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Original Investigation |

Trends in Sunscreen Recommendation Among US Physicians FREE

Kristie L. Akamine, MD1; Cheryl J. Gustafson, MD1; Scott A. Davis, MA1; Michelle M. Levender, MD1; Steven R. Feldman, MD, PhD1,2
[+] Author Affiliations
1Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
2Departments of Pathology and Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
JAMA Dermatol. 2014;150(1):51-55. doi:10.1001/jamadermatol.2013.4741.
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Published online

Importance  Sunscreen is an important part of sun protection to prevent skin cancer but may not be recommended as often as guidelines dictate.

Objective  To evaluate trends in sunscreen recommendation among physicians to determine whether they are following suggested patient-education guidelines regarding sun protection, and to assess data regarding physician sunscreen recommendations to determine the association with patient demographics, physician specialty, and physician diagnosis.

Design, Setting, and Participants  The National Ambulatory Medical Care Survey was queried to identify patient visits to nonfederal outpatient physician offices at US ambulatory care practices (January 1, 1989–December 26, 2010) during which sunscreen was recommended.

Main Outcomes and Measures  Frequency of sunscreen recommendation.

Results  According to the National Ambulatory Medical Care Survey, there were an estimated 18.30 billion patient visits nationwide. Physicians mentioned sunscreen at approximately 12.83 million visits (0.07%). Mention of sunscreen was reported by physicians at 0.9% of patient visits associated with a diagnosis of skin disease. Dermatologists recorded the mention of sunscreen the most (86.4% of all visits associated with sunscreen). However, dermatologists reported mentioning sunscreen at only 1.6% of all dermatology visits. Sunscreen was mentioned most frequently to white patients, particularly those in their eighth decade of life, and least frequently to children. Actinic keratosis was the most common diagnosis associated with sunscreen recommendation.

Conclusions and Relevance  Despite encouragement to provide patient education regarding sunscreen use and sun-protective behaviors, the rate at which physicians are mentioning sunscreen at patient visits is quite low, even for patients with a history of skin cancer. The high incidence and morbidity of skin cancer can be greatly reduced with the implementation of sun-protective behaviors, which patients should be counseled about at outpatient visits.

Figures in this Article

The incidence of skin cancer is on the rise.1,2 Its primary cause is UV radiation, which accounts for up to 90% of melanoma and nonmelanoma skin cancers.3 In addition, exposure to UV radiation is the only recognized modifiable risk factor for melanoma. Physicians play an important role in cancer prevention by counseling patients on modifiable lifestyle behaviors, such as smoking cessation to reduce the risk of lung cancer. However, sun-protection counseling ranks among the lowest topics of primary prevention discussed between physicians and patients.4,5

Acknowledging the importance of sun-protective behaviors in the prevention of skin cancer, multiple professional organizations, such as the American Academy of Dermatology, National Institutes of Health, American Cancer Society, American Academy of Pediatrics, American College of Gynecologists, and American Academy of Family Physicians, recommend physicians provide patient counseling regarding sun exposure and sun-protective behaviors.611 The US Preventative Services Task Force concluded in 2012 that there was “moderate certainty of moderate benefit” from recommending patient counseling on sun protection for fair-skinned patients aged 10 to 24 years and that there was insufficient evidence to recommend for or against sun-protection counseling in patients older than 24 years.12

Major recommendations for sun-protective behaviors are similar among different health care organizations. Such recommendations include: (1) seeking shade and avoiding the sun, especially during the hours of 10 am to 4 pm; (2) wearing sun-protective clothing, including long-sleeved shirts and wide-brimmed hats; (3) applying and reapplying sunscreen; and (4) avoiding artificial UV light.1,7,10,13 Although avoiding exposure to UV radiation is a key component of sun-protective behavior, this is not always practical. Therefore, sunscreen is an important component of sun protection, as it prevents epidermal and dermal damage secondary to UV radiation exposure. As a result, sunscreen decreases the incidence of actinic keratoses, squamous cell carcinomas, and melanoma skin cancers.1417 In addition, sunscreen is recommended for a diversity of photosensitive skin conditions, such as actinic dermatitis, melasma, porphyria cutanea tarda, polymorphic light eruption, actinic prurigo, lupus erythematosus, and drug-induced photosensitivity as seen with acne medications.1820 Although physicians are encouraged to counsel patients on sunscreen use, no studies in the medical literature, to our knowledge, report how often US physicians are recommending sunscreen. Therefore, the primary objective of this study was to assess trends in sunscreen recommendations by different physician specialties to determine whether physicians are recommending sunscreen as their respective organizations advocate. Also, patient education alters patient practices; however, physicians often reserve such counseling for certain subsets of patients. Hence, data regarding physician diagnoses and patient demographics were evaluated to determine which subsets of patients were most likely to receive sunscreen recommendations.

Data were obtained from the National Ambulatory Medical Care Survey (NAMCS), which is an ongoing survey conducted by the National Center for Health Statistics. The survey was started in 1974 but was not conducted annually until 1989. The NAMCS collects descriptive data regarding ambulatory visits to nonfederal, office-based physicians in the United States. Sampling is stratified by sampling units (county, contiguous counties, and standard metropolitan areas), physician practices within the sampling units, and patient visits within the practice occurring within 52 weekly periods. Participating physicians are instructed to record information about patient visits for a 1-week period and include patient demographics, insurance status, reason for visit, diagnoses, procedures, therapeutics, and referrals made at that time. Data collected for the NAMCS are entered into a multistage probability sample to produce national estimates.

In the present study, the NAMCS database was queried to identify patient visits between January 1, 1989, and December 26, 2010, during which sunscreen was recorded. When a medication or over-the-counter product is recorded for a NAMCS patient visit, it indicates the product was currently being used by the patient, was dispensed in the office, or was prescribed or recommended by the physician at that particular visit. After these visits were identified, data regarding patient demographics, physician specialty, and physician diagnoses were assessed. In addition, we looked at patient visits associated with a diagnosis of skin disease (as previously defined by Fleischer et al21) and, more specifically, a history of skin cancer (International Classification of Diseases, Ninth Revision, Clinical Modification codes V10.82 and V10.83), actinic keratosis (702.0), and current skin cancer (172.x, 173.x, and 232.x). These visits were further characterized as visits to dermatologists, internists, pediatricians, general or family physicians, and other specialists. The top 10 diagnoses associated with the highest frequencies of sunscreen use by each specialty were determined. Linear regressions were performed to determine trends in use during this period. All data were analyzed using SAS statistical software (SAS Institute Inc). The study was declared exempt by the Wake Forest University Health Sciences institutional review board.

From January 1, 1989, through December 26, 2010, there were an estimated 18.30 billion patient visits; of those, sunscreen was recommended at 12.83 million visits (0.07%) (Table 1). No differences in sunscreen recommendation were detected with respect to patient sex or ethnicity (Table 1). With regard to patient race, sunscreen was recommended in 237 visits annually for every 100 000 visits by white US residents compared with 26 visits annually for every 100 000 visits by black individuals. With data stratified by age groups of 10-year intervals, sunscreen was recommended the most for patients in their eighth decade of life (21.8% of visits associated with sunscreen recommendation). In contrast, sunscreen was recommended the least for children younger than 10 years.

Table Graphic Jump LocationTable 1.  Sunscreen Recommendation for All Visits vs Skin Disease Visits by All Physicians: NAMCS, 1989-2010

The frequency of sunscreen recommendation was 12 times greater for patient visits associated with a diagnosis of skin disease compared with visits with no reported skin disease. Although sunscreen use was mentioned more frequently to patients with skin disease, such recommendations were made at less than 1% of visits involving patients with a reported skin disease diagnosis. There were no statistically significant differences in sunscreen mention among different races in patients with skin disease. However, sunscreen use was recommended more frequently for Hispanic compared with non-Hispanic patients (1.2% vs 0.9%; P < .001).

Analysis by physician specialty revealed that dermatology visits accounted for most of the appointments associated with sunscreen recommendation (86.4%), followed by visits with general and family practitioners (9.6%), pediatricians (1.4%), other specialists (1.4%), and internists (1.1%). Although sunscreen was most frequently recommended by dermatologists, the mention of sunscreen was recorded at 1.6% of all dermatology visits (Table 2). In addition, sunscreen was mentioned by dermatologists at 11.2% of visits associated with a diagnosis of active or remote history of skin cancer. This low frequency of sunscreen recommendation by dermatologists is concerning because dermatologists saw more than 20 times the number of patients with a history of skin cancer (7.1 million) compared with general/family physicians (320 000). Moreover, the frequency with which dermatologists recommended sunscreen to this population of patients was significantly less than that of general/family physicians (11.2% vs 55.5%).

Table Graphic Jump LocationTable 2.  Sunscreen Recommendation by Physician Specialty: NAMCS, 1989-2010

According to the NAMCS, internists recommended sunscreen at 0.01% of all patient visits and 0.1% of visits associated with a diagnosis of skin disease. Interestingly, internists did not record sunscreen recommendations at patient visits associated with a diagnosis of actinic keratosis. Furthermore, there was no mention of sunscreen by internists at visits involving patients with an active or remote history of skin cancer.

Pediatricians recommended sunscreen at a trivial number of all visits (0.01%) and to 0.03% of patients with skin disease. Pediatric visits for actinic keratosis or skin cancer were not analyzed because these cutaneous conditions are extremely rare in children and adolescents. Analysis of sunscreen recommendations over time with the use of linear regression models demonstrated an annual increase of 0.02% (P = .02) in the frequency of sunscreen recommendation among all physicians, regardless of specialty, for patients with skin disease (Figure). Dermatologists demonstrated a greater increase in the rate of sunscreen recommendation to patients with skin disease (0.06% per year; P <  .001). Conversely, the mention of sunscreen by general/family physicians declined 0.03% per year (P = .03). In addition, mention of sunscreen by a family physician decreased 0.1% per year for patient visits associated with a diagnosis of actinic keratosis (P = .01). However, no statistically significant changes in sunscreen recommendation patterns were seen for patients with a history of skin cancer (P = .50).

Place holder to copy figure label and caption
Figure.
Trend in Sunscreen Recommendations by All Physicians at Skin Disease Visits: National Ambulatory Medical Care Survey, 1989-2010

The solid line represents the linear regression fit over time (SAS PROC SURVEYREG; SAS Institute Inc), which demonstrates an annual increase of 0.02% (P = .02) in the frequency of sunscreen recommendation among all physicians for patients with skin disease.

Graphic Jump Location

Among all specialists, actinic keratosis was the most common diagnosis reported at visits during which sunscreen was recommended, accounting for nearly a quarter (20.9%) of diagnoses (Table 3). This was followed by acne (8.1%), benign neoplasm of the skin (6.8%), other dermatitis due to solar radiation (5.6%), and malignant neoplasm of the skin (5.2%). The top 10 list of diagnoses associated with sunscreen recommendation was similar among all specialists.

Table Graphic Jump LocationTable 3.  Top 10 Most Common Diagnoses Associated With Sunscreen Recommendation by Physician Specialty: NAMCS, 1989-2010

Although multiple professional health care organizations highly recommend that physicians educate patients on sun-protective behaviors, including proper sunscreen use, NAMCS data indicate that physicians are mentioning sunscreen at a very low percentage of all patient visits. Compared with black patients, white patients were 9 times more likely to be recommended sunscreen. Children and adolescents were recommended sunscreen the least compared with all patient age groups. Likewise, sunscreen was mentioned at a low number of pediatric visits. Patients aged 70 to 79 years were recommended sunscreen the most frequently compared with other age groups, likely resulting from the tendency of this patient population to have visible solar damage and/or actinic keratoses appreciated on physical examination.

The findings are concerning because children and adolescents get the most sun exposure of any age group, as they tend to spend much of their time playing outdoors. Up to 80% of sun damage is thought to occur before age 21 years, and sunburns in childhood greatly increase the risk for future melanoma.1,22,23 The American Academy of Pediatrics recognizes the primary role pediatricians have in preventing skin cancer. New guidelines advise pediatricians to discuss sun protection at least yearly during health maintenance examinations and to familiarize themselves with medications with photosensitizing effects.10 The American Academy of Pediatrics also recommends assuring parents of the low likelihood of developing vitamin D deficiency in association with sunscreen application, since adequate levels are maintained through diet and supplementation.10 In addition, pediatricians are highly encouraged to be strong proponents of sun-protective policies, such as the SunWise program, which is similar to programs implemented in Australia.10 Similarly, the American Cancer Society and Centers for Disease Control and Prevention emphasize the importance of educating children and adolescents regarding skin cancer. These health care organizations also advocate the implementation of school interventions, such as permitting the use of hats and encouraging sunscreen use when children are outside, to reduce their risk for skin cancer.8

There are several limitations to the present study. The NAMCS survey collects cross-sectional data; therefore, when prescription or over-the-counter medications are reported, one cannot determine if the product was currently being used by the patient, dispensed in the clinic, or prescribed or recommended at that visit. Hence, we could not determine whether the sunscreen reported was a newly recommended or previously used product. Data reporting is another potential limitation. Although physicians may have provided sun-protective counseling, including sunscreen recommendation, they may have failed to document sunscreen on the survey reports. Also, the data include both new and follow-up visits, and sunscreen may have been discussed at an earlier visit than the one sampled.

In summary, many variables affect the likelihood of sunscreen recommendation, including physician specialty, presence of skin disease, and patient demographics. Recommendation of sunscreen use by physicians is infrequent, even in the setting of skin cancer. The American Academy of Dermatology, National Institutes of Health, American Cancer Society, American College of Gynecologists, American Academy of Pediatrics, and American Academy of Family Physicians all recommend sun-protection counseling, including sunscreen use; however, only a small percentage of physicians are implementing these recommendations into their practice. The high incidence and morbidity of skin cancer can be greatly reduced with the implementation of sun-protective behaviors, which patients should be counseled about at outpatient visits.

Accepted for Publication: March 19, 2013.

Corresponding Author: Scott A. Davis, MA, Department of Dermatology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157 (scdavis@wakehealth.edu).

Published Online: September 4, 2013. doi:10.1001/jamadermatol.2013.4741.

Author Contributions: Dr Feldman had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Gustafson, Davis, Feldman.

Acquisition of data: Davis, Levender.

Analysis and interpretation of data: All authors.

Drafting of the manuscript: Akamine, Gustafson.

Critical revision of the manuscript for important intellectual content: Gustafson, Davis, Levender, Feldman.

Statistical analysis: Davis.

Obtained funding: Feldman.

Administrative, technical, or material support: Levender.

Supervision: Gustafson, Levender, Feldman.

Conflict of Interest Disclosures: Dr Feldman reports being a consultant and speaker for Abbott Labs, Amgen, BiogenIdec, Bristol-Myers Squibb, Centocor, Connetics, Galderma, Genentech, Photomedex, and Warner Chilcott; having received grants from Abbott Labs, Amgen, Astellas, Aventis Pharmaceuticals, BiogenIdec, Bristol-Myers Squibb, Centocor, Connetics, Coria, Galderma, Genentech, GlaxoSmithKline, 3M, Novartis, Ortho Pharmaceuticals, Pharmaderm, Photomedex, Roche Dermatology, Stiefel, and Warner Chilcott; and having stock options from Photomedex.

Funding/Support: The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories, LP.

Role of the Sponsor: Galderma Laboratories, LP had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

American Cancer Society. Cancer Facts & Figures 2011.www.cancer.org/research/cancerfactsfigures/cancerfactsfigures/cancer-facts-figures-2011. 2011. Accessed August 16, 2011.
Rogers  HW, Weinstock  MA, Harris  AR,  et al.  Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol. 2010;146(3):283-287.
PubMed   |  Link to Article
International Agency for Research on Cancer. Solar and Ultraviolet Radiation. Lyon, France: IARC; 1997.
DePue  JD, Goldstein  MG, Redding  CA,  et al.  Cancer prevention in primary care. Prev Med. 2008;46(3):252-259.
PubMed   |  Link to Article
Oliveria  SA, Christos  PJ, Marghoob  AA, Halpern  AC.  Skin cancer screening and prevention in the primary care setting. J Gen Intern Med. 2001;16(5):297-301.
PubMed   |  Link to Article
Lin  JS, Eder  M, Weinmann  S.  Behavioral counseling to prevent skin cancer. Ann Intern Med. 2011;154(3):190-201.
PubMed   |  Link to Article
 Information from your family doctor: skin cancer: reduce your risk with “safe-sun” guidelines. Am Fam Physician. 2002;66(2):310-311.
PubMed
American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2011.www.cancer.org/Research/CancerFactsFigures/CancerPreventionEarlyDetectionFactsFigures/cancer-prevention-early-detection-facts-figures-2011. 2011. Accessed September 7, 2011.
Sun protection. MedlinePlus website. US National Library of Medicine and National Institutes of Health. www.nlm.nih.gov/medlineplus/ency/patientinstructions/000378.htm. Updated August 21, 2011. Accessed December 10, 2012.
Section on Dermatology; Council on Environmental Health; Balk  SJ.  Ultraviolet radiation: a hazard to children and adolescents. Pediatrics. 2011;127(3):588-597.
PubMed   |  Link to Article
American College of Obstetricians and Gynecologists. Primary and Preventive Care: Periodic Assessments. Washington, DC: ACOG; 2000.
Moyer  VA; US Preventive Services Task Force.  Behavioral counseling to prevent skin cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(1):59-65.
PubMed   |  Link to Article
American Academy of Dermatology. Sunscreen FAQs. www.aad.org/media-resources/stats-and-facts/prevention-and-care/sunscreens. 2012. Accessed December 10, 2012.
Green  A, Williams  G, Neale  R,  et al.  Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: a randomised controlled trial. Lancet. 1999;354(9180):723-729.
PubMed   |  Link to Article
Green  AC, Williams  GM, Logan  V, Strutton  GM.  Reduced melanoma after regular sunscreen use. J Clin Oncol. 2011;29(3):257-263.
PubMed   |  Link to Article
Naylor  MF, Farmer  KC.  The case for sunscreens: a review of their use in preventing actinic damage and neoplasia. Arch Dermatol. 1997;133(9):1146-1154.
PubMed   |  Link to Article
Thompson  SC, Jolley  D, Marks  R.  Reduction of solar keratoses by regular sunscreen use. N Engl J Med. 1993;329(16):1147-1151.
PubMed   |  Link to Article
Antoniou  C, Kosmadaki  MG, Stratigos  AJ, Katsambas  AD.  Sunscreens—what’s important to know. J Eur Acad Dermatol Venereol. 2008;22(9):1110-1118.
PubMed   |  Link to Article
Krutmann  J.  Ultraviolet A radiation-induced biological effects in human skin. J Dermatol Sci.2000;23(suppl 1):S22-S26.
PubMed   |  Link to Article
Kuhn  A, Sonntag  M, Richter-Hintz  D,  et al.  Phototesting in lupus erythematosus tumidus—review of 60 patients. Photochem Photobiol. 2001;73(5):532-536.
PubMed   |  Link to Article
Fleischer  AB  Jr, Feldman  SR, White  RE, Leshin  B, Byington  R.  Procedures for skin diseases performed by physicians in 1993 and 1994. J Am Acad Dermatol. 1997;37(5, pt 1):719-724.
PubMed   |  Link to Article
Markovic  SN, Erickson  LA, Rao  RD,  et al; Melanoma Study Group of the Mayo Clinic Cancer Center.  Malignant melanoma in the 21st century, part 1: epidemiology, risk factors, screening, prevention, and diagnosis. Mayo Clin Proc. 2007;82(3):364-380.
PubMed
Robinson  JK, Rigel  DS, Amonette  RA.  Summertime sun protection used by adults for their children. J Am Acad Dermatol. 2000;42(5, pt 1):746-753.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Trend in Sunscreen Recommendations by All Physicians at Skin Disease Visits: National Ambulatory Medical Care Survey, 1989-2010

The solid line represents the linear regression fit over time (SAS PROC SURVEYREG; SAS Institute Inc), which demonstrates an annual increase of 0.02% (P = .02) in the frequency of sunscreen recommendation among all physicians for patients with skin disease.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1.  Sunscreen Recommendation for All Visits vs Skin Disease Visits by All Physicians: NAMCS, 1989-2010
Table Graphic Jump LocationTable 2.  Sunscreen Recommendation by Physician Specialty: NAMCS, 1989-2010
Table Graphic Jump LocationTable 3.  Top 10 Most Common Diagnoses Associated With Sunscreen Recommendation by Physician Specialty: NAMCS, 1989-2010

References

American Cancer Society. Cancer Facts & Figures 2011.www.cancer.org/research/cancerfactsfigures/cancerfactsfigures/cancer-facts-figures-2011. 2011. Accessed August 16, 2011.
Rogers  HW, Weinstock  MA, Harris  AR,  et al.  Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol. 2010;146(3):283-287.
PubMed   |  Link to Article
International Agency for Research on Cancer. Solar and Ultraviolet Radiation. Lyon, France: IARC; 1997.
DePue  JD, Goldstein  MG, Redding  CA,  et al.  Cancer prevention in primary care. Prev Med. 2008;46(3):252-259.
PubMed   |  Link to Article
Oliveria  SA, Christos  PJ, Marghoob  AA, Halpern  AC.  Skin cancer screening and prevention in the primary care setting. J Gen Intern Med. 2001;16(5):297-301.
PubMed   |  Link to Article
Lin  JS, Eder  M, Weinmann  S.  Behavioral counseling to prevent skin cancer. Ann Intern Med. 2011;154(3):190-201.
PubMed   |  Link to Article
 Information from your family doctor: skin cancer: reduce your risk with “safe-sun” guidelines. Am Fam Physician. 2002;66(2):310-311.
PubMed
American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2011.www.cancer.org/Research/CancerFactsFigures/CancerPreventionEarlyDetectionFactsFigures/cancer-prevention-early-detection-facts-figures-2011. 2011. Accessed September 7, 2011.
Sun protection. MedlinePlus website. US National Library of Medicine and National Institutes of Health. www.nlm.nih.gov/medlineplus/ency/patientinstructions/000378.htm. Updated August 21, 2011. Accessed December 10, 2012.
Section on Dermatology; Council on Environmental Health; Balk  SJ.  Ultraviolet radiation: a hazard to children and adolescents. Pediatrics. 2011;127(3):588-597.
PubMed   |  Link to Article
American College of Obstetricians and Gynecologists. Primary and Preventive Care: Periodic Assessments. Washington, DC: ACOG; 2000.
Moyer  VA; US Preventive Services Task Force.  Behavioral counseling to prevent skin cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(1):59-65.
PubMed   |  Link to Article
American Academy of Dermatology. Sunscreen FAQs. www.aad.org/media-resources/stats-and-facts/prevention-and-care/sunscreens. 2012. Accessed December 10, 2012.
Green  A, Williams  G, Neale  R,  et al.  Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: a randomised controlled trial. Lancet. 1999;354(9180):723-729.
PubMed   |  Link to Article
Green  AC, Williams  GM, Logan  V, Strutton  GM.  Reduced melanoma after regular sunscreen use. J Clin Oncol. 2011;29(3):257-263.
PubMed   |  Link to Article
Naylor  MF, Farmer  KC.  The case for sunscreens: a review of their use in preventing actinic damage and neoplasia. Arch Dermatol. 1997;133(9):1146-1154.
PubMed   |  Link to Article
Thompson  SC, Jolley  D, Marks  R.  Reduction of solar keratoses by regular sunscreen use. N Engl J Med. 1993;329(16):1147-1151.
PubMed   |  Link to Article
Antoniou  C, Kosmadaki  MG, Stratigos  AJ, Katsambas  AD.  Sunscreens—what’s important to know. J Eur Acad Dermatol Venereol. 2008;22(9):1110-1118.
PubMed   |  Link to Article
Krutmann  J.  Ultraviolet A radiation-induced biological effects in human skin. J Dermatol Sci.2000;23(suppl 1):S22-S26.
PubMed   |  Link to Article
Kuhn  A, Sonntag  M, Richter-Hintz  D,  et al.  Phototesting in lupus erythematosus tumidus—review of 60 patients. Photochem Photobiol. 2001;73(5):532-536.
PubMed   |  Link to Article
Fleischer  AB  Jr, Feldman  SR, White  RE, Leshin  B, Byington  R.  Procedures for skin diseases performed by physicians in 1993 and 1994. J Am Acad Dermatol. 1997;37(5, pt 1):719-724.
PubMed   |  Link to Article
Markovic  SN, Erickson  LA, Rao  RD,  et al; Melanoma Study Group of the Mayo Clinic Cancer Center.  Malignant melanoma in the 21st century, part 1: epidemiology, risk factors, screening, prevention, and diagnosis. Mayo Clin Proc. 2007;82(3):364-380.
PubMed
Robinson  JK, Rigel  DS, Amonette  RA.  Summertime sun protection used by adults for their children. J Am Acad Dermatol. 2000;42(5, pt 1):746-753.
PubMed   |  Link to Article

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