Chapters Transcript Video Nevi, Melanoma and UV Protection So I'm going to introduce our speaker. So dr kelly cordero is a is a professor of dermatology and also the division division chief of our pediatric dermatology and the pediatric dermatology fellowship director at UCSF. Her clinical focus is complex medical dermatology, particularly inflammatory diseases and Children. Her primary research interest is in pediatric psoriasis. Um She is particularly interested in reducing the psychological and emotional stigma of visible skin disease and she takes great care to address this aspect when she's managing her patients and their families. So I'm gonna stop sharing my screen and I'm going to give it to Dr cordero so she can share her screen. Good afternoon everybody. Can you hear me? Yeah, okay and it's my screen up. Yes. Yeah. Okay great super thank you so much for inviting me. It's great to be here. It's really super to scroll through the chat and see so many of you out there who I know or know of and with whom I share patients. I really hope that this next hour is productive for you. I'm going to try to chat a little bit about a complex topic, really Niva and kids. Risk of melanoma and kids and then UV protection and really try to make it practical and something you can use in your office every day and I really look forward to having a discussion at the end and taking your questions as well which is I think is the most important part. I have absolutely no financial or medical or any other conflicts of interest related to any of this medication. The only interest is in helping you to care for your patients and helping our patients to not, you know suffer the consequences of either um sunburn, skin cancers, melanoma or even toxic effects of of sun protection. And I want to just set the stage by saying that you know nearby are hard, there are a ton of different variations. So that in and of itself is a special talk. I'll try to talk to you specifically about the basics of nearby and how to recognize nearby common versus worrisome when to refer And to let you know that melanoma does happen in kids. Absolute. It happens. It can be a typical 90% of melanomas that occur in Children happen in the teenage years between 15 and 19 years old, although you certainly can see melanomas, in in kids as early as newborns on up to young childhood and and then young adulthood and beyond. I think the upshot of this talk is that you know, please refer to Durham anytime you're unsure. I know that we have a backlog. We have enormous demand and we're trying to meet the demand. We have just added a few new faculty members to our sites in both Oakland and san Francisco and we're expanding our clinic submission based. So hopefully we can meet the need and at the end of the day remember your patients are what matter the most. So feel free to reach out to me, reach out to us, send us a message, we will find a way to get your your patient in. Um if you detect that it's urgent. So at the end of the talk we'll talk about prevention. I'll kind of Sprinkle that in throughout and I'm gonna do a mythbuster section two about navy melanoma, Sun safety and outdoor and indoor tanning. Certainly there's a dizzying array of sunscreens available now. The skincare industry of itself in and of itself is a multi billion dollar industry and so it's really difficult to give guidance to others when it's hard to even know as a trained dermatologist who's up to date on the literature and the science what to think when I walk into a store and and see something like this lower picture. So let's talk about the goals. I just want to show some introductory material to allow you to identify the clinical spectrum of benign me by a few pictures of melanoma, knowing when to refer. And then we're gonna talk about counseling about ultraviolet protection and I'm gonna tell you why I think it was a really bad idea for anybody to call it sunscreen because as we know living in SAN Francisco that you can get burned and suffer the effects of UV radiation even when it's cloudy. So that's really important and we'll talk about that first a quiz to test your knowledge, these are going to be a series of statements. I want you to think through whether you believe they're true or false and then I'll answer every single one of these questions in the next slides of content. Alright, so true or false freckles signal a patient who is at increased risk for melanoma. A bonus question is true or false, freckles occur at birth. True or false moly kids are at higher risk for skin cancer. Important. Morning signs of worrisome moles are rapid evolution or new symptoms such as it's scabbing or bleeding. A red bleeding nodule and a child could be a melanoma. True or false. Getting a base tan is a good idea to protect the skin either in the summer or before a tropical vacation. We should get some sun to make sure we keep up vitamin D. Levels. Finally, true or false sunscreens can have toxic ingredients so cover up and modify activity to reduce reliance on sunscreen. All right, let's roll through and answer these questions. So freckles market patients at increased risk of melanoma, this is absolutely true. Fair skin freckles and light hair patients are at higher risk, particularly those who have red hair. And throughout this talk, I'm gonna talk about some differences in skin of color. Patients who have much more men in the skin and therefore melanin is protective. And so we see a much higher risk for patients who are very fair and have white skin red hair freckles than we do in patients with darker skin, darker hair, darker eyes and in fact there's a genetic reason for this among many genetics of skin and skin color and um excuse me, protection the M. C. R. Or milan important one gene variant that signals for red hair and freckles can pretend a 42% higher rate of the cancer causing genetic mutations that lead to skin cancer than people who don't carry that gene variant. And for the bonus question, UV radiation is absolutely a prerequisite for freckles. So if your if your parents tell you that their child was born with freckles, ask them for photographic proof because such a case has not been described unless there's a genetic issue leading to pigmentation. Okay number two moly kids are at higher risk for skin cancer. That's absolutely true. Here's an example of a patient who has many moles. The worrisome numbers probably somewhere around 50 moles that vary in size greater than five millimeters. Can be a risk moles that are asymmetric, have ill defined borders or regular colors. And patients who have more that show up on unusual or covered sites such as the buttocks, the under, you know under areas that are covered like the armpits and so so forth. What this is telling us is that they have a genetic predisposition to getting a baseline number of nearby and then with UV exposure. Much more naive. I can develop as a way to try to protect the skin when you have multiple nearby you have multiple risk of getting a genetic mutation as those cells divide. So naive, I are comprised of certain genetic changes. And as you accumulate DNA change, you can accumulate enough result in skin cancer. And if you have more nearby, it's like having more lottery tickets, you have a more more a greater probability of getting a skin cancer. So you can see this child not only has several acquired nearby, but also evidence that you be damaged, such as these freckles across the shoulders, multiple sizes, and you can see here a scar from one being removed, another scar here from a biopsy. So kids up with multiple moles are at greater risk. Well who else is at risk? There are some risks for development of nearby as well as development of melanoma. And they overlap patients who genetically have a family history of melanoma have an increased risk. Those who have congenital nearby, such as giant nearby. As you can see in the photo on the lower left have an increased risk of melanoma given the melanocytes density in this skin, patients who are immune deficient, either from genetic abnormalities such as DNA repair defects. For example, in a condition called zero derma pigmentosa or those who have acquired immunodeficiency, such as our patients that are taking methotrexate that are taking other immune suppressants who have had medical radiation for cancers who have, who have had acquired immune agencies such as after bone marrow transplant when you are immune deficient that reduces your immune system's ability to do tumor surveillance. And so it's more of a permissive state for skin cancers to occur. So the idea of immuno suppression making a patient at risk for melanoma is true. The idea of more. The goal is increasing your risk for melanoma is also true. And you can see melanoma in both lighter skinned patients and darker skinned patients and we'll talk about protection behaviors to try to protect from some of these risk factors, certainly such as ultraviolet light, which is one of the number one ways we can protect either indoor via tanning and then with sunscreen, which we'll talk about later. Now, I just want to talk about the normal spectrum of acquired Niva and what can you expect in clinic. And these um, teaching points are based on referrals that I get questions that you all send me or ask me or come by way of the consults and so forth. So moles acquired levi as opposed to congenital nearby appear anywhere between zero and two years old. So it's normal for a child to start getting a few nearby early in life and then can develop a few more um, in early childhood by the time a child hits puberty, somewhere between 9 to 11 years. You know, it depends on girls versus boys, etcetera. We start recognizing the propensity for nevis density and you really have any of this explosion around the time of of puberty. Such that by the time a patient is anywhere between 12 and 18, we really recognize if they're moley, if they're at high risk and so forth. This is the time where you'll probably get the most moles. So this is to say that every child has a genetic predisposition to get a certain number of moles. This is typically due to their D. N. A. Their parents. Are they moly are they fair skinned and so forth? And then an environmental risk. So the more UV radiation they get from either, as I mentioned, medical causes or the sun um and other causes of radiation and immune suppression and so forth will increase their risk of getting more moles. So this leads me to mention. One of the questions I get most common from families and from pediatricians is when should I bring my kid in to start getting checks. Well, if we know that high mold density occurs somewhere around puberty, where we know the kids that are great at risk, greatest risk. Puberty is probably a reasonable time or a few years before puberty. But there's really no standard age to start screening, there's no guideline to suggest when to start. So it really depends on the patient's risk factors. As I just reviewed in the last few slides and whether or not they have a family history of of skin cancer or melanoma. A medical history that suggests risks such as immune suppression and certainly any time a parent or you want to send the child in dermatology. We do periodic full body skin exams. We take lots of fun photos. And one trick that you can learn is to get to know a patient signature nevis, which makes it a little easier to see the outliers. This used to be called the ugly duckling phenomenon, but I never use the word ugly ever in a dermatology clinic in front of patients who are vulnerable and susceptible to stigma because of visible differences but recognizes recognizing the signature Niva. So this guy on the right, the signature nevis, he has a couple. He makes these large pretty um pretty large, fairly evenly pigmented nearby that are both flat and pack mules and then these smaller flat nearby. And so his signature nearby are these two. But then he occasionally will get these, you know, red toned nearby tanda red. Here's one, here's one, here's one, here's one I would never expect you to feel comfortable following this patient. These kids make me feel uncomfortable. So a patient who is really moly send them over, let us help you do the clinical surveillance on these patients. We don't deem old kids. We don't remove benign appearing nearby. We only remove outliers um and nearby that have undergone decent change which will take us to our next our next couple of true false is so again, always okay to refer for a baseline skin exam and surveillance for this guy on the left who's got just a few moles, but they're very large and irregular. This child on on the right who has, you know, these are very benign, regular appearing nearby, but he's got a background of sun damage. You can see all the tan ish, Lenten journey looking red changes. This child has medical immune suppression so he's developing more naive. I and then this child who just absolutely has an unusual um focal area on the arm with multiple device. So anything that looks like an outlier like this is reasonable to refer. I want to make the point that it's really hard. On one hand, when we spew things like the A. B C. D. S. And evolution yet evolution is really normal and kids. So this makes the job of a pediatric dermatologist, I think a little bit more difficult. But also more important in collaborating with you because evolution is part of the normal history of Niva and childhood as they become adolescents. You know, they start low smaller, They start growing, they get these popular changes at the edge. This is with DeMoss Capi or magnification the picture you're seeing here and they really can be changes. So the most common reason for changing kids is just normal growth as the child grows. But growing out of proportion to normal childhood growth is a warning signal. So something that grows very quickly within a month or two doubles or triples in size that's never normal. And so let's look at a few photos of normal moles. You know, we're looking for uniformity. We're looking at symmetry even though these nearby all look a little different from each other. They're all in and of themselves benign. You can see there evenly pigmented, they're fairly regular. The presence of hair does not help the dignity or malignancy, the neutral finding. And um sometimes nearby will get these little cysts that grow in them that's normal. Sometimes nearby will puff up under areas of like the collar or the waistline because they're subject of friction. Those can be normal findings as well. So these are uniform and symmetrical. All benign. Well, I forgot to show you on this photo, moles that moles can sometimes go up in the left hand corner here. Sometimes moles will follow lines of skin tension, so on the feet, the hands and other areas. They might just start following the skin line so they can take on an ovoid shape which also is the normal phenotype and kits. Now you can see here that all of these look irregular. They're irregular at the edge. Some of them are two toned. These e centric pigment is very important. So when a mole has uniform pigment and then develops an east centric dot like this or starts growing out in a scalloped fashion. These are concerning all of these types of navy should be referred. And so the true false question about important warning signs of goals or rapid evolution or new symptoms like scabbing or bleeding or itching. That's absolutely true. So unless the patient has a reason for scratching it, like they say, oh I, you know, rubbed it across with my brush or I've been itching this one because I had a mosquito bite in the area or or G. I. S. So I scratched that arm and I scratched the Mola. That's all fine. But melanomas can be identified by changes such as asymmetry in the left two or the new ones out of a scab. Like in the 17 year old who their lesion scabbed over. I biopsied it was on the leg. It was a melanoma or this young adult, this 20 two year old who has early on had a normal appearing nevis that was there her entire life. And then she said that she hadn't checked a couple of times. This this cation actually haunts me. She hadn't checked a couple of times and was told it was okay. It was growing with her. And then over time she had just kind of forgotten about it. I had asked her if she had ever seen a doctor and she said, yeah, you know, I went in for my my checks all the time and I'm 22 she has an internist. Well I asked her if she had had a routine physical exam and she had her heart checked, her lungs checked and she said, yeah. But you know, the interesting thing is, is now that I think about it. They would always take the stethoscope over my shirt or just put it up under my shirt. This was in her middle, back in this room, reminds me to tell all doctors who carry stethoscopes and used to always pull that shirt up or go down your patient when you're using the stethoscope because you could save a life. This was in the office on a young lady who saw me, you know in college, she was in college at this time. Her lesion had become a symmetric and has border irregularity. It's got color change the diameters greater than six kilometers. And it had evolved. But it had evolved slowly. And so had we seen this earlier, we may have been able to prevent this young adult from getting this invasive melanoma. She ended up living, she's fine. She got a wide local excision. She gets checked in our adult melanoma clinic. But it's really important to look at moles and if you're unsure, just send them over for a referral. Okay. And this is a patient that I have seen just in the last 48 hours. An important sign of potential melanomas, rapid evolution. Now this is a child that you would never think twice about. There's this tiny little brown. the dorsal foot. Over time though. Within three months it more than tripled in size. It's gotten larger. It's gotten puff here, it's gotten a symmetric. And this lesion was biopsied and it shows an atypical milan acidic tumor. We're working collaboratively to do genomics on this lesion. But this this patient may end up being diagnosed with melanoma which is really rare in a three year old but crust rapid growth or any symptoms should prompt referral. Okay. A red bleeding nodule and a child could be melanoma. True. I want to just point out that pediatricians described this first in pediatrics clinics. A melon audit bleeding nodules are frequent presentations but the problem is they're often diagnosed. Asthma less comm works key Lloyd's and other benign lesions like bug bites. This is a patient who progressed through the stages. She was initially diagnosed as um Alaskan, it was frozen, it came back and they thought maybe it was award it got frozen again. Then the primary care position. Thought it was a key Lloyd star. So it got injected with catalog and then it was sent to dermatology at Harvard. This is this is this is a patient who was seen by my friend Elena Harlock at Harvard. She published this case in 2017 and this ended up being an a melanoma melanoma or a spitz melanoma which is actually relatively well behaving subtype but this child still needed a wide local excision still needed interfere on which was the standard of care at the time for a year. So just recognizing that melanomas can be read. In fact the common A. B. C. D. S that we know well and love here have been modified for Children to include a melon arctic lesions because so many melanomas and kids can be read. They can be bleeding bumps rather than just flat. They can have uniform color and not necessarily variation and they can be very small and they can show up de novo. In other words a lesion that shows up without a pre existing bowl. So sometimes just a new lesion. This is why photography and close surveillance are so important. This is a patient who had an a melanoma melanoma arising in a large congenital Niva. So unbelievably this adolescent patient who was at UCSF patient had this red nonfederal um shown up uh that showed up this ended up being representative of metastatic melanoma and sadly this patient is deceased now. So both acquired levi congenital nearby and other types of excuse me acquired and congenital nearby can change into melanoma. But melanoma can also arrived arise de novo and it may not always be black or brown. It might be read. So just something important. I want to end this section by showing you just some summary images of the spin of the clinical spectrum of nearby that range from congenital to acquired. There can be special site nearby to spitz nearby which are pink moles. These are their malignant counterparts, a congenital nevis that gets an abnormal lump of the edge. I showed you this patient nail unit milan acidic nevis that starts getting very wide and broad. Can be a sign of nevis. And benign spits nev. I have an atypical spitz tumor or spits melanoma counterpart. So another review of benign lesions across the top, malignant lesions across the bottom to show you the differences and you know not melanoma melanoma. Again, orderly, symmetric, uniform color on all of these patients. These are all benign and then melanoma asymmetric, not uniformly colored, dark black, rapidly changing eccentric pigment at the edges recently scabbed. So if you're confused or not sure that's why I'm here. Feel free to refer. Happy to see these patients and then also maybe melanoma. You know, what is this scab black lesion with a crust at the edge. What about this melanoma? There are this mole in the middle that turned to two toned. Just to add to the confusion. If I have seen probably 100 and 50 kids that have that lesion in the middle and they came back as benign that are just called hyper melon auto where they just have a focus of increased pigmentation. This kid on the right this looks like a melanoma but it could just be an atypical spitz nevis that the immune system is attacking. So these are really confusing. Don't let it keep you up at night refer, send me a photo, send us an email. I'll give you the contact information at the end to re reach out and refer your patients. This takes precedent. So you know um Alaskan that are spreading not urgent, itchy rash, not even necessarily urgent need is changing or you're not sure urgent. So we love to see these patients rather than feeling the clinic with patients that are less urgent because these are the patients who may have um you know life threatening finding. So this is a slide showing patients who have lesions particularly patients with skin of color. So nearby and patients with skin of color occur as well slightly less commonly. And melanomas when they arise in patients with skin of color tend to be more advanced because they tend to go undetected. They often show up on the palms or the soles. Um and in unusual places but patients with skin of color get nearby just like um Non just like caucasian patients get but less likely to get melanoma. But when it does show up it's usually of advanced stage. Either for lack of detection or because of health disparities and not seeing these patients soon enough or commonly enough Just want to make one comment about congenital nearby that can occur in 1-4% of Children. Those that are small and medium are very common, low risk of melanoma and melanoma is a greater risk and those are small or or you know less than five or 10 cm after puberty because they need time to accumulate genetic changes and UV exposure. However large congenital nearby have a much higher, higher melanoma risk and that risk happens before puberty because there's already so much genetic instability. So the overall risk of congenital nearby for melanoma is small, but we love seeing these patients and want to help you to follow them. So often we say refer kids who have congenital, nearby last two slides in terms of helping you with those things. You see common the the halo nevis phenomenon really, really common. They often are benign, they're often multiple and they're not synonymous with melanoma, but you can refer them, let us look at them, they get a full skin check, we look in the mouth. Sometimes we refer them in ophthalmology, we look in the, in the genital area to make sure there's not a melanoma somewhere or in a typical nevis that's generating an immune response to two other pigmented areas. If a patient has multiple halo halo nearby, that's a risk factor for vitiligo and patients who have vitiligo often have halo nearby. Um Now special sites don't necessarily carry higher risk. So patients who have nearby in their scalp or in the, in the genital area, they can be referred for baseline exam, we can discuss the risk but they can be large, look weird or atypical or cerebral form as you see up in the top and what Scout nearby and often genital nearby reflect is really just a benign lesion. Scout nev I tend to predict a moley child over time and general nearby tend to be very common. They grow with the child and often follow a benign force now nail unit Niva can be scary. These can in adults they these are almost always a sign of risk for melanoma. So in adults with Milan and Nikki estrada or that pigmented band in the nail they get biopsied and kids this just tends to be in need of a special site back in the nail matrix that's sending its pigment out onto the nail plate. But I say refer these patients so we can see them, photograph them, monitor them and make sure they're not at any risk. So special nights special sites aren't necessarily higher risk, they're not emergencies but often um you all are not comfortable with those parents aren't comfortable with this and I take that as an opportunity to be your collaborator, educate, share and follow these kids for you. Okay, spitz nearby, you may have seen them, you may have heard about them, we may send you reports back that say we think this is a spitz. They can range from benign to malignant but remember they can look like other things like moleskine like bug bites and so forth and they do have a cancerous counterpart. So if you're not sure about a persistent red nodule or a deeply black neighbors, you know every picture on this slide should be referred. So let us worry about it. Let us look at it and collaborate with you. Okay, so let's just talk about the next four and move the discussion to skin um to sunscreen. So we can so we can then have some time for Q. And A. And or U. V. Or U. V. Screening. So true or false. Getting a base tan is a good idea to protect the skin false based hands. Always any type of tan always represents damage from the skin. Next. Should we get some sun to keep up vitamin D. Levels? You can make the argument certainly because vitamin D. Is created first in the skin and then later in the kidney. So you do need some transformation to happen in the skin if that's your soul, the sole way of getting vitamin D. But because foods are fortified because there's other sources and because almost nobody protects their skin properly other than maybe me because I have really fair skin and I've also had melanoma. So I actually am vitamin D deficient. Um, a dermatologist and I'm careful and I've had a life threatening skin cancer, yep, I'm a little low low vitamin D. Could I supplement? Yes, and I do. But it would never be a good idea to tell families that their child is at risk of skin cancer if they get too much sun or that they need skin, I'm sorry, sorry, let me back up. I don't think it's ever a good idea to tell families to let their child get a lot of sun in an effort to maintain vitamin D. Levels. I think it's okay to get a little bit of sun and a little bit of sun, such as the amount you get on the back of your palms for 15 to 20 minutes is probably enough to metabolize enough vitamin D. To last you for a week or more. So there's a lot of falsehoods about vitamin D. And in my opinion, it's not a good reason to let kids get too much sun. Patients with skin of color or adults, patients with skin of color do not have to worry about skin cancer or protection. That's absolutely false. And I'll show you that these data down here, the incidence of skin cancer by race and ethnicity, you can see the large majority of patients who get skin cancer are white and much less in patients who have skin of color. But there is, as I mentioned earlier, a risk of sun damage from UV. In patients with very dark skin. And when patients with dark skin get skin cancers, they can be more advanced. So it's important to include patients with skin of color in your discussions. Not only that, but sun is also the number one cause of aging. So ring wrinkles, sunspots, you know, the whole reason that there's a cosmetic industry is because we're probably failing in the sun in the sun prevention industry, sun breaks down collagen. It causes wrinkles and age spots and so forth. So if we can't appeal to life threatening risk, we could at least appeal to vanity, what I say or not even vanity but wanting to look good and look our best. So sunscreens can have toxic ingredients. So cover up and modify activity to reduce reliance on sunscreen sunscreen. That's absolutely right. I'll show you some of that data, you know, as a very fair person who burns easily who's at really high risk. I should have taken a picture of some of my sun protection stuff hats, a buff that I keep around my neck. Sun protective gloves, you know, longer sleeve shirts and you know, in the bay Area, it's nice because it's easy to, it's easy to cover up to protect. So let's go through this and show some data and then open this up for Q and A. So prevention is key. Most UV damage occurs in the 1st 18 years. That's absolutely true. And ultraviolet radiation is the most preventable risk factor for all skin cancers. And for photo aging effects of sun exposure are cumulative. So starting in Children, you know, where kids are out playing there, the least clothed you probably in the entire life. They're going to spend the most time outside with the less amount of clothing for protection. And so if they get a lot of sun, they're just going to add to that throughout their life. So exposure and in particular sunburns in childhood dramatically increase the risk of developing skin cancer later in life. And one of the huge problems that we've had, that's a little bit less of a problem now um is indoor tanning. So tanning has been classified as a Class one carcinogen. It increases the risk of melanoma by 59% and that's often among adolescent women and young adult women. So no tan is a healthy tan every time your skin pigments, it's your body trying to make more melanin to protect its D. N. A. UV rays can damage or burst skin in as little as 15 minutes. So that's actually really important to know. And there's reasons then that we need to ask our patients to prevent and to be careful and to teach them how to do this. So practical prevention in my mind is most importantly as behavior at least trying to minimize unprotected, unprotected midday outdoor activity, you know, so reducing if you can going out on saturday and sunday from 11 to 2, you know, the absolute highest UV radiation in the in the sky, whether it's cloudy or sunny, trying to seek shade and avoiding indoor tanning. So having like the this family an umbrella if patients are outside or you're really giving this talk to you and your kids and your family members to as much as I give it to adults, all of this is relevant for kids as well. Excuse me for as much as I'm giving this as a pediatric foundation. This is relevant to all of us attire, clothing, hats, sunglasses, rash, guards, buffs. Um, you know, there's no guards. This is all really important and makes it a lot easier, frankly. It's so much easier to throw a long sleeve shirt on a kid than it is to try to slather sunscreen all over a child. And before I talk about sunscreen, I just want to take a minute to talk about messaging because you all know the brain on adolescence, right? The cognitive processing, the risk aversion, the worrying about the future. That is not something that comes together in the frontal lobe until patients are in their mid to late twenties, right? Kids are social social, they're emotional, they're driven by their peers by appearance by fitting in with the crowd. It is not cool to be the person rigged up in your, I'm here to prevent skin cancer. Um, gear, I wish it were. And we are thinking about trying to do more messaging on, you know, where he hits kids the most social media tiktok instagram all of these places because they're not listening to you and they're not listening to me because they're never going to be 40 and they're never gonna get, you know, send damage and they're never gonna have wrinkles, right? So we can't really appeal by just telling people we have to find another way to appeal to kids based on how this might hurt them. Now. Um 18 year olds are getting Botox by the way, which is crazy. Thanks to Tiktok and all of the, you know, skin skin google gurus on social media. And so do we appeal to appearance? Maybe that's where we need to go because appealing to health and protection is not working. So text me or put something in the Q and A. If you have a good way to get the majority of teens to actually follow instructions for protection. It's really hard to do. Let's talk about sunscreen. I recommend an SPF 30 minimum with re application every really 2 to 3 hours, but much more often of swimming. And we're gonna talk about SPF. This is a slide from my friend Renee howard, who is a pediatric dermatologist in Oakland. We share slides back and forth. Um You know, this is an awesome article by an Outside magazine is sunscreen. The new margarine and I added here a sunscreen. The new margarine, is that the new coffee? Is that the new egg? You know, one minute caffeine is good for you. One minute. It's gonna kill you. One minute eggs are good. One minute eggs are bad. You know, what about sunscreen? There's so many arguments to make about not using it. Well, there's ken, chemicals in it, it gets absorbed, it's killing the reefs. Um you know, working out toxic metabolites, it looks bad. it doesn't rub in there's been recalls because there's carcinogens in it. All. Those are totally reasonable arguments, you know, and we really have to put in place this idea that we need to protect from UV radiation. But I'm not necessarily doing a commercial for sunscreen because I agree with all of these concerns. And so let's get into that a little bit, you know, seeking shade wearing clothing is really important, but I'm certainly not going to do a commercial for putting chemicals all over our body. Physical sunscreen are probably the best. They work like a shield. The sun bounces off of them. Chemical sunscreens work like a sponge. They absorb sunscreen. They do a chemical reaction in the body and they help prevent DNA damage. Chemical sunscreens are also absorbed into the body into the bloodstream and are eliminated. I want to be very clear that no harm has been shown or proven by having these chemicals in the blood. But that data needs to be looked at. And it is in fact, FDA has mandated now we know that certain chemicals are absorbed. What does it mean? I would also argue that we're absorbing many things we put on our skin, including lotions that we use for moisturize ation and so forth. And so is there a health risk of absorption? Maybe not. A lot of people believe if you have a functioning liver, you have a good kidney, they're detoxifying your body. But is there a risk? We won't know for much later. And is there a risk in, you know, a three year old child, for example, or four year old who's on the beach and we're putting sunscreen every day three times four times a day for an entire lifetime. Could there be a cumulative toxicity? I'm not sure. And we don't know. And so it again underscores the importance of using sunscreen where you can't cover face backs of hands and so forth, but covering when you can, I'm gonna slip, I'm gonna skip this slide because I just said this, but this will this will be on your handout and this will be in my pearls, which is essentially to say that zinc oxide and titanium dioxide are the physical blockers, but they're not as effective as chemical blockers. The chemical blockers. The Ben zones and the EVO Ben zones are actually more effective in dispersing the energy, but they do get more absorbed their allergenic and they have metabolites and so using clothing, plus a little bit of a physical blocker, in my opinion, is one of the best ways to to use sunscreen. So some of my favorite tips and I have hashed out sunscreen here. I've crossed it out because it's really UV screen. So UV radiation tips, you don't need the sun to burn anybody who lives in the bay area knows that physical blockers are the best ones to use. As I just talked about their mineral blockers and they sit on the skin and block it. Broad spectrum is really important. You want to look for those that say UV A and UV B. You want to look for zinc and titanium lotions are much better than spray. So all of the recalls that all of them. But most of the recalled sunscreens that have Ben's scenes in them were sprays thought to be part of the manufacturing process as an error or introduced as some of those chemicals degrade over time and so forth. So actually the scientists aren't sure how Benzene got into some of those sunscreens that were recalled, but a lot of them have in general, I don't like sprays to begin with, Most of it goes into the air, it doesn't protect the skin, it can cause inhalation injury. Sunscreens are okay spray for like the part line on the scout as a touch up on the backs of the hands before you drive for kids that play sports, but it's not best as a one as a one stop shop. There are sensitive formulas um, that will say baby I get no, I have no conflicts of interest. I'm not paid by these companies. I just wanted to show you that some of the best sunscreens that have been rated or the three on this on the screen for sensitive skin um, effects of absorption. There was a big article and then followed by lots of editorials and discussions and podcasts about chemicals getting absorbed into the body. An article in Jama about this And I just commented that, yes, we can find sunscreen metabolites in the urine. We don't know if that translates to harm, but it's probably best to avoid widespread repeated use and use other use other ways of protection. So mythbusters, you can get burned on a cloudy day. You can see over here how much shut son gets actually through how much you be damaged. You can get sun damaged through window glass. If you google skin aging by sun, you'll see or if you look at your left side of your face and versus the right side of the face of like bus drivers, truck drivers. If your office is sitting at a window, look at one side of the face. So I actually put SPF on or put shades on when I'm in a room with a window if I can because movie only blocks. Sorry, window glass only blocks UV B U V a penetrates and goes deeper into the skin and can cause skin cancer. A tan is not protection, patients who have black skin have an SPF natural of about six. A white T shirt is SPF five. So you really need proper coverage. We talked about not needing intense unprotected sun for adequate vitamin deed. Now SPF is not a measure of how much time you can spend in the sun. This gets messed up all the time. It's actually a measure of the level of UV. Protection of the skin that has the screen on it. Protect verse the skin that doesn't have the sunscreen on it. S. P. F. Gives you a false sense of security which is actually most important. So studies show that sunscreen causes cancer. It's because people put SPF 15 on or 30 and they think they're protected all day. So the false sense of security can lead to a skewed data that shows sunscreen leads to skin cancer. And as we know, nothing works if not used properly or used at all. So getting it out, making sure you're using it applying it and being careful. What about babies? Less than six months? I just want to give the ap statement avoidance, avoidance avoidance and protective attire number one. But if you can't avoid and you can't shade you're gonna take the baby out. I always tell parents, make sure you have a stroller cover. Try to put a hat on the baby and then put sunscreen on the exposed areas like the little feet, the backs of the hands, the cheeks and sunscreen recall. I don't have time to talk about it in detail but it's been identified in many sunscreens including organic. So you are not better protected just because it's organic. There are awesome resources in both from both. The ap and the american Academy of dermatology. So the A. P. And the A. D. Have awesome stuff. Great videos send your patients to those websites and then you know before for your practice as I mentioned in this talk and showed you need to our hard there's tons of variations were trying to get your patients seen. We want to collaborate and help melanoma happens in kids. You don't want to disregard it. It's often a typical refer to Durham anytime you're unsure. And then prevention is key and trying to talk about UV safety rather than sunscreen and trying to find messaging that works in adolescents. How do you get your patients to us? Well you can refer to us anytime. We have a large group in san Francisco that you can see on the left. We've also hired another doctor named Joanna to she just did a fellowship with us. She'll start in november. We have um a big group in walnut Creek. We've got Renee and Nicole Anjali who's a piece physician of the system and then we also have um RC Ahmad who joins us. Um And we also hired Manisha note one of our fellows also for Oakland. So we've got four locations mouth die in Mission Bay Oakland Children's Hospital and then out in walnut Creek and here are the numbers I know we are absolutely hard to get into but please don't give up. We are here we're here for your patients and we're here for you. So on that end um let's talk let's have a discussion. Um And I'll stop sharing my screen so thank you and we have a couple questions already on the Q. And A. And if you have any more please feel free to start putting them in and dr corridor and I will go through them. Do you want me to read them off to you dr card or do you want to read them yourself? I'm happy to read the ones that are there are kids with moles and milana sitting nearby along the toes. Kids with moles um fine nearby on the toes are also a can look funny because it's a bit of a special site if they only have one, they often are angular waited there often that ovoid shape because they follow the dramatic Elif IX or the fingerprints on the toes. That's not necessarily a high risk location. Um HIV patients are at higher risk for getting melanoma. Yes because their immune suppression. Do you have any specific brand of sunscreen that you recommend from people of color that have zinc oxide or titanium dioxide that minimizes that white film appearance. Thank you for asking that question. I specifically um didn't put in a lot of specifics because it's personal preference. So the tinted sunscreens are best for skin of color in some of the but I'll just say I don't have a specific recommendation but if you send me an email I will send you some um you can also go on the skin of color dermatology website where they make some recommendations but it really depends on how dark the skin is, how large like the skin is. And look for those that are either microphone ized or tinted. Um How important is the SPF number? Yeah. Great question. Great question. SPF number is important. So an SPF of 30 blocks, about 97% of rays. SPF 50 blocks about 98 to 99% of ray. So the higher the number matters, but not that much. So SPF 50 is probably the highest you ever need to tell anybody to use. But SPF 30 is much better than SPF 15. So 15 is somewhere in the 80% protection, 30 is somewhere in the mid nineties, 50 is in the high nineties. Um What is the UV exposure for under an umbrella on a sunny day, yep. The cute baby under the umbrella. Yeah, absolutely gets reflected. So anytime there's sand, water, concrete um the sun will get the sun bounces around all the time. So and snow is the worst. This is why my kids who are skiers um give me chest pain. My kids who are water polo players and and water sports, the water bounces all around. So you're right, that's kind of a I'm glad that you picked up on that. So umbrellas aren't perfect. They're only good if you can actually see the shade in the area that's being shaded. So unless the whole faces shaded. Um then the umbrella isn't working in your right. There's always some scattered, so nothing is 100%. Um Are they recommending sunscreens for less than six months of age? Yeah. Physical, so mineral blockers. Physical blockers are the ones recommended for kids under six months. Can you speak to the powder, sunscreen efficacy? Very little. It's very little. So powder sunscreens or makeup sunscreen? Say they have an SPF 30 but they are tested heavenly with a thick application so somebody almost has to look like they have a pancake of makeup on to get that SPF. So I don't love powders at best, powders are good for a little touch up at noon. They're better than nothing. You can, you know, touch yourself up with them. But they are not, they shouldn't be primary sunglasses for kids. Really important if they're willing to wear them UV damage to the eyes, particularly kids who are sun sensitive kids who have eczema who are already rubbing and scratching may damage their eyes more and scratch their corneas. Can a general dermatologist do more chalk on young Children. So we'd be waiting to get them into Pete's turn, it depends on where you are. So medical dermatologists are absolutely able to do skin checks on Children and if there is an issue, they will refer them to a pediatric dermatologist if they're not comfortable. So, absolutely a general dermatologist is trained to do a skin check on a child. Um can I clarify how we should deal with spitz nev I I would say probably it's gonna be hard for you to know just if it's a spitz Niva. So if you think you're dealing with the spitz, I would recommend referring it because they come in so many shapes and flavors and they typically grow rapidly. So I would say to grow the guidelines on care of spits nearby are in kids less than 12 If they've grown relatively rapidly and they've stabilized quickly and they're staying and there's no other risk factors in the child. They can be watched if a child is greater than 10-12 and you think something is a spitz nearby, especially if it's greater than six, they're supposed to be biopsied. So it depends on age and evolution. Yeah. Do we think we may get to a point where chemical sunscreens are categorized as endocrine disruptors. There are some groups such as the environmental working group that are already characterizing them as an endocrine disruptors and largely this is based on animal data, but there are some early human data that are suggesting that some sunscreens when used perfectly, meaning full body application. Every three hours may have some hormonal may have some endocrine disruption and these are used the way they're supposed to be used in their full state. So head to toe. So application and so forth, putting some sunscreen on the face, the backs of the hands touching up the dorsal forearms. You know, it really gets into pharmacogenetics, pharma code dynamics body surface area relative to size. So a little babies who have a high body surface area relative to volume of the body. This is a big deal and adults, it's probably less of a big deal, but it's very, very, very nuanced. I shared with you in the beginning my risk factors and who I am. I like mineral sunscreens better because I use a lot of sunscreen that I don't really want to put toxins on. So, you know, or potential toxins. So coverage over chemicals is the way I proceed and I don't want to frighten anybody. You have to recognize the relative risk of the patient getting skin cancer and dying from it versus the risk of the medicine used to prevent it, right? We go through these gymnastics all the time. Um, what so that it's an individual decision. There's no broad statement I can make up and then we know UV radiation can cause melanoma can cause other types of skin cancer. I love the Consumer reports. I like that Jody that you put this in here. And the reason I like the Consumer reports is because they're actually testing whether or not SPF 15 performs is 15, whether 30 performs is 30 and whether 50 performs is 50 there's a million sunscreens on the market and many of them don't perform. So you all may remember the Washington post. um published this expose on the honest company sunscreen where kids and adults got second degree burns from using honest sunscreen. And so I call it dishonest sunscreen because it did not perform. The number one brand of sunscreen by Consumer reports for many years was walmart store brand SPF 50. So you know, you don't have to pay a lot of money, you just need to get what you're paying for. And so I do like the Consumer report guide. So the only one that they in the environmental working group don't hate is quite sunscreen is the only one that they like. Oh it's interesting. The equate sunscreens have not been recalled yet, any of them. So um bye. On the lips. More concerning. Not necessarily. We think about a condition called fingers which is nearby on the lips with predominant tendency for G. I. Colon G. I. Polyps and colon cancer. There tends to be a family history but nearby on their lips are just another special site. But they do show that a patient's probably getting too much UV radiation. Um I see more irritation of the eyes and skin from turf fields and Sf. You can't answer that question. I don't know or activate character cities, problematic impedes. We rarely see a. Ks and pediatric patients unless they have immune suppression, enormous UV radiation. Um We don't we tend not to see them, but sunscreen absolutely protects from actinic keratosis and adults or good sunscreens for swimming or kids. Or is it the same brands just used more often? Um any good sunscreen? Does that mean kids that swim more? You need to use the water. The there's all these weird designation. So water protection is 40 minutes of protection. And then X. I forget the water. Sorry, water resistant needs 80 minutes of protection in water. And that's all 80 minutes of protection will um that sunscreen will allow for. So um in the case of swimming you should apply sunscreen to areas that may be exposed, you know, quite a bit kid that's swimming. And first I would recommend a good bathing suit in a rash guard. I forgot to put that picture up, I apologize. A rash guard is just a, you know, like a surf shirt that's critical that can really help. So rash guard number one and then number two, a good blocker. I didn't get into the reefs because that's a whole nother story. Um there's a lot of controversy but there are some reef safe sunscreens which are also controversial because there's some are saying that and getting people to buy it. Um Each of these is a very long talk and I would like to meet each of you have a coffee or talk more about it. But if you read about reef safe sunscreens um it's important to make sure that they have a special designation that they've actually been looked at for reef safety. But there's no specific brands that I recommend because some that claim to be reef safe also have oxygen zone in them. And then you know they're thought to be toxic. So it's a very nuanced and challenging conversation. I don't know if I got to all of your questions were at the hour here so I'm happy to take any more. Um Yeah I think we got all the questions that were in the Q. And A. And if there's any you have a minute you have a minute if somebody wants to ask another question but if not please do not forget to um fill out your evaluation. It will pop up in a link after this webinar finishes and then you'll also receive a email without link tomorrow. So please don't forget to do that and it looks like there's no more questions. So thank you dr Cordaro so much for that great talk. Um we'll make sure that we share her slides with everyone so that you guys have that information. And if you have any questions you can go ahead and um send them to us and we can make sure she gets those questions or we can share her email address with you. Um If that if she's willing um so you can reach out to her. So thank you everybody for joining and have a great day. Yeah thank you so much. It was such a pleasure and thank you for your referrals and the collaboration and you are amazing doctors and I can't imagine doing the job that you do so, um thanks so much and Tabatha and Christine and the group at UCSF on behalf of me and my team, I really, really appreciate the opportunity to be here and talk to you about a very wide ranging topic and I apologize if I didn't get to your your questions, feel free to send me an email. Thank you. Good afternoon, everybody, by Created by
