studies, random-effects pooled relative risk = 1.14; 0.98 to 1.33). Our data and meta-analyses provide limited support for the hypothesis that increased exposure to sunlight may reduce prostate cancer risk. The findings warrant further investigation because of their implications for vitamin D chemoprevention trials.

Changes in common melanocytic naevi after intense sun exposure: digital dermoscopic study with a 1-year follow-up

Exposure to ultraviolet (UV) radiation induces acute changes in common melanocytic naevi (CMN). To analyse changes in size and dermoscopic structures of CMN in healthy individuals under the influence of intense sun exposure and to investigate effectiveness of sunscreen usage in preventing the appearance of dermoscopic changes. The subjects were divided into an SS group and a non-SS group, according to whether they used sunscreen or not. Digital epiluminiscence microscopy (DELM) was performed before sun exposure and 28 days and 1 year after the cessation of intense sun exposure. Eleven subjects with 60 naevi fulfilled the inclusion criteria. A significant increase in one diameter of the CMN was found 28 days after cessation of sun exposure, irrespective of sunscreen usage. There was no significant change in total dermoscopy score during the follow-up period in either the SS or non-SS group. There were definitive DELM changes at the 1-year follow-up in 10% of CMNs < 5 mm in size. Changes in pigmented network, globules and streaks were fully reversible in the remaining CMN. The use of sunscreen had no influence on these changes. The increases in the size of melanocytic naevi that we found 28 days after cessation of intense sun exposure are probably induced by UV radiation, whereas changes in DELM features that were not reversible in some small naevi at the 1-year follow-up could be related both to sun exposure and to the natural evolution of the naevi. The use of sunscreen does not seem to prevent these changes. Small naevi in low-risk young and middle-aged patients seem to be more prone to sun-induced DELM changes.

Clinical Study of Porokeratosis Associated with Immunosuppressive Therapy in Renal Transplant Recipients.

The etiology of porokeratosis (PK) remains unknown, but immunosuppression is known to be a factor in the pathogenesis of PK and it may also exacerbate PK. The aim of this study was to examine the clinical characteristics of PK associated with immunosuppressive therapy in renal transplant recipients. A total of 9 renal transplant patients diagnosed with biopsy-proven PK from January 2001 to December 2006 were enrolled. The authors analyzed the patient and medication histories, clinical characteristics, and associated diseases. The ages of the 9 patients ranged from 38 to 67 years (mean 52 years). All received multi-drug regimens comprised of two or three immunosuppressive agents (steroids, cyclosporine, mycophenolate mofetil, azathioprine and/or tacrolimus). Times between transplantation and the onset of PK ranged from 2 to 9 years (mean 4.1 years). No family history of PK or a history of intense sun-exposure was elicited. The number of the lesions was less than ten in 8 of the 9. Lesions were mainly located in the extremities, though some affected the trunk or neck (3). Three patients had disseminated superficial actinic PK (DSAP), PK Mibelli, or both types. Associated diseases included verruca (4), recurrent herpes simplex (1), actinic keratosis (1), and cutaneous B cell lymphoma (1). The three clinical patterns of PK occurred equally in our patients, namely, coexistent PK Mibelli and DSAP, or the DSAP and Mibelli types as independent forms. Our findings support the notion that the different variants of PK be viewed as parts of a heterogeneous clinical spectrum. Further studies are needed in order to establish the clinical patterns of PK in immunosuppressed patients.

An Exploratory study to evaluate the efficacy of pimecrolimus cream 1% for the treatment of pityriasis alba

Use of topical corticosteroids for the treatment of pityriasis alba is limited by their potential side-effects, such as skin atrophy especially with long-term use on the face. Pimecrolimus cream 1% is a topical calcineurin inhibitor that has anti-inflammatory properties, lacks the cutaneous side-effects associated with steroids, and provide a potential benefit for the treatment of pityriasis alba. This 10-patient, prospective, single-arm, open-label, single-center, 12-week, investigator-initiated proof of concept study assessed the efficacy, safety, and patient acceptance of pimecrolimus cream 1% twice daily. In addition to pimecrolimus cream, patients used facial emollient containing SPF 15 sunscreen and mild soap-free cleanser. Efficacy assessments were Investigator Global Assessment (IGA) of disease severity and evaluation of uneven skin color, scaling, eczema, follicular keratosis, and pruritus. All efficacy assessments were reported on a 4-point scale (0 = none to 3 = severe). Of the 10 patients enrolled (aged: 12-35 years), all had intensive sun-exposure, 90% had skin type IV-V, and 80% completed the 12-week treatment. At baseline, mean IGA was 1.20 (mild-moderate), uneven skin color was 2.3 (moderate-severe) and scaling was 1.2 (mild). IGA decreased to 0.25 by week 12, uneven skin color improved by week 3 with near complete resolution by week 12 (mean = 0.38) and scaling resolved at week 3. Pruritus, eczema, and follicular keratosis remained at low levels from baseline throughout the course of the study. Patients consistently reported satisfaction with the treatment ("satisfied" or "very satisfied"). No adverse events were reported. Pimecrolimus cream 1% may represent an alternative for the treatment of pityriasis alba.

Expatriates in High–UV Index and Tropical Countries: Sun Exposure and Protection Behavior in 9,416 French Adults

Overexposure to sunlight during long stays in tropical countries can reveal short- and long-term harmful effects on the skin of Caucasian residents, especially for fair-skinned subjects. The aim of this study was to describe sun exposure and sun protection behaviors during lifetime among French adults who declared having experienced at least one expatriation period in tropical or high-sun index areas for a duration of more than three consecutive months. A self-reported questionnaire on sun exposure behavior was addressed two times, in 1997 and 2001, to the 12,741 French adult volunteers enrolled in the SU.VI.MAX cohort. A total of 8,084 subjects answered to the first survey and 1,332 additional responders answered to the second. Among the 9,416 individuals, 1,594 (652 women and 942 men) corresponded to expatriates and the remaining 7,822 to nonexpatriates (4,972 women and 2,850 men). A descriptive analysis of sun exposure and sun protection behaviors during lifetime of expatriates and nonexpatriates was performed by gender. Among women, 39% of expatriates belonged to the 50 to 60 class of age at inclusion, versus 33% in nonexpatriates (72 and 55% in men, respectively). In women, expatriates declared more frequently having during lifetime exposed voluntarily their skin to the sun, practiced tanning between 11 a.m. and 4 p.m., less gradually exposed their skin, experienced intensive sun exposure, and exposed their skin during nautical sports and practiced naturism. In men, expatriates declared more frequently having experienced intensive sun exposure and exposed their skin during outdoor occupations and during nautical and mountain sports. Although expatriates are aware of travel health advices concerning the countries where they planned to stay, they are usually poorly informed about sun exposure risk factors. Such individuals who planned to expatriate in countries with a high ultraviolet index should benefit from a visit to a travel clinic including specific health care information for risk related to sun exposure, ie, skin cancers and photoaging.

Habitat suitability for three species of Anopheles mosquitoes: Larval growth and survival in reciprocal placement experiments

Larval habitats of the main malaria vectors in Belize are associated with three distinctly different aquatic environments: marshes with sparse macrophytes and cyanobacterial mats (Anopheles albimanus), tall dense macrophyte marshes (An. vestitipennis), and floating detritus assemblages within freshwater rivers (An. darlingi). We assessed species-specific habitat suitability based upon nutrient characteristics using larval survival rates (SR) and wing lengths (WL) from floating habitat enclosures. Anopheles albimanus showed a high SR (81%) in all three habitats, while An. vestitipennis had a similarly high SR in its own habitat (82%) and An. darlingi's habitat (81%). Anopheles darlingi only showed high SR (85%) in its own habitat. Both An. vestitipennis and An. darlingi showed very low SR in the An. albimanus habitat. There were no significant WL differences among field-caught, laboratory-reared, and experimental populations of An. vestitipennis and An. albimanus, with the exception of An. vestitipennis experimental populations and An. vestitipennis field populations placed in the An. albimanus habitat. Habitat quality indicators, particulate organic carbon (POC), dissolved organic carbon (DOC), and particulate organic nitrogen (PON), were consistently higher in An. vestitipennis habitats than in the habitats of the other two species. Correspondingly, An. vestitipennis adults were larger when measured both as dry mass and from WL. There were no differences in dry mass, lipids, or protein content among the same species reared at different locations. We compared SR and WL among mosquitoes from shaded and unshaded containers to test whether the high mortality rates for An. vestitipennis and An. darlingi in the An. albimanus habitat were due to intense sun exposure. There were no significant differences among developmental times, survivorship, or adult size for shaded versus sun-exposed populations. This indicates that other factors such as larval toxins, predator avoidance, interspecific species competition, etc. may be responsible for the higher mortality rates in those species not adapted to this particular habitat.

Travellers to high UV-index countries: Sun-exposure behaviour in 7822 French adults

Travel health information includes warning on sun exposure, particularly for fair-skinned individuals travelling to tropical countries. A self-completed questionnaire on sun exposure behaviour was sent to the 12,741 French adults enrolled in the SU.VI.MAX cohort. Among the 7822 participants, 196 (110 women and 86 men) declared at least one visit to a high UV-index country over the past year for more than 1 month, subsequently referred to as long-term travellers. The remaining 7626 participants (non-travellers) accounted for 4862 women and 2764 men. Women travellers declared more frequently skin exposure to the sun over the past year, practised tanning in high UV-index areas more than 2h daily, experienced intensive sun exposure than non-travellers. Moreover, they asserted that basking in the sun is very important. Comparable results were found in men. The use of sun protection products was similar in travellers and non-travellers, but women tended to use sunscreen products more often, more regularly and with a higher sun protection factor (SPF) than men. Specific health education campaigns and pre-travel advice aiming to reduce sun exposure and to improve protective measures against ultraviolet (UV) radiation should be addressed to travellers to countries with high UV-index.

A Scan for Signatures of Positive Selection in Candidate Loci for Skin Pigmentation in Humans

Although the combination of pale skin and intense sun exposure results in an important health risk for the individual, it is less clear if at the population level this risk has possessed an evolutionary meaning. In this sense, a number of adaptive hypotheses have been put forward to explain the evolution of human skin pigmentation, such as photoprotection against sun-induced cancer, sexual selection, vitamin D synthesis or photoprotection of photolabile compounds, among others. It is expected that if skin pigmentation is adaptive, we might be able to see the signature of positive selection on some of the genes involved. In order to detect this signature, we analyze a battery of 81 candidate loci by means of phylogenetic and population genetic tests. Our results indicate that both light and dark skin may possess adaptive value. Of the main loci presenting this signature, TP53BP1 shows clear evidence of adaptive selection in Africans, whereas TYRP1 and SLC24A5 show evidence of adaptive selection in Caucasians. Although we cannot offer a mechanism that based on these genes explains the advantage of light skin, if TP53BP1, and perhaps RAD50, have truly conferred an adaptive value to the African population analyzed, photoprotection against sun-induced skin damage/cancer might be proposed as a mechanism that has driven the evolution of human skin pigmentation.

Sun Exposure, Diet, and Melanoma in Hawaii Caucasians

Much uncertainty remains about the type of sunlight exposure that most increases risk of cutaneous melanoma and the role of diet. The authors conducted a population-based case-control study (1986-1992) of Caucasians living on Oahu, Hawaii; included were 278 cases and age- and sex-matched controls. Plasma samples were measured for retinol, carotenoids, and alpha-tocopherol by high-pressure liquid chromatography. Selenium was measured in blood and toenails by neutron activation. Celtic and English ancestries, migration to Hawaii before age 20 years, fair complexion, inability to tan, and family history of skin cancer, as well as height, hours spent in the summer sun, blistering sunburns during adolescence, and moles, all increased melanoma risk. With regard to diet and biomarkers, only alcohol was associated with risk. The odds ratios for increasing tertiles of lifetime ethanol intake were 1.0, 1.2 (95% confidence interval (CI): 0.6, 2.2), and 2.3 (95% CI: 1.2, 4.4) (p for trend = 0.01) for men and 1.0, 1.1 (95% CI: 0.5, 2.4), and 1.7 (95% CI: 0.7, 3.8) (p for trend = 0.19) for women. Dietary lipids were unrelated to risk, but polyunsaturated fat intake appeared to modify the effects of alcohol and toenail selenium on melanoma risk. These data provide additional evidence for the association of constitutional susceptibility factors, intense sun exposure (particularly before age 20 years), and alcohol consumption with melanoma risk.

Milio coloide del adulto. Presentación de 2 casos

Colloid milium is a degenerative process that is characterized clinically by the development of translucent, yellow, 1-2 mm papules located in photoexposed areas. Histologically, deposits of a colloid substance are seen in the papillary dermis. We present two cases of this infrequent pathology in two male patients, who had been subjected to intense sun exposure because of their work. We initiated treatment with photoprotective creams and topical tretinoin, with little clinical improvement.

Re: Sun Exposure and Mortality From Melanoma

The relationship between sun exposure and melanoma mortality and risk of lymphoma was explored in two recent articles and a related editorial ( 1 – 3 ) . Unfortunately, the discussion in the related editorial ( 1 ) was not supported by the data presented. The study by Berwick et al. ( 2 ) demonstrated, within the limits of a retrospective study, that patients with melanoma have a better prognosis if they had previous extensive sun exposure. The indices of sun exposure refl ected many years of exposure dating to youth and did not relate to exposure in the interval after diagnosis of melanoma. No data on vitamin D levels were provided. The data strongly suggested that melanomas induced by intense sun exposure have a more benign behavior than those not induced by intense sun exposure. This is the most direct explanation for increased survival from melanomas arising in patients with a history of intense sun exposure and is analogous to experience with other sun-induced cancers. Squamous cell carcinomas of the skin induced by sun have a much better prognosis than squamous cell cancers arising in scars. This relationship between melanoma survival and sun exposure may explain the stable melanoma mortality rate despite an increase in incidence in sun – induced melanoma and has consequences for public health. Data in the article by Smedby et al. ( 3 ) suggest that participants who had extensive sun exposure had a decreased lymphoma risk compared with participants with less sun exposure. However, there was an exception for patients with a prior history of skin cancer. Thus, lymphoma risk was elevated in patients with skin cancer plus extensive sun exposure and decreased in patients with extensive sun exposure without skin cancer. This difference in risk cannot be explained by vitamin D levels because vitamin D levels should also be elevated in patients with extensive sun exposure and skin cancer. The data suggest that suninduced skin cancer is simply a marker for a decreased ability to handle carcinogenic insult. The skin cancer data confl ict with a direct link between sun exposure and lymphoma risk or a role for vitamin D. This problem with the analysis, which attributed the results to vitamin D levels, is not without consequences because it would lead to the recommendation that people increase their exposure to a carcinogen.

Sonnenlichtgetriggerte granulomat�se Reaktion auf Permanent Lip-Liner

The demand for permanent make up and especially permanent lip liner has increased in recent years in Germany. Information about complications is not available in the medical literature, because tattooing is a trade whose results and problems are not monitored and documented, as is the case for medical procedures. A female patient with permanent lip liner experienced no complications for one year. Then, after intensive sun exposure she developed solid, linear papules along the outer margin of her lips. Histology revealed a granulomatous tissue reaction with a marked lymphohistiocytic infiltrate including epithelioid histiocytes. Treatment with topical steroids over three weeks led to a complete healing without relapse. To the best of our knowledge this is the first report on UV-light-induced granulomatous reaction to permanent lip liner.

Medical therapies for non-melanoma skin cancer

The epidemic of nonmelanoma skin cancer (NMSC) continues, in part due to aging of the world's population, the frequency of early childhood sunburns, and episodic intense recreational sun exposure as opposed to sun exposure related to outdoor occupations. A nonsurgical approach to selected skin cancers could potentially decrease the expense and morbidity of surgical treatment for NMSC. The increase of comorbid medical conditions in the elderly makes alternatives to surgical management preferable under certain circumstances. This review will discuss medical alternatives ranging from biologic response modifiers to COX-2 inhibitors to lifestyle modifications, as well as their roles in the management of NMSC. This preliminary information will expand to include more therapeutic options for NMSC in the future. Further clinical trials are needed to better elucidate possible alternative treatment strategies for NMSC.