Sunscreen Ingredients are Absorbed says FDA

For years public health officials, dermatologists and primary care physicians have been encouraging people to apply sunscreen before going out into the outdoors to reduce the risk of sunburn and skin cancers.  We are taught to apply it in advance of exposure by about 30 minutes and to reapply it every few hours especially if we are sweating and swimming.   Living in South Florida, sun exposure is a constant problem so we tend to wear long sleeve clothing with tight woven fabrics to reduce sun exposure.  My 15-month old grandson, visiting last weekend was smeared with sunscreen by his well-meaning parents before we went out to the children’s playground nearby.

These precautions seemed reasonable and sensible until an article appeared in JAMA Dermatology recently.  An article authored by M. Mata, PhD. evaluated the absorption of the chemical constituents of sunscreen after applying it as directed four times per day.  The article was accompanied by a supporting editorial from Robert M. Cliff M.D., a former commissioner in the FDA and now with Duke University School of Medicine and K. Shanika, M.D., PhD.

The study applied sunscreen four times a day to 24 subjects. Blood levels were drawn to assess absorption of the sunscreen products avobenzene, oxybenzone and octocrylene.  The results of the blood testing showed that the levels of these chemicals far exceeded the recommended dosages by multiples. The problem is that no one has evaluated these chemicals to see if at those doses it is safe or toxic causing illness?

The editorial accompanying the findings encourages the public to keep using sunscreen but cautions that the FDA and researchers must quickly find out if exposure to these levels is safe for us?  We do know that the chemical oxybenzone causes permanent bleaching and damage to coral reefs in the ocean from small amounts deposited by swimmers coated with sunscreen. The state of Hawaii has actually banned sunscreens containing oxybenzone to protect their coral reefs.

The fact that these chemicals have been approved and are strongly absorbed with no idea of the consequences is solely the result of elected officials wanting “small government” and reducing funding to the oversight organizations responsible for making sure what we use is not toxic.  It is a classic example of greed and profit over public safety.  The research on the safety of these chemicals must be funded and addressed soon. The American Academy of Pediatrics and Dermatology need to advise parents of youngsters whose minds and bodies are in the development and growth stages what is best to do for their children – sooner rather than later.

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Fever Blisters or Herpes Simplex Labialis Treatment with Honey versus Acyclovir

Herpes Simplex lesions cause mouth and gum ulcers and fever blisters. In order for the virus to be activated it requires exposure to sunlight. As these ulcerations appear they are painful, unsightly and the virus can be transmitted person to person.  Modern day treatment has consisted of taking an antiviral medicine such as Acyclovir in topical form applied four to six times per day for seven days. The medication reduces the healing time and pain in this infection.

Researchers in New Zealand decided to test their home grown Kanuka Honey versus Acyclovir in the treatment of herpes labialis. They randomized 952 adults who presented to community pharmacies with herpes labialis over a two year period to two groups.  One group received a traditional acyclovir 5% cream, the other kanuka honey (90%), and glycerin cream (10%). They applied their medication five times daily.

They then observed how long it took for the infected and involved skin to return to normal and pain resolution.  It took 8-9 days for the acyclovir to work and 8-9 days for the kanuka honey to return skin to normal appearance. There were no differences in pain observations or time for the open wound to close.

A large jar of Kanuka honey costs $60 by ordering online. A 15-gram tube of 5% acyclovir topical ointment sells for $379.99 locally.

Summer Insects, Ticks & Insect Repellant

As our climate warms, and we enter the summer season, the pathogens we face taking a walk outside have changed as well.  Recently in the northeastern US an individual walking through a well-manicured lawn in the mid-day sun was bitten by a type of disease spreading tick called the worrying long-horned tick never before seen in that region. Ticks primarily attacked in shaded areas with long uncut grass and shrubs. This is a new distribution of tick locations and behavior.

Mosquito borne diseases such as Zika (no reported cases in Broward, Dade or Palm Beach Counties in 2019), Chickengunya fever and even Yellow Fever are common in the Caribbean and parts of Central and South America. For this reason, the release of Consumer Reports’ recommended insect repellants prior to us spending more time outside in the summer weather is always of interest.

Consumer Reports emphasized that its top-rated products all contained either DEET, Picardin or Oil of Lemon Eucalyptus. DEET should have a concentration of 25-30% to be most effective and is considered safe at that strength.  Picardin is a synthetic relative of the black pepper plant and is suggested in the 20% range.  Oil of Lemon Eucalyptus should be in the 30% range.

Interestingly, Oil of Lemon Eucalyptus, a natural occurring product, is the only chemical not yet tested for safety in young children.  It consequently should not be used in children three years of age or younger. Sprays were felt to be more effective than creams or lotions.  In all cases they recommend spraying it on exposed skin and the outside of clothing – never on the skin under areas covered by clothing.  Don’t use the product near food and wash your hands after applying.

Their top two rated products were Total Home (CVS) Woodland Scent Insect Repellent, an aerosol spray containing 30% DEET and selling for $6.50 and Off Deep Woods Insect Repellent VIII Dry for $8.50 containing 25% DEET.   Rated right below these two was Repel and Oil of Lemon Eucalyptus pump spray for $7 a bottle.

Consumer Reports has stopped testing products for Tick effectiveness because in the past they found that DEET and Picardin products which protected against mosquitoes also protected against tick bites. They emphasized wearing shoes and socks, long pants and sleeves and spraying insecticide externally on the clothing helped protect against tick bites.  They advised seeing a physician quickly if you contract a tick bite. They additionally discussed the fact that many of these recommended insect products stained the very clothing you applied it to as protection.  These warnings are listed in their product ratings.

Consumer Reports Releases Sunscreen Ratings

Periodically, Consumer Reports aggressively reviews and tests sunscreens for effectiveness. Last month they posted their 2019 ratings.

The report was divided into creams and lotions versus sprays.   To test each sunscreen, they applied it to human skin then soaked the skin in water to duplicate the effects of swimming and sweat. They then exposed the volunteers to sunlight.  To cover the skin adequately they used about a shot glass worth of sunscreen on bodies wearing a bathing suit. They said this approximated using one teaspoon per body part area such as one teaspoon for your face, one teaspoon for your head and neck, one teaspoon for each arm and leg etc.

Their top-rated lotion was La Roche-Posay Anthelios 60 Melt In Sunscreen giving it a rating of 100.  A tube costs $36.  The next highest rated was BullFrog Land Sort Quik Gel SPF 50.  It was given a rating of 95 and only costs $13 for a bottle.

Consumer Reports also rated spray sunscreens. To properly apply the spray they suggested holding the nozzle close to the skin and then spraying until the skin glistens. At that point they advise rubbing it in even if the product is advertised as a “no rub“ product.  Once this is done, they suggest repeating the process. They emphasize to never spray directly into the face or eyes. They suggest trying to refrain from inhaling the spray which is why spray sunscreen is not recommended for children.  Their favorite spray choice is Trader Joe’s Spray SPF 50+.  It gets a rating of 100 and sells for $6.  They describe it as having a beach aroma in a combination of floral and citrus scents.   Banana Boat SunComfort Clear UltraMIst Spray SPF 50+ received a score of 96 and is priced at $13.

This past year research has shown that several sunscreen ingredients including oxybenzone are absorbed and achieve blood serum levels at much higher numbers than anticipated.  Oxybenzone is now forbidden in sunscreens used in the state of Hawaii because small amounts of bleach which can kill their coral reefs. There are now sunscreens without Oxybenzone.  Walgreens Hydrating Lotion SPF 50 achieved a score of 74 and has none of the offending ingredient.  It sells for $3. Hawaiian Tropic Sheer Touch Ultra Radiance Lotion SPF 50 achieved a score of 70 and cost only $8.

Mineral or barrier sunscreens composed of titanium dioxide and zinc oxide are known to be safe in major studies.  Consumer Reports believes these products do not provide as much protection as the products containing oxybenzone and similar active absorbable chemical.  “Some provide adequate SPF protection but not enough UVA protection and vice versa.”  The mineral sunscreens that performed admirably in their tests include California Kids # Supersensitive Lotion SPF 30+ for $20 and BadgerActive Natural Mineral Cream SPF 30 for $16.

Lung Cancer Screening is Underutilized

Dr. Jinai Huo of the University of Florida (Go Gators!) presented data to Reuters Health that primary care physicians are under-utilizing the technology available to screen for lung cancer. This is a particularly sore topic to me because my associate and I always screened smokers and heavy past smokers for lung cancer with an annual chest x-ray until the United States Preventive Task Force issued guidelines that it didn’t save lives and was not cost effective.  They said, it cost $200,000 in normal x-rays to find one cancer early and it was deemed not worth it.

We actually sold our chest x-ray unit, let go our certified radiology technician and cancelled a contract with radiologists to read our films because insurers stopped paying for chest x-rays after the USPTF ruling.  Twenty years later that same group said “woops” an error was made. The statistical analysis on that study was done incorrectly and actually screening does save lives and is cost effective.

Today we have the fast low dose CT scanner to screen for lung cancer and screening does save lives according to the data.  Who should be screened?

Current smokers or those who have quit smoking within the last 15 years who are 55 to 77 years old and have a smoking history of 30 packs or more per year (one pack per day for 30 years or 2 packs a day for fifteen years).  Screening should be done on individuals in good health so if a lesion is found they are considered well enough to undergo diagnostic tests and treatment.

Screening is also recommended in those individuals over 50 years old with a twenty (20) pack year smoking history and a family history of lung cancer or lung disease or occupational exposure to items associated with causing cancer such as radon.

I inquire about smoking at each visit and have been fortunate in that few of our patients still smoke so we spend less time on counseling for smoking cessation.  If you fall into one of the screening groups mentioned in this article, and have not been screened, please notify us so we can arrange for the testing which will be a low dose chest CT scan.

Acetaminophen May Blunt Empathy

In a unique and interesting study published in the online edition of Frontiers in Psychology researchers explored the effect of taking liquid acetaminophen (e.g., Tylenol) on the expression of empathy. Researchers took 114 Ohio State University graduate students and blinded them to whether they were administered liquid acetaminophen (1,000 mg) or placebo. They then showed them examples of life experiences and found that those who took acetaminophen experienced less pleasure and empathy toward the hypothetical characters in their stories than students who took placebo.

For those who took the acetaminophen, their ability to recognize pleasure and positivity were not affected – just their ability to be empathetic. The authors were quick to say that acetaminophen is an excellent and effective treatment for fever and pain and should not be eliminated as a medication because of these findings.

The study did not attempt to determine the mechanism of action of the reduction in empathy.

The Reality of Skilled Nursing Home Stays

The online journal Medscape published a Reuter’s article on Skilled Nursing Facilities and post hospital stays.  They discussed the often-lengthy time span between hospital discharge and the patient being seen by a physician or “an advanced care practitioner”.

Older, more infirm and cognitively impaired patients tend to be seen later than other patients. Apparently the later you are seen, the more likely it is that you will be sent back to the acute care hospital and be readmitted.  The study was conducted by Kira Ryskina of the Perlman School of Medicine at the University of Pennsylvania in Philadelphia. The researchers looked at Medicare claims from nearly 2.4 million patients discharged from acute care hospitals. Her data indicated that when patients were seen by doctors at the facility soon after discharge they tended to recover more often not requiring acute readmission to the hospital for the same problem.

The author went on to say that most families confronted with a family member requiring post hospital rehabilitation at a skilled nursing home do not know what to expect from a skilled nursing facility (SNF).  The truth is, most doctors who practice in the inpatient setting or in surgical and medical specialties have no idea what to expect. They have never gone into one, unless it is for their own recovering family member, and they have never cared for a patient on a daily basis in one.

My first month as a private physician in 1979, my employer took me to the local facilities to meet the administrators, charge nurses and social workers at the facilities. The medical director was a young internist who had no private outpatient office or practices just a nursing home practice at five institutions he called on.  I was told that the law required me to see new patients within 24 hours of arrival, examine them and write a note and review all orders and either approve or change them.  I was surprised that facilities were staffed with only one registered nurse per 40 patients. The RN was required to pass the medications each shift, with most patients being on multiple medications so that most RNs had little time per shift to do much else but pass the medications.

When a patient had a complication or problem the nursing staff called the family member and the doctor. The volume of calls was so immense that the young facility medical director could not find any physicians who would agree to cross-cover with him on the weekends so he could get some time off.  In most cases, even if I decided the phone call related medical problem could be dealt with at the facility, the family decided otherwise and wanted their loved one transported to the ER. Those of us who cared for patients at these SNF’s joked that the protocol for caring for a problem was to call 911 and copy the chart for transfer.

It used to disturb me that EMS services were being diverted to these facilities for non-critical issues taking them away from true emergencies, and delaying response times, but they seemed to like it.  The more trips they were called on, the more evidence they could present for a larger share of the city or county budget.

At some SNFs there was always an EMS bus or ambulance sitting in the parking lot outside.  The patients were insured by Medicare guaranteeing bill payment so the receiving Emergency Department and staff were happy as well.

We were required to see the patient monthly and write a note. I saw sicker and less stable patients more often than monthly.  Progress in rehabilitation was discussed at mid-day care planning conferences that the physicians were rarely made aware of.  My goal for discharge was when the patient could safely transfer from the bed to a walker or wheel chair, get to the bathroom and on and off the toilet safely and; get in and out of a car. If the family could convert their home into a “skilled nursing facility” the patient could go home as well.  Often the patient was sent home by the facility “magically cured” when their insurance benefits ran out.

Most of the work at the facilities is performed by lower paid aides. In my area of practice most of the aides are men and women of color from the Caribbean who have little in common with the mostly Caucasian elderly population they care for. The work is hard and the pay low with the employee turnover rate extraordinarily high annually at most institutions. The patients are elderly, chronically ill, often with impaired cognition, hearing, and vision. Their family’s vision of what should be done is vastly different from what can be accomplished.  I believe most of the staff are caring and well-meaning just under staffed and under trained.  Administrations concerns about liability from medical malpractice, elder abuse and other issues is well founded based on the plethora of ads on prime time TV, newspapers and the sides of travelling public buses touting law firms seeking elder care cases.

It is now harder and harder to actually see patients at these facilities even if you wish to.  While community- based physicians with local hospital privileges were once welcomed and encouraged to attend to their patients at the facility, now the facilities require doctors to go through a lengthy credentialing process – as if you were applying for hospital staff privileges.   When you actually show up and care for your patients you rarely see a physician colleague. Most of the care is assessed and provided by nurse practitioners and physician assistants working for physicians who rarely, if ever, venture into the facilities. They may supervise the care plan on paper but rarely lay eyes or hands on the patient.

These facilities serve a vital role in the post-acute hospital care of patients. According to this study and article, Medicare spent $60 billion dollars in 2015 on this care. When a hospitalized patient has a frail spouse or no spouse at home, with no local nuclear family able to provide home care, the SNF is the only real option.

I suggest families visit the potential choices first. Speak to patients and their families about the care and services.  Review online state inspection and violations records. Ask about the transition from the hospital to the SNF. Who will be responsible for caring for them at the facility?  Meet them and talk to them. Make sure you are on the same page. If you can find a facility that has an onsite physician team with a geriatrician as the chief medical provider.  It may be the best option.

For these transitions to work and save money by stopping the revolving door form hospital to SNF to emergency room for every medical question, the SNF’s need some form of sovereign immunity from frivolous lawsuits if their services and care meet the legally required standards. The recent post- hurricane heat-related tragedy at a Hollywood, Florida nursing home underscores the need for vigilant inspection and regulation of this industry. The good homes need to be identified and need to be given the support and latitude required to care for this ever increasing portion of our American society.