Sunburn In Childhood Research Articles

Neonatal sunburn and melanoma in mice.

Retrospective epidemiological data have indicated that cutaneous malignant melanoma may arise as a consequence of intense, intermittent exposure of the skin to ultraviolet radiation, particularly in children, rather than from the cumulative lifetime exposure that is associated with other forms of skin cancer. Here we use a genetically engineered mouse model to show that a single dose of burning ultraviolet radiation to neonates, but not adults, is necessary and sufficient to induce tumours with high penetrance which are reminiscent of human melanoma. Our results provide experimental support for epidemiological evidence that childhood sunburn poses a significant risk of developing this potentially fatal disease.

Exposure to ultraviolet radiation: association with susceptibility and age at presentation with prostate cancer

A positive association between latitude and prostate cancer mortality has been interpreted to indicate that ultraviolet radiation (UVR) protects against development of this cancer. We aimed to examine this hypothesis. We compared exposure between 210 cases and 155 controls. Childhood sunburn (odds ratio 0.18, 95% CI 0.08-0.38), regular foreign holidays(0.41, 0.25-0.68), sunbathing score (0.83, 0.76-0.89), and low exposure to UVR (3.03, 1.59-5.78) were associated with development of prostate cancer. Furthermore, cases with low UVR exposure developed cancer at a younger median age (67.7 years, IQR 61.5-74.6) than cases with higher exposure (72.1 years, 67.5-76.4); p=0.006. These findings are compatible with UVR having a protective role against prostate cancer.

Epidemiology of melanoma.

Melanoma incidence and morality rates are increasing in most countries throughout the world where they are being recorded. The annual incidence rates have increased in the order of 3-7% in fair-skinned populations in recent decades. The mortality rates have increased at a rate lower than for incidence. This has been attributed to educational programs designed to improve the early detection of melanoma, as the treatment of melanoma has not changed substantially in recent decades. There has been a decrease in the thickness of melanoma with an increasing proportion of thin melanomas at diagnosis. Causation of melanoma is a combination of constitutional risk factors of which skin colour is the major factor. The presence and number of common acquired and dysplastic melanocytic naevi is also a major constitutional risk factor in fair-skinned people. The only environmental risk factor that has been shown consistently is exposure to sunlight, particularly large doses of sunlight sufficient to cause sunburn in childhood that will be remembered many years later. However, recreational activity leading to sunburn in adulthood is also associated with risk. To date, no other environmental factors have been shown epidemiologically to be clearly associated with risk of melanoma. Recent epidemiological data from some studies suggesting that there is an increased risk of melanoma in sunscreen users requires further explanation.

Sun protection in children

~un protection in children has recently become a very important topic for health care professionals dealing with skin health issues. The strongest driving factor for this issue is skin cancer prevention. This relatively recent skin cancer epidemic has been causally linked to excessive ultraviolet (UV) radiation exposure. 1 Of greatest concern is the link between severe childhood sunburns and the later development of melanoma. In addition to skin cancer, many other adverse health effects have been described in association with excessive UV exposure: cataracts, premature aging of the skin, photosensitivity disorders (including exacerbation of autoimmune diseases), infections, and inmmnologic alterations. Why then is it important to specifically target children and their parents and other caregivers with sun-protection messages? Besides the melanoma link with severe UV overexposure in childhood, there is also the estimate that we obtain most of our fifetime sun exposure during the first couple decades of life. 2 It has been estimated that if sunscreen were used on sun-exposed areas of children from birth to age 20, their lifetime risk of nonmelanoma skin cancer would be reduced by 85%. 2 Furthermore, eliminating blistering sunburns before age 20 may reduce the risk of developing melanoma by half. 3 Along with risk reduction, another important reason to target children for sun protection efforts is the fact that preventive behaviors learned early in life will more typically be practiced in adulthood. 4

Towards a Better Understanding of the Molecular Mechanisms Involved in Sunlight-Induced Melanoma.

Although much less prevalent than its nonmelanoma skin cancer counterparts, cutaneous malignant melanoma (CMM) is the most lethal human skin cancer. Epidemiological and biological studies have established a strong link between lifetime exposure to ultraviolet (UV) light, particularly sunburn in childhood, and the development of melanoma. However, the specific molecular targets of this environmental carcinogen are not known. Data obtained from genetic and molecular studies over the last few years have identified the INK4a/ARF locus as the "gatekeeper" melanoma suppressor, encoding two tumour suppressor proteins in human, p16 $^{\text{INK4a}}$ and p $14^{\text{ARF}}$ . Recent developments in molecular biotechnology and research using laboratory animals have made a significant gene breakthrough identifying the components of the p16 $^{\text{INK4a}}$ /Rb pathway as the principal and rate-limiting targets of UV radiation actions in melanoma formation. This review summarizes the current knowledge of the molecular mechanisms involved in melanoma development and its relationship to sunlight UV radiation.

The prevalence and determinants of solar keratoses at a subtropical latitude (Queensland, Australia).

We report the association between skin pigmentation and individual sun exposure, and the occurrence of solar keratoses (SKs) in an unselected population, quantified for the first time. SKs were examined in a representative sample of 197 residents of the community of Nambour in Queensland, Australia. Estimates of sun exposure were combined with a measure of ultraviolet (UV) flux to estimate actual UV exposure, both occupational and recreational, during childhood and adult life. The number of episodes of painful sunburn was used as a measure of intermittent, intense UV exposure. Eight-three participants (43%) had at least one SK, while 35 (18%) had more than 10 SKs diagnosed. The age- and sex-adjusted odds ratios (ORs) for the development of SKs were higher in individuals with fair (OR = 14.1) or medium skin (OR = 6.5), compared with olive-skinned individuals. Individuals with poor ability to develop a suntan were similarly at increased risk compared with others. High levels of occupational UV exposure during adult life were confirmed as being strongly associated with prevalent SKs (OR = 2.4 for heavy/maximal adult exposure), with an even stronger association seen in those individuals with multiple SKs (OR = 4.3 for maximal adult exposure). Although no clear association was demonstrated between SK prevalence and accumulated childhood sun exposure, a history of even one episode of sunburn in childhood was strongly associated with SK prevalence (peak OR of 5.9 for one sunburn).

A 1-year prospective study of burns in an Irish paediatric burns unit

Burns are the fourth leading cause of injury death in children in the USA, accounting for 1300 paediatric deaths annually. The majority of paediatric burns mortality and morbidity result from simple domestic accidents that are preventable. A prospective study of paediatric burns from 1 January 1992 to 1 January 1993 was undertaken at our burns unit to outline the profile of the Irish paediatric burns problem. A total of 336 burns were referred to our unit over the 12 months (80 per cent self-referrals, 15 per cent tertiary referrals from district hospitals and 5 per cent GP referrals). Sixteen per cent (57) of the patients required admission and 33 per cent (112) required prolonged dressings as outpatients. Mortality and morbidity rates were comparable to other centres at 1.8 per cent and 39 per cent respectively. The demographic analysis of the patient population was similar to that seen in other studies from developed countries but there were some notable differences. First, there was an alarmingly high incidence of serious sunburn injuries, especially among young infants. Most parents were unaware of the association between childhood sunburn and the development of skin cancer in later life. Second, 90 per cent of the accidents occurred in the home and almost all were preventable. A parent or guardian was present in 87 per cent of cases but parental knowledge of the appropriate first aid measures was poor. It is suggested that a public health education campaign on this issue would help in reducing the incidence and severity of paediatric burn injuries in Ireland.

Constitutional factors and sun exposure in relation to nevi: a population-based cross-sectional study.

A survey of benign melanocytic nevi (moles), suspected precursors or markers for melanoma, was conducted in Washington State among 717 randomly selected 18- to 50-year-old white adults who participated in a telephone interview in 1990-1991. Participants were questioned about constitutional factors, time spent in the sun, and severe sunburns over three time periods and were asked to count the raised nevi on both their arms. Logistic regression was used to examine the risk for 2+ nevi compared with none. An odds ratio (OR) of 2.0 (95% confidence interval (CI) 1.3-3.1) was seen for current freckling. Skin color, tendency to burn, and inability to tan were important risk factors but were not independent of each other. Individuals with a history of severe sunburns had an increased risk of nevi: OR = 1.9 (95% CI 0.9-3.9) for 3+ severe sunburns compared with none in the last 5 years; OR = 2.0 (95% CI 1.2-3.1) for 4+ severe teenage sunburns; and OR = 3.1 (95% CI 1.7-5.3) for 4+ severe childhood sunburns. Furthermore, childhood sunburns were related to nevi independently of sun sensitivity and teenage and recent sunburns: OR = 2.0 (95% CI 1.0-4.0) for 4+ severe sunburns. These data suggest that childhood sunburns are important in the etiology of nevi. This study supports prior studies of the relation between melanoma and early sun exposure.

Protection of children against sunburn: a survey of parental practice in Leicester

The incidence of melanoma in the U.K. is increasing more rapidly than that of most other malignant tumours. Sunburn in childhood increases the risk of malignant melanoma in later life and it is therefore essential that protection of children is improved if primary prevention of melanoma is to be effective. We asked 238 parents in Leicester how they protected their children against sunburn, how often their children suffered sunburn, and whether they had heard of malignant melanoma. Although most (80%) had heard of melanoma, 47% did not regularly ensure that their children used a sunblock lotion, and only 34% regularly protected them from the midday sun. Forty-eight per cent of parents stated that their children burned at least once a year. New approaches to public education about melanoma may be needed to improve the protection of children against sunburn.

Cutaneous Melanoma in Women I. Exposure to Sunlight, Ability to Tan, and Other Risk Factors Related to Ultraviolet Light

A population-based case-control study of cutaneous malignant melanoma (CMM) was conducted in 452 women with melanoma and 930 control subjects aged 25-59 years in five San Francisco Bay Area counties between 1981 and 1986. Women were interviewed in their homes with regard to history of sunlight exposure and sunburns during different periods in their lives, phenotypic and host characteristics, medical history, occupation, and demographic factors. Data were analyzed by the patients' histologic type of melanoma; 355 women were classified as having superficial spreading melanoma (SSM), 61 had nodular melanoma (NM), 13 had lentigo maligna melanoma, and 23 had other melanomas that could not be further classified upon histologic review by University of California dermatopathologists. Univariate results from analysis of factors related to sun exposure showed that the risk of all histologic types of CMM, SSM, and NM increased with increasing tendency of the subject to sunburn and with history of increased severity and/or frequency of sunburns up to age 12 years. Risk of all types of CMM and SSM also increased with increasing number of sunburns for all age groups and with lack of use of sunscreen. After adjustment for each other and for phenotypic factors, history of sunburn up to age 12 and lack of sunscreen use were the primary sun-related factors associated with an increased risk of all types of CMM and SSM, while tendency to sunburn when exposed to 1/2 hour of noontime sun and lack of use of sunscreen were related to NM. Although having frequent sunburns before age 12 and having severe sunburns before age 12 were both strongly associated with melanoma, having large numbers of sunburns during any time period from elementary school through age 30 years and having sunburns during the 10 years prior to diagnosis or interview were all associated with a doubling of risk for SSM after adjustment for other factors. These results suggest that the increased risk of melanoma related to sunburns is not confined to childhood sunburns. Maintenance of an all-year tan provided no protective effect against melanoma after adjustment for tendency to burn. No association was noted with use of fluorescent lights or exposure to sunlamps for all types of CMM, SSM, or NM.

Sunlight Exposure, Pigmentary Factors, and Risk of Nonmelanocytic Skin Cancer

Basal cell carcinoma (BCC) of the skin is the most common neoplasm in white populations, and solar radiation is generally accepted to be the dominant environmental risk factor for this disease. However, little information is available on the nature of the relationship between BCC and sunlight. The purpose of this study was to evaluate the nature of the relationship between sunlight exposure, pigmentary factors, and BCC of the skin. A population-based case-control study of 226 male patients with BCC diagnosed from January 1, 1983, through December 31, 1984, and 406 randomly selected male control subjects was conducted in Alberta, Canada. The study was conducted using a standardized questionnaire, administered in person by trained interviewers. Data were analyzed using conditional logistic regression methods. After controlling for other host and pigmentary factors, the risk of BCC was increased in subjects with light skin color and those who freckled in childhood. A history of severe sunburn in childhood also increased risk. Subjects of southern European ethnic origin were at significantly lower risk of BCC. Surprisingly, no association was seen between mean annual cumulative summer sunlight exposure and risk of BCC. A significantly increased risk of BCC was seen in subjects with increased recreational sunlight exposure in adolescence and childhood (age, 0 to 19 years), although an inverse relationship was seen with lifetime recreation exposure. The relationship with childhood sun exposure was most pronounced among sun-sensitive subjects whose skin tended to burn rather than tan in the sun. The lack of association between cumulative sun exposure and BCC contradicts conventional wisdom about the cause of this tumor, and the increased risk with sun exposure at age 0 to 19 years suggests that childhood and adolescence may be critical periods for establishing adult risk for BCC.

Melanoma and sunburn

A computer-aided search identified 16 case-control studies which specifically assessed sunburn as a risk factor for cutaneous malignant melanoma. Using unadjusted estimates, a history of sunburn was associated with significantly increased risk of melanoma in all but one study. Four studies were defined as core studies after assessment of study quality; however, only two of these had sufficiently similar definitions of sunburn to allow pooling of results. Using pooled data, the risk of melanoma in those ever sunburned was 2.0 (95 percent confidence interval [CI] = 1.6-2.6), while the highest category of sunburn exposure had a risk of 3.7 (CI = 2.5-5.4). The suggestion that sunburns in childhood carry greater risk of melanoma cannot be supported by pooled analysis. This review demonstrated considerable variation in design and method among the studies, and identified sources of bias which prevented a pooled analysis using all available data. The need for strong epidemiologic evidence relating sunburn to melanoma, particularly in childhood, is of prime importance, since avoidance of sunburn is one of the few potential means of primary prevention of melanoma.

At what age do sunburn episodes play a crucial role for the development of malignant melanoma

The age relationship between sunburns and malignant melanoma was investigated in a population-based, matched, case-control study from the South Swedish Health Care Region (the highest risk area for melanoma in Sweden). Between 1988 and 1990, a total of 400 patients with a first diagnosis of malignant melanoma and 640 healthy controls aged 15–75 years answered a comprehensive questionnaire including questions regarding ultraviolet radiation exposure. In addition, a literature review was performed. The average number of episodes of sunburn per year was significantly associated with malignant melanoma (relative risk, RR = 1.9 for ≥ three episodes per year versus never). Outdoor employment during the summer was associated with a decreased risk for the development of malignant melanoma (RR = 0.8). Data from case-control studies and migration studies concerning age relationship between sunburns and melanom are inconsistent. From our own data, we did not find a higher risk of melanoma developed in individuals who had experienced severe sunburns in childhood. Instead, a significantly increased risk was associated with sunburns after age 19 years, RR = 2.2 for a history of more than five times versus never. Even if the hypothesis is biologically plausible, that episodes of sunburn early in life are associated with a higher risk of melanoma, so far epidemiological evidence is scarce. There is a need for better prospective epidemiological studies addressing this issue.

Primary prevention of malignant melanoma in the Stockholm Cancer Prevention Programme

Malignant melanoma is the most rapidly increasing tumour in Sweden. Sunburns in childhood and adolescence are considered a major risk factor. The Stockholm Cancer Prevention Programme addresses strategies to establish sun awareness in the population of Stockholm county by using existing networks of standardized child health and preschool services, educational systems including schools, colleges of nursing sciences and preschool teaching (integration of sun awareness in curricula, and in a new syllabus for environmental theory), the Federation of Swedish Pharmacies, and media. Health education is designed for key persons in these organizations and the media, who in turn diffuse sun awareness via their respective organizations. The education programme only deals with primary prevention by behavioural changes in exposure to UV rays, ie excessive exposure to sun, and it is primarily intended to raise sun awareness. Experiences have shown that information diffusion was good in spite of limited staff resources.

Cutaneous melanoma and sunburns in childhood in a Southern European population

A population-based case-control study of 260 patients (74 males and 186 females, mean age = 56) with cutaneous malignant melanoma and 416 controls (211 males and 205 females, mean age = 55) was conducted in Turin, north-west Italy, to examine the relation between timing of sunburns and sun exposure and melanoma risk within a southern European population, which is still relatively little investigated. Particularly elevated risk was associated with history of sunburns in childhood [odds ratio 5.9; 95% confidence interval (CI) 3.6–9.5], and such risk elevation persisted after allowance for other major melanoma risk covariates. Conversely, risk increase from history of severe sunburns lifelong was lower (odds ratio = 1.7; 95% CI: 1.1–2.4) and was eliminated by allowance fort ype of skin reaction to sun exposure and history of sunburns in childhood. A significant increase in the risk of cutaneous malignant melanoma was also associated with number of weeks spent on holiday at the beach not only as an adult, but also as a child.

Local Anesthesia Obtained via Iontophoresis as an Aid to Shave Biopsy

CLINICAL COURSE A 13-year-old white girl presented with a slowly growing lesion on the tip of her nose. She denied any personal or family history of skin cancer, blistering sunburns in childhood, or health problems. Findings from the physical examination showed few nevi over the upper aspect of the trunk and extremities. A 4-mm dome-shaped, evenly hyperpigmented lesion was present on the tip of her nose (Fig 1). WORKING DIAGNOSIS Benign dermal nevus. THERAPEUTIC CHALLENGE Lesions of this type can easily be removed for cosmetic reasons by means of shave technique. The nose, however, can be a painful area to anesthetize with injection of local anesthetics; younger patients often cannot or will not tolerate needle sticks into their face. Several methods to reduce the pain of anesthesia have been used in the past. Iontophoresis with lidocaine and epinephrine has been reported in the medical literature as an efficient and painless

A Relation between Childhood Sun Exposure and Dysplastic Nevus Syndrome among Patients with Nonfamilial Melanoma

We studied 117 patients with nonfamilial melanoma to determine whether melanoma patients with dysplastic nevus syndrome might be distinguished, on the basis of solar exposure, from melanoma patients without dysplastic nevus syndrome. Study participants were interviewed and received a skin examination, which included a total count of nevi, a standardized assessment of clinically atypical nevi, and the excision of each patient's clinically most atypical nevus. Based on the histologic review of the clinically most atypical nevus, each patient was classified as to whether dysplastic nevus syndrome was present or absent. Childhood sunburn with blistering and childhood recreational sun exposure were found to be associated with dysplastic nevus syndrome. The results suggest that childhood sun exposure increases risk of melanoma by initiating the melanoma precursor syndrome.

Primary prevention of malignant melanoma in a Swedish urban preschool sector

Malignant melanoma is the most rapidly increasing tumor in Sweden. Sunburns in childhood are considered a major risk factor. In the spring of 1989, a health education program was therefore initiated in Stockholm County in cooperation with the local preschool authorities in the area. Lectures on malignant melanoma, hazards of sunburns in childhood, and the importance of sun awareness were arranged for the nursery school matrons in the preschool sector. Thirty-five of 42 authorities (83%) wanted a lecture for their nursery school matrons, whereas 17% of the authorities wanted to spread information on their own. Of 1,991 nursery schools, 1,783 (90%) took part in the information program. These, the Stockholm nonparticipants, and the rest of the country received written information from the Federation of Swedish Municipalities by initiative of the Department of Cancer Prevention. A questionnaire distributed to 574 randomly selected nursery schools in Stockholm county and to 100 in a reference area outside Stockholm showed that sun awareness was reported high in both places. Face-to-face information disseminated by an established organization was more effective in increasing sun awareness in the preschool sector than mailed information alone. In the areas where lectures were given, the message of sun awareness practice was passed on to nursery school staff and parents twice as effectively as in the reference area (p less than 0.01).

Malignant Melanoma in England: Risks Associated with Naevi, Freckles, Social Class, Hair Colour, and Sunburn

In a case-control study in the Midlands of England, 195 subjects with superficial spreading or nodular melanoma were compared to age- and sex-matched controls chosen from all inpatients or outpatients in hospitals serving the defined source population. Significant increases in melanoma risk, after adjustment for other factors, were seen in association with total naevi on the arms (odds ratio (OR), for 15+ naevi compared to none = 3.8), intense freckling as an adult (OR = 6.2), and as a child (OR = 6.0), and higher social class (OR = 2.4). Positive single factor associations were also seen with light or red hair colour, tendency to sunburn easily, and a history of sunburn at ages 8-12, although these were not significant when adjusted for the other factors. No significant effect was seen with naevi greater than 6 mm, or with raised naevi, when adjusted for total number of naevi. Total arm naevi and density of freckling had independent effects, consistent with a multiplicative effect, the OR in those with 10+ naevi and heavy freckling being 20.8. The risk associated with red hair was independent of naevi, but associated with freckling. The strongest association with sunburn history was seen with a history of sunburn in childhood, with sunburn at later times, having smaller effects, or none. These results shows that freckling and social class as well as naevi are strong and independent risk indicators for melanoma. These associations were generally consistent by type of melanoma, sex, age, and extent of regular exposure of the body site affected, although the social class gradient was observed neither for nodular melanoma nor for melanomas occurring on the most exposed body sites.