Book Review

Sun-Damaged Skin

The Environmental Threat to the Skin

N Engl J Med 1993; 328:1048-1049April 8, 1993

Article

Sun-Damaged Skin
By Ronald Marks. 72 pp., illustrated. London, Martin Dunitz, 1992. £14.95. ISBN: 1-85317-077-1

The Environmental Threat to the Skin
Edited by Ronald Marks and Gerd Plewig. 414 pp., illustrated. London, Martin Dunitz, 1992. £65. ISBN: 1-85317-057-7

In Sun-Damaged Skin the author has condensed information about an extensive subject into a small book that can easily be read in a short time. The most pleasing aspect of the book is the beautiful presentation, including the photographs, photomicrographs, and other graphics. Images showing subtle findings, such as skin tone and skin color, are difficult to reproduce, but Dr. Marks and the publisher have done an outstanding job. One problem, however, is clearly identifying the book's audience, since it is too complex in some respects for the lay reader and is not an in-depth overview. Therefore, one would have to surmise that the intended audience is made up of first-year medical students and educators who have some background in relevant areas and who are interested in a quick overview. As a book for these readers it succeeds remarkably well.

The chapter outlining protection from the sun is especially important since sun avoidance is stressed as the mainstay of sun protection. Sunscreens are also mentioned, and the author emphasizes that unless they are esthetically pleasing, patients will not use them. Many key ingredients in sunscreen protection are not mentioned, however. This chapter could have presented a nice opportunity for the author to expand on the different types of sunscreens, and to offer criteria for selecting an appropriate one. The author states that sunscreen preparations with a sun-protection factor (SPF) in excess of 20 have no definable purpose; however, he makes no reference to opposing views. The lack of emphasis on the importance of avoiding acute sunburns during the first two decades of life is also disappointing, since it has been clearly established that sun protection in childhood pays great dividends in later life.

There are a few factual errors and misleading statements; the most prominent appears in chapter 3, where Dr. Marks refers to the “unfortunate and inadvertent `experiment' of PUVA [psoralens plus ultraviolet light A],” and points out that patients in some studies had a high frequency of skin cancers. His description of this as an “experiment” is inappropriate at best, since PUVA is a well-known, FDA-approved therapeutic procedure for psoriasis and is used in the treatment of many other conditions. PUVA has well-defined risks, including the potential to initiate or promote skin cancer, but it also has distinct benefits for patients who have severe or disabling psoriasis. I was also bothered by the lack of references. The list of further reading includes only seven articles.

Having said that, I found Sun-Damaged Skin a useful introductory book that provides a concise, easy-to-read overview and exceptionally good photographs. It should be enjoyed by medical students or other medical professionals who are not familiar with the general concept of sun-damaged skin but who plan to explore this subject in greater depth.

The Environmental Threat to the Skin, a gallant attempt to collect the information available on the various environmental hazards to the skin, presents a comprehensive overview of the subject. However, it is not a textbook, but a collection of papers based on a conference held in 1991, and it consists of summary presentations by recognized authorities in their fields, brief original papers, and case reports. The book is divided into three parts, which focus on solar radiation and other climatic influences, chemical hazards in the environment, and the microbial threat. The breadth of topics within each section is impressive, with selections ranging from excellent reviews on the ultraviolet environment, both solar and occupational, to discussions of toxic chemicals, plants, and arthropods, all of which may cause injury to the skin. There is also a collection of papers on quantitative biophysical assessments of skin injury, a topic not frequently found in textbooks on this subject. It would have been helpful if these papers had been organized in a technical section, so the reader could avoid having to thumb through the whole book; an excellent index has been appended, however.

The summary chapters are especially interesting. An excellent example is chapter 3, in which MacKie presents extensive data in such a well-organized fashion that the epidemiology of melanoma is clearly elucidated. Some of the research contributions are also excellent and thought-provoking and will stimulate further investigation. The disadvantage is that one has to sort through less elegant presentations in order to obtain the information needed. Chapter 36 by Ichmann et al. is an interesting and realistic presentation of the interplay between irritants and ultraviolet radiation. The chapter on mechanisms of cutaneous aging (chapter 15) is also well done, although it focuses primarily on alterations of dermal extracellular matrix protein; I wish that these authors had been given an opportunity to expand this section. For example, the discussion pointed out that photoaging is characterized by profound alterations in the dermal connective tissue, which is true. However, little mention is made of the effect of sunlight on the epidermis or other components of the skin. Another example of the book's limitations is the reports on skin-color variability, which address only Caucasian skin. The contributions in general reflect the geographic distribution of the individual authors.

Mixed with some of these provocative reports are anecdotal and case reports that in many cases do not contribute much to the book. They are in sharp contrast to the well-done summaries. In many chapters the subject matter is interesting but there is inadequate information about scientific design, data, or data analysis to substantiate the discussion. I found myself wanting more information because I could not tell which statements were supported and which were not, and in several instances the reference list was abbreviated and incomplete. Many of the short papers could have been improved had they been subject to peer review. As with many books that are multiauthored, there was also some overlap and duplication. For example, chapters 25 and 26 both address the notion of visual-display units and skin complaints and perhaps could have been condensed into one chapter.

In summary, the topic of this book is critically important, since it is increasingly clear that the environmental threats to the skin have an enormous effect on health. The strength of the book is that it provides a good overview of the breadth and depth of environmental threats to the skin. It is an excellent reference book for libraries. It should also be of interest to those who are entertaining the notion of entering this area, since it provides a glimpse into the research that is under way on related topics. Those who need a comprehensive overview will appreciate this book.

Lynn A. Drake, M.D.
Massachusetts General Hospital, Boston, MA 02114