Melanoma

WAILEA, HAWAII – In a video interview, Pedram Gerami, MD, professor of dermatology, pathology, and pediatrics, Northwestern University, Chicago, discusses the use of molecular testing for melanoma and suspicious lesions.

Molecular tests are available for various components of diagnosis and prognosis of melanoma, and one of the most popular scenarios for their use is to confirm a diagnosis if a lesion is biopsied and the histopathologist “feels that the diagnosis is ambiguous by standard pathology methods,” Dr. Gerami said in a video interview at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

On average, between 1% and 5% of cases of suspicious lesions may need molecular testing to confirm the diagnosis, he noted. Of the available options for molecular testing, FISH (fluorescence in situ hybridization) testing is the most validated in the setting of ambiguous histology, he said.

Dr. Gerami disclosed serving as a consultant and researcher for Castle Biosciences, Myriad Genetics, and DermTech.

SDEF and this news organization are owned by the same parent company.

WAILEA, HAWAII – In a video interview, Pedram Gerami, MD, professor of dermatology, pathology, and pediatrics, Northwestern University, Chicago, discusses the use of molecular testing for melanoma and suspicious lesions.

Molecular tests are available for various components of diagnosis and prognosis of melanoma, and one of the most popular scenarios for their use is to confirm a diagnosis if a lesion is biopsied and the histopathologist “feels that the diagnosis is ambiguous by standard pathology methods,” Dr. Gerami said in a video interview at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

On average, between 1% and 5% of cases of suspicious lesions may need molecular testing to confirm the diagnosis, he noted. Of the available options for molecular testing, FISH (fluorescence in situ hybridization) testing is the most validated in the setting of ambiguous histology, he said.

Dr. Gerami disclosed serving as a consultant and researcher for Castle Biosciences, Myriad Genetics, and DermTech.

SDEF and this news organization are owned by the same parent company.

WAILEA, HAWAII – In a video interview, Pedram Gerami, MD, professor of dermatology, pathology, and pediatrics, Northwestern University, Chicago, discusses the use of molecular testing for melanoma and suspicious lesions.

Molecular tests are available for various components of diagnosis and prognosis of melanoma, and one of the most popular scenarios for their use is to confirm a diagnosis if a lesion is biopsied and the histopathologist “feels that the diagnosis is ambiguous by standard pathology methods,” Dr. Gerami said in a video interview at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

On average, between 1% and 5% of cases of suspicious lesions may need molecular testing to confirm the diagnosis, he noted. Of the available options for molecular testing, FISH (fluorescence in situ hybridization) testing is the most validated in the setting of ambiguous histology, he said.

Dr. Gerami disclosed serving as a consultant and researcher for Castle Biosciences, Myriad Genetics, and DermTech.

SDEF and this news organization are owned by the same parent company.

Mohs micrographic surgery (MMS) remains the gold standard for the removal of skin cancers in high-risk areas of the body while offering an excellent safety profile and sparing tissue.¹ In the current health care environment, online patient reviews have grown in popularity and influence. More than 60% of consumers consult social media before making health care decisions.² A recent analysis of online patient reviews of general dermatology practices demonstrated the perceived importance of physician empathy, thoroughness, and cognizance of cost in relation to patient-reported satisfaction.³ Because MMS is a well-recognized and unique outpatient-based surgical procedure, a review and analysis of online patient reviews specific to MMS can provide useful practice insights.

Materials and Methods

This study was conducted using an online platform (RealSelf [http://www.realself.com]) that connects patients and providers offering aesthetically oriented procedures; the site has 35 million unique visitors yearly.⁴ The community’s directory was used to identify and analyze all cumulative patient reviews from 2006 to December 20, 2015, using the search terms Mohs surgery or Mohs micrographic surgery. The study was exempt by the Northwestern University (Chicago, Illinois) institutional review board.

A standardized qualitative coding methodology was created and applied to all available comments regarding MMS. A broad list of positive and negative patient experiences was first created and agreed upon by all 3 investigators. Each individual comment was then attributed to 1 or more of these positive or negative themes. Of these comments, 10% were coded by 2 investigators (S.X. and Z.A.) to ensure internal validity; 1 investigator coded the remaining statements by patients (Z.A.). Patient-reported satisfaction ratings categorized as “worth it” or “not worth it” (as used by RealSelf to describe the patient-perceived value and utility of a given procedure) as well as cost of MMS were gathered. Cumulative patient ratings were collected for the procedure overall, physician’s bedside manner, answered questions, aftercare follow-up, time spent with patients, telephone/email responsiveness, staff professionalism/courtesy, payment process, and wait times. Patient-reported characteristics of MMS also were evaluated including physician specialty, lesion location, type of skin cancer, and type of closure. For lesion location, we graded whether the location represented a high-risk area as defined by the American Academy of Dermatology, American College of Mohs Surgery, and American Society for Dermatologic Surgery.⁵

Results

A total of 219 reviews related to MMS were collected as of December 20, 2015. Overall, MMS was considered “worth it” by 89% of patients (Table 1). Only 2% of patients described MMS as “not worth it.” There was a wide range reported for the cost of the procedure ($1–$100,000 [median, $1800]). Of those patients who reported their sex, females were 2.5-times more likely to post a review compared to males (51% vs 20%); however, 30% of reviewers did not report their sex. The mean (standard deviation) overall satisfaction rating was 4.8 (0.8). With regard to category-specific ratings (eg, bedside manner, aftercare follow-up, time spent with patients), the mean scores were all 4.7 or greater (Table 2).

Regarding the surgical aspects of the procedure, the majority of patients reported that the excision of the lesion was performed by a dermatologist (62%). However, a notable portion of patients reported that the excision was performed by a plastic surgeon (21%). Physician specialty was not reported in 16% of the reviews. For the lesion closure, the patient-reported specialty of the physician was only slightly higher for dermatologists versus plastic surgeons (46% vs 44%)(Table 3).

The majority of patients who reported the location of the lesion treated with MMS identified a high-risk location (45%), a medium-risk location (18%), or an unspecified region of the face (15%), according to the appropriate-use criteria for MMS (Table 3).⁵ Patients did not specify the site of surgery 17% of the time. Only 5% of reported procedures were performed on low-risk areas.

Basal cell carcinomas were the most commonly reported lesions removed by MMS (38%), though 48% of reviews did not specify the type of tumor being treated (Table 3). A large majority (76%) did not specify the type of closure performed. When specified, secondary intention was used 10% of the time, followed by either a flap (6%) or skin graft (6%). Only 5% of patients reported an estimated size of the primary lesion in our study (data not shown).

The qualitative analysis demonstrated variance in themes for positive and negative characteristics (Table 4). Surgeon characteristics encompassed the 3 most commonly cited themes of positive remarks, including bedside manner (78%), communication skills (74%), and perceived expertise (58%). Specific to MMS, the tissue-sparing nature of the technique was cited by 14% of reviews as a positive theme. The most commonly cited themes of negative remarks were intraoperative and postoperative concerns, including postoperative disfigurement (16%), large scar (9%), healing time (9%), and procedural or postoperative pain (8%). A subtheme analysis of postoperative disfigurement revealed that eyelid or eyebrow distortion was the most common concern (29%), followed by redness and swelling (23%), an open wound (14%), and nostril/nose distortion (14%)(data not shown). Themes not commonly cited as either positive or negative included office environment, cost, and procedure time (data not shown).

Comment

The overall satisfaction with MMS (89%) was one of the highest for any procedure on this online patient review site, albeit based on fewer reviews compared to other common aesthetic surgical procedures. In comparison, 78% of 13,500 reviewers rated breast augmentation as “worth it,” while 60% of 6800 reviewers rated rhinoplasty as “worth it” (as of December 2015). Overall, the online patient reviews evaluated in this study were consistent with a previously published structured data report on patient satisfaction with MMS.⁶

The results show a greater than expected proportion of both the MMS excision and closure being performed by plastic surgeons compared to dermatologists. In reality, the majority of MMS excisions are performed by dermatologists. Based on a survey of American College of Mohs Surgery (ACMS) members, only 6% of procedures were sent to other specialties for closure.⁷ Our results may reflect reporting bias or patients misconstruing true MMS with an excision and standard frozen sections, techniques that have lower cure rates. If so, there may be a need to educate patients regarding the specifics of MMS. Other possible explanations for the discrepancy between the online patient reviews and ACMS data include misinterpretation by patients on the exact definition of MMS or that a higher than expected number of procedures were performed by non-ACMS Mohs surgeons.

Our qualitative analysis revealed that patients most frequently commented on the interpersonal skills of their surgeons (eg, bedside manner, communication) as positive themes during MMS, similar to prior analyses of general dermatology practices.³ In comparison to a recent study assessing patient satisfaction with rhinoplasty on RealSelf, the final appearance of the nose represented the most common positive- and negative-cited theme.⁸ Mohs micrographic surgery procedures typically are done under local anesthesia, which may explain the greater importance of bedside manner and communication intraoperatively in comparison to final surgical outcomes for patient satisfaction. For negative themes, 3 of 4 most common concerns were directly related to the intraoperative and postoperative periods. Providers may be able to improve patient satisfaction by explaining the postoperative course, such as healing time and temporary physical restrictions, as well as possible sequelae in greater detail, which may be particularly pertinent for MMS involving the nose or near the eyes.

The global ratings for MMS are high, as shown in our data set of patient reviews; however, patient reviews are highly susceptible to reporting bias, recall bias, and missing information. Prior work using this online patient review website to investigate laser and light procedures also demonstrated the risk for imperfect information associated with patient reviews.⁹ Even so, the data does provide a glimpse into what is considered important to patients. Surgeon interpersonal skills and communication were the most frequently cited positive themes for MMS. The best surgical aspects of MMS focused on the unique tissue-sparing nature of the procedure and the removal of a cancerous lesion. Potential areas for improvement include a more thorough explanation of the intraoperative and postoperative process, specifically potential asymmetry related to the nose or the eyes, healing time, and scarring. These patient reviews underscore the importance of setting appropriate patient expectations. As patients become more connected and utilize online platforms to report their experiences, Mohs surgeons can take insights derived from online patient reviews for their own practice or geographic area to improve satisfaction and manage expectations.

Mohs micrographic surgery (MMS) remains the gold standard for the removal of skin cancers in high-risk areas of the body while offering an excellent safety profile and sparing tissue.¹ In the current health care environment, online patient reviews have grown in popularity and influence. More than 60% of consumers consult social media before making health care decisions.² A recent analysis of online patient reviews of general dermatology practices demonstrated the perceived importance of physician empathy, thoroughness, and cognizance of cost in relation to patient-reported satisfaction.³ Because MMS is a well-recognized and unique outpatient-based surgical procedure, a review and analysis of online patient reviews specific to MMS can provide useful practice insights.

Materials and Methods

This study was conducted using an online platform (RealSelf [http://www.realself.com]) that connects patients and providers offering aesthetically oriented procedures; the site has 35 million unique visitors yearly.⁴ The community’s directory was used to identify and analyze all cumulative patient reviews from 2006 to December 20, 2015, using the search terms Mohs surgery or Mohs micrographic surgery. The study was exempt by the Northwestern University (Chicago, Illinois) institutional review board.

A standardized qualitative coding methodology was created and applied to all available comments regarding MMS. A broad list of positive and negative patient experiences was first created and agreed upon by all 3 investigators. Each individual comment was then attributed to 1 or more of these positive or negative themes. Of these comments, 10% were coded by 2 investigators (S.X. and Z.A.) to ensure internal validity; 1 investigator coded the remaining statements by patients (Z.A.). Patient-reported satisfaction ratings categorized as “worth it” or “not worth it” (as used by RealSelf to describe the patient-perceived value and utility of a given procedure) as well as cost of MMS were gathered. Cumulative patient ratings were collected for the procedure overall, physician’s bedside manner, answered questions, aftercare follow-up, time spent with patients, telephone/email responsiveness, staff professionalism/courtesy, payment process, and wait times. Patient-reported characteristics of MMS also were evaluated including physician specialty, lesion location, type of skin cancer, and type of closure. For lesion location, we graded whether the location represented a high-risk area as defined by the American Academy of Dermatology, American College of Mohs Surgery, and American Society for Dermatologic Surgery.⁵

Results

A total of 219 reviews related to MMS were collected as of December 20, 2015. Overall, MMS was considered “worth it” by 89% of patients (Table 1). Only 2% of patients described MMS as “not worth it.” There was a wide range reported for the cost of the procedure ($1–$100,000 [median, $1800]). Of those patients who reported their sex, females were 2.5-times more likely to post a review compared to males (51% vs 20%); however, 30% of reviewers did not report their sex. The mean (standard deviation) overall satisfaction rating was 4.8 (0.8). With regard to category-specific ratings (eg, bedside manner, aftercare follow-up, time spent with patients), the mean scores were all 4.7 or greater (Table 2).

Regarding the surgical aspects of the procedure, the majority of patients reported that the excision of the lesion was performed by a dermatologist (62%). However, a notable portion of patients reported that the excision was performed by a plastic surgeon (21%). Physician specialty was not reported in 16% of the reviews. For the lesion closure, the patient-reported specialty of the physician was only slightly higher for dermatologists versus plastic surgeons (46% vs 44%)(Table 3).

The majority of patients who reported the location of the lesion treated with MMS identified a high-risk location (45%), a medium-risk location (18%), or an unspecified region of the face (15%), according to the appropriate-use criteria for MMS (Table 3).⁵ Patients did not specify the site of surgery 17% of the time. Only 5% of reported procedures were performed on low-risk areas.

Basal cell carcinomas were the most commonly reported lesions removed by MMS (38%), though 48% of reviews did not specify the type of tumor being treated (Table 3). A large majority (76%) did not specify the type of closure performed. When specified, secondary intention was used 10% of the time, followed by either a flap (6%) or skin graft (6%). Only 5% of patients reported an estimated size of the primary lesion in our study (data not shown).

The qualitative analysis demonstrated variance in themes for positive and negative characteristics (Table 4). Surgeon characteristics encompassed the 3 most commonly cited themes of positive remarks, including bedside manner (78%), communication skills (74%), and perceived expertise (58%). Specific to MMS, the tissue-sparing nature of the technique was cited by 14% of reviews as a positive theme. The most commonly cited themes of negative remarks were intraoperative and postoperative concerns, including postoperative disfigurement (16%), large scar (9%), healing time (9%), and procedural or postoperative pain (8%). A subtheme analysis of postoperative disfigurement revealed that eyelid or eyebrow distortion was the most common concern (29%), followed by redness and swelling (23%), an open wound (14%), and nostril/nose distortion (14%)(data not shown). Themes not commonly cited as either positive or negative included office environment, cost, and procedure time (data not shown).

Comment

The overall satisfaction with MMS (89%) was one of the highest for any procedure on this online patient review site, albeit based on fewer reviews compared to other common aesthetic surgical procedures. In comparison, 78% of 13,500 reviewers rated breast augmentation as “worth it,” while 60% of 6800 reviewers rated rhinoplasty as “worth it” (as of December 2015). Overall, the online patient reviews evaluated in this study were consistent with a previously published structured data report on patient satisfaction with MMS.⁶

The results show a greater than expected proportion of both the MMS excision and closure being performed by plastic surgeons compared to dermatologists. In reality, the majority of MMS excisions are performed by dermatologists. Based on a survey of American College of Mohs Surgery (ACMS) members, only 6% of procedures were sent to other specialties for closure.⁷ Our results may reflect reporting bias or patients misconstruing true MMS with an excision and standard frozen sections, techniques that have lower cure rates. If so, there may be a need to educate patients regarding the specifics of MMS. Other possible explanations for the discrepancy between the online patient reviews and ACMS data include misinterpretation by patients on the exact definition of MMS or that a higher than expected number of procedures were performed by non-ACMS Mohs surgeons.

Our qualitative analysis revealed that patients most frequently commented on the interpersonal skills of their surgeons (eg, bedside manner, communication) as positive themes during MMS, similar to prior analyses of general dermatology practices.³ In comparison to a recent study assessing patient satisfaction with rhinoplasty on RealSelf, the final appearance of the nose represented the most common positive- and negative-cited theme.⁸ Mohs micrographic surgery procedures typically are done under local anesthesia, which may explain the greater importance of bedside manner and communication intraoperatively in comparison to final surgical outcomes for patient satisfaction. For negative themes, 3 of 4 most common concerns were directly related to the intraoperative and postoperative periods. Providers may be able to improve patient satisfaction by explaining the postoperative course, such as healing time and temporary physical restrictions, as well as possible sequelae in greater detail, which may be particularly pertinent for MMS involving the nose or near the eyes.

The global ratings for MMS are high, as shown in our data set of patient reviews; however, patient reviews are highly susceptible to reporting bias, recall bias, and missing information. Prior work using this online patient review website to investigate laser and light procedures also demonstrated the risk for imperfect information associated with patient reviews.⁹ Even so, the data does provide a glimpse into what is considered important to patients. Surgeon interpersonal skills and communication were the most frequently cited positive themes for MMS. The best surgical aspects of MMS focused on the unique tissue-sparing nature of the procedure and the removal of a cancerous lesion. Potential areas for improvement include a more thorough explanation of the intraoperative and postoperative process, specifically potential asymmetry related to the nose or the eyes, healing time, and scarring. These patient reviews underscore the importance of setting appropriate patient expectations. As patients become more connected and utilize online platforms to report their experiences, Mohs surgeons can take insights derived from online patient reviews for their own practice or geographic area to improve satisfaction and manage expectations.

Mohs micrographic surgery (MMS) remains the gold standard for the removal of skin cancers in high-risk areas of the body while offering an excellent safety profile and sparing tissue.¹ In the current health care environment, online patient reviews have grown in popularity and influence. More than 60% of consumers consult social media before making health care decisions.² A recent analysis of online patient reviews of general dermatology practices demonstrated the perceived importance of physician empathy, thoroughness, and cognizance of cost in relation to patient-reported satisfaction.³ Because MMS is a well-recognized and unique outpatient-based surgical procedure, a review and analysis of online patient reviews specific to MMS can provide useful practice insights.

Materials and Methods

This study was conducted using an online platform (RealSelf [http://www.realself.com]) that connects patients and providers offering aesthetically oriented procedures; the site has 35 million unique visitors yearly.⁴ The community’s directory was used to identify and analyze all cumulative patient reviews from 2006 to December 20, 2015, using the search terms Mohs surgery or Mohs micrographic surgery. The study was exempt by the Northwestern University (Chicago, Illinois) institutional review board.

A standardized qualitative coding methodology was created and applied to all available comments regarding MMS. A broad list of positive and negative patient experiences was first created and agreed upon by all 3 investigators. Each individual comment was then attributed to 1 or more of these positive or negative themes. Of these comments, 10% were coded by 2 investigators (S.X. and Z.A.) to ensure internal validity; 1 investigator coded the remaining statements by patients (Z.A.). Patient-reported satisfaction ratings categorized as “worth it” or “not worth it” (as used by RealSelf to describe the patient-perceived value and utility of a given procedure) as well as cost of MMS were gathered. Cumulative patient ratings were collected for the procedure overall, physician’s bedside manner, answered questions, aftercare follow-up, time spent with patients, telephone/email responsiveness, staff professionalism/courtesy, payment process, and wait times. Patient-reported characteristics of MMS also were evaluated including physician specialty, lesion location, type of skin cancer, and type of closure. For lesion location, we graded whether the location represented a high-risk area as defined by the American Academy of Dermatology, American College of Mohs Surgery, and American Society for Dermatologic Surgery.⁵

Results

A total of 219 reviews related to MMS were collected as of December 20, 2015. Overall, MMS was considered “worth it” by 89% of patients (Table 1). Only 2% of patients described MMS as “not worth it.” There was a wide range reported for the cost of the procedure ($1–$100,000 [median, $1800]). Of those patients who reported their sex, females were 2.5-times more likely to post a review compared to males (51% vs 20%); however, 30% of reviewers did not report their sex. The mean (standard deviation) overall satisfaction rating was 4.8 (0.8). With regard to category-specific ratings (eg, bedside manner, aftercare follow-up, time spent with patients), the mean scores were all 4.7 or greater (Table 2).

Regarding the surgical aspects of the procedure, the majority of patients reported that the excision of the lesion was performed by a dermatologist (62%). However, a notable portion of patients reported that the excision was performed by a plastic surgeon (21%). Physician specialty was not reported in 16% of the reviews. For the lesion closure, the patient-reported specialty of the physician was only slightly higher for dermatologists versus plastic surgeons (46% vs 44%)(Table 3).

The majority of patients who reported the location of the lesion treated with MMS identified a high-risk location (45%), a medium-risk location (18%), or an unspecified region of the face (15%), according to the appropriate-use criteria for MMS (Table 3).⁵ Patients did not specify the site of surgery 17% of the time. Only 5% of reported procedures were performed on low-risk areas.

Basal cell carcinomas were the most commonly reported lesions removed by MMS (38%), though 48% of reviews did not specify the type of tumor being treated (Table 3). A large majority (76%) did not specify the type of closure performed. When specified, secondary intention was used 10% of the time, followed by either a flap (6%) or skin graft (6%). Only 5% of patients reported an estimated size of the primary lesion in our study (data not shown).

The qualitative analysis demonstrated variance in themes for positive and negative characteristics (Table 4). Surgeon characteristics encompassed the 3 most commonly cited themes of positive remarks, including bedside manner (78%), communication skills (74%), and perceived expertise (58%). Specific to MMS, the tissue-sparing nature of the technique was cited by 14% of reviews as a positive theme. The most commonly cited themes of negative remarks were intraoperative and postoperative concerns, including postoperative disfigurement (16%), large scar (9%), healing time (9%), and procedural or postoperative pain (8%). A subtheme analysis of postoperative disfigurement revealed that eyelid or eyebrow distortion was the most common concern (29%), followed by redness and swelling (23%), an open wound (14%), and nostril/nose distortion (14%)(data not shown). Themes not commonly cited as either positive or negative included office environment, cost, and procedure time (data not shown).

Comment

The overall satisfaction with MMS (89%) was one of the highest for any procedure on this online patient review site, albeit based on fewer reviews compared to other common aesthetic surgical procedures. In comparison, 78% of 13,500 reviewers rated breast augmentation as “worth it,” while 60% of 6800 reviewers rated rhinoplasty as “worth it” (as of December 2015). Overall, the online patient reviews evaluated in this study were consistent with a previously published structured data report on patient satisfaction with MMS.⁶

The results show a greater than expected proportion of both the MMS excision and closure being performed by plastic surgeons compared to dermatologists. In reality, the majority of MMS excisions are performed by dermatologists. Based on a survey of American College of Mohs Surgery (ACMS) members, only 6% of procedures were sent to other specialties for closure.⁷ Our results may reflect reporting bias or patients misconstruing true MMS with an excision and standard frozen sections, techniques that have lower cure rates. If so, there may be a need to educate patients regarding the specifics of MMS. Other possible explanations for the discrepancy between the online patient reviews and ACMS data include misinterpretation by patients on the exact definition of MMS or that a higher than expected number of procedures were performed by non-ACMS Mohs surgeons.

Our qualitative analysis revealed that patients most frequently commented on the interpersonal skills of their surgeons (eg, bedside manner, communication) as positive themes during MMS, similar to prior analyses of general dermatology practices.³ In comparison to a recent study assessing patient satisfaction with rhinoplasty on RealSelf, the final appearance of the nose represented the most common positive- and negative-cited theme.⁸ Mohs micrographic surgery procedures typically are done under local anesthesia, which may explain the greater importance of bedside manner and communication intraoperatively in comparison to final surgical outcomes for patient satisfaction. For negative themes, 3 of 4 most common concerns were directly related to the intraoperative and postoperative periods. Providers may be able to improve patient satisfaction by explaining the postoperative course, such as healing time and temporary physical restrictions, as well as possible sequelae in greater detail, which may be particularly pertinent for MMS involving the nose or near the eyes.

The global ratings for MMS are high, as shown in our data set of patient reviews; however, patient reviews are highly susceptible to reporting bias, recall bias, and missing information. Prior work using this online patient review website to investigate laser and light procedures also demonstrated the risk for imperfect information associated with patient reviews.⁹ Even so, the data does provide a glimpse into what is considered important to patients. Surgeon interpersonal skills and communication were the most frequently cited positive themes for MMS. The best surgical aspects of MMS focused on the unique tissue-sparing nature of the procedure and the removal of a cancerous lesion. Potential areas for improvement include a more thorough explanation of the intraoperative and postoperative process, specifically potential asymmetry related to the nose or the eyes, healing time, and scarring. These patient reviews underscore the importance of setting appropriate patient expectations. As patients become more connected and utilize online platforms to report their experiences, Mohs surgeons can take insights derived from online patient reviews for their own practice or geographic area to improve satisfaction and manage expectations.

WAILEA, HAWAII – The Eighth Edition of the American Joint Committee on Cancer Staging Manual includes significant changes in how melanoma is classified.

The manual has already been published and is available for purchase. However, its implementation will be delayed until Jan. 1, 2018, to give physicians, software vendors, and all other interested parties time to get up to speed. All cancers newly diagnosed through Dec. 31, 2017 should be staged in accord with the seventh edition, released in 2010.

Bruce Jancin/Frontline Medical News

SDEF and this news organization are owned by the same parent company.

[email protected]
 

WAILEA, HAWAII – The Eighth Edition of the American Joint Committee on Cancer Staging Manual includes significant changes in how melanoma is classified.

The manual has already been published and is available for purchase. However, its implementation will be delayed until Jan. 1, 2018, to give physicians, software vendors, and all other interested parties time to get up to speed. All cancers newly diagnosed through Dec. 31, 2017 should be staged in accord with the seventh edition, released in 2010.

Bruce Jancin/Frontline Medical News

SDEF and this news organization are owned by the same parent company.

[email protected]
 

WAILEA, HAWAII – The Eighth Edition of the American Joint Committee on Cancer Staging Manual includes significant changes in how melanoma is classified.

The manual has already been published and is available for purchase. However, its implementation will be delayed until Jan. 1, 2018, to give physicians, software vendors, and all other interested parties time to get up to speed. All cancers newly diagnosed through Dec. 31, 2017 should be staged in accord with the seventh edition, released in 2010.

Bruce Jancin/Frontline Medical News

SDEF and this news organization are owned by the same parent company.

[email protected]
 

Photoprotection is the foundation of all skin cancer prevention, as UV radiation (UVR) exposure is the only known modifiable risk factor for skin cancer. With the majority of UVR exposure–induced skin cancers found on the scalp, ears, face, and neck, public health initiatives call for wise choices in personal fashion that emphasize the importance of covering these areas.^1-3 From a science of fashion perspective, research has shown that wide-brimmed hats provide better means of ensuring the largest area of coverage compared to standard baseball-style hats.⁴ Thus, for maximum protection, wide-brimmed hats should be favored. However, in academic and military settings, individual style is not optional and is instead influenced or directed by policy, which may not be aligned with the goal of providing photoprotection and raises additional concern for individuals working in environments with longer periods of peak daylight UVR exposure.

In all military branches, service members don uniforms that include head coverage when operating outdoors; however, the choice of headgear is not always aimed at reducing UVR exposure. Similarly, in our counterpart civilian populations, wearing hats that provide the best photoprotection may be influenced by school policies, which frequently mandate clothing choices for children, or by the press or fashion industry in the general public, which might portray sun-protective garments as unfashionable or in some cases threatening if perceived as demonstrating gang affiliation.⁵ This article serves to encourage health care providers to not only discuss the use of sunscreen when educating patients on sun protection but also to emphasize the benefits of wearing photoprotective garments, particularly wide-brimmed hats given their simplicity, reusability, and affordability. Hat use is particularly important for men with comorbid androgenetic alopecia.⁶

Skin Cancer Risk

Unfortunately, the incidence of most common types of skin cancer, specifically nonmelanoma skin cancers such basal cell carcinomas and squamous cell carcinomas (ie, keratinocyte carcinomas [KCs]), is difficult to estimate properly, as these cases are not required to be reported to worldwide cancer registries. However, more than 5.4 million cases of skin cancers were diagnosed among 3.3 million Americans in 2016, with an estimated 13,650 deaths associated with skin cancers (not including KCs).³ Tracking and data analyses of cases diagnosed in the active and reserve component populations of the US Armed Forces reflect parallel findings.⁷ Keratinocyte carcinomas could be considered largely preventable, as most are the result of UVR exposure.¹ Additionally, it has been suggested that the vast majority of mutations in melanoma skin cancers (up to 86%) are caused by UVR exposure.⁸

Prevention

United States–based national public health services such as the American Cancer Society, the Centers for Disease Control and Prevention, and the American Academy of Dermatology embrace photoprotection as the central practice in reducing risk factors for skin cancers. Guidelines put forth by these and other national preventive medical institutions specifically recommend the use of wide-brimmed hats as the best option for protection of the face, head, ears, and neck, in addition to more common recommendations such as seeking shade, avoiding sunlight during peak hours of the day, and using sunscreen.^1-3 At state and local levels, policies should be adapted from these recommendations to support protective practices and skin cancer education that begins early for school-aged children. Unfortunately, in some school districts, wearing hats of any kind may be perceived as disruptive or in some cases baseball hats may be a sign of gang affiliation and are therefore banned in the schoolyard.⁵ The opposite is true in certain parts of the world where sun protection is embraced by the population as a whole, such as Australia where the widely accepted “slip, slop and slap, seek and slide” campaign has extended to some school policymakers who have considered adopting a “no hat, no play” policy.^9,10

Sunscreen use as a primary component of photoprotection has its disadvantages in comparison to wearing protective clothing, as sunscreen cannot be reused and proper usage requires reapplication after swimming, when sweating, and following 2 hours of application.^1-3 The need for reapplication of sunscreen can lead to considerable expense as well as time spent in application and reapplication. Additionally, for individuals who are physically active (eg, operationally engaged service members, outdoor athletes), sunscreen applied to the face may become a hindrance to function, as it may drip or enter the eyes with excessive sweating, possibly impairing vision. Some individuals may be averse to applying lotions or creams to the skin in general, as they do not prefer the textural changes or appearance of the skin after application. The application of sunscreen also could impair use of lifesaving military gear (eg, gas masks, helmets) from fitting or securing appropriately.

Patient Education

From a military perspective, a review of a recent targeted pilot study in which skin cancer patients at a US Veterans Administration hospital were surveyed on personal knowledge of UVR protection showed that respondents who had a history of skin cancer diagnosis did not feel that they had ever been at an increased risk for skin cancers and did not receive skin cancer prevention education during their tours of service. The overwhelming majority of all participants in this study agreed that the military should issue sun-protective clothing and sunscreen to active-duty personnel.¹¹ Another 2015 survey of 356 current US Air Force flight line personnel noted that active-duty service members tend not to use sunscreen when at work or while at home, and 43% of participants reported using no sun-protective methods while working outdoors.¹² Although these studies focused on military personal, the data mirror findings within the general public, as it was shown in a survey by the Centers for Disease Control and Prevention that Americans do not fully take advantage of the benefits of UVR protection, specifically with regard to sunscreen use. Little to no usage was correlated with low socioeconomic status, suggesting that a reusable form of protection could be preferred.¹³

Public health initiatives typically promote education on the use of sunscreen in populations that spend a considerable amount of time working outdoors (eg, construction workers, farmers, military personnel); however, we feel emphasis should be placed on the benefits of wearing hats, as the UVR exposure protection they provide does not wear off, is cost effective, does not require reapplication, and has the advantage of being a recyclable and affordable form of photoprotection.

History of the Military-Grade Wide-Brimmed Hat

One military-specific example of a sun-protective hat is the boonie hat, known at the time of its inception as the tropical or hot-weather hat, which first became popular during the Vietnam War. This hat option was initially proposed on April 7, 1966, when it was realized that a full-brimmed field hat was needed to protect soldiers’ faces and necks from rain and sun in harsh tropical climates.¹⁴ Unfortunately, despite the protective advantages of this style of head covering and favorable support from service members themselves, the boonie hat was not widely accepted, as commanders disliked its “unmilitary appearance.” Fervent protests by units throughout Vietnam eventually led to a compromise in policy that allowed unit-level commanders to authorize the use of boonie hats for units in combat or combat support field operations.¹⁴ Today, the boonie hat continues to garnish mixed emotions from unit commanders, as wearing this garment often is interpreted as not being in line with an appropriate military appearance, which is similar to the public fashion zeitgeist that also does not openly endorse the use of sun-protective garments. A change in fashion culture and policy (both military and civilian) that promotes sun-protective measures is needed.

Wide-Brimmed Hats Are Superior to Baseball Hats

The distribution of skin cancers across anatomic sites is consistent and proportional with the level and frequency of chronic UVR exposure, with the occurrence of most skin cancers being greatest on the nose, forehead/temples, cheeks/perioral areas, and ears.¹⁵ Additionally, higher incidences of skin cancers have been noted in chronically sun-exposed areas of the head and neck in men versus women. It is thought that hair distribution in these areas may be the causal factor.⁶

Baseball-style hats are worn by all branches of the US military as part of standard training and work duty uniform requirements, primarily for the sake of tradition by maintaining a standard appearance and uniform dress code but also to provide photoprotection to these vulnerable areas of the body. Standard, nonmilitary, baseball-style hats have been shown to provide UV protection factor (UPF) equivalents ranging from 2 to 10 on sites known for the highest levels of exposure.¹⁶ Military “patrol caps,” fashioned similar to the baseball-style hat but constructed from military-grade textiles, provide greater levels of photoprotection with UPF ratings from 35 to 50 and higher depending on the fabric color.¹⁷ Although patrol caps have a favorable UPF rating and are advantageous compared to former military headgear styles (eg, berets), wide-brimmed hats would provide greater overall coverage.^4,6 Studies in school environments also revealed that wide-brimmed hats come out ahead in side-by-side testing against baseball hats and are shown to provide greater photoprotection for the cheeks, chin, ears, and neck.¹⁶

Final Thoughts

The battle to educate the public about adequate photoprotection to prevent skin cancers caused by UVR exposure applies to all providers, both military and civilian. Our ongoing initiatives should not only sustain current practices but should further stress the importance of wearing wide-brimmed hats as a vital part of coverage of the skin and protection from UVR. We must combat the public perception that wearing wide-brimmed hats is a detractor of personal fashion and that instead it is desirable to reduce the risk for skin cancer. The wide-brimmed hat is a simple, reusable, and easily executed recommendation that should be made to all patients, both military and civilian, young and old. In conclusion, by improving patients’ perceptions and acknowledgment of the importance of photoprotection as well as making a concerted effort to integrate our knowledge in the fashion industry, in policies at schools, in the military, and in popular culture, we will undoubtedly come to agree that it is not unfashionable to wear a wide-brimmed hat, but it is unfashionable to risk developing skin cancer.

Photoprotection is the foundation of all skin cancer prevention, as UV radiation (UVR) exposure is the only known modifiable risk factor for skin cancer. With the majority of UVR exposure–induced skin cancers found on the scalp, ears, face, and neck, public health initiatives call for wise choices in personal fashion that emphasize the importance of covering these areas.^1-3 From a science of fashion perspective, research has shown that wide-brimmed hats provide better means of ensuring the largest area of coverage compared to standard baseball-style hats.⁴ Thus, for maximum protection, wide-brimmed hats should be favored. However, in academic and military settings, individual style is not optional and is instead influenced or directed by policy, which may not be aligned with the goal of providing photoprotection and raises additional concern for individuals working in environments with longer periods of peak daylight UVR exposure.

In all military branches, service members don uniforms that include head coverage when operating outdoors; however, the choice of headgear is not always aimed at reducing UVR exposure. Similarly, in our counterpart civilian populations, wearing hats that provide the best photoprotection may be influenced by school policies, which frequently mandate clothing choices for children, or by the press or fashion industry in the general public, which might portray sun-protective garments as unfashionable or in some cases threatening if perceived as demonstrating gang affiliation.⁵ This article serves to encourage health care providers to not only discuss the use of sunscreen when educating patients on sun protection but also to emphasize the benefits of wearing photoprotective garments, particularly wide-brimmed hats given their simplicity, reusability, and affordability. Hat use is particularly important for men with comorbid androgenetic alopecia.⁶

Skin Cancer Risk

Unfortunately, the incidence of most common types of skin cancer, specifically nonmelanoma skin cancers such basal cell carcinomas and squamous cell carcinomas (ie, keratinocyte carcinomas [KCs]), is difficult to estimate properly, as these cases are not required to be reported to worldwide cancer registries. However, more than 5.4 million cases of skin cancers were diagnosed among 3.3 million Americans in 2016, with an estimated 13,650 deaths associated with skin cancers (not including KCs).³ Tracking and data analyses of cases diagnosed in the active and reserve component populations of the US Armed Forces reflect parallel findings.⁷ Keratinocyte carcinomas could be considered largely preventable, as most are the result of UVR exposure.¹ Additionally, it has been suggested that the vast majority of mutations in melanoma skin cancers (up to 86%) are caused by UVR exposure.⁸

Prevention

United States–based national public health services such as the American Cancer Society, the Centers for Disease Control and Prevention, and the American Academy of Dermatology embrace photoprotection as the central practice in reducing risk factors for skin cancers. Guidelines put forth by these and other national preventive medical institutions specifically recommend the use of wide-brimmed hats as the best option for protection of the face, head, ears, and neck, in addition to more common recommendations such as seeking shade, avoiding sunlight during peak hours of the day, and using sunscreen.^1-3 At state and local levels, policies should be adapted from these recommendations to support protective practices and skin cancer education that begins early for school-aged children. Unfortunately, in some school districts, wearing hats of any kind may be perceived as disruptive or in some cases baseball hats may be a sign of gang affiliation and are therefore banned in the schoolyard.⁵ The opposite is true in certain parts of the world where sun protection is embraced by the population as a whole, such as Australia where the widely accepted “slip, slop and slap, seek and slide” campaign has extended to some school policymakers who have considered adopting a “no hat, no play” policy.^9,10

Sunscreen use as a primary component of photoprotection has its disadvantages in comparison to wearing protective clothing, as sunscreen cannot be reused and proper usage requires reapplication after swimming, when sweating, and following 2 hours of application.^1-3 The need for reapplication of sunscreen can lead to considerable expense as well as time spent in application and reapplication. Additionally, for individuals who are physically active (eg, operationally engaged service members, outdoor athletes), sunscreen applied to the face may become a hindrance to function, as it may drip or enter the eyes with excessive sweating, possibly impairing vision. Some individuals may be averse to applying lotions or creams to the skin in general, as they do not prefer the textural changes or appearance of the skin after application. The application of sunscreen also could impair use of lifesaving military gear (eg, gas masks, helmets) from fitting or securing appropriately.

Patient Education

From a military perspective, a review of a recent targeted pilot study in which skin cancer patients at a US Veterans Administration hospital were surveyed on personal knowledge of UVR protection showed that respondents who had a history of skin cancer diagnosis did not feel that they had ever been at an increased risk for skin cancers and did not receive skin cancer prevention education during their tours of service. The overwhelming majority of all participants in this study agreed that the military should issue sun-protective clothing and sunscreen to active-duty personnel.¹¹ Another 2015 survey of 356 current US Air Force flight line personnel noted that active-duty service members tend not to use sunscreen when at work or while at home, and 43% of participants reported using no sun-protective methods while working outdoors.¹² Although these studies focused on military personal, the data mirror findings within the general public, as it was shown in a survey by the Centers for Disease Control and Prevention that Americans do not fully take advantage of the benefits of UVR protection, specifically with regard to sunscreen use. Little to no usage was correlated with low socioeconomic status, suggesting that a reusable form of protection could be preferred.¹³

Public health initiatives typically promote education on the use of sunscreen in populations that spend a considerable amount of time working outdoors (eg, construction workers, farmers, military personnel); however, we feel emphasis should be placed on the benefits of wearing hats, as the UVR exposure protection they provide does not wear off, is cost effective, does not require reapplication, and has the advantage of being a recyclable and affordable form of photoprotection.

History of the Military-Grade Wide-Brimmed Hat

One military-specific example of a sun-protective hat is the boonie hat, known at the time of its inception as the tropical or hot-weather hat, which first became popular during the Vietnam War. This hat option was initially proposed on April 7, 1966, when it was realized that a full-brimmed field hat was needed to protect soldiers’ faces and necks from rain and sun in harsh tropical climates.¹⁴ Unfortunately, despite the protective advantages of this style of head covering and favorable support from service members themselves, the boonie hat was not widely accepted, as commanders disliked its “unmilitary appearance.” Fervent protests by units throughout Vietnam eventually led to a compromise in policy that allowed unit-level commanders to authorize the use of boonie hats for units in combat or combat support field operations.¹⁴ Today, the boonie hat continues to garnish mixed emotions from unit commanders, as wearing this garment often is interpreted as not being in line with an appropriate military appearance, which is similar to the public fashion zeitgeist that also does not openly endorse the use of sun-protective garments. A change in fashion culture and policy (both military and civilian) that promotes sun-protective measures is needed.

Wide-Brimmed Hats Are Superior to Baseball Hats

The distribution of skin cancers across anatomic sites is consistent and proportional with the level and frequency of chronic UVR exposure, with the occurrence of most skin cancers being greatest on the nose, forehead/temples, cheeks/perioral areas, and ears.¹⁵ Additionally, higher incidences of skin cancers have been noted in chronically sun-exposed areas of the head and neck in men versus women. It is thought that hair distribution in these areas may be the causal factor.⁶

Baseball-style hats are worn by all branches of the US military as part of standard training and work duty uniform requirements, primarily for the sake of tradition by maintaining a standard appearance and uniform dress code but also to provide photoprotection to these vulnerable areas of the body. Standard, nonmilitary, baseball-style hats have been shown to provide UV protection factor (UPF) equivalents ranging from 2 to 10 on sites known for the highest levels of exposure.¹⁶ Military “patrol caps,” fashioned similar to the baseball-style hat but constructed from military-grade textiles, provide greater levels of photoprotection with UPF ratings from 35 to 50 and higher depending on the fabric color.¹⁷ Although patrol caps have a favorable UPF rating and are advantageous compared to former military headgear styles (eg, berets), wide-brimmed hats would provide greater overall coverage.^4,6 Studies in school environments also revealed that wide-brimmed hats come out ahead in side-by-side testing against baseball hats and are shown to provide greater photoprotection for the cheeks, chin, ears, and neck.¹⁶

Final Thoughts

The battle to educate the public about adequate photoprotection to prevent skin cancers caused by UVR exposure applies to all providers, both military and civilian. Our ongoing initiatives should not only sustain current practices but should further stress the importance of wearing wide-brimmed hats as a vital part of coverage of the skin and protection from UVR. We must combat the public perception that wearing wide-brimmed hats is a detractor of personal fashion and that instead it is desirable to reduce the risk for skin cancer. The wide-brimmed hat is a simple, reusable, and easily executed recommendation that should be made to all patients, both military and civilian, young and old. In conclusion, by improving patients’ perceptions and acknowledgment of the importance of photoprotection as well as making a concerted effort to integrate our knowledge in the fashion industry, in policies at schools, in the military, and in popular culture, we will undoubtedly come to agree that it is not unfashionable to wear a wide-brimmed hat, but it is unfashionable to risk developing skin cancer.

Photoprotection is the foundation of all skin cancer prevention, as UV radiation (UVR) exposure is the only known modifiable risk factor for skin cancer. With the majority of UVR exposure–induced skin cancers found on the scalp, ears, face, and neck, public health initiatives call for wise choices in personal fashion that emphasize the importance of covering these areas.^1-3 From a science of fashion perspective, research has shown that wide-brimmed hats provide better means of ensuring the largest area of coverage compared to standard baseball-style hats.⁴ Thus, for maximum protection, wide-brimmed hats should be favored. However, in academic and military settings, individual style is not optional and is instead influenced or directed by policy, which may not be aligned with the goal of providing photoprotection and raises additional concern for individuals working in environments with longer periods of peak daylight UVR exposure.

In all military branches, service members don uniforms that include head coverage when operating outdoors; however, the choice of headgear is not always aimed at reducing UVR exposure. Similarly, in our counterpart civilian populations, wearing hats that provide the best photoprotection may be influenced by school policies, which frequently mandate clothing choices for children, or by the press or fashion industry in the general public, which might portray sun-protective garments as unfashionable or in some cases threatening if perceived as demonstrating gang affiliation.⁵ This article serves to encourage health care providers to not only discuss the use of sunscreen when educating patients on sun protection but also to emphasize the benefits of wearing photoprotective garments, particularly wide-brimmed hats given their simplicity, reusability, and affordability. Hat use is particularly important for men with comorbid androgenetic alopecia.⁶

Skin Cancer Risk

Unfortunately, the incidence of most common types of skin cancer, specifically nonmelanoma skin cancers such basal cell carcinomas and squamous cell carcinomas (ie, keratinocyte carcinomas [KCs]), is difficult to estimate properly, as these cases are not required to be reported to worldwide cancer registries. However, more than 5.4 million cases of skin cancers were diagnosed among 3.3 million Americans in 2016, with an estimated 13,650 deaths associated with skin cancers (not including KCs).³ Tracking and data analyses of cases diagnosed in the active and reserve component populations of the US Armed Forces reflect parallel findings.⁷ Keratinocyte carcinomas could be considered largely preventable, as most are the result of UVR exposure.¹ Additionally, it has been suggested that the vast majority of mutations in melanoma skin cancers (up to 86%) are caused by UVR exposure.⁸

Prevention

United States–based national public health services such as the American Cancer Society, the Centers for Disease Control and Prevention, and the American Academy of Dermatology embrace photoprotection as the central practice in reducing risk factors for skin cancers. Guidelines put forth by these and other national preventive medical institutions specifically recommend the use of wide-brimmed hats as the best option for protection of the face, head, ears, and neck, in addition to more common recommendations such as seeking shade, avoiding sunlight during peak hours of the day, and using sunscreen.^1-3 At state and local levels, policies should be adapted from these recommendations to support protective practices and skin cancer education that begins early for school-aged children. Unfortunately, in some school districts, wearing hats of any kind may be perceived as disruptive or in some cases baseball hats may be a sign of gang affiliation and are therefore banned in the schoolyard.⁵ The opposite is true in certain parts of the world where sun protection is embraced by the population as a whole, such as Australia where the widely accepted “slip, slop and slap, seek and slide” campaign has extended to some school policymakers who have considered adopting a “no hat, no play” policy.^9,10

Sunscreen use as a primary component of photoprotection has its disadvantages in comparison to wearing protective clothing, as sunscreen cannot be reused and proper usage requires reapplication after swimming, when sweating, and following 2 hours of application.^1-3 The need for reapplication of sunscreen can lead to considerable expense as well as time spent in application and reapplication. Additionally, for individuals who are physically active (eg, operationally engaged service members, outdoor athletes), sunscreen applied to the face may become a hindrance to function, as it may drip or enter the eyes with excessive sweating, possibly impairing vision. Some individuals may be averse to applying lotions or creams to the skin in general, as they do not prefer the textural changes or appearance of the skin after application. The application of sunscreen also could impair use of lifesaving military gear (eg, gas masks, helmets) from fitting or securing appropriately.

Patient Education

From a military perspective, a review of a recent targeted pilot study in which skin cancer patients at a US Veterans Administration hospital were surveyed on personal knowledge of UVR protection showed that respondents who had a history of skin cancer diagnosis did not feel that they had ever been at an increased risk for skin cancers and did not receive skin cancer prevention education during their tours of service. The overwhelming majority of all participants in this study agreed that the military should issue sun-protective clothing and sunscreen to active-duty personnel.¹¹ Another 2015 survey of 356 current US Air Force flight line personnel noted that active-duty service members tend not to use sunscreen when at work or while at home, and 43% of participants reported using no sun-protective methods while working outdoors.¹² Although these studies focused on military personal, the data mirror findings within the general public, as it was shown in a survey by the Centers for Disease Control and Prevention that Americans do not fully take advantage of the benefits of UVR protection, specifically with regard to sunscreen use. Little to no usage was correlated with low socioeconomic status, suggesting that a reusable form of protection could be preferred.¹³

Public health initiatives typically promote education on the use of sunscreen in populations that spend a considerable amount of time working outdoors (eg, construction workers, farmers, military personnel); however, we feel emphasis should be placed on the benefits of wearing hats, as the UVR exposure protection they provide does not wear off, is cost effective, does not require reapplication, and has the advantage of being a recyclable and affordable form of photoprotection.

History of the Military-Grade Wide-Brimmed Hat

One military-specific example of a sun-protective hat is the boonie hat, known at the time of its inception as the tropical or hot-weather hat, which first became popular during the Vietnam War. This hat option was initially proposed on April 7, 1966, when it was realized that a full-brimmed field hat was needed to protect soldiers’ faces and necks from rain and sun in harsh tropical climates.¹⁴ Unfortunately, despite the protective advantages of this style of head covering and favorable support from service members themselves, the boonie hat was not widely accepted, as commanders disliked its “unmilitary appearance.” Fervent protests by units throughout Vietnam eventually led to a compromise in policy that allowed unit-level commanders to authorize the use of boonie hats for units in combat or combat support field operations.¹⁴ Today, the boonie hat continues to garnish mixed emotions from unit commanders, as wearing this garment often is interpreted as not being in line with an appropriate military appearance, which is similar to the public fashion zeitgeist that also does not openly endorse the use of sun-protective garments. A change in fashion culture and policy (both military and civilian) that promotes sun-protective measures is needed.

Wide-Brimmed Hats Are Superior to Baseball Hats

The distribution of skin cancers across anatomic sites is consistent and proportional with the level and frequency of chronic UVR exposure, with the occurrence of most skin cancers being greatest on the nose, forehead/temples, cheeks/perioral areas, and ears.¹⁵ Additionally, higher incidences of skin cancers have been noted in chronically sun-exposed areas of the head and neck in men versus women. It is thought that hair distribution in these areas may be the causal factor.⁶

Baseball-style hats are worn by all branches of the US military as part of standard training and work duty uniform requirements, primarily for the sake of tradition by maintaining a standard appearance and uniform dress code but also to provide photoprotection to these vulnerable areas of the body. Standard, nonmilitary, baseball-style hats have been shown to provide UV protection factor (UPF) equivalents ranging from 2 to 10 on sites known for the highest levels of exposure.¹⁶ Military “patrol caps,” fashioned similar to the baseball-style hat but constructed from military-grade textiles, provide greater levels of photoprotection with UPF ratings from 35 to 50 and higher depending on the fabric color.¹⁷ Although patrol caps have a favorable UPF rating and are advantageous compared to former military headgear styles (eg, berets), wide-brimmed hats would provide greater overall coverage.^4,6 Studies in school environments also revealed that wide-brimmed hats come out ahead in side-by-side testing against baseball hats and are shown to provide greater photoprotection for the cheeks, chin, ears, and neck.¹⁶

Final Thoughts

The battle to educate the public about adequate photoprotection to prevent skin cancers caused by UVR exposure applies to all providers, both military and civilian. Our ongoing initiatives should not only sustain current practices but should further stress the importance of wearing wide-brimmed hats as a vital part of coverage of the skin and protection from UVR. We must combat the public perception that wearing wide-brimmed hats is a detractor of personal fashion and that instead it is desirable to reduce the risk for skin cancer. The wide-brimmed hat is a simple, reusable, and easily executed recommendation that should be made to all patients, both military and civilian, young and old. In conclusion, by improving patients’ perceptions and acknowledgment of the importance of photoprotection as well as making a concerted effort to integrate our knowledge in the fashion industry, in policies at schools, in the military, and in popular culture, we will undoubtedly come to agree that it is not unfashionable to wear a wide-brimmed hat, but it is unfashionable to risk developing skin cancer.

WAILEA, HAWAII – When sunscreens are tested for their SPF, testers apply 2 mg/cm², but most people use only 20%-50% of that amount, which significantly reduces their protection, according to Dr. Julie C. Harper, director of the Dermatology & Skin Care Center of Birmingham, Ala.

The correct amount is 1 teaspoon of sunscreen on the face/head/neck, 1 teaspoon on each arm, 2 teaspoons on the torso, and 2 teaspoons on each leg, Dr. Harper said in a presentation at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation. Reapplication every 90 minutes to 2 hours is key to effective protection, Dr. Harper said.

However, “most people use less than one bottle of sunscreen per year,” she noted.

Prompting patients to improve their sunscreen use involves disproving some myths, Dr. Harper pointed out. When patients cite concerns about low vitamin D as a reason to avoid sunscreens, she recommended that they be counseled that there are three sources of vitamin D: foods such as fatty fish, vitamin D fortified foods, cheese, and egg yolks; vitamin D supplements; and skin synthesis through UVB exposure; and that only one of these – UVB exposure – is a known carcinogen.

[email protected]

WAILEA, HAWAII – When sunscreens are tested for their SPF, testers apply 2 mg/cm², but most people use only 20%-50% of that amount, which significantly reduces their protection, according to Dr. Julie C. Harper, director of the Dermatology & Skin Care Center of Birmingham, Ala.

The correct amount is 1 teaspoon of sunscreen on the face/head/neck, 1 teaspoon on each arm, 2 teaspoons on the torso, and 2 teaspoons on each leg, Dr. Harper said in a presentation at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation. Reapplication every 90 minutes to 2 hours is key to effective protection, Dr. Harper said.

However, “most people use less than one bottle of sunscreen per year,” she noted.

Prompting patients to improve their sunscreen use involves disproving some myths, Dr. Harper pointed out. When patients cite concerns about low vitamin D as a reason to avoid sunscreens, she recommended that they be counseled that there are three sources of vitamin D: foods such as fatty fish, vitamin D fortified foods, cheese, and egg yolks; vitamin D supplements; and skin synthesis through UVB exposure; and that only one of these – UVB exposure – is a known carcinogen.

[email protected]

WAILEA, HAWAII – When sunscreens are tested for their SPF, testers apply 2 mg/cm², but most people use only 20%-50% of that amount, which significantly reduces their protection, according to Dr. Julie C. Harper, director of the Dermatology & Skin Care Center of Birmingham, Ala.

The correct amount is 1 teaspoon of sunscreen on the face/head/neck, 1 teaspoon on each arm, 2 teaspoons on the torso, and 2 teaspoons on each leg, Dr. Harper said in a presentation at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation. Reapplication every 90 minutes to 2 hours is key to effective protection, Dr. Harper said.

However, “most people use less than one bottle of sunscreen per year,” she noted.

Prompting patients to improve their sunscreen use involves disproving some myths, Dr. Harper pointed out. When patients cite concerns about low vitamin D as a reason to avoid sunscreens, she recommended that they be counseled that there are three sources of vitamin D: foods such as fatty fish, vitamin D fortified foods, cheese, and egg yolks; vitamin D supplements; and skin synthesis through UVB exposure; and that only one of these – UVB exposure – is a known carcinogen.

[email protected]

Gluten-free food products have inundated the marketplace in recent years as the food industry has responded to greater awareness of celiac sprue disease and wheat sensitivity. Gluten is the primary form of wheat protein.

Wheat is a versatile and globally popular member of the Poaceae or Gramineae family known as grasses; it is of the Triticum species with Triticum aestivum and Triticum vulgare being particularly pervasive.¹ In traditional Iranian medicine, the topical application of wheat germ oil has been used to treat psoriasis.²

Moisturization

In 2008, N. Akhtar and Y. Yazan investigated the effects of a stable emulsion containing two ingredients included to exert anti-aging effects: vitamin C and wheat protein. The antioxidant vitamin C was entrapped in the inner aqueous phase of the water-in-oil-in-water emulsion while wheat protein was incorporated in the oily phase. The investigators prepared and applied stable emulsions to the cheeks of 11 volunteers over 4 weeks, finding that the formulation increased skin moisture.⁷

Melanoma and wheat supplementation

Demidov et al. reported in 2008 on a randomized, pilot, phase II clinical trial to assess the impact of the adjuvant use of a fermented wheat germ extract nutraceutical (Avemar) in high-risk cutaneous melanoma patients. Investigators compared the efficacy of dacarbazine-based adjuvant chemotherapy on survival parameters of melanoma patients to that of the identical treatment supplemented with a 1-year administration of fermented wheat germ extract nutraceutical (FWGE), which is generally recognized as safe. They reported that after a 7-year follow-up, significant differences favoring the nutraceutical group were observed in progression-free and overall survival. Including nutraceutical as an adjuvant treatment for such patients was recommended by the authors.⁸

Telekes et al. noted that nutraceutical is registered as a special nutriment for cancer patients in Hungary that has exhibited potent anticancer activity on cell lines and immunomodulatory activity in vivo.⁹ In 2005, Boros et al. reported that orally administered FWGE suppressed metastatic tumor dissemination and proliferation during and after chemotherapy, surgery, or radiation, with benefits seen in some human cancers and cultured cells as well as some autoimmune disorders and in chemical carcinogenesis prevention.¹⁰

Hypersensitivity and allergic reactions

The risks of sensitization to topical wheat proteins are thought to be higher in patients with atopic dermatitis, who have an impaired skin barrier.¹ Indeed, Codreanu et al. have suggested that topical products containing food proteins of known allergenicity (including wheat) are contraindicated for neonates and infants with atopic dermatitis.¹¹

In 2015, Bonciolini et al. studied 17 patients (13 females and 4 males, median age 36 years) with nonceliac gluten sensitivity presenting with nonspecific skin lesions. The eczema-, psoriasis-, or dermatitis herpetiformis-like lesions on the extensor surfaces of the upper and lower limbs, especially, were confirmed histologically, but immunopathological evaluations revealed pervasive C3 deposits along the dermoepidermal junction in a microgranular/granular pattern (82%). Notably, all of the patients improved markedly after initiating a gluten-free diet.¹²

In 2014, Fukutomi et al. conducted a case-control study of Japanese women aged 20-54 years (157 cases) who self-reported wheat allergy to ascertain the epidemiologic relationship between food allergy to wheat after exposure to facial soaps containing hydrolyzed wheat protein. There were 449 age-matched controls without wheat allergy. Participants answered a Web-based questionnaire about their use of skin and hair care products. The investigators found that current use of the facial soap Cha no Shizuku (Drop of Tea), which contains hydrolyzed wheat protein, was significantly linked to a greater risk of wheat allergy, with use of the soap more frequent in consumers whose wheat allergy had newly emerged (11% vs. 6% in controls).¹³

Cha no Shizuku had earlier been implicated in provoking hundreds of cases of allergic reactions between 2009 and June 2013. R. Teshima noted that the soap contains acid-hydrolyzed wheat protein produced from gluten after partial hydrolysis with hydrogen chloride at 95 ° C for 40 minutes.¹⁴

It is worth noting that case reports of allergic reactions to facial soap containing hydrolyzed wheat protein continue to appear. Iseki et al. described in 2014 a 38-year-old woman who experienced irregular headaches, sleepiness, and an episode of facial rash eruption after daily use for about 1 year of a facial soap with hydrolyzed wheat proteins (Glupearl 19s, which is also used in Cha no Shizuku). The investigators added that the patient’s serum contained wheat-specific IgE antibodies. Symptoms disappeared after the patient abstained from wheat.¹⁵

In 2012, Tammaro studied cutaneous hypersensitivity to gluten in 14 female patients (aged 12-60 years) with celiac disease who presented with eczema on the face, neck, and arms, after topical application of gluten-containing emollient cream, bath or face powder, or contact with foods containing wheat and durum. Five of the patients tested positive for wheat and durum wheat, while none of the 14 control patients tested positive. Improvement in cutaneous lesions, with no relapses during a 6-month follow-up, resulted when these patients used gluten-free cream and bath powder, and wore gloves before handling wheat-containing food.¹⁶

In 2011, Celakovská et al. studied the impact of wheat allergy in 179 adults with atopic eczema (128 females, 51 males; average age 26 years), using open exposure and double-blind, placebo-controlled food challenge tests, as well as specific serum IgE, skin prick, and atopy patch tests. The double-blind, placebo-controlled food challenge test showed that the course of atopic eczema was exacerbated by wheat allergy in eight patients (4.5%). A positive trend revealing that the course of atopic eczema was impacted by wheat allergy emerged during follow-up (at 3, 6, 9, and 12 months).¹⁷

Contact urticaria also has been reported to have been induced by hydrolyzed wheat proteins in cosmetics and is notable for the potential to precede food allergies.^2,3 A wide variety of protein hydrolysates found in hair products have been associated with inducing contact urticaria, particularly in patients with atopic dermatitis.⁴

In 2006, Laurière et al. studied nine female patients without common wheat allergy who presented with contact urticaria to cosmetics containing hydrolyzed wheat proteins; six also had experienced generalized urticaria or anaphylaxis in response to foods containing such wheat proteins. Analyses revealed the importance of hydrolysis in augmenting the allergenicity of wheat proteins through contact or consumption.¹⁸ Immediate contact urticaria in reaction to hydrolyzed wheat protein in topical products also has been reported in a child.¹⁹

Conclusion

Can the presence of wheat hydrolysates in personal care products adversely affect a patient with celiac sprue or wheat sensitivity? The short answer appears to be “yes.” Given the use of hydrolyzed wheat protein in various skin care products, it is important that consumers who have celiac disease or sensitivity to wheat be advised to avoid skin care formulations with such active ingredients. On the positive side of the wheat ledger, there are some indications (albeit in very limited research) that the plant protein may impart beneficial health effects. Much more research is necessary to delineate the full impact of wheat on skin health.

I thank my dermatologist colleague Sharon E. Jacob, MD, at the University of Miami, for suggesting this topic.

References

1. Dermatitis. 2013 Nov-Dec;24(6):291-5.

2. Iran J Med Sci. 2016 May;41(3 Suppl):S54.

3. Contact Dermatitis. 2007 Feb;56(2):119-20.

4. Ann Dermatol Venereol. 2010 Apr;137(4):281-4.

5. Allergy. 1998 Nov;53(11):1078-82.

6. J Drugs Dermatol. 2013 Sep;12(9 Suppl):s133-6.

7. Pak J Pharm Sci. 2008 Jan;21(1):45-50.

8. Cancer Biother Radiopharm. 2008 Aug;23(4):477-82.

9. Nutr Cancer. 2009;61(6):891-9.

10. Ann N Y Acad Sci. 2005 Jun;1051:529-42.

11. Eur Ann Allergy Clin Immunol. 2006 Apr;38(4):126-30.

12. Nutrients. 2015 Sep 15;7(9):7798-805.

13. Allergy. 2014 Oct;69(10):1405-11.

14. Yakugaku Zasshi. 2014;134(1):33-8.

15. Intern Med. 2014;53(2):151-4.

16. Dermatitis. 2012 Sep-Oct;23(5):220-1.

17. Acta Medica (Hradec Kralove). 2011;54(4):157-62.

18. Contact Dermatitis. 2006 May;54(5):283-9.

19. Contact Dermatitis. 2013 Jun;68(6):379-80.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever. Dr. Baumann also developed and owns the Baumann Skin Type Solution skin typing systems and related products.

Gluten-free food products have inundated the marketplace in recent years as the food industry has responded to greater awareness of celiac sprue disease and wheat sensitivity. Gluten is the primary form of wheat protein.

Wheat is a versatile and globally popular member of the Poaceae or Gramineae family known as grasses; it is of the Triticum species with Triticum aestivum and Triticum vulgare being particularly pervasive.¹ In traditional Iranian medicine, the topical application of wheat germ oil has been used to treat psoriasis.²

Moisturization

In 2008, N. Akhtar and Y. Yazan investigated the effects of a stable emulsion containing two ingredients included to exert anti-aging effects: vitamin C and wheat protein. The antioxidant vitamin C was entrapped in the inner aqueous phase of the water-in-oil-in-water emulsion while wheat protein was incorporated in the oily phase. The investigators prepared and applied stable emulsions to the cheeks of 11 volunteers over 4 weeks, finding that the formulation increased skin moisture.⁷

Melanoma and wheat supplementation

Demidov et al. reported in 2008 on a randomized, pilot, phase II clinical trial to assess the impact of the adjuvant use of a fermented wheat germ extract nutraceutical (Avemar) in high-risk cutaneous melanoma patients. Investigators compared the efficacy of dacarbazine-based adjuvant chemotherapy on survival parameters of melanoma patients to that of the identical treatment supplemented with a 1-year administration of fermented wheat germ extract nutraceutical (FWGE), which is generally recognized as safe. They reported that after a 7-year follow-up, significant differences favoring the nutraceutical group were observed in progression-free and overall survival. Including nutraceutical as an adjuvant treatment for such patients was recommended by the authors.⁸

Telekes et al. noted that nutraceutical is registered as a special nutriment for cancer patients in Hungary that has exhibited potent anticancer activity on cell lines and immunomodulatory activity in vivo.⁹ In 2005, Boros et al. reported that orally administered FWGE suppressed metastatic tumor dissemination and proliferation during and after chemotherapy, surgery, or radiation, with benefits seen in some human cancers and cultured cells as well as some autoimmune disorders and in chemical carcinogenesis prevention.¹⁰

Hypersensitivity and allergic reactions

The risks of sensitization to topical wheat proteins are thought to be higher in patients with atopic dermatitis, who have an impaired skin barrier.¹ Indeed, Codreanu et al. have suggested that topical products containing food proteins of known allergenicity (including wheat) are contraindicated for neonates and infants with atopic dermatitis.¹¹

In 2015, Bonciolini et al. studied 17 patients (13 females and 4 males, median age 36 years) with nonceliac gluten sensitivity presenting with nonspecific skin lesions. The eczema-, psoriasis-, or dermatitis herpetiformis-like lesions on the extensor surfaces of the upper and lower limbs, especially, were confirmed histologically, but immunopathological evaluations revealed pervasive C3 deposits along the dermoepidermal junction in a microgranular/granular pattern (82%). Notably, all of the patients improved markedly after initiating a gluten-free diet.¹²

In 2014, Fukutomi et al. conducted a case-control study of Japanese women aged 20-54 years (157 cases) who self-reported wheat allergy to ascertain the epidemiologic relationship between food allergy to wheat after exposure to facial soaps containing hydrolyzed wheat protein. There were 449 age-matched controls without wheat allergy. Participants answered a Web-based questionnaire about their use of skin and hair care products. The investigators found that current use of the facial soap Cha no Shizuku (Drop of Tea), which contains hydrolyzed wheat protein, was significantly linked to a greater risk of wheat allergy, with use of the soap more frequent in consumers whose wheat allergy had newly emerged (11% vs. 6% in controls).¹³

Cha no Shizuku had earlier been implicated in provoking hundreds of cases of allergic reactions between 2009 and June 2013. R. Teshima noted that the soap contains acid-hydrolyzed wheat protein produced from gluten after partial hydrolysis with hydrogen chloride at 95 ° C for 40 minutes.¹⁴

It is worth noting that case reports of allergic reactions to facial soap containing hydrolyzed wheat protein continue to appear. Iseki et al. described in 2014 a 38-year-old woman who experienced irregular headaches, sleepiness, and an episode of facial rash eruption after daily use for about 1 year of a facial soap with hydrolyzed wheat proteins (Glupearl 19s, which is also used in Cha no Shizuku). The investigators added that the patient’s serum contained wheat-specific IgE antibodies. Symptoms disappeared after the patient abstained from wheat.¹⁵

In 2012, Tammaro studied cutaneous hypersensitivity to gluten in 14 female patients (aged 12-60 years) with celiac disease who presented with eczema on the face, neck, and arms, after topical application of gluten-containing emollient cream, bath or face powder, or contact with foods containing wheat and durum. Five of the patients tested positive for wheat and durum wheat, while none of the 14 control patients tested positive. Improvement in cutaneous lesions, with no relapses during a 6-month follow-up, resulted when these patients used gluten-free cream and bath powder, and wore gloves before handling wheat-containing food.¹⁶

In 2011, Celakovská et al. studied the impact of wheat allergy in 179 adults with atopic eczema (128 females, 51 males; average age 26 years), using open exposure and double-blind, placebo-controlled food challenge tests, as well as specific serum IgE, skin prick, and atopy patch tests. The double-blind, placebo-controlled food challenge test showed that the course of atopic eczema was exacerbated by wheat allergy in eight patients (4.5%). A positive trend revealing that the course of atopic eczema was impacted by wheat allergy emerged during follow-up (at 3, 6, 9, and 12 months).¹⁷

Contact urticaria also has been reported to have been induced by hydrolyzed wheat proteins in cosmetics and is notable for the potential to precede food allergies.^2,3 A wide variety of protein hydrolysates found in hair products have been associated with inducing contact urticaria, particularly in patients with atopic dermatitis.⁴

In 2006, Laurière et al. studied nine female patients without common wheat allergy who presented with contact urticaria to cosmetics containing hydrolyzed wheat proteins; six also had experienced generalized urticaria or anaphylaxis in response to foods containing such wheat proteins. Analyses revealed the importance of hydrolysis in augmenting the allergenicity of wheat proteins through contact or consumption.¹⁸ Immediate contact urticaria in reaction to hydrolyzed wheat protein in topical products also has been reported in a child.¹⁹

Conclusion

Can the presence of wheat hydrolysates in personal care products adversely affect a patient with celiac sprue or wheat sensitivity? The short answer appears to be “yes.” Given the use of hydrolyzed wheat protein in various skin care products, it is important that consumers who have celiac disease or sensitivity to wheat be advised to avoid skin care formulations with such active ingredients. On the positive side of the wheat ledger, there are some indications (albeit in very limited research) that the plant protein may impart beneficial health effects. Much more research is necessary to delineate the full impact of wheat on skin health.

I thank my dermatologist colleague Sharon E. Jacob, MD, at the University of Miami, for suggesting this topic.

References

1. Dermatitis. 2013 Nov-Dec;24(6):291-5.

2. Iran J Med Sci. 2016 May;41(3 Suppl):S54.

3. Contact Dermatitis. 2007 Feb;56(2):119-20.

4. Ann Dermatol Venereol. 2010 Apr;137(4):281-4.

5. Allergy. 1998 Nov;53(11):1078-82.

6. J Drugs Dermatol. 2013 Sep;12(9 Suppl):s133-6.

7. Pak J Pharm Sci. 2008 Jan;21(1):45-50.

8. Cancer Biother Radiopharm. 2008 Aug;23(4):477-82.

9. Nutr Cancer. 2009;61(6):891-9.

10. Ann N Y Acad Sci. 2005 Jun;1051:529-42.

11. Eur Ann Allergy Clin Immunol. 2006 Apr;38(4):126-30.

12. Nutrients. 2015 Sep 15;7(9):7798-805.

13. Allergy. 2014 Oct;69(10):1405-11.

14. Yakugaku Zasshi. 2014;134(1):33-8.

15. Intern Med. 2014;53(2):151-4.

16. Dermatitis. 2012 Sep-Oct;23(5):220-1.

17. Acta Medica (Hradec Kralove). 2011;54(4):157-62.

18. Contact Dermatitis. 2006 May;54(5):283-9.

19. Contact Dermatitis. 2013 Jun;68(6):379-80.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever. Dr. Baumann also developed and owns the Baumann Skin Type Solution skin typing systems and related products.

Gluten-free food products have inundated the marketplace in recent years as the food industry has responded to greater awareness of celiac sprue disease and wheat sensitivity. Gluten is the primary form of wheat protein.

Wheat is a versatile and globally popular member of the Poaceae or Gramineae family known as grasses; it is of the Triticum species with Triticum aestivum and Triticum vulgare being particularly pervasive.¹ In traditional Iranian medicine, the topical application of wheat germ oil has been used to treat psoriasis.²

Moisturization

In 2008, N. Akhtar and Y. Yazan investigated the effects of a stable emulsion containing two ingredients included to exert anti-aging effects: vitamin C and wheat protein. The antioxidant vitamin C was entrapped in the inner aqueous phase of the water-in-oil-in-water emulsion while wheat protein was incorporated in the oily phase. The investigators prepared and applied stable emulsions to the cheeks of 11 volunteers over 4 weeks, finding that the formulation increased skin moisture.⁷

Melanoma and wheat supplementation

Demidov et al. reported in 2008 on a randomized, pilot, phase II clinical trial to assess the impact of the adjuvant use of a fermented wheat germ extract nutraceutical (Avemar) in high-risk cutaneous melanoma patients. Investigators compared the efficacy of dacarbazine-based adjuvant chemotherapy on survival parameters of melanoma patients to that of the identical treatment supplemented with a 1-year administration of fermented wheat germ extract nutraceutical (FWGE), which is generally recognized as safe. They reported that after a 7-year follow-up, significant differences favoring the nutraceutical group were observed in progression-free and overall survival. Including nutraceutical as an adjuvant treatment for such patients was recommended by the authors.⁸

Telekes et al. noted that nutraceutical is registered as a special nutriment for cancer patients in Hungary that has exhibited potent anticancer activity on cell lines and immunomodulatory activity in vivo.⁹ In 2005, Boros et al. reported that orally administered FWGE suppressed metastatic tumor dissemination and proliferation during and after chemotherapy, surgery, or radiation, with benefits seen in some human cancers and cultured cells as well as some autoimmune disorders and in chemical carcinogenesis prevention.¹⁰

Hypersensitivity and allergic reactions

The risks of sensitization to topical wheat proteins are thought to be higher in patients with atopic dermatitis, who have an impaired skin barrier.¹ Indeed, Codreanu et al. have suggested that topical products containing food proteins of known allergenicity (including wheat) are contraindicated for neonates and infants with atopic dermatitis.¹¹

In 2015, Bonciolini et al. studied 17 patients (13 females and 4 males, median age 36 years) with nonceliac gluten sensitivity presenting with nonspecific skin lesions. The eczema-, psoriasis-, or dermatitis herpetiformis-like lesions on the extensor surfaces of the upper and lower limbs, especially, were confirmed histologically, but immunopathological evaluations revealed pervasive C3 deposits along the dermoepidermal junction in a microgranular/granular pattern (82%). Notably, all of the patients improved markedly after initiating a gluten-free diet.¹²

In 2014, Fukutomi et al. conducted a case-control study of Japanese women aged 20-54 years (157 cases) who self-reported wheat allergy to ascertain the epidemiologic relationship between food allergy to wheat after exposure to facial soaps containing hydrolyzed wheat protein. There were 449 age-matched controls without wheat allergy. Participants answered a Web-based questionnaire about their use of skin and hair care products. The investigators found that current use of the facial soap Cha no Shizuku (Drop of Tea), which contains hydrolyzed wheat protein, was significantly linked to a greater risk of wheat allergy, with use of the soap more frequent in consumers whose wheat allergy had newly emerged (11% vs. 6% in controls).¹³

Cha no Shizuku had earlier been implicated in provoking hundreds of cases of allergic reactions between 2009 and June 2013. R. Teshima noted that the soap contains acid-hydrolyzed wheat protein produced from gluten after partial hydrolysis with hydrogen chloride at 95 ° C for 40 minutes.¹⁴

It is worth noting that case reports of allergic reactions to facial soap containing hydrolyzed wheat protein continue to appear. Iseki et al. described in 2014 a 38-year-old woman who experienced irregular headaches, sleepiness, and an episode of facial rash eruption after daily use for about 1 year of a facial soap with hydrolyzed wheat proteins (Glupearl 19s, which is also used in Cha no Shizuku). The investigators added that the patient’s serum contained wheat-specific IgE antibodies. Symptoms disappeared after the patient abstained from wheat.¹⁵

In 2012, Tammaro studied cutaneous hypersensitivity to gluten in 14 female patients (aged 12-60 years) with celiac disease who presented with eczema on the face, neck, and arms, after topical application of gluten-containing emollient cream, bath or face powder, or contact with foods containing wheat and durum. Five of the patients tested positive for wheat and durum wheat, while none of the 14 control patients tested positive. Improvement in cutaneous lesions, with no relapses during a 6-month follow-up, resulted when these patients used gluten-free cream and bath powder, and wore gloves before handling wheat-containing food.¹⁶

In 2011, Celakovská et al. studied the impact of wheat allergy in 179 adults with atopic eczema (128 females, 51 males; average age 26 years), using open exposure and double-blind, placebo-controlled food challenge tests, as well as specific serum IgE, skin prick, and atopy patch tests. The double-blind, placebo-controlled food challenge test showed that the course of atopic eczema was exacerbated by wheat allergy in eight patients (4.5%). A positive trend revealing that the course of atopic eczema was impacted by wheat allergy emerged during follow-up (at 3, 6, 9, and 12 months).¹⁷

Contact urticaria also has been reported to have been induced by hydrolyzed wheat proteins in cosmetics and is notable for the potential to precede food allergies.^2,3 A wide variety of protein hydrolysates found in hair products have been associated with inducing contact urticaria, particularly in patients with atopic dermatitis.⁴

In 2006, Laurière et al. studied nine female patients without common wheat allergy who presented with contact urticaria to cosmetics containing hydrolyzed wheat proteins; six also had experienced generalized urticaria or anaphylaxis in response to foods containing such wheat proteins. Analyses revealed the importance of hydrolysis in augmenting the allergenicity of wheat proteins through contact or consumption.¹⁸ Immediate contact urticaria in reaction to hydrolyzed wheat protein in topical products also has been reported in a child.¹⁹

Conclusion

Can the presence of wheat hydrolysates in personal care products adversely affect a patient with celiac sprue or wheat sensitivity? The short answer appears to be “yes.” Given the use of hydrolyzed wheat protein in various skin care products, it is important that consumers who have celiac disease or sensitivity to wheat be advised to avoid skin care formulations with such active ingredients. On the positive side of the wheat ledger, there are some indications (albeit in very limited research) that the plant protein may impart beneficial health effects. Much more research is necessary to delineate the full impact of wheat on skin health.

I thank my dermatologist colleague Sharon E. Jacob, MD, at the University of Miami, for suggesting this topic.

References

1. Dermatitis. 2013 Nov-Dec;24(6):291-5.

2. Iran J Med Sci. 2016 May;41(3 Suppl):S54.

3. Contact Dermatitis. 2007 Feb;56(2):119-20.

4. Ann Dermatol Venereol. 2010 Apr;137(4):281-4.

5. Allergy. 1998 Nov;53(11):1078-82.

6. J Drugs Dermatol. 2013 Sep;12(9 Suppl):s133-6.

7. Pak J Pharm Sci. 2008 Jan;21(1):45-50.

8. Cancer Biother Radiopharm. 2008 Aug;23(4):477-82.

9. Nutr Cancer. 2009;61(6):891-9.

10. Ann N Y Acad Sci. 2005 Jun;1051:529-42.

11. Eur Ann Allergy Clin Immunol. 2006 Apr;38(4):126-30.

12. Nutrients. 2015 Sep 15;7(9):7798-805.

13. Allergy. 2014 Oct;69(10):1405-11.

14. Yakugaku Zasshi. 2014;134(1):33-8.

15. Intern Med. 2014;53(2):151-4.

16. Dermatitis. 2012 Sep-Oct;23(5):220-1.

17. Acta Medica (Hradec Kralove). 2011;54(4):157-62.

18. Contact Dermatitis. 2006 May;54(5):283-9.

19. Contact Dermatitis. 2013 Jun;68(6):379-80.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever. Dr. Baumann also developed and owns the Baumann Skin Type Solution skin typing systems and related products.

Malignant melanoma has continually shown a pattern of increased incidence and mortality over the last 50 years, especially in fair-skinned individuals. In fact, malignant melanoma has the highest mortality rate of all skin cancers in white individuals. Currently, wide local surgical excision is the mainstay of treatment of primary cutaneous melanomas.¹ The margins vary in size according to the Breslow thickness (or depth) of the involved tumor. As such, advancements in melanoma treatment continue to be studied. We present the case of a patient with invasive melanoma that was cleared with topical imiquimod.

Case Report

A 71-year-old man presented with biopsy-proven malignant melanoma on the right posterior scalp that was diagnosed a few weeks prior. The melanoma was invasive with a depth of 0.73 mm. The patient also had an approximately 8-cm, irregular, patchy area of hyperpigmentation involving almost the entire crown of the head (Figure 1A). The biopsy site used for melanoma diagnosis was on the right posterior aspect of the hyperpigmented area where a symptomatic pigmented papule was located. To determine if the rest of this macule represented an extension of the proven malignancy, surveillance biopsies were taken at the 12 o'clock (anterior aspect), 3 o'clock, 6 o'clock, and 9 o'clock positions on the head. All of the biopsies came back as lentigo simplex, which presented a clinical problem in that the boundaries of the invasive melanoma merged with the lentigo simplex and were not clinically apparent. Because an exact boundary could not be visualized, the entire area was treated with imiquimod cream 5% once nightly at bedtime for 4 weeks prior to excision of the original biopsy site. There was a notable decrease in hyperpigmentation in the treated area after 4 weeks of therapy (Figure 1B). The original biopsy site was then excised with a 0.6-cm margin and a complex linear repair was performed. Histologic examination of the excised specimen showed no residual melanoma.

Comment

Although surgical excision is the recommended treatment of cutaneous melanoma,¹ in some cases the defect following an excision can be quite large or even disfiguring. To minimize the size of the excision site, other treatment modalities should be studied. Imiquimod is an immunomodulating agent that exerts antitumor and antiviral effects. The US Food and Drug Administration has approved imiquimod for treatment of genital warts, actinic keratoses, and superficial basal cell carcinoma.² The most common side effects of topical imiquimod involve application-site reactions such as erythema, swelling, and crusting of the treated area. Ulceration of the skin also is possible. A small percentage of individuals have experienced systemic flulike symptoms after using topical imiquimod. Topical imiquimod has been used off label to treat noninvasive forms of melanoma. The topical therapy has been reported to clear melanoma in situ and lentigo maligna.^2,3 In addition, imiquimod has been used as a palliative therapy for cutaneous metastatic melanoma.^4,5 In another case of a primary melanoma that responded to topical imiquimod, clinical and histological clearance of a recurrent oral mucosa melanoma was obtained.⁶

Moon and Spencer⁷ reported a case of an invasive melanoma that was cleared with topical imiquimod. A 93-year-old woman presented with a central 2.75-mm thick invasive melanoma surrounded by a large area of melanoma in situ involving the left cheek and eyelid. The excised tissue was stained for CD31 and D2-40 to rule out intravascular and intralymphatic spread (Figure 2A). The standard-of-care treatment for this case would involve surgical excision with 2-cm margins and a sentinel lymph node biopsy, but given the morbidity involved with the surgery, an alternative treatment plan was made with the patient. The patient completed 5 weeks of topical imiquimod therapy and then underwent wide local excision with a 1-cm margin. Extensive histological examination of the excised specimen showed no residual melanoma; in fact, there was a near absence of junctional melanocytes that would normally have been seen. The specimen underwent immunoperoxidase staining for Melan-A (Figure 2B). The patient was followed for 14 months with no evidence of recurrence.⁷

Conclusion

We describe a patient who achieved complete histologic clearance of invasive melanoma following treatment with topical imiquimod. Four weeks of topical therapy completely cleared an invasive melanoma that was 0.73-mm thick. Follow-up was recommended for the patient because long-term outcomes of this therapy are unknown. More studies demonstrating reliability and reproducibility are needed to evaluate the role of topical imiquimod in melanoma treatment; however, our case shows the potential of this topical modality.

Malignant melanoma has continually shown a pattern of increased incidence and mortality over the last 50 years, especially in fair-skinned individuals. In fact, malignant melanoma has the highest mortality rate of all skin cancers in white individuals. Currently, wide local surgical excision is the mainstay of treatment of primary cutaneous melanomas.¹ The margins vary in size according to the Breslow thickness (or depth) of the involved tumor. As such, advancements in melanoma treatment continue to be studied. We present the case of a patient with invasive melanoma that was cleared with topical imiquimod.

Case Report

A 71-year-old man presented with biopsy-proven malignant melanoma on the right posterior scalp that was diagnosed a few weeks prior. The melanoma was invasive with a depth of 0.73 mm. The patient also had an approximately 8-cm, irregular, patchy area of hyperpigmentation involving almost the entire crown of the head (Figure 1A). The biopsy site used for melanoma diagnosis was on the right posterior aspect of the hyperpigmented area where a symptomatic pigmented papule was located. To determine if the rest of this macule represented an extension of the proven malignancy, surveillance biopsies were taken at the 12 o'clock (anterior aspect), 3 o'clock, 6 o'clock, and 9 o'clock positions on the head. All of the biopsies came back as lentigo simplex, which presented a clinical problem in that the boundaries of the invasive melanoma merged with the lentigo simplex and were not clinically apparent. Because an exact boundary could not be visualized, the entire area was treated with imiquimod cream 5% once nightly at bedtime for 4 weeks prior to excision of the original biopsy site. There was a notable decrease in hyperpigmentation in the treated area after 4 weeks of therapy (Figure 1B). The original biopsy site was then excised with a 0.6-cm margin and a complex linear repair was performed. Histologic examination of the excised specimen showed no residual melanoma.

Comment

Although surgical excision is the recommended treatment of cutaneous melanoma,¹ in some cases the defect following an excision can be quite large or even disfiguring. To minimize the size of the excision site, other treatment modalities should be studied. Imiquimod is an immunomodulating agent that exerts antitumor and antiviral effects. The US Food and Drug Administration has approved imiquimod for treatment of genital warts, actinic keratoses, and superficial basal cell carcinoma.² The most common side effects of topical imiquimod involve application-site reactions such as erythema, swelling, and crusting of the treated area. Ulceration of the skin also is possible. A small percentage of individuals have experienced systemic flulike symptoms after using topical imiquimod. Topical imiquimod has been used off label to treat noninvasive forms of melanoma. The topical therapy has been reported to clear melanoma in situ and lentigo maligna.^2,3 In addition, imiquimod has been used as a palliative therapy for cutaneous metastatic melanoma.^4,5 In another case of a primary melanoma that responded to topical imiquimod, clinical and histological clearance of a recurrent oral mucosa melanoma was obtained.⁶

Moon and Spencer⁷ reported a case of an invasive melanoma that was cleared with topical imiquimod. A 93-year-old woman presented with a central 2.75-mm thick invasive melanoma surrounded by a large area of melanoma in situ involving the left cheek and eyelid. The excised tissue was stained for CD31 and D2-40 to rule out intravascular and intralymphatic spread (Figure 2A). The standard-of-care treatment for this case would involve surgical excision with 2-cm margins and a sentinel lymph node biopsy, but given the morbidity involved with the surgery, an alternative treatment plan was made with the patient. The patient completed 5 weeks of topical imiquimod therapy and then underwent wide local excision with a 1-cm margin. Extensive histological examination of the excised specimen showed no residual melanoma; in fact, there was a near absence of junctional melanocytes that would normally have been seen. The specimen underwent immunoperoxidase staining for Melan-A (Figure 2B). The patient was followed for 14 months with no evidence of recurrence.⁷

Conclusion

We describe a patient who achieved complete histologic clearance of invasive melanoma following treatment with topical imiquimod. Four weeks of topical therapy completely cleared an invasive melanoma that was 0.73-mm thick. Follow-up was recommended for the patient because long-term outcomes of this therapy are unknown. More studies demonstrating reliability and reproducibility are needed to evaluate the role of topical imiquimod in melanoma treatment; however, our case shows the potential of this topical modality.

Malignant melanoma has continually shown a pattern of increased incidence and mortality over the last 50 years, especially in fair-skinned individuals. In fact, malignant melanoma has the highest mortality rate of all skin cancers in white individuals. Currently, wide local surgical excision is the mainstay of treatment of primary cutaneous melanomas.¹ The margins vary in size according to the Breslow thickness (or depth) of the involved tumor. As such, advancements in melanoma treatment continue to be studied. We present the case of a patient with invasive melanoma that was cleared with topical imiquimod.

Case Report

A 71-year-old man presented with biopsy-proven malignant melanoma on the right posterior scalp that was diagnosed a few weeks prior. The melanoma was invasive with a depth of 0.73 mm. The patient also had an approximately 8-cm, irregular, patchy area of hyperpigmentation involving almost the entire crown of the head (Figure 1A). The biopsy site used for melanoma diagnosis was on the right posterior aspect of the hyperpigmented area where a symptomatic pigmented papule was located. To determine if the rest of this macule represented an extension of the proven malignancy, surveillance biopsies were taken at the 12 o'clock (anterior aspect), 3 o'clock, 6 o'clock, and 9 o'clock positions on the head. All of the biopsies came back as lentigo simplex, which presented a clinical problem in that the boundaries of the invasive melanoma merged with the lentigo simplex and were not clinically apparent. Because an exact boundary could not be visualized, the entire area was treated with imiquimod cream 5% once nightly at bedtime for 4 weeks prior to excision of the original biopsy site. There was a notable decrease in hyperpigmentation in the treated area after 4 weeks of therapy (Figure 1B). The original biopsy site was then excised with a 0.6-cm margin and a complex linear repair was performed. Histologic examination of the excised specimen showed no residual melanoma.

Comment

Although surgical excision is the recommended treatment of cutaneous melanoma,¹ in some cases the defect following an excision can be quite large or even disfiguring. To minimize the size of the excision site, other treatment modalities should be studied. Imiquimod is an immunomodulating agent that exerts antitumor and antiviral effects. The US Food and Drug Administration has approved imiquimod for treatment of genital warts, actinic keratoses, and superficial basal cell carcinoma.² The most common side effects of topical imiquimod involve application-site reactions such as erythema, swelling, and crusting of the treated area. Ulceration of the skin also is possible. A small percentage of individuals have experienced systemic flulike symptoms after using topical imiquimod. Topical imiquimod has been used off label to treat noninvasive forms of melanoma. The topical therapy has been reported to clear melanoma in situ and lentigo maligna.^2,3 In addition, imiquimod has been used as a palliative therapy for cutaneous metastatic melanoma.^4,5 In another case of a primary melanoma that responded to topical imiquimod, clinical and histological clearance of a recurrent oral mucosa melanoma was obtained.⁶

Moon and Spencer⁷ reported a case of an invasive melanoma that was cleared with topical imiquimod. A 93-year-old woman presented with a central 2.75-mm thick invasive melanoma surrounded by a large area of melanoma in situ involving the left cheek and eyelid. The excised tissue was stained for CD31 and D2-40 to rule out intravascular and intralymphatic spread (Figure 2A). The standard-of-care treatment for this case would involve surgical excision with 2-cm margins and a sentinel lymph node biopsy, but given the morbidity involved with the surgery, an alternative treatment plan was made with the patient. The patient completed 5 weeks of topical imiquimod therapy and then underwent wide local excision with a 1-cm margin. Extensive histological examination of the excised specimen showed no residual melanoma; in fact, there was a near absence of junctional melanocytes that would normally have been seen. The specimen underwent immunoperoxidase staining for Melan-A (Figure 2B). The patient was followed for 14 months with no evidence of recurrence.⁷

Conclusion

We describe a patient who achieved complete histologic clearance of invasive melanoma following treatment with topical imiquimod. Four weeks of topical therapy completely cleared an invasive melanoma that was 0.73-mm thick. Follow-up was recommended for the patient because long-term outcomes of this therapy are unknown. More studies demonstrating reliability and reproducibility are needed to evaluate the role of topical imiquimod in melanoma treatment; however, our case shows the potential of this topical modality.

As survival rates among pediatric organ transplant recipients increase, so do the rates of cutaneous malignancies later in life for this population, who are at a greater risk for skin cancers that include nonmelanoma skin cancers (NMSCs), melanoma, Kaposi sarcoma, and anogenital carcinoma, according to the authors of a literature review.

In studies, skin cancers account for 13%-55% of all cancers in pediatric organ transplant recipients (POTRs), according to Alexander L. Fogel of Stanford (Calif.) University and his coauthors. The review article provides an update on this topic, as well as information on the prevention and management of skin cancers in this population, and the differences between this group and adult organ transplant recipients (AOTRs).

This article was updated 12/8/16. 

[email protected]

On Twitter @whitneymcknight

As survival rates among pediatric organ transplant recipients increase, so do the rates of cutaneous malignancies later in life for this population, who are at a greater risk for skin cancers that include nonmelanoma skin cancers (NMSCs), melanoma, Kaposi sarcoma, and anogenital carcinoma, according to the authors of a literature review.

In studies, skin cancers account for 13%-55% of all cancers in pediatric organ transplant recipients (POTRs), according to Alexander L. Fogel of Stanford (Calif.) University and his coauthors. The review article provides an update on this topic, as well as information on the prevention and management of skin cancers in this population, and the differences between this group and adult organ transplant recipients (AOTRs).

This article was updated 12/8/16. 

[email protected]

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As survival rates among pediatric organ transplant recipients increase, so do the rates of cutaneous malignancies later in life for this population, who are at a greater risk for skin cancers that include nonmelanoma skin cancers (NMSCs), melanoma, Kaposi sarcoma, and anogenital carcinoma, according to the authors of a literature review.

In studies, skin cancers account for 13%-55% of all cancers in pediatric organ transplant recipients (POTRs), according to Alexander L. Fogel of Stanford (Calif.) University and his coauthors. The review article provides an update on this topic, as well as information on the prevention and management of skin cancers in this population, and the differences between this group and adult organ transplant recipients (AOTRs).

This article was updated 12/8/16. 

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On Twitter @whitneymcknight

At the 19th Annual Mount Sinai Winter Symposium, Dr. Orit Markowitz provided an update on dermoscopy as a first-line noninvasive imaging modality for skin cancer screening and diagnosis along with reflectance confocal microscopy and dynamic optical coherence tomography. She explained how noninvasive imaging offers a more complete picture of lesions along with what is seen clinically and on pathology and discussed how it can help catch aggressive melanomas and other skin cancers at earlier stages. For these reasons, she emphasized that increased use of dermoscopy can be used to justify the need for regular skin cancer screenings. Finally, she discussed how noninvasive imaging can be used to guide dermatologists in performing optimal biposies of suspicious lesions.

At the 19th Annual Mount Sinai Winter Symposium, Dr. Orit Markowitz provided an update on dermoscopy as a first-line noninvasive imaging modality for skin cancer screening and diagnosis along with reflectance confocal microscopy and dynamic optical coherence tomography. She explained how noninvasive imaging offers a more complete picture of lesions along with what is seen clinically and on pathology and discussed how it can help catch aggressive melanomas and other skin cancers at earlier stages. For these reasons, she emphasized that increased use of dermoscopy can be used to justify the need for regular skin cancer screenings. Finally, she discussed how noninvasive imaging can be used to guide dermatologists in performing optimal biposies of suspicious lesions.

At the 19th Annual Mount Sinai Winter Symposium, Dr. Orit Markowitz provided an update on dermoscopy as a first-line noninvasive imaging modality for skin cancer screening and diagnosis along with reflectance confocal microscopy and dynamic optical coherence tomography. She explained how noninvasive imaging offers a more complete picture of lesions along with what is seen clinically and on pathology and discussed how it can help catch aggressive melanomas and other skin cancers at earlier stages. For these reasons, she emphasized that increased use of dermoscopy can be used to justify the need for regular skin cancer screenings. Finally, she discussed how noninvasive imaging can be used to guide dermatologists in performing optimal biposies of suspicious lesions.