Tagged Skin

Sunscreen and Bug Spray: Children’s Summer Skin Care


Credit Getty Images

Summer is here, and we know we’re supposed to shield children from the sun. There’s strong evidence that early sun exposure can increase children’s risk of later skin cancer, and that’s true also for darker-skinned children who are less likely to burn. Boston and Miami Beach are providing free sunscreen in public places, and now New York is talking about it, too.

Parents have certainly gotten much more aware about sun protection, though they sometimes feel a little overwhelmed by the variety of products and by the job of keeping up with the imperatives for proper use.

And with old worries about ticks and new worries about mosquito-borne viruses, parents wonder if they should also be coating a child’s exposed skin with bug repellent.

But babies’ delicate skin is more permeable than adults’, so any chemicals we apply may be more likely to be absorbed, and their immature organs may be less able to handle those chemicals. What stays on the skin may be absorbed; but what doesn’t stay on the skin doesn’t shield. Dermatological toxicology involves considering the balance between “wash in,” the risk of absorbing potentially toxic substances through the skin, and “wash out,” the loss of protection as substances are lost by sweating or water exposure or rubbing. Both are highly complex processes, with many variables, and not necessarily well studied in young children.

With little babies, the advice is always to rely on reducing exposure, on shade and clothing for sun, and on adding screens and netting to keep the bugs off. Both the Food and Drug Administration and the American Academy of Pediatrics emphasize that babies under 6 months should be kept out of direct sunlight, protected with shade, shielded with sunhats and protective clothing when they do have to be out, rather than relying on sunscreen.

Babies’ skin surface is large in proportion to their body volume and their internal fluids, putting them at high risk for heat and dehydration. So make sure they are drinking and wetting their diapers regularly.

Adults and children alike are advised to avoid the hours of maximum exposure — to stay out of the sun between 10 and 2, and to avoid going outside at dusk in areas with lots of mosquitoes. But of course, that isn’t necessarily easy.

Sun hats and protective clothing are important for older babies and toddlers, and so is avoiding those peak hours. For children under 2, “the rule of thumb in this age group is clothing first,” said Jacqueline Thomas, an assistant professor of dermatology and surgery at Nova Southeastern University in Fort Lauderdale, who is the senior author on a commentary reviewing pediatric sunscreen and sun safety guidelines published last year in the journal Clinical Pediatrics. Dark colors and more tightly woven fabrics are more effective.

As to sunscreen, experts say not to choose by what is marketed for children or babies, and to read the label carefully. In 2011, the F.D.A. required much more information to be standardized on sunscreen labels; parents should look for products with an SPF of 30 or higher, advises the American Academy of Dermatology, and make sure they are labeled as “water resistant” (lasts 40 minutes in the water) or “very water resistant” (80 minutes), and as “broad spectrum,” meaning that they block both UVA and UVB rays, both of which do damage. There is no such thing as waterproof sunscreen.

The active agents in sunscreen can be either chemical blockers or physical blockers, and the physical blockers are safer for children because they are much less likely to be absorbed. For children ages 2 to 12, look for products with titanium or zinc as their active ingredients, rather than chemical agents, which really haven’t been studied in children.

The recommended amount for an adult-size body is variously described as a shot glass and a golf ball for the trunk and extremities; for under 12, some authorities suggest using the amount that would fill a child’s cupped hand as a rough guide. It needs to be reapplied after two hours, because the efficacy is gone, even if you can still feel the lotion on your skin, and sunscreens with higher SPFs don’t last any longer than those with lower SPFs (in fact, there is no evidence that SPFs over 50 are more protective).

Although spray-on sunscreens are popular, their efficacy has not been studied,, and there’s concern about children inhaling them. The F.D.A. has asked for more data.

What about insects? Mosquito repellents generally contain either DEET, picaridin or one of several essential plant oils, most commonly oil of lemon eucalyptus, as an active ingredient; permethrin, which is meant to be applied to clothing (or sometimes already applied by manufacturers) works to repel ticks.

There has been concern in the past about DEET toxicity, and the recommendation is to avoid DEET and picaridin for babies younger than 2 months, and to avoid oil of lemon eucalyptus for children under 3. But most pediatricians would recommend being very sparing with all of these substances on babies and young children, applying them only to exposed skin, right before going outside, and washing them off when you come back in. Don’t let young children apply the stuff themselves, and keep it away from their eyes and their mouths, and their hands if they tend to put those in their mouths. If possible, put the repellent on the clothing, or on the tent; there are also clip-on devices that can be attached to strollers.

Dr. Adelaide A. Hebert, a professor of dermatology and pediatrics at McGovern Medical School at the University of Texas Health Science Center at Houston, said she tends to recommend picaridin-based insect repellents such as Cutter Advanced and Off Clean Feel for children over those that contain DEET. “I like picaridin. I feel there’s less concern for parents using it with regard to toxicity,” she said. The strength of these insect repellents can vary as well, so again, it’s important to read the label. “We don’t recommend DEET strength above 20 percent because of concern about toxicity,” Dr. Hebert said.

Combination products are another problem, though the idea of a single lotion that protects against both sun and insects is very appealing. “I never recommend combination products,” said Dr. Hebert. “We don’t want to reapply the insect repellent as often as we may need to reapply the sunscreen.” Further, there’s evidence that the mixture may make the sunscreen less effective, and the chemicals more likely to be absorbed.

So keep babies out of the sun, be scrupulous about sun hats and protective clothing, about screens and mosquito netting. As children grow, don’t forget about protecting the eyes; think about broad-brimmed hats and sunglasses. If you need protection against insects, apply insect repellent over sunscreen, and reapply the sunscreen after two hours, on top of the insect repellent, which does not have to be reapplied so frequently.

The skin is the largest organ of the body, proportionally larger in the smallest children, and protecting it properly needs our care and attention.


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Skin Problem? Websites May Offer Poor Care


Consulting a dermatologist over the Internet may have serious drawbacks, a new study suggests.

Direct-to-consumer telemedicine, in which a patient receives an examination and treatment over the Internet, is rapidly expanding, and in 2015 attracted an estimated 1.25 million people seeking advice in the United States. And while telemedicine has substantial benefits, the researchers say — it is convenient and typically saves money – many of the websites they looked at were not providing adequate care.

For their study, published in JAMA Dermatology, the researchers submitted six simulated cases involving skin symptoms to 16 direct-to-consumer telemedicine sites and apps for diagnosis and advice. The study excluded sites that failed to respond or responded intermittently, or that delivered incomplete or inconsistent responses. In all, 62 responses were included in the analysis.

Most sites allowed patients to submit photographs, usually one to three images of the skin condition in question. In four cases, the site provided a diagnosis based only on the patient’s description.

Two thirds of the sites failed to collect a complete medical history, and only 52 percent asked female patients about pregnancy or lactation, even though such information can be essential in the diagnosis and treatment of some dermatologic disorders.

Diagnoses were sometimes missed. In one case, a 28-year-old woman presented with acne, but not a single website asked about excessive hair growth or irregular menstrual periods, symptoms that would have led to the correct diagnosis of polycystic ovarian syndrome. In another case, a woman with eczema complicated by a potentially fatal herpes infection was given a diagnosis of having an ordinary eczema flare-up in seven of nine encounters.

The lead author, Dr. Jack S. Resneck Jr., a professor of dermatology at the University of California, San Francisco, acknowledged that such misdiagnoses could occur even in a face-to-face meeting with a doctor. But, he said, none of the telemedicine sites engaged in the kind of patient-doctor discussion and “give and take” that would happen in an office and provide the information that leads to successful diagnosis.

“You could imagine a telemedicine conversation in which the patient discusses the diagnosis with the clinician,” Dr. Resneck said, “but none of that was going on. There were no instances in which the clinician discussed the problem, asked about other symptoms and so on.”

Of patients who got a diagnosis, 65 percent were given a prescription, but the risks and side effects of the medicines were mentioned only 32 percent of the time. In addition, “when people go to an office in person, they’re aware of who they’re seeing — a clinician, a doctor, a nurse practitioner,” Dr. Resneck said. “But only a minority of sites identified the person or gave information about licensure.” Only six of the 62 responses offered to send a report to a patient’s primary care doctor.

Dr. Resneck said he would like to see telemedicine succeed. “We’re inclined to support this kind of innovation,” he said, “but it needs to be done right. Our results were disappointing.”

Think Like a Doctor: Hurting All Over Solved

On Thursday, we challenged Well readers to figure out the case of a 36-year-old man with a 20-year history of migrating joint pains along with other strange symptoms. Nearly 300 of you offered thoughtful suggestions of what he might have had. And one out of 10 of you were spot on.

The correct diagnosis is:

Ehlers Danlos syndrome

The first reader to correctly make this diagnosis was Bryley Williams, of New York City. She told me she knows nothing about medicine but found the answer on the Internet by investigating noninflammatory causes of joint pain and pneumothorax. All of the winners of this contest are extraordinary, but I think Ms. Williams may take the prize. She is 15 years old, a freshman in high school in New York City. Well done, Ms. Williams! Maybe you should consider a career in medicine once you graduate.

The Diagnosis

Ehlers-Danlos syndrome, or EDS, is a group of inherited disorders that affect the body’s connective tissues – the skin, muscles, tendons and ligaments that hold us together. Since the 1990s, the disease has been divided into six main types, depending on which connective tissues are most affected. Based on the gene study done in this patient, he was given a diagnosis of the least severe and most common variety, which primarily causes hypermobility of the joints as well as skin that is easily damaged and scars badly.

EDS was probably recognized as early as 400 B.C., when Hippocrates noted that the nomads and Scythians had lax joints and multiple scars. This disorder came to more modern medical attention in the 17th century when, at a medical presentation in Holland, a Spanish sailor by the name of George Albes exhibited his remarkable ability to stretch the skin on his chest out an arm’s length.

The first complete description of the condition was given by a Russian physician, Dr. A. N. Chernogubov, at the end of the 19th century. He presented a 17-year-old boy who suffered from recurrent joint dislocations and easily stretched and fragile skin. The boy had many scars resulting from minor injuries, because these patients do not heal normally. Based on these observations, Dr. Chernogubov predicted that the clinical manifestations were caused by an abnormality of the connective tissues.

That report did not come to the notice of Western Europe for many years. So while the disorder still carries Chernogubov’s name in Russia, in most places it referred to as EDS, after the two physicians who first characterized the disorder in Paris decades later: Dr. Edvard Ehlers and Dr. Henri-Alexandre Danlos.

How the Diagnosis Was Made

The patient, a 36-year-old man with a 20-year history of migrating joint pain, had been to dozens of doctors – internists, orthopedic surgeons, rheumatologists. All had examined him and seen nothing. Indeed, his last rheumatologist kept saying that she wanted to believe that he had this much pain but that she couldn’t find anything physical to cause it.

One orthopedist had asked him if his skin was particularly stretchy or if he was very flexible – obviously thinking of a diagnosis like Ehlers-Danlos syndrome, but the patient said no. He didn’t think he was particularly flexible or that his skin was unusually stretchy. Later, once he had the diagnosis, he showed one of his doctors how he could move his thumb, and the doctor told him that he was popping it in and out of joint. And the geneticist told him that his skin was stretchy enough to fit the diagnostic criteria. Still, it all seemed normal to him. Not extraordinary in any way.

Still, after 20 years of searching, the patient was finally willing to accept that he was just more prone to getting these pains. And he began keeping a list of the types of exercises or activities that seemed most likely to trigger the episodes of joint pain. His wife was unwilling to give up. She continued to search the Internet for answers.

Like Son, Like Father?

The final clue came not from the man’s doctor but from his son’s. The boy, age 11, went to see his pediatrician, Dr. Renee Brand, for his annual physical exam. He was tall and slender, like his father. He had a colt-like awkwardness about him, with arms and legs that looked just a bit too long to be well managed. And he had a stooped posture, as if he spent too much time gazing into a smartphone he didn’t even have. Could he sit up completely straight? Dr. Brand asked. He couldn’t, though he tried.

Later the doctor asked him to bend over so that she could check his spine for scoliosis. He immediately flopped down, his chest almost touching his knees and his hands lying flat on the floor in front of him. Surprised by this remarkable degree of flexibility, Dr. Brand asked another questions. Could he press his thumb down and forward so that he could touch his own forearm with his thumb? He pressed the digit down toward his wrist and, sure enough, was able to make them meet easily.

I think maybe you should take him to see an orthopedic surgeon, Dr. Brand suggested to the boy’s mother. Two weeks later the mom called Dr. Brand with a report. She’d taken the boy to see the surgeo,n and he had in turn recommended that she take him to see a geneticist.

“I thought so,” replied Dr. Brand with satisfaction. Seeing how remarkably flexible the young man was, and how hard it was for him to stand up straight, Dr. Brand thought the boy might have a disorder known as Ehlers-Danlos syndrome.

Getting a Diagnosis

After making the appointment with the geneticist, the boy’s mother sat down at the computer to read up on Ehlers-Danlos. As she read through the descriptions, she could definitely recognize her son. But in those pages she also recognized her husband. Joint pain, check; pneumothorax, check; osteoporosis, check; scoliosis, check. Ultimately this inherited disease was diagnosed in both father and son.

There’s no cure for EDS, but it’s important to know that you have it. The son sees a cardiologist every couple of years, since EDS can lead to problems with heart valves and vessels. He was found to be at risk for a dangerous stretching of his aorta that, without repair, could lead to rupture. And both father and son now understand which exercises are going to be a problem for them – possibly causing joint dislocations or other musculoskeletal injuries.

Not Just ‘Crazy’

For the father, our patient, it’s meant a sacrifice that may sound trivial, but meant a lot to him: He’s had to give up running, his favorite form of exercise. The pounding is just too hard on his joints.

“I kept hoping that I could find a kind of physical therapy that would help me run the way I used to. Now I know I just can’t,” he said. Still, it’s a relief to be able to give a name to his mysterious problems. “It’s proof that I’m not just crazy.”