Letters
Vidhi V. Shah, BA their recommendations affect patients’ selection of sun-
Audrey A. Jacobsen, BA
Stephanie Mlacker, BS
Adam S. Aldahan, BS
Nick Carcioppolo, PhD
Fleta N. Bray, BS
Keyvan Nouri, MD
Author Affiliations: Department of Dermatology and Cutaneous Surgery,
University of Miami Miller School of Medicine, Miami, Florida (Shah, Jacobsen,
Mlacker, Aldahan, Bray, Nouri); Department of Communication Studies,
University of Miami, Coral Gables, Florida (Carcioppolo).
Corresponding Author: Vidhi V. Shah, BA, Department of Dermatology and
Cutaneous Surgery, University of Miami Miller School of Medicine,
1475 NW 12th Ave, Miami, FL 33136 (shahvidhiv@gmail.com).
Accepted for Publication: August 1, 2016.
Published Online: October 5, 2016. doi:10.1001/jamadermatol.2016.3505
Author Contributions: Ms Shah had full access to all the data in the study and
takes responsibility for the integrity of the data and the accuracy of the data
analysis.
Study concept and design: Shah, Mlacker, Aldahan, Carcioppolo, Bray, Nouri.
Acquisition, analysis, or interpretation of data: Shah, Jacobsen, Aldahan,
Carcioppolo, Nouri.
Drafting of the manuscript: Shah, Jacobsen, Mlacker, Aldahan, Nouri.
Critical revision of the manuscript for important intellectual content: Shah,
Aldahan, Carcioppolo, Bray, Nouri.
Statistical analysis: Shah, Jacobsen, Carcioppolo.
Administrative, technical, or material support: Shah, Mlacker, Aldahan, Bray,
Nouri.
Study supervision: Carcioppolo.
Conflict of Interest Disclosures: None reported.
Additional Contributions: Harleen Arora, BS, University of Miami Miller School
of Medicine, assisted with the distribution of surveys. Lourdes Forster, MD,
UHealth Pediatrics Professional Arts Center, helped initiate the study. We also
thank the entire faculty and staff of UHealth Pediatrics Professional Arts Center
for their support. They received no compensation for their contributions.
1. Gloster HM Jr, Neal K. Skin cancer in skin of color. J Am Acad Dermatol. 2006;
55(5):741-760.
2. Agbai ON, Buster K, Sanchez M, et al. Skin cancer and photoprotection in
people of color: a review and recommendations for physicians and the public.
J Am Acad Dermatol. 2014;70(4):748-762.
3. Hamilton K, Cleary C, White KM, Hawkes AL. Keeping kids sun safe: exploring
parents’ beliefs about their young child’s sun-protective behaviours.
Psychooncology. 2016;25(2):158-163.
4. Robinson JK, Rigel DS, Amonette RA. Summertime sun protection used by
adults for their children. J Am Acad Dermatol. 2000;42(5, pt 1):746-753.
5. Miller KA, Huh J, Unger JB, et al. Patterns of sun protective behaviors among
Hispanic children in a skin cancer prevention intervention. Prev Med. 2015;81:
303-308.
6. Rouhani P, Parmet Y, Bessell AG, Peay T, Weiss A, Kirsner RS. Knowledge,
attitudes, and behaviors of elementary school students regarding sun exposure
and skin cancer. Pediatr Dermatol. 2009;26(5):529-535.
Dermatologists’ Perceptions, Recommendations,
and Use of Sunscreen
Regular use of sunscreen is an important component of sun
protection and has been shown to reduce the risk of skin
cancer.1 Multiple professional organizations, including the
American Academy of Dermatology, as well as dermatolo-
gists themselves, have recommended patient counseling re-
garding the use of sunscreen.2,3 However, there have been other
conflicting messages about sunscreen (sometimes without sci-
entific support) that have led to confusion by the public.4 Der-
matologists regularly discuss these issues with patients and
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screen; however, to our knowledge, their actual views have not
been studied.2,5 The purpose of this study was to determine,
via a survey, US dermatologists’ perceptions of the safety and
efficacy of sunscreen, recommendations to patients regard-
ing its use, and their personal use of sunscreen (Figure).
Methods | The survey instrument was validated and adminis-
tered to US dermatologists attending a national educational
conference on April 9, 2016. Respondents provided answers
using a live interactive audience response system. Group re-
sults were not revealed until completion of the survey to mini-
mize response bias. To verify the representative nature of the
responding subset, respondent demographics were com-
pared with membership data from the American Academy of
Dermatology. Comparative data were analyzed using stan-
dard χ2 tests. The institutional review board at NYU School of
Medicine waived approval of this study. All participants pro-
vided verbal consent.
Results | Of the 165 US dermatologists offered the survey, 156
(94.5%) participated and completed enough of the questions
(26 of 28 [92.9%]) to be included in the outcome analyses. Der-
matologists have an overall positive view of sunscreen: 97%
agree that regular use of sunscreen helps lower the risk of skin
cancer, 100% agree that use of sunscreen reduces subse-
quent photoaging, and 99% recommend that their family and
friends use sunscreen (Table). Nearly all dermatologists (96%)
consider sunscreens approved by the US Food and Drug Ad-
ministration (FDA) that are currently available in the United
States to be safe. Ninety-nine percent of dermatologists be-
lieve that their patients generally do not apply enough sun-
screen.
Sunscreens with a higher sun protection factor (SPF) are
more protective when used at real-world application concen-
trations. Ninety-seven percent of dermatologists said they were
comfortable recommending sunscreens with an SPF of 50 or
higher and 130 (83.3%) believe that high-SPF sunscreens pro-
vide an additional margin of safety. Most dermatologists be-
lieve that oxybenzone and retinyl palmitate in sunscreens are
safe (91% and 87% respectively). Dermatologists used mul-
tiple criteria to recommend sunscreen, including SPF level
(99%), broad-spectrum protection (96%), cosmetic elegance
and/or feel (71%), and photostability (42%). For outdoor use,
100% of dermatologists choose a sunscreen with an SPF of at
least 30 for themselves and 76% typically wear sunscreen more
than half the time. There were no significant differences based
on respondents’ geographical location or years in practice.
Discussion | This study found that nearly all dermatologists agree
that sunscreens approved by the FDA are safe in protecting
against skin cancer and photoaging and recommend broad-
spectrum protection with sunscreen with an SPF of at least 30.
Dermatologists themselves often report using suncreen with
an SPF of 50 or more, possibly because they also believe it pro-
vides an additional margin of safety. However, only 42% of der-
matologists consider photostability a criterion when recom-
mending a sunscreen. Given the importance of photostability
(Reprinted) JAMA Dermatology January 2017 Volume 153, Number 1 99
 Letters

Figure. Survey Assessing Dermatologists’ Perception of Safety and Efficacy of Sunscreen, Recommendation Factors, and Personal Use

1. How many years have you been in practice? 13. The SPF level you typically recommend to patients who are planning to
be outdoors in the summer is:
1-10 years
11-20 years 70+
21-30 years 50 or higher
31+ years 30 or higher
15 or higher
2. What are the first 3 digits of the zip code in which you practice?
14. The criteria you regularly use to recommend a sunscreen includes
(please answer all):
Yes No
Do you agree or disagree with the following statements?
SPF level
3. The regular use of sunscreen helps lower skin cancer risk.
Broad spectrum (adequate UVA/UVB protection)
Agree
Cosmetic elegance/feel
Disagree
Photostability
4. The regular use of sunscreen helps reduce subsequent photoaging.
Agree 15. You are comfortable recommending sunscreens that:
Disagree Yes No
5. I consider FDA approved sunscreens currently available in the US safe. Contain oxybenzone
Agree Contain retinyl palmitate
Disagree Contain zinc oxide or titanium dioxide
6. I consider oxybenzone in sunscreen to be safe. Are SPF 50 or higher
Agree Are spray formulations
Disagree
Sunscreen Self-Usage:
7. I consider retinyl palmitate in sunscreen to be safe.
16. When planning to be outdoors in the summer, the SPF level you typically choose
Agree for you or your family is:
Disagree
70+
8. When using sunscreen, my patients generally underapply. 50
Agree 30
Disagree 15
9. High SPF sunscreens (SPF 50+) may provide an additional margin of safety 17. You typically wear sunscreen:
at real-life application levels.
Everyday
Agree Most days
Disagree About half the time
10. The best form of sunscreen is the one your patient will use regularly. Less than 25% of the time
Agree 18. You recommend your family/friends use sunscreen to help protect their skin.
Disagree Agree
11. I recommend that my patients maintain adequate vitamin D levels through Disagree
oral supplements rather than through intentional sun exposure.
Agree
Disagree
Sunscreen Recommendation Factors:

12. What percentage of patients do you recommend sunscreen for?

91-100%
81-90%
71-80%
61-70%
51-60%
41-50%
31-40%
21-30%
11-20%
0-10%

Questions asked in survey.

as a sunscreen characteristic, this finding may represent a
knowledge gap and corresponding educational opportunity for
both physicians and patients.
The FDA and the American Academy of Dermatology have
published guidelines to help consumers select and use sun-
screens appropriately.3 A recent study suggests that these
guidelines may not have been effectively disseminated.6 In ad-
dition, nonphysician groups have produced varying and con-
trary public recommendations about the use of sunscreen.4 In
some cases, these recommendations have led to confusion

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Table. Dermatologists’ Perceptions of Safety and Efficacy of Sunscreen,
Recommendation Factors, and Personal Use
Characteristic
Perceptions of safety and efficacy of sunscreen
Regular use of sunscreen helps lower risk of skin cancer
Regular use of sunscreen helps reduce subsequent
photoaging
FDA-approved sunscreens currently available in the
United States are safe
Oxybenzone in sunscreen is safe
Retinyl palmitate in sunscreen is safe
Patients generally do not apply enough sunscreen
Sunscreens with an SPF ≥50 provide an additional margin
of safety
The best form of sunscreen is one used regularly
Factors that influence recommending sunscreen to patients
SPF of the sunscreen
Broad spectrum coverage provided by the sunscreen
Cosmetic elegance and feel and feel provided by the
sunscreen
Photostability provided by sunscreen
Sunscreen contains oxybenzone
Sunscreen contains retinyl palmitate
Sunscreen contains zinc oxide or titanium dioxide
Sunscreen has an SPF ≥50
Spray formulation of sunscreen
Recommend vitamin D by oral supplement rather than sun 125 (80.1)
exposure
Recommend sunscreen for ≥80% of patients
Recommend sunscreen with SPF ≥30 to patients who are
outdoors
Recommend sunscreen with SPF ≥50 to patients who are
outdoors
Dermatologists’ personal and family use of sunscreen
Use sunscreen with SPF ≥30 when outdoors
Use sunscreen with SPF ≥50 when outdoors
Use of sunscreen at least half the time
Daily use of sunscreen
Recommend family and friends use sunscreen to help
protect their skin
Abbreviations: FDA, US Food and Drug Administration; SPF, sun protection
factor.
among the public, as people often choose not to heed any rec-
ommendations until consensus is achieved.
A limitation of this study includes selection bias, as der-
matologists who have stronger beliefs about sun protection
may have been more likely to respond. In addition, social de-
sirability bias may have been a factor, leading the dermatolo-
gists to provide more positive than negative answers.
As debate continues about optimizing the use of sun-
screen, it is important to assess and understand dermatolo-
gists’ views as well as the recommendations they provide to
patients. This study provides insights into these issues and
has identified potential knowledge gaps and corresponding
educational opportunities where existing recommendations
can be reviewed to better align with actual dermatologic
practices.
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Letters
Aaron S. Farberg, MD
Alex M. Glazer, MD
Adam C. Rigel, MMS, MS
Positive
Response, No. Richard White, MS
(%) Darrell S. Rigel, MD, MS
151 (96.8) Author Affiliations: Department of Dermatology, Icahn School of Medicine at
156 (100) Mount Sinai, New York, New York (Farberg); National Society for Cutaneous
Medicine, New York, New York (Glazer); Affiliated Dermatology, New York,
150 (96.2) New York (A. C. Rigel); Iris Interactive System, Cody, Wyoming (White);
Ronald O. Perelman Department of Dermatology, NYU School of Medicine,
141 (90.4) New York (D. S. Rigel).
135 (86.5) Accepted for Publication: August 12, 2016.
155 (99.4) Corresponding Author: Aaron S. Farberg, MD, Department of Dermatology,
Icahn School of Medicine at Mount Sinai, 35 E 35th St, Ste 208, New York, NY
130 (83.3) 10016 (aaron.farberg@gmail.com).
Published Online: October 19, 2016. doi:10.1001/jamadermatol.2016.3698
155 (99.4)
Author Contributions: Drs Farberg and D. Rigel had full access to all the data in
the study and take responsibility for the integrity of the data and the accuracy
155 (99.4) of the data analysis.
150 (96.2) Study concept and design: Farberg, D. Rigel.
Acquisition, analysis, or interpretation of data: All authors.
111 (71.2)
Drafting of the manuscript: Farberg, Glazer, D. Rigel.
Critical revision of the manuscript for important intellectual content: All authors.
66 (42.3)
Statistical analysis: Farberg, A. Rigel.
137 (87.8) Administrative, technical, or material support: Farberg, Glazer, White.
122 (78.2) Study supervision: Farberg, D. Rigel.
156 (100) Conflict of Interest Disclosures: Drs Farberg and D. Rigel reported serving as
consultants for Johnson & Johnson. No other disclosures were reported.
151 (96.8)
1. Bigby M, Kim CC. A prospective randomized controlled trial indicates that
114 (73.1)
sunscreen use reduced the risk of developing melanoma. Arch Dermatol. 2011;
147(7):853-854.
2. Winkelmann RR, Rigel DS. Assessing frequency and quality of US
123 (78.8)
dermatologist sunscreen recommendations to their patients. J Am Acad Dermatol.
156 (100) 2015;72(3):557-558.
3. American Academy of Dermatology. Sunscreen FAQs. https://www.aad.org
55 (35.3)
/media-resources/stats-and-facts/prevention-and-care/sunscreens. Accessed
June 1, 2016.
4. Environmental Working Group. EWG’s sunscreen guide: a decade of
156 (100)
progress, but safety and marketing concerns remain. http://www.ewg.org
105 (67.3) /sunscreen/report/executive-summary. Accessed June 1, 2016.
119 (76.3) 5. Xu S, Kwa M, Agarwal A, Rademaker A, Kundu RV. Sunscreen product
83 (53.2) performance and other determinants of consumer preferences. JAMA Dermatol.
2016;152(8):920-927.
154 (98.7)
6. Simmons BJ, Alsaidan M, Bray FN, Nouri K. US dermatologists’ knowledge of
current sunscreen recommendations. Int J Dermatol. 2016;55(9):e514-e516.
The Role of Bone Scintigraphy in the Diagnosis
of Calciphylaxis
Calciphylaxis is a rare, life-threatening small vessel
vasculopathy,1 predominantly seen in patients with end-
stage renal disease (ESRD). Most physicians rely on clinical
findings and risk factors to diagnose calciphylaxis. However,
mimickers exist,2 and tissue biopsy can be helpful to differ-
entiate these diseases. Unfortunately, histopathological con-
firmation sometimes requires multiple biopsies, resulting in
delayed treatment and possibly propagating new lesion
formation.3 A noninvasive early testing modality would be
preferred.
Using bone scintigraphy to diagnose calciphylaxis has been
reported.4-6 In the study by Fine and Zacharias,6 bone scin-
tigraphy was positive in 97% of cases, but only 4 of 36 pa-
tients with calciphylaxis had biopsy-confirmed disease, and
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