Men and women born in 1970 – now in their mid-30s – already are being diagnosed with malignant melanoma, the deadliest form of skin cancer. Shockingly, these young adults are being diagnosed with melanoma at the same rate as the elderly who were born in 1930 and who didn’t start developing melanoma until their 50s, according to a March 2005 warning by the SunSmart campaign of Cancer Research UK.

Melanoma risk throughout life is directly linked to excess sun exposure during childhood. A childhood sunburn can double the risk of melanoma later in life. The ozone layer of the atmosphere absorbs 95 to 99 percent of the sun’s ultraviolet radiation before it strikes the surface of the earth. But NASA estimates that the ozone layer is being reduced by 4 to 6 percent every ten years, largely from manmade chlorine products such as chlorofluorocarbons (CFCs) and hydrochlorofluorocarbons (HCFCs).

The US is on a schedule to completely phase out production and import of these substances by 2030 – but they will continue to affect the ozone layer for another century or more. Because of changes in the ozone layer and changes in behavior, children born in the 70s got far more childhood ultraviolet exposure than those born in the 30s. Today’s children are at a higher risk still. They are three times more likely than their grandparents to ever develop malignant melanoma.

It’s more important than ever for kids to avoid excess sun exposure by such measures as heading for the shade at peak sun hours (~11am to ~3pm), using T-shirts, wide brimmed hats, and sunglasses for physical protection, and not letting sunscreens that only protect from some parts of the UV spectrum lull you into a false sense of sun security.

The breezy television ads for certain steroid-free eczema treatments have always bothered me. While they don.t say anything untrue, they do incorrectly imply that this treatment is gentler and safer than the more commonly used hydrocortisone. In March 2005 the United States FDA issued a public health advisory about a potential cancer risk from the topical use of Elidel cream or Protopic ointment, two potent immunosuppressive drugs.

Not surprisingly, I’ve been contacted by many worried parents who have rubbed one of these medicines into their children’s skin. Those who have already used these medicines needn’t panic, but those who are considering using them should think twice first, to be sure the benefits are worth the risks.

At least 20 percent of all children in the U.S. battle with eczema, including more than 1.5 million kids under age 2 with eczema at any given moment. In recent years, more than 5 million people have been treated with Elidel or Protopic. Since 2000-2001, when Elidel and Protopic obtained approval by the FDA, thirteen cases of lymphoma and sixteen cases of skin cancer have been reported in people being treated with these drugs.

We don’t know that the medicines caused these cancers. But we do know that in at least three species of animals (mice, rats, and monkeys), both drugs are linked with lymphomas and skin cancers when used topically at high doses for long periods. And we know that Prograf (the oral or injected form of Protopic that is used to suppress the immune system in organ transplant cases) causes lymphomas and skin cancers when taken internally.

Usually when the drugs are rubbed on children’s skin, not much is absorbed into the body. But high levels of the drugs have been found in the blood of some children being treated topically with either drug. We won’t know the long-term safety of these drugs for at least a decade, but the FDA is acting now to create a black box warning label to warn of the cancer risk – the strongest warning carried on medicines.

The FDA recommends that Elidel and Protopic not be used in children before their second birthday. (These drugs have never been approved for use in children under two, but I know many infants and toddlers treated with them). In older children, they recommend that Elidel and Protopic only be used if the children are unresponsive to or are intolerant of other eczema medicines, such as the steroid creams and ointments. If Elidel or Protopic is used, only the minimum amount necessary should be applied (higher doses increase the cancer risk in animals), and the medicines should only be used for short periods of time to stop an eczema flare-up. They are not recommended for continuous use.

Both Elidel and Protopic work very well as eczema treatments. They are valuable medicines. Used at low doses and for short periods, they may prove to be quite safe for most children. But aggressive advertising, both to health care providers and to consumers, has created the false impression that these drugs are safe enough to use without a second thought. Not so. Perhaps the combination of the warmth of the ads and the chill of the FDA warning will create a more balanced impression.

How and when sun damage occurs to children’s skin may surprise you. Many parents know that in the United States alone more than 1 million skin cancers are diagnosed in adults each year, resulting from damage to the skin during childhood. Many of these cancers are deadly melanomas. Over the last thirty years, the frequency of melanoma has more than doubled, even though sunscreen use has increased.

About 80 percent of our total lifetime sun exposure happens during childhood. But there are two key ages to pay extra attention. The first of these is the toddler years. Sunburns and damaging tans more than double during a child’s second summer, according to a study in the August 2004 Archives of Dermatology. The surprising bit is that this occurs even though total hours of sun exposure stays the same, and the use of sunscreen triples in the toddler years! How can this be? The use of other sun protection efforts dropped, including strategies such as hats and other sun-protective clothing, shade, and non-peak hours for sun exposure. Many parents think that sunscreen alone is enough.

Another key age to pay special attention is when your child is 9 to 12 years old. Sunburns are most common at that age when kids are off enjoying activities without their parents. About 2/3 of American children do not get adequate sun protection. Some gifts we give our kids thrill for the moment, but soon fade. They are often discarded or broken soon after we give them. But whether it’s preventing wrinkles or skin cancer, sun protection is a great way to give your children healthy skin and a healthy complexion for years to come – a gift they will appreciate more with each passing year.

Related concepts:

Tanning, Radiation damage

Introduction to sunburn:

Even though skin cancer occurs in adults, the serious skin cancers are caused by the radiation damage (particularly the sunburns) that occurred in our youth. Similarly, adult cataracts can result from too much sun in the eyes during childhood.

What is sunburn?

Sunburn is visible radiation damage to the skin.
Most of the damage is caused by UVB radiation, although UVA radiation can also contribute to the damage. Radiation risk has increased greatly over the last twenty years.

Who gets sunburn?

Children are at the highest risk. More than half of a lifetime’s sun exposure usually happens during childhood.
The lighter the complexion, the greater the risk of radiation burns from the sun. Higher elevation also increases the risk. Some medicines also make the skin more susceptible to damage.
UV radiation reflects off of snow, sand, water, cement, and even grass, increasing the potential for damage. People often feel safer on a bright cloudy day, but significant sun damage can still occur.

What are the symptoms of sunburn?

In mild sunburn, the skin is red, hot and painful. Usually, the symptoms are noticed 6 hours or more after the first exposure and peak within 24 hours.
Moderate or severe sunburn often begins the same way, but continues to progress –often peaking in the second 24 hours. Symptoms may include radiation-induced blistering of the skin, nausea, fever, chills, headache, and even heat stroke.
Dehydration can result.

Is sunburn contagious?

No – although the behavior leading to sunburn is often contagious.

How long does sunburn last?

Mild sunburn usually lasts 3-5 days. Moderate or severe sunburn usually lasts at least several days longer.
The effects of each episode of this radiation damage, however, are long lasting. Each sunburn increases the risk of early wrinkles, premature aging, senile skin lesions, and skin cancers.
One of my college roommates met a tragic early death from malignant melanoma. He was a sports enthusiast who frequently spent hours unprotected in the sun — he always had a tan. Unfortunately, he’s not alone. The risk of developing malignant melanoma has more than tripled since 1980 — from one in 250 to one in 71. A person dies every hour from melanoma in the US. Skin cancer was once a disease of the middle-aged and elderly, but it is becoming a disease of people in their 20′s and 30′s. The skin damage that will result in melanoma most often happens during childhood — but kids have a hard time imagining 20 years in the future. It’s our job as parents to protect them. Who would have guessed that a cool hat could be a lifesaving gift for our kids!

How is sunburn diagnosed?

Sunburn is diagnosed based on the history and physical exam.

How is sunburn treated?

The radiation damage from sunburn is irreversible. No treatment exists.
Cooling the skin and keeping it from drying out can prevent further damage. Thus, cool compresses are the first line of treatment. Brief, lukewarm Aveeno baths may also be helpful. This can be followed by an alcohol-free moisturizer cream or lotion. Vitamin E or Aloe can be helpful ingredients. Topical anesthetics do not provide much relief and can lead to unpleasant reactions.
Anti-inflammatory medicines, such as ibuprofen, can reduce redness and pain.
If there is blistering, fever, or dehydration, the child should see a physician for further evaluation and treatment. Sometimes topical or systemic steroids are needed. In very severe sunburns, children may need to be hospitalized.

How can sunburn be prevented?

Sunscreen, loose clothing, and hats help protect children’s sensitive skin.
Try to avoid the sun’s most intense rays by staying out of the sun during the middle of the day. And don’t be lulled into complacency by overcast days, since most of the sun’s harmful rays will get through the clouds. Be especially careful if you are around water, sand, snow, or any surface that will reflect and therefore intensify the sun’s rays. Remember, the sun’s rays are more intense the higher you get in elevation.
The AAP used to recommend not putting sunscreen on infants under six months of age. This is no longer the case, because the danger from sunburns outweighs the risk of sensitivity to sunscreens.
When purchasing sunscreen, select a PABA-free brand with an SPF of at least 15. In general, infants’ skin is much thinner and more sensitive to the sun than adults’ skin, even in individuals with darker complexions. The amount of sunscreen needed depends on how light the child’s complexion is and I would recommend using sunscreen with an SPF of 30 or greater for fair-skinned children. Sunscreen is most effective if first applied 20-30 minutes before sun exposure. Use sunscreen whenever you expect to be in the sun for thirty minutes or more, and re-apply after swimming. Even waterproof sunscreens should be re-applied every 80 minutes or so, after being in the water.
Parents often think to apply sunscreens to exposed areas of skin, such as the face, but feel safe about areas under the clothes. Ultraviolet radiation, however, can penetrate clothes. Prolonged exposure can damage the skin. Typical cotton T-shirts offers sun protection equal to only SPF 7.
One solution for long outdoor days: sunscreen under the clothes.
A less messy solution: sun-protective clothing.
Sun protection depends on the fiber, weave, and fabric color. Sometimes a substance that blocks UV radiation is added to the fabric. The ultraviolet protection factor (UPF) of fabrics is similar to the SPF of sunscreens. A high UPF (40 to 50) is nice, because the ongoing sun protection is affected by stretching, shrinking, wetness, laundering, and the normal wear and tear of childhood.
Sunglasses protect children’s eyes from the UV rays and decrease the risk of cataracts in adulthood.
Most children love to be outdoors. By all means, take your children outdoors and enjoy. While you are giving your children a good time, though, you can also give them the gift of future good health by being careful. Protecting your children’s eyes from the dangerous rays of the sun and protecting their skin from sunburns is a gift that will last their whole lives.

Related A-to-Z Information:

Cataracts, Dehydration, Headache, Heat Stroke, Lyme Disease, Poison Ivy, Oak, and Sumac, Vomiting

Related concepts:

Heat cramps, heat exhaustion, heat prostration

Introduction to heat stroke:

Whether it’s a baby at the beach on a hot day, a toddler left in a sweltering car, or a budding young athlete at an exhausting practice in the sun, heat injuries are more common than people think.

What is heat stroke?

We are warm-blooded. Our bodies produce heat. When a muscle contracts, only about 25 percent of the energy is used for the muscle work. A surprising 75 percent of the energy is turned into heat to keep our temperature up.
If we didn’t have a way to get rid of extra body heat, our temperatures would keep on climbing. Strenuous exercise would raise the body temperature by about 2 degrees every five minutes, reaching fatal levels in only about 20 minutes.
We get rid of extra heat by radiating it to the cooler surrounding environment, by evaporating extra fluid, and by letting air currents carry it away through convection.
If the surrounding air temperature is hot, if the air is not moving, and if the person is getting dehydrated, heat becomes dangerous.

Who gets heat stroke?

The smaller the child, the less likely he is to be able to tolerate heat, especially if he is already a bit dehydrated or has a fever, and if there is poor air circulation.
Heat injuries can occur at any age. Sports and physical activity are generally beneficial and healthy for adolescents; nevertheless, heat injuries are among the leading causes of sports deaths.
People who have a prior history of heat injury, who are taking medicines or drugs (including antihistamines, Ritalin, thyroid hormone, some colic medicines, bed-wetting medicines, diuretics, or laxatives), or who have underlying illnesses (such as diabetes, cystic fibrosis, vomiting, diarrhea, bronchiolitis, or a variety of skin disorders) are at higher risk.

What are the symptoms of heat stroke?

Children’s skin can be quite sensitive to heat. Nursing mom’s often discover this, especially in the summertime, when their baby’s face turns red where it is against the mother’s skin. This redness comes from blood vessels in the area dilating to cool the skin down. Cooling the skin usually makes the rash disappear within hours, or even sooner. Prickly heat (miliaria rubra) is a type of heat rash that lasts.
Heat cramps are common with physical exertion. They usually affect the calf or hamstring muscles.
Heat syncope is fainting due to heat/dehydration.
Heat edema is swelling of the hands or feet from heat. People sometimes get this condition when initially exposed to hot weather.
Heat tetany is tingling, especially of the wrists. Hyperventilation in hot weather can cause heat tetany.
Heat exhaustion usually entails a body temperature of 101 to 104, headache, nausea, vomiting, dizziness, and fainting. It is important to recognize and treat heat exhaustion immediately.
Heat stroke is very serious. A person’s temperature rises over 104 degrees and he or she has an altered mental status. 50 percent of those with heat stroke die from it. There are two types of heat stroke: exertional, with profuse sweating; and classic, in which the skin is hot and dry. Classic heat stroke builds up over days and is most common in infants and in the elderly. It is a true emergency.

Is heat stroke contagious?

Although the desire to appear “tough” on a sports team can be contagious, heat injuries themselves are not contagious.

How long does heat stroke last?

Heat injuries generally last until the body temperature and fluids have been corrected, and any complications treated.

How is heat stroke diagnosed?

The diagnosis is suspected by paying close attention to temperature, airflow, exertion, and hydration. Watching for early symptoms is the key to prompt diagnosis.

How is heat stroke treated?

Heat cramps usually respond to gentle stretching and to re-hydration, especially with an electrolyte solution.
Heat syncope usually responds to cooling (a sponge bath), lying down, and drinking fluids.
Heat edema often goes away on its own, as the person adjusts to the heat.
Heat exhaustion is an emergency. Treatment includes cooling, fans, drinking liquids, and applying ice over the groin and armpits. People typically respond well but prompt treatment is necessary in order to prevent the condition from progressing to heat stroke where treatment may no longer be effective.
Heat stroke is very serious. Call 911. Initial attention should be paid to basic CPR (airway, breathing, and circulation). Aggressive cooling is important, with cooling fans and ice. The patient needs liquids as soon as possible, preferably IV fluids.

How can heat stroke be prevented?

Heat injuries can be prevented. Ensuring good hydration and air circulation are vital. Children should never be left alone in a car. Take care when spending time outdoors in the hot sun.
Children should drink before exercise or sports, and every 20 minutes throughout. Cool liquids are better than warm. Water is fine for exercise up to an hour, but electrolyte solutions are better for exercise that is more strenuous. Keep in mind that most children will not drink this frequently on their own while playing or exercising – they need frequent reminders to ensure that they stay well hydrated.
Lightweight clothes that breathe are preferable, and athletes should have time out of helmets at least every 30 minutes.

Related A-to-Z Information:

Dehydration, Diarrhea, Headache, Miliaria, Vomiting

One of my college roommates met a tragic early death from malignant melanoma. He was a sports enthusiast who frequently spent hours unprotected in the sun — he always had a tan. Unfortunately, he’s not alone.

The risk of developing malignant melanoma has more than tripled since 1980 — from one in 250 to one in 71. A person dies every hour from melanoma in the US. Skin cancer was once a disease of the middle-aged and elderly, but it is becoming a disease of people in their 20′s and 30′s.

The skin damage that will result in melanoma most often happens during childhood — but kids have a hard time imagining 20 years in the future. It’s our job as parents to protect them by applying sun block 20 minutes before they are in the sun, reapplying the sun block every 80 minutes if they have gotten wet or sweaty, and avoiding prolonged sun exposure during the hours of peak sun intensity. And who would have guessed, when we were kids, that a cool hat could be a lifesaving gift for our kids!

Even though skin cancer occurs in adults, the serious skin cancers are caused by the radiation damage (particularly the sunburns) that occurred in our youth. Children are at the highest risk for sun damage, and more than half of a lifetime’s sun exposure usually happens during childhood.

1. Try to avoid the sun’s most intense rays by staying out of the sun during the middle of the day — and don’t be lulled into complacency by overcast days, since most of the sun’s harmful rays will get through the clouds.
2. Keep babies younger than 6 months out of direct sunlight. Shade can be found under a tree, umbrella, or the stroller.
3. Be especially careful if you are around water, sand, snow, or any surface that will reflect and therefore intensify the sun’s rays. Remember, the sun’s rays are more intense the higher you get in elevation.
4. When purchasing sunscreen, select a PABA-free brand with an SPF of at least 15, preferably greater. Choose a sunscreen that says “broad-spectrum” on the label – this means it will provide protection against both UVA and UVB rays.
5. In general, infants’ skin is much thinner and more sensitive to the sun than adults’ skin, even in individuals with darker complexions. The amount of sunscreen needed depends on how light the child’s complexion is. I would recommend using sunscreen with an SPF of at least 30 for very fair-skinned children.
6. The AAP used to recommend not putting sunscreen on infants under six months of age. This is no longer the case, because the danger from sunburns outweighs the risk of sensitivity to sunscreens. For babies younger than 6 monhts, use sunscreen on small areas of the body, such as the face and the backs of the hands.
7. Sunscreen is most effective if first applied 20-30 minutes before sun exposure.
8. Use sunscreen whenever you expect to be in the sun for thirty minutes or more, and re-apply after swimming.
9. Even waterproof sunscreens should be re-applied every 80 minutes or so, after being in the water.
10. Make effective use of clothing, hats, and other physical barriers to protect the skin from the sun.