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Baseball caps are commonly worn in the United States, in part for photoprotection. Public health efforts to prevent skin cancers recommend wide-brimmed hats over baseball caps owing to caps’ incomplete coverage for face, neck, and ears; however, to our knowledge, their relative efficacy for scalp photoprotection has not been investigated. We report a case of focal chronic photodamage and actinic keratoses on a patient’s alopecic scalp despite his adherence to baseball cap use for photoprotection.
A 65-year-old white man with Fitzpatrick phototype 2 skin presented with a well-demarcated semicircular poikilodermatous patch on the occipital scalp and scattered erythematous gritty papules on the occiput (Figure 1) and the left nose, all of years’ duration. No similar lesions were found in hair-bearing regions of the scalp. He had no personal or family history of any skin cancers but reported extensive long-term sun exposures while previously working as a warehouse manager and numerous sunburns. He reported frequently wearing baseball caps since age 20 years and noted tanning on his posterior scalp for years as his hair loss gradually progressed.
A, Focal actinic damage and actinic keratoses on the occipital scalp. B, Snapback hat worn by patient with window of solar exposure.
He was diagnosed with actinic keratoses, treated with cryotherapy, and extensively counseled on the use of wide-brimmed hats to reduce further sun exposure. Owing to personal stylistic preferences, he declined to wear wide-brimmed hats but agreed to daily application of sun protection factor (SPF) 30+ sunscreen onto sun-exposed skin.
Frequent wearing of wide-brimmed hats and photoprotective clothing is an important intervention to reduce solar UV exposure and skin cancer risks. Wide-brimmed hats provide photoprotection to the scalp as well as adjuvant protection, with SPF equivalents ranging from 2 to 10 to facial sites such as the nose, ears, and neck.1 Prior research has assessed the relative degree of sun protection between hat styles, including “jungle” hats, “deerstalker” hats, Legionnaires hats, bucket hats, berets, straw hats, baseball caps, and others.1,2 These studies showed that baseball caps failed to provide adequate photoprotection for the cheeks, chin, ears, and neck.1,2 Our case study highlights the previously underappreciated UV exposure of the occipital scalp despite frequent wearing of baseball caps.
Photoprotection offered by different baseball cap styles has not been well characterized. Style variations include fitted caps that completely cover the posterior scalp, “snapback” hats that include semicircular windows, and “trucker” hats that additionally incorporate a net-like mesh posteriorly (Figure 2). The snapback, as worn by the present patient, and trucker styles provide inadequate solar coverage for the posterior scalp.
A, Fitted cap (left) with complete scalp coverage (right). B, Snapback hat (left) with window of occipital exposure (right). C, Trucker hat (left) with mesh covering (right).
In addition, diminished terminal hair density on the vertex and occipital scalp in this patient with androgenetic alopecia contributed to the focal development of actinic damage and actinic keratoses. The long-term photoprotective role of hair has been invoked by the sex differences in the topographical patterns of melanomas and keratinocyte carcinomas.3,4 Higher incidence of skin cancers in the scalp, ears, and other chronically sun-exposed areas of the head and neck in men than in women has been hypothesized to be attributable to differences in hair coverage.3,5 The natural photoprotective effect offered by hair is quantitated as exponential to scalp hair density.5 Therefore, patients with alopecia should be counseled on using additional sun protection by wearing hats with complete coverage for the scalp; applying SPF 30+ sunscreen lotion, spray or stick; or using handheld umbrellas to further minimize exposure to UV radiation.
Since baseball caps remain a popular style among US adults, the general public, particularly men at risk of developing androgenetic alopecia, should be made aware of their shortcomings in photoprotection and should be counseled to use additional means to protect against skin cancer development, especially on the scalp.
Corresponding Author: Suephy Chen, MD, MS, Department of Dermatology, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA 30322 (email@example.com).
Published Online: April 13, 2016. doi:10.1001/jamadermatol.2016.0733.
Conflict of Interest Disclosures: Dr Chen has served as a consultant for Astellas, investigator for Hoffman-Laroche and Celgene, and received royalties for quality-of-life instruments from Novartis (for Scalpdex) and Foamix and Cutanea Life Sciences (for RosaQoL). No other disclosures are reported.
Additional Contributions: We thank the patient for granting permission to publish this information. We also thank Kacie Baker, BS, for her illustrations. She received no compensation for her contributions.
Yeung H, Luk KM, Chen SC. Focal Photodamage on the Occipital Scalp. JAMA Dermatol. 2016;152(9):1060–1062. doi:https://doi.org/10.1001/jamadermatol.2016.0733
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