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British Photodermatology Group Position Statements on Sun Awareness and Safety

Below you will find the British Photodermatology Group's position statments on Skin Photo-Protection, Sun Protection in Schools and Vitamin D.

 

British Photodermatology Group Position Statements

Skin Photoprotection

 

Background

Excessive exposure to ultraviolet radiation (UVR), particularly from a young age, is the main cause of melanoma and non-melanoma skin cancer [1], and also skin ageing. Exposure causing sunburn is most harmful, but frequent non-burning exposures are also damaging [2]. People with fair skin that burns easily, many moles or freckles, red or fair hair and light coloured eyes are most at risk. Ethnically darker skin is mostly just at risk of skin ageing. UVR exposure both naturally from sunlight and artificially from sunbeds [3] is damaging, and with the latter there is the additional concern that skin protection from exposure is never used.

Reducing UVR skin exposure lowers the risk of skin cancer [4,5] and ageing. Absolute sun avoidance is not advocated, however, as casual brief sun exposure, well below that leading to burning, helps maintain bodily vitamin D sufficiency [6]. Subjects in whom such exposure for medical or other reasons is contraindicated or impracticable, however, can successfully maintain vitamin D sufficiency through oral supplementation.

Education can change behaviour [7]. School based educational interventions have been shown to raise children’s knowledge and awareness of sun safety [8]. Thus, promotion of sun safety in schools, particularly at primary school age when behaviour is most likely to be influenced, is expected to lead to long-term reduction in skin cancer incidence [9].

The most reliable means of minimising UVR skin damage is to limit sun exposure from 11am to 3pm to short periods, such as burning is avoided, during warm weather from April to September in the UK and year-round in tropical areas and to avoid sunbed use. UVR exposure is significantly increased at high altitude and after reflection from snow, white sand and white concrete. Cloud cover is very poorly protective, unless very dense, while swimming in water of any temperature or exposure to a cooling breeze offers no protection.

If significant outdoor exposure is necessary at these times, protection from deep shade such as from trees and buildings should be used whenever available and as much clothing cover as reasonable should be worn. A wide-brimmed hat protecting face, neck and ears and close-weave, loose-fitting clothing are required. Specially designed fabrics providing a high ultraviolet protection factor (UPF) are available [10].

For areas of skin unable to be protected by clothing, sunscreen use can be reasonably effective, but only if applied relatively thickly, which is generally not how they are used in practice. For greatest efficacy, use a high sun protection factor (SPF) sunscreen, preferably of 30 or more, also providing high levels of UVA protection. This is indicated by 4* to 5* in the Boots UK Limited system. Alternatively, the letters “UVA” printed in a circle ensures the sunscreen has a UVA protection of one-third of the labelled SPF. Applications should be made liberally to all uncovered areas 15-30 minutes before exposure, then again 15-30 minutes after exposure begins [11]. Repeat application preferably every couple of hours or so is necessary for most reliable efficacy, though many modern sunscreens can remain effective for much longer. Repeat application is also required after swimming or exercise and sweating [11]. Sunscreens should not be used to stay outside longer, as they lead to increased UVR damage if used carelessly [12], often giving protection less than a third of that stated [13].

Fake tan products are harmless and may be used as cosmetically required to give the skin a tanned appearance. They provide very low levels of protection against UVR exposure, so should not be relied on for sun protection.

Some people take medications or suffer from conditions that make them particularly sensitivity to light (photosensitivity) . Such individuals may need special, medically recommended photoprotective advice and treatment.


Recommendations

• Sunbeds should not be used as they significantly increase the risk of skin cancer, especially as always used without photoprotection. In particular, sunbed use before a sunny holiday results in UVR damage without giving any significant protection against subsequent natural sun exposure.

• In tropical areas and during periods of warm weather from April to September in temperate areas, sun-exposure should be limited to short durations, such that burning is avoided.

• If significant exposure is necessary at these times, then behavioural sun avoidance, use of hats and clothing and liberal application of high SPF/UVA protective sunscreens should be used.

• Sunscreens should not be used to stay outside longer or just to avoid more reliable protective measures such as clothing and shade.

Additional recommendations for schools and other childcare facilities

• Schools/ childcare facilities should be aware of school resources, for example “Sunsmart” and “Sunsafe Schools” [14,15] and minimise the risks of sunburn in children. Staff should act as positive role models.

• Educational activities to promote and sustain sun awareness should be part of the school curriculum. This should be balanced, appropriate to the level of individual risk and should not discourage outdoor activities, which have known benefits such as physical activity and vitamin D synthesis.

• Children with black skin do not routinely require sunscreen and should have sufficient UV exposure to allow adequate vitamin D synthesis.

• Environmental shade should be accessible for all children

• Teachers should be aware that occasionally an individual child may be particularly at risk of adverse effects on health through sun exposure (through a photosensitivity disease/ increased risk of skin cancer) and should allow for their special needs with regards to photoprotection.



References


1 El Ghissassi F, Baan R, Straif K et al (2009) WHO international agency for research on cancer monograph working group. A review of human carcinogens - part D: radiation. Lancet Oncol 10:751-2.
2. Seite S, Fourtanier A, Moyal D, Young AR (2010) Photodamage to human skin by suberythemal exposure to solar ultraviolet radiation can be attenuated by sunscreens: a review. Br J Dermatol 163: 903-914.
3. Diffey BL (2003) A quantitative estimate of melanoma mortality from ultraviolet A sunbed use in the U.K. Br J Dermatol 149:578-581.
4. Green A, Williams G, Neale R, et al (1999) Daily sunscreen application in prevention of squamous cell carcinoma and basal cell carcinoma of skin. Lancet 354: 723­94.
5. Green AC, Williams GM, Logan V, Strutton GM (2011) Reduced melanoma after regular sunscreen use: randomized trial follow-up. J Clin Oncol 29:257-263.
6. Rhodes LE, Webb AR. Fraser HI, et al (2010) Recommended summer sunlight exposure levels can produce sufficient (> or =20 ng ml(-1)) but not the proposed optimal (> or =32 ng ml(-1)) 25(OH)D levels at UK latitudes. J Invest Dermatol 130:1411-1418.
7..Behaviour change. NICE public health guidance 6 (2007). Available from www.nice.org.uk/guidance/PH6
8. Sun protection and sunburn in primary school children: the influence of age, gender and coloring. Dixon H, Borland R, Hill D. Prev Med 1999 28 (2) 119-30
9. Targeting children through school based education and policy strategies: comprehensive cancer control activities in melanoma prevention. J Am Acad Dermatol 2011 65 (S)104-13
10. Osterwalder U, Rohwer H (2002) Improving UV protection by clothing - recent developments. Recent Results Cancer Res 2002;160:62-9.
11. Diffey BL (2001) When should sunscreen be reapplied? J Am Acad Dermatol 45:882-885.
12. Dennis LK, Beane, Freeman LE, van Beck MJ (2003) Sunscreen use and the risk for melanoma: a quantitative review. Ann Intern Med 139:966–78.
13. Petersen B, Datta P, Philipsen PA, Wulf HC (2012) Sunscreen use and failures - on site observations on a sun-holiday. Photochem Photobiol Sci [Epub ahead of print, October 1]
14. SunSmart schools resources from www. Sunsmart.org.uk/schools/schoolsresources/sunsmart-schools-resources
15. Sunsafe school resources from www.sunsafe.co.uk/resources


PRODUCED JANUARY 2013
UPDATED SEPTEMBER 2016
REVIEW DATE SEPTEMBER 2019
 

 

Phototherapy for skin disease

 

Background

Phototherapy is the use of ultraviolet or visible light to treat disease. The main forms of phototherapy used for skin diseases are ultraviolet B (usually using lamps producing narrowband ultraviolet B) and psoralen plus ultraviolet A (PUVA). A specialised form of phototherapy called ultraviolet A1 is also used, although not widely.

Various skin conditions can be treated with phototherapy (including psoriasis [1,2], atopic eczema, chronic urticaria [3] and vitiligo); generalised itch (such as the widespread itch that is caused by some severe kidney problems) can be helped [4]; T cell lymphoma of the skin typically responds well to ultraviolet B [5] and to PUVA [6]. Phototherapy can also be used to build up tolerance in those with various sunlight sensitivity skin disorders [7]. Phototherapy is not ‘artificial sunlight’. Conditions that do not benefit from sunlight exposure, and even conditions triggered or made worse by sunlight exposure, often benefit from the correct choice of phototherapy [8,9].

For many conditions both narrowband ultraviolet B and PUVA are treatment options. As ultraviolet B is simpler and the risks of side effects are less, it is used more frequently. PUVA is a good option for some conditions that do not respond to ultraviolet B and also for people with conditions which usually respond well to ultraviolet B but who have not responded adequately to this therapy. PUVA and ultraviolet B work in different ways and PUVA can work well when ultraviolet B has not done so.

Usually, phototherapy with ultraviolet B is given three-times a week and twice a week for PUVA. Ultraviolet B phototherapy involves standing in an ultraviolet B treatment cabinet; PUVA involves taking psoralen tablets or soaking in a psoralen solution before standing in an ultraviolet A treatment cabinet. The number of treatments needed for a course of phototherapy varies across the different conditions and from person to person, but a typical course is between 15 and 30 treatments.

As with all effective treatments there are possible side effects with the phototherapies. The commonest unwanted effects are sunburn-like reactions (skin redness) and tanning. With PUVA, there is an increased risk of skin cancer which is related to the cumulative lifetime number of treatments. A large Swedish study found that one in 18 patients treated with more than 180 whole-body PUVA treatments developed a squamous cell skin cancer [10], confirming an increased skin cancer risk with PUVA that has also been shown in other studies [11]. The risks of alternative treatments, such as the risks of internal side effects as well as of skin cancer with immunosuppressant tablet treatments, need to be considered when deciding what this small increased risk of skin cancer, after a high cumulative exposure to PUVA, means. Although from what we know about ultraviolet in general, and from studies on cells and animals, it seems likely there should also be some increased skin cancer risk with ultraviolet B, to date no increased risk of skin cancer in people treated with narrowband ultraviolet B has been found [12].

Some people who could benefit from phototherapy find it difficult to attend for this treatment as they live too far away from the hospital or the opening times of a local unit do not fit in with their work and home commitments. Most dermatology services try to make phototherapy available through a ‘hub and spoke’ model with ultraviolet B and PUVA available in a central department as well as in smaller hospitals. In many places, efforts are also being made to extend unit opening times. Another complementary way of extending availability of phototherapy is to provide a hospital supervised home phototherapy service. Supervised home phototherapy has been shown to be as effective and safe as hospital phototherapy as well as being cost effective, but is not available in all regions. [13,14]. Unsupervised self-purchased phototherapy units are however not recommended due to lack of quality control, servicing of equipment, and accurate documentation of amount of UV exposure.

The phototherapies should be given in units participating in a clinical governance scheme, such as the national managed clinical network for phototherapy through which all phototherapy in Scotland is delivered (http://www.photonet.scot.nhs.uk/). This ensures the treatments are given as effectively and safely as possible, with ongoing audit to identify any problems. Such systems help to ensure that the correct phototherapies are used for the correct conditions. Prescription of courses of phototherapy must be by a dermatologist knowledgeable about these treatments and about any possible alternative treatments.

There are ongoing efforts to develop new phototherapy treatments as well as to work out how best (most safely and most effectively) to use the phototherapy treatments already available.

 

Recommendations

  • Phototherapy (at a minimum narrowband ultraviolet B and PUVA) should be available to all for whom a phototherapy treatment is indicated.
  • If ultraviolet B phototherapy has been inadequate, PUVA should be considered as a next line approach which is usually appropriate before systemic therapies.
  • The skin cancer risks of PUVA are important and should be considered when deciding on appropriate treatment for an individual, but these risks should be considered in context, including the skin cancer, and other, risks of any alternative therapies.
  • Phototherapy should be delivered in a clinical governance system, and following, at a minimum, the recommendations of the British Association of Dermatologists Phototherapy Working Party Report (2012)
  • Measures should be taken to make access to phototherapy as equitable as possible throughout the UK..Such measures to consider include ensuring adequate phototherapy units (in many areas a ‘hub and spoke’ model is appropriate), opening hours appropriate to the population served and hospital phototherapy unit supervised home phototherapy. Unsupervised treatment with phototherapy at home is not recommended.


References:

1 Sivanesan SP, Gattu S, Hong J, Chavez-Frazier A, Bandow GD, Malick F, Kricorian G, Koo J. Randomized, double-blind, placebo-controlled evaluation of the efficacy of oral psoralen plus ultraviolet A for the treatment of plaque-type psoriasis using the Psoriasis Area Severity Index score (improvement of 75% or greater) at 12 weeks. J Am Acad Dermatol 2009; 61: 793-8.

2 Dawe RS. A quantitative review of studies comparing the efficacy of narrow-band and broad-band ultraviolet B for psoriasis. Br J Dermatol 2003; 149: 669-72.

3 Engin B, Ozdemir M, Balevi A, Mevlitoglu I. Treatment of chronic urticaria with narrowband ultraviolet B phototherapy: a randomized controlled trial. Acta Derm Venereol 2008; 88: 247-51.

4 Gilchrest BA, Rowe JW, Brown RS, Steinman TI, Arndt KA. Relief of uremic pruritus with ultraviolet phototherapy. N Engl J Med 1977; 297: 136-8.

5 Clark C, Dawe RS, Evans AT, Lowe G, Ferguson J. Narrowband TL-01 phototherapy for patch-stage mycosis fungoides. Arch Dermatol 2000; 136: 748-52.

6 Stadler R, Otte HG, Luger T, Henz BM, Kuhl P, Zwingers T, Sterry W. Prospective randomized multicenter clinical trial on the use of interferon -2a plus acitretin versus interferon -2a plus PUVA in patients with cutaneous T-cell lymphoma stages I and II. Blood 1998; 92: 3578-81.

7 Collins P, FergusonJ. Narrow-band UVB (TL-01) phototherapy: an effective preventative treatment for the photodermatoses. Br J Dermatol 1995; 132: 956-63.

8 Boer J, Schothorst AA, Suurmond D. Ultraviolet B phototherapy for psoriasis in sunlight-responsive patients. Lancet 1979; 1: 773.

9 Dawe RS, Ferguson J. History of psoriasis response to sunlight does not predict outcome of UVB phototherapy. Clin Exp Dermatol 2004; 29: 413-4.

10 Lindelof B, Sigurgeirsson B, Tegner E, Larko O, Johannesson A, Berne B, Ljunggren B, Andersson T, Molin L, Nylander-Lundqvist E, Emtestam L. PUVA and cancer risk: the Swedish follow-up study. Br J Dermatol 1999; 141: 108-12.

11 Stern RS, Liebman EJ, Vakeva L. Oral psoralen and ultraviolet-A light (PUVA) treatment of psoriasis and persistent risk of nonmelanoma skin cancer. PUVA Follow-up Study. J Natl Cancer Inst 1998; 90: 1278-84.

12 Hearn RM, Kerr AC, Rahim KF, Ferguson J, Dawe RS. Incidence of skin cancers in 3867 patients treated with narrow-band ultraviolet B phototherapy. Br J Dermatol 2008; 159: 931-5.

13 Koek MB, Buskens E, van Weelden H, Steegmans PH, Bruijnzeel-Koomen CA, Sigurdsson V. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ 2009; 338: b1542.

14 Koek MB, Sigurdsson V, van Weelden H, Steegmans PH, Bruijnzeel-Koomen CA, Buskens E. Cost effectiveness of home ultraviolet B phototherapy for psoriasis: economic evaluation of a randomised controlled trial (PLUTO study). BMJ 2010; 340: c1490

 

PRODUCED JANUARY 2013

REVIEWED SEPTEMBER 2016

REVIEW DATE SEPTEMBER 2019

 

Sunbeds

 

Introduction

The availability and use of commercial ultraviolet-A (UVA) sunbeds has increased greatly in recent years. At the same time the intensity of UV emitted by these sunbeds has also increased such that their skin cancer risks are often equivalent to Mediterranean summer sunlight1.

There is strong evidence that use of sunbeds increases the risk of skin cancers, including malignant melanoma2. For those who start using sunbeds before the age of 35 years the relative risk of malignant melanoma and squamous cell carcinoma3 almost doubles.

Now all countries of the United Kingdom (UK) have introduced legislation controlling the use of commercial sunbeds. All European, and most International bodies concerned with advice on cancer or radiation protection have issued position statements or other guidance discouraging use of UV devices for cosmetic tanning and recommending restrictions on their use by under 18 year olds. The World Health Organisation classifies sunbeds as a “Group 1 Carcinogen”2,4-9.

Ireland has recently (2015) completed the enactment of all provisions of its Public Health (Sunbeds) legislation. These include prescribing the information given to sunbed customers, banning of advertising claims of health benefits of sunbeds, banning promotions such as ‘happy hours’ or ‘unlimited use of sunbeds offer’ and the requirement of notification of sunbed premises to the Health and Safety Executive. The governments of the individual countries within the UK should consider adopting these extra provisions in order maximise the benefit to Public Health.

Recommendations:

The British Photodermatology Group supports the provisions of the UK Sunbed Acts as good first steps towards a policy to minimise the risks of sunbed use. The BPG still calls for regulation of sunbed operators and inspection of premises.

In view of the statements, reports and advice of many National and International agencies on the use of sunbeds, and in light of the strong evidence of harm from the use of sunbeds for cosmetic tanning, the British Photodermatology Group make the following recommendations:

  • The use of UV equipment for cosmetic tanning should be strongly discouraged.
  • In commercial premises sunbed use should be banned for under-18s, as already enacted in all the countries of the UK.
  • Strong public information programmes should emphasise the risks of sunbeds, especially to children and young adults.
  • Advertising by the sunbed industry should be carefully scrutinised.
  • Any claims of health benefits from sunbed use should be banned.
  • Sunbeds should never be used by these groups:
    • Under 18 years of age
    • Those with fair/freckly skin that does not normally tan with sun exposure
    • Those with large number of moles
    • Those with a history of skin cancer;
    • Those with abnormal sensitivity to the sun either due to photosensitive skin diseases (sun allergies) or medication
  • As part of the Registration of owners/operators of sunbed premises and sunbed manufacturers:
    • Claims of health benefits for sunbeds must not be made.
    • All sunbeds should be limited to types I, II or III as defined by the IEC Standard (BS EN 60335-2-27: 2003)10. Use of UV tubes that exceed these limits should be banned.
    • UV goggles must be provided to clients.
    • All premises should be staffed by trained personnel.
    • Clearly visible information on minimising the risks from sunbeds and appropriate health warnings should be provided to clients prior to tanning exposure.

References:

1 Oliver H, Ferguson J, Moseley H. Quantitative risk assessment of sunbeds: impact of new high power lamps. British Journal of Dermatology August 2007; 157: 350-6.

2 IARC. International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer. The association of use of sunbeds with cutaneous malignant melanoma and otheer skin cancers: A systematic review. Int J Cancer 2007; 120: 1116-22.

3 Tierney P, De Gruijl FR, Ibbotson Set al. Predicted increased risk of squamous cell carcinoma induction associated with sunbed exposure habits. British Journal of Dermatology 2015; 173: 201-8.

4 WHO. Artificial Tanning Sunbeds Risks and Guidance. In. Geneva: World Health Organisation. 2003.

5 CR-UK. Cancer Research UK Policy Statement Sunbeds. In: Cancer Research UK. 2009.

6 ICNIRP. Health Issues of Ultraviolet Tanning Appliances Use for Cosmetic Purposes. International Commission on Non-Ionising Radiation Protection. Health Physics 2003; 84: 119-27.

7 COMARE. Committee on Medical Aspects of Radiation in the Environment (COMARE) Report 13: The Health Effects and Risks Arising from Exposure to Ultraviolet Radiation from Artificial Tanning Devices. In: Health Protection Agency. 2009.

8 SCCP. EU Scientific Committee on Consumer Products (SCCP) Preliminary opinion on: Biological Effects of Ultraviolet Radiation Relevant to Health with Particular Reference to Sun Beds for Cosmetic Purposes. In: EU SCCP. 2005; SCCP/0949/05.

9 CIEH. Chartered Institute of Environmental Health Policy Briefing Note - Sunbeds. In: Chartered Institute of Environmental Health. 2010.

10 IEC. Safety of Household and Similar Appliances. In: Part 2: Particular requirements for appliances for skin exposure to ultraviolet and infrared radiation., Vol. 335. Geneva: International Electrotechnical Commission. 1995; 2-27.

 

PRODUCED DECEMBER 2013

UPDATED JULY 2016

REVIEW DATE JULY 2019

 

Ultraviolet (UV) emissions and Compact Fluorescent Lights

Background

Legislation in Europe and United States has led to the phasing out of incandescent light bulbs. Similar legislation has been passed in several other countries. The principal driver is to improve lighting efficiency in order to reduce carbon dioxide emissions.

Incandescent (tungsten) bulbs have been replaced largely by compact fluorescent lamps (CFLs) and light emitting diodes (LEDs). CFLs with a bare tube are generally termed “single envelope” CFLs and those in which the tube is enclosed in a glass or polycarbonate cover are designated “double envelope” bulbs.

The UV spectrum is usually divided according to wavelength into UVA (315-400nm) which is closest to visible light, UVB (280-315nm) and UVC (100-280nm). The UV emission from each light source is very different. Although the traditional tungsten lamp emits measureable amounts of UVA, the UVB levels are extremely low and the heat from this lamp limits exposure at close distance. In contrast, the CFL emissions are widely variable, depending on the individual lamp. The single envelope CFL in particular has been shown to emit significant quantities of UVB in some cases and also measureable amounts of UVC. Light emitting diodes (LEDs) have virtually no UV emission.

There are many skin conditions caused or exacerbated by exposure to UV radiation. These include polymorphic light eruption, chronic actinic dermatitis, solar urticaria, xeroderma pigmentosum and lupus erythematosus. Investigations carried out on photosensitive patients have shown that exposure to single envelope CFL can induce an erythematous reaction in photosensitive individuals. The number of reactions was much reduced when double envelope CFLs were used and, for all UV-sensitive patients, responses to exposure from the LED were negative. Currently, there is no scheme in place to indicate to photosensitive patients or to healthcare professionals which lamps are safe to use. Some patients, including those with lupus and some other connective tissue diseases, describe a variety of symptoms both in the skin and systemically. Investigations carried out in patients with light-sensitive skin disorders found that CFLs, when situated in close proximity to the skin, can induce erythema that is more pronounced and persistent than in healthy individuals. Energy efficient halogen lamps can also induce skin erythema in some light-sensitive individuals. LEDs provide a safer alternative without the UV skin risk but it should be noted that they do exhibit a strong blue/violet emission.

The exposure to UV radiation is also recognised as a risk factor for skin cancer. However, any change in personal risk as a result of exposure to UV from CFLs is considered to be very small and much less than the risk from UV exposure outdoors.

Occupational exposure to UV radiation within the EU is subject to the Artificial Optical Radiation Directive which specifies exposure limit values for workers and also obliges the employer to consider any effects concerning safety of staff belonging to particularly sensitive groups. It should also be noted that the Health Protection Agency has issued precautionary advice to the public to maintain a distance of at least 30cm from a single envelope CFL.

Recommendations

  • CFLs present a low level of risk to the skin of individuals of normal sensitivity but are potentially harmful to photosensitive patients.
  • Some single envelope CFLs emit detectable levels of UVA, UVB and UVC that may provoke a skin reaction in photosensitive individuals.
  • Double envelope CFLs emit lower levels of UVB and UVC and are therefore a safer alternative for UV-sensitive individuals.
  • LEDs have minimal UV emissions and are therefore a safer alternative to CFLs for UV-sensitive individuals.
  • We advocate the introduction of a lamp classification scheme suitable for UV-sensitive individuals.


References

1 Eadie E, Ferguson J, Moseley H. A preliminary investigation into the effect of exposure of photosensitive individuals to light from compact fluorescent lamps. British Journal of Dermatology 2009; 160: 659-64.

2 Fenton L, Ferguson J, Moseley H. Analysis of energy saving lamps for use by photosensitive individuals. Photochemistry and Photobiological Sciences 2012; 11.

3 Moseley H, Ferguson J. The risk to normal and photosensitive individuals from exposure to light from compact fluorescent lamps. Photodermatology, Photoimmunology & Photomedicine 2011; 27: 131-7.

4 Khazova M, O’Hagan JB. Optical radiation emissions from compact fluorescent lamps. Radiation Protection Dosimetry 2008; 131: 521-5.

5 Nuzum-Klein A, Sontheimer R. Ultraviolet light output of compact fluorescent lamps: comparison to conventional incandescent and halogen residential lighting sources. Lupus 2009; 18: 556-60.

6 Sayre R, Dowdy J, Poh-Fitzpatrick M. Dermatolgical risk of indoor ultraviolet exposure from contemporary lighting sources. Photochemistry and Photobiology 2004; 80: 47-51.

7 Scientific Committee on Emerging and Newly Identified Health Risks. European Commission, Directorate-General for Health & Consumers. Health effects of artificial light. Opinion adopted on 19th March 2012. Available at: http://ec.europa.eu/health/scientific_committees/emerging/opinions/index_en.htm

8. Fenton L, Ferguson J, Ibbbotson S, Mosley H. Energy-saving lamps and their impact on photosensitive and normal individuals. British Journal of Dermatology 2013; 169: 910-915

9. Fenton L, Moseley H. UV emissions from low energy artificial light sources. Photodermatology, Photoimmunology & Photomedicine 2014; 30: 153-159

10.Fenton L, Dawe R, Ibbotson S, Ferguson J, Silburn S, Moseley H. Impact assessment of energy-efficient lighting in patients with lupus erythematosus: a pilot study.British Journal of Dermatology 2014; 170: 694-698

 

PRODUCED JANUARY 2013

UPDATED JULY 2016

REVIEW DATE JULY 2019

 

Photodynamic Therapy

Background

Topical photodynamic therapy (PDT) is widely used in Dermatology and involves photoactivation of a tissue-localised photosensitiser, with resulting photodynamic effect. To date, mainly porphyrin pro-drugs have been used. Topical PDT is highly effective for superficial non-melanoma skin cancer (NMSC) and dysplasia and is at least as effective as cryotherapy and imiquimod for actinic keratosis (AK), 5-fluorouracil and cryotherapy for Bowen’s disease (BD), and cryotherapy and surgery for superficial basal cell carcinoma (SBCC). Cosmetic outcome and patient preference is superior for PDT in comparative studies. Long-term recurrence rates are approximately 20-25% by three to five years which is consistent with other non-surgical therapies. British and European guidelines summarise the evidence base for topical PDT1-5

PDT is an important and advantageous therapeutic option for patients with multiple or large lesions and for field change and specific body sites where healing is compromised, such as the lower leg. It can be effectively used in immunosuppressed patients. For nodular BCC, topical PDT is inferior to surgery with follow-up to five years and topical PDT would not be the treatment of choice for nodular BCC unless surgery was contraindicated. Topical PDT is not recommended for invasive squamous cell carcinoma, malignant melanoma, other heavily pigmented tumours or subcutaneous metastases.

Topical PDT is generally well tolerated, although pain during irradiation can occur. Pain relief can usually be achieved by simple measures, such as cooling and reduction of irradiance of light delivery. The latter is being explored by use of very low irradiance portable or daylight PDT regimes. Nerve blockade is only occasionally required. There is a growing evidence-base to support the use of daylight PDT for field change mild to moderate actinic keratoses affecting larger areas on the face and scalp, with encouraging data showing treatment to be as effective but much less painful than hospital-based PDT for this indication6,7,8

Topical PDT was assessed by NICE (Interventional procedures guidance 155 (February 2006); Medical Technologies Guidance MTG6 (July 2011)). Topical PDT was also included in a systematic review of PDT in Oncology9 and was reviewed by the Department of Health.

In summary, topical PDT should be widely available in dermatology, and accessible to all involved in the management of patients via skin cancer pathways. Its main use should be for superficial AK, BD and SBCC and it is advantageous for patients with large and multiple lesions, field carcinogenesis, and difficult treatment sites such as the lower leg. Treatment outcomes should be recorded by local governance mechanisms. 

Recommendations

  • Topical PDT should be accessible to all dermatology departments and particularly for those involved in skin cancer management.
  • Topical PDT should be considered for patients with a diagnosis of superficial basal cell carcinoma, Bowen’s disease or actinic keratosis.
  • Topical PDT should be considered as treatment of choice for Bowen’s disease on the lower leg because of the proven reduction in risk of complications at this site.
  • Topical PDT is particularly advantageous and should be considered as first-line treatment for patients with large, multiple, low risk lesions and field change carcinogenesis, including in immunosuppressed patients.
  • Daylight PDT can be considered for use as a relatively painless effective treatment for patients with field change actinic keratoses on the face and scalp
  • Mechanisms of governance are desirable and should be encouraged in order to monitor treatment delivery and outcomes (the principles of phototherapy guidelines are allied and may be a useful resource to adapt in this context).

References

1 Morton CA, Brown SB, Collins Set al. Guidelines for topical photodynamic therapy: report of a workshop of the British Photodermatology Group. Br J Dermatol 2002; 146: 552-67.

2 Morton CA, McKenna KE, Rhodes LEet al. Guidelines for topical photodynamic therapy: update. Br J Dermatol 2008; 159: 1245-66.

3 Braathen LR, Szeimies RM, Basset-sequin Net al. Guidelines on the use of photodynamic therapy for nonmelanoma skin cancer: an international consensus. J Am Acad Dermatol 2007; 56: 125-43.

4 Morton CA, Szemies C, Sidoroff A et al. European guidelines for topical photodynamic therapy part 1: treatment delivery and current indications – actinic keratoses, Bowen’s disease, basal cell carcinoma. J Euro Acad Derm Venereol 2013; 27: 536-44

5 Morton CA, Szemies C, Sidoroff A et al. European guidelines for topical photodynamic therapy part 2: emerging indications – field cancerization, photorejuvenation and inflammatory/infective dermatoses. J Euro Acad Derm Venereol 2013; 27: 672-79

6. Wiegell SR, Wulf HC, Szeimies R-M et al. Daylight photodynamic therapy for actinic keratosis: an international consensus. J Euro Acad Dermatol Venerol 2012; 26: 673-79

7. Rubel DM, Spelman L, Murrell DFet al. Daylight photodynamic therapy with methyl aminolevulinate cream as a convenient, similarly effective, nearly painless alternative to conventional photodynamic therapy in actinic keratosis treatment: a randomized controlled trial. Br J Dermatol 2014; 171: 1134-71

8. Lacour J-P, Ulrich C, Gilaberte Y et al. Daylight photodynamic therapy with methyl aminolevulinate cream is effective and nearly painless in treating actinic keratoses: a randomised, investigator-blinded, controlled, phase III study throughout Europe. J Euro Acad Dermatol Venereol 2015; 29: 2342-48

9. Fayter D, Corbett M, Heirs Met al. A systematic review of photodynamic therapy in the treatment of pre-cancerous skin conditions, Barrett's oesophagus and cancers of the bilary tract, brain, head and neck, lung, oesophagus and skin. Health Technol Assess 2010; 14: No.37

 

PRODUCED JANUARY 2013

UPDATED JULY 2016

REVIEW DATE JULY 2019

 

Sun Protection in Schools

Background

Education can change behaviour (1) and school based educational interventions have been shown to raise children’s knowledge and awareness of sun safety (2).  Therefore promotion of sun safety in schools, particularly at primary level when behaviour is most likely to be influenced, is expected to lead to a long-term reduction in skin cancer incidence (3).

Recommendations

  • The BPG strongly recommends that educational activities to promote and to sustain sun awareness be part of the curriculum in all schools.  This should encompass:

Awareness of the risks of both natural sunlight and sun beds.

Promotion of methods to limit exposure through:

- Seeking shade

- Use of protective clothing and hats

- Use of broad spectrum, high SPF sun creams

  • Schools should be aware that sunburn (skin redness following sun exposure) should always be avoided and should be aware of the “SunSmart” schools resources (4).
  • Sun awareness education should be balanced, appropriate to the level of risk of individuals and not discourage outdoors activities, which have known benefits (physical activity, well being, vitamin D synthesis).  Advice should be reinforced regularly.
  • Environmental shade should be provided in schools wherever feasible (5).
  • Staff should act as positive role models.
  • Teachers should be aware that occasionally an individual child may be particularly at risk of adverse effects on health from sun exposure (through a photosensitive skin condition/sun allergy, or with increased risk of skin cancer) and have special needs with regards to sun protection.

References

1.Behaviour change.  NICE public health guidance 6 (2007).  Available from

2. Sun protection and sunburn in primary school children: the influence of age, gender and coloring.  Dixon H, Borland R, Hill D.  Prev Med 1999 28 (2) 119-30

3.  Targeting children through school based education and policy strategies: comprehensive cancer control activities in melanoma prevention.  J Am Acad Dermatol 2011 65 (S)104-13

4. SunSmart schools resources from www. Sunsmart.org.uk/schools/schoolsresources/sunsmart-schools-resources

5 Skin cancer prevention: information, resources and environmental changes

PRODUCED JANUARY 2013

REVIEW DATE DECEMBER 2015

British Photodermatology Group  www.bpg.org.uk

The British Photodermatology Group (BPG) is a special interest society of the British Association of Dermatologists, and acts as a forum of communication for all those with an interest in photodermatology.

 

Vitamin D

Background

Vitamin D is essential for bone health. The sources of vitamin D are diet and sunlight exposure, with sunlight being a major source in most people 1. However, the ultraviolet radiation in sunlight is the main cause of both melanoma and non melanoma skin cancer.  The sunlight exposure time to make significant vitamin D varies according to a number of environmental, physical and personal factors, but is typically short and less than the amount of time needed for skin to redden and burn 2,3. In fact, long exposures can break down vitamin D, reducing benefit whilst increasing risk of skin cancer 4. Casual brief sun exposures, while taking care not to burn and avoiding deliberate tanning, can help the body become vitamin D sufficient. Apart from oily fish, natural foods contain little vitamin D, but it can also be obtained through fortified foods and vitamin D supplements, the latter being particularly needed in those at risk of low levels. Presently, there is still uncertainty regarding vitamin D, including what levels qualify as “optimal” or “sufficient”, the risk/benefit balance of sunlight in people of different skin types and colours, whether vitamin D protects against chronic diseases such as cancer, heart disease and diabetes, and the benefits and risks of widespread supplementation. These and related areas are currently under review in the UK 5.

Recommendations

Vitamin D and health

·         Everyone needs vitamin D, which is essential for good bone health. Low levels are linked to bone disorders including rickets in children, and osteomalacia and osteoporosis in adults 4.

·         The evidence suggesting vitamin D might protect against cancer, heart disease, diabetes, multiple sclerosis and other chronic diseases is still inconclusive 6. Some studies have supported that high levels of vitamin D are associated with a reduced risk of bowel cancer. However, even for bowel cancer, it is too early to say if vitamin D directly protects against this cancer or if it reflects another aspect of our health 7.

Vitamin D status and levels

·         There is currently no accepted ‘optimal’ level of vitamin D. However, blood levels of 25(OH)D below 5-10 ng/ml (12.5-25 nmol/L) are agreed to be “deficient” since the severe bone disorders of rickets and osteomalacia can occur below these levels 1,4. Some authorities state that a 25(OH)D level of 20 ng/ml (50 nmol/L) represents a “sufficient” level, based on bone health findings 6.

·         Levels of 25(OH)D greater than 50 ng/ml (125 nmol/l) are not recommended 6,8.

Sunlight/ultraviolet radiation, skin cancer and vitamin D

·         Sun exposure is a major source of vitamin D in the UK 2,9, but particularly when excessive, is known to be the main cause of both melanoma and non melanoma skin cancers, which continue to escalate in number in the UK 10.

·         Environmental, physical and personal factors influence risk/benefit of sunlight exposure 4. In white-skinned people, casual short sun exposures a few times per week, taking particular care not to burn and avoiding deliberate tanning, can help provide the benefits of vitamin D while minimising risks 2,3.

·         Sunbed use increases the risk of skin cancer, and is not recommended as a method for enhancing vitamin D status 11.

Dietary vitamin D and vitamin D supplements

·         Vitamin D supplements, fortified foods such as fat spreads, and natural dietary sources particularly oily fish (including salmon, trout and sardines) can be useful for helping to maintain levels of vitamin D. These sources are particularly important during the winter and among people at higher risk of low vitamin D 1.

·         Population groups at particular risk of low vitamin D include pregnant and breastfeeding women, young children, older people, darker-skinned people, those who wear whole-body coverings or live in institutions. The Government currently recommends these groups take a 10 microgram (400 iu) vitamin D supplement a day (7 micrograms a day for children 6 months - 5 years) 1,12.

·         Certain patient groups are also at particular risk of low vitamin D. This includes patients medically advised to minimise sunlight exposure, i.e. those with photosensitivity/ photodermatoses (sun rashes), patients with skin cancer, and with increased risk of skin cancer including individuals who are immunosuppressed or  genetically prone. It is recommended that a blood test for vitamin D level is taken before and during treatment, to assess need for supplements and response to these.

·         Currently in the UK there is no recommendation for widespread vitamin D supplementation for the general population. Unlike vitamin D produced in the skin, which is biologically regulated, there is the potential that vitamin D from supplements and fortified foods could build up to high levels 4.

Reviews and recommendations on vitamin D

·         Vitamin D in the UK is an area under active research and debate, and is under current review by Government authorities 5

References

1.      Ashwell M, Stone EM, Stolte H et al. UK Foods Standards Agency Workshop Report: an investigation of the relative contributions of diet and sunlight to vitamin D status. Br J Nutr 2010; 104: 603-11.

2.      Webb AR, Kift R, Durkin MT et al.  The role of sunlight exposure in determining the vitamin D status of the UK white adult population. Br J Dermatol 2010; 163: 1050-55.

3.      Rhodes LE, Webb AR, Fraser HI et al.  Recommended summer sunlight exposure levels can produce sufficient (≥20 ng/ml) but not the proposed optimal (≥32 ng/ml) 25(OH)D levels at UK latitudes.  J Invest Dermatol. 2010; 130: 1411-8.

4.      National Radiological Protection Board. Health effects from ultraviolet radiation. Report of an advisory group on non-ionising radiation. Vol. 13. Didcot, United Kingdom: NRPB, 2002.

5.      Scientific Advisory Committee on Nutrition. http://www.sacn.gov.uk/

6.      Institute of Medicine. Dietary reference intakes for calcium and vitamin D. Washington, DC: The National Academy Press, 2011.

7.      International Agency for Research on Cancer.  2008. Vitamin D and Cancer.  IARC Working Group Reports. vol. 5. Lyon: International Agency for Research on Cancer. World Health Organisation.

8.      Michaelsson K, Baron JA, Snellman G et al. Plasma vitamin D and mortality in older men: a community-based prospective cohort study.  Am J Clin Nutr 2010; 92: 841-8.

9.      Macdonald HM, Mavroeidi A, Fraser WD et al.  Sunlight and dietary contributions to the seasonal vitamin D status of cohorts of healthy postmenopausal women living at northerly latitudes: a major cause for concern?  Osteoporos Int 2011; 22: 2461-72.

10.   Cancer Research UK.  http://www.cancerresearchuk.org/

11.   International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer.  The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systematic review.  Int J Cancer. 2007; 120: 1116-22.

12.   Department of Health (Great Britain). Nutrition and bone health with particular reference to calcium and vitamin D: report of the Subgroup on Bone Health, Working Group on the Nutritional Status of the Population of the Committee on Medical Aspects of Food and Nutrition Policy. London, United Kingdom: Stationery Office, 1998.

 

PRODUCED JANUARY 2013

REVIEW DATE DECEMBER 2015

 

British Photodermatology Group  www.bpg.org.uk

The British Photodermatology Group (BPG) is a special interest society of the British Association of Dermatologists, and acts as a forum of communication for all those with an interest in photodermatology.

 

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