Archive of the 24th Annual Meeting of The Photomedicine Society
March 19, 2015
8:00am - 5:00pm
Nob Hill Room
San Francisco Marriot Marquis
780 Mission Street
San Francisco, California, 94103, USA
|7:30 – 7:55||Registration|
|7:55 – 8:00|| Opening Remarks
Sewon Kang, MD, Baltimore, Maryland
|Session 1: Indoor Tanning|
|8:00 – 8:30||Markham C. Luke, M.D., Ph.D., Silver Spring, Maryland
“Update on HHS Actions on UV Indoor Tanning”
|Abstract Session A|
|8:30 – 9:45||Abstract Presentations|
8:30 – 8:43
8:45 – 8:58
9:00 – 9:13
9:15 – 9:28
9:30 – 9:43
|9:45 – 10:00||Break|
|Session 2: Photomedicine Implications for Medical Dermatology|
|10:00 – 10:40||Sewon Kang, M.D., Baltimore, Maryland
“UVB for Acne Keloidalis Nuchae”
|10:40 – 11:20||Amit G. Pandya, M.D., Dallas, Texas
“Update on Phototherpay for Vitiligo”
|11:20 – 12:00||Samia Esmat, M.D., Cairo, Egypt
“International Consensus of Guidelines for the
Phototherapy of Vitiligo”
|12:00 – 2:00||Break for Lunch|
|Session 3: Sunscreen Regulation|
|2:00 – 2:30||Farah Ahmed, B.Sc., J.D., Washington, DC
“Sunscreen Regulatory Update – FDA’s 2014
Sunscreen Advisory Committee Meeting, the Sunscreen
Innovation Act - and What to Expect Next”
|Abstract Session B|
|2:30 – 3:15||Abstract Presentations|
2:30 – 2:43
2:45 – 2:58
3:00 – 3:13
|3:15 – 3:30||Break|
|Session 4: Photodynamic Therapy|
|3:30 – 3:50||Rolf-Markus Szeimies, M.D., Recklinghausen, Germany
“Daylight PDT – A Novel Approach in
the Treatment of Actinic Keratoses
|Abstract Session C|
|3:50 – 5:05||Abstract Presentations|
3:50 – 4:03 |
4:05 – 4:18
4:20 – 4:33
4:35 – 4:48
4:50 – 5:05
The presentations were the following, in order of presentation
(Click on each title to see the abstract and its authors.)
Uli Osterwalder1, Bernd Herzog2, Brian Diffey3.
1 BASF PCN GmbH, Monheim, Germany
2 BASF Grenzach GmbH, Grenzach-Whylen, Germany
3 Dermatological Sciences, Institute of Cellular Medicine, University of Newcastle
Acquiring a tanned skin either by sunbathing, sunbed use, or a combination of both, is a desirable objective for many people. Tanning in sunlight and on sunbeds both contribute to the ultraviolet burden on our skin. The objective of the study was to compare the UV exposure resulting from a 2-week vacation spent sunbathing with sunscreen-protected skin, with that from a typical course of 10 sessions on a sunbed.
A numerical analysis combining data on sunlight and sunbed UV levels, time spent tanning and spectral absorption properties of different types of sunscreen has been applied.
The analysis showed that unless a sunscreen provides optimal broad-spectrum protection, a 2-week sunbathing vacation that avoids sunburn on sunscreen-protected skin can result in a higher cumulative UV exposure than a typical 10-session sunbed course. The lowest exposures for a given SPF are obtained when sunscreen delivers broad-spectrum protection that approaches the ideal of uniform absorption at all wavelengths throughout the UV spectrum.
Conclusion In extreme cases of recreational sun exposure where sunscreens providing sub-optimal broad-spectrum protection are used, the UV insult to the skin is likely to result in higher cumulative exposures than commonly-employed sunbed practices.
Danny Guo, Sunil Kalia.
Photomedicine Institute, Vancouver Coastal Health Research Institute and Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC
Purpose Ultraviolet radiation (UVR) exposure is linked to the development of skin cancer. Majority of studies have examined the amount of UVR acquired by individuals during the summer months. There is a large proportion of individuals in northern latitude countries that travel to sunny destinations, however there is a lack of studies examining the UVR received during the winter months by these individuals.
Methods The Second National Sun Survey was utilized in which 7121 Canadians were sampled to determine the: i) proportion of individuals traveling to a sunny destination during the past winter, ii) amount of UVR exposure obtained while traveling, iii) proportion of individuals trying to acquire a suntan, and iv) proportion that had a sunburn.
Results Of the 7121 individuals, 1268 (18.4%) traveled to a sunny climate during the past winter (from October to March). 87% of the 1268 individuals acquired > 1 hour of average UVR exposure during their trip. As well, 37% of individuals tried to acquire a suntan, and 19.1% received a sunburn. The rates of sunburn are comparable to individuals traveling during summer vacations, in which 20.7% had a sunburn.
Conclusion According to the Second National Sun Survey a significant proportion of individuals in Canada travel to sunny destinations during the winter. These individuals tend to acquire a large amount of UVR exposure, and have sunburn rates that are comparable to summer vacations. These results provide supporting evidence that in northern latitude countries a significant proportion of individuals receive fairly high UVR exposure during the winter months.
Vincent Richer1, Pegah Kharazmi1,2, Tim Lee1,2, Sunil Kalia1, Harvey Lui1,3.
1 Department of Dermatology and Skin Science, University of British Columbia and Photomedicine Institute, Vancouver Costal Health Research Institute
2 Cancer Control Research Program, BC Cancer Research Centre
3 Imaging Unit, Integrative Oncology Department, BC Cancer Research Centre
Background and Purpose Although sunscreens can prevent sunburn, diminish photoaging, decrease the risk of skin cancer, and prevent photodermatoses, their efficacy is limited by user adherence. The subjective visual appearance of sunscreens on the skin is one of many factors that influences if and how they are applied to the skin. Our objective was to objectively quantify the visibility of sunscreens on the skin.
Methods Four different sunscreens were applied at amounts of 0.5, 1.0, 1.5 and 2.0 mg/cm2 to the backs (50 cm2) of three subjects and the forehead (9 cm2) of one subject. High-resolution standardized photographs were taken using a digital SLR camera, a diffuse light source and a standard color reference card. L*a*b* color values were extracted using Adobe Photoshop CS5 software from averaged areas with sunscreen and from control areas without sunscreen. Differences in visible color between the controls and the corresponding sunscreen application areas were represented by ΔE, which in turn was calculated from the linear Cartesian distance between the two locations within the 3 D L*a*b* color space.
Results By the above image analysis, all sunscreens applied on the back were visible at all applied quantities (ΔE range 1.0-24.7; p=0.0005, Wilcoxon signed rank test). Visibility of sunscreen as manifested by ΔE was dependent on the sunscreen product applied to the skin (p=0.0174, Friedman test). Stepwise linear regression identified product amount, SPF, composition (physical vs. chemical) and baseline b* as pertinent variables. Data from the experiment on the face was plotted and analyzed qualitatively only.
Conclusion Standardized photography and computer analysis is a potential method to objectively assess the visual appearance of sunscreens applied on the skin. Validation of this method with subjective clinical appraisal of sunscreen visibility is required.
Kathryn L. Anderson, Karen E. Huang, William W. Huang, Steven R. Feldman.
Wake Forest Baptist Medical Center, Winston-Salem, NC
Purpose In-office phototherapy is underused due to cost and inconvenience to the patient. Home phototherapy may be underused due to inadequate training in its use. The purpose of this questionnaire was to evaluate the amount of didactic education and the level of comfort dermatology residents have in prescribing in-office and home phototherapy.
Methods We queried dermatology residents about the amount of training and their comfort in prescribing in-office and home phototherapy. We also queried about botulinum toxin and radiation therapy as positive and negative controls, respectively. A link to the questionnaire was embedded in a standardized email that was sent to program coordinators, asking for the email to be forwarded to their residents. Responses were anonymous. Responses were tabulated; comparisons between subgroups were made using the Fisher’s exact test with a Type I error rate of 5%.
Results 62 residents responded. 58% and 25% of residents reported didactic training in prescribing in-office and home phototherapy, respectively, compared to 85% for botulinum toxin and 9% for radiation therapy.10% of first-year dermatology residents were “extremely comfortable” or “very comfortable” prescribing in-office phototherapy and 0% for home phototherapy, compared to 5% and 0% for botulinum toxin and radiation therapy, respectively. For third-year dermatology residents, 61% were “extremely comfortable” or “very comfortable” prescribing in-office phototherapy and 17% for home phototherapy, compared to 17% and 6% for botulinum toxin and radiation therapy, respectively.
Conclusions The majority of residents receive didactic education in prescribing in-office phototherapy, but only a fourth receive didactic education for prescribing home phototherapy, and the majority of even third-year dermatology residents are not comfortable prescribing home phototherapy. Lack of home phototherapy training likely results in underuse in practice.
Jianhua Zhao1,2, Vincent Richer1, Mohammed AlJasser1, Soodebeh Zandi1, Nikiforos Kollias1, David McLean1, Sunil Kalia1, Haishan Zeng1,2, Harvey Lui1,2.
1 Department of Dermatology and Skin Science, Photomedicine Institute, University of British Columbia and Vancouver Costal Health Research Institute
2 Imaging Unit, Integrative Oncology Department, BC Cancer Research Centre
Background The optical properties of skin as extracted from non-invasive fluorescence spectroscopy provide valuable insights into epidermal and dermal properties such as epidermal pigmentation, proliferation, cornification, and matrix protein cross linkages. The fluorescence signal depends on the intensity of the exciting light, the absorption properties of the constituent molecules, and the efficiency with which the absorbed photons are converted to fluorescence emission. The optical features and appearance of vitiligo have heretofore been explained primarily on the basis of reduced epidermal pigmentation.
Objectives To explore the optical (fluorescence) differences between vitiligo and adjacent normal skin that arise from changes in epidermal pigmentation and other factors.
Methods Fluorescence excitation-emission matrix (EEM) spectroscopy measurements of affected and adjacent normal skin of 35 volunteers with vitiligo were acquired using a double-grating spectrofluorometer with excitation and emission wavelengths of 260-450 nm and 300-700 nm respectively.
Results and Discussion As expected, the most pronounced difference between the spectra obtained from vitiligo lesions compared to normally pigmented skin was that the overall fluorescence was much higher in vitiligo; these differences increased at shorter wavelengths, thus matching the characteristic spectral absorption of epidermal melanin. Additionally when comparing the fluorescence spectra from vitiligo to normal skin we also detected three distinct spectral bands centered at 280nm, 310nm, and 335nm. The 280nm band may possibly be related to inflammation, whereas the 335 nm band may arise from collagen or keratin cross-links. The source of the 310 nm band is uncertain; it is interesting to note its proximity to the 311 nm UV lamps used for vitiligo phototherapy.
Conclusion The fluorescence properties of skin affected by vitiligo are distinctly different from those of normal adjacent skin. These differences are accounted for not only by changes in epidermal pigment content, but also by other optically active cutaneous biomolecules.
Prithwiraj Maitra Ph.D, Associate Director, JNJ Research Fellow.
Global Sun Innovation Platform
Johnson and Johnson Consumer Products
Sunscreens are an important product category not only in the beauty category but also address public health. More than 90% of the visible changes commonly attributed to skin aging are caused by the sun. People who use sunscreen daily show 24% less skin aging than those who do not use sunscreen daily. Regular daily use of sunscreen reduces the risk of developing squamous cell carcinoma by 40 % and the risk of developing melanoma by 50 %.This presentation will focus on the commonly held myths on broad spectrum sunscreens in the scientific community. The presentation will cover both mechanism of action and efficacy of broad spectrum sunscreens. The presentation will also highlight benefits of high SPF sunscreens and will provide scientific evidence to support common misconceptions about high SPF sunscreens.
Suncare Research Laboratories; Winston Salem, NC
Purpose The purpose of this presentation is to discuss current problems of sunscreen testing, and new technologies that can replace the sun protection factor (SPF) test on human subjects
Method Recommendation based on personal experience.
Summary After five decades, with only minor changes, the SPF test on human subjects should be replaced with a test that does not require production of erythema on human volunteers. Moreover the limited lamp spectrum required for tests on humans over estimates the SPF encountered in sunlight. Finally, SPF testing results on human subjects vary widely among different laboratories. Currently, in vitro testing is useful for measuring absorbance ratios, such as critical wavelength, but has shown unacceptable variability among measurements of absolute values such as SPF and UVA protection factor. Further, in silico computations of SPF often under estimate SPF results, possibly because vehicle effects are not considered. A recently introduced robotic instrument for applying sunscreens to substrates may reduce the variability of in vitro estimates of SPF. Both in vitro and in silico results may be markedly improved, by novel applications of spin coating, and photonics. Spin coating has been used in the production of thin films for flat screen displays, compact disks and microcircuits for more than thirty years. Its application to sunscreen testing involves applying a known formula to a rapidly rotating substrate, spreading the sunscreen to a desired uniform film thickness, in the range of 1 to 20 micrometers. Measuring the combined absorbance values of a set of sunscreen films with a desired assortment of thicknesses, mathematically weighted by a known sunscreen film distribution, yields the absorbance spectrum and the SPF of the sunscreen. The sunscreen thickness distribution is estimated using processed histograms of fluorescence photographic images of the sunscreen, applied to the skin of one or more human volunteers.
Conclusion New technologies can advance sunscreen SPF testing, account for the entire solar spectrum and reduce the variability of results, using minimally-invasive methods.
9 Orchard Rd., Ringoes NJ
Purpose A study was conducted to evaluate the primary mode of action of physical sunscreen filters (titanium dioxide and zinc oxide) and to quantitate the level of protection attributable to scattering and reflection phenomena.
Methods Physical measurements of optical interactions of UV and visible light with sunscreen films containing titanium dioxide and zinc oxide particles (nano and pigmentary sizes) were conducted using a spherical integration chamber. Transmission and reflectance measurements were conducted and compared with a classical reflection standard (barium sulfate).
Results Physical measurements indicate that the primary mode of action of these filters is absorption of UV photons up to about 370nm where transition to reflection begins to predominate.
Conclusions The proportion of reflection and scattering constitutes 5% or less of the protection in the UV range below 370nm and the primary protection provided by these physical UV filters is by absorption, similar to other “chemical” soluble filters.
Paul Donald Forbes1, Julie Ann Woods2, Alan Evans3, Paul D Coates4, June Gardner2, Ronan M Valentine2, Sally Helen Ibbotson2, James Ferguson5, Christopher Fricker6, Harry Moseley2.
1 Toxarus, Inc., PA
2 Photobiology Unit
3 Dept. of Histopathology
4 Tayside Tissue Bank
5 Spectratox Ltd, Ninewells Hospital, University of Dundee, UK
6 GOJO Industries, OH
The need for microbial decontamination of water, circulating air and work surfaces has resulted in a proliferation of devices for producing and delivering ultraviolet radiation. One unintended consequence is that the sources for producing germicidal radiation (i.e., UVC; less than 280 nm), their embodiments in commercialized devices, and the advertised applications and claims of effectiveness have all rapidly exceeded the availability of reliable data on biological risk factors. For example, excimer lamp technology and deployment has progressed much faster than the knowledge of skin and eye response to short-wave UVC scattered during surface treatments, or even applied intentionally to skin (to reduce dependence on frequent antiseptic use). We devised an institutional board-approved test to provide human skin response data. Volunteers (skin type 1 and 2) received graded exposures (using an independently calibrated Sterilray disinfectant excimer source, emission 97% at 222 nm) to determine MED and to assess cyclobutane pyrimidine dimers (CPD) in punch biopsies (compared with those using a UVB radiation source). The determined MED range for the excimer source was 45+5 mJ cm−2, compared with 225+75 mJ cm−2 for the UVB source. Most critically, we found that this exposure regimen induced erythema and CPD formation even at doses below the reported threshold bacteriostatic effect, suggesting that frequent application of such radiation is unlikely to be tolerated as a non-chemical antiseptic for human skin. (Manuscript accepted for publication in Photodermatology, Photoimmunology and Photomedicine 2015.)
S Hughes1, N Lowe2, K Gross3, L Mark3, B Goffe4, H Hughes1.
1 Sun Protection Foundation, Sun Precautions, Inc.
2 The Cranley Clinic
3 Skin Surgery Medical Group, Inc.
4 Dermatology Associates, PLLC
In 1978, the FDA Advisory Panel proposed both indoor SPF testing and outdoor natural sunlight SPF testing as acceptable test methods. In 1993, the FDA removed natural sunlight SPF testing as an acceptable method stating the indoor method was more accurate, consistent and had been shown to be in general agreement with natural sunlight testing. Today, the accepted test methods to evaluate sun protection performance of sunscreens and sun protective clothing fabrics are indoor laboratory tests. Our research evaluates the natural sunlight protection of a representative sample of sun protection products used by consumers and whether the sun protection is comparable to that claimed on the products labels. We tested high SPF, broad spectrum sunscreens—with SPFs ranging from above 30 to 110—as well as six sun protective fabrics found in garments sold in North America. Each subject was protected by sunscreens and fabrics and then exposed to tropical, mid-day natural sunlight for 1 hour and 59 minutes using a protocol outlined by the FDA in 1978. Sun-induced skin injury, both erythema and persistent pigment darkening (PPD), was photographed 16 to 24 hours after exposure and was graded by four dermatologists. Discernible sun damage was observed at all of the sunscreen protected skin sites and minimal or higher sun damage (1 MED/MPPDD or higher) was detected at 67% of the skin sites. We evaluated the observed sun-induced skin injury by sunscreen SPF, ingredients, and recommendations by consumer organizations, as well as by a subject’s sun sensitivity. The sun protective fabrics tested provided excellent sun protection. The frequency and degree of sun damage the subjects experienced through the sunscreens in less than 2 hours was unexpected given the broad spectrum, high SPF claims found on the sunscreens’ labels. Additional research is needed to explain the large discrepancy between claims based upon the indoor test method and results from the natural sunlight test method.
Griffith, James; Kohli, Indermeet; Isedeh, Prescilia; Al-Jamal, Mohammed; Narumol, Silpa-archa; Lim, Henry; Hamzavi, Iltefat..
Henry Ford Health System, Detroit, MI
Purpose This study was designed to objectively evaluate the effect of oral Polypodium Leucotomos extract (PLE) on photobiologic changes within two hours of oral administration.
Methods 22 subjects with Fitzpatrick skin type I-III were enrolled. On day 1 of the study, subjects were irradiated with increasing doses of visible light (VL), ultraviolet A1 (UVA1), and 308nm excimer laser (UVB). Evaluation was done immediately and 24 hours after irradiation. On day 3 and 4 this process of irradiation and evaluation was repeated, but after ingestion of PLE 240 mg tablets two hours prior, and another tablet one hour prior to appointment time. Assessment methods include investigator’s global assessment of erythema and objective colorimetry measurements, whose a* value assesses erythema intensity. Four-mm punch biopsies were obtained to evaluate molecular damage 24 hours following UVB at the MED site pre and post PLE. A control biopsy of non-irradiated skin was also collected.
Results UVB-induced damage, identified by increase in MED and/or decrease in objective erythema intensity, decreased in 77% of subjects following PLE. Based on a*/ao* ratios, pre-PLE sites have 14% higher erythema intensity compared to post-PLE (p<0.05). Dose response (DR) slope for a*/ao* vs. UVB doses revealed pre-PLE slope was 37% steeper than post-PLE (p=0.033). a*/ao* has a linear relationship with UVB doses in the range of 0.5-2.8MED. No significant VL or UVA1 findings. Analysis of pathology is in-progress.
Conclusion This is the first demonstration that PLE has objective measurable suppressive effects on UVB-induced erythema within two hours of administration, which provides further insight on the photoprotective effects of PLE. The less steep post-PLE DR slope compared to that of pre-PLE implies PLE induced tolerance to UVB radiation, shifting the subject’s response towards that of a higher/darker skin type. Young et.al. (1998) showed molecular damage has a linear association with 0.53 MED doses; our study found similar linear association for a*/ao*, with lower a*/ao* post-PLE indicating possibly less molecular damage.
Eduardo Ruvolo Junior, Siming Chen and Uma Santhanam.
When skin is exposed to solar radiation, UVA photons interact with skin tissues and induce excessive reactive oxygen species, resulting in oxidative stress. It has been shown that dermal collagen cross-links are potential UVA photo-sensitizers and contribute to UVA-induced chemiluminescence. In this work, fluorescent bands believed to be associated with collagen cross-link are explored as a marker to help evaluate in vivo efficacy of anti-oxidants in skin.
A modified solar simulator from Solar Light Single Port Model 16S-150W was used for exposure. The UG 11 filter was eliminated; a WG335-3mm and narrow band pass filter at 370 nm + 36nm were added. Subjects were irradiated with 10J/cm2 of narrow band UVA and excitation fluorescent bands associated with collagen cross-link fluorescence bands and reflectance were acquired using a SkinSkan spectrofluorometer (Horiba Yvon, Edison, NJ) in the UVA-Visible range (320-460 nm).
In vivo excitation bands associated with collagen cross-link bands at 330-350 nm and 360-370 nm showed a significant decrease (~50%) immediately after UVA exposure and slowly returned to baseline levels 1 hour after irradiation. When skin was pre-treated with freshly prepared solutions of known antioxidants, Tocopherol Acetate and Green Tea polyphenols, in 70:30 ethanol: propylene glycol vehicle by patching the skin for 30 minutes prior to the exposure, the decrease in the bands was prevented by about 80%, indicative of a protective effect.
In conclusion, excitation fluorescent bands in 330-350 nm and 360-370 nm, believed to be associated with dermal collagen cross-links, may be used as a marker to evaluate the efficacy of anti-oxidants in vivo. It would be interesting to investigate how this correlates with in vitro assays like ARAC, ORAC, TEAC, OSI and ESR.
Sunil Kalia, Nikiforos Kollias, Jianhua Zhao, Haishan Zeng, Harvey Lui.
Photomedicine Institute, Vancouver Coastal Health Research Institute and Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC
Background Currently melanocytic lesions tend to be most commonly differentiated by the naked eye in clinical practice. Different melanocytic lesions include junctional nevi, compound nevi, intradermal nevi, blue nevi, seborrheic keatoses, congenital nevi, atypical nevi and melanoma. Diffuse reflectance spectroscopy (DRS) utilizes chromophores present in the skin to produce an optical spectrum. We hypothesize that melanocytic lesions will have characteristic DRS features to help distinguish them.
Methods Measurements were taken using DRS, which consists of a light source (a quartz tungsten halogen lamp), a bifurcated fiber bundle, a skin probe and a miniature CCD spectrometer (Ocean Optics, Model S2000). Absorption spectra of melanocytic lesions were analyzed from 400-800 nm to look for the following features, i) presence of melanin, ii) strength of hemoglobin and deoxyhemoglobin signal, iii) amount of scattering present.
Results Lesions with increased epidermal melanin (eg. junctional nevi), displayed increased melanin absorption at lower wavelengths. Whereas, lesions with increased dermal melanin (eg. intradermal nevi, blue nevi, melanoma) showed decreased melanin absorption at lower wavelengths (near 400nm) due to increased scattering. The presence of deoxyhemoglobin was seen in melanoma and congenital nevi lesions.
Conclusion These preliminary results show that DRS can be used to characterize different optical properties in melanocytic lesions. Further studies will be done to determine if the optical properties can differentiate benign and malignant melanocytic neoplasms.
S Hughes1, K Gross2, L Mark2, H Hughes1.
1 Sun Protection Foundation, Sun Precautions, Inc.
2 Skin Surgery Medical Group, Inc.
Our research evaluates the natural sunlight protection of 21 sunscreens and 6 fabrics used by consumers and whether the sun protection is comparable to that claimed on the product labels. All of the sunscreens were labeled broad spectrum and high SPF—ranging from above 30 to 110. Each subject was protected by sunscreens and fabrics and then exposed to mid-day natural sunlight for 1 hour and 59 minutes in late summer at a park near San Diego using a protocol outlined by the FDA in 1978. Sun-induced skin injury, both erythema and persistent pigment darkening (PPD), was photographed 20 to 24 hours after exposure and graded by two dermatologists who were not present during the outdoor testing. Minimal or higher sun-induced skin injury (1 MED or 1 MPPDD or higher) was observed at 63% of the sunscreen protected skin sites. We examine the data by sun-induced skin injury, SPF, ingredients, recommendations by consumer organizations, as well as by a subject’s sun sensitivity. There was an unanticipated discrepancy between the UVB/UVA related sun damage the subjects incurred and the broad spectrum claims found on these product labels. The sun protective fabrics tested provided excellent sun protection. The frequency and degree of sun damage the subjects experienced through the sunscreens in less than 2 hours was unanticipated given the broad spectrum, high SPF claims found on the product packaging. We suggest reestablishing natural sunlight sun protection testing as a method to ensure that consumers and patients are not injured in natural sunlight.