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Sunbed Lentigines

Authors:
BRITISH
MEDICAL
JOURNAL
VOLUME
296
16
APRIL
1988
1097
SHORT
REPORTS
Sunbed
lentigines
Despite
the
recent
publicity
of
the
Cancer
Research
Campaign
against
melanoma
and
the
cautionary
message
of
Hawk'
the
popularity
of
sunbeds
continues
to
rise.
A
vast
array
of
devices
is
on
sale
in
almost
every
high
street,
with
units
in
almost
all
larger
"health
clubs."
They
are
designed
to
emit
ultraviolet
light
A
(315-400
nm),
which
usually
tans
without
burning.
Many
units,
however,
are
contaminated
with
small
but
perceptible
amounts
of
ultraviolet
B
(280-315
nm),
whose
long
term
cutaneous
effects
such
as
premature
aging
and
skin
cancer
have
been
considered
more
deleterious
when
compared
with
ultraviolet
A,
though
evidence
is
steadily
accumulating
strongly
incriminating
ultraviolet
A
as
well.2
Not
only
may
they
seriously
exacerbate
photodermatitis
but
they
have
been
shown
to
be
ineffective
in
producing
a
satisfactory
tan
and
protecting
against
further
sunburn
in
most
patients
in
recent
studies.3
4
We
describe
a
35
year
old
woman
who
suddenly
developed
unusual
lentigines
on
her
legs
during
a
period
of
intense
exposure
on
a
sunbed.
Case
report
A
35
year
old
secretary
with
skin
type
3
(sometimes
burns,
always
tans)
presented
to
our
early
diagnosis
melanoma
clinic
with
an
unusual
pattern
of
lentigines
on
her
legs.
They
had
appeared
abruptly
two
years
previously
coincident
with
a
fivefold
increase
in
her
exposure
on
a
sunbed
to
a
total
of
50
half
hour
sessions
over
10
weeks
as
a
"special
offer"
at
her
local
solarium.
The
lesions
(figure)
were
unusual
in that
they
were
large
and
irregularly
pigmented
with
irregular
borders.
They
were
densely
scattered
on
the
fronts
of
the
shins
with
Densely
scattered,
irregularly
shaped
and
pigmented
lesions
on
fronts
of
shins
after
using
sunbed.
almost
complete
sparing
of
the
backs
despite
equal
exposure
times.
A
biopsy
sample
of
a
lesion
contained
increased
numbers
of
melanocytes,
some
of
which
showed
atypical
features
such
as
angular
hyperchromatic
nuclei
and
upward
migration.
The
patient
was
advised
to
observe
strict
avoidance
of
ultraviolet
light
and
six
months
later
a
further
biopsy
was
performed.
This
showed
persistence
of
the
melanocytic
hyperplasia
and
atypia,
and
electron
microscopy
showed
sparse
and
abnormally
clumped
melanosomes
in
the
melanocytes
and
keratinocytes
heavily
laden
with
melanosomes,
the
disparity
in
melanosomes
suggesting
that
melano-
some
production
had
decreased
during
the
six
months
of
avoidance.
During
18
months
of
strict
avoidance
of
ultraviolet
light
the
lesions
showed
no
seasonal
variation
in
number
or
colour
and
continued
to
enlarge
and
coalesce.
Comment
These
unusual
lesions
are
clearly
distinguishable
from
simple
freckles
(ephelides)
by
their
lack
of
seasonal
variation,
irregular
pigmentation
and
border,
and
increased
number
of
melanocytes,
some
of
which
may
be
atypical.
They
are
perhaps
best
described
as
"sunbed
lentigines"
and
share
some
of
the
clinical
and
histological
features
of
lentigines
seen
in
some
patients
receiving
long
term
photochemotherapy
(psoralen
plus
ultraviolet
light
A).
Their
sudden
appearance
during
a
period
of
intense
use
of
a
sunbed
suggests
that
these
lentigines
were
related
to
the
patient's
excessive
exposure
to
ultraviolet
A.
We
do
not
know
how
common
the
problem
is,
but
a
case
has
been
reported
of
a
woman
who
developed
similar
lesions
during
use
of
a
sunbed
at
home,
though
ultrastructural
studies
were
not
performed.5
The
biological
behaviour
of
the
lesions
is
unknown,
and
development
from
melanocytic
atypia
to
malignant
melanoma,
though
unlikely,
is
a
possibility.
With
the
small
but
growing
number
of
cautionary
reports
it
seems
foolish
to
irradiate
poorly
protected
white
skin
in
the
interests
of
short
term
fashion-far
better
to
remain
pale
and
interesting.
We
thank
Dr
L
Papadaki,
of
the
histopathology
department
at
the
Middlesex
Hospital,
for
her
help
in
interpreting
the
electronmicrographs.
1
Hawk
JLM.
Sunbeds.
BrMedJ7
1983;286:329.
2
Sterenborg
HCJM.
Tumorigenesis
by
longwave
UVA
radiation.
In:
Investigations
on
the
action
spectrum
of
tumorigenesis
by
ultraviolet
light
radiation.
Utrecht,
The
Netherlands:
University
of
Utrecht,
1987:79-92.
(PhD
thesis.)
3
Devgum
MS,
Johnson
BE,
Paterson
CR.
Tanning
protection
against
sunburn
and
vitamin
D
formation
with
a
UV-A
"sun-bed."
BrJ
Dermatol
1982;107:275-84.
4
Rivers
JK,
Norris
PG,
Murphy
GM,
et
al.
Effects
of
UVA
sunbeds
in
human
subjects.
Br J
Dermatol
1986;116(suppl
30):426.
5
Jones
SK,
Moseley
H,
Mackie
RM.
UVA-induced
melanocytic
lesions.
BrJ7
Dermatol
1987;117:
111-5.
(Accepted
6January
1988)
Departments
of
Dermatology
and
Morbid
Anatomy,
King's
College
Hospital,
London
SE5
9RS
HYWEL
C
WILLIAMS,
BSC,
MRCP,
registrar
in
dermatology
JON
SALISBURY,
BSC,
MRCPATH,
senior
lecturer
in
morbid
anatomy
JUDITH
BRETT,
MB,
BS,
Cancer
Research
Campaign
fellow
ANTHONY
DU
VIVIER,
MD,
FRCP,
consultant
dermatologist
Correspondence
to:
Dr
Williams.
Eye
injuries
caused
by
elasticated
straps
The
effects
of
blunt
trauma
to
the
eye
are
well
recognised.
'
Most
ophthalmologists
are
familiar
with
injury
caused
by
elasticated
straps,
but
to
our
knowledge
only
one
series
has
been
reported.2
Case
reports
Six
patients
presented
to
this
hospital
with
serious
eye
injuries
caused
by
the
accidental
release
of
tightened
elasticated
straps;
the
table
gives
details.
Four
patients
had
permanent
visual
impairment.
Comment
Elasticated
straps
with
metal
or
plastic
hooks
are
often
used
to
secure
luggage,
particularly
on
car
roof
racks,
which
are
at
eye
level.
The
hook
that
is
attached
first
may
slip
while
the
strap
is
being
tightened,
and
severe
ocular
injury
may
result
as
the
hook
and
strap
recoil.
This
occurred
in
three
of
our
cases.
One
patient
(case
2)
sustained
a
corneal
perforation
from
fragments
of
his
spectacles,
but
the
lens
may
have
protected
him
from
the
full
impact
of
the
hook.
Each
patient
needed
to
be
admitted
to
hospital
at
least
once,
and
four
patients
had
surgery.
The
average
time
spent
in
hospital
was
six
days
(range
three
to
14).
One
patient
(case
5)
was
admitted
five
times
and
had
four
operations.
We
suggest
that
the
design
of
the
hooks
used
to
fasten
elasticated
straps
should
be
changed.
A
spring
loaded
metal
gate
clip
like
those
used
on
dog
... 9,10 Associations between indoor tanning exposure and melanoma's risk factors such as high nevus count, atypical nevi and lentigines have also been suggested, though not extensively studied up to date. [11][12][13][14][15][16][17][18][19] Euromelanoma is a skin cancer prevention campaign that is conducted all over Europe since almost two decades. [20][21][22] Its main goal is to promote awareness of skin cancer among the general public. ...
... This confirms previous case reports of lentigines occurring after sunbed exposure. [14][15][16][17][18][19] Interestingly, these observations reported that the lentigines induced by artificial tanning (so-called 'sunbed lentigines') have more worrisome pathologic and ultra-structural features than common solar lentigines, such as the presence of melanocytic nuclear atypia and abnormally clumped, pleomorphic melanosomes. Moreover, excised 'sunbed lentigines' lacked solar elastosis, which is instead typical of common solar Figure 1 Forest plots of association of suspected skin cancer with ever use of sunbeds. ...
... However, the study by Stern and coworkers did not report the total phototoxic dose delivered to their patients or if the melanoma patients were at greater risk for melanoma in the first place (Wolff, 1997). Furthermore, it has been suggested that UV-A sunbeds may cause melanocytic lesions with malignant potential (Jones et al, 1987;Williams et al, 1988). Lastly, the only existing animal model of melanoma for which an action spectrum has been estimated, the platyfish-swordtail hybrid model, shows that UV-A exposure may be more important than UV-B (Setlow et al, 1993). ...
Article
In a population-based, matched, case-control study from southern Sweden of 571 patients with a first diagnosis of cutaneous malignant melanoma and 913 healthy controls aged 16-80 years, the association between sunbed use and malignant melanoma was evaluated. A total of 250 (44%) cases and 372 (41%) controls reported ever having used sunbeds. A significantly elevated odds ratio for developing malignant melanoma after regular exposure to sunbeds was found, adjusted for hair colour, raised naevi, skin type and number of sunburns (odds ratio (OR) 1.8, 95% confidence interval (CI) 1.2-2.7). A dose-response relationship between total number of sunbed uses and melanoma risk was only found up to the level of 250 times. The OR was higher in individuals younger than age 36 years (adjusted OR 8.1, 95% CI 1.3-49.5 for regular vs. never use). The association seemed to be true only for subjects with black/dark brown or light brown hair and among females. Lesions of the extremities showed the strongest association of increased risk with sunbed use. An increased risk was related to commercial exposure and to exposure during the winter. The results substantiate the hypothesis that exposure to sunbeds might increase the risk of developing malignant melanoma.
Article
The effects on 31 normal subjects following exposure to sunbeds containing UVA lamps with minimal UVB emission have been compared in a double-blind study with the effects on nine control subjects of a similar exposure course three times weekly for 4 weeks to sunbeds emitting visible light. On previously untanned areas, all those subjects on active treatment developed a mild tan; in tanned areas they all developed a moderate tan, while all control subjects developed a minimal to mild tan. The mean protection factor against later UVB-induced erythema was 3.2±0.3 after the active course and 1.6±0.2 among the controls. Significantlsy more frequent adverse cutaneous effects for active subjects were pruritus, erythema, freckling, burning sensation, dryness and polymorphic light eruption. Cutaneous Langerhans cell numbers, and blood CD3+ (pan T-cell) and CD4+ (helper T-cell) lymphocyte subsets were reduced in both active and control groups. CD8+ (cytotoxic/suppressor T-cell) counts were significantly reduced in both groups. The changes found in both groups seem attributable to small amounts of UVB emission from both active and control lamps.
Article
Malignant melanoma of the female genitalia is rare. A patient who regularly used a sunbed developed a malignant melanoma after 4 years. The possible aetiological role of sunbeds in the development of such a malignancy is discussed.
Article
In subjects older than 25-30 years the number of enzymatically active melanocytes detectable by the dopa reaction decreases by about 10-20% per decade, with exposed skin having approximately twice as many pigment cells as unexposed skin. Chronic exposure to sunlight may stimulate the epidermal melanocyte system rather than accelerating chronological ageing. The number of melanocytic naevi declines with age. Despite the decreased melanocyte density, photoaged skin has irregular pigmentation and, frequently, there is hyperpigmentation. This may be due to greater positivity of dopa of chronically irradiated melanocytes. Heterogeneity in skin colour in exposed areas of skin is due to uneven distribution of pigment cells, a local loss of melanocytes, and a modification in the interactions between melanocytes and keratinocytes. The most common pigmented lesions in sun-exposed skin include ephelides, actinic lentigo, pigmented solar keratoses and seborrhoeic keratoses, and lentigo maligna. The white spots in aged skin are usually stellate pseudoscars or idiopathic guttate hypomelanosis. Greying of the hair is due to progressive loss of melanocytes from the hair follicles. In vivo and in vitro studies are necessary to increase overall understanding of the processes involved and to improve treatment of the pigmentary changes in ageing skin.
Article
The effects on 31 normal subjects following exposure to sunbeds containing UVA lamps with minimal UVB emission have been compared in a double-blind study with the effects on nine control subjects of a similar exposure course three times weekly for 4 weeks to sunbeds emitting visible light. On previously untanned areas, all those subjects on active treatment developed a mild tan; in tanned areas they all developed a moderate tan, while all control subjects developed a minimal to mild tan. The mean protection factor against later UVB-induced erythema was 3.2 +/- 0.3 after the active course and 1.6 +/- 0.2 among the controls. Significantly more frequent adverse cutaneous effects for active subjects were pruritus, erythema, freckling, burning sensation, dryness and polymorphic light eruption. Cutaneous Langerhans cell numbers, and blood CD3+ (pan T-cell) and CD4+ (helper T-cell) lymphocyte subsets were reduced in both active and control groups. CD8+ (cytotoxic/suppressor T-cell) counts were similarly but not significantly reduced in both groups. Pityrosporum yeast counts were significantly reduced in both groups. The changes found in both groups seem attributable to small amounts of UVB emission from both active and control lamps.
Article
The development of naevus spilus-like hyperpigmentation at sites of resolving plaques of psoriasis has been reported previously. Although the mechanism is not understood, PUVA therapy has been implicated in most cases. We report an additional case in which lentigines, confined to sites of resolving psoriasis, occurred following oral PUVA. We also describe similar clinical features in two patients who had not received PUVA, which strengthens the observation that this treatment is not a prerequisite for development of this unusual pattern of pigmentation.
Article
Ultraviolet radiation (UVR)-emitting sunbeds for self-tanning purposes have been available for around two decades. Originally claimed to be safe by commercial interests, because new technology enabled the emission of mostly UVA (315-400 nm) radiation, rather than the more profuse UVB (280-315 nm) present with UVA in midday summer or tropical sunlight, these devices have now been demonstrated to have similar deleterious cutaneous effects. However, such effects have taken time to define, and sunbed operators have continued to advocate their equipment as safe, with a tendency to tan without the sunburn characteristic of sunlight exposure; now that it indeed appears that sunbed UVA, along with not inconsiderable amounts of UVB usually also emitted, is similarly damaging to sunlight, a recent move has been to produce lamps emitting truly sunlight-like radiation instead. UVB and UVA both apparently exert their effects mainly through cutaneous cellular DNA damage, probably particularly in the germinative basal cell layer, UVB very likely through direct absorption and UVA more through secondary photosensitisation effects. As a result, sunburn, a tissue repair process, is initiated, along with an immediate tanning effect in those who tan readily; the former reaction, which may vary from subclinical to severe, sometimes leads in excessive instances to a persisting cutaneous hypersensitivity, or very rarely in extreme cases a fatal outcome. Delayed tanning also occurs after UVR exposure, again as a result of cutaneous DNA damage, the latter more marked in the fair-skinned who are perhaps more likely to use sunbeds in the first place. In addition, a sunbed tan usually only mildly protects the skin against later sunlight-induced damage, while irregular patchy tanning, dryness and itching of the skin are also common outcomes, and induction of the unsightly, pruritic polymorphic light eruption and more severe potentially debilitating disorders such as lupus erythematosus are possible; severe cutaneous burning may also occur in sunbed users taking certain photosensitising medications. In the longer term, again particularly in the fair-skinned, skin fragility with blistering, crusting and often superficial scarring occasionally occur over months of sunbed use, while skin photoageing seems likely in all long-term regular users; this has not yet been unequivocally demonstrated in human subjects, however, although marked degenerative changes are readily induced in animals. Finally, there have now been reports of skin pre-cancers in man, particularly too in the fair-skinned who have used sunbeds regularly over several years; cancers are readily produced in animals. Adequate warnings on sunbeds are therefore strongly advocated and exposure to such devices strongly discouraged.
Article
There are many types of sun-beds, sun-benches and sun-panels containing fluorescent tubes which, because of their predominantly UV-A emission, are advertised to the public as a means of obtaining a tan without sunburn. This study reports the effects of a sun-bed on skin colour, on the protection afforded against sunburn, and on vitamin D formation. Side-effects are also recorded. It was shown that the sun-bed emits mainly UV-A but very little UV-B and some tanning occurred in most subjects. However, no correlation was observed between the subjects' stated ability to tan and the degree of pigmentation achieved at the end of the treatment. Most subjects also had itching and erythema, and three had polymorphic light eruption. Although very little UV-B irradiation was present, a significant increase in serum levels of 25-hydroxyvitamin D occurred, and possible explanations of this surprising finding are discussed. While the sun-bed proved popular with the subjects, only a modest tan was achieved and the incidence of side-effects appeared to limit the value of this type of appliance, especially with regard to the prevention of vitamin D deficiency.