June K. Robinson

Trends in sun exposure knowledge, attitudes, and behaviors: 1986 to 1996\

BACKGROUND The American Academy of Dermatologys national program Melanoma/Skin Cancer Detection and Prevention, developed in response to the rising incidence of invasive melanoma in the United States, has annually during the past decade produced extensive print, radio, and television coverage about the dangers of sun exposure and benefits of sun protection. OBJECTIVE We measured the progress achieved in increasing the awareness and knowledge of skin cancer and changing the attitudes, beliefs, and behaviors that affect skin cancer risk. We also describe current sun-related behavior including sunburning, assess the likelihood of practicing sun protection strategies, and provide a baseline against which future changes in sun protection behavior may be evaluated. METHODS A 1996 telephone survey repeated questions used in 1986 to evaluate change and used classifying questions to better define attitudes and behaviors. RESULTS From 1986 to 1996, the knowledge of the perceived harmful effects of the sun significantly broadened, but the UV exposure behavior as measured by sunburning (30% to 39%) and regular use of a tanning booth (2% to 6%) also increased. There was a decline in the attitude that having a tan was healthy; however, in 1996 having a tan was still considered to enhance appearance, particularly by men. Sunscreen use increased (35% to 53%). Women, younger persons, persons residing in areas with fewer sunny days, and whites were more likely to tan intentionally, but men who lived in the South were more likely to sunburn. CONCLUSION During the past decade, the early process of change involving cognitive and emotional activities began. With this study, high-risk population subsets performing specific adverse behavior were identified. In the future, they can be targeted with messages that promote attitudinal and behavioral change.

Measures of Sun Exposure and Sun Protection Practices for Behavioral and Epidemiologic Research

OBJECTIVE To develop, in a collaborative project, core measures of sun exposure and sun protection habits, since the lack of standard outcome measures hampers comparison of population surveys and interventions used in skin cancer prevention research. DESIGN A work group of investigators evaluated available questionnaire measures of sun exposure and protection. Their deliberations led to a proposed set of core questionnaire items for adults, adolescents aged 11 to 17 years, and children 10 years or younger. These core items were used in cognitive testing by the investigators. Cross-site summaries of methods, response samples, and descriptive data were prepared. SETTING Nine locations across the United States. PARTICIPANTS The study population comprised 81 individuals. RESULTS No unusual response patterns were detected in any of the respondent groups or for any specific question. Some revisions to the survey items resulted from the need for clarification or emphasis of frames of reference such as adding or underlining key phrases in a question. CONCLUSIONS The combination of expert review followed by cognitive interviewing yielded standardized core survey items with good clarity and applicability for measuring sun exposure and sun protection behaviors across a broad range of populations. They are appropriate for studies tracking morbidity and/or mortality and evaluating prevention program effects.

Margin control for lentigo maligna

BACKGROUND Lentigo maligna is an in situ malignant melanoma for which the treatment of choice is surgical excision. The current recommendation is local resection with a 0.5 to 1.0 cm margin of normal skin. Because many lesions occur on the face, the narrowest possible margin reduces the amount of scarring. Controversy surrounds the use of Mohs micrographic surgery to preserve normal skin and resect the lentigo maligna. OBJECTIVE The purposes of this prospective study were to determine the narrowest possible margin of resection of lentigo maligna and the accuracy of frozen and fixed histologic specimens from those margins. In addition, the benefit of adjunctive immunoperoxidase staining with antibodies to S-100 protein and HMB-45 monoclonal antibody was examined retrospectively. METHODS A Woods light was used to delineate the clinical margin in 16 cases of lentigo maligna that were resected with serial excisions 0.3, 0.6, 1.0, and 1.3 cm from the clinical border of the tumor. Frozen sections were confirmed by fixed histopathologic specimens. Subsequently these tissue blocks were examined with antibodies to S-100 protein and HMB-45 monoclonal antibodies. Patients were observed 5 to 9 years. RESULTS One of the 16 patients had a recurrence 8 years after surgery. Although lesions with a diameter less than 2.0 cm had narrower margins of resection, the majority of lesions were resected with a margin of 0.6 to 1.0 cm. Lesions larger than 3.0 cm in diameter required a margin of resection greater than 1.0 cm. The antibody to S-100 protein was neither sensitive nor specific enough to assist with identification of the process. HMB-45 monoclonal antibody was sensitive and assisted in the identification of atypical melanocytes. CONCLUSION The modifications of Mohs micrographic surgery including the use of fixed histopathologic specimens and the use of HMB-45 monoclonal antibody to help delineate atypical melanocytes offer the possibility of narrower margins of resection for lentigo maligna.

Surgical treatment of extramammary paget's disease. A report of six cases and a reexamination of mohs micrographic surgery compared with conventional surgical excision

Extramammary Pagets disease (EMPD) is a rare cutaneous malignancy, usually on the genitalia, that almost always extends beyond clinically apparent margins. Recurrences after standard methods of surgical excision are notoriously frequent; effective treatment with Mohs micrographic surgery was first reported in 1979. It has since been suggested this malignancy may be multifocal, and reports of recurrences after resection with micrographic surgery have appeared. The authors report six cases treated with Mohs surgery, two of which recurred. They also present data on 42 additional cases obtained from a written survey of members of the American College of Mohs Micrographic Surgery and comparison cases selected from the literature. The recurrence rate after micrographic surgery appears to be at least as low as that after conventional surgical excision with vertical frozen section or paraffin section margin control. Mohs micrographic surgery allows for maximal tissue sparing of critical anatomic structures and is performed under local anesthesia as an outpatient; because of this, it may be superior to conventional surgical excision. A scheme for management of this malignancy is presented. Surgeons should be aware radical excision is not needed for most cases of extramammary Pagets disease and very long‐term patient follow‐up is required.

Risk of developing another basal cell carcinoma. A 5-year prospective study

This 5‐year prospective study of 1000 people, who had one basal cell carcinoma treated, found that 36% develop a second basal cell carcinoma. The most important risk factors are a skin complexion with inability to tan and frequent sun exposure. There was no significant correlation between multiple basal cell carcinomas and sex or age.

Innate Immune-Related Receptors in Normal and Psoriatic Skin

CONTEXT A precise role for the innate immune system in psoriasis remains to be determined. Surface receptors, including Toll-like receptors (TLRs) that recognize bacterial ligands and CD91, which recognizes heat shock proteins (HSPs), are implicated in both innate and adaptive immunity. OBJECTIVE Since skin is exposed to various exogenous stimuli, which can provoke or exacerbate psoriasis, we characterized expression and function of TLRs, CD91, and HSPs in normal and psoriatic skin. DESIGN A variety of skin-derived cells and blood-derived cells were analyzed both in vivo and in vitro; samples were obtained from 24 different individuals for innate immune-related receptor expression and function. By comparing and contrasting individuals with healthy skin and psoriatic patients, several specific differences were identified. RESULTS Immunohistochemistry-based expression profiling revealed TLR1 expression in epidermal dendritic cells (DCs) and dermal dendritic cells (DDCs) in normal skin, as well as in pre-psoriatic skin and psoriatic plaques, with enhanced basal layer keratinocyte (KC) expression in pre-psoriatic and psoriatic plaques compared with normal skin; TLR2 expression primarily by DDCs; and TLR4 expression by epidermal DCs and DDCs, with mid-epidermal-layer KCs displaying cell surface staining. No TLR9 or CD14 was detected on DCs or KCs, although psoriatic plaques contained CD14-positive macrophages. Analysis of psoriatic epidermis revealed HSPs 27, 60, and 70. Keratinocytes were CD91 negative, but CD91 was expressed by fibroblasts and DDCs in normal and pre-psoriatic skin, with prominent accumulation of CD91-positive DDCs in psoriatic plaques. Cultured KCs revealed no surface expression of TLR2, TLR4, TLR9, or CD91. Exposure of fibroblasts, but not KCs, to lipopolysaccharide or HSPs triggered nuclear factor (NF)-kappaB activation. Heat shock proteins did induce maturation of blood-derived DCs accompanied by increased interleukin-12 production and enhanced antigen-presenting function. CONCLUSIONS These data demonstrate distinctive patterns of innate immune-related receptors by specific subsets of cells in normal and psoriatic skin, suggesting functional roles for HSPs and DCs in psoriasis.

A randomized controlled trial of an appearance‐focused intervention to prevent skin cancer

Skin cancer represents a significant health threat with over 1.3 million diagnoses, 8000 melanoma deaths, and more than

Indoor tanning knowledge, attitudes, and behavior among young adults from 1988-2007.

1 billion spent annually for skin cancer healthcare in the US. Despite findings from laboratory, case‐control, and prospective studies that indicate a link between youthful indoor tanning (IT) and skin cancer, IT is increasing among US youth. Appearance‐focused interventions represent a promising method to counteract these trends.

Actinie cheilitis: A review of the etiology, differential diagnosis, and treatment

OBJECTIVE To compare knowledge, attitudes, and behavior about indoor tanning and sources of information among young adults in the summer of 1988, 1994, and 2007. DESIGN Convenience survey of 100 Chicago, Illinois, beachgoers aged 18 to 30 years who were age- and sex-matched with Chicago-area residents who participated in random-digit-dialed telephone interviews in 1988 and 1994. SETTING Lakefront beach on weekday afternoons in July 2007. MAIN OUTCOME MEASURES Knowledge of melanoma/skin cancer link with tanning, and limiting tanning to help prevent melanoma/skin cancer; attitude about the appearance of tanned people; and knowledge of relevant information sources; and UV indoor tanning use in the past year. RESULTS Knowledge of the melanoma/skin cancer link with tanning changed from 1988 (42%) to 1994 (38%) to 2007 (87%). Knowledge of limiting tanning to help prevent melanoma increased from 1988 (25%) to 1994 (77%), but decreased from 1994 to 2007 (67%). This decline in knowledge about limiting tanning was concurrent with an increase in the attitude that having a tan looks better (1994, 69%; 2007, 81%). Use of indoor tanning beds increased from 1988 (1%) to 1994 (26%) and remained at the same level in 2007 (27%). Although physicians, especially dermatologists, were sources of information about tanning (1988, 2%; 1994, 18%; 2007, 31%) and were considered the most trusted source, only 14% of respondents in 1994 and 2007 reported ever talking to a doctor about indoor tanning. Conclusion Because young adults report that physicians are their most trusted source of information about tanning, a potential opportunity exists for physicians to influence indoor tanning behavior by counseling their patients.

What promotes skin self-examination?

With todays increase in sun worshippers, the number of sun-induced skin lesions is increasing. Actinic cheilitis is the counterpart of actinic keratosis of the skin and can also develop into squamous cell carcinoma. In this article we review the etiology, clinical spectrum, histology, differential diagnosis, and treatment of actinic cheilitis. Actinic cheilitis needs to be differentiated from many other lip conditions, and the dermatologist must be attune to its possibility whenever assessing scaly lips. Because of its potential to develop into squamous cell carcinoma, treatment should be instituted as soon as possible.