Annie Grossberg, M.D.
One of the fastest growing cancers among adults, skin cancer is also occurring more frequently in children and teens. Yet, it is also one of the most preventable cancers. Proper, protective skin care can help prevent its development in childhood, and subsequently in adulthood. That tan you might think is healthy – even a rite of childhood – is evidence, already, of DNA damage.
What causes skin cancer?
Skin cancer is caused by mutations, or errors, in the DNA of skin cells. These mutations permit the cells to grow in uncontrollably and result in the development of cancerous moles or other growths on the skin. Much of this DNA damage to our skin cells is caused by ultraviolent (UV) radiation, either from the sun or from tanning beds. Over time, the body works to keep these mutations in check. But when it’s unsuccessful, cells multiply rapidly and form malignant tumors. There are three main types of skin cancer. The type that develops depends on which type of skin cell the cancer originates from. Of the three types of skin cancer – basal cell carcinoma, squamous cell carcinoma and melanoma – melanoma is the most feared because it is more likely than the other types to spread to other body parts and be deadly.
For generations, children have played in the sun. What has changed?
We think the rise in pediatric skin cancers is linked to a host of modern factors: extended playtime in the sun (including sports), clothing that leaves more skin exposed, and, significantly, earlier exposure of teens and even younger children to tanning booths. These are the same factors contributing to the increased prevalence of skin among adults. Pre-teens and adolescents are increasingly modeling adults and experimenting with the tanning booth. As the cases of skin cancers in the young trend upwards, we are, at least, getting very good at picking up on these cases.
As a dermatologist, what do you look for?
We are trained in the ABCDEs of detecting potentially cancerous moles – Asymmetry, Border irregularity, Color variation, Diameter over 6 millimeters (or the size of a #2 pencil eraser), and Evolution or change over time – to identify which moles (nevi) might require biopsy or removal to test for skin cancer. As it turns out, however, while some skin cancers in children may be detected in this manner, melanomas in children may look entirely different, and not even like a mole. In children, melanoma may be more likely to present as a new growing bump on the skin that may appear pink or lack color entirely. This bump may bleed, which may also be a cause for concern.
Can skin cancer be prevented?
We believe that many instances of it can. Although sun exposure is, strictly speaking, not the only contributing factor, it is a chief one. Because skin cancer can often be effectively treated if caught early, we ask pediatricians to include conversations with parents and children about the imperative of proper skin protection at every visit. Here at Johns Hopkins, we teach children and teenagers what to look for, including how to spot potential pre-cancers or cancers. Parents should keep an eye on the skin of younger children by doing skin checks at home.
How can parents protect their children?
First, they should model good sun protection at all times while outdoors and avoid tanning beds, which are contributing to the rise of melanoma in kids. Babies under the age of 6 months should be shielded from the sun with blankets, hats and sun shades. After 6 months of age, sunscreen should be applied liberally to all exposed surfaces and reapplied at a minimum every 2 hours. In general, children should be kept out of the sun as much as possible between the hours of 11 a.m. and 4 p.m. and wear sun-protective clothing, including a hat.
What about protective eyewear?
Absolutely. Because skin cancers, including melanoma, can affect the eyelids as well as parts of the eye itself, use of protective eyewear is always a good idea when outdoors. Adults and children can get in the habit of wearing sunglasses with broad spectrum protection against both UVA and UVB rays, and those that cover and protect the delicate areas around the eyes, as well.
What should we look for in proper skin cream protection in children over 6-months-of-age?
Sunscreens for children should be a broad spectrum formula with both UVA and UVB protection. UVA and UVB refer to the two most abundant types of ultraviolet radiation, both of which are present in high amounts in natural sunlight and can be causes of skin cancer as well as premature skin aging. New regulations require manufacturers to note whether a product protects against both of these subtypes of ultraviolet radiation, and a product labeled “broad spectrum” is what I recommend. Although the specific sun protection factor (SPF) number needed varies by the individual, I often recommend at least SPF 30 for daily protection, and often higher for those skin types more prone to burning or if there are other risk factors for skin cancer. I recommend a good coat of sunscreen on children before they go outside, no matter the season, and even when it is overcast, for even then, harmful ultraviolet rays are present. Be sure to reapply every two hours or sooner if your child has been swimming or sweating.
What about clothing?
There are a lot of good new products out there – shirts, hats, and trousers – that have built in sun protection. Often they have a number just like sunscreens, but in clothing it is called UPF (ultraviolet protection factor) instead of SPF. These types of clothing can be very helpful to protect children while out at the pool or beach. I recommend looking for rash guards or swim outfits with UPF 50. But don’t forget that even clothing with a high UPF does not replace sunscreen, as several areas will often be uncovered, including the face, hands, feet, and back of kids’ necks.
Modeling is very important. If a child sees you doing something, it will be more acceptable to him or her. The earlier the education in skin protection the better. Even on a cold winter day, my daughter gets a coating of sunscreen on her face. She does not necessarily understand the reasons why, but seeing that I am also applying it makes her eager to do so as well.
But isn’t sunlight a vital form of Vitamin D?
Sunlight is a source of Vitamin D, and Vitamin D is essential to the health of our bones and immune system. There are other sources of Vitamin D besides sunlight, including our diet. Most children and adults can get sufficient Vitamin D through diets rich in fish, fortified dairy products and cereals, as well as supplements, without increasing the very real risk of skin damage and skin cancer.
What is your take-away message for parents?
Limiting exposure to sunlight in children and teens may pay large dividends in preventing cancers later in life. Research has shown that sunburns early in life increase a child's risk for skin cancer later in life. In addition, premature skin aging, such as fine lines and wrinkles, as well as some discolorations, are often the result of sun exposure that starts early in life. For young children, parents can set the tone by instituting good routines of sunscreen application and use of sun protective clothing early in life. For teens, have a discussion about the importance of sun protection early on. While the risks of skin cancer may not seem relevant to them, sometimes what does resonate is the importance of sunscreen and sun protection in preventing skin aging.
What drew you to pediatric dermatology?
As a specialty, dermatology appealed to me early in my medical training. I liked its broad scope, from common skin conditions to more serious diseases like skin cancer. During my residency, I began to develop a special interest in caring for children and their various skin conditions. Dermatology is a very appealing field in that it offers opportunities to establish long-term relationships with our patients. Here at Johns Hopkins, in addition to mole checks and skin cancer screenings, we see patients for numerous other skin conditions, including eczema, acne, psoriasis, and birthmarks of all types. In addition to medical treatments, we also offer laser and surgical treatments for many of these conditions.
An assistant professor of pediatric dermatology at Johns Hopkins, Annie Grossberg, M.D., completed a residency in dermatology at the University of Maryland School of Medicine. After a fellowship in pediatric dermatology at Johns Hopkins, she joined its faculty in 2013. She sees patients in the pediatric dermatology clinic at the Johns Hopkins Children’s Center as well as at Green Spring Station. Appointments and consultations