Practical Pearls

What does your patient need to know 
at the first visit?

Melanoma patient visits and communications are complicated. When possible, you can preview the surgical and prognostic expectations with the patient when you see the lesion clinically for the first time, especially for a lesion that you’re sure is melanoma before it even hits the specimen cup. Sometimes you have to convey important biopsy and treatment information over the telephone, or sometimes you have the luxury of an extra clinic visit to discuss it with the patient and perhaps a family member in person.

During the first set of conversations, I explain the things that are tangible: the depth of the lesion, the relationship it has to prognosis, surgical options based on staging, further testing/referrals, and known risk factors. Then I wait. The digestion phase is critical before you hang up and schedule a surgery.

Probably the most important thing I tell patients is that melanoma is unpredictable. Not everyone has the same kind of “surgery,” we don’t say “remission,” we don’t have a certain “chemo” that we know will be best, and not everyone will need “CAT scans.” I tell patients that they’re stuck with me. Skin examinations, talk of sun protection, photography of nevi, upkeep of health maintenance visits with other specialists (eg, primary care physician, optometry/ophthalmology, gynecology, dentistry), and education of family members on melanoma risk factors will be the norm.

What are your go-to treatments?

In the past, surgical management was perhaps streamlined, but as we learn more about melanoma tumor biology, the less we can form generalizable guidelines for surgery, margin control, and lymph node perusal. Wide local excision is paramount, but the evidence that guidelines for 0.5-cm, 1-cm, and 2-cm margins or greater fit for all types of tumors is lacking, and many have challenged the recommended margins, particularly for lentigo maligna subtypes (Kunishige et al).

The 0.75-mm Breslow depth threshold guides my sentinel lymph node (SLN) discussion, with upstaging based on primary tumor mitotic index and/or ulceration. But SLN biopsy is always still a discussion and not a foregone conclusion because the 
risk-benefit ratio and prognostic/survival data are very difficult to dissect for some cases. Certainly, mention of SLN biopsy morbidity, including lymphedema, is warranted before the patient consents. Then there is further explanation that more invasive lymphadenectomy could occur based on SLN findings. If applicable in advanced cases, options for imaging and adjuvant therapy are introduced by us but then primarily led by oncologists.

Patients are generally pleased that the approach to melanoma surgery, reconstruction, SLN biopsy, and oncologic care is increasingly becoming (almost) harmoniously multidisciplinary. Larger institutions have streamlined their melanoma providers into shared clinics or at least regional networks—dermatologists, plastic/otolaryngology/oncologic surgeons, oncologists, and radiation oncologists, for instance—and simplified patient access based on individual tumor treatment plans. Dr. Christopher J. Miller at Penn Medicine (Philadelphia, Pennsylvania) is excelling at a collaborative surgical approach for melanoma between dermatologic surgery and specialties such as otolaryngology and also spearheading the Mohs micrographic surgery approach for primary melanoma as possible standard of care for some cases (Etzkorn et al).

Also evolving is the access to clinical trials and care coordination regarding the most novel metastatic melanoma therapies, which can now be a short drive away for most patients as the National Cancer Institute broadens its clinical trial reach.

After the diagnosis of melanoma is made, care is becoming much more individualized for surgery and beyond, but true morbidity and mortality benefit for the more complicated regimens has become anybody’s guess as this research field grossly and rapidly swells. Then these discussions with the patient become longer and more open-ended.

How do you keep patients compliant 
with treatment?

Initial surgery and multidisciplinary management requires meticulous communication between providers to ensure that pathology reports, surgical findings, imaging, wound care, and follow-up are transparent. The easier it is for patients to navigate the medical system(s), the more likely they are to comply. Voicemail, e-mails, text messages, and/or mailings are standard for different offices for reminders, but an old-fashioned telephone call goes a long way for a patient who has melanoma on his/her mind. Adherence to sun protection, health maintenance, and skin examination appointments is then the challenge.

Sun protection strategies were well-represented in the Cutis July issue’s Practical Pearls featuring 
Dr. Vincent A. DeLeo. My script for sunscreen-averse patients as I leave the room is “Take a mosey through the sunscreen aisle. You may be surprised at what you find.” And sporting goods stores are chock full of UPF (UV protection factor) clothing 
options. I’m not a scolder, but I do utilize the power of repetition/the squeaky wheel.

Patient delay or cancellation of skin checks requires other types of surveillance. Here at Geisinger Health System (State College, Pennsylvania), when melanoma patients check out, they are placed in a “priority appointment” slot, meaning that if they cancel, their names are automatically put on an electronic list that is compiled weekly by our schedulers to ensure that patients are called for another appointment. To avert telephone tag and delay of care, melanoma patients also get our direct nurses station extension and are encouraged to use our chart e-mail system to communicate with us if they notice a new or changing skin lesion.

What do you do if they refuse treatment?

Initial consent and compliance with melanoma wide local excision are rarely challenged by a well-informed patient, but what I find more common is delay in treatment and nonadherence to periodic skin examinations.

What resources do you recommend 
to patients for more information?

The National Comprehensive Cancer Network clini-cal practice guideline resource in oncology (melanoma) is the place to start, as their Web site is easily naviga-ble for patients and providers (http://www.nccn.org).

The American Academy of Dermatology 
(http://www.aad.org) and Skin Cancer Foundation (http://www.skincancer.org) Web sites also provide useful information, and there are always copies of their key melanoma and nevi surveillance pamphlets in our office.

Most recently, my melanoma patients have been inspired by another local patient and her cause: a 28-year-old woman with metastatic melanoma on a National Cancer Institute BRAF inhibitor clinical trial who plans to run an Ironman race this year (Thomason, Ames). Her motivation to maintain her baseline health and fitness while still reaching for this further remarkable goal gives fellow melanoma patients a source for enthusiasm and hope.

Inspiration and adherence come in all shapes and sizes for patients with melanoma. I find you need to throw multiple resources and strategies at them and see what sticks.

What does your patient need to know 
at the first visit?

Melanoma patient visits and communications are complicated. When possible, you can preview the surgical and prognostic expectations with the patient when you see the lesion clinically for the first time, especially for a lesion that you’re sure is melanoma before it even hits the specimen cup. Sometimes you have to convey important biopsy and treatment information over the telephone, or sometimes you have the luxury of an extra clinic visit to discuss it with the patient and perhaps a family member in person.

During the first set of conversations, I explain the things that are tangible: the depth of the lesion, the relationship it has to prognosis, surgical options based on staging, further testing/referrals, and known risk factors. Then I wait. The digestion phase is critical before you hang up and schedule a surgery.

Probably the most important thing I tell patients is that melanoma is unpredictable. Not everyone has the same kind of “surgery,” we don’t say “remission,” we don’t have a certain “chemo” that we know will be best, and not everyone will need “CAT scans.” I tell patients that they’re stuck with me. Skin examinations, talk of sun protection, photography of nevi, upkeep of health maintenance visits with other specialists (eg, primary care physician, optometry/ophthalmology, gynecology, dentistry), and education of family members on melanoma risk factors will be the norm.

What are your go-to treatments?

In the past, surgical management was perhaps streamlined, but as we learn more about melanoma tumor biology, the less we can form generalizable guidelines for surgery, margin control, and lymph node perusal. Wide local excision is paramount, but the evidence that guidelines for 0.5-cm, 1-cm, and 2-cm margins or greater fit for all types of tumors is lacking, and many have challenged the recommended margins, particularly for lentigo maligna subtypes (Kunishige et al).

The 0.75-mm Breslow depth threshold guides my sentinel lymph node (SLN) discussion, with upstaging based on primary tumor mitotic index and/or ulceration. But SLN biopsy is always still a discussion and not a foregone conclusion because the 
risk-benefit ratio and prognostic/survival data are very difficult to dissect for some cases. Certainly, mention of SLN biopsy morbidity, including lymphedema, is warranted before the patient consents. Then there is further explanation that more invasive lymphadenectomy could occur based on SLN findings. If applicable in advanced cases, options for imaging and adjuvant therapy are introduced by us but then primarily led by oncologists.

Patients are generally pleased that the approach to melanoma surgery, reconstruction, SLN biopsy, and oncologic care is increasingly becoming (almost) harmoniously multidisciplinary. Larger institutions have streamlined their melanoma providers into shared clinics or at least regional networks—dermatologists, plastic/otolaryngology/oncologic surgeons, oncologists, and radiation oncologists, for instance—and simplified patient access based on individual tumor treatment plans. Dr. Christopher J. Miller at Penn Medicine (Philadelphia, Pennsylvania) is excelling at a collaborative surgical approach for melanoma between dermatologic surgery and specialties such as otolaryngology and also spearheading the Mohs micrographic surgery approach for primary melanoma as possible standard of care for some cases (Etzkorn et al).

Also evolving is the access to clinical trials and care coordination regarding the most novel metastatic melanoma therapies, which can now be a short drive away for most patients as the National Cancer Institute broadens its clinical trial reach.

After the diagnosis of melanoma is made, care is becoming much more individualized for surgery and beyond, but true morbidity and mortality benefit for the more complicated regimens has become anybody’s guess as this research field grossly and rapidly swells. Then these discussions with the patient become longer and more open-ended.

How do you keep patients compliant 
with treatment?

Initial surgery and multidisciplinary management requires meticulous communication between providers to ensure that pathology reports, surgical findings, imaging, wound care, and follow-up are transparent. The easier it is for patients to navigate the medical system(s), the more likely they are to comply. Voicemail, e-mails, text messages, and/or mailings are standard for different offices for reminders, but an old-fashioned telephone call goes a long way for a patient who has melanoma on his/her mind. Adherence to sun protection, health maintenance, and skin examination appointments is then the challenge.

Sun protection strategies were well-represented in the Cutis July issue’s Practical Pearls featuring 
Dr. Vincent A. DeLeo. My script for sunscreen-averse patients as I leave the room is “Take a mosey through the sunscreen aisle. You may be surprised at what you find.” And sporting goods stores are chock full of UPF (UV protection factor) clothing 
options. I’m not a scolder, but I do utilize the power of repetition/the squeaky wheel.

Patient delay or cancellation of skin checks requires other types of surveillance. Here at Geisinger Health System (State College, Pennsylvania), when melanoma patients check out, they are placed in a “priority appointment” slot, meaning that if they cancel, their names are automatically put on an electronic list that is compiled weekly by our schedulers to ensure that patients are called for another appointment. To avert telephone tag and delay of care, melanoma patients also get our direct nurses station extension and are encouraged to use our chart e-mail system to communicate with us if they notice a new or changing skin lesion.

What do you do if they refuse treatment?

Initial consent and compliance with melanoma wide local excision are rarely challenged by a well-informed patient, but what I find more common is delay in treatment and nonadherence to periodic skin examinations.

What resources do you recommend 
to patients for more information?

The National Comprehensive Cancer Network clini-cal practice guideline resource in oncology (melanoma) is the place to start, as their Web site is easily naviga-ble for patients and providers (http://www.nccn.org).

The American Academy of Dermatology 
(http://www.aad.org) and Skin Cancer Foundation (http://www.skincancer.org) Web sites also provide useful information, and there are always copies of their key melanoma and nevi surveillance pamphlets in our office.

Most recently, my melanoma patients have been inspired by another local patient and her cause: a 28-year-old woman with metastatic melanoma on a National Cancer Institute BRAF inhibitor clinical trial who plans to run an Ironman race this year (Thomason, Ames). Her motivation to maintain her baseline health and fitness while still reaching for this further remarkable goal gives fellow melanoma patients a source for enthusiasm and hope.

Inspiration and adherence come in all shapes and sizes for patients with melanoma. I find you need to throw multiple resources and strategies at them and see what sticks.

What does your patient need to know 
at the first visit?

Melanoma patient visits and communications are complicated. When possible, you can preview the surgical and prognostic expectations with the patient when you see the lesion clinically for the first time, especially for a lesion that you’re sure is melanoma before it even hits the specimen cup. Sometimes you have to convey important biopsy and treatment information over the telephone, or sometimes you have the luxury of an extra clinic visit to discuss it with the patient and perhaps a family member in person.

During the first set of conversations, I explain the things that are tangible: the depth of the lesion, the relationship it has to prognosis, surgical options based on staging, further testing/referrals, and known risk factors. Then I wait. The digestion phase is critical before you hang up and schedule a surgery.

Probably the most important thing I tell patients is that melanoma is unpredictable. Not everyone has the same kind of “surgery,” we don’t say “remission,” we don’t have a certain “chemo” that we know will be best, and not everyone will need “CAT scans.” I tell patients that they’re stuck with me. Skin examinations, talk of sun protection, photography of nevi, upkeep of health maintenance visits with other specialists (eg, primary care physician, optometry/ophthalmology, gynecology, dentistry), and education of family members on melanoma risk factors will be the norm.

What are your go-to treatments?

In the past, surgical management was perhaps streamlined, but as we learn more about melanoma tumor biology, the less we can form generalizable guidelines for surgery, margin control, and lymph node perusal. Wide local excision is paramount, but the evidence that guidelines for 0.5-cm, 1-cm, and 2-cm margins or greater fit for all types of tumors is lacking, and many have challenged the recommended margins, particularly for lentigo maligna subtypes (Kunishige et al).

The 0.75-mm Breslow depth threshold guides my sentinel lymph node (SLN) discussion, with upstaging based on primary tumor mitotic index and/or ulceration. But SLN biopsy is always still a discussion and not a foregone conclusion because the 
risk-benefit ratio and prognostic/survival data are very difficult to dissect for some cases. Certainly, mention of SLN biopsy morbidity, including lymphedema, is warranted before the patient consents. Then there is further explanation that more invasive lymphadenectomy could occur based on SLN findings. If applicable in advanced cases, options for imaging and adjuvant therapy are introduced by us but then primarily led by oncologists.

Patients are generally pleased that the approach to melanoma surgery, reconstruction, SLN biopsy, and oncologic care is increasingly becoming (almost) harmoniously multidisciplinary. Larger institutions have streamlined their melanoma providers into shared clinics or at least regional networks—dermatologists, plastic/otolaryngology/oncologic surgeons, oncologists, and radiation oncologists, for instance—and simplified patient access based on individual tumor treatment plans. Dr. Christopher J. Miller at Penn Medicine (Philadelphia, Pennsylvania) is excelling at a collaborative surgical approach for melanoma between dermatologic surgery and specialties such as otolaryngology and also spearheading the Mohs micrographic surgery approach for primary melanoma as possible standard of care for some cases (Etzkorn et al).

Also evolving is the access to clinical trials and care coordination regarding the most novel metastatic melanoma therapies, which can now be a short drive away for most patients as the National Cancer Institute broadens its clinical trial reach.

After the diagnosis of melanoma is made, care is becoming much more individualized for surgery and beyond, but true morbidity and mortality benefit for the more complicated regimens has become anybody’s guess as this research field grossly and rapidly swells. Then these discussions with the patient become longer and more open-ended.

How do you keep patients compliant 
with treatment?

Initial surgery and multidisciplinary management requires meticulous communication between providers to ensure that pathology reports, surgical findings, imaging, wound care, and follow-up are transparent. The easier it is for patients to navigate the medical system(s), the more likely they are to comply. Voicemail, e-mails, text messages, and/or mailings are standard for different offices for reminders, but an old-fashioned telephone call goes a long way for a patient who has melanoma on his/her mind. Adherence to sun protection, health maintenance, and skin examination appointments is then the challenge.

Sun protection strategies were well-represented in the Cutis July issue’s Practical Pearls featuring 
Dr. Vincent A. DeLeo. My script for sunscreen-averse patients as I leave the room is “Take a mosey through the sunscreen aisle. You may be surprised at what you find.” And sporting goods stores are chock full of UPF (UV protection factor) clothing 
options. I’m not a scolder, but I do utilize the power of repetition/the squeaky wheel.

Patient delay or cancellation of skin checks requires other types of surveillance. Here at Geisinger Health System (State College, Pennsylvania), when melanoma patients check out, they are placed in a “priority appointment” slot, meaning that if they cancel, their names are automatically put on an electronic list that is compiled weekly by our schedulers to ensure that patients are called for another appointment. To avert telephone tag and delay of care, melanoma patients also get our direct nurses station extension and are encouraged to use our chart e-mail system to communicate with us if they notice a new or changing skin lesion.

What do you do if they refuse treatment?

Initial consent and compliance with melanoma wide local excision are rarely challenged by a well-informed patient, but what I find more common is delay in treatment and nonadherence to periodic skin examinations.

What resources do you recommend 
to patients for more information?

The National Comprehensive Cancer Network clini-cal practice guideline resource in oncology (melanoma) is the place to start, as their Web site is easily naviga-ble for patients and providers (http://www.nccn.org).

The American Academy of Dermatology 
(http://www.aad.org) and Skin Cancer Foundation (http://www.skincancer.org) Web sites also provide useful information, and there are always copies of their key melanoma and nevi surveillance pamphlets in our office.

Most recently, my melanoma patients have been inspired by another local patient and her cause: a 28-year-old woman with metastatic melanoma on a National Cancer Institute BRAF inhibitor clinical trial who plans to run an Ironman race this year (Thomason, Ames). Her motivation to maintain her baseline health and fitness while still reaching for this further remarkable goal gives fellow melanoma patients a source for enthusiasm and hope.

Inspiration and adherence come in all shapes and sizes for patients with melanoma. I find you need to throw multiple resources and strategies at them and see what sticks.

What do your patients need to know at the first visit?

Pregnant patients need to know that it is important to carefully monitor them throughout their pregnancy. Although many drugs are not contraindicated, it is still important for the dermatologist to consult with the patient’s obstetrician to discuss risks and benefits of different therapies. Some women see an improvement in the severity of their psoriasis during pregnancy, while others report their condition gets worse. Changes in severity of psoriasis vary by individual and from pregnancy to pregnancy.

What are your go-to treatments? What are the side effects?

UV therapy, particularly narrowband UVB, is a good choice during pregnancy. Excimer laser is another good choice. Topical therapies are standardly employed. Although many of these topical therapies are pregnancy category C, we still employ them regularly in consultation with the patient’s obstetrician. Most biologic therapies are pregnancy category B. We still use these drugs with caution in the setting of pregnancy. If a pregnant patient does wish to continue a biologic therapy, close monitoring and enrollment in a pregnancy registry (http: //www.pregnancystudies.org) would be good options. This registry is analyzing whether medications that are used to treat autoimmune diseases are safe to take during pregnancy. Specifically, the investigators are looking at medications used to treat Crohn disease, rheumatoid arthritis, psoriasis, psoriatic arthritis, and multiple sclerosis. Generally speaking, systemic and biologic drugs should be avoided while pregnant or breastfeeding unless there is a clear medical need. Women of childbearing potential should avoid oral retinoids, methotrexate, and cyclosporine due to a link to birth defects with each of those treatments.

How do you keep patients compliant with treatment?

We see the patients regularly, and I am always available to take telephone calls if any questions arise.

What do you do if patients refuse treatment?

We keep the dialogue ongoing and monitor their condition. They may change their attitude if their condition worsens.

What resources do you recommend to patients for more information?

Patients should consult the National Psoriasis Foundation (http://www.psoriasis.org).

Quick access to more resources on our PSORIASIS page

What do your patients need to know at the first visit?

Pregnant patients need to know that it is important to carefully monitor them throughout their pregnancy. Although many drugs are not contraindicated, it is still important for the dermatologist to consult with the patient’s obstetrician to discuss risks and benefits of different therapies. Some women see an improvement in the severity of their psoriasis during pregnancy, while others report their condition gets worse. Changes in severity of psoriasis vary by individual and from pregnancy to pregnancy.

What are your go-to treatments? What are the side effects?

UV therapy, particularly narrowband UVB, is a good choice during pregnancy. Excimer laser is another good choice. Topical therapies are standardly employed. Although many of these topical therapies are pregnancy category C, we still employ them regularly in consultation with the patient’s obstetrician. Most biologic therapies are pregnancy category B. We still use these drugs with caution in the setting of pregnancy. If a pregnant patient does wish to continue a biologic therapy, close monitoring and enrollment in a pregnancy registry (http: //www.pregnancystudies.org) would be good options. This registry is analyzing whether medications that are used to treat autoimmune diseases are safe to take during pregnancy. Specifically, the investigators are looking at medications used to treat Crohn disease, rheumatoid arthritis, psoriasis, psoriatic arthritis, and multiple sclerosis. Generally speaking, systemic and biologic drugs should be avoided while pregnant or breastfeeding unless there is a clear medical need. Women of childbearing potential should avoid oral retinoids, methotrexate, and cyclosporine due to a link to birth defects with each of those treatments.

How do you keep patients compliant with treatment?

We see the patients regularly, and I am always available to take telephone calls if any questions arise.

What do you do if patients refuse treatment?

We keep the dialogue ongoing and monitor their condition. They may change their attitude if their condition worsens.

What resources do you recommend to patients for more information?

Patients should consult the National Psoriasis Foundation (http://www.psoriasis.org).

Quick access to more resources on our PSORIASIS page

What do your patients need to know at the first visit?

Pregnant patients need to know that it is important to carefully monitor them throughout their pregnancy. Although many drugs are not contraindicated, it is still important for the dermatologist to consult with the patient’s obstetrician to discuss risks and benefits of different therapies. Some women see an improvement in the severity of their psoriasis during pregnancy, while others report their condition gets worse. Changes in severity of psoriasis vary by individual and from pregnancy to pregnancy.

What are your go-to treatments? What are the side effects?

UV therapy, particularly narrowband UVB, is a good choice during pregnancy. Excimer laser is another good choice. Topical therapies are standardly employed. Although many of these topical therapies are pregnancy category C, we still employ them regularly in consultation with the patient’s obstetrician. Most biologic therapies are pregnancy category B. We still use these drugs with caution in the setting of pregnancy. If a pregnant patient does wish to continue a biologic therapy, close monitoring and enrollment in a pregnancy registry (http: //www.pregnancystudies.org) would be good options. This registry is analyzing whether medications that are used to treat autoimmune diseases are safe to take during pregnancy. Specifically, the investigators are looking at medications used to treat Crohn disease, rheumatoid arthritis, psoriasis, psoriatic arthritis, and multiple sclerosis. Generally speaking, systemic and biologic drugs should be avoided while pregnant or breastfeeding unless there is a clear medical need. Women of childbearing potential should avoid oral retinoids, methotrexate, and cyclosporine due to a link to birth defects with each of those treatments.

How do you keep patients compliant with treatment?

We see the patients regularly, and I am always available to take telephone calls if any questions arise.

What do you do if patients refuse treatment?

We keep the dialogue ongoing and monitor their condition. They may change their attitude if their condition worsens.

What resources do you recommend to patients for more information?

Patients should consult the National Psoriasis Foundation (http://www.psoriasis.org).

Quick access to more resources on our PSORIASIS page

What does your patient need to know at the first visit?

Patients need a realistic approach to photoprotection based on their genetics, including Fitzpatrick skin type and family history of melanoma and nonmelanoma skin cancer; skin examination for photodamage and photoaging as well as number and type of pigmented lesions; and lifestyle history, which should include location of residence as well as occupation and recreational pursuits. This discussion should, as usual, include questions about general health, systemic and skin disease, and medication usage, with particular focus on photoaggravated diseases such as lupus and melasma as well as ongoing use of topical agents and systemic photosensitizers. These inquiries should lead to a frank discussion of the patient’s risk for developing photodamage and skin cancer and other specific conditions that alter the advice you would give.

What are your go-to treatments? Is your recommendation anecdotal or evidence based? What are the side effects?

I always recommend that my patients use a product that they like, which may sound simplistic. But if the patient doesn’t like the feel and look of the sunscreen, he/she won’t use it. Patients routinely should use a sunscreen with a sun protection factor (SPF) of 30 or higher that also carries a “broad spectrum” label. At the beach or during sweaty sports, patients should use one with a water-resistant SPF.

I prefer spray sunscreens for application on the back if the patient is alone without someone to help apply sunscreen to hard-to-reach areas and for male scalps. But you never know how much spray to use, so use a lot!

If patients are at the beach, playing sports, or watching sports outside, then they should reapply sunscreen every 2 hours. If patients work indoors and use a facial sunscreen in the morning, that’s sufficient.

Although there is no evidence that sunscreens are harmful for children older than 6 months of age and pregnant women, if patients in these special populations have concerns, I recommend using agents with inorganic compounds (physical blockers) such as titanium dioxide and zinc oxide only. Children are best protected with clothing and hats.

The evidence supports this approach. Patients really don’t need SPF 30 protection, but no one uses the amount of product that will result in the SPF listed on the bottle. So if patients use an SPF 30 or greater, they will get at least an SPF 15, which is sufficient everywhere but at the equator. Using SPF 30 the way we all apply it will give SPF 15–level protection.

There is evidence that sunscreens prevent squamous cell carcinoma, actinic keratosis, and photoaging. Early evidence, less strong but positive, also suggests protection against basal cell carcinoma and melanoma.

The biggest side effect is not using the sunscreen. Others include irritation and allergy. Irritation is common, but finding a product to use without irritation should be easy. Allergy is rarer, and when it occurs, it is usually due to the preservative or fragrance, not the active ingredients. If allergy does occur, patch testing by a dermatologist is necessary to determine the allergen.

Although it is still controversial, wearing sunscreens religiously can lead to vitamin D insufficiency or deficiency, which is particularly true for individuals with skin of color—Fitzpatrick skin types IV, V, and VI—and those cancer patients who adhere to rigorous photoprotection. These patients should be encouraged to take supplemental vitamin D₃ and I suggest 2000 IU; this recommendation is my opinion and is not evidence based.

As to the literature in the laypress about hormonal changes from benzophenone, cancer from retinoids, and nanoparticle toxicity: There is no evidence to support those claims.

How do you keep patients compliant with treatment?

Keep telling them, and then tell them again. 

What do you do if they refuse treatment?

Tell them to see someone else. 

What resources do you recommend to patients for more information?

Consult the American Academy of Dermatology Web site (www.aad.org) and the Skin Cancer Foundation (www.skincancer.org).

Editorial Note

Practical Pearls From the Cutis^® Board is a new feature that will appear in print and online (www.cutis.com). Each month a member of the Cutis Editorial Board will provide pearls relating to the practice needs of dermatologists. Future topics will include:

Looking for pearls on a specific topic? The Editorial Board welcomes your feedback on potential topics. Send an e-mail to the Editorial Office ([email protected]) with your suggestions.

What does your patient need to know at the first visit?

Patients need a realistic approach to photoprotection based on their genetics, including Fitzpatrick skin type and family history of melanoma and nonmelanoma skin cancer; skin examination for photodamage and photoaging as well as number and type of pigmented lesions; and lifestyle history, which should include location of residence as well as occupation and recreational pursuits. This discussion should, as usual, include questions about general health, systemic and skin disease, and medication usage, with particular focus on photoaggravated diseases such as lupus and melasma as well as ongoing use of topical agents and systemic photosensitizers. These inquiries should lead to a frank discussion of the patient’s risk for developing photodamage and skin cancer and other specific conditions that alter the advice you would give.

What are your go-to treatments? Is your recommendation anecdotal or evidence based? What are the side effects?

I always recommend that my patients use a product that they like, which may sound simplistic. But if the patient doesn’t like the feel and look of the sunscreen, he/she won’t use it. Patients routinely should use a sunscreen with a sun protection factor (SPF) of 30 or higher that also carries a “broad spectrum” label. At the beach or during sweaty sports, patients should use one with a water-resistant SPF.

I prefer spray sunscreens for application on the back if the patient is alone without someone to help apply sunscreen to hard-to-reach areas and for male scalps. But you never know how much spray to use, so use a lot!

If patients are at the beach, playing sports, or watching sports outside, then they should reapply sunscreen every 2 hours. If patients work indoors and use a facial sunscreen in the morning, that’s sufficient.

Although there is no evidence that sunscreens are harmful for children older than 6 months of age and pregnant women, if patients in these special populations have concerns, I recommend using agents with inorganic compounds (physical blockers) such as titanium dioxide and zinc oxide only. Children are best protected with clothing and hats.

The evidence supports this approach. Patients really don’t need SPF 30 protection, but no one uses the amount of product that will result in the SPF listed on the bottle. So if patients use an SPF 30 or greater, they will get at least an SPF 15, which is sufficient everywhere but at the equator. Using SPF 30 the way we all apply it will give SPF 15–level protection.

There is evidence that sunscreens prevent squamous cell carcinoma, actinic keratosis, and photoaging. Early evidence, less strong but positive, also suggests protection against basal cell carcinoma and melanoma.

The biggest side effect is not using the sunscreen. Others include irritation and allergy. Irritation is common, but finding a product to use without irritation should be easy. Allergy is rarer, and when it occurs, it is usually due to the preservative or fragrance, not the active ingredients. If allergy does occur, patch testing by a dermatologist is necessary to determine the allergen.

Although it is still controversial, wearing sunscreens religiously can lead to vitamin D insufficiency or deficiency, which is particularly true for individuals with skin of color—Fitzpatrick skin types IV, V, and VI—and those cancer patients who adhere to rigorous photoprotection. These patients should be encouraged to take supplemental vitamin D₃ and I suggest 2000 IU; this recommendation is my opinion and is not evidence based.

As to the literature in the laypress about hormonal changes from benzophenone, cancer from retinoids, and nanoparticle toxicity: There is no evidence to support those claims.

How do you keep patients compliant with treatment?

Keep telling them, and then tell them again. 

What do you do if they refuse treatment?

Tell them to see someone else. 

What resources do you recommend to patients for more information?

Consult the American Academy of Dermatology Web site (www.aad.org) and the Skin Cancer Foundation (www.skincancer.org).

Editorial Note

Practical Pearls From the Cutis^® Board is a new feature that will appear in print and online (www.cutis.com). Each month a member of the Cutis Editorial Board will provide pearls relating to the practice needs of dermatologists. Future topics will include:

Looking for pearls on a specific topic? The Editorial Board welcomes your feedback on potential topics. Send an e-mail to the Editorial Office ([email protected]) with your suggestions.

What does your patient need to know at the first visit?

Patients need a realistic approach to photoprotection based on their genetics, including Fitzpatrick skin type and family history of melanoma and nonmelanoma skin cancer; skin examination for photodamage and photoaging as well as number and type of pigmented lesions; and lifestyle history, which should include location of residence as well as occupation and recreational pursuits. This discussion should, as usual, include questions about general health, systemic and skin disease, and medication usage, with particular focus on photoaggravated diseases such as lupus and melasma as well as ongoing use of topical agents and systemic photosensitizers. These inquiries should lead to a frank discussion of the patient’s risk for developing photodamage and skin cancer and other specific conditions that alter the advice you would give.

What are your go-to treatments? Is your recommendation anecdotal or evidence based? What are the side effects?

I always recommend that my patients use a product that they like, which may sound simplistic. But if the patient doesn’t like the feel and look of the sunscreen, he/she won’t use it. Patients routinely should use a sunscreen with a sun protection factor (SPF) of 30 or higher that also carries a “broad spectrum” label. At the beach or during sweaty sports, patients should use one with a water-resistant SPF.

I prefer spray sunscreens for application on the back if the patient is alone without someone to help apply sunscreen to hard-to-reach areas and for male scalps. But you never know how much spray to use, so use a lot!

If patients are at the beach, playing sports, or watching sports outside, then they should reapply sunscreen every 2 hours. If patients work indoors and use a facial sunscreen in the morning, that’s sufficient.

Although there is no evidence that sunscreens are harmful for children older than 6 months of age and pregnant women, if patients in these special populations have concerns, I recommend using agents with inorganic compounds (physical blockers) such as titanium dioxide and zinc oxide only. Children are best protected with clothing and hats.

The evidence supports this approach. Patients really don’t need SPF 30 protection, but no one uses the amount of product that will result in the SPF listed on the bottle. So if patients use an SPF 30 or greater, they will get at least an SPF 15, which is sufficient everywhere but at the equator. Using SPF 30 the way we all apply it will give SPF 15–level protection.

There is evidence that sunscreens prevent squamous cell carcinoma, actinic keratosis, and photoaging. Early evidence, less strong but positive, also suggests protection against basal cell carcinoma and melanoma.

The biggest side effect is not using the sunscreen. Others include irritation and allergy. Irritation is common, but finding a product to use without irritation should be easy. Allergy is rarer, and when it occurs, it is usually due to the preservative or fragrance, not the active ingredients. If allergy does occur, patch testing by a dermatologist is necessary to determine the allergen.

Although it is still controversial, wearing sunscreens religiously can lead to vitamin D insufficiency or deficiency, which is particularly true for individuals with skin of color—Fitzpatrick skin types IV, V, and VI—and those cancer patients who adhere to rigorous photoprotection. These patients should be encouraged to take supplemental vitamin D₃ and I suggest 2000 IU; this recommendation is my opinion and is not evidence based.

As to the literature in the laypress about hormonal changes from benzophenone, cancer from retinoids, and nanoparticle toxicity: There is no evidence to support those claims.

How do you keep patients compliant with treatment?

Keep telling them, and then tell them again. 

What do you do if they refuse treatment?

Tell them to see someone else. 

What resources do you recommend to patients for more information?

Consult the American Academy of Dermatology Web site (www.aad.org) and the Skin Cancer Foundation (www.skincancer.org).

Editorial Note

Practical Pearls From the Cutis^® Board is a new feature that will appear in print and online (www.cutis.com). Each month a member of the Cutis Editorial Board will provide pearls relating to the practice needs of dermatologists. Future topics will include:

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