Overexposure to the sun’s UV rays can cause skin damage. The damage can be both immediate and long-term, with effects ranging from sunburn, rashes, and cell and tissue damage to premature wrinkling. Unfortunately, many people do not realize that the damage can be irreversible and can even lead to skin cancer.

A survey conducted by the American Academy of Dermatology (AAD) identifies US cities whose residents take sun protection seriously and those where people fail to make the grade despite repeated health warnings. The survey shows that four out of five survey respondents are concerned about skin cancer and believe that it is important to protect themselves; that more than half have never been screened for skin cancer; and that one fourth never examine their own skin for changes to moles and other blemishes.

“It has become clear that skin cancer is increasing at an exponential rate with more than 1.5 million new basal cell cancers a year in the United States,” says David J. Goldberg, MD, JD, director of Skin Laser and Surgery Specialists in New York City.

“Thus, despite the advent of a wide variety of new sunscreens, the message has not gotten out that proper sunscreen use can protect against skin cancer [and wrinkles],” Goldberg continues. “Even those who use sunscreens often don’t realize that it must protect against UVA rays [for which there is no SPF rating scale] and UVB [as measured by the SPF factor]. Furthermore, most people do not realize that most sunscreens take 30 to 60 minutes to work. Putting sunscreen on at the beach will never work.”

The “Rays: Your Grade” survey polled adults in 32 US metropolitan regions in 29 states on their knowledge, attitudes, and behaviors toward tanning and sun protection. The cities were then ranked based on the percentage of people who scored As and Bs.

Of the 32 cities and states surveyed, Washington, DC, ranked No. 1, with 50% of its residents receiving As and Bs, followed by New York City. Miami, Tampa, Fla, and Los Angeles rounded out the top five rankings.

In Washington, there were three specific questions to which respondents rated significantly higher than average. For example, 45% of residents disagreed with the statement, “People look healthier with a tan.”

The results of the survey showed that the least sun-smart city was Chicago. Only 21% of Chicagoans received As and Bs on their tanning and sun-protection knowledge, attitudes, and behaviors. A high proportion of Chicagoans believed that the climate in which they live was a reason why they were not worried about skin cancer, and that the short period of sun exposure during the summer months could not cause enough damage to their skin to develop skin cancer.

“Unfortunately, many skin cancers, if left untreated, can lead to loss of a nose, an ear, or even an eye by local invasion,” Goldberg says. “A trip to the dermatologist once a year will prevent this from happening.”

The Truth About Melanoma

According to the AAD, melanoma is the most serious form of skin cancer and accounts for more than 75% of skin cancer deaths. A study published in the May issue of the Journal of the American Academy of Dermatology suggests criteria to gauge a patient’s melanoma risk and identifies those that may be deadly.

“The most important point to understand about detecting melanoma is that dermatologists [American Board of Dermatology-certified specialists who complete a minimum of 4 years of advanced training exclusively in the diagnosis and treatment of skin disease] have a significantly higher rate of diagnosing melanoma than nondermatologist physicians, nurses, or laypeople,” says Michelle Ehrlich, MD, a dermatologist in Rolling Hills Estates, Calif. “People who do not follow regularly with a dermatologist for skin screening are at greater risk for adverse outcomes from melanoma.”

The study, called “Risk Factors for Presumptive Melanoma in Skin Cancer Screening: American Academy of Dermatology National Melanoma/Skin Cancer Screening Program Experience 2001–2005,” discovered five factors that increased the likelihood of suspected melanomas.

Plastic Surgery at Bargain Prices?

May 15, The Wall Street Journal published an article that described discount programs for plastic surgery that are available through insurance companies.1 The companies recruit surgeons to offer procedures at deeply discounted prices, then make lists of the physicians available to subscribers as part of their plans or for annual fees in the $100 range.

The article quoted several patients who were pleased with the results of their procedures. But only two plastic surgeons were quoted: Mark Jewell, MD, of Eugene, Ore, and past president of ASAPS, remarked that the better surgeons wouldn’t need to participate in these programs; and Robert Winslow, MD, FACS, of Cameron Park, Calif, said that referrals from the program “keep me busy” when his practice gets slow.

PSP asked members of its Editorial Advisory Board to comment on the discount programs.

Loren S. Schechter, MD, FACS, Morton Grove, Ill: I do not intend on participating [in these programs]. As a whole, medicine has seen the difficulty with participation in insurance plans and discounted prices for services. If anything, practices are moving away from participation and toward concierge or boutique services. I think that this is a slippery slope, and one I don’t plan on traversing.

Douglas M. Senderoff, MD, FACS, New York City: Discount referral services for plastic surgery procedures are nothing new. Now the insurance companies want to use the discounted services not for a referral fee, but to attract new patients who will pay their premiums. It may seem tempting to plastic surgeons with a light caseload, but these types of arrangements can be detrimental to building a successful practice in the long run.

The busier a surgeon becomes as a result of a referral service, the more he or she relies on it for his or her patient base. And as dependency on discounted services increases, so does vulnerability to manipulation by the referral service in the form of further reduced fees. Sound familiar? In addition, it is not fair to the patients who are paying full fee through other marketing efforts or from patient referrals to pay much more for the same procedure that the surgeon is almost giving away to other patients.

Insurance companies have not been kind to the medical profession over the past decade. In makes no sense to allow them to increase their enrollment by setting plastic surgery fees.

It is better in the long run to build a successful practice through hard work and good results without succumbing to the temptation of third parties.

Anthony S. Youn, MD, Rochester Hills, Mich: My concern for this has to do with the quality of the plastic surgeons who participate in these plans. I would hope they undergo credentialing as they would for most insurance plans to make sure they have the necessary training and experience to receive cosmetic plastic surgery referrals.

I doubt that most plastic surgeons who perform primarily cosmetic plastic surgery and have good reputations would take part in this plan because they likely don’t need to join a network or offer discount prices to keep their practice busy. These listings may include new surgeons who aren’t busy or very experienced, or plastic surgeons who just aren’t that good and need help to get their practice referrals. I doubt that I would bother joining a plan like this.


  1. Rundle RL. Getting a discount on plastic surgery. The Wall Street Journal. May 15, 2007. Available at: online.wsj.com/public/article…
    Accessed May 22, 2007.

Darrell S. Rigel, MD, FAAD, dermatologist, clinical professor of dermatology at New York University Medical Center, and lead author of the study, suggested the use of the acronym HARMM to identify the factors associated with increased melanoma detection. They include history of previous melanoma, age greater than 50, regular dermatologist absent, mole changing, and male gender.

Rigel’s review included data from 365,000 individuals between the ages of 18 and 100 collected over a 5-year period. All the participants were required to complete a one-page form with demographic and melanoma risk-related questions before being examined by a dermatologist. Melanomas were suspected upon initial clinical diagnosis in 0.9% of those screened.

Gender and Age Factors

Women composed the majority of people attending screenings and accounted for 54% of the total suspected melanomas identified. Men older than 50 composed 23% of the screening population, yet accounted for 32% of the total suspected melanomas identified.

When the results of the data were evaluated, the researchers found that 98% of the study population had at least one of the HARMM risk factors, 75% had two or more risk factors, 33% had three or more, and 6% had four or five. The data showed that multiple risk factors corresponded to an increased likelihood of suspected melanoma.

In addition, participants who received a total skin examination during the screening were more likely to be diagnosed with suspected melanoma than those who received a specific lesion examination or a face and arms exam.

Dispelling Melanoma Myths

When patients think of melanoma, they often associate it with a black- or brown-colored lesion or mole that changes colors. Diane R. Baker, MD, FAAD, a dermatologist in Portland, Ore, and president of the AAD, says that nodular melanomas lack a change in color and she dispels common myths about melanoma to help patients understand their risk factors.

“Despite our ongoing public education efforts on the causes and symptoms of melanoma, a number of misconceptions about this potentially deadly disease exist,” according to Baker. “These myths could cause some people to think they are not at risk for melanoma because of their skin type or to dismiss warning signs because they are not typical symptoms of the disease.”

One myth about melanoma is that it follows the ABCD rule, which stands for asymmetry (one half of the mole is different from the other); border irregularity (the edges or borders of melanomas are usually ragged or notched); color (melanoma often has a variety of hues and colors within the same lesion); and diameter (most melanomas are usually greater than 6 mm in diameter when diagnosed, although they can be smaller). However, studies show that not all melanomas follow the ABCD rule. Nodular melanomas (NMs) do not fit the ABCD criteria for melanoma diagnosis. NMs commonly occur as symmetric, elevated lesions that are uniform in color and nonpigmented.

There is also a persistent notion that moles that have hairs are cancerous. Baker says that although the majority of melanocytic (or pigmented) moles with hairs are benign, studies show that the presence of one or more hairs in a pigmented lesion proved to be invasive melanoma. Baker cautions that patients should closely monitor all moles for signs of skin cancer, regardless of whether or not hair is present.

Another myth about melanoma is that people of color do not get skin cancer. According to Baker, when melanoma is diagnosed in patients of color, it has often spread to other parts of the body. That is why it is important that patients be vigilant in monitoring their skin for any changes that could signal a problem and visit a dermatologist so that they can diagnose the melanoma at its early and treatable stage.

“Malignant melanoma affects people of all skin types, including not only pale Caucasian skin, but darker skin types such as Hispanic, Asian, and even black skin or people of African descent,” Ehrlich says. “Sadly, persons of darker skin types or ethnic skin may not be diagnosed until more advanced stages of melanoma, and they often have a worse prognosis than lighter-skinned individuals diagnosed with melanoma.”