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Archive for the ‘Topical Products’ Category

 

Fighting that Itch!

Tuesday, October 28th, 2014

by Lindsay Mailloux, PharmD Candidate

We have all experienced it before. Whether it be a bug bite, a case of poison ivy, or the annoying t-shirt tag rubbing against your neck, you know what it feels like to have an itch. These cases usually have an easy solution—scratch your arm, cut off that tag, or maybe even apply some hydrocortisone cream. However, if you or your child is one of the many individuals who suffer from atopic dermatitis, more commonly known as eczema, you know the solution is not so simple.

Atopic dermatitis is the most common skin disease among children, affecting 20% of children in the United States and other developed countries.1 This skin condition usually starts affecting individuals during infancy and lasts into adulthood.2 Because atopic dermatitis acts like an allergic reaction, it cannot be cured—only managed. For less severe cases, the symptoms of itchy, dry, and irritated skin are usually treated with regular use of hypoallergenic moisturizers and maybe the occasional use of hydrocortisone cream for the bad flare-ups.2 Other non-medical practices can be used, such as applying lotion immediately after taking short baths to trap the moisture on the skin. Another handy tip is to keep nails clean and short to avoid damage to the skin from scratching.2 However, these measures are not always sufficient for the more severe cases of eczema, and individuals may have to resort to more intensive drug measures like taking prescription oral corticosteroids.1 Because these drugs have more serious side effects, especially for children, researchers are looking for better alternatives.

One study published this year suggests a new type of treatment called “wet-wrap” therapy. In this technique, a child with eczema takes a 10 to 20 minute warm bath and then rubs a moisturizer and medicated cream into his or her skin. The child is then wrapped in wet clothing to “trap” the medication and dressed in additional dry clothing over top. After a minimum of two hours, the wet clothing is removed.1 The goal of this therapy is to reduce irritation and help restore overall health and hydration of the skin. In this prospective cohort study, seventy-two children with moderate-to-severe cases of eczema were treated with wet wraps to test if the therapy improved their condition. However this study was limited by the fact that it did not have a control group for comparison, and its results cannot be generalized to adults.1

The study showed two major benefits of wet wrap therapy not seen with typical treatment. The first is that wet wraps were found to increase the effectiveness of a weaker medication, thus avoiding the need for a stronger drug with more worrisome side effects. Secondly, this technique was actually shown to help heal the skin and provide relief for a month after treatment.1

Since wet wrap therapy was first introduced about twenty years ago, various studies have shown its significant potential in treating eczema. One study showed that wet wrap therapy improved children’s eczema by an average of 74% when compared to their original condition. 3 In addition, a review of multiple studies determined that using wet wrap dressings with a medicated cream was both a safe and effective treatment.4

However, it is important to recognize that this treatment is currently only used for more severe cases of atopic dermatitis under the direct supervision of health care providers. One opinion from medical experts explains that wet wraps are currently used as a “safe crisis intervention.”5 This means that the technique should only be used in severe cases of eczema when the patient is too young to safely use prescription oral drugs. Another important point this expert makes is that use of wet wraps can result in side effects including lowering the activity of your adrenal glands or increased risk of bacterial infection. 5,6

One reason that this new practice is not used outside of the instruction and supervision of a health care provider is because of the complication of the process and the various methods of accomplishing it. One article pointed out that an official wet wrap method has never been established. For instance, various types of medicated creams and bandages have been used as well as different lengths of time for keeping the wraps on the skin. This lack of standardization makes it difficult even for health care providers to recommend wet wrap therapy.6

Current evidence strongly suggests that wet wrap therapy has definite potential as a safe and effective treatment for eczema. However, the major downside of this therapy is how complicated it is to use. At this point, it is not a good idea to try it out without supervision of a health care provider. But keep an eye out for guidelines on wet wrap therapy— this may be a huge area of treatment just around the corner. Also, consider asking your doctor about wet wraps if you or your child is losing the fight against that itch!

What are your thoughts? Do you think the benefits outweigh the risks? What other similar techniques would you recommend in the fight against the eczema itch?

References

  1. Nicol NH, Boguniewicz M, Strand M, Klinnert MD. Wet wrap therapy in children with moderate to severe atopic dermatitis in a multidisciplinary treatment program. The Journal of Allergy and Clinical Immunology: In Practice. 2014;2(4):400-406.
  2. Krinsky DL, Berardi RR, Ferreri SP, et al. Handbook of nonprescription drugs: An interactive approach to self-care. 17th ed. Washington, D.C.: American Pharmacists Association; 2012.
  3. Wolkerstorfer A, Visser RL, De Waard FB, Van DS, Mulder PGH, Oranje AP. Efficacy and safety of wet-wrap dressings in children with severe atopic dermatitis: Influence of corticosteroid dilution. Br J Dermatol. 2000;143(5):999-1004.
  4. Devillers A, Oranje A. Efficacy and safety of ‘wet‐wrap’ dressings as an intervention treatment in children with severe and/or refractory atopic dermatitis: A critical review of the literature. Br J Dermatol. 2006;154(4):579-585.
  5. Oranje AP. Evidence – based pharmacological treatment of atopic dermatitis: An expert opinion and new expectations. Indian J Dermatol. 2014;59(2):140-142.
  6. Devillers ACA, Oranje AP. Wet-wrap treatment in children with atopic dermatitis: A practical guideline. Pediatr Dermatol. 2012;29(1):24-27.

Can Diluted Bleach Reverse Skin Damage and Aging?

Sunday, December 1st, 2013

By Lauren Callahan, PharmD Student Cedarville University

You need not watch television long before an advertisement for an anti-aging product appears on the screen. Commercials boast of expensive creams, moisturizers, and other topical agents that can effectively reverse signs of aging. However, in a comprehensive review of all anti-aging compounds, it was concluded that these over-the-counter products alone will likely not produce the desired anti-aging effect. A dilemma is posed because the large market of users of anti-aging products are oftentimes unaware of this lacking evidence.1 However, there is hope for a cheap and evidence-based compound for anti-aging therapy: bleach.

On November 15th, The Huffington Post published an article entitled, “Study Suggests Bleach Can Reverse The Aging Process.” The article summarized research from Stanford University showing that diluted bleach may be used to treat skin aging and damage.  According to the study, exposure to 0.005% diluted bleach in mice blocked the expression of NFkB proteins that play a critical role in the inflammation process. Without the inflammatory process, there is increased cell proliferation, leading to younger-looking skin. The treatment also offers hope for those suffering from inflammatory skin conditions like eczema, radiation dermatitis, and diabetic ulcers. 2

There is high-quality data supporting these conclusions. The primary source, the research article from Stanford University, demonstrated the benefits of utilizing diluted bleach in mice. The mechanism of bleach (HOCl) was studied in mouse tissues and was found to inhibit NFkB signaling in keratinocytes. This inhibition decreased the amount of cytokines released, thereby inhibiting the recruitment of inflammatory immune cells. This was evidenced in the results as the bleach ultimately induced epidermal hyperplasia, increased cell proliferation, and reversed aging-associated genes.

With this evidence at hand, I do agree with the idea that bleach could offer a safe and effective way to prevent aging. After my own review of the research from Stanford University, it became apparent that the focus of the study was not simply anti-aging; it focused more upon the use of bleach for a variety of other skin disease states. 3 Even though The Huffington Post briefly mentioned these other skin problems, the title and focus of the article is misleading as it promotes anti-aging therapy alone.

The use of diluted bleach for any skin condition differs from the standard of care. For skin aging, self-care recommendations include the application of alpha or beta hydroxy acids two times daily. Current standards of self-care treatment for eczema basically include avoidance of the irritant and application of topical corticosteroids. 4 The possibility of 0.005% diluted bleach as a skin aging therapy does not change my self-care recommendations for anti-aging products and will not change them until further studies have demonstrated a safe and effective diluted bleach regimen in humans.  I would possibly allow my patients to use bleach treatment for atopic dermatitis (a form of eczema) colonized with a bacteria called Staphylococcus aureus under supervision from a doctor; diluted bleach has been tested in numerous studies, indicating its efficacy and safety in treatment of this condition. 5 Side effects that accompany bleach treatment include dry skin, rash, and nasal irritation.6 However, since diluted bleach has yet to be tested in humans for the indication of aging, the side effects may differ.Although the bleach therapy for atopic dermatitis colonized with Staphylococcus aureus works through the same NFkB inhibitor mechanism, I would remain hesitant to recommend this treatment for skin aging.

The glaringly obvious limitation of this article is that the bleach therapy has been tested in mice only. The bleach offers a theoretical solution to skin-aging and has yet to be proven in humans. Though I offer caution now, there may be a day in the near future in which my foremost recommendation for aging and inflammatory skin problems is diluted bleach. After all, diluted bleach treatment would be convenient, cost-effective, and evidence-based unlike the products on the market today.

With all of these desirable qualities, it may be difficult to dissuade a patient from experimentally utilizing bleach as an anti-aging treatment for skin. What would be your response to a patient that seeks counsel on bleach for anti-aging therapy? Would it be different if they were seeking to use bleach treatment for relief from an inflammatory skin condition?

 

References

1 Huang, C.K., & Miller, T.A. (2007). The truth about over-the-counter topical anti-aging products: a comprehensive review. Aesthetic Surgery Journal, 27(4), 402-412.

2 O’Connor, Lydia (2013). Study Suggests Bleach Can Reverse The Aging Process. The Huffington Post. Retrieved from: http://www.huffingtonpost.com/2013/11/15/bleach-skin-condition_n_4278058.html

3 Kim, S.K., Knox, S.J., Leung, T.H., Ning, S., Wang, J., & Zhang, L.F. (2013). Topical hypochlorite ameliorates NF-κB–mediated skin diseases in mice. The Journal of Clinical Investigation. doi:10.1172/JCI70895.

4 Berardi R.R., Kroon L.A., McDermott J.H. et al (2006). Handbook of nonprescription drugs, an interactive approach to self-care. APhA Publications.

5 Huang, J. T., Abrams, M., Tlougan, B., Rademaker, A., & Paller, A. S. (2009). Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics, 123(5), e808-e814.

6 Barnes, T. M., & Greive, K. A. (2013). Use of bleach baths for the treatment of infected atopic eczema. Australasian Journal of Dermatology.

 

Medical Mobile Apps Not Enough to Replace Face-to-Face Consultation

Tuesday, November 26th, 2013

by Lauren Williams, PharmD student

Today’s use of mobile technology heavily influences and expands the way we interact and communicate with others. Not only has it provided us new ways to interact with our friends and family, but it is currently expanding patient access to medical advice and opening the way for innovative interactions with medical professionals. According to the Research2Guidance mobile research specialists, “500 million smartphone users worldwide will be using a health care application by 2015”.1 With the great ease of access to medical information and advice today, self-care is very prevalent. Are patients more likely to skip out on pharmacist consultation and doctor appointments to rely on their easily attained materials and video calls with physicians?

The article, “Study finds dermatology apps useful, but they can’t replace a doctor’s visit”, published by MedCity News, discussed a study on the use and availability of dermatology applications.2 After searching the Apple, Android, BlackBerry, Nokia and Windows app stores for products related to dermatology, researchers reported finding over 200 apps that offered its users medical material, treatment help and guidance to self-diagnosis concerning dermatology. Specifically, they give the users what they need to identify and treat dermatological concerns without having to consult with their pharmacist or visit their doctor. Although these apps increase user accessibility to medical information and advice, researchers are highly concerned that people may be getting the wrong information since only a few of these apps were clearly created by medical professionals. Their other concern was that some patients would value and grow confident in their app facts, and forego actually visiting the dermatologist. Despite these concerns, mobile apps are used not only by patients, but also by health care professionals. Because trusted professionals use these, the FDA has stepped into the picture and declared that they will regulate and set apart medical apps intended for the use of doctors.

I agree with the article that medical apps may be great sources to increase medical knowledge; however, we must approach them with skepticism, recommending users to cross-reference the information and consult with their pharmacist or doctor before beginning treatment options based on apps. I am comfortable with patients self-educating and treating on more minor topics, such as sunburn, but I believe that they should present to their doctor with any more serious concerns, such as a lumpy mole that has changed color, which could indicate melanoma. Common conditions, such as eczema, dry skin, contact dermatitis, insect bites, stings, head lice and sunburn can all be immediately self-treated or referred with consultation from a pharmacist. Pharmacists are easily assessable and qualified to identify self-care exclusion criteria with these dermatological conditions. Some conditions may easily be detected simply by viewing, but others may not be so simple since a biopsy, or other procedure, may be necessary for better understanding. Mobile apps cannot perform biopsies; they cannot give thorough follow-up examinations. Teledermatology, one of the most promising apps, has similar limitations.3 Although the patient and dermatologist evaluate via a live video call, the patient’s interpretation of symptoms may be different from the dermatologist’s interpretation. These mobile apps can only be used so much in self-treatment and self-examination, but they can continue to educate the user.

A study published by University of Florence’s Department of Dermatology asked the question “Is skin self-examination for cutaneous melanoma detection still adequate?” Researchers found that although the largest percentage, 36%, of found melanomas were results of a regular annual skin examination by a dermatologist, the next largest group, 33%, of found melanomas were by self-detection. Because these percentages were so close, one may think that self-detection is just as good as a visit to the dermatologist. This study also concluded “self-detection was associated with a greater probability of having a thick melanoma and, therefore, a poor prognosis (odds ratio 1.56)”. 4 Therefore, I believe that although self-detection with the aid of medical applications is beneficial, it is more beneficial and important to pay a visit to the dermatologist or seek immediate recommendation from a pharmacist.

Using mobile devices for self-care is different from the standard of care, but it is progressive, innovating, and exciting to try. We must always be cautious with any type of progression simply because it often takes us on an untraveled road to new outcomes, studies, and experiments. I believe that the utilization of mobile applications is a part of the natural movement of converging health practices with modern technology. Mobile technology is heavily integrated in our society, so it makes sense that patient care and medical advice is accessible by it.

The point of these applications is to increase medical knowledge, not to replace face-to-face interaction with a medical professional. Do you believe that the designers of these apps are aiming to increase medical knowledge, or to replace face-to-face interaction with a physician or pharmacist? How do you think patients will use them?

References

 [1] Mikalajunaite, E. 500m people will be using healthcare mobile applications in 2015. http://www.research2guidance.com/500m-people-will-be-using-healthcare-mobile-applications-in-2015/. Published November 10, 2010. Accessed November 12, 2013.

[2] Pittman, G. Study finds dermatology apps useful, but they can’t replace a doctor’s visit. http://medcitynews.com/2013/09/study-finds-dermatology-apps-useful-cant-replace-doctors-visit/. Published September 26, 2013. Accessed October 23, 2013.

[3] Brewer A, Endly DC, Henley J, et al. Mobile Applications in Dermatology. JAMA Dermatol. 2013;149(11):1300-1304. doi:10.1001/jamadermatol.2013.5517.

[4] De Giorgi, V., Grazzini, M., Rossari, S., Gori, A., Papi, F., Scarfi, F.,Gandini, S. Is skin self-examination for cutaneous melanoma detection still adequate? A retrospective study. Dermatology. 2012;225(1), 31-6. doi: 10.1159/000339774.

Hand Sanitizer: Effective or Toxic?

Saturday, November 23rd, 2013

by Joseph Newman, PharmD student

Hand sanitizer is often used as a quick and convenient alternative to washing your hands. Whether it is a quick squirt after leaving the gym or the super market, or pulling it out after shaking lots of hands or coughing, it has become one of the most common ways to clean hands and get rid of germs. But is using all of this hand sanitizer actually preventing you from getting the flu or a cold? Is it any more or less effective when compared to washing with soap and water?

In his recent article1 on CNN, Bob Barnett evaluates the use of hand sanitizer and suggests that there are safety and efficacy concerns for hand sanitizers containing triclosan. Barnett states that according to Allison Aiello, an associate professor of epidemiology at the University of Michigan, there is no evidence that products containing triclosan have any benefit and that hospitals won’t use them. He goes on to cite other sources saying that there is little benefit of triclosan-containing products over washing with soap and water. Barnett claims that triclosan can disrupt the endocrine system and reduce muscle strength, as shown in animal studies. He also claims that triclosan does not protect against viruses and fungi. Barnett makes the distinction that alcohol-based hand sanitizers are good at killing bacteria and some viruses and can be used as an alternative to hand washing, but concludes by emphasizes the fact that washing with soap and water is the most effective way to eliminate germs.

I agree with most of this article. According to the World Health Organization, hand washing is “the most important hygiene measure in preventing the spread of infection.”2 I also agree that alcohol-based hand sanitizer is a good idea if you can’t wash your hands. Barnett’s recommendation for hand washing and alcohol-based hand sanitizer is one that is consistent with the standard for self-care in regards to hand hygiene. However, there are some limitations to his article, especially in his evaluation of triclosan-containing products. For one, he only cites a couple different sources. His claims of potentially harmful effects of triclosan and its limited effectiveness cannot be backed up without further research. Furthermore, Barnett says that studies support his claims, but then fails to provide information about or references to those studies.

Upon further research, I found that alcohol-based hand sanitizers are an “appropriate alternative to hand washing for hand cleansing”3 and that they improve hand hygiene practices within the home setting.4 Another study showed that alcohol-based hand sanitizers are safe. In this study, volunteers applied hand-rubs with varying amounts of ethanol onto their hands before being tested for blood concentrations of ethanol and acetaldehyde. According to the study, any alcohol absorbed through the skin was below toxic levels in humans.5 This supports Barnett’s claim that alcohol-based hand sanitizers can be safe and effective. As far as triclosan containing hand sanitizers, the FDA states that triclosan is not known to be hazardous to humans6 and according to one study, is “well tolerated by a variety of species, including human beings.”7 According to this research, it appears as though triclosan is not toxic, contrary to the research that Barnett refers to in his article.

Hand sanitizers that are alcohol-based appear to be safe to use as well as effective at promoting hand hygiene and preventing some illnesses, and while triclosan appears to be non-toxic, there was not very much research available on the effectiveness of hand sanitizers containing that ingredient. So what does this mean for me and you in terms of using these products to prevent colds, the flu and other common diseases? As a pharmacist, these types of questions come up often when discussing over-the-counter treatment of colds. Alcohol-based hand sanitizer can be a very useful tool in self-care of colds to prevent the transmission of germs while on-the-go. However, washing your hands is still the most important measure in preventing the spread of infection.2

So what do you think? Should we continue to use hand sanitizer? Should we switch to only soap and water? Or do you think there should be more research done on this issue?

 

References:

  1. Barnett, B. Is hand sanitizer toxic? CNN. October 16, 2013. Available at http://www.cnn.com/2013/10/16/health/hand-sanitizer-toxic-upwave/index.html?hpt=he_bn3. Accessed November 13, 2013
  2. Hospital Infection Control Guidance. World Health Organization Web site. 2003 Available at: http://www.who.int/csr/surveillance/infectioncontrol/en/print.html. Accessed November 13, 2013
  3. Vessey J, Sherwod J, Warner D, Clark D. Comparing Hand Washing to Hand Sanitizers in Reducing Elementary School Student’s Absenteeism. Pediatric Nursing [serial online]. July 2007;33(4):368-372. Available from: Consumer Health Complete – EBSCOhost, Ipswich, MA. Accessed November 14, 2013
  4. Sandora TJ, Taveras EM, Shih MC, et al. A randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home. Pediatrics. 2005;116(3):587-94. Available at http://pediatrics.aappublications.org/content/116/3/587.long. Accessed November 14, 2013
  5. Kramer A, Below H, Bieber N, et al. Quantity of ethanol absorption after excessive hand disinfection using three commercially available hand rubs is minimal and below toxic levels for humans. BMC Infect Dis. 2007;7(1):117. Available at http://www.biomedcentral.com/1471-2334/7/117/. Accessed November 14, 2013
  6. Consumer Updates > Triclosan: What Consumers Should Know. Federal Drug Administration Website. August 29, 2012. Available at http://www.fda.gov/forconsumers/consumerupdates/ucm205999.htm. Accessed November 14, 2013
  7. Bhargava H, Leonard P. Triclosan: Applications and safety, American Journal of Infection Control, Volume 24, Issue 3, June 1996, Pages 209-218, ISSN 0196-6553, Available at http://www.sciencedirect.com/science/article/pii/S0196655396900176. Accessed November 14, 2013

Sunscreen: Are You Protecting Yourself Againist Aging Skin?

Monday, October 7th, 2013

By Aaron Le Poire, PharmD Student Cedarville University

We have often sought healthy and youthful complexions throughout history.  One way people have tried to prevent aging is by using creams and lotions to protect themselves from wrinkling and the damaging effects of the sun on the skin.1,2 Exposure to the harmful A and B ultraviolet components of sunlight is one of the leading causes of skin aging and skin cancer.3,4  One of the most common ways used to prevent the aging of skin from the sun is sunscreen.5

Recently, a news article from USA Today was published lauding the benefits of sunscreen based on a study issued in the Annals of Internal Medicine.6 The study, which followed hundreds of people over a four and a half year period, found 24% less skin aging in people who regularly applied sunscreen.7 The researchers studied people who were less than 55 years old because their skin-aging is primarily from the sun and not due to their age.  The study made replicas of the skin on the back of the subject’s hands in order to measure the deterioration of the skin at the beginning and end of the trial.  The study concluded that the regular use of sunscreen by young and middle-aged adults could slow down the aging of their skin from the sun.7

There are other studies that support the same opinion that sunscreen can limit the effects of aging from the sun.8,9  Studies have found sun exposure can damage skin and can be avoided by protecting oneself from harmful UV rays.10 The FDA also suggests that skin aging and cancer can be avoided by the use of sunscreen.11 The difference between this study and others is this particular one actually put those findings to the test in a large-scale trial examining many subjects over a long period of time.  The study was also completed in a sunny part of Australia that is as close to the equator as Florida.6

One of the limitations of the study was one-third of the people enrolled in the study only completed one reading of their skin, usually the first time.  Another limitation of the study could be the use of lotions or moisturizers by the subjects to protect their skin affecting how much it deteriorated over time.  Using less effective sunscreen than what is on the market today is also another limitation of the study.  More research needs to be done to see if newly developed sunscreens help even more with the aging of skin.  There are some studies that could suggest the chemicals in sunscreen could be harmful to the body.  One study found some ingredients in sunscreen to cause genetic damage in mice, but this has not been tested in humans.12 Another study found sunscreen use tied to increased free radicals in the body, which could lead to an increased risk for cancer.13

The trial had a solid study design, as it was a randomized, controlled, clinical trial.  Along with the study design, the location of the study and efforts by the researchers to make sure the people enrolled were complying with the design make the results even more pertinent.  Any study longer than the one in the article is unlikely to be implemented because it would be considered unethical to keep people from using sunscreen for such long periods of time.6

The practice of sun protection as laid out by the FDA includes reducing time in the sun, wearing appropriate clothing such as hats, long pants, sunglasses, and long sleeve shirts.11 Another recommendation is the use of sunscreen.  The sunscreen used should be at least 15 SPF, which is what was used in the study.  It is also recommended to use a water resistant and “broad spectrum” sunscreen that protects against the different types of UV radiation from the sun.  Make sure to apply it evenly to all exposed skin at least 15 minutes before going out and reapply at least every 2 hours.11

Protecting your skin from the sun is very important, not only for it’s appearance but also for preventing the risk of skin cancer.  Sunscreen is one easy way to protect your skin from both aging and cancer.  Studies have shown the effectiveness of sunscreen for protection against UV radiation.8 The study mentioned in the article delivers confirmation of the benefits regular use of sunscreen can have on the aging of your skin over a prolonged time period.

So, do you think this trial provides enough evidence for the beneficial effects of sunscreen? Or do you think sunscreen has too many harmful effects?  Does this evidence change your opinion on how you will use sunscreen in the future?

 

References

 

[1] Brandt FS, Cazzaniga A, Hann M . Cosmeceuticals: current trends and marker analysis. Semin Cutan M ed Surg. 2011;30:141-3. [PMID: 21925366]

 

[2] Yaar M , GUchrest BA. Aging of skin. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, et al, eds. Fitzpatrick’s Dermatology in General Medicine. 5th ed. New York: McGraw Hill; 1999:1697-706.

 

[3] Rabe JH, Mamelak AJ, McElgunn PJ, Morison WL, Sauder DN. Photoag- ing: mechanisms and repair. J Am Acad Dermatol. 2006;55:l-19. [PMID:

16781287]

 

[4] Foote JA, Harris RB, Giuliano AR, Roe DJ, Moon TE, Cartmel B, et al. Predictois for cutaneous basal- and squamous-cell carcinoma among actinically damaged adults. Int J Cancer. 2001;95:7-ll. [PMID: 11241303]

 

[5] Antoniou G, Kosmadaki MG, Stradgos AJ, KaKambas AD. Photoaging: prevention and topical treatments. Am J Clin Dermatol. 2010;l 1:95-102. [PMID: 20141230]

 

[6] Painter K.  Regular sunscreen use slows skin aging, study shows.  USA Today. June 3, 2013.

 

[7] Hughes MC, Williams GM, Baker P, Green AC. Sunscreen and prevention of skin aging: a randomized trial. Ann Intern Med. 2013;158(11):781-90.

 

[8] Gilchrest, B.A.  A review of skin ageing and its medical therapy. Br. J. Dermatol. 1996;135: 867–875.

 

[9] Naylor, M.F. & K.C. Farmer.  The case for sunscreens: a review of their use in preventing actinic damage and neoplasia. Arch. Dermatol. 1997;133: 1146–1154.

 

[10] Taylor CR, Stern RS, Leyden JJ, Gilchrest BA. Photoaging/photodamage and photoprotection. J Am Acad Dermatol. 1990;22(1):1-15.

 

[11] FDA. Sun safety: save your skin! FDA website. 2012 available at http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm049090.htm. Accessed October 1, 2013.

 

[12] Trouiller B, Reliene R, Westbrook A, Solaimani P, Schiestl RH. Titanium dioxide nanoparticles induce DNA damage and genetic instability in vivo in mice. Cancer Res. 2009;69(22):8784-9.

 

[13] Hanson KM, Gratton E, Bardeen CJ. Sunscreen enhancement of UV-induced reactive oxygen species in the skin. Free Radic Biol Med. 2006;41(8):1205-12.