Читать книгу The Blue Man and Other Stories of the Skin - Robert A. Norman - Страница 12

CHAPTER TWO

CARE AND PROTECTION OF THE SKIN

Pull down thy vanity, it is not man

Made courage, or made order, or made grace,

Pull down thy vanity, I say pull down.

Learn of the green world what can be thy place

In scaled invention or true artistry,

Pull down thy vanity . . .

The green casque has outdone your elegance.

Ezra Pound, “Canto LXXXI”

As soon as I walked in the room to introduce myself to Guillermo, I knew he represented a challenge of long duration. Populating his face and neck were at least fifteen easily recognizable skin cancers spread out in odd arrangements and patterns. He had one of the worst collective cases of these cancers that I had ever seen. None of them were immediately life threatening, but the disfigurement was horrible. “I have most of these many years,” he said in halting English. “My family tell me I need to get them off.”

“Your family is right,” I said.

Guillermo spent his first fifty years in Cuba, a country with a poor record of skin cancer prevention. In my own sampling, many of my worst skin cancer patients have been from Cuba. And Guillermo had not fared much better after emigrating, as he had exchanged one tropical country for another. Since arriving in Florida five years ago, he had done little to protect himself from further skin insult and injury.

What’s more, our skin cancer prevention program in the United States is not much better than that of Cuba. According to the National Cancer Institute, 40–50 percent of Americans who live to age sixty-five will have skin cancer at least once.

FROM SUN GODS TO TANNING SALONS

Why does our skin get darker over time and exposure to the sun? The main reason is the oxidative stress placed on melanin as it interacts with ultraviolet light, protecting us from dangerous rays.

Melanocytes live in the bottom layer of the epidermis, just above the dermis, and manufacture melanin from an amino acid, tyrosin, with the help of an enzyme, tyrosinase. Exposures of five to ten minutes of sunshine do not bring on tan, but longer than that will initiate a process called melanogenesis. In melanogenesis, ultraviolet (UV) light stimulates the production of melanin in the form of insoluble melanosomes that surround the epidermal cells, which move up to the surface of the skin and result in a tan.

Though people with dark skin and people with light skin have the same number of melanocytes, the way the melanin is distributed and produced is quite different. Darker skin contains more melanin, which protects against ultraviolet radiation and damage to DNA. For this reason it is rare to see skin cancer in African Americans, though I recently saw an African American patient with early skin cancer on his chest. Research by Gloster and Neal, published in 2006, states that the incidence of skin cancer in African Americans is approximately 3 cases per 100,000 people; among European Americans it is 234 cases per 100,000 people. For both African Americans and European Americans, the primary risk factor is chronic UVB exposure.

Many societies today value the look of a dark tan, causing many people to expose themselves to high levels of UV radiation. But no safe tan exists; all tanning is another form of burning.

A quote that has been erroneously attributed to Kurt Vonnegut, but in fact was written by newspaper columnist Mary Schmidt, captures some of the importance of protecting skin from the sun. According to the urban legend, Vonnegut was asked to be the guest speaker for a prestigious college’s commencement exercise, and told the graduating class only: “Wear sunscreen. If I could offer you only one tip for the future, sunscreen would be it. The long-term benefits of sunscreen have been proved by scientists, whereas the rest of my advice has no basis more reliable than my own meandering experience. . . . Advice is a form of nostalgia. Dispensing it is a way of fishing the past from the disposal, wiping it off, painting over the ugly parts and recycling it for more than it’s worth. But trust me on the sunscreen.”

During my childhood summers in Michigan, where I grew up less than an hour from the beach, I cherished the sun. I recall the smell of baby oil mixed with the thin toasty smell of heated skin. I savored the precious two months when I could actually lay in the sun with scant clothing, the memories of giant snow piles melting to my mind’s periphery. As an adult, I began to consider that what I had thought of as a benevolent sun was instead some type of malicious nuclear reactor that had turned my DNA into a cancer-making machine. I added eternal vigilance about the devastating effects of the sun to all the other problems of day-to-day life—terrorism, Lyme disease, global warming, and long lines at Starbucks. And, as a dermatologist, I help others heed the wake-up call.

The healing power of the sun has always been evident. The first Greek sun god was Helios—his name gives us the term dermatoheliosis, for photoaging or sun damage on the skin. Later Apollo, also the god of health and prophecy, became the accepted sun god. Apollo’s mortal son Aesculapius was said to be the first physician, and his staff entwined by a serpent is Western medicine’s symbol. Where science is concerned, we have known for over five hundred years, since Copernicus asserted it, that the sun is literally the center of our universe. From cave dwellers to the present day, humans have borne witness to the sun’s healthful properties: its germicidal powers, its ability to diminish various skin diseases such as psoriasis, its vitamin D synthesis, and its feel-good effects (an antidote to seasonal affective disorder for those in dreary northern climates), to name a few. But perhaps not even Apollo could foresee the sun’s damaging effects on future generations.

How did this oceanic change in our sense of the sun come about? Much of the history of suntanning carries with it a media hype akin to that expended on cigarette smoking. During the 1920s and 1930s, many movie stars were paid to smoke at attention-getting locations, enabling tobacco companies to increase their sales dramatically. In similar fashion, the Coco Chanels of the world launched huge tanning spikes. Betty Grable, Rita Hayworth, and other bathing beauties were pictured in one- and two-piece bathing suits exposing their tan bodies.

European women sunbathed in decorative, attention-getting sun hats and shawls for fashionable reasons, not protection. And if their skin happened to have an untanned spot, tinted powders and creams were available. The fashion world created shoes to be worn without stockings and sleeveless dresses for women wishing to expose their tans. Although ivory skin had once been associated with wealth (and not working outdoors), this shifted in the social upheaval that followed World War I. A tan in the winter was a clear sign that the tan bearer had enough wealth and leisure to afford an exotic, warm climate.

In 1929 Helena Rubinstein, the cosmetics magnate, warned, “Sunburn menaces your beauty.” But women’s magazines pushed tanning. Cosmetic companies introduced suntanning oils; the ingredient PABA was introduced in 1943. While public ambiguity about the look persisted, women’s magazines encouraged sun lamps and suntanning and cosmetic companies introduced suntanning oils. The first so-called self-tanning product, Man-Tan, a tinted lotion that created the effect of tanning, hit the market in the mid-1950s, with beige, brown, or orange results. Certain science reporters used women’s magazines to suggest that gradual tanning could actually cancel out the sun’s damaging effects. The media slowly took in the message of the sun and the skin. Harper’s Bazaar reported in 1954, “There are sunscreen preparations that can cut the intensity of the sun’s rays by 75 percent.” In my medical practice, there is not a week that goes by when someone does not say to me, “We didn’t know about the problem with the sun when we were younger.” They may not have known about it, but it was already evident, if sometimes obscured, in the media.

Meanwhile, dark skin became a status symbol in the 1960s. Suntanning was no longer a spectator sport, especially among the young. Coppertone advertisements filled the airways—“Tan, don’t burn, get a Coppertone tan!”—and beach movies filled with bikini-clad teens populated the television. In the 1970s, with gallons of Johnson’s Baby Oil coating many an unsuspecting epidermis, another industry began to blossom—the indoor tanning industry. Even those in the cold North could try to keep a tan or could prepare for adventures to warmer climates with a series of trips to the tanning salon. Tan skin was a sign of having leisure time. The Hawaiian Tropic TV ad featured a beautiful blonde who sensually said, “White is for laundry.”

In the early 1970s, the Food and Drug Administration (FDA) began to treat sunscreens as over-the-counter drugs and not cosmetics. More stringent labeling was required. After the FDA began regulating sunscreens, the makers of Johnson’s Baby Oil warned that the heroine of their ads should “take a little less sun.” In 1978, the FDA declared sunscreens to be safe, effective, and useful to prevent skin cancer and sunburn and to slow premature aging of the skin. The SPF (sun protection factor) numbering system was developed using numbers two through fifteen.

During this period, the tanning industry, almost entirely unregulated, continued to prosper. Home-tanning units were particularly damaging: in addition to their cancer-producing and premature wrinkling effects, they emitted high levels of UVB light that burned the skin and didn’t tan. More advanced tanning units emitted both UVB (ultraviolet B or shortwave rays) and UVA (ultraviolet A or long-wave rays) and brought on further skin damage. UVA rays account for up to 95 percent of the UV radiation reaching the Earth’s surface and are less intense than UVB, but penetrate deeper. Tanning booths primarily emit UVA, using high-pressure sunlamps in doses of UVA as much as twelve times that of the sun. Ultraviolet (UV) radiation is responsible for 90 percent of the visible signs of aging on the skin of fair-skinned people.

By the mid-1980s, public education programs about the dangers of overexposure to the sun and the problems with tanning began to grow. The American Academy of Dermatology voiced its strong support for sun protection, and sunscreen manufacturers produced higher SPF products.

But the damage was done. Studies showed a 500 percent increase in malignant melanoma incidence between 1950 and 1985. A 1987 American Academy of Dermatology study revealed that 96 percent of Americans knew that the sun caused skin cancer. One-third of these same adults admitted that they had deliberately worked on a tan.

In the 1990s, the indoor tanning industry continued to be one of the fastest-growing businesses in the United States. The average age of indoor tanning patrons was twenty-six, mostly women. Almost two million of these patrons were considered “tanning junkies,” who made almost one hundred tanning parlor visits each per year. In 1991, eighteen hundred injuries were reported from tanning devices.

The pushback against tanning continued. Fashion design industry leaders such as Eileen Ford stated, “The tanned look is dead.” The American Academy of Dermatology stated there was “no safe way to tan,” following a consensus conference on photoaging and photo damage. And natural-looking tans sans streaking or discoloration became possible with improved tanning products. Wide ranges of protection against UVA as well as UVB radiation were created by the sunscreen industry in 1990 in response to the rising tide of information about skin cancer facts—600,000 new cases of skin cancers, 6,300 deaths from melanoma, and 2,500 deaths from squamous cell carcinoma in the previous year. The role of genetics, ozone depletion, and other skin cancer production factors took center stage.

The incidence of skin cancer continued to increase, with 700,000 new cases of skin cancer diagnosed in 1993, 32,000 of them malignant melanoma. Yet the popularity of tanning refused to wane. In a 1996 survey of young adults, 58 percent confessed to having at one point worked on a tan and 62 percent thought that people look better with a tan. In 1997, two-thirds of teens surveyed in Seventeen felt they looked better and felt healthier and more sophisticated with a tan. Half of them stated they looked more athletic with a tan. The tanning industry grew to almost twenty thousand salons in the United States, serving twenty-two million customers per year; tanning salons were regulated in only half of the states. The American Academy of Dermatology continued to warn the public to minimize the sun’s damage to the skin and eyes by planning outdoor activities to avoid the sun’s strongest rays, wearing protective covering, wearing sunglasses, and always wearing a broad-spectrum sunscreen.

SEEING THE LIGHT ON TANNING