Should You Get a Scary UV Photo of Your Skin Damage? | Hacker News Reader

Should You Get a Scary UV Photo of Your Skin Damage?

nytimes.com

49 pointsbookofjoe44 comments

The powerful dermatology lobby has consistently misled the public about the so-called dangers of sun exposure. We've known for decades that sun exposure has a strong inverse relationship with all-cause mortality.

The fact of the matter is that the vast majority of Americans should be getting a lot more sun exposure, not less. The intellectual sleight-of-hand comes from an obsessive focus on skin cancer mortality to the exclusion of all other causes of death. At the end of the day skin cancer is a relatively rare, easily treatable disease, which only makes up 1.2% of all cancer deaths and 0.25% of all deaths.

Another way to think about this is even if sun exposure increased skin cancer mortality by 250% (it doesn't), the documented 3%+ reduction in CVD is more than enough to outweigh it.

[1] https://www.ncbi.nlm.nih.gov/pubmed/28074966

[2] https://seer.cancer.gov/statfacts/html/melan.html

> At the end of the day skin cancer is a relatively rare, easily treatable disease

Please don't say that. Most skin cancers are indeed treatable (basal cell and squamous cell). But melanoma is not, unless caught early. Yes, there are some better drugs now, but it's far from treatable. I have heard too many stories of people who went to the dermatologist to have a mole checked, and 9 months later they were dead. Melanoma is scary.

Melanomas are largely treatable because they are caught early. People tend to notice fast-growing tumors on their skin, unlike in other areas of their bodies.

That's not always true. You have lots of skin in places you don't tend to look at regularly.

People often miss things, or mistake them for something else. My buddy thought he had a mole on his ear until it turned out it was aggressive melanoma. They reconstructed his ear and took out some lymph nodes, and 2 years later it came back in his lung. Fortunately he enrolled in a clinical trial of immune based chemo, so he only lost his thyroid and adrenal glands.

How likely is it that you'd notice melanoma on your scalp or back?

It’s scary so therefore he shouldn’t say that skin cancer is rare and treatable?

"Please respond to the strongest plausible interpretation of what someone says, not a weaker one that's easier to criticize. Assume good faith."

https://news.ycombinator.com/newsguidelines.html

I've never understood the sun exposure guidance to be "stay indoors", but rather wear sunscreen / hats / etc, esp if you are prone to sunburns or have a family history... which doesn't seem that sinister.

Aha! It was the powerful hat lobby all along!

You can wear sunscreen and still get the benefits of sun exposure. This isn’t an either/or situation. Portraying it as such is harmful.

Here is a pop-science account that contradicts that: https://www.outsideonline.com/2380751/sunscreen-sun-exposure...

> The powerful dermatology lobby has consistently misled the public

What is their incentive for misleading people about this? What goals are they achieving?

I'm not arguing, I still think the misleading happened - I just don't know what their incentives were. Without any incentives, the cause would probably have to be due to genuine misunderstanding of studies and statistical analysis.

I don't know the parent's reasoning, much less that of the doctors... but Upton Sinclair said, "It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

Dermatology in particular has many lucrative continuing treatments and rarely focuses on cures. Although many in the medical fields also say, don't ask a surgeon for an opinion unless you want to cut (e.g. everything looks like a nail).

> This community has gone to shit.

I want to upvote you because I think this is a great question too. Can you remove this part though? I don't think it's helpful.

maybe in america, but in australia we have a huge amount more UV because of the hole in the ozone layer. i was in the US for the first time a few weeks ago, and the first thing i noticed was “huh... i didn’t know that going out in summer, the sun could literally feel different”... in australia it feels, no joke, like you’ve stuck your arm under an oven: you can feel the dry heat and UV. in the US, the sun was just a nice warm heat.

please, it’s a big problem over here... people should go outside (and we have a very “beaches and surf” type culture), but sunscreen is hugely important, and often forgotten.

>the documented 3%+ reduction in CVD is more than enough to outweigh it.

People with high sun exposure have lower CVD mortality; this does not in any meaningful way suggest that sun exposure reduces CVD mortality. To quote from your linked paper: "we cannot exclude the possibility that a bias exists between a healthy lifestyle and high sun exposure habits."

It is notoriously difficult to control for confounding variables in observational studies of this sort and the authors have provided nowhere near enough information in their paper for me to have any confidence in their adjustment. I think anyone reading this comment can easily think of a multitude of reasons why people who get less sun exposure might have poor health habits, or why people in poor health might get less sun exposure.

Yep - play outside, but wear sunscreen.

The problem here is you're completely ignoring morbidity. Skin cancers are a whole lot easier and safer to cut out when they're small.

Of course, I do work in Australia, so pretty much everyone gets skin cancer.

Source: I cut out skin cancers.

> The powerful dermatology lobby has consistently misled the public about the so-called dangers of sun exposure

Amusingly, most of the people I know who are into things like high fat, red meat heavy, paleo/keto diets are also into things like intentionally getting way too much sun - and like with the diets, there's always some lobbying industry keeping the "real" medical information from us.

I suspect most of them will have heart disease and skin cancer when we're in our 60s.

> I suspect most of them will have heart disease and skin cancer when we're in our 60s.

You've got to die of something, if enjoying the sun and eating fatty tasty cuts of meat means dying 10 years earlier, I'm OK with that

Except they think it's going to help them live longer.

And quality of life is poorer with atherosclerosis and cancer - so the years that you do live could potentially be much worse ones.

Apparently the positive health effects of sun exposure are negated by sunscreen. Here's a pop-science explanation:

https://www.outsideonline.com/2380751/sunscreen-sun-exposure...

There was a very interesting essay that circulated earlier this year called "Is sunscreen the new margarine?" [1]. It was on the front page of HN [2].

According to the article there's also some evidence that long-term sun exposure correlated with a decreased risk of melanoma (outdoor workers have half the melanoma rate of indoor workers!). The hypothesis is that a tan protects against the DNA damage that causes it.

Some of the researchers quoted in the article believe that dermatology has gone too far in considering UV exposure a health risk, and that we're due for a correction in that thinking, because there's too much evidence that UV light is, in fact, healthy.

[1] https://www.outsideonline.com/2380751/sunscreen-sun-exposure...

[2] https://news.ycombinator.com/item?id=18890475

Thanks for linking to that article. I'd like to quote from the same paragraph that you quoted, about the outdoor workers:

“The risk factor for melanoma appears to be intermittent sunshine and sunburn, especially when you’re young,”

Sunburn is the real culprit. And according to my dermatologist, a sunburn now can cause melanoma 20 years hence. Do not get sunburnt!

Sunburn is cell death due to DNA damage. It's a fail-safe that tries to limit the chance of things like melanoma by killing damaged cells off before they can reproduce.

The real culprit is the small chance some cells didn't die off and an even smaller subset manage to replicate with damaged DNA. The actual sunburn is just an indicator that you've exposed a number of skin cells to those odds.

Seems like obvious selection bias. People who sunburn easily (and are thus more susceptible to melanoma) are less likely to take jobs that require working all day in direct sun.

Do you have data showing that, or are you just guessing because it "makes sense"?

Even for melanomas, the dangers of sun exposure have been misguided. It turns out getting regular sun exposure (not burning) appears to actually lower your risk:

"Overall the clearest relationship between reported sun exposure and risk was for average weekend sun exposure in warmer months, which was protective (OR 0.67, 95% CI 0.50-0.89 for highest versus lowest tertile of exposure)"

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3046902/

>The fact of the matter is that the vast majority of Americans should be getting a lot more sun exposure, not less.

Not if you don't want to look like leatherman (or leatherwoman) when you are in your 40s!

There are strong aesthetic benefits of never letting sunlight impinge upon your skin.

Women used to carefully cover exposed skin when outdoors and their skin would remain smooth and youthful into their 50s.

The point is to have more regular sun exposure, not stay locked up in an office for 6 months, then spend a week on a beach for 4 hours at a time.

To end up looking like that you need to do some serious sunbathing or outdoor work without covering yourself. You aren't going to end up looking like that just from walking outside for 30 mins a day, especially not at latitudes further from the equator.

I've been Googling it and simply cannot find, anywhere, an explanation of why areas of skin that reflect less UV (and are therefore darker) are "skin damage".

Is this medically legitimate, or just a cool camera effect whose medical causes/effects are unproven or uncorrelated with sun exposure or skin cancer?

To play devil's advocate, couldn't these just be spots that appear with genetics or age regardless of sun exposure? And are there statistics showing that skin cancer appears with significantly greater frequency on the dark spots as opposed to lighter areas? Or heck, couldn't the dark spots function as skin protection (rather than "damage") since darker skin protects you from the sun in general?

I can believe it -- but the complete and total absence of any easily verifiable facts here makes me skeptical about taking this at face value.

The thinking used to be that a tan (a complex process called melanogenesis) was the skin protecting itself from DNA damage. However, research in recent years suggests that DNA damage has already happened at the point when tanning occurs.

For example, there's this oft-cited paper: https://www.ncbi.nlm.nih.gov/m/pubmed/15748643/ ("Melanogenesis: a photoprotective response to DNA damage?"). Relevant quote: "Growing evidence now suggests that UVR induced DNA photodamage, and its repair is one of the signals that stimulates melanogenesis and studies suggest that repeated exposure in skin type IV results in faster DNA repair in comparison to skin type II. These findings suggest that tanning may be a measure of inducible DNA repair capacity, and it is this rather than pigment per se which results in the lower incidence skin cancer observed in darker skinned individuals."

This does seem to be the current paradigm in dermatology, and it reflects what I've been warned of by dermatologists. I've not been able to find any recent research that challenges this theory.

I never thought that a tan protected you from DNA damage from the sunlight that caused you to tan. I thought that it protected you from future DNA damage to the now more type IV-like skin.

Is this UV damage or just our reflecitivity to UV light?

Melanin converts 99.9% of UV radiation into heat.

Even the synthetic form as noted here https://www.ncbi.nlm.nih.gov/pubmed/15068035 The risk is poor nutrition, copper is needed for this skin pigment, which means competing with the demands placed by other parts of the body like collagen, (bones, skin, etc etc), blood cell production and more. Another problem is the skin is washed often, daily in most cases and exposed to chemicals which can become carcinogenic under the sun. Carcinogenic suncreams exist. So its a complicated picture, poorly understood. The photo's are useful for seeing the distribution of cells.

Hey! You! Schedule a visit with a dermatologist today.

The appointment takes about 20 minutes, and they do a great thorough check of all your moles and other skin irregularities. If you go once a year or so, they'll almost certainly catch anything that needs to be removed before it gets deadly.

Two stories:

First, a close friend of mine ignored a skin irregularity for years and years until he had to have his entire thumb amputated. Unfortunately, the melanoma had already spread, and now he's a terminal patient (although a few clinical trials have helped extend his life beyond the initially predicted timeline!).

Second, my business partner goes in to get his skin checked every year. The dermatologist caught an irregular mole, confirmed it was cancerous, but because of how soon it was caught, the doctor removed it, and he hasn't had any other signs of cancer since.

There's no evidence that population-wide skin cancer screening has any impact on overall mortality. And in fact dermatologists have an enormously high rate of misdiagnoses leading to a lot of unnecessary painful and stressful biopsies.

> The second ecological study compared the melanoma mortality experience in Germany with the melanoma mortality experience of subregions of 22 European countries for the years 2000 to 2013, none of which had organized screening programs. After adjustment for potential confounders, Germany and the 22 European regions had similar malignant mortality rates, suggesting no benefit of screening.[30]... One case of melanoma was detected per 28 excisions overall (for both men and women), while 52 skin excisions were required to detect one melanoma in men aged 20 to 34 years.[31]

https://www.cancer.gov/types/skin/hp/skin-screening-pdq#_24_...

My advice would be just the opposite. Unless you're an at-risk individual or have a family history of melanoma, skip the dermatologist appointment.

Very valid points, but for what it's worth some people will worry until they've got a negative from someone who knows what they're doing. False positives are stressful, but I like having someone who actually understands dermatology take a look, especially since I grew up getting way too much sun, and since I started balding have had a couple bad head burns (I now understand why hats are a good thing).

Also, if you don't have a partner who sees you naked on a regular basis, there are parts of your body you probably don't see too often. I have a birth mark my wife sees more than I do.

> Visual examination of the skin in asymptomatic individuals may lead to cosmetic or functional complications of diagnostic or treatment interventions and the psychological effects of being labeled with a potentially fatal disease, although robust data on the frequency of such events are lacking. Other harmful consequences are overdiagnosis, leading to the detection of biologically benign disease that would otherwise go undetected,[7,8,32] and the possibility of misdiagnosis of a benign lesion as malignant.

The potential harm does not sound too horrible, especially since anomaly detection normally results in removal of a small piece of your skin that heals easily and that's it.

> One case of melanoma was detected per 28 excisions overall (for both men and women), while 52 skin excisions were required to detect one melanoma in men aged 20 to 34 years.

On the other hand, the detection rate is actually quite high in my opinion, since they tend to cut out anything small that is suspicious and only do a thorough check afterwards.

It might be different from an economic point of view for the system paying for these checks, but as an individual I'd say there is little to lose and a lot to gain. (The options usually are: Nope, no cancer and you have a small wound/scar. / Yes, it was cancer, but we already took it out so you're fine now.)

Melanoma biopsies are not typically “small pieces of skin”.

Any other kind of biopsy will be unreliable and is more likely to be a waste.

How are you basing detection rate on that information? Hint: you can’t. Or if you are implying that detecting 1 case in 52 cases of melanoma is good (a sensitivity of 2%) then you’re nuts.

All medical students and dermatologists train on the basic guidelines for skin cancer screening. Please leave this to the professionals.

If you notice a something weird on your skin, you should definitely see a doctor. Otherwise, there's absolutely no benefit to routine dermatology check-ups; this sort of futile over-investigation and over-treatment is one of the major reasons why healthcare in the US is so cripplingly expensive.

I read the whole article expecting the question posed by the title to be answered. It never was, nor was there any appeal to science, data, or statistics on UV skin photography. Pretty disappointing.

Specifically, I wonder how good of an indicator of sun damage or cancer risk a photo like this really is, or if it's just an advertising gimmick.

It kind of is answered, at the end:

"Doctors don’t need UV photography for diagnostic purposes. “We are trained to pick up on subtle changes,” said Dr. Rachel Nazarian, a dermatologist with offices in Murray Hill. The pictures, she said, are “meant for dramatic effect."

>Betteridge's law of headlines is an adage that states: "Any headline that ends in a question mark can be answered by the word no".

https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headline...

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