CONTINUING MEDICAL EDUCATION

Cutaneous photodamage, oxidative stress, and

topical antioxidant protection
Sheldon R. Pinnell, MD Durham, North Carolina

New methods to protect skin from photodamage from sun exposure are necessary if we are to conquer skin
cancer and photoaging. Sunscreens are useful, but their protection is not ideal because of inadequate use,
incomplete spectral protection, and toxicity. Skin naturally uses antioxidants (AOs) to protect itself from
photodamage. This scientific review summarizes what is known about how photodamage occurs; why
sunscreens—the current gold standard of photoprotection—are inadequate; and how topical AOs help
protect against skin cancer and photoaging changes. This review is intended to be a reference source,
including pertinent comprehensive reviews whenever available. Although not all AOs are included, an
attempt has been made to select those AOs for which sufficient information is available to document their
potential topical uses and benefits. Reviewed are the following physiologic and plant AOs: vitamin C,
vitamin E, selenium, zinc, silymarin, soy isoflavones, and tea polyphenols. Their topical use may favorably
supplement sunscreen protection and provide additional anticarcinogenic protection. (J Am Acad Dermatol
2003;48:1-19.)

Learning objective: At the completion of this learning activity, participants should have an understanding
of current information about how the sun damages skin to produce skin cancer and photoaging changes,
how the skin naturally protects itself from the sun, the shortcomings of sunscreens, and the added
advantages of topical AOs for photoprotection.

PHOTODAMAGE
Sunlight coupled with living in an oxygen-rich Abbreviations used:
atmosphere causes unwanted and deleterious AO: antioxidant
stresses on skin. The most severe consequence of AP-1: activation protein-1
DMBA: 7,12-dimethyl benzanthracene
photodamage is skin cancer. Less severe photoaging ER␣: estrogen receptor ␣
changes result in wrinkling, scaling, dryness, and ER␤: estrogen receptor ␤
mottled pigment abnormalities consisting of hyper- LDL: low-density lipoprotein
MED: minimal erythema dose
pigmentation and hypopigmentation. For a photo- MMP: matrix metalloproteinase
chemical reaction to occur in the skin, ultraviolet NADPH: nicotinamide adenine dinucleotide
(UV) light from the sun must be absorbed by a phosphate reduced
NF-␬B: nuclear factor-␬ B
chromophore, beginning a series of photochemic PKC␦: phosphokinase C␦
reactions that may result in skin cancer or photoag- ROS: reactive oxygen species
ing changes.1 These photochemical reactions can SPF: sun protection factor
TPA: 12-0-tetradecanoylphorbol-13-acetate
result in changes to DNA, including oxidation of UV: ultraviolet
nucleic acids. Oxidative reactions can also modify VEGF: vascular endothelial growth factor
proteins and lipids, resulting in changes in function.
Their accumulation may result in tissue aging. The
body is well equipped to deal with oxidative stress,
naturally using antioxidant (AO) enzymes and non-
enzymic AOs to lessen these changes. However,
From Duke University Medical Center. sunlight and other free-radical generators (eg, smok-
Funding sources: None. ing, pollution) can overwhelm the system, making
Disclosure: Dr Pinnell is a consultant for SkinCeuticals, Dallas, Tex.
natural protective controls inadequate, resulting in
Reprint requests: Sheldon R. Pinnell, MD, Duke University Medical
Center, Department of Medicine, Division of Dermatology, PO oxidative damage.
Box 3135, Durham, NC 27707. E-mail: [email protected].
Copyright © 2003 by the American Academy of Dermatology, Inc. Chromophores
0190-9622/2003/$30.00 ⫹ 0 Many candidates for substances capable of ab-
doi:10.1067/mjd.2003.16 sorbing UV light in skin exist, but DNA and urocanic

1
2 Pinnell J AM ACAD DERMATOL
JANUARY 2003

acid have been identified as being biologically im- tive damage may occur. The most damage occurs
portant. from free radicals. Free radicals are defined as atoms
DNA may absorb UVB (290-320 nm), directly in- or molecules with an unpaired electron. Examples
ducing changes between adjacent pyrimidine bases include superoxide anion, peroxyl radical, and hy-
on one strand of DNA. Cyclopyrimidine dimers, par- droxyl radical. These molecules are extremely
ticularly thymine dimers or, less commonly, (6-4)- chemically reactive and short-lived; they react at the
photoproducts, may be generated. The action spec- place where they are created. Other reactive mole-
trum for these changes is maximal at about 300 nm, cules such as molecular oxygen, singlet oxygen, and
although UVA (320-400 nm) can also generate thy- hydrogen peroxide are not free radicals per se, but
mine dimers.2,3 These DNA changes are constantly are capable of initiating oxidative reactions and gen-
being repaired by nucleotide excision repair4; the erating free-radical species. Together, these free rad-
photoproduct recognition proteins are those defec- icals and reactive oxygen molecules are called ROS.
tive in xeroderma pigmentosum. Whenever repair is The cell is well equipped to deal with most oxi-
incomplete, signature C3 T and CC3 TT mutations dative damage.12 Cellular integrity is maintained by
characteristic for UV photodamage may result. If enzymes, including catalase, glutathione reductase,
damage to the genome is great, p53 and its associ- and glutathione peroxidases, which collectively de-
ated proteins will induce apoptosis of the irradiated stroy hydrogen peroxide and lipid hydroperoxides.
keratinocyte. p53 is induced by UVB, perhaps as a In addition, superoxide dismutase destroys superox-
response to excised thymine dimers.5 If the UV sig- ide. The extracellular space is protected from super-
nature mutations occur in p53, quality control over oxide anion by extracellular superoxide dismutase.
the genome may be lost. Clonal expansion of these Nonenzymic AOs protecting skin include glutathi-
photomodified keratinocytes may give rise to an one and ascorbic acid in the aqueous phase and
actinic keratosis.6 If the second p53 allele is also vitamin E and ubiquinol-10 in the lipid phase, par-
mutated, a squamous cell carcinoma may arise. If ticularly in membranes.
the signature mutations occur in patched or other
members of the hedgehog signaling pathway, a Photocarcinogenesis
basal cell carcinoma may occur.7,8 UVB irradiation is a complete carcinogen and can
Urocanic acid has recently been identified as a generate squamous cell carcinomas in animals.14 As
second chromophore for photochemic reactions in previously described (see “Chromophores” section),
skin.9,10 One photon of light contains enough en- DNA absorbs UVB, leading to signature UV-induced
ergy to generate singlet oxygen.11 When UV light is DNA mutations C3 T and CC3 TT. The UV action
absorbed by trans-urocanic acid, singlet oxygen is spectrum for generation of squamous cell carcinoma
generated. The peak action spectrum for this reac- occurs mostly in the UVB, although there is a peak
tion is about 345 nm. Urocanic acid occurs in skin as of activity in the UVA (320-400 nm).15 Whereas UVB
a by-product of filaggrin breakdown. It is found in is important for tumor initiation, UVA predominantly
high concentrations superficially in the epidermis. causes tumor promotion.16 Compared with UVB,
Once singlet oxygen is formed, this highly reactive UVA generates more oxidative stress.17-20 At levels
oxygen species (ROS) can attack cell membranes found in sunlight, UVA is 10 times more efficient
and generate additional ROS. than UVB at causing lipid peroxidation.21 UVA is
more cytotoxic than UVB.16 UVA damages DNA by
Reactive oxygen species causing strand breaks and oxidation of nucleic ac-
ROS are an inherent part of the anabolism and ids.16,22 The characteristic mutagenic lesion gener-
catabolism of tissues, including skin.11-13 Most oxy- ated by oxidative stress is 8-hydroxyguanine, which
gen in the body is used in cellular metabolism. generates G:C to T:A transversions by pairing with
Through a series of 1-electron subtractions, molec- adenine, instead of cytosine, during replication.23
ular oxygen is in sequence changed to superoxide UVA can inhibit DNA repair.24 In addition, UVA can
anion, hydrogen peroxide, hydroxyl radical, and, induce matrix metalloproteinase (MMP) synthe-
finally, to water. Most reactions occur in mitochon- sis25,26 that can augment the biologic aggressiveness
dria and are related to energy production. Cellular of skin cancer.
enzymes and controlled metabolic processes ordi- Sunlight can suppress the immune function of
narily keep oxidative damage to cells at a minimum. skin and promote skin cancer formation.27 Approx-
In times of increased oxidative stress, however— imately 40% of human beings are susceptible to UV
including high metabolic demands and outside immunosuppression; however, virtually all persons
forces such as sunlight, smoking, and pollution— with basal cell or squamous cell carcinomas demon-
protective controls may not be adequate and oxida- strate UV immunosuppression. Although most stud-
J AM ACAD DERMATOL Pinnell 3
VOLUME 48, NUMBER 1

Table I. Histology of photoaging can be produced by UVA alone. Indeed, these

changes have been produced in photoprotected
Epidermis
A. Keratinocytes—irregular size and shape, loss of polarity skin by a small number of low-dose exposures of
B. Melanocytes—irregular shape, pockets of increased and UVA irradiation.47,48 Similar changes can be pro-
decreased numbers duced by UVA1 (340-400 nm) exposure alone.49
C. Langerhans cells—decreased Small amounts of UV irradiation result in the induc-
Dermis tion of a series of MMPs including MMP-1, MMP-2,
A. Collagen—basophilic staining, irregular and MMP-3, and MMP-9.50 Together these proteases are
disorganized
capable of degrading the collagen framework of
B. Elastin tissue—increased, amorphous
C. Glycosaminoglycans—increased skin. At the same time procollagen synthesis is in-
hibited,51 perhaps by a mechanism related to de-
graded collagen.52 Levels of procollagen I protein
are decreased, whereas MMP-1 protein and MMP-2
activity are increased in exposed skin compared
ies of UV immunosuppression have been conducted
with unexposed skin.53 These changes apparently
using UVB,28 recent studies have highlighted the
occur through induction of transcription factor acti-
importance of UVA in causing immunosuppres-
sion29 and the ability of AOs to prevent immunosup- vation protein (AP-1) that is activated by a series of
pression.28 30,31 The importance of immunosuppres- mitogen-activated protein kinases. In addition, the
sion on the biologic behavior of skin cancer is best transcription factor, nuclear factor-␬ B (NF-␬B), is
appreciated in persons immunosuppressed for or- activated by UV irradiation, which stimulates neu-
gan transplantation, with their extreme incidence trophil attraction bringing neutrophil collagenase
and lethality of skin cancer.32-37 (MMP-8) into the irradiation site to further aggravate
In addition to more efficiently generating ROS in matrix degradation. Both AP-1 and NF-␬B are acti-
skin, UVA causes additional biologic effects different vated by ROS that may provide the common denom-
from UVB. Sunlight contains about 20 times as much inator for driving this complex biologic interac-
UVA as UVB. Whereas UVB is almost entirely ab- tion.54-57 Oxidative stress can also increase elastin
sorbed in the epidermis, UVA is capable of reaching messenger RNA levels in dermal fibroblasts provid-
dermal layers38,39 and even affecting circulating ing a mechanism for the elastotic changes found in
blood cells.40 Window glass blocks most UVB irra- photoaged dermis.58
diation but not UVA. This creates special problems ROS can modify proteins in tissue to form car-
for those who spend long hours in cars.41 Without bonyl derivatives.59 These carbonyls accumulate in
protection, their skin may be particularly susceptible the papillary dermis of photodamaged skin.60 Lipids
to oxidative stress. Indeed, pilots who fly transcon- can also be modified by ROS. UVA can induce lipid
tinental routes at high altitudes without protection peroxidation in membranes that can lead to altered
have an increased susceptibility to melanoma and membrane fluidity.61
other skin cancers.42,43 In addition to nuclear DNA, the DNA in mito-
chondria can also be altered by oxidative stress.62
Photoaging Because DNA repair is less efficient in mitochondria
Sunlight exposure has a profound effect on ex- compared with nuclei, mutations accumulate at a
posed skin, producing accelerated aging changes relatively rapid pace. A common deletion in the
consisting of wrinkling, dryness, telangiectasia, and DNA has been identified and shown to be very
pigmentary abnormalities—including lentigines as common in photoaged skin when compared with
well as guttate hypermelanosis and hypomelano- sun-protected sites.63 The deletion can be generated
sis44-46 (Table I). Histologically, the dermis is strik- by UVA and is mediated by singlet oxygen.64 These
ingly filled with an amorphous mass of deranged mutations may alter cell capacity to carry out oxida-
elastic fibers. Collagen fibers take on a basophilic tive phosphorylation and, in turn, may generate
hue and appear disorganized. Glycosaminoglycans more oxidative stress.
are prominent. Blood vessels are dilated and tortu- Uneven hyperpigmentation and hypopigmenta-
ous. Dermal inflammatory cells are increased. Kera- tion is extremely common in photoaged skin. Al-
tinocytes are irregular with a loss of polarity. Mela- though its cause is unclear, a recent study has dem-
nocytes are irregular with pockets of increased and onstrated increased endothelin-1 activity in
decreased numbers. Langerhans cells are dimin- keratinocytes, and increased endothelin-B receptor
ished in actinic skin. Because UVB is essentially and tyrosinase in solar lentigines.65 In addition, mel-
completely absorbed in the epidermis, it has been anogenesis can be stimulated by DNA damage. Sin-
important to understand that photoaging changes gle-stranded DNA oligonucleotides and thymine
4 Pinnell J AM ACAD DERMATOL
JANUARY 2003

erythemal levels of irradiation. Sunscreens may pro-

vide a false sense of security. Finally, no sunscreen
provides full spectral protection against UV light.
Sunscreen ingredients may become free radicals,
themselves, when activated by UV irradiation,72 and
sunscreen chemicals may be absorbed into skin73 to
potentially cause harm.

ANTIOXIDANT PROTECTION
The skin naturally relies on AOs to protect it from
oxidant stress generated by sunlight and pollution.74
A relative symphony of enzymic and nonenzymic
AOs interacts to provide protection in both the in-
tracellular and extracellular space. AO enzymes
function predominantly in cells. Glutathione perox-
idase and glutathione reductase reduce hydrogen
peroxide and lipid hydroperoxides using glutathi-
one. Catalase detoxifies hydrogen peroxide and is
an important AO in peroxisomes. Copper-zinc su-
peroxide dismutase and manganese superoxide dis-
mutase protect cells from superoxide; extracellular
superoxide dismutase protects the extracellular
space. Enzyme activities in human skin are higher in
Fig 1. Photoprotection from sunscreens. Sunscreen-use epidermis than dermis; catalase is especially high.75
studies have demonstrated that in actual use, sunscreen When skin fibroblasts were irradiated with UVA,
application is 25% or less of that used to measure sun- catalase activity was preferentially destroyed, super-
protection factor (SPF).69,70 SPF is not a linear relationship
oxide dismutase activity was diminished, but gluta-
with concentration; therefore, at 0.5 mg/cm2 application
thione peroxidase and glutathione reductase were
to skin, high SPF sunscreens provide less than SPF 3
protection. (Modified from Wulf HC, Stender IM, Lock- virtually unchanged.76 Similar results were seen
Andersen J. Photodermatol Photoimmun Photomed when murine skin was irradiated with solar irradia-
1997;13:129-32.) tion.76
Low-molecular-weight, nonenzymic AOs include
L-ascorbic acid in the fluid phase, glutathione in the
dinucleotide can stimulate pigment production in cellular compartment, vitamin E in membranes, and
melanocytic cells associated with increased tyrosi- ubiquinol in mitochondria (Table II). On a molar
nase levels.66 basis, L-ascorbic acid is the predominant AO in skin;
its concentration is 15-fold greater than glutathione,
SUNSCREENS 200-fold greater than vitamin E, and 1000-fold
Sunscreens are the “gold standard” for protecting greater than ubiquinol/ubiquinone.75 Concentra-
skin from photodamage.67 Many chemicals have tions of AOs are higher in epidermis than dermis;
been developed that absorb UV light efficiently14 6-fold for L-ascorbic acid and glutathione, and 2-fold
and protect against erythema.68 However, just re- for vitamin E and ubiquinol/ubiquinone. Solar-sim-
cently, we have learned that, in actual use, sun- ulated irradiation of murine skin reduced levels of
screens provide much less protection than expected. nonenzymic AOs. Ubiquinol/ubiquinone and gluta-
Sun protection factor (SPF) is measured and tested at thione were most sensitive; ␣-tocopherol and L-
an application to skin of 2 mg/cm2. Controlled stud- ascorbic acid were less sensitive.77 Patients with ac-
ies of actual sunscreen use reveal that sunscreens tinic keratosis and basal cell carcinoma have
are applied to skin at only 0.5 mg/cm2 or less.69,70 significantly decreased plasma levels of ascorbic
SPF is not linearly proportional; thus, at an applica- acid, ␣-tocopherol, and glutathione.78
tion of 0.5 mg/cm2, no sunscreen provides more Low-molecular-weight AOs work in tissues as a
than 3-fold protection (Fig 1). Moreover, important coordinated interactive group of chemicals related
biologic events such as DNA damage as measured to chemical structure, position in the tissue, and
by thymine dimer formation and 8-hydroxy-2⬘-de- relative redox potential (Fig 2).79 Thus, when a ROS
oxyguanosine formation,68 as well as p53 induction is generated in a lipophilic structure and is reduced
and UV immunosuppression,68,71 continue at sub- by ␣-tocopherol, the oxidized tocopherol can be
J AM ACAD DERMATOL Pinnell 5
VOLUME 48, NUMBER 1

Fig 2. Interacting network of nonenzymic antioxidants. When a reactive oxygen species

attacks membrane structure, it can be reduced by tocopherol that, in turn, can be regenerated
by ubiquinol or ascorbic acid. Reduced ascorbic acid can be regenerated by glutathione that,
in turn, can be reduced by nicotinamide adenine dinucleotide phosphate reduced (NAD[P]H)
pool. GSH, Glutathione; GSSG, oxidized glutathione; NAD(P)⫹, nicotinamide adenine dinu-
cleotide phosphate— oxidized form; NAD(P)H, nicotinamide adenine dinucleotide phos-
phate—reduced form; RO°, reactive oxygen free radical; RO, reduced reactive oxygen free
radical. (From Podda M, Grundmann-Kollmann M. Clin Exp Dermatol 2001;26:578-82. Repro-
duced with permission.)

regenerated by ubiquinol or L-ascorbic acid. In turn, composition for cosmetic use. In addition, many
dehydroascorbate can be reduced by glutathione, AOs are deeply colored, adding to the complexity of
which, in turn, can be reduced by the nicotinamide producing an acceptable aesthetic product. To pro-
adenine dinucleotide phosphate pool. This balance tect deeper layers of skin, AOs need to be formu-
may be essential for function and the system could lated in a way that delivers them into skin. Concen-
potentially fail when any step in the process be- trations need to be substantial and optimized to
comes rate limiting. maximize skin levels. Finally, AOs need to have
photoprotective effects including reduction of ery-
TOPICAL ANTIOXIDANTS
Because low-molecular-weight AOs protect skin thema, reduction of sunburn cell formation, reduc-
against oxidative stress, undergoing depletion in the tion of DNA changes such as thymine dimers or
process, it should be desirable to add to the skin oxidized nucleotides, reduction of UV immunosup-
reservoir by applying the AOs directly to skin. Al- pression, reduction of pigment abnormalities, and,
though AOs can be supplied to skin through diet eventually, reduction of skin cancer and photoaging
and oral supplementation, physiologic processes re- changes.
lated to absorption, solubility, and transport limit the
amount that can be delivered into skin. Direct ap- Physiologic antioxidants
plication has the added advantage of targeting the Perhaps the most obvious candidates for topical
AOs to the area of skin needing the protection. For AO protection are those naturally used by the body
topical application of AOs to be useful, however, for photoprotection. Those include vitamin C, vita-
several obstacles must be overcome. AOs are inher- min E, ubiquinol, and glutathione. However, gluta-
ently unstable compounds; this allows them to func- thione is a tripeptide and its ionic charges would
tion in redox reactions. Instability makes them diffi- make it an unlikely candidate for substantial percu-
cult to formulate in an acceptable, stable taneous absorption.
6 Pinnell J AM ACAD DERMATOL
JANUARY 2003

Fig 3. Vitamin E structures. Molecular structures of 4 tocopherols and 4 tocotrienols comprising

vitamin E. Substitution of methyl groups (CH3) at positions R1 and R2 determine whether the
molecules are ␣, ␤, ␹, or ␦.

Table II. Physiologic antioxidants

Concentration (nmol/g skin)
Antioxidant Source Distribution Epidermis Dermis

Vitamin C Diet Aqueous phase 7600.0 ⫾ 2498.0 1311.0 ⫾ 559.0

Glutathione Synthesized Cytoplasm 484.3 ⫾ 81.4 84.8 ⫾ 11.5
Vitamin E Diet Membranes, lipids 34.2 ⫾ 4.6 18.0 ⫾ 1.1
Ubiquinol/ubiquinone Synthesized Mitochondria 7.7 ⫾ 0.5 3.2 ⫾ 0.5

Data from Shindo Y, Witt E, Han D, Epstein W, Packer L. J Invest Dermatol 1994;102:122-4.

Vitamin C. Vitamin C (L-ascorbic acid) is the Virtually all plants and animals synthesize
body’s major aqueous phase reductant.80,81 It is a L-ascorbic acid. Human beings are an exception.
highly water-soluble, sugar-like, low-molecular- They have lost that ability as a result of a loss of
weight ␣-ketolactone. By a stepwise donation of an function mutation in L-gulono-␹-lactone oxidase.90
electron, the resulting ascorbate free radical that is Human beings must get their L-ascorbic acid
formed is more stable than other free radicals and through diet. Even with massive supplementation,
can serve as a free-radical scavenger. After loss of a biologic control mechanisms limit the amount that
second electron, the resulting oxidation product, can be absorbed and, subsequently, delivered into
dehydroascorbic acid, can be regenerated by dehy- skin.91 Topical application of L-ascorbic acid is the
droascorbic acid reductase, or as frequently hap- only way to further increase skin concentrations.
pens, may decay as the lactone ring irreversibly Delivery of L-ascorbic acid into skin depends on
opens. In addition to its AO properties, L-ascorbic removing the ionic charge on the molecule.92 Pro-
acid is essential for collagen biosynthesis; it serves as tonation is achieved at pH below 3.5. When thus
a cofactor for prolyl and lysyl hydroxylases, en- formulated, skin levels are maximized after 3 days of
zymes necessary for molecular stability and intermo- application of a 15% solution.92 Once in the skin, the
lecular cross-linking, respectively.82 In addition, it is molecule apparently stabilizes; disappearance oc-
important in transcriptional regulation of collagen curs with a half-life of approximately 4 days.
synthesis.83 L-ascorbic acid may inhibit elastin bio- Topical L-ascorbic acid protected porcine skin
synthesis84 and could, therefore, be useful for reduc- from UVB- and UVA-phototoxic injury as measured
ing the increased elastin accumulation that occurs in by erythema and sunburn cell formation.93 Topical
photoaged skin.50 L-ascorbic acid reduces pigment L-ascorbic acid protected against UVB-induced im-
synthesis in skin by inhibiting tyrosinase.85 L-ascor- munosuppression and systemic tolerance to contact
bic acid improves epidermal barrier function,86-88 allergens in mice.31 In human skin, topical L-ascor-
apparently by stimulating sphingolipid produc- bic acid slightly enhanced levels of messenger RNA
tion.89 for procollagens I and III; it also enhanced levels of
J AM ACAD DERMATOL Pinnell 7
VOLUME 48, NUMBER 1

procollagen processing enzymes, procollagen-N- greater AO activities in lipid structures than toco-
protease, procollagen-C-protease, and lysyl oxidase pherols.98 Vitamin E measurements in mouse tissues
in human skin.94 Although the results are intriguing, revealed substantial enrichment of tocotrienols in
it is not certain that the method used is sufficient to skin compared with other tissues.102 Vitamin E is
detect the small changes reported. especially abundant in stratum corneum, delivered
Derivatives of L-ascorbic acid have been substi- there in sebum.102,103 Its concentration is highest at
tuted for L-ascorbic acid in topical formulations to the lower levels of the stratum corneum, with a
improve stability. The most common of these, mag- decreasing gradient outward. The stratum corneum
nesium ascorbyl phosphate and ascorbyl-6-palmi- is the outermost defense of the body and first to
tate are readily converted to L-ascorbic acid in cell absorb the oxidative stress of sunlight and pollution.
and organ culture95 or after ingestion, but do not Vitamin E is depleted in the process and, in the
efficiently increase skin levels of L-ascorbic acid af- absence of co-AOs, is unable to be regenerated.
ter topical application.92 Magnesium ascorbyl phos- Vitamin E is important for protecting the lipid struc-
phate had a skin lightening effect in an open human tures of the stratum corneum and for protecting
study as determined by chromameter measure- stratum corneum proteins from oxidation. The li-
ments. The duration of use and time of year were pophilic nature of vitamin E makes it attractive for
not designated. In the same study, percutaneous application to and absorption into skin.104 Several
absorption was only 0.09% to 0.51% of the applied studies have documented photoprotective effects
dose. Intraperitoneal magnesium ascorbyl phos- when vitamin E was topically applied to animal skin.
phate delayed skin tumor formation in UVB-irradi- Topical ␣-tocopherol protected rabbit skin against
ated hairless mice.96 Skin levels of ascorbic acid UV-induced erythema,105 mouse skin against UV-
were increased consistent with tissue conversion of induced lipid peroxidation,106 mice against UV-in-
the derivative. Studies in hairless mice revealed per- duced photoaging changes,97,107 mice against UV
cutaneous absorption of ascorbyl-6-palmitate, but immunosuppression,108-110 and mice against UV
little effectiveness in an UVB-photoaging model.97 photocarcinogenesis.109,111 Follow-up studies to in-
Vitamin E. Vitamin E is the body’s major lipid vestigate the mechanism of inhibition of photocar-
phase AO.98,99 It consists of 8 molecular forms, 4 cinogenesis have revealed that ␣-tocopherol inhib-
tocopherols, and 4 tocotrienols (Fig 3). The mole- ited UV-induced cyclopyrimidine dimer formation in
cules consist of a hydrophobic prenyl tail that inserts mouse skin in the epidermal P53 gene.112 In addi-
into membranes and a polar chromanol head group tion to its photoprotective effects, ␣-tocopherol in-
exposed to the membrane surface. Tocopherols and hibits melanogenesis; it inhibited melanin formation
tocotrienols differ only in their prenyl tails. Toco- in human melanoma cells and demonstrated inhib-
pherols have linear, saturated tails whereas tocot- itory activity against tyrosinase and tyrosine.113 It
rienols have a nonlinear unsaturated tail. The chro- should be noted that ␣-tocopherol has modest UV
manol head of each is identical with ␣-, ␤-, ␹- and absorption near 290 nm and that some of its topical
␦-isomers, each containing an essential hydroxyl photoprotective effects may be related.114
group, necessary for AO activity, and methyl groups Esterification of the hydroxyl group on the chro-
varying in number and position. Although all of manol ring helps stabilize ␣-tocopherol in topical
these isomers are available in dietary sources, hu- formulations. Because this hydroxyl group is essen-
man beings use predominantly ␣-tocopherol be- tial for AO activity, the ester must be hydrolyzed
cause a specific ␣-tocopherol transfer protein selec- before there is biologic activity. This reaction readily
tively transfers ␣-tocopherol into lipoproteins.100 occurs after oral ingestion or in cell or organ culture
The major AO function of vitamin E is to prevent studies, but appears to be very slow after topical
lipid peroxidation. When an ROS attacks membrane application to skin. In human studies, ␣-tocopheryl
lipids, a peroxyl radical may form that can create acetate was substantially absorbed into skin, but was
more peroxyl radicals, resulting in a chain reaction not metabolized to free ␣-tocopherol.115 In mouse
that may threaten the structural integrity of the mem- studies, topical ␣-tocopheryl succinate and ␣-toco-
brane.99 Tocopherols and tocotrienols scavenge the pheryl acetate not only failed to inhibit UVB-in-
peroxyl radical, ending the chain reaction. Vitamin E duced immunosuppression and carcinogenesis, but
may also quench singlet oxygen.101 Once oxidized, actually appeared to enhance carcinogenesis.116
vitamin E can be regenerated back to its reduced Topical ␣-tocopheryl acetate was less effective than
form by L-ascorbic acid, allowing it to be reactivated ␣-tocopherol against UV-induced erythema in rab-
without creating a new membrane structure98 (Fig bits,105 UV-induced photoaging in mice,97 and UV-
2). The relative AO activities of tocopherol in lipid induced free-radical formation in mice.107 Topical
systems is ␣ ⬎ ␤ ⬎ ␹ ⬎ ␦.99 Tocotrienols may have ␣-tocopheryl succinate also was less effective than
8 Pinnell J AM ACAD DERMATOL
JANUARY 2003

␣-tocopherol in protecting against UV-induced blis- conformation, stability, and activity. Zinc serves as a
tering, tanning, and skin cancer in mice.110 catalyst for enzymes responsible for DNA replica-
Combination vitamin C and vitamin E. Sub- tion, gene transcription, and RNA and protein syn-
stantial experimental evidence reveals an interacting thesis.151,152 Zinc has an important AO effect in tis-
dependence of vitamins C and E in AO defense. In sues.153 Two different AO mechanisms have been
experimental lipid membrane117-119 and cellular sys- proposed. Zinc may replace potentially damaging
tems,120,121 vitamin C protects vitamin E from oxida- redox-active molecules, such as iron and copper, at
tion. Vitamin E in membranes ends chain reactions critical sites in cell membranes and proteins. Alter-
produced by peroxyl radicals and is oxidized in the natively, zinc may induce the synthesis of metallo-
process. Because the redox potential of vitamin C is thionein, sulfhydryl-rich proteins that neutralize free
below that of vitamin E, it is capable of reducing radicals.
oxidized vitamin E and regenerating its activity with- In cellular studies using human skin fibroblasts,
out replacing it in the membrane.122 Oral combina- zinc protected against UV-induced cytotoxicity,138
tion vitamins C and E in high doses provide protec- DNA damage,129,154 and lipid peroxidation.138,155
tion against UV-induced erythema in human Oral zinc supplementation reduced UV immunosup-
beings,123,124 whereas either vitamin alone is ineffec- pression to contact hypersensitivity in mice.150
tive.124 The topical combination of 15% L-ascorbic When similar studies were conducted in transgenic
acid and 1% ␣-tocopherol provided 4-fold protec- mice with null mutations in metallothionein-I and
tion against UV-induced erythema and thymine metallothionein-II genes, UV immunosuppression
dimer formation in porcine skin.125 In combination was not altered by zinc. These studies suggest that
with melatonin, vitamins C and E protect human zinc induction of metallothionein in skin protected
skin from UV-induced erythema.126 Topical combi- against UV immunosuppression. Topical application
nation vitamins C and E inhibit UV-induced tanning of zinc salts to mouse skin reduced UV-induced
and immunosuppression in mice127 and tanning in sunburn cell formation.156 Skin from metallothion-
human beings.128 ein-null mice was more sensitive to UV-induced
Selenium. Selenium is an essential micronutrient sunburn cell formation.157 Topical zinc was capable
required for at least 2 types of enzymes involved in of inducing metallothionein in hamster skin and may
defense against oxidative stress in mammals.129-132 explain the photoprotective effect of zinc.158
These enzymes, glutathione peroxidase and thiore-
doxin reductase, represent a significant portion of Plant antioxidants
the cell’s total defense against oxidative stress and Plants also have to protect themselves from the
are vital to maintaining a stable redox balance in the sun. In fact, they have an even greater struggle to
cell. In selenoenzymes, the selenium is present as avoid being oxidized to death because they are
selenocysteine, and a specific and elaborate system unable to move to avoid sunlight. Virtually all plants
exists for its incorporation into these proteins.133 The synthesize vitamin C159 and vitamin E99 to protect
activity of selenoenzymes can be increased by sele- themselves. In addition, they synthesize flavonoids,
nium supplementation.134-136 Several cellular studies polyphenolic compounds that are powerful AOs.160
have demonstrated the protective effects of sele- More than 8000 of these compounds have been
nium for UV-induced damage including cytotoxici- identified. Many of these plant AOs are consumed in
ty,137-140 DNA oxidation,141 DNA damage,129 inter- the diet and are believed to have important health-
leukin 10 expression,142 and lipid peroxidation.143 providing effects for human beings.161 Recently,
Oral sodium selenite protected hairless mice against some flavonoids have been demonstrated to have
UV-induced erythema and subsequent pigmenta- potent photoprotective properties when used topi-
tion.144 Oral selenium protected mice against UV- cally on skin, including silymarin, soy isoflavones,
induced skin cancer,145 146 although an oral trial in and tea polyphenols.
human beings failed to protect against basal or squa- Silymarin. Silymarin is an extract of the milk
mous cell carcinoma.147 Topical L-selenomethionine thistle plant, Silybum marianum. Milk thistle be-
protected mice against UV-induced erythema and longs to the aster family (Asteraceae or Compositae)
skin cancer.148 In human beings, topical L-sel- that includes daisies, thistles, and artichokes.162-164
enomethionine increased the minimal erythema Silymarin consists of a mixture of 3 flavonoids found
dose in a dose-responsive fashion.149 in the fruit, seeds, and leaves of the milk thistle
Zinc. Zinc is an essential human element. Skin plant: silybin (silibinin), silydianin, and silychris-
and appendages are rich in zinc, containing approx- tine.162 Silybin is the main component (70%-80%)
imately 20% of the body’s total.150 Zinc binds to a and is thought to have the most biologic activity.
number of biologic molecules and influences their Ancient physicians used silymarin; since the 4th cen-
J AM ACAD DERMATOL Pinnell 9
VOLUME 48, NUMBER 1

Fig 4. Multistage carcinogenesis. Skin tumors can be generated in hairless mice using series of
chemicals or with ultraviolet (UV) irradiation. Each stage of process, initiation, promotion, and
progression can be generated by UV irradiation, and each stage of process can be inhibited by
antioxidants.

induced low-density lipoprotein oxidation,174 and

scavenged ROS.175-178
Because tumor promoters cause oxidative stress
(Fig 4),179 silymarin was tested for its anticarcino-
genic effects in cancer-prone SENCAR mice. It was
demonstrated that low doses of topical silymarin
could almost completely inhibit the effect of 12-O-
tetradecanoylphorbol-13-acetate (TPA), a tumor
promoter, from inducing ornithine decarboxylase
activity.180 This suggested that silymarin might have
useful tumor prevention properties.
Subsequently, topical silymarin was demon-
strated to have a remarkable antitumor effect (Fig 5).
The number of tumors induced in the skin of hair-
less mice by UVB irradiation was reduced by 92%
(Fig 5).163 In addition, silymarin inhibited UVB-in-
Fig 5. Silymarin protection against ultraviolet (UV)-in- duced sunburn cell formation and apoptosis. Appar-
duced skin tumor generation. Topical silymarin was ently the result was not related to a sunscreen effect.
highly effective (92% reduction) against skin tumors gen-
Topical silymarin also inhibited chemical carcino-
erated in mouse skin by UV irradiation. (Modified from
Katiyar SK, Korman NJ, Mukhtar H, Agarwal R. J Natl
genesis of skin tumors in SENCAR mice.172 Tumors
Cancer Inst 1997;89:556-66.) were initiated with 7,12 dimethyl benzanthracene
(DMBA) and promoted with TPA. When tumors
were initiated with DMBA and promoted with ben-
tury BC, milk thistle extract has been used to treat zoyl peroxide, silymarin was also inhibitory, consis-
disorders of the spleen, liver, and gall bladder. Sily- tent with an AO effect as the cause of tumor inhibi-
marin has been shown to have use in many liver tion.181 Oral silymarin also effectively inhibited skin
disorders including hepatitis, alcoholic liver disease, tumor growth after DMBA initiation and TPA pro-
and cirrhosis.165-167 It also is useful for toxin-induced motion, and in addition, caused regression of estab-
liver toxicity, including poisoning from death cap lished tumors.182
mushroom (Amanita phalloides).162 In an animal The mechanism of the anticarcinogenic effect of
model of cirrhosis produced by bile duct oblitera- silymarin is unknown. Topical silymarin prevented
tion, silymarin had an antifibrotic effect.168 The an- the formation of pyrimidine dimers after UVB expo-
tifibrotic effect was apparently mediated by down- sure to hairless mouse skin.171 In human lympho-
regulation of procollagen a1(I), tissue inhibitor of cytes, silymarin protected against hydrogen peroxi-
metalloproteinase-I, and transforming growth factor de–induced DNA damage as revealed by the
␤-1.169 COMET assay.183 In cellular studies, silymarin inhib-
Silymarin has strong AO effects. Silymarin pre- ited mitogenic signaling molecules, resulting in
vented lipid peroxidation,170-173 inhibited copper- growth inhibition and apoptosis. Thus, at low doses,
10 Pinnell J AM ACAD DERMATOL
JANUARY 2003

silibinin inhibited activation of the epidermal growth Estrogens work by coupling with estrogen receptors
factor receptor and downstream mitogen-activated (ERs) in the cell’s nucleus, switching linked genes on
protein kinase-extracellular signal-regulated ki- or off. This may lead to proliferative or differentia-
nase-1 and ⫺2 activation, resulting in growth inhi- tion responses. Two types of receptors, ␣ and ␤,
bition.184 At higher doses, apoptotic cell death oc- have been identified. Both are present in skin.196
curred.185 Silymarin inhibited cellular signal Genistein has a 30-fold higher affinity for ER␤ than
transduction. Silymarin suppressed UV-induced186 ER␣197; however, genistein in reporter studies has
and tumor necrosis factor-␣–induced activation187 of greater ER␣ agonist activity than ER␤.198 In compar-
NF-␬B without affecting AP-1. In human prostate ison, estradiol has 700-fold more ER␣ and 45-fold
carcinoma cells, both constitutive and tumor necro- more ER␤ activity than genistein. Even though phy-
sis factor-␣–induced activation of NF-␬B were toestrogens are weak estrogens, soy may contain as
blocked by silibinin.188 Inhibition was associated much as 1/1000 of its content as phytoestrogens.
with an increase in inhibitory subunits of NF-␬ B␣, Circulating levels of phytoestrogens may be high,
the natural inhibitor of NF-␬B, and a decrease in and the subsequent biologic effect may be great.
phospho-inhibitory subunits of NF-␬ B␣; phosphor- Phytoestrogen receptor occupancy may potentially
ylation causes release of the inhibitor, apparently block the receptor and lead to antiestrogenic effects.
resulting from decreased I K␤ kinase activity. Sily- Skin changes dramatically during and after meno-
marin has anti-inflammatory effects.189 Inflammation pause. The thickness of the skin diminishes as does
was induced in skin of SENCAR mice with the tumor its collagen content.199-201 Administration of
promotor TPA. Pretreatment with topical silymarin oral201,202 or topical203,204 estrogen has been shown
reduced skin edema, lipid peroxidation, and myelo- to increase thickness and collagen content of skin.
peroxidase activity. Silymarin reduced TPA-induced Genistein may also have collagen-stimulating ef-
induction of epidermal lipoxygenase, interleukin fects. In studies using skin fibroblasts, genistein in-
1␣, and cyclooxygenase-2 but not cyclooxygenase-1 creased collagen (COL1A2) gene expression.205
activity. Silymarin also has antiangiogenic properties Soy isoflavones have potent anticarcinogenic ef-
that may contribute to its anticarcinogenic effects.190 fects that are largely independent of their estrogenic
In cultures of human vein endothelial cells, tube activities.194 Genistein is a strong inhibitor of ty-
formation, and secretion and cell content of MMP- rosine kinases, which are responsible for phosphor-
2/gelatinase A was inhibited by silymarin. In human ylating proteins necessary for regulation of cell di-
prostate and breast cancer epithelial cells, vascular vision.206 In animal studies, oral soy or genistein
endothelial growth factor (VEGF) secretion was re- protected against several cancers including bladder,
duced by silymarin. breast, colon, liver, lung, prostate, and skin.207 In
Soy isoflavones. Soybeans and their associated cellular studies, many cancer cell lines207 and non-
food products are a rich source of flavonoids called neoplastic breast cells208 were growth inhibited by
isoflavones. Isoflavones have attracted recent atten- genistein. Dietary soy inhibited skin tumor forma-
tion because epidemiologic studies have suggested tion in a chemical carcinogenesis study in mice.209
that they may be responsible for the lower risk of Likewise, topical genistein inhibited tumor number
cardiovascular disease and breast cancer in Asian by 60% to 75% in mice initiated with DMBA and
populations that consume large amounts of soy.191 promoted with TPA.210
In addition, these substances have estrogenic ef- The nature of genistein’s anticarcinogenic effect is
fects; phytoestrogens have been widely used in nu- unclear. In addition to its tyrosine kinase inhibitor
tritional supplements to treat menopausal symptoms effects, genistein is a potent AO. Genistein scav-
and postmenopausal effects, such as bone loss. For enged peroxyl radicals and protected against lipid
example, women in Asia have about 10% the inci- peroxidation in vitro211 and in vivo.212 Genistein
dence of hot flashes experienced by women in the inhibited in vitro UV-induced DNA oxidation213 and
United States.192 Their average intake of soy is be- cellular DNA oxidation induced by benzopyrene
tween 20 and 150 mg/d compared with 1 to 3 mg/d and UVA,214 psoralen plus UVA (PUVA) therapy,215
for women in the United States.193 and phorbol ester stimulation.216 Genistein reduced
The most plentiful isoflavones in soy are hydrogen peroxide– generated DNA damage in hu-
genistein and daidzein. In soy, they are present as man lymphocytes as determined by COMET as-
glycosides that are converted in the gut to the free say.217 Genistein reduced erythema and histologic
isoflavones.194 The glycosides are not estrogenically inflammation induced by PUVA in mouse skin.218
active, which may have implications for topical use Cells containing cleaved poly (adenosine disphos-
of soy.195 phate-ribose) polymerase and active caspase-3 gen-
Isoflavone phytoestrogens are weak estrogens. erated by PUVA were completely inhibited by
J AM ACAD DERMATOL Pinnell 11
VOLUME 48, NUMBER 1

genistein. In addition, genistein inhibited UV-in- cal,243 hydroxyl radical,244-246 hydrogen peroxide,247
duced apoptotic changes, including caspase-3 and and peroxyl radical.247 They work together with vi-
p21 activated kinase 2 activation in human epider- tamin E, regenerating it from its oxidation prod-
mal carcinoma cells219 and phosphokinase C␦ in uct.248 Tea polyphenols limited UV-induced lipid
human keratinocytes.220 Genistein inhibited UVB- peroxidation in skin249 and reduced oxidation of
induced c-Fos and c-Jun expression in mouse skin, proteins in a free radical– generating system in
apparently by tyrosine kinase inhibition.221 vitro.250 Tea polyphenols regulate cellular redox-
Genistein has anti-inflammatory properties. In hu- signal transduction. In human keratinocytes, (-) epi-
man epidermal cell cultures, it inhibited UVB-stim- gallocatechin-3-gallate inhibited UVB-induced AP-1
ulated prostaglandin E2 synthesis222 and suppressed activity251 and mitogen-activated protein kinase cell
UVB-induced expression of cyclooxygenase-2 in signaling pathways, extracellular signal-related pro-
keratinocytes.223 Finally, genistein has immune- tein kinase 1/2, c-Jun N-terminal protein kinase, and
modulating effects. Genistein inhibited UV-induced p38.252
immunosuppression in mice.224 Tea polyphenols are antimutagenic in microbial
Tea polyphenols. Tea (Camellia sinensis) is a systems, mammalian cell systems and in vivo animal
potent source of polyphenols, comprising 30% to tests.253 Tea polyphenols protected DNA from oxi-
35% of the dry weight of the leaf. During processing, dation by hydrogen peroxide and UVB in vitro.254 In
tea leaves are progressively fermented to produce human skin fibroblasts, tea polyphenols protected
green tea, oolong tea, or black tea. Green tea con- against radiation-induced DNA damage.255 In Jurkat
tains predominantly monomeric catechins including lymphocytes, epigallocatechin gallate reduced DNA
epicatechin, epicatechin-3-gallate, epigallocatechin, damage caused by free-radical generators and hy-
and epigallocatechin-3-gallate. Black tea contains drogen peroxide as revealed by COMET assay. 256
predominantly polymeric polyphenols.225
Topical application to skin of green tea polyphenols
Tea polyphenols have been widely studied for
reduced UVB-induced pyrimidine dimers in both
their anticarcinogenic potential. They have been ef-
epidermis and dermis.257
fective in animal models of cancer of skin, stomach,
Tea polyphenols induced apoptosis in several
lung, esophagus, duodenum, pancreas, liver, breast,
different tumor cells,184,258 but not normal human
and colon.226 However, epidemiologic studies have
keratinocytes that were apparently protected
failed to support protection in human beings,226
through induction of p57, a cell cycle regulator.259
with the exception of squamous cell carcinoma of
Tea polyphenols may affect invasiveness of tu-
skin, where a statistically significant inverse associ-
mors. They inhibited MMPs260-262 and inhibited ad-
ation between skin cancer and hot black tea con-
sumption was observed.227 hesion of tumor cells to laminin.263,264 Tea polyphe-
Tea polyphenols strongly inhibit skin cancer in nols may also have antiangiogenic effects. They
mouse 2-stage carcinogenesis models.228-231 Both inhibited induction of VEGF in human colon carci-
oral and topical green tea polyphenols decreased noma cells265 and inhibited VEGF-dependent VEGF
chemically induced232,233 and UV-induced skin tu- receptor 2 phosphorylation in bovine aortic endo-
mors.234 Green tea also inhibited growth of estab- thelial cells.266
lished skin tumors.235 It prevented conversion of Tea polyphenols have anti-inflammatory effects.
benign skin tumors to squamous cell carcinoma.236 Topical green tea polyphenols reduced UV-induced
Tumors were initiated by DMBA, promoted by TPA, erythema and sunburn cell formation in human
and malignant conversion achieved by benzoyl per- skin.267 Topical (-) epigallocatechin-3-gallate re-
oxide. Green tea and black tea were equivalent in duced UVB-induced inflammatory responses and in-
effect and decaffeinated tea was less effective.237 filtration of leukocytes in human skin.268 Green tea
Caffeine alone was effective and may importantly polyphenols also protected against erythema, and
contribute to the effect.238 Topical (-) epigallocat- c-Fos and p53 induction after PUVA phototoxic in-
echin-3-gallate inhibited UV-induced skin tumor for- jury to human skin.269 Tea polyphenols also have
mation, but oral administration was ineffective.239 immune-modulating effects. Green tea polyphenols
Oral tea polyphenols failed to protect against basal- protected human skin from UV-induced Langerhans
cell carcinoma in a UV-induced mouse model, cell depletion.267 Topical (-) epigallocatechin-3-gal-
ptc1⫹/-.240 late protected against UVB-induced immunosup-
Although the nature of the anticarcinogenic effect pression and tolerance in mice.270 Topical applica-
is unknown, tea polyphenols are strong AOs,241 tion of (-) epigallocatechin gallate also inhibited
more powerful than vitamin C and vitamin E.242 carcinogenesis and selectively increased apoptosis
They quenched singlet oxygen,241 superoxide radi- in UVB-induced skin tumors in mice.271
12 Pinnell J AM ACAD DERMATOL
JANUARY 2003

CONCLUSION 13. Bergendi L, Benes L, Durackova Z, Ferencik M. Chemistry, phys-

Oxidative stress can occur from many sources in iology and pathology of free radicals. Life Sci 1999;65:1865-74.
14. Black HS, deGruijl FR, Forbes PD, Cleaver JE. Photocarcinogen-
the skin including metabolism, pollution, and sun- esis: an overview. Photochem Photobiol 1997;40:29-47.
light radiation. A wealth of information supports the 15. de Gruijl FR, van der Leun JC. Estimate of the wavelength de-
photocarcinogenic damage to skin from sunlight pendency of ultraviolet carcinogenesis in humans and its rele-
and its relationship to oxidative stress. In animal vance to the risk assessment of stratospheric ozone depletion.
models of photocarcinogenesis, AOs provide pro- Health Phys 1994;67:319-25.
16. de Gruijl FR. Photocarcinogenesis: UVA vs UVB. Singlet oxygen,
tection when provided to the skin systemically or
UVA, and ozone. Methods Enzymol 2000;319:359-66.
topically. AOs work together in skin, supporting and 17. Danpure HJ, Tyrrell RM. Oxygen-dependence of near UV (365
regenerating each other. Topical AOs may provide NM) lethality and the interaction of near UV and X-rays in two
several advantages for photoprotection not pro- mammalian cell lines. Photochem Photobiol 1976;23:171-7.
vided by dietary supplements. If AOs can be deliv- 18. Gaboriau F, Demoulins-Giacco N, Tirache I, Morliere P. Involve-
ment of singlet oxygen in ultraviolet A-induced lipid peroxida-
ered into skin, they can be targeted to exposed skin,
tion in cultured human skin fibroblasts. Arch Dermatol Res
circumvent physiologic barriers to systemic tissue 1995;287:338-40.
delivery, and accumulate in pharmacologic concen- 19. Tyrrell RM. UVA (320-380 nm) radiation as an oxidative stress.
trations. Their presence should supplement the nat- In: Sies H, Oxidative stress, oxidants and antioxidants. London:
ural AO protection present in skin, and provide Academic Press Ltd; 1991. p. 57-83.
20. Tyrrell RM. Oxidant, antioxidant status and photocarcinogen-
supplemental reserves as oxidative stress depletes
esis: the role of gene activation. Photochem Photobiol 1996;
AO stores. 63:380-6.
Thanks and appreciation to Dr Doren Madey for her 21. Morliere P, Moysan A, Tirache I. Action spectrum for UV-in-
excellent ideas and suggestions and for her devoted help duced lipid peroxidation in cultured human skin fibroblasts.
Free Radic Biol Med 1995;19:365-71.
in preparing the manuscript. Thanks also to Mr Robert
22. Wenczl E, Pool S, Timmerman AJ, Vanderschans GP, Roza L,
Streilein for his excellent work in producing the figures. Schothorst AA. Physiological doses of ultraviolet irradiation in-
Thanks to Dr James Grichnik for his review of the manu- duce DNA strand breaks in cultured human melanocytes, as
script and helpful suggestions. detected by means of an immunochemical assay. Photochem
Photobiol 1997;66:826-30.
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Answers to CME examination

Identification No.803-101

January 2003 issue of the Journal of the American Academy of Dermatology

Questions 1-30, Pinnell SR. J Am Acad Dermatol 2003;48:1-19.

1. e 7. d 13. a 19. e 25. e

2. c 8. e 14. e 20. a 26. e
3. e 9. c 15. e 21. b 27. d
4. e 10. d 16. e 22. d 28. a
5. b 11. e 17. d 23. a 29. e
6. a 12. c 18. e 24. d 30. b
 Answer sheets are bound into the Journal for US, Canadian, and life members. Request additional
answer sheets from American Academy of Dermatology, Member Services Department, PO Box 4014,
Schaumburg, IL 60168-4014. Phone 847-330-0230; E-mail: [email protected]

CME examination
Identification No. 803-101

Instructions for Category I CME credit appear in the front advertising section. See last page of Contents for page number.

Questions 1-30, Pinnell SR. J Am Acad Dermatol 2003;48:1-19.

Directions for questions 1-30: Give single best response. 7. In the absence of erythema, sunscreens protect skin
from
1. In contrast to UVB, UVA a. UV immunosuppression
a. is more plentiful
b. DNA mutation
b. penetrates window glass
c. p53 induction
c. generates more oxidative stress
d. none of the above
d. none of the above
e. all of the above
e. all of the above
8. The skin uses which of the following to protect itself
2. The major chromophore in skin for the generation of
from the sun?
singlet oxygen is
a. L-ascorbic acid and ␣-tocopherol
a. DNA
b. Catalase and superoxide dismutase
b. keratin
c. Glutathione and ubiquinol
c. urocanic acid
d. None of the above
d. selenium
e. All of the above
e. hemoglobin
9. Which statement is incorrect ?
3. C3T CC3TT DNA mutations are characteristic for
a. oxidative damage a. ␣-tocopherol protects cellular membranes
b. UVA absorption b. L-ascorbic acid regenerates oxidized ␣-tocopherol
c. p53 c. ␣-tocopherol regenerates oxidized L-ascorbic acid
d. xeroderma pigmentosum d. Dehydroascorbic acid cannot be reduced back to
e. UV photodamage L-ascorbic acid
e. Physiologic AOs work together to protect cellular
4. p53 structures
a. monitors DNA quality control
b. is characteristically mutated in squamous cell car- 10. L-ascorbic acid
cinoma a. is synthesized in the body
c. is induced by UVB b. protects skin from sunlight by stimulating melanin
d. none of the above synthesis
e. all of the above c. stimulates elastin synthesis in skin
d. must be un-ionized to get into skin when applied
5. A free radical is most likely to react with topically
a. cell membranes e. Is synthesized only by animals
b. the nearest substrate to which it is created
c. DNA 11. Ester derivatives of vitamin C and vitamin E are often
d. proteins used in topical products of skin. Which statement is
e. lipids most true about these derivatives?
a. They must be converted to the vitamin to be ef-
6. Controlled studies have revealed that sunscreens are fective in skin
applied at only 20% to 25% of recommended levels. A b. The derivatives are not as effective as the vitamins
sunscreen with a sunscreen protection factor (SPF) of for preventing UV photodamage
30 applied at that level would provide the following c. Esterification often blocks the AO properties of the
protection: vitamin
a. SPF 2-3
d. None of the above
b. SPF 6-8
e. All of the above
c. SPF 10-15
d. SPF 20-25 12. L-ascorbic acid and ␣-tocopherol block UV-induced
e. SPF 30 pigment formation by

20
J AM ACAD DERMATOL CME examination 21
VOLUME 48, NUMBER 1

a. blocking the penetration of sunlight at the skin e. all of the above

surface
20. Topical application of each of the following reduced
b. absorbing UV light
experimental skin tumors in mice except
c. inhibiting melanin synthesis
a. zinc chloride
d. oxidizing tyrosinase
b. selenomethionine
e. enhancing endothelin-1
c. silymarin
13. Selenium d. genistein
a. protects the body against oxidative stress e. epigallocatechin-3-gallate
b. protects human beings against UV-induced cell
21. Each of the following are plant polyphenols except
cancer
a. daidzein
c. stimulates melanogenesis
b. tocopherol
d. None of the above
c. silymarin
e. All of the above
d. genistein
14. Zinc e. epigallocatechin-3-gallate
a. serves as a cofactor for enzymes responsible for 22. Each of the following statements is true except
DNA replication a. after menopause, skin becomes thinner.
b. induces metallothionein, an AO protein b. after menopause, collagen content in skin de-
c. may replace potentially damaging redox-active creases.
molecules c. oral estrogen increases postmenopausal skin col-
d. none of the above lagen.
e. all of the above d. oral genistein increases postmenopausal skin col-
15. Plants and animals protect themselves from sunlight’s lagen.
photooxidative stress by synthesizing e. topical estrogen increases postmenopausal skin
a. vitamin C collagen.
b. vitamin E 23. Genistein has an anticarcinogenic effect when used
c. polyphenols topically. The effect is least likely to be a result of
d. none of the above a. estrogenic effect
e. all of the above b. AO effect
16. AOs have strong antitumor effects. AOs can effect c. tyrosine kinase inhibition
a. tumor initiation d. reduction of DNA damage
b. tumor promotion e. inhibition of UV immunosuppression
c. tumor progression 24. Which of the following statements is least correct
d. none of the above about photocarcinogenesis?
e. all of the above a. UVB causes tumor initiation.
17. Which of the following statements is incorrect ? b. UVA causes tumor promotion.
a. Skin contains ER␣ c. UVB causes UV immunosuppression.
b. Skin contains ER␤ d. UVA induces cyclopyrimidine dimer formation.
c. Soy phytoestrogens may block ERs e. Sunlight is a complete carcinogen.
d. Soy isoflavone glycosides are estrogenically active 25. Which of the following statements is most correct
e. Soy isoflavone, genistein, is an inhibitor of ty- about photoaging?
rosine kinase a. UVA1 can cause photoaging changes.
18. Each of the following statements is true about silyma- b. DNA in mitochondria is altered by UVA.
c. Pieces of DNA can stimulate melanogenesis.
rin except
d. None are correct.
a. silymarin is derived from the milk thistle plant
e. All are correct.
b. oral silymarin is used as an antidote against mush-
room poisoning 26. Which of the following statements is most correct
c. oral silymarin reduces experimental skin tumors in about the anticarcinogenic effect of tea polyphenols?
mice a. Green tea inhibits skin cancer in mice.
d. topical silymarin reduces experimental skin tu- b. Black tea inhibits skin cancer in mice.
mors in mice c. Caffeine inhibits skin cancer in mice.
e. silymarin causes ER activation d. None are correct.
e. All or correct.
19. Silymarin may inhibit skin tumor development by
a. preventing formation of thymine dimers 27. Which of the following statements about selected
b. promoting apoptosis AOs is least correct?
c. AO effects a. ␣-Tocopherol is a major AO of the stratum cor-
d. none of the above neum.
22 CME examination J AM ACAD DERMATOL
JANUARY 2003

b. Ubiquinol protects cell mitochondria from oxida- 29. Sunlight produces which one of the following effects
tive stress. on DNA in skin?
c. L-ascorbic acid protects tissue fluids from oxida- a. Generation of cyclopyrimidine dimers
tive stress. b. Oxidation of guanine to 8-hydroxyguanine
d. ␣-Tocopherol protects the cytoplasm of cells from c. Inhibition of nucleotide repair
oxidative stress. d. None of the above
e. Vitamins C and E work together in the body to e. All of the above
produce synergistic effects. 30. Which of the following statements is incorrect about
UV immunosuppression?
28. Which of the following statements is incorrect about a. Almost all patients with skin cancer have UV im-
UV-induced melanogenesis? munosuppression.
a. Oral vitamin C and vitamin E reduce the tanning b. Almost all patients without skin cancer do not
response. have UV immunosuppression.
b. Topical vitamin C and vitamin E reduce the tan- c. Topical L-ascorbic acid blocks UV immunosup-
ning response. pression in mice.
c. L-ascorbic acid inhibits tyrosinase. d. Oral zinc reduces UV immunosuppression in
d. ␣-Tocopherol inhibits tyrosinase. mice.
e. Thymine dinucleotide can stimulate melanogene- e. Topical epigallocatechin-3-gallate reduces UV im-
sis in melanocytes. munosuppression in mice.