Sunscreen use in patients with cutaneous lupus erythematosus
Year: 2015
Type: article
Study design: Observational Study
Abstract: Dear Editor, Because ultraviolet radiation (UVR) is a well documented environmental trigger, patients with cutaneous lupus erythematosus (CLE) are advised to engage in photoprotective practices, including sunscreen use. Despite numerous studies demonstrating the efficacy of sunscreens,1,2 patients with CLE have not fully embraced sunscreen use. Daily sunscreen use was reported in only 23% of patients with CLE in Ireland.3 Our group previously found that 59% of patients with CLE used sunscreen ‘often’ or ‘always’, although those terms were not defined.4 The reasons for suboptimal sunscreen use in patients with CLE are not clear. From January 2012 to April 2013 a cross‐sectional survey to assess frequency, patterns and barriers to sunscreen use was administered by telephone, mail, e‐mail or in person to patients with CLE enrolled in the University of Texas Southwestern (UTSW) CLE Registry database in Dallas, TX, U.S.A. (Fig. S1; see Supporting Information). The inclusion criterion was a clinicopathological diagnosis of CLE. Exclusion criteria included being younger than 18 years old, and a history of drug‐induced CLE or another photosensitive disease. This study was approved by the UTSW institutional review board. Patient characteristics, outlined in Table 1, were obtained from the UTSW CLE Registry database. Patients with CLE who reported using sunscreen for 7 days and 0 days in the last week were designated as daily sunscreen users and those who did not use sunscreen, respectively. Sun protection habit scores were determined by calculating the sum of responses and the frequency of other photoprotective practices.5,6 Questions related to potential barriers to sunscreen use were assessed using a four‐point polychotomous scale (1 = strongly agree, 2 = agree, 3 = disagree, 4 = strongly disagree). A statement was considered a barrier if the response was ‘strongly agree’ or ‘agree’. Uni‐ and multivariate analyses of predictor variables in patients with cutaneous lupus erythematosus (CLE) who did and did not use sunscreen daily Data are given as n (%) unless otherwise indicated. OR, odds ratio; IQR, interquartile range; SLE, systemic lupus erythematosus; CLASI, Cutaneous Lupus Activity and Severity Index; SLEDAI, Systemic Lupus Erythematosus Disease Activity Index; SPH, sun protection habits; NA, not applicable. aDisease duration data were only available for 83 patients (including 28 daily sunscreen users and 32 who did not use sunscreen); bCLASI and SLEDAI scores were only available for 39 patients (including 15 daily sunscreen users and nine who did not use sunscreen) within 30 days of the collection of the survey data. Uni‐ and multivariate analyses of predictor variables in patients with cutaneous lupus erythematosus (CLE) who did and did not use sunscreen daily Data are given as n (%) unless otherwise indicated. OR, odds ratio; IQR, interquartile range; SLE, systemic lupus erythematosus; CLASI, Cutaneous Lupus Activity and Severity Index; SLEDAI, Systemic Lupus Erythematosus Disease Activity Index; SPH, sun protection habits; NA, not applicable. aDisease duration data were only available for 83 patients (including 28 daily sunscreen users and 32 who did not use sunscreen); bCLASI and SLEDAI scores were only available for 39 patients (including 15 daily sunscreen users and nine who did not use sunscreen) within 30 days of the collection of the survey data. Patient characteristics were summarized with frequency counts and percentages. Comparisons of continuous and categorical variables between daily sunscreen users and those who did not use sunscreen were performed using anova and χ2 tests, respectively. Comparisons of ordinal measurements were performed using Mann–Whitney U‐tests. Multivariate analyses were performed using predictor variables with univariate analysis P‐values < 0·10 and sex as independent variables. Statistical analyses were performed with SAS software version 9.3 (SAS Institute, Cary, NC, U.S.A.). One hundred of the 148 patients with CLE invited to take part, completed the questionnaire (demographics and disease characteristics are provided in Table 1). There were 32 (32%) daily sunscreen users and 40 (40%) patients who did not use sunscreen. Of the 60 who used sunscreen, 50% and 63% of patients reapplied sunscreen on a daily basis or when outside for more > 1 h, respectively. A total of 33% put sunscreen on at least 30 min before going outdoors. Univariate analyses revealed that daily sunscreen users were more likely to be married than those who did not use sunscreen (P =0·01). Those who did not use sunscreen reported annual incomes < $10 000 more often than daily sunscreen users (P =0·01). Daily sunscreen users also had significantly higher rates of completing a college (or above) education compared with those who did not use sunscreen (P =0·02). Daily sunscreen users more often sought other forms of photoprotection than those who did not use sunscreen (P =0·01). Multivariate analyses demonstrated that patients with CLE who were married (P =0·04) or who had college education or above (P =0·03) were highly associated with daily sunscreen use (Table 1). Other disease characteristics and demographic variables showed no significant differences between the groups in either the uni‐ or multivariate analyses (see Table 1). Forgetfulness was cited as the most common reason for not using sunscreen (42%), followed by the patients’ belief that sunscreens were ineffective in preventing lupus flares (41%) and by inherent features of sunscreens such as greasiness (39%). Those patients with CLE who did not use sunscreen were more likely than daily sunscreen users to ‘strongly agree’ or ‘agree’ that forgetfulness (P <0·01), inconvenience (P =0·01) and perception of futility in preventing lupus flares (P =0·03) were reasons not to use sunscreen (Table 2). Barriers to sunscreen use Data are given as n (%). CLE, cutaneous lupus erythematosus. Barriers to sunscreen use Data are given as n (%). CLE, cutaneous lupus erythematosus. The low percentage of patients with CLE using sunscreen daily underscores the need for providers to counsel such patients that optimal photoprotection requires daily sunscreen application. Moreover, we found suboptimal rates of patients with CLE reapplying sunscreen daily and applying sunscreen 30 min before going outside. Our data highlight gaps in knowledge in patients with CLE, who may perceive that once‐daily sunscreen application is sufficient and that applying sunscreen provides immediate photoprotection. Such inadequate practices could lead patients to conclude that sunscreens are ineffective in preventing lupus flares. In both uni‐ and multivariate analyses, marital status was a significant feature in distinguishing daily sunscreen users from those who did not use it. Given that patients with CLE who did not use sunscreen more often identified forgetfulness as a reason for not wearing sunscreen, we hypothesize that daily sunscreen users may have constant reminders from significant others to apply sunscreen. Although the survey did not ask patients about their sources of accountability, future projects seeking ways to increase the rate of sunscreen use in patients with CLE can include this question. More patients with CLE who did not use sunscreen had a lower level of formal education than daily sunscreen users, likely contributing to the greater percentage of those who did not use sunscreen citing their belief in sunscreen inefficacy as a barrier. Because this misperception of sunscreens may contribute to decreased sunscreen use in patients with CLE, this demonstrates a need for patient education to address this knowledge gap. Previous studies have shown that photo‐exacerbated CLE flares can be delayed by up to several weeks after UVR.7 Patients with CLE may not connect the two events because of the temporal delay, which may explain why patients may feel that sunscreens are ineffective. The two groups were analysed to see if one form of communication influenced reporting of sunscreen frequency. Despite an almost significant trend for those who did not use sunscreen to be interviewed by telephone, a reporter bias would have resulted in the opposite case of patients overestimating their sunscreen frequency by telephone in order to satisfy providers' expectations. To minimize this bias, we used personnel not directly involved with their medical care to conduct interviews. Our finding that only a minority of patients with CLE consistently wear sunscreen implies an opportunity to develop more effective patient education methods. Practitioners are encouraged to take time to educate each patient with CLE about the importance of sunscreen use. In addition, counselling patients about appropriate patterns of sunscreen use and emphasizing that there is a potential delay between UV exposure and CLE skin flares would potentially enhance sunscreen use in this at‐risk population. We are indebted to Rose Cannon for assisting in the preparation of the manuscript. We would like to thank Andrew Kim, Daniel Grabell, Julie Song, Rebecca Vasquez and Sandra Victor for their assistance with the compilation of patient data. Funding sources: The research reported in this publication was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award number K23AR061441. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Conflicts of interest: B.F.C. is an investigator for Daavlin Corporation. S.Q.W. serves as an advisor for Johnson and Johnson, L'Oréal and Avon. Fig S1. Survey administered to patients with cutaneous lupus erythematosus.
Source: British Journal of Dermatology
DOI: 10.1111/bjd.13736
Language: English
Topic: Skin Protection and Aging
Subfield: Dermatology
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W1924812684