Today’s discussion will be really on photo protection – on skin protection. I am sure – most of you are coaches or what do you do mostly? Yes, okay – in the sun a lot. Anyone swim in indoor pools? Are lucky enough? So some of you – in Miami I think we are pretty much all outdoor pools so everyone is in the sun all the time – me included and I preach against you know – staying out of the sun and being sun protected, but it is almost unavoidable in these kind of climates to get some kind of sun exposure at some point – especially in your professions. Our office is on Miami Beach actually. We are part of the University of Miami, but we have a laser center on Miami Beach so this is our view of Miami Beach so every day I am reminded about boating and swimming and being in the sun and that is really what Miami is about and you guys are more on this wave length – swimming every day with a lot of the reflection from the water. There is a lot of sun exposure so there are some positive sides of the sun, you know. We use it for warmth – photosynthesis – it is also a mood enhancer so some patients who are depressed actually go under sun lamps to enhance their mood and obviously it provides light, but there are also some down sides. This one being the most obvious – which is a sunburn – your classic sunburn, but here are some of the other things that the sun does that we do not really traditionally see very often, but this is called Porphyria cutanea tarda so this is blistering in sun exposed areas. It also activates collagen vascular diseases so patients with lupus do very, very poorly in the sun and their skin can blister easily. The same with these other collagen vascular diseases. The last one is called mixed connective tissue disease. Here is a young girl who came to the office who actually was squeezing limes in her bathing suit. You can almost see the outline of her bathing suit and actually some of these things make us more sensitive to the sun so celery, limes, some plants and trees just rubbing against your skin can also make you very sensitive to the sun and this is like a severe sunburn basically. It is called Phyto-photo dermatitis. We also see really young patients who already have a lot of sun damage and this kid was 19 years old and came in. You can see – he already has scars from blistering sunburns and you know – this is really a set-up for skin cancer at that age.
And then of course – the one that we deal with a lot in cosmetic dermatology – of the wrinkling that we see with photo aging. Lets talk a little bit about the cancerous things that come from the sun. These are called actinic keratoses and this is actually the scalp of one of my patients and they are basically rough, crusted lesions and these are considered to be pre-cancerous lesions. You will see them on the forearms of a lot of people – on the hands and sometimes people will scratch them off and then they grow right back and those are pre-cancerous lesions. In general, about 10% of them over about 5 or 10 years will turn into skin cancer so you know – on this person’s scalp he probably has about 50 pre-cancerous lesions so obviously at some point he is going to end up with a skin cancer on the scalp. They are pretty easy to treat at this stage. We can just burn them. We can do peels and things like that and prevent them from turning into skin cancers or something like this so whenever we lecture at schools to younger kids we kind of do the shock value pictures. I am going to give you some of those shock value pictures – this is a basal cell carcinoma of the nose – so this is from sun exposure. You can see that he is fair skinned, blue eyed – the typical patient and this one actually was a melanoma that we saw at the VA a couple of years ago and it actually invaded all the way through the bone and into the brain and he did not live very long, but you can see – there is another skin cancer on the cheek. So, some of these skin cancers can be very obviously skin cancer, but some of them might not be as obvious so the one on his nose actually was a skin cancer. It looks like a little scar and then to cut the whole entire thing out was a hole that big so sometimes they look smaller. They look like no big deal and then when you go in they end up being big problems so really skin cancer – the most common form of cancer in the United States.
More than half of all new cancers – every internal, external are skin cancers. That is very common. More than a million people will be diagnosed this year with skin cancer and 1 in 5 of every American will get a skin cancer in their lifetime and I am probably a set-up because I am blond hair, blue eyed and I was in the sun when we were younger. You know – we didn’t know until recently how important it was to use sun protection. During the past ten years – actually the incidence of melanoma has increased more than any other cancer and the worst part about it is actually that we are not any better at treating it so melanoma is not really chemotherapy responsive and it is not really radiation therapy responsive like other forms of cancer. So, when you get melanoma – if it is deep it is actually very, very bad.
Lets talk about some of the risk factors – #1. UV exposure – so anyone living in Miami or anyone with your profession is going to have that risk factor. Severe sun burn as a child seems to be a very important risk factor and we will talk about that later so you can talk to some of your younger swimmers about sun protection because really – the first 20 years is the most critical. Exposure to things that cause skin cancer like coal, arsenic – hopefully we are not getting exposed to those too much anymore. Fair complexion – the red heads – blond hair blue eyed – family history of skin cancer or multiple or atypical nevi and nevi are just moles and then where you live so obviously us in Miami and Ft. Lauderdale are at much higher risk than people in Seattle, but nobody is immune so this is Bob Marley – who passed away actually at the University of Miami Hospital from Melanoma so it doesn’t really matter what your skin color is – you are not immune to getting skin cancer and you are not immune to dying from skin cancer. Actually, the quote was is that “he had a melanoma on his toe and they said, we need to amputate” and he said – “in my religion we do not amputate” and anyway – he died very young of melanoma.
So recognizing the skin cancer: the first type – basal cell carcinoma. This is the most common. It is a pink, pearly papule in a sun exposed area. Sometimes they bleed and they do not heal very well and a lot of times they will have this little blood vessel in that little telangiectasia in the center of the lesion and they are locally destructive. They don’t metastasize so they do not go internally. This is not a life threatening skin cancer, but it can be locally destructive – just like the one that you saw on the nose of that guy. He is not going to look great when they take that skin cancer off. Here is another basal cell carcinoma – so they almost look skin colored and then they have a little blood vessel. This one actually ulcerated in the center. Here is another one a little more obvious. So, even though they are not – they do not metastasize and go to organs internally – they can cause local damage and actually he lost his eyelid and then later developed scarring on his eye because he could not close his eye and keep his eye moist so they can be problematic. Here is a younger person and this is called a pigmented basal cell so it has a little bit of color, but it is still very pearly pink in color. The next one is a squamous cell. This one is slightly more risky. These can metastasize. They are red and crusty generally and they usually have a crater in the center. They bleed. They can be superficial or they can be invasive and again – they can metastasize so here is the squamous cell on the leg. Here is one on the lower lip so the lower lip tends to be a very common place because obviously the sun shines down – the upper lip does not see a lot of sun, but that lower lip – a lot of times it is moist so it gets a good reflection. You put Vaseline on it and forget the sun block portion of it so you get a lot of sun in that center area and actually this place has the highest risk for metastasis of squamous cell carcinoma so this is a high risk place. Use your sun block on the lower lip if you are going to use it anywhere and the last one – melanomas. So these three, actually, are pretty obvious looking melanomas. There are different types of melanoma. All the way on the left you can see it is a mole actually that turned into melanoma and a lot of people worry about moles, but really melanoma – less than 50% of them come from moles themselves so most of them will just come up – you know. I will have someone come in at 8:50 and say this is a new mole and when you hear something like that at an older age – you are not supposed to get new moles – then that should be an alarm sound-off that that could be something so this is a mole that turned into melanoma.
This is – the bottom right – is actually a sun freckle that turned into a melanoma and that is called a Lentigo maligna and then the upper one is a traditional melanoma. So we use the A, B, C, D, E rule in detecting which lesions are good lesions and which are bad lesions so the A stands for asymmetrical. So you want it really to be the same on both sides. If you draw a line through the lesion and it doesn’t – it is not a mirror image of each other then that is an asymmetrical lesion. The border should be nice and round. You can see on this melanoma – it is jagged. It is irregular. The color should be one color. It doesn’t matter necessarily if it is light brown or dark brown, but it should be uniform throughout the lesion so you can see the upper portion of this melanoma is much darker than the lighter portion. Some of them will even get a grey look to them – some will be red and if it is more than one color that is a risky lesion. The diameter of greater than 6 mm. is about a pencil eraser size so when they start getting bigger than a pencil eraser you should have them checked and they added E to our A, B, C, D’s this past year and E stands for evolving so something changing – growing – not healing – itching – bleeding – things like that – that should bring you to the Dermatologist. So some of them are kind of obvious so this patient came in – he has a clearly irregular lesion on the right cheek. When you look at it up close it fulfills all those A, B, C, D rules. It is irregular. It has more than one color. It was evolving. It was a new lesion and this was a melanoma on the face, but some of them can hide and they are hard to find so you can see this patient has a lot of sun damage and it is pretty difficult to see where the melanoma is. When you get up close even – it is still difficult, but this lesion right here – that I will circle for you is actually his melanoma and it is just at the bottom portion with the part that was changing.
So – prevention. We talked about the bad stuff, but there are ways to help prevent some of these things from happening to you or even to your children or the younger people that you are training. So – sun protection is #1. Self-exams ever month – as people get older that is important. Usually we start self-exams at age 30 if you have had a significant history of sun exposure. Yearly professional exam for those 40 and over and high risk patients so patients with family members that have had melanoma or siblings that have melanoma and then we will talk a little bit about new ways to prevent skin cancer. So, when we talk about the sun – there is only a couple of wave lengths that are really causing all this cancerous damage so this is our electromagnetic spectrum. All these colored lights are basically what come out of your traditional lights and then the longer ones really are infrared lights that we use in lasers and things like that. So, the rays we are talking about are really just a small portion of rays. Even thought there was a ton of hype about UVC – it is still – we do not get a lot of UVC here. Actually, it is very, very carcinogenic – UVC – but still our ozone is remotely intact and we are not receiving a lot of UVC so right now are some protective agents that offer protection against UVB and UVA and we will talk about those.
So really – what do these rays do? Well, UVB actually is very good at making skin cancer and that is why originally all of the SPF numbers were related to UVB so SPF is a measure of UVB protection so it causes direct damage to DNA. It directly alters your chemistry of your cells and causes skin cancer. UVA actually acts in a round about way – it takes a little bit linger for it to make skin cancer, but it does cause wrinkling very, very well so you want to protect against both in order to have full sunburn protection. The UVB is what causes you to burn and UVA again causes aging and something we call persistent darkening. Sometimes you will see those people that have been in the sun for years and years and they are 75 years old and they still look very, very tan – even though they are living in a nursing home. They haven’t seen the sun in 10 years and that is UVA damage – that persistent darkening.
So, lets go over SPF – what does it really mean? Well, by definition it measures the amount of time that a product protects against getting red which is what UVB does, okay? So, obviously that is different for everybody so if you burn after 20 minutes and you put on an SPF5 – 5 X 20 minutes – extends it to about 100 minutes. Now – this is in a laboratory – ideal world – perfect application of sun screen – not getting in the water – not wiping your face with a towel – not being out for more than an hour and a half. These numbers do not really translate into our real world – even though this is what we see in the laboratory. So remember – SPF really only measures against UVB so we are not talking about UVA at all. We will talk a little bit about how to protect against UVA and it needs to be – all these SPF numbers are only real if you apply it at 2 mg. per centimeter square so what does that mean? Really – for your face – it means a full teaspoon of sunscreen which is a ton – even myself – who is crazy about sun protection – I do not use a tablespoon of sunscreen on my face. If you were going to do your whole body it would mean that you use the entire bottle of sunscreen and I do not know anybody that applies sunscreen like that so again – those numbers are not going to be what you are getting. If you put on an SPF 15 and you use about half of what you are supposed to use you are now talking about an SPF 7. Therefore we have to remember that when we apply it that we are not probably using it the way they used it in the laboratory and it needs to be reapplied at least every two hours – #1 because of what we do – swim – sweat – dry off with a towel, but also because these ingredients aren’t very photo-stable so the longer they are in the sun the less they tend to work. So, when we look at SPF in the real world – most people who put on a 30 do not get a 30 SPF protection. We do not put it on correctly because we do not put enough on. We sweat – we swim – we wipe with a towel – we apply it too soon to the time that we are going to go into the sun so most of the sun protection agents are chemicals. They need to be absorbed into the skin. They alter your skin and help you trap light basically – from going through the skin, but it needs about 30 minutes for that whole process to take place so if you want ideal protection you have to put it on 30 minutes before you go out in the sun.
We will talk a little bit about sun blocks versus sun screens and sun blocks tend to work a little bit quicker and then re-apply every two hours so I guess the biggest question is – what number do I wear? Everyone says do I need a 15 – do I need a 30 – I heard that a 50 isn’t any more than a 30 – what is the best number? Again – it goes back to how you apply it – when you apply it – where you live – what your risk factors are as to how much protection you are going to get so darker skin patients really may not need as much SPF. They have pretty good block in the melanin in their skin whereas a fair skinned patient really is going to need a much higher number. When we look at what they protect against you can see that SPF 6 gives you about a 50% protection. That jumps when you go to an SPF 15, but it doesn’t really jump after that. You get a little bit more protection as you go up to 50, but it is not the same increase that we see from SPF6 to SPF15 so really – an SPF30 is not a double of a 15, but if you are using it the way we talked about – the way I use my sunscreen – which is probably half as much as I should use – and when I put a 30 on I am really only getting a 15 or if you are putting a 15 on – unfortunately you are really almost unprotected so it is easier to go with a higher number. Even though a higher number is not going to offer you 100% more protection, but it will account for some of those mistakes we make in applying sunscreen.
Now the FDA is going to make it easier for everyone with sunscreen – they are going to make it a 50+ so these new brands you are seeing that say 80+ – 100+ – you know – those are going to be eliminated in the next year and you will see just 30 – 50 – 50+ and you can pick a 50+ and know that if you under-apply – at least maybe you are still at a 30. It also depends on the UV Index. This is usually in every local paper. Obviously – at greater than 10 – do not leave your house, but I have never seen it greater than 10 and the other ones you just really want to wear sunscreen – any time you can see your shadow. Also – the peak hours – use more sunscreen. UVB tends to really peak between that 10 and 2 – whereas UVA actually has an extended peak time. It is pretty strong all the way through the day.
Okay – UVA protection – again – it is measured by the persistent pigment darkening. It is a difficult thing to measure. You would not know after a day in the sun that you had too much UVA exposure. It is not like when you get a sunburn from UVB. You do not come in saying oh my God – I had so much UVA I can tell that I am overdone. Our rating system will come out – probably in the next year and a half when FDA is done and it will be a 1 – 4 star system. Really, if you are at a 2, 3, or 4 you are probably OK with DVA. It used to be 10 and above those are not printed on the bottles right now so it doesn’t offer us any advantage so look for that UVA star system – that will give you a clue, but still – going to the drug store is very confusing. There are rows and rows like this. It is impossible – even the same brand has 20 different versions with different ingredients. The easiest thing really is just to read the back of the bottles and I will tell you what things to look for.
So – UV rays that are absorbed are sunscreen so sunscreens are chemicals. They require that 30 minute change in the skin to offer protection so that you need to put on before you go out. Sun blocks actually are physical barriers like the life guards used to wear – the white zinc oxide. They have now made them micronize so they are not quite as white – they blend. They do have a little bit of a white hue, but they blend pretty well and those you can put on the minute you go outside because they work immediately. They do not require that 30 minute lag time so if you know – you are already at the beach you should likely go with a block as opposed to a screen. These are the ones right now that are FDA approved here. The red ones are UVB – the blue ones offer both and then the green are a classic UVA. Most of the ones that you probably use now are parcel and the helioplex and those new ones from Banana Boat – they are all stabilized parcels so it is the stabilized ingredient – it is just supposedly more sun stable so you don’t have to reapply as much. Most of the ingredients do not use ——— or ——— anymore – there are a lot of allergies and again, pava. Mostly we don’t see anymore because of allergies. The ones you want to look for really are the blue and then either that or parcel and that way you know you have UVA protection. There is always UVB. The UVB ingredients are inexpensive and easy to put into product, but the UVA can sometimes be left out. Your blocks block against UVA no matter what, Oxy-Benzene blocks against both and then Mexoryl is the newest one from La Roche-Posay. It is the one that got all the hype that it was the best UVA blocker. It is a great UVA blocker. Unfortunately, it is very non-water proof so it is probably a very bad choice for people who are going to be swimming and they had trouble making it water proof. It was too thick to get it to stick.
So, here is just a graph – showing you the same thing – which ones block against what and what wave lengths. UVA is a longer wave length so that is the right side and then UVC and UVB on your left side. Okay – so some of the UVA blockers you see on the shelf – this is the one that I was taking about that has Mexoryl. You will find it in all foreign countries – everywhere – every drug store, but here it just got approved so you will just start seeing it. It came out in a 15 and now it is available in a 40 0 again – not waterproof so only for day use. These are the stabilized parcels – Neutrogena products and now Aveeno and Banana Boat came out with them also and then this one is for patients who are really sensitive to sunscreen. It is all physical blocker so people who say I have an allergy to sunscreen and I can’t wear sunscreen – there are alternatives to that.
So – what is really the perfect sunscreen? For every day use you want at least an SPF 30 – unless you are really using the whole bottle for your body – then I guess you can go with a 15. Zinc or titanium greater than 4% will offer you UVA and UVB protection without chemicals so you can wear it immediately – get protection as soon as you go in the sun or if you want to go with a chemical you can go with one UVA Blockers that block against UVA and Oxy-Benzene which is the most common one here in the US – blocks against both.
Okay – waterproof: That is another thing that is going to change on the bottles. Now it still says waterproof, but they are changing it because the FDA thinks there is no such thing as waterproof. They are going to be called water resistant now so just basically water resistant means changes SPF after 40 minutes in the pool – which is pretty good. It gives you 80 minutes of emersion – that is if you apply it 30 minutes before, okay? You cannot put it on and jump in the water. For the little ones we typically go with the physical blockers because the chemicals are very well absorbed into baby’s skin so look for that zinc and titanium products. Not all products that say baby on them are really for babies. A lot of them have tons of chemicals in them. You know – there is no regulation about what to write. You can write whatever you want so zinc and titanium are really the best baby brands and the Pediatric Society recommends using sunscreen as early as 6 months if the baby is going to be in the sun so it used to be we said, “don’t put sunscreen on your children until they are 2 – now you put it on if they are outside. Do not use the bug spray sunscreen combo products. It actually decreases the SPF.
Question: At what age do you start putting adult lotions on a child?
Answer: There is no strict law. I usually tell people 3 is when the baby skin actually changes and it is less permeable. So it is a great time that you would be very, very safe using them. I think for kids it is great to use the clothing. Then, you have no chemical. You do not have to chase them and reapply. You just have to apply on their face if they are wearing the sun protective clothing. But, it was, just a couple of years ago that they changed their rules about using sunscreen and they said if the baby is going to be in the sun – you put sun protection on them because to have a sunburn at a young age is a much bigger risk than to have a reaction to a topical chemical.
Question: bug repellent and sunscreen – is that the only – what if I put bug repellant on after the sunscreen?
Answer: You can put the bug repellant on after. When they are mixed together they were not stabilized very well and so they decreased efficacy of this cream. But just an example – really – this is a patient who had her son’s photo taken with a special camera and it shows the sun damage so you can see all across the nose and the forehead. This is 6 months after just using sunscreen so a lot of it clears just by taking an active role in preventing the new stuff that is coming on. This patient is 45 years old so it was not as if we undid what she did in childhood, but it does make a big difference – even deciding to do it at an older age. Other types of protection – you know – everyone says – oh – I wear T-shirts so a wet white T-shirt gives you about an SPF 4 or 6. It is not great protection. They have the sun shirts now – they are not so uncomfortable so if you want to wear a shirt just at least wear a sun shirt. A thin layer of clouds offers again about an SPF4. If you can see your shadow you are usually at about 50% protection so that is about SPF 6. 12 inches deep in water offers about SPF 4-6 and at the surface of the water though you are at increased risk so even though maybe I guess if you are playing water polo your legs might be protected – the upper part of your body is going to be more exposed. The clothing is a great option for little kids. The hats – hats need to be at least 4 inches to offer good photo protection – only because you look up or the bottom of your face doesn’t get protected by the hat. It is actually great for protecting the forehead – a regular hat – but the lower part of the face is not as well protected. Tight weaved dark clothing or there are some products you can wash into your clothing so this – you can get it at any drug store – grocery store and you wash it into a regular shirt and it actually has something called tenasorb in it which is a sunscreen and offers some protection so you don’t have to go out and buy necessarily this specific UPF clothing.
So, about sunscreen and kids and melanoma – there are a couple of studies that actually show that if you could just decrease the blistering sunburn – just blistering – not even the mild sunburns – you could reduce the risk of getting melanoma by 50% in kids from birth to age 20. That is huge. I mean there is no other cancer that you can say that about that you could decrease the risk by 50% by doing something as simple as preventing a blistering sunburn. It is most important really for probably the high schoolers or the college age kids that you are coaching that this is the time really to protect themselves – not really by our age. Again – greater than 50% of a person’s lifetime sun exposure occurs in childhood so that is really the time to teach them and unfortunately only 14% of high school students actually use sun screen. We are still not doing a great job getting the message out – how important this is to them. They don’t really care about cancer. You have it in high school. I do tell the girls – I say – do you want to look like your mother and be all wrinkled and then all of a sudden they start to listen, but the cancer thing just doesn’t make sense to them at that age.
So, education – you know we target children with education. We try to tell them about the bad consequences of sun and the importance of using some protection. Now, for us who have already done our damage – what can we do? There are things that we can do to prevent the cancer from coming – even though we get exposed to the sun all the time. We call this chemo prevention so it is use of medications or vitamins to try to reduce the risk of cancer and the main ones that we use are anti-oxidants and Retinoids. There are a bunch of topicals and orals over-the-counter now and antioxidants that help with sun protection. We will talk a little bit about just so you know that they exist. The antioxidant list is huge. They are over the counter – they are in doctor’s offices. You can find them anywhere. You don’t have to spend a lot of money to get them. You can see Nivea, Eucerin make these products also and actually some of them offer additional photo protection so not only are you getting anti-aging effects, but also if you put them on underneath your sunscreen they will offer an additional protection from the sun so you wear them during the day generally and here is another whole page of them – there are a lot of them. So supplementation with antioxidants may decrease damage from UV exposure.
There are a bunch of supplements – one is Polypodium Lucatomatous which actually is available as a vitamin over the counter. It is a fern that you take and when they look at how fast you burn – if you are on this medication you are less likely to burn and so it is a pill that you can use for sun exposure. There are also green teas that actually help prevent getting sunburned so you can actually drink green tea or an easier one probably – is Briz Veratrol which is in red wine. You actually have to drink a lot of red wine to get sun protection, but it is an option and there are vitamins at Whole Foods or at the Nutrition Stores that have Briz Veratrol in them which is an easier way and a more sane way to get your Brix Veratrol. Retinoids are basically a synthetic vitamin A and we use these to treat skin cancers, but also to prevent cancer. It has been used in chemo prevention in a lot of cancers – breast cancer, prostate cancer and here is the prescription versions of them – I am sure that you have heard of Retin A which is used only at night time. All of these are only used at night. They are actually inactivated by the sun so you cannot use them during the day or they do not work. And a lot of patients with acne use them for acne, but in older patients we really use them for relieving further damage so undoing the damage that has already been done. There are over-the-counter versions of these Retinols.
Other ways to undo the damage are chemical peels – something called photodynamic therapy which is what this gentleman is receiving. We literally paint the face with a photo sensitizer and it gets absorbed by cells that are changing so even ones that you do not see that are turning precancerous will absorb this photo sensitizer. We then activate it with a light system – not an ultraviolet light so it is not a cancer causing light. It is a blue light actually and it burns off selectively all the places that are turning precancerous or cancerous which is nice because a lot of times you do not see them when you look at the skin so that is called photo dynamic therapy.
Question: Does that make you look red?
Answer: Yes, you look terrible for literally – probably 36 hours you look terrible and then it all peels off and then it looks great. Sometimes we look at people who – you know that in the sun, but you do not see anything and then when you do the treatment like this you will find these lesions that were kind of hiding.
Question: Is that something that is covered by insurance?
It is covered by insurance. Most insurances – yes.
Question/Answer: You know – right now it is approved for the face and it is not good at treating pigmented lesions so it would not be treating pre-melanomas, but it would be treating things like actinic keratoses or superficial basal cells or squamous cells – that non-pigmented group of skin cancers. For melanoma really – the best thing preventively is to do mole mapping where they literally take pictures of your moles with a microscopic camera so now they can look into the mole without cutting the mole at all. They take pictures and they store pictures in a computer and then you come back every six months and they look at the moles and make sure that they are not changing. They can also pick up new ones very easily because they have pictures of your whole body and they go in and they compare the pictures and then the computer says, wait – this was not there six months ago and then they can remove those lesions so it actually saves you from getting cut, but also catches things very early. Still again, the best treatment for melanoma is finding it early because if you find it in situ – which means in the very top of the skin – the cure rate is 99.9%. Once it gets through the skin – you know – the cure rates drop to about 20% so it is important to catch it early.
We talked a little bit about Retinoids – topical chemotherapy – that is like Fudex or 5FU which also make you look terrible, but usually for about 3-4 weeks. The Photodynamic therapy is about 24 hours of looking really bad and then regular skin exams – that is very important to do – a yearly skin exam – even without a history of skin cancer – once a year skin exam – head to toe. So here is someone – before and after photodynamic therapy. You can see the sun damage and that is after one session. It basically takes off all that rough hard skin. So really – summary of sun protection: It is going to depend on the type that you choose. You want to look for UVA, UVB. If you know you are not going to apply before you get out there – look for a physical blocker as opposed to the chemical blockers. Again – 30 minutes before for the chemical blockers. The amount is way more than you think so use much as you are willing to use and then reapply every 2 hours to get the best protection. And does it mean we have to eliminate this from our lives? No – because I was in your exhibition hall and I saw it – we are obviously still going to get sun. I still go to the beach and take my kids to the park in high sun hours. You know – it just means being a little bit smarter about what we do. You know – sun protective clothing – sun screen – a hat and you know – still live life. Don’t get scared by this, but prevention really is still key with a lot of the worst skin cancers and thank you.