382 Research Letters J AM ACAD DERMATOL

AUGUST 2018

Funding sources: None. Table I. State laws regarding sunscreen use at

schools listed in chronologic order
Conflicts of interest: None disclosed.
State Bill Date passed
Correspondence to: Werner Kempf, MD, Kempf und
California SB 1632 August 24, 2002
Pfaltz, Histologische Diagnostik, Affolternstrasse
New York S595A July 31, 2013
56, CH-8050, Zurich, Switzerland Oregon HB 3041 May 26, 2015
E-mail: werner.kempf@kempf-pfaltz.ch Texas SB 625 June 19, 2015
Utah HB 288 March 21, 2017
Reprint requests: Isabella Fried, MD, Department of Arizona HB 2134 April 26, 2017
Dermatology, Medical University of Graz, Auen- Alabama SB 63 May 3, 2017
bruggerplatz 8, A-8036 Graz, Austria Washington SB 404 May 4, 2017
Florida HB 7069 June 16, 2017
E-mail: i.fried@medunigraz.at Louisiana HB 412 June 22, 2017
Ohio HB 49 June 29, 2017

HB, House Bill; SB, Senate Bill.

REFERENCES
1. Hogendoorn GK, Bruggink SC, Hermans KE, et al. Developing
and validating the Cutaneous WARTS (CWARTS) diagnostic
tool: a novel clinical assessment and classification system for
cutaneous warts. Br J Dermatol. 2018;178:527-534.
2. Androphy EJ, Kirnbauer R. Human papilloma virus infections.
In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ,
Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine.
New York, NY: McGraw-Hill; 2012:2421-2433.
3. Kirnbauer R, Lenz P. Human papillomaviruses. In: Bolognia JL,
Jorizzo JL, Schaffer JV, eds. Dermatology. Philadelphia, PA:
Elsevier Saunders; 2012:1303-1320.
4. Rasmussen KA. On the spontaneous cure of plantar warts. Acta
Derm Venereol. 1954;34:144-151.
5. Bae JM, Kang H, Kim HO, Park YM. Differential diagnosis of
plantar wart from corn, callus and healed wart with the aid of
dermoscopy. Br J Dermatol. 2009;160:220-222.
https://doi.org/10.1016/j.jaad.2018.01.013
Sunscreen use in schools: A content
analysis of US state laws
To the Editor: Sunscreen use is well recognized as an
effective strategy for reducing risk of sunburn,
photoaging, and skin cancer.1-3 The US Food and
Drug Administration regulates sunscreen as an
over-the-counter drug product. In some states,
students’ ability to carry or use US Food and Drug
Administrationeregulated over-the-counter drug
products of any kind while on school property is
restricted, unintentionally creating barriers to
adequate sun protection for students. Realizing this
concern, major medical associations have called on
schools to allow sunscreen use,4 and some states
have passed legislation granting students the ability
to carry and self-apply sunscreen while at school. We
conducted a content analysis of this state legislation.
We entered the search term sunscreen into the
official legislative databases of all 50 US states to
identify those with laws in place related to sunscreen
use in schools as of December 1, 2017. We developed
a coding schema to describe and quantify the content
of the state laws, and each author coded the content.
Minor coding discrepancies were resolved by
reviewing and discussing the exact wording of the
laws.
Table I lists the laws in chronologic order based on
when they were passed. Table II reflects our final
coding schema and describes the content of these
laws. Of the 11 states that have enacted legislation
allowing students to carry and self-apply sunscreen at
school, 7 passed legislation in 2017. Most laws
included a definition for sunscreen, but definitions
varied across states. With regard to setting, some laws
spoke of schools generally, whereas others specifically
mentioned public (n ¼ 6), private (n ¼ 3), and/or
charter schools (n ¼ 1). Some also addressed
sunscreen use at school events (n ¼ 8), at summer
camps (n ¼ 3), on school buses (n ¼ 1), and while
under the supervision of school personnel (n ¼ 1).
None of the laws required a physician’s note or
prescription. However, 1 required parental consent,
another stated that school district policies may
require parental consent, and yet another noted
that the sunscreen must be supplied by a parent or
guardian.
Six of the laws granted employees and volunteers
permission to assist in sunscreen application with
parental/guardian consent, 1 granted permission ‘‘in
accordance with school district policy,’’ and another
gave permission without mentioning additional
requirements. Four of the laws specified that
school personnel were not required to assist students
in applying sunscreen, and another 4 included
language granting school personnel immunity from
civil liability in regard to adverse sequelae of
application or discontinuation of sunscreen.
Two laws granted students permission to use
sun-protective clothing, including hats, at school,
and 1 law encouraged schools to educate students
about sun safety guidelines.
J AM ACAD DERMATOL
VOLUME 79, NUMBER 2
Table II. Characteristics of state laws regarding
sunscreen use in schools (N ¼ 11 state laws)
Characteristic
Includes a definition of sunscreen
Yes
No
Language included in the definition of sunscreen
(categories not mutually exclusive)
Product is approved/regulated by the FDA for
nonprescription/over-the-counter use for the
purpose of limiting skin damage induced by UV
light/avoiding overexposure to the sun
A compound topically applied to prevent sunburn
Not for medical treatment of an injury or illness 2
Types of schools mentioned (categories not mutually
exclusive)
Public schools
Private/nonpublic schools
Charter schools
Does not specify beyond ‘‘school’’
Settings and scenarios specifically mentioned
(categories not mutually exclusive)
At school
At a school-sponsored, school-based, or school-
related event or activity
Children’s camp or summer camp
On a school bus
While under the supervision of school personnel
Parental consent required for students to
possess and self-apply sunscreen at school
Yes
No
School district policies may require parental
consent
Not specified
Physician’s note or prescription required for
students to possess and self-apply
sunscreen at school
No
Not specified
Employees and volunteers allowed to assist
in topical application
Yes (but parental/guardian consent needed)
Yes (in accordance with school district policy)
Yes (does not mention a requirement for parental/ 1
guardian consent)
Not specified
School personnel not required to assist students in
applying sunscreen
Yes
Not specified
School personnel not to be held liable/immunity from
civil liability
Yes
Not specified
Continued
Research Letters 383
Table II. Cont’d
Characteristic n
n Outdoor use of sun-protective clothing (including
hats) allowed
7 Yes 2
4 Not specified 9
Schools encouraged to educate students about sun
safety guidelines
4 Yes 1
Not specified 10
4
Our analysis demonstrates the attention that sun-
screen use in schools has gained among legislators
and may guide future policy by highlighting key
6 content and opportunities for comprehensive sun
3 safety practices in schools. Future research could
1 explore the impact of these laws and potential
5 benefits of implementing them in conjunction with
other school sun safety practices.5 Dermatologists
can play an integral role in the guidance of future
11 legislation by continuing to educate their patients,
8
communities, and decision makers.
3 Ravi R. Patel, MD,a and Dawn M. Holman, MPHb
1
1 From the Gwinnett Medical Center, Lawrenceville,
Georgia,a and Centers for Disease Control and
Prevention, Division of Cancer Prevention and
1 Control, Atlanta, Georgiab
2
1 Funding sources: None.
Conflicts of interest: None disclosed.
7
The findings and conclusions in this report are
those of the authors and do not necessarily
represent the official position of the Centers for
8 Disease Control and Prevention or the National
3 Institutes of Health.
Reprint requests: Ravi R. Patel, MD, Gwinnett
6 Medical Center, 1000 Medical Center Blvd,
1 Lawrenceville, GA 30046
E-mail: rapatel@gwinnettmedicalcenter.org
3
4 REFERENCES
7 1. Ghiasvand R, Weiderpass E, Green AC, Lund E, Veierød MB.
Sunscreen use and subsequent melanoma risk: a
population-based cohort study. J Clin Oncol. 2016;34:
3976-3983.
4
2. Green AC, Williams GM. Point: sunscreen use is a safe and
7
effective approach to skin cancer prevention. Cancer Epidemiol
Biomarkers Prev. 2007;16(10):1921-1922.
384 Research Letters J AM ACAD DERMATOL
AUGUST 2018

3. US Department of Health and Human Services. The Surgeon Table I. Survey respondents
General’s Call to Action to Prevent Skin Cancer. Washington, DC:
US Department of Health and Human Services, Office of the Characteristic n %
Surgeon General; 2014 Provider type
4. American Academy of Dermatology Association. Position Attending physician 157 56%
statement on access to sunscreen and sun protective clothing Resident physician 101 36%
in schools and summer camps. Approved by the Board of
Advanced practice provider 21 8%
Directors on May 21, 2016. Available online at: https://www.
aad.org/Forms/Policies/Uploads/PS/PS-Access%20to%20Sun
Age group primarily treated
screen_Sun%20Protective%20Clothing.pdf. Accessed January Adults 226 81%
16, 2018. Children 48 17%
5. Jones SE, Guy GP Jr. Sun safety practices among schools in the Adults and children 5 2%
United States. JAMA Dermatol. 2017;153(5):391-397. Site of majority of work
IP wards 145 52%
https://doi.org/10.1016/j.jaad.2018.01.026 ED 129 46%
50/50 split between IP and ED 5 2%
Provider age, y
Consultative teledermatology in the 20-29 62 22%
emergency department and 30-39 127 46%
40-49 56 20%
inpatient wards: A survey of
50-59 26 9%
potential referring providers
60-69 7 3%
To the Editor: Despite the validated reliability of $70 1 0%
teledermatology (TD) in the outpa tient setting and Provider sex
the promising accuracy of and shortened time to Female 144 52%
respond to TD compared with in face-to-face (FTF) Male 132 48%
consultations in the emergency department (ED) and Other 3 1%
Total 279
inpatient (IP) wards, its utilization depends on its
acceptability to referring providers. Although TD has ED, Emergency department; IP, inpatient.
been assessed as satisfactory and even preferable to
FTF consultation by outpatient primary care pro-
consultation (94% vs 83%, respectively). To
viders, there is no literature regarding the perception
generate a TD consult, most respondents (85%)
of consultative TD among referring providers in the
were willing to take and send patient photographs
ED or IP wards.1 We sought to understand the
and enter some patient information. Whereas 77%
acceptance and perceived utility of store-and-
of providers were willing to answer fewer than 10
forward (SAF) TD as a means of receiving expert
patient questions, only 52% were willing to answer
consultation in these settings.
more than 10.
Electronic surveys created on Google Forms were
Only 12% of respondents thought that TD could
administered weekly over a 4-week period to adult
effectively replace FTF consultation, and only 5% of
and pediatric ED practitioners, as well as to adult and
referring providers believed TD to be diagnostically
pediatric hospital medicine clinicians (residents,
equivalent to FTF consultation. See Table II for a
physician extenders, and attending physicians)
summary of responses by IP and ED providers to
who practice in teaching and nonteaching Emory
select questions.
Healthcareeaffiliated hospitals. The health care sys-
Our results suggest that FTF evaluation is preferred
tem surveyed had the benefit of staff dermatologists
over SAF TD and perceived as diagnostically superior.
broadly (but not universally) available for FTF
However, consultative SAF TD would be accepted by
consultation. Survey response was voluntary and
most providers and could be developed as a useful
not incentivized. Data were collected from Google
modality for dermatology consultation in the ED and
Sheets after the 4-week study period and exported
IP wards. The number of steps required to generate a
into Microsoft Excel for further analysis.
TD consultation should be limited to maximize
A total of 279 practitioners completed the survey
referring provider cooperation. SAF TD, if more
(34% response rate). See Table I for demographic
broadly deployed, could become a valued means of
information on the survey respondents.
expert consultation with time-sensitive benefits to the
Of all the respondents, 95% stated that they
patient and referring provider, especially when FTF
would utilize TD for dermatology consultation if it
consultation is not available.
were available. Practitioners in the ED were more
likely to utilize TD than IP providers were (98% vs Justin Cheeley, MD, Suephy Chen, MD, and Robert
91%) and to follow the recommendations of a TD Swerlick, MD