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December 13, 2000

Efficacy of Sunscreen in Preventing Nevi—Reply

Author Affiliations

Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Executive Deputy EditorIndividualAuthor

JAMA. 2000;284(22):2870. doi:10.1001/jama.284.22.2869

In Reply: We agree with Mr Barzilai that our study likely underestimates the true value of broad-spectrum sunscreens in attenuating new nevi in children. It is true that an ideal study to evaluate the efficacy of sunscreen as a protective factor against new nevi would randomize children into groups using sunscreen vs not using sunscreen. Such a trial design, however, would be unethical.

Barzilai suggests that we ignore the randomization and compare number of new nevi in children using sunscreen to avoid "unprotected sun episodes" with those not using it for this purpose. Unfortunately, this would negate one of the major benefits of a randomized trial—avoidance of uncontrolled confounding by host susceptibility factors. Results from previous nonrandomized studies consistently show a positive association between sunscreen use and new nevi.1,2 We think these results are most likely due to imperfect control of host susceptibility. Barzilai's suggestion that we adjust for susceptibility by measures of skin reflectance and other variables has not worked in past studies, and we have no reason to believe that our host susceptibility assessment variables are superior in any way to those of other investigators.1,2

The true degree of protection afforded by sunscreen against nevi will probably always be underestimated because of ethical concerns and practical considerations surrounding sunscreen trials. For public health purposes, we feel it is enough to demonstrate that these compounds do afford some degree of protection against melanoma precursor lesions.

Autier  PDore  JFCattaruzza  MS  et al. for the European Organization for Research and Treatment of Cancer Melanoma Cooperative Group, Sunscreen use, wearing clothes, and number of nevi in 6-to-7 year old European children.  J Natl Cancer Inst. 1998;90:1873-1880.Google Scholar
Luther  HAltmeyer  PGarbe  C  et al.  Increase of melanocytic nevus counts in children during 5 years of follow-up and analysis of associated factors.  Arch Dermatol. 1996;132:1473-1478.Google Scholar